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9<30S
Differential Diagnosis
VOLUME II
PRESENTED THROUGH
AN ANALYSIS OF 317 CASES
RICHARD C. CABOT, M. D.
PROFUSELY ILLUSTRATl
PHILADELPHIA AND LONDON
W. B. SAUNDERS COMPANY
1914
Copjrright, 1914, by W. B. Saundera Company
PRINTED IN AMERICA
PRESS OF
W. B. SAUNDERS COMPANV
PHILADELPHIA
• •• •
• » • • •
• • ■
• %
PREFACE
The first volume of this work dealt with the symptom paitiy and
with eleven other common symptoms. In the present volume the
same plan has been carried further. Nineteen other symptoms have
been selected, analyzed, and illustrated. I have profited much from
the study of the Index of Differential DiagnosiSy by Herbert French
and other writers, an admirable book published in 191 2, since my
first volume appeared. To the writers of that book I gratefully
acknowledge my indebtedness.
As in the previous volume, I have received very substantial help
from Dr. James H. Young, and from my secretaries, Miss Alice
O'Gorman, Miss Mary F. Foote, and Miss Florence Painter.
iv. (^. (^.
I Maklborough St., Boston, Mass.
DecembeTf 1914.
781 91
TABLE OF CONTENTS
CHAPTER I
ABDOMINAL AND OTHER TUMORS
Page
General Considerations 17
Case No.
1. Pregnancy 27
2. Echinococcus Cyst of Liver 28
3. Adenocystoma of Ovary; Thrombosis of Vena Cava Inferior 29
4. Myeloid Leukemia 31
5. Nephroptosis; Congenitally Deformed Kidney; Corset Lobe of Liver 34
6. (a) Hypernephroma (?) ; (6) Cervical Rib 37
7. Osteitis Deformans 39
8. Pelvic Cancer, probably Ovarian 41
9. Malignant Lymphoma (Lymphoblastoma — Mallory) 45
10. Hydronephrosis 49
11. Glanders 52
1 2. Phantom Tumor 65
13. Malignant Lymphoma of the Retrof)eritoneal Glands (Lymphoblastoma —
MaUory) 68
14. Axillary Abscess 69
15. Lymphoid Leukemia 70
16. Lymphoid Leukemia; Abdominal Masses and Ascites 72
17. Cancer of the Tail of the Pancreas with Extension to the Spleen, Liver,
and Glands 74
18. Multiple Lipomata 76
19. Extra-uterine Pregnancy 77
20. Gumma of Thigh 79
21 . Tuberculous Peritonitis 80
22. Cancer of the Cecum 85
23. Syphilis 86
24. Malignant Lymphoma (Hodgkin's Disease, Mallory 's Lymphoblastoma).. 88
25. Aortic Aneurysm 92
26. Syphilis 93
27. Syphilitic Gumma of the Sternum 95
28. Gumma of the Frontal Bone 97
29. Gastric Cancer 99
30. Gastric Cancer with Metastasis in a Supraclavicular Lymph Node loi
31. Syphilis 104
32. Syphilitic Periostitis of Cranial Bones 106
33. Chronic Family Jaundice (Hemolytic Jaundice) no
34. Cancer of the Cecum and Appendix 115
35. Walled-oflF Abscess about Gall-bladder 116
36. Kidney Stone; Pyonephrosis 119
7
8 TABLE OF CONTENTS
Cask No. Page
37. Phantom Tumor 121
38. Melanotic Sarcoma of Liver 1 23
39. Hypernephroma 1 26
40. Lymphoblastoma 127
41. Echinococcus of Liver 131
CHAPTER n
VERTIGO
General CoNsroERATiONs 134
Physiologic Vertigo 134
Pathologic Vertigo 136
Is There a Gastric Form of Vertigo? 139
Cask No.
42. Chronic Nephritis in an Excessive Smoker 139
43. Aneurysm of the Thoracic Aorta 140
44. Chronic Interstitial Nephritis (Arteriosclerotic Type) ; Uremia 142
45. Endothelioma of the Dura in the Posterior Fossa of the Skull 144
46. Typhoid Fever 146
47. Labyrinthine Disease 147
48. Addison's Disease 147
49. Heat Stroke 150
50. Alcoholism; Cirrhosis (?); Syphilis (?) 151
51. Chronic Glomerular Nephritis 152
52. Hysteria in a Syphilitic 153
53. Cerebellar Cyst; Arteriosclerosis 154
54. Cerebral Syphilis 155
55. Cerebral Syphilis 156
56. Miliary Tuberculosis with Tuberculous Meningitis 159
57. Myocardial Weakness; Arhythmia 160
58. Arteriosclerosis 162
59. Addison's Disease 163
60. Arteriosclerosis 165
61. Cerebellar Tumor 167
62. Miliary Tuberculosis 168
63. M^ni^re's Disease 170
64. Syphilis 172
65. Otosclerosis; Labyrinthitis 173
CHAPTER m
DIARRHEA
General Considerations i7S
Causes and Types of Diarrhea in Adult Life 175
Difficulty of Distinguishing Acute from Chronic Enteritis and Colitis — 176
Causes of Diarrhea 178
Types and Diagnosis 183
Cask No.
66. Pericecal Tuberculosis 185
67. Tuberculous Enteritis 187
68. Fat Intolerance; Abdominal Tumor (Lymphoblastoma?) 189
69. Neurasthenia 193
70. Cancer of the Bladder 194
TABLE OF CONTENTS 9
Case No. Page
71. Appendix Abscess « 197
72. Tuberculous Peritonitis and Enteritis 198
73. Infectious Colitis; Otitis Media 200
74. Cancer of the Sigmoid 201
75. General Infection due to Bacillus Coli; Typhus Fever 202
76. Meddlesome Surgery 204
77. Food Diarrhea 206
78. Tuberculous Peritonitis 208
79. Chronic Colitis; Starvation 211
80. Colitis of Unknown Cause 214
81. Chronic Diarrhea from Bad Habits 215
82. Chronic Colitis (Tuberculous?) 216
83. Chronic Glomerular Nephritis and Acute Endocarditis 220
84. Amebic Dysentery 223
85. Bilharziasis 225
86. Plumbism; Tabes; Morphinism 227
87. Pernicious Anemia 230
88. Pernicious Anemia 233
89. "Leather-bottle Stomach'* (Diffuse Cardnoina) with Cancerous Peritonitis 235
90. Stricture of Rectum (Syphilitic?) 237
91. Typhoid Fever 238
92. Constipation with Mucous Colitis 240
93. Trichiniasis 241
94. Ulcerative Colitis 243
95. Amebic Dysentery 244
96. Diarrhea of Unknown Cause 245
97. Typhoid Fever 246
98. Ulcerative Colitis 248
CHAPTER IV
DYSPEPSIA
General Considerations 250
What is Simple Indigestion? 257
Case No.
99. Duodenal Ulcer with Contracted Scar 258
[GO. Chronic Glomerular Nephritis 261
[Qi. Cancer of the Stomach 265
[02. Chronic Glomerular Nephritis 268
[03. Hysteria (Insanity?) 270
:c4. Cancer of the Gall-bladder 272
[05. Gall-stones 273
[06. Brain Tumor 275
[07. Bad Dietetic Habits; Constipation 277
[08. Chronic Glomerular Nephritis 278
C09. Hydronephrosis 279
10. Cancer of Vater's Papilla 281
11. Pregnancy 283
1 2. Chronic Plumbism (?) 285
13. Kidney Stones; Left Pyonephrosis 287
14. Bad Dietetic Habits 288
15. Cancer of the Bile-ducts 290
16. Acute Gastric Indigestion 292
lO TABLE OF CONTENTS
Case No. Page
117. Meddlesome Surgery; Mysterious Fever 294
118. Alcoholism 301
. 119. Social Maladjustment; Arteriosclerosis 302
120. Amyloid Nephritis; Ulcerative Enterocolitis; Purulent Bronchitis 304
121. Phthisb 306
122. Cirrhosis of the Liver; Syphilis (?) 308
123. Chlorosis; Social Maladjustment 310
124. Peptic Ulcer 312
125. Gastric Crisb in Tabes Dorsalis 314
126. Gall-stones in the Cystic Duct; Arteriosclerosis 316
127. Alcoholism; Chronic Peritonitis 318
128. Tabes Dorsalis 321
129. Psychoneurosis 323
130. Phthisis 325
131. Acute Indigestion (from overeating) 327
132. Cancer of the Stomach 328
133. Phthisis 330
134. Pernicious Anemia 333
135. Myeloid Leukemia 334
136. Cancer of the Cardiac End of Stomach 336
137. Addison's Disease 338
138. Gastric Cancer; Ovarian Fibroma 341
139. Nervous Dyspepsia; Starvation 344
140. Adhesions about Gall-bladder and Colon; Fibroid of Uterus 346
141. Gastric Crises of Tabes Dorsalis 348
CHAPTER V
HEMATEMESIS
General Considerations 350
Case No.
142. Peptic Ulcer; Mitral Stenosis 350
143. Cancer of Stomach; Ovarian Fibromata 353
144. Cirrhotic Liver; Internal Hydrocephalus; Hemophilia 357
145. Cirrhosis of the Liver 360
146. Menstrual Vomiting 361
147. Tabes Dorsalis; Gastric Crisis 361
148. Peptic Ulcer 364
149. Splenic Anemia 365
CHAPTER VI
GLANDS
General Considerations 369
Enlarged Glands and What Simulates Them 369
Clinical Groupings 373
Nomenclature op Glandular Tumors 374
What Other Lumps May Be Mistaken for Glands? 374
Gland Puncture 374
Case No.
150. Branchial Cyst 375
151. Lymphoblastoma (Hodgkin's Disease) 376
152. Cancer of the Thyroid 379
TABLE OF CONTENTS II
Case No. Paok
[53. Lymphoblastoma 380
[54. Lymphoid Leukemia 381
[55. Lymphoid Leukemia 384
:s6. Syphilitic Aortitis 386
:57. Septic Adenitis 388
[58. Neuroblastoma of the Neck, etc 389
[59. Tabes DorsaUs; Thyroid Enlargement 391
[60. Lymphoblastoma 393
[61. Multiple Myeloma 394
[62. Acute Lymphoid Leukemia 396
[63. Tuberculous Adenitis and Tonsillitis 399
[64. Tuberculous Adenitis 401
[65. Malignant Lymphoma (Lymphoblastoma) 402
CHAPTER VII
BLOOD IN THE STOOLS (MELENA)
General Considerations 406
Case No.
166. Cancer of the Rectum 408
167. Typhoid Fever 410
168. Ulcerative Colitis 411
169. Cancer of Stomach with Diffuse Infiltration and Contraction 413
1 70. Bilharziasis 414
171. Amebic Dysentery 415
CHAPTER VIII
SWELLING OF THE FACE
General Considerations 417
Case No.
172. Tertian Malaria 419
1 73. Actinomycosis of the Jaw 420
174. Mumps 421
175. Trichiniasis 422
176. Trichiniasis 424
177. Empyema of the Antrum 424
178. Erysipelas 425
179. Edema with Erythema; Vasomotor Ataxia 426
180. Acute Nephritis 427
181. Syphilitic Laryngitb with Stenosb: Deep Cervical Cellulitis (Ludwig*s An-
gina) 428
182. Chronic Glomerular Nephritis 430
CHAPTER IX
HEMOPTYSIS
General Considerations 432
Case No.
183. Mitral Stenosis; Phthisis 434
184. Phthisis 438
185. Lobar Pneumonia 440
186. Phthisb 443
12 TABL£ OF CONTENTS
Ca8b No. Page
187. Congenital Heart Disease 445
188. Abscess of the Lung; Septicemia 447
189. Phthisis (?) 451
190. Abscess of the Lung 452
191. Hysteria (?) 455
192. Incipient Phthisis 460
193. Arteriosclerotic Nephritis; Pubnonary Apoplexy 462
194. Arteriosclerosb; Glomerular Nephritis 463
CHAPTER X
EDEMA OF THE LEGS
General Considerations 465
Local Causes of Edema 465
Varieties and Sites of Edema 466
Edema in Convalescence 466
Case No.
195. Cirrhosis of the Liver (Syphilis?) 466
196. Phlebitis; Arteriosclerosb 469
197. Flat-foot 470
198. Pernicious Anemia 471
199. Trichiniasis 473
200. Endocarditis 475
201. Phlebitis; Pulmonary Infarct 477
202. Chronic Glomerular Nephritis 479
203. S3rphilis; Myocardial Insufficiency; Tabes; Paralysis of the Vocal Cords. . 481
204. Erythema Multiforme 481
205. Alcoholic Neuritis with Edema 482
206. Acute Nephritis; Cervical Adenitis 483
207. Alcoholic Neuritis; Myocardial Weakness 484
208. Cirrhosis of Liver; Arteriosclerosis; Subacute Glomerular Nephritis 485
209. Arteriosclerosis; Weak Heart 487
210. Elephantiasis 488
211. Phthisis; General Miliary Tuberculosis; Tuberculous Peritonitis 491
2X2. Acute Glomerular Nephritis 493
CHAPTER XI
FREQUENT MICTURITION AND POLYURIA
General Considerations 495
Case No.
213. Diverticulitis Perforating the Bladder; Syphilis 496
214. Cystitis; Streptococcus Infection 499
215. Anemia; Debility 501
216. Pyelonephritis 502
217. Vesical Calculus 504
218. Neurasthenia 505
219. Pyelonephritis 506
220. Tuberculous Peritonitis 509
221. Tuberculosis of the Kidney and Bladder 510
222. Tuberculosis of the Kidney and Bladder 512
223. Chronic Glomerular Nephritis; Arteriosclerosis; Myomalacia Cordis 515
TABL£ OF CONTENTS 13
Case No. Pack
224. Albuminuria and Glycosuria, Cause Unknown 518
225. Malignant Disease of the Ovary 519
226. Chronic Nephritis (Syphilitic?) 521
227. Colon Bacillus Infection of the Urinary Tract 522
228. Cystitis (Tuberculous?) 524
229. Bilateral Pyonephrosb; Secondary Anemia 525
230. Gonorrheal Pyelitis; Prostatitis; Arthritis 528
231. Cancer of the Bladder 529
232. Obstructing Prostate; Arteriosclerosis 530
233. Chronic Interstitial Nephritis 532
234. Diabetes Insipidus; Congenital Syphilis 533
235. Diabetes Mellitus 535
236. Diabetes Mellitus; Hemorrhoids; Secondary Anemia 536
CHAPTER XII
FAINTING
Genesal Considerations 541
Case No.
• 237. Chronic Lead-poisoning 542
238. Hemorrhage from Duodenal Ulcer 545
239. Chronic Glomerular Nephritis 546
240. Arteriosclerotic Nephritis 548
241. Arteriosclerosb; Cerebral Hemorrhage 550
242. Arteriosclerosis; Stokes-Adams Disease 552
243. Pernicious Anemia 553
244. Hysteria 555
245. Hysteria 557
CHAPTER Xin
HOARSENESS
General Considerations 559
Case No.
246. Acute Laryngitis; Syphilis (?) 560
247. Hysterical Aphonia 562
248. Thoracic Aneurysm 563
249. Papilloma of the Larynx 566
250. Mediastinal Neoplasm (?) 567
251. Recurrent Laryngeal Paralysb; Aneurysm (?) 570
252. Aneurysm 571
253. Syphilis of the Larynx 573
CHAPTER XIV
PALLOR
General Considerations 575
Case No.
254. Gastric Cancer 575
255. Acute Lymphoid Leukemia 578
256. Chlorosis ; 580
14 TABLE OF CONTENTS
Case No. Pags
257. Pemidous Anemia 581
258. Subdiaphragmatic Abscess (Secondary Anemia) 582
259. Pernicious Anemia; Arsenic-poisoning; Arteriosclerotic Nephritis 585
260. Chronic Glomerular Nephritis (Streptococcus Origin?) 588
261. Gastric Ulcer 590
262. Acute Glomerular Nephritis; Syphilitic Aortitis 592
263. Bothriocephalus Latus 594
CHAPTER XV
SWELLING OF THE ARM
General Considerations 597
Case No.
264. Phlebitis 597
265. Osteomyelitis of the Humerus 599
266. Phlebitis, Cause Unknown 600
267. Dilated Aortic Arch; Phlebitis; Edema Due to Pressure 601
268. Tuberculous Pericarditis with Effusion 603
269. Adherent Pericardium; Mitral Stenosis 608
270. Pellagra 610
CHAPTER XVI
DELIRIUM
General Considerations 612
Case No.
271. Typhoid Fever 613
272. Postfebrile Psychosis 615
273. Arteriosclerosis 616
274. Postfebrile Psychosis 61 7
275. Exhaustion Psychosis 619
276. Tertian Malaria 621
CHAPTER XVII
PALPITATION AND ARHYTHMIA
General Considerations 622
Etiology 624
Summary 624
Case No.
277. Myocardial Weakness; Hypertension 624
278. Neurosb 625
279. Paroxysmal Tachycardia 626
280. Dysthyroidism 628
281. Mitral Stenosis <>29
282. Pernicious Anemia 630
283. Dysthyroidism 633
284. Cardiac Neurosis (Tobacco?) 634
285. Sinus Arhythmia (Cardiac Neurosis) 635
286. Dysthyroidism 636
TABLE OF CONTENTS 1$
CHAPTER XVm
TREMOR Page
General CoNsroERAHONS 639
Case No.
287. Alcoholism 640
288. Paralysis Agitans 642
289. Multiple Neuritis (?); Syphilis 643
290. Hysteria 645
291. Multiple Sclerosis 646
CHAPTER XIX
ASCriES AND ABDOMINAL ENLARGEMENT
General CoNsroERAxiONS 649
Clinical Statistics op Ascites 654
Ascites with Soud Tumors op the Ovary 655
Ascites with Cystic Tumors of the Ovary 655
Ascites with Uterine Fibromyoma 655
Case No.
292. Hepatic Syphilis 656
293. Papillary Cystadenoma of the Ovary 657
294. Syphilis; Syphilitic Liver (?) 658
295. Syphilitic Nephritis 661
296. Chronic Adhesive Pericarditis 663
297. Cirrhosis of the Liver 666
298. Cirrhosis of Liver (Syphilitic?) 671
299. Tuberculous Peritonitis and Salpingitis 674
300. Cirrhosis of the Liver; Thrombosed Portal Vein 676
301. Ovarian Fibroma 677
302. Tuberculous Peritonitis 678
303. Chronic Glomerular Nephritis 679
304. Cirrhosb of the Liver 680
305. Pericardial Adhesions 681
306. Ovarian Cyst 682
307. Syphilis 683
308. Neoplastic Peritonitis (Lymphoblastoma) 684
309. Chronic Appendicitis with Abscess; Pylephlebitis 685
310. Syphilitic (?) Cirrhosis 687
311. Tuberculous Peritonitis 689
'312. Chronic Glomerular Nephritis; Arteriosclerosis; Myomalacia Cordis with
Thrombi 690
313. Fibromyoma of the Uterus 695
314. Gaseous Distension 697
315. Ovarian Cyst 698
316. Cancer of the Liver 700
317. Obesity 703
Index 705
DIFFERENTIAL DIAGNOSIS
CHAPTER I
ABDOMINAL AND OTHER TUMORS
The diagnosis of abdominal tumors is in most cases either easy
or impossible; but it is never easy unless one has a considerable
knowledge of what tumors are likely to occur in each of the regions
of the abdomen, unless one has taken a careful history and made the
ordinary manual exploration of the mass. In addition, laboratory
examinations and x-ray exposures are sometimes of importance.
Of these methods, direct palpation of the tumor may be the
most or the least important of all. Sometimes it tells us a good
deal, but usually what it tells us is interpreted and enlarged very
considerably by what we have learned to expect. For example,
an epigastric tumor is almost always cancer of the stomach. Should
such a tumor occur in a child, we should, of course, seek some other
diagnosis; but, then, such a tumor very rarely does occur in a child.
Certain regions of the abdomen are much more prone to contain
tumors than others; in other words, the diseases which produce
tumor in the abdomen are chiefly those of the pelvis and pelvic or-
gans, those of the stomach, liver, and kidneys. Tumors of the left
hypochondrium are comparatively rare, and almost invariably turn
out to be connected with the spleen or left kidney. In the right
hypochondrium we have not only those connected with the liver and
gall-bladder, but those connected with the hepatic flexure of the
colon, with the pyloric end of the stomach, with the right kidney,
as well as retroperitoneal and glandular masses which often push
the liver forward and are hidden behind it. It should always be
remembered that a doubtful tumor, seemingly springing from the
liver, may, in fact, be a normal liver pushed downward and forward
by some growth behind it. Some of the most humiliating mistakes
that I have known have been due to forgetting this point.
If ascites is present, our diagnosis is much simplified, as there
are comparatively few tumors often associated with ascites. Such
Vol. II— 2 17
Abdominal Tumors
PREGNANCY
PASSIVE CONGESTION OF THE LIVER
APPENDICITIS
SPLENIC TUMOR IN TYPHOID
SALPINGITIS
UTERINE FIBROMYOMA
OVARIAN CYST
HERNIA
ENLARGED GALL-BLADDER)
IN CHOLELITHIASIS i
CASE8 TOO MANV AND TOO VAGUELY ENU-
MERABLE FOR GRAPHIC REPRESENTA-
TION.
NEOPLASM OF STOMACH
SPLENIC TUMOR IN MA-
LARIA, ACUTE STAGES
CIRRHOTIC LIVER
SPLENIC TUMOR IN CIR-
RHOSIS OF LIVER
}
}
NEPHROPTOSIS
TUBAL PREGNANCY
SOLID TUMOR OF OVARY
NEOPLASM OF INTESTINES
NEOPLASM OF LIVER
TUBERCULOUS PERITONITIS
CYST OF BROAD LIGAMENT
ABSCESS OF ABDOMINAL!
WALL i
MALIGNANT NEOPLASM OFl
UTERUS )
HYPERTROPHY OF)
SPLEEN (UNKNOWN \
CAUSE) )
MALIGNANT NEOPLASM OF)
KIDNEY /
MALIGNANT NEOPLASM OF)
PANCREAS AND BILE- \
DUCTS )
ENLARGED LIVER IN PER-
NICIOUS ANEMIA
}
1095
811
753
428
428
370
348
272
224
201
163
132
131
129
121
119
119
117
Diagram I.
i8
Abdominal Tumors— c<»»ri«iMrf
TUMOROn HYPERTROPHVl
OF LIVER (UNKNOWN \
CAUSE) i
PYONEPHROSIS I
TUBERCULOUS KIDNEY I
NEOPLASM OF PERITONEUM {
CHRONIC PERICARDITIS .
HYDRONEPHROSIS
RENAL CALCULUS (WITH >
HYDRONEPHROSIS) I
ABSCESS OF LIVER
ENLARGED LIVER IN RICKETS I
PARANEPHRITIC ABSCESS
ACUTE INTESTINAL OB- 1
STRUCTION /
HYPERTROPHY AND)
TUMOR OF OVARY (UN- ^
KNOWN CAUSE) )
INTUSSUSCEPTION
Diagram I— Continued.
20 DIFFERENTIAL DIAGNOSIS
are drrboas of the liver, sxphilis of the liver and spleen, tuberculous
peritonitis with omental or glandular masses presenting as timior,
retroperitoneal cancerous metastases from neoplasm of the stomach,
gall-bladder, or pelvic organs. Lastly, a small percentage of the
cases of uterine nbroid and ovarian C}'st are complicated by ascites.
The list just given is not a ver>- short one, but it has this character-
istic, that a majority of its members can. as a rule, be easily
excluded and thus a diagnosis of the cause of ascites arrived at.
The most imix>rtant inquiries in relation to abd(»ninal tumors
are the foUowing:
(i) Duration and present 5\Tnptoms. including pain, soreness,
and the various disturbances of function eastric. intestinal. biliar\',
urinar>-V
(2) The location of the txmior, with especial reference to its con-
nection with one or another abdominal organ.
(3) Its size, shape, and consistency-.
(4) Its mobility and respiratory- mobility-.
(5) The determination of its relation to the stomach and colon:
(a) through infbtion of these organs, b through the obser\-ation or
historj- of peristalsis and intestinal noise.
Aside from these five methods of examination we must studv:
(a) The urine.
ib) The blood, especially in relation to the Wassermann reaction,
the presence of anemia, leukemia, or leukoc\tosis. Rarely one
must also search for the complement fixation in relation to hydatid
disease or gonorrhea.
(c) The stomach contents.
(d) The urine.
(e) The j-ray findings after a bismuth meal, a bismuth enema,
or the injection of a silver salt to the j>el\-is of the kidney.
(f) The temperature chart.
In the urine the most important jwints are the presence of blood
or of pus. In the feces, the presence of blood, pus, or parasitic eggs.
A knowledge of the relative frequency of abdominal timiiors is
an essential j>art of their diagnosis. Some guides to such a knowl-
edge may be obtained from the diagrams which follow. tSee Dia-
grams I, n. in, R\ V, VI. VII.) Combining the knowledge thus
obtained with a careful histor\- of the case, and esjxxially ^ith the
direct and indirect evidence touching the function of the differ-
ent abdominal organs, we may arrive at a diagnosis in the majority
of cases.
Causes of Tumors Involving the Abdominal Wall
HERNIA ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^ g^g
ABSCESS ^■■^^^■■■B 91
MALIGNANT NEOPLASM W^^M 34
ACTINOMYCOSIS WM 14
HEMATOMA ■ 11
LIPOMA ■ 9
FIBROMA
TUBERCULOSIS
Diagram II.
5
2
21
Tumors of the Kidney
NEPHROPTOSIS
MALIGNANT NEOPLASM
PYONEPHROSIS
TUBERCULOUS KIDNEY
HYDRONEPHROSIS
CALCULUS (WITH HY-
DRONEPHROSIS)
}
PARANEPHRITIC AB-1
SCESS /
CYST
370
119
103
101
73
67
69
22
Diagram III.
22
Tumors of the Liver
PASSIVE CONGESTION 1
GALL-STONES
CIRRHOSIS
NEOPLASM
PERNICIOUS ANEMIA
TUMOR OF HYPERTRO-
PHY OF LIVER (UN
KNOWN CAUSE)
MYELOID LEUKEMIA
CHRONIC PERICARDITIS
ABSCESS
RICKETS
LYMPHOBLASTOMA 1
(HODGKIN'S DISEASE)/
SUPPURATIVE PYLE-
PHLEBITIS
LYMPHOID LEUKEMIA
CASES TOO MANY AND TOO VAGUELY ENUMERABLE FOR
GRAPHIC REPRESENTATION.
428
201
117
^1
}
CHOLANGITIS, ACUTE OR \
SUPPURATIVE J
CATARRHAL JAUNDICE
CONGENITAL SYPHILIS
HYDATID CYST
ACQUIRED SYPHILIS
113
84
82
66
63
60
48
45
31
29
26
18
17
Diagram IV.
23
Tumors Involving the Uterus, Ovaries, or Tubes
PREGNANCY |
CASES TOO MANY AND TOO VAGUELY ENUMERABLE FOR GRAPHIC REPRE-
SENTATION.
SALPINGITIS
UTERINE FIBROMYOMA
OVAfilAN CYST
TUBAL PREGNANCY
SOLID TUMOR OF
OVARY (CANCER,
109; ADENOMA J 05;
FIBROMA, 31; PAP-
ILLOMA, 15; SAR-
COMA, 12)
>
CYST OF THE BROAD)
LIGAMENT /
2515
1539
1282
348
272
132
1
MALIGNANT NEO-
PLASM OF UTERUS .
(CANCER, 124; SAR- |
COMA, 5) i
HYPERTROPHY OR)
UNSPECIFIED^
TUMOR OF OVARY )
129
48
Diagram V.
24
Causes of Tumors Involving the Intestines and
Peritoneum
APPENDICITIS I
CASES TOO MANY AND TOO VAGUELY ENUMERABLE FOR GRAPHIC
REPRESENTATION.
NEOPLASM OF INTESTINES ■■■IHBiHHHHiHH^^HHHiHl 181
TUBERCULOUS PERITONITIS ■^■■■^^l^^H^HiaHaHB 146
NEOPLASM OF PERITONEUM m^^_|gg^gg|^BB 34
ACUTE INTESTINAL OB-
STRUCTION
}
49
ANEURYSM OF ABDOMINAL \ ^^^^^^^
AORTA i ^^^^^ ^^
INTUSSUSCEPTION ■■■■■■■ 31
30
CHRONIC INTESTINAL OB-1
STRUCTION* i
NEOPLASM OF OMENTUM ^K^^m 21
"FECAL IMPACTION '"* W^^M 12
}
DIVERTICULITIS
NEOPLASM OF RETROPER-
ITONEAL GLANDS
11
7
* Excluding cases known to be of neoplastic origin.
' Cause unknown; some organic cause (stricture, tumor) is almost invariably
present.
Diagram VI.
25
Causes of Splenic Tumor
TYPHOID
MALARIA, ACUTE STAGES
CIRRHOSIS OF LIVER
HYPERTROPHY, UNKNOWN 1
CAUSE /
PERNICIOUS ANEMIA
MYELOGENOUS LEUKEMIA
HODGKIN'S' DISEASE
BANTI'S DISEASE AND SPLENIC 1
ANEMIA J
LYMPHATIC LEUKEMIA
CONGENITAL SYPHILIS
ACQUIRED SYPHILIS
POLYCYTHEMIA
CHRONIC MALARIA
HEMOLYTIC FAMILY JAUNDICE
MALIGNANT NEOPLASM
ABSCESS
AMYLOID DISEASE
FLOATING SPLEEN
I
ANEMIA INFANTUM PSEUDO-\
LEUK>EMICA I
3519
753
426
151
90
88
70
56
51
28
19
19
13
7
7
4
3
2
Dl\g&.vm \n.
so
ABDOMINAL AND OTHER TUMORS 2^
Yet, as I said at the outset, there are a number of cases which
will utterly escape us despite the use of all the methods and pre-
cautions above suggested. I have seen, for instance, a tumor of the
tail of the pancreas which could not by any possibility have been
recognized during life. Such bafl^g tumors are, fortunately, not
very common, but they will occur in the experience of every one who
sees many patients. Among pelvic tumors diagnosis is frequently
impossible, partly because several of the alternative possibilities may
give precisely the same history, the same data on palpation, and the
same laboratory findings; partly also because these supposed alterna-
tives may all be present at once. One breaks one's heart to distin-
guish a fibroid tiunor from a cystic ovary, or a salpingitis from an
extra-uterine pregnancy, and then at operation finds both the dis-
eases present at once. Such mistakes are not often very serious, for
what we have chiefly to decide is whether an exploratory operation
is necessary or not.
Case 1
A waitress of twenty-seven entered the hospital March 29, 1909.
The patient has two children, the yoimgest four years old. She had
a miscarriage two years ago, and was operated on at that time; she
has never felt well since. She had typhoid in the Massachusetts
General Hospital two years ago. Her menstruation comes every
twenty-four days. The last period was three weeks ago.
Three days ago she fell, striking the right side. At 9 o'clock last
night, without warning or pain, there was a gush of bright blood from
the vagina. She went to bed and had continuous flowing for an
hour or more, with slight staining since then.
Physical examination was negative, save for a tumor above the
pubes, firm, smooth, rounded, not tender, about the size of a grape-
fruit. There were no masses or tenderness in either culdesac, but
the mass described was easily felt and was apparently continuous
¥dth the cervix. It was freely movable. The urine, temperature,
and pulse normal. Dr. Brewster thought the patient probably
pregnant and advised waiting a month. She left the hospital April
2d, but re-entered April isth, having been at the Waverley Con-
valescent Home until the day before, when she thought she felt a
lump drop down in her abdomen. She also said she felt as if she was
"going to bust." On examination, the tumor reached from just
above the umbilicus to the pubic bone; it was freely movable
from side to side, dull on percussion. The vagina was bluish, the
28 DIFFERENTIAL DIAGNOSIS
cervix soft and "taken up." There was no demonstrable milk in
the breasts.
Discussion. — With no cessation of menstruation, one naturally
does not consider pregnancy in this case imtil other and more obvious
alternatives have been ruled out. A distended bladder is the first
possibility to be excluded. Such a condition is not common in
women except after anesthesia or other causes of coma. In the
present case the use of a catheter promptly made us certain that
the bladder was not distended.
Fibroid tumors are not common in women of this age, are rarely
so smooth and symmetric, and are often well recognized by the
patient herself as of long duration before it seems necessary to consult
a physician. Fibroid timiors are often associated with metrorrhagia,
such as was present in this case, and this possibility cannot be ruled
out. There is no way of being any surer as to diagnosis unless Ab-
derhalden's test can be tried. WTien the present case was seen Ab-
derhalden's work had not been published, but it is in cases such as
this that the serum diagnosis of pregnancy is most valuable.
Outcome. — On the 20th it seemed that parts of the fetus could
be distinctly felt, and being assured that there was no timior, but
only pregnancy, the patient felt better, slept well, and was able to
leave the hospital on the 23d. During most of her stay the tempera-
ture ranged between 99° and 99^° F. In due time she gave birth to
a normal child.
Case 2
A Greek of twenty-seven, employed in an automobile shop, en-
tered the hospital December 23, 1909. The patient came here from
Greece seven years ago. He has never been sick until the present
illness, and denies the use of alcohol. About a month ago he felt a
little pain in the region of the liver and noticed a very consider-
able mass in that region. The mass has steadily increased in size
ever since, and for two weeks he has had enough pain there to disable
him from work and disturb his sleep. The pain is worse at night.
Physical examination shows marked bulging of the lower right
ribs, and a smooth, firm mass, dull on percussion, extending from the
fourth intercostal space in the nipple line to the umbilicus and as far
as the left nipple line. No thrill or crepitus is felt over the mass.
There is no edema. Blood and urine negative.
Discussion. — The essentials of this case are as follows: A mass,
which appears to be an enlarged liver, has been noticed for a month
ABDOMINAL AND OTHER TUMORS 29
by a young Greek. He has watched it grow considerably within
that time. He is unusually young for cancer or any other malignant
disease of the liver. Moreover, we have no evidence of disease in
the stomach or in any other organ whence the neoplasm could have
been carried to the liver by metastasis.
Syphilis or cirrhosis of the liver are possible diagnoses, but
neither of these diseases often causes as much pain as appears to have
been present here. There is no reason to suppose that the mass is
due to leukemic, amyloid, or fatty infiltration.
If these diseases are excluded, it is natural to consider the pos-
sibility of hydatid disease, especially as the patient is Greek. For
the association of Greeks with sheep and sheep dogs, in their own
country, is well known to be a potent source of hydatid disease.
Nevertheless, nothing better than a tentative diagnosis could have
been made in this case, unless additional evidence could be obtained
by testing for deviation of the complement. The absence of eosino-
philia is notable.
Outcome. — Operation, January 6th, showed .presenting in the
wound a large liver, in which there was a cyst the size of a lemon.
This cyst was shelled out whole. A 4-inch incision was then made
in the anterior surface of the liver and another large cyst with a
thick white wall bulged through the wound and ruptured, with the
escape of a large quantity of yellow fluid. This cyst turned out to
be about the size of a grape-fruit and was removed entire. A third
cyst, bulging against the diaphragm from the upper surface of the
right lobe, was about the size of a baseball. This cyst was ruptured
into the cavity of the larger cyst and its sac was removed through
the original liver wound. On further examination, a fourth cyst,
about the size of a baseball, was felt in the left lobe of the liver, but
was not removed. The fluid removed at operation from the cyst
looked like serum, but contained no albumin. The patient recov-
ered fairly well from the operation, but developed pneumonia and
died January 14th. The autopsy, January i6th, showed echinococcus
cyst of the liver, double chronic pneumonia, and purulent bronchi-
tis; fibropurulent pleuritis on the right, obsolete tuberculosis of the
bronchial lymphatic glands, enlargement of the spleen, and chronic
perisplenitis.
Case 3
A housekeeper of fifty-seven entered the hospital January 21, 1908.
Three years ago the patient began to have indigestion and simul-
3°
DIFFERENTIAL DIAGNOSIS
taneously uterine flowing at very irregular intervals. About three
months ago she noticed that her lower abdomen was bard. For
many years she has had varicose veins in the right leg and for ten
years has worn an elastic stocking. A week ago she woke up in the
night with severe pain in the right leg. This pain has continued
since and has disturbed sleep. For three days it has confined her to
bed.
Physical examination was essentially negative' except as related
to the abdomen, in the lower part of which was a large, nodular,
tender, rounded mass, extending from the pubic bone to a point
3 inches above the umbilicus,
and from the right flank to a
point 4 inches to the left of
the median line. It was dull
on percussion and slightly mov-
able. The rest of the abdomen
was negative. On the inner
surface of the right lower leg
was an area of redness and
sft-elling, extending from the
shin around to and past the
median line behind, and from
the ankle nearly to the knee.
On the inner portion of this
were several large blue veins;
\\*ithin the area firm, venous
trunks could be felt and could
be traced from there up past the
knee, on the irmer side. The
urine was negarive. The blood
showed a leukocytosis van,ing from 20.000 at entrance to 36,000 on
the 5th of February- and accompan\-ing a slight febrile reaction
(Fig. i). After that it gradually declined, although on the 12th of
March it was still iq.ooo. On the Jist of March it was lo.ooo. On
the i^d a vein, large, firm, and slightly tender, could be traced from
the kjl knee to the groin. There was a good deal of edema of the
leg and thigh. This increased up to the first week in Februarj-, then
began to go down. The thigh measured ^4 inches as against 17 on
the other side. On the ;ist of Februarj- the patient was deUrious
and disorientated, with marked weakness and a poi>r pulse. On the
23d free fluid was demonstrable in the abdomen. On the Sth of
Fig. I. — Chart of Caae 3.
ABDOMINAL AND OTHER TUMORS 3 1
March there was slight divergent strabismus and extensive edema
of the skin of the back, extending up to the midscapular region, and
associated with duhiess and riles at the bases of the lungs. On the
29th of March the eyes were a little puflfy in the morning. Meantime
the patient had steadily emaciated. The superficial veins over the
abdomen were beginning to enlarge.
Discussion. — Fibroid of the uterus, complicated by a phlebitis
of the leg, is naturally the first thing to consider in this case. The
leukocytosis is naturally to be explained as a result of the phlebitis.
Later on in the course of the case, however, when ascites was
demonstrated, mental symptoms appeared, and the edema extended
up the thorax, it became clear that the inferior cava must have be-
come blocked. This accident is very rarely associated with fibroid
of the uterus. The rarity of this combination and the steady emacia-
tion of the patient might have led us to change our diagnosis. Never-
theless, up to the time of death, no such change was made, and the
case was believed to be one of uterine fibroid with complicating
phlebitis.
Outcome. — The patient showed but little change except for gradual
failure, and on the 23d of May she quietly died. Autopsy showed
multilocular adenocystoma of the right ovary. Thrombosis of the
inferior vena cava, of the iliac veins, and their tributaries; slight
chronic interstitial nephritis; senile degeneration of the myocardiiun;
small myomata of the uterus; ascites; double hydro thorax.
Case 4
A hardware merchant of thirty-four entered the hospital March
15, 1908. The patient's mother died at forty-six of apoplexy, one
sister of Bright's disease, otherwise the family history is negative.
His own health and habits have been excellent.
Six months ago he began to have a cough with considerable sputa
and pain in the arms and legs. At the same time he noticed enlarge-
ment of the abdomen. It felt "a little crowded." These symptoms
have continued without much change, but have not prevented him
from working in his store imtil three and a half weeks ago, when the
cough ceased and he noticed in the left side of his abdomen a bunch
as large as a croquet ball and tender, especially when he coughed.
He went to bed at his doctor's suggestion and the tumor and tender-
ness disappeared. Two weeks ago he was again up, but felt worn out.
Six days ago a second bunch appeared in his right side, about as
large as the first, but more tender. From this time the abdomen
32 DIFFERENTIAL DIAGNOSIS
has Steadily enlarged. He has noticed no change in color, but his
bowels have been loose for six months, moving, as a rule, four times
a day. Four or five weeks ago he had a nosebleed. Two weeks ago
the abdomen was tapped, but no fluid obtained. Yesterday mom-
ning he began to notice that the light hurt his right eye, which felt
as if it were bulging out.
Physical examination shows fair nutrition, mucous membranes
pale. The right eye protrudes farther than the left, and its move-
ments are markedly limited in all directions. The pupils are normal.
There is systolic pulsation in the suprasternal notch. The heart's
impulse is seen and felt in the fifth space, zj inches outside the nipple
line; right border i^ inches to the right of midsternum. In the third
left space, near the sternum, systofic pulsation is \-isible and palpable.
Substernal dulness J§ inches wide at the second interspace. No
murmurs. First apex-sound forcible. Blood-pressure 125 mm. Hg.
Lungs negative save for dulness at the bases, especially the right, and
ABDOMINAL AND OTHER TUMORS
33
occasional moist rSles. The abdomen is prominent, navel flushed,
and the veins well marked. It is flat on percussion and everj'where
resistant, except for small areas of tympany and softness in the
flanlu (Figs. 2 and 3). In the right lower quadrant there is a very
I tender, rounded prominence, rising above the hard, smooth surface
of the surrounding parts. A somewhat similar enlargement is noticed
in the left upper quadrant. The whole mass moves very slightly
with respiration. The liver edge is not felt, there is no edema, no
glandular enlargement- Reflexes normal-
Fig. 3. — Chest signs in Case 4.
Discussion.— A bunch in the left upper quadrant usually repre-
laents some disease of the spleen or kidney. Organic disease of the
I stomach or pancreas very seldom gives us s. tumor in this vicinity,
I though gastric flatulence is a frequent cause of pain in tJiis spot.
' Occasionally we have pain and tumor in this region from cancer of
the splenic flexure of the colon. The association of tumor with diar-
rhea in this case makes the possibility of intestinal cancer more
considerable, since it must never be forgotten that the intestinal
cancer produces diarrhea as often as it does constipation.
Vol. II— 3
34 DIFFERENTIAL DIAGNOSIS
With the appearance of the second bunch on the other side of the
abdomen and also of a source of pressure behind the right eyeball,
we are forced to suppose that more than one focus for disease is
present and, therefore, that cancer of the intestine is improbable.
If the mass were a hypernephroma, these second bimches might repre-
sent metastases; or, if the blood turned out to be normal, a malignant
lymphoma would be a possibility. Indeed, the symptoms and tumor
masses are strikingly similar to those that I have seen in some cases
that turned out to be malignant lymphoma. Everything must rest,
in such a case, upon the results of blood examination.
Outcome. — The blood showed 2,680,000 red cells; hemoglobin,
70 per cent.; white cells, 290,000. Differential coimt showed: poly-
nuclears, 51 per cent.; myelocytes, 42 per cent.; lymphocytes, 2 per
cent.; eosinophiles, 2.5 per cent.; mast cells, 2.5 per cent. The urine
showed a slight trace of albumin with many fine and coarse granular
casts, otherwise negative. Treatments by a:-ray were begun at once
and by the i8th the eye had returned to its normal position and moved
freely. The fimdus oculi showed a few small hemorrhages in the
right retina^ more on the left. By the 4th of April the patient was
free from pain and showed very great subjective improvement. The
blood, however, had not essentially changed. He left the hospital
that day.
Postscript. — A rare feature of this case is the association of mul-
tiple glandular tumors (for apparently that is what we are dealing
with) with a blood-picture ordinarily associated with the myelogenous
(not with the glandular) form of leukemia. Ordinarily the bone-
marrow — not the lymph-glands — is the seat of the trouble in cases
showing such a blood-picture as this.
Case 5
A German housewife of forty-six entered the hospital August 22,
1908. The patient's family history and past history are negative.
She passed the menopause three months ago. Eighteen months ago
she began to have headache and vomiting in attacks lasting from a
few hours to a few days and increasing in frequency. The vomiting
came usually after meals and consisted of food. No blood; no pre-
ceding nausea. The appetite has remained good. The headache
came always on the top of the head and has recently needed morphin
for relief. She had lost much in weight and strength. She occa-
sionally felt backache and a dull ache in the right side of the abdomen.
ABDOMINAL AND OTHER TUMORS
35
In the evenings she had noticed a slight sweJling of the ankles. No
nocturia.
Physical examination (including the urine and blood -pressure) is
negative, save for the abdomen. Just inside the right anterior
superior spine of the ileum is a fairly soft, tender, movable mass,
about 7 cm. in diameter. Near this mass the right kidney can also
be felt, but the two are separate. Dr. C. A. Porter made diagnosis
of cancer of the cecum (Fig. 4).
FiG. 4— rhy_*i(.iUit;ri
i ulLimalely proved lo lit u ilisplai
kidney as «e Ihoughi, but a ''co
—The headache, loss of weight, vomiting, and edema
ike us think of nephritis first of all, but the negative urine and
nrmal blood-pressure exclude this. Our attention, then, is concen-
rated upon the mass or masses felt in the right upper quadrant.
Against the diagnosis of cancer of the cecum is the fact that there
have been no symptoms referable to the intestine, no marked consti-
, no pain localized at the cecum, no intestinal noise or visible
ristalsis, and, so far as we know, no blood in the stools. It must
I
36 DIFFERENTIAL DIAGNOSIS
be remembered, however, that cancer of the cecum is sometimes
an extraordinarily latent disease, co\-eiing considerable periods
of time. Several patients whom I have studied and in whom cancer
of the cecum has been proved by operation, have assured me that
the lump which I felt prior to the operation had been there for sev-
eral years without producing any other s^-mptoms. I have m)rself
studied such a lump, discovered by a patient, utterly symptomless,
and finally proved to be cancer after I had watched it (the patient
refusing operation") throughout nearly a year's time. Further evi-
dence on this question of cecal cancer might be obtained by bismuth
x-ray examination, which in igoS we were not canying out; also by
repeated tests of the feces for occult blood. Malignant h-mphoma
of the small intestine i^ordinarily called sarcoma"^ cannot, so far as I
see, be positively excluded. Such tumors, in my e3q)erience, are
much more movable than was the tumor present in this case. They
are often multiple and usually give rise to some intestinal symptoms,
the absence of which in this case has alreadv been mentioned.
Can this mass be connected with the liver? It seems decidedly
too far to the right to be a distended gall-bladder, unless we assume
that in some mvsterious wav a jrall-bladder is dislocated far from
its normal position.
Malignant disease invohing the liver usually produces an en-
largement of the whole organ and shows multiple nodules, pro\'ided
that it is accessible to ph\"scial examination at all. A single circum-
scribed mass, like that here represented, is not at all common in
hepatic nec^lasms.
Sxphilis of the liver might produce such a tumor. One would
expect, however, if s\philis were present, to feel other lobules or
masses, the result of scarring of the liver substance by gummata.
Further CN^idence misrht be obtained hv a Wassermann reaction.
Tumors of the omentum which are usually metastatic) are
among the most freely moN-able of all the abdominal tumors, and
are seldom if e\-er found nxed near the spine of the ileum.
If we assume that the phx^sioal examination is correct and that
the right kidney is entirely separate from the tumor mass, we can-
not further discuss an invoK-ement of the kidney itself. It might
well be. howex-er. that we were mistaken in belie\Tng that the kidney
could be dearlv differentiated from the tumor. In that case, hvdro-
nephrosis, cx-siic kidney, renal luberculosis. and hypernephroma
would all need to be considered. There is nothing in the urine to
indicate any renal disease and nothing in the histon* to indicate
ABDOMINAL AND OTHER TUMORS 37
tuberculous infection or neoplastic cachexia. If cystic kiflney were
present, we should usually be able to feel a similar mass upon the
other side, since this disease is almost invariably bilateral and con-
genital. The question of hydronephrosis might be settled by taking
an x-ray plate after the injection of coUargol into the renal pelvis.
Outcome. — On the 3d of September the abdomen was opened.
The cecum was foimd normal, but behind it was a mass which seemed
to be a low-placed kidney. A lobe of the liver projected downward
like a tongue, assuming the shape and position of the normal
kidney (Fig. 4). The stomach, pylorus, duodenum, gall-bladder
and ducts, the pelvic organs, the intestines, and the left kidney were
examined and foimd normal. The posterior wall of the peritoneum
was then opened and the right kidney exposed. The kidney was
foimd to be large, irregular in shape, and the vessels and ureter placed
high in the anterior wall. A partial nephropexy was done. The
[>atient recovered well from the operation, but a few days later nausea
returned. On the 9th of September a peristaltic wave was seen
sweeping across the middle of the abdomen, where it appeared that
a large coil of intestine was pushed forward and fixed. In Dr. Cod-
man's opinion this was the duodenum. Washing out the stomach
gave some relief. The patient was advised to lie continuously on
the right side and on the abdomen. A good deal of relief resulted
from this, and by the 13th the patient was taking liquids well by
mouth and steadily gaining. On the 26th of September she left the
hospital apparently well. October 7, 1909, the patient reported at
the accident room in perfect condition. The diagnosis stands as
congenitally deformed kidney, gastromesenteric ileus. The upper
mass, supposed to be the kidney, was apparently a "corset lobe'' of
the liver, while the lower mass was the kidney itself.
Case 6
A housewife of seventy entered the hospital August 28, 1908.
The patient's mother and one brother died of consumption; otherwise
the family history and past history are good. For the past year she
has had some general abdominal pain, not severe or localized, not
preventing work or sleep. Appetite fair; bowels very costive. She
had several short attacks of vomiting and has lost much in weight and
strength.
Six days ago she began to have severe pain in the right side of
the abdomen, but has remained up and about imtil today, and has not
vomited. Food does ftot seem to influence the pain.
38 DIFFERENTIAL DIAGNOSIS
Physical examination shows poor nutrition and pallor. Above
the middle of the left clavicle is a small, hard, round, pulsating tumor,
3 cm. in diameter. (The patient had never noticed it.) The heart's
impulse extends 13 cm. to the left of midstemum, 2 cm. outside the
midclavicular line. There is no enlargement to the right. The
action is somewhat irregular. A rough systolic muimur is heard at
the apex and in the axilla. The systolic blood-pressure is 160 mm. Hg.
Lungs negative. Filling the right upper quadrant of the abdomen
and extending below the umbilicus is a hard, tender, irregular mass,
Fig, s.— Phj-Mcal agns in Case 6.
palpable bimanually. not descending with inspiration (Fig. 5).
Otherwise the abdomen is negative. There is a slight edema of the
lower legs. Blood and urine normal. Xo fever in a week's observa-
tion.
Discussion.— The history- gives us no clue at all. We know that
the patient has lost weight, but at her age this helps us ver>- little.
The pulsating tumor abo\-e the cla\icle should suggest, to anyone
who has ever seen a similar case, that we are dealing with a displaced
subclaNian arter\' crossing a cervical rib. This is practically the
ABDOMINAL AND OTHER TUMORS 39
only common cause of pulsating tumors in the neck. Aneurysms
very seldom present at this point, that is, in or outside the mid-
clavicular line. They are almost always in the vicinity of the supra-
sternal notch, when they extend above the thoracic cavity.
A soft pulsating neoplasm, probably metastatic, deserves merely
to be mentioned. Such a tumor is very rare. The diagnosis between
this and a misplaced subclavian artery can easily be made by x-ray
examination.
Beyond this we have to deal with the tirnior in the right upper
quadrant and flank. From a diagnostic point of view, the most
important facts about this tumor is that it does not descend with
inspiration and that we have no evidence of its connection with the
liver. Its size and position correspond much more nearly with a
tumor connected with the kidney than with any other growth. To
determine this point more accurately, the colon should be inflated.
If the inflated colon comes in front of the tumor, the latter is, in
all probability, connected with the kidney. On statistical grounds
we should assume that if it is a renal tumor, it is probably a hyper-
nephroma.
The patient, no doubt, has some arteriosclerosis, both in and
beyond the renal vessels. The heart is doubtless hypertrophied
and dilated and its walls weakened. There is no reason to believe
that any valvular lesion exists. Murmurs like those here described
are very common in hearts which turn out at autopsy to be quite free
from any valvular lesion.
Outcome. — ^The inflated colon traversed the tumor; a:-ray showed
bilateral cervical ribs. The left subclavian artery traversed one of
these. Operation (for possible hypernephroma) was refused, and the
patient left the hospital on the 2d of September.
Case 7
A housekeeper of forty-five entered the hospital September 16,
1908. Two years before entrance the patient noticed prominence
in the region of each collar-bone, and for one year has thought that
the right side of the face was swollen. She has had indigestion for a
long time when she is careless as to diet. If she is careful she has
no trouble. Three months ago she began to lose weight and strength.
Her usual weight being 144 pounds, she has fallen within a short time
to 132 pounds. She has a desire to regurgitate food after a good many
meals. Her family history is negative, likewise her past history, ex-
cept for an attack of sharp pain in the right hypochondrium eighteen
40
DIFFERENTIAL DIAGNOSIS
&^
»^ lr<< ^.■i',*i
/ / M
■ •"T
/-I*
TT-T
years ago. This was called "inflammation of the liver," was not
accompanied by jaimdice, and passed off within a few days.
Physical examination shows poor nutrition, slight pallor, pupils,
glands, and reflexes normal. In the region of the right temple is a
slight prominence, hard, not tender, apparently connected with the
bone. The left cla>'icle is prominent and apparently thickened
throughout. Scattered over the face there are numerous areas of
erj-thema, 2 mm. in diameter. There are a few larger areas on the
chin covered with fine, white scales. The heart is negative save for a
soft, s^-stolic murmur at the apex, not transmitted. The left pulse
is slightly greater than the right; otherwise both are negative. The
limgs are normal. The edge of the liver can
be felt below the ribs, and in the epigastrium
there is an indefinite resistance. The upper
border of liver dulness is at the sixth rib.
The edge of the spleen is felt 4 cm. below
the ribs. There are dilated veins on both
legs and slight soft edema of the ankles.
The tibiae seem rather rough and irregular.
S\"stolic blood-pressure, 115 mm. Hg. Blood
and urine negative. Slight irr^ular fever as
shown in the accompanying chart (Fig. 6).
Tube-examination showed apparently a small
amount of food in the fasting stomach. On
inflation, its upper border was at the ensifonn;
the lower border 4] cm. below the navel.
Xo additional information about the abdo-
men was obtained through this inflation.
Microscopic examination of the fasting con-
tents showed that what had been taken for
food was not such, mucus and epithelial cells making up the whole
residue, Guaiac test was negati\-e and free HCl present. After a
test-meal the stomach contents showed free HCl. but too small an
amount to be tested quantitatix-ely.
► — Prominence of the collar-bones and of ewe temple,
with loss of weight, are apparently the essential data in
this case. There are also facts suggesting enlargement of the spleen
and li\-er. and possibly some s\-philitic or other t>-pe of periostitis
on the shin bone. The hisior>- of lewr and the negati\-e results of
stomadi examination are also of in:portanct\
So slow an enlaigemenl of both cwUar-boncs is not likelv to be
Fig. 6. — Chxn ci Case 7.
ABDOMINAL AND OTHER TUMORS 41
due to syphilis. Syphilitic lesions of the collar-bone are generally
unilateral and circumscribed. They are apt to be associated either
with tenderness or areas of softening, such as were absent in this
case.
Metastatic neoplasms dependent upon hypernephroma or some
other distant focus are very rarely bilateral or synmietric. More-
over, we have nothing to suggest the presence of any primary focus
of malignant disease.
Rachitis and other congenital malformations can be excluded
only by x-ray examination. Everything in the case points to this
method of examination as the most important step next to be taken.
The x-ray should include the tibiae, as well as the collar-bones. I may
add that the findings shown in the outcome, presently to be men-
tioned, were wholly unexpected to me and, I think, to all who saw
the case.
Outcome. — ^After the time of entrance the edge of the liver was
never felt again, though the spleen could always be felt; x-ray plates
were taken of the whole bony skeleton, and no changes found except
in the clavicles, which showed lesions of osteitis deformans in the
opinion of Drs. Dodd and of E. A. Locke, whose experience with
this disease is more extensive than that of any living observer. The
patient left the hospital September 26th, considerably relieved,
having gained 3J pounds.
Case 8
A housekeeper of fifty entered the hospital October 15, 1908.
For three months the patient has had severe headaches, constipation,
and loss of appetite. For a week she has had pain in the left lower
quadrant, never sharp, not influenced by food, not preventing sleep,
often relieved by lying on the right side. She thinks there has been
some fever. Her family history and previous history are negative.
She has six well children and two dead. Her youngest child is seven-
teen. Catamenia ceased two months ago.
Physical examination showed good nutrition and was otherwise
negative save for a blowing systolic murmur at the apex, and a harsh
systolic murmur at the base, of the heart. Physical examination of
the chest was negative. In the right lower quadrant was a hard,
smooth, tender mass, extending to the navel and to the median line
(Fig. 7). The cervix uteri was pushed upward and forward, the
fundus not felt. In the posterior culdesac was a hard, slightly nodu-
lar mass, the size of a lemon. This could also be felt by rectum.
42
DIFFERENTIAL DIAGNOSIS
The mass shown in the diagram could be felt bimanually. The blood
and urine were negative. The temperature was as shown in the
accompanying chart (Fig. S). On the igth of October the abdomen
was more relaxed and the mass was of the shape shown in Fig. 9.
Active carthasis produced no change in it. Menstruation began
October 17th.
Discosaoo. — We are confronted here with a pain in the left
lower quadrant. In men such pain ordinarily means cancer of the
^gmoid or diverticulitis of the same region. Tumors due to hemia
Fi?. 7.— Plijaal signs in C»se S, tXtobcr 15. loaS^
or to swollen glands are lower down. In women we ha\'v to consider
not only these diseases, but those arising itvim the pehis,
^lien we come to the pb}-sical examinatioa. we nnd a mass not
in the left, but in the right, lower quadrant. Such Dndings often
lead U5 to disregard the historv', assuming that the patient must
hzve been mistaken, but. as the outc»ime i>l this case shows, such
assumptions are dangerous. Indeed. I think the habit »if disregarding
the hiitor^'. pro\ided it is carefully taken, is a wn- disastrous one.
Ph>3icians should culti\-ate the sort of {«i^\vhic judjpi^enl which en-
ABDOMINAL AND OTHER TUMORS
43
ables them to distinguish, better than many "scientifically trained"
physicians do, the occasional patient whose words are valueless, and
the much commoner patient whose words are precious as guides, but
need a good deal of interpretation. A lack of skill in history taking
seems to me to mislead us more often than faulty physical exami-
nation.
Naturally, one first considers here some tumor arising from the
pelvic organs, especially from the uterus or ovary. The mass is
obviously too large for any inflammatory exudate starting from a
tube. It might conceivably arise from the pelvic bones, but such
tumors are very rare. That it is not at all influenced by active
catharsis renders doubly sure
our natural assurance that it
is not connected with the in-
testine. In view of its situa-
tion— very much to one side of
the median line — and consider-
ing the position of the cervix
and the mass in the posterior
culdesac, it seems more than
probable that the tumor origin-
ates in an ovary.
Outcome. — The mass was
believed by the surgeon to be
multiple uterine fibroids, but
at operation, October 24th, two
ovarian cysts, purple and about
the size of a child's toy balloon,
were found connected with each
ovary. Each was pedunculated,
and the cyst on the right had a double twist of its pedicle, but had not
ruptured. The uterus was normal. The gall-bladder was distended and
full of stones, but was not molested. The cysts were removed. Micro-
scopic examination by Dr. W. F. Whitney showed that both ovaries
were replaced by multilocular cysts, one dark red and fiUed with
hemorrhagic fluid, the other a cystoma, one portion of which was
thickened and looked sUghtly medullary. This latter portion was
made up of dense connective tissue in which were some gland-like
growths, lined with epithelial cells. Diagnosis, cyst adenoma. The
patient made an excellent recovery and left the hospital November
II, 1908, apparently in excellent condition.
Fig. 8.— Chart of Case 8.
44
DIFFERENTUL DIAGNOSIS
Second Entry. — She entered again October 20, 1910, having re
mained well in the previous two years until September, iqio, when
she began to have diffuse abdominal cramps, with more than usual
constipation, so that the bowels moved only about every three days,
although without medicine. Eight days ago she had an especially '
severe attack of cramps and next morning vomited a small amount
of blood. Yesterday and today she again vomited, this time greenish
material. Her bowels have now had no movement for seven days.
Her chief complaint at present is of a burning sensation at the ensi- j
Fig. g. — Signs in Case 8, October ig,
form. For the past month she thinks her skin has been growing
yellow and her urine more red. At times of late she has had severe
sweating, but does not think she has lost any weight.
Physical examination showed poor nutrition, no jaundice, maA-
edly distended abdomen, tj-mpanitic in the lower half, slightly tender
throughout, no shifting dulness or fluid wave. Pelvic examination
showed a round, hard, slightly nodular mass, pushing the cervix up
behind the pubes and filling all the vaults, but not tender. The
patient's blood and urine were normal. On the 21st of October the
ABDOMINAL AND OTHER TUMORS 45
abdomen was again opened and the pelvis and lower abdomen foimd
filled by a growth surrounding and infiltrating the intestinal walls.
The j>eritoneimi was covered with small nodules, a few of which were
excised for diagnosis. Microscopic examination showed a solid mass
of epithelial cells in small plexuses. Diagnosis: "Cancer." The
patient recovered well from the operation and left the hospital on
the 28th of October, 191 1. A letter sent March 13, 1913, was returned
marked "Dead."
Postscript. — In connection with what was said above as to the
values and errors of the patient's own account of his troubles, I call
attention to the statement made by this patient at her second entry,
that her skin had been growing yellow and her urine red. I have
foimd these particular statements peculiarly misleading. One is apt
to take them as evidences of jaundice with bile in the urine, but
they are more often the patient's way of expressing the fact that hi3
skin is yellow or anemic rather than jaimdiced, and that he happened
to notice imusual concentration of his urine, with the natural in-
crease of color associated with such concentration. At the time of the
second entry it seems reasonable to beUeve that the patient's s)mip-
toms were due to intestinal obstruction, depending on the mass
described in the latter part of the preceding paragraph.
Case 9
A shoemaker of fifty-three entered the hospital November 12, 1908.
The patient's family history and past history were not of importance.
His habits were good.
Eight years ago Itunps appeared in the left side of his neck. After
the first few months they have not enlarged further. *A year ago
additional lumps, larger than the first group, appeared in the neck.
At the same time other lumps appeared in both axillae and groins.
Nine months ago a limip appeared in the rectum and one in the region
of the gall-bladder.
Three weeks ago the abdomen began to swell, and soon after the
legs also. A week ago, in the Out-patient Department, he was tapped
and 2200 c.c. of ascitic fluid removed; specific gravity, loii; sediment,
l)miphocytic. The patient's best weight was 180 pounds a year and
a half ago. Just before the abdomen began to enlarge he weighed
160 poimds. His appetite is now good; he feels in most respects well
and complains of no pain.
Physical examination shows fair nutrition, moderate pallor.
The right pupil is slightly larger than the left. Both react normally.
46 DIFFERENTIAL DIAGNOSIS
All the reflexes are normal. The heart's apex is seen and felt in the
fifth interspace, 12 cm. to the left of midsternum and i^ cm. outside
the nipple line. There is a soft systolic murmur in the pulmonary
area; otherwise nothing abnormal on auscultation. The lungs are
negative. Abdomen prominent, navel bulging. Dulness in the
flanks, shifting with change of position. Below the right ribs is a
hard, smooth mass, internal to the mammary line, not adherent to the
skin, not moving with respiration. In the hypogastric region another
mass is shown in the diagram of November 12th (Fig. jo). Below ,
Fig. 10. — Tumors and
the angle of the jaw, on the left, is a mass of glands, 8 by 10 an., and
elsewhere in the neck, axillae, and groins are lumps the size of a bean
to that of a hickory nut. The epitrochlear glands are palpable.
The liver and spleen not felt. By rectal examination a nodular mass,
half the size of a man's fist, pushes inward on the posterior and right
wall. Blood and urine negative.
Discussion. — With multiple lumps in the abdomen and also in
the neck, axillte, and groins, the "snap diagnosis" would naturally
be Hodgkin's disease (a term the value of which I shall discuss in a
ABDOMINAL AND OTHER TUMORS 47
moment), but first one should exclude, if possible, tuberculosis and
syphilis as causes of general glandular enlargement.
Tuberculosis rarely, if ever, produces glandular enlargement
lasting eight years without any suppuration. It would be almost
certain to produce fever if it were as extensive as the physical signs
indicate. K the ascitic fluid were part of a tuberculous process, the
specific gravity should be in the vicinity of 1020.
As regards syphilis, there are few if any cases on record showing
glandular enlargements of anything like this size in the neck, axillae,
and groins, as well as in the abdominal glands. So extensive a process,
if due to syphilis, would probably show cutaneous, oral, osseous, or
visceral changes. In this case, therefore, it seems to me that syphilis
can easily be ruled out, but it should be borne in mind that when
glandular enlargement occurs only in the neck, the confusion of
syphilis and tuberculosis is not unusual. I have recently seen, with
Dr. Abner Post, a case of syphilitic adenitis of the neck which had been
treated for months as tuberculosis. The Wassermann reaction and the
results of treatment soon made it clear that the adenitis was syphilitic.
After excluding these two diseases, the affection often known as
Hodgkin's disease is naturally the next to be considered. To me it
has become increasingly clear, of late years, through the studies of
the most accomplished histologists, that there is no proper distinc-
tion to be drawn between the various tumors known as Hodgkin's
disease, lymphosarcoma, malignant lymphoma, and lymphatic
leukemia, except that in the latter case there is a continuous cir-
culating metastasis in the blood, whence the term "leukemia." Why
it is that in certain cases this blood metastasis takes place, while in
other cases, histologically identical, there is no multiplication of cells
in the blood-stream, no one has yet explained. Meantime, it seems
well to abandon the attempt to distinguish the various types of dis-
ease whose names I have just listed. Minor differences there may be.
Clinical varieties, so far as the rate of progress is concerned, there
certainly are. A case of malignant lymphoma, with or without leu-
kemia, may remain confined to a few small neck glands for years
mthout any appreciable harm to the general health. In other cases
the spread of the disease and the constitutional effects are fearfully
rapid. Between these two extremes there is every grade of transition.
To render the diagnosis certain beyond any doubt and to exclude
syphilis and tuberculosis finally, a gland should be excised in every
case like that just described. The operation could be done under
local anesthesia and is of no risk to the patient. It should be remem-
48 DIFFERENTIAL DIAGNOSIS
bered, however, that occasionally in the vicinity of tuberculous or
otherwise diseased glands one often finds a simply hyperplastic gland,
which when excised throws no light upon the dis^nosis. Abdomi-
nal glands excised from the vicinity of a cancerous tiunor often give
us this sort of misleading and disappointing evidence, and seem to
tell us that the tumor is not malignant when we have every reason to
believe that it is, and when its course often proves it to be so.
Outcome. — A gland was excised from behind the ear and showed
structure of a malignant lymphoma (lymphoblastoma — Mallory).
Coley's serum, every second day, in increasing doses, was given,
beginning with \ minim and working up to 12 minims. A febrile
reaction, sometimes carrj^g the temperature as high as 104° F.,
followed most of the injections. The patient often has a rhill lasting
an hour. The abdomen was tapped on the 23d and 82 oimces of
brownish-red fluid obtained. It was tapped again on the 4th of
December, when 86 ounces of similar fluid were removed; sj>ecific
graN^ty, 1015. Smear of the sedirhent showed mostly epithelial
cells. On the third tapping, December 7th, 115 ounces of the same
fluid were obtained. After this the abdomen continued to drain
imtil the nth of December, at which time the patient began to be
somewhat drowsy. By the 14th the abdomen was again filled, but
when the needle was inserted the fluid would not run, though it
drained freely from the tap-hole.
About this time diuretin, 15 gr. four times a day, was begun, and
the amount of urine rose to 65 ounces, vdth considerable improve-
ment in the edema of the legs. On the 20th he was again tapped,
but only 12 ounces obtained. The tj-mpany now extended fairly
well into the flanks and but little fluid could be obtained. Upon the
23d 17 ounces were removed. On the 28th a loud friction-rub was
heard in the left axilla and x-rav showed shadow over the whole left
side of the chest. Another course of diuretin was given, beginning
December 26th, 15 gr. four times a day. The urine rose to 62 oimces
and a large amount continued to be passed for three days more.
On the 29th of December 7 pints of fluid were removed from the
abdomen, after which he felt better and had less edema of the legs;
50 more ounces of fluid were removed January" 2d; specific gravity,
ion. At this time and for two weeks preN-iously x-ray treatment was
used. Other tappings occurred: on the 9th of January, 6 pints; on
the 14th, 106 ounces; on the 19th, 06 ounces. The patient grew
steadily worse and was discharged on the 21st of January. He died
soon after at home.
ABDOMINAL AND OTHER TUMOKS 49
Case 10
A housewife of thirty-nine entered the hospital September 9, 1905.
Her family history is negative, her past history not remarkable. She
has had three children, the youngest six years old. Her menstruation
is irregular; it often lasts ten days. The last period lasted two
weeks.
Five years ago she began to have dull aching pain in the region
of the left hip which lasted ten days and then left her. Ten days ago
she had sudden pain in the left side of the chest, following an attack
of indigestion. It was sharp at the beginning. It is now dull.
Between the attack five years ago and the present one there have
been some seizures similar to the first. She thinks in the attacks that
she passes less urine than ordinary, and after them, more.
Physical examination was not remarkable, except that in the
upper left quadrant there was a sense of resistance and slight tender-
ness and on deep breathing the tip of the kidney (or spleen?) was
palpable. An indefinite mass Uelow this was felt, which seemed to
be about the size of a lemon. Pelvic examination showed in front of
the uterus, in the median line, behind the pubes, a hard mass the size
of an egg. The uterus was retroverted; not otherwise remarkable.
The urine averaged 35 ounces in twenty-four hours; specific gravity,
1020; slightest possible trace of albiunin; a few hyaline and fine granu-
lar casts, some with red cells adherent. The blood showed 30 per cent,
hemoglobin; red cells, 2,400,000; leukocytes, 4000. The stain smear
showed all the characteristics of secondary anemia. During the
first week of her stay in the hospital the temperature was slightly and
irregularly elevated at times, the highest point reached being loo.S*' F.
Discussion. — The spleen or the left kidney are the only organs
which often produce a mass like that here described. As3uming that
we were correct in feeling a mass behind the spleen, we must be
dealing with the left kidney. We have also to account in some way
for the mass behind the pubes and for the marked secondary anemia.
Both these facts would lead us to suppose that we were dealing with
a neoplasm from which metastasis has taken place. Since hyper-
nephromata are specially prone to form bony metastases, one might
surmise that the hypergastric lump is connected with the pubic bone
and represents such a metastasis. Non-malignant lesions of the
kidney, such as cyst or tuberculosis, seem improbable on account of
the marked anemia which is not often found in these diseases. Reason-
ing in this way, the clinical diagnosis of the case, prior to operation,
was hyi>emephroma with menorrhagia.
Vol. II— 4
50 DIFFERENTIAL DIAGNOSIS
Outcome. — September 13th the cervix was dilated and the uterus
was steamed forty minutes, then wiped out with gauze. On the i8th
of September the hemoglobin was 35 per cent.; September 29th
hemoglobin 55 per cent. September 30th an incision was made from
just above the left anterior superior spine of the ileum for 5 inches,
upward and outward. Sections carried down behind the peritoneum,
and a cystic tumor was revealed in the region of the kidney. The
cyst was ruptured with the escape of clear fluid. No kidney sub-
stance and no ureter were found. Nothing was removed. The
patient did well and left the hospital October 19, 1905. November
20, 1906, the patient reported by letter that she had improved steadily
until March, 1906, and at that time seemed perfectly well.
Soon after that her former s>Tnptoms recurred and have persisted
since. December 20, 1908, she writes that she has aching in the left
side, just above the hip-bone, following down toward the groin, also
a backache and "a large bunch reaching toward the pit of the stom-
ach." She has attacks of gastric distress lasting from a day to a
week, accompanied by a scanty urination and vomiting.
She re-entered the hospital Februar>' 9, 1909, stating that for the
past year she had many attacks of pain so great as to produce nausea
for several daj-s at a time. In these attacks a mass appears in the left
hjTKxrhondrium and gradually increases in size. At first it is only
the size of a walnut, later as large as the fist. Later it extends into the
flank and grows tender. While it is enlarging, very little urine is
passed, but by pressing upon the mass the patient can cause it to
disappear. Simultaneously she feels urine accumulating in the
bladder and can then pass about a pint, which is dear and without
sediment. Despite these s>Tnptoms her general health has much
improved since her last ojxTation.
Phj'sical examination is essentially negative except for a mass
in the left hyjxxhondrium (,Fig. ii\ which is smooth, roimd,
fluctuant, not tender, moves an inch ^-ith respiration, and is felt
bimanually in the flank. Cj-stoscopy by Dr. Lincoln Davis showed
a normal bladder. From the right ureter indigocarmin was ex-
creteil within fiftivn minutes. The left ureter excreted no coloring-
matter whatever during half im hour*s obserx-ation. On the 14th of
February the n\ass in the left hy|xx^hondrium increased in size dur-
ing the day sv^ that at night it was the size of a grape-fruit and showed
two definite lolx^s. It was iv\ii\ful and fluctuant. By manipulation
the size of the mass was considerably decreased and the pain relieved.
February- lO, 1000, the old scar was n;vpened and a large cystic
ABDOMINAL AND OTHER TUMORS 51
tumor ruptured, with the escape of a pint of fluid resembling urine.
This time the remains of the kidney and ureter were found and re-
moved. Examination by Dr. W. F. Whitney showed a kidney with
a very large dilated pelvis, one end of which extended into a large sac;
the ureter very small. The patient did well after operation and left
the hospital on the iSth of March. 1909. March 24, 1910, the patient
reported by letter that she has been perfectly well since operation
and does all the work for a family of five. When in the hospital she
weighed 104 pounds; now. 120 pounds.
Fig. II.— Ma55 telt in Case lo.
Postscript. — The sj-mptoms which the patient presented during
her second visit to the hospital were obviously those of intermittent
hydronephrosis. Presumably, therefore, that disease was the cause of
her symptoms throughout, and the supposed cyst, opened at the first
operation, was a hydronephrotic sac. The cause of the anemia was
Ifsobably the menorrhagia. As the patient has now been imder ob-
fervation for five years, it seems very improbable that any type of
Balignant disease is present. As to the mass felt near the pubic bone
Htthe first examination, I can only say that it was forgotten for some
■me. and when looked for again was not to be found!
Sa
DIFFERENTIAL DIAGNOSIS
Case 11
A laborer of fgrty-five entered the hospital February 4, 1909.
Family history and past history not interesting, and the patient's
habits good. Four weeks ago the patient felt perfectly well. He was
then obliged to work, for the whole of one day in the wet, cleaning out
a cess-pool, Tho noxt day ho folt ail right, but the day after he began
to have pain in tht- loft calf antl in tho inside of the left knee, eq>e-
dally on g^'tting up in tho morning. This pain compelled him to stop
work and incwastnl in the subsoqucnt daj-s. Lumps upon his legs
were tirst noticoil fv>ur wivks ago. For the last two weeks the pain has
become somewhat "doadcnt.\i." as ho sa;-s. and the swelling is less
ABDOMINAL AND OTHER TUMOKS
S3
marked. Nevertheless, he has been confined to his bed practically
all the time in the last four weeks. He has no digestive symptoms,
no cough, no loss of weight. He sleeps poorly.
^
- -3 cm
/
Fig. 14.
Physical examination shows good nutrition. Pupils, glands, and
reflexes negative. Chest and abdomen negative. On the right
thigh, in the middle of the anterior aspect, is a hard, tender mass,
54 DIFFERENTIAI. DIAGNOSIS
apparently not connected with the skm, nor with the blood-vessels or
the bones. Iliere is no fluctuation in the mass, but it has no sharp
limits. Ilie size and situation of this and the other swellings
present in the case is shown in the accompanying diagrams (Figs.
12, 13, 14). There was considerable muscular tremor of the calves
and thighs. When the patient stood, one of the masses became bluish
led. The course of the temperature is shown in the accompanying
chart (Fig. 15). The blood and urine showed nothing abnonnal.
Drs. Mixter and Brewster
could make no diagnosis. Dr.
±1
■V.-"^Vw' -Irt^r-
U\
m
i
ft::
H. C. Baldwin thought it
probably in)ositis, and noted
increased muscular irritability.
Dr. F. S. Bums said, "I think
that trichiniasis and dermatitis
coccidioides should be con-
sidered." A swelling on the
nasal septum was examined by
Dr. J. P. Clark and found to
be nothing but a slight devia-
tion covered by a superflcial
excoriation.
Discussion. — In view of the
obscurity of the diagnosis in
this case and of the great
variety of opinions expressed
about it (I have quoted only
a few of them here), it seems well to make a sur\ey of the whole list
of affections which are known to produce multiple subcutaneous
lumps. Such a list is as follows:
1. V, Recklinghausen's disease, or neuro&bromatosis.
2. Nodular liponiatosis ('■adiposis dolorosa"), with or without
pain.
3. Sy-philis, in the fonn of periostitis or gumma.
4. TubiTcuIosis, csiit'cially osseous and periosteous.
5. Sepsis with embolic abscesses.
6. Rheumatic nodes.
7. Erythema mnlnsum,
8. Urticarial lesions, with or without associated hemor-
rhages.
9. Angioniata or l)iiiphangiomata.
Fig..
—Chart of Case 11
ABDOMINAL AND OTHER TUMORS 55
10. Malignant lymphomata, with or without leukemia. (Such
growths can arise from the minute lymph-follicles present
in the deeper layers of the skin and in the subcutaneous
tissues).
11. Carcinomatosis.
12. Multiple exostoses (or enchondromata).
13. Coccidioidal granuloma.
14. Scurvy.
15. Myositis.
16. Actinomycosis.
17. Glanders.
18. Leprosy.
Di£ferential Diagnosis and Outcome. — Trichiniasis does not pro-
duce such swellings. The encysted embryos produce no palpable en-
largement of the muscles. Further discussion of the above list of
possibilities will follow when we have disposed of this case. The
course of procedure was as follows : Within a few days one of the timiors
upon the arm showed distinct fluctuation. A needle was introduced
and a thick pus obtained. There were many trabeculae running
across the cavity. On the loth two more tumors were aspirated and
about 2 ounces of blood-stained pus obtained from each. On micro-
scopic examination well-preserved leukocytes, but no organisms,
were seen. Dr. James H. Wright reported that the smear prepara-
tions and cultures from the pus showed a bacillus not inconsistent with
the bacillus of glanders in morphology and cultural peculiarities. A
guinea-pig which had survived subcutaneous injections of the pus
was given a fresh culture intraperitoneally. Two days later the
animal died, and autopsy showed numerous white nodules varying
in diameter from a fraction of a millimeter to several millimeters,
adherent to the peritoneum in the great omentiun, in the testicles,
and elsewhere. In one of these nodules bacilli like the bacillus of
glanders were found. Diagnosis, glanders.
With these facts in our possession, the patient was carefully ques-
tioned in relation to his association with horses, but no such history
could be obtained, though he admitted that he had slept in horse
blankets. On the i8th he was transferred to the surgical service,
where he ran a continuous fever between 99° and 100° F. for four
months. The pulse during this time ran between 80 and 100. The
abscesses were very slow in healing. April 8th a large slough was
removed from the left leg. May nth Dr. C. A. Porter, under whose
care the patient was, thought there was thrombosis in the iliac vessels.
56 DIFFERENTIAL DIAGNOSIS
with establishment of a collateral circulation by way of the epigastric I
vessels. May 15th a new nodule appeared upon the arm (Fig. 16). ,
The old wounds upon the arm were practically healed and that upon ^
the leg was gradually getting well. May 20th the patient was dis-
charged to the Out-patient Department.
ilh gangrene.
The patient re-entered the hospital December 30, 1909, with a ]
persistent ulcer in the calf of the left leg, all his other wounds having
healed properly (Fig. 17). This ulcer was removed with a consid-
erable margin of skin and its base cureted. As there was some '
contraction of the foot on this side, the Achilles tendon was cut.
The patient left the hospital January 7, 1910,
February a2, iqij, Vt, H. Lincoln Chase, of Brookline, Mass.,
reports that patient is very well and working, though there is still a
small unhealed ulcer on one calf, probably corresponding to the lesion
shown in Fig. 17, All the other subcutaneous abscesses have wholly.
healed.
I. Neurofibromatosis.— Reluming now to the list of diseasesJ
producing subculaneous lumps, neurofibromatosis usually presental
ABDOMINAI. AND OTHER TUMORS
57
I difficulties of diagnosis whatever. It is a rare disease, and, if
not congenital, appears usually early in life, and has generally existed
for many years practically unchanged before we have any oppor-
tunity of seeing the patient. The appearance of the nodules is seen
in Fig. i8. The number of nodules often runs into the hundreds or
into the thousands. They ordinarily cause the patient no pain or
other trouble, and he seeks advice from curiosity or apprehension.
They do not disturb nutrition or general health, and the patient often
I Bves to old age. A few of them are sometimes sensitive to pressure.
Occasionally nodules within the spinal canal or cranium may give rise
to serious symptoms by means of their pressure. The tumors are
soft, sometimes pedunculated, ordinarily not larger than a chestnut.
Occa^onally they may reach enormous size. Histologically they are
composed of nerve substance and fibrous tissue in varj'ing pro-
portions. Patches of brown pigmentation on or near the tumors
are frequent. Some of the nodes may contain so little nerve tissue
58 DIFFERENTIAL DIAGNOSIS
that they are practically fibromata, but there is no need to establish a
separate disease entity for the purpose of covering these slight varia-
tions from the ordinary type.
2.. Nodular Lipomatosis. — The ordinary subcutaneous fatty tumor
so frequently seen and so harmless, is sometimes present in consider-
able nimibers and in varying sizes. The different t3^es and varieties
of this trouble have been described and photographed by Dr. Irving
P. Lyon.^ As a rule, these lumps are wholly symptomless and pain-
less, and the physician is consulted only because the patient wants to
be reassured. Occasionally, however, they are quite painful, like
the larger areas and deposits of fat first described by Dercum imder
the term "adiposis dolorosa." There is no sharp line to be drawn
between the small, discrete, painless lipoma — single or multiple —
and the extensive, sometimes symmetric, depx)sits of fat tissue — sensi-
tive or insensitive — over various parts of the body. The diagnosis
of this condition rests upon the feel, the lobulation and position of
the tumors, their long persistence without change and usually with-
out any symptoms whatever, and, in the last resort, upon histologic
examination of an excised specimen.
3. Syphilitic periostitis may affect a number of bones simul-
taneously and thus give rise to multiple lumps. It is often painful
or tender. The connection with bone can usually be demonstrated
by palpation. The absence of suppuration, the evidence of S3^hilis
elsewhere in the body, and the presence of a Wassermann reaction are
the most helpful points in diagnosis. Gummata arising in the sub-
cutaneous tissues are not likely to remain long without ulcerations,
hence they are not often seen as subcutaneous lumps. They are
recognized by the presence of other evidences of syphilis and by the
exclusion of the other px)ssibilities now under discussion.
4. Tuberculosis. — This lesion does not often give rise to difficulties
in diagnosis, as it is very prone to involve the skin and lead to sinus
formation and suppuration. Slow-healing sinuses, leading to necrotic
bone, are more often tuberculous than anything else. OccasionaUy
they may be due to septic osteomyelitis. Other lesions of tubercu-
losis in the glands or internal viscera or the genito-urinar\' tract are
often present. The x-ray appearances are ordinarily characteristic.
A negative Wassermann reaction may be of great value, and in yoimg
children a positive tuberculin reaction is also useful. In older persons
it is almost or quite useless, as a considerable j)ortion of them give a
positive reaction, whether they are actively diseased or not.
*The Archives of Internal Medicine, July, 1910, vol. \n, pp. 28-120.
ABDOMINAL AND OTHER TUMORS
59
5. Sepsis with Embolic Abscesses. — The evidences of acute inflam-
lation and the rapid accumulation of pus ordinarily makes the diag-
>sis clear. In any doubtful case, incision and culture should clear
1 the doubt,
6. Rheumatic nodes are practically confined tendons and aponeu-
, 19, 20, 21, 22, 23, and 24). One sees them on the ten-
Ions of the wrists, about the knuckles and near the elbow-joints and
nee-joints, on the forehead near the roots of the hair, and about the
xiput. They are practically always connected with other manifes-
tions of that form of streptococcus infection usually called acute
;. 19, — Kheunialic nodes on the forehead. These wholly disappeared
r subacute rheumatism. Endocarditis is almost invariably present-
I follows, therefore, that they are usually seen in children, rarely in
fults. They are very hard and almost invariably painless, averaging
iie size of a small pea, but their most characteristic feature is the
remarkable fact that although they are so hard that it seems they
must last forever, they may absolutely disappear within a few days or
teks, only to be followed by new crops. Eventually they disappear
i and all, and if the patient conquers his endocarditis he may
main in full health. They are apt to be confused with the bony
ntgrowths known as Heberden's nodes which appear on the termi-
joints of the lingers, and, once established, last for life. The
DITFESENTIAL DIAGNOSIS
latter have no connection with streptococcus disease, Theumatism,
or endocarditis.
7. Erythema Nodosum. — Red, painful, sensitive lumps appear
suddenly upon the flexor surfaces of the foreanns and lower legs,
Fig, 10. — Rhcumaiii- nodes on elbow. Same case as Fig, 19.
rarely elsewhere (Fig. 24.) They are almost never suppurated and
ordinarily disappear within a few weeks. In most cases they are
associated with joint disturbances and often nith endocarditis.
They are usually believed, therefore, to represent one more mam-
festation of the picture of streptococcus infection above referred to.
Fie. ."I, — Rhi'umalk ncxle
8. Urticaria, or ftivcs, is recognized by its severe itching, its
rapid apix-arance and disappearance, and other well-known charac-
teristics not needing further description here. It may be associated
with joint manifestations, and when it occurs within the intestine,
J'^-*
k
;. 14, — Erylhtma nodce>um (from C Hcgler, Hrgtb. d. Inn. Med., igij. p. 630),
ABDOMINAL AND OTHER TUMORS 6l
lay be operated upon for appendicitis, as in the case described in
Vol. I, p. 447. Similar lesions in the bronchial mucous membrane
may also give rise to acute respiratory symptoms. (See Vol. I, pp.
73, 447-)
g. Angiomata are generally bright red and make clear their nature
by their color. They are not often much raised above the surface.
Between them and the ordinary birth-mark there are all grades of
transition. Lymphangiomata seldom produce discrete lumps, but
rather misshapen enlargements of a part; for example, of the hand and
forearm or of the foot. They fade oft into the tissues around them.
As a rule, they are congenital or of very long standing before a medi-
cal man sees them. They cause nu sj-mptoms, and advice is sought
Fig. 23. — Rheumatic nodes on finger- 1 endoi
<si account of the disfigurement. Occasionally we find combina-
tions of angiomata and lymphangiomata.
10. Malignant Lymphomaia. — So long as malignant lymphomata
remain confined to the ordinary sites of Ij-mphatic enlargement—
the neck, the axillae, groins, mesentery, etc. — they are not likely to
be confused with any of the lumps which I am discussing at present.
6j
DIFFERENTIAL DIAGNOSIS
Occasionally, however, and especially in the leukemic varieties of
Ijinphoma, we have nodules in the subcutaneous tissues (Fig. 25).
The nature of these will not be suspected unless the blood is
examined or unless one is excised for histologic study. They pre-
sent no distinguishing characteristics on physical examination. They
are very rare.
(
9
4
^V 1
■■.V
»
1
m
1
*
r
Fig. js-— PhotORraph of a watet-color drawing of skin nodules in a cose of myelemia.
(By kind pennission of Drs. H. U. Rotlestoa and Wilfred Km,)
II. CardnomatosU. — Multiple foci of cancer arising in the ■;ltin
as well as in the internal organs, sometimes present a clinical picture
^•ery difficult of recognition.
A clerk of thirty-five, who handles raw pork and sometimes eats
it, entered the hospital May 13. 1913. Ten years ago be had syph-
ABDOMINAL AND OTHER TUMORS 63
ilis. Now he has had fever, backache, leg ache, cough, and diarrhea
of two and one-half weeks' duration. The entrance diagnosis was
syphilis cerebrospinal. Physical examination (including the urine)
was negative save for two small subcutaneous nodules on his chest,
each surrounded by a hemorrhagic area. The blood showed 3,200,000
reds, gradually falling to 2,752,000. No achromia or deformities.
May 2sth, 12 normoblasts per 100 leukocytes {i. e,, 1320 per cubic
millimeter). Polynuclear leukocytosis (80 per cent.) at entrance,
gradually falling to 60 per cent. Eosinophils, 3 per cent.; the rest
lymphocytes. The total leukocyte count varied frorb 10,000 to
18,000.
During the next two weeks he sank and died without any new
symptoms except the appearance of firm, insensitive, irregularly
shaped subcutaneous nodules in various parts of his body. The largest
was 1.5 cm. in diameter. The Wassermann reaction and blood-culture
were negative. There was a good deal of bleeding from the nose and
rectum. Coagulation-time (venous blood) eight to sixteen minutes.
The clinical diagnosis was lymphatic leukemia. Autopsy showed
carcinoma of the liver, lungs, pancreas, spleen, mesentery, adrenals,
pelvic cavity, epicardiimi, pleura, sternum, vertebrae, pelvic bones,
and subcutaneous tissue; also vegetative endocarditis (mitral), with
infarcts of the spleen and subcutaneous hemorrhages.
12. MuUiple Exostoses. — Aside from the enlargements of the ter-
minal finger- joints (Heberden's nodes), and the similar but less
striking enlargements near the articular surfaces of the other long
bones, the occurrence of multiple exostoses is very rare. Most
of what is known upon the subject has been recently summarized by
Dr. Channing C. Simmons in his article on "Localized Osteomyelitis
of the Long Bones," which appeared in the **Boston Medical and
Surgical Journal" of May i, 1913.
13. Coccidioidal granuloma is a rare disease practically confined to
California and difficult to distinguish from blastomycosis. It seldom
presents subcutaneous lumps at the time when it comes under ob-
servation, as the lesions are very prone to involve the skin, to break
down and produce chronic abscesses or lesions, from which the char-
acteristic yeast-like budding organisms can be easily obtained, in
the great majority of cases. Lesions very similar to those of tubercu-
losis may also be found in all the organs which tuberculosis attacks.
The diagnosis depends upon the exclusion of S3^hilis, tuberculosis, and
malignant disease, and upon the presence of characteristic organisms
on coverslip examination.
64 DIFFERENTIAL DIAGNOSIS
14. Scurvy. — Over the shins, forearms, and near the insertion
of any tendon there may occur in scurvy subcutaneous hemorrhages,
very slow of absorption and producing slightly raised tumors, not
unlike those of syphilis or tuberculosis. The diagnosis of such tumors
is, however, perfectly easy in the majority of cases, owing to the other
evidences of scurvy in the patient and owing to the conditions of
diet revealed by the history. Such swellings are usually very tender
and painful.
15. Myositis, — Those who practice massage probably have a
much greater practical knowledge of myositis than anyone else,
but as masseurs seldom have an adequate medical training, they have
not yet succeeded in getting their observations thoroughly recognized
by medical men. Every experienced masseur can tell us how often
subcutaneous indurations are discovered during the course of a treat-
ment, and how, as a result of repeated rubbings, these indurations
may be removed. Occasionally such forms of localized myositis form
visible and palpable lumps, especially about the occiput, where the
neck muscles are inserted. They are much larger than rheumatic
nodules, and they are much less differentiated from the surroimding
tissues and often much less tender. Their exact relation to rheu-
matic and streptococcic infection is not clear. Indeed, very little
is known of them, as very few histologic examinations have been
made.
Besides these forms of low-grade inflammation, there have been
reported, especially by Japanese observers, a good many cases of sup-
purative myositis occurring in discrete foci in various parts of the body.
Such foci are to be differentiated from glanders only by bacteriologic
examination. From ordinary- subcutaneous abscesses they are dis-
tinguished by their deeper position. Outside of Japan very few such
cases are on Record.
16. Actinomycosis, involving the subcutaneous tissues, usually
occurs about the jaw, in the neck, or over the elbows. It seldom
produces lumps, but forms a bluish, porky, suppurating sinus indis-
tinguishable from tuberculosis of gland or bone unless careful micro-
scopic examination of the discharge is made by an expert. The
disease is ver>' rare and is usually mistaken for tuberculosis or chronic
osteomyelitis.
17. Glanders, — WTien the disease has become generalized and is
no longer confined to the mucous membranes, it often manifests
itself by subcutaneous abscesses, the so-called *'farcy buds" of the
veterinarian, which must be remembered in human as well as in equine
ABDOMINAL AND OTHER TUMORS 65
glanders. The diagnosis rests upon the history of a nasal discharge
in one closely associated with horses, and upon the microscopic ex-
amination and culture of the pus obtained from the lesions.
18. In leprosy the nodules are almost all upon the exposed parts,
especially upon the hands and face, though it is believed that the
disease most often starts in the nasal cavities. No description of the
disease will be attempted here, but it should be remembered as among
the possible causes of subcutaneous lumps, especially when these
occur in the sites just mentioned.
Aside from the causes of subcutaneous lumps just listed, we may
mention the epiphyseal enlargements of rickets ordinarily seen at the
wrists, ankles, and near the stemimi. The deposits of sodimn biurate
in gatU sometimes advance along the tendons to a considerable
distance from the joints. The pigmented nodes of melanotic sarcoma
are usually secondary to similar growths in the eye or the liver, but
are sometimes mistaken for moles or warts. Multiple wens about the
scalp or about the genitals sometimes give rise to a good deal of doubt
and apprehension on the patient's part, and even a physician is some-
times in doubt as to their nature imless he investigates their contents
and recognizes the greasy, sebaceous material with which they are
filled. I recently mistook a soft metastatic neoplasm of the scalp for
a wen.
Case 12
A housewife of twenty-nine entered the hospital February 23, 1909.
The patient was sent in from the Out-patient Department with a
diagnosis of "retroperitoneal cyst (?).'' The patient's husband died
eight months ago of phthisis. The patient took entire care of him.
Her family history is good, but since the age of sixteen she has had
paroxysmal epigastric pain in attacks lasting a few minutes at short
intervals for periods of three or four days and recurring at intervals of
weeks or months. She sometimes has to go to bed with these attacks.
Occasionally the pain is in the lower abdomen. It does not radiate,
has no relation to meals, and is never associated with jaundice or
changes in the urine. It is often accompanied by vomiting.
Eight years ago her appendix was removed in the hopes of reliev-
ing the trouble, but no relief followed. Her appetite is good, her
bowels habitually constipated. Her menstruation is irregular, often
skipping a period.
Two years ago she noticed that her corsets seemed abnormally
tight about the waist, especially just below the ribs in front. Soon
Vol. II— 5
66
DIFFERENTIAL DIAGNOSIS
after this a swelling became visible and paJpable in the epigastric
region. This tumor has increased considerably in size in the past
year and tiie whole abdomen seems somewhat larger. The tumor also
seems to be growing firmer. It throbs and beats. Her weight has
been slightly increasing for a year. For the past six weeks her face
has been puffy, especially about the eyes, and she is somewhat short
of breath, which she accounts for as due to the pressure of the tumor.
Physical examination shows good nutrition, many small papules
over the back, shoulders, and neck. Pupils, glands, and i
Fig. ;6. — Signs in Case 13,
normal. When she hes on her left side a faint presystolic roll can be
heard at the apex; otherwise the heart is not abnormal. The lungs are
negative. Between the ensiform and the navel is a rounded, tense
prominence, about 5 by 7 inches, duU on percussion in its upper two-
thirds. During examination the tumor seems to vary somewhat
in size. The rest of the abdomen is tympanitic except in the flank,
where there is dulness, not shifting with change of position. No
fluid-wave can be demonstrated and there are no other masses. The
epigastric tumor is moderately tender. No respiratory mobility can
be demonstrated. There is notable tenderness in both costovertebral
ABDOMINAL AND OTHER TUMORS 67
angles. Leukocytes, 8500; hemoglobin, 90 per cent. Urine normal.
No fever in ten days' observation. The possibilities considered were
retroperitoneal cyst, connected with the pancreas or kidney, hour-
glass stomach, lipoma of the abdominal wall, and phantom tumor.
Inflation of the stomach showed that the tiunor was displaced or
overridden by it (Fig. 26). The capacity of the stomach was 40
ounces. After a test-meal free HCl was 0.09 per cent. ; total acidity,
0.2 per cent.
Discussion. — The history gives us nothing definite. The essen-
tials of physical examination are the epigastric tumor of long dura-
tion, occurring in a well-nourished woman of twenty-nine. Such a
tumor obviously presents something out of the ordinary, for epigastric
tumors ordinarily occur in emaciated old people (cancer of the stom-
ach) and are not of long duration.
We must consider a pancreatic cyst, which is a benign, slow-
growing affair, and may occur at any age. Such a cyst can be recog-
nized only by ruling out, through extensive examination, any disease
of the stomach, liver, and spleen, and then by tapping the cyst and
examining its fluid for the presence of pancreatic ferments. If the
function of the pancreas is seriously interfered with, we may have
glycosuria or fatty stools, In this case the urine and the feces were
normal. There was no evidence of disease of the stomach, liver, or
spleen. The tumor was not tapped for reasons apparent in the out-
come.
Retroperitoneal new-growth, ordinarily malignant lymphoma,
would probably have been associated with ascites, emaciation, and
pain. Other tiunors would, in all probability, be demonstrable within
or without the abdominal cavity. The blood might show leukemic
characteristics.
The excellent condition of the patient makes us wonder whether
the mass may not be in the abdominal wall. A mass of fat or one
of the bellies of the rectus sometimes becomes perceptibly prominent,
and leads the patient, as well as the physician, to suppose that some
disease exists. These possibilities could not be excluded in this case.
No positive diagnosis was made.
Outcome. — On the 3d of March the patient was etherized and the
tumor wholly disappeared, promptly reappearing when she came
out of the ether. Apparently it was a **phantom tumor." She left
the hospital on the 4th of March.
68 DIFFERENTIAL DIAGNOSIS
Case 13
A woman of sixty-two entered the hospital April 21. 1909. A
year ago she had an attack called "inflammation of the bowels."
She has also had two previous attacks, rather vaguely dated. In
each she had diarrhea, without blood, but with much pain in the left
side of the abdomen. Since the last attack, a year ago, she has never
been strong, and has never been free from pain in the left side of the
abdomen. For four or five months this pain has been quite severe at
times, occasionally cramp-like. Hot applications relieve it.
Nearly a year ago she noticed in the region of pain a lump the
size of her fist. For some time she has been losing weight and strength,
ajid for a year she has done no regular work. Her appetite is good
except when the pain is bad; then she vomits everything. Her
bowels move daily.
Physical examination shows fair nutrition and is in all respects
negative except as relates to the upper left quarter of the abdomen,
where there is a hard, irregular, slightly movable mass, not descending
with respiration, slightly tender. The colon traverses it (Fig. 27).
Blood, urine, and feces normal. No fever in a week's observation.
ABDOMINAL AND OTHER TUMORS 69
Discussion. — Diarrhea and crampy pain in an emaciated patient
of sixty-two, with a liunp in the left upper quadrant, suggests at once
a carcinoma of the splenic flexure. The fact that the bowels move
daily does not exclude such a disease. The absence of blood in the
feces is more definite evidence against cancer of the colon. Still
more important as negative evidence is the fixity of the tumor and its
size. So extensive a neoplasm connected with the intestine would
almost certainly have given rise to marked obstructive symptoms.
May not the tumor be connected with the kidney? That the
colon traverses it is wholly in favor of such a supposition, and the
negative condition of the urine does not rule it out, though with a
tumor of so great a size one would expect a hematuria sooner or later.
Tumors arising in the tail of the pancreas are rare, and if they
attained so great a size would probably show some deficiency of pan-
creatic fimction, manifested in the stools or urine.
Retroperitoneal tiunors arising from the prevertebral glands often
give rise to ascites and to fever. The amoimt of pain associated with
them varies greatly. It is often not greater than in this case. After
considerable study and after excluding, so far as possible, the other
alternatives considered above, I made the diagnosis of retroperitoneal
neoplasm in this case.
Outcome. — ^Dr. C. A. Porter thought the tumor retroperitoneal,
possibly sarcoma of the pancreas, the fixedness of the mass suggesting
this. April 2Sth Dr. Porter opened the abdomen and found a tmnor,
the size of two fists, springing from the retroperitoneal tissues on the
level with the lower border of the left kidney. Further exploration
showed in the pelvis a hard, irregular mass, the size of an orange,
apparently connected with the left ovary. The left broad ligament
was thickened and nodular. Between the first tumor and the pelvic
mass just described there was another retroperitoneal swelling, about
2 inches wide and nodular. The gastro-intestinal tract was wholly
iminvolved. No attempt was made to remove the mass. There
was no vaginal examination previous to operation. The patient
recovered from the operation and left the hospital on the 13 th of
May, but died seven weeks later, after much sufl'ering.
Case 14
An automobile repairer of twenty-four entered the hospital De-
cember 7, 191 1. The patient's family history is negative and he has
had no previous disease. For the past three weeks he has noticed a
lump in his right armpit. It caused no pain or discomfort until a
70 DIFPEKENTIAL DIAGNOSIS
week ago. Since then the pain has been increasing and now he is
unable to work. For a month he has noticed some headaches, but no
defect in sight. His eyes have not been examined.
Physical examination is negative, except for the right axilla,
where there is a soft, tender, rounded mass of doughy consistency,
about the size of a large plum.
Discussion. — ^A Imnp in the right armpit, noticed for three weeks,
painful for one week only, is not at all likely to be due to any form of
neoplasm. Such growths, if occurring in the axilla, are almost in-
variably bilateral and accompanied by similar tumors in the neck
and groins.
Much more probable is a tuberculous or septic type of adenitis.
The absence of any evidence of tuberculosis in any other part of the
body and the good previous history and family history make us
incline toward a septic type of adenitis. Deep axillary abscesses,
which have already been referred to on pages 334 and 484 of Vol. I,
should be recognized as a distinct clinical entity of insidious course,
and are often unrecognized because the pus is situated so deeply,
pressing into the foreground swollen glands which often engross the
physician's attention and mask the existence of any other disease.
Outcome. — December 8th the axillary mass was cut open and 2
ounces of thick yellow pus removed, revealing the tumor proper.
Complete dissection was carried round the timior, cleaning out the
entire axillary structures, including the brachial vein. The mass
thus removed was hard and about 4 by 4 cm. Microscopic examina-
tion showed lymph-nodes with slight hypertrophy of the lymphoid
elements and a hemorrhagic infiltration of the surrounding tissues.
The glands varied in size from that of a pea to an English walnut.
The microscopic diagnosis was chronic inflammation. The patient
promptly recovered and left the hospital on the nth of December.
There has been no recurrence (19 14).
Case 15
A coachman of thirty-seven entered the hospital June 10, 1909.
Five years ago the patient noticed a mass in the left side of his ab-
domen. He is quite sure that that lump is the same which is now
palpable there. For the first two years this grew steadily in size.
He then began to have x-ray treatment and has had it two or three
times a week for the past three years. Under this treatment he has
felt very well and has worked until three weeks ago. About six
months ago he began to cough, and this s>Tnptom continues.
ABDOMINAL AND OTHER TUMORS 7 1
Three weeks ago he began to feel weaker and had to give up work.
During this period his throat has been sore and swollen. He has also
had dyspnea and edema of the feet. At the beginning of this illness,
five years ago, he weighed i8o pounds, with clothes; now, 152 pounds,
without clothes. The following notes from the out-patient record
show his condition three years ago: October 6, 1906, Weight, 160
poimds; hemoglobin, 70 per cent. The liver reaches from the sixth
rib to a point 8 cm. below the costal margin. Spleen 16 cm. below
the costal margm, in the nipple Une and 6 cm. to the right of the
umbilicus. White cells, 49,200; red cells, 4,072,000; lymphocytes,
95 per cent. February 7, 1907, White cells, 11,300; lymphocytes, 75
per cent. Spleen much smaller. April 30, 1907, White cells, 8200.
May 8, 1908, Hemoglobin, 90 per cent. The liver still reaches 2 cm.
below the costal margin. August 2, 1908, White cells, 11,200; lympho-
cytes, 89 per cent. April 9, 1909, White cells, 20,000; hemoglobin,
85 per cent.; lymphocytes, 98 per cent.
Physical examination June 10, 1909, showed fair nutrition, slight
pallor, slight enlargement of the tonsils, moderate enlargement of
the cervical, axillary, inguinal, and epitrochlear glands. The heart was
negative, save for a blowing, systolic murmur, loudest at the apex,
transmitted to the axilla. Lungs negative. The liver edge was felt
6 cm. below the ribs, in the nipple line. Its dulness extended to the
sixth rib above. Its surface was slightly tender. The lower edge of
the spleen was 20 cm. below the costal margin; its right border at the
umbilicus; its surface hard, slightly irregular, not tender. There was
moderate soft edema of the lower legs, a considerable discoloration of
the skin over the shins and over the spleen. The red cells during the
month of his stay in the hospital gradually declined from 1,750,000 to
750,000. The white cells at entrance were 19,000; fell a week later to
13,000; then gradually rose to 20,000. The lymphocytes made up
from 95 to 99 per cent, of all the white cells present. Most of them
were of the smaller type, but the large forms grew more numerous
toward the end of the patient's stay.
At entrance there was some achromia, but this disappeared gradu-
ally, and toward the last of his stay the color-index was decidedly
high. Examination of the fundus oculi showed numerous hemor-
rhages throughout the retina of each eye. The temperature during
the first three weeks of his stay ranged most of the time between 99°
and 100® F., rarely touching normal. In the fourth week it became
subnormal. The patient was given atoxyl solution, 5 minims sub-
cutaneously, once a day. Later this was omitted and 15 minims of the
72 WFFEKENTIAL DIAGNOSIS
green citrate of iron were administered subcutaneously every second
day. Still later Fowler's solution was tried.
Discussion. — ^When a man notices a lump in his abdomen it is
generally a spleen. An enlarged liver is not nearly so often foimd,
and tumors of the stomach are rarely found by the patient himself.
In women, pelvic tumors, especially uterine fibromyoma, are more
apt to be found by the patient herself.
The enlarged spleen thus found, if it occurs in a temperate climate,
is most often due to leukemia. The blood examination of this case
leaves no doubt that leukemia of the lymphoid type is the diagnosis.
Attention may be called to the following points:
First, The long duration of the case under x-ray treatment. It
seems to me very doubtful whether this patient would have lived
and worked three years after the diagnosis was made unless he had had
the advantage of x-ray treatment.
Second, The long latent period of the disease. The mass was
noticed at least five years before his present entry to the hospital.
I have seen at least three patients with lymphoid leukemia and
enlarged cervical lymph-nodes who stated very positively that these
lymph-nodes had been present for thirty or forty years, i. c, since
childhood. Presumably the blood during the greater part of this
period was normal. In other words, the tumors which Dr. F. B.
Mallory teaches us to call lymphoblastoma^ often remain for many
years non-leukemic. Why they finally begin to discharge cells into
the blood we do not know.
Third, Note that the liver as well as the spleen is considerably en-
larged, yet was not noticed by the patient himself.
Outcome. — Despite all attempts at drug treatment, the patient
lost ground steadily, and by the 4th of July had considerable ascites.
The patient desired to go home, and left the hospital on the 7th of July.
Case 16
A baker of forty-five, a Scotchman, entered the hospital July 16,
1909. After an uneventful life the patient began ten months ago to
have severe, steady pain in the right side of the abdomen. He be-
came so weak that he went to bed for a month, though the pain was
gone in about two weeks. When he got up his legs began to swell and
have remained swollen ever since, though he has regained some strength.
He has been unable to work for ten months. Six months ago he
^ Principles of Pathologic Hbtology, Frank B. Mallory, p. 326, W. B. Saunders Co.,
1914.
ABDOMINAL AND OTH£R TUMORS 73
noticed enlargement of the abdomen. He has coughed all his life,
he says; no more now than previously. It is his habit to take four or
five drinks of whisky a day. The present swelling in his legs began
also ten months ago. His usual weight is 140 pounds, with clothes;
at entrance, i28f pounds, without clothes.
Physical examination shows poor nutrition and pallor. The
cervical, submaxillary, axillary, and inguinal glands are enlarged,
some to the size of a pigeon's egg, some to the size of a hen's egg. The
heart's impulse extends 2 cm. outside the nipple line, the right border
3^ cm. from midstemimi. There is a slight systolic murmur at the
apex transmitted to the axilla. Pulmonic second sound is not ac-
centuated. The limgs are negative save for flatness, absent breath-
ing, and fremitus below the angle of each scapula behind.
The abdomen shows tiunor masses, one in the suprapubic and
right iliac region, another under the right ribs. There is also a
suggestion of a mass in the neighborhood of the navel. The rest of
the abdomen is occupied by fluid. The veins over the abdomen are
considerably enlarged.
During six weeks' observation the patient had no temperature,
but gradually lost 5 poimds. The urine was negative. The blood
showed red cells 2,760,000 at entrance, and this figure did not vary
much during the period of observation. The hemoglobin gradually
rose from 65 to nearly 80 per cent. The white cells ranged from
85,000 to 100,000, over 95 per cent, of them being small lympho-
cytes, with a few per cent, of large lymphocytes. The red cells showed
considerable achromia, slight deformities, no nucleated forms.
Discussion. — In view of the blood examination, there can be
no considerable doubt of the diagnosis in this case. It difl'ers from the
last case, notably, in the presence of pain. In my experience pain is
much more apt to be present in those cases of leukemia arising from
abdominal timiors outside the spleen and liver or from thoracic tumors.
When the main growths are in the cervical, axillary, or inguinal
lymph-glands or are confined to the spleen and liver, the patient does
not usually complain of pain, but when, as in the present case, we
have masses arising from the abdominal lymph-glands and pressing
forward beneath the abdominal wall, pain is usually more or less
troublesome. The association with ascites is to be expected, since
the enlarged glands and extraglandular masses surround and com-
press the vascular root of the mesentery.
The commonness of these lymphoblastic tumors without leukemic
blood has been concealed, to a certain extent, from our recognition on
74 DIFFERENTIAL DIAGNOSIS
account of complications in terminology. We have called them sar-
coma, lymphosarcoma, and laid stress upon the particular organ in
which they arise. But if their fimdamental similarity in structure is
recognized, it will be seen that timiors of this general type, the type
which may or may not be associated with leukemic blood (lymph-
emia), are not at all unconunon.
Note that in this case the hemoglobin showed considerable improve-
ment, but the patient did not. Such discrepancies are not infrequent
and remind us that the blood represents, after all, only a minor feature
of the disease. In some cases the patient gets much better, although
his blood remains unchanged.
Outcome. — The patient had x-ray treatment, but showed no con-
siderable improvement, and left the hospital August 25th.
Case 17
A farmer of thirty-eight entered the hospital August 5, 1909. The
patient has an excellent family histor\' and has alwa>'s been well and
strv>ng until last fall, when he was operated upon for 2q^>endicitis. His
habits are gooil. He denies venereal disease.
After the ojx^ration he did not regain his strength, and began to
notice that any considerable exertion caused an ache in the right side
of his aUlomen, though there was no sharp pain such as he had had
before the i^penilion. This ache has gradually become omtinuous and
now disturbs sloop. iXvasioniUly the ache extends to the right leg
or to the genitals. For one month he has had to pass urine four or
t\\T limes daily wuul onoo or twiox'' at night. Eating seems to increase
his discvunforts ;uul his a|v|xnite is pi.v>r. He thinks he has lost 5 or
o IXHimls in the lAst tNw nuxnths. He has alwa\"s Ii\"ed in New Eng-
rhx-^oal exami!\ativ>n shvnv^ eniaciadvin. \'elio¥rish skin, but no
vlenuilo JAumlivv. l\ij>ils. ^rUnvis. anvi r^exes negative. Chest
nejatiw saw tor tlAtucsss. dimimshevl bwathing. dunimsbed fremitus,
axkI dno nuMs: rAIcs ai the Iv*,^ v>{ wch hirur below the an^ of the
5CA|xi*A, I'lio A\{v>:r.ca :>hv^\if>i viu-ncss izi the dinks not ^Aiffing with
chAi\ct^ vv: iv\si:Ky\ lu tho r^^.: Iv^wvr ^uidnnt are bunches, prob-
aK> •^.s:v. a hcnv^A r,x tho ^^v wr o: :hc v\vi xjwtxiix operation. The
^wr v:u'^:>v'>i5i o\;c^,k> ::vr,\ :hc si\:h rib :s^ a rvi:::: ^ cm. below the ribs,
i,^ vtv.- Sc^x^>^ ;hv^ i-^^.sitortv, l:^ 5i*'\v>;h. r^oc-tecoer surface can be
i:v.i>:i:v:N v,\^vV x\;: l>,v s:v.vx-:h vV^ cc Uie spween can also be
^^: ," c.v. Knv^^ :Hv* :;N> v,\ :>.v r.^^jvc '::r>e Lit^- jl chitting of the
vh:>,N:^ ;:t ;Sr :x^;\i<s >fc^> >kr,xN:xs::;fc!Sjc vx: c'Mrjy 01 pc^tioQ and a
ABDOIONAL AND OTHER TnUOKS
75
mass was made out in the right iliac region. This mass was about the
size of half a lemon, egg shaped, slightly irregular in surface, fixed,
not tender. Examination of the urine and stools showed nothing
abnormal. The blood was also negative. The course of the tem-
perature during twenty days' observation is shown in the accompany-
ing chart (Fig. 28). The patient's girth at the umbilicus was 87 cm.
before tapping, August loth, when 2 quarts of fluid were removed.
After this no new masses were felt, hut the edge of the spleen and
the lump in the right groin were very distinct and there was a visible
and palpable mass in the epigastrium, probably part of the liver, and
descending freely with respiration. The tap fluid measured 1850 c.c.
with a specific gravity of 1008;
differential count: lympho-
cytes, 65 per cent.; endothelial
cells, 35 per cent.
Dr. Wilder Tileston made a
diagnosis of hepatic cirrhosis,
luetic or alcoholic in origin,
with tuberculosis of the lung.
The blood showed red cells,
i,joo,cxx>; white cells, 5000;
hemoglobin, 40 per cent. ; differ-
ential count, normal. Marked
achnnnia, some stippling and
deformity of the red cells. No
nucleated forms. August 15th
a transfusion of blood was done,
after which there was slight
icterus and the urine was bile
stained. The red count rose to
3,300,000. Dr. Tileston at this time regarded the case as Banti's
disease. Dr. C, A. Porter thought it was probably malignant disease.
Discussion. — The history gives us no clue, although it suggests
that the trouble is probably abdominal. The chest signs indicate
nothing more de&nite than a high position of the diaphragm. Despite
the opinions of the distinguished consultant, who suggested cirrhosis
or Banti's disease, it seems to me that attention should naturally be
concentrated upon the mass felt in the right iliac region. Neither
cirrhosis nor Banti's disease can account for this mass. It is situated
in the vicinity of the cecum and its association with a continued
fever suggests tuberculosis. I do not see how this disease can be
Fig. s8. — Chart of Case i
76 DIFFERENTIAL DIAGNOSIS
positively excluded, but the characteristics of the tap fluid are not at
all those which we would expect in tuberculous disease of the peri-
toneum. A specific gravity of 1008 corresponds rather with a drop-
sical effusion or a pressure fluid than with exudate accompanying
tuberculosis of the peritoneum.
Cancer of the cecimi is also a possibility, but it is not probable,
because we have no symptoms pointing distinctly to the intestine,
no evidence of obstruction, and no diarrhea. Cancer of the cecum
usually remains for a considerable period without forming extensive
metastases, and the presence of ascites, which would have to be refer-
able to such metastases, is, therefore, somewhat against cancer of the
cecum.
A lymphoblastoma, involving the spleen, liver, and abdominal
lymph-glands, would seem to fit the facts better than any other
diagnosis. In view of the blood examination, this tiunor must be
supposed to be of the non-leukemic type, sometimes called Hodgkin's
disease.
Outcome. — The patient left the hospital August 24th and died
September 14th. Autopsy showed malignant disease in the tail -of
the pancreas, with extension to the spleen, very slight involvement of
the liver, but considerable deposits in the retroperitoneal and thoracic
glands.
Case 18
A jeweler of thirty-seven entered the hospital January i, 1912.
The patient has been well except for children's diseases until five weeks
ago, when he lost his voice for a few days and felt so weak and listless
that he stayed in bed for a week, coughing up much phlegm at that
time. He still has a slight cough. Two years ago he noticed a tumor
in the region of his loin about the size of a lemon. This tumor seemed
to cause him pain when he lay down or sat for any length of time.
He now has a cluster of three bunches upon his left forearm which
cause a drawing pain when he chops wood. Other similar bunches •
have been noticed in various parts of his anatomy in the past ten
years, but have given no trouble.
Physical examination is negative save for moderately enlarged
tonsils, elongated uvula, a chronic pharyngitis, and innumerable
subcutaneous tumors with which the patient's body was ahnost
covered. They were firm, freely movable, not tender, varying in size
from that of a walnut to that of a duck's egg. Both arms are also
covered by these nodules, but there are none upon the legs.
ABDOMINAL AND OTHER TUMORS 77
Discussion. — ^When a patient has had bunches in or under his
skin in various parts of his body for ten years, without any noted
increase in their size, we can only suppose that a neurofibroma, an
angioma, or a lipoma is present. The more malignant types of tumor
mentioned in the discussion of case No. ii can be excluded. So far
as I am aware the non-leukemic lymphoblastomata, while they may
involve the skin, never last so long as these without producing more
marked symptoms. Further evidence as to the nature of these lumps
can only be obtained by excising one.
Outcome. — Three small nodules upon the forearm were dis-
sected out imder ether anesthesia, and another group in the left back
below the twelfth rib, just outside the erector spinae muscles. Ex-
amination of these tumors by Dr. W. F. Whitney showed nothing but
fat tissue.
Case 19
A housewife of twenty-four entered the hospital August 7, 1909.
The patient has had an imeventful past history, has one child, and
has had no miscarriages. Her menstruation has always been pain-
ful. She has had no regular period for two months, but some flowing
for three weeks.
Three weeks ago, while ironing, she felt as if something suddenly
slipped down in the pelvis, and immediately felt sharp pain there
and down the left leg. She felt faint and lay down, with much relief.
Since then she has not been free from pain, though it has usually been
only a dull ache. At times, however, it has been so sharp as to awake
her from sleep or to cause vomiting. These attacks are relieved by
morphin. Of late she has several times felt chilly or feverish. Her
appetite is good, bowels loose; she sleeps only with drugs.
Physical examination shows good nutrition and color. Pupils,
glands, and reflexes normal. Abdomen negative except as shown in
Fig. 29. White corpuscles, 13,400; hemoglobin, 85 per cent. Urine
negative. Temperature, 99.5^ F. at entrance. Pulse, 80.
Discussion. — The essential points in this case are the irregularity
of menstruation, the sudden onset of pelvic pain and presence of
pelvic tiunor, without signs of peritoneal inflammation. The two
pelvic diseases which most often begin suddenly and present a tiunor
on examination are extra-uterine pregnancy and the torsion in the
pedicle of an ovarian cyst. Pyosalpinx may, of course, begin sud-
denly, yet not, as a rule, so suddenly as in the present case. The
amount of tenderness and fever is usually greater in salpingitis than
78 DIFFERENTIAL DIAGNOSIS
in the present case. It is notable that the patient has good color a
a normal hemoglobin. Were there any extensive hemorrhage acM
peritonitis, the color and hemoglobin would probably be poor.
Since menstrual irregularities are somewhat more often asso
dated with extra-uterine pregnancy than with ovarian cyst, the latt^'l
diagnosis seems less probable in this case.
Outcome. — Operation, August 9th, showed a large blood-stained
mass in the left tube. The left tube and ovary were removed, also
I
Fig. 19. — The dolled outline shi
the appendix. Pathologic examination showed a mass the size of an
orange, made up of a thickened tube, much blood-clot, and the ovarj-.
Microscopic examination shows thickening of the walls of the tube
with engorgement of the vessels and some inflammatory reaction,,
also a few structures suggesting villi, but no positive signs of preg-
nancy. Nevertheless the case was considered one of extra-uterine
pregnancy. The patient made an uneventful recovery and left
the hospital on the 23d of August.
4
ABDOMINAL AND OTHER TUMORS 79
Case 20
An unmarried girl of twenty-five was sent into the surgical wards
with an Out-patient Department diagnosis of ^'sarcoma of the thigh,"
November 3, 191 1. The patient had never been sick before, but had
a cataract removed from the right eye a year ago at the Carney Hospi-
tal. At that time she had enlarged glands in the groins and first
noticed contractions of the cords behind the knee. The inguinal
glands have grown steadily, but have not been severely painful,
though the discomfort from them has sometimes kept her awake.
For a month she has not worked. She has lost in the past year 15
pounds in weight.
Physical examination shows good nutrition. The pupil of the left
eye showed an irregularity corresponding to the operation above
referred to. The other pupil normal. Mouth and glandular struc-
tures negative. Chest and abdomen negative. Over the left thigh,
beginning just below the groin and extending down the anterior and
internal surface about 14 cm., is a tender swelling, not connected with
the superficial tissues, not fluctuant, and apparently beneath the
superficial muscles. An x-ray showed no involvement of the bone.
Discussion. — ^The tumor in this case occupies an imusual position.
One sees in this situation a glandular mass extending downward from
the inguinal lymph-chain, thrombosed veins, inflammatory exudates
originating in an osteomyelitis of the femur, and malignant tumors
springing from the same bone. The latter, however, would present
a much larger, more diffuse growth. Lymphoblastoma, involving the
mguinal glands, would probably appear elsewhere, and is rarely so
tender. Such glandular masses would be very unlikely to seem so
deeply situated beneath the superficial muscles.
A phlebitis should show involvement of the vein above and below
the point described in this case. It would hardly be possible for a
phlebitis to be confined to a space 14 cm. in length.
Since the x-ray shows no involvement of the bone, it is not likely
that we are dealing with an exudate springing from an osteomyelitis.
Herewith I have excluded all the possibilities suggested in the
first place, and must confess that I was at a loss to make a diagnosis,
and was quite imprepared for the lesions shown in the outcome.
Outcome. — Operation on the loth of November showed a mass
mvolving the muscle tissue and not incapsulated. The tissue was
white and fibrous, strongly suggesting sarcoma. A piece the size of
the palm of the hand was removed. Examinadon by Dr. W. F.
8o
DIFFERENTIAL DUGNOSIS
Whitney showed dense fibrous tissue, in the midst of which there
were irregular areas of cheesy material. On the edge of this cheesy
degeneration were lines of round-cell infiltration and in the adjacent
tissue small vessels with marked proliferation of the intima. In one
of these vessels a slightly cellular nodule, lying just beneath the
intima. In several places there were large scattered giant-cells.
Diagnosis, gumma. Wassermami reaction positive; 0.6 gui. of "606"
was given intravenously, and iodid of potash, 5 to 30 gr., three times a
day. The patient left the hospital on November 29, 1911. Decem-
ber 6 1912, she was seen and was apparently in perfect health.
Case 21
A colored boy of fifteen, employed in a shoe factory, entered the
hospital January 19, 1910. The patient's family history and past
history were negative until last May, when his abdomen got large
Fig. 3*. — Mass felt
and tight; on the 19th it was opened and much fluid removed, with
great relief. He then remained well all summer and up to a month
ago, when he began to have pain in the region of the scar and to the
right of it. This pain was always worse at night, especially after a heavy
supper. It usually came about three hours after eating and lasted
four or five hours. His appetite and digestion were good, bowels
J
ABDOUINAL AND OTHER TUMORS 8l
He had no cough until within the past two days. For
three weeks he has been much troubled by itching all over his trunk.
Physical examination showed fair nutrition. At the right pul-
monary apex behind there were fine crackles, with cough, and over
the left clavicle the breathing was abnorrtiaUy liigh pitched. The
heart was normal. The abdomen was slightly full and spastic, espe-
cially in the right half, where there was an indefinite mass, as shown
in the accompanying diagrams (Figs. 30, 31, 32}. The temperature as
k the accompanying chart (Fig. 33). During his two months' stay
Fig. 31.— Chesl agns in Case 11, January, igio,
in the hospital he slowly lost weight. At entrance it was iiij pounds;
at discharge, 104 pounds. He was perfectly comfortable, as a rule,
but unless his bowels were kept very free he had attacks of sharp pain
in the right lower quadrant, relieved by glycerin enema. He did not
improve in any respect and was sent, on the 17th of March, to the
Lakeville Sanitarium. His itching was due to scabies.
He entered the Massachusetts General Hospital again July 5,
1910, coming there straight from the sanitarium, where he had gained
6 pounds and for two months had less pain. The condition of his
Vol. II— 6
DOTEBEfTIAL DIAGNOSIS
■hdoBim fe sfaown in fig. 34. In oCfaer reelects be was pnctkally
■s before. OperaticHi was advised, and m view of the Iowet tempera-
tuie (Fig. 5^) and the negative blood and orine, be was tzansfened
to the sorgicaJ wazds.
Dtsotssian. — In view oi the soondiKss of tbe heart and kidney
in this case, one can scarceiT cxaiadeT with seriousness any diagnosis
except tuberoiJous pentoahis. This b by far the commaQcst cause
of free fluid in tbe abdooun in a boy oi fourteen. Malignant disease,
especiaU>- lymphohlastoma. is potable, but rare.
Ac the time 01 his second entiy. when a tumor was present, there
could no longer be any question of any diagnoas exc^t the two
alfeady mentioned, and the duration of thu iilness, together with
the adstence of fe\-er. makes tumor verj- improbable. The fact that
there has been a gain in weight and improvement in the general
1 maites it practically certain that he is not suffering from
t discase-
-On tbe igth of July the abdt»nen was opened with
B-difieulty. owing to adhesions between the intestines and the
il wall. The tumor proved to be a mass of Lu^ and small
ABDOMINAL AND OTHEK TDUOKS
intestines matted together about the cecum. Numerous miliary
tubercles were scattered over the intestine and on the parietal peri-
toneum. The remainder of the peritoneal cavity was not explored,
owing to numerous adhesions. The boy recovered well from the
operation, but continued to run a temperature between ioo° and
ioi° F. until his discharge, August ist.
The patient was seen February 19, 1913. He was then at work,
eating ravenously, sleeping well, and free from fever. His bowels
DIFFERENTIAL DL\GNOSIS
moved three or four times daily and the movements were rarely solid.
When he left the hospital he weighed 104 pounds; at this time be
ABDOMINAL AND OTHER TUMORS 85
Case 22
A farmer of fifty-seven entered the hospital January 28, 1910.
The patient's mother died of tuberculosis, otherwise his family history
is good. He has had indigestion for ten years, beginning sixteen years
ago and ending six years ago. He denies venereal disease and has
good habits.
Six months ago he began to notice soreness in the right lower
quadrant of the abdomen, with occasional attacks of dyspepsia, and
soon after this he felt a mass in the region of the soreness. He thinks
it has grown slightly since that time. Three weeks ago he lost his
appetite and for three days vomited almost everything and had
more pain than usual. The vomiting grew less and ceased four days
ago, since when he has felt comfortable, though weak. Bowels
slightly irregular, but he now eats and sleeps fairly well. Last spring
he weighed 165 pounds, with clothes; September 6th, 151 poimds, with
clothes; now 129 poimds, without clothes. He stopped work three
weeks ago. For some time he has had attacks of sharp pain, last-
ing two or three minutes, after meals, and accompanied sometimes by
nunbling noises, sometimes brought on by pressure upon the abdomen.
For the last three weeks he has needed laxatives to make his bowels
move.
Physical examination shows fair nutrition, considerable sallow
pallor, though his hemoglobin reads 90 per cent, and the stained smear
is normal. Pupils, glands, and reflexes normal. Chest normal. In
the right lower quadrant is a hard, nodular mass, slightly tender and
movable on palpation. In the flank peristalsis is visible near it
(Fig. 36). Blood and urine negative. Temperature normal for a
week.
Discussion. — ^A mass in the region of the cecum, coming on at
the age of fifty-seven, with disturbances of intestinal fimction, is
strong presumptive evidence of malignant disease of the large intes-
tine. In a yoimger person tuberculosis might produce the same
symptoms, although the intestinal symptoms of pericecal tubercu-
losis are rarely as marked as in this case. A renal tumor might show
itself in this part of the abdomen, but would hardly be associated
with such marked intestinal symptoms as this patient presents.
Regarding the variety of neoplasm, we have only to distinguish
between carcinoma (epithelioblastoma) and malignant lymphoma
(lymphoblastoma). The latter txunor, which is ordinarily called
saicoma when met with in this site, is much less common than the
I
[
86
DirEERENTlAL DIAGNOSIS
former in a patient of fifty-seven. On the whole, I think the diag-
nosis of cancer of the cecum is satisfactorily clear.
Outcome. — On the 5th of Februarj- the patient's abdomen was
opened. A considerable amount of clear, dark yellow fluid escaped.
At the ileocecal valve a large, firm, freely movable mass was found,
with extensions running down into the pelvis and up toward the liver.
Several loops of intestine were adherent to it. A bit was excised
I
I
Fig. 36.— Mass felt in C;
for diagnosis and the abdomen then closed. Microscopic examina-
tion by Dr. J. H. Wright showed adenocarcinoma.
The patient left the hospital February 15, 1910, and gradually
failed at his home, dying March 26th. During the last months of his
life he lived almost entirely on buttermilk.
Case 23
A maid of thirty entered the hospital April 4, 1910, For many
years the patient has noticed tender swellings over the left clavicle and
on the forehead. Four weeks ago she began to have headaches.
Two weeks ago she began to get hoarse. For five days she has had ',
ABDOMINAL AND OTHER TUMORS 87
rapidly increasing dyspnea, otherwise she has had no respiratory
symptoms. Her husband has had consumption for two years. Her
family history and past history are negative. She has six healthy
children. She is now nursing a healthy five months' baby. Eleven
years ago she had a miscarriage at eight months. She has had four
healthy children since.
Physical examination shows good nutrition. The right pupil is
slightly irregular and is larger than the left. Both react normally.
No glandular enlargement. Chest, abdomen, and reflexes negative.
On each frontal eminence is a tumor about 2 cm. in diameter. On the
left clavicle is a similar rounded enlargement, and on the external
condyle of the left hxunerus is a swelling the size of an English wabiut,
somewhat tender. On the left leg, below and outside the knee-cap,
is a fluctuant mass 5 cm. in diameter. In the middle of the left tibia
is a deep dry ulcer J cm. in diameter. There is forward bowing of the
right tibia 8 cm. below the knee pan and the lower portion of this
tibia is much thickened laterally.
The patient was greatly troubled by dyspnea at entrance and
showed evidence of laryngeal stenosis. The Wassermann reaction
was positive. Otherwise the blood was normal. Ten examinations
of sputa for tubercle bacilli were negative, as were the feces. There
was no fever.
Discussion. — ^Here we are dealing with a case presenting multiple
fluctuant lumps. Among the possibilities are wens, fatty tumors,
abscesses due to pyogenic cocci, glanders, tuberculosis, syphilis, neo-
plasm, and, as bare possibilities, coccidioidal granuloma, blasto-
mycosis, and actinomycosis.
If we are to make one diagnosis covering all the functional dis-
turbances present in this patient, we can exclude at once wens, lipomata,
glanders, and pyogenic abscesses, as those cannot well be a part of any
general pathologic process which produces hoarseness, bony lesions,
and dyspnea. Tuberculosis, syphilis, and the other lesions men-
tioned might accoimt for all the other symptoms. The family history
of tuberculosis makes that especially deserving of consideration, but
the site of the lesions, especially their presence on the clavicles and
the changes in the tibiae, are not at all characteristic of tuberculosis.
Moreover, a tuberculosis which has produced so many external lesions
is likely to have involved the Iimgs by this time. Against malignant
disease are the patient's age and the involvement of the bones. Against
syphilis we have nothing except the fact that the patient has six healthy
children, and that fact, on the whole, is a much less important one
DIFFERENTIAL DIAGNOSIS
than those which have been mentioned as militating gainst the
other diagnoses previously discussed. On the whole, syphilis seems
the most probable diagnosis. Coccidioidal granuloma, blastomyco-
sis, and actinomycosis can only be excluded by a careful examination *
of the discharge from the lesions, but they are all very improbable.
Outcome. — Under mercurial inunctions and potassium iodid the
dyspnea rapidly improved, but on the 4th of April again became so
distressing that tracheotomy was considered. After April 5th the
dyspnea steadily improved and by the 14th was ahnost gone. The
patient went home on the 19th, much relieved.
Case 24
A tailor of thirty-seven, bom in Russia, entered the hospital
March 2, 1910. The patient complained chieSy of pain in the left
hypochondrium, with loss of
appetite and fatigue on sli^t
m
M'
exertion. The pain was worse
after meals, and espedally bad
at night, when it often woke
him up. In the past six months
he has lost 24 pounds and much
strength. Since he was a boy
he has been in the habit of pass-
ing urine one to four times in
the night. Since February 5th
he has been unable to work and
has been in bed. Two weeks
ago his physician noticed a
mass in the left upper quadrant.
For as long as he can re-
member he has taken three
whiskies and three beers a
day, but has had no previous
illness. His family history is good. He has three children living and
well. His wife has had no miscarriage.
On the patient's entrance to the hospital his temperature was
101.2° F., which rose the next morning to 103° F {Fig. 37). His
nutrition was good, but he showed distinct paUor. Under each
ear, between the mastoid process and the jaw-bone, was a smooth,
tender gland. A few other flattened glands were felt in the left
axilla. In both groins glands the size of large beans were felt. The
Pig. 37.— Chart I ol Case 14.
ABDOIONAL AND OTHER TVMOSS 89
heart's apex extended 2 cm. outside the nipple line by percussion, but
was never seen nor felt. Right border of dulness 2 cm. from midster-
num. Pulmonic second sound seemed somewhat accentuated and
there was a very soft systoUc murmur at the apex. The lungs were
normal. A rounded edge, apparently belonging to the spleen, was
felt 7 cm. below the left ribs and could be traced into the flank. Per-
cusaoD dulness extended up under the ribs so that the vertical diameter
of the organ was in the vicinity of 17 cm. Its horizontal diameter
was 25 cm. The rtd cells numbered 3,450,000; white cells, 10,700;
hemoglobin, 75 per cent. Of the leukocytes, 38 per cent, were poly-
nudears, 44 per cent, large lymphocytes and transitional cells, 18
per cent, small lymphocytes.
Fig. 38.— Chart n ot Case
Ob the 3d of March I noted that the mass in the splenic region
was deeper and more roimded than is the rule when one palpates a
large spleen. The glandular enlargement seemed to me demon-
strable only in the groins. The blood-platelets numbered 122,000.
The patient complained of pain in the region of the spleen. The
mine averaged 30 ounces in twenty-four hours, with a specific gravity
in the neighborhood of 1014. The sediment contained a small
amount of pus on every examination. By the 9th of March the poly-
nuclear cells had risen to 48 per cent.; lymphocytes were 47.9 per cent.,
40 per cent, being of the large type; eosinophils made up the remainder.
9°
DIFFERENTIAL DUGNOSIS
The blood-platelets were 209,000. A swathe entirely relieved the ,
complaint of pain in the region of the spleen. No medication except
laxatives was given.
He left the hospital on the 12th of March and did not re-enter
until a year later, February- 13th; he said that he had done well all
through the summer and autumn; three months ago he began to
ha\'e chills followed by headaches, but, so far as he knows, by no
fever. He sweats freely each night and sleeps poorly. He thinks
his spleen is growing larger. It hurts htm to lie on the left side.
I
He has done no wort for nfteen montfas and has heai in bed for three 1
tnooths. Fiftcm mootfas ago be wci^wd 165 pounds. He lost a
^wd deal of wri^t during th« tune of his pievious stay in the ho^tal;
next be guiK^l u pouiuU during last summer, but has lost rapidly in
ibe List thrw months. His wei^t. without doUies. Febniaiy 15.
iQii. was toH pouMk.
XevTftbdess. he was now UixW notuished and <fid not kwt sick.
His pi^iOs w«e noraul. TV «r>-kal Ix-v^ih-nades were not enlarged,
la the risht anOa thne was a ghnd the sne of an ahaood. The
AfiDOlDNAL AND OTHER TUMORS
91
inguinals were as large as beans. The condition of the spleen was as
shown in Fig. 39, and did not appear to exceed that previously meas-
ured. The heart showed the same lesions previously noted. The
knee-jerks were both reduced; in fact, they were present only on re-
inforcement. There was no edema. During the two months of
tiiis his second stay in the hospital his red corpuscles remained in the
vicimty of 3,000,000, though they gained slightly in the last two weeks.
His hemoglobin rose from 60 to 85 per cent. The course of his white
corpuscles is seen in Fig. 40. ^^ ^
The red cells showed marked
achromia with some abnormal
staining and stippling, also con-
siderable variations in size and
shape. About 30 per cent, of
the lymphocytes were of the
small type, the rest large. The
patient had x-ray treatment
every other day and improved
very markedly. His tempera-
ture was elevated for the first
two weeks and a half. After
that it was normal. Systolic
blood-pressure, no mm. Hg.
The urine, as before, showed
considerable pus in the sedi-
ment, but 20 minims of this sediment injected into a guinea-pig
produced no results. The Wassermann reaction was unsatisfactory.
Discussion. — ^The essentials of this case are a dyspepsia of long
duration in an alcoholic patient, associated with emaciation and an
apparently habitual nocturia. The physical examination shows espe-
cially a mass in the left hypochondrium strongly suggesting the
spleen, a general glandular enlargement, and a curious blood-picture,
involving an increase of lymphocytes.
There can be little doubt, I think, that the tumor is a spleen.
The blood-picture is not precisely characteristic of any known disease.
It is most suggestive of a transition from a non-leukemic to a leukemic
form of lymphoblastoma. The case is a most interesting one, be-
cause just this transition is very rarely observed. Despite all that
has been written by Bunting, Lazarus, and others, we have today no
characteristic blood-picture for the greater part of the duration of the
disease formerly known as Hodgkin's disease, and now more generally
Ziooo
T
3 til
L
Ol
Yt
M
aaooo
>,
IS 000
^^
V
,
1
V" "^
n<~*
'
V
\
1
■^
/
■d
p,
^
V
10»
|W,n
Fig. 40. — ChEirt of white corpuscles of Case 14.
92 DIFFERENTIAL DIAGNOSIS
known as malignant lymphoma or lymphoblastoma. The Ismipho-
cytic increase described by the writers just mentioned is not always
present and the blood is often essentially normal. In the present
case there is certainly an increase in the number of Ismiphocytes and
espedally in the larger varieties. This increase is hardly enough to
deserve the name of leukemia, but might be called subleukemic.
Without much doubt the typical leukemic blood-picture will appear
later.
Outcome. — He left the hospital on the 21st of March, promising
to report at the Out-patient Department.
The patient was seen in Februar\% 1913, and said he was getting
on verj' fairly. He had some trouble with headache and pain in the
splenic region and was unable to work, but when at rest had no con-
siden\ble disa^mforts. The blood showed practically the same
picture as when last examined.
Case 25
A stationar\- engineer, a Swede, of fort}% entered the hospital
March 26, loio. The patient's family historj' is good. He had a
chancre without other s\Tnptoms se\'enteen \-eais ago. ffis habits
are gvxxl, IVo years ago he had a slight swelling to the left of his
breast bvxne. It \*arievi a good deal in size, appearing and dis£^p>ear-
inj:, tirst on i>ne side and then on the other side <rf the breast bone.
Ne\Trthelesj!s ho k^s cv^n>dden\l himself well and has d<Hie his usual
wvurk until last D^vember. During that month he was examined at
the B\>stvxn Dis|xn\sar\* and stales that nothing abnormal was found.
Since that time the tumv^r near the breast bone has appeared again.
He has had Uv^ sjewrx^ j\ua an\-where ejccept nagging discomfort in
bv^th aru\s auvl shvHiIdcr^ tiv^t asskvi^uv. with exerticn. For over a
x^ar he has uv^icevl sv^xixe siK^niiet?5> ox breath ^xi sevwe exertion.
i>lher«is<^ he has havt uo sytv^ptv^is.
rhY:>icAt e.vamuutkv:\ sho>*>\t that the left pupd was larger than
the right . I'he heart '5^ ajv\ extettvkvt ^ on. outsiie tlie nqpple Bne, the
right bv>rvkr 5 ciu. trvstu mkt^terrul 'jbe. Tbe socn^ were rather
ttiutSevl juxi ther^" v^ as 4 sv^^ >vstv\ic ciunsxur a: the apex, not transmit-
tevl AoJTtic >*;\\^nI s!;^,ght\ avvectxia:;^i S\^o5c biood-pressure, 14^
t:uv, llg. v^cc : V uj^x^ i\*rt v^ th<^ <:^fr:xur:: arxi to the r^t of it was
a o.H.ticaI >>fcv\.v,^^ tS;^ >:^c o: b^>, a V^,ve. ^fcse. d]ukscx\ and pulsating
i3t all vlir^\ :viis. V vlvxstvvv N^Vvi ^^as^ cVfar-y >*i* ov^r it. The ri^t
pc'^?e ^ji>Si:\\> iM^xiMv. ^X"^ Vet. oc ^wi wVscrae. s^ithr increased
tettsicc- l>s^;h>fcv«v;v^ui^:. l"^ ^^vv^^d^j^ju^ ^i$cee ia the left rai^
ABDOMINAL AND OTHER TUMORS 93
was 30 points higher than in the right. This discrepancy slightly dimin-
ished in the next month and markedly in the succeeding month, so
that at the time of his discharge, May isth, the two pressures were
practically identical. Between the spine of the right scapula and the
median line was an area the size of the palm where bronchovesicular
breathing and egophony were made out, but there was no dubiess
there. There was at no time any thrill or murmur over the mass near
the sternum, and the absence of pain was quite striking.
Discussion. — ^Aneurysm or mediastinal tumor are practically the
only conditions which deserve consideration here. Tuberculosis is
altogether improbable. Against aneurysm is the absence of all pain
and the absence of any palpable thrill or audible murmur. The two
last signs, however, are not infrequently wanting in aneurysm.
In favor of aneurysm are the presence of a syphilitic history, the
condition of the pupils, and the definite pulsation palpable over the
tumor. All of these conditions might coexist with a neoplasm, but
such a coincidence is improbable.
Outcome. — Hypernephroma with metastasis was considered, al-
though the blood and urine were normal. At times the right hand
was colder than the left. The Wassermann reaction was positive. On
the 6th of April the tumor was about half the size it had been at
entrance. Potassium iodid, 20 gr. three times a day, had been given
in the interval, together with mercurial inunctions. Operation was
advisedy but refused; x-ray, taken at entrance, showed a shadow
14^ cm. in diameter, and on the 30th of April there was no change in
this shadow. Later the aneurysmal tumor increased to its former size
and remained there until the time of his discharge. May i6th.
The patient died at his home March 10, 191 2. During the last
six months of his life he was subject to spells of choking, and it was in
one of these spells that he died very suddenly.
Case 26
An ironworker of thirty-three entered the hospital August 25,
1910. Two or three years ago the patient first noticed a hard mass
in the left hypochondrixun. It has grown steadily since, and in the last
year he has lost 1 5 poimds. It is only in the last six months, however,
that he has felt a gradually increasing fatigue at his work as an iron
molder. His appetite and sleep are good, his bowels regular, and,
save for weakness, he still feels well.
Nine years ago he had a chancre and took *'blood medicine*' for a
year thereafter under the advice of a druggist. He had no skin erup-
94
DITFERENTIAL DIAGNOSIS
tion or sore throat. Four years ago he was married and has two
healthy children. His wife has had no miscarriage. His habits are
good. He has lived in New England practically his whole life.
Physical examination shows good nutrition, pupils slightly non-
circular, but reacting normally. L>Tnph-nodes somewhat enlarged in
the axilla?, groins, and epitrochlear region, not in the neck. At the
angle of the right jaw is a pigmented scar, 3 by 5 cm. There is
visible lateral pulsation in the brachial arteries and the arterial walls
arc palpable between beats. The chest is negative. The belly is '
I
iwjntiw. csKvp* **«* in the kf I h\-p<xlMndrium there is a firm, non-
IcfKkr mass with a shai^* «t.I^, itesoroding with re^Mratioo, easily '
felt hin'MUiuAlK-. not i»\xr»d by tbf indated aAoa (Fig. 41).
Thcrr is a »-ar. with c\>k*Kt- oi k«s ^li $ubstatKc 00 the frenum.
The ri$ht shin is much bowv\l ukI thictcAed in the upper half, but
saiKxith.
Buiti'stK»«.-v. >(4mic Anrmia. $>-¥<tiiais,.«Dd Imfceoiia were consid-
ei«if . hut the Skxx) »bow<xt ni^ exS^kiKV of the hncr duease. the white
ocfls Bumberioie .«w with j<> (wr ««. of polvwicfeai^ i per cent.
ABDOMINAL AND OTHER TUMORS 95
eosinophils, and the rest lymphocytes. Red cells numbered 4,000^000,
hemoglobin 70 per cent., no nucleated forms. The stools showed no
reaction to guaiac. Urine negative. Weight, 141 poimds at en-
trance; 146 poimds at discharge, two weeks later. The temperature
was occasionally elevated in the afternoon, once to 99.5° F., once
to 100.5° F. As a rule it was normal. Daily x-ray treatment to the
spleen had no considerable effect upon its size. On the ist of Sep-
tember a high-pitched inspiration and a few crackling r&les were
heard below the right clavicle, and in the right back, near the angle
of the scapula, inspiration was also somewhat high pitched. The
fundus oculi was normal.
Discussion. — In summary, this patient presents an enlarged
spleen, a general glandular enlargement, a scar on the frenum, a slight
degree of secondary anemia, and a thickening of the right shin-bone.
Syphilis is the only disease that easily accoimts for all these facts,
although malaria is much commoner than syphilis as a cause of splenic
enlargement. This patient certainly had no acute or present malarial
affections and, in view of his residence, there is no probability of any
chronic malaria or any tropical disease such as might cause enlarge-
ment of the spleen.
Lymphoblastoma (Hodgkin's disease) produces just such a spleen
and such a simple adenitis, but would not accoimt for the scar on the
frenum nor for the changes in the shin.
Banti's disease and splenic anemia cannot be excluded, but these
are diagnoses which should never be made unless syphilis can, with
all reasonable probability, be excluded, and such exclusion is certainly
not yet possible here.
Against sj^hilis we have no evidence except the healthiness of the
patient's children. This cannot be considered evidence of any impor-
tance. The bimch of r&les and the changes in respiration noticed on
September ist lead us to speculate as to whether tuberculosis may not
cause some, if not all, of his symptoms. These pulmonary signs,
however, were not constant and it was impossible to lay much stress
upon them.
Outcome. — The patient did well imder antisyphilitic treatment
and left the hospital on the loth of September.
Case 27
A porter of thirty-eight entered the hospital November 7, 1910.
The patient was in the New York City Hospital two years ago for
swelling and pain in his ankles. He had chancre fourteen years ago,
q6 differential diagnosis
after which he doctored for two or three months, but took no inunc-
tions. Ten years ago his hair gradually fell out. Five years ago there
were red spots on his hands and over his body; these lesions soon dis-
appeared when he took mercury to the point of salivation. He has
been married two years. His wife has had no children and no mis-
carriage. He takes a pint of whisky a week.
For about one year he has had frequent headaches, which ar
unusual for him. They are bilateral or frontal, and confined mostly ti
Hg, 4i. — Lump dacritxd b Case 17.
the afternoon and c\-cning. He uses his e\-es a good deal and has had
no examination of them. Later, in September. 1910. for the first
time in his life, he had a 6t just when leaxSng his shop at the end of
the day. He fell unconscious and Temained so for ten minutes, nearly
or quite motionless. After resting fifteen minutes he seemed to be
«5 vTcll as usuaI. but since then has h»d four similar attacks, the last
00c tivlay ai noon. Thou^ he is alira>-s cunsckius oi the immediate
«ppt\uch of the iwizurc. be has nc^vr be^i quick esuu^h to lie down
before be fell, and has bruised himself se\'«nl tunes. He has new ,
hitttn hb tongue or passed mine during an attack.
ABDOMINAL AND OTHER TUMORS 97
Three weeks ago he first noticed a lump on his breast bone. It
has rapidly increased in size since then and has become tender. His
appetite, digestion, and sleep are good and he feels well in most
respects.
Physical examination shows good nutrition. The right pupil is
greater than the left, irregular in shape, and does not react either
to light or distance. The left pupil reacts slightly to distance, not
at all to light. The lymph-glands are enlarged in the neck and groins.
Knee-jerks and plantars are normal. The heart and lungs negative,
likewise the abdomen. There is a large scar on the frenum with a
considerable area of erosion. The skull is smooth. The right shin
shows thickening and elevation in the lower third. In the region shown
in Fig. 42 is a rounded eminence, i^ cm. in height, slightly painful on
palpation, showing no thrill or pulsation. Percussion over it is
resonant.
On the night of entrance he had a convulsion lasting three min-
utes.
Discussion. — Such a lump upon the sternum might be due to tuber-
culosis, to a neoplasm, to aneurysm or gumma, but the rest of the
patient's history should incline our judgment strongly in favor of one
of these alternatives and against the rest. The condition of the
pupils, of the glands, of the shin-bone, when taken in connection with
the sudden onset of headaches and fits and with the syphilitic history,
makes it obligatory that we should exclude syphilis by the therapeutic
tests before seriously considering any other disease. If syphilis is
the underlying disease, the tiunor is, in all probability, a gumma, since
there is no other evidence of aneurysm.
The headaches and fits may be the result of an early dementia
paralytica or of a syphilitic meningitis. Between these two possibilities
one could decide only by a study of the patient's mental condition
and by the subsequent course of the case.
Outcome. — ^The next day 6 mg. of "606" was given intramuscularly.
This produced great pain and no demonstrable change in the tumor.
Wassermann reaction was positive. He left the hospital on Novem-
ber 15th.
Case 28
A man of thirty-two, a manufacturer of x-ray apparatus, entered
the hospital November 16, 1910. The patient came for treatment for
swelling over the right eye. His general health has been ordinarily
good. He had typhoid fever at twelve years and has been subject to
Vol. n~7
98 DIFFERENTIAL DIAGNOSIS
nasal catarrh for many years. He had all the evidences of sjrphilis
fourteen years ago and was treated with mercury for a year or more.
He uses whisky occasionally to excess. Early in September, 19 10, he
suddenly fell unconscious and remained so for an hour. Afterward
he felt dazed and vomited twice in the evening, but walked a mile
and a half to his train without help. Next day he had in the right half
of the forehead a severe pain, which has continued ever since, though
less in intensity. He got no relief from hot-water bag or cracked ice.
His eyesight was excellent. Since his first unconscious attack he
has had several other attacks at intervals of several weeks. In the
latter part of September a swelling appeared above the right eye-
brow. It gradually increased in size and became tender. As the
swelling increased the headache lessened in intensity, but for the past
two days it has again become aggravated. At the onset of these
troubles the patient was working very hard and sleeping very little.
His appetite was also poor and he lost about 20 pounds, which he has
since regained. He now eats ravenously.
On physical examination the man did not look sick and was well
nourished. The right pupil was greater than the left and was irregular
in outline. Both reacted normally. Glands and reflexes not ab-
normal. Aortic second sound not accentuated. Systolic blood-pressure,
145 mm. Hg. Chest and abdomen otherwise normal. There was a
scar on the frenum and the right epididymis was slightly thickened
and nodular. His shins were smooth, but showed depressed and
pigmented scars. Over the right eyebrow was a soft oval tumor,
about I by 2 inches. It was tender and fluctuant throughout.
The bone about the periphery of the tumor was roughened and
raised.
Discussion. — Summarizing the patient's history, we have here
evidence of a syphilitic infection, followed fourteen years later by
headaches, fits, and a swelling over the right eye. Physical examina-
tion shows abnormal pupils, a scar on the frenum, a thickening of the
epididymis, scars on the shins, and a soft tumor on the frontal bone.
Taken together, all of this evidence points very strongly toward the
diagnosis of syphilitic gumma.
The scars on the shins are very possibly due to trauma or to
varicose ulcers. We should be very careful not to attribute syphilis
to any patient merely or largely on the evidence of shin scars. I do
not believe there are any characteristic peculiarities by which we can
distinguish shin scars of syphilis from those produced by the other
causes just named.
ABDOMINAL AND OTHER TUMORS 99
Outcome. — He was given "606" November i6th, and within six-
teen hours the tumor had decreased two-thirds in size and lost its
tenderness. On the 21st about i ounce of pus was discharged from
one nostril. It contained, apparently, no spirochetes. On this date
the frontal tumor was apparently gone. The patient gained 4 pounds,
and was discharged on the 23d.
Case 29
An Italian housewife of forty- two entered the hospital March 31,
191 1. The patient's father died at fifty-seven of ''abscess near the
heart." One brother died of cancer of the intestines. One sister
died of shock. Three brothers and one sister are living and well.
No other cancer in the family except that noted. The patient has
been married eight years, has two living children, and has had two
miscarriages.
The patient's general health has never been very good. At nine
she had ulcerations of the cornea, which healed at fifteen, and she
has been troubled with her eyesight at intervals ever since. At twenty-
three she had another illness characterized by vomiting, diarrhea, and
fainting spells. She has had loose movements of the bowels at times
ever since. She has had frequent attacks of tonsillitis. Her tonsils
were removed two years ago, the operation being followed by a severe
attack of bronchitis.
For twelve years she has been troubled with eructations of gas
and sharp epigastric pain occurring about an hour after meals, some-
times associated with vomiting. She has never vomited blood.
This trouble is benefited by liquid and other soft diet. There is no
relief from soda. Since Christmas she has had severe intermittent
headache, especially when tired, not associated with vomiting. This
headache has been better for the past month since she has been diet-
ing and resting. Her appetite is good, her bowels move daily. She
has done her usual housework until two weeks ago. Up to seven
years ago she worked as a seamstress.
Five years ago she first noticed a mass in the epigastrium, and
since then she has observed a slow increase in its size. There is no
j>ain associated with it except when she is indiscreet in her diet, but
she says that all her life she has been bothered by pain in the left
ovary. She thinks in the course of the last two years she has lost 10
or 12 pounds in weight.
Physical examination shows good nutrition, a garrulous, nervous
patient Pupils, glands, and reflexes normal. Chest negative except
DO-FERESTIAL DUGNOSIS
for a soft, blowing, systolic murmur over the whole precordia, best
heard at the apex. The right kidney is felt with ease. Reaching
across the epigastrium in the region shown in Fig. 43 is a hard, irreg-
ular, very movable tumor, free from tenderness, about 5 cm. above
the navel. There is also tenderness in the left ovarian region. Blood-
pressure, 115 mm. Hg. Weight, without clothes, i3i pounds at.
entrance; iisj pounds two weeks later. Blood and urine negative.
Fundus oculi negative. Two examinations of the stools were made,
one showing a negative guaiac reaction, the other a positive reaction.
I
Fig. ^3. — Ma» fdt m Case :■).
The gastric secretions are normal. The stomach was inflated and
found to be in nomnal position and ai^>arently above the tumor,
which seems to be attached to the greater curvature. The colon
seems to have no connection with the tumor.
Discussion.— What were the nature of the illnesses which this
patient had at tiftei^n and at twenty-three? I can form no reason-
able conjecture. We Icam only thai she has had a tendency to bowel
trouble, and that for the past lwel%-c j-ears she has been having a
d>-spepsia which does not correspond syn^>tomatically to any single,
4
ABDOMINAL AND OTHER TUMORS lOI
well-marked clinical type. That is, it is not strikingly characteristic
of gastric cancer, gastric ulcer, or any othei; clinical entity. The most
notable fact in the case is the presence of the epigastric mass which
the patient has noticed for five years. Such a combination of facts
is very unusual. A mass noticed in this situation for a few months or
even for a year is common enough, but slow-growing tumors are very
rarely found in the epigastrium. Those connected with the pancreas
and with the abdominal wall are almost the only exceptions to this
statement. We have no right to say that cancer of the stomach can-
not exist for five years and produce such a tumor as is here described,
but certainly such a history is very rare, especially as the patient has
lost only ID or 12 pounds, and those in the last two years.
It is quite possible, however, that the tumor which she has felt
(assuming that her statement is correct) was originally a perigastric
exudate, originating in a peptic ulcer which later became cancerous.
Pathologists are sharply divided on the question whether or not
peptic ulcer often becomes cancerous, and no authoritative solution
of the question can be given at the present time.
Lesions originating in the pancreas or in the abdominal wall
can be ruled out in this case: the first, because the tumor is very
movable; the second, because it was demonstrably unconnected with
the abdominal wall. Under these conditions gastric cancer seems
the most probable diagnosis, despite the prolonged history, despite
the absence of emadation, and the negative results of gastric ex-
amination. I regret that no bismuth x-ray test was made in this
case.
Outcome. — ^April 15th the abdomen was opened, and immediately
below the epigastric incision, which was in the median line, there
presented an elongated mass of hard, fused glands which were situated
in the omentum, along the greater curvature of the stomach, which
region was also itself infiltrated with neoplastic tissue. Large hard
glands were also felt around the pylorus. The pylorus was free and
there was no infiltration for a distance of 2 inches above it. The flanks
and pelvis were normal. No operation was done. The patient
promptly recovered and left the hospital on the 23d.
She lived until March 9, 191 2, dying gradually from exhaustion.
Case 30
A farmer of forty, an Italian, entered the hospital April 14, 191 1.
The patient's family and past history show nothing of interest. He
had felt i>erfectly well until January, 191 1, when he began to have
I02 DIFFERENTUL DIAGNOSIS
epigastric pain which has persisted since and is increased by food.
Six weeks ago he noticed a lump and pain above his left clavicle.
For several weeks he has taken only liquids. He never vomits.
His weight in November was 145 pounds, with clothes; now, 104J
pounds, without clothes.
Physical examination shows obvious loss of weight, though the
patient cannot be said to be emaciated. The pupils react slug-
gishly to light, normally to distance. Over the left clavicle is a mass
the aze of a chestnut, hard, freely movable, not tender. No other
Fig. 44.^Ma33 felt in Case 30.
evidence of glandular enlargement. The chest is negative, save for a
few groaning riles at the right apex. Abdomen shows a hard, nod-
ular mass in the epigastrium (Fig. 44), This mass moves freely
with respiration and fades out into an indefinite resistance which
disappears below the costal margin. Only its lower edge is distinctly
felt. The knee-jerks and Achilles' jerks are not obtained, eVen on
reinforcement. There is slight edema along the shins. Blood and
urine negative.
The patient's temperature during the first week in the hospital
ABDOMINAL AND OTHER TUMORS IO3
rose to 99.5° F. every evening except two, when it went to ioo° and
to 100.5° F. During the second week of his stay the temperature
was normal. Blood-pressure, 105 mm. Hg. at entrance; 130 mm. Hg.
ten days later. The stomach-tube showed no food in the fasting
stomach, and after a test-meal the stomach contained no hydrochloric
acid and the wash-water was positive to guaiac. There were no
sarcinse.
Discussion. — The essential points in this case are:
First, A history of three months' dyspnea with loss of weight and
with masses in the epigastrium.
Second, A painful lump noticed for six weeks over his left collar-
bone.
Third, An Argyll-Robertson pupil and an absence of knee-jerks.
Fourth, A slight fever.
Tabes should be our first thought when a patient with such pupils
and reflexes as this patient presents complains of any sort of abdominal
discomfort. The mass over the clavicle might quite conceivably
represent a sjrphilitic adenitis, and the mass in the epigastrium the
edge of a S3q>hilitic liver. This diagnosis is all the more probable be-
cause of a slight fever. It is to be regretted that no Wassermann
test was done in this case. Certainly syphilis cannot be excluded
without such a test and without trying the eflfects of antisyphilitic
treatment.
Gastric cancer might well account for the mass in the epigastrium
and, by metastasis, for the lump above the clavicle. The stomach
symptoms arising suddenly in a patient who has never had stomach
trouble before and who is now forty years old, certainly suggest
cancer, but cancer will not account for the condition of the pupils
and reflexes, and if we decide to call the case one of cancer we must
also make a diagnosis of early tabes dorsalis as a separate malady.
Tuberculous peritonitis is suggested by the presence of fever and
by the patient's race, since this disease is especially common among the
Italians in Boston and its vicinity. The mass in the epigastrium
might represent the rolled-up omentum, which is not uncommon in
tuberculous peritonitis. It is unusual, however, to see the disease in a
patient of this age. Most of the cases of tuberculous peritonitis in
Italians appear in children or, at any rate, before the thirtieth year.
Cirrhosis of the liver would produce just such a mass and would
account for the patient's stomach symptoms. It is not common in
the Italian immigrants, as one sees them in New England, but this is
not nearly sufficient to exclude the disease. The lack of any enlarge-
104 DIFFERENTIAL DIAGNOSIS
ment of the spleen is the most important consideration against cir-
rhosis.
The four possibilities just mentioned seem to me all that need to
be seriously considered. Were the urine not normal, one might need
to consider a uremic type of stomach trouble, such as often appears
in the arteriosclerotic variety of chronic nephritis and less often in the
chronic glomerular forms.
All things considered, gastric cancer with tabes seemed, to
those who saw this patient in the hospital, the most probable
diagnosis.
Outcome. — Under cocain the supraclavicular gland was removed.
Examination by Dr. J. H. Wright showed metastatic adenocarcinoma.
The patient's epigastric pain was so great that he needed morphin
from time to time and his bowels could only be moved by strong
cathartics. He left the hospital on the 29th, having lost 2 pounds
during his stay.
Case 31
.An engraver of fifty-seven, bom in Turkey, entered the hospital
May 23, 191 1, He complained of lumps upon his skull and in his
abdomen. He says his father died because he was not fed enough by
his wife, who was too sting>\ The lady in question is living and well,
as are two brothers. The patient has four healthy children and his
wife has had no miscarriages. He has never been sick before, has ex-
cellent habits, ;md denies venereal disease. The patient saj's he is in
perfect health, and only on this understanding furnishes us the follow-
ing facts: He has always been much interested in astronomy and has
ideas about the creation of the universe. These he regards as of high-
est importiuice. ;md U\o resix^nsibility of these ideas, combined with
his exhausting ^xxuixilion as ;m engraver, has much to do, he thinks,
with his present cvnuiition. Two years ago. while wotting night and
day vAS he had to engniw K>th for the day and the night editions of
his p;\ixT\ he notia\i s^^me lumjis upon his head, and at his doctor's
ad\ioe tvx>k a trip to rxirkey. This was in the fall of 1909, and after
it ;U1 the lun\j\< dis.\pjx\in\l and he busied himseU in explaining to his
bewikierxxi vVuntr\n\on that HalleyV cx>met wvxild miss the earth by
some So.oco.cvo miles. When the v\>met wriaed this prediction,
he nnumeil u> this i\>vu\tr\ ar.v', tix>k up his work in the fall of 1910.
At this time anv^thor group ot *;::r,;\< Aj'*|x\Arevi. They have grown but
litt:e sinvx their apjxwranvw ;xr,v:, oxayt vr one behind the left ear,
arv r.ot tenvier. Ho has no Actua* ;\iin. thvv^gh the discomfort asso-
ABDOMINAL AND OTHER TUMORS I05
dated with the lumps is worse if he gets hungry. His appetite, he
sajrs, reqxiires attention, but, if properly cared for, is excellent. Tender
steak and rice pudding are his mainstays. More vulgar foods are
promptly and painlessly ejected, especially if he sings too soon after
eating. He has lost no weight. He usually weighs 155 pounds.
His bowels are regular. He sleeps well and declares emphatically
that he is well.
Physical examination shows good nutrition and excellent facial
color. Scattered over the scalp are many low, firm, painless, rounded
elevations, about 4 cm. in diameter, not sharply circumscribed, not
attached to the skin, but firmly adherent to the parts beneath them.
There is slight tenderness over the left mastoid. Pupils, lymph-
nodes, and reflexes negative. Chest negative save for a late, blow-
ing systolic murmur, best heard at the apex. The abdomen shows
shifting dulness in the flanks. The liver dulness extends from the
fifth rib, nipple line, to a point 7 cm. below the ribs, where a smooth,
rounded, insensitive edge is felt. The spleen is considerably en-
larged by percussion and its smooth edge is felt 12 cm. below the ribs.
The shaft of the right humerus, near its lower end, of each ulna near
its lower end, and of the femur near its upper end, show some enlarge-
ment. The x-ray shows marked increase in the density of the skull
and of the affected long bones, with much roughening of the perios-
teum, but no rarefaction. Wassermann reaction was strongly posi-
tive. Blood and urine negative. Systolic blood-pressure 150 mm.
Hg. No fever in three days' observation. Weight, 135 pounds.
Two members of the staff considered the disease osteitis de-
formans. Dr. J. H. Wright considered all the lesions, both in the
spleen, liver, and bones, due to syphilis. The late Dr. R. H. Fitz
thought hypertrophy of the liver and spleen quite independent.
The latter represented to him the chronic splenic tumor of the Levan-
tine races. He expressed no opinion as between osteitis deformans
and syphilis. The patient would stay in the hospital but a short time,
as he felt so well. He was given iodid of potash, 15 gr. three times a
day, and allowed to leave on the 19th.
Discussion. — The positive findings in this case are an ascites, with
enlargement of liver and spleen, lesions involving several bones and a
number of subcutaneous areas, and a positive Wassermann reaction.
Enlargement of the spleen is very common in Turks, Syrians, and
Levantines generally, but enlargement of the liver does not usually
go with it and requires some other explanation.
Syphilis is the only diagnosis which can explain all the facts.
I06 DIFFERENTIAL DIAGNOSIS
The patient would not consent to the excision of a subcutaneous nodule.
Without this, no further certainty could be arrived at.
As regards the mental symptoms, one should be careful and hesi-
tate seriously before attributing such unusual ideas as this patient
exhibits to mental disease. In the average American, such ideas would
probably be abnormal, but we should be slow to put our local stamp
upon all other nations or to interpret their imaginative flights in terms
of our own literal-minded habits.
Syphilis, then, is the most reasonable hypothesis on which to base
treatment. It should be observed that this patient did not receive
antisyphilitic treatment while in the hospital.
Outcome. — ^The patient returned to Turkey June, 1911, and died
there in October of the same year. Headache was his chief com-
plaint. The bones of his forehead and wrists are stated to have been
swollen, but caused no suffering. He died quietly, without pain.
Case 32
A housewife of thirty-eight entered the hospital July 2, 1910.
The patient's mother died of Bright's disease and one sister of
tuberculosis of the bowels. Otherwise the family history is good.
The patient herself was always well until her marriage. Her first
pregnancy ended in a miscarriage at seven months. Eight years ago
she had times of being very weak and pale. Five years ago she did
not menstruate for eleven months. Three years ago she had some hard
bunches, the size of half a hen's egg, tender and painful, upon her
arms and legs and on her head. These grew slowly and disappeared
slowly. While they were enlarging they were exceedingly painful.
Several times before and since this they have come and gone, but
have never been as severe as they were three years ago. They were
never red or discolored. The positions of the lesions, as described,
are shown in Figs. 45, 46.
Through the spring of this year she has been troubled by general
weakness and tiredness and sometimes has felt too weak to walk.
From time to time she has had sudden attacks of sharp pain in the
right side of the abdomen, radiating to the groin, and followed by
soreness between the attacks. She never has them when she stays in
bed. She has never had jaundice, vomiting, or urinary symptoms
in connection with these attacks, and has done her housework for five
people until recently. She used to weigh 114 poimds, with her
clothes; now 81 pounds, without clothes.
Physical examination showed fK)or nutrition, a waxen skin, pale
ABDOMINAL AND OTHER TCMOKS
107
lips. Pupils and reflexes nonnal. There were a few small glaJids
in the neck, many in the axillse and groins, of the ^ze of peas. Chest
negative save for a few 6ne crackles at the left base. The arterial
walls were apparently thickened. The abdomen was negative.
The tip of each kidney was palpable. Wassermann reaction
ta.\t,tb OVlEint
No fcibtolofOLTion
'Like bone.*.
Fig. 45- — Diagren of described lesions existing
years ago.
n^;ative. Urine averaged 60 ounces in twenty-four hours, with a
^>ecific gravity of loio to 1014, no albumin, no sugar. No fever in a
month's observation. Blood-pressure, 120 mm. Hg., systolic. Red
cells on three examinations ranged in the vicinity of 3,800,000; hemo-
globin, 6$ per cent.; leukocytes, 5000 to 7000. Differential count,
Io8 DIFFEKENTIAL DIAGNOSIS
normal. Slight achromia and defonnities of the reds. Of ten ex-
aminations of the feces, two showed a slight reaction to guaiac. The
cause of her anemia and other symptoms remained obscure. Skin
tuberculin test was positive^ x-ray showed slight thickening of the
cortical bone on the anterior surface of the right tibia.
Fig. 46. — Diagram of described lesions exbling over a period of a year or more, tluvc
Discussion. — This patient, suffering from anemia, emaciation, an
abdominal pain of the t>pe often associated with renal colic, gives
a histon- of small, tender bunches, which have appeared and disap-
peared in various parts of her bod>-. E.xamination of the abdomen is
negative and there is no Wassennann reaction. The latter test threw
ABDOmNAL AND OTBER TUMOKS
109
US disastrously off the track at the tune of this patient's first entrance
to the hospital. Such symptoms as she had had, when associated
with the x-ray findings in the right tibia, should have led us to push
anti^philitic treatment, whatever the blood showed. I am sure that
we are often lead astray in this way by negative Wassennann reac-
tions, which are, of course, nothing like so significant and so import-
ant, as guides to action, as positive reactions.
The positive tubercidin reaction, in the absence of fever and in a
woman of her age, was, of course, a matter of no importance.
At the time of her second entry the Wassennann reaction had
become strongly positive, and the mental symptoms, presumably of
syphilitic meningitis, made the diagnosis unusually clear. The
promptness and thoroughness
of her recovery under anti-
syphilitic treatment is only
what we have a right to ex-
pect in cases of this type.
Outcome. — The patient had
an operation done for double
femoral hernia, after which she
left the hospital, August loth.
She returned June 3, 191 1, hav-
ing taken up her housework
immediately on her discharge
and continued it as best she
could ever since, though with
great exhaustion. For the
past month she has had to lie
down part of each day. Never-
theless, in October, 1910, her
weight reached 128 pounds.
Since then it has markedly failed. AU winter she has had hard,
tender lumps upon her head which have changed lately in size. She
has slept very poorly for some weeks.
Physical examination shows a thin, exhausted woman, with loose,
dry skm, and marked p>allor. Over the left eye are two elevated,
rounded areas, about 4 cm. in diameter, covered by very tense skin,
tender, hard, not fluctuant. Near the right ear are two more, about
the same size. The pupils are not circular, but react normally.
There seems to be a general thickening of the left humerus. Chest
and abdomen n^ative. No edema. Red cells, 4,000,000; hemo-
Flg, 47.— Chart of Case 33.
no DIFFERENTIAL DIAGNOSIS
globin, 85 per cent. The course of the temperature is shown in Fig. 47.
Wassermann reaction now strongly positive. Urine negative. Her
husband states that she has been very irrational and restless at night
for some days before entrance, and this state continued and was
aggravated, so that by the loth of June she was delirious most of the
time, carrying on conversations with imaginary i>ersons and con-
stantly trying to get out of bed; a;-ray showed typical syphilitic
changes in the skull and other bones. On the 20th she had become
rational again, but could not remember being brought to the hospital
or anything during the first week of her stay there. The patient is
a nurse, and there is reason to believe the infection was acquired in
the performance of her professional duties. The amoimt of iodid of
potash administered is indicated upon the chart. By the 24th of June
she seemed to be in very good condition and was discharged.
The patient was seen in January, 19 13, and reported that she
had had various ups and downs since leaving the hospital eighteen
months previously. The periostitis upon the forehead had bothered
her off and on, especially at the time of the menstrual i>eriod, and
there had been swellings upon the arms and legs. Her general health
had been fair. She had had no salvarsan.
Case 33
A Swedish housewife of thirty-four entered the hospital April 27,
1911. One of the patient's sisters "died at thirty-four of an enlarged
spleen." This is now precisely the patient's age. There are no
other known cases of enlarged spleen in the family and no other
points of interest in the family history. WTien seventeen the patient
had a severe attack of pain in the region of the gall-bladder and was
jaundiced at that time; she thinks she has been yellow at varying
intervals since. The patient has had no menstruation for the past
four months. She suspects pregnancy. She has known that she had
a large spleen since she was twelve years old. The lump gradually
grew until the patient was nineteen, but not since that time. She
has never had any pain or any other s>Tnptoms with it. At the
present time her only symptoms are weakness and loss of weight.
She has an excellent appetite and worked until yesterday. There
has been no morning vomiting.
Physical examination showed a well-nourished patient, very pale,
and with a yellowish cast. The sclerae showed jaundice. Pupils,
reflexes, and glands normal. No unusual pigmentation of the breasts.
Harsh systolic murmur at the base of the heart, transmitted to the
ABDOMINAL AND OTHER TUMORS III
' apex and axilla. Pulmonic second sound slightly accentuated. No
evidence of cardiac enlargement. Pubes and arteries not remark-
able. Lungs negative.
The abdomen was distinctly distended below the navel, especially
on the right side. The edge of the spleen extended 5 ""■ below the
navel and a notch was felt on its median border. There was no tender-
is. On the right lower quadrant deep palpation outlined a rounded
tstance, duU on percussion (Fig, 48),
The uterus appeared to be symmetrically enlarged and about the
size of an orange. Blood-pressure, 115 mm. Hg.; urine negative. Blood
as described below. Stools always negative to guaiac. Urine nega-
tive. No bile. Wassermann reaction negative. After purgation
the mass on the right side seemed larger, more movable, and quite
distinct from the fundus uteri. The mass felt cystic to the examining
hand. The cervix uteri was normal and there were no concomitant
evidences of pregnancy-. During two months' observation tempera-
nre, pulse, and respiration remained normal. The patient gained
k pounds. There was no change in the size of the uterus. She left
lia DIFFERENTIAL DIAGNOSIS
the hospital June 14th and returned July roth. There had been then
no considerable change in her condition and no menstruation. Fetal
movements could now be felt and there was a placental souffle in
the right lower quadrant. The fetal heart was not heard. Secretion
was expressed from the enlarged breasts. The cervix was slightly
elongated and softened.
At this time she remembered that one maternal aunt was always
verj" pale, but not yellow, and died in middle age of heart trouble and
chronic cough. She stated that she herself was verj' pale before I
I
Fig- 49- — Condition of pitiest July lo, igii.
the appearance of the splenic enlargement, but did not become yellow
until that time. She has noticvd no change in the color of the stools '
and has had no scwre attacks of diairfaea. She b ae\-er unduly j
somooknt. and has hiul do arttcular pains and no \-er>- dennite stomadt ]
qnnptonis. She has had some indigestkiD brought on by strong j
oDotion or by worry, ami she thinks that at such times ber ydlowneas -|
becooKS more pronuuncvd.
Sfig^t «ksM of Uk fe^ was ootked at this time. Tbe number cf i
red coqMisdBs nagcd dose to 1,000.00a for the three weeks (tf her '
ABDOMINAL AND OTHER TUMORS
113
stay in the hospital; hemoglobin about 60 per cent., leukocytes 6000.
Smear showed slight achromia, many large well-stained red cells,
sUght variations in shape, considerable variations in size, many
stippled and abnormally stained cells. On the 29th of July four nor-
moblasts and one megaloblast were seen. The condition of the
abdomen July 10th is shown in Fig. 49. The red cells showed
increased fragihty, in that hemolysis began in the patient's blood
when a -5% per cent, saline solution was added. She left the hospital
August 2d.
This patient's sister was persuaded to enter the hospital for
observation. Her spleen was also considerably enlarged (Fig. 50).
Fig. so. — Signs in paticDt's
Red cells. 3,300,000; white cells, 7000; hemoglobin, 65 per cent.
Smear practically the same as her sister's. The reds showed increased
fragility. Wassermann reaction negative. Urine negative. This
patient has been yellow since twenty, but has always been up to her
"ork. Her present age is thirty-six and she complains of nothing.
Tte spleen extended from the eighth rib, midaxillary line, to a point
4 on. below the ribs.
Discussion. — Clearly, the abdominal tumor present in this case
Vnt. 11—8
114 DIFFERENTIAL DIAGNOSIS
represents an enlarged spleen associated with that ill-defined but
most interesting disease variously known as family jaimdice, con-
genital jaundice, acholuric jaundice, hemolytic jaimdice, etc. Doubt-
less some cases of this type merge into those called by that equally
vague term, Banti's disease (splenic anemia), or into the Hanot
type of cirrhosis. There is nothing, however, in this case to suggest
any involvement of the liver, and without that none of the diagnoses
just mentioned could be justified.
The chief interest in cases of this type is the very notable degree
of success which has followed splenectomy in this and in all other
types of anemia demonstrably associated with pathologic hemolysis
and an enlarged spleen. While this operation, splenectomy, has
within the past year been used quite unjustifiably in other dis-
eases associated with anemia and with enlarged spleen, and while
there is no justification for attempting it in pernicious anemia, in
leukemia, or in any case of well-developed liver cirrhosis, it certainly
is of great value in tj-pical cases of splenic anemia and in some phases
of the disease represented in the case just discussed.
I append here some details descriptive of the stained smears of the
patient's blood at different stages of her disease:
April 27th. Smear shows considerable variation in size, but only
slight \'ariation in shape of red blood-corpuscles. No achromia, six
normoblasts, no megaloblasts seen. No stippling.
May 2d. Variation in size ver\' marked, variation in shape slight;
markeil ix>lychromatophilia, with many coarse and fine stippled cells.
May Sth. Same. Blasts fewer.
May nth. Still considerable \-ariation in size. Variation in
shape not marked, but greater than before. Stippling rare. Eleven
nonnoblasts and one megaloblast in count of 100 cells.
May 20th. No notable change e:ccept disappearance of blasts.
June 0th. Still grt^it >*;iriation in size, x^ry Httle variation in
sha|x\ four nomiobUists.
Outcome* The j>ationt was seen in February, 1913, eighteen
months after she had left the hi>$pital, and seemed to haN^e improved
\Tr\' mutably. Her weakne:?^ and anemia be^an to leave her about
tour nuuiths after her hi^s^Mtal oxperienoe. and fnnn that time on she
has felt prx^ty wyU anvi has dvMie all the hvHisewvMrk for a family of two ^
Her n>enstruativ^n has Uvn alv?cnt tW the post three months. Skx*^
has no jvtin, m^ vXHi^h. anvi ax\ exorlkni appetite.
ABDOMINAL AND OTHER TUMORS
Case 34
A motorman of thirty-eight entered the hospital July 25, 1911.
; patient's famiJy history and past history show nothing of inter-
est, though he has had constipation and indigestion for years. When
constipated he has gas and epigastric heaviness after meals, his tongue
is coated, and he feels tired and sleepy. When the bowels move, these
symptoms disappear entirely.
_ For ten months he has noticed constant soreness and a tender
I the right lower quadrant. The lump was at first soft, but
Fig. 51, — Lump felt in Case 34.
has grown harder and more easily palpable. It troubles him more
■ TtheDhe is constipated and when he walks much,. but he never has
\ *hat he calls "real pain" there. Six months ago this symptom pre-
'wted his working (or two weeks, and three weeks ago he was dts-
iblcd during a period of hot weather. Over the whole abdomen he had
Mvere cramp-like pains which followed the drinking of a large amount
o{ ice-water. He thinks that the size of the lump has not increased
^"'Ce he first noticed it. It has always been about as large as a hen's
I
Il6 DIFFERENTIAL DIAGNOSIS
egg. The patient eats and sleeps well, but has chronic constipation
of moderate severity.
Physical examination shows a patient who is the picture of health
and is altogether negative except as concerns the abdomen (Fig. 51),
where there is a mass the size of a hen's egg, somewhat tender, not
moving with respiration, slightly dull on percussion. Otherwise the
abdomen is also negative. The blood and urine show nothing abnormal.
The patient had no temperature in three days' observation.
Discussion. — With a lump in the region of the cecimi one has al-
ways to consider especially cancer of the cecum, appendix abscess,
and pericecal tuberculosis. The latter disease does not often begin
in a man of this age. It would also probably be associated with some
fever and the palpable mass would be less sharply outlined and cir-
cumscribed.
An appendix abscess would hardly persist so long imchanged.
Ten months without more variation in sjTnptoms or signs is a very
long period for an appendix abscess.
Against cancer of the bowel we have nothing except the fact
that the patient is the picture of health. It seems extraordinary
that a cancer which has existed as long as we have reason to believe
it has in this patient should have affected the patient's general condi-
.''tion to so trifling an extent. This consideration led me to think
that a pericecal exudate, dependent upon an inflamed appendix,
was the mt^t probable diagnosis.
Outcome. - On the 2Sth of July the abdomen was o|)ened and the
cecum found to bo involved in a hard mass of tissue, apparently not
inflammatory, but more like malignant disease. This mass extended
up about I inch into the boweL which was bound to the mass. The
base of the apjHMulix was app^arently normal. Its tip was lost in the
mass alH>vo mentionoti. .\ bit of the tumor was excised, and when
exuminai in frozen section scvnuxi to be not inflammatory or tuber-
culous, but pri>lK\bly now-gnnvth. There was no obstruction and
further ojHTation was dtvmcvi inad\isable. No further examination
of the tuntor is on rtwnl. The p;itient had an uninterrupted con-
\-alescona" and loU the hi^pital on the 14th of August.
The jwtient dii\i at his own home Januarj- 26. 1913. There was
no autoi>sy.
Case 35
A housewife of fortv-thrtv ontorevl the hospital July 25, 1911.
Her family history and jv^st history arv nog;iti\x\ For the past four
ABDOMINAL AND OTHER TLTMORS
117
ihe lias noticed an occasional soreness in the right hypochon-
rium, usually at night when changing her position in bed. This
notion sometimes is followed by a sharp, brief stitch.
Two years ago she had an attack of vomiting in the night, not
accompanied by pain, and leaving her as well as ever after a day or
two. Four weeks ago she awoke at night with nausea, but without
pain, and vomited almost constantly until morning. This vomiting
recurred the following night and was accompanied by fever and recur-
I ling chilly sensations. There has been no jaundice, but since the
fell JQ Case 35.
t she has felt weak, has had no appetite, has lost 16 pounds in
weight, and has become conscious of a lump in the upper right comer
of the abdomen which occasionally is somewhat painful.
Physical examination shows obesity, no jaundice, pupils, glands,
and reflexes normal. The chest is negative save for a soft systolic
murmur, loudest at the apex, transmitted over the precordia and to
the anterior axillary line. Aortic second is greater than the pulmonic
second. Peripheral arteries not abnormal. Systolic blood-pressure,
135 mm. Hg. In the right upper quadrant is an irregular, smooth,
inded mass, descending with inspiration, but very slightly movable
(ftterally. A blunt edge, apparently the liver, is felt in the flank. There
Il8 DIFFERENTIAL DIAGNOSIS
is no tenderness to speak of. The mass is dull on percussion. The
upper border of liver dulness is at the sixth rib (Fig. 52). Leukocytes,
12,000; hemoglobin, 85 per cent. Urine negative. Fever during
ten days' observation usually reaches 99.8° F. at night. The patient
has lost 10 pounds in these ten days. No fluctuation or elasticity is
detected. Bimanual transmission to the back is clear. Such pain as
she has is referred to the right groin and the right iliac region. The
mass is believed to be a dilated gall-bladder and the cause suspected
to be cancer.
Discussion. — When a fat, middle-aged woman complains of stitch-
like pain in the region of the gall-bladder, extending over a period of
four years, one necessarily considers gall-stones before studying any
other possibility. Some affection of the gall-bladder is made more
probable by the presence of a lump, such as is shown in Fig. 52.
It is an unusual and rather inexplicable feature of the case that her
pain seems to be associated especially with change of position. Un-
usual, also, is the occurrence of attacks of nocturnal vomiting, without
abdominal pain. Moreover, we do not expect a distended gall-
bladder to be palpable bimanually, as an enlarged kidney is, with
one hand in the lumbar region below the last rib.
Despite these unusual features, it seems to me that in diagnosis
we can certainly go so far as to say that some trouble in or about the
gall-bladder is the most probable solution of our problem. It remains
to inquire whether we are dealing yrith a neoplasm, a distention of the
gall-bladder from stone in the cystic duct, or with an inflammatory
exudate in or about that \4scus. The absence of jaundice encourages
us to believe that there is no neoplasm present. The presence of fever
favors an infection. Beyond this, I do not see that we have groimds
for further diagnostic speculation.
Outcome.— OjxTation, August 5th, showed that the mass was made
up largely of omentum adherent to the liver above. The liver edge
extendeii almost as low as the navel. The adhesions between the
liver and the omentum were bn^>ken through and 15 ounces of thick
pus was evacuateil cither fn>m the gall-bladder or from the region
imnuxiiately alwut it. S<*von\l stones, the size of filberts, were found
in the gall-bladder and in two crj-pts in the gall-bladder walls, as
though ulceration had tiiken place, One pocket which extended up-
wan.1 fR>m the junction of the gall-bladder with the cystic duct was
especially difficult to empty of its three or four stones. After this
normal bile welleii up fn.>m the g;ill-bladder. With constant drainage
and removal of all stones the (xiticnt made an excellent recovery and
ABDOMINAL AND OTHER TUMORS
left the hospital on the 29th of August. A year later, September 4,
1912, the patient reported entirely free from pain, jaundice, or other
symptoms pointing to the biliary tract.
Case 36
A housewife of fifty-four entered the hospital August 8, igii.
There was nothing of interest in her family history. She had "grip"
a year, and again six months, ago. She has had twelve children and
one miscarriage.
For ten years she has had occasional brief attacks of cramp-like
pain in the left side of the abdomen, but it has never been severe and
i never troubled her much. Two years ago, after the menopause,
e began to lose flesh, and then noticed a large, hard lump in the left
hypochondrium. This lump has increased in size since then, and the
cramps in the same region have become more frequent and more
severe, sometimes shooting across to the right side of the abdomen or
into the left flank and back. This pain lasts, however, but a few
minutes, though there is a heavy, dragging sensation in the same
region most of the time. Since the menopause, two years ago, she
[ has lost 50 pounds and considerable strength. Her appetite is good.
i
I20 DIFFERENTIAL DIAGNOSIS
She has no indigestion or vomiting, and though her bowek are con-
stipated she has never had to stop work.
For sixteen years she has noticed that her urine is turbid and
milky in appearance, but it has never caused any pain or been passed
with abnormal frequency or in abnormal amount. She passes it once
in the night.
Physical examination is negative save as relates to the abdomen,
where in the left upper quadrant a hard, rounded mass is felt, dull
on percussion, extending under the left costal margin, slightly tender,
immovable with respiration or under pressure (Fig. 53). The in-
flated colon traverses this lump. Apparently it has a sharp edge
and a notch on the inner side. The urine, averages 35 ounces in
twenty-four hours; specific gravity, 1016; a sediment estimated at 4
per cent, pus (by volume).
Discussion. — When a patient has had a turbid urine for sixteen
years and a left-sided stomachache for ten years — the latter finally
associated with a palpable lump, gradually increasing in size for the
past two years — one can hardly help suspecting some benign disease
of the kidney, even though, as in this case, there has been a loss of
strength and of much weight — **5o pounds'' — and even though the
palpable mass in the left h\pochondrium has a sharp edge and a
notch. The latter observation would tend to make us think we were
dealing ynth a splenic enlargement, but against this is the presence of
a demonstrable pyuria; also the fact that the inflated colon traverses
the mass.
In \-iew of the facts last mentioned, it seems to me clear that the
proper diagnosis in this case is of some chronic non-maUgnant disease
of the kidney. The p\-uria makes it ver\- probable that this disease is
either a tuberculous or a non-tuberculous pyonephrosis. C>'stoscopy
should make the diagnv^sis more certain and give us a material with
which, thn^ugh p;ithologic tests, we can settle the question of a tuber-
culous or a non- tuberculous lesion.
Outcome. Cx'stosa^py showed a ribbon of pus coming from the
left uTtner. especially when pressure was exerted over the mass in the
left side. The right ureter was catheterized and a urine of normal con-
stituency obtaincii. The phthaloin test showed that the color appeared
in nine minutes. Dr. Hugh Calx>t had no doubt that the tumor was
a pyonephTv>si> and that the right kidney would support life. Twenty
minims of the scvliment fi\>m the urine wert^ injected into a guinea-pig
August 13th. Auto^v>y on this pig September ^oth showed nothing
abcsMTiial. Bactcriologio exAiuinativMi of the urine from the right
ABDOMINAL AND OTHER TUMORS 121
ureter showed no growth. The leukocytes numbered 7500; hemo-
globin, 75 per cent. In ten days' observation the temperature rarely
rose above 99° F. The systolic blood-pressure was 1 20.
Operation, October 17th, showed a great deal of dense, inflanmia-
tory tissue beneath the costovertebral angle. With great difficulty the
kidney was dissected free from the inflammatory mass above described.
This mass was so gristly that a sharp pair of heavy scissors were
necessary to dissect the kidney free.
The pathologist's examination may be simuned up as follows:
The kidney measured 14 by 12 cm. On section it was filled with pus
and contained many abscess-cavities surrounded by fibrous and fatty
tissue. In one portion there was a large branching stone, firmly
embedded in the kidney substance. Microscopic examination showed
no recognizable kidney structure.
Case 37
An unoccupied American girl of eighteen, who has always lived
in New England, entered the hospital October 27, 1908. The patient
was recommended to the hospital by Dr. W. M. Conant for relief of
an epigastric tumor. Two sisters and one brother have died of tuber-
culosis of the lungs. The parents, two sisters, and three brothers are
living and well. Her menstruation began at twelve years and was
regular for the first six months. Since then it has been very irregular,
the intervals varying from two to seven weeks. At the time of the
period or just before it she notices sharp pain in the region of her
epigastric tumor. This pain lasts until she has finished menstruation.
The pain radiates to the region of the spleen. She has had a little
intermenstrual flowing, lasting from one-half to one hour, coming
perhaps once a week. With this flow there is also pain in the region
of the tumor.
The tumor above referred to has been noticed for about three
years, but the patient's pain has troubled her much longer. In the
past three years the mass has been gradually enlarging, especially in
the last five months, and with its growth it has become more painful,
until now it is associated with a constant dull ache and with pains
darting to the left. There have been occasional attacks of vomiting
both before and since the time at which this tumor was discovered.
These attacks are not now more frequent than they were three years
ago. They usually come about three hours after eating and the ex-
pelled fluid is green and frothy. The bowels are regular. A small
amoimt of food satisfies her; any more causes nausea. She has never
122 DIFFERENTIAL DIAGNOSIS
been jaundiced. She thinks of late she has been losing weight, as her
clothes seem to be too loose for her.
Physical examination shows excellent nutrition, normal pupils,
normal chest, sluggish reflexes, no enlarged glands.
The epigastrium is occupied by a tumor mass of the size, appar-
ently, of an infant's head. It is symmetric, save at the costocartilagin-
ous junctions of the sixth, seventh, and eighth ribs on the left, where
there is a smaller swelling about the size of a hen's egg. The larger
tumor mass is somewhat soft. The smaller one, which seems to be
attached to the ribs, is also soft. The entire left lower quadrant is
hyperresonant. Light percussion over the larger tumor shows
relative dulness. Heavy percussion gives resonance. Moderate
pressure on the epigastric mass elicits some pain. Vaginal examina-
tion is negative. The inflated colon apparently overlies the tumor.
The blood and urine are negative.
During most of her three weeks' stay in the hospital the patient's
temperature reached 99° or 99.5° F. each evening. Twice it rose a
little above 100° F. There was no free fat in the stools. The Cam-
midge test was negative. Dr. F. B. Harrington considered the case
a pancreatic growth and ad\ised operation. Dr. Hugh Cabot con-
sidered it a cyst, connected either with the pancreas or the mesentery,
or possibly a hydatid. Dr. Maurice H. Richardson considered it a
pancreatic cyst caused by impaction of a stone in the canal of Wirsimg.
Dr. Wilder Tileston considered it a phantom tumor.
Discussion. — From reading this case and noting especially the
long duration of the s>Tiiptoms, the good nutrition of the i>atient,
and the presence of a large tumor near the liver, one's first thought
might easily be of a hydatid c>*st. Against this, however, is the
patient*s residence. So far as I know, up to the present time, no case
of hydatid disease originating in Xew England has ever been re-
ported. Most of the pi\tients that I have seen have been Greeks.
The stn^>ng tuberculous family histor\* and the slight fever might
make us conjecture that a tuberculous peritonitis, producing a mass
of adherent intestinal ivils, has caused the tumor, but I have never
hoani of a tumor s^> large as this in tuberculous peritonitis, and the
absence of fe\*or is ag;unst it.
The situation of the mass favors a pancreatic cyst, but we have
no further evidena* to IxUstcr up this case. Functional tests of the
pancrx^as should at least Ix^ tritxl Ix^fore any such diagnosis is made.
On the ^d of XowmlxT a stv>mach-tube was passed, with the
rtsult that when pressure was made ox'er the epigastrium a large
ABDOBflNAL AND OTHER TUMORS 1 23
amount of gas was expelled through the tube and the tumor com-
pletely disappeared. The stomach was then inflated and foimd to
be of normal size. After the injected air had been again expelled no
tumor could be felt, but after withdrawal of the tube the swelling
immediately reappeared; x-ray examination was apparently negative.
On the 3d of November the abdomen was opened, but absolutely
nothing abnormal was foimd in any part of it. The patient made an
uneventful recovery and left the hospital November 19, 1908.
This case seems. to me of special value because we were not con-
tent in seeing the tumor disappear after the passage of a stomach-
tube, but went on to final proof through exploratory indsion. Just
what a phantom tumor means it is not easy to say. Doubtless the
swallowing of air and its retention in the stomach is the most import-
ant element, but it is hard to see how this air can remain in the stomach
throughout the processes of digestion.
The slight fever in this case is interesting and tends to prove that
we may have fever in the absence of all known pathologic processes,
the so-called neurotic fever.
Case 38
A reed-chair maker of thirty-eight entered the hospital March 6,
1Q12. His family history and past history are not of special interest.
The patient occasionally goes off on a spree, perhaps three times a
year. On these occasions he drinks mostly beer. Otherwise his
habits are good. Four months ago he began to have attacks of pain
in his right hip, knee, or ankle, the pain shooting from one point to the
other and lasting from four to eight hours, gradually subsiding. Up
to four weeks ago he had had seven of these attacks. Each of them
forced him to quit work and remain quiet for two or three days, and
each attack was followed by numbness in the leg and a diflBculty in
extending it.
Three months ago he first noticed a painless swelling on one of
his right ribs. This has remained stationary in size. Four weeks
ago he observed a bulging in the right hypochondrium and a con-
stant slight pain there. Both have steadily increased. For three
months he has had vomiting attacks two or three times a week and
ejected moderate amounts of greenish fluid, but never any food or
blood. His bowels have required cathartics for the last four months,
and even with cathartics he often goes two or three days without
movements. He has noticed nothing abnormal about the stools.
He has never been jaimdiced. His appetite has been poor. He has
124 DIFFERENTIAL DIAGNOSIS
had, SO far as he knows, no fever. Four months ago he weighed
i6s pounds, now 167 pounds, though he is quite sure he has lost
flesh. He has done no work for four weeks.
Physical examination shows a marked loss of subcutaneous tissue.
The right eye is missing. The left pupil is slightly irregular, but re-
acts well. Over the third right rib. in front, is a firm, nodular, tender
mass, the size of an egg. apparently attached to the rib, but not to
Fig. 54.^Signs found in Case
the overlying skin. The condition of the lungs and abdomen is 1
shown in Fig. 54.
Save for slight edema of the ankles the extremities are negative.
The knee-jerks obtained only on reinforcement. Blood-pressure,
165 mm. Hg, systolic. The urine at entrance seems to be negative,
but is somewhat turbid. There is no Bence-Jones albumose. Red
cells, 5,120.000; white, 17,200 at entrance, 24,400 MarcJi 8th. Poly-
nuclears, 80 per cent. Slight achromia of the red cells, hemoglobin
70 per cent. Wassermann reaction negative. Feces negative. The
ABDOMINAL AND OTHER TUMORS 1 25
patient's girth over the most prominent part of the epigastric tumor
is 98.5 cm. Diagnosis at entrance seemed to be hypernephroma or
sarcoma with a possibility of cyst, involving the liver or pancreas.
x-Ray showed the diaphragm very high on both sides and the heart
slightly enlarged on the left, but there was no evidence of bony in-
volvement. The right eye had been removed three years previously
after an injury from a piece of steel.
Discussion. — ^A nodular mass, occupying the site of the liver, is
the most important fact in this case. Apparently this mass has ex-
isted at least three months. Whether or not it is connected with the
sciatic pains which appeared a month earlier we cannot say. Pos-
sibly those pains were associated with the patient's alcoholism.
Possibly they inay be tabetic, as the condition of the pupils and knee-
jerks shoidd make us suspicious of a latent tabes, although the Was-
sermann reaction is negative.
The presence of a lump over one rib suggests a metastasis, and
makes us think at once of the timior which most often produces bony
metastasis, namely, hypernephroma. It is not at all impossible that
a large renal timior might push forward to the anterior abdominal wall,
displacing the liver to one side, but such occurrences are rare, and there
is nothing in the urine to support the hypothesis of hypernephroma.
The lump on the rib might be a myeloma, though such tumors
are usually midtiple and are usually associated with the Bence- Jones
body in the urine. Only histologic examination could make us pos-
itive on this point.
Nodular timiors in the region of the liver should always make us
think of the possibility of melanotic sarcoma, especially if the patient
has had anything wrong with his eye, for in this organ, as is well known,
such tumors are most apt to originate. Despite the positive state-
ment in the history of this case that the eye was removed on accoimt
of traimia, one of the physicians who saw the patient insisted on believ-
ing that we were dealing with a melanotic sarcoma of the liver, second-
ary to a similar growth in the eye. This chain of reasoning leads
us to consider the possibility of finding melanuria in the urine. Such
a test should certainly be made, for although in most cases the dis-
coloration of the urine makes itself obvious, this is not always so.
Outcome. — Dr. J. H. Wright considered the growth a melanotic
sarcoma, originating in the eye, with metastases in the liver and
pectoral region. The urine was examined for melanin and positive
tests obtained March 9th and 17th. S3T)hilis was also considered.
On the 9th there was slight shifting dulness in the abdomen. The
126 DIFFERENTIAL DIAGNOSIS
tumor over the rib was opened and found to consist of thin-walled
capsule, containing grayish, grumous material. The rib surface was
eroded and the sac seemed to lead up between the ribs. No micro-
scopic examination is recorded.
The patient lost groimd rapidly and died on the 2 2d. There was
no autopsy.
Case 39
A suspender maker of sixty-two entered the hospital Jime 25,
191 2. The patient states that he "had the pox thirty years ago'*
and has had a group of pimples every sunmier since. About two
years ago he first noticed an easily movable lump, the size of a hen's
egg, just below the left costal border. This has gradually grown to its
present size, without producing any symptoms. He has worked
steadily, but five weeks ago, while lifting a trunk, he strained him-
self. Since then he has been steadily nmning down. The mass is
now tender on pressure and there is a constant dull ache in it, with
occasional attacks of sharp pain radiating to the back and left groin.
The pain has no relation to food or to the passage of urine or feces.
For the past month he has lost much weight and strength and is now
in bed much of the time. Appetite is poor; bowels move every one
to three days. He has noticed nothing abnormal about his urine.
Physical examination shows moderate emaciation, many acne
papules and pustules, mucous membranes slightly cyanotic. Inguinal
glands slightly enlarged. Chest negative. In the left hypochondrium
is a smooth, hard, rounded, slightly movable tumor, filing out the
flank and pushing up the ribs. Impulse exerted upon it is felt in the
left lumbar region. The inflated colon lies between the tumor mass
and the abdominal wall. The urine shows numerous pus-cells and a
good deal of mucus, no blood. The blood is normal. Blood-pressure,
135 mm. Hg., systolic; 80 mm. Hg., diastolic. No fever in three
days' observation. Wassermann reaction negative. Feces negative.
Discussion. — In view of the s3T)hilitic history, it is worth ques-
tioning, for a moment, whether the lump in the left hypochondrium
may possibly represent a gumma of the left lobe of the liver. The
negative Wassermann reaction is somewhat against this, and the
large mass and characteristic situation of the tumor makes it much
more probable that we are dealing with a kidney.
Apparently the lump has existed in this region for at least twa
years, although the patient's health was good imtil five weeks ago.
It is not at all probable that the strain mentioned in the history has
ABDOMINAL AND OTHER TUMORS 1 27
anything to do with making the patient run down. Presumably
the change which occurred five weeks before he entered the hospital
was not due to any external cause, but rather to the natural progress
of the disease. Our belief that the lesion is connected with the
kidney is strengthened by the fact that we have no symptoms refer-
able to the other organs which most often cause symptoms in the left
hypochondrium, viz., the stomach, the spleen, and the colon.
Assxuning, then, that we are dealing with a renal tumor, asso-
ciated with pus in the urine, pyonephrosis is the first thing to be
considered. The absence of fever and leukocytosis are somewhat
against this supposition. It is also unusual to encounter a case of
pyonephrosis the symptoms of which originated at the age of sixty.
Nevertheless, without a cystoscopic examination, we cannot exclude
renal suppuration.
Against renal tuberculosis the same reasons just given hold good,
yet this disease cannot possibly be excluded without further ex-
amination.
Renal neoplasm was considered the most probable diagnosis by all
those who saw the case. The absence of a hematuria does not mili-
tate against this diagnosis, as blood appears in the urine in cases of
hypernephroma only when the growth reaches the renal pelvis.
Outcome. — On the 29th the abdomen was opened and a tumor the
size of a child's head presented in the left hypochondrium. While
removing this tumor the spleen was torn and there was a considerable
hemorrhage, controlled by packing. This damage was so great that
the spleen had to be removed. After the ether was removed the
patient stopped breathing, but promptly began again. He recovered
well from the ether, but died on the 4th of July. Examination of the
tumor showed it to measure 19 by 24 cm., with a smooth surface.
It conskted of a firm, thick capsule, enclosing a putty-like mass, with
a large amoxmt of bloody fluid. Microscopic examination showed a
richly cellular tumor with numerous large necrotic areas. The cells
were of rather small size, with deeply eosin-staining protoplasm, and
deeply staining nuclei. These cells were embedded in firm, fibrous
tissue and had a papillary arrangement on connective-tissue stalks of
various widths. The diagnosis was hypernephroma. The spleen was
normal.
Case 40
A Greek mill hand of twenty-four, bom in Turkey, was seen
November 10, 1913, complaining of abdominal pain. Family history.
128
DIFFERENTIAL DIAGNOSIS
past history, and habits negative. In the past three months he has
had ten attacks of colicky umbilical and epigastric pain, with vomiting
at a variable interval after meals. Duration usually three or four
hours; last night, eight hours. The pain is not relieved by food,
pressure, or posture. Morphin has been used in three attacks.
Vomiting and hot applications give some rehef. Vomitus not charac-
teristic. Much gas after food. He has lost much weight and has
done no work for three months.
Fig' SS- — Masses felt
I
On physical examination a hard lump, the size of a walnut (Fig. 1
55, No. i), is felt to the right of and below the navel. In the vidni^ ]
of the descending colon is another mass the size of a small egg (Fig,
55, No. ;). Both masses at times disappear. No visible peristalsb.
Left epididymis slightly thickened. Pupils normal. Knee-jerks absenL
Other reflexes and the rest of visceral examination negative,
test positive m fasting gastric contents and after test-meal. Free t
absent. No stasis. Six stools guaiac-negative. Bismuth ai-ray shoi
a small, high stomach, with irregular peristalsis, especially at les
ABDOMINAL AND OTHER TUMORS 1 29
curvature, where the outline also shows shortening and irregularity.
Pyloric sphincter and duodenal cap not abnormal. Bismuth enemata
gave negative results.
Blood and urine negarive. Wassermann negative; sr-ray of chest
negative. Blood-pressure 100, systolic; 80, diastolic. Pulse, tem-
perature, and respiration normal for three weeks' observation. Bowels
move well.
Clinical diagnosis: Dr. R. I, Lee, Gastric ulcer of lesser curvature.
Dr. E. A. Codman, Chronic intussusception.
Fig, 56. — Lumps felt December i, igij.
November 24th masses are felt as in Fig. 55. An oil enema pro-
duces a tremendous mass of feces. November 2sth he had severe
colidy pain ^11 day, with hard, distended belly. Morphin and
^iTDpio relieved the pain. Masses were still clearly felt. November
^1^< after test-meal, free HCl 0.04; total acidity 0.027; guaiac test
P*'^"ive. On the 28th there were two more lumps {Fig. 56, Nos. 3
*"" <). Tuberculous glands was the diagnosis most considered, with
'"aligaant disease second.
Discussion. — A great many diagnoses were considered by members
I30 DIFFERENTIAL DIAGNOSIS
of the attending staff in this case. At the beginning of his hospital
stay, before the tumor masses had made themselves obvious, our
chief evidence of disease was the a[:-ray and the finding of blood in the
stomach-contents. From these facts a peptic ulcer was suspected.
Later, when the tumors have made their appearance, but appeared
to be curiously fugitive — shifting their place from day to day — the
idea of a chronic intussusception was entertained. Earlier still,
the colicky epigastric pain, leading to the use of morphin, had made
us consider gall-stones.
After the administration of the oil enema and the evacuation of a
very large amount of feces the question of fecal impaction was con-
sidered, although, I think, wrongly. I have yet to be convinced that
fecal imf>action, without some organic disease producing a previous
intestinal stenosis, ever produces any important symptoms or tumors.
Fecal impaction seems to me largely a diagnostic myth, especially
when considered as a possible cause of intestinal obstruction. In the
vast majority of cases in which I have known it to be considered in
differential diagnosis, it has turned out, as the present case did, to
involve some verj- different diagnosis as the true one.
Multiple tuberculous tumors, due to adenitis or adherent intes-
tinal coils (tabes mesenterica\ was the diagnosis made by the major-
ity of those who Siiw this case. It was almost the only common
disease which a>uld produce such an assembly of lumps as finally
made themselves felt.
The alternative supjx>sition of malignant disease was also upheld
by sexTral memln^rs of the staff, but the patient seemed hardly sick
enough, ivnd few of us had seen so many tumors in any type of neo-
plasm involving the intestine.
Outcome. December i. 1013. he w^s transferred to the Surgical
Wanls, Meantime he had been home and had secured from his
attending ph\-^ciivn a diagn^^sis of •^pyloric stenosis." Dr. W. N.
Conanl first mavlo diagnosis of tuberculous peritonitis. Under ether
the lowvr lump vN^^» ^^ >vas easily fell, and was so hard that the diag-
HiVNis w^s prv>mplly chang<\l to malignant disease of the gut. Inci-
sion o\*\T it shvnxwl this lump to inwK-e the intestine and adjacent
mos<"niery. The lump was ^; inchtL^ long. i| inches wide, spool
>haix\l. The KavoI alxnv it was thickened and dilated; below it.
In the si^kuiv Tx-^on atK^thor iuivaK No. ^\ also invoh-ing the gut,
was tou:\vi. It was as Ur^^ as :h<^ r.s;, haivi azxi iKxiular. In handling,
it brv^kc, anxi ox\isiv>i\ x^-^s iKvx:^?5sArv\ Eixi-ivv^nd intestinal anas-
ABDOMINAL AND OTHER TUMORS I3I
tomosis was done. No. i was side tracked by a lateral anastomosis.
No. 3 was felt in the left inguinal region, but was not connected with
gut. Dr. Whitney's report showed a round-cell sarcoma (i. e., lympho-
blastoma).
December 27th, after an uneventful convalescence, the patient
went home.
Case 41
A Greek of twenty-two entered the hospital February 21, 1914.
His family history was negative. He denies venereal disease. Seven
years ago he felt a pain and non-tender lump in the right side of belly,
xmder the belt. The lump disappeared in a week or so. Two years
ago he had a similar attack and lump. Four and a half months ago
he had headache, "yellow skin," fever, and nausea. The fever left
in a few days. At this time he felt a lump in the right upper quadrant,
not tender, not constant. The "jaundice*' ceased in one month.
Soon after he noted pain in left upper quadrant, worse on exertion,
but never severe. He lost some strength, but kept at work until
a week ago, when he gave up on account of left-sided pain and disten-
tion. He was costive, but noticed no blood or tarry stools. Appetite
and sleep good; no loss of weight.
Physical examination showed no jaundice, no emaciation. There
was a scar in neck, S by i cm. [From this point a mass was removed
when he was a child.] The contour of the right lower axilla was
slightly more full than the left. There was a high-pitched musical
systolic murmur over the whole precordia, not heard in the axilla.
The first sound was obscured by it. The pulmonic second was greater
than the aortic second and double. The apex shifted 3 cm. with change
of position. There were three nodules on the liver edge and extend-
ing over its surface, which was not tender, and moved freely with
respiration (Fig. 57). There was an extensive scar on the outer
lower right leg, just below the knee. Rectal examination showed
above the prostate an irregular nodular mass, 2 to 3 cm. in diameter,
projecting into the rectum, immobile, and attached to the anterior
wall. The "liver mass" extends through to back. It did not feel
like a cyst. Dr. W. H. Smith made a preliminary and tentative diag-
nosis of h5T)emephroma or liver neoplasm, but the home officer
records that the patient "Looks too well nourished for malignant."
Stomach-tube examination was negative; :r-ray was negative. Blood
and urine negative. Wassermann negative.
The following diagnoses were also considered: (i) Distended gall-
132
DIFFERENTIA!. DIAGNOSIS
bladder; (2) cyst or tumor of kidney; (3) cyst or tumor of the under
part of right lobe of liver. Bismuth j:-ray examination of the stomach
showed "pressure on lesser curvature from some tumor outside digest-
ive tract."
February 27th a coUargoI plate showed apparently some patho-
logic process in right kidney.
March 6lh the record states: "He has had no pain while here.
Weight of evidence is for lesion of kidney."
Fig,5 7---Mj
fell in Case 4
Discussioa. — The most important points about this case were the
following :
The occurrence of a mass in the right hypochondrium, known to
be of long duration, associated with good nutrition, in a Greek.
Were the patient older and of the other sex, his history of jaundice
and pain in the region of the gall-bladder would have made it neces-
sary for us to put gall-bladder disease first among the diagnostic possi-
bilities. Against this, however, is the actual condition which was felt
in the region of the liver. Unless we were wholly mistaken, it was
a sharp edge ;ind not a round sac which we felt in the right hypo-
chondrium.
ABDOMINAL AND OTHER TUMORS I33
Supposing that we were correct in our belief that a nodular enlarge-
ment of the liver existed, there are really but three reasonable possi-
bilities: first, malignant disease; second, syphilis; third, hydatid.
The patient is extraordinarily young for cancer of the liver. He
has had no gastric symptoms such as usually accompany the primary
gastric cancer, from which the liver metastases follow. Moreover,
this patient's nutrition is extraordinarily good for so serious a neo-
plasm.
Syphilis cannot be excluded and the absence of a Wassermann
reaction does not rule it out. We cannot say, however, that we have
any positive evidence of such disease unless the presence of an accom-
pan3dng splenic tumor is so regarded.
Hydatid is suggested by the patient's race and by his good nutri-
tion, despite the presence of a large tumor. Against it we have the
lack of any eosinophilia and the general rarity of the disease in New
England. We have ahnost ceased to look for the classical hydatid
thrill about which the older text-books used to excite us so much.
Outcome. — Operation showed a liver studded with cysts, whence
scolices were obtained.
In view of all the facts and of the patient's good recovery, there
seems no good reason to believe that there is any disease in the kidney
or in the region of the prostate. The findings recorded in these organs
are regarded as errors.
CHAPTER II
VERTIGO
Vertigo, or the disturbance of static control, cannot be defined
in purely objective terms. We cannot deny that a person is dizzy,
even if we cannot see him stagger or verify the existence of nystagmus.
Nevertheless, such objective verifications are always to be sought for,
especially in medicolegal cases, traumatic neuroses, etc. As a pre-
senting symptom, vertigo is not at all common. Joseph Collins*
states that among 425 neurologic cases of all types, seen by him in the
New York Neurological Institute during 1910, only 22 complained of
vertigo, in the sense of a definite disturbance of equilibrium. He
excludes here sensations called dizziness, but consisting chiefly
of blurred vision, minute black spots in the visual field, and dis-
agreeable sense of mental confusion.
PHYSIOLOGIC VERTIGO
(a) Most normal individuals occasionally become dizzy if they look
down from a great height or look up to a great height, or if they spin
round rapidly, as in waltzing without reversing. A certain number
of people become dizzy if they ride backward in a railroad train or if
they watch moving objects, such as a waterfall, a snowstorm, water
flowing under a bridge, or clouds overhead.
(b) Probably in a different group should be placed the occasional
attacks of dizziness on suddenly rising from a stooping posture or
suddenly lying down, on quickly turning the head, or quickly looking
at the ceiling.
(c) What is called car-sickness and sea-sickness are probably exag-
gerations of these physiologic types of vertigo.
(d) In many persons the passage of a galvanic current through the
head or a syringing of the external ear with hot water is sufficient to
produce dizziness, without there being any organic disease present or
any pathologic sensitiveness to ordinary stimuli.
^ New York Medical Record, 191 2, vol. Ixxxi, p. 1019.
134
Causes of Vertigo
AURAL DISEASE
ARTERIOSCLEROSIS
OTHER ORGANIC BRAIN DISEASE NOT NOTED BELOW
THE MENOPAUSE
ACUTE INFECTIOUS DISEASE -ONSET)
NEUROTIC STATES (NEURASTHENIA, HYSTERIA, MI-
GRAINE)
OCULAR DISEASE
ANEMIA
HEART DISEASE
TABES
EXOPHTHALMIC GOITER
CEREBRAL TUMOR
EPILEPSY
CEREBELLAR TUMOR
MULTIPLE SCLEROSIS
CEREBRAL AND CERE-
BELLAR ABSCESS
CASES TOO MANY AND
TOO VAGUELY ENU-
MERABLE FOR
GRAPHIC REPRE-
SENTATION.
952
631
172
129
121
108
28
20
}
135
136 DIFFERENTIAL DIAGNOSIS
PATHOLOGIC VERTIGO
Dizziness, as a result of disease, may be divided intx> four main
groups:
Vertigo from organic brain disease.
Labyrinthine vertigo ("aural").
Vertigo in neurotic patients.
Vertigo from cerebral anemia or transitory cerebral intoxication.
In a general way we may say that the dizziness of yoimg people is
ordinarily transient and unimportant; that the dizziness of elderly
people is apt to be recurrent and serious because it usually depends
upon organic disease of the brain or internal ear. Each of these main
groups will now be discussed more in detail.
Vertigo from Organic Brain Disease
In organic brain disease we must distinguish, as the commonest
of all causes of vertigo, arteriosclerosis. When an elderly person
begins to have attacks of vertigo, we may usually make a correct
guess that it is due to arteriosclerosis. These attacks may be mild
and occur off and on for years without ushering in anything more
serious; but in many cases they are either the beginning or the pre-
cursor of apoplectic seizures. It seems to me impossible to distinguish
the vertigos of cerebral syphilis, so called, from those of arteriosclerosis,
just described.
In cerebral tumor, vertigo is a frequent symptom, especially if the
growth involves the frontal lobes or the cerebellum. The best authori-
ties find vertigo in almost every case of cerebellar disease, in the major-
ity of frontal tumors, and in not more than one-third of the tumors
occupying other parts of the brain. Cerebellar vertigo tends to be
associated with staggering or s\vaying in one particular direction.
According to Hitzig, paroxysmal attacks of vertigo in brain tumor
tend to prove that the growth is in the regions of the motor areas.
In multiple sclerosis there is probably no more constant symptom
than vertigo. Three-fourths of the best studied cases show it.
In dementia paralytica, vertigo is common as an early symptom,
before the disease is fully developed. Later in the course of the dis-
ease it always appears a few minutes or hours before an acute seizure
(coma, convulsion, hemiplegia).
Before cerebral hemorrhage or acute softening, vertigo is one of
the commonest of prodromata. It is distinctly commoner than
headache.
VERTIGO 137
Aural Vertigo
A patient may have advanced disease of the ear and deafness,
without vertigo, in case the labyrinth is not in any way affected.
Nevertheless, in the vast majority of affections of the ear, with or
without deafness, vertigo is a more or less common symptom. The
complex of symptoms, known as Meniere's disease, is not properly a
disease. It may occur without any organic lesion of the vestibule or
of any other part of the body. In the latter cases, for example, in
traumatic neurosis, one may use the term pseudo-M6nidre's disease,
but this seems to me foolish. The complex of symptoms usually
associated with Meniere's name is deafness, tinnitus, vertigo, and
nausea or vomiting, the whole group appearing with alarming sud-
denness and often utterly prostrating the patient. Less constant are
the sense of pressure in the head, nystagmus, ataxia of the cerebellar
type, and, rarely, diarrhea. In all cases of this type the help of an
aurist should be sought, although a treatment directed to the ear is
often imavailing.
To determine whether the labyrinth is actually involved and is the
cause of vertigo the general practitioner is rarely sufl&dently expert, >
and a specialist should be consulted. It may be said, however, that ^^^ ^
lab3ainthine vertigo can rarely be diagnosed unless nystagmus can be
observed. On the other hand, it must not be forgotten that nystag-
mus sometimes occurs spontaneously and habitually in otherwise
healthy people. When nystagmus can be produced by spinning the
patient upon a rotary stool or by hot ear injections, labyrinth disease
is much more strongly suggested.
Neurotic Vertigo
Whatever else we may or may not mean by the neurotic state
(neurasthenia, psychoneurosis, congenital nervousness), it certainly
involves an imdue sensitiveness to stimuli and impressions of all sorts.
Most cases of neurotic vertigo occur when a person is exposed to some
sudden change of position or to some other environment which in
ordinary persons would not be sufficiently strange to upset their static
control. Thus, in many neurotics, especially in traumatic neuroses,
sudden turnings, bendings, any associations with the conditions which
have produced the original injury, walking, driving, and other common
acts, are sufficient to produce giddiness. Especially common in the
neurotic is giddiness or headache on exposure to the sun. Many of
the cases of vertigo, supposedly due to alcoholism, to tobacco, or to
138 DIFFERENTIAL DIAGNOSIS
indigestion, are probably of the neurotic type. In this form of vertigo
there are often no objective manifestations, no staggering or nystag-
mus. If the patient does stagger at all, it is usually an imsystematic
lurching, without any constant tendency to go to one side. Patients
with neurotic vertigo almost never fall, and in this respect their
troubles contrast sharply with those occurring in arteriosclerotics and
in other forms of organic brain disease. In the latter, serious injury
not infrequently results from a fall during an attack of vertigo.
In the neurotic type of vertigo the symptom is often associated
with or initiated by fear and autosuggestion. Thus, the neurotic
often suffers from vertigo when he gets into a large open space, and in
such cases his dizziness may be associated with or substituted for an
agoraphobia. Conversely, the neurotic is often dizzy in enclosed
places, in church, at the theater, and here, again, his giddiness is
associated with fear and the senseless dread that he cannot get out.
Autosuggestion plays a large part in both the last-named types of
vertigo, but there is another element — an ocular element — ^in many
cases. In these the dizziness seems to be associated with inability to
fix or focus the eyes upon any f)oint near at hand. Sometimes this
weakness is transferred wholly into the psychic field, and the patient
is dizzy because he cannot concentrate his mind upon any single
point.
Vertigo in Connection with Epilepsy. — With epilepsy, as with all
acute cerebral seizures, any t\-pe of vertigo may occur, either as a
prodromal sjTnptom, ushering in the attack, or as a supposed equiva-
lent for the conx-ulsive attack. The great majority of epileptics are
conscious of such troubles more or less frequently.
Vertigo from Disturbed Cerebral Circulation. — In the vasomotor
disturbances, at the time of the menopause, vertigo is often asso-
ciated with flushing, heat, and sweating about the head. Here it is
natural to assume that the dizziness results from cerebral hyperemia,
Ver\- possibly a goixi deal of the giddiness associated with cardiac
disease is als<^> of this t\pe, though it may belong to the group of cases
next to bo mentionovi.
Cerebral anemia . either in the form associated with fainting or in
that which forms a jxirt of a general anemia, as in chlorosis or after
hemorrhage, is a frequent and familiar source of vertigo. In this,
as in all other tyjxi> of dizzint'ss, the s^-mptom may be associated with
nausea, jxiUor, and kv>s of cv>usciousne:>s.
VERTIGO 139
IS THERE A GASTRIC FORM OF VERTIGO?
Thirty years ago I suppose that the majority of cases of vertigo
would have been explained as resulting from stomach trouble {vertigo
a stomacho Utso). Nowadays we are very skeptical about these cases.
The more carefully they are studied, the fewer of them appear to be
of gastric origin. Thus, Charles G. Stockton^ reports that out of 828
patients treated by him for stomach trouble, 55 complained of vertigo,
"but in 30 of these the symptom was traced to aural defect, renal dis-
ease, or arteriosclerosis. In 15 it was dependent upon neurasthenia,
intoxication, circulatory disease, or gout. Only in 10 did the dizzi-
ness appear to arise from dyspepsia," and even these were more or less
doubtful. In Gower's text-book the author conjectures that not
more than 5 per cent, of the cases of vertigo are of gastric origin.
It is, of course, well known that vertigo is very frequently associ-
ated with nausea, vomiting, and other gastric symptoms, but in the
great majority of cases in which this association is found, the dizziness
arises from the same cause that produces the nausea, as, for example,
in sea-sickness, car-sickness, brain tumor, syncope, etc.
Vertigo of reflex origin — for example, the so-called laryngeal ver-
tigo— ^is subject to a good deal of skepticism by the most competent
authorities. Many of the cases of laryngeal vertigo are associated
with a violent cough, and this, with cerebral congestion, would bring
them into the same general group with the vertigos of the menopause.
The same skepticism exists with regard to the majority of so-called
toxic vertigos J such as those from tobacco or alcohol. Circulatory
influences can rarely be excluded, and if the dizziness is of more than
transitory occurrence some organic basis may usually be found.
In conclusion, it may be said that the great majority of cases of
severe chronic or paroxysmal vertigo are found, if carefully studied,
to have involved some disease of the labyrinth.
Case 42
An Irish hostler of thirty-one entered the hospital October 26,
i9cx>. The patient has always used tobacco to excess, but has felt
perfectly well xmtil yesterday morning, when he got up feeling very
dizzy and unable to walk straight. Vomiting of bitter, green fluid
soon followed. After that he managed to do his work as a hostler,
but this morning the symptoms recurred and were so severe that he
came to the hospital in the afternoon. He has noticed a dazzling of
vision for two days, but has no headache and no other complaints.
* New York Journal of Medicine, August, 191 2, p. 416.
I40 DIFFERENTIAL DIAGNOSIS
At entrance his temperature and respiration were normal. His
pulse was 50, and during his ten days' stay in the hospital it ranged
between 50 and 60. He had a very marked polyuria throughout: — on
the 28th, 125 ounces; on the 29th, 165 ounces; thereafter in the vicinity
of 100 ounces a day. The specific gravity varied from 1008 to 1017.
Albumin was always present in traces, and the sediment showed a
rare hyalin and granular cast, with small, round cells and fat adher-
ent; also an occasional fatty cast. The fundus oculi was normal.
There was marked nystagmus. Below the right scapula breathing,
voice sounds, and percussion resonance were diminished. The heart
was not enlarged. The pulses were of high tension. Aortic second
sound very sharp. The blood-pressure not measured. No edema.
By the first of November he was much better, had no dizziness or
gastric symptoms, and felt as well as before the present trouble.
The tension of the pulse was less high. The night amount of urine
never exceeded the day amount until the last two days of his stay,
when the figures were as follows: November i, day, 34; night, 78.
November 2d, day, 38; night, 60. He left the hospital on the 4th of
November.
Discussion. — In the hospital record of this case the vertigo is
attributed to the use of tobacco, but from my study of the record it
seems to me clear that tobacco had little, if anything, to do with it.
In fact, I doubt whether tobacco ever produces vertigo except in a
novice. Although we lack several pieces of information which in a
more modem record would be present, viz., a blood-pressure measure-
ment and further functional tests of the kidney, I feel no doubt that
the vertigo in this case was due to a chronic nephritis with hj^r-
trophied and dilated heart. In such disease it is well known that
cerebral seizures of various kinds and of various degrees of severity
are common, and whether or not PaPs idea of a vascular spasm is the
correct explanation of these seizures, the important fact is their
constant association with chronic nephritis and hypertension, with or
without arteriosclerosis of the cerebral arteries.
I have searched the hospital records diligently for a more plausible
case of vertigo due to the use of tobacco, but this is the best that I
have been able to find, and, to my thinking, the vertigo is in this case
certainly due to the condition of the renal and vascular S3rstems.
Case 43
A housewife of fifty-two entered the hospital March 27, 1902.
Three years ago the patient had a bad fright and bec^x* ^^■■yf.
VERTIGO 141
SO that she had to lie down to prevent fainting. Since then she has had
similar attacks of vertigo about once a month, relieved by lying down.
Since last November, however, these attacks have been more frequent
and now occur four or five times a day. Of late they have been asso-
ciated with dyspnea and palpitation, but are still relieved by lying
down for five or ten minutes.
For several months she has noticed pain in the lower abdomen and
the small of the back, especially after exertion, accompanied by fre-
quency of micturition. She passes urine twice in the night. Since
November she has had more or less hoarseness, aggravated by ex-
citement, and steadily increasing of late.
On further questioning, she remembered that three winters ago
she had neuralgia in the upper part of her back, across the shoulders,
in the nape of the neck, and in the right hand. These attacks have
recurred each winter and are assodated with tenderness of the pain-
ful areas, but not with any redness or swelling. The attacks usually
last about two months. She had one child bom thirty-three years
ago; no miscarriage. All her life she has been more or less troubled
by dyspnea and palpitation on exertion.
Her mother died at fifty-five of consumption. She has also lost
three brothers and two sisters of consumption. Three other sisters
and two other brothers are living and well.
Physical examination showed good nutrition, moderate cyanosis,
normal pupils, glands, and reflexes. At the left apex behind there
was a slight dulness, with high-pitched expiration, increased whisper,
and decreased tactile fremitus. Otherwise the lungs were normal.
The heart's apex was in the fifth interspace, 5 J inches from the median
line, the right border 2^ inches from median line. There was well-
marked pulsation at the junction of the clavicle and sternum on the
right side, and considerable bulging of the clavicle and supraclavicular
space. The veins of the upper sternal region were prominent. At
the apex there was a slight systolic and a loud diastolic murmur,
with absence of the second sound. At the base the first sound was
replaced by a blowing systolic murmur and there was also a faint
diastolic murmur. Over the seat of pulsation, below the right clav-
icle, was a loud, blowing systolic murmur and a slight systolic shock.
The abdomen was negative. Both tibiae were nodular and there was
slight edema over them. The pulse was not obtained in the left
wrist. Blood and urine normal. Tracheal tug present. No fever in
a week's observation.
Discusskm. — Although this patient has a strong tuberculous his-
142 DIFFERENTIAL DIAGNOSIS
tory, there are no actual symptoms in the case which we can attrib-
ute to a tuberculous lesion, and presumably the patient has not been
infected in any important degree.
In working our way into the case it is important to note that the
attacks of vertigo are associated with dyspnea and with a condition
in which the patient nearly faints. Vertigo of cardiac origin is not
at all infrequent, and such an origin is suggested by this patient's
dyspnea, though the force of the suggestion is weakened when we
read her statement that she has had dyspnea more or less all her
Ufe.
After reviewing the physical signs in the case, the bulging and
pulsation at the right sternoclavicular joint, the diastolic murmur,
with absence of the aortic second sound, the nodes upon the shin-
bones, the absence of the left pulse, and the presence of a tracheal
tug, we can have little doubt that the patient has an aneurysm of the
aortic arch, and that her hoarseness, her neuralgia of the shoulder,,
nape and hand, and probably her dyspnea, are due to the same cause.
That cause, syphilis, has probably produced also changes in the cere-
bral arteries, whereby the amount of blood passing through them does
not vary as it should, according to the demands of the moment.
One can well conjecture that such vascular changes would produce
vertigo.
Outcome. — The patient's rest in bed seemed to do her much good.
By the 30th she was very anxious to get home. No medication was
given save an occasional counterirritant or hypnotic, and on the 3d
of April she left the hospital.
Case 44
A druggist of fifty-eight entered the hospital December 8, 1902.
The patient was always perfectly well imtil last July, when, after a
hearty dinner, he became dizzy and could not talk. This passed off
in a few minutes and he has felt well imtil yesterday, when the same
symptoms recurred and were followed by suffocation and soon after
by unconsciousness.
For two years he has noticed that he had to rise twice in the night
to pass urine, and last summer he had one short spell of vomiting and
diarrhea. His eyesight has been excellent.
Physical examination showed good nutrition, partial coma, pallor,
and a peculiar odor to the breath, not urinous, a high-tension pulse,
a sharp aortic second sound, marked pulsation of the brachials,
visible throughout the whole arm. There was no paralysis. At the
mt'i
.V"J
H3
apex ol the heart a soft systolic and a blowing diastolic murmur was
heard. No enlargement, however, of the organ was made out. The
pulses had a Corrigan quality. The bladder reached to the umbilicus
and 42 ounces were withdrawn by catheter. The rectal temperature
was loi" F. (Fig. 58). The leukocytes were 14,500; hemoglobin,
75 per cent. The urine was 40 ounces
in twenty-four hours; specific gravity,
1009 to 1012; albumin, from J to 1 per
cent. ; a few hyaline and highly refrac-
tive casts.
Discussion. — When vertigo is associ-
ated with aphasia in a man of fifty-
eight, and especially when six months
later these same symptoms are followed
by an attack of coma, there is Utile
doubt that we are dealing with cerebral
arteriosclerosis. The history of noc-
turia makes it probable that further
examination of the heart and kidney
would reveal similar arteriosclerotic
changes in these organs. Unfortun-
ately, we have no blood-pressure meas-
urements, as in 1902 we were not
making them in all cases, but it seems
to me clear that the coma which led to his becoming a hospital
patient was of the type associated with a chronic nephritis and
cerebral arteriosclerosis.
Since the Wassermann reaction had not been discovered at the
time when this case was seen, and since no j-ray examination of the
aortic arch was made, we cannot decide whether or not the diastolic
murmur was due to a syphilitic aortitis.
The fever present during the first forty-eight hours of his illness is
probably of the cerebral type, the type often seen in cerebral hemor-
rhage, cerebral tumor, concussion or fracture of the skull, even when
all infection can be excluded. This point is sometimes of importance
in differential diagnosis, as many physicians are prone to believe that
the presence of such a fever proves infection.
Outcome. — Under hot-air baths and purgatives he rapidly im-
proved; by the 19th he felt very well and was able to go home, but
died there on the 23d of December.
Fig. 58.^Chart of Case 44.
144 DIFFERENTIAL DIAGNOSIS
Case 45
A wood-chopper of sixty- two entered the hospital February 3, 1904.
The patient's mother and one sister died of consumption; his father, of
some unknown cause; two other sisters, of typhoid. The patient him-
self has been in perfect health until ten months ago and his habits have
been excellent. At that time he first noticed dizzy spells, slight head-
ache, and dimness of vision. The attacks lasted ten to fifteen minutes
and gradually increased in frequency, until during the last month
the three symptoms above mentioned have been constant and walk-
ing has become very difficult. He has noticed numbness in his right
arm and leg, also a very slight numbness in his left arm. His appetite
and digestion are excellent, bowels regular.
Examination of the internal viscera is negative. The arteries
are somewhat thickened and tortuous, with a lateral excursion in the
brachials. The right knee-jerk is more marked than the left. Plan-
tars normal. Sensation to touch and temperature is absent in the
right thigh and leg. Pain sense and muscle sense present. Cremas-
teric reflex absent on the right. Fibrillary twitching in the extensor
of the right thigh. Skin reflex on the right side of the abdomen
much diminished. The right hand is weaker than the left. No dis-
turbance of sensation in the arms. Blood and urine normal. Speech
slow, but not aphasic. Double optic neuritis is found on examina-
tion of the fimdus oculi.
Dr. G. L. Walton thought there was a new-growth in or near the
Rolandic region on the left, and advised operation for decompression.
During the patient^s six weeks' stay in the medical wards there was
no abnormal temperature or pulse recorded. The patient had a good
deal of headache up to the 12th of February, after which it was less.
On the 17th it again increased and his mental condition became duller.
He also had some difficulty in swallowing, which lasted, however, only
a few days.
On the 12th of March it was noted that his headache has not in-
creased, but the dizziness was more troublesome and he began to
become stuporous, so that he snored continuously, day and night. As
the degree of optic neuritis steadily increased, he was transferred to
the surgical wards. Examination there showed incomplete fixation
of the eyes when they were turned toward the left, the effort being ac-
companied by twitching muscles of the eyeballs (nystagmus). When
the effort was made to turn the eyes to the right, the right eyeball
did not go beyond the median line. The pupils were normal. The
VERTIGO 145
masseter muscles were contracted on each side. The right side of the
face below the eye moved less well than the left. There was diminu-
tion of sensation over the whole right side of the face, both to touch
and temperature. There was considerable deafness in the right ear.
There was no Babinski. Both knee-jerks were lively. The muscles of
the right leg were weaker and less complete than those of the left.
Sensation of position for the toes of the right foot diminished. A
half-dollar piece was not recognized by the right hand and was called
a jack-knife, but it was at once recognized by the left hand. There
was some inco-ordination of the hands, especially of the right.
Discussion. — The history shows vertigo associated with numb-
ness in the right half of the body. Physical examination shows
weakness; in addition, ataxia of the right side, associated with optic
neuritis, and later with mental changes and dysphagia. All this
points directly to some focal brain lesion, probably brain ttmior.
Arteriosclerosis is to be excluded. It does not ordinarily, if
ever, produce a double optic neuritis, and the gradual onset of mental
cloudiness is not characteristic. The type of hemiplegia associated
with arteriosclerosis is apt to appear more suddenly and to involve
more extensive loss of power.
Dementia paralytica might begin in this way and might produce
many of the symptoms present in this case. It would be imusual,
however, to have no more definite mental symptoms, and double
optic neuritis is not the usual lesion found in these cases. Spinal
pimcture and the examination of the spinal fluid for evidence of
syphilis would be the most important point in making more certain
our right to exclude dementia paralytica, but spinal puncture is
sometimes an operation of serious danger in cases of brain tumor,
and when that lesion is suspected should be performed with extreme
caution and only for the best of reasons. The appearance of nystag-
mus and astereognosis goes to confirm a diagnosis of localized cerebral
lesion and, therefore, of a tumor.
The point of special interest is thie fact that vertigo was his first
symptom.
Outcome* — On the 26th the patient was trephined over the
Rolandic area on the left, the dura was opened, and the brain exposed.
Nothing abnormal was seen. The operation made no difference at
aU in the patient's s)miptoms except that on the 3d of April he was
aphasic. On the i6th of April the brain was further explored for
tumor, but nothing found. There was no considerable change in the
patient's condition untU the 5 th of May, when he began to have
Vol. 11—10
146 DIFFERENTIAL DIAGNOSIS
convulsive movements on the left side. There was considerable
hemia of the brain substance. On the 24th of May he died. Autopsy
No. 1220 showed an endothelioma of the dura mater in the p)osterior
fossa; purulent meningitis; multiple gas-cysts of the brain; broncho-
pneumonia of the left lung; lymphoma of the mediastinal region;
cysts of the kidney. Obsolete tuberculosis of the upper lobe of the
left lung and of the bronchial lymphatic glands. Slight arterio-
sclerosis of the aorta.
Case 46
A gymnastic instructor of twenty-eight entered the hospital
September 21, 1904. For the past two weeks the patient has been
feeling weak and has been troubled with dizziness and headaches.
He has slept but little and has no appetite. He has never been sick
before and has an excellent family history and habits.
Physical examination was negative. There was a continued fever
and a positive Widal reaction. The white cells at entrance numbered
11,200; hemoglobin, 80 per cent. The urine was 30 ounces in twenty-
four hours; specific gravity, 1020; albumin, very slight trace, and a
few hyaline, fine granular and coarse granular casts. The patient
ran the ordinary course of a typhoid with relapse, and left the hospital
in good condition on the 5th of November. At the time that he left
he had slight cystitis and typhoid bacilli were recovered from his
urine. His white count remained above 9000 during the whole of his
fever.
Discussion. — The case is a typical illustration of vertigo asso-
ciated with an acute infectious disease. Presumably the dizziness
has the same significance here that headache does. Precisely what
the significance is we do not know. It may be toxic, but it may also
be circulatory. The occurrence of nosebleed at the same period at
which headache occurs in the beginning of infectious diseases inclines
us to believe that vasomotor changes rather than purely toxic in-
fluences are at work. In typhoid fever this is all the more probable
because the headache and vertigo are apt to decrease in the second
and third week of the disease, when the general manifestations of
what we call toxemia are at their height.
There can be no doubt that this illness was typhoid fever, but
it should be specially noted, as a point of great rarity, that the white
cells were slightly elevated during the whole of his fever. This
probably does not occur more than once in a thousand cases, if so
often. But for the finding of typhoid bacilli in the urine one might
VERTIGO 147
be almost disposed to doubt the diagnosis of typhoid because of the
elevated leukocyte count.
Case 47
A hack driver of forty-three, bom in Russia, entered the hospital
January 9, 1905. For the past eight months the patient has had a
full feeling in his head. On attempting any exertion he becomes
dizzy and feels as if he would fall. During the same period he has had
buzzing and roaring in his left ear or sometimes a noise like a bell,
and did not hear well. In other respects he feels perfectly well, but
he has fallen twice in six months owing to vertigo. He always falls
to the right.
Physical examination is negative save as relates to the ears, which
show evidence of labyrinthine disease. Romberg's sign absent.
Discussion. — This case illustrates a typical Meniere's complex
(not Meniere's disease), which in this case depends upon definite
disease of the labyrinth. The diagnosis depends upon a lack of evi-
dence for any other cause of vertigo and the presence of a labyrin-
thine disease, as determined by an expert.
Outcome. — The patient was transferred to the Eye and Ear In-
firmary, where diagnosis of labyrinthine disease was confirmed.
Case 48
A sailor and marketman of thirty-two entered the hospital March
II, 1905. The patient has been in the habit of taking three whiskies
a day, occasionally one before breakfast. He had gonorrhea ten years
ago, soft chancres eight years ago, and erysipelas of the face five years
ago. In the past six months he has been troubled by dizzy spells,^
occurring at least once a day and lasting a few minutes, especially
when he rises suddenly from a chair or goes from a hot room into
the open air. He is obliged to sit down when the attacks come,
otherwise he would fall. DuVing the attacks he is conscious, but his
limbs, he says, are in clonic spasm. There is no involuntary mic-
turition and in a couple of minutes he is perfectly well and laughing
at himself. ,
For six months he has noticed dyspnea, palpitation, and edema
of the legs after exertion, and for three months there has been dis-
coloration of the lower part of the legs. All winter he has found it
very difiicult to get warm and he never sweats except in a Turkish
bath. During the last six months his color has been changing, so
that his friends have nicknamed Him "the Jap.'* For two weeks he
148 DIFFERENTIAL DUGN05IS
has been unable to work on account of weakness, yet he seems to feel
better when exercising. His appetite is good, his bowels regular, his
sleep restless. He often passes urine involuntarily at night.
Physical examination shows marked pallor of the skin and mucous
membranes. There is a systolic murmur audible all over the pre-
cordia, not associated with other abnormalities of the heart. There
is soft edema of the lower legs and marked varicose veins on both of
them. Otherwise physical examination is negative. The blood
shows red cells, 2,428,000; white cells, 3400; hemoglobin, 50 per cent.-
Stained specimen shows well-marked achromia, but do other changes
Fig. sg. — Chart of Case 48.
in the red cells. Diilerential count normal. The urine averages
60 ounces m twenty-four hours; specific gravity, ■ 1009 to 1012; no
albumin; a rare hyaline cast in the sediment. On the 15th of March it
is noticed that his spleen is palpable and he has been having a good
deal of nosebleed. Examination of the ears shows no explanation of
the dizziness. The temperature is seen in the accompanying chart
■ (Fig- 59)-
The bowels were very loose during the first and last week of his
stay, at other times they were normal. A few darkened spots were
found on the mucous membrane of the mouth and about the scrotum.
On the 26th of March he seemed to be a little browner, but felt better
and stronger. There was no reaction to tuberculin. The blood-
VERTIGO 149
count had risen to 2,872,000. The red cells showed marked achromia
and defonnities in shape, otherwise the blood was as before. The
stools were negative. There was no incontinence of urine after
entering the hospital, and that previously mentioned was probably
due to drinking heavily. On the 2d of April the patient was again
given tuberculin, and fourteen hours later showed a rapid rise in tem-
perature to 104° F., followed by rapid lysis. On the 12th of April
the patient seemed to be stronger and had gained 10 pounds in four
weeks, but his blood-coimt showed, April 15th, red cells, 1,976,000;
otherwise it was as before. He left the hospital on the 2 2d of
April.
Summary of subsequent out-patient records: April 27, 1905, Well
except for lame back. !^. Straps.
May 4th. Feels "elegant" — active, lively, 3 to 4 mile walk today.
Before entrance much dyspnea, n9w none. Vertigo only when he
first gets up. Much improved in this respect. Appetite, bowels,
and sleep O. K. Not at work yet. Color still poor. Weight, 184
poimds. Hemoglobin, 55 per cent. Reds, 3,456,000; whites, 6800.
Achromia, small-sized red cells, slight deformities, and increased
blood-plates. No blasts or stippling. Normal differential count.
Discussion* — I have introduced this case because it seems to
me one of great interest, although the diagnosis is by no means clear.
The essential features of the case are as follows: Marked secondary
anemia associated with enlargement of the spleen, evidence of cardiac
weakness, vertigo, a brownish color to the uncovered parts of the skin,
and a negative tuberculin reaction, all these symptoms in an alcoholic
patient who very possibly has had syphilis.
Addison's disease must, of course, be considered, and it is impos-
sible to say that Addison's disease never gets well and to deny the
possible correctness of that diagnosis in this case because the patient
apparently recovered or, at any rate, greatly improved. It is greatly
to be regretted that we have no measurements of blood-pressure.
Were a strikingly low pressure recorded — 75 nun. Hg. or lower for
the systolic pressure — evidence of Addison's disease would be strength-
ened. The presence of pigmentation within the mouth is of special
importance as further strengthening this diagnosis. On the other
hand, the negative tubercuUn reaction, and especially the fact that two
subcutaneous injections of a large dose of tuberculin were borne so
well by the patient, militates against the diagnosis of' Addison's
disease. Such injections are very dangerous, and in at least two
instances known to me have been followed immediately by death.
150 DIFFERENTIAL DIAGNOSIS
They should never be given in any case of suspected Addison's dis-
ease.
Syphilis must certainly be considered and might account for all
the symptoms in the case. It has been often noticed that vertigo is
a frequent and early symptom in cases of syphilis aflfecting the brain,
and there is a great deal in this case to suggest organic brain disease,
especially the clonic spasms of the limbs, the involuntary micturi-
tion at night, and the causeless anemia which, in a man of his age
and especially in a sailor, is more often due to syphilis than to any
other disease. It is greatly to be regretted that no Wassermann
reaction was done. As far as I know he received no antisyphilitic
treatment, but the fact that he nevertheless improved does not in-
validate the diagnosis of possible syphilis. A good many similar
cases are on record.
Since the anemia was associated in this case with splenic enlarge-
ment, we are forced to consider the complex called splenic anemia
as a possible explanation of his symptoms, but this would necessi-
tate neglecting altogether the cerebral aspects of the case, and
would make it improbable that so prompt an improvement should
occur.
Outcome. — November 10, 1905. Feels first rate. Notices some
loss of strength in legs. Appetite good. Bowels move daily. Comes
to hospital for eczema on legs.
Case 49
An Irish laborer of sixty entered the hospital July 12, 1905. Three
days ago the patient was exposed to very hot weather, and his head
became so dizzy that he did not know what he was doing part of the
time, yet he did not give up work, and next day felt well. At noon
today, after working in the sun all the morning, he again began to be
dizzy, and finally could not see and lost consciousness. He was
brought to the hospital in coma, with stertorous breathing.
On physical examination the left pupil was larger than the right;
both reacted normally. Coma was complete. The internal viscera
showed nothing abnormal. The temperature was 104.4° F-J pulse,
112; respiration, 40. The plantar reflexes were normal, the others
not obtained. The urine showed a very slight trace of albumin, but
was otherwise negative, as was the blood.
Discussion. — Although we do not understand the pathogenesis
of sunstroke, we have reason to believe that the temperature is ex-
cessively elevated, not only in the places at which we can measure it.
1
-■
:
-■
»
«
_;
g
g
-
VERTIGO 151
but within the semicircular canals and everywhere else. It has been
well established experimentally that caloric stimulation of the in-
ternal ear, such as might be pro-
duced by hot syringing of the ex-
ternal ear or otherwise, is prone
to produce vertigo.
Most cases of sunstroke, if we
are so fortunate as to obtain a
good history, are preceded by ver-
tigo which may last for minutes
or for hours, and should warn the
patient that be is in danger.
Such premonitory symptoms, like
sunstroke itself, are much more
frequent in alcohoUc patients. One
rarely sees a case of sunstroke
not previously weakened by alco-
hoUc or some other deleterious in-
fluence.
Outcome. — ^After a cold bath
he became conscious and the tem-
perature dropped, as shown m the accompanying chart (Fig. 60).
He rapidly convalesced and left the hospital on the second day.
Case 50
An Irish laborer of forty entered the hospital June 5, 1907. His
family history and past history are negative. The patient has been
a hard drinker for many years. For the past two years he has taken
nearly a quart of whisky a day. He had a touch of the "horrors"
five years ago. For two years his eyesight has been failing, and nine
months ago he had to stop work on this account. Since then "he has
had dry heaves in the morning" and has lost strength.
For seven months he has had frequent dizzy spells, which are now
his main complaint. For five months his hands and feet have been
swollen, and occasionally his face has been puffy. For a month he has
eaten irregularly and little, has drank heavily, and been very fidgety.
Physical examination shows good nutrition, extreme motor
restlessness, marked tremor of the hands and lips. Pupils, glands,
and reflexes are normal. Chest negative. The abdomen is dis-
tended and shows shifting dulness in the flanks, but no other ab-
normality. There is sli^t edema of the feet. Urine, 25 ounces
Fig. 60. — Chart of Case 49.
152 DIFFERENnAL DIAGNOSIS
in twenty-four hours; specific gravity, 1016; very slight trace of al-
bumin, and a very rare hyaline cast. Systolic blood-pressure 128 mm.
Hg. Blood negative. Examination of the fundi shows optic atrophy
in the temporal half of each disk.
Discussion. — On the hospital record the diagnosis of this case
stands as "alcoholism,'' and it may well be that no other diagnosis is
possible with the known facts, but we have every reason to believe
that he has some severe circulatory disturbances in the portal sys-
tem, presumably cirrhosis, and the bitemporal atrophy of the optic
disks makes us very suspicious of some organic cerebral lesion, pos-
sibly arteriosclerosis or gumma. Internal pachymeningitis is also a
possibility, but we have no way of coming to any closer certainty in
the matter. As regards the supposed connection between alcohol-
ism and vertigo, it is notable that although this patient has been a
hard drinker for many years and has taken a quart of whisky a day
for two years, he had no vertigo untU the past seven months. These
facts strongly suggest that some organic lesion, something other than
the purely toxic effects of alcohol, has been at work since he began to
be dizzy.
Outcome. — Within a few days he had lost his nervousness and
tremor; he liked the hospital as a hotel, but did not seem to need it
in other respects. He was allowed to go home on the 13th.
Case 51
An Italian shoemaker of forty-one enters the hospital January
29, 1908. About two years ago the patient began to be dizzy, at times
drowsy, and at other times to have cramp-like muscular pains. He
was in the Boston City Hospital for three months without great im-
provement. Nevertheless, he has been able to do less and less work
since that time, and for the last nine months has done none at all.
Nocturia, i to 2, has been present for years, but in the last seven
months has increased to 4 or 5. He has no headache, no vomiting,
dyspnea, or edema, but for six months his eyesight has been faiUng.
His family history and past history are entirely negative.
The man is poorly nourished and has a funnel breast. Cardiac
apex extends J inch outside the nipple, in the fifth interspace. There
is no increase of dulness to the right. At the base there is a faint sys-
tolic murmur. There are no other abnormalities. The artery walls
seem to be thickened. Systolic blood-pressure is 205. Limgs and
abdomen are negative. Blood is normal. The urine is 35 ounces in
twenty-four hours; specific gravity, 1013; a trace '^^ alhunuii; a few
VERTIGO 153
hyaline and granular casts. Retinal examination shows hemor-
rhages on each side. During his four days' stay in the ward he felt
perfectly able to work and had no symptoms except failing vision.
Discussion. — ^Although we do not imderstand precisely what is
the relation between vertigo and high blood-pressure, we cannot doubt
that there is some such relation. Not every case of hypertension
su£fers from vertigo, but a considerable percentage of such cases do
suffer in this way, and that percentage is about the same whether the
cause of the vertigo and hypertension resides wholly in the kidney or
not.
In the present case everything points to the presence of a chronic
glomerular nephritis. The age, the long-standing nocturia, the enlarged
heart and high blood-pressure, the condition of the urine, and retinal
hemorrhages — ^all point in the same direction.
Case 52
An Irish laborer of twenty-seven entered the hospital July 9, 1909.
The jmtient has a good family history and past history, though. he has
been treated in the Out-patient Department for two months for
psoriasis.
Five weeks ago he began to have constant vertigo, day and night,
so severe that he was unable to walk without staggering. This
vertigo was accompanied by headache, especially on the right side
of the head and in the right eye. It came usually at 8 p. m., lasted a
week, did not disturb sleep. After that it shifted to the left side of
the head and the left eye for a week. For the past fortnight he has
had no headache and his vertigo has been much less severe, so that he
can walk without difficulty. He has never fallen and has no spasms
or convulsions, though occasionally his left hand trembles a little.
For the past month his eyesight has been poorer than usual, but lately
is improving again. The cessation of his headaches was coincident
with the beginning of hydrotherapeutic procedures two weeks ago.
He has no deafness and no other symptoms except those above men-
tioned. His appetite and digestion are good and his bowels regular.
Save for the areas of psoriasis, physical examination is negative.
Temperature, blood, and urine were normal throughout. The
fundus oculi also normal. Under encouragement, hydrotherapy,
and static electricity he did very well, but on the 21st of July the
Wassermann reaction was found to be positive. Nevertheless, he was
difldiaiged the same day.
—This case was diagnosed as one of "hysteria" at
154 DIFFERENTIAL DIAGNOSIS
the hospital, but in view of the positive Wassermann reaction this
diagnosis seems to me improbable. Of course, it is perfectly possible
for hysteria to exist in an Irish laborer of twenty-seven, but such a
coincidence is certainly infrequent, and as we know that vertigo is a
frequent accompaniment of various stages of syphilitic infection, it
seems much more reasonable to explain this patient's dizziness as
due to some cerebral change dependent upon the activities of the
Spirochaeta pallida. The chief reasons for the diagnosis of hysteria
seem to be the improvement of the patient following encourage-
ment, hydrotherapy, and static electricity, but this improvement
may well have been a coincidence. I am inclined to think that such
was the case.
Outcome. — August 20th he was walking better and improving
generally. Soon after he returned to Ireland and was lost sight of.
Case 53
An Armenian laborer of seventy-one entered the hospital Sep-
tember 29, 1909. Six months ago the patient began to have pain in
his neck and the back of his head, gradually extending to the fore-
head, though it was still in the back of the neck. The pain is con-
tinuous and accompanied by occasional dizzy spells, with ringing in
the left ear. Turning his head causes pain in the right side of his
neck. He has no other symptoms, and has never been sick before
except for an attack of rheumatism, two years ago, which confined
him to bed two months.
Visceral examination was negative except that deep pressure in
the right flank during inspiration was slightly painful. The knee-
jerks were increased. There was no stiffness of the neck, no dis-
turbances of sensation. The right pupil was circular and reacted
normally. The left eye was glass. The fundus oculi showed optic
neuritis, the disk border completely obliterated, and moderate prom-
inence of the disk surface. There was a very little exudate, but
numerous hemorrhages extending from the upper inner quarter out
into the adjacent retina. The headache persisted (though there
was no vomiting) until the 6th of October, when, without preceding
nausea, he suddenly emptied his stomach. Lumbar puncture showed
clear fluid under no excessive pressure and with no increase of cel-
lular content. Wassermann reaction was negative. Under two
weeks of antis>T3hilitic treatment the patient did not improve at all.
Discussion. — Brain tumor is unusual at the age of seventy-one.
We should make every effort in a case presenting cerebral symptoms
VERTIGO 155
at this age to explain them as results of arteriosclerosis or syphilis;
but in this patient the negative results of the Wassermann test, the
lumbar puncture, and the antisyphilitic treatment make it improb-
able that he is suffering from syphilis.
In favor of brain timior are headache, vertigo, cerebral vomiting,
and the double optic neuritis.
Outcome. — October 15 th the skull was first opened in the right
temp>oroparietal region. When the outer table was penetrated and
before the skull was opened the patient stopped breathing. His
pulse was of good quality, and artificial respiration was done for
about half an hour without improvement in the power of spontaneous
respiration. The wound was then closed and artificial respiration
continued steadily for six hours, during which period his color remained
good, but his pulse gradually weakened until his heart stopped.
Autopsy No. 2464 showed cyst of the cerebellum with old hemorrhage
into it, internal hydrocephalus, arteriosclerosis of the coronary arte-
ries, and hemorrhagic edema of the lungs.
Case 54
A bartender of thirty-four entered the hospital January 22, 1910.
Family history was negative. Ten years ago he had what was called
"syphilis" and was imder treatment two or three years. Three years
ago he had severe headache for two or three weeks. After glasses
were fitted the headache ceased and has rarely troubled him since
until last fall, when he began to have pain at the nape of the neck,
always worse at night, and usually confined to the nape, but occa-
sionally affecting the left side or the forehead.
December 10, 1909, the pain was so severe that he stopped work.
For the week succeeding that time he was very dizzy, vomited fre-
quently, and had cramps and numb feelings in his right arm, leg,
and the right side of his face. About this time he was almost blind
for three days, after which his sight improved. The headache con-
tinued, and five days ago he had another bad attack of vertigo and
vomiting and lost power over the right side of his body. The next
three days he was blind, but all of these symptoms have now cleared up,
though he still has some headache and does not see well. His sleep
has been poor for six weeks and he has had no appetite for a week.
On physical examination the patient was well nourished, the left
pupU larger than the right, both reacting normally. There was no
glandular enlargement and the tongue came out straight. Visceral
examination was normal. There was a slight loss of power in the
156 DIFFERENTIAL DIAGNOSIS
right arm and leg, but no paralysis. The fundi were perfectly normal.
Dr. James J. Putnam, who saw him on the 24th, thought the hemi-
plegia might be functional. He found some paresthesia of the right
hand, arm, leg, and the right side of the face, and slight ataxia of both
arms, especially the right.
Discussion. — The essentials of the history in this case are a syph-
ilitic infection ten years earlier, a headache of three years' duration,
apparently relieved at first by glasses, but recently returning; then
one month ago, vertigo, vomiting, paresthesia, and, later, hemiplegia
on the right side, with poor eyesight for three days.
In a patient of thirty-four it seems unreasonable to explain these
symptoms as a result of arteriosclerosis unless we are perfectly cer-
tain that we cannot refer them to syphilis. With so much in this
patient's history that suggests syphilis, it seems to me that treat-
ment must be based on this belief.
We may admit that cerebral tumor or abscess might produce
the same troubles, but the negative fundus is against both of these
diagnoses. In point of fact, what we really recognize by the symptom
group presented in this case is the presence of increased intracranial
pressure and of some focal lesion such as can produce partial hemi-
plegia. Beyond this, our reasoning to more exact diagnosis must
be based upon our statistical knowledge of a relative frequency of the
diseases capable of causing such a group of symptoms in a bartender
of thirty-four.
Outcome. — Within a few days after this he began to show marked
improvement under antisyphilitic remedies. His headache was
much less and he was up and aboutf the ward. At no time was there
any abnormality about his temperature, pulse, respiration, blood-
pressure, blood, or urine. He gained 5 pounds during his ten days in
the hospital and went home on the 2d of February.
Two years later he reported, looking and feeling perfectly well.
He had had two bad attacks in the past summer, with nausea and
blindness, lasting two hours, and one still worse attack in August,
191 1, when he was unconscious for thirty-six hours. His vertigo is
now practically gone, but it is noticeable that as he gives the fore-
going account he stumbles now and then in his speech. Perhaps
paresis is developing.
Case 55
A mill operative of twenty-six, bom in Russia, entered the hospital
March 14, 1910. The patient was sent in from the Out-patient
Department (No. 154,217) for vertigo and staggering gait. Cerebral
VERTIGO 157
tumor, syphilis, and ear disease had been considered as diagnoses.
The patient's family history and past histoiy were negative,
Tlie patient has had dizzy spells for five months, and says she
has had headache night and day for three months. She now cannot
walk alone. There has been no vomiting, and her eyes and ears do
not trouble her.
Physical examination showed good nutrition, slight pallor, pupils
slightly irregular, but reacting normally. Visceral examination was
negative, but the patient could not stand with the feet together and
the eyes shut, and walked with a very imsteady gait. TTie plantars
and knee-jerks were normal. The fundus
oculi normal. Ears negative. Wasser-
mann positive. Dr. J. J. Putnam con-
sidered it tumor of the cerebellum. By
April 12th she was able to walk with only
a little assistance. In the meantime
mercurial inunctions had been given daily,
and 20 gr. potasdum iodid, three times
a day. The stoob showed many e^s
of the Trichiuris trichiura. The blood
diowed slight achromia and some varia-
tions in size and shape, otherwise nothing
abnormal. Systolic blood-pressure, 155.
The fever during first week in the hospital
was as seen in the accompanying chart
(Fig. 61). After that it was normal.
Blood and urine normal. Studied in
the neurologic wards, it was found that the
patient would stand if she were scolded,
but if not scolded she would sway and tend
to fall to the left. She remained there three weeks and left with the
diagnosis of "debility." At the time of discharge nothing abnormal
could be found.
Discnssion. — On the hospital records the diagnosis of this case
stands as "debility." This diagnosis was made four years ago, and I
caimot believe that anyone would consider it justified today. Ap-
parently the idea that this patient had no organic disease was based
upon the fact that she stood without swaying when they scolded her,
and could not stand so imless they scolded her. But this only gives
the proof that there may be a functional and psychic element in the
case at a person suffering from severe organic disease.
S:
m
yl
Fig. 61— Chart of Case 55.
158 DIFFERENTIAL DIAGNOSIS
To me it seems tolerably obvious that when a woman of twenty-
six has a blood-pressure of 155, a slight anemia, a positive Wasser-
mann reaction, and has suffered for five months with headache,
vertigo, and ataxia, we should make a diagnosis of syphilitic disease
affecting some part of the brain, presumably the meninges, possibly
the arteries. Certainly she should be treated upon this basis, though
brain tumor cannot be excluded. Apparently no careful tests of
labyrinthine function were made.
I wish to express here my conviction that a great many bad mis-
takes are made in the management of cases of illness because we have
in our minds a hard-and-fast alternative. The patient before us
must, we say, have either an organic disease, a fimctional disease, or
no disease at all. But it seems to me most important to recognize
that the patient with indubitable anatomic changes in one or another
organ may also have, on top of this, a variety of symptoms which are
essentially fimctional or mental and can be removed by change in
environment, in the patient's point of view, or by anything that
instils hope. I have in mind a case of tabes dorsalis following a
known syphilitic infection; the patient had Argyll-Robertson pupils,
absent knee-jerks, Romberg's sign, lancinating pains, and some dis-
turbances in the sphincters, but, in addition to these troubles, he was
obsessed with the idea that he could never work or walk again, that
he was a useless encumberer of the earth, and forever disgraced. When
these ideas were expelled from his mind and a good job was found for
him, he lost his pains altogether, became able to walk as well as any
one else, gained 20 pounds in weight, and is today a picture of health
and happiness, although he has his tabes and always will have it, and
although his pupils and knee-jerks are as abnormal as ever.
The lesson taught by this case should always be remembered at
the outset of our treatment, and especially of our prognosis, in cases
of incurable organic disease. Recognizing that we cannot cure the
latter, we must remember that there is no limit to the amount of
functional and curable trouble which might be superimposed upon
and mixed up with the imderlying trouble. Recognizing frankly that
we cannot cure the disease, we may yet hope to cure the patient of
most of the troubles which torture him. It is here that quacks and
irregular practitioners of various types score their successes in patients
*^given up by regular physicians."
Outcome. — December 28, 1912, a letter received from a friend
states that the patient returned to Russia, and has been better during
the summer and worse in the winter, since leaving this country.
VERTIGO 159
Case 56
A brick-mason of fifty-six entered the hospital February 28, 1910.
The patient was sent in from the Out-patient Department with a
diagnosis of "general paresis" or "cerebral syphilis." One paternal
uncle died insane; otherwise the patient's family history is excellent
and he has three healthy children. Three weeks ago he had an ab-
scess in the region of the anus; otherwise he has considered himself
entirely well. Last September his mother, with whom he has lived,
died, leaving him only a quarter of her property. This resulted in
litigation which has continued ever since. Since last October he has
noticed a girdle sensation about his waist and he has been short
of breath, but considered himself fairly well imtil three weeks ago,
when he began to stagger in his gait on account of dizziness, and this
symptom has rapidly become aggravated since. At present he gropes
about upon his feet as if he were blind. Twelve days ago he began to
vomit profusely, and ten days ago he began to talk in a rambling
manner, turning rapidly and irrationally from one subject to another.
In the last two days his friends say there is no sense in what he says, but
he has had no hallucinations or illusions. His head feels full, but does
not ache. He seems listless and sleepy, but has not been in bed,
though he gave up work three weeks ago.
Physical examination showed poor nutrition, good color, and slight
puffiness under the eyes. The pupils were oval in outline, irregular,
the left greater than the right. They reacted fairly well to light, but
better to distance. The tongue showed no tremor or deviation.
The heart's apex extended i^ cm. to the left of the nipple. The
right border 4 cm. from midstemum. No murmurs or accentuations.
Slight dulness and diminished breath sounds were detected at the
base of the right lung behind. Otherwise the limgs were normal;
likewise the abdomen. At the top of the right testis a small nodular
mass was felt, and on the front of the scrotum there were a few soft
yellow areas, surrounded by an infiltrated reddened zone. Knee-
jerks were sluggish and there was a suggestion of Babinski's reaction
on each side. No clonus. Double Kemig sign. Gait very un-
steady. Neck somewhat stiff.
White cells, 12,500; hemoglobin, 90 per cent. Urine 1018 in spe-
cific gravity, with the slightest possible trace of albumin and with an
occasional hyaline or fine granular cast. Systolic blood-pressure, 145.
Temperature as seen in the accompanying chart (Fig. 62). The fundus
ocuU was normal.
i6o
DIFFERENTIAL DUGNOSIS
i
if^i
^^
The patient's handwriting was veiy poor and he often made
meaningless signs. March ist lumbar puncture was done, and about
lo c.c. of clear colorless fluid was obtained under slightly increased
pressure. The fluid reduced Fehling's solution, did not clot, was
negative on culture, and showed in the sediment only a rare lympho-
cyte. The Wassermann reaction was positive. On March 3d ptosis
of the left eyelid appeared. On the 4th the
left pupil became larger than the right.
DiscuBSioQ. — The gist of this case seems
to be that the patient has suffered from ver-
tigo, ataxia, dyspnea, and a girdle sensation
for five months; that for twelve days he has
had vomiting and an abnonnal mental state
characterized by listlessness, stupidity, and
rambling talk.
In the physical examination part of the
findings suggest a tuberculous process and part
a syphilitic. The signs at the base of the right
lung, the nodule in the testis, the stiff neck, the
fever and Kemig's sign, are what we should ex-
pect with a tuberculous process involving the
brain and other organs. On the other hand,
the condition of the pupils, the sluggish knee-
jerks, the positive Wassermann reaction, the
speech, and handwriting incline us toward a
diagnosis of syphilis.
The ocular ptosis might be explained either by syphilitic or tuber-
culous meningitis at the base of the brain. The condition of the
spinal fluid does not favor either hypothesis.
On the whole, the diagnosis which I favored during the patient's
life was syphilis.
Outcome.— He was given vigorous antisyphilitic treatment, but
got steadily worse and died on the 7th; in the last twenty-four hours
of life there were signs of soUdification at the right base. Autopsy
No. 2553 showed general miliary tuberculosis, tuberculous meningitis,
chronic adhesive pericarditis.
Case 57
A laborer of forty-six entered the hospital May 27, 1910. Vertigo
was the patient's chief complaint, and this was first noticed five
weeks ago, when it attacked him while at work and was accompanied
Fig. 6
.—Chart of Case
S6.
VERTIGO l6l
by a shaking chill. Since then he has had many such attacks, though
he has never fallen or lost consciousness. During the first week of this
trouble he vomited much and he has been unable to work since the
onset of his symptoms. He has had no edema, no loss of weight.
Physical examination showed a well-nourished, ruddy looking
Irishman. Normal pupils and refiexes. Heart's apex extended i
inch outside the nipple, the right border ij inch from midstemum.
The soimds at the apex were
irregxilar in force and frequency; pan^^fea;
second sound always faint, yT~i^^J^'J-
sometimes inaudible. The heart
sounds came in pairs, the first
sound of the second pair being
less booming and more valvular
than the other. With the sec-
ond ,of the pair there was a
venous pulse in the neck. Sys-
tolic blood-pressure, 130 mm,
Hg. The apex pulse was very
slow at entrance (Fig. 63).
Many beats were not trans-
mitted to the wrist. Blood and
urine normal. Lungs and ab-
domen normal. The patient's
physician, seen on the 3i5t, said
that he saw the patient April
18th and found his pulse then regular,
when the patient was lying quietly in bed.
Discussion. — Five weeks' vertigo in a patient with an enlarged,
irregular, weak heart and no definite signs of arteriosclerosis, of
kidney disease, or of aural trouble, may naturally, I think, be at-
tributed to poor cerebral circulation, local anemia. The only diffi-
culty with this explanation is that the patient's vertigo continued
even when he was lying flat in bed. Possibly the very slow pulse
may have had something to do with it.
Precisely what the relation is between heart disease and vertigo
no one seems to know. A considerable proportion of all these cases
of failing heart, probably one-tenth, are more or less troubled with
dizziness, but it is not always those with the poorest circulation who
have the most vertigo, nor can we associate the giddiness with any
single type of heart trouble. It has not seemed to me any commoner
Vol. 11—11
Fig. 63, — Chart of Case 57.
Dizziness continued even
l62 DIFFERENTIAL DIAGNOSIS
in the elderly than in the young subjects of heart disease. K this
impression is true, it militates against the supposition that cerebral
arteriosclerosis is at the bottom of the whole thing.
Outcome. — ^As the pulse-rate rose this dizziness did not seem to
disappear, but by the middle of Jxme he felt a good deal better, and
on the 1 6th he was allowed to go home. Throughout his stay in the
hospital he had a good deal of headache. Tracings were made from
the neck veins, but were not satisfactory. I cannot make a diag-
nosis in this case, but should suspect that the vertigo is due in some
way to poor cerebral circulation.
Case 58
A man of seventy-three enters the hospital Jime 13, 1910. The
patient has lost one brother by tuberculosis; except for this his family
history is negative. Thirty years ago he had an attack of inflamma-
tory rheumatism. Otherwise he has been well xmtil the present year.
His habits are excellent. A year ago he had to give up work on accoimt
of dizziness, which was first noticed five years ago when he started
quickly to walk or to rise from a chair. These attacks have increased
in severity and frequency since that time and he has fallen uncon-
scious many times. Within the past year he thinks he must have
had two hundred attacks, varying from three minutes to three-quarters
of an hour in length. He usually has about half a minute's warning,
then everything turns black, he sees stars, his head whirls, and he
falls imconscious. After the attack he often has a severe general
headache, lasting about three-quarters of an hour. He can easily
bring on another attack by exertion, and for a year past any such
exertion produced considerable dyspnea. Previous to a year ago he
could run or make any other severe exertion easily. For ten years
he has had nocturia, 2 to 3. He has always been very emotional, and
as he told the above story his eyes filled with tears several times.
Physical examination shows a poorly nourished old man, who yet
seems young for his age. His pupils are slightly irregular, the right
larger than the left, and both react sluggishly. The heart's apex
is in the nipple line, fifth space; sounds regular and of good quality.
At the apex a loud systolic musical murmur transmitted all over
the chest. The pulmonic second sound slightly accentuated. The
artery walls are thickened, cord-like, and a few roughnesses are pal-
pable on the right radial. The brachials are tortuous and pulsate
laterally. Systolic blood-pressure is 137 mm. Hg.; diastolic, 72 mm.
Hg. The second soimd, both at the apex and in the second right
VERTIGO 163
interspace, is feeble, but there is no diastolic murmur. The pulse
is of the Plateau type. The Wassermann reaction is negative. A
radiograph taken at 7 feet shows an aortic shadow, 9 cm. wide, oppo-
site the manubrium.
Discussion. — A good many things in this case suggest a simple
senility without definite organic lesion, but an aortic shadow 9 cm.
wide cannot be thus explained. The aorta must be either tortuous or
dilated, and the condition of the heart and arteries also suggest arterio-
sclerosis. On the whole, I do not see anything in the case which
cannot be explained by arteriosclerosis, though it is a little surprising
that his blood-pressure is so low.
The condition of the pupils is such as we often find in arterio-
sclerotic old men. Whether the arteriosclerosis has anything to do
with it or not I do not know. The case might be taken as typical of
a very large number in which vertigo is the presenting symptom, and
arteriosclerosis is the best diagnosis that we can make.
Outcome. — During a week's stay in the hospital the patient was
entirely comfortable and showed nothing abnormal in the ears, blood,
and urine. He had headache almost daily, and on the 20th was
allowed to go home.
Case 59
A steamfitter of thirty-four entered the hospital Jime 24, 1910.
His family history is negative and he has never been sick until within
a year. In February, 1910, he had "the grip" and was in bed a week.
Since that time he thinks he has not been as strong and has had a slight
cough, off and on, but has had«no definite symptoms until twelve days
ago.
Twelve days ago, whild threading a pipe, he was suddenly taken
with weakness, dizziness, faintness, together with shortness of breath.
He had to give up work and has had more or less similar trouble ever
since, associated with a rather sharp pain in the region of the navel,
coming once or twice a day, usually about four hours after meals and
lasting four or five minutes. This pain usually causes vomiting and is
relieved by it. He has seen no blood in the vomitus or in the stools.
He has lost about 25 pounds in four months, but worked until about
a week ago.
On physical examination the patient's face was tanned and he
looked healthy. There was no lead line; pupils and reflexes normal;
internal viscera normal. Blood and urine not remarkable. Systolic
blood-pressure, 90 mm. Hg. Temperature, pulse, and respiration
164 DIFFERENTIAL DIAGNOSIS
normal during five weeks' observation. Guaiac reaction negative in
ten examinations, positive in one. The patient vomited almost every
day imtil July 3d, no cause for the vomiting being apparent. Blood-
pressure continued between 80 and 90, more often at the lower figure
during the first three weeks of his stay. Later it rose somewhat, so
that by the end of July it ranged about 100. The skin tuberculin test
was positive. After the 3d of July he ceased vomiting and gradually
gained strength. On the i8th the stomach-tube was passed, but no
fasting contents obtained. After a test-meal the gastric contents
showed no hydrochloric acid and a moderately strong reaction to
guaiac. The capacity of the stomach could not be ascertained. The
Wassermann reaction was negative.
During his first week in the hospital the patient lost 5 pounds, but
after that time held his weight steadily, and on the 28th of July
left the hospital, much relieved.
He re-entered on the nth of August, 19 10, after being at the
Waverley Convalescent Home in the interim. At this time he
remembered that in the previous April and May he had been so
thirsty that he drank 5 gallons of water a day when working. Never-
theless he says that up to June loth he was reputed the strongest man
in his shop. This time it was noticed that the skin of his axillae and
groins was pigmented and the mucous membranes of his lips as well.
On the hard palate a few fine pigmented spots were also noticed.
Othen^'ise the physical examination was essentially as before. He
could eat nothing but crackers and milk, and vomited that occa-
sionally. On the 1 2th he had a severe attack of abdominal cramps,
doubling him up, and relieved only by morphin. The pain was
in the center of the abdomen and did not radiate. He remembers
that he had an attack like this five years ago, but none so severe since.
At that time he was exposed to lead and one of his fellow-workmen
had lead-poisoning.
Discussion. — From a histor\' like this, duodenal ulcer is perhaps
the first thought that enters our minds. The sudden attack of
faintness while at work might be due to a hemorrhage, the blood
passing into the bowel, but the continuous vomiting and low blood-
pressure in a patient completely at rest and not suffering any further
hemorrhage (if. indeevl, any has occurred^ is not characteristic of
peptic ulcer. The negative physical examination does not incline
us either for or against a jx^ptic ulcer, since in the majority of ulcer
cases physical examination shows nothing of any importance.
At the time of liis second entrance the e\"idence of pigmenta-
VERTIGO 165
tion, especially in the mouth, becomes important. Taking this in
connection with the low blood-pressure, the cardiac and gastric symp-
toms xmexplained by any obvious cardiac or gastric lesion, Addison's
disease seems probable.
Lead-poisoning, however, must be seriousiy considered. The
cramps of which this patient complains are fairly typical of lead-
colic, and his occupation is one which might well expose him to the
absorption of lead. But lead-poisoning, when it affects the blood-pres-
sure at all, is apt to raise it. Moreover, when a patient is put at rest
and all possibility of lead absorption is stopped, he almost always
shows prompt improvement. There was no such gain in this case. Yet
the absence of lead line and of stippling in the blood does not exclude
lead-p>oisoning. This is a matter of some importance, as many
early cases pass unrecognized in our clinics because the physical
examination is negative in these two respects.
If Addison's disease is our diagnosis, the vertigo is naturally
to be explained as a result of cerebral anemia from low blood-
pressure.
Outcome. — ^At 4 o'clock on the morning of the 13 th his respira-
tions became very slow and shallow and soon after he died. Autopsy
No. 2657 showed tuberculosis of the adrenal glands. No evidence of
tuberculosis elsewhere in the body. Slight chronic pleuritis and peri-
carditis.
It is notable in this case that so marked a period of improvement
took place in a patient who must have been suffering from Addison's
disease from the beginning of his symptoms. Addison's disease is
often stated to be progressive in its course. This case proves the
contrary.
Case 60
An Italian laborer of fifty-nine entered the hospital June 8, 1911.
He has previously been well and his family history is good. He
began in Jxme, 1910, to suffer from dizzy spells. In the first one he
fell and was unconscious half an hour. He has never fainted since,
but ever since then has had a tight feeling in the front and left side
of the head, with stiffness about the muscles of the neck and some
numbness in the neck and back. At times he is also very dizzy or,
again, he has failures of memory, or is unable to tell what he is doing
on accoimt of a cloudy, peculiar sensation in his head. For the last
six months his appetite has not been good and his eyesight has failed
somewhat. During the last year there has been some loss of power.
1 66 DIFFERENTIAL DIAGNOSIS
together with pain and numbness in the right arm. Nevertheless,
he has worked ahnost steadily until entrance.
Physical examination shows fair nutrition and marked tanning
of the skin. The pupils are equal, circular, and react well to light,
but slightly to distance. The left epitrochlear gland is palpable,
otherwise there is no glandular enlargement. The heart's impulse
extends i cm. outside the nipple line, in the fifth space. The sounds
are regular, faint, and at the mitral area the first sound is accompanied
by a blowing murmur, transmitted over the whole precordia. The
aortic second is sharp and greater than the pulmonic second. The
tension of the pulse seems to be somewhat increased. The walls
not demonstrably thickened. Systolic blood-pressure, 135 mm. Hg.
Blood and urine normal. Wassermann reaction negative. Coarse
moist rales are heard with inspiration and expiration over both lungs,
especially at the right base. The right shoulder seems to be a little
stiff. The grip in the right hand is somewhat less strong than in the
left. The elbow-jerks and wrist-jerks are obtained on each side and
are equal. The knee-jerks and plantars are normal.
Discussion. — The essential points in the case seem to be attacks
of vertigo and a cloudy mental state occurring in an old man with
increased arm reflexes, peculiar pupils, and diminished power in the
right arm. This is the sort of case to which we are accustomed to
attach the diagnosis of arteriosclerosis, although we do so wholly on
the history. There is nothing in the physical examination to support
such a belief. Our course of reasoning is something as follows:
Arteriosclerosis is very frequent in old men. An Italian at fifty-
nine is an old man. The symptoms here present might be all caused
by arteriosclerosis. Therefore, in the absence of any positive evi-
dence of any other disease, it is best to guide our action in prognosis
and treatment upon the hypothesis of arteriosclerosis.
What else could it be? Conceivably it might be dementia paral-
ytica, but we have no positive evidence of that disease, and the pupils,
though abnormal, are not those ordinarily associated with cerebral
spinal syphilis. The Wassermann reaction is negative, there are no
mental changes, and no defect in sphincteric action.
Could it be syphilitic meningitis? Again we have no definite
evidence, and such a disease is much less common than arteriosclerosis.
Outcome. — He stayed in the hospital only a few days, and there
seemed to be little that we could do for him. He went home on the
13th of June and died at the end of September.
VERTIGO 167
Case 61
A teamster of twenty-four entered the hospital August 12, 191 1.
Three weeks ago his head began to feel queer, contained a buzzing
noise, and felt xmsteady. Soon after appeared dizzy spells, so that
he could hardly keep his balance while walking, because the objects
around him wavered and swam about. He staggers and falls, always
to the left. Two weeks ago he had to give up work and go to bed.
For ten days he has had frequent severe headaches, beginning in the
left frontal region and lasting an hour or so. For five days he has
vomited about once a day, without relation to food. The vomiting
is preceded and followed for about half an hour by nausea. He has
noticed no weakness, no change in sensation.
Physical examination shows good nutrition, pupils normal. Nys-
tagmus. No other ocular defect superficially. Optic atrophy in the
right eye. Thorax and abdomen negative. The left plantar reflex
absent, the left cremasteric sluggish. Superficial abdominal reflexes
not obtained. Other reflexes normal. Blood and urine normal.
Blood-pressure, 130 mm. Hg., systolic; 90 mm. Hg., diastolic. No
temperature in two weeks' observation. Wassermann reaction nega-
tive. Dr. E. W. Taylor suggested aural vertigo; Dr. John Homans,
cerebellar tmnor. On the 13th the left knee-jerk is found to be more
active than the right. On the i6th there is ankle-clonus on the left
and a plantar reflex suggesting Babinski. Ankle-jerk increased.
The deep reflexes of the left arm increased. Superficial abdominal
reflex present on the right; absent on the left. A thorough examina-
tion of the ears shows no disease.
Discussion. — ^A severe headache and vertigo in a patient of twenty-
four, unexplained by any simple or obvious cause, makes us think of
cerebral tumor. In this case the vertigo is of the aural or cerebellar
type, that is, it is associated with staggering in a certain definite
direction and always the same direction. Concomitant and reinforc-
ing S5nnptoms are the vomiting, nystagmus, increase of deep reflexes,
diminution of the superficial reflexes, and optic atrophy. If the
trouble were wholly labyrinthine, many of these symptoms would
not be explicable. On the other hand, there are no symptoms in the
case that could not be explained by cerebral tumor, and this seems, on
the whole, the most reasonable diagnosis. Since localizing symptoms,
most of them concern the left side; we may suppose that the trouble
is on the right side of the cerebellum.
Outcome. — On the 12th of September the occipital region was de-
1 68 DIFFERENTIAL DIAGNOSIS
compressed with considerable difficulty, as the skull was very thick.
While the operation was going on the blood-pressure gradually fell to
85 and the pulse became impalpable. The patient's position was then
changed, and the respiration, which had stopped, improved. The
exposed dura was tense and bulging, but was not opened. After the
operation he did very poorly. While in the ward respiration sud-
denly became labored and irregular. Cyanosis supervened and the
patient died of respiratory failure. Autopsy showed a cholesteatoma
in the median line between the two lobes of the cerebellum, but not
actually in the cerebellar tissue. The tumor was encapsulated and
about the size of a fist.
Case 62
A locomotive inspector of forty-seven entered the hospital Novem-
ber 9, iQii. The patient's mother died at seventy-six of consumption;
otherwise the family histor\* is excellent. He takes a glass of whisky
once a day and smokes a pipe incessantly. He denies venereal disease.
Ten days ago he felt as well as ever, but as he started to go home
from work he suddenly felt weak, light headed, and short of breath.
Then came nausea and vomiting, but he reached home, there ate
heartily, and went to sleep. He woke ver\- tired, and while walking to
work the next day he felt weak and vomited again. While at work
that day he had several giddy spells and had to grasp a support to
prevent himself from falling. Ever>- day since that time he has had
similar experiences and a constant sense of fatigue. He vomits only
when walking to or from his work, and he has to walk very slowly.
He needs half ;m hour to cover a distance which he formerly did in
ten minutes.
L;ist night, for the first time, he fell during one of his giddy spells
and, Ixnng detectevi in this by his foreman, was sent to the hospital.
He did not K>se cv^nsciousness and had nothinsr like an aura. He has
had no tnnible in cv>ntn^lling his sphincters and no fever, but remembers
four da\*s agv> a heavy sweat. During the ten da\-s of his illness he
thinks he has Kxst 14 [x^umis.
rhysical ex;m\ination shows a thin. pvUe man. lying flat without
d>*^>nea, but with slight c\'anv>sis of the mucous membranes. The
pupils arx" circular, tx^ual, and rx\u t normally. There is no glandular
enlargement and no lead lino. Internal \-isoera n^ative. Knee-
jerks not obtaiiuxl cwn with rxnntorcvment. Ankle-jerks slight,
but prx^^nt . The nux^" of the ton\{x^raturv is shown in the accompany—
ix\g chATi vtis* ^^- ^^^' urine Axx^ragevi 45 ounces, with a ^>ecific^
VERTIGO 169
gravity of 1020, a very slight trace of albumin, and a few hyaline casts.
The leukocyte counts are as follows: November 9th, 6000; November
13th, 7000; November 2ist, 8000; December 2d, 5500; December 8th,
8500; December nth, 11,000; December 14th, 8000. The Wasser-
mann reaction is negative; blood culture is also negative. Widal
reaction is positive at entrance, but the case did not seem at all
typical of typhoid fever, as there is no prostration and no rose spots
or splenic enlargement, and the fever is often higher in the morning
than at night; in fact, this is the rule during the £rst week of his
stay in the hospital. The Widal reaction is recorded as follows:
On the loth, suggestive; on the 14th, slightly positive; on the 17th,
Fig. 64.— Chart of
positive; on the 29th, suggestive. On the 20th a few sharply resound-
ing r41es were heard at the base of each lung, and from that time
<» the tendency to hypostasis steadily increased and the respirations
rose, but no evidence of solidification was made out. December 14th
^^ seemed to be improving and the outlook for recovery seemed
topeful. At times during this week he had patches of crackling rales
io the front of the chest without any signs of solidification and without
*°y persistence in a single site.
Discussion.— The history gives us no light at all on the diagnosis.
It is not until we get to the physical examination that it becomes
'^'ivious that we are dealing with some sort of an infectious disease,
170 DIFFERENTIAL DIAGNOSIS
probably with typhoid fever, since we have a continuous pyrexia,
low white coxint, and positive Widal reaction. Against typhoid we
have mainly the fact that the fever is higher in the morning than at
night. I do not remember to have ever seen this happen in typhoid
fever. On the other hand, I have often seen the temperature higher
in the morning than at night in cases of phthisis, and Dr. James A.
Honeij has recently reported the same thing in leprosy. The posi-
tive signs of typhoid, such as enlarged spleen, rose spots, and ty-
phoid bacilli in the blood-stream, are not present here, but they are,
as we know, frequently absent in demonstrable typhoid fever.
Can this patient have a sepsis of any type? There is nothing to
suggest it, and no evidence of a focus of infection or of any source
from which he could have acquired it. Nevertheless, we must admit
that sepsis may occur without our being able to discover any point
of entry or any present focus of infection.
Tuberculosis will account for all the symptoms except for the
positive Widal reaction. The initial and persistent cyanosis and the
rising respirations suggest the miliary form.
As I remember the case, the majority of us considered it one of
typhoid, and explained the vertigo as that ordinarily associated with
the beginning of an infectious fever.
Outcome. — He died on the i6th. Autopsy showed miliary tuber-
culosis of the lungs, liver, spleen, and kidneys, solitary tubercle of the
small intestine, obsolete tuberculosis of the bronchial lymphatic glands
and right lung, chronic pleuritis of the right.
Case 63
A box maker of forty-three entered the hospital November 14,
iQii. The patient's father died at eighty-four of gastric cancer.
Otherwise the family history is good. The patient denies alcohol and
venereal disease, and, though always dizzy, has been well and strong
all his life. Sixteen months ago dizzy spells began to bother him
increasingly and are now his chief complaint. They begin with a
hissing sound in his right ear. A few minutes after this things begin
to spin round in the horizontal plane, from left to right. This lasts
about two minutes, and unless he sits down or takes hold of some sup-
port he invariably twists round from left to right and tumbles upon
his right side. The noise in the ear stops immediately before the
vertigo does. After an attack he perspires, vomits, and is weak.
Within fifteen minutes he is all right again. He never loses con-
sciousness.
VERTIGO 171
The attacks have come at various hours in the daytime, never
at night. The early attacks were separated by a week or so, but for
the last year he has had them every few days and sometimes two or
three in a day.
Eight months ago, after a severe attack, he was semiconscious
for some hours, and since then he has not felt able to work and has
gradually come to notice a deafness in the right ear.
Three months ago he noticed cloudiness and specks before his eyes
when he raised his head after stooping. Glasses gave him no relief,
though they improved his vision. He notices, however, that if he
takes off his glasses while standing or sitting he sometimes has an
attack of vertigo. In fact, this is the only thing that he knows of as
capable of bringing on an attack. He has had a few attacks of sharp
frontal headache, and for the last three months a feeling of fulness or
pressure, almost constant, in the right half of the head.
Every week or so and sometimes for several days in succession
he has a discomfort, compared to a sense of a hot stone below his
right ribs in front. This comes most often at night and has no rela-
tion to meals, but he thinks he can feel a lump in the seat of discom-
fort at the time of these attacks, which, however, bothers him very
little. His bowels are very constipated and require medicine daily.
His best weight, eighteen months ago, 122 poimds; now, 112 poimds.
He has no further complaints.
Physical examination shows poor nutrition, normal pupils and
reflexes, no nystagmus, no abnormalities in the internal viscera,
normal blood, urine, and blood-pressure; no fever. The diagnosis
at entrance was enteroptosis, with a question of cancer near the
ceciun. On the i8th he was sent to the Massachusetts Charitable Eye
and Ear Infirmary, where examination showed that the hearing in
both ears was excellent. Tests for labyrinth disease showed a slug-
gish reaction in all three directions, but nothing positive enough to
ix)int definitely to either ear or to suggest an operation. The Wasser-
mann reaction was negative. The fimdus oculi normal. A neurologic
consultant believed the case to be Meniere's disease, despite the
report of the aural consultant. At the advice of the former, 25 c.c. of
spinal fluid was removed by lumbar pimcture. The fluid was limpid
and came out under moderate pressure. The patient felt imme-
diately relieved from a sense of tightness in the right side of his head
and from the sharp pumping in his ear with each heart-beat, but next
day he vomited and had a severe attack on getting up. These attacks
continued daily, and after the spinal puncture he seemed distinctly
172 DIFFERENTIAL DIAGNOSIS
worse, in that a new set of sensations were now complained of, radiat-
ing from the point of lumbar puncture. High-frequency electricity
and hydrotherapy were given during the last week of his stay in the
hospital, whence he was discharged December 31st.
Discussion. — ^This patient says that he has always been dizzy.
A statement like this generally means a neurotic patient, and that,
naturally, is our first impression of this case, but when we find that
he has the typical Meniere's complex, we may properly doubt our first
guess. It must be admitted that Meniere's complex has been shown to
exist in patients seemingly free from any aural disease and appar-
ently belonging in the neurotic group. The results of aural ex-
amination and of lumbar puncture go to support the idea that we are
dealing in this case with what has been called a pseudo-Meniere's
complex. This is further suggested by the fact that after lumbar
puncture the patient experienced a new set of symptoms, radiating
from the point of puncture and apparently due to the strongly un-
pleasant effect made upon his mind by that operation.
The gastric s>Tnptoms may well be interpreted as those of a
nervous hypochlorhydria.
Outcome. — June 17, 1914, the patient writes that he is about the
same, that he has had several of the dizzy spells, the last four weeks
ago. He complains, moreover, of a profuse flow of perspiration in
the right side of his head. His appetite is good, weight imchanged,
and general health apparently very fair.
Case 64
A housewife of twenty-nine entered the hospital May 13, 1912.
For six months the patient has been troubled much by spells of dizzi-
ness and by severe temporal headaches. Her eyesight has always
been unsatisfactory. For the past week she has been in bed most of
the time on account of weakness and sore throat. She has fainted
once or twice, and vomited once a week ago. She has four children,
living and well, but since the last child has had four miscarriages.
In August, 1909, small sores came out upon her arms and legs, and in.
November a general eruption on the face and neck.
Her appetite, bowels, and sleep are normal. Her hands and feet
feel numb a good deal of the time. She has no cough, dyspnea, or
edema. For the last two months her menstruation has been absent.
On physical examination the patient is well nourished, drowsy,.
and slow mentally. She complains and cries out, but cannot locate
pain anywhere. The skin shows ichthyosis. The pupils are irrcg-
VERTIGO 173
ular, the right larger than the left, both reactmg sluggishly to light.
The uvula is absent and the surrounding area has a ragged edge.
The internal viscera show nothing abnormal and the reflexes are
negative. The lower legs are covered with depressed circular scars,
I to I J cm. in diameter, some white, some red, some slightly crusted.
In the wards the patient was constantly distressed by vertigo
and headache when not sleeping or drowsing. When spoken to she
answered in a weak, high-pitched, whining voice. Her mental proc-
esses were slow. The Wassermann reaction was weakly positive.
Discussion. — ^The history is not in any way definitive. The four
miscarriages may well have been self -induced. We cannot justly
take them as evidences of syphilis.
But when we come to the physical examination and find Argyll-
Robertson pupils, a throat strongly suggestive of syphilitic ulcera-
tion, and a weakly positive Wassermann reaction, I do not see how we
can fail to believe that syphilis is the most probable diagnosis. The
nature of the scars upon the lower legs is not clear from the descrip-
tion here given, but they are perfectly consistent with a diagnosis of
syphilis. If this be correct, the vertigo is to be explained as that
accompan}dng the earlier state of an infectious process. Such vertigo
is especially common at the beginning of this particular disease, per-
haps because it so early involves the cerebral spinal system.
Outcome. — On the 2 2d and the 28th ^ gram of salvarsan was given
intravenously. By the 30th she showed marked improvement, was
bright, smiling, free from headache, and eating well. The voice had
lost the distressing whine and she was able to sit up all day. On the
3d and loth of June salvarsan was given as before. On the nth the
soft palate was entirely healed, the Wassermann reaction negative.
Case 65
A machinist of forty-six entered the hospital August 7, 191 2.
The patient's father died of tuberculosis at sixty-three, otherwise
his family history is excellent. The patient had bloody dysentery
at eighteen, and for many years has had indigestion, with gas and sour
stomach, imless he is careful of his diet. He denies venereal disease.
Twenty-seven years ago his hearing began gradually to be impaired
and this trouble has progressed until now he is stone deaf. He also
has a sense of pressure in his head and noises in his ears, especially
during the last few weeks.
For two years he has had occasional attacks of dizziness and
VQmitiDg, attributed to and treated for stomach trouble, and never
174 DIFFERENTIAL DIAGNOSIS
occurring at his work, but always upon Sundays and holidays.
During the last few weeks he has felt light headed a good deal of
the time, but without vomiting. He always feels better when lying
down, and apparently can sometimes stave off an attack by lying
down and going to sleep.
Today, while on a trip to Revere, he was taken, on the electric
car, with severe vertigo, so that he staggered like a dnmken man.
He leaned against a fence and vomited; later he was brought to the
hospital.
Physical examination was entirely negative except for the deaf-
ness. Urine and blood-pressure were within normal limits. An
aural consultant found otosclerosis and considered disease of the
labyrinth possible. The Wassermann reaction was negative.
Discussion. — The patient's deafness makes it natural to attribute
his vertigo to aural trouble. Why he should have had vertigo at
first only on Sundays and holidays I have no idea. People are more
apt to overeat and overdrink at these times, and this fact may have
led his local physician to treat him for stomach trouble. One
may blame the general practitioner in a case like this for giving
treatment directed to the stomach when there is good reason to sup-
pose the ears to be at fault, but, after all, we cannot say that any
harm results therefrom, since the aural specialist can almost never do
anything to benefit the patient, who finds the latter's discouraging
prognosis by no means palatable. The patient always prefers to
refer the vertigo to his stomach. It is very natural, therefore, to
accept his view of things and treat him accordingly. Nevertheless,
if we want the truth, we have no right to allow the patient to be
without the services of an expert aurist.
Outcome. — For more thorough examination he was transferred to
the Eye and Ear Infirmary, where positive evidence of labyrinthitis
was found.
i
CHAPTER III
DIARRHEA
CAUSES AND TYPES OF DIARRHEA IN ADULT LIFE
I UNDERTOOK recently a fresh study of this ancient problem, with
the collaboration of Dr. Haven Emerson, of New York, beginning with
the necropsy records of Bellevue Hospital in New York and the
Massachusetts General Hospital in Boston. In the latter institu-
tion I examined 3000 of the necropsy records, searching for lesions
ordinarily supposed to produce diarrhea. I then traced the cases
showing these lesions back to the clinical records, trying to ascertain
first whether the lesions actually produced diarrhea, and if so, in what
proportion of cases; second, whether any special type of symptoms or
of discharges was associated with any special lesion of the intestine,
the endeavor being to mark out clinical types so far as this was pos-
sible. Finally, I reviewed the results of treatment both in necrop-
sied cases and in a considerable series of cases which did not come to
necropsy, and endeavored to estimate the value of the different
methods used.
For various reasons I have excluded from this study certain dis-
eases often associated with diarrhea. I have taken no account of the
cases of ^jghoW fever, partly because the relation of this disease to
diarrhea has already been thoroughly studied in large groups of cases,
and, second, because I was anxious to get some idea of the relative
frequency of the different diseases showing this symptom, and I am
well aware that the number of persons sick with typhoid in these two
ho^itals was not a fair sample of the number of cases of this disease
existing in the commimity outside, since cases of typhoid are quite
abnormally collected from large areas in hospitals such as that in
which I have pursued my studies. The parasitic diarrheas have also
been excluded because of the small niunber of these cases available in
Boston or New York. I have made no effort to study the cases of
mercurial or arsenical poisoning or cases of dysentery due to organisms
of the Shiga type, or other organisms closely allied to it. I have also
excluded all cases occurring in persons under sixteen years of age.
Leaving out the types just mentioned, we have left 640 cases of the
varieties ranged in Table i.
175
176 DIFFERENTIAL DIAGNOSIS
TABLE I.— RELATIVE FREQUENCY OF DISEASES CAUSING DIARRHEA
IN ADULTS— MASSACHUSETTS GENERAL HOSPITAL, 1905-1912
Acute enteritis and unknown (acute) causes — clinical cases 244
Acute enteritis — necropsied cases:
"Primar/* 9
Secondary [with and without intestinal lesions] to:
Nephritic lesions 10
Cardiac lesions 2
Cardiorcna lesions 2
Arteriosclerotic lesions 3
Acute infectious lesions 5
Various acute and chronic conditions 10
Intussusception i
42
Acute enteritis — total 286
Chronic enteritis and unknown (chronic) causes — clinical cases 139
Chronic enteritis, necropsied cases:
"Primary," i. f., of unknown cause 8
Secondary to:
Cardiac 7
Renal i
Cardiorenal i
V'arious chronic conditions 2
19
Chronic enteritis — total 158
Cancer of bowel 52
Pernicious anemil 34
Mucous colitis 32
Exophthalmic goiter 25
Ner\*ous diarrhea 17
Tuberculosis of bowel 15
Amebic dN-scnterv* 14
Fat intolerance 7
Total 640
DIFHCULTY OF DISTINGUISHING ACUTE FROM CHRONIC
ENTERITIS AND OCXJTIS
It is clearly desirable to distinguish the acute from the chronic
cases, but this I have found unexpectedly difficulL The intes-
tine is like the kidney, in that a long-standing disease may show
clinical s\Tnptoms only now and then, presenting itself suddenly
under the guise of an acute disease. Just as the acute exacerbations
of chnmic nephritis appear under the guise of an acute nephritis, so
the acute exacerbations of a chronic colitis (due to amobse or other
causes^ often ap^x^ar \snth all the e\ndences of acute disease, run a short
course and subside, though wo have good reason to suppose that the
intestine, like the kidney, remains diseased throughout long symptom-
Relative Frequency of the Common Causes of
Diarrhea in Adults
MASSACHUSETTS GENERAL HOSPITAL, 1905-1912
ACUTE ENTERITIS
CHRONIC ENTERITIS
CANCER OF BOWEL
PERNICIOUS ANEMIA
MUCOUS COLITIS
EXOPHTHALMIC GOITER
NERVOUS DIARRHEA
TUBERCULOSIS OF BOWEL
AMEBIC DYSENTERY
CAUSE UNKNOWN, 268.
CAUSE UNKNOWN, 147. KNOWN, 11.
FAT INTOLERANCE
TOTAL
KNOWN, 33.
DnnnniD 286
158
52
34
32
25
17
15
14
7
640
Vol. n— 12
177
lyS DIFFERENTIAL DIAGNOSIS
less periods. Only by following individual cases in large numbers and
over a long period of time would it be possible to ascertain whether a
diarrhea which appears to be evidence of an acute disease is really
such, or merely one of the exacerbations of a chronic process. Since
I have been unable to follow any large number of cases in this way over
a long period, I have not found it possible in this study sharply to
separate the acute from the chronic cases.
Further, the attempt to classify all the long-standing diarrheas as
due to organic intestinal disease and all the acute diarrheas asfunc-
tionaly breaks down, both for the reason just indicated and because in
some cases a purely functional disturbance hardened into a habit may
produce a long-standing diarrhea, though organic disease is demon-
strably absent.
CAUSES OF DIARRHEA
"Indiscretions in diet" have long been blamed for a large propor-
tion of the brief diarrheas occurring in adults as well as in children.
There is no reason to doubt that these indiscretions are in a certain
number of cases responsible, but a careful analysis of the records
shows that many patients suffering from precisely the same symp-
toms as those supposedly due to indiscretions of diet have, in fact,
committed no such indiscretions and eaten nothing imusual. These
patients are often badgered about dietetic history imtil some damag-
ing admission about diet is with difficulty extracted from them, the
physician feeling it incumbent on him to find something wrong in the
diet at all hazards. By leading questions, almost any patient can be
induced to assert that he has eaten something unusual or deleterious
within a more or less extended period previous to the begiiming of his
symptoms. But if we are fair and do not try to prejudge the case,
we must admit that the number of cases in which faulty diet is ob*
viously the cause of an acute diarrhea is much smaller than is ordinarily
supposed.
Among a group of 89 patients suffering from acute benign diar-
rhea, presenting in the stools no evidence of bowel ulceration and
recovering within from ten to fourteen days, 41 patients ascribed the
trouble to some supposed indiscretion in diet or to some food believed
to have been poisonous, while 48 patients, exhibiting precisely the
same symptoms, signs, and course, remembered no dietetic cause for
their trouble and, indeed, no obvious cause of any kind.
In but few cases out of this whole series was there any convincing
evidence that the patient i»' " ' vna had partaken of a certain
food and that all >^ while other
DIARRHEA 1 79
persons under the same conditions, except for abstention from that par-
ticular food, remained well. A study of the clinical records has con-
vinced me that even in the group of cases labeled by the patient or by
his physician as due to indiscretion in diet, this diagnosis is often
retrospective and made simply for the reason that other cause could
not be found.
Ptomain-poisoning is one of the commonest and one of the most
popular and fashionable diagnoses of the day among a certain class of
practitioners. Yet this diagnosis will seldom stand criticism. Many
of the cases to which this name is given turn out to be appendicitis,
gall-stones, intestinal obstruction, pancreatitis, a gastric crisis in
tabes, lead-poisoning, and other diseases having nothing to do with
ptomains. In another group of cases the evidence points simply to
an acute diarrhea of unknown origin which is labeled **ptomain-
poisoning" presiunably because of the impressive sound of the term.
The number of cases in which a chemical poison properly to be called
a ptomain or leukomain has been isolated from the food taken by the
patient is almost negligible. In my series there are no cases at all of
this kind. I have not found a single case which deserves the term
"ptomain-poisoning," although there were cases in which the diarrhea
seemed attributable, with reasonable certainty, to something wrong
in the food. In these cases the much vaguer and less high-sounding
term of "food poisoning" seems to me more proper.
I have merged in a single group a large number of cases variously
designated on the clinical records because there seemed to be no good
reason for the employment of the different terms such as dysentery,
gastro-enteritis, enterocolitis, colitis, etc. To the same group of cases,
now one, now another of these terms is applied without any clear reason,
according to the taste and fancy of the individual physician.
In a small group of cases, only 7, in the Massachusetts General
Hospital series during a period covering the years from 1895 to date,
there has seemed to be a genuine intolerance of the intestine for one
or another foodstuff, chiefly /a/. Intolerance for a protein or a carbo- ^^ j^
hydrate was very rarely identified, but in the small group of cases ^<y^
previously referred to, an excess of fat was present in the stools on
ordinary diet, and when a diet free from fat was given, the diarrhea
oessed. In none of these cases was there any definite evidence of
ptDCieatic disease or of any other organic cause for the anomaly;
•HO cases of diarrhea definitely to be referred to pancreatic dis-
4iidied in this series.
Men of the intestine is not a cause of diarrhea. This
i8o
DIFFERENTIAL DIAGNOSIS
lesion was present in a large number of the cases of my series in
which necropsy was performed, but was seldom associated with
diarrhea. Thus in 88 cases of badly compensated cardiac lesions
producing death with dropsy and general stasis, only 8 patients had
diarrhea at any time. In 7 other cases of general cardiac stasis the
intestine showed postmortem the lesions of enteritis, 3 of the ulcera-
tive and 4 of the diphtheric type, but in only one of these 7 cases was
there any diarrhea. Among 13 patients with chronic nephritis, djdng
by cardiac failure with general passive congestion of all the organs,
not one had diarrhea. Constipation is the rule in cardiac or cardio-
renal disease with stasis.
Tuberculosis of the intestine is a favorite diagnosis among general
practitioners confronted by intractable and chronic cases of diarrhea,
n my experience such a diagnosis is almost never warranted, for it is
likely to be made in patients showing no pulmonary lesions of tuber-
culosis and despite the well-known fact that tuberculous enteritis
almost never occurs except as a complication of phthisis. A striking
result of our studies is this: Even when there is a demonstrable tuber-
culosis of the intestine (complicating pulmonary disease) diarrhea
occurs in only i case out of 3. Thus in only 10 out of 31 cases,
of tuberculous enterocolitis which came to necropsy at the Massa-
chusetts General Hospital (32 per cent.) and in only 29 out of 100
similar cases studied postmortem at the Bellevue Hospital (29 per
cent.) was diarrhea present. The two series of cases here support
each other in a very striking way (Table 2).
TABLE 2.— RELATIVE FREQUENCY OF CERTAIN FATAL DISEASES
ASSOCIATED WTTH DIARRHEA (6000 NECROPSIES)
Disease.
Acute and chronic enteritis (unknown cause)
Cancer of colon
Tuberculosis of intestine
Tuberculosis of the lungs; intestine not dis-
eased
Bellevue Hospi-
tal, 3000 ne-
cropsies.
it
M
2
o
o o
E
3
55
III*^
18
100
71
45
4
29
II
Massachusetts
General Hos-
pital, 3000
necropsies.
(4
O
H
71
64
35
o o
ci
U
V
.§
32
20
10
Per cent, hav-
ing diarrhea.
8
X
40
23
29
15
9 • 9
i s 8
45
32
32
IX
^ Seventy classified as acute postmortem; 25 of these had diarrhea. Forty-one classi-
fied as chronic ix)stmortem; 20 of these had diarrhea.
DIARRHEA l8l
Even when diarrhea occurs in patients suflfering from distinct
tuberculosis of the lungs, one is by no means certain that the flux is
due to intestinal tuberculosis, for diarrhea is nearly half as common
in cases of pulmonary tuberculosis without intestinal lesions as in
cases with these lesions. Thus in io6 cases of pulmonary tuberculosis
studied postmortem at the two hospitals referred to, 15, or 14 per cent.,
had diarrhea, although the intestines showed no lesions whatever.
All this emphasizes the fact further to be insisted on that even when
intestinal ulcerations are present in a case of diarrhea we are by no
means certain that the ulcerations cause the diarrhea.
Cancer of the intestine was studied in 159 patients, postmortem
or after operation, at the Massachusetts General Hospital, and in 18
patients postmortem at the Belleyue Hospital. The percentage of
diarrhea in these cases, taken as a whole, is almost identical with that
found in tuberculous enteritis. Thus 52, or 32 per cent., of the Massa-
chusetts General Hospital cases showed a diarrhea either steadily or
intermittently, while 22 per cent, of the Bellevue cases showed the
same symptom. Contrary to the accepted idea on this subject, I
did not find that diarrhea was any commoner in cases involving the
lower part of the intestine than in those involving the upper part.
Thus in 43 cases of cancer of the rectum, diarrhea was present in 37
per cent., while in 67 cases involving the hepatic flexure, the ascend-
ing colon, or the cecum, diarrhea was present in 41 per cent. In 32
cases involving the intermediate portion of the colon, including the
transverse colon, the splenic flexure, and the descending colon (above
the sigmoid), diarrhea was present in only 18 per cent.
In chronic renal disease, diarrheas of a supposedly compensatory
Xyp^ are often said to occur. My studies did not tend to confirm this
supposition, for in 72 cases of chronic nephritis diarrhea was present
only II times either in the history previous to hospital treatment or
during that treatment.
Intussusception has for many years been associated in text-books
with a bloody diarrhea and been supposed to diflfer thereby from other
types of intestinal obstruction. This idea was borne out only to a
limited extent in the cases studied in the present series, for only 3 out
of 10 showed any diarrhea at all.
I have had no opportunity to advance my knowledge on the ,
subject of so-called morning diarrheas, the association of which with *^ ^jC\
achylia gastrica has recently been referred to. Such cases are ordinar- f^ ' t>.^
Uy too mild to need hospital treatment and, therefore, did not come
within my study. My experience, however, with similar cases in
«
1 82 DIFFERENTIAL DIAGNOSIS
private practice confirms that of others, in that I have frequently
found that hydrochloric acid is absent from the gastric contents of
such patients. The special treatment of this class of cases will be
referred to later.
Closely associated with these, according to my belief, is the type
known as nervous diarrhea or simple hyperperistalsis. Presumably,
there is some connection here between the hyperperistalsis and low
blood-pressure in the peripheral blood-vessels with vasodilatation in
the splanchnic area. The feeble rapid heart and the tendency to
faintness in such cases goes to strengthen this supposition.
An important group of cases, not very numerous, fortunately for
us, but very obstinate and mysterious, are those associated with
intestinal ulceration of unknoum cause. Many of these cases are de-
monstrably non-amebic and not due to infection by any known type
of micro-organism. Some of them bear the marks of infectious dis-
ease— fever, leukocytosis, and albuminuria. In others there is no
such evidence. The diagnosis is made from the condition of the
stools (see hereafter) or by proctoscopy. Sixty cases of ulcerative
colitis of this kind were studied at the Massachusetts General Hospital,
beginning with the necropsy record and following the case back into
the clinical history. One hundred and eleven similar cases were
studied at Bellevue Hospital. In 55 per cent, of the Massachusetts
General Hospital cases and 60 per cent, of the Bellevue cases diarrhea
was absent, and the diagnosis of intestinal ulceration or ulcerative
colitis was often quite unsuspected before necropsy. Even when the
colon is deeply and universally ulcerated, "hanging in rags," as one of
my colleagues expressed it, the bowels may be constipated throughout
the disease. Although there is nothing new about this statement,
I desire to emphasize it afresh, since there is so strong a tendency to
use the words diarrhea and enteritis as s\Tionvmous.
In cases of enteritis without diarrhea the diagnosis is, so far as I
can see, impossible, unless something suggests proctoscopy. There
may be no local tenderness in the abdomen and nothing whatever to
indicate the disease. This silence is only what one might have ex-
pected from the analogy- of t>-phoidal and tuberculous ulcerations,
which produce in the great majority of cases constipation rather than
diarrhea. Thus in only 17 per cent, of the 1495 cases of typhoid
analyzeil in Osler^s **Mcxlern Medicine'* was diarrhea present, though
in ever}* case pu^sumably the intestines were extensively ulcerated.
The conditions existing in tuberculous enteritis have already been
referred to.
DIAKKHEA 1 83
Finally, I would lay especial emphasis on the fact obvious from
the study of the cases in this series, that in many, perhaps most,
cases of diarrhea the cause is utterly unknown. No evidence of in-
fection, ulceration, food poisoning, cancer, or other disease can be
foimd. In some of these cases we have evidence that the patient has
been subjected to imusual overstrain, such as may well have lowered
his powers of resistance or upset the vasomotor tone of his splanchnic
vessels. Thus, loss of sleep and overwork often appear to be causa-
tive factors; but the intermediate steps between these strains and the
diarrhea are not clearly known.
TYPES AND DIAGNOSIS
Can we recognize what pari of the intestine is afected? Many
text-books describe symptom-groups supposed to characterize diar-
rheas originating in the small intestine and in the large intestine,
respectively. I have not been able, however, to identify any diar-
rheas originating in the small intestine. If there is a characteristic
symptomatology for such cases I have not been able to find it. As
regards the portion of the colon affected by disease one can say only
this: that the presence of marked tenesmus points almost certainly to
inflammation of the rectum. Beyond this we cannot go with any
certainty.
The study of the stools is of much importance, especially in prog-
nosis. Cases in which blood and pus are frequently present in the
stools are almost certainly associated with ulcers of the large intes-
tine and run a much more chronic course than those in which blood
and pus are absent from the stools. The presence or absence of
mucus in the stools seems to be of little importance, especially when
there is no other abnormality. Mucus is not proper ground for the
inference that enteritis or ulceration is present. In many persons
mucus is passed from time to time without any disturbance of the
general health and without any known reason whatever.
An eoccess of fat, starch, or protein in the stools is much less often
of value in diagnosis or prognosis than the evidences of ulceration just
referred to. In the routine examination of stools for causes of diarrhea
such an excess of food products is distinctly infrequent and rarely
characterizes a case for more than a short time.
Proctoscopy is of great importance in prognosis. The presence
or absence of ulceration in the rectum and sigmoid can readily be
decided by this method and, other things being equal, a much longer
course can safely be predicted in cases showing ulceration of this
l84 DIFFERENTIAL DIAGNOSIS
kind than in those free from it. Thickening and infiltration of the
bowel wall may also be recognized in this way, and may furnish evi-
dence of a long-standing, relatively intractable process. In 9 cases
of the Massachusetts General Hospital series the Anueba histolytica
was recognized in the stools and led to the identification of amebic
dysentery. Such cases, however, are rare in Massachusetts even as
importations. In parts of the country in which the Anueba histol-
ytica is common stool examination may be of the greatest importance
as a means of identifying diarrheas of this type, since it may lead to
their treatment by the recently discovered specific, emetin.
Diphtheric colitis, or enterocolitis^ produces no characteristic symp-
toms and no recognizable abnormalities in the stools. This was proved
by the clinical record of diphtheric cases in which necropsy was per-
formed at the Massachusetts General Hospital.
^'Mucous colitis, ^^ or colica mucoj^, is, in my opinion, not a colitis at
all, but a form of neurosis associated with constipation and sometimes
with starvation. Of 22 cases of this disease studied at the Massa-
chusetts General Hospital, in only 10 was diarrhea present at any time
and, even in those, constipation was much more frequent. As a cause
and a result of their neurosis many of these patients have acquired the
disastrous habit of examining their stools themselves, and it is almost
pathognomonic of the disease if the patient produces a bottle in which
curious materials have been accumulated as the result of a minute
study of his dejecta. Habit and the mental attitude are the essential
factors in these cases.
Prognosis. — The general measure of effectiveness in the treat-
ment of chronic diarrheas of all types may be seen from the follow-
ing figures drawn from the records of the Massachusetts General
Hospital: Out of 90 cases of diarrhea lasting over four weeks previous
to hospital treatment, there were apparently cured 54 , or 60 per
cent., and unrelieved (including deaths) 36, or 40 per cent. We
have called the favorable cases "apparently cured" because we have
not often been able to follow their progress after discharge from the
wards.
Further analysis of the results of treatment in 25 cases of chronic
non-fatal diarrhea, averaging about four years in duration, shows that
chronicity is not necessarily of bad prognostic import. It was found
quite easy to check the process and even to cure it in 12 out of these
25 cases in which organic ulceration and infiltration of the bowel were
not indicated by the presence of blood and pus in the stools or by proc-
toscopy. Chronicity, then, does not necessarily mean intractability.
DURBHEA 185
Our fatal cases have rarely been chronic. They averaged less than
four months in duration. In contrast with this were 2 cases diagnosed
as nervous diarrhea and yielding readily to suggestive therapeutics,
though they had lasted two years and five years, respectively.
Of 13 patients with chronic ulcerative colitis, 5 were apparently
cured, 2 were improved, and 6 not improved at all.
Acute Diarrheas. — So far as duration measures severity, the non-
ulcerated acute cases, lasting five weeks or less, were as severe as the
ulcerated cases. The average duration of 17 ulcerated cases (with
blood and pus in the stools) was fourteen days before treatment began
and thirty-eight days after treatment. In 21 non-ulcerated cases the
average duration was thirteen days before treatment and twelve days
after treatment.
The response to our therapeutic endeavors shows that the ulcer-
ated cases were far more intractable. In 17 out of 21 acute non-
ulcerated cases the movements ceased promptly after treatment by
rest, diet, and catharsis only. Three patients needed also saline irri-
gations, and one, bismuth. Opium and silver nitrate were never
needed in this group of cases.
Of the 17 ulcerated cases, on the other hand, only 2 yielded to rest,
diet, and catharsis alone. Three of the 17 patients needed opium also;
5 needed bismuth; 7, silver nitrate, and 8, normal saline irrigations.
Three of the 7 patients receiving silver nitrate had saline irrigations
as well.
Case 66
A child, four years old, entered the hospital September 9, 1908,
with a diagnosis of "subacute appendicitis,** made in the Out-patient
Department by Dr. Sinmaons. For nine weeks he had been having
diarrhea, six to seven movements a day. Every three or four days he
has had an attack of epigastric pain and vomiting. With the earlier
attacks the child was feverish. Weight and strength have been failing,
thou^ the appetite has been good.
Physical examination showed poor nutrition, good color, normal
chest. The right side of the abdomen showed slight dulness and
slight rigidity. In the right iliac fossa a soft, indefinite mass, about
the size of a lemon, could be made out. It was only slightly tender.
The range of the temperature, pulse, and respiration are seen in the
accompanying chart (Fig. 65).
Discussion. — Here is a subacute diarrhea of moderate intensity,
in a poorly nourished child, showing a mass in the right iliac region
i86
DIFFERENTIAL DIAGNOSIS
and some fever. The slow course of the disease, the lack of any severe
pain, or acute onset are against appendicitis.
Rickets is often accompanied by such a diarrhea, but there are
no evidences of rachitic changes in the bones or muscles, and no way
of explaining, by this diagnosis, the right iliac mass.
tu,-] 1 ;^Tt'ir''f^
J J . tjc w
' «. M J _ 1 J 1 J
^y it ' 4^2 f^ •
5™. ^d. . Jll^. -l/j .
^ I tttLii^^ ^
" Z i , t'^^i- tt^t.t
^ ...ttt i:':^/: t .. ^t
Vi-^ \-^V-
I ~i
, ?f
' , n.,
= « -^-^ \
S^Sr-^fj-. H
Vl^lzhdklt'L
« * r X
• "
^ - " :
|i -
Z '•'^^^ 7 '^•*'^ j^»* ■
J -, ^ ^ / ^ 1^- ^
_u BtB.B.s.a.as.BB.B.a.a
^^SS??**^- ^"^"^^
Fig. 65.— Chart ot Case 66.
Malignant disease, in a child of this age, rarely involves the right
iliac region unless a large tumor of the kidney extends unusually far
down. There is no evidence of such a tumor here.
If the liver and spleen are normal, as is here stated, we have no
reason to consider syphilis.
Tuberculosis of the mesenteric glands is common at this age, is
apt to produce a mass in the region of the cecum, and is often asso-
ciated with diarrhea and fever. One should look carefully for evi-
DIARRHEA 187
dences of tuberailosis elsewhere and for free fluid in the peritoneum,
but such evidences are often absent. A tuberculin test should be
done.
Outcome. — ^After waiting a week for some improvement in the
child's condition, the abdomen was opened on September i6th.
A small amoimt of clear serous fluid escaped. The appendix, cecum,
and the whole of the large intestine were dotted with small nodules,
thought by the surgeon to be miliary tuberculosis. The appendix was
removed, but on microscopic examination found to be entirely normal.
Its external surface, however, showed infiltration with round cells,
in areas containing cheesy centers and giant-cells. The condition was
pronounced tuberculosis by the pathologist. After operation the
child continued to lose weight and strength, and on October 6th was
discharged in poor condition.
Case 67
A girl of eighteen, working in a hat factory, entered the hospital
March 25, 1907. For two years the patient has had pain in the lower
left side of the abdomen, radiating to the median line, but never be-
yond it, occasionally upward to the left shoulder. This pain has been
worse for the last six months, troubles her more in the morning, more
when she is constipated and when she is on her feet. It has no rela-
tion to food or to micturition and does not keep her awake. She has
no cough and no vomiting. She has had no previous ilhiess. Her
family history is good, except that her father has been ill for as long
as she can remember; why she does not know.
Physical examination shows good nutrition and is negative, save
that the abdomen is somewhat tender and rigid between the imi-
bilicus and the pubes. Temperature, blood, and urine normal.
Stomach-tube examination shows nothing remarkable. Guaiac test
in the stools negative. After a few days of liquid and soft-solid diet,
with Carlsbad salts and a bitter tonic, she feels much improved.
Examination of the abdomen under ether, with rectal examination,
reveals nothing and she is discharged "well" on the ist of April,
1907.
She continued well and worked until the summer of 1908, when she
had to give up on account of lack of strength. Although she has been
at work she has had epigastric pain ever since leaving the hospital,
her pain aggravated by food, but not asssociated with any lack of
appetite. For eight weeks she has been able to take nothing but milk.
For a week she has had diarrhea and swelling of the ankles. There has
DITFEHENTIAL DUGNOSIS
been no vomiting at any time, but she has lost steadily in strength
and weight.
She enters the hospital for the second time November 7, 1908,
emaciated, but without any demonstrable phyacal ^gns except
moderate edema of the feet and ankles. The blood and urine are
negative and there is no fever during the three weeks' stay in the
hospital, but her pulse is often above no (Fig. 66). Her weight at
the time of entrance is only 75 pounds. Guaiac test is positive in
the stools, which contain blood
ill
and mucus. The first week she
gains 5 pounds, but ascites is
demonstrable on the i8tb, and
there is a slight edema of the
skin over the abdomen and
back. The guaiac test con-
tinues strongly positive and the
diarrhea cannot be checked.
No tubercle badlli are foimd
in the stools.
DiscuBsioD. — We utterly
failed to understand the case
during the patient's first stay
in the hospital. She remaihed
only a week because we could
find nothing wrong on physical
examination. The long-stand-
ing pain in the left iliac re^on
might have su^ested in an older person a diagnosis of cancer of the
sigmoid or diverticulitis, but the patient's age makes these prac-
tically impossible.
Pelvic disease, such as pus-tube, was considered, but apparently
ruled out as a result of the thorough examination imder ether. Our
diagnosis, when she left the hospital April ist, was gaslru; neurosis.
When she returned, six months later, the steady loss of weight
and strength, the diarrhea, swollen ankles, emaciation, and fever made
it clear that we were dealing with a chronic infectious disease. The
most definite localizing sign was the character of the stools, which
showed conclusive evidence of intestinal ulceration, namely, blood
and pus.
Ordinarily, I think, not enough attention is paid to the importance
of pus in the stools. Many hospital records never mention it, yet it is
Fig. 66. — Chart ot Case 67.
DIARRHEA 189
present in a great majority of cases of intestinal ulceration and is more
distinctive of that condition than blood. Given the evidences of ul-
ceration in the bowel, one has still to inquire the cause of this ulcera-
tion. In temperate climates one may rule out amebic dysentery imless
the patient has previously resided in a tropical or subtropical climate.
Aside from this variety of ulcerative enteritis, we know nothing of the
causes of such a condition, except that a small proportion of them are
due to tuberculosis. The great majority reveal no cause, either
during life or after death. It sometimes^ appears that diseases which
lower the patient's power of resistance make him liable to infection
in the intestine, as well as elsewhere. Perhaps the bacteria ordinarily
present in or upon the intestinal wall may attack the tissues when
long-standing diseases, such as cirrhosis, nephritis, diabetes, or
arteriosclerosis, have weakened the system. However this may be, it
is certainly true that, in the great majority of cases, ulcerative enteri-
tis, arising in temperate climates, shows no known etiologic agent.
This is of some importance because the diagnosis of tuberculous
enteritis is so often made wrongly in cases of long-standing diarrhea.
In my opinion this diagnosis should never be made imless there is
abimdant evidence of tuberculosis in the lungs or peritoneum, to one
of which intestinal tuberculosis is usually secondary. The demon-
stration of ascites on the i8th made it natural to assume that the ac-
compan)dng enteritis was of tuberculous origin.
Outcome* — On the 26th I made the diagnosis of tuberculous peri-
tonitis with tuberculous enteritis. On the 29th the patient died.
Autopsy showed tuberculous ulceration of the small intestine and
one tuberculous ulcer in the large intestine; also tuberculosis of the
mesenteric and peritoneal lymph-glands; amyloid degeneration of
the spleen and kidneys; no tuberculosis of the peritoneum; no ascites.
Although my diagnosis was half-right in this case, even this degree
of success was largely accidental, for my diagnosis rested chiefly on
the suppK)sed presence of free fluid in the peritoneal cavity. This is a
mistake not infrequently made in patients who have diarrhea, as the
intestines with their fluid contents can probably shift from side to
side in such a way as to simulate the movement of free fluid.
Case 68
A baker of twenty-eight entered the hospital July 9, 1909, for
diarrhea. Ten years ago he had syphilis; one year ago, gonorrhea.
Otherwise he has been well. Ten weeks ago, after eating half a dozen
overripe bananas, he began to have abdominal pain and diarrhea.
190 DIFFERENTIAL DUGNOSIS
Five or six watery movements a day have continued ever since.
There is no blood and no pain with movements, but the taking of food
excites pain. The appetite is poor, but he has never vomited. He
has been losing weight and strength and thinks he has had fever at
times. Three months ago he says he weighed 150 poimds, with his
clothes. At entrance he weighed 114 pounds, without clothes. He
worked until three days ago.
On physical examination the patient was well nourished, and
during a month's stay showed almost constantly subnormal tem-
perature and pulse, the latter ranging between 50 and 60, while the
temperature averaged 97° F. The physical examination was wholly
negative. The blood and urine were normal. The stools contained
much undigested food — meat, potato, and com were identified with
the naked eye. Microscopic examination shows an excess of fat,
soap, and fatty acid; no mucus, pus, or parasites. Guaiac test
strongly positive. On a Schmidt diet the amount of muscle was
somewhat less. There was still much free starch and fat, especially
neutral fat, calcium soaps, and colorless soaps. Guaiac test was still
markedly positive. Dr. H. F. Hewes saw the patient July 8th, and
thought there was either some involvement of the pancreas or some
lesions high up in the intestinal tract. He prescribed a diet consist-
ing of meat once a day, milk once a day, four slices of toast, custard,
jelly, macaroni, potato puree, and white of egg. On this diet the
patient's diarrhea ceased, and he began to gain in weight and strength
as soon as glucose, 100 grams a day, was added to the diet, though
there still continued to be an excess of fat in the feces. After the
24th he began to gain in weight, and in the week following that date
gained S pounds, so that he left the hospital, July 31st, weighing 121
pounds. At that time Dr. Hewes considered the case one of func-
tional diarrhea, due to some disturbance high up in the intestine, pos-
sibly an interstitial pancreatitis.
August 6th the patient re-entered the hospital, stating that he
had been unable to work since leaN-ing the hospital, as his diarrhea
at once recurred, three or more movements a day. Three days ago
he began to have alxlominal pain and the stools increased to nine
a dav. He stated that he had adhered strictlv to the fat-free diet
given him when he left. His weight August 6th was 118 pounds.
He was put at once upon the s;\me fat-free diet and gradually improved.
Nevertheless, August 15th there was still a great excess of fatty adds,
cr>"stals, and soaps. He was then given a diet containing nothing
but lean meat, albumin-water, and toast. This checked his diarrhea.
although microscopic examination of the formed movements showed,
August 37th, that some excess of fat was still present. In five weeks'
stay he increased in weight to 124^ pounds and during the last three
weeks had no diarrhea.
He left the hospital September gth, but returned December 24th,
having been two months at Tewksbur>' Almshouse in the interim.
His abdomen had been sore, especially near the navel and to the left
of it, for two weeks. The diarrhea had gradually returned and he said
he had lost 30 pounds in three months, though adhering closely to a
fat-free diet. The examination of the abdomen now showed a nodu-
Fig. 67.— Mass felt in Case 68.
lar, tender mass, as indicated in Fig. 67. During this, his third stay In
"le hospital, he had no diarrhea, but his weight was only 105 pounds
St entrance, increasing a couple of potmds in the next ten days. Jan-
"^ i, igio, the tumor was very much less distinct, if, indeed, it was
M^ble at all. He was given pancreon, 10 gr. three times a day after
'"^, but without effect.
January gth it was decided to open the abdomen, with a view to
ffiieving^ if possible, some lesion of the pancreas, but on examination
"'^ stomach and pancreas were found to be normal. At the splenic
"^^Me of the colon there was a solid tumor the size of a hen's egg,
192 DIFFERENTIAL DIAGNOSIS
from which a projection extended downward, beneath the perito-
neum. At the root of the mesentery, corresponding to the jejunum,
a soft mass of glands was found. One of these was removed, but
showed, on examination by Dr. W. F. Whitney, a normal lymph-
gland structure except for some evidence of hypertrophy. As it was
thought impossible to remove the splenic mass, the abdomen was
therefore closed. The fatty stools continued after operation. He
seemed to have considerable pain and some tenderness to the right
of and above the navel.
On the 29th of January both hands were forcibly flexed at the
wrist, with all the fingers likewise flexed. Although the latter could
be readily straightened out, they immediately returned to their
former position when let alone. At this time he could speak only in
a whisper. The house officer considered the attack one of hysteria.
On the 17 th of February there was an attack similar to that above
described, but this time the patient seemed very much confused and
semicomatose. The knee-jerks were normal. Later in the morning
the patient complained of numbness in his hands. From time to
time thereafter he vomited large amounts of food material. He
remained in the hospital until February 23d, but did not gain appre-
ciably and was discharged unrelieved.
Discussion. — The recurrence of diarrhea in this case, and its cessa-
tion when the fats of the food were limited, seem to prove an intoler-
ance of the patient's system to fat. We have no special reason to
incriminate the pancreas, since after the very first the proteins and
carbohydrates seemed to be well taken care of. We were altogether
in the dark as to the cause of the fat intolerance until the mass shown
in the diagram made its appearance, and even after that was discov-
ered there was no good explanation of the diarrhea, since the intestine
was apparently not interfered with.
From the situation of the mass and the age of the patient a malig-
nant lymphoma or a tuberculosis of the retroperitoneal glands seem
most probable. The softness of the gland at the root of the mesentery
favors tuberculosis, but the histologic examination negatives this, at
any rate, so far as the gland examination is concerned.
The attack of the 29th of January may have been hysteria, but
was more probably tetany.
Outcome. — He went to Tewksbury State Hospital and died July
21, 1 9 10. The cause of death was believed to be carcinoma of the
splenic flexure. Lymphoma seems to me more probable. There is
no record of any postmortem examination.
DIARRHEA 193
Case 69
The patient, a housewife of twenty-nine, was first seen July 3,
1907, when she entered the hospital for dysmenorrhea, nervousness,
and a mass which she feels moving in the abdomen. Both tubes and
ovaries were removed supposedly for subacute salpingitis. She did
well after that, but came to the hospital again October 8, 1908, on
account of diarrhea which began in July, 1908. The movements at
first were as frequent as fifteen in an hour and contained fresh blood.
They were associated with pain during and just before the evacua-
tion. In July she also had epigastric distress after eating, and soon
after began to vomit green and slimy material in small amounts.
For the past eighteen days she has been improving and was now
troubled with raising large amounts of gas. Her bowels were con-
stipated and she had very little gastric distress. She had been much
in the open air, and her color, which was naturally dark, had become
much darker. During this sickness she has lost about 25 pounds.
She now weighs 119 pounds.
Physical examination showed a dark skin, especially on the arms
and face. The folds of the axillae were also markedly pigmented and
above the crests of the ilia the skin was dark brown in color. She was
well nourished and showed no pigmentation in the mouth. Physical
examination was generally negative except for dulness in the flanks
of the abdomen, shifting with change of position. There was no fever
in two weeks' observation. Systolic blood-pressure, 125 to 130.
The blood and urine were normal. The stomach capacity was 44
ounces. There was no residue before breakfast. Gastric acidity
was not tested. On the i6th of October the ascites seemed to be in-
creasing, though she seemed in other respects better. At times it
seemed as if the fluid were encysted, as it did not shift freely with
change of position. At other times a demonstrable shifting seemed
clear. After 5 mg. of old tuberculin, subcutaneously, there was no
reaction.
On the 22d of October, 1908, she left the hospital. August 16,
1909, she returned, having been in fair health and having attended to
her housework meantime, though she had been subject to crying
spells, with nervousness and shivering. In June, 1909, she began to
have abdominal pain and diarrhea, with blood and mucus in the
stools. These symptoms had continued ever since, save for remissions
of a few days, from time to time. She had had no formed stools since
June. Their number was six to ten daily and they were accom-
VoL. 11—13
194 DIFFERENTIAL DIAGNOSIS
panied by griping, paroxysmal pain, lasting ten minutes and rep>eated
every hour or so. She had had practically no gastric troubles. When
seen August i6, 1909, she was well nourished and showed no physical
sign of disease.
Discussion. — Here is a patient who has sujffered during two suc-
cessive summers from severe diarrhea. There are some suggestions of
a neurotic temperament. Addison's disease is suggested by the dark-
brown pigmentation of the skin, as well as by the loss of weight and
vomiting. There was no record of low blood-pressure and no cardiac
symptoms; the remissions which have characterized the disease are
very unlike the progressive course of Addison's disease, also her good
condition in August, 1909.
The apparent presence of fluid in the abdomen and the pigmenta-
tion, as well as the diarrhea, are common in tuberculous peritonitis,
but against this are the negative tuberculin reaction, the absence of
temperature, and the lack of any spasm or pain, even slight, in the
abdominal muscles.
The diagnosis made and thus far imrefuted was of a diarrhea de-
pendent upon the patient's nervous and mental condition. There
were many indications that if a Social Service worker had gained her
confidence and looked into her home conditions, her worries and asso-
ciations, some more definite cause might have been found in her tem-
perament or environment.
Outcome. — There was no fever in four weeks' observation, during
which time she gained 8 pounds in weight, which was at the end 119
pounds. On a Schmidt diet she had no diarrhea, normal stools, and
within a short time was given house diet, which was also well borne.
Though very nervous, she improved markedly, and went home on the
8th of September. She was seen again December, 1910, when she
had an incomplete miscarriage (?), but no more trouble with her
bowels. January, 191 2, she had continued well. Obviously, there
must have been some mistake in the report that both tubes and
ovaries were removed in 1907.
Case 70
A janitor of thirty-four, bom in Russia, entered the hospital
November 22, 1909. His family history and past history were not
remarkable, and he had been perfectly well until last May, when,
after working hard and getting very hot, he drank some ice-water.
This was followed by a pain in the epigastrium and right hyjxxJion-
drium, and within a few hours by a bad diarrhea with some blood in
DIASRHEA 195
the stools. At first he had four or live movements an hour, and since
then he has been unable to work on account of diarrhea. Excessive
frequency of micturition accompanied his other troubles. At first
there was blood in his urine, but this was not seen again until this
morning, when he passed small amounts of blood frequently. Of late
he must pass his urine at least twenty times in the night. There has
been pain low down in the abdomen for four months and a half.
His appetite has remained good and he has had no vomiting, but
meat causes distress.
Physical examination was nL-galivu except as relates to the ab-
domen, where "a hard slightly irregular mass, dull on percussion and
tender," was found in the position shown in Fig. 70. There was no
■evidence of fluid in the belly. Rectal examination showed a large
lard mass in the region of the prostate, not tender, but apparently
'■ connected with the suprapubic mass. After catheterization the latter
disappeared and was evidently due to a distended bladder. The
urine, at the time of entrance, contained almost nothing but blood
and was 1030 in specific gravity. Leukocytes, 9700. Hemoglobin,
90 per cent. Weight, 133 pounds. Temperature as in the accom-
I
=«1
i^^m
m
196 DIFFERENTIAL DIAGNOSIS
panying chart (Fig. 71). The patient refused operation. The blad-
der was washed free of blood-clots, and thereafter he was able to pass
a fair amount of bloody urine. December ist gonococd were found
in his urethral discharge. He continued to complain of pain on mic-
turition and would drink but little water. The urine contained so
much blood that nothing else could be distinguished in it. Its amount
averaged 40 ounces in twenty-four hours. He seemed to be in pretty
fair condition until the afternoon of the 24th of December, when he
complained of pain and slept so poorly
that he was given J gr. of morphin, sub-
cutaneously.
Discussion.— The association of diar-
rhea with hematuria is common in cancer
of the bowel extending to the bladder;
also in neoplasms of the bladder and
prostate, involving the bowel. In the
tropics, bilharziasis is also a common
cause of proctitis and hemorrhagic cys-
titis, but, so far as is known, this patient
has never lived in a country where such
infections are common. Since rectal ex-
amination shows no evidence of rectal
cancer, it seems more reasonable to be-
lieve that the trouble originated in the
bladder or prostate.
Gonorrhea can afiect both bladder and
rectum, but never produces so profuse a
discharge of blood. The presence of gonococci in the urethral dis-
charge had nothing to do with his main disease.
The excessive and continued hematuria are not consistent with
any known disease of the kidney. Hematuria from this source is not
often associated with such dysuria and frequency.
Malignant disease of the bladder is not common at thirty-four, but,
taking all things into consideration, no better diagnosis can be made.
The drinking of ice-water was probably of no importance in the case.
Outcome. — Two and a half hours after the morphin injection of
December 24lh he was found to be pulseless, and on the arrival of the
house officer was dead. Autopsy (No. 2492) showed: Squamous-cell
carcinoma of bladder with bone formation in the stroma; occlusion
of ureters in bladder wall; suppurative nephritis of right kidney;
atrophy of right kidney with dilatation of its pelvis; compensatory
:^::
Fig. 7i.^<;hatl of Case yi
hypertrophy of left kidney; dilatation of ureters; obsolete tuberculosis
of the mesenteric lymph-glands; chronic pleuritis. The intestine was
not remarkable.
Case 71
A salesman of twenty-four entered the hospital January 27, 1910,
with a diagno^ of "tubercular enteritis" (Out-patient Department,
142,612). Family history negative. The patient had typhoid fever
eight years ago and no other illness of importance. He smokes one
or two boxes of cigarettes a day.
January 3d he had severe pain in the right lower quadrant and a
temperature of 102° F. Also some pain in the left upper quadrant.
He went to bed for five days,
and since he got up, nineteen
days ago, he has had an ob-
stinate diarrhea, sometimes
twenty-four movements a day,
with much colorless mucus.
He has now no pain in the
right lower quadrant, but a
week ago he was so sore along
that side of his abdomen that
he could hardly move his right
leg, and he has therefore re-
mained in bed since that time.
There has been no nausea or
vomiting since the 3d of Janu-
ary, but he believes that he
has had a little fever for at
least forty-eight hours. His
appetite for the past ten days
has been poor, and his sleep poor for three weeks,
ginning of his illness he has lost 13 [raunds.
Temperature at entrance, 99.2; pulse, 102; respiration, 25. White
cells, 27,000, the stained smear showing polynuclear leukocytosis.
Urine negative. Chest negative. Abdomen tympanitic, the upper
portion gradually becoming dull as one approached the pubes. In the
right lower quadrant an indistinct mass, the size of an egg, was felt,
and there was some spasm and tenderness in this region. "Rectal
examination reveals a hard prostate, either enlarged or pushed down.
The large mass felt seems like a full bladder." The course of the
Fig. 73
—Chart of Case 71.
Since the be-
198 DIFFERENTIAL DIAGNOSIS
temperature during the patient's three weeks in the medical wards
was as seen in the accompanying chart (Fig. 72).
Discussion. — The age of the patient, together with the diar-
rhea, the soreness, and the mass in the cecal region, are quite consist-
ent with an abdominal tuberculosis. The duration of the symptoms
also favors this. Against it, however, are the high leukocyte count
and the absence of any considerable fever during most of his three
weeks in the ward.
The only type of neoplasm often seen in persons so young k
malignant lymphoma, and this is seldom associated with so marked a
leukocytosis or so obstinate a diarrhea. In the majority of cases,
moreover, malignant lymphoma is multiple.
Appendicitis would account for the mass and the leukocytosis,
but against appendicitis are the prolonged diarrhea and the absence
of any marked elevation in temperature or pulse. The clinical diag-
nosis favored abdominal tuberculosis.
Outcome. — On the 29th of January the abdomen was opened,
the small intestine found matted together about the cecum. A small
cavity of pus, containing about 2 drams, was found at one side of the
cecum. The appendix was found adherent to the cecum and perfor-
ated at the tip. No evidence of perforation was found in the gut
The patient did well after operation and was discharged February
i6th. Examined February 18, 191 1, he seemed to be entirely well.
Why the patient never had any elevation of temperature and pulse,
and why he had so much diarrhea, I do not know.
Case 72
A schoolboy of eighteen, bom in Turkey, enters the hospital
April 19, 1 9 10. He has been in this country only eight months, but
has been sick for considerably more than a year with obstinate diar-
rhea in recurrent attacks and with almost constant abdominal pain.
Owing to his scanty acquaintance with English, no further history is
obtained.
The patient is emaciated and has a dr>', harsh skin. His eyelashes
are noticeably long. Fingers slightly clubbed at the ends. His chest
negative. Abdomen slightly distended, tympanitic in the epigastrium,
dull in the flanks, the dulness shifting with change of position. The
whole right side is slightly spastic, especially in the right lower quad-
rant. Visceral examination otherwise negative. Urine negative.
White cells, 6000 to 8000. The stained smear shows moderate achro-
mia and slight deformities of the red cells. Marked increase of
DLUIBHEA 199
blood-plates. The bowels moved three to ten times a day during
his month's stay in the hospital. Feces contain much mucus and an
occasional leukocyte. No excess of fat, muscle, or carbohydrate.
Guaiac test alwajre negative and no tubercle badUi or other organisms
of importance. The temperature as in the accompanying chart
(f"ig- 73)- Weight, 72§ pounds, gradually decreasing to 68 pounds
during the course of his stay. The camphor, opium, and tannin pill,
large doses of bismuth, lactic add milk, the fluidextract of coto bark,
tincture of catechu, the Schmidt diet, and various other modifica-
K ! 1 : s = «r?jf -;-)-:: UlifS ! t!*m5 S ?:: :
- ' - - -r - - -R- s ^"-l^^--f--
! Zi:^--z::n^iz-,:i:z±:±--z----y-:z:--z-.
Fig. 73. — Chart of Case 71.
^ons of diet were given without result. When the boy left the hos-
I*ital, May 20th, he was worse than at entrance.
Discussion. — In many ways this case resembles the last {Case
^To. 71), although there was only spasm, no mass in the right iliac
region. A year's diarrhea in a Turk, with fever reaching repeatedly
above 102° F,, and free fluid (apparently) in the peritoneum, suggests
abdominal tuberculosis, especially as the diarrhea proved intractable.
It is conceivable that in this case, as in the last, appendicitis may
have been present, but the low white count and the long course of the
case are against this. Unfortunately, we have no definite knowledge
of the outcome.
DIFFERENTIAL DIAGNOSIS
Case 73
A girl baby, seventeen months old, entered the hospital June 13,
1910. Its parents and the rest of the family are healthy. The
baby was breast fed for eleven months and has always been well
until yesterday, when it ate a large amount of fresh bread, potatoes,
and macaroni. At 2 a. m. today the baby waked, feverish and vomit-
ing. After castor oil it slept, but awakened at 5 a. u. and had general
convulsions with cyanosis and dyspnea. More castor oU was given,
but at 8 o'clock there was another convulsion, lasting three minutes.
The bowels moved five times normally yesterday, once this morning
after 2 o'clock and again after an enema.
The baby is fat and healthy looking. Tonsils much enlarged and
reddened. Anterior surface of the pillars is covered with small red
papules. Physical examination
^liiliiittrk|^lulH["|i kl'l otherwise negative. The strep-
"'"'"' ' ■ ' ■ ■ " T M I tococcus is the predominating
organism in the throat. The
blood shows 15,500 leukocytes,
with a slight polynuclear leuko-
cytosis. Urine norma!. Nu-
merous loose stools continued
during the first ten daj^ of the
child's stay in the hospital, the
stools containing blood and pus.
There are numerous riles scat-
tered in various parts of the
chest. The ears are examined,
June i8th, by Dr. Mosher, who
finds both ear-drums reddened,
and on puncture recovers a little
pus from each. By the 25th
the bowel movements are fewer
in number, the lungs clearer, and the ears discharging less. By the
29th the stools are normal in frequency and quality. This evening
the pulse is very slow and a little irregular. Temperature abnormally
low, but nothing of importance results from this state of things.
Discussion.— So high a fever in a young child should make us
search for ail the commoner sites of infection, and exclude otitis
by examination of the ears; bronchopneumonia, by examination
of the chest; and pyelitis, by examination of the urine.
Fig. 74. — Chart of Case 73.
DIARRHEA 20I
Evidentiy the child had a streptococcus throat, and the small red
papules in the pharynx made us look carefully for an exanthem.
None such, however, appeared, and when all the infections mentioned
in the previous paragraph had been ruled out, there remained no
serious doubt that the infection was of intestinal origin. That it was
not a mere food diarrhea was shown by the presence of blood and pus
in the stools, as well as by the duration and obstinacy of the symptoms.
Intussusception would produce diarrhea more or less similar to
this, but would be imlikely to last so long without producing any
tumor, abdominal distention, or other severe symptoms.
Since no cultures were made from the stools, there is nothing more
to be said regarding the organism at work there.
Otttcome. — By the 2d of July the baby seemed quite normal,
except for a slight discharge from the right ear. The treatment con-
sisted of milk feedings, 3 6unces every three hours, alcohol sponges at
80® F. for fever, and rectal irrigations every six hours with a quart of
warm salt solution. The ears were syringed every two to four hours
with warm boric acid solution. Water was offered' the child very
frequently. The course of the disease is well indicated in the ac-
companying temperature chart (Fig. 74).
Case 74
A widow of sixty-four entered the hospital June 21, 19 10. Family
history and past history uneventful. In August, 1909, she began to
have diarrhea, with five or six loose movements a day, each preceded
by cramps in the left lower abdomen, radiating from the region of
the hip down the leg, and relieved by the passage of feces. She
has had no normal movements since August, 1909. In February,
1910, she began to notice blood-streaked, jelly-like masses in the
movements, and since that time she has been confined to bed for a day
or two, off and on, in order to relieve the pain. For four weeks her
bowels have been costive at times. Since February, 19 10, the ab-
domen has been greatly swollen, the swelling more or less relieved in
the last two months by four spoonfuls of castor oil each morning.
The appetite has been fair until about a month ago, at which time
she had to give up work. Her usual weight, 180 pounds; now, 151
poimds.
On physical examination the patient is still fat, but sallow and
I>ale. The head and chest are negative. The abdomen shows in
the left iliac fossa an indefim'te, very tender mass, about the size of an
orange, but is otherwise negative.
202 DIFFERENTIAL DIAGNOSIS
Discussion. — Malignant disease of the sigmoid is certainly the
diagnosis which comes first to our minds, but we are less confident
of this impression's correctness when we note that the patient con-
tinued her work until a month ago and that she is still fat, despite
the loss of nearly 30 pounds. Nevertheless, it is well known that
intestinal neoplasms have a remarkable latency and mildness in
many cases.
Diverticulitis is a possibility which must always be taken into
consideration when cancer of the sigmoid is our first choice, since
the cases published within the past five years make it clear that these
two diseases may be almost or quite indistinguishable without his-
tologic examination of the tumor mass.
In this case the absence of fever and leukocytosis and the notable
discharge of blood incline us to favor cancer.
Tuberculosis rarely appears in the abdomen at this age, and rarely
shows itself in the region of the sigmoid. The cecum and the epi-
gastric region are its commonest sites of manifestation.
Outcome. — June 27 th the abdomen was opened and a cancerous
mass found in the sigmoid, involving the entire gut for 4 or 5 inches,
the mass itself being about the thickness of a man's wrist, hard and
nodular. Glandular infiltration was extensive in the neighborhood. A
right inguinal colostomy was done. The patient made a good recov-
ery from the operation and was discharged in good condition on
July 19th.
Case 75
A shirtwaist maker of twenty-two, unmarried, entered the hospital
August 16, 1 9 10, with a diagnosis of typhoid fever. Thirteen days
previously she began to have diarrhea, four or five movements daily,
continuing until three days ago, since when she has been constipated.
Nine days ago she left work and went to bed on account of weakness.
She has felt feverish and chilly, and during the last two or three days
has had severe headache.
Physical examination showed good nutrition, normal chest and
abdomen. Normal extremities. White cells, 7000, with 55 per cent,
of polynuclear cells. Urine negative. The Widal reaction was done
every second day for two weeks, and every four days thereafter, until
the 20th of September. At no time was there any evidence of a posi-
tive reaction. She had no diarrhea during her stay in the hospital.
Temperature was as in the accompanying chart (Fig. 75). She
looked typically typhoidal. At one time in the early days of Sep-
DIAKBHEA 203
tember she had con^derable pain od micturition, but this pain ceased
when the urotrt^in was omitted, a drug which had previously been
given in doses of 5 gr. every four hours. The agglutinative reaction
with the alpha- and beta-paratyphoid were negative, but with the
Bacillus coli a positive reaction was obtained in a dilution of i to 40.
Discussion. — A short fever, preceded by ten days' diarrhea and
Elding in recovery, presents itself in this case. Arguing from the
agglutinative reaction with the colon bacillus, one is inclined to class
this as a colon bacillus infection, but it is to be remembered that the
number of demonstrated cases of generalized infection from colon
Fig. 7S. — Chart of Case 75.
bacilli is very small, and that many strains of colon bacilli are ag-
glutinated in considerable dilution by normal blood-scrum.
But for the absence of the Widal reaction the case would un-
doubtedly be classed as one of abortive typhoid, and I do not see
that this disease can be excluded. It is not reasonable to hang our
diagnosb or our refusal of diagnosis wholly upon a single laboratory
finding, such as a Widal reaction. The presence of diarrhea is, if
anything, rather against typhoid, as it occurs in only 20 per cent, of
Typhus fever (Brill's disease) was not considered in this case, yet
it seems to me to deserve consideration because of the duration of the
204 DIFFERENTIAL DIAGNOSIS
case and the tolerably rapid lysis. Against typhus is the normal
white count (it should be ii,ooo to 13,000) and the absence of any
cutaneous eruption. Nevertheless, I do not think that this diagnosis
can be excluded.
I see no reason to consider seriously the phrases "grip" or "fe-
bricula," terms often applied to short fevers of unknown origin, but
undesirable because they give the appearance of knowledge without
the reality.
Outcome. — Blood culture was negative. September 20th she had
gained 7 pounds, was walking without fatigue, and was allowed to go
home.
Case 76
A sewing girl of twenty entered the hospital September 15, 1910.
The patient's mother died at forty-two of gastric cancer. All her
family are nervous. In April, 1908, she was operated upon in St.
Joseph's Hospital, Providence, for a cervical swelling of four months'
duration. Otherwise she was well until her present illness, but she has
been in the habit, during the last three or four months, of drinking
19 to 20 cups of fairly strong tea a day. Before this time she took
only about 3 cups of tea a day.
In March, 1909, without known cause and without previous
stomach symptoms, she was suddenly seized with severe epigastric
pain, relieved only by morphin. In the course of three days this
pain wore off and she went back to work, but never since that time
has she been free from epigastric pain and hardly a day has passed
without vomiting. During July, August, September, October, and
November, 1909, she was in St. Joseph's Hospital at Providence.
In November she was operated upon by Dr. Harris, and in January,
1910, she went to work again, but in March began to have pain in the
right iliac fossa, which led to a second operation at the same hospital
by Dr. McKenna, April ist. For the past two months she has had
an attack of pain in the left iliac fossa every few days, lasting fifteen
to twenty minutes, and sometimes extending down the front of the
thigh.
Meantime the stomach symptoms have continued without much
variation. Knife-like epigastric pain comes immediately after eat-
ing, and, if not relieved by vomiting, lasts fifteen or twenty minutes.
After that it becomes moderate and constant. Her pain is not re-
lieved by soda, by food or drink, and does not radiate, but is much
relieved by vomiting, which occurs after almost every meal, is never
DIARSHEA 205
large in amount, and never contains blood or food eaten the day
before.
Throughout the iUness her appetite and sleep have been good.
Bowels usually regular. She has not worked for six months. Two
years ago her weight was 143 pounds; December i6th her weight,
without clothes, was found to be ioo| pounds.
Despite this apparent loss of weight, she was well nourished and
had a good color. Her hands and feet were always cold and clammy.
On the right side of the neck, below and behind the ear, was an opera-
tion scar, I inch long. There were no enlarged lymph-glands present
anywhere. Chest negative. The abdomen was tympanitic in the
lower part, dull above, with slight involuntary resistance in the right
upper quadrant and epigastrium. A 9 cm. vertical scar was seen
above the umbilicus, to the left of the median line. Another, 8 cm.
long, in the right lower quadrant.
The blood was negative; likewise the urine when obtained by
catheter, though the routine specimen obtained without special
precautions showed a pus sediment of about 5 per cent, of the total
amount of urine when centrifugalized five minutes at the rate of one
thousand revolutions per minute. Her vomitus contained free HCl
and reacted strongly to guaiac. It contained no food residue or any-
thing else of interest.
At first the patient could retain no food and was given only salt
solution by rectum, 200 c.c. every six hours. By the third day she was
able to take crackers and toast with butter, but the rectal salt solu-
tion was kept up imtil the 27th. She kept down her crackers and toast,
but vomited liquids and commeal mush. Meantime a letter was sent
to St. Joseph's Hospital, and an answer received, stating that a gastro-
enterostomy had been done, but making no mention of the pathologic
condition found. By October 3d the patient had advanced to the
third stage of gastric ulcer diet (see Vol. I. of this work. Appendix)
and was perfectly comfortable. Thereafter she gained steadily, and
had less epigastric soreness.
She went home October 23d, having gained 13 pounds in weight,
but returned November 19th, stating that since her discharge she
had been very miserable, vomiting almost everything eaten. Bowels
very constipated, her condition altogether preventing work. She
had got back to 102 pounds in weight. This time, despite treatment
similar to that previously given, she continued to vomit occasionally,
although she gained 6 pounds during her first week's stay in the
hospital*
2o6 DIFFERENTIAL DIAGNOSIS
Discussion. — On a first reading of this case it is obvious that she
has too many pains in too many places to fit any known localizable
disease, and of the generalized diseases, such as infection or carcinoma-
tosis, we have no evidence, especially as the appetite and sleep are
good and there is no falling off in nutrition or color. Despite the
absence of hydrochloric acid from the gastric contents, there is no
good clinical evidence of cancer or of any other organic disease of the
stomach.
Tabes dorsalis might account for her pain, and, although this is
an imusual disease in a girl of twenty, I do not see that it can be
absolutely excluded in this case, since no spinal puncture was made.
I am thoroughly convinced that there are cases of tabes presenting
no symptoms excepting abdominal pain and a characteristic spinal
fluid, that is, cases in which the pupils and reflexes are normal. In
the latter part of her history pain is much less prominent, and the
possibility of tabes becomes correspondingly less.
At one time we were strongly inclined to consider that some form
of tuberculosis was at the bottom of her troubles. This was sug-
gested by the scars in the neck, the loss of weight, and the supposed
presence of pyuria. When the pyuria was disproved, there seemed no
sufl&cient ground for considering this hypothesis any longer.
There seemed to be nothing left but to suppose that the case was
one of functional or neurotic stomach trouble, greatly aggravated by
hospitalization and by unnecessary surgery.
Outcome. — On the 8th of December she was operated upon by
Dr. Codman. The old gastro-enterostomy was dosed, so as to restore
so far as possible a natural condition of the stomach. No evidence of
gastric or duodenal disease was found. The old gastro-enterostomy
was in excellent condition and working as well as could be expected.
Slight adhesions between the pylorus and the gall-bladder and between
the old scar in the abdominal wall and the anterior wall of the stomach
were separated. After operation the patient did fairly well, but was
troubled very much by toothache. She was entirely relieved of her
vomiting and was able to eat almost every sort of food. She left the
hospital January i6th.
Case 77
An Italian caterer of fifty-six entered the hospital September i8^
1 910. Six of his cousins and one sister died of tuberculosis. His
wife has had tuberculosis for seven years. He has three healthy
children and his family history is otherwise good. At thirteen he had
m
DIARSHEA 207
pleurisy, but was not tapped. Up to four and one-half years ago he
worked as a courier, conducting parties on the West African Coast, in
the West Indies, and in various parts of Europe. On these travels
and occasionally since he has had attacks of diarrhea, lasting two or
three days, and in winter has bad frequent slight attacks of bronchitis.
TTiree and one-half years ago he had a severe cough, lasting two
months. Dr. J. Payson Clark has amputated his uvula and removed
several polypi and turbinates. He denies venereal disease. He taies
2 or 3 glasses of wine and about 3 ounces of
whisky a day.
Six weeks ago he had an accident, diagnosed
by a skilful physician as "rupture of the plan-
taris." During the succeeding weeks of en-
forced idleness he lost his appetite completely
and ate nothing but bread and milk. On the
seventh day, at 2.30 p. M., his abdomen be-
came distended and painful. Nausea, vomit-
ing, and diarrhea followed, movements occur-
ring forty to fifty times a day for twelve days,
according to his statement. After that he got
better and went to work, though his bowels
continued to move eight or ten times a day.
He blamed an overripe peach, eaten yester-
day, for a return of vomiting, cramps, and
diarrhea. Yesterday, he said, his bowels moved
fifty times. Six weeks ago his weight was 170
pounds; at entrance his weight, without clothes,
was 150 pounds.
He was well nourished. The heart's apex extended 2^ cm. out-
side the nipple line. The aortic second sound had a metallic and
ringing quality. The systolic blood-pressure was from 160 to 170
mm. Hg. The heart showed no murmurs and no other abnormality.
Physical exammation, including the blood and urine, was otherwise
negative. The range of his temperature is shown in the accom-
panying chart (Fig. 76).
Discussion. — ^There is strong tuberculous taint in this case, as
shown by the family history and the early pleurisy. His two months'
cough and his frequent attacks of "bronchitis" strengthen this sus-
picion, but there is nothing in the physical examination at the present
time that points to any tuberculous lesion.
He has been in countries where bilharzia is common, but the
Fig. 76.— Chart of Case
2o8 DIFFERENTIAL DIAGNOSIS
absence of blood and eggs in his stools leaves no further ground for
this suspicion.
Alcoholics are especially subject to diarrhea. This patient has
taken a good deal of alcohol, and if no other explanation can be found,
it may seem most reasonable to blame this habit for his symptoms.
Can his high blood-pressure explain the condition of his bowels?
Various writers have attempted to show that in interstitial nephritis,
such as might explain his hypertension, a compensatory diarrhea
occurs as an expr^sion of nature's effort to rid the body of poisonous
substances normally excreted by the kidney. I have never been
able to satisfy myself, however, that such a compensatory diarrhea
exists. Moreover, the urine shows no evidence of nephritis. The
enlarged heart and high blood-pressure are more reasonably explained
as part of a general arteriosclerosis.
Why should we not adopt the patient's own suggestion — ^viz.,
a food diarrhea? The last attack is more easily explained in this way
than the earlier one, which occurred when he was taking only bread and
milk. Nevertheless this was the best explanation which we could
offer and it seemed to be confirmed by the outcome.
Outcome. — ^The patient was given only water by mouth, and
after twelve hours of such starvation was started on liquids and soft
solids. Food was excellently well borne. He had no diarrhea after
the first two days. The stools during the first two days contained
no guaiac reaction and no other evidence of consequence. September
22d he went home well.
Case 78
An Italian laborer of twenty entered the hospital September 21,
1910. His family history and past history were negative. His
habits include the use of three or four beers and one or two whiskies
daily. About a month ago he began to have moderate diarrhea, ac-
companied by abdominal distention, and he quit work for two weeks
on account of weakness. For the past eight days the bowels have
moved six to eight times daily. He has had an occasional attack of
pain over the lower left ribs in the axilla, lasting a few days at a time.
For the past day or two he has had a slight dr>' cough. Five weeks
ago he weighed 140 pounds, with his clothes. At entrance he weighed
122 pounds, without clothes.
Physical examination showed a boy with long eyelashes and bright
sclerae. The heart was negative. The lungs showed the appearance
depicted in Figs. 77 and 78. The abdomen was distended, and flat on
DIFFERENTIAL DIAGNOSIS
percussion in the flanks and over the pubes. A fluid wave was pres-
ent. The right epididymis was slightly thickened. Stools negative.
September 22d the abdomen was tapped and 3350 c.c. of yellow,
slightly turbid fluid removed. Its specific gravity was 1019, Albu-
min, 3J per cent. The sediment consisted wholly of lymphocytes,
90 per cent, of which were of smaU size. No tubercle bacilli or other
organisms were found. Cultures were negative. Twenty minims of
the fluid were injected into a guinea-pig September 23d. Autopsy
of this pig showed nothing abnormal. The range of the temperature
is shown in the accompanying chart (Fig. 79). On the 2Sth of Sep-
tember he complained of pain
in the left azilla and a loud
friction sound was heard there.
Discussion. — The associa-
tion of diarrhea with ascites,
chest pain, cough, fever, and
epididymitis is strongly sug-
gestive of tuberculosis, even
though the guinea-pig test of
the ascitic fluid showed noth-
uig. That the temperature
rapidly subsided after rest in
bed does not in any way mili-
tate against this diagnosis.
The character of the ascitic
fluid is wholly consistent with
tuberculous peritonitis, and the
evidences of fluid and friction
in the right chest confirms it.
Need we suppose that tuberculous enteritis was also present?
There seems no such necessity, especially as the stools were negative
and by no means excessively frequent.
Outcome. — By October 5th the fluid in the right chest was disap-
pearing and the friction-sounds gone. He had gained 10 pounds and
much strength, but, as he was still unfit for work, he was transferred,
October 8th, to the State Hospital at Tewksbury. Two years later the
Superintendent of the Institution writes that the patient remained
there from October 8, 191a, to April 29, 1911, and left improved.
On October 11, 1910, and on March 14, 1911, the right chest was
tapped. Each time 45 ounces of amber-colored fluid was with-
drawn.
l-.W n-y-"---]---^
:=-'"^'^f|""ft:=
I'^^j^^mf?'^^^-'-
\h\M^mM'~'-'-
', '---i^^ '-\±f--t--;.'.
Fig. 79. — Chart of Case 78.
DIARRHEA 211
October 24, 1910, an exploratory laparotomy was done and the
diagnosis of tuberculous peritonitis was confirmed. At this time the
patient was very sick, and the marked improvement which occurred
later was quite unexpected.
Case 79
An unmarried woman of forty-four was seen in consultation in
September, 1910. For twenty years she has been suffering with diar-
rheGy alternating with short periods of constipation. Fifteen years
ago she spent five consecutive years in bed, and since then has fre-
quently been bedridden for months at a time. It is years since she
has ventured outside the house, and she never takes more steps than
is absolutely necessary within the house, as exercise invariably brings
on increased diarrhea. She now lives quite alone, in a rural district,
getting her own meals, which consist exclusively of the juice chewed
out of i\ pounds of broiled steak, per day, the whey from 2 quarts of
milk, and \ pint of heavy cream. This is absolutely the whole of her
diet and has been the same for some years. She states that any at-
tempt to eat more is followed by an increased diarrhea and an enor-
mous production of "membrane" within the bowel, which blocks it
and sets her physicians to working for weeks before the bowel can be
made to move. Her appetite is good. She longs to eat more, but
does not dare to.
The patient states that she has been able throughout this long
illness to keep her mind well occupied by reading and sewing. Con-
siderable study of her convinces me that this is perfectly correct,
and that she is not at all self-centered or morbid in any way. Ex-
cept for this diarrhea and a gradually increasing deafness during the
past six years, she complains of nothing and has an excellent family
history.
Physical examination shows emaciation, but is otherwise negative.
Blood and urine show nothing abnormal. Systolic blood-pressure
140 mm. Hg.
The patient stayed nearly nine months in the hospital, which she
entered weighing 70 pounds; on leaving she weighed 86} pounds.
During the first three months of her stay the bowels were constipated
and at no time in the nine months was there any diarrhea. Her
pulse, temperature, and respiration were always normal except during
an inflammatory complication, to be referred to presently. There
was always a guaiac reaction in the feces, but nothing else of im-
portance was discovered, despite frequent and careful examinations.
212 DIFFERENTIAL DIAGNOSIS
Treatment was begun with the patient's usual diet. For abdominal
pain she was given hot fomentations and a daily high enema of warm
oil. October 3d commeal mush and ice-cream were added to the diet.
She complained of much pain thereafter, but managed to retain them
and slept fairly well each night. October 6th a raw egg daily was
added. October 12th hot rice with cream and bread-crumbs with
beef-juice were added, and after the isth of the month she took
apple-sauce or the juice of an orange daily. In the open ward she
did not do well, but when put into a private room began to gain.
Her pain was still severe, sometimes constant, sometimes in parox-
ysms, accompanied by abdominal distention, November loth toast and
milk were added to the diet, and she was given, despite her protes-
tations, a dropped egg on toast. When she found that she could eat
this without increase of distress and much relish, her spirits were
exuberant. The upright position and attempts to walk increased her
pain, and were followed by periods of general abdominal tenderness
and rigidity. Nevertheless, she was urged to persevere, and suc-
ceeded in overcoming her discomfort.
December 26th she began to have great pain about the rectum
and perineum, accompanied by a slight rise of temperature and a
leukocytosis of 18,000, which rose January 4th to 30,000, when a vul-
var abscess was opened by Dr. Cobb and 50 to 100 c.c. of foul pus,
containing colon bacilli, evacuated. It took her imtil about the 19th
of January to get over this. The oil enemata were increased about
this time to 16 ounces every night. This enema was followed by a feel-
ing of great comfort and enabled her to sleep. After February ist she
gradually increased her walking distance until she was able to walk
an eighth of a mile within the hospital and to take Zander exercises
without discomfort. By May she appeared really perfectly well,
though subject to occasional attacks of abdominal pain. She was
eating everything, including many foods which she had not taken for
twenty years.
Discussion. — This case is remarkable in several respects. First,
in that a woman who had lived the life of an invalid for twenty years
and had not been able to cross the threshold of her house for at least
a decade was restored to perfect health, practically without any
treatment except diet. Her recover}' would have been impossible, I
think, but for her unusual force of character, for several times in the
course of her treatment her sufferings were ver>' great, and any but a
ver}' determined person would have given up the effort to eat unac-
customed food and returned to starvation diet.
DIABSHEA 213
At times the abdominal distention and pain were so severe that but
for the normal temperature and pulse she would have undoubtedly
been operated upon.
In view of the outcome of the case, I believe that her sufferings
were wholly due to constipation, with resulting irritation and ulcera-
tion of the bowel. At times the case took on the features of colka
mucosa, but most of the time the symptoms were simply those of con-
stipation. Practically no medicine was given by mouth, but she got
great relief from her pain by the enemata of olive oil.
No bismuth or-rays were taken in this case, but it closely resembled,
on the clinical side, many that get operated upon for adhesions.
I should like at this point to express my belief that when patients
improve after operations done for the relief of adhesions, the relief is
not due to the operation, except in rare cases. It is just now the
fashion to lay great stress upon adhesions, veils, or membranes about
the cecum, about the gall-bladder, and the pyloric end of the stomach,
but I am convinced as a result of my study of cases, postmortem and
antemortem, that such membranes and adhesions rarely cause any
symptoms, and that the symptoms attributed to them are just as
frequent in patients having no adhesions. The present fad, for oper-
ating on such cases rests upon evidence as unsatisfactory as that which
led us a few years ago to operate upon so-called floating kidneys, and
to make diagnoses of **auto-intoxication," **litheinia,** and **ptomain-
poisoning."
It must be admitted that many patients imprpve after operations
for the relief of adhesions, but I believe that this improvement is to
be explained by the dietetic, hygienic, and psychic regime to which the
patient is submitted after the operation. Some patients cannot be
induced to diet or to submit themselves to any regime unless some sort
of an operation is performed. This sort of irrationality is parallel
to the foolishness of those who would not stop overeating and over-
drinking xmless they are sent to some spa or springs to drink a large
quantity of disagreeable water. But it seems to me altogether un-
necessary and wrong for the medical profession to encourage people .
in such wasteful and ridiculous performances. In the long run the
public will not thank us for helping them to deceive themselves and to
waste their money.
Outcome. — She left the hospital May 5th, 191 1 , but was heard from
subsequently as enjoying splendid health and getting back intb the
world of affairs which had been unknown to her for many years.
Ischiorectal abscess later developed and was operated on at the
214 DIFFERENTIAL DIAGNOSIS
Baptist Hospital by Dr. Hugh Cabot, after which she made a good
recovery and has remained well since (1914).
Case 80
A married woman of twenty-four entered the hospital September
29, 1910, with a diagnosis of "tubercular enteritis." Her family his-
tory was negative and she herself has always been well except for an
occasional "summer diarrhea," never lasting more than a week.
She has two children, the youngest fourteen months old. This child
she nursed until two or three days ago.
For nine weeks there has been steady diarrhea, first, three move-
ments a day, but lately increasing until she says that movements come
every ten minutes and feel like hot water. For a week there has been
considerable blood in them and always much mucus. For a fortnight
she vomited after nearly ever>' meal, and once last week raised a tea-
spoonful of blood. She has had slight dry cough for nine weeks, but
never raised blood. Up to a week ago she kept at work, but since
that time severe and frequent abdominal cramps doubled her up and
compelled her to stay in bed. Previously her diarrhea had been
nearly painless.
Her appetite and sleep were very poor. Her best weight, two years
ago, was 138 p)ounds; six weeks ago, 97 pounds; now, without clothes,
81 p)ounds.
The patient was emaciated and pale, with flushed cheeks. A few
squeaks were heard at the right apex, where the physiologic dulness
seemed to be increased. Otherwise the chest was negative. The ab-
domen was concave and acutely tender throughout. Coils of intestine
could be seen and felt in it. The stools, examined every day or two
for three weeks, showed no reaction to guaiac and no other features
of imjx>rtance. Tubercle bacilli were never found. Blood and urine
were normal. Bkxnl-pressure, 105 mm. Hg., sj^stolic; 80 mm. Hg.,
diastolic. Temperature, pulse, and blood normal.
The patient was put on a Schmidt diet with subnitrate of bismuth,
I dram tour times a day, and a suppi>sitor>* of gall and opium, when
neeileti for pain. The movements were live or six daily during the first
three days. After that there was no iliarrhea in three weeks' observa-
tion. The otVu inal pill of camphor, opium, and tannin was given four
times a day for four da>-s, beginning October ist. After that no
nuxlicine was nev\le\l except high oil enema daily.
Discussion. In all pr^^bability this jxitient had a mild tubercu-
losis at the right aiX'X. ;md, avimitting that, many a phj-sician would
DIARRHEA 215
conclude at once that the diarrhea must be due to tuberculous enteritis.
That this is often a mistake I have shown elsewhere.^ Not every case
of diarrhea associated with pulmonary tuberculosis is due to tubercu-
lous enteritis. A quite curable non-tuberculous enteritis is common
in such cases, and this fact is of much importance in prognosis. The
patient's response to treatment in this case made it very improbable
that there was any tuberculosis in the bowel.
The tenderness of the abdomen and the visible peristalsis gave rise
in this case, as they frequently do, to unnecessary anxiety. Peritoni-
tis and obstruction were suspected, but in view of the normal tempera-
ture and pulse, the normal blood, and the frequent stools there was
never any good reason for anxiety. Such tenderness and peristalsis
are conmion when enteritis occurs in an emaciated person.
The rapid disappearance of a diarrhea which lasted nine weeks b
due largely, I think, in this case to rest in bed. It will be noted that
the patient had kept at work until a week before her entrance to the
hospital. I know no disease comparable to enteritis in the rapidity
of benefit produced by rest in bed and change in environment, even
when no dietetic or medicinal remedies are used. Since blood and
pus were absent from the stools, we have no good reason to suppose
that any ulcerations were present in the bowel. The exact cause of
the diarrhea is obscure, as it is in a very large number of mild cases.
We cannot reasonably assume that colitis or any other anatomic
change is present. The trouble may well be due to anomalies of secre-
tion, of motility, or to some circulatory disturbance. The latter is
somewhat suggested by the low blood-pressure.
Outcome. — ^By October 3d she looked and felt like a different per-
son. The appetite rapidly increased, and by October 9th she had
gained 9 pounds. From that time until her discharge, October 2 2d,
she gained steadily in weight and strength, and when discharged
weighed 94 pounds, an increase of 13 pounds.
Case 81
A weaver of thirty, bom in Finland, entered the hospital October 14,
1910. Ten years ago he was in bed a week with diarrhea and ex-
I>elled a tapeworm 20 feet long. Otherwise he has been well and
denies venereal disease. He confesses that every now and then
he is in the habit of drinking a pint or so of straight alcohol, when
his wife happens to have it in the house for non-medicinal purposes.
* " Causes, Types, and Treatment of Diarrhea in Adult Life," Journal of the American
Medical Association, September 27, 1913.
2l6 DIFFERENTIAL DIAGNOSIS
For one year he has been disabled by a persistent diarrhea, ten
or twelve movements occurring daily. During this time he has eaten
enormously, often feeling so full after supper that he could scarcely
walk, yet still himgry. For four months last winter he would vomit
after each meal, but immediately after vomiting would devour more
food in a vain effort to appease his inordinate appetite. His wife now
works and so keeps him supplied with food.
The patient is found, on physical examination, to be moderately
obese. Otherwise external examination is entirely negative. Like-
wise the blood and urine. The systolic blood-pressure is from i6o to
165 mm. Hg.; diastolic, no mm. Hg.
On a Schmidt test-diet there is no diarrhea, and after two days
he is given house diet, which also produces no diarrhea. His wife
avers that his "insides must have been burnt,'* for until she stopped
using alcohol for household purposes he was constantly consiuning it,
undiluted, until he became so drunk that he could not move. Since
she has stopped buying alcohol he has been better. October 21st
he left the hospital, apparently in perfect health.
Discussion. — The association of diarrhea with alcoholism is a
very familiar one, and in view of the negative findings, on physical
examination, I see no reason to doubt that alcohol was the cause of
all this patient's troubles. It is very striking that a man who has
had diarrhea for an entire year should get over it within a week,
in fact, within forty-eight hours, as a result of nothing in the world
but abstention from alcohol and rest in bed. Such cases, however, are
very familiar and have already been referred to. No doubt his
habits of gourmandizing also played a part in upsetting him.
I would call attention to the fact that no medicine and no anti-
diarrhea diet was given in this case.
Case 82
An English laborer of forty- three entered the hospital October 21,
1910, for a continuous diarrhea of six months' duration, averaging
three or four watery, sometimes bloody, movements a day. In this
period he had lost 50 pounds, his usual weight being 160 pounds, and
had become very weak. Attempts to work had been quite futile.
There has been considerable burning pain in the left iliac fossa and the
epigastrium and some colic before stools. He continued to eat ordi-
nary food, with good appetite, and no vomiting, but frequently felt
chilly, especially in the evening. For the past four or five months
he had had a slight, dry cough. His previous history was good and
DIARRHEA 2 1 7
been farther south than Baltimore, The past eleven
months he had been living in New Hampshire, but has been told that
several peopie in his neighborhood also had dysentery.
His stools were examined thirty-three times during his five weeks'
stay in the hospital. The guaiac test was positive eight times, and
negative in the remainder, otherwise there was nothing remarkable on
gross or microscopic examination. Culture from the stools showed the
colon bacillus as the only micro-organism present.
^^— The patient was fairly nourished. Along and behind the right
Fig. 80.— Signs
glands, the size of a pea to that of a bean, partly conglomerate, not
attached to the skin. The axillary and inguinal glands were some-
what enlarged. The epi trochlears were enlarged on both sides.
Lungs showed the lesions pictured in Figs. 80, 81; a:-ray examination
showed extensive involvement of the left lung, as low as the fifth
rib, apparently an old infiltration and largely healed. The right
lung also showed involvement down as far as the third rib. The
temperature was as in the accompanying chart (Fig. 82). Abdomen
was dull everywhere except in the left upper quadrant. There was
general tenderness on deep pressure. Otherwise physical examina-
tion was not remarkable. The diarrhea ceased after the
examina- ^^m
first two ^H
DIFFERENTIAL DIAGNOSIS
weeks of hospital care. During the last four weeks of his stay in
the hospital he had absolutely no sputum and almost no cough.
Fig. S2.— Chart of Case 8i.
The diarrhea had entirely ceased after he was put to bed, NovemtX
13th. His weight on leaving the hospital was 107 pounds, withi.
y
a pound of that with which he eiilerfd. Apparently, rest in bed was
the treatment which helped him most. Fnt-frec diet and colonic irri-
E^noDSwith i-dram doses of bismuth, three times a day, gave him no
^*°^ reliei; Figs. 83 and 84 show the lesions found November 24th.
220 DIFFERENTIAL DIAGNOSIS
Discussion. — This case presents the picture of a diarrhea continu-
ous for six months in a patient showing extensive puhnonary lesions,
in all probability tuberculous. Although there is no pus in the stools,
the frequent presence of the guaiac reaction makes it not improbable
that intestinal ulcerations are present. This is not negatived by the
fact that no diarrhea occurred after he was put to bed. This is often
the case in ulcerative colitis.
The chief point of doubt is whether or not the diarrhea is of tuber-
culous origin. The fact that it complicates pulmonary tuberculosis
in no way proves that the colitis is tuberculous. (For further dis-
cussion of this point see Case No. 80.) Even the finding of tuberde
bacilli in the stools would not prove that the intestinal lesions were
tuberculous, since the bacilli may come from swallowed sputa. The
main point to be insisted upon in this case is that if the patient can
master his pulmonary tuberculosis, there is not necessarily any incur-
able complication in the intestine to cloud the outlook.
The examination of the stools makes it unlikely that any specific
type of infection (Amoeba histolytica or Shiga's bacillus) is present.
Outcome. — ^The patient went home November 25, 1910, and died
February 12, 1911. The diarrhea continued unchecked. There were
no pulmonary symptoms.
Case 83
A kitchen man of thirty-five, born in Russia, entered the hospital
September 13, 1910. The patient is a steady drinker and occasionally
gets drunk. He also smokes to excess. He has had no previous sick-
ness except typhoid, which he had in Russia many years ago. Three
or four weeks ago he began to be bothered by diarrhea, eight or ten
watery movements a day, without blood or tenesmus. At the same
time he had severe, almost constant, headache, occasional attacks of
vomiting, and on exertion experienced a pain referred to the hepatic
area. He has also noticed shortness of breath, with palpitation and
precordial pain on exertion.
Physical examination showed good nutrition. Pupils slightly
irregular, otherwise normal. Glands and reflexes negative. The left
border of cardiac dulness extended 13 cm. from the median line and
was outside of the nipple. Right border 5 cm. from midstemal line.
There was some increase in the width of the dull area behind the man-
ubrium and a palpable impulse in the suprasternal notch. There
was a harsh systolic murmur at the apex, transmitted inward and
outward. In the axilla a diastolic murmur was heard. In the second
right interspace there was a blowing systolic murmur, different in pitch
and quality from that at the apex. The aortic second was high
pitched, sharp, and ringing. The pulses showed no Corrigan quality.
The arteries were thickened, tortuous, and in places beaded. Blood-
pressure i6o mm. Hg., systolic, at entrance; 105 mm. Hg., diastolic.
The lungs showed dulness and a few fine crackles at each base behind.
The liver extended from the sixth interspace, mammary line, to a
point four fingers below the ribs, where an edge was indistinctly felt.
Manipulation of this region caused pain and dilatation of the neck
veins. The spleen was felt two fingers' breadth below the ribs and
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Fig. 85.— Chart of Case 83.
its percussion area was enlarged. The blood was negative. Tem-
perature as shown in the accompanying chart (Fig. 85.)
The urine averaged 25 ounces in twenty-four hours during the first
week of his stay in the hospital; after that, from 40 to 50 ounces; this
increase corresponding with a fall in blood-pressure to 135, and on the
4th of October to 125. Diastolic pressure varied very Uttle during
these changes. The specific gravity of the urine varied from 1008 to
1012, with a shght trace of albumin, many hyaline, granular, and
cellular casts, and a Uttle blood, free and adherent. Later in the
course of the disease casts were abnost impossible to find. On the
18th of September the red cells numbered 4,300,000; hemoglobin, 60
222 DIFFERENTIAL DIAGNOSIS
per cent. The reds showed moderate achromia. The patient had at
this time no symptoms whatever, seemed bright and happy. He
was given potassium iodid and hydrargyrum imtil salivation was
produced, but without any effect upon the temperature or other
physical signs. Blood-cultures were negative.
The heart signs did not change at all, but toward the middle of
September there was a little edema over the sacrum and in the legs.
By the last of the month he was obviously losing groimd. On the
28th he had a profuse nosebleed, requiring to be packed. The neirt
day the blood showed: red cells, 3,000,000; white, 4500; hemoglobin,
54 per cent. The second blood-culture showed again negative results.
The salivation produced by mercury continued into the early part of
October. At this time the diastolic murmur could clearly be heard
along the left border of the sternum. Pulmonic second soimd was
reduplicated. There was no thrill anywhere. The fundus of the
eye was normal.
Discussion. — Headache and dyspnea are not symptoms of any
form of enteritis, and suggest at once that this patient's diarrhea is
symptomatic of some non-intestinal disease. The blood-pressure
and the condition of the urine strongly suggest chronic nephriUs,
probably of the glomerular type. The nosebleeds further support
this diagnosis.
Beyond this the early arterial changes, the splenic enlargement,
and the evidences of aortic regurgitation, without previous history of
rheumatism, chorea, or sore throat, lead us to consider S3rphilis as a
possible cause for his symptoms. (Note the positive Wassermann
reaction obtained at the Boston City Hospital and recorded below
under Outcome.)
A glance at the chart reveals a fever not well accoimted for either
by glomerular nephritis or by late syphilis, such as he must have if
there was any syphilis about him. Neither of these diseases causes
such a fever as this patient had. This fact should have made us sus-
pect that the cardiac murmurs might be due to an acute endocarditis,
even though leukocytes were normal.
Outcome. — On the 13th of October he was transferred to Tewks-
bury Hospital, where he stayed two months without improvement,
and then went to the Boston City Hospital, where his condition was
essentially the same as that previously recorded, blood-pressure, May
22, 191 1, being 130 mm. Hg. The Wassermann reaction at this time
was strongly positive. On the 14th of September hemorrhages were
found in the fundus of the right eye. On the 17th of June, 191 1, after
DIAKSHEA 223
a gradual failure and slight, irregular temperature, edema, hydro-
thorax, ascites, and anasarca, the patient died.
Autopsy showed subacute infectious endocarditis of the mitral and
aortic valves; heart's weight, 775 grams; chronic glomerulonephritis.
It is interesting to speculate here whether the nephritis was the
cause of the endocarditis or vice vers&. Libman's studies of subacute
bacterial endocarditis (endocarditis lenta) led him to believe that
chronic glomerula nephritis is often a result of emboli thrown oflF from
an inflamed heart-valve. In view, however, of the enormous size of
the heart in this case, it seems more probable that the nephritis has
existed for a long time, and that the endocarditis should be regarded
as a manifestation of lowered resistance to infection, dependent upon
the nephritis.
Case 84
A metal polisher of twenty-eight, bom in Russia, entered the hospi-
tal May 7, 1910. For six years, beginning eleven years ago, he has
been a sailor, and has visited Australia, India, Egypt, Turkey, and
Chili. The last five years he has done metal polishing, chiefly of brass,
and uses an emery wheel, but has considered himself well imtil the
present illness.
Diarrhea and cramps began two years ago and have been present
continuously ever since, except for short intervals, never exceeding
a week in duration. The cramps are never severe or localized and
never radiate upward or downward. They precede stools, and are
brought on by exertion, by soups, fruits, or large meals. His stools
are brown and never contain blood. Bowels move every two hours
at night and somewhat less frequently during the day. He is always
himgry and has no nausea or vomiting, but is afraid to eat because
of the effect upon his bowels. He has lost 7 poimds in two years.
The patient is well nourished, but markedly pale. He appears
to have two radial arteries in his right wrist. Chest, abdomen, and
extremities show nothing abnormal. Urine is normal. Blood con-
tains 13,500 leukocytes per cubic millimeter, 6 per cent, of them being
eosinophils. Red cells show sb'ght achromia and some varieties in
size. Feces show flagellates in great numbers, their rapid motion
preventing accurate identification. An occasional egg of the tricho-
cephalus is seen. The guaiac reaction is always positive, but there is
no pus or obvious blood, no mucus or excess of food elements. On
the 8th of May two or three amebae are seen in active motion. The
endoplasm is gradually and easily distinguished from the highly
224 DIFFERENTIAL DIAGNOSIS
refractive ectoplasm, even when the amebse are at rest. The diam-
eter seems to be from 35 to 50 microns. The nucleus is not made
out and there is no contractile vacuole. One inclusion, apparently
a red corpuscle, is seen. Charcot-Leyden crystals are numerous,
some of them 50 microns in length.
Discussion. — This patient raises the question how we are to differ-
entiate the harmless Amoeba coli from the pathogenic ameba, ordi-
narily known as the Amoeba histolytica or the ameba of dysentery.
The histologic and tinctorial differentiae will be referred to presently.
Meantime, it is obvious that this patient has visited a number of
coimtries, in any of which he might have picked up amebic dysen-
tery. This disease is still further suggested by the long duration of
the diarrhea and by the apparent efficiency of the ipecac treatment
(See below.)
The more important distinctions between the harmless ameba
and the dysenteric ameba are as follows:
1. The dysenteric ameba, or Amoeba histolytica, is more active
in its movements, and these movements often persist for hours in the
cold, while the harmless ameba (Amoeba coli) is always more sluggish
and soon loses its movements at room temperature.
2. The dysenteric ameba much more often contains red corpuscles
and other cells within its protoplasm. The harmless ameba rarely
takes these up.
3. In stained specimens the Amoeba histolytica shows an indis-
tinct nucleus containing but little chromatin, while the Amoeba coli
has a much clearer nucleus, containing abundant chromatin.
In the encysted state the Amoeba histolytica has a smaller, less
refractive, and thinner cyst, and usually contains the elongated refract-
ive so-called ^^chromidial" bodies, which are not found in the Amoeba
coli. In this encysted state the nuclei of the Amoeba histolytica are
never more than 4, while those of the Amoeba coli are 8 or more.^
Outcome. — The patient was given a diet of liquids and soft solids
and the bowel was irrigated with i quart of quinin solution, i : 2500.
Following this the diarrhea ceased and no amebae could be foimd dur-
ing the last ten days of his stay in the hospital. The bowel move-
ments were formed and occurred but once daily. He left the hospital,
much improved. May 20th, but returned November 29th, stating
that for two months after his last treatment at the hospital he was
quite well, then his diarrhea gradually returned and has continued
^ Walker and Sellards, Philippine Journal of Science, Section B, vol. viii. No. 4^
August, 1913.
DIARRHEA 225
since, though he has gained 4 or 5 pounds 'since he was last in the
hospital and has worked until five days ago. At this time no amebse
could be foimd in the stools. Nevertheless, he was given the ipecac
treatment, namely, 10 gr. of ipecac in salol-coated pills twice a day
for three days; then, later, the same dosage for nine days. Quinin
irrigations, i : 2000, were also given daily. The stools occurred only
once or twice a day during his stay in the hospital. His weight at
this time was 10 poimds greater than at his last entrance and the
eosinophils made up i per cent, of the leukocytes present. December
19th he was discharged considerably relieved.
Case 85
A meat packer of twenty-two, bom in Greece, entered the hospital
January 23, 191 1. The patient had always been perfectly well ex-
cept that once, six months ago, he had been laid oflF for three days
with a condition similar to the present. For the past three months he
had felt imduly tired. His bowels move from three to five times a
day. Duration of this diarrhea not clearly made out. (See Out-
patient Department record No. 154,759.) Patient had lost no weight
and had had no trouble with his urine. His appetite was excellent
and he had worked until four days before entry.
Physical examination was entirely negative except as related to
the stools, which contained in each slide examined a few eggs like those
shown in the accompanying figures. Twice a free-swinmiing ciliated
embryo was seen. There was a good deal of pus and mucus and a
little blood in the well-formed stools.
After the first day in bed there was no diarrhea for a week. After
that he began to have three or four stools a day. Rectal examina-
tion showed numerous polypoid projections, ^ to i cm. long and about
the same in thickness, but no ulcers. One of these pol3rps was re-
moved and showed, on microscopic examination of paraflSn sections,
a tissue richly infiltrated with plasma-cells and some leukocytes,
in the midst of which were eggs and embryos of the Schistosoma
haematobium, surroimded by giant-cells. Atypical epithelial tubules,
like those of the rectal mucous membranes, were also seen.
The patient was given "606," 0.6 gram into a muscle, but no
particular effect was observed.
Discussion. — The findings on rectal examination and stool ex-
amination make any discussion of differential diagnosis unnecessary.
The eggs shown in Figs. 86 and 87 are entirely characteristic of bil-
harzia disease. This parasite, as is well known, affects usually the
Vol. 11—16
DIFFERENTLA.L DIAGNOSIS
bladder, the rectum, or both, producing a most intractable form of^
chronic inflammation.
Fig S().— I'll rup lured bilharzia eggs. Ni>ii- ilii- hiiLT;:U|iiEie in each. (Photographs
by L. S. Brown, ot the Pathological Laboratory of the Massachusetts General Hospital.
The case waa under the care of Dr, Arthur K. Stone, by whose kind permisaon it is re-
ferred to here.)
This patient was taken into the hospital in order to see whether
the effectiveness of salvarsan upon some organisms of the protozoan
group extends to bilharzia disease. The outcome showed that there
was apparently no such action.
i i^ ■^:. i'i!|iuirc(l bilharzia eggs. Near one Ihe free embryo is visible. (Photo-
gr^i'li- ii I.. > Brown, of the Pathological Laboratory of the Massachusetts General
Ho=i,iiiil.",
Outcome.^The patient came in again on June i, 1911, stating thi"^
since leaving the hospital, February 17th, he has had three or fotxr
movements a day, usually with some blood, but has worked con-
DIARRHEA 22?
tinuously. The condition was exactly as before, and, after staying
in the wards a couple of weeks and gaining 4 pounds, he was allowed
to go home again. His blood on this occasion showed 9 per cent, of
eosinophils in a total leukocyte count of 12,000.
September 14, 1912, the patient came to the dispensary for pains
in the "calves" of both his legs, also a bad headache, especially on the
left side, and slight pains in his abdomen. Examination of the
stools showed spatters of soft, brick-red juice. Bilharzia eggs present.
No food seen. Many soap and fatty acid crystals. Guaiac test
positive. Pus-cells and blood present.
Case 86
A telephone operator of thirty- two entered the hospital March 21,
191 1. His family history was entirely negative, and he had been quite
well and strong xmtil seven years ago, though he was in bed for some
time at the age of nineteen, owing to stiff and painful knees. His
work had never exposed him to lead-poisoning, as far as he knew,
but for eighteen years he had lived in a house where drinking-water
came through lead pipe. He denied venereal disease; was in the
kibit of taking four whiskies a day.
Seven years ago he had an attack of cramp-like abdominal pain,
accompanying diarrhea and vomiting, and lasting a week. During the
following year he had two or three similar attacks, and ever year since
then he had been disabled several times by similar paroxysms. In
each attack there was diarrhea, followed by griping pain. He had
noticed no influence of food in the production of these attacks. For
the past six months he had been out of work and had so much pain
that he had been too discouraged to look for another job.
During the past two years he has several times fallen in the street
on account of sudden dizziness, although he has never become im-
consdous, and has been able to get up again without assistance.
For years he has had pains of a few seconds' duration, off and on, in
^e muscles of the thigh and calf. On further questioning he admits
^t these sensations are not genuine pain, but rather a tingling and
numbness. He has no symptoms of bladder trouble and his eyesight
is excellent.
For the above symptoms he was operated on four months ago by
Dr. John C. Mimro, at the Carney Hospital. A few adhesions were
found and separated, but the S3anptoms continued as before. A year
^0 he was admitted to the Boston City Hospital for the tenth time,
^d was operated on by Dr. E. H. Nichols, who did laminectomy, ex-
DIFFERENTIAL DIAGNOSIS
posing the cord from the second to the sixth dorsal vertebra;, and
cutting the dorsal nerve-roots at the level of the third, fourth, fifth,
and sixth vertebra, on both sides of the cord. The dura was edema-
tous and considerably thickened. He stated that he experienced no
relief after this operation. For the past month he had had some
cough and sputum. His best weight four years ago, 125 pounds;
at tills time, 98 pounds. For the past seven years he had taken
morphin, by the mouth, in gradually increasing amounts, until during
the last six months he had needed 18 to 20 gr. a day.
The patient was poorly nourished and pale. His pupils were c
cular, equal, reacted normally to distance and sluggishly to light,;!
CaseS6.
especially the right pupil. There was no glandular enlargement.
His teeth were very poor. He had a marked and tjpical lead-Une
on the gums. Except for a slight soft systolic murmur at the apex,
the chest was negative, likewise the abdomen. The right knee-jerk
active; the left present, but only on reinforcement. The right ankle-
jerk likewise active; left not obtained. An area of anesthesia was
mapped as shown in Figs. 88. S9. The urine showed nothing of
interest. Blood-pressure. 130 mm. Hg. The red cells showed slight
achromia, and in every few fields of the oil-immersion lens a stippled
cell. The leukocytes, i j,ooo. On lumbar puncture a limpid fluid was
Wjk
229
'obtained in which the white cells numbered 74 per cubic millimeter,
99 per cent, of them being lymphocytes. The fundus oculi normal.
Wassennann reaction negative in the blood. For a few days he
excreted 5 to 10 grams of sugar in the urine, and this was still present
when he left the hospital.
Discussion. — The history of exposure to lead -poisoning through
drinking-water makes it possible that the abdominal pain is lead-
colic. It is very unusual, however, for this colic to be associated with
diarrhea. Constipation is the rule. Nothing in the physical ex-
amination excludes lead, and there is every reason to suppose that
part, at least, of the patient's sufferings are due to this metal, since
Fig, 89.— Numb area in Case 86,
the gums show its presence and the blood examination strongly
suggests the same thing.
Kevertheless, the history of very brief pains in the legs and the
long intervals between the attacks of abdominal pain should suggest
some other disease, even in advance of the physical examination.
The absence of the left knee-jerk and ankle-jerk and the poor
reaction of the pupils to light prepare us for the findings in the spinal
fluid, which leave no reasonable doubt that the patient's abdominal
atlacb represent gastric crises in tabes dorsaJis. But for the examina-
lion of the spinal fluid, this diagnosis might not have been dear. As
it is, the case adds one to the long Ust of surgical blunders due to failure
1
230 DIFFERENTIAL DIAGNOSIS
to examine the nervous system. During the past five years I have
known 5 patients who, though suffering from the gastric crises of
tabes, were operated upon by competent surgeons in the hope of
finding gall-stones, peptic ulcer, or acute appendicitis. Even after the
operation surgeons sometimes fail to notice their mistake. A shriv-
eled appendix is removed and the case is called chronic appendicitis.
This case also illustrates the proneness of surgeons to suppose that
adhesions are a sufficient explanation of well-marked clinical symp-
toms. A very large number of unnecessary or mistaken operations
fail to be recognized as such, and are called successful because a few
adhesions are found and divided. In my experience, adhesions in any
part of the abdominal cavity are very seldom, per se, of any import-
ance.
Had not the evidences of tabes been found in this case, one might
have been forced to investigate the possibility that the pain was due
to morphin. Morphin is a very frequent cause of pain, a fact which
does not seem to me sufficiently realized. Just how the drug produces
pain I cannot say, but practically every patient suffering from the
morphin-habit takes the drug at times for the relief of some pain, which
will stop only when the drug is eliminated from the system and the
habit is broken up. I have seen lightning pains in a tabetic which
ceased as soon as the morphin-habit, contracted for the relief of these,
same pains, was broken. In this case one must suppose that the pain
due to tabes itself had long ago ceased, its place being taken by
suffering connected in some way with the drug habit.
Outcome. — ^As the morphin-habit seemed to be the most import-
ant feature of the patient's case at the time, he was transferred on
April 6th to Tewksbury.
Case 87
A housewife of forty entered the hospital April 11, 191 1. The
patient has been nervous all her life and has had stomach trouble,
consisting of vague epigastric distress after meals, never severe. Has
also had a good many sick headaches. Throughout her life she has
had a dread of crowds, and never goes to the theater without a feeling
of great discomfort. In church she sits as far back as possible. Dur-
ing the past year she has sometimes fainted when in crowds.
She had an Alexander operation nine years ago, and seven years
ago was operated upon for the freeing of peri-uterine adhesions.
For the past year she has had diarrhea, gradually increasing, until
now she has six to twelve stools a day, which are occasionally very
dark, though she is taking no medicine. Her fainting attacks, for-
merly rare, have now become much more frequent. She consulted her
physician in November, 1910, for the above symptoms, and also on
account of weakness and dyspnea. At that time she says that her
blood showed "marked secondary anemia," with a hemoglobin of 60
per cent. Under treatment she greatly improved, and hemoglobin
rose to 85 per cent., but in the past few weeks her symptoms have
"LlJai^e- -— -- _ Ward Hosp. No.
Z" n'T'i 1 1 1 1 1 1 [ M 1 1 1 \Tjn':£'' ,LLUi u umi 1
i "— J uj, „| u. Mi .i i.-y.M- ^•iM4
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1
Rg. 90.— Blood chart of Case 87.
recurred and she has vomited very frequently. According to her
statement she retains hardly any food. Three years ago her weight
was 138 pounds; in November, 1910, 132 pounds; now, 125 pounds.
On physical examination she is well nourished, nervous, and ap-
prehensive. Her hands in constant motion, with some coarse tremor.
Skin, scleriE, and mucous membranes of good color. Visceral examina-
tion negative. Reflexes and pupils negative. Very slight soft edema
of the ankles. Urine normal. Blood shows reds, 2,6oo,cxx>; whites.
232
DIFFERENTIAL DIAGNOSIS
3000; hemoglobin, 70 per cent. During her month's stay in the
hospital the course of the red cells, white cells, and hemoglobin was
as shown in the accompanying chart (Fig. 90). In the stained smear
the red cells show moderate variations in size and shape, no achrconia.
Occasional slightly abnormal staining or stippling. No nucleated
forms. Among the leukocytes 82 per cent, are lymphocytes, the rest
polynuclears. This percentage does not vary during her stay in the
hospital. Blood-plates seem to be about normal in number.
The stools were negative to guaiac and showed nothing else of
interest. The patient's tongue was unusually smooth and she had
frequent attacks of herpetic stomatitis. The range of temperature is
seen in Fig. 91.
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" ;
I —
z z :::::-., t:-
--ix±' .-?!■.< — :
^
-Siwtr^^i-ir-
44-1- -
— _.. ,,,""■■.■; V,
Fig, 9
-Chart of Case 87.
Discussion.— The neurotic taint in this case is so obvious that one
suspects a nervous diarrhea, but the presence of blood in the stools
rules this out.
The tremor and the slight fever suggests that a thyrotoxicosis
tGraves' disease) may be the cause of the svTnptoms, but the absence
of any tachycardia, any exophthalmos or thjToid enlargement, and
the presence of marked anemia make this ver>- improbable.
Cancer of iho bowel would produce a similar diarrhea and anemia,
but if this diajniosis were correct, one would expect periods of pain,
amstipation. visible peristalsis, abdominal distention, and intestinal
DIARSHEA 233
noise. The good nutrition of the patient is further evidence against
the diagnosis of cancer.
Colitis, with or without ulceration, is very improbable in view of
the negative condition of the stools.
Pernicious anemia is suggested by the condition of the mouth, the
details of the blood-picture, and the tendency to periodicity which the
history portrays.
Outcome. — She was given two doses of "606," the first, 0.3 gram;
the second, a week later, 0.2 gram. The diarrhea ceased after the
second week, but slight fever continued and the blood showed no
considerable improvement. Nevertheless, on the 4th of May, she
felt so comfortable that she decided to go home.
In this, as in many other cases of pernicious anemia, sympto-
matic improvement occurs, though the blood remains unchanged.
The effect of salvarsan is sometimes much more favorable than in this
case. Under its use, as also imder treatment by atoxyl, some patients
improve very markedly not only in their symptoms, but in their blood-
picture. Arsenic, given in the form of Fowler's solution, may be less
effective than when it is taken as salvarsan or atoxyl. It must be
recognized, however, that no known form of treatment, whether by
arsenic or by the recently much-heralded thorium, or by splenectomy,
does anything more than retard for a few months the fatal termina-
tion of the disease.
This patient died on the 6th of June, 191 1.
Case 88
A banker of thirty-six entered the hospital July 14, 191 1. The pa-
tient's father died of "anemia" at sixty-six; otherwise family history is
excellent and past history negative, except that he has had ever since
twelve years of age a good many attacks of abdominal pain and diar-
rhea. Two years ago he weighed 145 pounds and felt reasonably well,
when he was attacked by a severe diarrhea and was in bed three weeks.
Since then he has never been really vigorous. Most of last summer
he was in bed in a hospital and gained somewhat, but every few weeks
he has attacks of pain and diarrhea, the pain being at times very severe,
but never localized. He rarely vomits, but several times has had
slight jaundice. Tenesmus has been a troublesome symptom. Since
January of this year it has been noticed that he is paler than usual.
His best weight, 145 pounds, was maintained up to two years ago,
since when he has gradually fallen to 120 pounds. He worked until
the 28th of June.
234
DIFFEBENTIAL DIAGNOSIS
On physical examination he is rather sallow, mucous membranes
pale. A soft systolic munnur replaces the first heart soimd all ova
the precordia. The aortic second sound is faint. Abdomen shows a
marked visible pulsation in the epigastrium, and some tenderness with
shght rigidity, most notable in the region of the gall-bladder. Visceral
examination and the reflexes otherwise normal. Proctoscopic ex-
amination shows nothing abnormal in the
lower 8 inches of the bowel. The stools
are negative to guaiac and show no other
abnormalities. A specimen of urine,
taken under aseptic precautions, shows
moderate growth of streptococci. Tem-
perature ranges as seen in the accom-
panying chart (Fig. 92).
The blood shows red cells, 1,500,000;
white cells, 3000; hemoglobin, 40 per
cent. In the stained smear the red cells
show marked variations in ^ze and shape,
with many huge oval forms. One megalo-
blast and one normoblast are seen while
counting 200 leukocytes, among which 65
per cent, are lymphocytes; the rest, poly-
nuclears. A few stippled forms and
many abnormal staining reactions were
found. The urine is negative.
Discussion. — The history of this case gives no distinct clue to its
nature. The abdominal pulsation might bring aneurysm into con-
sideration. The absence of pain in the back, of any definite tumor,
and the central position of the pulsation (that of aneuryan is usually
to one side of the median line) make this very improbable. More-
over, with such an anemia as is here present, unusual pulsations of
one or another artery are very common. Indeed, they have often
been mistaken for aneurysms, as in the case reported by Dr. A. R.
Edwards, in the "Transactions of the Association of American Phya-
cians," for the year 1902.
The presence of streptococci in the urine points to a mild degree
of urinary sepsis. In the absence of pus, this finding is probably not
of great importance. It certainly cannot be responsible tor so mailed
an anemia.
The epigastric tenderness and rigidity, taken in connection with
the evidence of a severe anemia, bring cancer of the stomach into
Fig. 9». — Chart of Case 8;
DIARRHEA 235
consideration, but the history of two years' iUness, the rarity of
vomiting, and the gradual and only moderate loss of weight are
against this idea.
The details of the blood-picture, with the negative results of
physical examination and of x-ray examination, point straight to
pernicious anemia.
Outcome. — On the 17th the edge of the spleen was felt. After
the i8th the gastric symptoms were very slight. The appetite gener-
ally good. Bismuth :r-ray examinations showed that a considerable
amount of bismuth remained in the stomach an hour after ingestion,
but no intestinal lesion and no obstruction of the pylorus was made
out. Stasis of this degree has been noted in several of our cases of
pernicious anemia, proved by autopsy to be such.
The patient went home, without any change in his condition, July
2ist. He improved somewhat after this, and about the ist of January,
1912, was much better, but in April he began to run down again, and
on the 15th of May he died.
Case 89
A housewife of forty-seven entered the hospital October 6, 191 1.
The patient's mother died at sixty-one of a "growth in the liver."
One brother died of consumption at twenty-three. The patient has
had no serious illness, but has always been very nervous and lacked
vitality. Since the menopause, two years ago, she has had "nervous
prostration and neurasthenia" many times. A year ago she had
"acute indigestion," and since then has suffered constantly from sour
stomach. For the past few months she has vomited sour material a
good many times. She says her pain is due to hydrochloric acid
trickling about the abdominal interstices and coming up into her
throat in burning waves. She has never vomited blood.
One week ago she began to have severe diarrhea, and her ab-
domen, previously "small and shriveled," began to be distended.
With this change came cramp-like pain and constant soreness in the
lower abdomen.
Since her stomach trouble began a year ago her legs have been
swollen and have felt very heavy at times. This has been especially
marked in the last two weeks. A year ago she weighed 135 pounds,
with clothes, but she has lost much weight since, and for the past year
has done but little housework and has been recumbent most of the
time, though lying down often increases her abdominal pain.
On physical examination the patient was foimd to be emaciated
236 DIFFERENTIAL DIAGNOSIS
and so weak that she spoke with dfficulty. Pupils and reflexes nega-
tive. Tongue dry and cracked. Left border of cardiac dulness was
3 cm. outside the nipple line. The apex impulse could be seen and
felt indistinctly almost as far as the anterior axillary line. The
sounds were of good quality, the action regular, the first apex sound
loud, accompanied by a slight systolic murmur. The aortic second
and pulmonic second sounds were of equal intensity. The pulses
were equal and normal in volume and tension. Artery walls not felt.
Limgs negative.
Abdomen moderately distended; it showed dulness in the flanks,
shifting with change of position; also a fluid wave. The vaginal walls
seemed to be pushed together by masses of considerable hardness,
apparently outside the vault. The cervix uteri was normal, the
fundus not made out. The rectum, like the vagina, seemed to be
enlarged by external pressure, but both examinations were unsatis-
factory because of pain.
There was marked soft edema below the knees. • The patient
vomited almost everything and could not hold fluid by rectum.
The stools were small and consisted largely of liquid and mucus.
Operation was considered, but discouraged.
Discussion. — Although this patient has been supposed to have
nervous prostration, the fact that her troubles began after forty
makes this improbable.
Stomach symptoms beginning at her age and followed by swelling
of the legs, even in recumbency, make a very ominous combination
of symptoms. It suggests gastric cancer followed by peritoneal
metastases. The dropsy is not at all easy to explain on the groimd
of any cardiac disease, for although the heart shoWs evidences of en-
largement and of weakness, the dropsical fluid seems to be confined to
the abdomen and legs, the lungs remaining clear. The finding of
pelvic masses went to confirm the diagnosis suggested above.
Outcome. — The patient died October isth. Autopsy showed a
gastric cancer of the "fibromatous" infiltrating type, extending not
only throughout the stomach, but over a considerable part of the large
intestine in the form of a tough, whitish membrane, resembling that
of chronic peritonitis, also spreading along the peritoneal surface
from the stomach by contiguity. The stomach was not enlarged,
showed no tumor, no ulceration, and no pyloric obstruction. The
pelvis was wholly clear and showed no glandular metastases. One
ureter was blocked by a cancerous membrane and a hydronephrosis
had resulted on that side. The other kidney showed suppurative
DIARRHEA 237
nephritis. The cancerous growth along the large intestine had
resulted in numerous carcinomatous strictures. There were also
some cancerous nodules in the right kidney and in certain perito-
neal lymphnodes.
The heart showed a well-marked mitral stenosis, though the
organ weighed only 212 grams. Moderate ascites was present.
Case 90
A French Canadian barber of forty-four entered the hospital Sep-
tember 26, 191 1. For years, he says, his bowels have moved three or
four times a day, usually in the morning, but several times more
later in the day if he drinks cold water. He has noticed nothing re-
markable about the movements and has had no tenesmus. He
thinks he has lost about 15 pounds in the past year. Liquid diet,
especially milk, makes his diarrhea worse. On a diet of meat alone he
has only one or two movements a day.
Eighteen days ago he got a cold in his head, felt chilly, and had
vague pains in his legs and back. These symptoms have continued
since. A nasal discharge is very profuse in the morning, sometimes
slightly blood tinged. A frontal headache, more marked on the left
side, has been present from the beginning of his cold. It begins in
the morning, before he gets up, and wears away toward night. His
nose, cheek-bones, and bones behind his ears are sore. He has had
some cough for eighteen days and raises a little thick, yellow sputum.
Appetite is very poor, and he has speUs of retching every morning
since the cold came on.
Physical examination shows poor nutrition, moderate pallor.
Pupils slightly irregular, equal, reacting sluggishly. The glands on
the left side of the neck are slightly enlarged and tender. Both
epi trochlears are palpable; they are about the size of small beans.
The throat shows a dry, chronic pharyngitis. The first heart sound is
short and feeble, otherwise the heart shows nothing abnormal. The
radials are moderately thickened and tortuous. Blood-pressure,
systolic, 150 mm. Hg.; diastolic, no mm. Hg. Physiologic peculiari-
ties of the right pulmonary apex seem somewhat exaggerated. A few
tortuous dilated veins are seen over the abdomen, which is otherwise
negative. The reflexes are normal. There is moderate tenderness
over the left eyebrow, none over the right. Mastoid and cheek-bones
not tender. White corpuscles, 13,800, with a normal differential
count. Urine averages 45 ounces in twenty-four hours, a few hyaline
or granular casts. The range of the temperature is seen in the ac-
DIFFEREHTIAL DIAGNOSIS
companying chart {Fig. 93). Examination by Dr. Algernon Coolidge
showed acute frontal sinusitis, in the sta^e of recovery, and chronic
atrophic rhinitis. Rectal examination showed that the ^hincter
admitted the tip of the finger only.
Discussion. — The long duration of the intestinal symptoms in
this case makes it natural to speculate whether the patient is not
one of those persons who habitually have several movements of the
bowel each day while in full health. The loss of 15 pounds in weight
within a year, however, makes this supposition improbable.
From the history alone no diagnosis
possible in this case. The most
definite points are the loss of weight
and the presence of some infecticm of
the upper air-passages and facial bone-
cavities. The presence of a rectal stric-
ture is a much more enlightening datum,
and su^ests at once the possibility of
syphilis. This is further strengthened
by the irregularity and sluggishness of
the pupils, by the general glandular en-
largement, the premature sclerosis of the
arteries, and the slight elevaticm of blood-
pressure.
Outcome.— All attempts to penetrate
further into the rectum were prevented by
pain. Dr. Daniel F. Jones believed this
sphincter to be of syphilitic origin and
adWsed gradual dilatation with bougies.
Wassermann reaction was negative. Mercurial inunctions and iodid
of potash were given during his stay in the hospital. Diarrhea soon
ceased and the frontal sinus cleared up.
Case 91
A freight ainductor of twenty-seven entered the hospital October
27, 1911, comphuning of a diarrhea of eight da>-s' duration. His
mother diixl of inflammation of the boweb. His wife was then imder
treatment for s\philis. Wassermann reaction positive. One child,
agixl three and a half years, had iritis and was also under treatment
One child died, at two months, of s\philis. The patient himself had
a hanl chancre sue years ago. but no other s\'mptoms, and had con-
sidered himsi-lf entirely well until of late. In this attack he had be^
l^r^,||^?;|,[.j.|.|M|
.„_
'lilt i'i%^
".'■;" " " ' —
: --. --i-iiFJj
'-■jj i-sii'-^
:::: :i::-l::zz
i::: k:::::::::
i:::l ;;:;;;;::3
Fig. oj. — Chan of Case 90.
DIARltEEA 239
aware of headache and fever since the second day and had felt in-
creadngly weak, but kept at work until two days before. Smce
that he had stayed at home, but had uot remained in bed.
Phyacal examination showed good nutrition. Nothing abnormal
in the internal viscera. Blood-pressure, no mm. Hg. Temperature
as in the accompanying chart (Fig. 94). Urine normal. White
corpuscles, 8000. Widal reaction negative.
240 DrPFERENTIAL DIAGNOSIS
Discussion. — ^Here we have an obvious syphilitic history in the
patient and his family. In this infection diarrhea may result either
as a part of the general intoxication or from a stricture of the rectum,
with irritation of the bowel above it from retained feces. But for the
blood-culture, mentioned below, it certainly would have been im-
possible to make a diagnosis of this patient's trouble on the 27th of
October. When one looks at the chart and takes it in connection
with a physical examination, which enables us to exclude tuberculosis
and sepsis with considerable probability, typhoid fever becomes prob-
able, even in view of the negative Widal reaction.
Outcome. — Blood-culture, October 28th, was positive for typhoid
bacilli. Widal reaction did not become positive imtil November 9th.
White corpuscles ranged at their highest to 10,000, November 23d.
Five days before this he had a moderate-sized intestinal hemorrhage,
which was treated by starvation and morphin. The course of his dis-
ease was otherwise uneventful, and he left the hospital in good condi-
tion January 4, 191 2.
Case 92
An unmarried woman of twenty-eight, living at home, entered
the hospital December 2, 1911. Her family history and past history
were not remarkable. Until six years ago, when she had the measles
and was sick for four weeks, she was well, but since that time she says
that "her stomach has never been right." Her bowels have moved
from two to five times a day, and four times she has noticed a small
amount of fresh blood in the movements. She has distress after her
meals and belches much gas and sour material. She has no vomiting
and no sharp or localized pain. Her discomfort is sometimes relieved
by hot drinks. Her weight four months ago was 128 pounds; three-
weeks ago, 112 pounds. She has worked during the whole of hei^
illness except for a vacation of three weeks in July.
On examination the patient was well nourished. Chest negative^
Abdomen showed slight diffuse tenderness and a firm, slightly tender"
sausage-shaped tumor in each lower quadrant. There was no spasm^
but much intestinal noise. The right kidney easily palpable. Blood —
pressure, no mm. Hg. Blood and urine normal. A stool showe(5
no food residue to the naked eye, but under the microscope muct»
undigested food was seen, with considerable mucus and a positive
guaiac test. Bacteriologic examination of the stools showed nothing
remarkable. She remained three weeks in the ward and gained ^
pounds. Tube examination of the stomach showed nothing wron^^
DIARRHEA 241
except that hydrochloric acid was absent on one occasion. After the
loth of December her bowels moved regularly and her appetite was
fair. The epigastric soreness and tenderness persisted. She left the
hospital December 24th.
Discussion. — ^There is nothing in this case to indicate organic
disease. The sausage-shaped tumors are probably fecal. Her diar-
rhea is probably the expression of poor general condition. The pres-
ence of undigested food, under the microscope, is of no special im-
portance, in view of the repeated disappearance of her diarrhea under
no special treatment except rest. In many cases of this type it turns
out that diarrhea is dependent upon constipation and the irritation
produced by this. Many of these cases have pain and pass mucus,
so that the term "mucous colitis" is applied to them, but the distinc-
tion between this type of disease and ordinary constipation is by no
means a sharp one, especially when the trouble occurs in high-strung
women.
Outcome. — The patient has been followed by Drs. H. F. Hewes
and John W. Dewis since leaving the hospital. The former con-
sidered the case one of functional diarrhea, with incapacity to take
care of fats. When she rests the diarrhea ceases. When she gets
tired, it recurs and lasts a month or so. I agree with Dr. Hewes'
diagnosis.
January 12, 191 2, Dr. Scudder operated, removed an appendix,
and severed some adhesions about the ascending colon. There were
also adhesions extending from the duodenum to the gall-bladder and
some indications of a Lane's kink. There was no evidence of gall-
stones. The stomach and pancreas were also explored through the
epigastric incision and nothing found.
Through the sunMner of 191 2 she was under the care of Dr. John
W. Dewis. In August the hemoglobin was 75 per cent., and a stained
specimen showed moderate achromia. Physical examination and
examination of the stomach contents and feces showed nothing ab-
normal. November 13, 191 2, she reported, saying that she was
doing excellently and feeling like her old self. The blood was then
normal.
Case 93
A cigarmaker of forty- two entered the hospital March 17, 191 2.
Family history and past history are negative except that one sister
died of cancer, situation unknown. Four weeks ago he began to have
a bloody dysentery. He had committed no indiscretion in diet and
Vol. 11—16
242 DIFFERENTIAL DIAGNOISS
there were no similar cases at his boarding-house. The day after the
onset of this trouble he took to bed and has been there ever since,
suffering from slight fever with pains in his arms, legs, and throat.
For the last two weeks he has had headache, increasing mental con-
fusion, and loss of memory. His diarrhea has now ceased and his
bowels are moving daily with laxatives.
The predominating symptoms at entrance are cerebral. Drowsi-
ness, slowness in answering questions, and aphasia are marked. He
appears to have forgotten many important events of his life and has
no clear idea of his present illness. He would often stop in the middle
of a sentence, yet show no, consciousness that he had stopped. Occa-
sionally he stuttered or slurred over words.
Physical examination shows exaggeration of the knee-, elbow-, and
wrist-jerks. No ankle-clonus or Babinski. The patient's move-
ments seem slightly unsteady, but he can write and pick up objects
without difficulty. Physical examination is otherwise quite negative.
The urine is negative. Blood-pressure, 140 mm, Hg. Wassermann
reaction negative. Stools negative. The blood shows i9,cxx> leuko-
cytes, March 17th, with 90 per cent, hemoglobin. Among the white
cells there are polynuclears, 43 per cent.; hmphocytes, 30 per cent.;
eosinophils, 27 per cent. March 21st the leukocytes are 27,500,
with polynuclears, 37 per cent.; lymphocytes, 2^ per cent.; eosinophils,
39 per cent. Mast-cells, i per cent.
On the day after entrance a marked injection of the conjunctivae
and slight edema under the eyes were noticed. This, with the eosino-
philia, let! to an examination of a bit of calf muscle, where trichinae
were found. Within a week the mental SNTnptoms wholly cleared up
and the man seenuxl eniirely normal. At no time was there any marked
muscular st^roness, but Dr. Honr\- Jackson, who had seen him pre-
vious to his entrance to the hospital, repnuted that he had been eating
jxx^rly c^x^kcil s;ius;igcs before the onset of the present attack.
Discussion. The mental s\-mptoms which were so prominent
in the clinical pictun* of this patient's illness would naturally sug-
gest arteriosolerosis or dementia pxiralytica. As his diarrhea had
coasixi botoro ho came under obsorvation, his only sNTnptoms, beyond
the pswhosis jusi moniivM\c\i, wore headache, slight fever, and gener-
alJAxl pains.
With thi^o vlata vMily and without the routine blood examination,
whiv h has btvn IvMig one ot ov.r n-iv^st valuable safeguards against errors
of diacnv>sis. this vMm" vor:air.:\ could not have been unraveled, but^
the ivsinv>pl\iiia, onoo vii>vO\crc\i, has enormous importance in thi^-
DIARIOIEA 243
case because most of the causes for that symptom (causes such as
intestinal parasites, chronic skin diseases, and anaphylactic reactions)
can be easily excluded. This done, trichiniasis is at once suggested.
Case 94
A clothing salesman of thirty-one, bom in Russia, entered the
hospital June 3, 191 2. He has been troubled for four weeks with
diarrhea, severe in the last four or five days, with noticeable loss of
weight and strength. These are the patient's chief complaints. At
present he has twelve or more movements daily, consisting of mucus,
blood, and watery fluid. Preceding each stool there is cramp-like
pain in the lower abdomen. At other times no pain. The appetite is
fair, but he frequently has slight epigastric discomfort an hour after
meals. Has noticed slight dyspnea on exertion and some swelling
of the ankles. Four months ago his weight was 155 pounds, with
clothes; June 12th it was 129 pounds, without clothes.
Physical examination shows fair nutrition. Negative pupils and
reflexes. Chest negative. In the abdomen nothing of interest except
a sausage-shaped mass in the left lower quadrant.
Microscopically the stools show mucus, blood, epithelial cells,
and leukocytes, with very little fecal matter. The sigmoidoscope
shows that the mucous membrane of the rectum and sigmoid, as far
up as visible, is red and covered with numerous minute ulcerations and
blood-clots. It is subsequently learned that the patient spent six
weeks in Rutland, at a boarding-house for tuberculosis, but was not
in the sanitarium. This was six years ago, following a cough which
had lasted twelve weeks.
The patient's blood and urine are not remarkable except that
the blood-smear shows 6 per cent, of eosinophils. The Wassermann
reaction is negative. Culture from the stools shows the gas bacillus.
A pint of 5 per cent, silver nitrate solution is injected June 5th and
9th, but is held only a minute and produces no improvement.
Discussion. — The presence of 6 per cent, eosinophils in this
patient's blood suggests that the diarrhea may be due to some intes-
tinal parasite, but the examination of the stools showed no such
p>arasite and the eosinophilia remained unexplained.
The history of a residence at a health resort for tuberculosis,
a. fter a cough which lasted twelve weeks, makes it necessary to con-
5xcl^^ tuberculosis of the bowel, but the fact that six years have elapsed
ixxi^^ ^^^ patient has had any pulmonary symptoms, and that his
244 DIFFERENTIAL DIAGNOSIS
lungs are now normal, makes it unlikely that tuberculosis now exists
in the bowel.
Direct inspection of the bowel proves the presence of an ulcera-
tive colitis, the causal agent imknown. There is no good reason for
connecting the presence of a gas bacillus with the diarrhea. Cases
of this type represent an unexplored country in medicine. We know
nothing of their cause and but little of their prognosis and treatment.
Outcome. — ^June 12 th he left the hospital unimproved. On the
2 2d of June Dr. Daniel F. Jones opened the bowel at the cecum, pro-
ducing an artificial anus, and instituted regular washings of the colon
with normal saline solution, injected through the artificial opening,
twice daily. This was kept up until the 25 th of August. By that
time the opening had closed so that no feces escaped, yet it was suflS-
dently open to permit the colonic washes to be continued. He went
to work again in October, and by December 5th had gained 25 pounds
and was still free from diarrhea, though his movements occasionally
contained a little blood. Later he relapsed, and on May 22, 1914,
reported that he was in about the same condition as when he first
entered the hospital.
Case 95
A mechanic of thirty-four entered the hospital May 17, 1912.
The patient's family history was negative. Fourteen years ago he
had a chancre and a bubo. Was treated by an army doctor. While
in the Philippines in 1899 he had mountain fever and was sick for ten
days. Otherwise he had been well until the present illness. In the
autumn of 1909, while in Georgia with Buffalo Bill's show, he began
to have diarrhea, the stools preceded by severe cramps, and con-
sisting of mucus and dark, clotted blood. In the following winter
he was for three months in St. John's Hospital in Brooklyn, New York.
The next spring he was able to do heavy work and has kept at it ever
since, though having occasional cramps and one or two loose stools
daily. He has eaten no meat, potato, cabbage, peas, or com.
Nine months before entry his diarrhea recurred, and three months
before he gave up work. For the past six weeks he had had twelve
to eighteen stools a day and a constant burning pain in the abdomen.
His appetite was good, but if he ate as much as he desired he had to
vomit, though the vomiting was not preceded by nausea. Four years
ago he weighed 180 pounds; six months ago, 169 pounds, in his clothes;
at this time, 145^ pounds, without clothes.
Physical examination shows slight tenderness along the colon on
DIARRHEA 245
the right side of the abdomen. Otherwise the internal viscera are
negative. The blood showed 29,000 leukocytes, with a polynucleosis
at the time of entrance. Four days later, leukocytes, 16,500. The
urine was negative. The stools showed many amebse in active mo-
tion, some of them containing numerous included red corpuscles.
Discussion. — Repeated and prolonged attacks of diarrhea in a
patient who has lived in the tropics are strong presumptive evidence
of amebic dysentery. A careful study of the characteristics of the
amebse found in the stools dispelled all doubt of the diagnosis. The
case is detailed here chiefly on account of the treatment followed.
Outcome. — The patient was given quinin injections, with some
relief, but May 20th the following treatment was substituted: The
patient received no food except broth after 12 noon of the first day of
treatment. At 6 p. m. he was given 40 gr. of ipecac in 5-gr. capsules
coated with keratin. Each night, after a similar half-day's starvation,
the patient was given ipecac, the dose being reduced 5 gr. each day
imtil a dose of 10 gr. was reached. The latter then continued each night.
The patient bore this treatment excellently well. Pain during bowel
movements stopped within a few days, the first relief, he says, since
the onset of his trouble. The bowel movements at first became very
watery, several large evacuations taking place during the night and
the day. By May 30th he had only one or two movements in twenty-
four hours. The feces were formed and amebae could no longer be
found. Several of the large doses of ipecac caused nausea and slight
watery vomiting three hours after taking, but only once was the
medicine vomited (the 2S-gr. dose). On the 31st he left the hospital,
preferring to finish up treatment at home.
Now that we have the emetin treatment, introduced soon after
this date by Rogers, we need no longer struggle against the difl&cul-
ties of administering ipecac.
Case 96
A conductor of thirty, born in Austria, here thirteen years, entered
the hospital March 30, 191 2. For two years, without known cause,
he had been having diarrhea with a few intervals of comparative
freedom. His family and past history negative. The stools were
three to twelve a day and preceded by cramps. Until two weeks ago
his appetite had been good. He had had no vomiting or other symp-
toms. Three years ago he weighed 198 pounds, with clothes; now
149 pounds, without clothes. His bowels never move at night.
On physical examination he was not emaciated, muscular, but looked
246 DIFFERENTIAL DIAGNOSIS
worried. Visceral examination, together with the blood and urine,
temperature, pulse and respiration, showed nothing abnormal. Proc-
toscopic examination in the Out-patient Department was negative,
The stools showed no blood or pus or food residue, and were always
negative to guaiac. During a week's stay in the hospital the patient
had but one movement daily while under treatment by buttermilk,
and a diet consisting of eggs, fish, and meat, with one slice of toast
three times a day. Toward the end of his stay he was so constipated
he had to receive laxatives.
Discussion. — Of special importance seems to me the fact that this
man's bowels never move at night. I have never known a case ol
diarrhea due to ulcerative enteritis in a patient whose bowels move
only in the daytime. Moreover, the examination of the stools has
never shown evidence of intestinal ulceration, and the patient's weight
has been steadily though rather slowly increasing. The case remains
a somewhat mysterious one, as it is diJSScult to conceive that psychic
causes or mere habit can be responsible for so long a trouble in a pa-
tient of this type and temperament. He shows no evidence of a ner-
vous make-up.
Outcome. — For two weeks after leaving the hospital the patient
was free from diarrhea, then it returned, and by the 24th of April
was worse than ever. He followed the diet closely, but without good
result. There has been mo soreness of the mouth. The stool ex-
amined at that time showed much mucus, a large excess of meat fiber,
no fat. He was given a prescription for paregoric, i dram, to be
repeated after each loose movement. On the 28th of April, 1914, the
patient reported, at my request. He then weighed 170 pounds, with
clothes, and averaged about four days' work a week. He never has
any looseness of the bowels or any movements at night, but he is still
bothered with gas, cramps, and loose movements in the daytime.
Spinach, prunes, and pie are especially likely to upset him. He has
seen no blood in his movements, but thinks they contain consider-
able pus.
The cause of this diarrhea I do not know.
Case 97
A laborer of forty-five entered the hospital July 24, 191 2. The pa-
tient has always been well. Takes two or three beers and one whisky
a day. Two weeks ago he began to have diarrhea, loss of appetite,
poor sleep. He had been working on a stone-crusher in great heat,
but as he felt no better when he stayed away from work a couple ol
DIARSUEA 247
days, be resumed his occupation; a week ago he gave up once more,
aithoi^ he has not felt very sick. He has no headache and no other
symptoms. Ten years ago he weighed 175 pounds; one year ago,
150 pounds; now, 139 pounds.
■ Physical examination shows the patient well nourished, active,
and bright mentally. Right pupil smaller than the left. Both react
normally. Tongue clean. Heart's apex in the fifth space, inside
the nipple line. Loud, blowing systoUc murmur heard all over the
precordia, not replacing the first sound. Pulmonic second not ac-
centuated. Systolic blood-pressure, 115. Lungs, abdomen,- and
extremities negative. Temperature as seen in the accompanying
F'8- 95- — Chart of Case 57.
™*'"t (Fig. 95). Urine averages 40 ounces in twenty -four hours, with
a speei£c gravity 1026 to 1032. and occasionally a granular cast.
rose
'te cells, 5500, July 24th; 4500, July 26th; 4600, August 2d; 4000,
St 11th; 6000, August 2ist. The spleen was never felt and no
spots were seen.
■*^iscussion. — During the early weeks of observation no diagnosis
^•<i le made. A latent acute endocarditis or a deep lying broncho-
" ^^itionia were thought the most probable explanations of hin
^^^t*toms. Against both of these, however, a persistently low leuko-
^ ^ Count had to be considered. Without the positive Widal reac-
248 DIFFERENTIAL DIAGNOSIS
tion we should have been utterly in the dark. As it is, the positive
blood-culture remains a mystery. It may have been a false report.
Typhoid fever seems to me clearly the diagnosis.
Outcome. — August 2 2d the patient seemed to be well and left
the hospital.
Case 98
A hotel worker of thirty-one entered the hospital September 27,
191 2. The patient's father died at sixty of dysentery; otherwise the
family history is not of interest. The patient had left-sided pleu-
risy when seventeen, but had otherwise been well until he was twenty-
four, when he had a diarrhea lasting six months. He was in Aus-
tralia at this time. After that he was well until six months ago,
when the bowels began to be loose and occasionally a little blood was
noticed in the movements, yet the condition had not been trouble-
some until about two months ago, when he began to suflFer from
tenesmus and noticed mucus in the stools and a little cramp-like pain
in the lower abdomen and before movements. Still the frequency of
stools was not much increased until within the past month, when
all his symptoms had been aggravated and his appetite and strength
had failed. Proctoscopy in the surgical Out-patient Department
September 17, 191 2, was negative.
Physical examination showed a man well nourished and appar-
ently not much pulled down. The viscera were entirely negative.
The temperature during the seven weeks in the ward was not ele-
vated. The blood and urine not remarkable. Systolic blood-pres-
sure, 130. The stools were liquid and always showed a positive guaiac
reaction, with numerous pus cells and red corpuscles under the micro-
scope, but no macroscopic pus or blood. The gas bacillus was abun-
dant in the stools. No amebae or eggs were found in the stools. Under
the Schmidt diet the frequency of stools was somewhat improved, but
the quality not much changed until October 6th, when they became
formed and occurred only once a day. On the 14th the patient was
put on special diet, consisting of meat, 400 grams; toast, 40 grams;
four eggs, and enough macaroni, cheese, and butter to bring the value
up to 2000 calories. This produced no special change, and on the 17th
the patient was given strict diabetic diet, with 50 grams of carbo-
hydrates, 75 grams of protein, and enough fat to make up 3000
calorics. On this diet the stools became more frequent, and on the
20th he was given a fat-free diet for a few days, without improve-
ment. He then was once more put upon the special diet previously
DIAREHEA 249
ordered on the 14th, and showed a very marked unprovement. On
the 7th of November he was given butter and potato in addition to
the foods previously allowed, but this did not work well, and on the
loth he was again restricted to the special diet above listed. Im-
provement once more followed, and he was allowed to go home on
the 13th of November in good condition.
Discussion. — This case is typical of a mild degree of ulcerative
colitis. It is interesting chiefly because of the dietetic experiments
tried.
Outcome. — The patient was seen December 13, 1912, and stated
that for the first two weeks, since leaving the hospital, he was as
badly off as ever. Since then he has been much better, and though
he has not yet gone to work, he expects to do so within another week.
For the first two weeks after leaving the hospital he had diarrhea
between 2 and 9 a. m. each day, with complete freedom from such
trouble for the rest of the day. Now he has but one movement a
day, which is preceded by some griping pain. There is no blood in
the stools. He states that cold meat always agrees with him, while
hot meat makes his bowels loose. He has taken no medicine lately,
eats and sleeps well, and feels as well as ever.
CHAPTER IV
DYSPEPSIA
The vast majority of the causes for indigestion have nothing to do
with the stomach, that is, with any disease of the stomach. There
is not an organ in the body which may not produce gastric symptoms.
The vomiting of brain tumor and of uremia are familiar examples.
Indeed, I think we should recognize the fact that the stomach may be
thrown out of its regular routine of work almost as easily as the
heart. We are perfectly familiar with the fact that any bodily and
mental exertion and any sort of illness may increase the heart-beat.
We do not, therefore, suspect any disease of the heart itself. We
must learn to be as familiar with the fact that when patients com-
plain of their stomachs they are generally free from gastric disease.
This is the more important because the patient's own well-meaning
efforts go very far to mislead us. A patient whose heart happens to
be rapid, by reason of some disturbance in another part of the body,
is not apt to complain of his heart, but if a patient has any stomach
trouble he always complains of his stomach, no matter where the
trouble originates. Gastric complaints are very urgent; they press
themselves very forcibly on our notice and bulk large and gloomy
in the foreground. This is the source of the old medical adage that
"patients with disease above the waist are cheerful; those with dis-
ease below the waist are despondent.'* Disease below the waist
means something that produces gastric symptoms, and gastric symp-
toms are, as I have just said, very plangent, aflFecting our spirits
strongly.
The truly gastric causes of indigestion may be reduced almost
entirely to two — cancer and ulcer. Nervous dyspepsia is fearfully
common, but it does not originate in the stomach. It is so with the
other varieties, such as functional h^pochlorhydria, dyspepsia de-
pendent upon constipation, and other types to be mentioned later.
They do not in any sense deserve to be called gastric disease.
What, then, should be especially present in our minds as possible
causes of gastric s>Tnptoms, when a patient comes to us for these and
for these alone?
250
DYSPEPSIA 251
(i) In a woman who has not passed the menopause, pregnancy
should always be remembered as a. possibility. I have known a
number of cases unsuccessfully treated for stomach trouble without
any investigation for the possibility of pregnancy, although the latter
was later found to be the entire cause of the gastric complaint. I do
not think there is any characteristic peculiarity about the stomach
symptoms of pregnancy. The eariy morning nausea and the vomiting,
which are so often present, are also seen in dyspepsia of the uremic
type, in lead-poisoning, in alcoholism, and in phthisis.
(2) Chronic nephritis is much more often a cause of dyspepsia
than most of us recognize. It is, of course, the types of nephritis
which do not produce edema or obvious changes in the urine which
are most likely to mislead us. In my own experience, it has been
chiefly the vascular types of nephritis, associated with arteriosclerosis
of the heart and brain, that have caused mistakes, owing to the pres-
ence of indigestion as a presenting symptom. Since it has become a
matter of routine for all conscientious physicians to measure the
systolic blood-pressure in every patient, mistakes of this sort are less
^nd less frequent, for the great majority of nephritic cases associated
^th indigestion show a notably high blood-pressure. A further dis-
™ction between true gastric disease and the indigestion due to
uremia is the fact that the latter has no association with the presence
^^ absence of food in the stomach. The patient's nausea or distress
°^ay come at any time in the day, after any kind of food or no food
^^ all. It is utterly irregular. Further proof that the indigestion
IS of uremic origin may be obtained by treating the patient for uremia.
^^st in bed, low protein diet, purgation, sometimes venesection or
tot-air baths, should produce improvement, unless the patient is in
^^^ last stages of the illness.
(3) Tuberculosis, pulmonar>^ or other, is very frequently over-
'^^ked because gastric symptoms are all that the patient complains
. • Unexplained indigestion coming on in a person previously healthy,
^ a. person who has not changed his diet or his work, who is not
^'^^inic or nephritic or overw'helmed by mental torture and worrj-,
f^^Uld be suspected of being due to tuberculosis. True gastric
.digestion should have a demonstrable cause, either a local cause
^ ^^e stomach itself (cancer or ulcer), or an external cause in some
^t>vious indiscretion in diet. Such indiscretions are much less common
^^xi the diagnosis of them. We often badger the patient and force
^^^ into the reluctant admission that he has eaten something out of
^^ 'Way, when, in point of fact, he has not. We are so determined
\
Dyspepsia
NON>GASTRIC
GASTRIC
* Including cancer, ulcer, and the anomalies of gastric secretion, si
position.
252
Dyspepsia
^H
^^DEBIUTATED STATES
^^^^1
INDUSTRIAL OVERSTRAIN
" mif ™REP«m*NT»Tioh. "°
ELV fOH ^^H
ALCOHOLISM
FAIUNO HEART
PHTHISIS
ANEMIA AND CHLO- >
ROSIS f
J
1
■■ 1929 ^1
H
^ ^H
NEUROSIS AND PSY-|
CHO NEUROSIS >
\ CHRONIC NEPHRITIS
GASTRIC ULCER
GASTRIC CANCER
DVS PEPSIA -UN-i
1482 ^H
1197 ^^M
1140 ^H
toco ^H
624 ^H
KNOWN CAUSE) )'
CANCER OF THE!
BOWEL i
GALl__STONES
CONSTIPATION
CIRRHOTIC LIVER
^^_
GASTRITIS, GASTRO-1
EN-TERITIS. ALCO-J
Ho Lie GASTRITIS '
-^
^1
NERVOUS DYSPEPSIA
^^
^1
DUODENAL ULCER
IB^
360
°*strectasia
^
271
'■^*'O~P0IS0NING
^
174
°^®T BOPTOSIS
^
130
"'^'^eRCHLORHYDRIA
K
109
"^f^Oaddity
■
28
L.
I
22
3S3
254 DIFFERENTIAL DIAGNOSIS
to find a case of this nature that we find it even when it is not there.
A more sensible course would be to have the patient's temperature
measured night and morning for a week, inquire carefully into his
family history, and to examine his lungs with the utmost care in a
perfectly quiet room, and, if possible, by the a:-ray as well as by the
ordinary methods. It is surprising how many cases of unexplained
dyspepsia will yield to treatment directed toward tuberculosis and
to no other treatment.
(4) In women a great many cases of indigestion are due to star-
vation. This 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 again
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, imtil the
patient gets down to a regimen of slops or their equivalent. 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 sufiFering.
An ill-nourished stomach will complain, yet it must be nourished
nevertheless. If we can persuade the patient to undergo such suffer-
ing, 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 unneces-
sary suffering. Most cases of this t>T)e can be cured by nothing in the
world but forced feeding.
The greatest improvement that I have seen in the management of
stomach cases in the last twenty years has been the recognition 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 starvT 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.
DYSPEPSIA 255
(5) Gall-stones are a very frequent cause of attacks attributed to
the stomach. When cancer and ulcer can be excluded, it is almost
invariably wrong to attribute to the stomach any malady that causes
severe pain. Otherwise stated, the only gastric diseases that cause
severe pain are cancer or ulcer. All other forms of indigestion run
their course with varying degrees and combinations of flatulence —
heart-bum, distress, pressure, nausea, vomiting, but not with severe
pain.
Now, gall-stones often produce pain squarely in the pit of the
stomach and not in the region of the gall-bladder. Failure to realize
this accounts for many mistakes. If the patient has many attacks,
some of them are likely, sooner or later, to be localized in or to radiate
to the right hypochondrium, but in the early stages of the disease we
may not have any such symptom. True stomach trouble rarely
begins in the night. Gall-stone pains are very apt to begin in the
night. Gall-stone pains are generally relieved promptly and per-
manently by morphin. Gastric disease can seldom, if ever, be so
relieved. Further details as to this differential diagnosis will be given
later in this chapter.
(6) Angina pectoris is again and again treated for dyspepsia.
The pain may be at the epigastrium, and is very often preceded or
accompanied by flatulence and belching. Moreover, it not infre-
quently comes after meals. These three facts, taken together, lead
to many erroneous diagnoses of stomach trouble, when a measure-
ment of blood-pressure or a careful history would have revealed the
obvious presence of angina pectoris. A characteristic of angina pain
is that it is almost invariably excited by exertion or emotion, and
promptly quelled by rest and peace. Gastric indigestion does not
behave this way. In the majority of cases careful questioning brings
out the additional fact that epigastric pain of anginoid origin is asso-
ciated, sooner or later, with pain in the left arm.
Why angina attacks are associated with belching I have no idea.
It may be that this, like most belching, is really due to air sucking,
produced by the attempt to gain relief from previous gastric discom-
fort, and followed by the discharge of the air thus sucked into the
stomach. Why do angina attacks sometimes come after meals?
Because the muscular work of digestion, like any other muscular work,
increases the work of the heart.
(7) Tabes Dorsalis. — ^Among 136 gastric cases reported by Dr.
Frederick T. Lord before the Bristol County Medical Society at Fall
River, May 14, 1914, 12 were tabetics, and 3 of these were operated
256 DIFFERENTIAL DIAGNOSIS
upon for supposedly local disease of the abdomen. Such a mistake
is inexcusable when previous evidence of tabes, such as an Argyll-
Robertson pupil or absent knee-jerks, can be obtained. But we have
had at least 2 cases in which the syphilitic nature of the under-
lying disease was discoverable only by lumbar puncture, the pupils
and knee-jerks being normal. What we are learning in the last few
years, since lumbar punctures and Wassermann reactions in the blood
and spinal fluid have become matters of routine in doubtful gastric
cases, is that any type of stomach trouble^ acute or chronic, mild or
severe, sharply painful or merely distressing, may be due to cerebro-
spinal syphilis. Until within the past few years one was on the look-
out, if he were conscientious, for so-called gastric crises in tabes, f . e.,
for sudden paroxysmal attacks of abdominal pain and vomiting, asso-
ciated with the obvious nervous lesions of posterior spinal sclerosis.
What we have learned lately is —
(a) That we must suspect the possibility of tabes, even when the
pupils and knee-jerks are normal, and must investigate this possi-
bility by means of spinal puncture.
(6) That any sort of gastric abdominal pain or distress may be
due to tabes.
Actual syphilitic disease of the stomach, resulting in an hour-
glass configuration of the organ or in scars of other kinds, must be
remembered as a possibility and investigated, so far as possible.
(8) Lead-poisoning is not a common cause of indigestion among
well-to-do people, but among factory workers, especially rubber
workers, painters, and printers, it is much more common than is
ordinarily recognized. Any causeless dyspepsia in a person exposed
to lead and even any causeless loss of appetite should be suspected of
being due to lead-poisoning. When this dyspepsia is associated with
colic, and especially when a lead line or characteristic blood changes
are present, there is no excuse for failing to make the diagnosis, but
in the earliest cases we cannot get beyond a presumption, and we
should act upon this presumption by urging the patient to put
himself, at any rate for a time, imder conditions in which lead ab-
sorption is impossible. If, then, he rapidly improves, he should be
urged either to change his job or to take more effective precautions
against the ingestion of lead.
(9) Cancer of the large intestine sometimes deceives even the
elect when presenting itself with irregular periods of nausea, dis-
vomiting, and without any special intestinal complaints.
^h, cases in which there was no flatulence, no severe
DYSPEPSIA 257
pain, and no more constipation than might be associated with any
type of indigestion or even with seasickness. Should any question
arise, a bismuth enema and x-ray study should be carried out and,
if a doubt still remains, exploratory incision should be advised.
(10) Organic cerebral disease, arteriosclerosis, syphilis, or tumor
are not often ijiistaken for indigestion; headache and vertigo usually
call attention to the brain. It should be remembered, however, that
all of these cerebral lesions may be associated for weeks and months
with headaches of a type ordinarily called "bilious" and attributed to
indigestion. Such attacks are often unilateral and get called "mi-
graine." This mistake can only be avoided by early and frequent
examination of the fundus oculi and by a careful history, such as will
bring out transient paresthesias of one or another extremity, transient
fits or paresis, aphasia, or clouding of consciousness.
(11) Industrial J menial y and moral causes of indigestion are very
common and, by physicians not trained to investigate every part of
the patient's life, often imrecognized. Fatigue, worry, fear, or re-
morse may, quite unknown to the patient, be at the bottom of his
sufferings. In the hospital a social service worker is indispensable in
the diagnosis and treatment of such cases.
WHAT IS SIMPLE INDIGESTION?
When the stomach is upset, yet is free from organic disease, and,
so far as we can ascertain, from any outside influences, such as those
which have been detailed in the preceding paragraphs, what has
occurred? We are very apt to say that the patient has eaten some-
thing indigestible, and doubtless this is sometimes true, although I
think it is rarely a sufficient explanation. Or, again, we say that
gastric fermentation has occurred; but this is always secondary to
some cause producing arrest of digestion and stasis of gastric con-
tents. This is where our attention should be focused. In healthy
persons, now and then, something causes an arrest of digestion.
The gastric contents are not passed on into the duodenum. They
remain in the stomach and imdergo abnormal fermentation, causing
flatulence and other forms of distress. But why do they remain in the
stomach? What inhibits digestion? Two causes are known, others
su^)ected.
(a) We know that severe bodily exertion immediately after a
meal may slow or altogether stop digestion, presumably by calling
away so much blood from the stomach that its motility is interfered
with.
Vol. 11—17
258 DIFFERENTIAL DIAGNOSIS
(ft) Psychic disturbances, such as fear, grief, rage, worry, may
frequently upset digestion by slowing or inhibiting the gastric move-
ments, possibly also by affecting secretion. One cannot help being
somewhat skeptical as to the importance of secretion, its lack or excess,
when we see how well patients with tabes or pernicious anemia may
digest their food for long periods of time without any HCl discover-
able in the gastric contents. I am not yet convinced that deficient
gastric secretion is, in itself, enough to produce dyspepsia. Many
tired, anemic, or tuberculous patients have deficient gastric secretion
and also indigestion, but in these cases motility is usually disturbed as
well. When motility is good and secretion absent, as in diabetes,
digestion seems to go on perfectly well.
Beyond the two known causes for gastric inhibition — ^bodily
exertion and excessive emotion — there are doubtless many others,
concerned, perhaps, with the action of the glands of internal secretion
about whose bearing and suggestion we know, at present, very little.
What, it seems to me, important that we should recognize is that the
majority of all gastric upsets are not easily explained, and that the
old idea of improprieties in diet has been seriously overworked. K
we will recognize how little we know in this field, we may progress
more rapidly.
Case 99
A shoemaker of sixty-seven entered the hospital May 16, 1908.
The patient's mother died of cancer of the throat at sixty-eight; other-
wise his family history is good. He was sick for a month, when twenty
years old, with a fever of unknown nature. He says he has had dys-
pepsia all his life, distress after eating being the chief symptom.
There has been no vomiting. Four months ago he weighed 175
pounds, with clothes; now, 142^ pounds, without clothes.
Four months ago his dyspeptic symptoms became worse, and he
began to have sharp, constant pain in the epigastrium, not radiating
and not affected by food. At times this p>ain is severe enough to double
him up. For three weeks he has had nausea and vomiting immediately
after meals, with some relief of pain. The vomitus shows no blood or
coffee-grounds and no food taken the previous day. For the past
month he has eaten almost nothing, and, according to his statement,
his bowels have moved but twice during this time. He has emptied
his stomach either by vomiting or by the help of the stomach-tube
each day.
Physical examination showed rather poor nutrition, skin and
DYSPEPSIA 259
mucous membranes pale, but was otherwise negative. Weight, 142^
pounds, without clothes. Temperature, blood, and urine negative.
With the stomach-tube no contents were obtained from the fasting
stomach. The capacity of the organ was 84 ounces. When inflated
it occupied the position shown in Fig. 96. After a test-meal free HCl
was present, 0.18 per cent.; total acidity, 0.26 per cent. Guaiac
negative. Microscopic examination negative. The patient improved
markedly on a liquid and soft solid diet with nux vomica and a
laxative.
Fig. 96. — Gastric outlines in Case og.
Gastric neurosis was the preliminary diagnosis. On the 24th he
had moderately positive guaiac lest in the stools. Tube examina-
tion of the stomach was repeated on the 36th, with practically identi-
cal results. The patient was examined in a warm bath and seen by
several consultants. Nothing further developed. He ate and slept
well and felt subjectively much better. Lavage was repeated every
third morning. A surgical consultant saw no indication for operation,
and the patient left the hospital on the 6th of Jime very much im-
proved.
He re-entered on the 6th of July, iqo8, having done no work since
he left before, and having lived upon a diet of milk, crackers, grape-
26o DIFFERENTIAL DIAGNOSIS
nuts, and eggs. Once he took clam chowder and vomited, but this
was the only time. He has no pain except when he takes a deep
breath or on certain motions, and he has no distress except after a
hearty meal. His belching has not returned. His bowels move every
other day. He has dull, constant headache.
Physical examination shows poor nutrition, but is otherwise nega-
tive. Blood and urine negative. Stomach-tube examination showed
a little food residue in the fasting stomach. Guaiac test on that
residue negative. After a test-meal free HCl was present, 0.18 per
cent.; total acidity, 0.26 per cent. Guaiac test in the stools was
positive on the gth, 12th, and 13th. His weight was 140 pounds,
2 pounds less than at the previous entrance.
Discussion. — The age, the family history, and loss of weight
point toward cancer, but we note also that this patient has been
dyspeptic all his life, and that his pain does not seem to be affected
by food and is more severe than we usually see in gastric cancer.
It is rare to hear a person say that the pain doubles him up when
gastric cancer turns out to be the cause.
Physical examination shows a large but apparently competent
stomach. There is practically no stasis, always the most important
thing to know about a stomach. This does not exclude cancer, but
militates more or less against such a diagnosis, because at least three-
fourths of all gastric cancers obstruct the pylorus and produce stasis.
The presence of blood in the stools with no stasis, and an abundant
secretion of HCl, is quite compatible with a diagnosis of peptic ulcer,
although the patient's age makes us doubt the probability of this
lesion.
We have no evidence of any disease outside the stomach, such
as nephritis, gall-stones, or tuberculosis. On the whole, gastric cancer
seems the most probable diagnosis.
Outcome. — Operation on the 17th of July showed a stomach not
enlarged, thickening of the pyloric ring, and a small, whitish patch on
the anterior surface of the pylorus. The pyloric opening was con-
siderably obstructed. On the duodenmn was a small, whitish patch,
3 cm. in diameter, similar to that at the pylorus, but there was no
thickening of the duodenal wall. In the head of the pancreas there
appeared to be a small tumor, about the size of the end of the thumb.
At this point the patient stopped breathing, and only after ten min-
utes of artificial respiration could he breathe spontaneously. A pos-
terior gastro-enterostomy was then done. He recovered weU from
operation, but had rather a poor appetite, and vomited from time to
DYSPEPSIA . 261
time large amounts of greenish fluid. He left the hospital August 9,
1908. August 19, 1909, he wrote that he had been distinctly better,
but not well. For the past several months he had not vomited and had
gained some weight. He could eat almost anything in moderation.
His bowels were normal. March 24, 1910, he wrote that he was
better than before operation, had no pain, and weighed 145 pounds.
He felt finely at bedtime, but had some hunger pain after i a. m. He
had done no work, but walked two to four miles daily and had done
so for the past year.
In view of the fact that this patient was so well two years after the
operation, we may feel confident that no cancerous growth was over-
looked at the time of operation. We cannot say that any positive
evidence of ulcer was discovered, but the obstruction of the pyloric
opening and the whitish patch upon the duodenum makes it prob-
able that we are dealing with a peptic ulcer and cicatrix. The patient's
improvement, after gastro-enterostomy, gives support to this belief.
A point of some interest in the findings at operation is the state-
ment that the stomach was not enlarged, although when distended
with water, through a stomach-tube, it held nearly three quarts.
This tends to show that these measurements by water distention are
by no means conclusive. The most useful test of gastric dilatation is
the presence or absence of food in the fasting stomach ten hours or
more after the last meal.
Case 100
A motorman of forty-four entered the hospital September 12,
1900. Two weeks before entrance the patient began to feel tired
and to lose his appetite. A week ago he gave up work and went to bed.
His only local symptoms are pain in the epigastrium on taking food
and general soreness in the abdomen. For the past week he has ,
vomited almost every day and has had diarrhea. The pain in the
epigastrium has been very severe, requiring poultices and plasters.
For a week he has had fever. No cough at any time.
Physical examination showed good nutrition, a dull and heavy
expression. Normal pupils, glands, and reflexes. No stiffness of
the neck. Chest negative. Scattered rose spots on the abdomen.
Some tenderness and muscular rigidity in the epigastrium. Some
tenderness on the tibiae and lower calves. On the 14th the spleen
was also palpable. The white count was 6000. Widal reaction
strongly positive. Hemoglobin, 83 per cent. The specific gravity
of the urine was 1023; slightest possible trace of albumin, no sugar;
DIFFERENTUL DUGNOSIS
in the sediment a few hyaline
and granular casts, with an
occasional cell adherent, now
and then a fresh blood-cor-
puscle. The patient ran a con-
tinuous fever, never below loo"
F., and usually between loi"
and 102° F., frora Septem-
ber i2th to December loth,
practically three months (Fig.
97)-
The pulse remained be-
tween 80 and 90 from the i2th
to the 28th of October, then
a left-sided orchitis developed,
and the leukocytes rose to
18,600, and to 26,000 the next
day, when a friction rub ap-
peared in the left axilla. By
the 2d of October the tender-
ness and swelling were gone
from the testicle and the fric-
tion rub had disappeared.
Nevertheless the pulse con-
tinued elevated, and from Oc-
tober 4th to December 30th,
nearly three months, was
rarely below 120, often above
130. Routine examinations
during October revealed no
local complication, but on the
Sth of October the white cells
numbered 35,600, and on the
10th. 36,000. He had drenching
night-sweats in the early part
of October. After the middle
of the month harsh breath-
ing and bronchophony were
detected over a dull area,
about the size of the palm, in
the right back opposite mid-
scapula.
DYSPEPSIA 263
On the 25th of October the white cells were 26,800, and there were
fairly clear evidences of solidification at the right apex on the level
of the spine and the scapula, over an area the size of a silver dollar.
These signs were vaguely corroborated from time to time up to the
8th of November, when the note says that they seemed sometimes
more marked than at other times. The white cells were then 41,000.
On the 14th of November there was sharp pain in the splenic region
foUowed by a drenching sweat, with general abdominal rigidity. The
blood at this time showed red cells, 3,880,000; white ceUs, 40,800;
hemoglobin, 43 per cent. Among the white cells there were 88 per
cent, of polynuclears, 11.8 per cent, lymphocytes, 0.2 per cent, eosino-
phils. The red cells showed considerable irregularity in size, slight
irregularity in shape. There were 160 normoblasts per cubic milli-
meter. November 20th the note reads, "Dr. R. H. Fitz finds signs
in the lungs the same." White cells 28,400. December 4th signs
were gone from the right lung; white cells, 22,800. He eats very
Uttle.
At this time, although the patient's temperature was still over
100® F., he was gotten out of bed, and within a week the temperature
fell almost to normal, although on the i8th the white cells were still
23,100. On the 29th he was up and walking about, gaining daily;
white cells, 12400. January 14th he was able to walk about fairly
well, had gained 6 pounds in two weeks, had a negative physical
examination, and was allowed to go home, although his hemoglobin
was still only 48 per cent.
Nine years later he entered the hospital again, stating that for
the first year after leaving the hospital before he felt very well, then
he once more began to have distress in the epigastrium, especially on
the left side. It was not increased by hearty meals and did not
produce vomiting. Sometimes hot drinks relieved it. This condi-
tion remained unchanged and did not prevent his working.
A year ago the pain began to grow worse and extended also
to the left flank, under the ribs. It was now described as a dull, sick-
ening feeling.
For a month he has noticed some headache. For three days
the pain in the epigastrium has been increased, and the pain in the
flank has disappeared from time to time. During these days he has
vomited each morning once, and has noticed a slight dyspnea on ex-
ertion and some palpitation. His appetite, until the last week, has
been excellent. Up to a year ago he weighed 200 pounds (136
264 DIFFERENTIAL DIAGNOSIS
pounds on leaving the hospital after his typhoid), but within the
past year he has lost somewhat in weight, and now weighs 167
pounds, without clothes. He kept at work until three days before
entrance.
Physical examination showed fair nutrition, the right pupil larger
than the left and slightly irregular; both, however, reacting normaUy.
Glands and reflexes normal. The heart's impulse seen, felt, and
percussed in the fifth interspace; nipple line 11 cm. from midstemum.
Right border of dulness 6 cm. from midstemum. At the apex the
second sound was louder than the first, which was accompanied by a
harsh, systolic murmur, loudest in the apex region. The aortic second
sound was markedly accentuated. The arteries thickened and tor-
tuous. Blood-pressure, 260 mm. Hg. The lungs were negative,
save for slight dulness and crackling r&les at both bases. The ab-
domen showed shifting dulness in the flanks. There was a slight
tenderness and resistance in the epigastrium and very slight edema
of the shins. The urine averaged 25 ounces in twenty-four hours;
specific gravity from looi to 1005; albumin a trace; sediment, few
hyaline and granular casts. Blood negative. During the first week
of his stay in the hospital the temperature ranged between 99° and
100^ F. The patient did not improve at all. Vomiting and headache,
with poor sleep, continued despite purgation, hot-air baths, and
cardiac stimulation. On the 6th leeches were applied over the liver.
Very free bleeding followed. Next day the vomiting and general
condition seemed improved, but his arms had meantime become very
much swollen and tender. After the loth of March edema of the
feet and legs increased. He took little food, passed less urine, com-
plained of dyspnea and precordial distress, not relieved by nitro-
glycerin or amyl nitrite. On the loth he had an attack of very severe
precordial pain with dyspnea which was not relieved. At six in the
evening he died.
Discussion. — There is no reason to doubt that the illness from
which this patient suffered in September, 1900, was typhoid, with
thrombi in the lung and spleen. Doubtless the pyrexia toward the
end of November and the early part of December was of the type
known as ''bed fever/' since it so promptly subsided when the patient
got up. Just what bed fever is we do not know, but may surmise
that it is due to some disturbance of metabolism or of heat regulation,
connected with the abnormal existence of the patient deprived of the
normal stimuli of exercise and the normal variations in temj>erature.
Nine years later this patient suffered from a dyspepsia associated
DYSPEPSIA 265
with a good appetite. Had not the urine and blood-pressure been
tested, we might have had no suspicion of the true origin of this
dyspepsia until the edema of the peritoneimi and lungs appeared.
The latter is probably of comparatively recent origin, since the
patient has only had dyspnea for a few days. Uremia, then, is
doubtless the cause of this patient's symptoms.
We are accustomed to say that when a patient past forty begins
to have dyspepsia out of a clear sky — that is, without any obvious
cause or any previous habit — cancer is the most probable diagnosis,
but when saying this we must remember that the cancer age is also
the arteriosclerotic age, and, therefore, the time for nephritis and
uremia. Furthermore, the cancer age is also the gall-stone age and
the age for angina pectoris. All of these possibilities should, .there-
fore, be investigated before we settle down on even a preliminary diag-
nosis of cancer.
Outcome. — ^Autopsy showed chronic glomerulonephritis; slight
arteriosclerosis; hypertrophy and dilatation of the heart; serofibrinous
pericarditis; cholelithiasis; slight chronic pleuritis on the right.
Case 101
A ship carpenter of forty entered the hospital March 15, 1909.
The patient was sent in from the Out-patient Department (No.
123,290) with a diagnosis of **splenic anemia.'' His family history is
exceUent. He states that ten years ago he had what he calls "rheu-
matism," which began in the instep of each foot, was associated with
fever for the first week, and kept him in bed for six weeks. He says
he was paralyzed from the waist down, could not move his legs at all,
and had much pain in the backs of them. Recovery, however, was
complete. He takes three or four beers a day, some whisky Saturday
nights, and a pint over Sunday.
Two years ago he began to feel run down, had considerable cough
when working in a dusty mill, but this cough ceased when he got an
out-of-door job. At this time he weighed 155 pounds. Last Decem-
ber he had a day or two of indigestion, relieved by taking salts. At
the end of January he stopped work after a hard job aboard ship.
He had then a crowding feeling in the epigastriiun after meals,
and an "all gone" feeling later. He took an abundance of salts and
lost in strength and weight. This he has continued to do in spite
of medicine and diet. His appetite has increased, and he takes two
quarts of milk a day. He had no pain, no edema, an excellent appe-
tite, better than usual, fairly good sleep. Nevertheless, he had to
266
DIFFERENTIAL DUGNOSIS
stop work January 20th on account of weakness, and now weighs only
125 pounds.
Physical examination showed fair nutrition, skin and mucous
membranes pale. Red cells, 3,912,000; whites, 14,300; hemoglobin,
55 per cent.; polynuclear leukocytes, 78 per cent.; l>'mphocytes, 21
per cent.; eosinophils, i per cent. Urine negative. Pupils equal and
react normally, slightly irregular in outline. Reflexes normal. Glands
enlarged in the neck, axilla;, groins, and epitrochlear regions. Artery
walls thickened and slightly tortuous. Visible pulsation in the
brachialis. Chest negative. The liver extended from the sixth rib
i
Tig. 98. — CondiEian o£ the spleen and liver
to a point 11 cm. below the ensifonn, where an edge was felL
Splenic dulness was 11 by 15 cm. The edge of the organ was felt
(Fig. 98).
I made the diagnosis of questionable syphilis of the liver, as the
surface of that organ was irregular, its edge rounded. Examination
in a hot bath showed no palpable spleen, but otherwise confirmed
results of previous study. Stomach-tube showed no contents in the
fasting stomach. After a test-meal there was no free HCI or other
acidity. Guaiac was positive. On the 33d there was some food
residue in the fasting stomach. After a test-meal the contents were
I
DYSPEPSIA 267
still alkaline. The patient's gastric distress was considerably re-
lieved by resordn, 5 gr, three times a day, which was given after a
fruitless trial had been made of antisyphilitic treatment. After
losing 7 poimds in the first week he got most of it back again. His
temperature was somewhat elevated throughout (Fig. 99). His
stools were always negative to guaiac.
Discussion. — ^Apparently this patient had aa alcoholic neuritis,
or possibly a rheumatic attack, ten years ago, and a decided cough,
possibly tuberculous, two years
ago, but there seems no good
reason to connect either of these
illnesses with his present ax
weeks' attack of rather mild
dyspepsia, in which he has lost
weight and strength despite an
excellent ^jpetite. (This last
combination, it should be noted
—loss of weight and an excellent
appetite — is a rather rare one,
occurring chiefly in diabetes and
Graves' disease.)
The presence of an unex-
plained anonia in a man of this
age, with a generalized adenitis
and enlargement of the liver
and spleen, may mean syphilis.
Sailors are notoriously apt to
Jiave syphilis. Whether ship carpenters are as bad, I do not know.
The condition of the liver edge gives support to this sunnise, yet it must
be confessed that we have no positive evidence of syphilis in this case.
His habits are neither of the best nor of the worst as regards
alcohol. It is certainly possible that he may have acquired cirrhosis
of the liver, and cirrhosis might account for all his symptoms except
his adenitis and his rather premature arteriosclerosis. The absence
of free HCl in the gastric contents and the presence of positive guaiac
reaction are not infrequently associated with cirrhotic liver.
Why may not the patient have peptic ulcer? His anemia might
be accounted for by some unrecognizable hemorrhage which passed
out by the bowel. His good appetite is entirely consistent with such
a diagnosis, and is more easily explained than by either of the diag-
noses previously considered.
Fig. 99. — Chart of Case n
268 DIFFERENTIAL DIAGNOSIS
Ulcer, however, has a much longer history of paroxysmal dys-
pepsia than is present in this case, and it is not often associated with
absence of HCl in the gastric contents.
We have some hints of phthisis in the case, especiaUy the cause-
less indigestion and the slight fever. No one of the diagnoses yet
considered, unless possibly syphilis, will accoimt for this fever, and
it still remains a mystery in this case. No explanation of it has
ever been oflFered. Arteriosclerosis might be imagined as a cause of
the patient's troubles, even though his urine is negative, as we have
no blood-pressure measurements recorded. An arteriosclerotic kid-
ney or arteriosclerosis of the abdominal blood-vessels cannot be ex-
cluded as a possible cause of his symptoms, but if we adopt this
theory we cannot explain his anemia. I have never seen any good
reason to beUeve that arteriosclerosis can, by itself, account for
anemia.
Cancer of the stomach would explain the anemia and the achylia,
but not the fever, enlarged spleen, and good appetite. I was unable
to make a diagnosis in this case, and recommended exploratory in-
cision in view of our uncertainties.
Outcome. — On the 5 th of April operation revealed a mass in the
greater curvature of the stomach and a larger mass underneath the
stomach. Both masses were presumably cancerous. No operation
was attempted. The patient was sewed up. He left the hospital
April 25, 1909, and a letter sent to his address a year later was
returned marked **Dead."
Case 102
A married Russian Jewess of forty-four entered the hospital
February 22, 1909. Her family and past history were not remark-
able. For three months she has vomited in the morning whenever
she takes anything to eat or to drink. At times when vomiting her
fingers stiffen out, but her thumbs do not turn inward. During this
same period she has had some shortness of breath on climbing stairs,
and for two months has used two pillows at night and passed urine
once in the night.
Physical examination showed poor nutrition, good color, negative
pupils and reflexes. The heart showed no enlargement, but there
was a rough systolic murmur, best heard at the apex and transmitted
to the axilla. The pulse showed increased tension, but no blood-
pressure measurement was recorded. There was visible pulsation
in the brachial arteries and some thickening of the radials. The
DYSPEPSIA 269
aortic second sound was loud and ringing. Both hands showed in
the ward a tendency to a spastic contraction of the fingers, with
occasional turning in of the thumbs. The little finger and fourth
finger would turn under together, so as to make the knuckle of the
middle finger very prominent. Vaginal examination was negative.
The uiine averaged 35 ounces in twenty-four hours; specific
gravity, 1005; slight trace of albumin. No casts. Blood normal.
The fundus oculi showed narrowing of the arteries at various points,
no hemorrhages or areas of retinal degeneration. Stomach-tube
revealed no contents in the fasting stomach and no enlargement of
the organ. After a test-meal there was no acid in the gastric con-
tents. Despite various measures designed to relieve it the vomit-
ing continued until the 2d of March, when she was given corn-
meal mush and did very well, but with more varied diet vomiting
recurred.
Discussion. — Morning vomiting in a woman always suggests
pregnancy, but there is no possibility of that in this case. Next to
that, nephritis is the commonest cause that I know for morning vomit-
ing. The condition of the heart and urine strongly suggests that
there is a nephritis in this case. It is, moreover, notable that dysp-
nea began at the same time as the vertigo.
This patient is at the cancer age, and any such symptoms be-
ginning in a patient of that age who has never had stomach trouble
before should suggest cancer, but we have here rather more vomiting
and rather less evidence of objective gastric disease than one expects
with early gastric cancer. The absence of HCl in the gastric contents
is not in any way characteristic of cancer, and does not constitute
evidence against the diagnosis of chronic nephritis, which seems to
me the most reasonable one.
The contractions of the fingers are to be regarded as tetany,
a disease about which we know very little, except that it seems to
have some association with gastric dilatation and with extirpation
of the parathyroid glands. There seems no good reason to believe
that either of these conditions is present in this case. Nevertheless,
I suppose the tetany would be classed under the general type of
gastric tetany.
It is worth while noticing that the vomiting was checked in this
case by the administration of commeal mush. I have seen a simi-
larly successful result in a good many cases. In the treatment of
vomiting, when starvation does not sufl&ce and when the patient must
be fedy it is generally a mistake to give bland liquids, such as milk
270 DIFFERENTIAL DIAGNOSIS
and broth. The patient needs something with a fairly strong taste
to it, and solids are usually better than liquids.
Outcome. — The pulse grew steadily weaker, and on the loth
the family decided to take her home, where she died March 11, 1909.
Case 103
A housewife of thirty-six entered the hospital April 17, 1909. The
patient's father died of ^'rheumatism of the heart," her husband, of
consumption; one child also of consimiption. She had typhoid at
fifteen, and a year later had jaundice which lasted almost a year.
For many years she has had stomach trouble, especially in the
last three years, in which time she has been vomiting about twice
a week and had pain after taking food; also burning sensation in the
epigastrium, with marked constipation. August 31, 1908, she entered
the Boston City Hospital with a diagnosis of gastromesenteric ileus.
The stomach was found markedly dilated. Posterior gastro-enter-
ostomy was done. Four days after operation nausea and vomiting
began. September 23d she was discharged against advice. She
now states that since the operation she has been much worse than
before. She vomits everything that she eats and has constant epi-
gastric pain, which confines her to bed about half the time and causes
her to lose weight rapidly. She has never vomited any blood.
Physical examination showed fair nutrition. The pupils, glands,
and reflexes normal. Chest negative. Abdomen negative, save for
moderate epigastric tenderness. Urine negative. The blood showed
20,000 white cells with polynuclear leukocytosis; hemoglobin, 85 per
cent. Four days later the leukocytes were 17,600. Later it was
discovered that for the last three months she had had morphin to
relieve the pain, usually J to J gr. Her stomach was washed out
and its contents found to be mostly bile. She continued to vomit
and needed a great deal of morphin, bromid, and chloral. On the
23d she was seen by Dr. C. A. Porter, who advised exploratory opera-
tion. On learning this news the patient stopped howling and vomit-
ing, became cheerful and intelligent, said there was nothing the
matter with her stomach, and that the only trouble was she had been
given too much morphin. She said she would not be operated upon
and wanted to go home. Said she wanted some food, was given
an egg on toast, turned over, and slept comfortably all night. The
next morning she again began howling and vomiting. In the after-
noon the patient, who was in a private room, was found with a towel
wound into the shape of a rope. Fearing that she might do herself
DYSPEPSIA 271
harm, the house officer ordered restraint. The patient escaped
from the restraint, but was so enraged with the treatment that she
ceased howling and vomiting and became rational. After that she
took considerable nourishment and vomited less.
Discussion. — ^A patient who has been exposed to tuberculous
infection, has suffered from a long-standing dyspepsia, was shown at
the Boston City Hospital to have a dilated stomach and has acquired
a moiphin habit, now comes under observation with a leukocytosis of
unknown origin. What the cause of that leukocytosis may have been
we are unable to discover.
As we read over the history, we are inclined to say at once, "Oh,
yes! hysteria!" but the question is, is there not something behind her
lack of mental control? Are we certain that, even at her age, she
has not some arteriosclerosis or cerebral syphilis? All we can say
on this point is that there is no evidence of either trouble. I am
inclined to think that it is correct to attribute her troubles wholly
to her mentality, though we cannot account satisfactorily for the
leukocytosis.
It is a point of interest in this case that although she had demon-
strably a dilatation of the stomach, for which gastro-enterostomy
was done without any relief, she later got along with her stomach
perfectly comfortably when mental conditions were changed. I have
become very skeptical of the diagnosis of dilated stomach as a patho-
logic entity. I doubt if we know enough to make such a diagnosis
in the absence of stasis. We do not know how large a stomach
may be and still be normal, nor what temporary stretching the organ
may be subject to without becoming in any way diseased or ineffi-
cient. The diagnosis of dilated stomach used to be a very frequent
one. In the better clinics of the country it is now becoming rare
and, as it seems to me, should disappear altogether. A dilated
stomach with stasis is important, but it is of precisely the same im-
portance as stasis without the dilated stomach. In other words, the
stasis is the point, and that is to be proved either by x-ray or, better
still, as I think, by the passage of the stomach-tube before breakfast.
We cannot be sure that a bismuth stasis discovered by jc-ray repre-
sents the actual functional ability of the stomach when working
upon food materials. Bismuth is, after all, a foreign substance, very
different from anything that we ordinarily ask our stomachs to deal
with.
Outcome. — It was learned later that her mother had died in the
Danvers Insane Hospital. On the 29th she left, against advice.
272 DIFFERENTIAL DIAGNOSIS
Case 104
A widow of sixty-four entered the hospital December 18, 191 1.
She says she had stomach trouble for twenty years, and mentions
"auto-intoxication" and "dilated stomach" as causes. Occasionally
has colic or acute distress, otherwise she has been well, and, despite
habitual constipation and frequent headaches, has led an active life.
Now and then her activities have been interrupted by a paroxysm
of what she calls "meat-poisoning," with some vomiting and diarrhea.
She passes urine twice at night. Has had no other urinary disturbance
and has never been jaundiced.
For about a month she has had frequent attacks of nausea and epi-
gastric pain. Ten days ago, after lunch, she had a severe attack of her
usual trouble and since then has been constantly nauseated and
in pain. She has been losing weight and getting worse in other
respects for a month. She stated that her bowels had not moved for
the ten days preceding December i6th. She has taken no cathartics
or enemata. She has had considerable cough, but no fever or chill.
Physical examination showed a poorly nourished woman, nega-
tive pupils and gums, very poor teeth, many of them missing. Chest
showed nothing of interest except a scattering of coarse r&Ies in both
backs. Abdomen was slightly distended, and showed slight spasm
and considerable tenderness in the right upper quadrant, where an
indefinite mass could be felt to move with respiration. There was
also a tenderness over the pubes. The reflexes were normal. Urine
normal. Blood at entrance showed 19,000 leukocytes. Hemoglobin,
85 per cent.
Soon after entrance she vomited 100 ex. of grayish fluid, with a
positive reaction to guaiac, but no free HCl. This reaction was
present also in the stools. Throughout the ten days' stay in the
medical wards (808-241) the abdomen remained moderately distended,
and despite the good results of enemata and cathartics there was often
general alxlominal pain, occasionally crampy. She vomited more or
less each day, retaining liquids until about 12 ounces had been taken
and then rejecting almost the entire amount. The temperature during
this period was normal, but the pulse gradually rose from 80 to no.
Discussion. — Although this patient has been habitually consti-
patetl, we cannot attribute her present stomach trouble to that
cause, for the present trouble is acute, the other chronic.
We note that this patient has had a good deal more pain than the
t\-pical d\-speptic. We note, also, that she is at the cancer age,
DYSPEPSIA 273
though we put less stress upon this, in relation to gastric cancer,
when the patient has had chronic stomach trouble, as in the present
case.
In favor of gastric cancer we have the presence of a mass in the
right hypochondriiun, with blood in the stomach, absence of HCl,
and stasis. The fact that she has had no movement of the bowels
for ten days makes it necessary to consider cancer of the bowel also.
It is always to be remembered that cancer of the bowel can reproduce
almost all the symptoms of cancer of the stomach. The persistence
of crampy abdominal pain, after she had been put at rest and had
had her bowels emptied, favors intestinal neoplasm. The condition
of the lungs shows a weak heart. The leukocytosis is not accounted
for. No definite diagnosis was made.
Outcome. — December i8th the abdomen was opened and hard
masses found all about the lower border of the liver, the gall-bladder,
and the pylorus. The abdomen also showed a number of other hard
masses, presumably in the omentum and mesentery, but no evidence
of intestinal obstruction was found. After operation she vomited
less and was«more comfortable, but gradually lost strength, and died
December 31st. Autopsy showed cancer of the gall-bladder, with
extensive metastases in the neighboring lymphatic glands. There
was also a streptococcus septicemia, with a small abscess in the right
limg, together with obsolete tuberculosis at the apex of each lung
and a moderate amount of arteriosclerosis. There is very little in
the case, as we look back over it, to set us right in diagnosis. The
absence of jaundice and of any tumor, recognizable as the gall-bladder,
makes it diflScult to see how a correct diagnosis could have been
made. It is striking that with a normal stomach and intestine such
marked gastric and intestinal symptoms were nevertheless present.
Possibly the metastatic masses may have had some connection with
this.
Case 105
A housewife of forty-eight entered the hospital December 19, 191 1.
Her father and grandmother died of "stomach trouble," otherwise
her family history is good. Six years ago she had some abdominal
operation done at the Homeopathic Hospital. The nature of the
operation is not known, but menstruation has been absent ever since.
For twenty years she has been troubled with indigestion, chiefly a
form of epigastric distress, without apparent relation to meals. The
distress comes at irregular intervals, and is associated with nausea
Vol. 11—18
274 DIFFERENTIAL DIAGNOSIS
and flatulence, but not with vomiting. Besides this distress she has
several times had attacks of very severe pain in the epigastrium,
which double her up and need morphin for their relief. She has never
been jaundiced and had no fever, but she has had a series of chills
which often accompanied the epigastric pain. The most recent chill
accompanied an attack of pain last night. The urine has been dark,
the stools sometimes black. The last severe attack was four weeks
ago. As a rule, pain lasts about six hours.
The physical examination is negative, except for rigidity of the
whole abdomen, preventing further examination. Tenderness is
complained of throughout, but it is not severe. It is apparently most
marked in the right half of the abdomen, which is tympanitic and
level throughout. The blood and urine are normal; likewise the
pulse, temperature, and respiration.
Discussion. — What can we infer from a family history such as is
present in this case? Nothing definite. The so-called stomach
trouble from which her father and grandfather died may have been
uremia, angina pectoris, hepatic cirrhosis, pernicious anemia, or
many other diseases. We have no good reason to suppose that it was
really connected with the stomach.
The patient has had twenty years of indigestion, but the striking
thing is that there has been no relation between this indigestion
and the taking of food. In other words, there is no good reason to
attribute the distress to the stomach itself. The occurrence of severe
pain, relieved by morphin and associated with chills, leads us to con-
jecture that gall-stones are present. Indeed, the chief difliculty be-
fore us is to avoid jumping at the conclusion that it must be gall-
stones before we have adequately thought out the other possibilities.
The history is certainly typical of gall-stones, and the physical ex-
amination also, since the physical examination of most gall-stone
cases reveals nothing whatever, as in this case. What else could it
be? Duodenal ulcer, first of all, for it is notorious that gall-stones
and duodenal ulcer may absolutely simulate each other. The pres-
ence of gastric trouble, between the sharp attacks of pain, is what one
would expect with ulcer. Against ulcer, however, is the absence of
any tjT^ical hunger pain, any definite relation to meals, or any relief
by food. Positive evidence of ulcer, such as blood or x-ray findings,
is absent, and it is certainly unusual to meet with ulcer pain requiring
morphin and promptly relieved by it.
It is now the fashion to attribute sj-mptoms of this kind to chronic
appendicitis and to remove the appendix for their reUef, but it seems
DYSPEPSIA 275
to me that it is becoming more and more difficult to defend this
standpoint. The revelations of Dr. E. A. Codman's paper on **Chronic
Appendicitis"* are more impressive the more thoroughly we study
them. Personally, I do not think there is the slightest evidence that
symptoms like this patient's were ever produced by chronic appendi-
citis.
Renal colic, due to stone or other causes, might produce such a
pain, but I have never known it to be confined to the epigastrium.
Moreover, we have no confirmatory evidence in the urine.
Outcome. — December 20th the abdomen was opened and the gall-
bladder found to be distended. About ten gall-stones, of various sizes,
were removed from it, but none were felt in any of the ducts. The
patient made a good recovery and was discharged the 9th of January.
December 16, 191 2, her family physician reported that she is and
has been perfectly well.
Looking back over the case, with the operative findings in our
minds, have we good reason to believe that the patient's twenty years
of indigestion were due to the gall-stones removed at operation or
to other similar stones? It is customarj' to answer this question
in the affirmative, but I cannot see that the custom has any good basis
in experience. There are plenty of patients who have just such
indigestion yet who show postmortem no evidence whatever of
gall-stone. The association may well be a coincidence.
Case 106
An Irish housewife of twenty-three entered the hospital August
19, 1909. Two months ago she began to have nausea, vomiting, and
headache. Previous to that she has always been well, and has a good
family history except that one sister died of tuberculosis, nine years
ago, while Uving in the same house with the patient. Early in the
present illness the vomiting was accompanied by nausea, and oc-
curred especially on rising in the morm'ng. Later, it occurred more
generally through the day. After three weeks of this trouble she be-
gan also to have headache, a dull frontal and occipital pain, with
frequent sharp attacks, which have continued ever since. A week
ago the sight of the right eye began to be dim, and now she cannot
distinguish objects with it. About the same time she noticed slight
numbness in the left side of the face and occasional slight vertigo.
Within the last week she has fainted twice.
Physical examination shows a well-nourished patient, with a
^ Boston Med. and Surg. Jour., October 2, 1913.
276 DIFFERENTIAL DIAGNOSIS
marked internal squint of the right eye. The left eye does not move
past the median line toward the left. Other movements are well
made. Pupils normal. Choked disk in both eyes. Chest and ab-
domen negative. Slight dulness of sensation, especially to pain, on
the left side of the face, neck, and upper arm. She cannot count
fingers with the right eye. The reflexes of the jaw, biceps, wrist, and
knee are exaggerated. The ankle-jerks not obtained. Babinski's
reflex is negative on both sides. Gordon and Oppenheim positive
on the right side. Blood-pres-
sure, 140 mm. Hg. Tempera-
ture, blood, and urine negative.
Discussion. — The age of the
patient and the exposure to tuber-
culosis hint at a dyspepsia symp-
tomatic of that disease, but the
loss of sight in one eye, the numb-
ness about the face, and the unex-
plained fainting makes it pretty
clear that we must look for some
deeper cause for the patient's
vertigo.
The physical examination
makes it reasonably certain what
this case is. The choked disks,
the increased reflexes, and pares-
thesia of the focal type consti-
tute a sjTnptom complex pointing
without any considerable doubt to a circumscribed intercranial lesion,
of which the vastly most common example is brain tumor.
Syphilis can cause similar symptoms, but we have no definite
evidence of that disease, and double choked disk is not common in the
early stages of cerebral syphilis. Arteriosclerosis at twenty-three is
rather a far-fetched surmise. Tuberculous meningitis does not pro-
duce double choked disk and rarely presents such definite focal symp-
toms. Brain tumor is the only reasonable diagnosis.
Outcome. — Operation August 21st for decompression; the record
does not state which side, but apparently in' the temporal region.
There was no improvement in her condition after this operation, and
on the nth of September the same opening was enlarged, still with-
out any gain. After the 23d of September the patient ran a steady
fever, most of the time above 100° F.
DYSPEPSIA 277
On the gth of October she died. Autopsy showed glioma of both
frontal lobes and of the basal ganglia on both sides. The fever was
unexplained (Fig. 100).
Case 107
A fisherman of thirty-eight entered the hospital November 15,
1909. Family history and past history negative. For three years
he has been bothered with attacks of epigastric soreness and disten-
tion, somewhat relieved by belching. In the intervals between these
attacks he is perfectly well and never vomits at any time. During
one attack, three weeks ago, he thinks he was slightly jaundiced
and had dark urine. His appetite is ravenous. He eats at irregular
intervals and bolts his food. His bowels are very constipated. The
last two attacks have been more severe than usual, and pain has been
referred to the back. In the past three years thinks he has lost 5
poirnds.
Physical examination shows a marked funnel breast, but is other-
wise negative. A stomach-tube is passed and shows no contents in
the fasting stomach. The water capacity of the organ is one quart.
After a test-meal the stomach contents show free HCl, 0.027 per
cent.; total acidity, 0.116 per cent. Blood and urine are normal.
There is no fever.
Discussion. — The patient has had three years of typical dyspepsia
in paroxysms, with a fine appetite and a marked constipation. Phys-
ical examination shows nothing. Is the constipation in itself enough
to account for the patient's symptoms? If we take it in connection
with his bad dietetic habits, I think we can say yes. It is not quite
certain whether the bad habits are the cause of the constipation or
vice vers&y but taken together they should be enough to upset his
digestion. At any rate, treatment should proceed upon this theory
until it is clearly disproved.
This is the sort of case in which many a surgeon rushes in where
the internist fears to tread, and it is perfectly possible that in the
long run, after thorough study, an exploratory incision might be
justified in such a case, but certainly not until we have obtained reason-
able assurance that the correction of his symptoms is not all sufficient.
Outcome. — ^He went home November 18, 1909, seemingly quite
well. November i, 191 2, his family physician writes that the patient
has been able to work steadily since leaving the hospital. He still has
some left epigastric pain and is badly constipated, but when he
keeps his bowels open he gets along quite comfortably.
278 DIFFERENTIAL DIAGNOSIS
Case 108
A janitor, a negro of forty, entered the hospital November 2,
1909. 'J'he patient's family histon* is good. His wife has had two
living diildren, followed by seven miscarriages early in pregnancy.
'J'he i>atienl has been in excellent health, and, according to his own
account, has excellent habits.
Last June he l>egan to have excessive flow of saliva, eructations
with epigastric pain, and vomiting. He had never had any trouble
with his digestion before. His pain was never severe. His vomit-
ing was at first alxml once a week, now after almost even' meaL
He ejei^ts part uf the food eaten, sometimes more than he can account
for. The vomitus is aJwavs >our. never bloodv. He is somewhat
ease<l by soda. Recently he has been getting weak and short of
breath and has had night-sweats. Since June he has lost 30 pounds.
Physical examination showed fair nutrition, considerable loss of
flesh. Pupils equal, slightly irregular, reacting nonnally. Aortic
seiond soumi much accentuate<i — loud, ringing, deliberate. Blood-
pressure, 2O0 nmi. Hg. No evidences of cardiac enlargement. Lungs
and aWomen negative. Blood negative. Urine averaged 40 ounces
in Iwenly-four hours; 1005 to 1009 in specific gra\'ity; trace of al-
bumin; no ca^ts.
llie slomach-tubc. passed before breakfast, showed some remains
of food eaten the day b<*!ore. Gastric capacity, 54 ounces. After
a test-meal HCl was absent. On the 4th of November the pati^it
bi'gan to coni[)Liin of nocturnal headache, dizziness, muscular tremor,
and vomiting wt .ui expulsive character without preceding nausea.
He continued tu vumit once or twice a day. but in other reinjects
seemed somewhat impruved after antisj^Kxific treatment had been
stuppeil an«l purgati«jn Ixgun. Examination of the fundus showed
exudate and hemorrhages around each optic disk.
Discussion. The chief features in the historv is the occurrence
ol seven niLscarrLiges in the patient's wife, the sbt months' sali\'ation«
epigastric {>iiin ami vrimiting. with a loss of 30 pounds in wei^t, and,
mi»re recently. «lyspnea ami sweating. This is just the sort of case
in which anvtjne who tries to practice medicine without routine
measurement •)! LIihhI -pressure will go clean astray. Without the
hliXH^l-pressure niea-urement one might not feel at all sure of cardiac
h>pertruphy. ami withi»ut that it would be impossible to be positive
that the patient has nephritis. The combination <rf the urinarjr
tuulings, the examination of the heart and the blood-pRSSure
DYSPEPSIA 279
be practically diagnostic of nephritis, even if we did not have the
retinitis to make certainty doubly sure.
It is to be noticed that the vomiting is distinctly of the cerebral
type, the type often associated with brain tmnor, but more properly
associated with increase of intercranial pressure, whether by reason
of brain timior, hypertension, or other causes.
One might easily have been puzzled in this case if one were in the
habit of putting imdue stress on the significance of gastric stasis and
achylia. These findings are often of great importance when there is
nothing outside of the stomach to account for them, but only then
should we think of them as direct evidence of gastric disease.
Outcome. — ^The headache after the 8th of November was slight
and he slept well. The vomiting seemed to have no relation to
eating, and on the 17th his relatives became alarmed and took him
home. His blood-pressure by this time had fallen to 200.
Case 109
A married woman of fifty-two entered the hospital January 10,
1910. Family history and past history negative. Always subject
to sick headache, and thinks that fifteen years ago she had same
trouble as now. States that she always had "delicate" stomach, but
no particular trouble with it until the i6th of September, when she
began to have epigastric pain and vomiting. These symptoms
lasted a few days and then she was comfortable, but there have been
three similar attacks since December 1 5th, and a good deal of flatulence
between them. The epigastric pain comes at a variable time after
eating. Since the middle of December her appetite has been poor
and her bowels have needed laxatives. She has lost much strength
and considerable weight. Her diet has been mostly rice, milk, Indian
meal, and raw eggs. For the past fiv5 days she has not vomited, but
has been troubled a good deal with vertical headache. For the past
four or five years she has passed urine twice each night after bedtime.
Physical examination of the chest was negative. General nutri-
tion was good. Had a well-marked herpes upon the lips. The heart's
apex was in the fifth space, 14^ cm. from midstemum. Pulse of high
tension and aortic second sound accentuated. Blood-pressure not
measured. On right side of the abdomen a hard, elastic, insensitive,
slightly movable tmnor was felt, about the size of a grape-fruit.
It was easily felt in the flank with bimanual palpation and did not
descend with respiration. It was not fluctuant and did not seem to
be connected with the Uver. The colon was inflated and the tympany
28o DIFFERENTIAL DIAGNOSIS
SO produced came in front of the tumor. Urine and blood were
entirely normal. Cystoscopy by Dr. Lincoln Davis, January 14th,
showed a normal bladder. Indigocarmin was excreted from the left
ureter in ten minutes, but none came out of the right. The ureteral
catheter, passed into the right ureter, met an obstruction about
2 inches from the orifice. Dr. Davis made a diagnosis of right hydro-
nephrosis, due either to stone or a kink in the xireter. The obstruction
above referred to was only partial, for a pressure over the tumor
caused a flow of urine on that side. The urine obtained by catheter
from the right kidney showed 0.06 per cent, urea; that from the left,
1.5 per cent. After indigocarmin the urine from the right side was
pale greenish; that from the left, dark blue.
Discussion. — The history gives us merely the knowledge that the
patient has had three months of epigastric pain and vomiting. Ap-
parently the pain is not severe. There is nothing that suggests the
severity of the average gall-stone colic. In addition to this, we have
one month of anorexia and constipation. Previous to the physical
examination, then, we have nothing distinctive.
In the internal viscera, the most important items are the cardiac
hypertrophy and the tumor in the right loin. The increase in blood-
pressure is also significant, though we have no exact measure of it.
Turning attention to the tumor, it certainly occupies the position of
the kidney, and, from its characteristics, should be either a neoplasm
or a hydronephrosis. The absence of fever and leukocytosis is
against the existence of a pus sac. The further cystoscopic examina-
tion leaves little doubt that we are dealing with hydronephrosis.
The obstructed ureter and diluted urine are characteristic. There
can be no reasonable doubt, it seems to me, as to the diagnosis, but
why should a hydronephrosis produce gastric symptoms? As the
disease has, in all probability, come on gradually, the other kidney
should have taken up the renal function as it diminished upon the
diseased side. We should not expect, therefore, any evidence of
renal insufficiency or uremia, especially as the mixed urine of the
two sides presents apparently normal characteristics. It is hard to
believe that merely by pressure a hydronephrotic sac could bring
about the gastric symptoms of this case, and I am unable to answer
the question which I have just put. It is, however, a not unfamiliar
fact that such symptoms are frequently associated with hydronephro-
sis, although the other kidney remains sound.
Akin to the same problem is the question why an operation does
good, and I am unable to answer this question any better than the
DYSPEPSIA 281
other, although I think there is no possible doubt that operation is
of benefit.
Outcome. — ^January 21st the kidney was operated upon and found
to be hydronephrotic. The pelvis and calyces greatly dilated, cortex
very thin and consisting mostly of fibrous tissue and thickened
blood-vessels. The glomeruli sclerosed and atrophied. The cause
of the hydronephrosis was not discovered. The hydronephrotic sac
was a single one. After operation the patient did very well, and
February isth reported that she had no symptoms, but was still
rather weak.
Case 110
A canvasser of forty-five entered the hospital January 18, 1910.
His family history, past history, and habits not remarkable. He
considered himself perfectly well until October, 1909, when he began
to notice an add taste in his throat, about three hours after eating.
This taste would soon be followed by partly intentional vomiting of the
contents of the previous meal. This continued until five weeks ago,
when the vomiting ceased. Since October his appetite has been
failing and he can now hardly taste his food. At that same time he
noticed jaundice and pain in the region of the navel, increased by
exertion. Early in November a diarrhea appeared, and this has re-
curred whenever he is tired. He is much troubled by flatulence,
especially at night. The old discomfort two or three hours after
eating and the acid taste in his mouth still bother him, but meat and
eggs seem to go as well as any food and his appetite is fair. Bowels
now move daily. He has lost 20 pounds since October.
Physical examination shows poor nutrition, distinct yellowing of
the skin and sclerae, normal chest, general rigidity and tenderness of
the abdomen, most marked in the upper portion. No abnormal dul-
ness or masses. Liver and spleen not felt. Reflexes normal.
A stomach-tube shows no fasting contents. On water-distention
the stomach contains 61 ounces, its lower border reaching i inch
below the navel. An hour after a test-meal nothing can be recov-
ered. The stools always show sUght reaction t6 guaiac. Blood and
urine normal; no fever.
"By examination in a hot bath an indefinite mass can be felt in the
right hs^pochondrium (Fig. loi).
On the 26th of January I noted, "No gastric trouble at present.
The lumps above referred to does not seem to be connected with the
kidney. It is probably associated with the gall-bladder."
I
I
282
DIFFERENTUL DIAGNOSIS
Discussion.— The history is not distinctive, but when taken
with the observed facts of Jaundice, a large but rapidly emptied
stomach, and a small mass in the region of the gall-bladder, it seems
to me that the recorded data point strongly toward gaQ-bladder
disease. The mass shown in the diagram might perfectly well be
attached to the stomach or kidney, but we have no gastric or renal
symptoms, while we have one definite liver symptom, jaundice.
If, then, we are dealing with gall-bladder trouble, what is that
trouble? The lump, as described, does not sound like a dilated gall-
bladder. If it is not a dilated gall-bladder, and yet is connected with
the biliary tract, it must, in all probability, be cancer. The m^tti
point to doubt is whether we are right in supposing that it is coik]
nected with the gall-bladder at all. It is mainly the presence of jam
dice which gives us the assurance on this point. But suppose the'
jaundice was due to some independent cause, such as catarrhal cho-
langitis, gall-stones, or cirrhosis of the liver, the palpable mass might
then be attached to some other organ. It might arise from the
pyloric end of the stomach, despite the absence of any evidence in-
criminating that organ. On the whole, however, the weight of c
dence seems to be against this theory.
Outcome.— January 28tii the abdomen was opened. The gall-
DYSPEPSIA 283
bladder was found much enlarged and tense. Considerable greenish
fluid was evacuated; no stones found. The second part of the duode-
num seemed to be filled by a hard mass, and on opening this a
cauliflower-like mass, about the size of a pigeon's egg, was found in
the region of the pancreatic duct, with its base in the ampulla of
Vater. The tumor was removed. Microscopic examination showed
it to be a papillary adenoma. After operation the patient did very
well until February ist, when he suddenly vomited about 3 pints of
altered blood, and had, at the same time, a large liquid movement.
He collapsed and became pulseless, his extremities cold. February
3d the lower end of the wound opened and there was a profuse dis-
charge of intestinal contents, evidently coming from the upper bowel.
All fluids taken by mouth issued from this opening, and he was unable
to retain food by the rectmn. He died February 9th. Autopsy
showed chronic interstitial hepatitis and the evidences of the recent
operation, together with a duodenal fistula. The presence of a
cirrhotic liver was presimiably a coincidence. There is no good
reason to suppose that it had any connection with the tumor which
was removed.
Case 111
A married Russian Jewess of thirty-eight entered the hospital
May 8, 1910. Her family history was negative, likewise her past
history, except that three and a half years ago she had an attack
similar to the present one, lasting three weeks. Her menstruation
has been normal imtil seven weeks ago. None has been seen since.
Has had three children, youngest thirteen years old. No miscarriage.
For seven weeks she has been troubled by pain in the epigastrium
and by vomiting. Now she can retain no food, and vomits imme-
diately after eating. Pain is sharp, but does not radiate. The kind
of food makes no difference. She has never vomited blood. She has
lost 15 to 20 pounds in weight.
Physical examination shows emaciation, moderate pallor, normal
pupils and gums. Heart's apex not seen, but felt in the fifth space,
18 cm. from midstemimi in the nipple line. Right border, 4 cm.
from midstemum. The sounds are regular and of good quality, no
murmurs. Abdomen and reflexes normal. Gastric examination
shows a stomach capacity of 32 ounces, the position of the organ being
as in Fig. 102. There is no food residue before breakfast. The test-
meal was so largely disposed of at the end of an hour that nothing
of importance was recovered. In the wash-water free HCl is present.
DIFFERENTIAL DIAGNOSIS
The blood and urine are normal. Blood-pressure, 115. No fever.
Ten examinations of the stools in two weeks show nothing remark-
able. Guaiac reaction always negative. Wassermarm reacUoD is also
negative.
Vaginal examination showed uterus enlarged, about the size of a
three months' pregnancy, and displaced decidedly to the right. On
the surface of the fundus several nodules can be felt. She ceased
vomiting on the 2pth and went home June 3d in ver^' good condition,
though she had lost i^ pounds since entering the hospital.
Discussion. — This is a case of obstinate vomiting associated with
absent menses, and apparently with displacement of the heart's apex
to the left. The latter finding suggests cardiac hypertrophy and
possibly uremia as the basis for the dyspepsia, but the low blood-
pressure and normal urine make this improbable and the results of
pelvic examination give us a much more plausible hint.
In view of the negative results of gastric and intestinal investiga-
tion, there is every reason to believe that pelvic tumor is the cause of
the patient's symptoms. That tumor might be a fibromyoma, ovarian
cyst, or a pregnant uterus. The other possibilities are too rare to need
discussion. A fibroid or a cyst would be less likely to be associated
DYSPEPSIA 285
with vomiting and amenorrhea. The most reasonable supposition,
therefore, is that we are dealing with a case of vomitmg of pregnancy.
Outcome. — The patient was visited January 7, 1914, and said
that a son was bom to her in the autumn of 1910, She has since
had another child and is perfectly well, though she looks sixty rather
than forty.
Case 112
A laborer of forty-nine entered the hospital April 26, 1910. His
family history was good. He states that he had lung fever, typhoid
fever, intermittent fever, and pleurisy, one right after the other.
Fig. 1 03 .^Physical signs in Case
when very young. Otherwise he has been well, except that lor the
past eight years he has had a little stomach trouble, which he did not
notice enough to give a clear description of until February z6, 1910,
when he began having sharp pains in the pit of his stomach and right
hypochondrium, coming at any time of day without relation- to meals
or kind of food. He also had spells of vomiting three to five hours
after a meal, the act usually relieving him. He never vomited large
amounts at one time, nor recognized any blood or any substance eaten
the day before. The pain which immediately precedes vomiting is
very sharp and "cuts his wind." He now vomits three or four times
286 DIFFERENTIAL DIAGNOSIS
a week. His bowels have always been very costive, and he has once
gone twelve days without a movement. Nevertheless, his appetite
has remained good. Since February he thinks he has lost 40 pK)unds
and has been practically unable to work. He uses no alcohol and is
generally a man of exemplary habits.
Physical examination was negative except for slight rigidity of
the whole abdomen. Preliminary diagnosis was malignant disease of
the stomach or intestines. Stomach examination showed a capacity
of 56 ounces (Fig. 103), but no fasting contents, and a motility so
active that an hour after test-meal there could be nothing recovered.
Free HCl, however, was present in the wash-water. May ist he had
some spasm and slight tenderness in the region of the cecum and
above it. He was eating well and had vomited but once since
entrance. Examination of a stool by Dr. W. F. Boos showed about
i^ mg. of lead calculated as lead sulphate. The blood showed no
stippling or achromia and was in all respects negative, as was the
urine. No elevation of pulse, temperature, or respiration. Systolic
blood-pressure, 130. Ten examinations of the feces in three weeks
were uniformly negative to guaiac. During most of his stay in the
hospital, which ended May 21st, he was comfortable and his weight
increased 25 pounds. No source of lead-poisoning was discovered.
Discussion. — The loss of 40 pounds of weight in two months with
epigastric pain and vomiting in a laborer of forty-nine suggest espe-
cially a gastric cancer, gall-stones, and tabes dorsaUs. Uremia is also
to be considered.
The results of physical examination enable us to exclude all of these
possibilities with reasonable certainty, although it is conceivable that
his trouble may have been tabes, as no spinal puncture was done.
The finding of lead in the stool does not seem to me altogether con-
clusive evidence that the patient's sufferings were due to lead-j)oison-
ing, since we have no possible inkling as to the source of any lead and
no other symptoms characteristic of lead-poisoning. I have no
better diagnosis to suggest, but do not feel at all certain that we have
hit upon the real nature of the man's trouble.
Outcome. — Three and one-half years later, in the autimtm of 1913,
the patient was perfectly well. This excludes tabes, but does not
settle the question of diagnosis in any positive way. If he had lead-
poisoning, why should his symptoms have ceased, since we have dis-
covered no source whence he might have absorbed lead?
DYSPEPSIA 287
Case 113
A billiard clerk of fifty-nine entered the hospital June 2, 1910.
Until March ist of that year he was perfectly well, when he began to
have dyspepsia and severe constipation, followed later by diarrhea
and considerable loss of weight. Solid food caused nausea and dis-
tress, followed by vomiting. He has never vomited blood or large
amounts of any material. He has had no severe pain. He has lived on
cocoa, rice, milk, and eggs, and has eaten as much as he wanted, yet
in the past three months has lost 27 pounds. The bowels are regular
and he had never seen any tarry stools. For the past month he has
not worked on account of weakness. He has had no other symptoms.
On phjrsical examination he was poorly nourished and showed evi-
dent loss of flesh. Over his chest, shoulders, and back were many
irregular, raised, scaly areas, bright yellow to brown in color, and
from i to I inch across. They were papular or flat, sometimes verru-
cosa. The pupils and gums were normal. He had practically no
teeth. The left tonsil showed an excrescence, size of a pea; no exudate.
There were a few inguinal lymph-nodes, the size of large beans.
The heart, vessels, and blood-pressure showed nothing abnormal,
except that the arteries were thickened and beaded. At the base of
the left lung the breathing was somewhat diminished and there was a
slight dulness; otherwise the lungs were negative.
In the left loin a mass corresponding to the position of the left
kidney was palpable. There was no tenderness and no movement
with respiration; otherwise the abdomen was normal, likewise the
remainder of the physical examination, including temperature, pulse,
and respiration. The urine averaged 25 ounces in twenty-four
hours, with a specific gravity 1015 to 1020. It contained from o.i
to 0.3 per cent, of albiunin and a sediment of pure pus from 50 to 120
c.c. in a urine-glass containing 5 ounces. One centimeter of this
sediment injected into a guinea-pig June sth. Six weeks later the
animal was killed; autopsy showed nothing. Half a centimeter of the
urine collected under aseptic precautions was planted on appropriate
culture-media and found to contain a pure culture of Staphylococcus
aureus. The pus was present in the urine intermittently, some
specimens being quite clear of it.
CjTstoscopy by Dr. Lincoln Davis showed normal bladder, with a
slight intravesical projection of the prostate. From the left ureter,
which appeared normal, there issued at regular intervals a stream of
thick pus. Clear urine came from the right. Stomach examination
288 DIFFERENTIAL DIAGNOSIS
showed no fasting contents and no reaction to guaiac. After a test-
meal, free HCl, 0.09 per cent.; total acidity, 0.2 per cent.
During his two weeks' stay in the medical ward the patient seemed
comfortable, complained of nothing, lost 5 poimds, but subsequently
regained it.
Discussion. — This man has no teeth, but as he has gotten along
without them for fifty-eight years, more or less, it is not probable that
their absence would suddenly begin to produce such severe symptoms
as are now troubling him.
He is at the cancer age, and, unless evidence of other disease is
positive, one must certainly consider gastric neoplasm.
The mass in the loin, when considered with the pyuria, which
is of the intermittent (that is, the renal) type, leaves little doubt that
the patient has a pyonephrosis. The negative guinea-pig test
excludes tuberculosis with practical certainty. Cystoscopy confirms
what was reached as the result of other methods of examination, and
the negative results of stomach tests further reassure us with regard
to that organ. It remains somewhat mysterious that the patient has
no fever. But for the presence of pus in the urine, we might suppose
that we were dealing with a hydronephrosis.
From the condition of the patient's arteries we may assume that
he also has arteriosclerosis, but there is no reason to believe that this
is connected with his present suflfering.
Outcome. — June 20th Dr. F. G. Balch cut down upon the left
kidney, which consisted only of a pus sac, containing large quantities
of dark reddish pus and blood. Two or three large rough calculi were
found in the sac. Attempts to ligate the pedicle were useless on
account of its infiltration. Histologic examination of the mass showed
a kidney 16 by 8 by 6 cm., the wall consisting of fibrous tissue, with
occasional remains of tubules and glomeruli. One of the calculi
removed in the sac measured 4 by i^ cm. No evidence of tuberculosis
was found. The patient gained rapidly after operation and was dis-
charged July 6, 1 910, to the Waverly Convalescent Home, the wound
not quite healed. November 7. 1912, he reported that he tad been
perfectly well for over two years.
Case 114
A clerk of twenty-seven entered the hospital June 13, 1910. His
family history, past history, and habits were not remarkable. Three
years ago he began to have "water-brash" and nausea, coming on at
any time without relation to food. He is sometimes free from it for
DYSPEPSIA 289
three weeks at a time, but in the past two years his troubles have been
aggravated, and there have been occasional attacks of vomiting and of
dull pain in the epigastrium, which attacks make V>iTri feel like lying
down. At the present time he usually vomits twice or thrice daily
and has no appetite.
Formerly he ate a good deal of candy, hurried through his meals,
chewed them very little, and took them at very irregular hours.
While in Ireland, a year ago, on a vacation, he lived upon simple food
and had no trouble. For the past two years his bowels have needed
laxatives. He has worked steadily up to entrance. His best weight
was 135 pounds; now he weighs 112 pounds.
Phjrsical examination shows poor nutrition, no teeth upon the
upper jaw, negative chest and abdomen, normal reflexes, blood-press-
ure 100, normal urine and blood. Four examinations of the feces
showed a positive guaiac test but once, when streaks of fresh blood
were visible in the sediment. A stomach examination showed no
contents in the fasting organ and no enlargement. After a test-meal
the percentage of free HCl was 0.09 per cent.; total acidity, 0.17 per
cent. He remained two weeks in the ward, taking at first nothing
but water by mouth, and undergoing a good cleaning out of the
bowels with magnesium sulphate and calomel. Twenty-four hours
later he was fed on milk and toast, with gastric lavage daily before
breakfast and sodimn bicarbonate when needed for gastric distress.
On the 2oth of Jime he was taking all liquids and soft solids, and on
the 2ist, house diet.
Discussion. — ^We do not know whether the 23 pounds which this
patient has lost left him gradually or suddenly. The patient's poor
condition is the most important fact in his case, and makes us hesitate
somewhat to attribute his symptoms to his dietetic habits and the lack
of any upper teeth. Physical examination, including the investiga-
tion of the stomach, is practically negative. The single positive
guaiac test is of no importance. Doubtless his constipation aggra-
vates his other troubles, and, if no deeper cause can be found, we may
be content to believe that a reform of his habits will cure him.
Many such cases, however, turn out later on to have tuberculosis,
lead-poisoning, or some extra gastric cause for their complaints. The
decision must rest upon the results of treatment and the subsequent
course of the case.
Outcome. — ^June 25, 1910, he had gained 2 J poimds and was practi-
cally comfortable, and that day he was discharged. August 2, 1914,
he writes that he is still troubled with dyspepsia, but is at work.
Vol. n— 19
290
DUTERENTIAL DIAGNOSIS
Case 115
A dergjTnan of sixty-one entered the ho^ital June 13, 1910,
stating that in March, 1910, he had overworked and "his stomach
struck for higher pay/' causing flatulence and sourness usually after
meals, relieved for about an hour by eating more food or by taking hot
water with a half-teaspoonful of soda. This medicine caused the
escape of gas. His pains have never radiated and have been diffused
in different parts of the abdomen. He has never pre\'iously had any
acute attacks of abdominal pain, and until the present time has
been absolutely free from nausea and vomiting.
Aside from the sxTnptoms just described, he is also troubled by
weakness. He has lived the last two months on liquids and soft
solids.
Three weeks ago he noticed a slight yellowing of his eyes and
the darkening of the color of his urine, while his stools became lifter
colored, though daily movements occurred. He gave up work two
weeks ago and has been in bed since. He thinks he has lost 10
pounds.
Phj'sical e3^amination shows marked jaundice and emaciation.
The pupils are slightly irregular and do not react to light <Mr distance.
There is a l\Tnph-gland, the size of a bean, at the ang^ erf the left
jaw. Chest is negative. Liver dulness extends from the fifth rib in
the nipple line to a point three-fingers' breadth below the ribs,
where a sharp, irregular, nodular edge can be felt > Fig. 104), ^leen is
not |)alpable. Knee- jerks are sluggish. Plan tars normal. No edema.
Elxcept for the presence of bile, his urine is normal; likewise his blood,
the coagulation time seeming to be unusualh* short. Wasseimann
reaction was negative. Stomach examination showed a content of
54 ounces and no e\-idence of stasis. C>n inflation the lower border
extends two and a half fingers below the navel. After a test-meal
the percentage of free HCl was 0.07; total acidity, 0.16.
He stayed two wed:s in the medical wards, suffering no pain and
seeming generally comfortable. His jaundice. stooK and urine re-
mained the same. Stools alwax-s day explored, Tlie condition of the
belly is seen in Fig. 104.
DiscosaoQ. — Pre\Tous to the appearance of jaundice and emacia-
,tion — that is, during the first two or three months of his illness —
I see nothing in the histoiy of this case to tell us what is the matter.
Our first thought would naturally K" cancer of the stomach because
of the sudden appearance of gastric s\Tiiptoms in a man of sixty-one.
DYSPEPSIA 391
I do not see that we could have done better than a guess until the
jaundice appeared.
Besides cancer another guess previous to the appearance of the
jaundice would have been tabes, as presumably at that time, as well
as in June, the pupils failed to react to light and the knee-jerks were
sluggish. The gastric disturbances are a good deal less intermittent
and paroxysmal than those traditionally associated with tabes, but,
as I have already stated, this tradition is by no means a reliable one,
and any sort of stomach trouble associated with evidence of tabes
should be assumed to be due to that trouble until proved to the con-
trary.
Fig- 104. — Palpable muss ;i^ ilcsLribcd in Case 115.
With the appearance of Jaundice and emaciation, our attention
h naturally drawn to the liver or gall-bladder as the probable source
of the trouble. The nodular mass in the region of the gall-bladder is
necessarily another alarming fact. But for that one might imagine
that gall-stones were the root of his trouble, for emaciation as well as
jaundice may be marked in gall-stone obstruction of the bile-ducts
and pain is not a necessary symptom of such obstruction. But the
absence of fever or any waxing and waning of the Jaundice is evi-
dence against stone in the common duct, and if the stone were else-
where jaundice would be unusual.
If the observation of a nodular mass be taken as correct, one
292 DIFFERENnAL DIAGNOSIS
cannot well suppose that the diagnosis is gall-stones. The patient's
best hope rests in the possibility that this observation may be mis-
taken, and that the supposed mass might be nothing but an enlarged
gall-bladder or the edge of a distended liver. The probabilities all
point to cancer in or about the gall-bladder. This cancer may be
secondary to a similar growth in the stomach or may be primary in the
biliary passages.
Outcome. — He lost weight steadily and went home on the 25th,
diagnosis being malignant obstruction of the bile-duct. On the 6th
of July he returned for operation, which was performed by Dr. F. G.
Balch. The gall-bladder was foimd moderately distended with a
thick greenish pus, about 4 ounces in amoimt, and contained no bile.
A stone, size of a robin's egg, was found low down in the gall-bladder,
close to the duct. It was removed. The entire course of the conmion
duct showed infiltration and suggested a malignant process. After
operation he improved slowly, but his stools still remained very
light and his urine dark, always containing bile. On the 25th of July
he went home. During the summer he was tapped five times for the
relief of ascites. The presence of ascitic fluid previous to these tap-
pings seemed to produce most of the discomfort which he experienced.
Emaciation and cachexia were progressive. He died November 7,
1910. It is notable that even at operation the surgeon was not per-
fectly sure that the stone found in the common duct was not the
whole cause of the illness. He suspected a malignant process, but he
was not sure of it. The patient's steady downfall, despite the removal
of the stone, and especially the fact that ascites accumulated repeat-
edly, proves beyond reasonable doubt that the trouble was cancerous,
and that it later spread into the abdominal glands so as to block the
portal circulation.
It seems to me a point of great interest, as we look back over
this case, that although the stomach was presumably free from any
disease, the only symptoms in the earlier months of the illness were
dyspeptic symptoms. These were not due to jaimdice, and I do not
know how they are to be explained. The association of such symp-
toms with malignant disease of the gall-bladder has often been ob-
served, but never, so far as I know, elucidated.
Case 116
A factory hand of twenty-three entered the hospital June 17, 1910,
stating that two nights ago he ate some hashed ham and pickles at
supper, and that about midnight he was seized with sharp, colicky
i
DYSPEPSIA 293
pain in the abdomen. The pain did not radiate, and was somewhat
relieved by pressure and by vomiting. He has continued to vomit
since, mostly brown stuff. Last night his pains ceased. He has had
green slimy movements of the bowels. This morning his stomach
was washed out, and since then he has felt better and is hungry.
Physical examination negative except for rigidity of the abdomen.
Slight spasm throughout and dulness in the flanks, which shifted
freely with change of position. He ran a sUght fever, 99° to 100° F.,
until the 21st. For the week following that date he was afebrile. At
entrance his white cells were 24,000, showing polynuclear leuko-
C3rtosis. Next day the leukocytes were 10,000. The blood otherwise
negative, likewise the feces. Systolic blood-pressure, 140. On the 28th
he seemed entirely well and had no physical signs of disease. His
vomitus at the time of entrance was brownish and had strong reaction
to guaiac. His treatment was starvation for twenty-four hours, and
then small feedings of simple ingredients. He gained 2 poimds
during his ten days' stay in the hospital.
Discussion. — The history starts out in this case like an acute
gastric upset due to indiscretion in diet, but when physical examina-
tion revealed abdominal rigidity and leukocytosis, with shifting dul-
ness in the flanks and a fever running to 100° F., it certainly looked
as if something more serious was going on. Peritonitis has often been
diagnosed on sUghter grounds than these, especially with a brownish
guaiac positive vomitus.
But, to my mind, all such possibilities are negatived by the prompt
improvement within twenty-four hours; also by the fact that the
patient is himgry and that his leukocytosis promptly fell. I do not
see how we can attribute any serious disease to a patient whose troubles
clear up so rapidly.
Just what was the nature of his attack I do not know. Something
checked his digestion and started him vomiting. Gastric crises in
tabes may begin in just this way, but we have absolutely no evidence
of that disease, and the course of the trouble, as shown in the outcome,
makes this very improbable. The case seems to me of great interest,
as showing how many serious signs may be present in an acute gastric
upset, which yet disappears within twenty-four hours. I take it that
the observation of shifting dulness in the flanks need not necessarily
be incorrect, but probably was due to the shifting of intestines dis-
tended with fluid feces.
Outcome. — In November, 191 2, a friend reported that he was in
perfect health.
294 DIFFERENTIAL DIAGNOSIS
Case 117
A cook of twenty-nine entered the hospital June 15, 1910, for the
third time. One sister died of consumption, nineteen years ago;
family history otherwise not remarkable. November, 1902, she was in
bed for three weeks with a sharp epigastric pain and vomiting, the
latter persisting until she entered the Boston City Hospital, Decem-
ber, 1902. While there she once vomited a pint of blood. She
remained under treatment at the hospital imtil February, 1903, but
still vomited daily at the time of her discharge. During her stay in
the City Hospital she was on rectal feeding for three weeks, but has
been no better since discharge.
March 31, 1903, she entered the Massachusetts General Hospital,
complaining of five months* suffering with sharp pain in the epigas-
trium, often lasting all night and accompanied by tenderness of the
abdomen. Such attacks occurred frequently, often many times a
day, lasting about ten minutes each. After about three weeks in bed
these pains gradually ceased, but a few days after getting up again
she began to have chills every morning and vomited everything that
she ate; yet the previous pains did not return. For the ten days pre-
vious to March 31, 1903, she vomited even small amoimts of milk
and lime-water, and had a good deal of burning pain after the attacks.
In the week before entrance the vomitus had contained material
resembling coffee-grounds. For the same period she had also a slight
cough, with frequent attacks of spasm of the glottis, lasting a few
moments. On a few occasions she has had moderate sweating at
night, and for the past two months moderate frequent headache.
Has not menstruated since December 4th.
At this time physical examination showed considerable spasm of
the left rectus near the ribs, with tenderness, but no other abnor-
mality, except a slight elevation of temperature, usually 99^° or
99 1° F., during the whole twenty-four hours, with an occasional
fall to normal. This persisted during the twelve days of her stay
in the hospital. Her pain was reUeved by soda, and after April 2d
she had no vomiting. She developed a good appetite during the
period of rectal feeding, which lasted until the nth of April; then her
friends decided to take her home.
She was not seen again for five years, when she re-entered the
hospital July 18, 1908, stating that after her last hospital treat-
ment the vomiting persisted, occurring at least once a day. About
a year after leaving the Massachusetts General Hospital she had a
DYSPEPSU 295
gastro-enterostomy done at the Boston City Hospital. Four weeks
later she was again operated upon; six weeks after that, again,
and six weeks later, still again, for adhesions. Again, later, she
was subjected to still a fifth operation at St. Elizabeth's Hospital,
also for adhesions. Since that time she has vomited three to six times
a day a sour, green fluid, mixed with unchanged food. She has had
no pain, but a distress which is relieved by vomiting. Her bowels
have moved only with enema. She has a dull, constant pain in the
right flank and right lower quadrant. When she walks she has a pull-
ing sensation near the navel. Despite all this suffering her appetite
/ ou
~-^,— -^
--i^ftbtroenTeirosteTny,
7^
'"■'■\^ closed by ThW
(CT^
^X,^\ otJeraTion.
K::
yJ---^^o
-^^,^_^_^^
i>^,ej««ostomy.
/'•f^o\r,\i at wV^'ieU
\ 1 ivtw eT>&.To-tnS
y ooa^-towobifc w&ft
V <■
'maJ&.
has remained good. Her best weight was 135 pounds six years ago,
I..ast winter she weighed 120 pounds.
At this time her chief complaint was still of vomiting. The
vomitus always contained bile and often pancreatic juice; i. e., 10 c.c.
of vomitus plus 5 c.c. of 0.05 per cent. NaCO, digests egg-albumin.
At none of the operations was any ulcer, scar, or evidence of organic
disease found. The patient's sister says that she eats well and only
vomits a little "off the top."
On examination the patient was well nourished, and, aside from
tenderness in the region of her numerous scars, showed nothing
abnormal.
DIPFEHENTIAL DIAGNOSIS
July 2oth the abdo-
men was opened for the
sixth time with consider-
able difficulty, the omen-
tum being found adherent
in many places to the
anterior abdominal wall.
The gastro- enterostomy
was found in good condi-
tion and freely admitted
the tips of two fingers. A
jejunojejunostomy, about
8 inches below the stom-
ach, was likewise found
in good condition. The
pylorus was found to be
patent. The old gastro-
enterostomy wound in the
stomach was dosed and
the old direct route
through the bowel re-
stored (Fig. 105).
During the month of
this stay in the surgical
wards after this opera-
tion she had three waves
of fever, ranging in the
neighborhood of 100° F.
and lasting about a week
each, with four or five
days intervening. She
continued to vomit, but
somewhat less severely,
and also gained in
strength,
A year later, August
27. 1909, she reported,
feeling well but looking
thin. She was at that
time eating no meat and
was given advice as to
her diet.
DYSPEPSIA 297
She was next seen June 10, 1910. and stated at that time that
she had not been troubled with vomiting since her last operation,
but that two or three months ago she was kicked in the abdomen
by a drunken man and since that has gradually lost strength, though
her pain has been only slight. A week ago she began to have more
or less persistent retching and slight epigastric pain when standing.
She had much nausea and tenderness, and was unable to stand on
account of weakness. There was also edema of the feet on stand-
"ig- July isth she was transferred to the medical wards, where she
1 remained until September 21st.
The most striking feature of her case during that period is shown
in Fig. 106, which displays a continuous fever, lasting thirteen weeks.
It will be noted that during Oie first week of her stay in the medical
wards there was no fever to speak of. Another remarkable feature
of her stay was a gain of weight during this period of prolonged
pyrexia. She weighed 82 pounds June 22d, when her fever began,
and September i5th, after three months' fever, weighed SSJ pounds.
During most of the three months of this third stay in the Massachu-
setts General Hospital she complained of epigastric pain for which
nothing could be found to account. An area of superficial skin
tenderness was constant and marked (Figs. 107 and 108). The
DIFFERENTIAL DIAGNOSIS
leukocytes were never increased. There was at no time any spasm or
deep tenderness, but the pain was severe enough to require morphia
at times.
There was at no time any agglutinative reaction with tjphoid
culture or with alpha or beta paratyphoid. The Wassemiann reaction
was negative. "Bed fever" was excluded by having the patient sit
up for a number of days iftithout producing any diminution in the
fever. A perinephric abscess, subacute peritonitis, tuberculous
peritonitis, subphrenic abscess were among the diagnoses suggested.
The urine was never abnormal. Orthopedic examination by Dr. R. B.
Fig. loS.— ,Wa of cul.-incviu! Mpcrrsihesia in Case 117,
Osgood showed nothing of significance. The fundus of the eye was
nonnal. Blood-culture and cultures from the urine remained sterile.
The color fields were plotted (Fig. 109) and found normal. Ten tests
of the feces were ne^tive to guaiac. She was repeatedly x-rayed
without result.
Her pain was partJy relieved in August by the aid of higi oil
enemata. but she remained ver\' nervous and thin and ate but litde.
Agar-agar increased the bulk of the stools, but had no effect upon
the temperature. The skin reaction to tuberculin was slightly posi-
ttvei 15 miDims <rf tbe sediment of « catheter qjedmai of urine 1
DYSPEPSIA 299
' injected into a guinea-pi^ July 22d. The anitnal was autopsied
September i, 1910, and no results found. On the 21st of September she
went home quite unimproved, quite unexplained, and still markedly
[ febrile.
October 24, 1910, she returned to the hospital to report, and
stated that she had been up and about the house at home, gaining
strength, and having less pain. She has kept her temperature chart,
the range of which is shown in Fig. 1 10.
The area of cutajieous tenderness was as before. She stayed only
' a few days this time for observation and went home on the 27th,
weighing 92 pounds.
M
Fig. tog.-^— Chart of color fields of Case 117.
Discussion. — It does not seem to be worth while to discuss the
various possibilities of diagnosis at the time of this patient's first
visit to the Massachusetts General Hospital. The most mysterious
and interesting part of her illness begins when she returned to the Mas-
sachusetts General Hospital, after five years, of what she called vomit-
ing and five operations for supposed adhesions about the stomach. The
fact that she was well nourished at this time makes me tolerably sure
that her "vomiting" never deserved that term, but was wholly a matter
of regurgitating a small part of the meal last eaten, a process familiar
lOugh in babies, whose mothers often refer to it as "spilling over."
^ At this time tAe rather unusual operation of undoing gaslro-enleros-
4
300
DITFERZNTIAL DIAGNOSIS
lomy and attempting to restore the normal course of the bowel was
performed. The idea of this operation was that the i>atient's troubles
were due more to meddlesome surgery than to any other one factor,
and that the best help we could give her was to restore her as nearly
as possible to her natural condition before surgery was attempted.
Apparently, then, this attempt to undo the bad effects of surgery
was a successful one, for she had two years of good health, de^ite a
curious and quite unexplained fever during convalescence from this
last operation.
We come next to the most inexplicable chapter of this patient's
hospital life, namely, her thirteen weeks of unexplained fever asso-
f
i^l'f^|;^^^.i^ji|ij4,!.[.|iH.t-|tm-|'f'hH-'ti 1 1 ' H 1 1 1 1 1
Fig. I
— Second temperature chart ot Case i:
ciated with gain in weight. I have never been more thoroughly
baffled in the study of a case than in this. As the record shows, we
did everything that anyone could suggest to find out the cause of
her fever, but in the end we knew as little as in the beginning. Ther
important point is that after she left the hospital and without any
reference to treatment given by us or anyone else, her fever went:-
down and she got entirely well. To my thinking, the case illus-
trates several points; First, the harm of operating merely for adhe-
sions. The more I see of such operations, the less I think of them-
I have yet to be convinced, that adhesions about the stomach, gall-
bladder, or appendbt are the cause of symptoms in any considerable
DYSPEPSIA 301
proportion of the cases in which they occur. The vast majority of
operations done for adhesions and carefully followed afterward prove
to be useless or worse. The second point of interest is the definite
record of what our grandfathers used to call a " simple fever," or per-
haps a "gastric fever," wholly imexplained, entirely bem'gn, and,
strangest of all, concident with gain in weight! They covered up
their ignorance with names. We are as ignorant, but confess it. I
have no explanation to give of the area of cutaneous tenderness
which occasioned some of the bitterest of her complaints, and was
just as marked after her complete recovery as during the worst of her
illness.
Case 118
A housewife of thirty-five entered the hospital June 26, 1910.
At the age of seventeen she says she had trouble with both limgs and
"pined away to nothing," as the result of a cough with which she
raised blood. For the last four years she has again had a cough, but
has not raised blood. Four years ago she used to have what she calls
"nervous fits," but for the past two and a half years has not had any.
Within the last four months she has taken a littie brandy for her
symptoms. She states that her menstruation comes every two weeks.
She has had no children, but two miscarriages, the last eight years
ago.
Four months ago her food began to "lie like a lump" in her stom-
ach, and she had nausea, but no vomiting. The epigastric distress
was not worse after meals and was not relieved by cooking soda.
Three weeks ago she vomited a teaspoonful of blood after violent
retching before breakfast. Morning nausea has been frequent since
that time. Meat is particularly distressing to her. She states that
she has lost no weight, but feels very weak.
Physical examination showed an obese Scandinavian woman with
pupils irregular, but reacting normaUy. The heart was negative and
the limgs likewise, except for a few squeaks scattered in both backs
and in the left front. The abdomen is full, tympanitic, and some-
what tender throughout, especially in the epigastrium, left flank, and
right iliac fossa. In the left front, near the second and third ribs,
inspiration is interrupted and high-pitched. Blood and urine are
normal. Systolic blood-pressure, 145 mm. Hg.
The patient was starved for thirty-six hours, after which she
was given a diet of crackers and milk and speedily recovered her
strength. By July 3d she was able to take an ordinary diet, imd by
■i
302 DIFFERENTIAL DIAGNOSIS
the sth she seemed perfectly well and ready to go home. Our suspi-
cions were that she took more than a little brandy.
Discussion. — Evidently this patient had pulmonary tuberculosis
in her younger days and got over it without any special treatment.
It is worth noting that this often happens. It may serve to make us
somewhat less confident that the recoveries following sanitarium
treatment are always due to that treatment.
We have no way of telling what her "nervous fits" were. No
trained observer watched them, and they did not occur during the
period of illness which we studied.
The dyspepsia of the last four months is not characteristic in any
way of any particular disease. It obviously has not interfered with
the ordinary functions of the stomach, for the patient is still obese.
That it resulted in the vomiting of a teaspoonful of blood after violent
retching is not especially significant or helpful as to diagnosis. It
seems clear to me that this may result, whatever be the cause of the
retching. I have seen it occur on shipboard as the result of sea-
sickness.
The physical signs in the chest are presumably those of a healed
phthisical process. Otherwise the physical examination tells us
nothing of importance. In the end we could not be sure of the diag-
nosis, but the prompt improvement, dating from the time when she
was separated from her brandy, is certainly suggestive.
Case 119
A Scotch-Canadian laborer of fifty-eight entered the hospital
August 28, 1910. For about twenty years he has had attacks of indi-
gestion at intervals of a few weeks to two or three years, lasting a few
hours to several days. Between attacks he is fairly well, except for
constipation and a little vague abdominal distress. The present
attack, which he considers a fair sample of others, began nine days
ago with slight heart-burn. Next day his stomach soured and he
vomited twice, but worked all day. This continued for the following
day and more or less ever since. Pain is increased during the hour
following the meal, but relieved by soda or by vomiting. Six days ago
he had severe cramps in different parts of the abdomen, and heard a
good deal of gurgling, accompanying a slight diarrhea, which ceased
the same day. He has worked until three weeks ago, and says that in
those three weeks he has lost 20 pounds. According to his statement,
he has passed urine but once in the last six days without catheteriza-
tion, though he never had to be catheterized before.
DYSPEPSIA 303
On examination he was emaciated and looked twenty years older
than he was. His pupils and gums were normal, chest negative,
artery walls tortuous and thickened. Abdomen tender on deep
pressure in the left hypochondrium. Reflexes normal. Blood and
urine normal. The feces, examined every day or two for a month,
showed a slight or moderate reaction to guaiac in about half the
examinations. They were not otherwise abnormal. The stomach
showed no fasting contents, and, after a test-meal, free HCl 0.03 per
cent.; total acidity, 0.07 per cent. No reaction to guaiac. Rectal
examination negative. Capacity of the stomach was 1900 c.c, and
the inflated stomach reached from the ensiform to a point 3 cm.
below the navel.
The patient was exceedingly reticent and morose, but did not
appear to suffer much. During the month of his stay in the hospital
he gained 3 pounds in weight, showed no fever, and complained chiefly
of gas in his stomach. His abdomen was always soft. He had one or
two attacks of vomiting, but nevertheless improved very much.
Upon the whole, it was thought that there was no basis to warrant
surgical interference. He was seen by Dr. C. A. Porter, who did not
desire to operate.
A year later, July 7, 191 1, he entered again, and stated at that time
that he got along comfortably until two months ago and had gained
5 poimds over his weight at the time of leaving the hospital. About
May I, 191 1, he began to vomit approximately once a week, but by
care in his diet could usually avoid it. The vomitus has never been
bloody, but sometimes brown. He has distress in the epigastrium
about fifteen minutes after meals. This distress is relieved by sodium
bicarbonate, but he regards this as an unnatural and dangerous drug,
vicious as whisky, hence has used it very little. At the time of enter-
ing the hospital he had a spasmodic stiff neck which troubled him
more than his stomach. Physical examination was essentially the
same as before; x-ray examination showed no important abnormality
in the spine. The stiff neck disappeared in the course of ten days.
It was not accompanied by any fever. During the last of his three
weeks' stay in the hospital he complained of nothing and seemed to be
entirely well, though on the day following entrance he vomited 16
ounces of a brownish watery fluid, with a strong reaction to guaiac.
Dr. Porter saw him again and did not advise operation. Guaiac test
was positive in the stools on the day following the vomiting of blood,
not at any other time.
Discussion. — This patient has had twenty years of short dyspeptic
304 DIFFERENTIAL DIAGNOSIS
attacks associated with diarrhea. At the present time he shows a
positive guaiac test in about half the stools examined. His stomach
is a little large, but shows nothing of importance. We did not settle,
to my satisfaction, the cause of his troubles. Possibly his arterio-
sclerosis may have accounted for them, but my impression is that
some mental or social trouble was back of all his symptoms. There
was no proper follow-up work done upon the case, so that I cannot re-
cord anything better than my own impressions; but I have seen a
number of similar cases in which the study of the patient's personal
and family life revealed an abimdance of disturbing causes, such as
were quite sufficient to upset anyone's stomach. In many hospital
cases these causes are entirely neglected or forgotten. The old-
fashioned family practitioner, who still plies his beneficent work
in smaller towns and country districts, understands and treats this
sort of a case far better than the so-called scientific physician, whose
clinic is so arranged that he cannot possibly know anything about the
mental life or personal problems of his patient.
Case 120
An Italian laborer of fifty-six entered the hospital August 28, 1910,
complaining of a month's abdominal pain, nausea, and vomiting.
For two years he has had also a persistent cough, and a year ago a
slight hemoptysis, lasting intermittently for a week and recurring
three or four times since. Never been sick in bed. He denies venereal
disease, but has drank heavily until two years ago, since when he has
been moderate. The family history is good.
At the present time the cough has subsided and the gastric symp-
toms are his main trouble. His bowels have moved two or three times
daily and the movements have sometimes contained blood. His
appetite has been good, but food causes gastric pain. Last night he
vomited three or four times and was afterward unable to retain any
food. The vomitus was said to be black.
On examination patient was somnolent and slightly pale. Pupils
negative. No lead line. Heart's apex in the fifth interspace nipple
line, right border 2.5 cm. from midsternum, no murmurs. Pulmonic
second greater than the aortic second.
Lungs showed throughout increased resonance, diminished breath
sounds, prolonged expiration, and many squeaks and crackles. Show-
ers of fine crackles were especially numerous at the right base. The
abdomen showed considerable tenderness in the right upper quadrant
with involuntary spasm. The liver dulness was normal, reflexes
DYSPEPSIA 305
normal. The rectum was ballooned and empty, and a little pure pus
was expelled soon after entrance. Next morning his chief complaint
was of severe pain across the upper abdomen and lower chest. The
urine was 17 oimces in the first twenty-four hours, the small amoimt
being accoimted for by profuse catharsis. Specific gravity, 1012,
with a trace of albumin and no recognizable sediment. White cells
numbered 22,500, with 89 per cent, of polynuclears. Hemoglobin,
75 per cent. A specimen of urine planted on blood-serum showed no
growth. His purulent sputum planted on blood agar showed no
growth of influenza bacilli, though film specimens of the same sputum
showed influenza bacilli. No tubercle bacilli. Examination of the
feces August 29th and 30th showed large amount of pus, but little food
residue and strong reaction to guaiac. No blood-pressure recorded.
The patient could retain nothing by mouth or by rectum. He
"was given subpectoral injections of glucose solution, but they were
not well absorbed. On accoimt of the abdominal spasm and the pur-
ulent rectal discharge it was thought that the patient had a local peri-
tonitis which had broken into the intestine and was draining by rectum.
As a source for this peritonitis, perforated duodenal ulcer and empy-
ema of the gall-bladder were considered. The oliguria soon im-
proved, and it was thought to be due either to some serious kidney
lesion or simply to the fact that he was absorbing no fluid to speak
of either by the stomach or otherwise. The similarity between the
sputum and the pus passed by rectum, both in its appearance and bac-
teriologic contents, was remarked upon. He was seen twice by Dr. C.
A. Porter in order to determine the question of surgical interference,
but no such interference was advised.
Discussion. — Very possibly this patient had phthisis at the time
of his persistent cough two years ago, but, so far as we can see, the net
effect of this illness was good, for it seems to have resulted in his giving
up akohol or, at any rate, moderating his reaction to that stimulant.
At the present time he has a dyspepsia without any special diag-
nostic ear-marks or peculiarities. From the history alone no one
could guess its cause.
From the physical examination one would suppose that he had
had a bronchiectasis, an ulcerative colitis, and some type of nephritis.
When the predominating organism in the sputum is the influenza
bacillus, when the patient's lung signs are distributed throughout both
limgs and are presumably of long duration, bronchiectasis is usually
the correct diagnosis. His dyspepsia is presumably a resultant of the
different infections above enumerated.
Vol. 11—20
chrc
prot
of t
DIFFERENTIAI. DUGNOSIS
Outcome.— The patient died August 31st, the diagnosis beir»^^
chronic bronchitis, emphysema, bronchiectasis, and some suppurati-'Si^- ^
process in the abdomen, perforating the colon.
Autopsy showed amyloid nephritis, hypertrophy and dilatati^:— .^.
of the heart, localized bronchitis, and purulent bronchitis of the 1^^-.—
lung; bronchopneumonia of the right lung; chronic pleuritls, ulc^^^ -
of the gall-bladder, ulcerative enteritis, and colitis.
Case 121
A shoemaker of sixty-four entered the hospital September 10, i^ -^-,,
complaining that for the past year he has gradually lost his appe*^_3i,
Fig. Hi. — Lung signs in Case 121.
and strength. He has been more constipated than usual and has h^°
severe headaches. For about two montlis he has had constant soren^^
in the epigastrium and a sensation "like a bullet trying to come up-
The latter usually comes on about 9 P. u. and lasts several ho^^^'
Somewhat relieved by hot drinks. During the last ten days he h^^
begun to vomit, the vomitus being always small in amount, but oi^*-
containing skins of peaches eaten twenty-four hours previously'
It has never contained blood or coffee-grounds. Usual weight up
last winter, 145 pounds; his present weight, 125 pounds. He reti*"*
DYSPEPSIA 307
t from work two years ago to take care of an invalid wife. He entered
b the hospital with a diagnosis of gastric cancer.
On physical examination he was fairly nourished, normal pupils
and gums, heart negative, abdomen negative, knee-jerks and other
reflexes negative, lungs as per Figs. 111,112. His sputum negative for
tuberculosis. No single type of organism predominates. The stools
September 13th and 15th gave a reaction to guaiac. The stomach-
tube was introduced and showed no fasting contents. Test-meal
was gone at the end of an hour. In the wash-water no free hydro-
1 chloric acid was detected. Capacity of the organ was 870 c.c.
rig. III. — Lung signs in Case ui.
During a week's stay in the hospital he had no fever and his blood
■and urine were normal. He seldom coughed, and had no gastric
symptoms after the first few days of thorough rest.
Discussion.^But for the negative results of gastric examination,
thU case might well be one of gastric cancer. As it is, I see no good
reason to doubt that it is similar to many others which I have studied
within the past ten years in which the entire foreground of the clinical
picture is occupied with gastric complaints, while phthisis is their real
cause. It is to be noted that this patient said nothing about cough
or any other pulmonary symptom, yet the signs in his lungs were very
marked. Although bacilli were not found, there is no considerable
doubt that he bad had tuberculosis.
308 DIFFERENTIAL DIAGNOSIS
Outcome. — It was subsequently learned that twenty-six years
ago he had a fistula in ano, lasting about a year and cured by opera-
tion. At this time he was having a slight cough, and one day, during
a fit of laughter, blood gushed in great mouthfuls from his throat
and nostrils. He was very weak after this and spent a year in
recuperating, but after that time seemed to be well. For the last
fifteen winters he had coughed a good deal, but had never given up
work.
The patient died a few months after leaving the hospital.
Case 122
A house painter of fifty-seven entered the hospital September 28,
1910, with a diagnosis of "family jaundice" or gall-stones. His
mother died at sixty-three of dropsy. She suffered from jaimdice
for twenty years before her death and had attacks of pain and vomit-
ing at various times. One of her children was slightly jaundiced,
oflF and on, for years, but died at fifty-nine. Another, still living at
sixty-eight, has had attacks of abdominal pain with vomiting and
jaundice in periods covering thirty years. Five other children have
never been jaundiced. The patient's maternal aimt had similar
attacks of pain, vomiting, and jaundice for a number of years.
The patient's own past history is negative. He takes three
sherries a day and an occasional drink of rum. Sometimes he has
whisky before breakfast. Otherwise his habits are good.
For twenty years he has had attacks of jaundice once or twice
a year, lasting from one to three weeks. Of late these attacks have
been somewhat more frequent. At the onset of such attacks he feels
unusual sleepiness and is sometimes feverish. Shortly after this he
begins to vomit, usually from one-half to one hour after meals. Vom-
itus has never been large in amount, but has sometimes contained food
eaten the day before. Twenty years ago he vomited about a pint of
' blood, and twelve years ago saw streaks of blood in the vomitus.
He has sometimes noticed that his stools are "black as ink," even when
taking no medicine. At other times they are clay colored. He com-
plains of three varieties of pain: First, heartburn, coming on an hour
or two after meals, for the relief of which he has consumed large
quantities of soda; second, colic in the middle and upper abdomen,
relieved by passing gas downward; third, a vague discomfort in the
right flank, which makes him unable to lie upon his right side, but
bears no relation to meals.
For ten years he has had to urinate about twelve times each
DYSPEPSIA 309
night, the aggregate result being about a quart. Twenty years ago he
weighed 160 pounds, a year ago 131 pounds, now 121 pounds. He
has followed his present occupation as a house painter for eighteen
years, but says that he had these attacks "before he ever saw a paint-
brush."
Ph3rsical examination showed poor nutrition and marked weak-
ness. The abdomen was strikingly freckled with brown spots, 2 to 3
mm. in diameter. Mucous membranes were pale and slightly cyan-
osed. The sclerse showed a slight lemon tint in the deeper parts,
but around the iris were white. There was no lead line, but his teeth
w^ere all gone on the upper jaw and few were left upon the lower.
The heart and lungs showed nothing abnormal. Blood-pressure,
150 systolic, 80 diastolic; urine, 70 to 90 ounces in twenty-four hours;
specific gravity, loii to 1017, sediment not remarkable. Examina-
tion of the blood showed red cells 3,000,000; white cells, 4000 to 8000;
hemoglobin, 55 per cent. The stained specimen showed no achromia
and a tendency to an increased size in the red cells; some variations
in size and shape, no nucleated forms, no stippling. The general
appearance of the blood distinctly suggested pernicious anemia.
The abdomen was tympanitic throughout, and showed a slight
general tenderness on deep palpation, most marked on the right
flank. The liver dulness extended from the sixth rib to a point 5 cm.
below the costal margin. Its surface and edge were apparently
smooth. Spleen not felt. Reflexes normal.
Discussion. — Our attention is at once attracted by a number of
different diagnostic possibilities:
(i) In the first place he is a painter, and almost any sort of indi-
gestion might be the result of lead-poisoning.
(2) In the second place he is an alcoholic, and the same might be
said as to the effects of alcohol.
(3) In the third place he gives a history of vomiting a large
amount of blood and having black stools. The commonest cause of
these occurrences (if they really did occur) is hepatic cirrhosis.
(4) He, as well as his mother and two other members of the
family, seem to have suffered from jaundice. According to his own
account he must have had forty attacks, which seems highly im-
probable.
(5) His nocturia may mean failing heart or prostatic obstruction.
(6) Besides all these definite possibilities, he launches us upon a
wholly imcharted sea, as he tells the story of his three varieties of
pain. None of these pains gives us anything characteristic or definite
3IO DIFFERENTIAL DIAGNOSIS
to take hold of. We must look to the physical examination to orient
us.
One of the first facts to be noted in the physical examination
tends to mystify us still further. Why should he have freckles on his
abdomen? I know no way to answer the question. As we go on
through the physical examination, we note that he has a tyi>e of
urine often associated with a contracted kidney, whether of the arterio-
sclerotic or glomerular type of nephritis. We note, moreover, that
he has a severe anemia, which might perfectly well be of the pernicious
type, as the history suggests. In the internal viscera the enlarged
liver is the most striking abnormality.
Putting this all together, it seems to me that the two most probable
diagnoses are cirrhosis or syphilis. Either of these might cause all
his symptoms. For the one we have an efficient treatment, for the
other no treatment at all. The reasonable course, therefore, is to
treat him for syphilis.
Outcome. — It was subsequently learned that three years ago he
spent eighteen months at an almshouse hospital, with marked edema
of the legs and ascites. At that time he was tapped three times, and
on the first occasion 4 gallons of slightly bloody fluid were evacuated.
For the last eighteen months there has been no edema and no ascites.
He worked imtil ten days ago. After ten days' stay in the hospital,
with laxatives and an occasional hypnotic, he presented no symptoms,
seemed very cheerful, and was discharged.
Case 123
A factory girl of nineteen entered the hospital September 28, 1910,
complaining of stomach trouble, constant and increasing in severity
for the last year, especially for three months. She has continual dull,
non-radiating pain in the epigastrium, less severe in the first hour after
meals, then sharper for the next hour. It bears no relation to the kind
of food. In the last two months she has vomited about an hour after
almost every meal. Vomitus never contains blood, has been small in
quantity, occasionally showing traces of the food eaten the day before.
During the past two months her appetite has failed and she has lost
weight. Usual standard weight being 158 pounds, she now weighs
145 pounds. She has worked about half-time until four days ago.
There are no disturbing mental factors as far as she knows. Bowels
move daily. She has no cough. Family history, past history, and
habits are good.
On physical examination she is well nourished, skin and mucous
DYSPEPSIA 311
membranes very pale. The heart's apex is 13 cm. from midstemiim
and 2 cm. outside the midclavicular line. The right border 2 cm.
from midstemum. There is a soft systolic murmur heard all over
the precordia and in the axilla, but loudest at the apex. The pulmonic
second sound is accentuated. The pulses are not remarkable. Sys-
tolic blood-pressure, 105. Urine averages 30 ounces in twenty-four
hours; specific gravity, 1009, no albumin, no sugar. There is moder-
ate tenderness in the epigastrium, but visceral examination is other-
wise negative. Blood examination, September 28th, shows the follow-
ing: red cells, 2,500,000; white, 3000; hemoglobin, 30 per cent. The
stained smear shows marked achromia, moderate variations in size,
shape, and staining reaction of the red cells, no nucleated forms.
The feces were negative to guaiac on four occasions.
Discussion. — The dyspepsia of anemic factory girls is a very
familiar phenomenon and dependent, I believe, upon many causes.
In the present case the anemia is so marked that all other causes
must be relegated to a secondary or tertiary position, but when the
anemia of such a working girl is of lesser grade we often find a multi-
tude of hygienic errors and mental worries which have to be corrected
before we can help the patient.
Some years ago one would have felt pretty certain of the existence
of gastric ulcer in a case of this sort. To-day we know that such
lesions are far less common in young girls than they are in middle-aged
men, and that most of the symptoms formerly attributed to ulcer in
yoimg girls are due to errors in hygiene, to industrial overpressure,
to incipient tuberculosis, to thyrotoxicosis, or lead-poisoning.
It is, of course, possible that this patient may have lost blood
from a peptic ulcer of the duodenum, and that her anemia may be
secondary to this, and there is nothing in the case which enables us
absolutely to exclude such a diagnosis, but the history is certainly
not at all typical of ulcer, and much more nearly resembles that of
chlorosis, a disease which used to be common and is now rapidly
becoming a rarity in all parts of this country. No doubt her working
conditions have contributed something to her troubles or have aggra-
vated her chlorosis, but it is not at all probable that they are a suffi-
cient cause of her anemia. Chlorosis is the most probable explanation.
Outcome. — By October 19th the red cells had risen to 3,500,000,
the hemoglobin to 55 per cent., and there was less abnormality in the
individuality of the red cells. She was able to eat everything with-
out discomfort. The treatment during this period consisted of
gastric ulcer diet and Blaud's pills, 20 gr. three times a day, and an
312 DIFFERENTIAL DIAGNOSIS
occasional dose of sodium phosphate. On further questioning, it
was found that she had for a long time been taking a scanty and
hurried breakfast, or none at all, and a cold lunch, bought at a lunch
« counter and eaten at the factory, where she had been working ten
hours a day. Dr. E. A. Codman considered the case one of ulcer of
the lesser curvature, but advised against operation. Patient gained
4 pounds during her stay in the hospital. In November, 191 2, she
reported that she was at work and feeling perfectly welL Further
details were obtained at this time regarding the conditions of her
work. She has been in industrial life since thirteen, and for the past
five years has been fusing wires into the glass stems of incandescent
electric-light bulbs. The fusing is done with a gas flame. She has
been doing piece-work, and in a ten-hour day fixed 3000 of these wires
in their glass stems. No windows could be opened in the room where
she worked, and the temperature was very high. A month ago she
changed to a paper and pasting job, and now has good air where she
works and only an eight-hour day. At the present time her hemo-
globin is 85 per cent, and her weight 145 poimds.
Case 124
A housewife of forty entered the hospital October 27, 1910. The
patient's complaint was that for six months she had had slight epi-
gastric distress and regurgitation of sour material soon after eating,
especially after eating cabbage or acid fruits. Her father died
at seventy- two of "pleurisy/' and her mother at sixty of *T)ronchial
trouble." The patient had rheumatic fever at fifteen, and was three
months in a hospital. In 1908 a painless lump, the size of a pigeon's
egg, was removed from her right forefinger, near the tip. It had been
growing there four years. The patient has one healthy child, ten years
old, and has had one miscarriage.
Five days ago, just after taking a little toast and tea, she expe-
rienced an entirely new sensation — a queer feeling of fulness at the
epigastrium, followed in a minute or two by dizziness and blackness
before her eyes. She was chilly and perspired profusely. She had
to lie down and wanted the windows open, but remained conscious.
Within a few hours she seemed to be nearly as well as usual, and in the
next two days washed and ironed and felt as well as usual. Two
nights ago she felt a little faint, but this soon passed off. Yesterday
morning, while ironing, she fainted away, and soon after recovering
consciousness vomited over a quart of bright red blood. Since then
she has been in bed, star\*ed, but comfortable.
DYSPEPSIA 3 13
Her phyacal examination was negative except as concerns the
blood and the feces. The course of her blood changes is seen in Fig.
113. A strong guaiac reaction was present in the feces continuously
from the time of entrance until November i6th ; after this it was slight
or absent for a few days, and on November 26th disappeared alto-
gether. At entrance she vomited 26 ounces of bright blood. The
pulse was almost impalpable at the wrist, but was counted later at
150. She was given } gr, of morphin subcutaneously, a hot-water bag
at the abdomen, while the foot of the bed was raised. Under this
treatment the pulse rapidly improved, but she was given nothing by
OfT
W
^
'■""™
N
'2l::2*1''Xc.
wot
•It-
Fig. 113. — Blood chart of Case 1*4.
mouth until the 31st, when 2-ounce feedings of milk were given every
two hours.
During the &rst twenty-four hours of her stay in the hospital she
received ij gr. of morphin, and her respirations were kept at from
12 to 15 per minute. Normal saline solution was given by rectum,
6 ounces every six hours, and was well retained. An ounce of brandy
was added to each enema. The bleedings did not recur. The amount
of milk was gradually raised to 5 ounces every two hours, and Novem-
ber 3d crackers were added; November 4th, lactose; November 13th,
eggs, toast, and potato. She had no symptoms and gained steadily,
and by December 8th she felt well and was allowed to go home.
Discussioa. — The most outstanding fact about this patient at
the present time is her anemia (Fig. 113). This is presumably due
to loss of blood vomited the day before entrance. It is notable
314
DIFFERENTIAL DIAGNOSIS
in the blood chart that her anemia did not reach its maximum imtil
four days later. This is just what one should expect. The blood
mass is diminished from the start, but the sample drawn for examina-
tion is unchanged. Later, fluid is absorbed into the blood-vessels
from the surrounding tissues. The blood mass is restored and the
blood-corpuscles diluted at the same time. This ordinarily takes
from one to three days, sometimes longer.
What is the source of this patient's hemorrhage? Cirrhotic
liver and peptic ulcer are the most probable causes. There is nothing
in her history to substantiate the idea of cirrhosis, but such negative
evidence is by no means sufficient to exclude it. The patient is
about the right age for peptic
ulcer, though her previous his-
tory is not at all typical of that
affection. Possibly much light
might be thrown upon her case
could we know the nature of
the painless lump which was
removed from her finger two
years previously, but it does
not seem at all likely that this
was either a gumma, a tubercu-
lous lesion, or a neoplasm.
The slight fever which was
present in the first two weeks
of this patient's illness is char-
acteristic of earUer stages of
posthemorrhagic anemia and
does not indicate any infec-
tion. This point is not always
suSiciently realized when we are busy with the differential diagnosis
of a fever following hemorrhage. On the whole, peptic ulcer seems the
most reasonable diagnosis.
Outcome. — On tlie 8th of March, 1911, she wrote that she was
feeling remarkably well and had gained in weight. The course of her
temperature during the first three weeks in the hospital is seen in
Fig. 114.
Case 125
A dressmaker of thirty-six entered the hospital October 30, 1910.
She has been recommended, October 7th, from the Out-patient De-
Fig.,
— Temperature chart of Case 1*4.
DYSPEPSIA 315
partment by Drs. Badger and Lincoln Davis, for subacute appendi-
citis, and was in the West Surgical wards from October 2 2d to 30th.
During that time the patient was afebrile and had negative urine, but
complained of vomiting, pain, and tenderness in the epigastrium and
right hypochondrimn, with a leukocytosis of 25,000 and 90 per cent,
of polynuclear cells. The fasting contents of the stomach showed
food, hydrochloric acid, and a negative guaiac test. Vaginal ex-
amination was negative.
The more careful history taken in the medical wards showed no
hereditary taints. Her husband died two years ago of a paralytic
shock, at forty-six. He had been hemiplegic for four years. His
mother, sister, and brother have had similar paralyses in middle life.
She believes that her husband never had venereal disease. She
herself had chorea for two years, from her sixth to her eighth year.
Her habits have been good. She has had no children and no mis-
carriage.
For three months she has had attacks of the above distress, first
three at intervals of a week, after that almost daily until her entrance
to the hospital. Between attacks she has some vague epigastric dis-
comfort. A typical attack begins with a sense of bloating, extending
from the level of the breasts to the pubes. This bloating she asserts,
very confidently, is such that at times she bursts her corsets. After
a period varying from a few moments to an hour a liunp the size of a
fist seems to form in the epigastriiun and right hypochondrium. It
becomes hard, relaxes, and contracts again, rhythmically, with about
two contractions per minute. By this time the bloating subsides, but
without escape of gas. She may then vomit several times with con-
siderable relief, and the rhythmic contractions are replaced by a dis-
tressing sense of emptiness in the lower abdomen. The whole attack
lasts an hour or more, and is not relieved by food or drink. There is
very little pain connected with it, and none that radiates to the back,
scapula, or groin. The attacks prevent sleep, but not work. They
may come at any hour of the day or night without relation to meals,
rest, or exercise. The vomitus is never large in amount and never
contains food eaten the day before. It occasionally shows a fine
dark-brown sediment not accounted for by food eaten. There has
been no jaimdice, no colic, no change in the color of the urine or
feces. Appetite and sleep are fair. She has worked steadily. Her
best weight, seven years ago, was 142 pounds; now, 136 pounds.
Physical examination showed good nutrition, pupils equal, circular,
and reacting normally to light and distance. No glandular enlarge-
3l6 DIFFERENTIAL DIAGNOSIS
ment. Chest negative, save for a very soft systolic mxirmur heard
over the whole precordia, loudest at the apex. Abdomen was also
negative. Knee-jerks not obtained. Examination in a hot bath
showed nothing abnormal in the abdomen.
Discussion. — The account given of this patient's husband leads us
to surmise that he may have had syphilis, especially as the patient has
had no children.
The account of the epigastric pain sounds like that often present
in appendicitis. It also reminds us of pyloric spasm, the gastric move-
ments representing gastric peristalsis. The gastric symptoms, how-
ever, do not read true to any single type of recognized gastric disease,
and this fact makes us all the more keen to look elsewhere in the body
for a source of the stomach symptoms. We naturally alight on the
absence of knee-jerks as a most significant fact in this connection.
It is true that the pupils give no support to the hint aroused in our
minds by the absence of knee-jerks. The pupils are not those of
tabes. But if the disease is confined to the lower segments of the
cord we do not expect involvement of the pupils. Further evidence
of tabes should certainly be sought, and until this is ruled out no
other diagnosis should receive equal consideration.
Outcome. — It was subsequently learned that for the past four or
five months she had felt darting pains, as if a needle were thrust into
the fleshy part of both calves and passed rapidly through at right
angles to the Umb. Occasionally she has had similar sensations in the
heels or on the dorsum of the foot. There has been no disturbance of
sphincteric control, no ataxia or abnormal sensations. A spinal
puncture was done November ist and 5 c.c. of colorless fluid obtained,
the cell-count in which was 3 per cubic millimeter. Differential
count showed small lymphocytes, 80 per cent.; large lymphocytes, 4
per cent.; endothelial cells, 13 per cent.; polynuclears, 3 per cent.
The patient had a typical attack on November 6th, although the
bowels by this time had started and were moving well. The attack
was apparently aborted by giving 5 minims of a mixture containing
equal parts of tincture of capsicum, tincture of belladonna, tincture of
aconite, and tincture of actea racemosa.
Case 126
A housewife of fifty-one entered the hospital November 17, 1910,
complaining of epigastric distress which has troubled her for three
years. It seems to have no relation to meals, but is worse at night.
She has considerable nausea and vomits very easily. In November,
DYSPEPSIA 317
1909, she consulted Dr. Chase, of Plymouth, on account of vomiting
of yellowish-green bitter fluid. Later she came to the Out-patient
Department and was benefited by treatment, but still occasionally
vomited. Her bowels are costive, and at times she has seen blood in
the movements. Nocturia, two to three times, for several years.
Slight hacking cough for a few months. She has no severe or parox-
ysmal pain. Her best weight, 163 pounds, with clothes, was three
years ago. She thinks she has lost 20 pounds in the last four months.
Her weighty without clothes, November i8th, was foimd to be 129
pounds. She has had considerable vertigo and some mental confusion
at times.
Yet the patient was well nourished and rosy. Chest negative.
Abdomen slightly tender on deep pressure on the right half. Reflexes
normal. Blood and urine negative. Systolic blood-pressure, 160.
Examined in a hot bath, nothing could be made out except consider-
able tenderness under the right costal margin. She was seen by
Dr. Maurice H. Richardson on the 20th of November. His opinion
was as follows: "The history is suggestive of gall-stones or thick, dark,
tenacious bile in the gall-bladder. The pain is probably due to irrita-
tion and spasm of the gall-bladder. I find no physical signs of dis-
ease. I advise an x-ray examination of the kidney. If this is nega-
tive for stone and other renal lesions, I advise exploratory operation,
at which I should expect to find a gall-stone too large to pass the
cystic duct."
Discussion. — ^We certainly must assume a large element of arterio-
sclerosis in the pathology of this case. The nocturia, the slightly
raised blood-pressure, the vertigo, and mental symptoms are best
explained in this way. The question then arises whether all the other
symptoms, including the abdominal symptoms, can also be thus
explained. It must be confessed that we have not as yet any clearly
recognizable picture of abdominal arteriosclerosis from the clinical
point of view. At the postmortem table it often seems as if there
must be clinical manifestations corresponding to the decided pre-
dominance of the sclerotic changes in the vessels of this part of the
body, yet, as a clinical entity, abdominal arteriosclerosis rests chiefly
upon scattered observations by French writers and has never yet been
put upon a firm foundation.
Dr. Richardson's theory of gall-stones was probably based upon
the occurrence of an unexplained epigastric pain in a stout elderly
woman, but surely there have been no typical gall-stone attacks and
nothing to give us any certainty of this diagnosis. On the other
3l8 DIFFERENTIAL DIAGNOSIS
hand, gall-stones are probably the most frequent cause of vague
symptoms of this type in a woman of her age, and, in the absence of
any other well certified cause, it is perhaps as good a hypothesis as
any to follow up, especially as the attacks have no relation to meals
and are often nocturnal.
Her loss of weight can be explained either by the poor nutrition
attendant upon her dyspepsia or by arteriosclerosis.
I see nothing in the case to suggest renal stone.
Outcome. — Since a:-ray proved negative, operation was done No-
vember 23d. The gall-bladder was found to contain several stones,
one large stone being firmly fixed in the cystic duct. Colorless fluid
was removed by aspiration from the gall-bladder, which was then
removed.
The patient left the hospital in good condition, December 11, 1910.
December 15, 191 1, she wrote that she had gained in weight and had
a good appetite, but that pain had returned in her left side, and she
still vomited frequently in the morning. In May, 191 1, she had some
trouble in her back, for which a corset belt was prescribed in the
Orthopedic Out-patient Department. This she has worn since.
In November, 191 2, she had a dull, steady ache near the heart
and under the left shoulder-blade. There was no vomiting except
after hot water taken before meals, as a rule, to cleanse the stomach.
The water was taken into the stomach and rejected, bitter. Consti-
pation was extreme, requiring laxatives constantly. She bled much
at times from the rectum, sometimes had to wear a napkin. Com-
plained of vertigo and queer feelings as if she would fall — as if she were
walking on sponge. These were accompanied by precordial and
wrist pains, especially on hurrying. She was confused and dis-
oriented at times, but much better in most ways. Examination
showed a blood-pressure of 160 and the aortic second sound ac-
centuated. At this time arteriosclerosis, cerebral and cardiac, was
evident. No evidence of other disease.
Case 127
A butcher of forty-seven entered the hospital November 6, 1910.
His family history and past history were negative. Habits good.
Three months ago he began to have sour stomach and to vomit
about ten minutes after every meal. Constipation was troublesome.
Appetite was absent, so that, though he continued at work, he would
eat almost nothing for two or three days at a time and lose flesh
rapidly. After two or three weeks he got his bowels regulated with
DYSPEPSIA 319
the aid of Epsom salts. He then felt much better, and gained in
weight and strength during the following three weeks. After that he
has been gradually running down again up to the present time.
The physical examination showed emaciation, but was otherwise
negative, except that the heart-sounds were somewhat irregular, an
entire beat being skipped every four to seven cycles. There was no
lead line and no stippling in the red blood-cells. The patient showed
distinct mental deficiency with memory defect. In a hot bath noth-
ing could be felt in the abdomen and the urine was negative. Blood
showed red cells, 3,800,000; white cells, 15,000; hemoglobin, 65 per
cent. The stained smear showed slight achromia, but no other
changes of importance. Stools showed a slight reaction to guaiac on
about half the examinations. With a 6-inch proctoscope nothing
abnormal could be found in the rectum. Lead was found by Dr. Boos
in the stools, and examination of the patient's drinking-water showed
in 100,000 parts 0.0086 of lead.
During his seven weeks' stay in the hospital the patient had no
fever, normal blood-pressure, and gained i| pounds in weight. He
complained during the first ten days chiefly of paroxysmal cramps
in the abdomen, imaccompanied by any distention, visible peristalsis,
or constipation. He ate everything that was given him and called
for more. Each morning he greeted the house officer with the remark,
"My friend, I never felt better in my life." On the i6th of November,
at seven in the evening, the patient cried out loudly. His right hand
began to twitch and the spasm followed up the arm to the face, then
to the arms and legs, and the whole body became stiffened in convul-
sions, with slight cyanosis and deep respirations. He was uncon-
scious for several minutes, but had no disturbance of the sphincters
and seemed practically all right when he came to.
On the 20th he suffered again from severe cramps and the abdo-
men was slightly distended. In a subsequent attack of cramps the
abdomen was rigid. On the nth peristalsis was quite visible, and,
despite the patient's emaciation, the belly was slightly distended.
In the day time he frequently slept with his eyes open. He left the
hospital December 22d, without any considerable improvement in his
condition.
Discussion. — Three months of sour stomach and vomiting, asso-
ciated with emaciation, abdominal cramps, and visible peristalsis
with anemia and blood in the stools — such a group of data should
surely make us investigate the stomach and bowels as carefully as
possible for evidence of malignant disease. Yet there were indications
320 DIFFERENTIAL DIAGNOSIS
pointing in another direction. Extrasystoles and memory defects,
together with such twitchings and spasms as were exhibited during his
hospital stay, certainly gave us an inkling of arteriosclerosis, cerebral
and cardiac.
The finding of lead by Dr. Boos does not seem to me in any way
conclusive evidence that this patient was suffering from lead-poisoning.
Such a supposition is perfectly conceivable, but it is a well-known fact
that lead circulates throughout the bodies of many of us quite imde-
tected and harmlessly. The same is true of arsenic, in small amoimts.
The mere presence of these metals, therefore, is no evidence of their
toxic eflfect, and, in the absence of any stippling in the red cells, any
lead line, or any occupation leading to the ingestion of lead in consider-
able quantities, it seems to me we should look elsewhere for a more
plausible explanation of the patient's cramps and dyspepsia. It is
certainly unusual to see lead-poisoning with so fine an appetite.
There was hardly any symptom in the case which might not be
explained either by dementia paralytica or by sclerosis of the cerebral
arteries. The anemia would be unusual in this connection, and the
patient is a little young for arteriosclerosis. The absence of a syph-
ilitic history does not seem to me of any importance.
Toward the end of the record we get the definite observation
of visible peristalsis in the abdomen, with some distention and rigid-
ity. This is not easily accounted for by any of the hypotheses thus
far considered, and I am not able to explain it. When the patient
was in the hospital we were quite suspicious of a cancer in the large
intestine, but we got no proof of it. Such a growth would explain
the anemia and guaiac-positive stools, but would not account for the
mental symptoms, the convulsions, and extrasystoles. It is also
very unusual to see a ravenous appetite with any such growth. On
the whole, I think arteriosclerosis, involving the heart, brain, ab-
dominal and peripheral arteries, is the best conjecture that I can
ofifer.
Outcome. — The patient entered the Massachusetts State Infirmary
at Tewksbury January 25, 191 2; that is, more than a year after he left
the Massachusetts General. At Tewksbury the provisional diagnosis
was cancer of the stomach, but he was so noisy and violent that he
was seen by alienists and some psychosis diagnosed. He had pre-
viously been committed to an asylum, February 17, 1911. In Jan-
uary, 191 2, he no longer complained of severe abdominal pain, though
he had occasional attacks of diarrhea. He was then cachectic and
confined to bed on account of general weakness.
DYSPEPSIA 321
A year later, January 15, 1913, he died, and there was found a
diffuse chronic peritonitis, most marked about the liver and stomach,
but also involving the right lower quadrant. The appendix was
normal. The right lung showed extensive tuberculous infiltration,
there being practically no normal pulmonary tissue in any part of the
lung. The upper lobe contained several large cavities. The upper
lobe of the left lung was also filled with cavities, while its lower lobe
showed smaller ulcerating areas. The kidneys showed a chronic
nephritis. There were numerous adhesions between the heart and
pericardiiun and some firm outgrowths in the mitral valve. The rest
of the organs were not remarkable.
Remarks. — Presumably, the abdominal symptoms were due to
the chronic peritonitis just described. As we have no record of an
examination of the brain, it is difficult to make any definite statement
about this, but the Tewksbury records show that the patient was
much more alcoholic than we had gathered when he was at the Massa-
chusetts General Hospital, and it seems quite probable that his
psychosis was due to alcoholism. I trust that the tuberculosis, so
extensive at the time of his death, had not made much progress when
we saw him. Certainly we had no idea of its presence.
Case 128
A naval engineer of thirty-one entered the hospital November 2 1 ,
1910. Previous to November, 1909, he was chief engineer of a United
States scouting cruiser, and for eighteen months was in a position of
great responsibility and fatigue. In November, 1909, he noticed that
smoke did not taste right to him. He began to diet and cut out his
daily beer, but two weeks later he began to feel nauseated and occa-
sionally vomited. This time he had the feeling of a lump somewhere
in his upper chest, and a sense of indefinite distress when he spoke or
swallowed. He was given two months' sick leave and went home
to Maine, but in February, 1910, and while on sick leave, he had an
attack of nausea and vomiting without any known cause and was in
bed seventeen days, part of the time on rectal feeding. He gradually
recovered from this attack, but still felt weak after it. May, 1910,
was his third attack, after he had been on duty for a month. In this
attack he got great benefit from hypodermic injection, the nature
of which he does not know. Ten days after he had taken the test
of walking fifty miles in three days. In June, August, and October,
1910, he also had attacks like the others, feeling fairly well in the in-
terim.
Vol. 11—21
322 DIFFERENTIAL DIAGNOSIS
For five or six years he has noticed a littie bright blood in the
movement of the bowels and some difficulty in controlling the sphinc-
ter. In the morning he also has slight incontinence of urine. At
irregular intervals he has sudden, sharp pains in the thighs, knees,
or heels, less often in the chest or arms. These pains may trouble
him for half an hour or continue all night. His best weight was in
1899, when he weighed 145 pounds. October, 1910, he weighed 125
pounds; now, 133 pounds.
On physical examination he was found to be thin, nervous, with
cold, moist hands. His pupils were slightly non-circular and equal.
The left reacted normally to light and distance; the right, to distance
only. The lymph-nodes showed slight general enlargement to about
the size of a pea. Heart and lungs were negative, likewise the
abdomen. Knee-jerks were lively and equal. The plantars normal.
All the superficial reflexes, especially the abdominal, seemed to be
abnormally lively. There was no Romberg sign, but slight hypotonus
of the hamstring muscles. No paralysis of the cranial nerves, but the
hearing of the left ear seemed to be impaired. No disturbances of
tactile or muscular sensation. Wassermann reaction was positive.
The blood otherwise negative, likewise the urine. Systolic blood-
pressure, 140. No fever.
Discussion. — It is worth noting, first of all, that in November,
1909, before any other distinctive symptoms were present, the patient
noticed, as the first deviation from the normal, that tobacco did not
taste right to him. I have been told this by many a patient at the
very beginning of his illness, long before any other distinctive symp-
toms appeared to suggest disease of any particular organ. I think
the disinclination to smoke and drink is often one of the most delicate
indications of the beginning of ill health. It is not that the patient
leaves off these habits as precautions, but that he actually loses his
taste for them.
Between November, 1909, and November, 1910, there is a history
of six attacks, with good health between times. One of these attacks
was relieved by hypodermic injection.
Still further back in the history, some time before he considered
himself in any way indisposed, we note that there was difficulty in
controlling the sphincters, also some sharp pains, which remind us of
tabes.
The physical examination supports the theory mentioned at the
end of the last paragraph. We have an Argyll-Robertson pupil on
the right side, a general adenitis, a positive Wassermann reaction, and
DYSPEPSIA 323
»
abnormal slackness of the hamstring muscles when the leg is hyper-
extended upon the chest. Although the knee-jerks are normal, this
is abundant evidence on which to found an inference of tabes dorsalis.
Gall-stones are suggested by the sharp gastric attacks and the
relief by morphin, but there are many features in the case which
cannot be thus explained, and with such definite indications of organic
nervous disease we have no right, certainly, to suppose a merely
functional or dietetic upset.
Outcome. — ^At this time the patient stayed in the hospital only a
day or two, but January 6, 191 1, he re-entered, stating that he had
been in first-rate condition since leaving the hospital before, but had
had at times slight prickly sensations in the thighs, legs, and heels.
To-day there is a small area of superficial tenderness on the upper
front of the right thigh. Physical examination was otherwise as
before. January 9th he was given "606," and a few days later left
the hospital.
Case 129
An immarried girl of twenty, a mill hand, entered the hospital
November 23, 1910, complaining of a burning pain in the stomach
two or three hours after meals, often relieved by vomiting. She has
had this pain for a year and has been disabled by it. It is never re-
lieved by eating or by water. It often wakes her in the night. She
has never tried soda for it. The vomitus is green and bitter, but never
contains food or blood. Nine months ago she was operated upon for
appendicitis without relief of her symptoms. She feels best when on
a diet of milk and eggs. Bowels are costive. Best weight, 122 pounds,
at the present time; six months ago, 114 pounds. When she was
two, and again when she was ten, she had for some weeks difficulty
in passing urine. This was somewhat relieved by hot fomentations.
Otherwise her past history, family history, and habits are not remark-
able. She is a French Canadian; speaks no English. Menses began
at seventeen, but have now been absent for a year. For most of the
last year she has been in bed, suffering from pain in the head, back, and
legs.
On physical examination patient is well nourished, skin very dry.
Hands cold and clammy, with eczematous patches over the knuckles.
Chest negative. Abdomen shows slight tenderness on deep pressure
in the left flank. There is a surgical scar on, the right iliac fossa.
The little fingers of both hands cannot be straightened entirely, and
there is an apparent atrophy of the fingers about the proximal pha-
324 DIFFERENTIAL DIAGNOSIS
langes and some swelling of the knuckles. She attributes the condi-
tion to being cut with a sickle when harvesting. There is sli^t
edema of both ankles and both shins, which the patient had noticed
for the last two weeks.
Patient stayed five weeks in the ward and failed to gain wei^t.
The blood and urine showed nothing abnormal, and the stools were
negative to guaiac on five examinations, scattered throughout the
month.
Discussion. — ^At twenty years of age most d>'spepsias are func-
tional, temporarj-, and, when they occur in a girl, very dependent
upon ps\xhic causes or bad hygiene. As usual in such cases at the
present day the appendix was taken out, and. as usual, without
relief. The case is t>pical of the most popular and most signal abuse
of surgerj' tolerated by the profession at the present time. A few
N-ears ago a similar case would have been subjected to an (^)erat]an {or
suspension of a low right kidney, which doubtless was present, al-
though we had not taken the trouble to record it. Ten years
earlier she might have suffered an o\*ariotomy. Doubtless it will
be manv x^ears before we shaU rid ourselves of the curse of unneces-
sary surgery.
TweK^ months* cessation of menstruation is not so significant at
this age as it would be later in life. and. when menstruatioD has been
established for only a few year^, it needs but little depression of the
general xitality to suspend the function for a number of months. Yet,
even at twenty, amenorrhea should make us suspect serious disease,
such as tuberculosis, and do our best to exclude il. This was done
in the present case, and I do not see that we can profitabh' consider
tuberculosis anv further.
A point of great imix>rtance, it seems to me. in the histon- of this
case is the simple statement that the pvatient has been in bed for most
of the last year. In a person not already serioush' ill, such a proced-
ure is enough to produce ver\' great discomfort, if not actual illness.
All our sensations are greatly magnified under those oonditians, and
it needs a ver\' steady head and strong character to keep us out of the
clutches of a pisychoneurosis, when cut off by **rest in bed'' from the
normal stimuli and interests of life. WTiile no fKisitr\'e diagnosis can
be made upon the facts given us in this case, we can say that ancere
and earnest effort has been made to find oriranic disease and that such
efforts have been wholly unsuccessful. This did not necessarih' mean
that we must incriminate the nervous s\*siem. Not all sack piatients,
with a normal physical examination, have a psychoneurosis. Many
DYSPEPSIA 325
of them have chronic industrial poisonings. Many more are subject
to chronic mahiutrition, due to faulty habits and poor hygiene. Still
others have been thrown off their balance and put out of normal con-
verse with the world by some misfortune, by some secret sorrow, some
half-recognized source of worry, or of remorse. In other words, they
are in need of the sort of help which a social worker can give. They
need to be carefully and sympathetically studied by some one who is
used to the commoner sources of trouble in girls of her age, and can
gradually find and help to remove the obstacles which for the time have
incapacitated them. In the course of such a study, the patient's
environment, mental as well as physical — her total environment so far
as we can reach it — must be studied. This is difficult, sometimes
impossible, but recovery is often out of the question on any other
terms.
Outcome. — ^Dvuing most of her stay she had no stomach symp-
toms. She vomited only once in the five weeks. The treatment
consisted mostly of massage, electric-light baths, and Zander ex-
ercises. Mild laxatives, occasional doses of sodium bicarbonate and
of veronal sodium were given.
Case 130
A housewife of thirty-five, a Russian Jewess, entered the hospital
December 4, 1910. Family history negative, and she has always been
well and strong. She has had three children, the youngest six years
old, and has done all of the work of her household without fatigue.
She has had no special cause of worry and has had plenty of sleep.
Six days ago she began to be nauseated about 10 a. m. A physician
was called, who gave castor oil and put her to bed, where she has
remained since, suffering from more or less constant nausea and
vomiting, especially at night. The sight of medicine makes her
worse. She has eaten nothing for six days, but has been wholly
free from pain. Her vomitus has been green and watery, without
food or blood. Bowels moved daily.
On physical examination nothing abnormal was detected, ex-
cept that there was slight dulness and bronchovesicular breathing at
the right apex, above and below the clavicle, as far down as the
second rib. After cough a few crackles were elicited. The systolic
blood-pressure was 95. Vaginal examination negative. The vomit-
ing continued intermittently until the 14th of December. X-ray, No.
18,341, showed sUght but suggestive shadows in both lungs, especially
the left. On the 19th she was given subcutaneous injection of tuber-
DIFFEKENTIAL DIAGNOSIS
336
culin, 0.005 gram, and showed the temperature reaction indicated in
Fig. 115. At entrance the urine showed an intense reaction for diacetic
acid, but was otherwise negative, as was the blood. Stool showed do
guaiac reaction.
Discussion. — This is the history of what we would ordinarily
call simple acute dyspepsia. It comes out of a clear sky, as it were,
without previous illness, without known cause. Yet, on phy^cal
examination, there is enough in the lungs to hint strongly at pul-
monary tuberculosis. The low
blood-pressure and the a:-ray ex-
amination afford confinnatory
evidence. It is noteworthy that
in the a:-ray picture the left lung
appears more extensively in-
volved than the right. The
tuberculin reaction does not
seem to me of much importance.
Almost any one of her age and
living in a large city will have a
positive tuberculin reaction, al-
though the size of the dose
which produced this reaction
gives it, perhaps, some signifi-
cance.
The chief ptrint of interest in
the case is the presence of gas-
tric symptoms, which may con-
ceivably have had no relarion to the pulmonary processes, but are
yet extraordinarily common in association with such a process.
I may mention in connection with this a similar case in a man
of forty, who came to the hospital December 5, 1910, complaining of
nothing whatever except pain in the stomach, so severe that he could
take only liquids. He had no loss of weight and no cough, yet there
were well-marked signs of phthisis at both apices and down as low
as the second rib in front. There was, moreover, an old healed
tuberculous process in the lower third dorsal and first two lumbar
vertebrfe.
Outcome.^She left the hospital on December 19, 1910, and on
March 10, 1911, Dr. Cleaveland Floyd, of the Boston Consumptive
Hospital, reported that she was doing very well at home, under the
guidance of the hospital nurse.
"fltlTt'tlT^I !'tF''ti
::---3±-5:--t1;
!;::-±t--3i-fl:
I^JijilJillii-trrrMTtl
_ * LLi- rh-'l 'r^-
- - ;--w — -p-L_^ — |_j-^-
! - - ^ -(-_l 1^_ -^ :
: i^"i2i4~''si;''^i + —
" ■ . ' ■ :
j ; ^::pt- + --^J-
= : ::s44^;it-± +----
■^ = ;"S'i^-i--=====
S:=:--fft"T"'T
Fig. iij. — Chart of Case 130.
DYSPEPSIA 327
Case 131
A cutler of forty-six entered the hospital December 4, 19 10. The
night before he went to bed feeling perfectly well, after a supper of
simple foods, except for two pig's feet. At four this morning he
waked from soimd sleep with a feeling of pressure in the flanks. At
the end of an hour this pain traveled to the median line in front and
became severe and constant, causing him to double up. It did not
radiate. Was accompanied by a slight nausea, but no vomiting.
The bowels had moved normally the morning previous. A year ago
had an attack like the previous one after a meal of rather indigestible
food, but a movement of the bowels completely relieved him. Was
at work again within thirty-six hours. As a rule he takes no
alcohol, but several times a year he stops work and drinks imtil
he "sees cats and dogs." The last occasion was three weeks ago.
Otherwise his past history, habits, and family history are not re-
markable.
When examined he was in considerable pain. His pupils slightly
irregular, but reacting normally. No lead line. Chest negative.
The whole right side of the abdomen, especially the upper portion,
was rigid and moderately tender. The knee-jerks normal, and there
was no other abnormality. In the course of the afternoon the pain
and spasm subsided, and next morning he seemed to be well and was
accordingly discharged.
Disctission. — Here is a case which we may (although with some
hesitation) call acute dyspepsia, meaning thereby an arrest or delay
of digestion without known cause and running a short, afebrile course
to complete recovery. Such a diagnosis is warranted only when the
patient's history and physical examination reveal absolutely nothing
except the digestive attack itself, and when, moreover, the outcome
of the case supports this h3^othesis. I know of no diagnosis more
often contradicted by the subsequent outcome than that of acute
indigestion. We are constantly reading in the newspapers that so
and so was seized at a banquet or while making an address with an
attack of acute indigestion. The statement practically never turns
out true. In the great majority of cases the attack is a cardiac or a
cerebral one.
Outcome. — ^The patient was seen November, 191 2, and stated that
he had been working steadily since he left the hospital. A year ago
he had one attack similar to that described above, although it lasted
but a few hours and went off of itself as soon as his bowels moved.
328 DIFFERENTIAL DIAGNOSIS
This attack, he says, he is quite sure was brought on by overeating.
"I am like a boy with a stick of candy," he said. He was at work
again the next morning and has been perfectly well since.
Case 132
J. C. E., a pattern maker of seventy, entered the hospital March
20, 191 1. Was formerly a hard drinker, and twenty years ago had
sores on his shins and knees. Later a chancre, but no secondary
symptoms. Was never treated for this. For the past thirty years
has taken practically no alcohol. Tobacco, ten cents a week.
His present complaint is of indigestion, which has troubled him
more or less for twenty years. An uncomfortable, empty feeling imder
the left ribs is present oiBF and on, but he may be free from it for months
at a time. At its worst this discomfort is never severe, and until
the past few months has never disabled him or needed treatment.
During these twenty years his bowels have been regular, but the
daily movement has been loose. During the past two years he has
been constipated and has taken agar-agar and sodium phosphate in the
Out-patient Department, with relief. During the past few months the
bowels have moved only with enemata.
Besides the discomfort above mentioned, he sometimes has a
dull ache in the abdomen and back, especially after a day's work or
when he is worried. Food seems to make no difference. The pain
never comes at night. Though he has periods of improvement, often
lasting weeks, on the whole, he grows weaker and more miserable.
Until the past few weeks there has been no vomiting; since then he
has often raised a little sour water after periods of pain. A bowel
movement gives more relief than anything else. Since last summer
he has been imable to work. Five years ago he weighed 150 pounds.
Within the last two years he has lost weight and now weighs 119
pounds. Lavage by Dr. H. F. Hewes last September showed no food
residue, no positive guaiac test either in the stomach contents or in
the stools. After a test-meal a free HCl was 0.08 per cent. The
family history is negative.
Physical examination showed a marked emaciation. Good
color, normal pupils, no glandular enlargement. There was a marked
depression at the lower end of the sternum. The heart and lungs
negative. The abdomen showed slight tenderness on deep epi-
gastric palpation. There was a marked right inguinal hernia and
slight left inguinal hernia, otherwise the abdomen is negative. The
right shin showed a brownish discoloration. Reflexes were normal.
DYSPEPSIA 329
On the 2ist the stomach-tube, passed before breakfast, showed a
few shreds of orange fiber, but no other food residue. The capadty
of the stomach was 1900 c.c. On mflation, the lower border came just
below the navel, the upper border at the ensiform. After an Ewald
meal the stomach contents showed a faint guaiac reaction and free
HCl 0.04 per cent.; total acidity, 0.07 per cent. On the 24th there
was a very considerable food residue before breakfast. Free HCl
0.07 per cent.; guaiac test negative. It was difficult to wash the
stomach clean on this or on subsequent attempts. Guaiac test was
positive in the stool of March 24th, though negative two days pre-
viously.
Discussion. — Points of interest in this case are: (i) The history of
twenty years' gastric discomfort upon a basis of alcoholism and
possible s3T)hilis. (2) The fact that throughout the illness pain has
been comparatively slight. (3) The negative stomach examination
seven months ago, although at the present time his stomach shows
obvious evidence of stasis. (4) The presence of HCl in the gastric
contents. (5) The negative physical examination, except for the
evidence of emaciation, which apparently has been going on for two
years.
In a man of seventy such history certainly justifies us in surmis-
ing that gastric cancer is present. At the same time we must remem-
ber that renal insufficiency (that is, uremia or its equivalent), gall-
stones, arteriosclerosis, or cirrhotic liver might produce the same
troubles.
The physical condition seems to be fairly good despite the marked
emaciation, and it seems to me that he has a right to exploratory
incision for possible gastric cancer.
Outcome. — On the 30th of March Dr. G. W. W. Brewster advised
exploration, which revealed a mass just above the pylorus, and ex-
tending along the lesser curvature nearly to the cardia. The mass
at the pylorus was the size of a hen's egg. Posterior gastro-enteros-
tomy. Patient made a good recovery, and left the hospital on the
13th of April with the wound well healed and with a considerable
gain in weight. Seen May 19, 191 2. States that since leaving the
hospital has been in good health and gaining weight, up to about
four weeks ago. He has not vomited at all. For the last four weeks
he has been having severe pain in the left loin and back. A tumor
the size of two fists is now palpable in the epigastrium and to the
left of it. The patient is now losing weight.
Remarks. — It is notable that the patient had at least a year of
330
DtFFEBENTIAL DUGNOSIS
good health and gain in weight. Presumably within the last four
weeks the growth has begun to progress, but it seems to me clear that
the gastro-enterostomy was well justified.
Case 133
A bacteriologist of forty-three entered the hospital April 6. 1911.
He states that he has always been below his proper weight in spite of
careful and long-continued efforts to raise it. His digestion is capri-
cious and uncertain. Eggs, fish-chowder, oysters, and creamed soups
have been hard to get in and easy to gel out of his stomach for a num-
Case 133.
ber of years. For the last four years he has had pain following any
acid food. Meats agree with him well. If he eats rapidly he gets in
more food than if he stops to talk between rimes, and chiefly on this
account he has found it impracticable to dine in company. He says
that he has not eaten a square meal for years, partly from lack of
appetite and partly from fear of consequences.
As a rule, he wakes up about 4.30 a. m. very hungry. Hiu
ripens into epigastric pain if he does not get breakiast by 8 i^
He has some epigastric pain all the morning, and by 1 1 .45 it is severe.
If lunch is prompt he gets relief from food, but if it is delayed, a pain
i A. vfl
DYSPEPSU 331
as sharp as toothache in the epigastrium causes distaste for all food.
After lunch he has a sense of weight, which gradually develops into
pain and bothers him all the afternoon. After an early supper he goes
to bed and to sleep. He is rather chagrined to be obliged to state
that immediate sleep prevents the completion of the history of his
pains for the day.
In December, 1909, he had a pulmonary hemorrhage after the
inhalation of the fumes of hot glacial acetic acid. During the next
two weeks there were several more hemorrhages, a or 3 ounces at a
time. Associated with these, there was a slight cough. Dr. J. J.
Fig. 117. — Chesl signs in Case 133.
^-ioodale examined him at this time and found varices at the base
^^f the tongue.
At the same time of these hemorrhages the patient had also
Vhree attacks of hematemesis, about 8 ounces in amount, with tarry
^lools. He was quite sure that this blood was not previously swal-
lowed.
Since June, 1909, he has done no work, as he had at that time
a heat-stroke and has had irregular fever ever since. Most of last
■winter he was in bed, apparently because that was the only warm
place he could find.
His family history is excellent.
332
DITFEBENTIAL DIAGNOSIS
Physical examination shows emaciation, flushed face, slight cyano-
sis, chest as in Figs. ii6 and 117. Puhnonic second sound sharply
accentuated. Apex first sound reduplicated. Heart otherwise nega-
tive, likewise the rest of the visceral examination. The blood shows
a leukocytosis of 15,000 to 19,500. Range of temperature shown in
Fig. 118. Stomach-tube reveals no fasting contents. A test-meal was
not given, as his stomach improved rapidly
imder a diet of liquids and soft solids.
He was soon changed to a normal diet.
DiscuBslon. — The nature of the varie-
gated dyspepsia from which this patient
has suffered for four years ought to have
been clear long ago, when it was known
that he has been having fever for at least
two years, yet it is clear from the way
in which the history was given that the
pulmonary hemorrhage of December, 1909,
was not at once recognized for what it
must have been, namely, an evidence of
pulmonary tuberculosis, buj, was faultily
connected with the inhalation of add
fumes. The fumes may have started the
patient to coughing, but the hemorrhage
was undoubtedly of tuberculous origin.
The same fatuous eagerness to avoid facing the facts, and to snatch
at any explanation other than the obvious one, is shown in the impor-
tance attributed to finding dilating varices at the base of the tongue.
Such findings are not uncommon when people are trying with all their
might to blind themselves to the existence of pulmonary tuberculosis.
There is some doubt as to the origin of the blood vomiting. The
patient may be right in supposing that he had not previously swal-
lowed the blood, but I do not feel nearly as sure upon this point as
he did. There can be no reasonable doubt of the diagnosis in this
case, but to me the point of chief interest is the rapid improvement
following the administration of a good deal more food than the patient
had believed himself able to take. As in so many other cases, dys-
pepsia is due to starvation and starvation to dyspepsia. Break the
circle by forced feeding, despite discomfort, and we soon get back to
normal digestion.
Outcome.^ — Tubercle bacilli were abundant in the sputum. Stools
were always negative to guaiac.
_- J U J-, .
\zrr/ii\lVz'^'
:| linTinT^
* " — ~!
5:^-""-S=-
^Z--^\t:':^---z--:
- X " —
i::::-V_-.-Azzzz:
{---;?;'■■;'■'- = -
' : J":::::::-:::
Fig.i
J.— Chart of Case i.
DYSPEPSIA 333
Case 134
A rivet driller of forty-nine entered the hospital May 26, 191 1.
Twelve years ago the patient was troubled with indigestion for a week,
otherwise he has been well all his life until his present illness, despite
the fact that he smokes and chews thirty cents' worth of tobacco a
week. His family history is negative. For the past year he has been
troubled more or less by indigestion, showing itself in gas and epi-
gastric distress one-half to one hour after food, relieved by belching of
gas or by vomiting. He has never tried soda or food for relief. The
onset of this trouble was rather sudden, and it has grown neither
better nor worse. He is never free from it more than a few days at a
time. He never has vomited any blood or coffee-groimd material,
but only food recently eaten. His bowels have been constipated
throughout the year of his trouble with indigestion, though they had
never )yeen so previously. In February, 191 1, he did not feel up to
his work, but he kept at it imtil a month ago, when increasing weak-
ness and lack of ambition compelled him to desist. He first came to
the Out-patient Department on account of stiffness, lamepess, and
swelling of his feet. He has no other complaints.
Physical examination showed poor nutrition, but was otherwise
negative. Systolic blood-pressure, 120. Urine negative. Stools
negative to guaiac on six examinations and free from any abnormal
constituents. Red cells, 1,600,000; white cells, 6000; hemoglobin,
50 per cent. Blood-plates, 196,000. Differential count normal.
The stained specimen showed many large and well-stained red cells
and a few that were achromic, marked variations in size and shape,
occasionally an off-colored or stippled cell. Four normoblasts were
seen while counting 200 whites. Wassermann reaction was negative.
The patient stayed two weeks in the hospital and improved consider-
ably in all respects, his red cells rising to 2,500,000, hemoglobin 70
per cent, during that period. On the 8th of June he left the hospital.
Discussion. — There is nothing characteristic in the history,
although at his age any abruptly appearing dyspepsia threatens
cancer. It is, however, rather suggestive that when he gave up work
it was on account of weakness and not for any other reason. This
state of things is especially apt to be associated with a blood-coimt like
that recorded in the physical examination; in other words, with per-
nicious anemia, of which that blood-picture is ahnost typical.
It has been repeatedly said in text-books and elsewhere that gastric
cancer not infrequently is associated with a blood-picture indistinguish-
334 DIFFERENTIAL DIAGNOSIS
able from that of pernicious anemia, and, doubtless, in rare cases this
must be true, since it has been believed by excellent observers, but
in my own twenty years of observation of pernicious anemia and of
gastric cancer I have never known a case in which a mistake was
made. Indeed, in comparison with the frequency of mistaken diag-
nosis in other diseases — a frequency on which I have insisted^ — ^it
seems to me very notable how rarely one makes any such mistakes in
differential diagnosis involving pernicious anemia as one of the dis-
eases considered. Prior to autopsy in such cases I have repeatedly
made positive statements as to what would befoimd by the pathologist
-^statements which I should not be willing to make regarding any
other disease.
Case 135
An Irish housewife of fifty-six entered the hospital July i, 1911.
The patient has always been well until the winter of 1910 and 191 1,
when she noticed that she became easily tired when at work. She
had had no previous illnesses and had an excellent family history.
For the past three months she has had epigastric distress, coming an
hour or two after eating and lasting from two to four hours. It comes
especially after eating potatoes or other heavy vegetables. She never
vomits and has noticed no jaundice or blood in the stools, but het epi-
gastric distress is constantly aggravated.
For the same period she has been losing strength and weight, about
20 pounds in all, she thinks. She has also had a great deal of sweating
and a dull, heavy feeling at the top of her head.
Physical examination shows good nutrition, normal pupils, glands,
and reflexes. Chest negative, save for a soft systolic murmur follow-
ing the first sound at the apex, and not transmitted. The liver dulness
extends from the fourth interspace, mammar>' line, to a point 3 cm.
below the ribs, where a smooth, tender, rounded edge is felt. The
splenic dulness is increased, and the spleen is palpable and very
slightly tender. It extends into the left flank and can be felt bi-
manually (Fig. 119). Urine negative. No fever in two weeks*
observation. Systolic blood-pressure, 120. Fundi normal. Stools
negative. The blood shows reds, 5,000,000; whites, 212,000; hemo-
globin, 100 per cent. The differential count showed polynuclears,
* "Diagnostic Pitfalls Identiticd During a Study of Three Thousand Autopsies,"
R. C. Calxn, Jour. Amer. Moil. Assoc.. December rS. 1012, vol. lix, pp. 2295-2298; "A
Study of Mistaken Diagnoses," R. C. Cabot, Jour. Amer. Med. Assoc., October 15, 1910,
vol. Iv, pp. 1343-1350-
DYSPEPSIA 335
)er cent.; myelocytes, 47 per cent.; eosinophils. 2 per cent.; mast-
cells and basophilic myelocytes, 4 per cent. ; transitional forms, 2 per
cent. Ten normoblasts and one megaloblast seen while counting 500
cells. The red cells show no changes except rarely a little fine stip-
pling. Blood-plates, 572.000.
Discussion. — The cause of this woman's three months' dyspepsia,
with emaciation and sweats, could never have been found without a
general physical examination of the kind that many physicians rarely
niake in an office \'isit, because of the waste of lime involved in getting
rid of corsets and other impediments. The case is typical of many
others in which diagnosis is so easy as to be almost inevitable, provided
we make a general physical examination, but wholly impossible if we
neglect thi'j procedure. As soon as the spleen was felt (and it could
hardly have been missed by anyone who went through with the
routine procedures of abdominal examination) it would naturally
occur to any educated physician to examine the blood, which, in turn,
would lead straight to the diagnosis of myeloid leukemia.
Outcome,— The patient was given x-ray treatment, and showed a
fair degree of improvement during the two weeks of her stay. She
left the hospital on the 15th of July.
336 DIFFERENTIAL DIAGNOSIS
Case 136
An Irish housemaid of thirty-nine entered the hospital August lo,
191 1, after considerable study in the Out-patient Department. For
the past year she has been troubled almost constantly by flatulence
and slight epigastric distress, coming either directly after meals or an
hour or two later, relieved by soda or by hot water, which exp>elled gas.
There has been no vomiting, no nausea, no pain, no loss of weight, and
no weakness. In the Out-patient Department her case was studied by
Dr. F. T. Lord and no evidence of stasis found. The guaiac reaction
was slightly positive in the wash-water before breakfast and no free
HCl was foimd after a test-meal.
For three months her symptoms have been aggravated, and have
consisted chiefly of pain and vomiting. The pain is in the epigas-
trium, extending to the left axilla and back. It is sharp and cutting,
comes within a very few minutes after the taking of any food, liquid
or solid. It is intermittent, the sharp attacks lasting not over five
minutes and being relieved by belching. In the intervals between
these attacks there is a sense of epigastric soreness.
The vomiting which began three months ago has gradually in-
creased in frequency. Now she vomits after almost every meal. The
vomitus is small in amount, white or greenish, never dark or blood
stained, and never containing food eaten the day before. Throughout
the day and night she belches large quantities of gas. The bowels are
no more constipated than they have been all her life. A year ago she
weighed 135 pounds, and until the last three months she thinks there
was no loss of weight. Since then she believes she has lost 25 pounds,
together with much color, and has become very weak. For three
weeks she has been unable to work. Her appetite, formerly very
good, has failed during the last two months, and for five weeks she has
eaten scarcely anything. There has been no jaimdice.
The patient is emaciated and slightly pale, skin very dry. Pupils
and mouth negative. Over the left clavicle are a few small painless
glands. There is marked suppuration at the roots of the teeth, which
are in very poor condition. The chest is negative. The abdomen is
relaxed, and shows just above the umbilicus in the middle line a small
rounded mass, moving slightly with respiration and moderately tender
(Fig. 120). The outlines of the stomach by auscultatory percussion
are shown in the same diagram. The reflexes and pelvic examination
were negative except for moderate chronic thickening in both culde-
sacs. Blood-pressure, no mm. Hg. Blood and urine normal. No
DVSPEPSU 337
fever in four days' observation. The stomach-tube is easily passed
for a distance of 49 cm. Attempts to pass it further are unsuccessful
and cause pain. No fasting contents are obtained. After a test-meal,
which was vomited, the vomitus contains no free HCl. The gastric
capacity was not measured. Well-marked visible peristalsis is ob-
served. The patient continued to vomit frequently during the four
days of her stay in the medical wards, free HCl being always absent in
the vomitus. The diagnoses considered were gastroptosis, gastric
stasis, and cancer of the pylorus and cardia.
Discussion. — Although this patient is only thirty-nine, and al-
though the amount of pain which she has suffered is greater than that
which we usually see in gastric cancer, the fact that she now has a pal-
pable epigastric mass (Fig. 120) and has lost 25 pounds' weight within
three months, must surely make us verj- apprehensive of cancer,
especially with a positive guaiac test and no HCl in the gastric con-
tents on repeated tests. The fact that the stomach-tube would pass
00 farther than 4q cm. from the teeth is evidence that the growth
involves the cardiac oritice of the stomach, but, in all probability,
it is not confined to that region, since we observed peristalsis, appar-
Vot, H— 22
338 DIFFERENTIAL DIAGNOSIS
ently gastric in origin. Such peristalsis usually means pyloric ob-
struction, although in a very thin person it may sometimes be ob-
served with a normal pylorus. Further evidence pointing toward an
obstructed pylorus is the great dryness of the skin.
With pyloric stenosis, water is not passed into the intestine as it
should be, and, as water is not absorbed in the stomach, the ^issues
become abnormally desiccated. This should always be remembered
when we note striking dryness of the skin in a patient complaining of
any gastric symptoms.
A point of notable interest in the case (provided that I am correct
in the diagnosis of gastric cancer) is the preservation of a good appetite
until the last two months before she came under observation.
Outcome. — Bismuth x-ray, August 14th, showed dilatation of the
lower end of the esophagus and obstruction of the cardiac orifice.
On the 1 6th Dr. Scudder opened the abdomen and found a hard
nodular mass along the lesser curvature, most noticeable at the cardiac
end. The pylorus was patent and normal. No liver nodules w^ere
made out. An opening was made in the anterior wall of the stomach,
3 inches above the pylorus, a soft rubber tube was introduced, and the
wound closed around the tube. The patient did very well after opera-
tion until about the first of September, when she began to lose ground
despite the attempt to nourish her through the tube. She was,
accordingly, discharged. Three months later she died at her home.
Case 137
A school-teacher of thirty-two entered the hospital September 23,
iQi I. Her father died of tuberculosis three years ago, and was taken
care of by the patient some months before death. The mother also
dial of tuberculosis last May, and was also taken care of by the
jxitient. One maternal uncle diet! of the same disease. Four brothers
and four sisters are living and well. Patient has been well until four
years ago, when, during a jx^riod of ver>- hard work, she began to have
attacks of **slomach trouble," characterized by epigastric pain,
nuHloralely st^'vert\ not radiating, coming most often before breakfast
anil somewhat roliovtxi by tixxl. The attacks were accompanied by
tlalulonoo. hut not bv vomilini:.
riieso attacks cv^me when she is esf>ecially overtired and last one
or t\vv> wivks. For iho last two years she has noticed a ver>' gradual
k^ss of stroncth. though she has continueii to do her work with occa-
sional "vi,us v^iT.** Purine the last two vears she has had occasional
"hreathK^< sjhIIs,** varying from half an hour to a day in length.
DYSPEPSIA 339
The slightest exertion makes her very weak and short of breath at
these times. These spells have increased in frequency of late. There
has been no edema except from varicose veins and when she has
been standing all day. She has had grumbling pain in the liunbar
region, ascribed to much walking. During the past summer there
have been occasional "fainting spells," in which she prevents a com-
plete loss of consciousness by quickly lying down. During this same
period ^ging and buzzing noises in her ears have also troubled her.
Her bowels are habitually constipated. She has had no cough and no
sputum at any time. She has kept steadily at work until five days ago,
when, without known cause, she began to vomit, and has not since
been able to retain any food.
Her best weight, 132 pounds, was
a year ago, but she thinks she has
lost somewhat since that time.
Physical examination showed
the patient poorly nourished and
looking sick. The face and neck
showed marked brown pigmen-
tation and the skin of the body
was generally dark. Patient in-
^ts that she has always been
"almost as dark as now and that
last spring she was much darker. "
Later she admitted that the
lower part of her body had
definitely, but very gradually,
been growing darker during the
past year. The lower part of
the sternum, where the corset
Chart o( Case 137.
presses, was more deeply pigmented than elsewhere, except in the
axilhe and groms. The pupils slightly irregular, otherwise normal.
There was no pigmentation in the mouth.
The heart's impulse was not seen or felt, but its sounds were best
heard in the fifth space, 9.5 cm. from midstemum. There was no
enlargement on the right. The apex first sound was distinct, re-
duphcated, and accompanied by a faint systolic murmur, not trans-
mitted. There was no accentuation with the pulmonic second. Lungs
and abdomen showed nothing abnormal. Reflexes were normal.
There were moderate varicose veins in the left lower leg. Blood-
pressure was 85 nun. Hg, systolic, 68 mm. Hg. diastolic, and during
340 DIFFERENTIAL DIAGNOSIS
her month's stay m the hospital the systolic pressure ranged close
to 80 (Fig. 121). Blood showed red cells, 4,960,000; white cells,
10,000; hemoglobin, 80 per cent. The stained smear showed slight
achromia. The polynuclear cells, 49 per cent. ; lymphocytes, 49 per
cent.; eosinophils, 2 per cent. The urine averaged 25 oimces in
twenty-four hours; specific gravity, loio to 1012. Trace of albumin
was always present, and in the sediment there were many hyaline
and finely granular casts with cells or fat adherent. At three exam-
inations the feces were in every way negative.
The vomiting was controlled by limiting the nourishment to
liquids in very small amounts, i to 2 teaspoonfuls at a time, given
frequently. Meantime 6 ounces of normal saline solution, contain-
ing 15 per cent, glucose, were injected every six hours by rectum.
Iced champagne in small amounts helped to relieve her. Later,
albumin-water, oatmeal gruel, toast, and minced chicken were added.
She ceased vomiting the day after entrance and gained somewhat
in strength. By October 3d she was eating meat and vegetables,
and was able to sit up with a bed-rest and read a little. Up to the
i6th of October she seemed to be gaining, sat up out of bed, and was
cheerful. On the i6th nausea began again and could not be checked.
By midnight on the i8th she was pulseless and completely exhausted.
At 2 A. M. she went into a stupor and at 7 a. m., October i8th, died.
Discussion. — A family history of tuberculosis, four years' trouble
with dyspepsia, two years' suffering with cardiac attacks, and three
months during which the patient has been subject to fainting spells —
such data lead us to look carefully for any evidence of Addison's
disease, and, despite her statement that her skin has always been
brown, despite the absence of pigmentation in the mouth, we can
hardly fail to interpret the discoloration of the skin and the low blood-
pressure as confirmatory evidence of Addison's disease. This holds
good despite the fact that the brownish areas are more marked where
the corsets bring pressure.
The only question which seems to me deserving of further discus-
sion is this: Has she, in addition to her Addison's disease, any nephri-
tis? The urine has a notably low specific gravity, but this may very
possibly be accounted for by deficiency of solids, especially of pro-
teins, in her nutrition. The number of casts is somewhat greater
than that ordinarily seen in the urine of Addison's disease, and one
might well conjecture that some amyloid disease of the kidney is
present, were it not for the fact that amyloid disease is usually asso-
ciated with those forms of tuberculosis which involve chronic sup-
DYSPEPSIA 341
puration. We have nothing to suggest any such suppuration in this
case.
If the diagnosis is Addison's disease, we have in the family history
a reason for believing that the adrenals are tuberculous.
Outcome. — ^Autopsy No. 2940 showed Addison's disease, but no
nephritis. The cortices of the adrenals were very atrophic, but there
"was no tuberculosis.
Case 138
A housewife of twenty-nine entered the hospital October 18, 191 1,
for the third time. Her first entry was August 10, 1906. At that time
she stated that she had had dull constant pain in the epigastrium for a
year, not aflfected by food and not Uterally constant, and also a similar
pain low down in the back, not affected by menstruation or by pos-
ture. For a week she has had six to ten watery movements a day,
^without blood or tenesmus. Yesterday the pain in her back became
very severe, and was compared, by her, to the pains of childbirth.
Morphin was given subcutaneously. Since yesterday there has been
no movement of the bowels.
Physical examination showed normal pupils and gums, normal
chest and abdomen, normal reflexes. No tenderness along the spine
or over the sacro-iliac joints. Hip movements and back movements
free and painless. Uterus was sUghtly antiflexed, but freely movable
and of normal size. There was tenderness and thickening in the
region of the left broad ligament. Blood and urine negative; no fever.
Patient seemed so slightly sick that she was allowed to go home in four
days.
Her next entry was April 18, 191 1, when she said that she had
felt pretty well imtil a year previously, when she began to have an in-
termittent blood-tinged vaginal discharge, lasting during Jime, July,
and August, 1910, and accompanied by epigastric pain. The latter
has persisted ever since. Catamenia began April 17th, a week before
time^ Previously to that time it had not been abnormal.
Three months ago she began to notice a sense of pressure in the
epigastrium, producing eructations of gas and regurgitations of fluid
after meals. Soon after that she noticed a pain in the small of the
back, especially when lying down, and subsequently frequent and
scanty though not painful urination, occurring by night two or three
times and more often in the daytime. Two weeks ago she became
conscious of a mass in her abdomen which feels to her different from
the enlargement present when she has been pregnant.
342 DIFFERENTIAL DIAGNOSIS
Physical examination showed a mass the size of a very large grape-
fruit, extending from the pelvis to a point 2 inches above the navel,
broader below than above, and extending into the right lower quadrant
farther than to the left. It was freely movable from side to side, felt
firm and not fluctuant, but also not nodular. Bimanually the uterus
was felt in front of and below the tumor mass, with which it seemed
only slightly connected. Pressure upon the tumor was not trans-
mitted to the cervix, but pressure upon the fundus uteri was trans-
mitted to the cervix. April 2 2d the abdomen was opened and a
single solid fibroma of the right ovary, the size of a grape-fruit and
weighing 2000 grams, was removed. Microscopically, it consisted of
edematous fibrous tissue, with occasional small cysts in the midst of it.
The appendix was normal, but was removed on general principles.
The uterus was suspended from the abdominal wall.
After operation the patient did very well, and was discharged May
8th. October i8th, of the same year, she entered once more, and this
time it was learned she had been treated in the Out-patient Depart-
ment since October, 1904, complaining chiefly of pain in the back and
constipation. A diagnosis of chronic bronchitis and also of obesity was
made at that time.
After leaving the hospital in June, 191 1, she remained well for
about three weeks and weighed 140 pounds. Then she began to
vomit more and more frequently, and went to the Baptist Hospital
about July ist, where Dr. M. H. Richardson removed a large left
ovarian cyst. She stayed in the hospital until August ist and vomited
occasionally throughout this period. Since discharge she has vomited
once or twice every dav, usually after meals in the latter part of the
day, but she sometimes is awakened in the night by vomiting. She
has ejected large amounts — a gallon, she says — at one time, always
green and slimy, but without blood. Vomiting bears no relation
to the kind of food taken. She has no severe pain and no jaundice,
but some irregular cramp-like discomfort in the lower abdomen. Her
appetite is very poor and she says she has lost 56 poimds. Her pres-
ent weight, without clothes, is 102 pounds. At the Baptist she
weighed 134 pounds.
Physical examination showed moderate emaciation, marked
tympany in the epigastrium, a sense of resistance in the right lower
quadrant, antl a s;iusage-shaixxl, probably fecal, tumor in that region.
The firm shar{> eilge of the liver was felt at the costal margin, and an
irregular, rounded, t'lrm, insensitive mass was also felt across the epi-
gastrium, under the costal margin. This mass descended with respira-
DYSPEPSIA 343
tioQ. but the examiner was in doubt whether it was continuous with
the Uvcr, and surmised that it might be of fecal origin. Except as
above, external examination was negative. In the fasting stomach
a large amount of dark-brown fluid was present, probably 200 c.c. or
more. Microscopically, it contained many sarcinar, yeast cells, and
epithelial cells. The reaction to HCl was strong; that to guaiac, nega-
tive. A test-meal was vomited at the end of fifteen minues. Second
test-meal, removed at the end of an hour, showed free HCl 0.039 P^r
cent.; total acidity, 0.135 P^^ cent. No guaiac. The capacity of the
stomach was 1560 ex.; it was almost impossible to wash the organ
, — Gastric outlines in Case i.tS,
clean. On inflation the outline was as in Fig. 122. The mass de-
scribed in the epigastrium disappeared after the first examination
and was not found again. Vaginal examination was negative, iike-
I wise the blood and urine. Systolic blood-pressure 105; no fever. No
f guaiac reaction in the stools on three tests. October 2 2d peristalsis
5 seen in the region of the stomach, especially in attacks of pain
I and distress. She vomited large amounts of partially digested food
[each evening, fifteen minutes to one hour after supper.
Bismuth i-ray examination showed a typical picture of dilated
V^Stomadi, with practically complete obstructions at the pylorus and
344 DIFFERENTIAL DIAGNOSIS
absence of peristalsis. When standing up the patient's stomach was
low and far to the right. The cause of this obstruction was not dear,
but the record states that ptosis and adhesions were considered the
most probable cause.
Discussion. — Summing up this rather prolonged case, one may say
that a woman of twenty-nine, complaining of a year's d)rspepsia
and of a recent diarrhea, with very severe lumbar pain, is first treated
in 1906 for a few days, and recovers so speedily that no definite diag-
nosis is possible.
Five years later she notices intermittent metrorrhagia and
return of the dyspepsia, which in the meantime has been in abeyance
although she has had some constipation and lumbar pain and bee
treated for obesity. She is operated on in 191 1 for fibroid of the righ
ovary and soon after undergoes a second operation for a cyst of th<
left ovary. After this second operation she becomes rapidly emaci —
ated, losing apparently 56 pounds within six months. At the end ok:
that time a mass is found in the epigastrium, associated with gastri
stasis, visible peristalsis, and x-rsiy evidence of pyloric obstruction
All this evidence, despite the fact that the epigastric mass soon dis-
appeared, would lead us to conjecture that the patient now h
gastric cancer. Whether or not this growth has any connection wi
her previous ovarian tumors I have no means of judging.
Outcome. — October 24th she was operated upon the third time
and a hard tumor found at the pylorus, extending down upon thi
duodenum about i inch and also in scattering areas over the anterior:
surface of the stomach. Hard glands were found along the lessees
curvature as high as the pyloric vessels and behind the stomach
The liver was apparently not diseased. Posterior gastro-enterostom
was done, and she was allowed to go home November 14th, after hav-
ing an uneventful convalescence.
Remarks. — The case is worth remembering as a proof that gastri
cancer may occur at twenty-nine.
Case 139
A housewife of thirty-six entered the hospital November 16, 191 1 —
For the past two months she has had indigestion, characterized by ^^
heavy ache and distressed feeling with a sense of pressure in the epl —
gastrium, one to three hours after meals. Never any sharp pain.-
Distress lasts one to two hours, and is relieved by lying down, but not.
by medication. Occasionally vomits in these attacks, vomitus being*
sour and containing food eaten the same day. At first she was re-
DYSPEPSIA 345
lieved by vomiting, but at present is not. Bowels have always been
constipated, but are specially so of late. She has had no jaundice,
no headache, or edema. She has gradually eliminated everything
from her diet except milk and lime-water. A year ago her weight
was 125 pounds; now, 100 pounds.
Physical examination shows poor nutrition, negative chest.
Systolic blood-pressure, no; abdomen rigid, tympanic, not tender.
Reflexes normal. Before breakfast stomach contained about 20 c.c.
of brownish turbid fluid, with a slight reaction to guaiac, and 0.04
per cent. HCl, but no evidence of food. After a test-meal the con-
tents showed HCl 0.05 per cent. The blood and urine were normal.
Discussion. — Here we have the familiar picture of a person who,
with the best intentions, has been starving herself to death by gradu-
ally eliminating from her diet one food after another which seem to her
the cause of her discomforts.
The chief point of interest in the case is that merely by starving
herself she has brought her dyspepsia to such a point that it is now
associated with gastric stasis, doubtless of the atonic type. Such a
stasis need cause no apprehension, and should never be considered a
ground for operative interference.
A great many such cases are allowed to run on into chronic in-
validism because the medical attendant has not the courage or the
personal force to compel his patient to eat despite her own certainty
that she cannot do so, and despite the very real discomforts which
follow all attempts to take the foods which have previously troubled
her. To such patients I frequently quote a saying of a lady whose
force of character should be more widely admired and emulated, "I
am not going to be bullied by my stomach. When a thing disagrees
with me, I eat it again.'*
Outcome. — She remained in the hospital until December 4th, and
it became evident that she was thoroughly tired out. She steadily
improved under rest and an occasional dose of sodium bicarbonate
and cascara, with mild tonic baths. Stools always negative to guaiac.
She gained 4 pounds in seventeen days.
Remarks. — Cxenuine fatigue (which must be clearly distinguished
from the nervous sensations of fatigue often seen in persons who
have undergone no physical or mental strain and have done no phys-
ical or mental work for many months) is not infrequently a source of
very persistent gastric and cardiac weakness. Prolonged rest of
mind and body will accomplish, in such cases, the beneficial results
for which we look in vain in neurotic cases subjected to a rest cure.
346 DIFFERENTIAL DIAGNOSIS
Case 140
A maid of forty-eight entered the hospital November 25, 1911.
Family history negative. Five years ago she was taken with sudden
severe pain in the epigastrium, coming immediately after a luncheon
and lasting three or four hours. It did not radiate and was finally
relieved by powders, the nature of which she does not know. In this
attack she vomited food just eaten, but no blood.
Eight months ago she had an exactly similar attack every day
for a week, and in this attack she was jaundiced. Pain usually re-
lieved by hot drinks and by "something injected into her arm."
After this she was free from trouble until her present attack.
For the last month she has had almost daily attacks of indigestion,
characterized by gastric distress and a gnawing sensation immedi-
ately after meals, lasting one-half to one hour and not amounting to
actual pain. Twice she has vomited sour material. There has been
no jaundice. Four days ago she had a severe attack of pain in the
epigastrium immediately after lunch. The pain lasted until fi^'e
O'clock the next morning and was ver\- severe. She took no medicine
for it and vomited repeatedly.
Two days ago she was comfortable, but yesterday had moderately
severe pain, coming on just after she had taken her soup for dinner,
lasting six hours, and relieved by ''mineral water." Xo vomiting this
time, but the patient felt feverish. For the last four days she has
eaten nothing but malted milk, oatmeal gruel, and cocoa. Through-
out her last attack her bowels were ver\- contipated and her urine
dark. Her best weight, eight months ago. 162 pounds; now. 150
pounds.
For four vears she has noticed a bunch in the lower abdomen.
Never painful or inconvenient in any way. It has remained of
the same size. Her menstruation often lasts between one and two
weeks.
Physical examination shows a slight yellowish tint to the skin
and possibly a slight yellowish discoloration of the sclerae. The
pupils are slightly irregular in outline, but otherwise normal. The
gums normal. Chest negative.
In the abdomen an uneven nodular tumor is fell above the pubes,
in the area shown in Fig. 1 23. It is not tender, but extends down well
into the pehis, where it seems to be connected with the uterus. It
can also be felt by rectum. Reflexes and other features of ph\*sical
examination are negative. Bkxxl-pressure. 115. Urine and blood
DYSPEPSIA 347
negative, except for a slight poiynuclear leukocytosis. No fever
during ten days' observation.
Discussion. — A bunch noticed for four years in the lower ab-
domen is generally a fibroid tumor of the uterus or an ovarian cyst,
but we have no good reason to suppose that this patient's dyspepsia
of the past eight months has necessarily any connection with the
long-standing hypogastric mass.
The nature of the present dyspeptic troubles becomes much
clearer when the jaundice is found on physical examination. This
felt in Casf i*o.
jaundice, taken in connection with the attacks of pain described in the
history and relieved apparently by an injection of morphin, makes us
pretty confident that we are dealing with an obstruction in the biliarj-
tract. Such an obstruction is most often due to gall-stones, and this
may be assumed to be the case in this patient, although cancer and
other causes of obstruction cannot be positively excluded without
operation. Such an operation should be ad\ised without qualification.
Outcome. — December 6th the abdomen was opened. No stones
found in the gall-bladder or ducts. There were firm adhesions from
the fundus of the gall-bladder along the whole length of the cystic
348 DIFFERENTIAL DIAGNOSIS
and cominon ducts, attaching them to the transverse mesocolon.
Wlien these were detached it appeared that they had constricted the
fundus of the gaU-bladder.
A large fibroid tumor adherent to the omentum and the intestines
was seen, but not disturbed. The patient made a good recovery and
went home December 23d. November 3, 1912, she wrote, "I have
gained steadily and am now in good health.''
Remarks.— It is to be noticed that the surgeon, by a remarkable
act of self-restraint, abstained from remo\Tng the fibroid timior.
Such an example is to be emulated.
Case 141
A house^sTfe of thirty-two entered the hospital December 14, 1911,
stating that since the first week in October she had been treated for
''nervous dyspepsia/' October 24th she ate steamed clams, and next
day was seized with vomiting and diarrhea; also had three con\adsioiis
within twenty-four hours, each lasting three or four minutes, the
patient becoming cyanotic during them, but recovering consciousness
immediatelv. Her diarrhea soon ceased and she had no more con-
NOilsions, but for the next week the vomiting continued and was so
obstinate that she was put on rectal feeding. The vomiting alwaj'S
came from two to twenty minutes after eating, consisting of sour,
waterj' material in large amounts. Food rarely seen, blood never.
For the next week follo\^ing that just described she retained food
by mouth, then the vomiting recurred and has continued ever since.
There is constant nausea and epigastric distress, but no pain. All
sorts of medicines and foods have been given without relief, although
her sjTnptoms can be temporarily checked by suppositories of codein.
She has lost 15 pounds in weight. Her appetite is alwa\"s good.
Although the con\-ulsions above described are something entirely
new for her. she remembers having had. seven years ago, a ''dizzy
q)eU,'' which kept her in bed all day, and was accomjxmied by numb-
ness of the tongue, mouth, and left arm. The dizziness has recurred
twice lately, ''but since the doctor took blood from her arm there
has been no numbness in it."
The pupils are irregular, the left larger than the right. Both
react well to distance, but not to light. There is a slight general
glandular enlargement. Chest and abdomen negative. Slight left
dorsal scoliosis. The right knee-jerk was present, the left not ob-
tained; there was no swa\ing when she stood with the eyes closed
and the feet together. Stomach-tube, jxassed before breakfast.
DYSPEPSIA 349
showed no food and no blood. Capacity of the organ, looo c.c.
Contents of the fasting stomach showed free HCl 0.31 per cent.
After a test-meal, free HCl 0.35 per cent.; total acidity, 0.41 per cent.
No reaction to guaiac. Blood and urine normal. No fever in two
weeks' observation, during which time she gained 4 pounds. The
Wassermann reaction of the blood was negative; in the spinal fluid,
December 19th, strongly positive. The fundus oculi was normal.
During the first four days in the ward she continued to be nau-
seated, the nausea bearing no relation to food, and being relieved by
vomiting about once in eight hours. Atropin, -^^^ grain, three times
a day on December 17th, twice daily from the i8th to the 26th,
seemed to control the vomiting better than any other drug. By the
23d she was eating well. While taking atropin she had night-sweats.
Following the omission of this drug they ceased.
Discussion. — This is a fairly typical case of gastric manifestations
in tabes dorsaUs. The condition of the pupils, knee-jerks, and glands
should have made clear the nature of her trouble, especially as she
had previously had a convulsion and some symptoms suggesting a
focal brain lesion. The positive Wassermann reaction in the spinal
fluid put the case beyond any doubt, yet I have known patients pre-
senting symptoms just as clearly tabetic as those just described who
were, nevertheless, operated upon because a routine examination of the
nervous system has not yet become part of the medical technic of the
average surgeon. Failure to recognize tabes dorsaUs is excusable
when the pupils and knee-jerks are normal, but not in a case like
this.
Outcome. — It was subsequently learned that her pupils had failed
to react alike at any time in the last eight years. That one year ago
she had sharp stabbing pains in her knees, lasting a few days and
accompanied by marked hyperesthesia. She has been married for
three years, has had no children, and no miscarriages. January i,
191 2, she left the hospital in good condition.
CHAPTER V
HEMATEMESIS
There are but two common causes of hematemesis, by whichi^^ ^
mean the vomiting of pure blood in considerable quantity, an our -ai^ <e
or more. Those causes are peptic ulcer and cirrhosis of the lit. "^
When an alcoholic vomits blood, it is often impossible to de<
whether the hematemesis is due to cirrhosis or to congestion of
stomach itself, but this distinction is not of great practical important
At the end of any period of violent retching, however produc-
a small amount of blood may be ejected without there being
organic disease responsible for it.
A third, but much less common, cause for hematemesis is tfczm_^t
vaguely defined condition known as splenic anemia, and the la^ '^^ <t
sequel of the same malady called BaniVs disease.
Gastric cancer is rarely associated w^ith the vomiting of p*"
blood in considerable amounts. The ulcerated surface of the can.
oozes continually, and the blood thus discharged is digested intcz^ a
material resembling coffee-grounds. This may be ejected when "tlfce
patient vomits. It must be remembered, however, that a vomit-i^ag
of brownish fluid indistinguishable from that of gastric cancer" is
frequently seen after surgical operations upon the abdomen. It Im^
no special significance, and, although it occurs in general and '^^
local peritonitis, it is not at all peculiar to these conditions.
The differential diagnosis of the causes of hematemesis i^r^'^
largely upon a good history of the case. Digestive disturbances ^^
the type characteristic of ulcer are usually distinguished with<:>'«J^
much difficulty from those secondary to cirrhosis of the liver. I-^
ulcer the physical examination is usually negative. In cirrhosis '^^^^
may be able to make out changes in the liver or portal stasis. I^
splenic anemia the spleen is usually so much enlarged that anyone ^^b^
knows enough to feel for it will recognize it.
Case 142
A plasterer of fifty-two entered the hospital June 27, 1904. A^"
cording to the patient's account he has never been sick until within
the past month, when he began to have dull, steady pain in the epigB^
350
Hematemesis
AFTER VIOLENT RETCHING (FROM ANY CAUSE)
PEPTIC ULCER
}
GASTRIC CANCER
CIRRHOSIS OF THE
LIVER
UNKNOWN CAUSE
SPLENIC ANEMIA
ALCOHOLIC GASTRITIS
261
233
135
88
22
8
351
352 DIFFERENTIAL DIAGNOSIS
trium, not increased by food and not relieved by pressure. Yesterday,
while in the elevated train, he suddenly vomited much dark-brown
fluid. This was repeated several hours later, and this time the
vomitus contained blood. Since then he has felt weak.
During the past month he has lost some weight, but previous to
that time he positively denies any stomach trouble. His appetite is
fair, bowels regular, sleeps good. He takes no alcohol.
Physical examination shows good nutrition. The heart's apex,
of a heaving quality, is felt in the sixth space, i^ inches outside the
nipple. There was no increase of dulness to the right. Its action is
markedly irregular. There is a presystolic thrill and a presystolic
murmur at the apex, transmitted to the axilla and back. At the
third left costal cartilage there is a blowing systolic murmur. The
pulmonic second sound is greater than the aortic second. The right
pulse is larger than the left, artery walls easily palpable. The ab-
domen is somewhat retracted and rigid, but shows no masses or ten-
derness. Visceral examination is otherwise negative, as is the urine.
The blood shows red cells, 1,728,000; white, 11,600; hemoglobin, 55
per cent.
On the morning of the 28th he had a copious gastric hemorrhage,
about a quart in all. At 10 a. m. 6 ounces more were ejected. The
blood-smear showed marked achromia, considerable deformities, some
stippling, no blasts; differential count negative.
Discussion. — When a man of fifty-two vomits blood without any
previous gastric symptoms, cirrhosis of the liver is the most probable
cause. In this case there have been gastric symptoms, although
moderate in degree and lasting only a month. There has been no
alcoholic history, no splenic enlargement, or previous anemia. The
amount of blood vomited is large and the resulting anemia extreme.
With this picture, peptic ulcer of the stomach or duodenum is the most
probable diagnosis, however little the physical examination may show.
Gastric cancer may cause a similar hemorrhage, but this is very rare.
We have also the evidence of mitral stenosis, with a markedly
enlarged heart, such as many clinicians are in the habit of supposing
to be incompatible with mitral stenosis. I see, however, no consider-
able reason to doubt that the mitral valve is contracted. Has this
any relation to the vomiting of blood? I see no reason to believe so.
Blood coming from the lungs, as a result of pulmonary infarct in
mitral stenosis, may be swallowed and then vomited, but not in any
such amount as is here described and not without previous symp-
toms of pulmpnary congestion.
HEllATEMESIS 353
The case illustrates one of the extraordinary varieties in the clinical
picture of peptic ulcer, a disease which may produce symptoms lasting
over twenty years or may produce no symptoms at all, and may be
foimd at autopsy in a patient who dies of something else. Perfora-
tion and general peritonitis may be the first hint that any such disease
exists, or, as in the present case, after a brief and mild dyspepsia we
may have a large gastric hemorrhage.
I have no idea why the right pulse is larger than the left in this
case. Such difference is of significance only when it is linked up with
other signs pointing to an aortic aneurysm. As an isolated fact, it is
fairly common in health and in a variety of diseases. So far as I
know, it has no significance.
Outcome. — ^About 4 p. m. on the 28th the pulse became very poor,
and during that night he vomited 8 oimces more of blood and died on
the 29th. Autopsy showed ulcer of the stomach; erosion of a branch
of a gastric artery; mitral stenosis; arteriosclerosis; hypertrophy and
dilatation of the heart; obsolete tuberculosis of the left limg and of a
bronchial lymph-gland.
Case 143
A housewife of thirty-five entered the hospital March 24, 1908.
The patient has lost one brother by phthisis, otherwise her family
history is excellent. Three years ago she was in St. Elizabeth's
Hospital for ten weeks with stomach trouble. While there the uterus
was cureted. Five years ago she weighed 144 pounds; now, no
pounds.
In the intervening five years she has had attacks of vomiting at
intervals not exceeding two weeks at a time. At first they came before
the menstrual period; later, at other times. The vomitus contains
food of the previous meals and some watery material. Pain in the
epigastrium comes soon after eating. It is relieved by vomiting.
Three years ago she vomited two cupfuls of dark blood. This was at
the time she was in St. Elizabeth's Hospital. She was put on a milk
diet. In November, 1907, five months ago, she again vomited
blood, and this time had black stools and was in bed a week. She
lias never vomited blood again so far as she knows, but has continued
to have epigastric pain and tenderness after eating. The last attack
of vomiting was on March 15th. Appetite is poor, bowels costive;
no other symptoms.
Physical examination showed fair nutrition, slight pallor, normal
p^ils, gkjids, and reflexes. The chest was negative, save for a soft,
Voi^ 11—23
354 DIFFERENTIAL DIAGNOSIS
systolic murmur, limited to the region of the cardiac apex. The
abdomen was negative. • Examination of the stomach with a tube
showed no evidence of enlargement; negative guaiac test, free HCl,
0.14 per cent.; total acidity, 0.25 per cent. The stools were negative
to guaiac at entrance. Upon a diet of eggs and milk the patient did
fairly well. The gastric distress markedly diminished and there
was no more blood, either by stomach or rectum. May 2d she left
the hospital to continue her treatment at home.
August 3, 1908, she entered the second time, stating that two
weeks after she left the hospital she had another attack of vomiting,
and then was quite well until July 17th, when she had another attack
at the time of her menstruation, lasting three days. The vomitus
was dark brown in color, accompanied by epigastric pain.
This time the patient was well nourished, and showed no abnor-
mality except for the red cells, which were now 3,050,000; white,
13,4000; hemoglobin, 45 percent. Differential count showed 82 per
cent, polynuclear cells, and in the stained smear there were two nor-
moblasts, some deformities, and achromia of the red cells. The urine
was negative. The entrance diagnosis at this time was gastric ulcer,
but the morning after entrance a small, hard mass was felt in the
epigastrium, just to the left of the median line. There was no food
residue in the fasting stomach. On inflation its outlines were normal
and the mass could not be felt. Guaiac test was positive in the con-
tents after a test-meal; HCl 0.84 per cent. Stools negative to
guaiac.
Discussion. — The patient has had vomiting spells, lasting two
weeks or less, for the past five years and has lost 34 pounds in that
period. The first hematemcsis was three years ago; the second, five
months ago. Presumably the association with the menstrual period,
at the time of the first hematemesis, was a coincidence. Unlike most
patients with gastric ulcer, she had a poor appetite. Nevertheless,
the total impressions of her illness during her first stay in the hospital
is that of a peptic ulcer. She improved as such cases do, and the
condition of her stomach contents was fairly typical of that disease,
although the guaiac test was negative.
When she entered the hospital the second time, with a well-marked
anemia and a palpable mass in the epigastrium, the question at once
arose, Is this lump a perigastric exudate representing a local peritoni-
tis about the site of an ulcer? Such an exudate may fed as haid at
any cancer. Against ulcer, however, is the fr*^
any recurrence of the hematemesis. It is '
HEMATEMESIS 355
•hat there may have been bleeding without the patient's knowledge
^d without vomiting. On the whole, the evidence for ulcer and that
for cancer is ver>- evenly balanced, and it is difficult to make a choice.
Tie rarity of perigastric exudates producing epigastric tumor inclines
'"e, on the whole, toward the diagnosis of cancer.
Outcome. — On the 14th of August the hemoglobin had risen to
Jo per cent, and the abdomen was opened. The posterior wall of the
siomach contained a tirm, hard mass, the size of an almond, with
24.~-Keloid-1ike masses in old tinea alhicantes (Case 143).
"^^ating branches extending t
the whole posterior side of the
sloina,^^ especially at the pyloric end. The omentum was filled with
^"^^U> hard nodules. An anterior gastro-enterostomy was done,
after which the patient did well and left the hospital on the 17th of
^^Ptember. On the i8th of January. 1909, she came back again,
slating that since the first of October, iqo8, she has had a sense of
P Assure on the bladder with frequent micturition. This was soon
^ lowed by enlargement of the abdomen, which has gone on up to the
356 DIFFERENTIAL DIAGNOSIS
present time. The stomach, on the whole, has done very weU, except
for occasional attacks of nausea or vomiting. Hemoglobin at this
time was 75 per cent. Urine negative. The linese albicantes below
the navel have developed into branching ridges which suggest keloid
(Fig. 124).
The lower half of the abdomen is occupied by an irregular, hard,
insensitive mass, the size of a football, reaching as high as the navel
and extending into the iliac fossae, with slight depression in the median
line. There are no sounds over it on auscultation. No blueness
of the vulva. Vaginal examination shows just behind the pubes a
mass, which is interpreted as the fundus of the uterus. Pressure
over the abdominal tumor causes movement on the part of the cervix.
On the 25 th the abdomen was opened again and found to contain
several quarts of fluid and two tumors, each the size of a large grape-
fruit, nodular, grayish-white in color, and apparentiy arising from
the ovaries. These were removed and showed the microscopic struc-
ture of fibroma, with small cyst-like cavities. The patient left the
hospital on the 23d of February in good condition, but died at the
Vincent Hospital Jime 11, 1909. After May 20th she was kept imder
opiates.
Remarks. — The mass felt in the lower abdomen in January, 1909,
was at first interpreted as a metastasis from the stomach. Later
the question of pregnancy arose, as the tumor seemed obviously
connected with the cervix uteri. The final interpretation given to
this mass was that it represented a uterine fibroid. No one suspected
ovarian tumor.
The condition of the abdominal wall is fairly well suggested in the
accompanying photograph (Fig. 124). Those curious scars, ordinarily
known as linecB albicantes, had, in this case, become hypertrophied like
keloid and then edematous and at times inflamed. They stood up
from the surrounding tissues J inch or more, and were as thick as a
finger.
Familiar as are linecB albicantes upon the abdomen of women
who have borne children, I do not think their nature is yet well
understood. One sees them not only in this situation, but over the
deltoids, along the lower ribs in the axillae, and in many other parts of
the body, under conditions which makes their occurrence distincdy
mysterious. They seem to have something to do with loss of weight,
yet in the abdomen we have usually explained them as a result of
stretching of the skin and splitting of its superficial layers. This
explanation, however, will not hold, when one sees them about the
HEMATEMESIS 357
shoulders and back during the convalescence of a case of scarlet
fever or after other infectious diseases. Under such conditions there
can have been no stretching of the skin, as neither emaciation, obesity,
nor other cause for pressure and stretching has been present.
It is not always realized that these lines, which in their later
stages are white, are in their earlier stages bright red and suggest
inflammation or, at least, hyperemia. As far as I know, they have no
useful lessons to teach us, so far as diagnosis is concerned, but it is
important to be familiar with the variety of appearance which they
may present, otherwise one may be unduly puzzled when discovering
them in a case which seems in other respects clear.
Case 144
An imoccupied man of thirty-six entered the hospital January 29,
1909, with a diagnosis of **gastric ulcer." One month ago he began to
vomit immediately after eating. Ice-cream and raw oysters were the
only foods that he could take. For the past two weeks he has vomited
blood, dark and clotted, as much as a cupful at a time, both after eat-
ing and between meals. The blood is sometimes clear, sometimes
mixed with food.
Physical examination showed loss of weight, marked pallor, normal
pupils, glands, and reflexes. Chest negative, save for a soft systolic
souflie at the apex, not transmitted. In the epigastrium and right upper
quadrant there was tenderness and muscular spasm; otherwise physical
examination was negative. Red cells, 800,000; white cells, 21,000;
hemoglobin, 20 per cent. Differential count normal. The stained
smear showed marked achromia, slight deformities of the cells; other-
wise normal. Urine normal. He was given at entrance horse serum,
20 c.c, subcutaneously. By the 5th of February the red cells had
risen to 2,400,000, the hemoglobin to 40 per cent. On gastric ulcer
diet he had had no bleeding.
By the loth of February he could eat a full diet without any
trouble, and the diagnosis of gastric ulcer would undoubtedly have
been made but for the following additional facts, which were added to
the history at this time. He first entered the hospital September 21,
1899, when it was learned that there was a good deal of mental defi-
ciency on the mother's side of the house. Some of her family were
"queer and silly." The boy had convulsions for five days after his
birth. He was born jaundiced. This lasted two weeks. He was,
nevertheless, a healthy baby, and had no more convulsions until
he was five. Ever since then he has had them frequently, sometimes
358 DIFFERENTIAL DIAGNOSIS
twice a week, sometimes skipping several weeks. They are preceded
by a typical aura and cry. The head always turns to the right, and
he bites his tongue unless his jaws are kept separated. After two or
three nunutes he awakes from his coma with severe headache. Under
treatment he once went two years without convulsions, but when
medicine was stopped the convulsions returned. He often has spells
of what he calls "smothering," when his lips get blue and he cannot
speak for a minute or two.
He has always been subject to bleeding on slight provocati(Hi since
he was six years old, when he cut his face, and the bleeding lasted five
weeks; it was finally stopped by cautery. In 1895 two teeth were
pulled to stop his biting his tongue and the bleeding lasted four
weeks. Four years ago he had "some bones taken out of his chest,"
and he raised a great deal of blood at that time. On one occasion a
puncture of the ear, made for blood examination, bled for three days.
Eight years ago, July 30, 1901,
he was recommended to the sur-
gical wards mth a question of
renal stone or tuberculosis, be-
cause for a week his urine had
contained much blood. He had
also had much pain and burning
sensation in the back and in the
genitals; also pain in the peri-
neum when sitting He had an
epileptic fit in the ward, and was
soon discharged to the medical
service. The urine then con-
tained a large amount of blood,
but was not otherwise remark-
able. 150 c.c. of 2 per cent.
gelatin, in sterile salt solution,
were injected on the 3d of August
and followed by a rise of tem-
perature, as shown in Fig. 125. There was considerable pain and
tenderness at the site of injection, which was repeated on the 6th
and on the loth. On the 5th of August he had considerable ab-
dominal pain and passed bloody stools.
He had several convulsions during this stay in the ward, but his
urine became free from blood on the 12th of August and remained so.
In the absence of any other special symptoms he was discharged on
5. — Chart of Case 144.
HEMATEMESIS 359
the 2 1 St, and was not seen again until his entrance ten years later
in 1909, as described above.
The patient left the hospital on the nth of January, 1909, and
re-entered on the 25th of February, stating that five days pre-
viously hematemesis recurred and has been frequent ever since.
Two days ago, after a violent epileptic attack, he complained of
occq)itaI headache, with coldness and chilliness of the left arm.
He has slept but little, he says, for some weeks, and has had
much heartburn. At entrance he was very restless, asking for hot
whisky and mother. His head is described by the house oflScer
as faim-like, with pointed ears, narrow forehead, eyes small and
dose together. No history of bleeding by any of his ancestors was
obtained.
Physical examination was, as before, practically negative. Red
cells, 1,056,000; white, 9200; hemoglobin, 20 per cent.; polynuclear
cells, 79 per cent. The red cells showed marked deformities in size
and shape; no other abnormality. The patient continued to vomit
blood in spite of morphin and horse serum. His pulse grew steadily
weaker, and he died on the 26th of February, without any other symp-
toms.
Discussion. — ^We had no doubt of the diagnosis of peptic ulcer
when we made our earliest record of this patient's case. Later,
when we learned that he had been a bleeder, we naturally shifted our
diagnosis and considered the gastric bleeding as part of the hemo-
philiac diathesis. It appeared that he had had hemorrhage from the
lungs, bowel, and kidney, as well as subcutaneously.
His convulsions were attributed to epilepsy, and we supposed them
to be without any connection with his other symptoms. His un-
satisfactory inheritance made the epilepsy easily explicable.
Outcome. — ^Autopsy showed chronic interstitial hepatitis with focal
necrosis; hyperplasia of the spleen; fatty degeneration of the myo-
cardium; chrom'c pericarditis; hypertrophy and dilatation of the
heart; obsolete tuberculosis of a bronchial Ijmiphatic gland; chronic
pleuritis; internal hydrocephalus of the left cerebral hemisphere, with
marked atrophy of the surrounding convolutions.
Remarks. — ^After the autopsy we were not quite certain how
far our previous diagnosis of hemophilia was a mistake. Gastric
bleeding in a patient with interstitial hepatitis is naturally attributable
to the latter disease. Nevertheless, this patient had had blood in his
urine and from other sites not to be connected with any disease of
the liver. Since no definite point of hemorrhage was noted in the
360 DIFPERENTIAL DIAGNOSIS
autopsy record, there is no proof, so far as I see, that his cirrhosis was
the cause of his bleeding from the stomach. Such connection, how-
ever, cannot be excluded.
It is quite possible that his hepatitis may have been syphilitic,
although no Wassermann reaction was done.
The diagnosis of epilepsy was certainly wrong, as one can only
use that term to denote cases in which no organic lesions exist. As
to the origin of his hydrocephalus, I have nothing to suggest.
Case 145
A druggist of fifty-four entered the hospital January 20, 19 10.
The patient's father died of cancer of the face at sixty-one; otherwise
his family history is good, and he has always been well. For years
he took ten to fifteen glasses of beer or whisky daily, now four or five
whiskies daily. On this diet he has seemed to thrive.
Yesterday at 7 a. m., after a coughing spell, he began to raise
blood, at first in 2-ounce quantities. At 2 p. m. he vomited i pint,
at 6 p. M. ^ pint more, and soon after this he passed two dark and
tarry stools. At 3 a. m. to-day he vomited ^ pint more, and at noon
to-day again ^ pint and had two more tarr>' movements. In all, he
thinks he has raised i quart and 18 ounces.
Physical examination shows obesity, pallor, normal pupils, glands,
and reflexes. The heart's apex is i cm. outside the nipple line.
Slight systolic murmur along the left sternal border. Systolic
blood-pressure, 125. The right pulse is greater than the left, both
slightly irregular. The Uver dulness extends from the sixth rib,
mammary line, to a point 6 cm. below the ribs, where a rounded edge
is felt.
Discussion. — Such a hemorrhage occurring, as we say, out of a
clear sky, in an alcoholic, with a palpable liver, can scarcely be at-
tributed to a cause other than interstitial hepatitis. We have no
reason to be surprised that the patient has no portal stasis, that is,
none of the ordinary evidences of that condition. Whether the
hemorrhage is due to passive congestion of the gastric mucosa or
to dilatation of the peri-esophageal plexus of veins, we cannot say.
The latter is the more common.
Outcome. — On the evening of the 2 2d he suddenly became de-
lirious and tried to get out of bed, complaining of feeling queer.
His pulse soon became slow, weak, respirations labored, and the pic-
ture, save for the pulse, was one of internal hemorrhage. In two
hours he died.
HEMATEMESIS 361
Remarks. — Such a hemorrhage is rarely fatal. As a rule, the
patient lives on for months, often for many years, and may die of
some other disease.
Case 146
An Irish cook of twenty-two entered the hospital June i8, 1910.
The patient has a good family history and past history, but has al-
ways had much pain at menstruation, especially during the last year,
when the period has been accompanied by nausea and vomiting for
one or two days. Of late she vomits first food, then bile, and finally
dark clots of blood at the end of half an hour of steady retching.
She is much exhausted by these attacks and sweats profusely. Be-
tween periods she has no symptoms, and can eat anything without
distress. She has no loss of weight, good appetite, and has worked
steadily.
Physical examination was wholly negative, including the blood,
urine, and temperature. Stools were negative to guaiac. The stomach-
tube showed no contents in the fasting stomach. A test-meal was
vomited after thirty-five minutes, the vomitus containing no free
HCl and no blood. A retroverted uterus was replaced under ether.
Discussion. — It is notable that the patient has no symptoms
at all between the attacks of vomiting; that is, between the menstrual
periods. Were there any organic lesion in the stomach it would be
almost certain to show itself between times. It might well be aggra-
vated during menstruation, but would not be confined to that time.
The negative results of physical examination go to strengthen the
assmnption of a normal stomach.
Can we attribute the vomiting to retroversion of the uterus?
I do not think so. There seems to be no evidence to show that
retroversion, per se, can produce this or any other symptoms. The
chief lesson of the case seems to me to be that violent retching from
any cause — for example, from sea-sickness — ^may produce hematemesis.
Outcome. — The patient left the hospital on the 26th in good con-
dition.
Case 147
A ladderman in a fire department, thirty-three years of age, en-
tered the hospital April 25, 1910. The patient lost one sister, one
aunt, and one uncle of tuberculosis. One brother died of drink; other-
wise the family history is good. Except for two attacks of gonor-
rhea, twelve and nine years ago, he has always been well until the
present illness.
362 DIFFERENTIAL DIAGNOSIS
Eighteen months ago he had a feeling of distress and heaviness
in his stomach, as if something was rolling about there. Vomiting
relieved this for a time, and now he makes himself vomit whenever
he feels any such trouble. The first attack lasted about three weeb
and was accompanied by lack of appetite. Since then he has had
about a dozen similar attacks, lasting from three days to three weeb.
Between attacks he feels perfectly well and eats all foods very heartily.
He thinks the attacks are brought on by eating too much, or by eating
something which disagrees with him, and that they are usually pre-
ceded by more constipation than is his usual habit. He never has any
severe pain in the attacks, only a dull ache at the pit of the stomad
and in the left hypochondrium. Sometimes he vomits unchanged
food eaten twelve hours before. Three months ago, for the first time,
he raised a large amount of bright blood. The last attack, seven
weeks ago, began after a drinking bout.
In eighteen months he has lost 40 pounds. Following each at-
tack he has profuse cold sweats at night. For two weeks he has had
a hard dry cough with slight expectoration, frequently blood-tinged.
During attacks he is very nervous and passes urine three or four times
each night.
Physical examination showed good nutrition despite evident loss
of weight. His skin became cyanotic when he was asleep, other-
wise it was of good color. His pupils were small, circular, equal, and
reacted very slightly to light. Glands and reflexes were normal. Heart
negative. Lungs negative, save for a few fine rales and diminished
breathing at the bottom of the right axilla. The stools were positive
to guaiac only on the 27th of April. On the other days of his two and
a half weeks' stay they were negative. He had no fever during this
period, and his blood and urine were negative. The sputum vvas
twice examined for tubercle bacilli with negative results. Wass^^'
mann reaction negative. On gastric ulcer diet he made an iminter-
rupted recovery and left the hospital on the 12th of May.
The patient re-entered the hospital September 2 2d with a dia-g-
nosis made by Dr. H. F. Hewes of gastric ulcer. Since leaving tie
hospital he had worked only three weeks, vomited much, and been
treated mostly by gastric lavage. At this time he admitted that t^
had had slight pains, quickly darting into his calves and out aga-i^?
and that in the previous winter and for the past two or three weeks he
has had a good deal of pain below his left shoulder-blade, mostly on
moving his arms. For the past year he has had slight difiiculty ^
starting micturition. Knee-jerks and Achilles' jerks were active,
HEMATEMESIS 363
the right greater than the left. At this time the right pupil was larger
than the left, otherwise they were as before. The stools were four
times negative to guaiac; the sputa three times negative to tubercle
bacilli. He showed no temperature reaction after 7 mg. of old tuber-
culin.
Discussion. — ^Despite the family history of tuberculosis, the two
^weeks of dry cough with blood-tinged sputa, the loss of weight, and
the presence of night-sweats, we have no good reason to attribute this
patient's symptoms to tuberculosis. Night-sweats may result from
any disease which produces exhaustion, with or without fever. The
popular belief that night-sweats mean phthisis is justified only to the
extent that phthisis is in all probability the commonest cause of such
sweats. Nevertheless, there are many others.
The salient feature of the case seems to be the occurrence of a
dozen or more attacks, lasting from three to twenty-one days, char-
acterized by gastric distress and vomiting. Although these attacks
are by the patient attributed to bad diet or to constipation, there
seems no good reason to agree with him on this point. There are
some doubtful physical signs in the lungs, but it seems very improb-
able that these signs are the cause of his troubles or have anything
particular to do with them, for the gastric symptoms are paroxysmal
with long intervals of good health between, and stomach symptoms of
this t3rpe are rarely, if ever, produced by lung trouble.
The condition of his pupils should lead us to make careful search
for evidences of tabes, even though the knee-jerks are normal and
the Wassermann reaction negative in the circulating blood. In
such a patient we should always examine the spinal fluid and look
carefully for patches of anesthesia or hyperesthesia.
At the time of his second entrance the evidence pointing to tabes
was much clearer, and we need have no considerable doubt of that
diagnosis.
Outcome. — Dr. E. W. Taylor pronounced the diagnosis tabes. The
patient sweat profusely at night during most of his week in the
hospital. Systolic blood-pressure at entrance was 160. He ate
very well during the whole of his stay this time. His condition was
explained to him when he left the hospital on the ist of October.
The patient was seen in January, 19 13, and stated that his vomit-
ing had now ceased, as it had been cured by a Chinese doctor. The
treatment given him at the Massachusetts General did not help him
at all, and after leaving the hospital he could scarcely walk and did
no work for six months. Since that time, however, he has been
364 DIFFERENTIAL DIAGNOSIS
able to work, and his appetite, bowels, and sleep are now normal.
Off and on he has attacks of frequent micturition, and about every
five or six weeks he has a pain over his right kidney and his urine
looks like pea soup. These symptoms, however, do not disable him.
Case 148
A Swedish dressmaker of thirty entered the hospital September
29, 1910. The patient has had slight heartburn and epigastric pain
for a few days at a time, once or twice a year, for the past ten years.
She has thought nothing of it, and has always been very well and
strong up to a year ago, when she began to have almost daily tender-
ness and burning pain in the epigastrium, the latter coming from one-
half to one hour after meals and relieved by soda. She has vomited
two or three times a week, sometimes a quart at a time, but has never
noticed in the vomited matter food eaten the day before. Two days
ago, for the first time, she vomited blood, small amounts frequently,
and yesterday she vomited half a basinful. This morning she brought
up the same amount. She has worked continuously until this bleed-
ing began and has lost no weight. Immediately on entrance to the
hospital she vomited 10 or 12 ounces more of blood. She was given
J grain of morphin, subcutaneously, repeated every four hours when
necessary, to control vomiting. All food was omitted, and she was
given 6 ounces of salt solution every four hours by rectirai.
Physical examination was wholly negative, save for a soft systolic
murmur, loudest at the apex. The stools showed a strong reaction
for guaiac every day until October 5th, after that none. The urine
was negative. The red corpuscles at entrance were just below
4,000,000, and in the course of the next two weeks sagged nearly
to 3,000,000. The hemoglobin remained all the time about 70 per
cent. The leukocytes at entrance numbered 15,000, with 80 per cent,
of polynuclears. The appearance of the red corpuscles at entrance
was wholly normal; no achromia. She had no fever in three weeks*
observation. Blood-pressure, 105 mm. Hg.
«
Discussion. — ^Any patient who has had stomach trouble for ten
years, off and on, and at the end of that time brings up from the
stomach a large amount of blood and shows a well-marked anemia
thereafter is rightly assumed to have a peptic ulcer until evidence
is adduced to the contrary. Cirrhosis of the liver is always a possible
source of mistake in such a case, but in a woman of this age, who
denies all contact with alcoholic liquor, the chance of mistake is not
very great. The rarer and more serious causes of hematemesis are
HEMATEMESIS 365
all of them highly improbable in a patient who is at work when the
bleeding begins, and seems, in most respects, healthy on physical
examination.
It may here be noted that the physical examination of the ab-
domen in cases of peptic ulcer is almost invariably negative. The
only objective evidence we have is the evidence of hemorrhage and
that furnished in some cases by bismuth x-ray examination or by the
string test. It should never surprise us to find the abdomen soft and
free from tenderness, as in perfect health.
Outcome. — On the 3d of October crackers and milk in small
amounts were begun, and thereafter the amount of food was steadily
increased. She had no symptoms or complaints, and October 20th
seemed entirely well and left the hospital. Three years later she
reported that she had no further trouble and was perfectly well.
Her appearance confirmed this opinion.
Case 149
A housewife of twenty-five entered the hospital February 16, 191 1.
The patient's family history is negative. Her general health has been
always poor. Previous to the age of twenty-one she had a great deal
of diarrhea.
For the past three weeks has had a great deal of indigestion and
heartburn, with considerable hematemesis, the dates and amounts not
being dear. About a week ago she began to vomit three or four
times a day for the relief of epigastric distress. Yesterday she sud-
denly vomited a quart of pure blood, followed by small amounts at
intervals since. She worked until two days ago.
While this history was being taken she raised 30 c.c. of bright
blood. On the afternoon of the i6th she also passed much blood by
rectum; her pulse rose to 156. She was kept under morphin and the
bleeding ceased until the 19th,. when about 160 c.c. were raised and a
few clots passed by rectum. Tarry stools were passed on the 20th and
2ist. She was given salt solution under the skin and seepage, 15 per
cent, glucose in normal salt solution, 500 c.c. daily. On the 2 2d she
was fed small quantities of milk and lime-water and did well there-
after. No cause was found for the continued fever.
On the first of March the nurses suddenly noticed that she had a
fixed stare and did not seem to breathe. The pulse was very small,
but not rapid. A few minutes later the left arm and leg began to
twitch, and this continued several minutes. Five minutes later
she was crying, semirational, objecting to having the pupils tested,
366
DIPFESENTIAL DIAGNOSIS
m
Ittz^-
-•t*(i>e| -witCtiit ^■^■Cf "Mi^u.
Fig. 126. — Blood changes in Case 149.
but the left was considerably larger than the right. She complained
of a very queer feeling in her left hand, and for a minute or two ground
HEMATEMESIS 367
her teeth furiously. Within an hour she seemed as well as usual.
At that time, March ist, the first physical examination was done
and showed nothing remarkable except a much enlarged spleen, reach-
ing 7 cm. below the ribs. Splenic dulness i8 cm. in length. On the
2d of March there was ankle-clonus on both sides, especially on the
left, and her general restlessness and poor condition had increased.
The course of her blood chart is shown in Fig. 126, The stained smear
showed nothing remarkable except achromia and stippling. The
red cells were not enlarged. At
times normoblasts were numer-
ous, some of them showing mi-
tosis. The fundus oculi was
negative. Urine negative. Tem-
perature as in Fig. 127. Sys-
tolic blood-pressure, 95 mm. Hg.
On the 3d of March she was
transfused, the blood being al-
lowed to flow twenty-five minutes
until the donor became pale and
restless, with sighing respiration.
The patient was intensely pale
at the beginning of the operation,
but after it her color had re-
turned and her respiration was
deep and regular. She slept
well the next night and was
very hungry. After that she
■Chart of Case 149.
very rapidly improved. Before operation she was practically mor-
ibund, gasping for breath, and very pale.
Discussion. — Association of splenic enlargement with the vomit-
ing of blood has been recognized, since Osier's classical paper ,• to point
with a considerable certainty to the diagnosis of splenic anemia. In
most cases the hemorrhage is due to mechanical causes related to the
splenic enlargement and to obstruction of venous return, yet the
bleeding may result from any of the causes ordinarily associated with
cirrhotic liver. That the patient has had three weeks of dyspepsia,
and has suffered a good deal in her earlier years from diarrhea, does
not invalidate our theory of splenic anemia nor does the convulsion
of March ist upset the diagnosis. Such a convulsion may well be
associated with the patient's anemia.
' Transactions of the Association of American Physicians, 1902.
368 DIFFERENTIAL DIAGNOSIS
The best that can be said against the diagnosis of splenic anemia
is that that disease itself represents a very loose and unsatisfactory
grouping of symptoms. Of its pathogenesis we know little or nothing.
We are not even certain that there is any such entity. Many of the
cases reported under this title are doubtless due to malaria, syphilis,
or to the ordinary type of hepatic cirrhosis. I say to the ordinary
type, since it is generally admitted that what we call splenic anemia
may be only the first stages of a disease which in its later course is
indistinguishable from liver cirrhosis. To this sequence of events —
primary splenic enlargement, with anemia and subsequent develop-
ment of interstitial hepatitis — the term "Banti's disease" is now pretty
firmly attached, but there is much that is unsatisfactory in our knowl-
edge of this disease, as well as in the so-called splenic anemia.
The life-saving efiiciency of transfusion, as recently reintroduced
into medicine through the technical improvements of George W. Crile,
has not as yet been sufficiently realized by the medical profession.
Patients die every week, I believe, whose lives might have been
saved by transfusion of blood. Unfortunately, even in communities
where the importance of the operation is recognized, there are few
surgeons who know enough to do it. The technic of the operation
has recently been so much simplified that it is a disgrace to our pro-
fession that any patient should be without the benefits to be derived
from transfusion. The operation is indicated in cases of posthemor-
rhagic anemia, when the patient fails to show a prompt or satisfactory
impetus toward regeneration of blood. It is also indicated in other
forms of secondary anemia, where an operation is desirable, but is
postponed or frowned upon because of the patient's anemia. In
such cases a bad surgical risk may be turned into a good one by
transfusion properly performed.
A third and less common indication for transfusion is uncon-
trollable oozing from cutaneous mucous or serous surfaces.
Outcome. — She returned to the ward in excellent condition, and
after two and a half weeks of uneventful convalescence was allowed
to go home. The course of her blood changes during this time is seen
in Fig. 126. It was noticeable that she ran a slight temperature most of
the time, varying between 99° and 99.6° F. during her convalescence.
CHAPTER VI
GLANDS
ENLARGED GLANDS AND WHAT SIMULATES THEM
Not all palpable glands are enlarged. The normal wear and tear
of existence in civilized communities produces enough infection or sub-
infection to bring about some enlargement of the glands without our
being able to say that any disease has aflSicted the individual or his
glands. It is a mistake, therefore, to suppose or to state that glands
are enlarged merely because we feel them, and it means nothing to
record in our case histories that they are palpable, unless in some very
unusual situation. The best way is to state approximately how large
the glands are. In general, it may be said that a considerable pro-
portion of all adults living in cities have in their groins one or more
glands twice the size of a pea. In the axilla? glands of this size are less
Common, and a considerable number of healthy persons have none that
one can feel at all in that situation. The same is true of the neck and
epitxochlear regions, yet it must be recognized that palpable epitroch-
lear glands, while less common than palpable inguinal glands, are
nevertheless not at all rare in perfectly healthy persons, and should
not be made the ground of any suspicion of any syphilitic infection,
as has been the custom in certain clinics here and in Europe.
It is a very familiar fact that enlargement of the inguinal glands
accompanies infection of the leg, thigh, or genital tract; that enlarge-
ment of the axillary glands follows infection of the arm and of certain
parts of the chest wall; that enlargement of the glands of the neck is
associated with infection of the mouth, throat, face, or scalp.
Beyond this, the attempt is often made to associate certain groups
of cervical glands with certain drainage areas, but in practice there is
seldom any such actual delineation. The drainage areas surely must
cross or anastomose. It is true, nevertheless, that enlargement of the
posterior cervical glands behind the sternomastoid is very frequently
associated with syphilis and with German measles.
So much is relatively clear. Much less clean cut is the associa-
tion of certain pelvic and abdominal growths with enlargement of the
inguinal glands and of certain thoracic growths with enlargement of
Vol. 11—24 369
370 DirrERENTIAL DIAGNOSIS
the axillary or cervical glands. In many cases there is no such asso-
ciation. The pelvic and abdominal growths have their glandular
metastases in the mesentery and other prevertebral glands, while
infections and tumors of the thoracic cavity affect the branchia\
and tracheal lymphatics. This, I say, is the rule, and, therefore,
a considerable portion of all the glandular enlargement altogethm^^x
escapes our notice on physical examination. We can rarely rea-^fc
the deep abdominal glands either by palpation or in any other w
and even by the aid of x-ray and of spinal percussion we are far fr
certainty in the diagnosis of enlarged branchial or tracheal glan
yet these sites of adenoid tissue must always be present in the phy^
cian's mind. He must never think of the neck, axillae, and gro
as the normal sites of possible glandular enlargement, but only
the more obvious and visible sites.
Cancer of the stomach, tuberculous peritonitis, the gall-blad
infections, peptic ulcer of the stomach or duodenum, and m
of the abdominal lesions which present the greatest difficulties
diagnosis do not produce, as a rule, any glandular enlargement wh
we can recognize on physical examination. In a very small
centage of cases, gastric cancer and some other abdominal neoplas
are associated with a glandular metastasis above one clavicle, the
called sentinel gland. Such a gland should always be felt for when
we are in doubt about a diagnosis of malignant disease in the abdomen,
and if any such gland is present it should be excised and examined
microscopically for evidence of malignant disease.
Cervical or axillary metastases are seen with considerable fre-
quency in cancer of the lung and pleura and in lymphoblastoma of the
mediastinal glands, yet this association is mysterious, vague, fickle,
and unreliable. We do not understand why it occurs as often and
no oftener.
Another point hitherto not clearly explained is the occasional ex-
tension of a streptococcic sepsis, starting in a tonsil, not only to the
cervical glands, but to the axillary glands as well. I have several
times seen axillary suppuration containing a pure culture of strepto-
cocci in association with a similar cervical adenitis, apparently originat-
ing in a streptococcic sore throat of the mild epidemic type. Thi
brings me to another problem regarding the glandular hypertrophic
and inflammations of the tonsillar ring. It is ordinarily assumed th
when a tonsillar inflammation arises it has been acquired through so'
food that has passed over the tonsil or through the inspired air «'
its contact with the tonsil. In other words, it is through the fau
Glands
Metastatic (neoplasm-
septic ADENITIS (INCLUDING SEPSIS FROM CUTANEOUS AND DENTAL
DISEASE.)
SYPHILIS
ADENITIS (UNKNOWN >
CAUSE) i
TUBERCULOUS ADEN-
ITIS
}
HODQKIN'S DISEASE >
AND LYMPHOMA J '
LYMPHATIC LEUKEMIA I
5145
3160
725
65
27
^ These figures are taken from the records of the Out-patient Department and
include no ward cases.
371
372 DIFFERENTIAL DIAGNOSIS
surface of the tonsil that that gland becomes inflamed. This assump-
tion is very natural, but not necessary. It is natural because the ton-
sillar crypts open into the fauces and because foci of pus or bacterial
growth are usually to be found in these crypts. One naturally assumes^
therefore, that infection has gone into the crypt through the mou
of the crypt. But this is obviously a superficial view. Tonsillar in
flammation is by no means confined to the crypts and often has n
obvious connection with them. The so-called quinsy sore throat o
peritonsillar abscess has its origin very deep in the tissues, far fronr— ana
their faucial surface. How do we know that the infection does noWr ^t
come from within rather than from without? Such a question has
often occurred to me when I have observed in a child, first, endocardi-
tis or arthritis, and later a tonsillitis. Such a sequence suggests tha~
an infection widely generalized within the body has been carried firs
to the heart or to the joints and later to the tonsillar tissues. Hav»
we any good reason to believe that the tonsils are not often infecte
in this way, from within rather than from without? I do not see
we have. No one supposes, I take it, that similar glandular
ments of the intestine (Peyer^s patches and solitary follicles) are prczzi^o-
duced through the entrance of typhoid bacilli from the interior of th^cne
intestine. It is generally assumed that the typhoid bacilli, which w^ *^e
can usually isolate from the circulating blood, are carried by th^^e
blood-stream and by the l>Tnphatics to all parts of the body ai^ d
appear in the lymph-glands of the intestine from within rathe=?r
than from without. Why should not the same be true of tonsill^«.r
infection?
In addition to the foci of lymphadenoid tissue which have bee^n
mentioned in the foregoing paragraphs, there are, in all probabilit>'',
minute collections of similar tissue scattered in all parts of the body,
including the serous surfaces and subcutaneous tissues. We get no
clinical evidence of the existence of these minute foci, except in
lymphoid leukemia and multiple lymphoblastoma. In these condi-
tions the minute foci just referred to become enormously enlarged, and
the subcutaneous group show beneath the skin as lumps of various
sizes scattered diffusely over the body surface. Similar nodules ap-
pear in the internal ear, producing deafness; in the orbit, displacing the
eyeball, and in many other less conspicuous situations. Under such
conditions the body seems to be riddled or honeycombed with lymph-
adenoid tissue, of whose presence we are not ordinarily aware.
GLANDS 373
CLINICAL GROUPINGS
Glandular enlargements in the neck, axilte, and groins are ordinar-
ily of four types, so far as they can be studied by the ordinary methods
of physical examination; that is, without the excision of a gland:
(i) Simple glandular hypertrophy.
(2) Glandular hypertrophy with inflammation and with or without
suppuration.
(3) Glandular enlargement with caseation.
(4) Glandular enlargements of the hard, nodular type.
The enlargements of the first type are seen in syphilis, in lympho-
blastoma, with or without leukemia, and in many cases without known
cause.
The septic type of adenitis is conunonest in connection with ton-
sillitis and other inflammations of the mouth and throat, also in septic
processes of an arm or one or another extremity, and in gonorrhea. A
peculiar type belonging in this group is the idiopathic axillary ab-
scesses (non- tuberculous), a suppuration which arises without known
cause, deep in the axillary tissues, pushes forward to the superimposed
axillary glands, so that the pus concealed beneath them is often not
suspected.
Caseous glands are generally associated with tuberculosis.
The hard, nodular glands are usually neoplastic and may some-
times contain cartilaginous or even bony substances.
But, although these clinical groups guide us in many cases to a
sufficiently accurate and prompt diagnosis, there are many other cases
in which we are wholly at a loss to decide what type of adenitis is
present, unless a gland is excised and examined histologically. This
should be done much more frequently than it is. As a rule, some one
of the enlarged glands or some portion of one is placed so superficially
that it can be taken out under local anesthesia without any consider-
able pain or hemorrhage.
The other characteristics of the glands are less valuable in differ-
ential diagnosis. It usually helps us very little to know whether the
glands are discrete or matted together, and almost any of the four types
above mentioned may be either hard or soft, either attached to the
skin or freely movable beneath it. Nevertheless, it is true that the
septic and tuberculous types are more likely to involve the skin
than either of the others. Tenderness and redness of the overlying
skin are rarely seen except in the inflanunatory type of adenitis,
but occasionally an inflammatory reaction occurs about a lympho-
blastoma.
374 DIFFERENTIAL DIAGNOSIS
NOMENCLATURE OF GLANDULAR TUMORS
The weight of opinion among competent pathologists inclines
more and more toward a simplification and unification of the terms
ordinarily applied to the new growths involving lymph-glands. The
terms lymphoma, malignant lymphoma, lymphosarcoma, small round-
cell sarcoma, pseudoleukemia, lymphocytoma, leukemic infiltration,
leukosarcoma, and others appear to represent different varieties
of the same pathologic lesion. The growths of the firmer and more
chronic type are apt to be called Hodgkin's disease, especially if they
originate in the superficial lymph-glands of the neck, axillae, and groins.
The same, originating in the mediastinal or in the abdominal glands,
is apt to be spoken of as a ^'lymphosarcoma," while, if the spleen is
notably enlarged, the term ' 'pseudoleukemia" is applied, so long as the
blood remains normal. The same disease may be dubbed "leukemia" a
week later, when the blood has become invaded with cells like those
of the tumor. I shall follow in this book the terminology of Frank B.
Mallory. He names all such tumors by their type cell, the lympho-
blast, the cell occurring normally in the germ centers of lymph-nodes
and lymphadenoid tissue. Tumors of this group are differentiated
both from myeloblastoma — the histologic basis of myeloid leukemia
with its subvariety, chloroma — and from myeloma, a tumor arising
only within the bone-marrow and never associated with leukemic
blood.
WHAT OTHER LUMPS MAY BE MISTAKEN FOR GLANDS?
I have known fatty tumors, subcutaneous cysts, abscesses, and
the infiltration of actinomycosis to be mistaken for enlarged glands,
but such mistakes arc not common. Ordinarily, the soft lobulated
surface of the fatty tumor and its situation away from the ordinary
sites of glandular enlargement makes it easy to identify.
Cysts, especially those occurring in the neck, are less easily recog-
nized, but they are rare, and, as a rule, their position and fluctuating
consistency makes clear their origin.
Abscesses and subcutaneous infiltrations are much less circum-
scribed and definite in outline when compared with glands.
GLAND PUNCTURE
To introduce a hollow needle into the substance of an enlarged
gland and withdraw gland juice has for some years been an important
diagnostic procedure in cases of suspected trypanosomiasis, but the
GLANDS 375
)rocedure has not yet come into any general use as a part of the diag-
losis of other diseases. It seems to me it should be more frequently
mployed, as by such means the organisms of syphilis, tuberculosis,
ind the more ordinary varieties of septicemia could perhaps be iden-
ified in culture or cover-slip.
Case 150
A clerk of twenty-nine entered the hospital December 7, 1905.
?0T the past nine months a bunch has been noticed in the left side of
he neck. It made its appearance rather suddenly and was at first
ibout as big as a walnut. Three weeks ago he was thrown out of a
:arriage; since then the bunch has grown larger. For a few days he
las had some trouble in swallowing.
Physical examination is negative save for scattered squeaks in
x)th lungs, and in the left side of the neck an irregular-shaped, elastic
nass the size of a child's fist, slightly tender, not adherent to the skin,
3ut not freely movable. No fever. Blood and urine normal. Diag-
aosis, tuberculous glands of the neck.
Discussion. — Unlike tuberculosis or Hodgkin's disease, the lump
present in this case has been recognized for nine months without any-
thing on the other side of the neck. Another point of peculiarity in
this case is the apparently sudden appearance of the bunch. I say
'apparently sudden,'- as we must be on our guard lest the patient quite
mintentionally misleads us upon this point. I have repeatedly had
patients tell me most earnestly and in good faith that a certain lump
lad appeared over night, although investigation showed that the
ump in question was a portion of the bony skeleton which had pre-
lumably existed for forl>' years or more.
But if the patient is correct in believing that this bunch has made
ts appearance suddenly, we may be somewhat suspicious that it is
lot a gland at all, especially as there is nothing in the mouth to sug-
gest an origin.
Outcome. — At operation, December 8th, the supposed gland was
lissected out. It was found to be adherent at its base, and in freeing
t the gland broke, with the discharge of 2 ounces of watery pus.
The wound healed normally. At the end of the operation the diag-
losis is written, "Removal of tuberculous glands from the neck."
ilicroscopic examination by Dr. W. F. Whitney showed a cystic
umor, the inner surface of which was lined by low, flat epithelium, the
mter wall composed of an extremely vascular connective tissue, /. c,
)ranchial cyst.
Remarks.— Branchial cysts are of three tjpta:
(i) Those that communicate with the mouth or throat through -a
sinus, so that pressure upon the cyst forces fluid into the patient '
mouth.
(2) Those opening externally in the neck and discharging more c
less intermittently their contents.
(3) Those which are bUnd at both ends and have no opening £
aU.
In the present case the cyst was apparently of the latter type.
saw not long ago a patient with a branchial cyst of the first type, whic
was about the size of an egg, situated above the left clavicle;
pressing it the patient was conscious of a gush of disagreeably tastinm- j
fluid in the mouth.
Case 151
A laborer in a factory, age fifty-two, entered the hospital J
12, 1904. The patient has never bfun sick before and denies v
j
(
Fig. 12a. — Chest signs in Case 151.
disease. He drinks beer and whisky freely and is drunk about onceB
month. July jd he noticed a lump in his left armpit. He has h
GLANDS 375
procedure has not yet come into any general use as a part of the diag-
nosis of other diseases. It seems to me it should be more frequently
employed, as by such means the organisms of syphilis, tuberculosis,
and the more ordinary varieties of septicemia could perhaps be iden-
tified in culture or cover-slip.
Case 150
A clerk of twenty-nine entered the hospital December 7, 1905.
For the past nine months a bunch has been noticed in the left side of
the neck. It made its appearance rather suddenly and was at first
about as big as a walnut. Three weeks ago he was thrown out of a
carriage; since then the bunch has grown larger. For a few days he
has had some trouble in swallowing.
Physical examination is negative save for scattered squeaks in
both lungs, and in the left side of the neck an irregular-shaped, elastic
mass the size of a child's fist, slightly tender, not adherent to the skin,
but not freely movable. No fever. Blood and urine normal. Diag-
nosis, tuberculous glands of the neck.
Discussion. — Unlike tuberculosis or Hodgkin's disease, the lump
present in this case has been recognized for nine months without any-
thing on the other side of the neck. Another point of peculiarity in
this case is the apparently sudden appearance of the bunch. I say
"apparently sudden,'' as we must be on our guard lest the patient quite
imintentionally misleads us upon this point. I have repeatedly had
patients tell me most earnestly and in good faith that a certain lump
had appeared over night, although investigation showed that the
lump in question was a portion of the bony skeleton which had pre-
sumably existed for forty years or more.
But if the patient is correct in believing that this bunch has made
its appearance suddenly, we may be somewhat suspicious that it is
not a gland at all, especially as there is nothing in the mouth to sug-
gest an origin.
Outcome. — At operation, December 8th, the supposed gland was
dissected out. It was found to be adherent at its base, and in freeing
it the gland broke, with the discharge of 2 ounces of watery pus.
The wound healed normally. At the end of the operation the diag-
xaosis is written, "Removal of tuberculous glands from the neck.'*
JVIicroscopic examination by Dr. W. F. Whitney showed a cystic
tuinor, the inner surface of which was lined by low, flat epithelium, the
outer wall composed of an extremely vascular connective tissue, /. e.,
l>iraJichial cyst.
37^ DIFFERENTIAL DIAGNOSIS
neck, groins, and right axilla. The left axilla was filled by a mass of
matted glands, hot and tender. This time the spleen was not palpable.
The blood was negative. By the 1 7th the tenderness and inflammation
was gone from the glands, but the mass seemed larger.
Discussion. — This patient has been conscious of a lump in the axilla
for nine months only, but on examination he turns out to have, in
addition, an enlargement of the spleen, a fever without leukocytosis,
a negative Widal reaction and tuberculin reaction, and no recognizable
focus of infection or source of neoplastic metastasis. At the time of
the patient's entry the spleen is not felt and the axiUary lump shows
all the evidences of acute inflammation. Moreover, it is now asso-
Fig. 130.— Ch
[. — Chart 2 of Case 151.
ciated with glands in the neck, in the other axilla, and in the groins.
At this time diagnosis is much more possible than at the time of his
first appearance. Considering the generalization of the glandular
lumps and the absence of any known infection prior to the glandular
infection itself, it seems probable that we are dealing with a case of
lymphoblastoma of rather an acute t>pe. associated with secondary
infection of the gland.
Outcome.— On the 19th a large infiltrating mass, extending deep
under the pectoral and down the great vessels, was exposed by opera-
tion. A piece, 4 by 3 cm., was removed, and consisted of hard,
gray tissue with a few necrotic areas. Examination by Dr. Channing
GLANDS 379
C. Simmons showed the structure of Hodgkin's disease. Dr. J. H.
Wright concurred in the description given by Dr. Simmons, but
preferred to regard the tumor as a form of lymphosarcoma. The
Wound healed well, and the patient left the hospital on the 28th.
Remarks. — I have given the terminology of the last paragraph
exactly as it was written in the hospital records, but at the present
time I think both these gentlemen would use Dr. Mallory's term,
' * lymphoblastoma. ' '
Case 152
An Italian teamster of twenty-five entered the hospital March 7,
191 1. He has a negative family history and past history. A year
ago he noticed a swelling below his right ear and one below his Adam's
apple. Both of these have increased in size since. He has had a good
deal of trouble with his teeth in the past two years. He sweats much
at night and has occasional buzzing in his ears.
Physical examination showed a few pea-sized glands in the poste-
rior cervical triangles. In the region of the thyroid was a synmietric,
bilateral, crescent-shaped tumor, about 2 by i^ inches, moving upward
when the patient swallowed. There was no thrill or murmur over it.
At the angle of the right jaw a mass of glands, from the size of an
English walnut to that of a pullet's egg, somewhat adherent to the
surrounding tissues, firm, not tender. There was no exophthalmos,
no tachycardia, no tremor or sweating. Blood and urine negative.
No fever. Pulse 80.
Discussion. — The case is a very unusual one from a clinical stand-
point. Two tumors are present, one occupying the ordinary site
of the thyroid gland, the other, at the angle of the jaw, being appar-
ently separate. There are none of the toxic manifestations of Graves'
disease, yet the patient is obviously much sicker than most of those
in which what is called a simple goiter or enlargement of the thyroid
gland is recognized.
The patient is very young for malignant disease, yet the gland
at the angle of the jaw suggests metastasis. Possibly he has two inde-
pendent diseases, a thyroid tumor of some kind or an adenitis, syph-
ilitic, tuberculous, or septic in type. The characteristics of the cervical
gland, however, are not those ordinarily seen in any of these forms of
adenitis.
As usual in cases of doubt, the excision of a gland is the obvious
indication.
Outcome.— One of the glands was removed and examined by
380 DIFFERENTIAL DIAGNOSIS
Dr. Wright, who found carcinoma. The tumor involving the thyroid
was then removed. The larynx was found to be pushed to one side.
The thyroid tumor was also proved to be cancerous when examined
by Dr. W. F. Whitney. The patient made a good recovery and left
the hospital March 20, 191 1.
He returned to the wards December 26, 191 1, having been treated
regularly in the Out-patient Department in the meantime. Various
cancer fluids had been injected without relief and his diflSiculty in
breathing had become steadily worse. Dr. Coolidge suggested a
deep tracheotomy. While being etherized the patient stopped
breathing. Immediate incision into the cancer, over the windpipe,
was followed by profuse bleeding which could not be controlled.
The trachea was opened in the midst of the blood, with immediate
cessation of part of the bleeding, but there was inhalation of some of
the blood. A tracheal tube was inserted and the patient began to
breathe. By the i6th of January he was breathing easily through
the tube, which had, however, to be adjusted twice a day. He was
then discharged to the Long Island Municipal Hospital.
The patient remained at this hospital for some months, and then
was discharged at his own request, against advice. Nothing new
was ascertained. A letter was sent to him, March 27, 1913, and was
returned, marked **Dead."
Case 153
A night-watchman of forty-two entered the hospital October 28,
1909. Five years ago the patient noticed a small swelling, the size
of a hazelnut, near the back of his neck. It was painless and very
hard. Soon after two similar lumps appeared in the neck and were
removed. A month later the side of the neck began to swell slowly,
its size var>dng a good deal from time to time. There was still abso-
lutely no pain. A year later he had the lump removed. It recurred
in a month and was removed again a month ago. Since the last opera-
tion he has had a slight pain in his neck, but he still complains of noth-
ing except that the growth recurs. Since the last operation he has
lost a good deal of weight, he cannot say exactly how much. His
appetite is good and he sleeps well.
Physical examination shows good nutrition and color. Right
pupil larger than the left, both reacting normally. All other reflexes
normal. On the left side of the neck, extending from the ear to the
clavicle and from the median line in the back to the stemomastoid
muscle in front, is a firm, insensitive, fixed mass, about the size of
GLANDS 381
two fists, with firm, discrete nodules, from the size of a pea to that of
a bean, along its edge. A tongue of similar tissue extends imder the
chin to join a similar mass on the right side of the neck, about one-
half the size of that on the left. In the left axilla a mass about the
size of a hen's egg is palpable, but the right axilla is free, and there is
nothing in the groins or epitrochlear regions. The chest and ab-
domen are negative. Blood and urine negative. No fever in two
weeks' observation.
Discussion. — ^The most important point about this case is that the
glands (if glands they be) have been present for five years in the
postcervical region and have returned and increased, despite re-
moval. There are only two types of glandular enlargement which
behave in this way, the lymphoblastoma and the tuberculous gland.
Nothing else is so chronic.
Against the diagnosis of tuberculosis is the fact that there has
been no softening or suppuration in the glands, although they have
been enlarged for five years. Further than that they do not mvolve
the skin. Under these conditions the diagnosis of lymphoblastoma
is strongly probable. It is notable that we have a similar glandular
enlargement in one axilla only and none at all in the groins. The old
idea that glandular growths of the chronic type (Hodgkin's disease)
were always generalized or spread over many parts of the body is
being gradually abandoned, as the result of histologic examinations
which show that we may have a lymphoblastoma either of the slow-
growing, hard, scirrhous type or of the more rapid and progressive
form, yet remaining confined to a single group of glands.
Outcome. — ^A gland was removed for microscopic examination
by Dr. J. H. Wright, who reported that it consisted of lymphadenoid
tissue, but differed from a normal lymph-gland in having fewer sinuses
and in not possessing the definite architecture of the lymphatic gland.
The patient left the hospital on the 8th of November.
Case 154
A junk dealer of forty-eight, bom in Russia, entered the hospital
May 16, 1910. Eight weeks ago the patient began to feel weak. Five
weeks ago he "caught cold." Two and a half weeks ago he noticed
a sore on his left forearm with severe pain there; also pain in the right
side of the head and deep in the right eye. Since the trouble began
he cannot see with the right eye. There is also pain in the left shoulder,
going down the outer side of his arm, and associated with weakness
of the arm. The little finger and ring finger are almost useless. The
382 DIFFERENTIAL DIAGNOSIS
headache is associated with dizziness, which makes him unable to
work. There has been no vomiting and no known fever. His past
history is negative, save that he takes one or two glasses of whisky
and two or three of wine a day. His wife has had no miscarriage.
Physical examination shows good nutrition. The right eye is
blind and the right pupil is larger than the left; both pupils inegular
and reacting sluggishly. The right abducens is paralyzed. Reflexes
normal. Over the ulnar side of the left forearm are numerous rounded
white scars, and others of the same character are seen on the inner side
of the knees. On the radial side of the left forearm, at the junction of
the lower and middle third, is a thickened, raised, reddish-brown crust,
^i by i| cm., surrounded by a red infiltrated area, 5 cm. in diameter.
At the junction of the first right rib with the manubrium is a firm,
oval tumor, 4 by 3 cm., i| cm. high, cartilaginous in feel, and slightly
tender. A slight rachitic rosary is palpable on both sides. Under the
angle of the right jaw is a large tender lymph-node, many bean-sized
glands in the axillae and groins. The epitrochlears are palpable.
Chest and abdomen are negative. Wassermann reaction negative.
Urine negative. White cells, 24,000; hemoglobin, 70 p>er cent. Differ-
ential count of 200 white cells shows polynuclears, 7 per cent.; small
lymphocytes, 4 per cent.; large mononuclear cells with "azure"
granules, 89 per cent. The fundus of the right eye shows two hemor-
rhages near the disk.
The condition of the eye and the skin lesions suggest syphilis.
Further examination of the left arm showed that there were irregular
areas of anesthesia and no power to extend the forearm.
Discussion. — The symptoms are curiously scattered and various.
First an intracranial group, with troubles in the arm, pain, paralysis,
and soreness. The particular localization of these is unlike that of
peripheral neuritis or any other peripheral disease, and suggests
trouble in the brain. The condition of the pupils and the paralysis
of one eye muscle suggests the same thing. The scars and the infil-
tration upon the arm, when considered in connection with the ocular
lesions, lead us to surmise that the intracranial lesions may be sjT)h-
ilitic.
But the tumor on the rib and the glandular enlargements of the
neck, axillae, and groins draw our attention in another direction. The
rib tumor might well be a myeloma, a metastasis from hypernephroma,
or possibly a bony or cartilaginous outgrowth. The remains of a
rachitic rosary suggest still another possibility that the rib tumor
might be rachitic.
GLANDS 383
All these doubts are settled by the blood examination which
is characteristic of lymphoid leukemia, that is, of the type of lympho-
blastoma associated with a multiplication of tumor cells in the blood;
in other words, with lymphemia. Note the very moderate increase
in the total number of white cells. This is what we should expect in
a case of this sort. The counts of 100,000 or more per cubic milli-
meter are usually in the myeloid type of leukemia. The greater
number of the lymphoid cases, during most of their course, have a
leukocyte count of 40,000 or less.
At the time of the patient's second hospital visit the cUnical
picture was still clearer. Fever and more infiltrating nodules had
now appeared and the growth had doubtless involved the marrow,
crowding out the erythroblastic centers and producing an anemia of
the type known as myelophthisic anemia, that is, where the red
cells of the marrow are starved out, pushed to the wall — the bony
wall of the marrow — and gradually exterminated. This is the ordinary
type of anemia occurring in the course of a lymphoblastoma or myelo-
blastoma of the leukemic type.
A nodule was excised from the axilla and examined by Dr. J. H.
Wright, showing a lymph-gland, very rich in the larger lymphocytes
and continuous with a mass of connective tissue and fat tissue, more
or less densely infiltrated with large lymphocytes, associated with
some eosinophils and myelocytes and a few small lymphocytes.
Diagnosis, malignant lymphoma or leukemic tumor.
The patient left the hospital on the 19th of May and returned on
the 27th. Since leaving the hospital he has had constant headaches,
very severe and confined to the right side of the head. He has now
no pain in the left arm, but much in the left shoulder. His right eye
is still blind, the left normal. Since he left the hospital his right ear
has become deaf and **roars like an engine.'' He has been in bed since
he left the hospital because of fatigue; increased pain in the shoulder
seizes him as soon as he stands up, and is accompanied by an uncon-
trollable desire to defecate.
Physical examination showed at this time a freely movable lymph-
node over the middle of the right clavicle. The epitrochlears were
of the size of a lentil. By percussion the spleen measured 8 by 10 cm.,
but its edge could not be felt. The entire left arm was now atrophic
and the deltoid group of muscles soft and flabby. The crust, pre-
viously described, was still present, also the tumor near the breast bone.
The red cells at this time numbered 1,780,000, and the white,
37,000. Differential count was practically as before. During the
Jim
-ItJit
m
llU
P-
m
sJgs
384 DIFFERENTIAL DIAGNOSIS
two weeks of his stay in the hospital the red count steadily declined
until it reached 976,000, with 30 per cent, hemoglobin, on the 6th
of June. The leukocyte count also de-
clined from 37,000 at entrance to 14,000
June 1, and 13,000 June 6, The dif-
ferential count, however, did not change
in any important respect. The red cells
showed slight achromia and abnormal
staining, with considerable variations
in size and shape. The patient ran a
continuous fever, as shown in Fig. 132.
The urine was negative. Examination
of the cars by Dr. H. P. Mosher showed
a moderate diminution of hearing in
each ear, apparently due to middle-ear
catarrh. Tests for involvement of the
labyrinth were negative.
On the 5th of June there was evi-
dence of involvement of the mastoid,
and purulent discharge from the ear
began the ist of June. Coincident with
the appearance of this suppuration occurred Ihe fall of white cor-
puscles mentioned before. The patient lost ground steadily, and
died on the 7th of June. Autopsy showed l>*mphoid leukemia.
Case 155
A gardener of fifty entered the hospital August 22, 1910. The
patient has been well until the present illness; he denies venereal
disease and has a negative family history. Three weeks ago he
noticed a small lump in his neck and others in both axills and groins.
They were then about half their present size. He feels perfectly well,
except that he gets fatigued more easily than before. He has lost no
weight. He has a good appetite and sleeps well.
Physical examination shows good nutrition, pupils slightly irreg-
ular in shape, equal in size, and reacting normally. Tonsils are very
large. All the superficial lymph-nodes, including the epitrochlear,
mental, submaxillar^', and occipital, are enlarged. They vary from
the size of a pea to that of a walnut, are freely movable, and not
tender. The axillarj' glands extend along the pectoral muscle toward
the nipple. Chest and abdomen negative, except that the sharp,
firm, painless edge of the spleen can be felt on deep inspiration.
Fig. ijJ. — Chart of Case i;
GLANDS 385
R'assermaim reaction is positive. Blood-pressure, 140 mm. Hg.
Viiae negative. Blood examination shows red cells, 5,900,000:
beoK^obin, 80 to 90 per cent. In stained smears the red cells are
ortnal. The course of the white cells is seen in Fig. 133. The per-
3ita.ge of polynuclear cells is from 5 to 25 per cent., the rest of the
■JSS
.»
I
,4
.)
^1
i
3
S ,»«.
=
100%
WW
*
v
1
■-
^
\
/
'—
-
■ /
Fig. 133. — Chart of white cells in Case iss-
white cells being of the lymphocytic type. The small lymphocytes
markedly predominate and make up from 55 to 66 per cent, of all the
white cells present. The fundus oculi is normal.
Discussion. — The patient feels so well that it is difficult to believe
that he has any serious disease, yet, with three sets of enlarged glands,
Vol. 11—25
386 DIFFERENTIAL DIAGNOSIS
he certainly is far from well. The positive Wassermann reaction,
in connection with the generalized adenitis, might lead us to assume
that the latter was of syphilitic origin, but no one, I suppose, would
undertake to make a diagnosis in such a case without counting the
white corpuscles, and if this were done there could be no further
doubt regarding the diagnosis of the case. It is clearly one of lym-
phemia with lymphoblastoma.
Outcome. — Under x-ray treatment the glands diminished in size.
The health of the patient seemed to be perfect, and after the loth of
September he preferred to continue treatment in the Out-patient De-
partment and was accordingly discharged, having gained 3 pounds
since entrance^
Case 156
A carpenter of forty entered the hospital October 3, 1910. The
patient *s father died at sixty-five of unknown cause; his mother, of
cancer of the breast; one cousin, of tuberculosis. Four brothers and
one sister are living and well. The patient's wife has had two or three
miscarriages, and is said to have had a sore throat, possibly of syph-
ilitic origin. The last child, just bom, seems healthy. The patient
was always well until June, 1909, when he was in the Natick Hospital
and an operation was done upon his left foot. The diagnosis was "os-
teitis, possibly malignant.'* July 27th he was at the Carney Hospital,
and Dr. Macausland removed a tumor from his left foot which was
said to be mixed sarcoma and carcinoma, but no pathologic report
could be found. After that he seemed to be fairly well ^ntil two or
three months ago, when he began to be very nervous and restless,
frequently rubbing different parts of his body, bathing his feet to
allay itching, complaining of vague abdominal discomforts and belch-
ing. Some deafness in one ear was noticed ten days ago. This morn-
ing he seemed to be completely deaf in both ears. His bowels are very
constipated. Nothing else can be ascertained about his history.
Physical examination showed good nutrition, dry, harsh skin,
the right pupil larger than the left, both reacting normally. The
tongue showed a very thick, brown coat. Superficial lymph-glands
not enlarged. Chest and abdomen negative. Knee-jerks not ob-
tained. Achilles' jerk not obtained. In the left groin are a few
confluent glands, making up a mass the size of two walnuts. The left
knee is somewhat smaller than the right. On the outer side of the left
foot, near the ankle bone, are a depressed scar and some red sub-
cutaneous lumps, free from tenderness. The blood shows leuko-
GLANDS 387
*
cytes varying from i2,ocx> to i6,ocx>, with 79 per cent, polynuclear
cells. Urine negative.
During the month of his stay in the ward his temperature ranged
usually between 99° and 100^ F.; his pulse between no and 130;
respiration about 25. The feces were negative for guaiac on three
occasions. Sputum showed no prevailing type of organism. Ex-
amination of the ears by Dr. H. P. Mosher showed acute double
labyrinthitis, probably specific. The fundus oculi was normal.
A neurologic consultant could throw no light upon the case, though
the patient had a well-marked Romberg sign, poor co-Qrdination in
the arms, dull and delayed sensation in the legs. There was much
twitching of the muscles of the arms, with scratching and restlessness.
October 7th the right pupil reacted poorly.
October 7th, 5 c.c. of clear fluid were withdrawn from the spinal
canal. Cell count, i per centimeter. Stained smear showed polynuclear
cells, 66 per cent.; lymphocytes, 32 per cent.; eosinophils, 2 per cent.,
and many red cells; in other words, probably an admixture of blood.
Discussion. — The syphilitic history, the absence of tendon re-
flexes, the condition of the pupils, and the deafness may well be
symptoms of syphilis. On the other hand, the presence of the lumps
upon the foot and in the groin and the curious restlessness suggest a
possible brain metastasis from neoplasm. Possibly he has more than
one disease. It seems very difiicult to reconcile or organize under
one diagnosis all the facts given. As a matter of fact, until the
histologic examination of the excised gland (see below) was made,
no satisfactory diagnosis was arrived at in this case during life, al-
though we had very little doubt that sv-philis accounted for at least
a part of his troubles.
Outcome. — On the 8th of October the glandular mass in the left
groin was excised. Microscopic examination by Dr. J. H. Wright
showed malignant lymphoma. No diagnosis could be made, and the
patient remained in the ward without change until the latter part of
October, when he became incontinent and delirious at night. On the
23d he had convulsive twitching and jerking of the arms and legs for
a couple of days. At this time the reflexes could not be obtained.
November 3d the patient died. The clinical diagnosis was malignant
disease of the foot and inguinal glands, with metastases in the central
nervous system, possibly also syphilis and tabes. Myxedema was
also considered. Autopsy No. 2713 showed no sufficient cause for
death. There was a syphilitic aortitis, a small hypernephroma of the
kidney, and hemorrhagic areas in the lungs.
388 DIFFERENTIAL DIAGNOSIS
Case 157
A teacher of thirty-five entered the hospital December 28, 1910.
Her family history was negative. She has been subject to colds and
tonsillitis in the past and has had a slight dry cough for a year. She
has had "bronchitis" every one or two years.
In the summer of 1909 she was at Rutland, with constant low
fever, and an eruption which started in the ears and nose and gradu-
ally covered the lower part of face. There was a free discharge of pus
from it and some blood. This began to go three months ago and has
now nearly ceased. Her menstruation is regular and habits good.
In September, 1909, she noticed **glands" on each side of her
neck. They were largest in January, 1910, and have been smaller
since, but others have appeared behind the left ear and in the right
axilla. In January, 1910, she was in bed six weeks with "heavy grip
cold" and epigastric pain. She had a similar attack in March, 1909.
After it the left leg was lame and the foot was painful and had purple
spots on it. She has not walked since January. In June, 1910, she
wakened one morning to find her left hand and left leg useless and the
right side of her face "drawn down." Her speech was poor. She has
gradually improved since, but the left hand is still weak.
She has not worked since March, 1909. There has been no loss
of weight and no pain. Her appetite is fair. The bowels are costive;
sleep is good.
Physical examination is negative except for hard, matted, non-
tender, large pea-sized glands over the left clavicle and larger ones in
the right neck and axilla.
There is edema in the left leg and foot and the calf is slightly
tender. There is ankle-clonus (four to five oscillations) on the left.
The left-hand grip is weaker. The blood and urine are negative; blood-
pressure, 115 mm. Hg.; Wassermann negative. There is no fever in
one week.
Discussion. — Despite the negative Wassermann reaction there is a
good deal to suggest syphilis as a cause of the adenitis in this case.
The attack of June, 1910, might well be the result of syphilitic vascular
lesions in the brain. The presence of ankle-clonus and muscular weak-
ness upon the left side, six months later, gives support to the idea
that some organic cerebral lesion is present.
There is good reason for referring the glands to the lympho-
matous or lymphoblastic group and there is no evidence of tubercu-
losis.
GLANDS 389
The fact that glandular enlargement was noticed immediately
after the purulent cutaneous lesions of the summer of 1909 renders it
barely possible that a septicemia, with glandular hypertrophy in
response to it, may be at the root of her troubles. Such a septicemia,
producing not only local but general glandular enlargement, is not
infrequently seen in the form beginning with tonsillitis and associated
with streptococci.
Outcome. — ^April 11, 1913, Dr. James L. Wheaton, Jr., of Paw-
tucket, R. I., the patient's family physician, writes as follows: After
leaving the Massachusetts General Hospital the patient was given
x-ray treatment to the glands, as recommended there. She grew
progressively worse and the glands in the neck enlarged. In every
way she appeared to be ncaring the end, which was predicted when
she was at the hospital. She has had a good deal of facial acne, and
in the attempt to clear this up a staphylococcic vaccine was given,
and, "much to my surprise, not only did the acne improve, but the
glands began to diminish in size and her strength gradually returned.
Ever since that time I have given her regular doses of staphylococcic
vaccine. She has regained her weight and most of her strength.
The glands have almost disappeared, and it seems as if she was to be
well again.'*
The diagnosis of Hodgkin's disease or lymphoblastoma was that
thought the most probable when she left the hospital, but, in view
of the above information, this seems to be very improbable. An
adenitis of the septic type seems the most reasonable diagnosis.
Case 158
A cook of forty-one, a Swede, entered the hospital November 22,
1 9 10, on account of frequent attacks of tonsillitis and enlarged tonsils.
On the 23d the tonsils were removed, also the adenoids. The patient
left the hospital the same day. December 20th, 1910, the patient
came into the hospital again, stating that since last July he had been
bothered by stiffness and pain in the lower back, increased by quick
motion or lifting. For the last eight weeks, in addition to this pain,
he has had soreness and stiffness in the right shoulder and elbow.
Since his operation of three weeks ago he has had a painful swelling
in the glands of his neck. He has no cough, but raises a good deal of
matter from his throat. For years he has always had some shortness
of breath on exertion and occasional attacks of pain in the left axilla.
He uses ^ pint of whisky a day, but has never lost a day's work on
account of liquor. His family history is negative, his appetite has
39°
DIFFERENTIAL DIAGNOSIS
been good, but he has lost markedly m weight. Eight years ago be
weighed 172 pounds; a year ago, 154 pounds; now, 127 pounds.
Physical examination showed fair nutrition. Normal pupils and
reflexes. Throat slightly reddened, but usually no exudate. Id the
right side of the neck were tender, matted masses of glands; mmy
similar glands about the size of a pea below this. AxiUary, ingumal,
and epitrochlear nodes were palpable, but not abnormal. Chest and
abdomen negative. There was some tenderness and pain about the
left scapula and right sacro-iliac joint. Urine negati\-e. The blood
showed a slight polynuclear leukocytosis, ranging from ii,oco 10
Fig. I j4. — Condition o( liver and glands in Case 1 58
ig,ooo. Dr. Osgood considered the condition of the back an infeO
tious arthritis. On the 14th of January the conditions were as shop
in Fig. 134.
Discussion. — This history reveals an alcoholic, with enlai
cervical glands, followHng a tonsil operation, with pain rather v
distributed in the trunk and right arm, with marked loss of we^
dyspnea, and anginoid paroxysms.
The physical examination shows, besides the cervical mass, ;
GLANDS 391
enlarged liver, the surface of which is so uneven that only three possi-
bilities need to be considered— malignant disease, syphilis, and
hydatid. We have nothing in the patient's history nor in his blood
to support the theory of hydatid, and his marked loss of weight and
severe general discomfort is not what one expects in patients suflfer-
ing from hydatid disease. As a rule, such patients complain of very
little, but we need an explanation of the lump below the ribs. This
patient does not want explanation, but relief.
Syphilis cannot be excluded, but we have no positive evidence of
it. Malignant disease is probable.
Outcome. — One of the glands was excised and examined by Dr.
J. H. Wright, who foimd it to be a metastatic malignant tumor, the
nature of which he could not at first determine. January isth a
red patch appeared on the right cheek, which was pronounced "erysip-
elas" by a skin consultant. The patient lost ground rapidly, and died
on the 30th of January. Autopsy No. 2785 showed a neuroblastoma
of the neck, pleura, liver, retroperitoneal and bronchial IjTnph-nodes;
tuberculosis of a bronchial lymphatic gland, chronic perisplenitis,
hydrothorax.
Case 159
A farmer of thirty-six entered the hospital January 2, 1911.
In the fall of 1909 he was laid up four days with an attack of nausea
and vomiting without assignable cause. Before this he had always
been well. Family history excellent. His next attack was from the
spring of 1910 to the 3d of July, 1910. Since then he has had an
attack about every third week, lasting three or four days at a time.
The vomitus is brown and never contains blood. His stomach has
been washed out a number of times without any special benefit in the
way of information or improvement. His last attack was December
15th. His appetite, bowels, and sleep are good and he feels perfectly
well. He loses about 10 pounds with each attack, but quickly regains
it. He has never had anything like lightning pains or other sensory
symptoms.
Physical examination shows normal pupils, glands, and reflexes,
and is in other respects wholly negative, save for a rapid pulse and a
slight excess of blood-pressure (Fig. 135). Blood and urine were
normal. Weight, 119 pounds, stripped. Wassermann reaction nega-
tive. Dr. J. J. Putnam found no lesions of the central nervous system.
Examination of the eyes was negative, as was examination of the cars.
There was a very slight enlargement of the thyroid. The edge of
392
DIFFERENTIAL DIAGNOSIS
the liver, finn, smooth, not tender, was felt 2 inches below the ribs
on the 3d of Januarj-. There was a very shght, fine tremor of the
fingers. No bulging of the eyes, no sweating. The patient had no
symptoms during his week in the hospital and left on the 7th of
January-.
On the 28th of March, 1913. he writes that his vomiting spells have
been coming somewhat more frequently during the past two years.
The)- are not accompanied by pain, and he recovers very rapidly from
them. He states that the nerves of his stomach are stronger, but that
his throat seems to be swelling and that he has some spells of choking.
Discussion. — The periodic spells of vomiting
arc like those often seen in tabes, but there is
nothing else in the case to suggest this, and the
important points in the physical examination
are the palpable liver, the slight enlargement
of the thyroid, the tremor, and the rather high
blood-pressure. I have never known such vom-
iting spells as this to result from a thjToid in-
toxication. Vomiting may form a part of such
intoxication, but only in patients whose other
toxic S)-mptoms arc much more marked. It
seems to me very doubtful whether the thyroid
has anything to do with this patient's vomiting.
Outcome. — The patient was seen again April
33. 1013- Hf stated that his vomiting spells
now lasttxl only part of a day instead of two
or throe da\*s. as former!)-. This lime he men-
tione<i that tluring the pre\ious year he had
had four spoils of pain in the logs, each attack
lasting liir a whole night, and darting, as he
sa)s. like a pleurisy, which, to him. means very
quickly. Although the pain, as he says, darts,
it is yet confined to one spot, and in each at-
tack this spot has been st>mevvhere between the
knee and the anklo. Durina the past six months
his vomiting attacks have come everT.' other day. usually starting
about 0.30 A. M. There is no nau^-a with the attacks, but he b ver>-
nervous in them and wants to bo alono in a dark rtiom. He has done
no work for three )ears. Occasional!)- a ilrink ol water sticks some-
where in his gullet and is regurgitated. Fo^xl is sometimes regurgitated
in the same way. and after such an attack he has lor some minutes a
;.— Chart >H"Caj*-
GLANDS 393
sense of obstruction in the gullet. The patient entered the hospital
again on the 23d of April, 1913, stating that the attacks of vomiting
had gradually grown more frequent. He has lost 5 pounds in weight.
Examination shows normal pupils, very lively knee-jerks and
plantar reflexes, but is otherwise negative. Systolic blood-pressure
is 156 to no mm. Hg.
His lumbar puncture fluid shows 50 cells per cubic millimeter, all
of them lymphocytes. Wassermann reaction in this fluid is positive;
in the blood, negative. An x-ray shows no change in the outline of
heart and aorta, no evidence of aortitis. Cerebrospinal syphilis with
gastric crises is evidently the diagnosis, despite the normal pupils
and knee-jerks. The enlarged thyroid is probably unimportant.
Case 160
A farmer of sixty-five entered the hospital January 23, 1911.
The patient had "scrofula" in childhood; that is, the glands in the
neck were then enlarged and discharged for a time, but have never
bothered him since until three months ago, when he noticed that on
the right side of the neck the glands were larger than usual. For
a week they have been painful and tender. The tonsil was removed
this morning in the Out-patient Department for diagnosis. His
apf)etite is good, and he has slept well until this week, when the pain
has kept him awake. He had worked until entrance, has no cough, no
fever, no loss of weight.
Physical examination shows a well-nourished, healthy-looking
man. Pupils and reflexes normal. Under the angle of the jaw, on the
right, is a nodular mass the size of a fist. Elsewhere the glands are
not enlarged. The right tonsil is about the size of a plum and is ab-
normally red. Physical examination otherwise negative, blood and
urine normal, no fever in ten days' observation.
Discussion. — Apparently this patient had adenitis in his child-
hood, perhaps tuberculous, but we have no reason to connect that
with his present troubles. The essentials in his present clinical condi-
tion are three months' complaint of cer\dcal adenitis, with one week of
pain and tenderness, in a man of sixty-five who feels perfectly well.
The physical examination adds nothing except on the negative side.
There is no reason to assume that the glands represent metastatic
deposits, for there is no disturbance in the function of any thoracic or
abdominal organ. It is not at all probable that they are tuberculous
or syphilitic, since neither of these types of adenitis is apt to appear
in a healthy man of sixty-five. There is no evidence of sepsis. A
394 DIFFERENTIAL DIAGNOSIS
primary tumor of the gland itself is the only plausible h}rpothesis
remaining.
Outcome. — Pieces were removed from the tonsil and examined by
Dr. W. F. Whitney. Diagnosis given, lymphosarcoma. Dr. Mau-
rice H. Richardson saw the patient in consultation and advised no
operation. The Wassermann reaction was negative. The patient
was given a;-ray treatment and improved considerably. Nevertheless,
on February ist he felt that he must go home and did so.
Remarks. — ^Although the diagnosis of lymphosarcoma is here re-
corded, there is no reason to believe that this represents anything but a
variety in terminology. What we are dealing with is that same extra-
ordinary multiple form of disease, already several times exemplified
in this chapter, lymphoblastoma. It may be worth while here to
indicate some of the extraordinarily wide clinical differences which are
now included under this single term:
(i) The disease may be acute or chronic. It may last forty or fifty
years. It may run its course within a few weeks and prove fatal within
a few weeks.
(2) It may be confined to a single gland or group of glands, either
inside the body cavities or in the familiar external sites of glandular
enlargement.
(3) It may or may not be associated with involvement of the spleen,
the bone-marrow, and the minute lymphadenoid foci situated in the
skin and subcutaneous tissues and elsewhere.
(4) It may be associated with normal blood or with lymphemia.
(5) The glands may be few or many, large or small, hard or soft.
Owing to its extraordinary chronicity in certain cases, one hesi-
tates to class it with the malignant neoplasms, yet in other cases no
known tumor is more rapidly fatal or invades more disastrously the
surrounding parts.
Case 161
A storekeeper of forty-eight, bom in Russia, entered the hospital
Februar>' 21, 191 1. A year ago the patient began to get weak and
could not do his usual work. Three months ago he noticed a lump
under the skin of the right temple; two weeks later, another over the
left eyebrow; a fortnight later, two more in the same region. After
this last group appeared, he began to have headache and noticed
a squint, for which he consulted an eye doctor, three months ago,
without benefit. For the last two months he has noticed no change
in the size of the lumps, but his headache often keeps him awake.
GLANDS
395
It was a good deal relieved, a week ago, by a nosebleed. He gave
up work, finally, about a month ago, though he had not been working
well for some time before that. Eighteen months ago he weighed
148 pounds; seven months ago, 135 poimds, with clothes; now, 118
pounds, without clothes.
Phy^cal examination shows poor nutrition, slight pallor, five
tumors about the face, in the positions indicated in Fig. 136. Nimiber
I was soft, unattached to the skin, not movable or tender, not fluctuant,
about 3 J cm. in diameter; No. 2 is firmer, otherwise about the same.
The others resemble No. 2. The
left eyeball is somewhat protu-
berant and shows external squint.
The left pupil reacts very little
to light and not at all to distance.
The lymph-glands are not re-
markable. The heart is negative,
save for a late, blowing systolic
murmur, transmitted to the axilla
and the whole precordia. The
ai>ex extends 4 cm. outside the
nipple line in the fifth space. The
impulse is diffuse and heaving. ^. ^ cu • • • r 1
^ ^ Fig. 136. — Showing position of lumps in
At the base hardly any first Case 161.
sound is audible. The pulmonic
second is accentuated. Blood-pressure, 135 mm. Hg., systolic; 80
mm. Hg., diastolic. The lungs are negative.
The abdomen is negative except for a deeply felt sharp edge, cor-
responding to the spleen, and a similar edge, probably the liver; both
of these edges about 2 inches below the ribs. There was no tempera-
ture in ten days' observation. The urine was not remarkable, save
for the presence of the Bence- Jones body. The blood showed red
cells, 2,100,000; white cells, 7500; hemoglobin, 75 per cent. Differ-
ential coimt not remarkable. Stained smear shows a few abnormally
stained or stippled red cells, moderate achromia, and deformities of the
red cells. Examination of the fundus by Dr. Quackenbos shows
nothing abnormal. Wassermann reaction is negative. On the 26th
I examined the blood and found a high color index, with much ab-
normal staining and stippling, but no other changes in the red cells
and no abnormal variations of the white cells. X-ray, No. 18,631,
shows areas of rarefaction, average size that of a twenty-five-cent
piece, throughout the skull bones, also suggestions of similar proc-
396 DIFFERENTIAL DIAGNOSIS
esses on one or two points on each humerus and quite clear evidence
of a similar tumor on one or two ribs. The stemxmi, pelvic bones, and
scapulae are negative.
Discussion. — This patient has been losing strength for a year and
is 20 pounds imder weight, yet his local symptoms are confined to the
last three months, when there appeared a group of symptoms con-
fined to the head, namely, palpable lumps, headache — ^more or less
relieved by nosebleed — and a squint. Physical examination shows
that there is, in addition, an enlargement of the liver and spleen, a
curious atypical anemia, and, most significant of all, the Bence- Jones
body in the urine. In the differential diagnosis, chloroma may be
excluded by the blood examination. Hypernephroma is possible,
but the presence of the Bence- Jones body is strongly against it.
Moreover, hypernephroma is rarely associated with any such anemia.
Syphilitic gummata are not associated with the presence of the
Bence- Jones body in the urine, and after a duration of three months
would probably have involved the skin. Moreover, there are no
other manifestations of syphilis. The ic-ray examination excludes
syphilis and shows lesions quite unlike those of metastatic hyper-
nephroma. Indeed, our radiologists were quite ready to make the
diagnosis of multiple myeloma from the x-ray picture alone.
Outcome. — ^A bit of tumor No. 2 was excised on the 2Sth and ex-
amined by Dr. James H. Wright. He considered it to be a myeloma
of the plasma-cell type. The excised tumor was embedded in a crater
of bone with a sharp edge. A blunt instrument, inserted i cm. over
the edge of the crater, did not strike bottom. March 3d the patient's
wife insisted on taking him away. He died early in the following
May.
Case 162
A laborer of eighteen entered the hospital July 12, 191 1. Nine
years ago the patient had irregular chills and fever for six months.
It was called "malaria,** but there was no blood examination. He was
never disabled except during chills. There is no other malaria in
his region. He has never been out of Massachusetts. November,
1910, he had pain in his ankles, which prevented him from working
all winter, and was associated with a gradually increasing weakness.
During May, 1911, he gained somewhat in strength and weight, but
otherwise he has been losing. In March, 1911, lumps apf)eared in
the right side of his neck, but they are now smaller than they were in
March. His best weight was 143 pounds in November, 1910, in
GLANDS 397
clothes; now he weighs 105 pounds, without clothes. Save for weak-
ness be still feels perfectly well, but has done no work since November,
1910.
Phy^cal examination showed very poor nutrition ; normal pupils
and refiezes. Enlarged glands were palpable in the neck, on the right
side of which is a firm, adherent, insensitive mass, 10 by 6 cm., with a
few smaller masses at its edges. Other glands, the size of peas or
beans, were to be found on both sides of the neck. The axillary glands
were nearly as large as a pigeon's egg. The groin glands were not
enlarged. The chest was negative; the edge of the spleen reached
nearly to the navel. The edge of the liver was also easily palpable.
F'K- 137- — Chart of Cast i6.'.
There was no edema. The course of the temperature is seen in Fig.
137. The red cells numbered 2,000,000 at entrance and declined in
a fortnight to 1,000,000; later, to somewhat below that point, where
they continued up to the loth of August. The course of the white
cells is seen in the accompanying chart (Fig. 138). The stained smear
showed almost no achromia, no macrocytosis, considerable deformity,
occasional abnormal staining. Blood-plates diminished. By the
29th of July there was marked achromia, and on the icth of August
considerable stippling. The polynuclears were hardly larger than
red cells. The patient had severe nosebleed soon after entrance, the
source of which could not be located by a larj'ngologist. A spray of
398
DIFFERENTIAL DIAGNOSIS
^^HW fc-" -^
alilii2ait£4il.£il ^--
X :
-i-s" M :. --
i"'""--J^^"-"-"
zz X
. • '--'-l-
fl ■. = ---,== = .--.. — :
..-—
1'-' "I" - - ---
Fig. 13S.— Blood chart of Case 161.
GLANDS 399
adrenalin, i : 10,000, four times a day in both nostrils, checked the
bleeding.
Discussion. — No one could have any considerable doubt regard-
ing the diagnosis of this case, provided he examined the blood at all,
and with such glandular and splenic enlargements I fancy that few
would to-day neglect blood examination. Taking together the re-
sults of blood examination and the blood-picture, we have a fairly
typical case of what used to be called acute lymphatic leukemia, or of
what is now interpreted as the sudden outpouring of lymphoblastoma-
tous cells into the blood-stream.
I have called attention to the fact that for many months this
patient complained of but little but weakness; that the appearance
of the lumps in his neck occurred considerably later, and that during
this period of weakness the diagnosis could probably have been made
by blood examination. I have twice made such a diagnosis in a
patient complaining of nothing but weakness and presenting no
glandular or splenic enlargements.
A second point of interest is the remarkable leukopenia during the
last weeks of the patient's life. On the 8th of August the number of
white cells was only 600 per cubic millimeter. Such a terminal fall
in the leukocyte count is not uncommon in cases of this type. Some-
times the leukopenia is the result of infection, streptococcus septi-
cemia, pneumonia, or erysipelas; sometimes, as in this case, its cause
is entirely obscure.
Outcome. — There was no improvement, and the patient left the
hospital on the 12th of August.
Case 163
A printer of twenty-six entered the hospital November 8, 1911.
The patient's wife has one child, now a month old and apparently
healthy. A year ago she had a miscarriage, and two years ago a baby
bom prematurely at the eighth month. The patient has always been
well until three weeks ago and denies venereal disease. Three weeks
ago, after recovery from a slight sore throat, he noticed a swelling in
the left side of his neck. This swelling reached its present size in
about two weeks and has not changed in the past week. A week ago
a swelling began on the other side of the neck and was accompanied
by some pain. He has noticed sweating in the night several times,
especially at the beginning of this illness. His best weight is 142
pounds; present weight, 128 pounds. He has worked steadily, though
feeling unusually weak. His family history is excellent. He comes in
400 DIFFERENTIAL DIAGNOSIS
from the Out-patient Department with a diagnosis of "acute adenitis
of unknown origin."
Physical examination showed poor nutrition, pallor, pupils slightly
irregular and reacting very sluggishly. In the left side of the neck
was a mass of glands the size of a baseball, hard, not tender, showing
no fluctuation. Below this and above the clavicle were small, hard,
discrete, insensitive glands. On the right side of the neck a gland the
size of a large pecan nut was movable, insensitive, not fluctuant. No
other enlarged glands detected. The teeth in very fair condition.
The throat showed general reddening and the hard and soft palates
look granular. The chest and abdomen were negative. The artery
walls showed slight fibrous thickening. The reflexes were normal.
Blood-pressure, 82 mm. Hg., systolic; 55 mm. Hg.. diastolic, at
entrance. A month later, 100 mm. Hg., systolic; 50 mm. Hg., dias-
tolic; December gth, 110 mm. Hg., systoUc; 60 mm. Hg., diastolic
The course of the temperature is seen in Fig. 139. The urine was
negative. The blood showed red cells, 3.200,000; white cells, 10,000;
hemoglobin, 72 per cent. Stained smear showed moderate achromia,
a rare stippled cell, and slight variations in size and shape. Differen-
tial count showed a slight polynuclear leukocytosis.
During his stay in the hospital the red cells rose to 3,500,000;
the white, to 13,000. There was no other considerable change in the
GLANDS 401
blood. Wassermann reaction was negative. A throat consultant
thought the glands were of tonsillar origin and advised removal of the
tonsils. Dr. G. F. Balch advised no operation. On the 14th of No-
vember a gland was removed from the neck for diagnosis.
Discussion. — There is a good deal in the case to suggest syphilis,
for, although the patient denies venereal disease, his wife has had one
miscarriage and one premature child. The pupils have points in
common with those seen in tabes, and for a considerable period the
glands were smooth, hard, and insensitive, like those seen in syphilis.
The anemia, the fever, the loss of weight, the night-sweats are
all perfectiy consistent with the diagnosis of syphilis. On the other
hand, the negative Wassermann reaction and the very low blood-
pressure militate to a certain extent against this diagnosis.
It is of interest that the consultant from the throat department
considered the glands of tonsillar origin and advised tonsillectomy,
although it would be hard to explain the anemia, the low blood-
pressure, and the loss of weight and strength upon this hypothesis.
Tuberculosis and Ijonphoblastoma remain. Between these dis-
eases only histologic examination can decide.. The low blood-pressure
slightly favors the former.
Outcome. — Dr. W. F. Whitney reported that the gland showed
increase of follicles and some small cheesy centers, with large giant
cells and an occasional epitheloid cell. Diagnosis, tuberculosis. On
the 20th the tonsils were removed. One of them examined in paraffin
section, by Dr. J. H. Wright, showed typical tuberculosis. An
emulsion of the tonsil in salt solution was made, and 20 minims in-
jected in a guinea-pig November 20th. December 2sth the pig
was killed. Autopsy showed tuberculosis of the glands and spleen.
The patient ran a higher fever after the tonsillectomy, but otherwise
seemed to feel well. No signs developed in the lungs. He seemed
considerably better. He ate well and nothing could be found in his
lungs, but on the 9th tubercle bacilli were found in his sputum. He
promised to report to the Social Service in the Out-patient Depart-
ment and was accordingly discharged. He went to Rutland State
Tuberculosis Hospital, and died there November 13, 191 2.
Case 164
A Greek baker of twenty-one entered the hospital April 23, 191 2.
For three months he has had lumps on each side of his neck, gradually
increasing in size. He feels perfectly well in other respects. Family
history and past history good. He denies venereal disease.
Vol. 11—26
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Case 165
\ r.-^T':'" '.• ^ v.* : *y *r r^r vr/v'.- : ::h ::^<«::»i! May 25, 1912.
'I fi' '..'•iM/ ■;.♦».'- ':]*■■) •: J •: 'TTj 't.c »::..\i:.. Hi> family histon*,
;••■/'■ :. * I :,:: ^ * i *• -rv . ^.::."'rvvi>t- eiK'ii Hi iir.ii^vi-norcal disease.
I '. .• ".'.' ": : :". *!' :!":i '.••] :. lur-.v- ir. \b: !i-:"i >irli- of his neck
; ri' :• • I-..!';'" ;,:(■■: :;rTT. :. >:iL''r.: ;.v":.;r.L ^^ hich LTaduallv wore
:.','. 'I*.-«' ••.■.•■•►: \:i". 'd ■<v::\vj.r rri:.>> ..■.»;u ;.rivl in I he left axilla.
'Iv-. vp- !'.*•: : :'■■ :: :■;:• :• :.i)j»*-:;rtvi ir \hv fvSvx >ivii of his neck and a
rti'i!.tf ;■:•■. 'tu* ;ri Mi' ri-j : iixill::. Hi !..i> ivJ^*. wriLihi and sironglh.
;iTi'l !••» 'V.'. \v«l h;: M'»Tic tj" \v.»rk. \\;iik;;;L v';.;isi'> his ihigh? ^^"^
;i' h' Hi ;i|»|i«tit« lijim di.L'f.-livn ari- iTiKK:. He has no fever a? ^^^
CIj\NDS 403
le knows. Four months ago he weighed 165 pounds, with clothes;
now, 142 pounds, without clothes.
Physical examination shows a well-developed muscular young man
»ith normal pupils and reflexes. Heart and abdomen negative. On
each side of the neck, between the sternomastoid and the trapezius,
is a mass of glands, larger on the left side. Similar masses in the
axillie. The left side 5 cm. in diameter, the right somewhat smaller.
No enlargement of inguinal or epitrochlear glands. The left lung
Fig. 140. — Cfaest signs in Case 165.
shows at the apex, posteriorly, dulness, bronchial breathing and
whisper, normal fremitus. No riles. At the base, dulness, de-
creased whisper and fremitus, normal breathmg. The substernal
dulness is increased (Figs. 140, 141). The course of the temperature
is shown in Fig. 142. The urine is normal. Blood-pressure normal.
The blood shows 22,000 white cells, with 89 per cent, polynuclears.
There is slight secondary anemia.
Discussion. — We have some reason to suspect that the patient's
father was syphiUtic, but there is no positive evidence of this disease
1
404
DIFFERENTIAL DIAGNOSIS
in the patient himself. Generalized adenitis, with loss of flesh and
strength, fever, anemia, and polynuclear leukocytosis, are signs com-
patible with any of the three causes of general glandular enlargement
most frequently demanding consideration in differential diagnosis — I
sjphilis, tuberculosis, and lymphoblastoma.
But against tuberculosis is the presence of mediastinal pressui
symptoms, such as, so far as I know, are never produced by tubeM
Fig. 141. — Chest signs in Case 165.
culous glands. I have called the pulmonary signs those of mediastinal
pressure, because of the absence of riles and sputum and because
of their association with an increase of substernal dulness. But for
these facts the lung signs might well be interpreted as tuberculosis.
Leaving tuberculosis out of consideration, we have to consider
whether syphilis would be likely to produce so much glandular enlarge-
ment without any other lesion, ami especially whether it could account
for the intrathoracic signs. The substernal dulness might be accounted
for by an aneurysm and the pulmonary pressure signs in the same way.
It would be rather unusual, however, to find such an aneurysm with-
out any paralysis of the vocal cords or evidence of tracheal displace-
GLANDS 405
ment. X-ray evidence of aneurysm should be sought for. Does the
tumor pulsate? Is it typically situated? The Wasscrmann reaction
should, of course, be done. If negative answers are obtained to all
these questions, the diagnosis should be lymphoblastoma.
Outcome. — An aJtillary gland was removed May 28th, and showed
entire disappearance of lymphoid structure and replacement by
small, round cell growth with a marked excess of fibrous tissue. The
'57;
25:
Fig. 141— Chart of Case 165.
cells were a little larger and more irregular than normal lymphoid
cells. Diagnosis^lymphoma. X-ray, No. 20,850, showed a shadow
in the left side of the chest, more dense at the apex than at the base.
The shadow at the base suggested a small amount of fluid. There
were enlarged glands at the roots of each lung. The shadow of the
heart and great vessels was generally enlarged. The patient entered
only for diagnosis, and left the hospital on the 29th.
CHAPTER \TI
BLOOD IN THE STOOLS iMELENA)
Melena means daric blood in the stools. so<alled tarrv sto(^
\llien this is present it means that the blood has been poured oat
high up in the intestinal tract. In practically everv' case this means
the gullet, stomach, or duodeniun. It is very rare to see a taxT>' stool
as a result of any hemorrhage in the small intestine.
Hemorrhages in the large intestine or in the rectum show them-
selves by the e3q)ubion of rebtively fresh and unaltered blood. The
latter are common and usuaily unimportant. The former, tarry
stools, are relativelv rare and much more im^rtant. Thev often
escape obser\-ation. as their color is much less alarTrurg and they
make less impression upon the patient's niizd.
Besides cross heiTiOrrhaees of either of the :\T>es iust mentioiied,
we have minute hemorrhages, demonstrable by chemical tests, such as
guaiac or benzidin. The latter are o: especial impcinaiice in connec-
tion with gastric cancer and gastric ulcer.
Fresh blood in the stoiils is due in the vast m^joiitj- of cases to
piJes in case the patient is constipated, or to nsi^riiis in case the
bowels are loose. These are the commcc ani relarrveh- mdizportant
causes for the ai>i>earance cf b'.cod in the s:>:ls. I: sbc»uii be remem-
bered, however, thai in elier'.v r»er>:ns canrer c-f the rectum is not
infrequcaitly mistaken fc^r pi-es and neclectei accc'rdingly. Every
case of recta! hem.irrhaire recurring in an elierS- r^rscin shoold be
carefulh* investiratei. in rier t ex:Iuir the rKJSsfbizrv' cc cancer.
The diagnosis i.f hemiirrh-iis internal :r external, is easily made b>'
inspection, especially if a rr •:t:»>: ci: tu'tie is used.
The suppctsed relatic»ns±ip between hemc^rrboids and cinhosis of
the iiver is probablv leeendan*. There is no ecvx: reason to beHe^'c
that piJes ccrur any more frequently in cdrrhorics than in other per-
sons of the same age.
Xext to hemorrhoids and acute diarrheas, cjmr^ o; ihc iniestine
or c»f the siomiach is the most imj>onaiit catise c»: a dischaixre of blood
with the feces. Tne amount o: bicKxi thus discharged is usually
verv small, and recofmizabie :inh- bv ih- chem.ical tests above mea^
tioned. In cancerous cases the dischar^re :•: b.i.xic is usur^Jrv steady^
40c
Blood in the Stools
(GROSS BLEEDING— NOT MICROSCOPIC)
HEMORRHOIDS ■^■■■i^^HIHHBI^^^H^^Hi 2290
COUTIS, ULCERATIVE)
COLITIS, PROCTITIS, \ ■■■■■■^^■^ 518
AND "DYSENTERY" i
CANCER OF RECTUM ^HlHHHHllH 475
PEPTIC ULCER ^HH^IH^H 370
TYPHOID 1 wt^a^mmm 332
CANCER OF STOMACH ^H^^ 209
CANCER OF SIGMOID HIH 117
CIRRHOSIS OF LIVER ■ 58
BILHARZIA DISEASE I 4
^ Disproportionately large because of the abnormally great number of t3rphoid cases
treated at this hospital.
(In phthisis, pulmonary blood is often swallowed and passed by rectum. How often
cannot be said.)
407
4o8 DIFFERENTIAL DIAGNOSIS
though small. In gastric ulcer, on the other hand, it is usually intet-
mittent, and the amount discharged is usually larger than in canoer.
Tarry stools — that is, the expulsion of a large quantity of blooA
changed by its retention in the intestine — are rarely seen in gastric
cancer or in any affection other than peptic ulcer or cirrhotic liveir -
Ulcerations of the large intestine, whether acute or chronic, usua^Hy
discharge pus as well as blood into the stools, and are to be dis
guished in this way from the causes previously mentioned.
In typhoid fever the hemorrhages are usually from the la^
intestine or the lowest portion of the small intestine, and the bl
is, therefore, relatively fresh or but slightly altered.
Syphilis of the lower portion of the colon usually shows itself
the first time by symptoms of intestinal stricture, but occasionally^ in.
the earlier stages of the same disease blood is discharged in the sto<:>ls,
and is then often attributed to hemorrhoids. Intussusception p>x~o-
duces bloody stools in a relatively small proportion of cases. TTr^e
same is true of infarction of the intestine, which usually results. in
symptoms indistinguishable from those of intestinal obstruction.
Bilharzia disease is a common cause of bloody stools in trop£<:=^
climates.
It must also be remembered that blood swallowed, either as *^i^c
result of a nosebleed or pulmonary hemorrhage or from some ulc
tive condition of the mouth, will appear in the stools and may
rise to the mistaken belief that the intestine or the stomach is
A careful history of the case will usually determine this point.
Case 166
An Italian laborer of twenty entered the hospital November ^*^ 7'
1902. About a month and a half ago the patient began to have dS-^^^'
culty with his bowels, frequent desire to defecate, but would pass o:^c^^*-^y
blood mixed with pus and mucus. This continued until three we^^^-*^
ago, when, under medicine, brown, watery movements began. Dur:»^^^8
the last five days he has passed very little blood or pus. He has ne*^*^^'*
had an attack like this before. Just before movements there i^^ ^
good deal of abdominal pain. The patient has lost no weight, ha^^ ^
good appetite, no nausea or vomiting.
Physical examination showed good nutrition, and was othen^^i^
negative, save as related to the abdomen, which showed dulness i^
the right flank, not changing with position. There was some general
tenderness, most marked in the left iliac region. The temperature
was 100° F.; pulse, 120; respiration, 32. Widal reaction negative.
^-
i
BLOOD IN THE STOOLS (mELENA) 409
The white cells were 26,700; hemoglobin, 98 per cent. The urine
was normal in amoimt; specific gravity, 1028; slightest possible trace
of albumin; rare hyaline and fine granular cast.
The patient seemed to have little or no control of the sphincter.
The stools were semisolid in consistency, dark brown to blue in
color. Most of them contained a little blood. Rectal examination
showed, projecting into the rectum and narrowing its lumen as far
as the finger can reach, frequent nodules, varying in size from that
of a large bean to that of a horse chestnut. They were very hard.
A surgical consultant could not decide whether the trouble was syph-
ilitic or malignant, but favored the former and advised antisyphilitic
treatment, which was immediately given, according to the local
custom of that day, in the form of potassium iodid, 5 gr. three times
a day, increasing 5 gr. each day.
Discussion. — The symptoms are those of proctitis with fever and
leukocytosis in a man of twenty. Such a condition would be of no
importance if it were acute. Most brief and mild diarrheas begin in
this way, but in this case the symptoms have lasted six weeks and
very little true fecal matter is seen in the discharges. Taking these
facts alone, one would conjecture that a chronic ulcerative proctitis
or colitis is the cause of his troubles. Without rectal examination,
such a diagnosis would probably never have been questioned. The
whole interest and significance of the case centers around the results
of rectal examination.
Nodules, such as those here described, may be due to bilharzia
disease, to syphilis, or to cancer, possibly also to a lymphoblastoma, al-
though in this case they would certainly appear elsewhere. The latter
observation applies to all of the other possible causes known to me.
Outcome. — A week later, as there was no improvement, a small
piece of the rectal growth was removed. Examination by Dr. J. H.
Wright showed a tissue characteristic of colloid carcinoma. The
cause was explained to the patient, and his friends then decided to take
him back to Italy. He left the hospital on the 4th of December.
Remarks. — This case shows that one must always consider cancer
of the rectiun, no matter how young the patient is. I remember a
similar case which I saw many years ago with Dr. Reginald H. Fitz.
There was much in the case to suggest cancer of the sigmoid, but as
the patient was only twenty-one years of age we excluded this from
consideration wrongly, as the outcome of the case showed. The
main lesson of the case is the importance of rectal examination, digi-
tal or ocular, in all cases of rectal disease lasting more than a few days.
DIFFERENTIAL DIAGNOSIS
Case 167
N
A jeweler of twenty-nine entered the hospital May 9, 1904- —
Twelve days ago the patient had a severe headache ajid felt weak- —
He took to bed, but did not stay there. After getting up again, how
ever, he grew rapidly worse; six days ago he woke in the night and hac^^k-
a profuse hemorrhage from the bowels, followed four days ago by an
other. The day before this last hemorrhage he took to his bed for *>"-
second time and has renuiined there since. Except for the hemor
rhages, his bowels have not moved at all as far as he knows. Hi* — s
family history and past history are excellent.
Physical examination is negative, except as relates to the abdomen _
which is markedly distended, and, upon the right side, somewbaA=:^
rigid. It is tympanitic throughout anc^
not tender. The temperature is 103.2" F. ^
pulse, 130; respiration, 24. The red cell &
are 2,396,000; white cells, 8900; hemo
globin, 55 per cent. The urine averagetS^
40 ounces in twenty-four hours; spedfic^:^
gravity, 1023; slight trace of albumin^
rare hyaline and granular casts. WidaS.
reaction was doubtful. On account oC
the spasm of the abdomen a surgical con —
sultant saw the patient on the 9th an<X-
found no evidence of peritonitis. Th^=- "
patient was slightly delirious, but hatV- —
no more hemorrhage and the distentioi^i- —
gradually decreased. On the 15th therms' '
was evidence of a moderate cystitis, antS- —
the bladder was washed three tiroes ^i- —
day with 2 per cent, boric add. Oi^
the 17th the blood showed red cells -^
4,800,000; whites, 4400; hemoglobin, 70 per cent. Differential counK-
normal.
Discussion. — Hemorrhage from the bowels in a patient previously
well, or comparatively well, is a ver>- rare occurrence, or, at any^
rate, is ver>- rarely recognized. Intussusception or infarction of th«
bowel may occasional!}- produce such a hemorrhage, but only in con-
nection with the evidences of intestinal obstruction such as are absent
here.
The different varieties of intestinal ulceration from which bleed-
±-
tZ:-r^7U:y-^±z
- -T— L-/I '\ \-\-
\v--XMi\m.
-1. ■':i^:.:
Fig. 143. — Chart of Case 167.
i
BLOOD IN THE STOOLS (mELENA) 411
ing may occur do not bleed with such suddenness and without pre-
vious evidences of intestinal irritation.
I think one would be altogether at a loss for a diagnosis here but
for the later appearance of abdominal distention, with fever and
deliriiun. This group of symptoms should make anyone of ordinary
intelligence search carefully for evidences of typhoid fever. There
are very few causes for intestinal hemorrhage combined with fever.
Dysentery may produce both these symptoms, but there is no dysen-
tery present in this case. Syphilis may do it, but the symptoms are
usually more definitely localized in or near the rectum and the
amount of blood discharged is smaller. I see nothing in the case to
invalidate a diagnosis of typhoid fever. A doubtful Widal reaction
should not weigh at all against such a diagnosis.
It is unusual to see intestinal hemorrhage so early in the course of
typhoid. As a rule, the bleeding comes in the latter weeks of the
disease. Still the case is by no means tmique, and will be classed
as one of "walking typhoid," with early hemorrhage.
Outcome. — Within a few days after this the temperature fell to
normal, having been continuously elevated before that time (Fig.
143). Convalescence was uninterrupted. He left the hospital on
the 14th of June.
Case 168
A housewife of thirty-eight entered the hospital Jxme 4, 1906.
Twenty years ago the patient first noticed bright blood and mucus in
the stools, which averaged six a day, almost all of them in the morning
and none of them at night. There was very slight pain just before
movements and relieved by them. Some of the discharges contained
fecal matter, others consisted wholly of blood and mucus. There was
no incontinence. Nine months ago she began treatment by daily
irrigations, and improved steadily up to three weeks ago. For ten
weeks there was no blood in the discharges, and the movements were
reduced to one daily and of normal consistency.
Three weeks ago the blood reappeared and the discharges be-
came more frequent. For nearly a year she has lived on nitrogenous
diet and has lost in weight, strength, and color. Except for lack of
appetite and weakness she feels perfectly well, and throughout the
trouble has been able to do most of the work for her husband and
three children.
Physical examination showed good nutrition. The patient did
not look sick. There was a soft, systolic murmur, loudest in the
412 DIFFERENTIAL DIAGNOSIS
pulmonary area, heard all over the precordia and faintly in the axilla.
The abdomen was tympanitic in the center, dull in the flanks, the dul-
ness not shifting with change of position. During the five weeks of
her stay in the hospital the evening temperature often reached 99.5**
or 99.8° F., usually normal in the morning. The pulse during the
first two weeks was between 80 and 90; after that, between 90 and 100.
The stools contained a moderate amount of mucus and were positive
to guaiac. Microscopically, they contained no blood or eggs, but
many undigested muscle-fibers. The patient was put on nitrogenous
diet, colonic irrigations at 116° F. twice a day, orphol 5 gr., three times
a day, after meals. 7 mg. old tuberculin was injected, without any
reaction. Proctoscopic examination showed no ulcerations in the
rectum. The blood and pus, however, did not disappear from the
stools.
Discussion. — When the stools contain only blood and mucus,
dysentery is usually the diagnosis, and by '^dysentery" in this connec-
tion I mean chronic ulcerative colitis. But at first sight this diag-
nosis seems to be impossible, because the patient has been doing all
the housework for a family of four and still shows good nutrition.
Any one of large clinical experience, however, has often seen similar
cases. It is really extraordinary how bad an ulcerative colitis
may exist without disabling the patient or even reducing his nutri-
tion to any extent. In other cases, apparently no worse from the
anatomic and pathologic point of view, the patient is utterly pros-
trated, emaciated, and useless. I know no way to explain these^
differences.
In the present case we have dulness in the flanks, without anjr
shifting with change of position. This physical sign is often seen ia
dysenteric cases, acute or chronic. The sUght fever present does
not help us toward more accurate diagnosis. The negative tubercu-
lin reaction, on the other hand, is of considerable importance. A
positive reaction would mean very little, but a negative reaction goes
far to exclude tuberculosis. Taking the negative features of the case
and the condition of the stools, I do not see how any other diagnosis
than ulcerative colitis is possible.
In New England one sees a good many cases like this in which
a non-amebic, chronic, and largely afebrile colitis arises without known
cause, and runs its course either to recovery or to a fatal termination
quite uninfluenced by treatment. Prognosis is never hopeless as long
as the patient is alive. I have seen the most seemingly pernicious and
virulent cases recover after all treatment had been given up. On the
BLOOD IN THE STOOLS (mELENA) 413
other hand, cases which, like the present one, seem in many respects
mild because their effect on general nutrition is for months and years
so slight, may at any time be transformed into a progressive, finally
fatal, disease.
In differential diagnosis one might consider cancer of the intestine,
but the long duration of the patient's illness makes this very im-
probable, especially as no tirnior has developed.
Outcome. — Pills of camphor, opium, and tannin were tried from
June 14th to^ June 29th, three times a day, before meals, also tannic
add irrigations, i dram to the quart. None of these methods of
treatment helped her. She left the hospital July 7th, unrelieved.
Case 169
A Canadian brick-maker of fifty-eight entered the hospital January
24, 1910. After fifty-seven and a half years of excellent health the
patient noticed last July that for a period of two weeks his stools
were tarry black. He felt well, however, until the first of October,
when he began to notice a distress fifteen minutes after eating, and
would often vomit soon after heavy food. Since this he has vomited,
as a rule, about twice a week, a large amount being ejected each time.
Soon after meals, always within an hour and a half, he has epigastric
pain and gas. He has never vomited blood. Meat and eggs give
him special trouble. His appetite is fair. He has no nausea. Bowels
are constipated. He sleeps well. Since last spring he has lost 32
pounds. He gave up work last August on account of this illness.
Physical examination shows fair nutrition, slight pallor, the right
pupil irregular and not responding to light or accommodation. The
left pupil normal. Glands and reflexes normal. Chest and abdomen
negative. The capacity of the fasting stomach is 28 ounces, and
the wash-water contains fragments of food and shows a positive
guaiac reaction. No free HCl. The lower border of the stomach
is at the navel after inflation. After a test-meal free HCl is absent
and blood present. The stools are strongly positive to guaiac on
each of five tests. Blood and urine normal. No fever. Blood-
pressure, 105 mm. Hg.
Discussion. — The point of special interest in this case is the
appearance of black stools as the first or presenting symptom and at
a time when the patient was feeling in other respects well. Indeed,
it was not until three months later that the group of gastric symp-
toms typical of gastric cancer made their appearance. The ex-
istence of gastric stasis, with a positive guaiac reaction and no HCl,
414 DIFFERENTIAL DIAGNOSIS
in a man of fifty-eight, who has lost 32 pounds in nine months and has
always been well until the present illness, leaves us little doubt that
gastric cancer is the diagnosis.
Why did the patient first bleed from the bowel? I am imable to
say.
Outcome. — On the sth of February operation showed a markedly
contracted stomach, infiltrated with new growth, from one end to the
other. There was not even enough normal stomach to allow gastro-
enterostomy. The patient was discharged February isth. A small
lymph-node excised at the time of operation showed no evidences of
tumor. Nevertheless, he died in January, 191 1.
Case 170
An Irish laborer of twenty-six entered the hospital March 3, 191 1.
The patient's family history was good and his past history unevent-
ful up to the time of the present illness. In 1896 he enlisted in the
British Army, and was four years in South Africa and then a year
in Mauritius, whence he was invalided home on account of the illness
next to be described. In 1900, when in South Africa, he noticed blood
in the stools and in the urine, but after a few days off duty felt well,
and six months later was transferred to Mauritius. After four months
there he began to notice blood in the urine, and stayed in a hospital
twelve weeks without improvement. Ever since then he has been
unable to work, and has had blood in the urine and pain on micturition
steadily. He urinates about twenty times a day and three or four
times in the night. Nevertheless, he has done some work, off and on,
until eight weeks ago.
Physical examination was negative, except that the urine con-
tained considerable blood and pus and large numbers of bilharzia
eggs, with spines at the end. The blood was negative. No tem-
perature in three weeks' observation. On one occasion there was a
considerable amount of blood in the stools, but no eggs.
Discussion. — When blood appears both in the stools and the
urine of a patient who has been in the Tropics, we should always
consider, first of all, bilharzia disease of the bladder and rectum, and
examine the urine and feces for the characteristic eggs with their
terminal or lateral spear point. In certain parts of Egypt and other
tropical regions, bilharzia disease is by far the commonest cause of
bloody stools. In this country it is rare, and, so far as I know, has
never occurred except in patients who have brought it from some
tropical region.
BLOOD IN THE STOOLS (mELENA) 415
Cancer of the bladder or of the rectum, infiltrating the wall inter-
vening between the two organs, may produce a simultaneous dis-
charge of blood in the urine and feces. Such a growth, however, is
easily detected by rectal examination or by cystoscopy, and at the
age of twenty-six would be extraordinarily rare. Aside from tuber-
culous disease and cancer, there is practically nothing else which can
produce a simultaneous discharge of blood in the urine and feces,
although, in hemorrhagic diseases, such an association is occasionally
to be observed.
Outcome. — Bilharzia eggs were later found. The patient was
given 0.6 gram of *'6o6" intravenously in alkaline solution, and, after
a moderate reaction, left the hospital on the 20th of March.
Case 171
An Italian laborer of forty-one entered the hospital March 20,
191 1. The patient lived in southern Italy until fifteen years ago,
then was in Russia five years, then in South America a few months.
For the past ten years he has been in Massachusetts. He had syph-
ilis four years ago. Up to three years ago he was a heavy drinker of
wine, beer and whisky, and was often drunk.
For three or four years he has noticed blood with every move-
ment of the bowels. The movements are soft and occur four or five
times a day, but cause no pain. His appetite is ravenous. Any
con^derable amount of solid food makes his bowels move more fre-
quently, so that he has lived mostly on eggs, milk, and macaroni.
For the past four months he says he has had to give up his work as a
ditch digger on accoimt of coldness of the feet. He has lost no weight
or strength, and feels well in other respects.
Physical examination showed a well-nourished patient who did not
look sick. The stools at this time showed no amebae or other ab-
normality. Wassermann reaction was negative, and, after two weeks'
observation, with normal temperature, blood, and urine, and a sys-
tolic blood-pressure of 135 mm. Hg., he left the hospital.
Discussion. — ^Three causes for bloody stools are suggested by this
history — syphilis, cirrhosis of the liver, and amebic dysentery. Of
cirrhosis we have no evidence. Syphilis of the rectum or sigmoid
should give us some evidence of intestinal stenosis. Nothing of the
kind is present here. The further determination of the disease rests
upon the study of the stools and proctoscopic examination. If
nothing particular is found in the stools, a diagnosis of ulcerative colitis,
cause imknown, will be our best surmise. In this case, as in one of
41 6 DIFFERENTIAL DIAGNOSIS
those previously recorded, the good nutrition of the patient is in
striking contrast with the long duration and apparent severity of his
disease.
Outcome. — Later on he returned and amebae of the histolytic
type were found.
Remarks. — Unfortunately, this patient was not given the benefit
of the emetin treatment, which had not at that time been discovered.
With such treatment a speedy recovery might have been expected.
CHAPTER Vm
SWELLING OF THE FACE
FmsT of all, it should be recognized that a certain amount of
swelling about the eyes and a trifling puffiness of the rest of the face
is normal in certain individuals when they first wake in the morning.
Doubtless there are individual di£Ferences of tissue which explain
why some people have this symptom and others do not. Nothing is
more striking than the individual differences between healthy people
as regards the dryness or juiciness, the firmness or flabbiness of their
tissues. Fat people are perhaps a little more apt to have this symp-
tom (early morning edema of the face) than others.
After an alcoholic debauch persons who never suffer from this
symptom at other times often present it in a marked degree. Just
M^hy I do not know.
During pregnancy a certain amount of edema, both in the face
3Jid elsewhere, is not infrequently seen, despite a normal condition
of the kidneys and heart. Such an edema, however, should always
lead us to a most searching investigation of the urine and of the
pjrecordia.
Local skin lesions, such as severe sunburn, eczema, measles, and
erysipelas, are associated with edema of the face, sometimes of tre-
xnendous degree. Especially in erysipelas one often sees a total
cdosure of both eyes, owing to the acciunulation of fluid in the loose
'tissues around them.
The familiar swollen face of toothache leads, as a rule, to no diflS-
culties of diagnosis, because it is unilateral and because the affected
tooth calls attention to its presence in unmistakable ways. Occa-
sionally, however, an affection of the antrum or a local abscess of the
cheek may accompany or simulate the edema of toothache. Careful
examination should set us right.
In glomerular nephritis, and in some of the degenerative tubular
lesions of the kidney, such as corrosive sublimate kidney, marked
edema of the face often precedes or exceeds the edema of other parts.
The vascular forms of nephritis and the more chronic slow-going
types less often produce facial edema. Children seem to be some-
VoL. 11—27 417
4l8 DIFFERENTIAL DIAGNOSIS
what more subject than adults to severe edema in connection with
nephritis, and this appUes to the face as well as to other parts of the
body.
Some years ago it was customary to say that cardiac edema was
never in the face, while renal edema was very apt to begin there.
This can no longer be maintained in any strict sense, although it repre-
sents the truth as regards the majority of cases. Pure cardiac dropsy,
without any nephritis, may produce swelling of the face, although
such swelling rarely precedes or exceeds the dropsy of other parts.
Of special diagnostic importance is the facial edema of trichiniasis,
first, because it is often forgotten, and second, because we are dealing
here with a disease which is much less simple than that of cardiac and
renal causes of edema. In trichiniasis the puffy face accompanies, as
a rule, a greater or lesser degree of conjunctivitis, and the swollen
lids are often red, in addition. Should such a group of signs be
associated with any unexplained fever, trichiniasis should always be
suspected, whether the classical pains and soreness are present or not.
When trichiniasis is suspected, as it should be, owing to conditions
described above, the next step should always be the examination of
the blood for eosinophilia. If that is present, trichiniasis is almost
certainly the diagnosis, provided, of course, that the renal and cardiac
and local dermatologic causes of edema are excluded. If eosinophilia
is absent, we cannot exclude trichiniasis, since there are now and
then cases in which this symptom is for a long time missing. Where-
ever it is possible the diagnosis should be further substantiated by
histologic examination of a bit of excised muscle, or, failing this,
by the study of the sediment of a specimen of venous blood, laked
with 3 per cent, acetic acid, according to the methods suggested by
Staubli^ and Janeway.^
In pernicious anemia edema of the face is much less common than
swelling of the lower extremities. Nevertheless, it is occasionally
seen, especially in cases which are being treated with large doses of
arsenic. How far arsenic-poisoning is the cause of such an edema it
is often difficult to discover, but whenever arsenic is being given in
supposedly therapeutic doses, edema of the face should make us sus-
pect that we are poisoning the patient.
Tumors of the neck or mediastinum may interfere with the venous
return from the head in such a way as to produce an alarming edema
of the head and neck. Thoracic aneurysm may occasionally produce
^Mtinch. med. Woch., 1908, Iv, 2601.
' Archives of Internal Medicine, vol. iii, p. 263.
Swollen Face
MORNING DEBILITY
ALCOHOLISM
TOOTHACHE
^ CASES TOO MANY AND TOO VAGUELY ENUMERABLE FOR GRAPHIC
REPRESENTATION.
J
CHRONIC NEPHRITIS
ACUTE NEPHRITIS
ERYSIPELAS
EPIDEMIC PAROTITIS
TRICHINIASIS I
WHOOPING-COUGH I
MYXEDEMA I
TUMORS OF THE -I
MEDIASTINUM / '
506
301
168
64
39
34
27
SWELLING OF THE FACE 419
»
the same result. In such cases the edema usually appears rather sud-
denly, and is associated with other pressure symptoms, such as pains
or dyspnea. Any reasonably careful physical examination should
reveal the cause of such an edema. Lymphoblastoma (Hodgkin's
disease) is probably the commonest cause of this type of edema.
Rarer diseases, leading to the same kind of venous obstruction, are
thrombosis of the superior vena cava or one of its main branches,
chronic mediastinitis, and angina ludovici.
In myxedema there is often some true edema accompanying the
myxedematous enlargement, whether in the face or other parts of the
body. Such cases are sometimes mistaken for nephritis, especially
if there chance to be some albuminuria and cylin4ruria.
Inflammation of the subcutaneous tissue due to anthrax, the
septic cellulitis of insect bites, and actinomycosis are rare causes of
facial edema.
In typhus fever (BrilPs disease) a suffusion of the* conjunctivae
is not infrequently associated with some edema about the eyes.
Drug eruptionSy such as an iodid of bromid rash, may be accompanied
by marked edema of the face.
Finally, we must always remember the possibility of an unex-
plained edema, to which we sometimes give the name of angioneurotic
in an attempt to cover up our ignorance. All that can be said of this
variety of swelling is that it may be extreme, may appear suddenly,
and almost always disappears within a few days.
Differential diagnosis of the different types just listed is usually
easy, provided we know what to look for and give the time neces-
sary to get a good history and to make a thorough physical exami-
nation.
Case 172
An electrician of thirty-three entered the hospital September 10,
1907. The patient was perfectly well up to two weeks ago, when he
began to have puffiness and redness of the face and hands, more
marked each morning, and accompanied by frontal headache. During
the past week he has had several chills, and sweats more than usual.
Yesterday he had a severe attack of vertigo and was for a moment
completely blind. He did not fall. He has gastric distress and
flatulence after meals and yesterday vomited once. He is very
nervous, and in the last two weeks has lost 8 pounds.
Physical examination showed good nutrition, marked puffiness
of the face, in which many muscles twitch involuntarily from time
420 DIFFERENTIAL DIAGNOSIS
to time. This twitching, he said, was never present until within
two weeks. The chest was negative, save for a sjrstolic murmur at
the apex, not transmitted. The spleen was not palpable, abdomen
negative. The white cells were 3400; hemoglobin, 100 per cent.
Blood normal. Blood-pressure, 100 mm. Hg. Owing to the history
of chills the blood was stained for malarial organisms, but none were
found. At entrance everything seemed to point to uremia, but the
urine and the condition of the blood-pressure seemed to negative this.
He was given a hot bath and collapsed twenty minutes later. His
temperature when first seen was 102.6° F.; pulse, 120. Both these
fell to normal the next morning and remained so throughout the day.
On the 14th the temperature again rose, as it had on the 12th.
Discussion. — The history of this case gives us no certain clue to
diagnosis. The morning headache, with puffy face, twitching, and
temporary blindness, hints strongly at a nephritis, but the negative
condition of the urine and blood-pressure enable us to rule this out
with reasonable certainty.
The type of fever is very unlike that of trichiniasis, and we have
no pain and no blood changes characteristic of that disease.
Since we note that the patient had fever on the loth, the 12th, ^ ^,
and the 14th of September, we at once think of malaria. Neverthe- — --
less, it should be remembered that tuberculosis or septicemia occa- — a-
sionally produce a tertian type of fever. Only by careful blood ex- — j^-
amination can the possibility of malaria be settled. I recently saw a «j^ a
case of tuberculous peritonitis in which the fever was strikingly like ^^^e
that of tertian malaria.
Outcome. — On the 14th a considerable number of malarial para ^ib-
sites were found. Under quinin the symptoms all promptly disap ^ig)-
peared, and by the 20th he was well.
Remarks. — How does the malaria account for the swelling of this
patient's face and hands? I am quite unable to answer the questioriMr^^n
and I have seen no explanation of it in literature.
Case 173
A shoemaker of thirty- three entered the hospital August 29, 191 rr _i.
Fourteen weeks ago the patient had toothache and swollen jaw. ^ A
dentist extracted the tooth and later lanced the jaw twice. The sweEZi/-
ing continued, and twelve weeks ago the jaw was again lanced at .. jd
poulticed. Ten weeks ago he was in a hospital and was operated cziZDn
for abscess of the jaw. The swelling was then much reduced, but io-^Mjr
days ago again increased. At entrance, August 29th, the whole facre^
SWELLING OF THE FACE 421
jaw, and neck were swollen and tender, especially on the right side.
There was no definite fluctuation, save about a small ulcer in the
center of the mass, where a crater-like depression was felt.
Ph}rsical examination, including the blood and urine, was other-
wise negative.
Discussion. — ^The swollen jaw is like that accompanying tooth-
ache and due to alveolar necrosis and sepsis. The history shows
that this was the first diagnosis made, but the continuance of the
swelling, despite the dentist's best efforts, makes us surmise that this
diagnosis may be wrong.
In 191 1 the Esch bill prohibiting the use of phosphorus in the
manufacture of matches had not been passed. Phosphorus necrosis
of the jaw was, therefore, a possibility at the time when this patient
^as seen, but as he had had no dealings with phosphorus this was
not seriously considered. Evidences of syphilis or tuberculosis must
be looked for in any lesion in this part of the body.
In relation to syphilis, our best procedure is to take a careful
history, do the Wassermann reaction, and, if necessary, try the thera-
peutic test. Tuberculosis can be diagnosed with any certainty only
by histologic examination of an excised portion. It is not common
in patients of this age and in this situation. The actual disease
foimd in the outcome would probably be suspected by very few of us.
Outcome. — Operation showed a honeycombed mass of pus pockets.
Microscopic examination of the discharges showed the organism of
actinomycosis. The patient left the hospital in good condition on the
9th of September.
Case 174
A laundress of twenty-four entered the hospital February 22, 1909.
The patient's family history and past history excellent, save for
scarlet fever seven years ago. She woke up this morning to find the
left side of her face and neck swollen. She had a slight headache and
the bowels did not move. Her temperature was 99.5° F. Physical
examination was negative, except for swelling and tenderness in the
region of both parotids, especially the left.
Discussion. — What else could this be besides mumps? Obviously
we have swelling of the glands, which are attacked by mumps. It
remains to inquire what else can attack them. A septic parotitis
not infrequently complicates typhoid fever, and is sometimes seen
as an inexplicable complication of peptic ulcer, gastric or duodenal.
Suppurative parotitis also occurs in acute and chronic endocarditis,
422
DIFFEREXTLAL DIAGNOSIS
:|-
*\t~i ■• [
Jetrf/i
' I
lirf/i!in»r9
ETJa
/f iicfi t n I
(i-ir »— I
^
in cerebrospinal meningitis, small-pox, Asiatic cholera, yeUow fever,
and, rarely, in lobar pneumonia. Parotitis complicating heart infec-
tion should be regarded as part of a general sepysis, and a similar in-
flammation of the parotid may be found in other tjpes of sepsis — for
example, hepatic abscess.
If none of these causes can be found, any acute parotitis should
be called mumps. If previous cases can be discovered and their con-
tagion proved, the diagnosis is all the more certain, but we cannot
always acquire such proof.
Outcome. — By the 3d of March the swelling was gone and she was
allowed to go home, but kept in isolation for ten days more.
Case 175
An Italian barber of twenty-tive entered the hospital April 6,
1909. Five days ago, while at work, he noticed that his eyes were
swelling up. Later, he had a
severe headache and pains all
over his bodv. The next dav he
remainerJ in bed. had no appetite,
felt feverish, nearly vomited sev-
eral times, and was constipated.
Phvsivral examination shows
good nutrition, eyelids red and
swollen, conjunctivae much in-
jectciJ and swollen. At the apex
of the heart is a ver\" harsh
b!r>win£:. ^y^t^>lic murmur, trans-
mitted to the axilla. Xo enlarge-
ment of the organ. Pulmonic
second sound not accentuated.
There is slight tenderness of the
biceps and calves: slight edema
of the legs. The urine is nega-
tive. The temperature is as
shown in Fig. 144. The blood showed ir.j;oo leukoc>'tes. 26 per
cent, of which were eosinophils.
Discussion. — The initial s\Tiiptoms are merely those common to
many infectious diseases and peculiar to none, but the fever and
leukocvtosis ass«)ciated with coniunctixitis. red and swollen evelids,
should make us ver\- suspicious of trichiniasis. Since there is an
eosinophilia. the diagnosis is rendered almost certain. What should
%md
V^
.m^^-i^
-W— •
'^W..-
-- — l
— ^
^
»«~
• *
tTT-
Fig. 144. — Temperature range in Case irs-
SW'ELLING OF THE FACE
423
be said regarding the cardiac murmur? In my opinion, it is explained"
merely by the fever and represents simply one manifestation of the
general infection. On the other hand, it is quite conceivable that the
murmur may represent the effects of some previous endocarditis.
Tht question can be decided by following the condition of the heart
after the fever has subsided.
Outcome. — On the i3th of April the eosinophilia had fallen to
ij per cent., at whicli point it remained April 14th. About 30 drops
■. Fig. 145. — Embryo o[ Trichindla spiralis in blood lajted with 3 per cent, acetic acid.
■'-<jkocytes and disintegrated red cells also are shown ( X 800). (Reproduced by kind
^^^'TnissioQ of Dr. T. C. Janeway, from the .'\rchitfes of Internal Medicine, where it
"^^tJeaied in April, igoy.)
'"^t blood were squeezed out of the ear into acetic acid solution, then
^^ntrifugalized. and the sediment examined. Two trichina embryos
"^^ere found in this sediment without much difficulty. The patient
•^ad practically no symptoms or signs except dull aching of the muscles.
t"his was present as late as the 19th of April, but he gained rapidly
^fter that date and left the ward well on the a4th. It was later
Warned that he had eaten uncooked sausages two weeks before the
beginning of this illness.
424 DIFFERENTIAL DIAGNOSIS
Remarks. — ^This method of demonstrating the trichiniasis embryo
is of special importance when the patient refuses to consider it a favor
for us to take out a piece of his muscle, or when the investigation
of such a specimen is negative. In certain cases the embryo may be
found in the blood without a long hunt (Fig. 145).
Case 176
On the same day, the 6th of April, 1909, an Italian tailoress of
twenty-one (whose case was in all respects similar to that just nar-
rated), was examined in the same way for trichinae in the blood, but
none were found. A teased specimen of muscle, taken from the calf,
serial sections of this muscle were trichinae finally found,
was then examined. It was also negative. Only on examination of
Discussion. — This case is inserted merely to show how difficult
it sometimes is to find the trichiniasis embryo. The examination of
serial sections is a task which not every pathologist will imdertake.
Case 177
A laborer of thirty-two entered the hospital December 23, 1911.
About five weeks ago the patient consulted his physician for swelling
of the right cheek. The physician made a small incision and let out a
cupful of pus. The cheek first looked like erysipelas, and was treated,
after incision, with wicks and poultices. Later, the inflammation
extended up toward the eye and the cavity had to be explored with
the finger. After this the swelling went down under poultices and
the patient did well until a week ago, when the edema returned.
A dentist declared that the trouble did not come from the teeth.
No general physical examination was made, but an x-ray showed pus
in the antrum and some bone necrosis.
Discussion. — Clearly we are dealing with some suppurative proc-
ess in the region of the cheek. It might be a local abscess or one orig-
inating in a tooth or in the antrum. Careful local examination alone
can decide.
As a more remote possibility, however, we should remember that
tuberculosis, syphilis, or malignant disease might be accompanied
with a good deal of suppuration, and are sometimes mistaken for
simple abscess. In the present case, however, the acute onset of the
s>Tnptoms and absence of any deep inflammation or induration makes
these three diseases impossible. It is in the relatively chronic in-
durated cases that the trio — tuberculosis, sjphilis, neoplasm — should
especially be borne in mind.
SWELLING OF THE FACE
42s
Erysipelas, which was considered here, is more superficial in its
effects and the amount of redness should be greater.
The case demonstrates the need of x-ray examination in all doubt-
ful swellings about this part of the body.
Outcome. — On the 2d of January, 1912, the wound was opened
and the probe touched bare bone in the region of the antrum. The
malar bone in the superior maxilla showed necrosis, which was chiseled
away and a large opening made into the antrum. On the 6th of Jan-
uary the patient felt much better, though there was still some dis-
charge. As he had had no temperature in two weeks' observation
he was discharged.
The patient reported at the Out-patient Department, where the
wound was treated, but January aad there was still some edema of the
flap, with irregular intervals of pain, lasting twenty to thirty minutes.
On the 29th of January the swelling was less, and careful examina-
tion showed no reason to doubt the original diagnosis.
Case 178
A coachman of fifty entered the hospital October 30, 1911. Three
nights ago he noticed swelling and tenderness of the right cheek.
The next morning it was mostly
gone, and that night it reappeared
and was then accompanied by red-
ness. Yesterday the swelling al-
most closed his right eye. He has
had no pain and no burning sensa-
tions. He attributes the trouble
to a bad second right lower molar,
which has been tender for a year or
two. His temperature has been
normal until last night, when it
rose to 101° r.
Physical examination is nega-
tive, save for a rough-blowing sys-
tolic murmur at the apex of the
heart, transmitted to the axilla,
a scar in the appendix region, and
a marked swelling of the whole pig. 146.~Tempen.ture range in Case 178.
right side of the face, closing the
right eye. The color was now bright red, with a sharp border along
the right side of the nose, and in the temporal region an area was
m
*s
ll^
m^
M%nv
S^
426 DIFFERENTIAL DIAGNOSIS
indurated and slightly hot. Temperature was as in Fig. 146. On the
31st he had a chill and his temperature rose to 104.4° F. The right
ear was now swollen and the left side of the face became involved.
Discussion. — In the early stages of this disease, before the sharp
line of demarcation, the deep red color, and the elevation of the
advancing margin have made their appearance, the symptoms might
be attributed, as in this case, to a bad tooth. The true diagnosis,
erysipelas, rests upon the local features just mentioned, upon the
presence of marked constitutional symptoms, the history of previous
attacks, the situation near the nose, eye, or ear, and the absence of
any deeper local cause of suppuration.
Outcome. — On the 3d of November the swelling was subsiding, and
by the 7th all redness and swelling were gone. He left the hospital
on the nth.
Case 179
A Russian storekeeper of forty-five entered the hospital January
6, 1910. Family history negative. Had rheumatism in his right leg
for eight years. Last August he was in a runaway, broke his left
forearm and injured his head. Denies venereal disease. Is not alco-
holic.
Five weeks ago his entire head and the upper part of his chest
became red, and his head swelled up so that he could not see. This
was accompanied by a great edema of the scrotum. The left hand and
fingers have been stiff since his accident, and his right hand and arm
and both legs, from the knees down, have been gradually getting stiff
for five weeks. They have never been swollen. For three weeks he
has not been able to walk. His physician has no knowledge of any
spinal injury. He has had no pain, no headache or backache, but
has lost 28 pounds since his accident eight months ago. For the past
month his sleep has been poor and he has been very nervous.
At entrance there was no fever, no edema, and physical examina-
tion was altogether negative. After considerable persuasion he was
enabled to walk. By the 12th of January he walked about the ward
and received Zander treatment. He complained enthusiastically of
many weird symptoms, such as fever in his teeth, blood in his belly,
and so forth, and, although he improved considerably, went home,
dissatisfied, on the 2Sth.
Discussion. — This is one of those curious cases in which the
diagnosis of hysteria or angioneurotic edema represents the best that
we can do, but they never should satisfy us or make us believe that
SWELLING OF THE FACE 427
we have got to the bottom of the trouble. Mediastinal pressure
was at first suggested by the marked swelling of the entire head and
upper chest. Local inflammatory causes are excluded by the absence
of fever and leukocytosis. The swelling of the scrotum makes it
clear that no local pressure in the mediastinum' will account for the
edema imless we suppose two separate causes.
There is much in the case to suggest a traumatic neurosis or
traxmiatic hysteria, but the interval of time between the runaway
accident and the beginning of these symptoms seems sufficient to
exclude this.
By the accuinulation of negative evidence against the more exact
and well-known causes for edema, we come down to hypotheses about
the vasomotor system, hypotheses such as have been expounded at
length by Solomon Solis-Cohen in various volumes of the "Trans-
actions of the Association of American Physicians." Vasomotor
ataxia, as Dr. Solis-Cohen calls it, is perhaps as good a name as
any for many mysterious symptom complications, of which the
present cause is an example.
Outcome. — Dr. E. W. Taylor considered the case one of hysteria.
Case 180
A Greek pedler of twenty-five entered the hospital March 21, 1910.
He was never sick until four years ago, when he had erysipelas. His
habits are excellent, and he denies venereal disease. Three weeks ago
he "caught cold." Eight days ago his face became swollen and the
next day his feet also. At the beginning of the illness he ha*d a chill,
felt feverish, with slight headache and pains in his legs and in the soles
of his feet. His bowels have not moved for four days. He has had
several nosebleeds and has bled from his ears.
Physical examination showed edema of the face, legs, and feet.
The heart's apex was in the fifth space, 2J cm. outside the nipple, the
right border 5 cm. in the median line. Sounds snapping in quality,
aortic second accentuated, no murmur; the pulse apparently of in-
creased tension and notably slow, 50 to 60. Systolic blood-pressure,
150. Otherwise physical examination was negative. The urine aver-
aged 40 ounces, slightly smoky in color. The specific gravity was
1025 on the average; albumin, 1.4 per cent. There were many casts,
mostly hyaline, with varying amounts of fat and epithelial cells ad-
herent. The blood showed slight achromia, 78 per cent, hemoglobin,
no leukocytes. In four days the edema was gone, under milk diet,
daily hot-air baths, and i ounce of magnesium sulphate every morn-
428 DIFFERENTIAL DIAGNOSIS
ing. Toward the end of his stay the edema persisted only in the
lungs and on the top of his head.
Discussion. — What else could this be but acute nephritis? We
have the sudden appearance of edema, with evidence of infection,
bleeding at the nose and ears, anemia, slight hypertension, and the
classical urine of acute nephritis.
I have seen a classical picture much like this in cerebrospinal
meningitis, but in that case the brain symptoms soon become more
marked. Nevertheless, the diagnosis of uremia was actually made
in this case and only the autopsy sets us right.
Trichiniasis would account for the edema, the pains in the legs,
and the evidence of infection. It is to be excluded chiefly by the
negative blood examination, the significant urinary findings, and the
course of the case.
Outcome. — On the loth of May, 1913, and on the nth of March,
1914, he reported at my request and declared himself perfectly well,
although it took him a year to recover his full strength. He went to
work three months after he left the hospital and has not had to give
up since. At the present time his blood-pressure is 125 mm. Hg.
and his urme is normal.
Case 181
A colored laundress of thirty-three entered the hospital February 9,
1 9 10. Her family history was negative. Five years ago she had a
red rash all over her body, a severe headache, and falling of the hair.
Since th^t time she has had various skin lesions on her face. In
October, 1909, she caught cold and had a severe sore throat and
cough. She was unable to swallow anything but milk and eggs on
account of pain in her throat. She was in bed four weeks. For the
past two weeks she has been hoarse, and for ten days has had diflB-
culty in breathing, with attacks of suffocation, lasting ten to fifteen
minutes. She weighed 130 pounds in October, 106 pounds in De-
cember, 116 pounds now.
Physical examination was negative, save for the evidences oi
laryngeal stenosis. There was marked infiltration of the left aryten-
oid and of the left half of the larynx. Dr. H. P. Mosher considered
the condition syphilitic. The Wassermann reaction was p)ositive.
Under daily inunctions of mercury and moderate doses of iodid of
potash the condition of the larynx rapidly improved, and on the 17th
of February the dyspnea was slight. On the 2 ist she was out of danger
and went home.
SWELLING OF THE FACE
429
May 18, 1910, she returned, having been at the Out-patient De-
partment since her previous stay in the hospital, with more or less
trouble all the time. Six days ago she was awakened in the night
with earache, toothache, and pain in the throat, and the next morning
the whole throat was swollen, as it now is.
Physical examination showed the cardiac apex 1 1^ cm. from mid-
stemum, 3 cm. outside the nipple. Fuhnonic second accentuated.
No murmur. An irregular area of discoloration was seen on the out-
side of the right leg, from the hip to the dorsum of the foot. The
whole face was somewhat swollen. From the right side of the lower
jaw, reaching down on the neck, there was an area of induration,
10 by 7 cm., very tender, and a small area of fluctuation was made
out, anteriorly to the stemomastoid muscle. The temperature
ranged as in Fig. 147. Blood-pressure, 112
xsm. Hg. Blood and urine normal. The
laryngeal stenosis was now much less
troublesome, and she suffered more from
<jysphagia than from dyspnea. She was
salivated and her gums swollen and tender.
Discussion. — The hoarseness and at-
lacks of suffocation following a syphilitic
infection leave no reasonable doubt that at
"the time of the first hospital visit the pa-
tient suffered from laryngeal syphilis. At
the time of the second hospital visit we
lave apparently a general cellulitis, repre-
senting one of the transitions from the most
superficial type of sepsis (erysipelas) to the
deeper and more localized infiltrations of
pus. The facial edema in this case is of the
same type seen in erysipelas. Presum-
ably there is a burrowmg of pus deep in the "^ ase 1 i.
tissues of the neck and face, the type of lesion often called deep cervical
abscess or angina ludovici.
Just what connection there is between this sepsis and the previous
syphilis I do not know. Probably the syphilis has predisposed the
patient to septic infection.
Outcome. — On the night of the 20th of May an abscess broke some-
where in her throat and she spat up pus. After that she was more
comfortable, and was referred on the 28th to the Out-patient Depart-
#;
f5
*:
1
Fij..
430 DIFFERENTIAL DIAGNOSIS
Case 182
A letter-carrier of forty-six entered the hospital December 2, 191 1.
The patient had scarlet fever in infancy; otherwise he has been
well and has an excellent family history. Denies venereal disease.
Takes no alcohol.
Eight days ago, while he was driving his letter-carriers' wagon, he
got his feet wet, and next morning his legs were swollen and his eyes
puffy, and he had some shortness of breath, with a slight dry cough.
His appetite, bowels, and sleep continued normal. For six months
he has noticed slight dimness of his eyesight.
Physical examination shows hearths impulse at the sixth rib,
2 cm. outside the nipple, 14 cm. from median line. Aortic second was
accentuated. Blood-pressure, 180 mm. Hg., systolic; no mm. Hg.,
diastolic. No cardiac murmurs. Lungs and abdomen negative.
Slight edema of the lower legs and ankles. Wassermann reaction
negative. Urine 40 ounces in twenty-four hours, with a specific
gravity of 1020 and ver}^ slight trace of albumin, occasional hyaline
and granular casts, with now and then a red blood-cell adherent.
Throughout his stay in the hospital, which lasted until December
13th, he felt entirely well.
Discussion. — The history' is a good example of the quite uncon-
scious sophistry- whereby patients continue the ancient tradition that
wet feet have something to do with kidney disease. The more one
studies the histories of cases of this t\pe, the less one is inclined
to beUeve that cold and wet have any considerable part in their
etiology.
Although the onset is here acute, the condition of the urine and
blood-pressure makes it clear that we are dealing with a chronic
nephritis, possibly one that originated in the scarlet fever of the
patient's infancy. Acute nephritis is a rare disease, and in our
hospital records is steadily becoming rarer. This means, of course,
that we do not see the patients, as a rule, during the acute stages of
their disease, but only in the acute exacerbation of a chronic process
or in the frankly chronic stages of the disease. Since blood-pressure
measurements have been made a routine, most of the cases formerly
called acute nephritis are now labeled chronic.
It seems to me of interest that this patient felt entirely.well through-
out his illness, and would never have sought medical advice but for
the swelling of his face and legs, which naturallv alAimed him. Lnaginc
now that the edema had bew ' "^ n«^SiiV*
A
SWELLING OF THE FACE 43 1
it is, the patient would then have had no knowledge of his disease
and would not have consulted a physician. This is presumably what
happens in the majority of cases of acute nephritis.
Outcome. — July 6, 1914, the patient writes that he is feeling
pretty well, working daily as mail collector, and that his water has
recently been examined and found to be normal.
CHAPTER rX
HEMOPTYSIS
The spitting of pure blood in any considerable quantity means
pulmonary tuberculosis in the vast majority of cases, no matter what
other symptoms are or are not present. We should always assume
such a symptom to be due to tuberculosis until it is proved to the
contrary.
But we must distinguish between the raising of pure blood in con-
siderable quantity (a teaspoonful or more) and the raising of streaks
of blood mixed with mucopurulent sputimi. Blood-streaked sputum is
often due to other causes not tuberculous, although it may also occur
in tuberculosis itself.
The conmionest mistake in relation to true hemoptysis, as above
defined, is the assumption that it is not tuberculous in origin merely
because the lungs show no abnormal signs and the patient feels per-
fectly well. This is just what we should expect in early phthisis.
The majority of cases of hemoptysis, examined within a few days
of the attack, show absolutely no signs in the lungs and the patients
feel perfectly well, but if they go on living and working as before the
occurrence of the attack, tuberculosis will probably show itself in a
few months in an unmistakable form. This advance of the disease
should be forestalled by putting the patient, inmiediately after the
hemoptysis, under treatment for incipient tuberculosis, without wait-
ing for absolute proof that the blood spitting is really tuberculous in
origin.
Aside from the group of cases just referred to in which bl
spitting is the first symptom of tuberculosis, and comes, as it were^
out of a clear sky, there is the much less important group of
in which blood is raised during the advanced and obvious stages
phthisis. Here it is merely worth while to say that such blood spittir^g
is not necessarily or often a bad symptom. The patient need not fe-^J
that he is any worse after it or by reason of it, for occasionally a large
hemoptysis leads straight on to acute tuberculous pneumonia and a
rapidly fatal termination, but in the vast majority of cases the patient
is as well within ten days after the hemoptysis as he was before it.
432
Causes of Hemoptysis in Prussian Soldiers
Tuberculosis mmmmmim^mmammmmm^^^mmmam 848
xrauma ■ 1 1
■ 7
■ 5
i^NEUMONlA
HEART DISEASE
BRONCHIECTASIS I 4
INFLUENZA
SYPHILIS
ABSCESS AND GAN-
GRENE OF T
LUNG
3
3
He)
HYDATID CYST OF^
THE LUNG i
IRRITATING FUMES)
INHALED /
(F. Strieker, Festschrift zur loo-Jahrigen Stiftungsfeier des Med. Chirurg. Friedrich-
Wilhelms-Instituts, page 183.)
Causes of Hemoptysis
MASSACHUSETTS GENERAL HOSPITAL
maam^^ama^m^mmm^ammK^mm 1723
MITRAL DISEASE ■■^■■l^HHHi^HHHH 1177
UNSPECIFIED CAUSE H^^^ 183
141
PULMONARY THROM-^
BOSIS OR EMBOLISM /
PULMONARY ABSCESS)
OR GANGRENE i
77
BRONCHIECTASIS ^H 68
PNEUMONIA Hi 62
ANEURYSM ■ 22
TRAUMA I 17
NEOPLASM I 6
Vol. 11—28 433
434 DIFFERENTIAL DIAGNOSIS^
Next to pulmonary tuberculosis, but a very poor second in relation
to it, comes pulmonary infarct as a cause of hemoptysis. Puhncmary
Infarct is usually the result of mitral disease, but may occur in any
type of heart disease with failing compensation. It is generally recog-
nUed without difficulty, because of the presence of a well-marked heart
lesion and of prcceiling or coincident symptoms of pulmonary enlarge*
ment (cough, dyspnea, orthopnea, scattered rides, hydrothorax). Oc-
casionally both phthisis and mitral disease occur at the same time.
It may then be ver>' difficult to decide which is the cause of the
bleeding*
In the United States there are no other common causes of hemop-
tj'sis. All the chrmiic diseases of the lung, such as bronchiectasis,
abscess^ gangri^no, nci>plasm, sN-philis. may in excepticmal cases [voduce
heroo(i»t\':ias« but the total number of such cases is ver>' smalL Tliis
is well shown in diagram, p. 43^;. In Japan the parasitic famg flnke is
a not infrequent cause of hcnu^^tx'sis. and upon our Pacific coast Japait-
e^ immigratiiui has now made this tx-pe of hemoptysis a possiMe ex-
perience for physicians in that part of the countrj-.
Thoracic anour\sm is not infrequenth- associated with honop-
tY^iJs. llus is usually a rtrt>ult 01 cv>n^:e<tivxi of the tracheal waD
throush \Uwvt i^rvs!>ure of the oneur^-sm outside. Less frcqnmthr
it is due to ijut actual leoiin^ of the aneun-^^^ni itself thnm^ a per-
for^j^tkxt in the tracheal wall. Luckilv i\Nr all ooaceciMd. it is rare to
§ee ^A *ttifur\>r-i kilL by suoder-Iy bcrstin^ in^o ^he respmtonr tract.
Small anx>cv,:s or bAV\:. vxvurrj:^ ir. screaks or rrfrerf <ffiEierfjr
with mU!Cv>tH;Tulec: SK^c:*j:r.v ar^ :r^^\;uec:ly setai ni pacfeats v&o
{.>hia:Ytx^ijL sevrtr:*.^^.^. >cch a.:::«;c> -^w arc ^ni scntdt ami vni-
tate t^ :b."va: >rfvc:i'> :.* yrxvi',":; 1 >:r-ai :c tlc^xL ObTOm^y.
a^ytbixj:;^ eibc ::?a: "r:ai;:r> :i'-' vjL:ii.'f:: :-.c;i!r :r ia.Trk vSjIeittry anEjr
jtve U:> biocc-scmi,'*.* H.^c:'j..r ':: :'ic surnr viy
OccasicttaJy a:i ■irrjiciLtiy o:ciii::i;n :£ liii; zuais* widr or wtchinxt
a:t •,*bvii,^it> sccwiiiciN p.T.Hiuo^ :m ^ujk "-i^r:. jmi al haniJLLiiaagr
viii^dscs. suca a> Turoura, -joar/y. Itrnk-^atiu. iray ?m:w bliHjd in. the
s{,Hi^,Uitt a:< Weil aa^ ;rit?cwin?re.
C»« IS?
A be!l-Ix».v -*i <'vi::!ii?::en .•!! :.':!>:•: i-K* "K»s:itii Juiy ri, rnc*. TSe
p^titmc'^ a-Jivr iie»i -ji <;r'.>i|,t:ias ^ur uixi me-^raif y^irs ajiri. JQ
tihr v/chtrr mvmixTN A !ii> auiii' im: >>:•!. Vicre is nu uUO«:rcuiu^
in tiht iuiniiv Tht: -judiruc 'rau ncajse^ viitui uirtK vwirs-'iid. jctrec
HEMOPTYSIS 435
fever at four, immediately followed by whooping-cough. Last summer
he was sick for three weeks with pain in the left cjiest, fever, cough,
and hemoptysis. Last winter he was in bed three weeks with a
similar trouble. Two years ago he weighed 93 poimds; now, 85 pounds.
For a month he has been in bed with pain in the front of the left
chest, worse on deep breathing. Three times in this month he has
raised about half a cupful of blood, and between these times he has
raised a small amount of thick, greenish-yellow sputum. He has had
fever without chills. As long as he can remember he has had dysp-
nea and palpitation, but has been otherwise well.
Physical examination showed poor nutrition, pallor, normal pupils,
glands, and reflexes. The heart's impulse seen and felt in the fifth
interspace, nipple line, 3 inches from midstemum. Right border of
dulness J inch from midstemum. At the apex there was a presystolic
thrill, and a long, rough presystolic murmur, ending in a sharp first
sound. There was no second sound at the apex, its place being taken
by a short, diastolic murmur. Just inside the apex both these mur-
murs were more distinct. The pulmonic second sound was accen-
tuated. Physical examination was otherwise negative. No tem-
perature in a week's observation. Urine negative. Hemoglobin
70 per cent., stained specimen showing moderate achromia. The
sputum showed no tubercle bacilli. Tuberculin was injected sub-
cutaneously — on the i6th, ^ mg.; on the i8th, 5 mg.; on the 20th,
10 mg. No reaction followed. The patient's family physician states
that he was a blue baby.
He did well while in the ward, and left on the 21st, having gained
4 pounds in the week. On the isth of February, 1909, he returned
to the hospital, having felt well until he got into a fight with the cook
at the Waverley Convalescent Home and was chased about and had
to be put to bed. He soon recovered and went back to work. Two
months ago, after a heavy day's work, he began to cough and raised
about a wineglassful of blood. That night he had marked orthopnea.
After about two weeks of rest he went back to work again, though
still short of breath, but after a day and a half he had to give up on
account of dyspnea and pain in the chest. These symptoms have
continued ever since and been associated with indefinite pains about
the right knee. There has been no hemoptysis for a month, but the
cough has been rather persistent. His weight is now 93 pounds.
Appetite and bowels in good condition; sleep disturbed by headaches.
At this time the heart's apex extended i| cm. outside the nipple
line and the dulness extended 3 cm. to the right of midstemum.
436 DIFFERENTIAL DIAGNOSIS
The auscultatory conditions are shown in Fig. 148. The heart
was regular. Pulmonic second accentuated and doubled. Th.^
lungs showed at entrance high-pitched squeaks, scattered in eacLB[v
lung, otherwise physical examination is normal, including the bloo--^
and urine. There was no temperature in two weeks' observatiotni:^.
The boy gained 5 pounds. Under rest, magnesium sulphate, ^
ounce in concentrated solution, tincture of digitalis, 5 minixn^^^^
four times a day, and an occasional dose of aspirin, 10 gr., tta^je
boy rapidly recovered, and by February 26th was ready to go hom^^-^g
Lungs entirely negative.
He re-entered the hospital for the third time March 3, 1909, oi^rrmly
five days from the time when he last left it. March ?d, while dressic^^jg^
^^i....tmnll
lilll llluuillllllllll
SCUIKiA,
I StMiiA nu«A. -i»«4«^t. I
Fig. 148. — Diagram of heart sounds in Case 183.
he began to cough up blood. It appeared at this time that ^^
patient's mother is a drunkard, that there is much trouble at hcrr:^me,
and that the boy himself takes some whisky. This time the h^^^^
was irregular, and there was some arthritis of the ankles. H^^ ^^
mained in the hospital five weeks and gained 12 pounds. On the^^'^^
of ^larch he spat up a cupful of fresh blood. Immediately
this the breathing was harsh and noisy throughout the left c*^^^
feeble throughout the right, and accompanied by crackles. In. ^^
right axilla the heart's sounds were very loud. The raising of \^Jood
continued until the nth. At this time a capillary pulse and sug:gc^
tion of Corrigan pulse were noticed, and he had a good deal of pre-
cox A\'\\ pnm, increased by exertion. The diminished breathing in tie
ter
HEUOPTYSIS
437
lli*ii
5^^
itt-.
right Ixmg was still present March 30th, but no other abnormalities
were detected.
November 4, 1909, he entered for the fourth time, having been at
work in July and August as a bell-boy. Three weeks ago he began to
have hemoptysk as before, and has had four hemorrhages, about a
cupful at a time. For the last two days he has been very feverish,
ached all over, and had urgent dyspnea. The heart's impulse is now
4 cm, outside the nipple line, right border 5 cm. from midstemum.
Otherwise his condition is practically the same as before, except for
evidence of scabies. The temperature
is as in Fig. 149. Blood and urine
normal.
Discussion. — The condition of the
heart is typical of mitral stenosis, and
under observation the patient had more
than one attack of arthritis, presumably
of the rheumaUc or streptococcic type.
There have been no signs in his lungs but
such as might have been accounted for
by passive congestion, the result of his
mitral disease. The surprising thing is
that he should have so many attacks of
hemoptysis without other signs of failing
compensation. It is also somewhat re-
markable that he should have fever and
pain in the chest with each of his attacks,
yet this might be explained as a protein
fever due to absorption of blood-clot in
the infarcted lung.
During his stay in the Massachusetts General Hospital we did
our best to discover any evidence of tuberculosis. No bacilli could
ever be found in the sputum, and no reacUon followed the injecrion of
a large dose of tuberculin. His prompt gain in weight and strength,
under conditions not especially favorable for tuberculous lungs, also
argued against the existence of any phthisis, yet his cough persisted
in a rather inexplicable way. My diagnosis was of mitral stenosis
with regurgitation, without lung disease. No doubt was enter-
tained upon this point when he left my wards.
Outcome. — February i, 1911, he came to the Municipal Hospital
for Tuberculosis, in Burroughs Place, Boston, and there a very differ-
ent family history was obtained. He stated that his step-father
m
— -^
Fig. 149-
-Tempenture
a Case 183.
438 DIFFERENTIAL DIAGNOSIS
died of pulmonary tuberculosis a year previous, that is, a year after
he left the Massachusetts General, and a sister of the same disease two
years ago, the same year in which he left us. An examination made
by Dr. N. K. Wood showed extensive signs in both lungs — namely,
dulness, bronchovesicular breathing, increased fremitus, and a few
riles from the top of each lung to the midscapular behind and third
rib in front. The sputum was examined and reported as positive for
tubercle bacilU. February 16, 191 1 , he was admitted to the Mattapan
Municipal Hospital for Tuberculosis and discharged April 7, 1911, with
a diagnosis of ''mitral stenosis y probably not tuberculous J^ At this time
the signs were diffuse upon the left and absent upon the right side.
Three negative sputum examinations were recorded.
He re-entered this hospital on the 12th of July, 1912, and stayed a
month. After 2 mg. of tuberculin O. T. his temperature rose to
100.8° F. The local and constitutional reactions were considered
typical. Except for this fever, however, he had no other rise of
temperature. The physical examination showed rather more definite
signs at the left apex.
On the 7th of August, 191 2, Dr. S. W. Ellsworth x-rayed his chest
at the Boston City Hospital, and reported extensive changes involv-
ing the upper two-thirds of each lung and interpreted as tuberculous.
In view of this, the discharge diagnosis, August 15, 191 2, was 'Huber^
cutosis with mitral stenosisJ^ Later he went to Utica, New York.
In April, 191 3, a letter from a friend of his states that **his health is
just about the- same.'' The records of the Associated Charities states
that he lost another brother of tuberculosis in 191 2. On the whole,
the diagnosis must remain in doubt, but I am inclined to believe that
he had both tuberculosis and mitral stenosis.
Case 184
A plate-printer of twenty-one, born in Russia, entered the hospital
December 18, 1909. The patient's father died of cancer at fifty-six;
otherwise his family history and past history are good.
Three years ago he began to cough. Eight days ago, after strain-
ing himself with Ufting, he began to raise blood and has raised it
every day for the past week, the amount being ^ cupful three days ago
in the morning and a like amount this morning. He has lost no
weight, has never coughed up blood before, has an excellent appetite,
no pain, and feels generally well.
Physical examination shows good nutrition and is otherwise nega-
tive save as relates to the left lung, at the apex of which there is slight
HEilUPTYSIS
Fig. 15!.— Chest signs in Case
«ess, bronchovesicular breathing, increased voice, and fremitus
*^»»(Ung down to the second rib (Figs. 150 and 151). The
440
DIFFERENTIAL DIAGNOSIS
\
¥z.
m
-m--
^^^M
a^'^i-"^
n
temperature as in Fig. 152. Blood and urine nonnal. TTie sputum
was examined eight times' and no tubercle bacilli found eatcqjt in one
small mass on the 23d of December, when the organisms were seen u^
very small numbers. Five examinations after that showed no bacilli.
Discussion. — Sudden hemoptysis in good health at the age oi
twenty-one generally means phthisis. This assumption k verifi.^^
by the physical signs present at the top of the left lung. Such si^^Kss
would have been of no special significance had they occurred at the «i «>p
of the right lung. Their association with the slight fever shown in F~is-
152 makes them sufhdent evidence io:Mr a
presumptive diagnosis of phthisis.
The sputum examination would se^^n^Tn
to settle the matter beyond doubt, bu "fci- I
cannot feel quite certain upon this poi-j^cnt.
When the laboratory observer repc^^^crts
tubercle bacilli present he should, in strrn^ -wet-
ness, say "acid-fast bacilli, having "T^lie
usual morphology of tubercle bacilli." It
has been shown in recent years that ot-^fc- -*er
acid-fast organisms besides the tubei— ^c=u-
lous are not very uncommon (streptotfc^- ^»ii
group).
In doubtful cases we should be nm, ■^' '"
ready to make sputum inoculation i.:^cr:"'o
animals. Nevertheless, it seems to r^cne
there is no very great doubt that this
tient has tuberculosis. He has none of
other well-known causes of hemopty —
and there is no other disease of anything like the same conmm-
ness which could explain his symptoms.
Outcome. — The hemoptysis ceased on the 2gth. It began
on the 10th of January and continued until the 16th, and in si
quantities off and on after that. He gained 25 pounds during his
months' stay in the ward, A few riles were heard over the afff
area, January 22d, February 5th, and February 19th. March ^
he went to Rutland Sanitarium. In a letter, sent April aoth, 1913 —
patient states that he is feeling fine and is at work.
Case 185
A clerk of twenty-one entered the hospital March 16, 191^. A
week ago the patient felt tired, feverish, and short of breath. "Xbe
—Chart in Case il
HEMOPTYSIS
I Fig. is4.^Chest signs in Case 185.
xt day, Thursday, he began to vomit and continued for three days.
I Friday he began to raise bloody sputa, had a pain in the right side
«»
differznual diagnosis
M
iif?ViM
^A2:si
m
of his chest, and an eruption like cold sores on his eyelids and about
his nostrils.
Physical examination shows fair nutrition. Heart's impulse extends
I cm. outside the nipple, in the fifth space; heart otherwise negative.
Lungs as in Figs. 153 and 154. The abdomen is negative save that
the liver dulness extends 8 cm. below the ribs, where a tender edge was
indbtinctly felt. Temperature as seen in Fig. 155. The blood showed
at entrance i8,cx» luekocytes, and on the 26th, 30,500. The urine
showed a slight trace of albumin and an
occasional granular cast; otherwise nega-
tive. On the z6th the patient seemed
perfectly well, and, in spite of his high
leukocyte count, he was discharged to the
Convalescent Home.
Discussion. — The hemoptysis in this
case began with all the evidences of acute
infection, especially the vomiting and the
herpes. The heart showed evidence of di-
latation, perhaps from infectious weaken-
ing of the muscle; the lung signs are on the
right side, and may account wholly or in
part for the position of the liver, 8 cm. be-
low the ribs. The physical signs are those
of solidification, and the remaining ques-
tion is whether we are dealing with a tuber-
culous pneumonia or an ordinary pneimio-
coccus infection of the lung. These two
diseases are notoriously difficult to distinguish, at times actually un-
possible, until we have been able to follow the case for a number of daj's
or even weeks. Since the pneumonic signs of the two diseases may be
identical, diagnosis depends upon the question whether tubercle bacilli
later appear, and whether the lung signs clear up as they ordinarily do
in pneumonia or persist as they do in phthisis. The persistence of
leukocytosis suggests either a tuberculosis or a developing empyema
or an unresolved pneumonia; but, as the physical signs were negative
at the time of his discharge, we threw out all these possibilities and
considered him well in spite of his leukocytosis.
Outcome.— April 16, 1913, the patient writes that he is perfectly
well, and has been so since he left the hospital. In view of this outcome,
we may feel confident that a leukocytosis in itself is no reason for keep-
ing a patient in the hospital in the fear that an empyema may devel(^.
Fig. 1
—Chart of Case i)
\
/
HEMOPTYSIS
443
Remarks. — Why do certain cases of pneumonia begin with hemop-
tysis instead of the ordinary rusty sputum? No answer, so far as I
am aware, has ever been given.
Case 186
family history and past
912. Three weeks ago the
A housewife of twenty-three, with
liistory, entered the hospital March
patient began to lose appetite. Two weeks ago she felt a little weak,
but still worked steadily. Eight days ago, while at work, she raised
several raouthfuls of bright itiuod. Since thou she has had slight
morning cough, with a constant sputa, headache, and fever, ranging
between 101° and 103° F. She has had no pain, dyspnea, or sweats.
She has lost no weight.
Physical examination showed fair nutrition, moderate cyanosis,
rapid, shallow breathing, physical signs as in Figs. 156 and 157. Ex-
amination was otherwise negative. The crackles, March ad, were very
extensive and very coarse. Through and behind them evidence of
solidification was clear in the left front, but hardly any in the corre-
sponding situation behind. The number of white cells was never
elevated, March 2d being 9000; March 7th, 8000; March 14th, 10,000.
^
I-H.RENTIAL DI,\GNOSlS
Chcbt sisni in Case iSb.
lU-moRlnhin. oo ppr ctnt. Urine normal. SystoUc blood-[Hcssiiie,
no, 'IVnijHTalurcassecnin Fig. 15S. On the id of March I thought
the case more probably pneumooia
than tuberculosis, but on the ttth
tubercle bacilli were found in abun-
dance in the sputum, and the patient
was Uausieired on the 15th to the
Somerville HoepitaL
DSBcossioa. — This case makes a
good cootiast with tWt IkK db-
Cttsscd. The onset and Ae pMk-
■wuc signs an not nock dBcRBt.
Tht knr wkjKe ceoMt, hawtwi, m a
I
HEMOPTYSIS 445
Case 187
A sign painter of thirty-seven entered the hospital April 15, 1910.
The patient has one sister now sick with tuberculosis; otherwise his
family history is good. He had bronchitis when sixteen, pneumonia
at twenty-two, syphilis at twenty-nine, "rheumatism" at thirty-two.
He has always been very nervous. He has been a hard drinker for
ten years, averaging three whiskies and six beers a day; twenty
cigarettes a day. Six weeks ago he caught cold, and felt weak and
I III.. ■ I III., i eifrT
1*^ ,.-* i'^ t.'"*
Tig. 159. — Heart sounds at the apex.
tired. Thirteen days ago he began to cough and have pain in both
sides of his chest. Five days ago, while working, he coughed up a
mouthful of bright blood and ever since then has raised blood and
greenish material, i or 2 ounces a day. At the- same time that the
cough began he became short of breath, especially at night, when he
needs two pillows. He gave up work eleven days ago. He has lost
8 pounds in three months.
On physical examination the patient was well nourished, pupils
irregular and reacting slowly to light; tongue tremulous, brown coated;
\ iJCT
Fig. 160. — Heart sounds at the third left interspace. The point "ist" indicates that
part of the cardiac cycle where the first heart sound should be. No first sound is heard.
The murmur is continuous, with a systolic accentuation.
general enlargement of the lymph-nodes. The apex impulse was not
seen, but was felt in the fifth space, 3^ cm. outside the nipple line,
13^ cm. from midstemum. At the apex a late systolic murmur was
audible (Fig. 159). In the left third interspace, near the sternum,
was a continuous murmur and thrill, with a systolic accentuation
(Fig. 160). No heart sounds were audible in this situation. On
the right side of the sternum, in the fifth space, a ringing second
sound could be heard, which grew fainter toward the base of the heart.
There was no pericardial friction, but many rubs, squeaks, and
crackles, scattered over both fronts. By percussion the heart seemed
446
DIFFERENTIAL DIAGNOSIS
considerably enlarged to the right of the sternum. Systolic blood-
pressure was 115. The systolic portion of the murmur above d^
scribed was audible over the greater part of the back, especially on the
right side. The backs of the lungs showed scattered squeaks and
crackles, similar to those heard in front, but there was no evidence of
fluid or solidification. The patient showed no fever in three weeks'
observation. Blood and urine normal. Four examinations of the
blood-stained sputa showed no tubercle
baciUi and nothing of note.
^ m © ^y ^^ 27^ ^^ ^^^^ ^^^ disap^
J ^^ peared from the chest and the patiem^
^ c>n^^ ^g^g quite comfortable. At this
^-ray (Fig. 161) showed that the hea
was not enlarged.
Discussion. — Syphilis, rheumatisrr — - i^t^
Nipple
Fig. 161. — Sketch on fluoroscopic
screen. Tube at a distance of 7 feet.
Notice the absence of any bulge on
the left border, and its position with
relation to the nipple.
alcoholism, and possibly plumbism a-
suggested by this patient's history,
favor of tuberculosis as a cause of
hemoptysis are the cough and dyspn
the family history of tuberculosis, a
the acute onset of the trouble.
favor of syphilis are the Argyll-Robertson pupil and the glandu
enlargement. The physical signs are not characteristic, though m
like those of pulmonary edema than of any other disease.
With so small a heart it does not seem to me at all probable
syphiUtic aortitis, the commonest form of cardiac syphilis, is
Pulmonary stenosis or mitral disease, which were among the di
noses suggested in the case, should give a very different x-ray pict
from that which is shown in Fig. 161.
Moreover, none of these diseases has any right to give a c
tinuous murmur, lasting through the whole cardiac cycle. I thi
would be of some interest if I record some of the opinions give
the case.
Outcome. — The following opinions were expressed: Syphi
aortitis, with ulceration into the pulmonary artery, Dr. Roger I.
syphilitic aortitis, with extension to the aortic valve. Dr. James
Wright and Dr. Charles H. Lawrence; aortic stenosis and r
tion. Dr. Wm. H. Smith; aortic and mitral regurgitation, with st
sis of the pulmonary arter>% Dr. Frederick C. Shattuck; pulmor^^^V
stenosis and regurgitation, Dr. George C. Shattuck; congenital Ii.«i^^
disease, with patent ductus arteriosus. Dr. Frederick T. Lord aurf
at
t
g-
re
m-
it
in
\XQ
0-
HEMOPTYSIS 447
Dr. F. W. Palfrey; congenital lesions, probably patent ductus arte-
riosus or septal defect, Dr. Richard C. Cabot. By May ad the
patient seemed perfectly strong and well, had no symptoms of any
kind, and was allowed to go home.
Case 18S
A housewife of thirty-one entered the hospital August 31, 1910.
Ten days ago the patient had a miscarriage. Since then she has
been feverish and had one or more chills each day. Four days ago
she had pain in the right side of the chest and began to raise bloody
Fig. 161. — Chest agns in Case
sputa. Previous history and family history negative, but she has
had three miscarriages, including the one just mentioned. Previous
to that she had three healthy children.
Physical examination showed obesity, pallor, cyanosis, twitching
of the hands and arms. The tongue was very dry and cracked, with
a thick, brown coat. Pupils, glands, and reflexes negative. Heart
negative, save for a systoUc murmur, loudest in the third left inter-
space. The left lung was normal. The right showed duhicss through
the back, with increased voice sounds. Breathing bronchial near the
angle of the scapula over an area size of the palm, elsewhere dimin-
ished. In the front there was friction between the right nipple and
448 DIFFERENTIAL DIAGNOSIS
the axilla, and the breathing beneath the right clavicle was dimm-
ished (Figs. 162, 163). Abdomen negative.
There was a foui vaginal discharge. The patient was actively
dehrious. Temperature as seen in Fig. 164. The urine averaged 35
ounces in twenty-four hours; specific gravity between 1013 and ro:K S-
albumin present in slight traces up to the first of October, and thfc^en
usually absent. The sediment showed at first granular casts 1^ 3tJi
cells adherent; later on, nothing of interest. The blood showed ^t
entrance 3,000,000 red cells. A week later it had fallen to j,300.cfc^;x,
from which puinl it gradually ruse until, on the 27th, the cells nu^^^j-u-
Fig. iGj.— Chest signs in Case i38.
bered 4,000,000. Hemoglobin was 40 per cent, at entrance ^-^^^
gradually rose to 60 per cent. The white corpuscles varied £^*-*^^
16,000 to 20,000 during the first week; after that remained in ^'^
neighborhood of 12.000. October 12th the last blood examino- tJ*-*"
showed reds 4,800,000; whites, 8000; hemoglobin, 80 per cent. 'T*'^
smear in the earlier days of her illness showed moderate achrofT^'
considerable variation in size, and a good deal of abnormal staini^i^*
On the r4th four normoblasts and three megaloblasts were seen whi'*^
counting 200 while cells. All of these abnormalities disappt-'ar^
before she left the hospital. Blood-culture August 31st was negS"
tive.
HEHOPTYSIS 449
^utum was very profuse, purulent, foul, and contained a
of organisms. No tubercle bacilli or other predominating
ms could be discovered. The vaginal discbarge soon ceased
ml and the pelvis showed nothing markedly abnormal. Each
g she was comfortable and in good condition. Toward night
lally had a chill, became restless and delirious, with a weak
ligh temperature, and respiration. The evidences of pulmonary
catitHi were quite clear during the first week, but after the 6th
4SO
DIFFERENTIAL DIAGNOSIS
of September the lungs were much clearer, though the chills and
sweats continued.
The uterine discharge had almost ceased by September 6th.
September 8th the heart's apex extended to the anterior axillar\' line
and there was a soft s\-stolic murmur there. On the 2 2d of September
the signs seemed ob\'iously those of pulmonarj- abscess or gangrene,
though no localization could be made. On the 9th of October in the
right axilla there was tympanitic resonance, amphoric breathing, and
cracked-pot sound. Nevertheless, the patient seemed much better.
The sputum was stiU profuse and somewhat bloody. October nth
she was sitting up in a chair daily, and from the 13th of October a
chart was kept showing the amount of sputum daily I Fig. 165). Cough
was easily brought out on change of position. The fingers were sli^tly
clubbed.
Ctr
■5=sC
13 *t x.* '■ 'i^'^^Ji
ii ^>2V-a-ii^?ifJLfi«
^ 1
1
CwCKS
"Iff «i It icai at n SI at
a».l
*y
1
11
4
1
1
1
^ ■ '■ •
1
\ t . ^
1
f ^
• 1
October :is: x-rdv showevi dinu>e shadow thrcc^out the li^t
hmc. but no recoiirii-ible ci\"::v.
Discussion. — Of >cvv::^I inirvrtjjicr. :: seenis :o m-e. is the fact
thai this pa::er.:*> >\-::ip:on:5 cj^.e inmie-iij.ie/.- ifter i zJsciniage.
Pu2:nv>nar\* sxT-iri^^r/.s ^: such a :irr.e sh:.:li :.":"»■ j.y5 5Uig>?<: ihrombosis
o: U:e per.u:erj:e veir.s. -a-::.": ri>u.:ir.^ y,:.r..:r-irr ernrcosn. bland
or 5«?odc, T:ie :\Lct :hi.: chills ^cc^:r.v.\ir-:ivl -^e h-errvx^rvas and
or.es: pvins .eics us :c uni^^.e 112: trie eiurcjisn 2s oc the septic
In :he r^:«eii: Cj^«^ reisv-r-uic :: chis r^T>e serfrr.s :c be-i> us rather
* W « « ^.
*« «« ^V** ^^
j..--.i-. — ■ — :. — ^^>ri^N>. . -"i" >» . i .^ ->-^ — ...H-r: **..'c . 1^ "Tr .ire api
••. ,. , > _> ,-^:l ,. . '— .T..>'— — - » ,.^>;.-.>c> j— '.. —C ^^'TTSfViljCSfc' O* OUT
s:u^y J-: :r.: scuu. jjj:: it.: Msicr* :^:.r. uyvc viii: we jeatm by
iusvu'.:.i:i:c :r r^rruss5:c
HEMOPTYSIS 45 1
The anemia, the fever, and leukocytosis are consistent with any
one of the puhnonary diagnoses just listed. Of decisive importance
is the condition of the sputiun, which is characteristic of abscess and
distinctly different from that of bronchiectasis, phthisis, pneiunonia,
or empyema. Of special interest is the sputum chart presented here-
with, and showing how the enormous amount of sputiun (almost
I quart in twenty-four hours at the start) gradually fell to zero.
In all probability, then, we are dealing with a septic embolus of
the lung, thrown off from the periuterine flexus or veins which had
become clogged and infarcted as a result of the septic miscarriage.
Hemoptysis is not the rule in such a case, but is not at all rare.
Outcome. — From October 21st the amount of sputum rapidly
diminished, the temperature ranged lower, and finally disappeared,
while the patient gained steadily in weight and strength. Oil of
eucalyptol, 10 minims, three times a day, began September 17th.
The patient weighed 170 pounds when she left the hospital in excel-
lent condition on the 30th of October.
Case 189
A housewife of sixty-two, bom in Russia, entered the hospital
August 19, 1910. The patient states that eighteen years ago she
brought up about ^ cupful of blood, whether by coughing or otherwise
she cannot state; otherwise she has been well. She has had twelve
children and no miscarriages. Menopause occurred twenty years
ago.
Two days ago she coughed up about a cupful of blood, and since
then has had a slight cough and raised a small amount of blood.
Family history is negative; habits good.
Physical examination shows poor nutrition; cataract in the right
eye. Left pupil non-circular and eccentric, but reacting normally.
Glands and reflexes normal. Lungs negative. The heart's apex
found in the sixth space, 14 cm. from midstemum. Aortic second
sound metallic and ringing. Blood-pressure, 165 mm. Hg., systolic.
No murmurs. Artery walls tortuous and thickened. Abdomen very
much relaxed. Right kidney palpable. Liver edge felt three-fingers'
breadth below the ribs.
A laryngologist could find no bleeding points in the nose, larynx,
or trachea. On the day after her entrance she raised 6 or 7 ounces of
bright alkaline blood; 4 mg. of old tuberculin was injected imder the
skin, and was followed by a rise in temperature to 101° F. without
constitutional symptoms. The sputimi was examined three times for
452 DIFFERENTIAL DIAGNOSIS
tubercle bacilli with negative results. On the 3d of November, as she
felt perfectly well, she was allowed to go home.
Discussion. — That the patient's first hemoptysis, eighteen years
ago, did not seriously impair her health, seems to be the fact. Ap-
parently she underwent no treatment after it and has had no symp-
toms. This is all the more interesting and significant because, in
the minds of many physicians, this would constitute proof that it was
not of tuberculous origin. Yet now, after the lapse of eighteen years,
we have a repetition of hemoptysis, which was this time of consider-
able amoimt and occurred under observation in the hospital, so that
there can be no possible doubt as to the fact, yet still no signs appear
in the lungs.
The heart is not normal, but there is nothing about it, nor about
any part of the body, to suggest a failing cardiac compensation or any
such pulmonary suggestion as could produce hemorrhage by infec-
tion. Undoubtedly she has arteriosclerosis and a low, sagging liver,
the latter accounted for probably by the abdominal relaxation fol-
lowing her twelve pregnancies.
The tuberculin reaction is proof of tuberculosis, obsolete or active,
past or present, but has no necessar>' bearing upon her present symp-
toms. If she were younger we should have no doubt of the diagnosis
of tuberculosis. As it is I cannot feel sure, and must leave the case
in doubt. Tuberculosis, however, seems to me the most probable
theory.
Outcome. — She was seen again in December, 1910, and December
30, 191 1, and had had no recurrence of s>Tnptoms. February, 1913,
she reported, looking and feeling perfectly well. Phj'sical examination
of the lungs negative; of the heart unchanged.
Case 190
A woman of twenty-four entered the hospital November i, 1910.
The patient has a negative family histor\' and has been well until
within the past year, though she has had a number of attacks of
tonsillitis. For a year she has felt p>oorly and been below her normal
weight. Varicose veins were excised by Dr. Bottomley at the Carney
Hospital a few months ago.
For a month she has complained of pain in her right shoulder,
and for a few weeks she has had pain and swelling in the region of
the right tonsil. After a chest examination, to see if there were any
contra-indications for operation upon the tonsil, the tonsils were re-
moved by Dr. Mosher, sLx weeks ago. For five days after operation
HEMOPTYSIS
453
she did well and had no temperature; then she complained of acute
pain in the left lumbar region, but examination disclosed nothing.
After going home from the hospital where this operation was done
she continued to cough, the expired air being very foul. For a month
she has been feverish, the temperature reaching ioo° F. in the morning,
103° F. in the evening. She has remained in bed. At the beginning
of this period a patch of bronchopneumonia, the size of a dollar, was
found half-way between the left nipple and the clavicle. There were
also a few fine rSles in the left back. Later these disappeared. Five
, — Chest aipis in Case 190.
^ays ago the sp^utum was blood stained. Three days ago a slight dulness
M-as found in the right back, accompanied by fine, moist riles. Last
night signs of cavity were discovered in the left chest. The amount
of sputum has been i or 2 ounces a day.
On physical examination the patient was emaciated and constantly
raised very foul sputum. The lymph-nodes in the left side of the neck
^vere enlarged. The pupils and reflexes were normal. In the left front
was an area of tympanitic resonance, as depicted in Figs. 166 and 167.
Over this area was amphoric breathing, cracked-pot sound, coin sound,
and increased voice, also a few fine riles at the lower margin of the
I
454
area. Th
in the bac
DIFFF.RESTLAL DIAGNOSIS
Fig. 16;.— Chest signs in Case 190. ^^
ese signs extended into the left axilla, but were less inarl«-^«^
k. The heart and abdomen negative. The urine sho'**^ ™
a trace of albumin, o.ii per cent, of sucar. spec*-*"^
X£.Tl--
. __^ .^-r— U-
eukocytt>^*^
sepUc xr^—'^^'
)le risks ;^*i-
Fig. i58.-Ch
Case iQ
physical si
of the brea
a^in of the veins higher up, and. finally, by puhnona*T
embolism and resultmg abscesses or infection. Tt:*^
gns as shown in such cases are not distinctive, but the exit*''
th leaves no doubt that we are dealing with an
HEMOPTYSIS 455
Can this abscess be tuberculous in origin? The character of the
sputum is wholly against it. A patient whose tuberculosis was so
extensive as to result in so large a bulk of sputum would almost cer-
tainly have demonstrable signs in the other lung.
Bronchiectasis, which may be associated with a very foul sputimi,
rarely develops in so short a time and is almost invariably bilateral.
Outcome. — ^At four the next morning she had an attack of cyanosis,
with shallow, difficult breathing, and died. Autopsy No. 2712 showed
abscess and gangrene of the upper lobe of the left lung with excessive
hemorrhage; fetid bronchitis; obsolete tuberculosis of a bronchial
lymphatic gland.
Case 191
November i, 1902, an Irish ward maid of the hospital, nineteen
years old, was taken into the ward. She had diphtheria in the pre-
vious January and was ill six weeks. Otherwise she has always been
well. Her family history is negative. Her habits are good. Her
menstruation is normal, except for considerable pain. Yesterday she
noticed sore throat, chills, headache, backache, coryza, watering of the
eyes. Last evening she vomited four times.
Physical examination showed large reddened tonsils, with whitish
exudate and enlarged glands below the angle of the right jaw. Cul-
tures from the throat were negative. After a week in the wards the
patient seemed to be practically all right and went back to work.
March 16, 1903, she had a similar attack and was in the ward five
days, but recovered promptly. January 6, 1905, she entered for the
third time, stating that five years ago and three years ago she had had
attacks like the present, when she vomited considerable blood, al-
though nothing relating to this is contained in either of the previous
hospital records. The patient also stated at this time that one sister
had died of consumption.
Thirteen days ago she began to have sharp epigastric pain radiat-
ing to the back. It was constant, increased by pressure, not increased
or relieved by food. The pain lasted two days, then ceased for two
days, began again and lasted twelve hours, then left her until this
morning. Twelve days ago and eleven days ago she either vomited
or coughed up 3 or 4 oimces of dark blood, none since. She states that
for two years she has had pain during micturition.
Physical examination showed good nutrition, normal throat, nega-
tive chest and abdomen. The patient remained three months in the
ward, and during most of that time had no fever. On a few occasions,
45^ DIFFERENTIAL DIAGNOSIS
to be mentioned subsequently, there was a short period of pjrrezia.
The blood at entrance showed 15,400 white cells; hemoglobin, 90 per
cent. The urine was negative save for the slightest possible trace of
albumin. The patient was kept on nutrient enemata for six days,
and after that did well on feeding by mouth. From time to time she
had some abdominal distress or vomiting, the vomitus once con-
taining several streaks of blood.
On the 8th of Februarj* she vomited about 2 ounces of bright blood.
March 3d this happened again. In the meantime she was free from
I>ain and eating well. On the 7th blood was found in the basin by
her side. It seemed to be mixed with mucus or sputum. Examina-
tion of the lungs showed questionable dulness and increase of voice
sounds at the left apex. The sputum was repeatedly examined for
tubercle b;\cilli without results. Guaiac tests of the stools were
negati\'e. Alter 10 mg. of tuberculin the temperature rose to 102.5° F.
This was the only period of considerable p\Texia during the wfacde
three months of her siav.
On the 22d oi March there was again a question of the source of
blood found in the basin beside her. The blood was mixed with
mucus and had a faintiv acid reaction. It became clear at this time
that she was ver>* untruthful as well as impudent. She refused to
leave the ward when it came time for her to go, but was discharged.
ne\*ertheless. March j;cth. Gastric ulcer and pulmonarj- tubercukxsis
were the diagr.v>se> considered, but no cennite eWdences of either dis-
ease was obrainevi.
She was acain in the wapvi in Tune. :;:c-. in the meantime hivirac
been at Rutland Sanitarium for tubercul-jsis. While there she hid
much digastric pain, increasec by fooi. never relieved by it. and
vomited once a day some tin: e< j.ni s^-meiimrs le<i? frequently. She
sax-^ she has vomirevi no blvo She r.j.s piin::o neariy 14. pocnids. and
has not coughed a: all. though she hjj> riisei ojc^iierable sputa, once
with a srnall lump of blood.
Ph\-^otI examination shows that the .rums are sr«:c::rv an»i bieed-
ing. the r».^teri,^r pGar>"ngeal wall c-.vereri with mucus. A systolic
murmur, loc-iest at the ape.\. wis hear: jIs*: L-. the ixilln ami all rvw-
the t^reconiia. .'ther*:se the chest was ne^ritfvr:. ikewise the abo-inen-
B'.ooii JLT.'.: urine normal. The carajity :f the stjmach ttls .: pints.
ic- ocn-.-^js, no rrfsiiue ?ef :r^ bn^akfis:. ii'tir 1 :=st-meal. "-^e HCl c.-c*.
t::il uidrtv :r._^-'. z»: bi'.oi H:!'* :h:»r: ::ir::iai-:: vis :f pain ibcuc
the ? lao. ' i«: r .* u rin z iT'i ifter rue tu r. ti« ; r jj: •! i y am :n t .te .c w»;r part
Oi the baoi ;vcsi«ier^'i bv .lt .rthoceiio :vcsu_tant. Dr. Rjcert B.
HEUOPTYStS
457
Osgood, to be of attitudmal origin. The course of the patient's
temperature is seen in Fig. 169. On the aist she was impudent and
disobedient, and told that she would be discharged the nest day.
The next day she developed earache, abdominal cramps, pain in the
back, and many other symptoms. Examination of the ears was nega-
tive. She was k^t in the ward, and then seemed perfectly contented.
No cause for the fever could be foimd.
On the 2d of July she was allowed to get up and showed no ill
effects. On the 3d of July it was found that the thermometer regis-
tered 104° F. The patient's pulse was low, skin cool, and there was
no other evidence of fever. Tlie patient was given another thermom-
Fig. 169. — Course of temperature (as recorded)
eter and secretly watched. She was then seen to shake the instru-
ment, point upward, so as to make it register high. The nurse then
took the temperature by rectum and found it to register 98° F,
The next day she refused to have her temperature taken. During
this stay in the ward she frequently spat up i or 2 ounces of foul-
smelling bloody fluid which evidently came from her giuns.
She was discharged July 4th and re-entered September 22d, stat-
ing that she had felt well and done her work regularly since she was
last in the ward. She had vomited five or six times, but never anything
abnormal until this morning, when, at three o'clock, after a restless
night, she vomited ^ cupful of bright blood. She has a slight cough,
4S8 DIFFERENTIAL DIAGNOSIS
mostly at night. Physical examination showed nothing abnormaL
Pelvic examination was negative.
She was discharged September 2Sth, and re-enteredT December 23,
1905, having been well in the meantime. Yesterday at 9 a. m. she
vomited i pint of dark-brown fluid which she thought was old blood,
and immediately after this a mouthful of bright blood. Twice since
then she has raised blood. Two days ago she had a very dark-colored
stool, otherwise she has noticed nothing abnormal about the stools.
This time the patient stayed five weeks in the wards. As on pre-
vious occasions, blood was foimd in her spit-cup, but the source of it
was not clear. Bleeding points were found on the gums. After the
patient was told that the bleeding came from the gums, she ceased to
spit blood until January 6th, when, after violent retching, she brought
up 2 or 3 oimces of a mixture of food and bright blood. On the 23d
she seemed perfectly well, and was discharged from the ward. At
the foot of the ward stairs she made a scene — screamed, struck at-
tendants, and finally fell in a limp heap. She was brought back to the
ward and was very difficult to manage, insulted the nurses, ran her
finger into her throat, and tried to make herself vomit, threatening
to take corrosive sublimate. Her condition was explained to her
sister, and she was discharged on the 27th.
In February, 1906, she got into the Carney Hospital, then under the
management of a ver>' enthusiastic stomach surgeon, and was oper-
ated upon for gastric ulcer (exploratorj^ incision; nothing foimd).
After that she had no stomach symptoms until September, 1910,
but in Jime, 1906, she still complained of pain, and her appendix was
also removed at the Carney Hospital. At that place she told the
house officer that her mother died of phthisis.
In December, 1906, she was in the Boston City Hospital, with a
diagnosis of intraperitoneal adhesions, and, after being treated medi-
cally, was transferred to the surgical ward with a diagnosis of cystic
ovary, which was operated upon in the usual manner, February 14,
1907.
Re-entered Massachusetts General Hospital February 9, 191 1.
Since operation at City Hospital she has been much less well, has had
much sharp pain in the lower abdomen and occasional sharp pains
in the rectum; also frequent and painful urination. Phj'sical examina-
tion showed nothing new except three surgical scars on the abdomen.
February' 9th she passed about 80 c.c. of bright red blood into the bed.
Twice after that bright blood was found in her bed-pan or in her bed.
Proctoscope examination by Dr. Brewster was entirely negative. The
HEMOPTYSIS
459
it was evidentiy rejoiced by the prospect of some operation,
f enjoyed the preparations for it and the trip to the amphi-
ir. From March ist to March 6th she ejected a good deal of
from the mouth and some from the rectum. On the 24th she
ransferred to a private ward and constantly watched. There
"en no blood passed from any source until the 2gih, when she was
'■ rubbing her gums, and raised a mouthful of watery blood. On
h of April she was discharged as a maUngerer. Later, she wrote
,' rambling letter and something apparently intended for a poem.
her transfer to Ward C, and careful watching, the irregular fever
had been present before (Fig. 170) disappeared. February 9th
460 DIF7ES£NTIAL DIAGNOSIS
the red ceDs were 3^00,000; hemo^obiiiy 70 per cent, slight admnni,
moderate variatkxis in size and shape. Mardi nth, 1911, icd cdk,
4,100,000; hemo^obin, 80 per cent.
DiscnsrioiL — ^This is one of the most interesting and irmarkahlff
cases that has ever come to my notice. There is no possible doubt
that she was malingering; that she deceived us into the belief that she
had fever and hemoptysis when there was no such thing. On the other
hand, there is no doubt that her gums were spongy and bleeding and
that she did not produce this conditioa herself. Granted that she
did not have any of the diseasfs whkdi were most seriously consid-
ered in her case^eq^edally phthisis and pq>tic ulcer; granted that the
stay at the hospital for tuberculosis was a farce, we stiD have to ex-
idain her hemorrhagic tendenc\\
Outcome. — Further letters from the patient show that January
I, 1914, she was still in a hospital, making a record of twelve years,
during whidi, to our knowledge, she has been going from hospital to
hospital. During that time she has been operated upon seven times
and has been in six different hospitals — a most noteworthy ^'""■p*^
of the harm that can be done because surgeons do not study their
cases and because hospitals do not ocMipeiate with one another.
In the spring of 1912 the patient's hemo^obin got down as low as
20 per cent. It is dear that she must have lost a good deal of blood.
The cause of this, and what, if any. parddpation her own morbid ac-
tions had in it, I cannot sav.
Case 192
A weaver of thirty-three, a Finlander. entered the hospital June
26. 191 1. The patient has an excellent famih' history and was never
si(^ until three years ago. when he had an attack Eke tlie present.
He takes about i pint of whisky each Saturday and occasionally
earlier in the week.
Three \iears ago and one irar ago he had an attack fike tlie i»es-
cnt. Three times during the past year these attacks have been
repeated. On the loth of June he raised a few ounces of bright blood.
This evening he raised about 10 ounces in the same way. He has no
oc3Qgh. no pain, and feels perfectly well in other reqxcts. Seven years
ago he weighed 156 pounds; now, 145 pounds. Laiyngologic ex-
amination in the Out-patient Department flowed the vessels at the
base of the tongue rather lai^^ the lanux somewhat injected, a little
blood on the trachea below the vocal cords. Tht sputum was ex*
^'mif^^if^ five times for tubercle bacilli without results.
HEUOPTYSIS 461
The patient was powerfully built and looked well. At entrance
the lungs and the rest of the physical examination were entirely
negative. He continued to raise purulent sputum mixed with dark
blood. During the first week of his stay he had no temperature
above 99.2° F. The second week it touched 100° F. several times, and
never (ell below 99° F. His systolic blood-pressure was 115. Blood
and urine normal. X'-ray showed mottling at the roots of both
lungs, most marked on the right; the right apex was also mottled
(Fig. 171). Some of the blood raised July ist was injected into a
guinea-pig. August 5th the pig was killed. Autopsy showed tuber-
culosis.
Discussioii. — Here we have four attacks of hemoptysis in three
years. The laryngologic examination is of great value, demonstrat-
171. — Sketch of z-ray plate in Case igi. The shadows at the lung roots s
rather more marked than in the average case.
Uig, as it does, that the blood comes from below the vocal cords and
io all probabihty from the lung. Yet against this we have the five
negative sputimi examinations and the absence of any physical signs
pointing to pulmonary abscess, bronchiectasis, or any other local
lung lesions ordinarily associated with hemoptysis.
The point of special interest in the case is the fact that through
animal inoculation we were able to prove the presence of tubercu-
losis, when by other methods it would have been impossible. The
Search for tubercle bacilli in bloody sputa is particularly unsatisfac-
tory, and yet such sputum can well be used for animal inoculation.
Outcome. — The patient left the hospital on the 8th, and returned
to Finland, where he caimot be traced.
463 DIFFERENTIAL DIAGNOSIS
Case 193
A German gardener of thirty entered the hospital January io»
191a. The patient has always been well and strong until a year ago,
when the right eye suddenly became swollen, painful, and inflamed.
An ulcer followed, and he was ill a month with it Seven months ago,
without any warning whatever, he q>at up a mouthful of bright blood
shortly after eating. There was tickling in the throat, he coughed
slightly, and up came the blood. The attending ph}rsician could find
no cause for the trouble, and he seemed all right again the next day.
Five months ago the same thing happened again. Three and a half
months ago he had a third attack. Ten days ago he was watching a
gang of men blasting, ran to escape a blast, suddenly fdt nauseated,
and ^>at up two or three mouthfuls of dark blood. Since then he has
raised at least a mouthful of blood daily, and at least twice has raised
d^t to twelve mouthfuls, the last time two nights ago.
He feels perfectly well, has worked steadily, and new cou^is
txctpt when raising blood. He has no fever or sweats and has never
vomited. Appetite, bowels, and sleep are normal. No dyspnea or
edema. No headache or change in eyesight. No loss of wcq^t.
On examination by a lar>iigolpgist in the Out-patioit Dqiartinent
free blood was seen on the tracheal waU below the laiyiuL In the
ward he pnn-ed to be well nourished; the right eye showed anterior
staphyloma, the left normal. Glands and reflexes nonnaL Chest
and abdomen negatlN-e. Wassermaim reaction n^ative. Examina- ^
tkm of the e>^ by Dr. Quackenbos showed that the iiis was tied to
the scar in the cx^mea on the lower and outer side. The ocular tension
was incTvai^. The left ex-e also showed scar> on the cornea. Five
m
examinations of sputa were negatix-^. Bkxxi and urine negative.
BkxtdfutsssuTv. i::5 nun. Hg.. sn^^ioHc: x-ray shomd peribrandiial
thickemng to the ri$fat of the sternum, cilvined spots at both apices,
a pivminent aortic aivh. The patient was given i mg. of oU tuber-
culin subcutane\Mish\ had no neaction. but after 5 and 7 mg. the
tcsnpentunr ivxsie to loi" F. No physical <unKS developed in tlie famgs
alter tkc<^ injectioiis and thexr was xk^ genenl ssjLliise. Tlicre was a
slight kval reaction at the site 01 inxvtioD. az>d the voa Piiqiiet
reaction, wiuch had been xnode^a^^> pct«cdvf S»«x>f the subcnta-
ntv>ixs inxvtioc^ was nix>ch r:xve nkazk^vix <o ^f^Kwaid. Xo ioither
tacts cv>cV! Se brvx;$ht oc:. aixi. aocvciur^x. tbe ruzxnt wtnt home
on tJie ^:^.
-I haxY x>i> rxtass cc kr^^vz^ v^: aikd &e patient's
HEMOPTYSIS 463
eye and no good reason for connecting it with the present seven
months' iUness. Regarding the hemoptysis, I want to call attention
to the fact that the blood came up in the characteristically stealthy
way in which blood appears in pulmonary tuberculosis. Now and
then blood comes with hard coughing, but in the majority of cases the
patient is astoimded to find blood in his mouth and is by no means
sure where it comes from. Often he is imaware of having done any-
thing whatever to cause it; is quite sure he has not coughed.
This type of hemoptysis, as I say, is particularly characteristic
of tuberculosis.
The laryngologic examination, proving that the blood comes from
below the larynx, adds a valuable piece of evidence pointing in the
same direction. The five negative examinations of the sputa do not
in any way exclude tuberculosis. On the other hand, the x-ray find-
ings and the tuberculin reaction do not prove anything. They might
both of them correspond to a wholly obsolete or healed process of no
present significance. This is just the sort of case in which animal
inoculation with the blood or sputum raised would be of the greatest
importance. Nevertheless, despite the absence of any such inocula-
tion, the subsequent history of many similar cases convinces me that
this patient is, in all probability, tuberculous.
Case 194
An engineer of forty-six entered the hospital January 22, 191 2.
The patient's father died of heart trouble; his mother, of dropsy. He
had rheumatism when a boy in two attacks, each lasting all winter
and keeping him on crutches. He has slept with at least two pillows
all his life. For the past four years he has passed urine five times each
night. A year ago he had "pneumonia" in both lungs and was sick
seven weeks. His habits are excellent.
Since the pneumonia he has been short of breath on exertion,
but otherwise has done his work, as a stationary engine fireman,
without any trouble. Seven weeks ago, after a physical strain, he
began spitting blood, and in the course of a night raised almost a quart.
After that his wind became so short that he could not work and when
he lay down he choked. Soon after the hemorrhage his legs began to
swell. He has not been in bed, has a good appetite, and no head-
ache or dizziness.
Physical examination shows fair nutrition, marked pallor, normal
pupils, glands, and reflexes. The heart's apex extends 3 cm. outside
the nipple line. The aortic and pulmonic second sounds are both
>
464 DIFFERENTIAL DIAGNOSIS
sharp, the latter reduplicated. There is no fever; there are riLles at
the bases of both lungs, and at the right apex dulness, bronchovesicular
breathing, and crackles, extending down to midscapula and to the
third rib in front. The arteries were very rough and tortuous, the
abdomen negative, save for tenderness and resistance under the right
ribs. Wassermann reaction negative. Urine, 70 ounces in twenty-
four hours; specific gravity, 1008; slight trace of albumin, no casts.
Red cells, 3,500,000; white cells, 15,000; hemoglobin, 60 p>er cent.
Stained smear shows deformities in size and shape, polynuclear
leukocytosis, with 82 per cent, of polynuclear cells. Blood-pressure
at entrance, 220 mm. Hg., systolic; 130 mm. Hg., diastolic. On the
27th it was 290 mm. Hg., systolic; 150 mm. Hg., diastolic. No
temperature in a week's observation. On the 24th the evidences of ^^f
solidification had disappeared, though there were still numerous fine ^^^e
crackles over the right apex, front and back. The edema disap- — ^
peared soon after entrance and the lungs slowly cleared, but the patienLz^- ^t
did not gain. He slept a good deal of the time and seemed on the^^^^e
edge of delirium. A hot-air bath made him restless and excited. He^^He
died on the 30th.
Discussion. — The patient's history of rheumatism and |>artiar
orthopnea at night, together with the supposed pneumonia of a year-
ago, are suggestive of cardiac mischief and pulmonary congestioi
Nocturia points in the same direction. Hemoptysis in such a patienti^^^t,
followed immediately by dropsy of the legs, is excellent evidence tha-^fl^cat
the heart is the source of the trouble.
The pulmonary signs in the lungs are equivocal. They are coi
sistent either with tuberculosis or with pulmonary congestion
infarction. The existing anemia is presumably of the posthemorr'^or-
rhagic type.
In the heart and vessels we have evidence of arteriosclerosis anf
very possibly, contracted kidney. In my experience a blood-pressur
as high as 290 is generally the result of a combination of arteri*
sclerosis with chronic glomerulonephritis, both of the ordinary cai
of hypertension acting in conjunction. We may call the case one
pulmonary apoplexy, provided we recognize that this does not diff^- "rer-
entiate it from the infarctions seen in young persons and without artei io-
sclerosis. It is presumably the back pressure in the limg or the si ow
circulation through its vessels, not the weakness of those vessels, t^Kat
leads to the infarct and hemorrhage.
i
CHAPTER X
OF THE LEGS
Edema of the legs, like all edemas, has three main causes — the
heart, the kidney, and the blood.
(i) Cardiac edema includes not only the obvious lesions of the
heart valves or heart wall, but also the swelling of the feet seen so
commonly in the obese.
(2) The edema of renal disease is traditionally believed to begin
with the face and show itself later in the feet. This, however, is not
invariably the cause.
(3) In anemia the edema may quite possibly be of the cardiac
variety, i. e., anemia may have produced cardiac weakness and thus
an edema, indirectly rather than directly due to the blood.
Besides these causes, all possibly connected with the first of them,
the only common type is the slight edema of the hands and feet, not
infrequently seen in hot weather.
LOCAL CAUSES OF EDEMA
Varicose veins are by far the commonest cause for swelling of the
legs. Their presence is usually obvious and needs no discussion.
Local skin disease, involving the legs, may have the same effects,
usually bilatetal, usually making clear their nature by the ordinary
signs of inflammation. Phlebitis, almost invariably unilateral, may
be unaccompanied by pain or tenderness, but, as a rule, there is sore-
ness over the course of the vein on the inner side of the leg. The diag-
nosis can sometimes be made only by study of the associated disease;
for instance, typhoid fever or the puerperal state. An enlargement
or edema of one leg, coming on in either of these conditions, should
always be assumed to be due to phlebitis imtil proved to the con-
trary, whether any local pain or tenderness is present or not. Chill,
fever, and leukocytosis may accompany the onset of such a phlebitis.
Alcoholic neuritis is a cause of edema often forgotten. It is, pre-
sumably, akin to the edema seen in infectious peripheral neuritis
(beriberi). The accompanying loss of knee-jerks and changes in
sensation usually make the diagnosis clear.
Vol. 11-30 465
466 DIFFERENTIAL DIAGNOSIS
In cirrhosis of the liver an edema of the legs, appearing usually
subsequent to the development of ascites, is the rule. How far
cardiac and renal elements enter into the production of this swelling
it is often impossible to determine during life.
Hereditary trophedema^ a mysterious condition probably akin to
elephantiasis y offers no special difficulty in diagnosis, owing to the
fact that it is present from the time of birth. It rarely affects both
legs, and it is usually associated with some thickening of the sub-
cutaneous tissues. Myxedema is occasionally associated with true
edema of the legs, the two diseases resulting in a very tough, brawny
enlargement, very puzzling at first sight. The coincident changes in
the face, skin, hair, and cerebration should make the diagnosis clear.
VARIETIES AND SITES OF EDEMA
Swelling of the legs usually appears first upon the front of the
shin and the back of the thigh. This is doubtless due to the arrange-
ment of the blood-vessels. At the very beginning of an edema the
shin bones are often notably tender, and it is good practice in mak-
ing routine physical examinations to press strongly upon the shin
bone in search of such tenderness.
Brawny edema, tough and difficult to indent, usually means a
relatively long-standing and high degree of dropsy, but it is also de-
pendent more or less upon the quality of the tissues in which it accu-
mulates.
EDEMA IN CX)NVALESCENCE
After any prolonged illness, such as typhoid fever, the patient is
apt to show edema of the legs when he first gets out of bed. This
may persist for some days or even weeks, but ultimately clears up,
and should occasion no alarm. Doubtless this is due to the fact that
the circulatory system cannot at first accommodate itself to the greater
strain thrown upon it by the perpendicular position, in comparison
with the previous horizontal position of the body.
Case 195
A brakeman of fifty- three entered the hospital October 24, 1903.
For six months the patient has noticed swelling of his legs, and for
about four weeks some enlargement of the abdomen, with dyspnea, and,
of late, orthopnea. Nocturia, 2 to 3 . Appetite poor. Bowels normal,
sleeps well. The patient takes three or four glasses of whisky and
three or four of ale a day. He had typhoid fever at eighteen and frac-
ture of the skull in 1876. He has had gonorrhea twice; denies s>philis.
f
Edema of the Legs
HEART DISEASE ^^tmmK^mmim^ma^m^^mim^tmm 8236
NEF>IHRITIS H^H^^I^H 2856
AIM E MIA H^IH 923
VARICOSE VEINS ^m 487
PI-IL.EBmS' ■ 390
CIRRHOSIS OF LIVER ■ 309
ALCOHOLIC NEURITIS I 16
OBSTRUCTION OF\ .
VENA CAVA / ' ^
BERIBERI I 2
Affecting almost invariably one leg. The other diseases here listed affect both
legs.
467
468 DIFFERENTIAL DIAGNOSIS
Physical examination showed good nutrition; pupils, glands, and
reflexes normal. Heart and limgs negative, except for diminished
breathing over the lower quarter of the left back, where numerous
crackling ikles were heard. Abdomen showed shifting dulness in the
flanks and the superficial veins were rather prominent. The girth,
2 inches above the umbilicus, was 44 inches. Marked edema of the
legs. The urine averaged 35 ounces in twenty-four hours, smoky,
acid; specific gravity, 1020; albumin, | per cent.; sediment, much
normal blood, nimierous hyaline, fine and brown granular casts, with
blood adherent. Blood negative.
The abdomen was tapped on the 28th and 18 pints of straw-
colored fluid withdrawn, with a specific gravity of 1009. The urine
continued bloody. The abdomen was tapped again on the 7th of
November and an equal quantity of fluid of practically the same
characteristics was evacuated. After this tapping the edge of the liver
was felt in the epigastrium. For a few days, before and after the 8th
of November, there was a slight rise of temperature, associated with
nausea and occasional vomiting.
Discussion. — The patient is alcoholic and, therefore, very possibly,
syphilitic. No physician should put any weight upon the negative
statement of an alcoholic in regard to syphilitic infection. His state-
ment may well represent his belief, but he really knows nothing about
the matter.
The patient's dropsy appeared six months ago in the legs, and only
a month ago in the belly. Nevertheless, the liver must first be sus-
pected as a cause of the edema, because of the enlarged veins visible
over the abdomen, the palpable liver edge, and the alcoholic history.
The condition of the urine makes it probable that some degree of
nephritis exists, either acute or acute exacerbation of a chronic proc-
ess. The low specific gravity of the ascitic fluid may be taken as ex-
cluding tuberculous or cancerous peritonitis, and, as the heart shows
nothing of note, we may conclude that the edema is of hepatic origin,
renal origin, or due to both sources at once. Unfortunately, we have
no record of a blood-pressure measurement to confirm our diagnosis
of nephritis; in 1903 such measurements were not a routine.
Outcome. — After November 8th the ascites returned more slowly
than before, and he did not have to be tapped again before he left the
hospital on the 21st of November. The urine at this time showed
very few casts, but still contained a large trace of albumin and had a
good deal of normal blood in the sediment.
EDEMA OF THE LEGS 469
Case 196
A farmer of seventy-seven entered the hospital May 4, 1904.
The patient has a negative family history, and has always been very
strong and rugged, except for an attack of sciatica in 1885 and a second
attack six months ago, lasting five weeks. After this the left great
toe and the side of the foot remained numb and have been so ever
since.
A week ago, while dressing, he noticed that his left foot was swollen.
This has gradually spread up the leg and tenderness has appeared here
and there; in other respects he feels perfectly well. Appetite, bowels,
and sleep are normal.
Physical examination is negative, save that the left leg and thigh
are swollen, slightly reddened, and, along the course of the internal
saphenous vein, tender on pressure. Blood and urine normal. The
temperature during the first week rose to qq-S*' F. each night, falling
to normal in the morning.
Discussion. — Edema of one leg narrows the field of consideration
at once. We must be dealing with a local cause. The recent his-
tory of pain and niunbness in the left leg in a man of his age leads
us to surmise that arteriosclerosis may have something to do with his
troubles. The residual numbness of the foot may possibly be at-
tributed to this cause.
Nevertheless, we must reckon with an acute affair in addition to
the long-standing malady. Something has happened within the past
week, and that something bears all the marks of a phlebitis. The
local redness and tenderness such as is here described is produced,
so far as I know, by nothing except phlebitis with the accompanying
thrombus. Were the tenderness less accurately limited one might
have to consider lymphangitis, erysipelas, or a diffuse cellulitis, a trio
of lesions which in the leg may melt into each other in a way to make
sharp diagnostic distinctions valueless.
Doubtless the underlying arteriosclerosis and the malnutrition
resulting from it have something to do with the acute phlebitis, but
just what the connection is I do not know. Phlebosclerosis might be
a possible intermediary link, but the physical examination does not
confirm it.
Outcome. — Under poulticing and salicylate of sodium the swelling
and tenderness were gone from the leg by the isth of May; by the
20th of May he seemed perfectly well and was allowed to go home.
470 DIFFERENTIAL DIAGNOSIS
Cai6 197
A man of fifty-eight, employed in a paper-mill, entered the ho^i*
tal AugUHt II, 1904. For four months the patient has had pain and
swelling in both feet, worse on standing. In other respects he feds
well, though he has used alcohol to excess up to four months ago.
Hiti family history and past history are negative. His knee-jerks
were not obtaineil. Both ankles were somewhat reddened and
ai^newhat swollen, the arches of both feet broken down, some Tar-
Ices ablaut the ankles.
Vhysica) exanunation, including the blood and urine, was other-
wise negative.
IHactta«ioD«— Alcoholic neuritis is probably the cause of the
of knee-jerks in this case, and if the edema were ^read
ov^ the Wgs the neuritis would probably be accountaUe for that
^v. Ii is notable. hv»i^*cver. that the redness and sweffing of
Ke complains arv cvnitmevt to the region of the ankles and aic
cialevl with pK\>natevt te^t.
Thfe^ c^smbination o£ inflammatory- and mechanical changes
iKe tarsus is a ^\>iK{ition v.\>mmoixIv seen and not we&
iKe dat-Joot the cjiuse 01 the tnAimm.ition or the
Cftuse of the flat Jwt? The latter setfms more probable, yet
ca$e^ the dat-Kvt >ieems to precede the indaznnadoa. Olt
haad> trvadutent oi the dat-toot is often the ctiickesc mieans of
k^ the iodiuimuLtion. Rest dnc silicyiates io something, bat <iD
luush up the K.K>. Ljiji measures ot rtfiief inif the esential tftm^
It must be ;issumcii that th^f carciac. r^nul. ami rwrmir causes of
dropcsv dr^ ruled ou: by the physicil c^.xaminadcg in diis case: also
mof< obvious superdcial and Iccil cauises ji ^iema. sodt as
[ I ( • ( •• t^^ 1 1 1 «
Whv Jo peopie jet dat-ioot? The jniinary oxediamcal
tjons vio not su&>f. The p«^?pte who ire oiost on dtdr «t ace mat
always those who ^ iat-ajoc Ph^-suiiogic factuis of mitxztiaB ;ind
^eneml vitaaty. wiiatevi»r that meansw w* c^tainly of hnpartance.
The peopie who lose skep. eat irreguiariy. subject dnsnseives to aA
sores oi Ixxiily and mental strain ore especiaily pc«d£sp«»aet to tfuB-
apportrnviy ^uitc local odection.
OufiDHEM.- He was- itted with Jac>:ooc :7Licts ami '.eft the b
OQ the 2^111 oi Au^xtsc The iiagnosis :t;aiis. ±ic-;ooc and so b
EDEUA OF THE LEGS
Case ]
A cook of fifty first entered the hospital March i6, 1908. He
entered the hospital the second time February 6, 1909, having been
working since his discharge, April 8, 1908. For the past month he has
served as a cook in a lumber camp and has felt well and strong,
though he noticed that his legs had begun to swell and- his face to grow
pale. For the past two or three weeks he has also noticed much
weakness. Three weeks ago his bowels became more costive than
usual. A week later he noticed that the fecal discharges were very
irritating to the skin. This condition he has noticed many times be-
Ftg. 173.— Chart in Case 19S.
fore. Ten days ago his appetite failed, but he worked until four days
ago. He has had a Uttle pain across the small of his back of late,
possibly caused by a strain when carrying a quarter of beef which
weighed z6o pounds. He has lost no weight. At the present time
his boweb are regular.
Physical examination showed poor nutrition, marked pallor.
The apex first sound of the heart was sharp, and was followed by a
systolic murmur transmitted to the axilla. A harsher systolic was
heard over the pulmonary area. Visceral examination was otherwise
negative. There was moderate edema of the legs and thighs. For
the first two weeks of his stay in the hospital the temperature ranged
472 DIFFERENTIAL DIAGNOSIS
as shown in Fig. 172. His urine was of low gravity, but otherwise
negative. The red cells at entrance numbered 900,000, and white,
2000. Hemoglobin, 40 per cent. There was moderate deformity of
the cells, with stippling and discoloration. Nucleated red cells were
occasionally seen, the normoblast type always predominating. The
patient remained a month in the hospital, during which time his red
cells rose to 2,250,000, his white to 6000, his hemoglobin to 70 per
cent. The number of oversized red cells grew more and more marked,
but at the time of his discharge there was no stippling, no abnormal
staining of the red cells, and practically no deformities. During the
last ten days of his stay he passed a large amoimt of urine and th(
edema disappeared from his legs. He left the hospital February 10,
1909.
Discussion. — ^Although the blood in this case makes a diagn<
of pernicious anemia almost inevitable, one hesitates for a momenta .^civt
when one notes that he has been working hard until within four da}rs..^»-^.
A moment's reflection, however, reminds us that this is one of th^-Mithe
pecuUarities of pernicious anemia, that the patient's working strengthlj^;gth
may continue despite a degree of anemia which makes it seem almost .^sioost
inconceivable that the patient should be out of bed.
In the present case there should have been no doubt about th»-ci:^^tlic
diagnosis, because such marked pallor would have attracted attentioK<:>£ion
at once and led, in all probability, to a blood examination. But m ::Mt if
this patient had been one of the 10 per cent, of pernicious anemi^.MLc:a=inia
cases, which are not pale but show a perfectly normal complexioinc<i^jon,
the diagnosis would surely have been missed by anyone not accustome»^-c:«ed
to make some blood test as a matter of routine. Even the hemoo-c:*:!!©-
globin test will not always set us on the right track in this case, foo^ for
owing to the high color index the hemoglobin is often but littlt^^ttle
lowered.
It may be well to recall in this connection that cases of pemicioim-r<i>ious
anemia may come to us in many strange disguises. They may appeas:^^^5ear
without any symptoms suggesting anemia and with complaints merelE^'^Tely
of paralysis in the legs — a paralysis of the spastic type. Anoth^^M^K^Mber
type of the same disease appears with fever as the presenting symptoBCK'^ii^-Oin,
so that typhoid fever is not infrequently the first diagnosis madfc>-i^sa(fe.
Others begin with diarrhea, and any anemia that is recognized is a^^ apt
to be falsely attributed to the diarrhea, when the etiologic sequent^r-^^aEDoe
is really in the other direction. The majority of all cases, howev^^^-ver^
are distinguished by the fact that they present themselves cc^zrvm-
plaining of one symptom only — viz., weakness, a weakness
EDEMA OF THE LEGS 473
leled in any other disease, because it is not associated with pain, loss of
weight, or functional disturbances, such as almost invariably accom-
pany any other disease producing a similar degree of prostration.
Outcome. — ^His previous entry, March, 1908, had shown practi-
cally the same signs and course, his red cells rising on that occasion
from 1,000,000 to 3,000,000 within two weeks. This was apparently
his first attack, but he rapidly relapsed and died August 14, 1909.
Case 199
A schoolboy of eleven entered the hospital June 4, 1909. The
eliild has not felt well for a week and has complained of headache and
£ibdominal pain. These are both gone now. His appetite is good,
iDowels loose. At times he has spoken of chilliness. There is nothing
else of interest in his history.
On physical examination the boy did not look sick. The chest
^nd abdomen were negative. Urine negative. White cells, 12,400.
'No Widal reaction. No eosinophils. The case was considered one of
'(3^hoid fever, though the boy seemed imusually bright and active.
^lood-pressure was normal. Skin tuberculin reaction negative. On
-the 6th there was slight stiflfness of the neck and Kemig's sign was
present on both sides. The next day muscular tenderness and pufl5-
sess about the eyes suggested trichiniasis, but there was no eosino-
philia. On the nth a spinal puncture was done and 10 c.c. of clear
:fliiid obtained, containing no cells or bacteria. On the 1 2th the heart's
2ipex extended a centimeter beyond the nipple line, and there was a
slight systolic murmur which led us to suspect acute endocarditis.
TTie reactions with two different strains of paratyphoid were negative.
TThe fundus oculi was examined and foimd normal. The middle ears
•were apparently normal.
Discussion.— Fever without known cause in a boy of eleven is most
often due to tuberculosis. When I say "without known cause," I
mean without any local lesion, such as an exanthem, a sore throat, a
typhoid infection, or a septic focus.
In the present case typhoid seemed at first the most probable diag-
nosis, although the Widal reaction was negative and the white cells
somewhat increased. When later the neck became stiff and the
hamstring muscles contracted we thought of meningitis, and tried to
get proof of the diagnosis through lumbar puncture. This proving
negative, we looked for a confirmatory evidence of trichiniasis, but the
persistent absence of eosinophiUa made it difficult to confirm such a
hypothesis. I feel sure but for the house officer's unusual persistence
474
DIFFERENTIAL DIAGNOSIS
we never should have discovered any eosinophiUa in this case. Why
the blood changes appeared so late I have no idea. Had we been
unable to get a bit of calf muscle, the diagnosis might well have been
missed, or the case might have been put down as one of those mys-
terious instances of nephritis without albuminuria, which are met with
now and then in literature.
I have no explanation of the marked general edema seen in
this case. It was as striking as that of typical acute nephritis,
J e
'
-^ -rr'—
:::::]:::;::.:::::
yet the urine gave no support to any such idea. Edema is, of course,
the rule in trichiniasis, but it is usually confined to the region of the
eyes.
Outcome. — On the 17th a bit of calf muscle was excised and
abundant trichina were found. There was no infiltration of eosino-
phils about the parasites. Up to this time there had been no eosino-
philia in the blood. On the aad of June eosinophilia appeared for the
first time. On the 4th of July he developed general edema, involving
EDEMA OF THE LEGS
the hands, legs, back, and abdominal wall. The course of the eosino-
philia is shown in Fig. 173. The temperature range is also of inter-
est (Fig, 174). By the 20th of July he was up and about, and on
the 3tst was discharged, the eosinophilia still continuing.
Case 200
A child of four years entered the hospital February 14, 1910.
Four days ago the child began to complain of pain and swelling in her
legs, said she felt tired, and, later, fainted. At the present time she
has pain in the pit of the stomach, in the calves, and the heels. This
morning her face became swollen. Her apjwtite has been poor for
six months, and for three weeks she has eaten almost nothing. The
patient's father died of tuberculosis and her mother at this child's
birth. The child was said to have had tuberculosis of the kidneys
when very young, and when two years old had sores all over her
hands.
Physical examination shows poor nutrition, heart's impulse in the
fifth space, 2j cm. outside the nipple line, the right border 3 cm. from
midstemum. A late diastolic murmur was heard at the apex and,
later, a systolic murmur also. Pulmonic second sound was accentu-
ated. In the middle of the left back there were slight dulness and
bronchovesicular respiration. The liver dulness extwided from the
axth rib to a point 2^ cm. below the ribs, but the edge was not felt.
476 DIFFEBENTIAL DUGNOSIS
At entrance the white cells numbered 38,000, from which pcnnt they
gradually decreased to 17,000, March 14th. The urine was nc^tive,
likewise the stools. By the 13th of March the heart was perfectly
regular and much slower than at entrance. Although the child was
somewhat anemic, she was allowed to go home on the 34th.
She re-entered March 8, 1911. During the year that had passed
the child had seemed perfectly well, and had run about as actively as
ever. For six weeks she had now complained of being dred and for
four days had been in bed, dozing, moaning, and unable to eat. At
this time there was a systolic murmur at the apex and a diastolic on
the left edge of the sternum.
The pulse had a Corrigan
quality.
She rapidly improved, the
pulse and respiration coming
down as shown in Fig, 175.
She was discharged on the
24th.
Discussion. — Unfortun-
ately, no Wassermann reac-
tion was done. Without this
we cannot exclude syphilis
with certainty, but as there
is no positive evidence of
that disease we may reason-
ably assume that the other
common cause of cardiac
lesions in young children —
namely, a rheumatic or strep-
tococcic endocarditis — is the
correct diagnosis.
The notable point is the extraordinarily high respiration, 100 per
minute, as recorded at the time of entrance, and the gradual fall of
this rate, which required a full week to reach normal (Fig. 175).
Outcome. — March 8, igii, the child entered the hospital again,
with a clear case of aortic and mitral endocarditis.
April 6, 1913, she reported at the Out-patient Department. She is
now going to school regularly and has no cardiac symptoms. The
heart's apex is in the fifth space, 7 cm. from the median line. Save for
a soft diastolic murmur, loudest over the third left costal cartilage, the
heart shows nothing abnonnal.
Fig. 175. — Course of temperature. puJse, and
Kspinition in Case loo. Note the extraordinary
faL in the respiration. The star near the figure
70 stands for the systolic blood-pressure.
EDEliA OF THE LEGS
Case 201
A saw-filer of thirty-one entered the ho^ital January 26, 1910.
Novemiser 30th, following an active half hour after breakfast, he sud-
denly vomited "3 quarts" of food and dark clotted blood. After this
he felt dizzy and weak, but worked until three o'clock, when he went
home and again vomited food and bright blood. In the four days
following he vomited blood six times, losing consciousness with the
last hemorrhage. He had tarry stools during this attack. Since the
5tb of December he has had no more hemorrhages, but soon after that
date he had a cramp-like pain in the bottom of his left foot. Tender-
ness appeared in the inside of the ankle, and shifted up the inside
Fig. 176.— Chart of Case
of the leg to the groin in the course of the next seven weeks. Most of
the pain at the present time is in the groin. Coincidently with this
pain, the whole leg has been swollen. For the past week he has had
night-sweats; for the past two weeks, a cough and poor appetite. He
sleeps well; since last summer has lost 40 pounds.
The onset of these symptoms was practically acute, though he
had noticed some distress in the epigastric region before and after
meals for five years. Otherwise his family history and past history
are good. His habits excellent.
The course of the patient's temperature is shown in Fig. 176.
At entrance his blood showed 3,100,000 red cells, and during bis
478 DIFFERENTIAL DIAGNOSIS
Stay this gradually rose to 3,500,000. Hemoglobin gained during
that period from 60 per cent, at entrance to 70 per cent, at discharge.
The white cells showed nothing abnormal. There was moderate
achromia at all times. The urine was normal. There was no blocxi
in the feces at any time. The heart's apex extended 2 cm. outside the
nipple line; the right border 3 cm. beyond midstemum. There was a
soft systolic murmur in the pulmonary area, otherwise the organ was
normal.
The left foot was reddened and edematous, and from the knee to
the groin an irregular cord-like mass was palpable on the inner side
of the thigh. The left groin was reddened and edematous and a
large mass was felt in the midinguinal region; also at a point 2 indies
above the pubic bone, midway between the median line and Poupart's
ligament, a small tender mass was indistinctly felt.
On the 31st the patient was seized during the night with a sudden
sharp pain in the back of the left lower chest. Morphin was required.
Next morning feeble respiration and a few moist rS^les were detected
in a small area in the left back. The edema of the foot thereafter
steadily diminished, and by the 13th of February was gone. On the
15th there was a sharp rise in the temperature, headache, nausea, and
pain in the right leg. The left leg was then apparently well, and the
right leg showed nothing but tenderness in the popliteal space. This
lasted until the first of March, when he seemed to be perfectly well and
went home with both legs bandaged.
Discussion. — What is the probable relation between the hematem-
esis and melena with which this patient's illness began and the sub-
sequent edema and pain in the left leg?
It seems to me probable that the slowing of circulation and de-
pression of vitality which the hemorrhage brought about favored the
occurrence of phlebitis. That process showed in this case more than
the usual evidence of its infectious origin ; but there is much to persuade
us that most, if not all, cases of phlebitis have an infectious factor in
their causation. Very few cultures made from thrombi have ever
proved sterile. The anorexia, sweats, and prostration are doubtless
due to this infectious element in combination with the weakness in-
duced by loss of blood.
All this, however, does not explain why he has lost 40 pounds in
the past six months. Were any evidence of hepatic cirrhosis present,
we might easily account in this way for the loss of weight, for the
hemorrhage, and the subsequent phlebitis; but, in point of fact, we
have not a scrap of evidence on which to incriminate the liver.
EDEMA OF THE LEGS 479
The later chapters of this patient's history are to be explained by a
migration or recurrence of thrombosis in other veins, first in the lung,
later in the right leg. Such recurrent attacks of phlebitis are some-
times extraordinarily tedious and discouraging. They may occur in
perfectly healthy people — in my experience generally males — and flit
from vein to vein without cause or cessation for a year or more. In
the end the whole process usually clears up and leaves good health
behind it, but from the point of view of therapeutics we are distress-
ingly helpless.
Outcome; — ^June 4, 1913, he writes, "I am not what you would
call a well man, but I am trying to get by with the rest. In January,
1913, a surgeon removed the veins from both my legs, but they did
not come out very well."
Case 202
A butler of twenty-six entered the hospital June i, 19 10. Five
weeks ago the patient's ankles were swollen for a few days. Three
weeks ago the swelling returned and traveled up the legs and thighs
to the abdomen, hands, face, and the top of his head. Except for
this he has no symptoms and feels perfectly well, although he has
noticed for the past few days some shortness of breath on exertion.
His ordinary weight is 155 pounds; now, 172 poimds. Except for a
soft, low-pitched murmur at the heart's apex the chest is negative.
There is marked edema, as described by the patient. Systolic blood-
pressure, during most of the four weeks in the ward, varied between
140 and 150. The highest reading was 170 mm. Hg.; the lowest,
120 mm. Hg. He was afebrile throughout the month of observation.
The Wassermann reaction was negative.
The urine averaged 35 ounces in twenty-four hours, was of normal
color, slightly cloudy; specific gravity, 1018 to 1023; albumin from
I to 1.8 per cent. The sediment showed many hyaline and granular
casts with a little fat and a few cells adherent. Blood showed at
entrance 23,000 white cells, with a polynuclear leukocytosis. This
disappeared within a few days. The stools showed ova and live
embryos of Strongyloides intestinalis, also a few eggs of Trichiuris
trichiuria. He did not improve much during the month in the ward,
though his edema readily disappeared when he stayed in bed. Con-
centrated magnesium sulphate solution, hot-air baths, pilocarpin,
and salt-free diet had no considerable effect.
He left the hospital on the 27th of June, and re-entered on the 13th
of July in practically the same condition. At this time the abdomen
480 DIFFERENTIAL DIAGNOSIS
had to be tapped, and a quart of chyliform fluid was obtained whidi
had a specific gravity of 1006. Examination of the fluid by Dr.
W. F. Boos showed the turbidity to be due to pseudomudn. There
was no fat present. The sediment was mostly lymphocytes and endo-
thelial cells. He had the same parasites in the intestine and also a
varying number of adult hookworms and their eggs.
Discussion. — Bilateral edema, associated with dyspnea, well-
marked urinary changes, and a slight increase of blood-pressure, is
probably renal in origin, especially as it is associated with such a n^id
gain in weight. When there is any possibility of renal or cardiac
disease a gain of weight, which we ordinarily welcome, should be
viewed, as the politicians say, with alarm.
The only thing to confuse the diagnosis in this case is the presence
of three different intestinal parasites and of a somewhat sXypkal fluid
obtained by tapping the abdomen. Neither of these facts, however,
is of any importance. Intestinal parasites cannot possibly have any-
thing to do with the production of edema. Only the blood parasite
of filaria can produce edema, when it blocks the lymphatics.
The presence of pseudomucin, rendering ascitic fluid milky in ap-
pearance, is a spectacular event, often exploited with great satisfac-
tion in clinics, but of no practical importance as far as is known at the
present time.
A point of interest in the case is the blood-pressure record. The
vast majority of blood-pressure readings are either normal or
notably increased. Border-line readings, such as 150, are rare, a
fortunate thing for our diagnoses. This means that there is usually
no disturbance of function, no symptom that brings the patient to
his physician until the hypertension has reached a notable degree.
Whether it takes months or years to convert a normal blood-pressure
into an elevated one in cases of chronic nephritis or arteriosclerosis
we have no means of knowing, but there are certain facts reported
by the life insurance companies which lead me to believe that the
change may be a relatively sudden one.
If this is true, it would help to explain the fact that we so seldom
see the patient when his blood-pressure is slightly or doubtfully el^
vated.
Outcome. — Blood-pressure ranged between 140 and 150 nun. Hg.
for three weeks. The urine was practically the same as during his
previous entry. Diagnosis: Chronic glomerulonephritis. He left the
hospital on the 29th of July.
EDEMA OF THE LEGS 481
Case 203
A clerk of fifty-three entered the hospital June 3, 1910. The
patient denies venereal disease, and has never been under a doctor's
care before. He has taken five or six whiskies and five or six beers
a day for thirty-five years. For a month and a ialf his legs have been
slightly sore and swollen, and for five or six weeks he has noticed some
shortness of breath. Yesterday he had a dizzy spell and has had
several more since.
On physical examination the patient's pupils did not react to
light. There were blotchy pigmented areas scattered over his face
and forehead. The heart's apex extended i^ cm. outside the nipple
line. The sounds were very irregular in force and frequency and
were of p>oor quality. Pulses were equal, irregular, of poor volume
and tension. Pulmonic second accentuated, occasionally a slight
systolic murmur heard at the apex. The abdomen measured 97 cm.
the largest circumference, and was markedly dull in the flanks, the
dulness shifting with change of position. Knee-jerks were not ob-
tained. There was marked edema of the legs and thighs. Systolic
blood-pressure was 130. Blood and urine normal. Laryngoscopic
examination showed abductor paralysis of both vocal cords.
Discussion. — In an alcoholic any leg edema is suspected, first
of all, of being due to neuritis, but in this case we have, in addition,
an ascites suggesting a possible cirrhosis, especially in a man of his
habits. Moreover, we have all the evidences of a weakened heart.
Syphilis is more than possible in any patient with such a history.
Unfortunately, we have no Wassermann reaction, but it may well
be that both the heart and the liver have been affected by this disease.
Since the knee-jerks are not obtained, and the pupils fail to react
alike, there is additional reason for suspecting syphilis and tabes
dorsalis as fimdamental causes of all his troubles. Whether the
heart or the liver is chiefly at fault we cannot, from the facts be-
fore us, determine. The abductor paralysis is doubtless of syphilitic
origin.
Outcome. — Intubation was considered, but not done. Later in
the day tracheotomy was obviously necessary and was done by
Dr. Mosher. He died soon after.
Case 204
A maid employed in the hospital, thirty-seven years old, entered
the ward July 31, 19 10. She has noticed for a week that her legs were
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482 DIFFEBENTUI. DIAGNOSIS
swollen, slightly tender, and slightly painful on walkii^. At first the
right leg was more swollen than the left; now the reverse is true. She
has absolutely no symptoms, thou^ tiie
nurses say that she has been ine£Eicient hi
her woric of late.
Fhyacal examination is wholly n^ft-
tive, except that the l^s and ankles are
moderately swollen, the skin red, glazed,
and markedly tender. Blood and urine
normal.
DiBcuBsion. — The general causes fd
edema are obviously absent. Just what
the local cause may be it is not so easy to
say, but certainly some cutaneous or sub-
cutaneous disease is the cause of the
edema. The absence of leukocytosis
makes it improbable that any erys^ielas
or cellulitis was present. Further tiun
that, without s[>ecial dermatcdo^ knoiri-
edge, we cannot go.
Outcome. — ^A dermatfdogic omsultant
pronounced the trouble erythema multiforme in a stage <A ooavales-
cence. By the 12th of August the whole trouble had disaj^ieaRd.
Tlie range of the temperature is shown in Fig. 177.
Case 205
A fireman of twenty-nine entered the ho^ital Juty is, 1910.
A m(mth and a half ago the patient's right ankle and calf became
swollen. He felt perfectly well in even* other way, and this swelling
disappeared in four days. Two weeks ago both legs swelled. This
has continued since, although he has absolutely no other synq>toms
and feels perfectly well. He has had no hereditary taints and no pre-
vious illness. He has beoi a good deal in the Tnqucs, the last time a
year ago. For the past two months he has beoi drinking heavily
and has gained weight.
Ph>-sical examination shows that the apex of the heart attends
I cm. outside the nipple line, the right border 4 cm. bam midstemum-
At the apex is a soft sj-stolic murmur, heard louder as one a{^roaches
the base and loudest at the aortic cartilage. The pulmonic seccoid
sound is not accentuated. The knee-jerks are not obtained, and there
is brawny edona below the knees; otherwise phyacaJ examination.
Tig. tjj.—Chan in Case 304.
EDEMA OF THE LEGS 483
including the blood and urine, is negative. Systolic blood-press-
ure, 125. No temperature in ten days' observation, during which
time he lost 5 pounds and got rid of his edema.
Discussion. — ^The patient has been in the Tropics, and the idea of
filariasis comes at once to mind as soon as edema of the legs is men-
tioned. Filariasis, however, almost invariably affects one leg by
blocking the lymphatics in the neighborhood of the groin. I have
seen no record of a filarial disease affecting both legs.
Beriberi is another tropical disease causing edema and having no
predilection for imilateral distribution. This disease, however, is
never confined to the legs, though its manifestations may be most
xnarked there. The absence of knee-jerks is compatible with beri-
l>eri, but also with the diagnosis next to be mentioned.
It is notable that his excessive alcoholism began shortly before
the trouble in his legs. The only reason for any doubt regarding the
<liagnosis of alcoholic neuritis in this case is the condition of the
lieart, which appears to be somewhat enlarged, although the ab-
normality is not very notable. The effects of alcoholism upon the
lieart have not, in my opinion, been very thoroughly recorded. In
some cases we seem to have an acute and ominous weakening of the
lieart during or after an alcoholic debauch, yet without any permanent
changes in the organ. Such, at any rate, is the most natural con-
clusion from the rapidity with which such patients pick up and their
steady good condition thereafter, provided they will stop drinking and
continue their abstinence. In the present state of our knowledge it is
impossible to determine when one sees a bad cardiac dropsy in an
alcoholic whether the condition will result in a permanently weakened
heart or whether it will all clear up. We have to wait until the effects
of the alcohoUsm have worn off. After that quite marvelous improve-
ments sometimes occur.
Outcome. — On the 21st of July he seemed to be well and left the
hospital.
Case 206
A child of seven entered the hospital July 27th, 1910. Four
years ago the boy had a lump appear under the right jaw; after
four weeks it was opened and discharged profusely and in two weeks
was well. Otherwise he has been perfectly well until five days ago,
when small tender tumors were noticed on both sides of his neck.
Two days ago he was a little sleepy in the daytime, but played as
usual. Yesterday he complained that his shoes were too small and
484 DIFFERENTIAL DIAGNOSIS
his ankles were found to be swoUen. He lay about the house and
would not eat. Last night he seemed feverish and breathed very
hard. To-day, for the first time, his urine appeared red.
On physical examination the heart's apex extended i cm. outside
the nipple line, right border 2 cm. from midstemum. The heart
was negative, save that the first sound was somewhat \'al\'ular in qual-
ity and the strength of successive beats varied a good deal. The
lungs were negative. The abdomen showed shifting dulness in the
flanks, with moderate edema of the legs. Systolic blood-pressure,
125. The temperature ranged from 99° to 100.5" ^' during first week;
after that normal. The urine averaged 2$ ounces in twent>"-four
hours, was always smoky in color: specific gra\-it>' a\'eraged 1016-
The sediment contained much free blood and a moderate numb^ of
blood-casts, as well as fine and coarse granular casts. Xo fat was seen
upon the casts in fourteen examinations. At entrance the white
cells numbered 25.50c. \%-ith a pol\Tiuclear leukocytosis. This de-
creased dav bv dav. and was normal Aumst 2d.
Discussion. — Presumablv. a tonsillitis or some other oral infecticm
has preceded the glandular suppuration ^^nth which this malady was
ushered in. WTien anv such infection is followed bv edema of the
legs, we should at once call to mind the fact that even a verj- trifling
tonsillar infection may be followed by severe nephritis. AH the
recent milk epidemics of streptococcic sore throats have shown ex-
amples of this t\pe of nephritis. The ascites, the fever. d\'spnea,
anorexia, leukocvtosis. and for a child the slight h>pertaisioa lead
US to take the condition of the urine ver\- seriouslv. The amount of
blood in it would probably have made the diagnosis of nephritis in-
e\"itable in anv case.
WTiat is to be said regarding the condition of the heart? It seems
to me more than possible that the same infection which has damaged
the kidney has not sparetl the heart. How great the damage is only
time can show. There is no reason, however, to believe that the
edema is of the cardiac t\pe. The heart's action is not sufficiently
disturbed.
Outcome. — By the 12 th of August the albumin had disappeared
and the sediment was at that time negative. The edema and ascites
had gone and he felt well. On the i ;th he went home.
Case 207
A sisrnal man on the Boston and M^ine. thirty-nine \-ears old.
entered the hospital December S, 10 ic. Four days ago the patient
EDEMA OF THE LEGS 485
noticed that his calves were swelling. This swelling gradually ex-
tended to include the ankles and feet and then the thighs, and was
accompanied by constant aching. On further questioning, he remem-
bers that on November 29th he took a 3-mile walk, very xmusual for
him, after which his legs trembled and felt very weak. For two or
three weeks he noticed dyspnea on exertion. For the past four days
he has had an unusually good appetite. He worked until last night.
He has been steadily gaining weight. There is nothing of interest in
his family history or in his past history, except that for several years
he has noticed palpitation on exertion or on excitement. He has
be«i a pretty steady drinker for sixteen years, and occasionally takes a
drink of whisky before breakfast. He smokes constantly.
Physical examination shows good nutrition, pupils slightly irregu-
lar, but reacting normally. The heart is negative except for a very
soft systolic murmur at the apex. Abdomen and urine negative.
Reflexes normal. Much soft edema of the legs and thighs.
Discussion. — In the absence of any cardiac hypertrophy, and with
a systolic blood-pressure of 135, such as is present in this case, with
normal blood and urine, it is diflScult to explain the symptoms of
myocardiac weakness. There is no evidence of any infectious disease
and no signs of nephritis. It seems to me that we must attribute the
heart weakness, as in a previous case, to the alcoholism. Just why
this trouble should have fallen upon him now rather than sooner I
cannot say. Only the outcome of the case, carefully followed for
months, can tell us whether the heart is permanently crippled or only
temporarily poisoned. It is one of the standard wonders, revealed
in medical practice, what an alcoholic can throw off in the way of
cardiac, renal, cerebral, and other manifestations, provided he can
once decide to cut out alcohol.
Outcome. — When examined December nth the edema had left
the calves, but they were still extremely tender. There were then
riles in both bases. Wassermann reaction negative. By the 28th
of December he seemed to be practically well and left the hospital,
having lost 1 1 pounds in three weeks, owing to the disappearance of
dropsy.
Case 208
A cigar maker of fifty-nine entered the hospital March 14, 191 2.
The patient's only complaint at the present time is of swelling of the
legs, which appeared ten days ago. He admits on cross-questioning,
however, that a year ago he was in the Out-patient Department com-
486 DIFFERENTIAL DIAGNOSIS
plaining of six weeks' dull steady pain across the upper abdomen,
that time he was jaundiced and had morning nausea, but he
recovered from all these symptoms and has had no treatment ani
For the last fifteen years he has passed urine two or three times at nig!
He now feels strong and works as usual, has a good appetite, and s](
well. He has no headache, nausea, or dyspnea. He takes two or thr -
whiskies and three or four beers a day. He denies venereal disease^
Physical examination showed a well-developed, flabby patiein
making jerky or poorly co-ordinated movements, and with a stro^
odor of alcohol on the breath. Pupils and reflexes nonnal. Hi
apex extended ij cm. outside the nipple line. Sounds were rej
good quality, no murmurs. Aortic second accentuated. The
^^ rial walls not felt, lungs n^atii
Abdomen showed dull tympa:
in the flanks, but no shifting wi
change of position. The edge
the liver was not felt. "ITii
was marked edema of the 1<
and thighs. Dr. F. C. Shatti
said, "Inferentially, cardiac
sufficiency in a potator."
own diagnosis was arteriosclerc
hypertrophied and dilated heiv — ^"^
cirrhosis of the liver, questic^-^-n-
able chronic glomerular nepfc^»-^"^"
tis. Stomach-tube examinatE^ ■^^'^
showed that the stomach ^fc^^-^
empty before breakfast, was rri-^ ^'^
enlarged or displaced, and i
tained no free HCl after a t
meal. Wasserraann reaction w
suspicious March isth, negative March 19th. Blood-pressure,
mm. Hg. at entrance, systolic; 90 mm. Hg., diastolic; 175 mm. I
the next day (Fig. 178).
The blood was not remarkable. The urine averaged 30 oun <
in twenty-four hours; specific gravity ranged about 1014. There t^*-^^^
an occasional granular cast and a little free blood in the sedim^^^^^'*
During the two weeks of his stay in the hospital the edema sligts. "^^Y
increased, and there was constant mental dulness or confu^on. A^"^^
the 26th he was entirely irrational and took almost no food. On tie
30th he died.
EDEMA OF THE LEGS 487
Discussion. — ^Apparently, the first symptom was nocturia. This,
is well known, may be due to either the heart or the kidney, and,
ais is somewhat less well known, to hepatic cirrhosis. The year's
history of jaundice, morning nausea, and steady epigastric pain in an
alcoholic patient points strongly toward hepatic cirrhosis. The main
question of interest, as it seems to me, is, what else has he? With
so high a blood-pressure the heart is almost certainly affected, the
kidney .very possibly. The presence of free blood in the renal system
makes the latter suspicion more probable. We have no reason to
believe that the heart valves are damaged. Enlargement and dilata-
tion are the probable inferences. At his age this condition is as
likely to be due to arteriosclerosis as to kidney trouble, despite the
definite evidences in the urine.
When this patient first entered, we felt that he might clear up
like some of the other alcoholics whose history has been given in pre-
vious pages. We were not prepared for his steady decline.
Outcome. — ^Autopsy showed cirrhosis of the liver, arteriosclerosis,
hypertrophy, and dilatation of the heart, subacute glomerular nephri-
tis with arteriosclerotic degeneration, obsolete tuberculosis of the
left apex.
Case 209
A machinist of eighty entered the hospital March 30, 191 2.
The patient's father died of what was called "tobacco lieart," his
mother of shock, one brother of diabetes. His wife died of shock.
She has had one child, who is living and well; no miscarriage. The
patient lives alone, and spends his time working on an invention for
"increasing and transmitting power; that is, for making five pounds
lift six pounds." He expects soon to sell the machine for $15,000.
For the present he is spending 15 cents a day for food.
For the past three weeks he has noticed swelling of his feet and
iegs and says that he has lost all ambition. He has no dyspnea. On
the contrary, he climbs four flights of stairs a day without resting and
mthout losing his wind. He has no headache, good appetite and
digestion, and says he has not lost weight or strength.
Physical examination showed poor nutrition, pallor, and dry
skin. Pupils and reflexes normal. Heart and urine negative. Arte-
ries slightly tortuous and beaded. Blood-pressure, 155 mm. Hg.,
systolic; 90 mm. Hg., diastolic. Blood and urine normal. No fever
in ten days' observation. The edema disappeared in a week, during
most of which time he was eating or sleeping. At the end of that time
488 DIFFERENTIAL DIAGNOSIS
he was anxious to go back to work, and was allowed to go home.
Treatment consisted of magnesium sulphate, i ounce in €oncen-
trated solution before breakfast, for two days. This, with an occa-
sional hypnotic and laxative, was all that was given him.
Discussion. — ^At this patient's age, and with arteries' like those
described, it is almost inevitable to attribute his edema to arterio-
sclerosis, even though he has shown no dyspnea or distinctively
cardiac symptom.
At this age an edema of the legs is a much more serious symptom
than in a younger person. With the absence of headache, marked
hypertension, and anemia it does not seem possible to incriminate the
kidney. There is nothing pointing to cirrhosis. Cardiac weakness,
therefore, is our best surmise.
Outcome. — He died October 28, 1912, at Tewksbury State Hos-
pital. Diagnosis: Arteriosclerosis and acute bacillary djrsentery.
Two months earlier he had seemed quite well.
Case 210
A man of twenty-three, in a cotton mill, entered the hospital
April 13, 191 2. The patient's family history is negative. His mother
tells him that when he was a year old his face was so swollen for two
months that he could not open his eyes. Otherwise his past history
and habits are good. When he was five years old, his right 1^, below
the knee, "began to swell, and a few years later his left. This swelling
has slowly increased ever since and has extended into the thighs and
scrotum, but not elsewhere. It is always less when he lies down and
can be reduced by the use of a rubber bandage. There is no pain or
other discomfort. At intervals of from three to five months (except
during the last two years) he has had attacks, substantially as follows:
Severe pain and tenderness would appear in both groins, soon followed
by a shaking chill and the vomiting of much fluid, then by a fever and
somnolence. He has not h'ved in a malarial region, so far as he
knows. His urine has never been milky, but he passes it twice or
thrice in the night. The swelling of his legs has never interfered
seriously with his work, and has sometimes been a source of income
in circus shows.
On physical examination the right pupil is larger than the left;
otherwise both are normal. The chest and abdomen show nothing
of interest. The condition of the legs is shown in Figs. 179 and 180.
The skin of the thighs and calves was much thickened and covered
in places with crater-like elevations, some old and white, some recent
■ EDEUA OF THE LEGS
and red. The right calf is 88 cm.; the left, 68 cm.; the right thigh,
S3 cm.i the left, 82 cm. Blood and urine were normal. No fever
in two weeks' observation.
By the use of silver ointment the skin became soft and dean. He
■was kept in bed with the legs raised, but given no medicine. During
the last three days of his stay in the medical ward he voided 430
ounces of urine (Fig. 181), with marked reduction in the size of his
legs.
Discussion. — An enlargement which has existed since the age of
five, and which was confined for some years to one leg, has evidently
490
DIFFERENTIAL DIAGNOSIS
the local, not the general, type of etiology, llie statement Hat. bis
urine has never been milky and that he has never lived in the Tro^pics
tends to rule out filarial disease. Blood examination is also q-ciite
negative.
We cannot call the condition hereditary, since he was free fr"«m
it for the first four years of his life. What was the cause of his swollen
face when he was a year old? We can only conjecture. With the
exclusion of heredity, trophedema, and filariasis, we have nothing but
elephantiasis left, and the local signs support this diagnom.*
Of much interest was the prodigious diuresis which we were a.ble
to observe when we got bim at rest in bed. Clearly, the juice ■<
-1^
Fig.
I.— Chart of Case
of urinuy secret*""
running out of his legs. Edema was, therefore, an element in ^
condition. Of further interest is the result of operation showT> "
Figs. 182, 183.
Outcome.— He was transferred to the surgical wards, where a con-
siderable amount of the h>-pertrophied tissue was removed. "Tbt
resulting changes are shown in Figs. 182, 183. The thighs after opera-
tion measured 22 inches; the calves, 17; inches. Examination of ^^
' "Three Cases of Sporadic Elephantiasis o( the Lymphatic Type," by Gtocg* *-■
Shattuek, M. D., Boston Med. and Surg, Jour., January 17, 1910; "Etiology of £'*'
phantiasis." by George C. Shattuek, M. D.', Boston Med. and Surg. Jour., Novcmte'
/
EDEMA OF THE LEGS
491
excised tissue, by Dr. W. F. Whitney, showed fibrous tissue filled
with lymph-spaces containing serum. The fibrils were more or less
separated by serous fluid. The patient left the hospital on the 25th
Fig. 183. — Condition of patient's legs after
operation (Case zio).
Fig, 183. — Condition uf patient's legs after
operation (Case no).
of May, 1912. In February, 1913, the patient writes that he is feeh'ng
very well, and that the elastic stockings which he is now wearing pre-
vent any recurrence of the enlargement at the site of operation.
Case 211
A draughtsman of sbtty-five entered the hospital May 11, 1912.
The patient's wife died of tuberculosis thirty years ago. His family
history is good. He has two children living and well. He remembers
no previous illness, and says he has been well and strong. He has
taken no tobacco or alcohol and denies venereal disease. He has been
492
DIFFERENTIAL DIAGNOSIS
accustomed to work twelve to eighteen hours a day, and has taken loo|
bicycle rides on Sundays. He entered the hospital with a diagocas
of "chronic nephritis and chronic bronchitis," made by his (arcfls
physician.
For three months he has been running down, losing wet^^t,
strength, and ambition. For two months he has had modcTsate
swelling of the feet and a persistent dry cough. His appetit.^'^ is
poor, his digestion good. He has had no headache, no nausea ^ no
dyspnea or nocturia. He sleeps well. Cramps in his hands and
feet he has noticed for three or four years. He finished his mni rarl
as a draughtsman this morning, then immediately gave up and ■ «"«
to the hospital. Two months ago he weighed 136 pounds, witi ihis
clothes; at entrance he weighed loS pounds, without clothes.
Physical examination showed "*"^ """"
emaciation, but nothing abnormal wa^^=s de-
tected in the chest or abdomen ei^a^cept
spasm and duhiess in the right fa ^ypo-
chondrium. The urine averaged 35 ™»~ '""^
in twenty-four hours; specific gra- — vily,
1020; very slight trace of albumin az^ nd a
few granular casts. Blood normal. BCZZIood-
pressure, 125 mm, Hg., systolic; 75 mm.
Hg., diastolic. My diagnosis wasar^Exiio-
sclerosis, myocardial weakness, vas— •cular
crises in the peripheral arteries. The
course of the temperature is shown ii»_ Fig.
184. Wassermann reaction negative. He
coughed up a good deal of mucopur'«-iIent
sputum which contained no tubercle b^^tilK.
His edema rapidly cleared up, his S:^eait
seemed to be well compensated, ancJ ^
chief trouble seemed to be mabiutrition. He slept most of his time
and took food poorly. On the 17th riles were noted throughout
both lungs, especially in the middle of the left back, where they ""'Sfs
coarse and loud. At the same time he became incontinent of ■Jriw
and feces. He was considered to have a terminal bronchopneu-
monia.
Discussion. — It seems to me altogether pathetic that a man oiios
age, with such obviously serious illness, should have worked up
to the very day that he entered the hospital. His history is of time
months' weakness, with two months of cough and edema of the
\
s ■, - . - - jT -
I'.: |/?::5I
■■ . 1 . ^ J ^ -. _
,:BiuM|l
■'V:,r:-::V:-:-:
! : - '-^
l:.: .--, ^
" " i - J;
-Chart of Case a
EDEMA OF THE LEGS 493
feet, and the loss of 20 pounds in this time. The cause of his edema
and fever we were altogether unable to determine. We supposed
his cough to be of nervous origin, though possibly due to cardiac
i^eakness. There was nothing of any special significance in the lungs
until the day before his death, and the conditions then found were
taken as terminal rather than etiologic.
The case illustrates a total failure of our diagnostic resources.
Outcome. — ^He died on the i8th. Autopsy showed chronic tuber-
culosis of both lungs, general miliary tuberculosis, tuberculous peri-
tonitis, tuberculosis of the ileum, slight arteriosclerotic degeneration
of the kidnejrs.
Remarks. — In looking back upon the case in the light of the autopsy
I do not see how we could have done much better. The edema was
doubtless due to an infectious myocarditis with weakening of the
heart's action.
Case 212
•
A shoemaker of eighteen, bom in Turkey, entered the hospital
June 22, 1912. He quit work two weeks ago because of swelling of his
feet, headache, and nosebleed. He has never been sick before and has
excellent habits. During the two weeks that have passed the swelling
has extended up the legs and thighs, but has never been noticed in
the face. Appetite and digestion are excellent, eyesight good, no
dyspnea or nocturia.
Physical examination shows a respiration suggesting Cheyne-
Stokes. The heart's impulse seen and felt in the fourth space, § cm.
outside the nipple line. No enlargement on the right. Pulmonic
second greater than the aortic second. Apex second sound ringing.
Radials and brachialis slightly roughened. The course of the blood-
pressure is shown in Fig. 185. The urine averaged 25 oimces in
twenty-four hours for the first week, with a very slight trace of al-
bumin and a moderate number of hyaline casts, some with a few
cells adherent, many red corpuscles. Blood negative. Wassermann
reaction negative. After two days in the ward, with a nephritic diet,
and I ounce of concentrated solution of magnesium sulphate every
morning, the edema was gone. A week after entrance the urine rose
to 70 ounces and the patient felt perfectly well. At times there was
a suggestion of presystolic thrill and roll at the apex.
Discussion. — Edema of the legs in a man of eighteen, associated
with headache and nosebleed, and later with Cheyne-Stokes' breath-
ing and hypertension, compels us to make the diagnosis of nephritis,
494
DIFFEKENTIAL DIAGNOSIS
whatever the urine shows. As a matter of fact, the urine woul^
probably have mclined us strongly toward such a diagnosis even had
the other symptoms been less clear.
The point of interest is to determine whether this is an acute
nephritis, as the history suggests, or an exacerbation of a chronic
process. At the time of entrance the blood-pressure of 215 mm. Eg.
made me feel confident that we were dealing with a chronic case,
and even when the pressure had decUned so wonderfully (Fig. 185)
I still felt that the case must be a chronic one.
KMf«*|# + --
' - \ V^r ^ ? ■!
: &s#,.:.::
::' ±;S-:::::
; of systolic and diastolic blood-pressure (starred Vo") >"
Note the diuresis as blood-pressure falls.
Outcome.— The patient left the hospital July ist. March i9>
1913, the patient's physician writes that he is feeling perfectly "«"
and working daily. The doctor has recently examined his urine ana
finds it entirely normal.
Remarks. — In view of this outcome, it seems to me clear that 1 "**
wrong in calling the case chronic rather than acute nephritis. If *•
it is a matter of some importance as proving that even a temporary
and curable disease of the kidney may produce so marked a hyp""
tension.
CHAPTER XI
FREQUENT RnCTURITION AND POLYURIA
Polyuria, or an abnormally large daily excretion of urine, is, of
cx)urse, quite different from frequency of urination. Nevertheless,
"they are so often associated in cases of disease that it is convenient
to consider them in the same chapter.
Persons vary a good deal in perfect health in the number of times
that they pass urine during twenty-four hours. The great majority
of healthy persons do not have to rise during the night to pass urine,
1)ut in a small majority this is habitual and does not seem to depend
upon any unusual amount of water ingested during the evening. Of
course, it is obvious and familiar that anyone who takes a large amount
of liquid, especially of beefy during the evening, is likely to have to
pass urine during the night; but aside from this cause, and from the
rare cases of habitual nocturia, there are a good many people who
suffer from nocturia whenever they are "nervous. *' Sometimes it
appears as if both the nervousness and the increased frequency of mic-
turition had a conmion cause in the nervous and vascular ataxia.
If this is so, we cannot truly say that the nervousness is the cause of
the urinary trouble, but is rather a concomitant effect of a deeper
cause, perhaps low peripheral pressure and splanchnic congestion.
Aside from these temporary causes, any of which may, of course,
act during the day as well as during the night, the conmionest type
of urinary frequency is that associated with prostatic enlargement,
whether simple or carcinomatous. In elderly men this is by far the
commonest cause of frequency.
In women the pressure of uterine or ovarian tumors and the
irritation of pelvic exudates blend their effects with psychic influ-
ences in a way that makes it difficult to distinguish the two. Either
or both sets of causes affect women all the more strongly because of
the shortness of the female urethra.
Bladder irritation, whether from definite cystitis or from the
presence of urine sent down from a tuberculous kidney, is perhaps
the next most frequent cause of urinary frequency. Cystitis, of course,
is also an accompaniment of many prostatic enlargements in men.
405
4g6 DIFFERENTLAL DIAGNOSIS
In children the irritation due to h\peracid urine, to balanitis,
or to phimosis may be sufficient to produce frequencj- or e\-en in-
continence.
Among the rarer causes of frequency are stone in the bladder,
cancer of the bladder, bilharzia disease, and appendicitis. All of these
act, of course, through the local irritation of the disease present.
In diabetes and contracted kidney frequent micturition is the
result of a large amount of urine which has to be discharged. It is
noticed most at night.
Pregnancy is a common cause for urinary- frequencj*.
Just why the local affections of the kidney and renal peh-is < nephro-
lithiasis, pyelitis, pyelonephritis, renal tumor produce urinar\* fre-
quenc\' I do not clearly understand. To call the frequenc>" reflex
is merely to cover up our ignorance. Perhaps the urine itself is espe-
cially irritating to the bladder wall. But why?
Case 213
A butler of forty-three entered the hospital December 21, 1911.
His family histor\- was not important save that one sister had phthisis.
He has had no serious illness in the past, but has been troubled with
constipation, poor appetite, and sleeplessness. He has used consider-
able alcohol up to SL\ months ago. but none since. He denies venereal
disease, but has taken potassium iodid and mercurj- for two or three
years. There has been pain of nve years* duration in the abdomen and
over the s\"mphysis ever\' month or less, accompanied by constipation.
Diagnoses of constipation, then oi lead-poisoning, and later of chronic
appendicitis have been made. About one and a half years ago a lump
appeared on the scalp, was not painful, but broke, discharging yellow
serum ■?'. A few months later another appeared and also broke.
Both healed ver\- slowly after discharging a couple of months.
Eight weeks ago. after a movement of bowels, he urinated; at end
of urination gas came out of the penis. Since then he has had burn-
ing and painful micturition, frequency and cloudy urine, at times ver>-
foul and of a peculiar muddy color. There has been considerable
loss of weight during the past two months jc pounds ?\ Frequency
is not so market:! of late, but he continues to pass gas, which is pre-
ceded by a peculiar pain. There has been no cough, dyspnea, or night-
sweats, but he has had an occasional chill. He has taken some
morphin. but not recently. He has never noticed blood in the urine,
but there has always been a thick sediment. At times he has had pain
in the left sacro-iliac region.
Frequent Micturition
PREGNANCY
GONORRHEAL URETHRITIS
CYSTITIS (UNKNOWN CAUSE)
CHRONIC NEPHRITIS
PROSTATIC OBSTRUCTION
STONE IN BLADDER
DIABETES MELLITUS
\
NEUROTIC STATES (ACUTE OR CHRONIC ) cases too many and too vaguely
ENUMERABLE FOR GRAPHIC REPRE-
SENTATION.
2378
1050
1009
749
729
647
539
423
liTERINE FIBROMYOMA
OVARIAN CYSTOMA
a he
URINARY TUBERCULOSIS* 1 I Tl
MALIGNANT NEOPLASM OFl ^^
BLADDER / ^^
STONE IN KIDNEY IH
PAPILLOMA OF BLADDER
367
152
150
55
^Urinary tuberculosis — i. e.y
(a) Tuberculosis of the kidney 248
(6) Tuberculosis of the bladder 94
(c) Tuberculosis of the kidney and bladder 25
Vol. 11—32
497
498 DIFFERENTLVL DLAGNOSIS
On examination, he is rather thin and pale; ears waxy. Tlie
right pupil is larger than the left and both react normally. There are
two scars of abscesses in the scalp. The throat is red; breath foul.
There are no glands and the heart is negative. In the lungs the right
apex is duller than the left, with breath sounds exaggerated, fremitus
increased, and an occasional musical r^le. The abdomen is negative
save for a burn-scar. The genitals are normal; knee-jerks present.
The patient passed 4 ounces of cloudy urine, the last ounce of
which was thick, white, and caused some burning. There was no
blood seen, no "gas.'' Temperature, 99.6^ F.; pulse, 108; respiration,
^2, The white cells were S600. The urine was normal, acid; specific
gravity, 1012; albumin, slightest possible trace, no sugar. The sedi-
ment contained leukocytes, bacteria, a few red corpuscles, and many
pus clumps. Wassermann reaction was slightly positive. Cystos-
copy was done and the bladder washed clean. In upper left quadrant
was what appears to be the opening of a sinus from which a plug of
pus protruded. No discharge of pus seen.
0.6 gm. of **6o6" was given; considerable discomfort and vomiting
followed. During the next three weeks the patient showed little
change, and was given a second dose of '*6o6," u^-ith some dis-
comfort. A second cystoscopy shows the same ulcer pre\'iously seen,
from which a ribbon of pus can be squeezed out by pressure on left
lower quadrant of abdomen. The specitic graxity of the urine at this
time is 1012. with a slight trace of albumin, much pus, and red cells.
No fecal matter can be found.
Discussion. — Pneumaturia, or the passage of gas with the urine,
may be due to infection of the urinar\' tract by bacilli-producing gas
or to a communication between the bladder and the intestinal canal.
Among the micro-organisms which prcxiuce gas in the urine the com-
monest are the veasts, which in diabetes often dll the urine with air-
bubbles. Apparently the colon bacillus is also capable of splitting
up sugar in the urine so as to produce pneumaturia. In the present
case the extreme foulness of the urine and its peculiar muddy color
suggest a communication between the bladder and the rectum.
Some features in the case suggest sN-philis, notably the lumps
upcn the scalp, the histor>- of antis\'philitic treatment, and the Was-
sermann reaction. If the patient is s\-philitic. it may well be that a
gummatous process of the lower bowel has perforated the bladder, so
that the intestinal contents are discharged with the urine.
Another possibility is of a diverticulitis connecting with the
bladder.
FREQUENT MICTURITION AND POLYURIA 499
The results of cystoscopy leave little doubt that such a com-
munication exists.
Outcome. — On the i8th of January the abdomen was opened
and a mass the size of the fist was found, involving the sigmoid flexure
and its appendices. There was also an abscess near the rectum.
After the drainage of this abscess the patient improved, had normal
bowel movements, together with a profuse foul purulent discharge
from the woimd. Rectal examination, February 8th, showed con-
siderable thickening and moderate tenderness, but no fluctuation high
up upon the left. The temperature was from one to two degrees
above normal.
The urine was now pale, cloudy, looS in specific gravity, free from
albumin and sugar, free from gas, and showing nothing of importance
in the sediment. On the morning of June 20th the patient com-
plained of shortness of breath, became excited, and rather hysterical.
The temperature was then 99° F. ; pulse, 1 10; respiration, 20. During
the afternoon the pulse was of poor quality, heart sounds regular but
weak, and there was distention and pain in the abdomen. Next day
he died, rather suddenly. The autopsy showed a retroperitoneal
pelvic abscess, presumably arising from diverticulitis of the intestine.
The lesion upon the scalp was regarded as probably a gumma.
Case 214
A tailoress of thirty-eight, bom in Russia, entered the hospital
June 24, 1908. The patient's mother died of cancer of the stomach
at sixty- three; otherwise her family history is excellent. She had
typhoid fever fifteen years ago. Four years ago she had an illness of
six months' duration similar to the present.
For three months her urine has been thick and red and for eight
days bloody, and passed, as she says, about forty times a day, with
great pain. She has no other symptoms.
Physical examination was negative, save for a slight systolic
murmur at the apex of the heart and tenderness over the pubes.
The urine showed considerable sediment of pus and blood, otherwise
nothing abnormal. The blood was negative. There was no fever
in two weeks' observation. A catheter specimen of urine, drawn under
aseptic precautions, showed, on bacteriologic examination, atypical
streptococci. It was then injected into a guinea-pig, July ist. Au-
gust 29th, autopsy of this animal showed nothing.
Cystoscopy, Jime 25th, by Dr. Fred T. Murphy, showed no stone
and nothing abnormal about the ureters. The base of the bladder was
500 DIFFERENTIAL DIAGNOSIS
generally injected. The patient showed no reaction after the injec-
tion of lo mg. of old tuberculin. A vaccine was made from the
streptococci isolated from the urine and administered.
Discussion. — The history of typhoid fever fifteen years ago brings
to our mind the possibility of typhoid cystitis, since we know that
typhoid fever is prone to settle down into the bladder after the patient
is otherwise well.
But this is apparently an acute cystitis, lasting only three months
and beginning suddenly. It is hard to connect such an illness vdth
the typhoid fever of fifteen years ago. The whole question is as to the
nature of the cystitis. We have no reason to believe that it is due to
any disease either above or below the bladder, although in the vast
majority of cases cystitis is to be thus explained and is not an inde-
pendent entity. The fact that streptococci are the only organisms dis-
coverable does not in any way prove that the lesion is not tuberculous,
for tubercle bacilli may easily be overgrown by organisms of more
rapid development. Much more important is the negative result of
animal inoculation, which may be taken as practically excluding
tuberculosis.
The cause of cystitis remains somewhat of a mvsterv. The time
at which the disease originated is the time when streptococcic in-
fections, especially those showing themselves in the throat, are most
common. Is it not possible that a streptococcic infection was arrested
in its wav out of the body and took root in the bladder?
Outcome. Hy the 5th of July she was much better, and was
allowed to continue her treatment in the Out-patient Department.
July 18, 1908, she reported that she was still urinating ever}" half-
hour. The urine was normal.
December 26, 1908, the patient was complaining chiefly of pre-
cordial distress with occasional dyspnea. The heart and abdomen
showed nothing abnormal. She was evidently worrying a good deal.
As the urine continual to contain streptococci, on May 11, 1909,
cystoscopy was ad\'ised, but refused. A guinea-pig test, made with
the sediment of the urine, showed no evidence of tuberculosis.
June 24, 1910, she reix)rted that she was passing water ever}' fifteen
minutes. The urine at that time contained considerable pus. She
was given an injection of 10 i>er cent. arg}'rol, and a week later the
urine was considerably improved.
Februar}' 2i5t the urine was in all respects normal, except that
the specific grax-ity was looO.
July 12, 191 1, she reporteil that she no longer was troubled about
FREQUENT MICTURITION AND POLYURIA 50I
her urine. She came then for pain in the back, thought to be due
to a strain from falling down stairs.
December i6, 1913, she came to the hospital for coldness and pain
in the little and ring fingers of the left hand. Hydrotherapy was
advised and produced much improvement.
Case 215
A housekeeper of thirty-four entered the hospital August 5, 1908.
The patient's mother died of cancer; one brother of "blood-poisoning";
her father of "asthma"; one brother in infancy. Another brother was
murdered. The patient had rheumatic fever twelve years ago and
typhoid fever ten years ago. She has taken a good deal of wine, ale,
and brandy.
As long as she can remember she has been troubled with frequent
and somewhat painful micturition. At the time of menstruation this
trouble is increased and is associated with headache and backache.
For the past two years her symptoms have been much worse, and the
desire to pass urine is almost constant, though, in fact, she passes it
about seven times during the day and not at all at night. She has
worn a pessary without relief. Her urine has been normal in appear-
ance. She has been able to do no work in the past two years on
account of backache.
On physical examination, the patient was well nourished and
showed no abnormalities except a blowing, systolic murmur at the
base of the heart and an antiflexed uterus. The urine was normal.
The blood showed hemoglobin, 65 per cent.; red cells, 4,860,000;
white cells, 5700. The stained smear showed achromia, but was
otherwise negative. While in bed she had no trouble with frequency.
Discussion. — The rheumatism of twelve years ago, the typhoid
fever two years after that, and the alcoholic history are probably
of no special significance in this case. A point of great importance
is the presence of frequency only in the daytime and worse at the time
of the menstrual period. This would seem to connect the symptom
with the pelvic organs, and the fact that the urine looks normal
strengthens the plausibility of this theory. Any type of cystitis is
likely not merely to produce abnormalities in the urine which the
patient herself notices, but to distress her as much at night as in the
daytime.
The idea of those who saw this patient in the hospital was that
local irritation from the anteflexed and deformed uterus was the
cause of this patient's frequency, but I think the conclusion may be
502 DIFFERENTIAL DIAGNOSIS
doubted. One sees so large a number of people who have exactly
the same pelvic condition without any frequency at all that I am
inclined to believe that another factor is the important one — the
factor, namely, of individual hypersensitiveness, which would prob-
ably have resulted in frequency even had the uterus been wholly
normal. The common tradition which attributes urinary frequency
to anteflexion of the uterus rests, I think, upon insecure foundation, «
for the reason suggested in the last sentence.
I believe that the patient's anemia and general debility, as shown ^
in her headaches and backaches, have rendered her oversensitive on ^
the physical side, and are the chief factors in accounting for her "i
frequent micturition.
Outcome. — An examination under ether, August 14th, showed that S
the uterus was drawn to the right by what seemed to be a tubo- — ^
ovarian mass. Operation showed a fibroid, the size of a hen's egg, on n
the right side of the uterus, near the fundus, and another posteriorly. . ^
These were both shelled out and removed; a ventrosuspension was ^
done. The patient convalesced normally and left the hospital on the ^j
2d of September, 1908. September 17, 1909, she reported, in answer -y«
to a letter, that she was still troubled by pain at the time of urination.
No cause for this pain was found. I believe it due to a nervous hyper-
sensitiveness.
Case 216
A housewife of thirty-four, bom in Austria, entered the hospital
April 12, 1909. For the past four months she has passed urine very
frequently, sometimes as often as every half-hour, with pain and burn-
ing after it. Sometimes the urine looks normal, sometimes like coffee.
Three weeks ago she gave birth to a child, and for a week after that ^,^2a(
time her symptoms were relieved, then they recurred, and were as
severe as before. Two years ago she weighed 1 20 pounds, with clothes; -
now, 78I pounds, without clothes. She has no appetite and occa —
sionally vomits. She remembers no previous illness and has
five living children.
Her mother died of "a cold"; otherwise the family history is
The patient was poorly nourished and pale. The chest was n^ativ^^ — ;,^e.
In the left upper quadrant of the abdomen was a rounded mass, \hmr:Mie
size of an orange, transmitting an impulse to the flank and back wl
as
grasped bimanually (Fig. 186), descending slightly with respiratioi
slightly tender. After inflation of the colon, tympany appeared o\^
the mass. There was tenderness in the left costovertebral triangt^
FREQUENT MICTnEITION A>fD POLYURIA
503
none in the right. There was slight edema of the ankles. Physical
examination was otherwise negative. The blood was normal. The
urine averaged 20 ounces in twenty-four hours; specific gravity, 1026;
albumin, a trace; sediment, much pus, a few red corpuscles, no casts.
The patient had no fever above 99.5° F. during her week's stay in
the medical wards. The temperature always fell to normal in the
morning.
Cystoscopy, by Dr. Lincoln Davis, showed a sluggish stream of
thick pus issuing from the left ureter. Indigocarmin was excreted
normally from the right ureter and none at all from the left. The
bladderwas somewhat inflamed and sensitive, but showed no ulceration.
I
Discussion. — When the urine is said to- look like coffee we must
remember that the presence of precipitated urates or phosphates is
the commonest cause of such an appearance, and renders it, in the
great majority of cases, medically insignificant. Provided, however,
that the urinary turbidity is due to pus and micro-organisms, there
is something in the intermittcnce of its turbidity which suggests pus
of renal origin. When pus comes from the kidney rather than the
bladder it is discharged intermittently into the urine, so that some
specimens are clear and others turbid. In cystitis, on the other hand,
tevery specimen is turbid.
504 DIFFERENTIAL DIAGNOSIS
The emaciation, the family history, the mass in the region of the
left kidney, and the abnormal urine shown on examination to con-
tain pus, make it clear, even in advance of cystoscopy, that we are
dealing with a purulent aflfection of the kidney, that is, either with
pyonephrosis, pyelonephritis, or tuberculous kidney. The absence
of ulceration in the bladder favors a non-tuberculous renal lesion.
Outcome. — Operation, April 21st, showed a kidney increased in
size transformed into a sacculated tumor, 15 cm. in diameter and filled
with pus. The ureter was much thickened. No definite evidence of
tuberculosis was found. The kidney and 7 cm. of ureter were removed
without difficulty. The patient made an excellent recovery and left
the hospital May 24th, apparently well.
Case 217
A housewife of forty-nine entered the hospital December 11, 191 1.
The patient's mother died of cancer in the neck; otherwise her family
history is good.
Thirteen years ago she began to have marked frequency of xirina-
tion, passing water ever>- fifteen minutes in order to relieve her pain
in the region of the bladder. At times the stream was checked sud-
denly, causing great pain. Twelve years ago she was in the Massa-
chusetts Homeopathic Hospital, but did not improve. The above
s>Tnptoms continued until ten years ago. when she began to have
incontinence of urine, which has continued ever since, except for some
periods of eight to ten hours, during which she has srcere pain.
Physical examination shows a stout woman, good color, negative
chest and abdomen, lacerated peritoneum, exquisite tenderness over
the urethra. On the 12th the patient was anesthetized, the urethra
dilated, a searcher introduced, and a stone felt, apparently incrusted
in the tissues at the neck of the bladder. It was crushed and washed
out. The fragments examined by Dr. \V. F. Whitney were shown to
be portions of phosphatic calculus.
Discussion. — So long a histor>' of frequency and incontinence,
without any lesion of the central nervous system, makes us suspect
an organic lesion of the bladder, benign in t\pe — in other words, a
stone. Subsequent results of sounding, and the px)sition of the stone
in the neck of the bladder, make it probable that sphincteric efficienc\'
<^annot be restored, and that when this stone is removed another is
quite likely to re-form in the old ulcer left by the first.
Outcome. After operation the patient was more comfortable, but
still incontinent of urine, and continued so at the time of discharge.
FREQUENT MICTURITION AND POLYURIA 505
December 21st. On December 3, 191 2, the patient writes, "I am no
better than when I left the hospital, in some ways not as well, as I
suffer more pain now than I did then. I am not having any doctor
now, as they don't seem to do me any good. Sometimes I think I
will see a doctor and perhaps he can give me something for the pain,
but I have no faith in any of them. This is rather a hard way to
talk to a doctor."
Case 218
A housewife of thirty-one, born in Russia, entered the hospital
March 5, 1901, for the first time, for pelvic pain, which had been
present for a year since the birth of her last child. Operation by Dr.
Maurice H. Richardson showed double pyosalpinx. One tube was
removed, and on the other a plastic operation was done so as to make
possible the passage of the ovum. The patient convalesced rapidly
and left the hospital on the 8th of April, after which she was perfectly
Well tmtil a few weeks before her next entrance to the hospital, Decem-
ber 15, 1909, when she began to be bothered very much by frequent
micturition, constipation, hemorrhoids, and pain in the lumbar re-
gion. She is also much troubled by her heart. She says that her
urine is small in amount, but never bloody.
Physical examination shows excellent nutrition, and is negative
in all respects except for very slight edema over the shins. The blood
and urine show nothing abnormal. She is very apprehensive about
her heart.
Discussion. — It all comes to this, that the patient's physical ex-
ajnination is negative, that she has many complaints affecting all
parts of her body, and especially, as I see it, that she is afraid of heart
trouble. This point is of importance, and it may well be that by
p)sychotherapy addressed to cure this fear, her urinary frequency may,
without any direct attack, be conquered. It is in just this type of
case that we must hunt for psychic and social causes if we are to make
treatment effective. We ought to know everything we can about
this patient's environment, physical and psychic, in order to aid her
state of mind if we are to help her bladder symptoms.
In any such psychotherapy the first and most important step is
a thorough physical examination and the elimination of doubt, first
from our own mind and then from the patient's mind, regarding
organic disease. In the first instance, it does not seem to me that
cystoscopy is called for in a case of this kind. If our other efforts fail,
we must come back to that. First, we should try the effect of telling
5o6 DIFFERENTIAL DIAGNOSIS
the patient that she can and must control her frequent micturitiML
Patients are apt to think that dreadful consequences will follow any
such attempt to control. When they are assured to the contrary, they
may, within a day or two, convince themselves of their power to check
the symptom unassisted.
Outcome. — When reassured about her heart and given a wedt's
rest she was able to control the frequency of micturition, and »is
finally convinced that it was a matter of habit. She left the hospM
on the 2oth.
Case 219
A milliner of forty entered the hospital April 2, 1910. Her mother
died of consumption at forty-six. Her family history is otherwise
good. The patient herself had "typhoid fever" fifteen years ago.
Fig. 187.— Chart of Case iig (first entrance).
Twelve years ago, and again eight years ago, she raised blood in small
amounts. On the second occasion she was awakened from sleep by "i^
bleeding. She has had "bladder trouble" ever since she was a child;
i. c, intermittent attacks of frequency and burning micturition.
She has always been subject to severe "colds." Since she got stout,
four years ago, she has had some shortness of breath.
Ever since her t>'phoid she has noticed that her legs are swollen
at night. A year ago she had no menstruation for three months, but
since then she has been regular.
FREQUENT MICTURITION AND POLYURIA 507
Ten days ago she "txK)k cold," and began to have bladder trouble
as before. The next day she had chills, headache, and pain over the
pubes. Last night she vomited.
On physical examination she was well nourished. Her chest was
negative, except for a soft systolic murmur at the apex, transmitted to
the axilla. Abdomen negative. At entrance the diagnosis was of
acute infection of unknown cause. Next day the patient's sclerae
were slightly yellow. The urine for the first ten days averaged 20
ounces in twenty-four hours, then rising to 60 ounces (Fig. 187).
The specific gravity varied from 1013 to 102 1. Pus was always
present in the sediment in large amounts, even when the urine was
drawn by catheter. At entrance the blood contained 28,000 leuko-
cytes per centimeter, with a polynuclear leulcocytosis. The counts
thereafter were — ^April 4, 22,000; April 7, 14,500; April 13, 8000;
April 27, 10,000. Wassermann reaction was negative. Her vomitus,
April 4th, contained brownish material and showed positive test for
guaiac. On the loth of April diminished breathing was noticed in
the right back and diminished excursion of the lower right lung
border.
Cystoscopy, April nth, by Dr. Hugh Cabot, showed chronic
cystitis. The ureters looked normal. The right kidney excreted
indigocarmin in normal time and amount. The left kidney ex-
creted nothing but thick yellow pus. Culture from the urine, which
was always acid, showed only a slight growth of cocci, probably due to
contamination. Blood-cultures were negative; i cm. of urine from
the left ureter was injected into a guinea-pig, April 6th. Autopsy,
May 23d, showed nothing.
Discussion. — There is a good deal of evidence pointing to tubercu-
losis in this case, but the very long duration of her s>Tnptoms, thirty
years or more, makes it very improbable that they are due to tuber-
culosis.
The fifteen years of edema affecting the legs is probably due to
phlebitis after typhoid, and has no connection, I take it, with the
present trouble.
She now comes to a physician by reason of an acute upset, ap-
parently infectious in type, and associated with jaundice and pyuria
in a urine always acid. The latter fact strongly suggests tuberculosis
as the underlying disease.
Note, in the first temperature charts (Fig. 187), how the tempera-
ture goes up when the amount of urine excreted is small and falls as
the urine increases. This might be due either to retention of urine
DOTEKENTIAL DIAGNOSIS
during a period of infection in the urinary tract or possibly to a on-
centration of urine due to the infection itself.
Cystoscopy leaves no doubt that there is pus in the kidney. Since
animal inoculation shows no tuberculosis, and no sac of any size is
to be felt in the region of the kidney, we may exclude tuberculoaa
and pyonephrosis and conclude that a pyelonephritis of septic origiii
is the diagnosis.
Outcome. — May 3d the left kidney was cut down upon, but while
being stripi^ed of its fat was ruptured and pus spilled into the wound.
Externally the kidney was soft
and somewhat enleLTged. Nq)h-
rectomy was done. Examination
by Dr. W. F. Whitney showed
the following: Kidney, 13 by4 by
4j cm., sacculated. Oa section,
the cortex was thin and the lining
- of the calices and pelves thickened
and reddened. Microscopic ex-
amination showed entire destruc-
tion of the cortical substance, all
of the glomeruli being sclerosed
and the tubes being entirely de-
stroyed. The tissue was every-
where infiltrated with round mUs.
many of them leukocytes. After
operation the temperature ranged
high for a long time (Fig. iW,
with a positive Widal reaction-
On the 23d of June some p«s
pockets were opened up. July 19th the wound was better, the tem-
perature was lower, and the patient was allowed to go home.
In April, 1913, the patient reported that she weighed 167 pounds,
the most that she has ever weighed, and had no trouble any longer
with her urine except the frequency, which still continued. She
passes urine four times in the night and four times in the day. If she
is prevented from emptying the bladder she gets fits of shivering-
She says that she is very nervous and has no strength. Nevertheless,
she is pursuing her trade as a milliner.
Remarks. — How should we interpret the persistence of a positive
Widal reaction? Probably, I think, as a result of typhoid infection
remaining in the gall-bladder. There seems no evidence of typhoi"^
zntUiUiihii^S:
Kg. 188.— Temperature at the end of the
patient's second hospital stay (Caseitg).
FREQUENT JUCTURITION AND POLYURIA
509
urinaiy tract, or of any generalization of the process such as
in what we call typhoid fever.
te are other cases on record in which typhoid infection has
id in the gall-bladder after typhoid fever for periods much
than fifteen years.
Case 220
lousewife of thirty-eight entered the hospital April 5, igio.
nily history was excellent. The patient had "pneumonia and
/" two and a half years ago, otherwise has been well, and has
le healthy children and three miscarriages. Last fall she felt
wn, but picked up until
eks ago, when she began
0 feel weak and tired.
; there has been occa-
ncontinence of urine with
■equency. Incontinence
akness are now her chief
DIS.
sical examination showed
utrition, moderate fever
.9). The pupils were un-
1 size, slightly irregular,
ct slowly. Lymph-nodes,
s of beans, were felt in
ht axilla. Chest nega-
Reflexes and urine nor-
Vbdomen as in Fig. 190.
tient remained a month
:ards without any gain in
but with considerable gain in strength. The skin tuber-
action was slightly positive. Bowels rather costive.
:ussion. — ^The diagnosis seems to be tuberculous peritonitis.
at is the relation of this to the urinary frequency I do not know.
perfectly normal urine we have no good reason to suspect
losis of the bladder or kidney. If tuberculous peritonitis is a
diagnosis, it may well be that there are glandular masses around
ider which interfere, possibly, with its action. Possibly her
weakness affects the sphincteric control and contributes to or
ler frequency. The case is an unusual one and not altogether
FiR. 18Q.
510 DIFFERENTIAL DUONOSIS
Outcome. — She went home on the aoth, much relieved. The
patient died in September, igio. Her daughter writes that she got
along nicely after leaving the Massachusetts General Hospital untii a
nurse came to the house and told her that it had been reported itat
she was a consumptive. "After that she worried and pined hersdi
away." Her physician. Dr. W. P. Cross, of South Boston, writa
that she died of pulmonary tuberculosa.
Case 221
An Armenian tailor of twenty-five entered the hospital March Q.
iQio. His family historj' and habits are good. Ten years ago he had
some trouble with his left hip, lasting three months. A year ago he
began to have slight pain in the region of the right costovertebral
angle, troubling him both by day and by night, and radiating doffn his
back and to the grtiin. This was accompanied by frequency of m"^"
turition. at first every five to twenty minutes. The urine was bUw^y
and painful in passage. For three months he has been having amil*^
pain in the left side. During the past fifteen days he has passed »
FREQUENT MICTURITION AND POLYUBIA 511
number of times what he calls "pieces of meat," For three weeks his
appetite has been poor, boweb have been irregular, and his sleep poor,
A year ago he weighed 135 pounds; now, 141 pounds. He has done no
work in the past year and "feels tired."
Physical examinations, including x-ray and the blood, were nega-
tive, except that the left leg was slightly atrophied and the hip motions
limited. The urine averaged 40 oimces in twenty-four hours; specific
gravity, 1016; albumin, 0.2 per cent. The sediment contained much
pus and blood. There were no tubercle bacilli and no casts. Tem-
perature was as shown in Fig. 191. On the nth of April a few acid-
fast bacilli were found in the sediment of the urine obtained imder
aseptic precautions. March 14th cystoscopy by Dr. Hugh Cabot
showed that the bladder was
much contracted and ulcerated.
Indigocarmin excretion was
very poor, and not enough com-
ing from either kidney in half
an hour to make clear the posi-
tion of the ureter. The condi-
tion was believed to be an ad-
vanced bilateral tuberculosis,
but another cystoscopy, April
18th, showed that the right kid-
ney now excreted indigocarmin
promptly and in full amount,
while none at all came from the
left side in thirty-five minutes,
A cubic centimeter of urine from
the left kidney was injected into
a guinea-pig April 14th. Au-
topsy, May 23d, showed tuber-
culosis of the spleen and liver.
The urine was always acid during the patient's hospital stay. He com-
plained of considerable pain in the right flank at times. The bladder
held only 3 ounces. He gained 4 pounds during his stay in the medical
wards, where the treatment consisted of sandalwood oil, 10 minims,
three times a day, and an occasional dose of aspirin or phenacetin,
with a maximum of fresh air and food.
Discussion.- A point of interest is that the pain was mostly on
the right side, though the disease was mostly on the left. This not
infrequently happens in tuberculous disease of the kidney. One
Fig. 191.— Chart of Case an
oi operation.
>
SI2 DIFFERENTIAL DIAGNOSIS
side becomes diseased, the other kidney hypertrophies, and in con-
nection with this hypertrophy there may be pain. This leads to
examination of the kidney region. We feel the hypertrophied kidnej^^'^y
and decide that it is diseased. The sick organ on the other side mean- .mr:mi'
time keeps quiet.
Note that the urine contains blood, which is somewhat unusua^E^ jal
in renal tuberculosis.
Note further that there is actual tuberculosis of the bladdenK--saBr.
In many cases of renal tuberculosis the bladder is normal, despit-*ite
the very marked urinary frequency and pain. This case is one of tLc-iIJie
exceptions.
Outcome. — On the 23d the left kidney was cut down upon,
kidney seemed small, but otherwise not abnormal, as was the let
ureter. The right kidney was hypertrophied and was considere
tuberculous, while the left was merely somewhat atrophied. It w£^ ^-sdiras
deemed unwise to remove the left kidney on the ground that the oth*^ -Mrzier
was also diseased. It was thought that the condition of the lea^t^ eft
kidney was not such as to account for the urine.' The patient d -tzdid
well after operation, except for. an attack of scarlet fever, but a lett^^" ter
from his son tells us that he died three months after leaving tr ~ghe
hospital.
Case 222
A Scotch motorman of forty-three entered the hospital May
1910. The patient's father died of '^inflammation of the bowel
otherwise nothing of importance was contained in the family histo
The patient had '^rheumatism'' in his back and hip seven or ei
years ago, and was confined to bed two months at that time. 0th
wise his past history and habits are good.
For seven or eight years he has noticed that in certain positi
he had twinges of pain and a sense of something moving in the rii
flank. During the same period he has had to pass urine about ev
three hours, night and day. He thinks the total amount is not
creased. Several times during the last six years he has passed sm--^alJ
clots of blood, and in the last month this has happened two or thi^K^ee
times a week. During the past winter he often felt lame in ti^Bithe
right lower quadrant after a day's work, and on lying down sometin^^es
felt soreness beneath the left ribs. His discomforts are always w(^^ Tse
on exertion and always relieved by passing urine.
All winter he has had slight cough and some expectoration, S3a,nd
on his car has noticed shortness of breath and some fatigue. ^For
la
FREQUENT MICTUBITION AND POLVUKIA
513
the past month these symptoms have been accompanied by dizzy
spells and frequent nausea when getting off his car at the end of his
run. His appetite during the past month has been poor and he has
had some headache. He weighed himself four weeks ago and found
he had lost 12 pounds. Since that time he has lost about 12 pounds
more. He quit work eleven days ago.
Physical examination showed good nutrition and slight pallor.
The heart's apex extended 2 cm. outside the nipple line. The pul-
monic second sound was accentuated. There were no murmurs or
other abnormalities. There was slightly diminished breathing at
the right base behind. Otherwise the lungs are normal. The ab-
Fip. igj. — OutUnea of mass fell in Case la.
domen showed a mass, the outlines of which are shown in Fig. 192;
otherwise nothing abnormal.
During his two weeks' stay in the hospital his temperature occa-
sionally rose to 99.5° or 100° F., but was usually normal. He lost
4 pounds in weight in this period. The urine averaged 40 ounces in
twenty-four hours; specific gravity, 1020; albumin, -^a per cent, or
less. The setliment consisted chiefly of pus. which made up about
one-tenth of the specimen. No tubercle bacilli were present in it.
The blood contained from 15,000 to 18,000 leukocytes per cubic
millimeter, with a polynuclear leukocytosis. Hemoglobin, 85 per
cent.; blood-pressure, 150 mm. Hg.
Vol- 11—33
514 DIFFERENTIAL DIAGNOSIS
Cystoscopy by Dr. Hugh Cabot showed that the bladder hdd
6 ounces. There was marked ulceration of the right lateral waD
and about the right ureter, from which a "worm" of thick yellow
pus issued. No excretion of color or urine from it. The left side
and ureter appeared normal and secreted indigocarmin eight and
one-half minutes after injection and in normal amount. After
the cystoscopy he had to be catheterized during the ten days pre-
ceding his transfer to the surgical ward. The diagnosis was ri^t
pyonephrosis, probably tuberculous. Twenty minims, drawn by
catheter from the right ureter, were injected May 19th into a guinea-
pig. Autopsy, June 29th, showed tuberculous lesions of the glands
and spleen. The patient was entirely comfortable in the ward. A
skin tuberculin reaction was strongly positive. The urine was always
acid.
Discussion. — The duration of the patient's symptoms is of inter-
est. Apparently he has had something the matter with his kidneys
for eight years, yet he has got along fairly well and done his work
until eleven days ago. In view of the diagnosis, to be mentioned in a
moment, this is of much interest. The fact that his pain was always re-
lieved by micturition connects it very certainly with the urinary tract
It is important to note that he has had cough and loss of weight
for six months, with other symptoms, such as vertigo, headache, and
nausea, pointing to some infectious disease.
In advance of the cystoscopic examination we can conclude, in
the presence of fever, leukocytosis, pyuria, and a mass in the region
of the right kidney, that he has pus in or about that organ. The
presence of cough and emaciation gives us ground to conjecture
that his kidney may be tuberculous.
Cystoscopy increases the probability of this hypothesis, and the
results of animal inoculation prove it.
Outcome. — ^June 3d the kidney was cut down upon and found very
adherent, greatly enlarged, and fluctuant. The kidney was removed.
No attempt was made to resect the ureter. Pathologic examination
by Dr. W. F. Whitney was as follows: Kidney, 13 by 5 cm., sacculated
and filled with pultaceous material, consistency very soft and putty-
like. Cortex thin. Microscopic examination showed the cortex ex-
tremely infiltrated with round cells, and here and there small fod of
rounded and epithelioid cells with giant cells and cheesy degeneration.
Tuberculosis.
The patient did well after op^eration, and was. discharged June 22d
in excellent condition.
FREQUENT MICTURITION AND POLYURIA 515
In the spring of 19 13 the patient reported himself to be in perfect
health, stouter than ever, and working steadily since September, 19 10.
Such perfect results in renal tuberculosis are among the most satis-
factory in medicine and, fortunately, they are not very rare.
Case 223
An Armenian butcher of thirty-eight entered the hospital June 3,
1910. In 1903 the patient began to have trouble with frequency of
micturition. This continued to trouble him, but was unaccom-
panied by any other symptoms until one year ago, when he noticed
slight swelling of his legs with shortness of breath and fatigue on
exertion. During the last four weeks his eyesight has been growing
poor, and for two weeks he has had orthopnea and been unable to
sleep in bed. Cough and night-sweats have also been troublesome.
He thinks he has lost weight. In former years he has had a great
deal of generalized headache; for the past three months, none. He
has rather frequent nosebleeds. Seven months ago he weighed
145 pounds; now, 128 pounds. He has had no previous illness except
"stomach trouble," in 1893, for which he was treated in the Out-patient
Department. Diarrhea and pain after eating, with occasional vomit-
ing, were his symptoms at that time. He was sick three months,
but has ever since been well and strong until the present illness.
His family history is good. His wife has had three healthy children,
one child still-bom, one miscarriage.
The patient was well nourished, and breathed easily but rapidly
as he sat propped up in bed. On his left cheek was the scar of an
Aleppo boil (Leishmaniasis). Pupils, glands, and reflexes were normal.
The heart's area of dulness extended 5 cm. outside the nipple, in the
sixth interspace, and 2^ cm. to the right of the median line. There
were no murmurs. Its action was regular, slightly rapid. The
pulmonic second was louder than the aortic second. The artery
walls were thickened. The brachials show lateral excursion. The
systolic blood-pressure was 210 mm. Hg. in the right arm, 180 in the
left, and the right radial pulse was markedly greater than the left.
The blood-pressure was measured sixteen times during his three weeks
and a half in the hospital. It remained at about the same level,
and also showed approximately the same discrepancy between the two
arms.
At the base of the right axilla and below the angle of the scapula,
on the right side, posteriorly, there was dulness, absent breath sounds,
and voice sounds. The abdomen was negative, except that the edge
>
5l6 DIFFERENTIAL DIAGNOSIS
of the liver could be vaguely felt i inch below the ribs. He ha* mh
moderate edema of the legs and sacrum. The blood showed nothin.-^czig
abnormal. The urine averaged 30 ounces in twenty-four hourg=g^rs;
specific gravity, 1009 to 1012; albumin, 0.25 to 0.50 per cent.; sedimen*^^^it,
hyaline and granular casts, with cells and fat adherent. Wassermann^flr^on
reaction was negative.
During his stay in the hospital the patient was quite comfortabU <^)le
during the day, and his lungs at that time were usually clear, excepci^^t
in the area above noted. But at night he had a terrible time of it" i it,
wheezed alarmingly, and had to sit leaning forward in a chair in ordc^^er
to breathe. The attacks were not at all relieved by inhalation of stra^-^a-
monium, cubebs, or potassium nitrite, and even morphin did not gi>^^^ive
him relief. Hot-air baths seemed more efficient.
By the 9th he was distinctly better, and was able to sleep throu^g^^h
the night, except for one slight attack. "Theocin, 5 gr. three tim^..«nes
a day, had no special effect. Digipuratum was equally ineflfectiv-^^^pve.
By the 14th the lungs were entirely clear, and there was no edema
the legs, except after being up all day, but as soon as he began to
up and about the ward he got worse again and the night attacks
curred. He was then put back upon his daily hot-air baths
marked relief followed. By the 24th he was again sleeping all nij
and was thereafter able to be up and about all day, free from -
evidence of decompensation, except slight edema of the legs.
He left the hospital on the 28th of June, and returned on the SSSSb^
of July, 1910, having been much worse since he left the hospit a I.
At this time the systolic blood-pressure was 230 mm. Hg. in t he
right arm, 200 in the left. His blood showed 20,000 leukocytes, w— 3th
81 per cent, polynuclear cells, although fever and all evidences of
inflammation were absent. His urine was practically as befc^^re.
At entrance he was fighting for breath, sweating profusely, and lool^^:ed
very pale, although his hemoglobin was 80 per cent. There ^^-^as
some ascites and occasional vomiting. All these symptoms continujaied
for about forty-eight hours, during which time morphin was the ct^ef
aid given. After that hot-air baths were started, and with these ^mJid
10 minims of digitalis, three times a day, he showed a wonde:MrfuJ
improvement.
In five days his edema was gone and he had changed from a^ /at
to a thin man. The cardiac and pulmonary signs were practically as
before described; during the attacks of dyspnea his expiration i^ras
always prolonged, intensified, and accompanied with wheezing Tiles
("renal asthma")- At times his dyspnea was very great, and was
FEEQUENT MICTURITION AND POLYUWA 517
relieved only by standing up and leaning upon the back of a chair.
On the 2 2d of July his right chest was tapped and 1900 ex. of slightly
cloudy, yellow fluid removed. Its specific gravity was 1006; albumin,
0.5 per cent. ; sediment, mostly endothelial cells, with a few polynu-
clears and lymphocytes. After this tapping there was a loud, dry,
painful friction rub, audible over the entire right back. Ice-pack and
morphin were required for its relief. The blood at this time showed
14,000 white cells, 81 per cent, of polynuclears.
After the pleural pain had subsided the patient was much more
comfortable, but early in August he became very drowsy and his
dyspnea gradually increased. The fluid re-accumulated in his right
chest, and on the 4th of August 1350 c.c, with a specific gravity of
1009, were removed. Things seemed to be going on from bad to worse,
and on the 5th of August the patient was given 15 gr. of diuretin
at 2, 3, and 4 p. m. His digitaUs was increased to 25 minims, three
times a day, his liquids limited to 1000 c.c. After that his condition
markedly improved for a time. His urine output increased to 60
ounces, his hydrothorax and edema diminished, and he was able to
sleep for several nights without sedatives. A week later he began to
lose ground steadily. His chest was tapped again on the 23d of
August; 1000 c.c. were removed; again, on the 27th, 850 c.c. were
withdrawn. The characteristics of the fluid were as before. On
the 12 th of September he died.
Discussion. — Here the frequency is associated with headache, and
lately with dyspnea, edema, and poor sight. This differentiates
the case sharply from those previously discussed. With the appear-
ance of orthopnea and cough in the last two weeks, we have every
reason to expect the hypertension and urinary abnormaUties which
physical examination reveal.
The leukocytosis at the time of his second entrance to the hospital
may have been of the uremic type or may have been connected with a
terminal septicemia. The dyspnea at this time was of the type often
known as renal asthma.
The point of special interest in the whole case is that the first
of all his symptoms was urinary frequency. In the form of nocturia
this symptom is often the earliest manifestation of renal disease,
but, unfortunately, it is often overlooked by physicians as they take
their patients' histories. In my own routine I never omit to ask about
nocturia? in connection with the other routine questions regarding
appetite, bowels, sleep, and weight.
Outcome. — Autopsy, No. 2676, showed chronic glomerulonephritis;
5i8 diffekexhal dl\gxosis
arteriosclerosis of the aorta and conHiar>' arteries; mvomalada of the
left ventricular wall near the apex, with mural thrombi on the cone-
spcxiding area of endocardium; h>'pertrophy and dOatatioa of the
heart, acute terminal pericarditis, general passive ccxigestion. drop-
sical effusion in the serous ca>'ities; obsolete tuberculosis of a tracheal
h-mphatic gland. The cause of the difference in blood-pressure in
the two arms was not ejplained.
A housewife of fortj'-three entered the ho^ital November lo. 1910.
The patient has had eight healthy children and 5e\'en miscarriages.
During her last pregnane}', three and one-half years ago, she spent
three weeks, at the fourth month, in the Maternity- Hospital cm West
Xewton Street, where she was said to have albuminuria and "acute
diabetes.'' Carbohvdrates were restricted, she was deli\'ered of a
healthy child at term, and remained well until the present illness.
Since earlv summer she has eraduallv become more and more
tired and irritable. She thinks the amount of urine has been increas-
ing, and is quite sure she passes it more frequently than is normal.
Two daj's ago she vomitai. and this s\-mpton: has continued night and
dav since that time. Yesterdav she besan to have some headache.
Visceral examination is entirely negative. The urine averages
30 ounces in twenty-four hours, specinc gra\-ity usually about 1012:
it contained a few hvaline casts, but nothing else abnormal in the
sediment. After the 17th of November albumin was absent. On
the nth and 12th of November no su^ar was present in the urine.
On the 13th. 15th. and 17th traces were found, the amount being
from 0-4. to 0.6 per cent. BI«»i-pressure. 135 mm. Hg. The blood
at entrance showed hem»>g:«.bin. cc per cen:.: ieukoc\'tes, 19,000,
falling in two days to i^.occ. V-jciiting was easily controlled by
star\*ation for twenty-four hours, during which time she was given
cracked ice by mouth and 6 ounces of normal saline solution by
rectum e\'er\- four hours. November nth she be$:an to take milk
and lime-water. 2 to i, 2 ounces ever\- two hours, and the amount of
food was doubled next dav. After the nrst twent\'-four hours there
was no v<3miting and no other s\"mptoms of importance, and on the
i6th she felt line and was out of bed.
Discussion. — The case is an obscure one. For six months the
frequency" has been associated with a psychic irritability*, which may
be its cause or its concomitant. The appearance of headache and
vomiting within the last two days, and the slight albuminuria and
FREQUENT MICTURITION AND POLYURIA 519
glycosuria, may also be either the cause or the result of the psychic
disturbances. Frequency, as we know, may be associated not only
with diabetes, but with the psychic type of glycosuria. The diffi-
culty of such an explanation in the present case is that the amount of
sugar is so small. Possibly when the symptoms began and the fre-
quency was at its height, she may have had more glycosuria than she
did imder our observation. The point of greatest importance in the
whole case is the total disappearance of all symptoms in the end.
Possibly, when we know more about the action of the ductless glands
a case like this may be explained by some temporary excess or defi-
ciency in that function. For the present it remains rather mysterious.
Outcome. — November 13th she was given egg-nogs, toast, crackers,
and on the 14th a normal diet. By November 2 2d she seemed per-
fectly well.
Case 225
A housewife of forty-seven entered the hospital December 28, 1910.
The patient's mother died of phthisis at thirty-five and her father of
kidney trouble at fifty. From girlhood she was always delicate and
subject to sore throats and headaches, especially when nervous or
excited. Often these headaches are accompanied by vomiting.
Three years ago she had pain in the left side of the abdomen, which
was diagnosed as "fibroid of the uterus.'* Ever since that time she
has had a little of the same pain, off and on.
For a year she has had constant dull epigastric pain, sometimes
very severe, radiating to both breasts, both shoulders, and the small
of the back, sometimes waking her at night, and temporarily relieved
by taking a raw egg and brandy or by other food. Otherwise the
pain seems to have no relation to meals. The patient's menstruation
ceased seven years ago.
For a month her epigastric pain has been much more severe. It
is constant with sharp exacerbations, perhaps a dozen times a day,
and without known cause. The appetite is very variable, and she is
afraid to eat. She passes urine a dozen to fifteen times a day and once
or twice in the night. During the past month the urine has been very
high colored. She thinks she has been losing weight for a year and a
half, but worked until five weeks ago.
On physical examination the patient is pale and thin, shows a
lymph-node the size of a filbert over the right clavicle, and several
large nodes in the left groin. The other lymph-nodes are not abnormal.
For the chest, see Fig. 193. The abdomen showed masses as de-
5JO
DIFFERENTIAL DIAGNOSIS
Uneated in Fig. 193. The pelvis is filled with a hard, somewhat elastic,
apparently c>'stic mass. The cervix is pushed close behind the pubic j
bone and the uterus to the right.
Discussion. — Presumably the family history of tuberculosis is not
of importance, as there is nothing in the patient's present condition
to suggest any form of that disease. The abdominal tumor is not
likely to be produced by tuberculous peritonitis. The sjinptoms of
the past year were such as at first to suggest gall-stones, but during
the past month the pain has been much too constant to be explained
— Chest and abJom
in that way. Whether it b connected with the pelvic lesion asso-
ciated with the frequency it is difficult to say.
What is the nature of the pelvic mass? The patient's emaciation
and the nodule above the clavicle are ominous signs, unless we can
explain the latter as a relic of the old tuberculous trouble — a rather
far-fetched hypothesis. Our attempts to make the case out tuber-
culous are not successful, and if this is excluded we have every reason
to fear malignant disease, perhaps originating in an ovary. The
lung signs are much less significant than they would be if they had
FREQUENT MICmaTION AND POLYURIA 52 1
occurred upon the other side. I am not at all sure that they are not
physiologic.
Outcome. — Operation was advised, but refused. She went home
January 5, 1911, and died within that month.
Case 226
A cook of fifty-eight entered the hospital March 2, 191 1. The
patient's family history is not important. Three years ago he vomited
a large amount of blood, having four attacks of this trouble within
two weeks and remaining in the hospital for that period. Two years
ago he began to notice increasing frequency of micturition, and thinks
this was due rather to an inability to hold his water than to an in-
crease in amount passed. This troubled him intermittently, but has
gradually grown worse, until now it prevents his working. He has
never had pain or retention or seen any blood in the urine. He now
passes water eight to ten times a day and six to eight times at night.
For six months he has noticed slight dyspnea on exertion, and has
needed three pillows under his head at night. He has a voracious
appetite. No headache, no loss of weight, no edema.
Physical examination showed good nutrition and no anemia.
Heart's apex extends i cm. outside the nipple line and the retrosternal
dulness seemed to be increased at the level of the second rib. At
the apex and in the aortic area a systolic murmur was heard. Aortic
second was sharp and ringing. Systolic blood-pressure at entrance,
300, and ranged above 250 during the first week of his stay. In
the next two weeks it was usually in the vicinity of 230, with occa-
sional spurts up to 280. After that it ranged between 220 and 250,
until he left the hospital, April isth. The lungs and abdomen
showed nothing abnormal. The pupils were irregular, but reacted
normally. Reflexes negative. The prostate was slightly enlarged
by rectum, but cystoscopy showed no intravesical prostatic enlarge-
ment. The bladder was trabeculated, but not inflamed, and emptied
itself rapidly and freely. Dr. Hugh Cabot believed the condition
to be dependent upon the heart. Later, the pupils seemed to react
somewhat sluggishly and the question of tabes and a tabetic bladder
was seriously considered. The urine ranged from 50 to 80 ounces in
twenty-four hours. Specific gravity, loio to 1012, usually near the
lower figure. Many hyaline and granular casts with round cells and
leukocytes adherent were found. The Wassermann reaction was nega-
tive.
Additional history obtained from the patient's wife showed that
522 DIFFERENTIAL DIAGNOSIS
the patient had been bothered for five years by attacks of weakness
in his legs, occasionally accompanied by pain throughout his thiols
and calves. After such attacks his legs remained sore. During the
same period he has become much more irritable, and has sometimes
awakened in the night somewhat dazed, not knowing where he is.
His wife states, however, that he has had enough trouble in this period
to change his disposition.
Discussion. — There seems no good sense in connecting the i>atient's
hemoptysis of three years ago with his present symptoms. What was
the cause of that hemoptysis we have no means of judging.
His frequency, which antedated all his other symptoms except the
hemoptysis, begins to get its explanation as soon as we know that he has
dyspnea and orthopnea, and becomes clearly recognized as a mani-
festation of chronic nephritis as soon as the blood-pressure measure-
ments are known. The only remaining question is whether the slight
prostatic enlargement felt by rectum has anything to do with his
frequency. In view of the results of cystoscopy, I doubt it.
Tabes was seriously considered after the condition of the bladder
and pupils had led us to question his wife more closely. The mental
condition which she reports and the pains in the legs are significant,
even though the knee-jerks are normal. The negative Wassennann
reaction should not lead us to exclude tabes.
If he has had syphilis affecting his spinal cord, it is quite possible
that his renal lesion has a similar origin.
Outcome. — During the earlier part of his stay in the hospital
he occasionally had incontinence, but this was controlled by
tincture of hyoscyamus, lo minims, three times a day. Each time
this drug was omitted the incontinence returned, disappearing again
when the drug was resumed. April loth the patient had a sudden
attack of vomiting, without known cause. The attack did not
recur. The renal functions were tested by an injection of phthalein;
8 per cent, were excreted the first hour, 9 per cent, in the second.
He left the hospital April 15th, and died September i, 191 2.
Case 227
An engineer of forty entered the hospital May 25, 191 1. There is
nothing worthy of note about the patient's family history or about his
past history until three weeks ago, when he had a shaking chill, accom-
panied by frequent and painful micturition, with a little blood at the
end. These symptoms have continued since, micturition coming
every half-hour and being very painful. The urine is cloudy, fairly
FHEQUENT MICTURITION AND POLYUKIA
523
abundant. Nevertheless, the patient has worked until to-day, be-
cause he could not find a substitute as engineer at the Children's
Hospital. He is always thirsty, because, he believes, of his work in
the boiler-room. Has no abnonnal appetite. During the past six
months he thinks he has lost 10 pounds in weight and some strength.
Physical examination shows a well-nourished, powerful man,
without visceral lesions. The reflexes and pupils are n^ative.
Rectal examination shows a soft, enlarged, symmetric prostate.
Good i-ray plates of both kidneys and bladder show notliing ab-
normal. Cystoscopy by Dr.
Hugh Cabot shows a normal
bladder capacity. The trigo-
num, the internal urethral ori-
fice, and the fundus of the
bladder show evidence of
chronic cystitis, suggesting tu-
berculosis. The ureteral ori-
fices apparently normal. Urine
from the right side seems to be
slightly turbid, that from the
left normal. Cultures from
the right ureter show moderate
growth of colon-like bacilli;
that from the left shows the
same thing. Specimens in-
jected into a guinea-pig yield
no information of value. The
sediment of the urine from the
right ureter and from the left
show essentially the same
thing. Both contain hyaline and granular casts and leukocytes. A
functional test of the kidneys with phthalem shows normal capacity.
The dysuria following cystoscopy is relieved by 5 minims of
sandalwood oil, three times a day. The amount of urine passed,
under advice to "drink plenty of water," is shown in Fig. 194.
Strangely enough, the specific gravity of the urine varies little from
loio; the sediment always shows considerable pus. The blood is
normal. Blood-pressure, 130 mm. Hg.
Discussion. — Without cystoscopy we should be utterly at sea in
a case of this kind. We should know that he had some sort of an
infection, probably involving his urinary tract. Beyond that we
524 DIFFERENTIAL DIAGNOSIS
should be in the dark. With the cultivation of colon bacilli from
the urine of each kidney we may conclude that operative interfer-
ence is out of the question. Whatever infection he has in the kidney
or bladder he must conquer by his own vital forces with whatever
non-surgical help we can give him.
The negative results of animal inoculation are reassuring as to
prognosis. If there were an extensive pyonephrosis or pyelonephritis,
we should probably be able to feel one or the other kidney, and the
patient would probably have been imable to work as he did up to the
time of entering the hospital.
Outcome. — The patient left the hospital on April ii, 1911, in
fair condition. November 25, 1912, the patient reported himself in
excellent condition and at work. He is still taking the capsules of
sandalwood oil. He drinks a great deal of water and sweats pro-
fusely. The urine at this time was 68 ounces in amount, showing no
turbidity, no albumin, sugar, or pus. The specific gravity was ico8.
Case 228
A schoolboy of fourteen entered the hospital February 14, 1912.
His family history is negative. Two and a half years ago the patient
noticed a swelling in his left neck; it lasted three weeks, and went down
without treatment. He believed it to be due to a bad tooth. Other-
wise he has been well and strong, though he has worn glasses for seven
years.
December 1,1911, two and a half months ago, he developed "ery-
sipelas** of the right foot, the part being painful, hot, and red. This
lasted seven weeks before the foot was finally healed, the doctor having
tried various liniments and plasters as well as internal medicine in
the meantime. There was fever with this attack, but no chills.
After the foot was better, three weeks ago, he began to pass small
amounts of urine every ten minutes. This frequency has gradually
decreased, until now he passes urine about ten times in the day and
four or five at night. He often has the desire, yet cannot pass unne
without considerable forcing. At the onset of this frequency there was
pain and burning as well, symptoms which now occur only at the end
of micturition, when blood is also occasionally seen.
Physical examination shows large red ragged tonsils. Chest and
abdomen negative. Systolic blood-pressure, 120. The right tarsus
is slightly hot, red, and tender, and a little larger than the other side.
The motions of the ankle and toes are free and painless. Reflexes
are normal. Blood normal. The urine averages 25 oimces in twenty-
FREQUENT MICTURITION AND POLYURIA 525
four hours, with a specific gravity of 1020 and a trace of albumin,
probably accounted for by a considerable amoimt of pus and blood in
the sediment. No casts. X-rays of the renal regions were negative
for tuberculosis or stone anywhere in the urinary tract. The bones
of the right foot showed slight atrophy and a moderate periostitis of
the OS calcis. Cystoscopy by Dr. Hugh Cabot showed what he con-
sidered bladder tuberculosis; 20 minims of urinary sediment were
injected into a guinea-pig February 15th. The pig was foimd dead
March 21, 191 2, but the autopsy was negative. A culture from the
urine at the same date, February isth, showed no growth.
The X'T^ys of the foot were not considered characteristic of tuber-
culosis, yet this disease could not be excluded. Hygenic treatment
was thought to be the most important measure, hence the boy was
discharged on the 24th of February.
Discussion. — The results of inoculation in this case are not con-
clusive. The pig may have died of some intercurrent infection before
the tuberculosis had time to develop. Only by a knowledge of the
later course of this patient's symptoms can we be sure what the nature
of the bladder trouble was. A "primary cystitis" is always a doubtful
and imsatisfactory diagnosis, yet nothing much better than that is
possible in this case. The disease in the foot and in the neck may have
been tuberculous, but we have no proof of it. This is the sort of case
in which only time can make good the deficiencies in our diagnosis.
Outcome. — ^A year later he reported that since March, 191 2, he
had been perfectly well, save for an attack of "malaria'' in the summer.
Case 229
A housewife of forty entered the hospital April 15, 191 2. Her
family history and past history were not remarkable. For three
months she has had frequent and burning micturition, and noticed a
white sediment in her highly colored urine. She has grown pale and
short of breath, but until ten days ago had no pain ; then she began to
suffer in both sides of her chest, high up, and in her shoulders, especially
the right. The pain is not constant, but leaves a steady soreness and
is worse when she breathes. It is suflScient to confine her to bed.
There are no suggestive symptoms except poor appetite. Four
months ago she weighed 115 pounds, with clothes; now, 96 pounds,
without clothes.
Physical examination showed obvious loss of weight. Veins of
the neck prominent. Skin pale yellow, but without jaundice in the
sclerae. No substernal dulness. Physical examination was negative,
Fig. J96. — Chest signs in Case iig,
except as shown in Figs. 195, 196. The urine averaged 40 ounc«B
in twenty-four hours, with a specific gravity from 1004 to lOeo^B
FBEQDENT UICTUXITION AND POLYUKIA
5 = 7
as always present in large amounts, and there were also a good
red blood cells. Cystoscopy by Dr. Hugh Cabot, April 17th,
d a nonnal bladder and ureteral orifices. Both ureters were
etized and both contained cloudy, foul urine. Bilateral infec-
i the kidney, probably not tuberculous and not demanding
ion, was the diagnosis. On the 19th of April the same con-
t found the urine from both kidneys loddng better and washed
nal pelvis on each side. Cultures from each kidney showed
g distinctive, and a blood-culture
Iso n^ative. The course of the
aisshowninFig. 197. Thestained
showed always a marked sec-
f anemia with a moderate leu-
>^
the 25th the patient was examined
ot bath and showed a large non-
' tumra:, palpable bimanually, in
i^ticH) shown in Fig. 195. May
i patient was up and felt much
. The precordial pain, which was
lost distressing symptom at en-
, had entirely disappeared. The
was reported improved, but the
a was worse, and she was dis-
si on the 3d of May.
jcussion. — From the history of
h urine, with pallor and the loss
pounds' wei^t during the first
months of pregnancy, a septic or
ulous process in the kidney comes
•e to mind as the most probable
lation of the patient's frequency.
ondition of the blood is puzzling,
iken by itself, would strongly sug-
;micious anemia, though the slight
3e of leukocytes would be atypical
such a diagnosis. I looked at the
myself on the i6th of April and called It a secondary anemia,
count of the notable leukocytosis, although I could find no
nia. There were moderate variations in the size and shape of the
Us, no stippling, no blasts. Such an anemia is more often seen
BM
jjt
p
p
p
p
p
p
pi
r
E
1
-.
"*
1 z
»,
tM
wg
i ""•
<m
Fig. :97. — Blood chart b Case sag.
\
528 DIFFERENTIAL DIAGNOSIS
in septicemia than in tuberculosis. As a result of cystoscopy there
a demonstration of infection in both kidneys. Operation was
course, impossible. It is to be regretted that no animal inocula'
was made.
At the time she left the hospital we expected a steady proj
of the disease to a fatal termination.
Outcome. — November 23, 1912, her husband reported that . she
"got along fine after leaving the hospital" until the last week in Au-
gust, when diarrhea and vomiting began (after a vacation trip) and
lasted until her death, September 6, 1912.
Case 230
A teamster of forty-one entered the hospital April 22, i =1=912.
The patient is moderately alcoholic, but otherwise shows nothin^^g of
importance in past history or family history. Eight weeks ago
micturition became frequent and caused burning pain, especn" JaDy
in the latter portion. Seven weeks ago he noticed that the urin^^e at
the end of micturition was bloody. At the same time the left ar iHe,
hip, and knee became so sore and painful on motion that he stg==iyed
in bed for a week. Six weeks ago he had severe colicky pain ii^R_ the
right lumbar region and flank, radiating down the ureter. ~ Ihis
pain lasted half an hour and has not recurred. There was no rh-^F=>nge
in the urine at the time. Since then he has been fairly well ^ve
for the local urinary symptoms, but he has noticed that his mimcnt is
cloudy and has a white sediment.
Two days ago his right knee suddenly swelled and became red,
hot, and tender, so that he walks on crutches. Despite these troi-imbles
his appetite has remained fair and he has kept his usual weight,
145 poimds.
Physical examination shows in the precordia a soft systolic imui'
mur, present only during inspiration. The aortic second soun<f is
more intense than the pulmonic second; otherwise visceral exam-
ination is negative. The right knee is swollen, hot, red, and tender.
The patella floats and there is considerable thickening about the
jomt. On the dorsum of the right foot there is a tender spot. A
smear of pus obtained from the prostate shows a few polynuclear
leukocytes and a rare diplococcus, negative to Gram. By rectum the
prostate is tender, imeven in consistency, and contained an excessive,
slightly purulent secretion, believed to be due to gonorrheal prosta-
titis. The treatment advised is irrigation and massage of the pros-
tate. The gonococcus fixation test is moderately positive; the Was-
FREQUENT MICTUiaTION AND POLYURIA 529
sermann, negative; x-ray, No. 20,646, shows evidence only of an in-
fectious arthritis in the right knee.
Gonococcus vaccines, 50,000,000 every four days, were given by
Dr. Steele. During four weeks in the ward the patient ran a slight
irregular fever, now and again, never exceeding 100° F. The urine
averaged 60 oimces in twenty-four hours, with a specific gravity of
loio, and during the first few days a slight trace of albumin. The
sediment always contained pus, though the amoimt became much
less during the later weeks of treatment.
Discussion. — ^When the joints are eflFected simultaneously with
bladder symptoms of this type a general infection is naturally our
first thought. The fact that he has had a pain along the ureter leads
us to imagine that the trouble may have extended up to the pelvis of
the kidney, wherein a blocking with pus might cause pain. The
condition of the right knee on physical examination is that most
often seen in gonorrheal arthritis, and the blood-test goes to confirm
this, likewise the rectal examination. Presimiably he had a gonor-
rheal prostatitis and pyelitis as well.
Outcome. — By May ist the right knee was almost normal, but the
left knee was very large and showed practically the condition present
in the right at entrance. This condition in the knees progressed
and improved, from day to day, in an irregular way until the isth,
when both knees seemed to have cleared up and the patient was
allowed to go home.
Case 231
A housewife of sixty-six entered the hospital July 18, 191 2. Her
family history was negative and past history not remarkable.
About a year ago she began to have frequent and burning mic-
turition. The urine looked a little darker than usual, but was never
bloody. The quantity was not increased and there was no inconti-
nence, but at times the urine was passed every half hour, night and
day. With slight periods of improvement this has persisted ever
since, though she has kept about and worked imtil six weeks ago.
-At that time she began to have severe pain in the small of her back
and in one or the other hip. The pain was increased by motion, and
'Was similar to the attacks of "lumbago," which she has often had
fcefore. This pain, however, disappeared a month ago and has not
■recurred.
For six weeks she has been in bed most of the time and has lost
appetite. She is constipated and is much troubled with gas
Vol. II-^
530 DIFFERENTIAL DIAGNOSIS
in the bowels. For six months she has noticed shortness of breatfecinou
exertion, and for three months swelling of the feet and ankles, di_:==sa^
pearing when she goes to bed. There has been no fever, cougfa^^, or
jaundice. Her main complaint^ are of the urinary frequency and
great weakness.
Physical examination shows the patient moderately emadiML^iited.
The heart is negative except for a soft systolic murmur at the
and there is an accentuation of the pulmonic second sound. Th<
soft edema of the lower back from the twelfth rib to the sa(
over the anterior abdominal wall. Some also in the thighs. Vj
examination shows that the base of the bladder is thickened
firm, forming a rounded mass several centimeters thick, which bw^^ifcgj
slightly in the anterior vaginal wall. The urine averages 35 01 :jqq^
in twenty-four hours, with a specific gravity in the neighborhw^iDrf Qf
1018. It contains much fresh blood and many masses of im^uJii,
nuclear epithelial cells; no casts and few leukocytes. Culture Jrom
the urine showed no growth. Blood showed red cells, 4,7oo,oc3o-
white cells, 10,500; hemoglobin, 60 per cent. Stained smear ^ve
evidence of achromia.
Discussion. — ^At this patient's age such bladder symptoms are
probably due to stone or malignant disease. Emaciation favois
the latter alternative, and if her dyspnea and edema are not due
to some separate cause they would round out the diagnosis of
malignant disease, which the vaginal examination renders prac-
tically certain. Tuberculosis originating at her age is practically
unknown.
Outcome. — Cystoscopy, July 19th, by Dr. Hugh Cabot, showed a
new growth in the bladder, believed to be cancer on account of the
suggestion of glandular involvement given by the edema. No opera-
tion was advised. Accordingly, the patient left the hospital July
20th and died three days later.
Case 232
An Irish laborer of seventy-nine entered the hospital July 18,
191 1. The patient says he has had pain in the epigastrium for
twenty years and that it has steadily been growing worse. He to
no other gastric symptoms and has otherwise been well. He drinks
whisky two or three times a day.
For a year he has noticed that his urination was frequent and
caused burning. There has been no retention and no incontinence,
but for the past two weeks he has passed urine about every hour
FSEQUXNT laCTDKinON AND FOLYDSIA
531
: daytime and five or six times at night. The urine is foul and
y; sometimes only a teaspoonful at a time is passed,
lysical examination showed tortuous, hard, beaded arteries,
leart's apex was in the sixth space, i cm. outside the midclavic-
ine. Aortic second was accentuated. A soft systolic murmur
xalized in the apex region. The chest was barrel shaped, hy-
(onant throughout. The expiration was prolonged, accompanied
[ueaks and crackles. The bladder was distended, reaching to
I 3 inches of the umbilicus,
t was right inguinal hernia,
ectum the prostate was
rately enlarged, not tender,
firm in consistency; 22
s of urine were drawn by
ter, alkaline in reaction,
in gravity, containing much
md blood. The twenty-
lour amount thereafter
ged 50 ounces. The tem-
ure as in Fig. 198. The
it was put on constant
ige and kept so for four-
days. By the phenolsul-
^phthalein test 6 per cent.
:xcreted in the first hour,
color first appearing in
-five minutes the first time,
II fifty-five minutes. On the 14th of August he developed acute
lymitis on the left; by the 17th that had begun to subside,
iscussion. — The patient clearly has arteriosclerosis and an
;ed heart with emphysema, but at present his trouble is a dis-
d bladder, presumably due to prostatic enlargement. The
question of interest is whether or not he has cancer of the pros-
Of the latter condition, the rectal examination gives no evi-
and there is nowhere else to look for any. We are dealing
s case purely with symptoms of obstruction, not with pain or
turia, such as arc associated with tuberculosis, cancer, or primary
is. The development of acute epididymitis is one of the un-
able complications of constant drainage, in a certain percentage
static cases, and does not complicate in any way the diagnosis,
it may darken the outlook.
z X i " "
„ _i ^^4 — 1_. . . j-
" ::&?A^'iiyfc^:^t:st^;
Z ~ ' ":
;; " "■
_ ,
;„ 1_|
l-mm.'^^ ''f&^''-
LT'TT"^T
: ;^ji^-±|:± ii
Fig..
—Chart of Case 3:
532 DIFFERENTIAL DIAGNOSIS
Outcome. — By the 2 2d of August he was much better in his general
condition, and was allowed to go home.
Case 233
A housewife of fifty-two entered the hospital May 12, 1908.
For the past three or four months the patient has been troubled with
thirst, polyuria, and increasing nocturia, now eight to ten times; also
dyspnea, which in the past two weeks has amounted to orthopnea.
She has had occasional attacks of vomiting, has lost considerable in
weight, and her eyesight has rapidly been growing poor. Her head-
ache has also been a troublesome symptom of late. Previously to this
she has always been well, has had fifteen children, and three mis-
carriages.
Physical examination showed obesity, pale, dry skin; pupils,
glands, and reflexes negative. The heart's apex was i inch outside
the midclavicular line. Right border dulness f inch to right of mid-
sternum. The heart's action was irregular, with frequent premature
contractions. The aortic second sound was markedly accentuated,
no murmurs. The artery walls were thickened. Blood-pressure,
240 mm. Hg., systolic. Slight dulness and crackling rdJes at both
bases behind. Abdomen negative. Considerable edema of the 1^
and back. Blood negative. Urine, 32 ounces in twenty-four hours;
specific gravity, loio; sediment negative. She did not improve during
her week in the hospital, and was taken home by her friends on the
19th of May. She returned on the 20th of Jime. She has had attads
of vomiting four or five times a day since she left. She has been in
bed; had no appetite and some dyspnea, but no orthopnea. The
heart's apex was at this time in the anterior axillary line, right border
of dulness i| inches to right of midsternum. Blood-pressure, 23S
mm. Hg. In the left lung there was dulness, absent breathing, and
faint nasal voice sounds, with crackling r^es below the lower angle of
the left scapula. Abdomen negative. Slight edema of the legs. At
this time she seemed a good deal better than when she left the hospital
before, and improved still further during her ten days' stay, though
she still vomited each morning. The condition of the urine was as
before, although an occasional hyaline and granular cast was found.
She went home on the 30th of June.
Discussion. — When a patient consults a physician primarily for
thirst and polyuria, the diagnosis is usually saccharine diabetes. The
imusual thing about this case is that the urine contained no sugar.
As soon as we go beyond the presenting symptom, we find dysp-
PSEQUENT laCTURITION AND POLYURIA 533
nea, headache, vomiting, poor eyesight, and, above all, an enormous
degree of hypertension; in other words, the complete clinical picture
of chronic nephritis, which in this patient has run probably its entire
course up to this, its terminal stage of contracted kidney, without
any symptoms at all. So it is with most cases of chronic nephritis.
They are entirely symptomless until their later stages. This is espe-
cially true of the arteriosclerotic varieties and of all mixed cases in
which the arteriosclerotic element predominates over the glomerular
element. There is no reasonable doubt of the diagnosis and no need
of discussion.
It is worth mentioning, however, that now and then a patient
comes to us complaining of dry mouth and of nothing else, but pre-
senting on careful study a picture similar to that of this case, though
less in degree and intensity. A good many such "dry mouth" cases
are associated with prostatic obstruction and are regarded by the
genito-urinary surgeon as poor risks. The dry mouth is often, but not
always, an ominous sjnnptom. Curiously enough, it is now and then
wholly relieved by chewing dry crackers.
Case 234
A schoolboy of seventeen entered the hospital August i8, 1909.
Family history is negative. During the first months of his life he
had convulsions, but since then has had nothing of the kind, though
he has occasionally been troubled by '^rushes of blood to the head and
by choking sensations."
In June, 1909, eight weeks ago, he first noticed that he was passing
a great deal of urine, getting up three or four times in the night to
urinate, and drinking a great deal of water. Appetite very good imtil
two weeks ago, since then poor. He has been constipated of late
and has vomited once or twice. He has no headache and sleeps very
well, but his mouth is always dry, and he thinks he has lost a little
weight.
Physical examination shows good nutrition, a dry, harsh skin.
Otherwise negative. The range in the amount of urine is shown in
Fig. 199. Fimdus oculi was normal. The patient was put on Folin's
diet and the amount of urinary excretion, as compared with the salt
ingestion, was studied. Later he was put on a diet of protein without
salt, and the amount of urine, together with the thirst, rapidly de-
creased. As soon as salt was added to the diet the urine returned to
nearly its former amount. September 13th a positive Wassermann
reaction was obtained. September i6th he was given a salt-free diet
534 DIFFERENTIAL DIAGNOSIS
containing nitrogen and again the amount of urine Himini*Jied,
though still remaining considerably above the normal. In view (»"dlie
positive Wassennann reaction, the patient was given mercuria,! io-
unctions and iodid of potash in increasing doses. He decided to go
home on the 30th, having lost no weight since the first week of ei^'
trance and having achieved no gain.
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Discussion. — The enormous degree of frequency and polyui — ^
which this boy exhibited, when associated with a poor appetite arj</
known to be continuous, leaves only one probable diagnosb in the
foreground, diabetes insipidus. The presence of a positive Wasser-
mann reaction is no reason for changing this diagnosis, since we still use
the term "diabetes insipidus" to cover cases with some organic braui
FREQUENT laCTUIOTION AND POLYURIA 535
esion as well as those with unknown pathology. In diflferential diag-
losis the main thing is to exclude nephritis, which in this case was
asy, and to determine that the frequency and polyuria are not of tem-
x>rary nervous origin. The lapse of time and the careful study of the
ase exclude these possibilities beyond doubt.
We tried various experiments with this patient's diet and showed
hat a salt-free diet would for a time reduce his polyuria, but, as such
I diet could not be kept up for any length of time without great
ianger, its temporary effects were of no benefit to the patient.
It is of some importance to note that antisyphilitic treatment
)roduced no benefit. This is what we have learned that we must
sxpect in many cases of diabetes insipidus, even when the Wassermann
"eaction leads us to hope that we may secure good therapeutic results.
Outcome. — ^The patient died February 27, 1910. During most of
he latter months of his life he could eat scarcely anything. He drank
in enormous amount of milk and water, but vomited most of it within
lalf an hour. After Thanksgiving he was confined continuously to bed,
ind for three months before his death he took absolutely no solid food
ind lived wholly on orangeade and moxie. He suffered no pain, but
luring these bed-ridden months there were troublesome cramps in his
irms and legs, and finally contractures developed in all four ex-
xemities. There was no fever or cough, no headache, no trouble with
he movements of his bowels. Toward the end of life he was not
bowsy, but emaciated to skin and bone, the enormous polyuria
lontinuing up to the very end, although he was too weak to pass
irine spontaneously and had to be catheterized. There was much
tching of the skin.
Case 235
A schoolboy of fourteen entered the hospital February 14, 1910.
le has always been well. Good family history. Eighteen days ago
le ate a hearty dinner, with a good deal of ice-cream, and drank
nuch water. During the next twenty-four hours he passed more
urine than usual, and after that seemed to be all right, but a week later
le had another attack of polyuria, and since then has passed over
f quarts, sometimes 3 quarts, daily. Four days ago sugar was dis-
overed in the urine. His appetite has been very good all winter,
>ut not imtil the last two weeks did he notice any thirst or dryness in
he mouth, and not imtil that time did he lose any weight.
On physical examination he is well developed, dry skin, viscera
nd reflexes normal. Urine, 40 gm. of sugar a day, quickly yielding
\
536 DIFFERENTIAL DIAGNOSIS
to Strict diet. The boy stayed twenty days in the hospital, and during
the last five days had no sugar in the urine. Acidosis was very slisbt,
and the boy held his weight at 118 pounds without considerstble
change.
Discussion. — ^The sudden onset of symptoms is of some interest
The diagnosis could never have been in doubt, provided the urine
were examined. It is notable that he never suflFered from thirst or dry
mouth and that for a considerable period he maintained his wei^lit,
although no changes were made in his diet. The prognosis for sixdi
a case is poor, even when response to treatment is excellent, as dmxng
his hospital stay. Very few such cases live more than a year or t^iro.
Outcome. — ^He went home on the 2d of March, 19 10, and died in
coma, March 14, 191 1.
Case 236
A carpenter of thirty-eight entered the hospital March 31, 19 10.
The patient's family history and past history are excellent. He xxscd
to drink heavily until two years ago.
About Christmas-time he began to notice that he passed IsLTg^
amoimts of urine. He was much worried by the statement of lis
doctor that he had tuberculosis. Since last Christmas he has done no
work, and for the past six weeks can scarcely go up stairs because of
weakness and shortness of breath. His appetite is good and he Iws
no cough, but there is some palpitation and some swelling of the legs.
His legs seem much weaker than any other portion of his body. Be
has no pain anywhere.
Physical examination showed fair nutrition and marked pall^^-
About the knees and elbows were many small flattened red papules,
covered with scales. His teeth were poor and many missing. Ch^^i
and abdomen were negative. Reflexes and pupils normal. BicKX
showed red cells 2,144,000; white, 9500; hemoglobin, 50 per ceX^^
In the stained specimen were marked achromia, slight variations ^
size and shape of the red cells. Differential count normal. T0^^
yellowish tint of the skin was such as to suggest pernicious anem^ ^'
but the blood-picture was that of secondary anemia (Fig. 200^^''
There was a positive guaiac reaction in the stools at entrance, b\ — -^
this was found to be due to piles, for which operation was advise-^^^^
by Dr. Mixter.
The urine contained sugar in amount varying between 40 an^^
60 gm. a day on a strict diabetic diet with 200 gm. of bread, ani
on all the subsequent reductions in the amoimt of bread no chan
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538 DIFFERENTIAL DIAGNOSIS
occurred, though during the last week of his stay in the hospital the ,
diet contained no carbohydrates. He went home on the iilh. 1
The patient entered the second time on the 17th of January, 1911,
stating that since his discharge he had been much the same, gaining
weight when he loafed and losing it when he worked. He has not
stuck to his diet (Fig. 201).
Three weeks ago he got what was called "pneumonia," beginning
with a heavy cold, followed by chills and fever, with pain in the left
lower chest and cough . with scanty whitish sputum. A little cough per-
sists. At this time physical examination showed slight dulness and
■- — Chest siuns in Case 136.
occasional moist rales at the left base (Fig. 202). Just Inside the
angle of the left scapula was a patch of bronchovesicular breathing and
increased whisper. Otherwise physical examination was unchanged.
except for his red cells, which had risen to 3,200.000; white kII*-
19,000. Hemoglobin remained at 50 per cent. The stained snu^
still showed marked achromia with a polynuclear leukocytosis, ^h^
amoimt of sugar was considerably greater than on previous examina-
tion. Under strict diet it was gradually brought down to about
40 gm. a day. At this time, as on the previous occasion, he had
considerable diarrhea.
FKEQUENT mCTUWnON AND POLYUBIA
539
After leaving the hospital the last time he adopted a diet of his
own, containing as much milk and cereals as he liked and two slices
of bread. On this diet he worked at carpentering two or three days
a week and felt well and fairly strong until a week ago, though he
has had several spells, lasting a week or two, when he would be "all
done up" and feel very weak and drowsy.
A week ago he caught coki, felt tired and miserable. Four days
ago he was feverish and chilly at night and felt sore all over. The
next morning he began to cough and felt pain in the left lower chest.
These symptoms have continued since, though his appetite has
been good. Hb weight has gradually
fallen since spring from 145 pounds at
that time to 133 pounds now.
Physical examination showed essenti-
ally the signs given in Fig. 202. X-ray,
according to Dr. Walter J. Dodd, showed
a less local and more diffuse process than
would be expected from tuberculosis.
The diaphragm was found to move poorly
on the left. September 27th the chest
showed all the signs of solidification in
the left middle back, with some crackles
at both bases and an occasional friction
soimd.
Discussion. — The remarkable feature
of this case is the anemia. Most diabet-
ics have no considerable anemia, and the
opposite condition, a concentration of
the blood with polycythemia in the unit
obtainable, is the rule. It does not seem to me that the patient's
hemorrhoids are likely to be the explanation of his anemia, for under
observation it was proved that he lost scarcely any blood, and the rise
in his red count under treatment was not at all marked.
Another feature of interest is the cause of his dyspnea. Although
his local physician told him three months before we saw him that he
had tuberculosis, we could not find the evidence of it at the time of
his first entrance to the hospital. Later, we found some dubious signs
which might be interpreted as tuberculosis or as bronchopneumonia.
At no time was there any considerable cough or sputa. Dyspnea was
his only pulmonary symptom.
All this is quite in accord with the fact that at postmortem many
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FTg. ioj. — Chart ot Case 336,
CHAPTER Xn
FAINTING
Appabently, fashions have changed since Walter Scott's time.
Ladies do not faint as they used to, and I do not suppose we shall
ever know exactly what was the pathologic condition of Scott's heroines
and the other ladies of that time. At any rate, it must be clear that
fainting is much rarer than we used to suppose it to be.
But beyond the narrowing scope of the term in its popular use,
and its availability in diflScult situations, there is certainly a medical
narrowing of its use as well. Many attacks of unconsciousness which
used to be called fainting would now receive some more significant
and more serious name. The typical fainting attack, as we know it at
the present time, is such as comes on in persons predisposed to such
attacks when they are confined in a poorly ventilated room, or when
they are compelled to witness some disaster involving bloodshed.
Just what happens in these cases we do not know. It is customary to
suppose that the individual loses consciousness because of cerebral
anemia. The face is pale, the extremities cool, pulse feeble, and
it seems as if the heart was doing very little work. But exactly why
cerebral anemia, when produced in chronic diseases, such as pemidous
anemia, so seldom leads to fainting is not at all clear. Perhaps chronic
anemia with its slow onset gives the brain opportunity to accommo-
date itself in some way.
However this may be, it is certainly true that we are much more
cautious than we used to be, when we decide to call a given attack of
unconsciousness a fainting fit. Many such attacks turn out to be
epilepsy in its minor form. Others manifest cerebral arteriosclerosis
or a lesion of His' bundle. The diagnosis, then, is only to be made
after every effort to find organic disease has failed.
It is important to realize that just before the end of a fainting fit
the patient not infrequently has a brief, generalized convulsion. One
need not give up the diagnosis of fainting or swing over to epilepsy
merely because of such a convulsion. I have repeatedly observed it
in attacks which deserved to be called fainting, if the term is ever to
be used at all.
541
542 DIFFERENTIAL DIAGNOISS
Another point not always realized in relation to genuine fainting
fits is that the patient may altogether stop breathing for a period
long enough to cause considerable alarm, even to the physidan.
Such a period of aphonia would doubtless end itself before any serious
results occurred, but it may be brought to an end promptly by the
use of artificial respiration.
In a general way, such attacks are unimportant in the young and
serious in the old. The exception to this statement is found in the
possibility that a petit tnal — in other words, a minor epileptic attack-
may be mistaken for a faint.
Hysteric coma differs from fainting in that it has less definite
relation to bad air and sudden fright. It is more imder the control
of the will, and usually lasts much longer than a fainting fit. The
latter is usually over in a minute or two, the former lasts for hours.
Fainting fits have always marked circulatory phenomena suggesting
cerebral anemia, while in hysteric attacks such evidence is wanting.
Aside from the tendency to bad air and mental shock to cause
fainting, it is well recognized that such attacks are more prone to occur
in certain predisposed individuals or families.
Many such individuals outgrow the tendency to faint as they
advance in years. Beyond this, it may be stated that all diseases
which weaken the patient profoundly make him more likely to faint
Fainting and vertigo are symptoms often closely associated.
Almost all of the causes of vertigo are also, on occasions, causes of
fainting and vice versa.
Case 237
A man of forty-two, occupied in making white lead, entered the
hospital December 8, 1900. The patient had never been sick before,
except for ''brain fever," which he had eighteen years ago in St. John's
Hospital, Newfoundland. He was in bed seven weeks and delirious
seven days.
Ten years ago an empty water barrel fell 35 feet and struck him
in the forehead. He was unconscious several minutes, in bed three
days, out of work two weeks. Since that time he has had a sense of
burning above the left eye whenever he thinks about it. He uses
about ^ pint of whisky in five weeks and ten cents' worth of tobacco a
m
week.
He now comes to the hospital on account of fainting spdls, which
began eight weeks ago with dizziness and nausea which three or four
times have led to vomiting, brought on, apparently, by suddenly
FAINTING 543
lifting his head from the pillow or turning quickly. He never has
trouble while lying down or standing quietly. Three weeks ago, as
he started to turn over in bed, he grew so dizzy that he fell over the
side of the bed on to the floor. He was unconscious a few minutes,
vomited several times, and had some stomach trouble for the next
week. He has had four similar attacks, each one milder than the last.
For four years he has had occasional spells of abdominal pain, lasting
an hour or two, attributed by him to constipation. Bowels move
every day or two. He has had nosebleed almost every day for two
weeks. For two months his head has felt heavy, as if it were an effort
to hold it up and prevent its dropping on to his left shoulder.
Fig. 104- — ^Area of partial anesthesia in Case 237.
Physical examination shows pallor, good nutrition, a spotted black
line on the gums at the border of the incisors and bicuspids. No
blue patches anywhere. In the left back there is an area of diminished
sensation, as shown in Fig. 204. Otherwise the chest shows nothing
abnormal. The radials are somewhat tortuous and thickened. All
the reflexes are normal and there is no muscular weakness. The ears
are negative, likewise the eye-grounds. Blood examination shows
red cells, 5,000,000; whites, 9400; hemoglobin, 60 per cent. The
urine is normal.
Discussion. — This patient is burdened by exposure to lead-poison-
544
DIFFEKENTIAL DIAGNOSIS
ing and to alcohol. In view of his occupation we may imagine that the
brain fever of eighteen years ago was very possibly a lead-encq>hal-
opathy.
Whether the traiunatism of ten years ago has any special rela-
tion to his present symptoms I cannot say, but it seems to me very
doubtful.
At the present time he is troubled not only by fainting, but by
vertigo, vomiting, nosebleed, and abdominal pain. The last two of
these symptoms are not ordinarily associated with fainting and sug-
gest that some other malady is at work. Another bizarre symptom
is his difficulty in holding up his head, which in a man of forty-two is
more notable than during the first year of Ufe.
The other points of note in this case are the patch of diminished
sensation in the left back, the evidences of arteriosclerosis, and the
anemia.
Out of this rather miscellaneous group of complaints and lesions,
several draw attention strongly toward lead-poisoning as a possible
diagnosis. This would explain the stomachache, the arterial changes,
the anemia, the nosebleed, and very possibly the nervous lesions
responsible for his patch of anesthesia and his difficulty in holding up
his head. The condition of the gums strongly supports this hypoth-
esis, but before conmiitting ourselves absolutely, however, certain
alternatives should be mentioned.
Brain tumor could cause many of his symptoms, but the negative
eye-grounds, the absence of focal symptoms, and of any persistent
headache are against any such idea. Arteriosclerosis might cause all
his symptoms, except his anemia and the black spots upon his gums.
Doubtless he has some arteriosclerosis, but in all probability plumbism
is its cause.
Alcoholism would account for his vertigo, possibly his fainting,
certainly his vomiting, but beyond that it cannot help us to straighten
out the complicated symptomatology of the case.
Outcome. — The patient was given magnesiiun sulphate, § ounce
before breakfast daily, and potassium iodid, $ gr., twice a day.
improved steadily and had no more fainting attacks, but during tb
nights of the 9th and loth had abdominal pain, keeping him a
about two hours, and relieved by pressure and hot-water bag. C^
the 12 th of December he was so much better that he was allowed -
go home. For the past seven years he has worked making white le^^
and his hands are constantly covered with it.. He always washes tb^jj
before eating, but some of the paint sticks about the finger-nails.
FAINTING 545
Case 238
An Irish butler of thirty-one entered the hospital May i6, 1907,
complaimng of aching in the region of the ensiform, relieved by food
for several hours, also by hot drinks. Two weeks before this he began
vomiting early in the morning, the vomitus being sour and relieving
the pain. Lavage also relieved him. His appetite was good, bowels
constipated. The previous year he had been operated upon; the gall-
bladder was drained and some adhesions about it separated. The
appendix was also removed at this time, though no disease was found
in any of these viscera. Another operation was done February, 1907,
and some more adhesions freed. After this he was well for two months.
At the time of his first entrance to the Massachusetts Hospital he was
very neurotic and had but little pain. Examination of his stomach,
both fasting and after test-meal, showed normal contents and physical
examination was otherwise negative, except that his stomach after
inflation reached 2 inches below the navel. Operation was consid-
ered, but not advised.
January 29, 1908, he returned, stating that four days ago, while
working as a waiter, he fainted away three times. During that night
and the following day he passed four black stools. Since then he has
had some epigastric pain, which last night kept him awake, and he has
grown very pale and weak.
Physical examination was again negative, except that his hemo-
globin was reduced to 75 per cent., and his stools were strongly posi-
tive to guaiac during the first few days. After that time they were
negative. There was no fever. He had occasional night attacks of
pain in the upper abdomen, but under a diet of milk and lime-water
continued for two weeks, and then followed by carbohydrate and
milk diet, he did ver>' well, and left the hospital March 26th. Such
pain as he had at the end of this time came about three hours after
eating, and was relieved by soda. He was again in the hospital No-
vember 3 to December 9, 1908, having had pain off and on since his
previous entrance. Meat-free diet and sodium bicarbonate relieved
him as before.
Discussion. — Fainting associated with black stools leaves little
doubt of its cause. In the majority of cases such an association is
not noticed by the patient, but when he is aware of it and remembers
to tell his doctor, the latter can hardly be excused for not putting
two and two. together and recognizing that the fainting is due to
hemorrhage. Among the causes of gross bleeding from the bowel in
Vol. 11—35
546 DIFFERENTIAL DIAGNOSIS
a man of this age, typhoid fever, cirrhosis of the liver, peptic ulcer
are the only ones of any importance. Typhoid can easily be ruled out
by the absence of fever and other evidences of infection. Cirrhosis
is possible, but there is nothing to suggest it. On the other hand,
the symptoms are all such as one expects with peptic ulcer, a diag-
nosis which doubtless would have been made long ago had we not
been thro\\Ti off the track by the previous operation, at which the real
cause of the trouble was not recognized, though it must have, in ail
probability, been present at that time.
Faintness from this cause is not unusual and is sometimes very
sudden. I have known two patients to fall out of their chairs in such
a fainting attack.
Outcome. — Soon after this Dr. E. A. Codman operated on him
and found a duodenal ulcer with marked local peritonitis. Posterior
gastro-enterostomy was done.
April 24, 1 913, he was reported to be perfectly well and working
regularly.
Case 239
A janitor of thirty-seven entered the hospital Januarj- 19, 1909,
for the second time, largely on account of fainting spells which ha\'e
troubled him. off and on. for the past ten months. At the time of his
first entr>*, January i. iqoS. he stated that he had rheumatic fever at
fifteen and as:ain at twentv-five. and was told that he had severe
heart trouble with his second attack, but completely recovered from
it. so far as he knows. He denied venereal disease.
About fifteen vears aso he did not feel well and went to a doctor,
who found albumin in his urine. Under treatment this disappeared,
and he was perfectly well until five years ago. when he again consulted
a doctor, who found albumin once more and put him to bed for a
month. The albumin then disappeared as before, and after a couple
of months more of convalescence he went back to work.
In the spring of 1007 he again felt weak: he ga\-e up his job as
janitor in June and went to work on a farm, where he remained untfl
the end of November. He worked hard all the time and felt perfectly
well. He returned to Boston in December and worked at \'arious
jobs. In December. 1007. a week before the time of his first entrance
to the hospital, he began 10 feel faint and saw spots before his e\"es.
but did not actuallv faint awav. Four davs later his face and his
« « «
feet swellevi. but he had no other s\-n:ptoms at the tone of entering
the hosj^ital on New Year's Day. 1006. At that time ph^-sicil ex-
FAINTING 547
amination was negative, save for pufiiness of the face and the follow-
ing cardiac abnormalities: The hearths sounds were best heard and the
left border of dulness found at a point f inch outside the left nipple;
the right border dulness i J inch to the right of midstemum. A moder-
ate systolic murmur was heard at the apex, transmitted to the axilla
and all over the precordia. The pulmonic second sound was con-
siderably louder than the aortic. Systolic blood-pressure was 175.
Urine averaged 40 ounces in twenty-four hours, with a specific gravity
of 102 1 and a very large amount of albumin. Many hyaline and fine
granular casts, some with red corpuscles and fat drops adherent.
A few highly refractile casts. Occasionally an epithelial cast. Blood
normal; fimdus oculi also normal.
January 5th slight edema appeared in the legs and in the ab-
dominal wall. There were occasional attacks of shortness of breath
in the night. On the 19th ascites was made out, but by the 2 2d this
had almost disappeared, and on the 29th he was allowed to go home.
Discussion. — This is the type of case to which Libman, of New
York, has drawn attention in a recent series of interesting papers,
the last of which was published in the Transactions of the Associa-
tion of American Physicians, vol. xxviii, p. 307. Libman called at-
tention specially to the fact that attacks of rheumatic — that is, strep-
tococcic— endocarditis such as affected this patient in his early life
are likely at the same time to produce renal lesions which appear much
later in Ufe, after a period of intervening good health, in the form of
chronic nephritis. Whether the renal lesions are actually embolic
in type, as Libman supposes, or whether they are produced by cir-
culating toxins, need not at present be decided.
For the past fifteen years the patient has certainly had evidence
of glomerulonephritis. At the present time the condition of the
urine and blood-pressure leaves little room for doubt that his present
cerebral symptoms are due to his kidney trouble and to the vascular
cerebral crises associated with it.
Outcome. — He returned a year later, January 19, 1909, on account
of the fainting spells above referred to. He has no headache, no
dropsy, and no vomiting. Nocturia, four. He comes this time
wholly for the fainting spells and for weakness.
Physical examination was essentially as before, b\it edema was
absent. Systolic blood-pressure, 170; urine, 0.3 per cent, albumin;
casts much fewer than before. He went home on the 23d.
548 DIFFERENTIAL DIAGNOSIS
Case 240
A Scotch housewife of fifty-seven entered the hospital January 9,
191 1 . Her family history was good. For about eleven years she has
been troubled by "biliousness," coming about once a week and cul-
minating in the vomiting of bitter green fluid, relieved by soda water
and not accompanied by pain. Menopause occurred seven years ago.
In August, 1910, she had swelling and pain in her knees, but was not
in bed with it. Four weeks later, after the swelling had disappeared,
there was much itching in both legs for a month, thought by her
physician to be connected with varicose veins. This itching has
occurred at times since.
For eight weeks she has had many chills and two periods of un-
consciousness, the first eight weeks ago and the second six weeks ago,
each accompanied by a chill, with cyanosis and imconsdousness last-
ing a few minutes only, though the chill lasted four hours. In the
second attack she fell.
For four weeks she has vomited each night, following an attack
of colic at about 2 A. m. The attacks are in the left side of the ab-
domen, later in the back. The pain is sharp, but does not radiate.
During this time she has eaten but little, and feels very much as she
usually did in the early months of her pregnancies. Her bowels are
costive. There is no nocturia. The urine was. examined a week ago
and found normal. Two years ago she weighed 160 pounds, with
clothes; now, 137 pounds, without clothes. She thinks she has lost a
good deal of weight in the last few months.
Physical examination showed a patient well nourished. Normal
pupils and reflexes. Chest and abdomen negative, except for slight
tenderness on pressure on the left flank. On the front of the ri^t
thigh there was a white scar the size of a dime. Systolic blood-
pressure, 1 70. Urine averaged 30 ounces in twenty-four hours; specific
gravity, 1007 to loio. Slight trace of albumin. There was a small
amount of pus and red corpuscles in a catheter specimen. No casts.
White cells, 12,000, with a slight polynuclear leukocytosis; hemo-
globin, 85 per cent. Wassermaim reaction negative. Fundi negative.
The urine showed a pure culture of colon bacilli, but 20 minhns
injected into a guinea-pig produced no results. X-ray showed appa*
rently two stones in the left kidney. The patient continued to vomit
despite diet and purgation and took very little nourishment.
January i6th, soon after breakfast, she began to have peculiar
spasmodic attacks, as follows: She lies quiet, the radial pulse dis^
FAINTING 549
pears, aiid the heart's sounds are reduced to a very slight ticking
sound corresponding to first sound , and best heard just to the left
of the sternum. The rate is 70 to 80 and the rhythm quite regular.
No second sound is heard. In five or ten seconds the face becomes
pale, then gray, the eyelids droop, and eyeballs roll up with widely
dilated and non-reacting pupils. Then follow a few quick, deep respira-
tions. Then twitching of both arms, with or without a strong back-
ward extension of the neck. All of this lasts perhaps twenty to thirty
seconds. Then there come a few violent irregular thumpings of the
heart, the eyes and mouth become greatly puckered, then the face
relaxes and becomes pink, the spasmodic movements of the arms
cease, the pupils quickly contract to their normal size, and the patient
looks up in mute astonishment as if waking from a bad dream. Within
a moment another seizure may occur.
In the interims the pulse is regular, at about 40 per minute, and
there seem to be two beats in the neck veins for every beat at the
wrist. During the day of January i6th she had twenty-five attacks
of this kind and ten to twenty in the following night. In one of these
attacks, while the nurse had gone for a glass of water, she wriggled
out of bed.
Discussion. — Bilious attacks are among the most mysterious
and tantalizing of all the symptoms of which our patients tell us.
They always seem to know so much- about them and we so little.
In the present case there is reason to suspect that these attacks have
the same fimdamental cause as the later periods of unconsciousness
and chills.
The condition during the last four weeks seems to be somewhat
different. The nightly attacks of abdominal pain and the marked loss
of weight seem to point to something different from what is suggested
in the earlier history. Presumably, she has two separate diseases.
The nocturnal attacks, when taken in connection with the physical
signs in the left flank, the condition of the urine, and the :r-ray picture,
point pretty clearly to renal stone.
Quite separate from these are the attacks of January i6th and
the following night. These evidently involve the brain, and our
further consideration must be directed to an attempt to make out
what brain trouble she has. First of all, we may note that there are
no infectious symptoms, no persistent headache, and no optic neuritis;
brain tumor is, therefore, improbable. Can we account for the at-
tacks as uremia? Possibly, although one would expect a higher blood-
pressure and more marked urinary abnormalities.
550 DIFFERENTIAL DIAGNOSIS
Vascular crises, associated with arteriosclerosis, give perhaps the
most tempting explanation. The pulse is slow enough for a Stokes-
Adams sjoidrome, and to some of those who saw the case this
seemed obviously the diagnosis. No satisfactory tracings, however,
were obtained from the neck veins, and I have long ago come to dis-
trust any diagnosis of heart-block based on simple observation of
neck pulsation. On the whole, then, the diagnosis seemed to rest
between Stokes-Adams' disease and vascular crises. The cause of
death is not obvious, but is presumably the same as that which pro-
duced the cerebral attacks. The loss of weight must be attributed
to arteriosclerosis.
Outcome. — On the day following she died in an attack which began
just like the rest. Autopsy showed arteriosclerotic nephritis with a
stone in the pelvis of the left kidney and slight hydronephrosis, also
some calcium oxalate stones in the tissue of both kidneys; sKght
hypertrophy and dilatation of the heart; chronic pleuritis, obsolete
tuberculosis at the apices of both lungs, and cholelithiasis. The heart
showed no lesion in the region of His' bundle and was not remark-
able save as above noted. The brain was normal.
Case 241
A contractor of sixty-five entered the hospital November 30, 1910.
His family history was excellent. He has been imable for some time
to sleep on his left side. He cannot say why. He has been active
and strong muscularly, but has had some sort of stomach trouble, the
nature of which cannot be definitely described. For three months he
has been losing weight.
Ten years ago he had an attack similar to the present one, and
since that time he has had six or seven in all. In each of these attacks
he suddenly faints, without the least warning; once in the middle of
a sentence. After ten or fifteen minutes he begins to recover and in
two or three hours is all right. During the attack he is chilly, but
sweats profusely. There has been no convulsion, no foam at the
mouth, no cry, and no loss of sphincteric control. A drink of whisky
appears to shorten the attacks. Pallor and cyanosis accompany them-
His last attack was three months ago and was longer than the oliers.
About 2.15 p. M. this afternoon he was picked up on the street
unconscious. At 5.15 p. m. he recognized his son, but seemed still
much dazed. Later in the day the patient showed slight aphasia, but
answered questions fairly well, and stated that at the beginning of the
attack he noticed that he could not use his hands and that they shook
FAINTING 551
I Uttle. A window was opened, but he does not remember what hap-
)eQed next. He has never had dyspnea or precordial pain. He was
xamined after an attack in 1904 and told that his heart was all
^t and that his fainting was caused by indigestion and worry.
Physical examination showed well-developed pupillary reactions,
omewhat sluggish on the left. Tongue came out straight. Heart's
pex just outside the nipple line. Action slow, regular, no murmurs.
hilses showed increased tension. Systolic blood-pressure fell from
80 mm. Hg. at entrance to 105 a week later. Pulse-rate was in the
leighborhood of 60 throughout his week's stay in the hospital. Lungs
nd abdomen negative. Reflexes, motion, and sensation negative,
(lood and urine normal, except for an occasional hyaline and granular
ast in the specimen of December ist.
On the 2d of December it is noticed that the wrist reflex and the
Achilles reflex are slightly increased on the right and the cremasteric
[iminished on the right. Thinking and talking are slow and un-
atisfactory. He can scarcely read or spell, though he used to be pro-
Ldent in these respects.
Discussion. — Fainting attacks beginning at the age of fifty-five
ire, of course, spurious. No one has true fainting attacks independent
)f organic disease at that age, and most attacks which receive that
lame, in people past middle life, turn out to be due to uremia or arte-
iosclerosis. Yet, when the mistaken diagnosis of fainting is avoided,
lie other commonest mistake is to refer such attacks to indigestion,
rhis blimder also was conmiitted in the present case. It is high time
Jiat we all came to realize that indigestion never causes marked cere-
Dral symptoms, and that the indispositions of prominent elderly men
it banquets and elsewhere, though ordinarily called indigestion, are
isually of vascular origin and mean disease of the heart, brain, or
ddney.
In the present case the aphasia, the paretic hands, the suggestion
>f hemiplegia contained in the physical examination, the high blood-
Dressure and mental changes, make a diagnosis of cerebral arterio-
sclerosis inevitable. Whether an actual hemorrhage has taken place,
3r whether, as is more probable, we are dealing with a vascular crisis,
irannot be positively decided. Such attacks are sure to be repeated
md become more severe.
Outcome. — By December 9th he could read and spell normally,
i^alked strongly, and was allowed to go home.
DIFFERENTIAL DIAGNOSIS
Case 242
A pedler of sixty-five entered the hospital March 23, 1911. Htj
family history was negative. He has always been well until six week -at^^s
ago, February 15, 1911, when he suddenly fainted in a store and fell" J-^ril,
cutting his head. Within a minute he was conscious and clear-heade(E:»^aed,
but had a peculiar throbbing in the epigastrium and felt weak for i -sr a
few minutes. He was taken to the hospital room within the stom«3ore
and his wound sewed up, but fainted again and was unconscious foKz>1for
thirty seconds. He was then seiM::M:^3iit
to the Municipal Relief Statioirs^i^on,
where he fainted once more an^xrauKl
stayed in bed twenty-four houi'= .m. jts,
after which he was sent home Li: io
an ambulance and has remained i£ J in
bed since. During the past SE-^aax
weeks he has had many atta
almost exactly like the first, buv*
for the last three days these a -^3
tacks have ceased. There ha^^'J
never been any convulsive n
ments in the attacks, no dyspne.-^
cough, or cyanosis, no headact£-=3Che
or vertigo, no urinary symptomr^ans.
He says he has eaten ahncH
nothing. His time has ;
ently been consumed in takim^KJng
many medicines, powders ar«i-^d
pills, both day and night. h^C He
says he has bushels of emp"'«::g>ty
bottles as a result.
Physical examination shows nothing remarkable except as cotzz^cn-
cems the circulatory system. The heart's dulness extends to Ui^Ube
second rib above and 11 cm. to the left of the median Une, 3 c-=rnj.
inside the nipple. Right border behind the sternum at a point 1 -^lot
clearly determined. The impulse is not seen or felt. The sounds s ^tre
regular and forceful. A rough systolic murmur is heard all over -^Khe
precordia, loudest just inside the apex. The neck veins are distencrJerf
and pulsate twice between each of the radial beats, which occur, as
a rule, from 30 to 35 times a minute. The urine is negative. TTie
blood-pressure, systohc and diastolic, is recorded in Fig. 205. Fluoro-
Plg, 205. — The systolic and diastolic
blood-pressure (starred lines) in Case 242.
Note also the alow pulse, subnormal tem-
perature, and low urinary output (cross-
dotted line) recorded in ounces.
/
FAINTING 553
scopic examination is negative. Atropin and strychnin subcuta-
neously have no special effect. Blood and urine show nothing of
importance.
Discussion. — Of course, it was not a fainting fit which happened
to this patient six weeks ago. There are many such tales about
people of his age, tales of falling down stairs and striking the head,
tales of stimabling and falling with a stunning blow. Many of such
stories go hindside foremost. What has happened is that the person
has become unconscious and therefore falls; not fallen and therefore
becomes unconscious.
In the present case it might perfectly well have been a fainting fit
had it occurred in a younger p>erson, but at sixty-five we should be
very skeptical of any diagnosis of fainting.
When we come to the positive side of the question, we must con-
fess that without polygraphic tracing from the neck and wrist we
cannot be certain whether the observation of two venous beats be-
tween each pair of radial beats is true or not. The attack seems like
one of Stokes-Adams' disease, but there are many mistakes in this
diagnosis unless the most accurate methods of observation are used.
If the attack was not Stokes-Adams' disease it was, in all probability,
a vascular crisis.
Outcome. — He left the hospital April 12th, having had no attack
of sjoicope in the meantime.
Case 243
A chauffeur of thirty-six entered the hospital July 10, 191 1. His
family history and past history are excellent. Ten years ago the
patient was very active and worked in a gymnasium. Since he gave
up exercise, nine years ago, on account of business, he has been less
athletic than before, but felt no other special change until a year ago,
when he began to notice that he tired very easily and had to give up
his work as chauffeur for a day or two at a time. Nevertheless, he
worked, with slight intermissions, until two weeks agp. Ten days
ago he fainted for the first time in his life, though he has felt faint
several times in the last few months. Palpitation and dyspnea on
exertion have been noticed for several months. The appetite has
been excellent until ten days ago; since then, poor. His bowels are
irregular, but usually constipated. For a week he has noticed that his
mouth is sore. Nine years ago he weighed 170 pounds; now, 143
pounds.
Physical examination shows evidence of some loss of weight.
4 B
^NanK
[FFERENTIAL DIAGNOSIS
Wani Hnsfi Nn
P^^ET'nXlfcL.****^
-< :
«. J.
■ .< '_
i .. _ . .
1 ». _ . .
!i ■ ,i
~
Fig, so6. — Blood rhart in Case 143.
FAINTING 555
tdene slightly yellow; murous membranes very pale. Pupils
al; knee-jerks reduced, but present. The heart area is normal,
he i^)ez impulse is sot seen or felt. A blowing systolic munnur
the whole precordia, loudest at the apex. Lungs and abdomen
ive. Urine negative. Blood as in Fig. 3o6.
tecuwion.— This appears to be a fainting fit due to general weak-
what might be called the cachectic tyjie of fainting. From the
y I do not see that any guess could be made as to the underlying
of his weakness. The blood-picture leaves no doubt that the
osis is pernicious anemia. Fainting is relatively uncommon
Fig. iD7.^Tenipenture, neigbt, pulse, urine, and respiraiioa in Case 343.
it disease, surprisingly uncommon when we consider how great
be the degree of cerebral anemia.
Dtcome. — The patient gained 4 pounds in his first week, but lost
nds in his second. He ran a slight, irregular fever, as is shown
;. 307. He left on the 24th, feeling better than at entrance.
Case 244
n unoccupied woman, aged twenty-one, entered the hospital
mber 8, 1911. The patient's family history and past history
ccellent. She has never been nervous. Six months ago, without
n cause, she began to have fainting spells, coming at uregular
556 DIFFERENTIAL DIAGNOSIS
intervals, sometimes every day or several times daily, sometimes
only once in a fortnight. In these attacks she loses consciousness and
falls, sometimes to the floor, sometimes to a bed, but has never hurt
herself. In the attacks her arms and legs become rigid and flexed,
and when she is coming out of them her mouth "works." The attacks
last fifteen to thirty minutes, and are followed by a period of weak-
ness lasting about half an hour. They are more troublesome just
before the menstrual period. In the interval she feels entirely well.
She is occasionally nauseated after one of these fits, but never
vomits. Her eyesight is good and she has no other symptoms of
any kind.
Physical examination shows good nutrition; small white scars
on the cornea of each eye; the right pupil larger than the left, both
reacting normally. A soft-blowing systolic murmur is heard at the
apex, not widely transmitted. Pulmonic second sound is greater
than the aortic second, but not accentuated. The right pulse larger
than the left. The lungs show nothing abnormal. There is a slight
general tenderness in the lower abdomen, but nothing else of note.
The hjTnen is normal, the labia not h>pertrophied or pigmented.
Reflexes normal. The left leg slightly smaller than the right. Systolic
blood-pressure, 115. Wassermann reaction is recorded as suspicious,
but not positive. Temperature, pulse, respiration, blood, and urine
normal.
Discussion. — Are we dealing vath organic or with fimctional dis-
ease? In favor of some organic lesion is the smallness of the left
pulse, the left pupil, and the left leg, the suspicious Wassermann
reaction, the scars upon the cornea. None of these data, however, is
conclusive.
In favor of functional disease is the age and sex, the connection
of the s\Tnptoms with the menstrual period, the negative ph>"sical
examination, and, above all. the fact that the attacks are nev^v
nocturnal, never injurious to the patient, and never present any ^
the characteristic signs of epilepsy. \
The attacks are ob\nously too long to deserve the term "^^IK ^
fit/' and the rigidity during them is quite uncharacteristic. ^^ VVv
other hand, both of these features are what we expect in ^w ^ ^5
and I see no good reason to doubt this diagnosis. ^\,v ^^
Outcome. — During her five days in the has{Mtal Hie pitw^ ^^ti^»
attack and refused treatment, ^^V
FAINTING 557
Case 245
A factory girl of eighteen entered the hospital March 14, 1912.
Her family history and past history not remarkable, though the
patient eats 15 cents' worth of candy every other day. Ten months
ago, without known cause, the patient began to have fainting spells.
In the first three weeks they came fifteen to twenty times a day.
Since then they have grown more infrequent, until now they only
come once a month. They are often preceded by lack of appetite,
headache, and drowsiness. After the fainting fit she feels better.
In the attack she sometimes falls, bumping her head. Sometimes
she is able to get a glass of water and recover without losing con-
sciousness. She has no twitching or convulsions and no warning of
the approach of an attack, except through the general symptoms above
mentioned. The attacks may occur at any time of day, but never
during the night. Except during the first three months of her trouble
she has worked steadily.
She has no appetite at the present time and her food tastes queer
to her. Her bowels are regular. She eats at a restaurant, where her
food costs $3 a week. She sleeps well.
On physical examination the patient is pale and looks tired.
Pupils and tendon reflexes normal. Viscera negative. Blood and
urine negative. No fever in ten days* observation. Systolic blood-
pressure, 120 mm. Hg.
Further investigation showed that she lived in a room with her
sister and in the same house with a girl chum, whose brother is said
to be engaged to the patient^s sister. The chum's brother and father
drink much and work little, and it is thought by some friends that the
three girls support the two men. All three girls work in an ink factory.
A friend describes an attack which took place at a lecture. The
patient's neck gradually stiffened, head drawn back, eyes closed.
She then slipped unconscious between the seats and remained so for
five or six minutes. The legs were stiff and straight. There was no
cry and no convulsion, except that while slowly coming out of the
attack there were slow spasms of the arms and legs. On the 24th
she had an attack, beginning with a shuddering sort of tremor, with
the legs stiff and the eyes tightly closed. She was then referred to the
Social Service Department for more thorough investigation.
Discussion. — The poor hygienic and mental conditions surround-
ing the patient seem in all probability of importance, whether as
aggravating or producing the attack. The most important diagnostic
558 DIFFERENTIAL DIAGNOSIS
fact is the negative physical examination, especially wlim considered
in connection with the patient's age and sex. Clearly, we aue not
dealing with fainting q>ells, for these never occur fifteen or twenty
times a day, nor does a person feel relieved after a fainting fit.
The description of the attack, beginning with q)asm and ijgidity,
is strongly suggestive of hysteria, and in the absence of physical
signs no other diagnosis is possible.
Outcome. — ^Worries and mental conflicts sufficient to produce her
symptoms were foimd. November 29, 1912, she was better and having
much fewer attacks.
CHAPTER Xni
HOARSENESS
Cases of hoarseness may be divided into those which are acute
and usually of trifling importance, and those which are chronic and
usually serious. Any one who shouts much at a college game or a
political rally acquires, I take it, an acute laryngitis as the cause of his
inevitable hoarseness. Just how this irritation is produced I do not
know. If a person knows how to use his voice, he may make a great
deal more noise than his neighbor who gets hoarse, and yet retain
his voice quite clear. In some way it is the misuse, rather than the
simple overuse, of the voice that produces such trouble.
After an ordinary acute laryngitis, such as occurs as part of a
"common cold," men's voices behave quite differently from those
of women. In men the vocal cords slacken down, the voice becomes
a deep bass, but is seldom lost altogether. In women, on the other
hand, we see no such marked lowering in the pitch of the voice, but it
is far more common to see complete aphonia or voicelessness after
slight laryngitis. This is of considerable importance in connection
with the explanation of what is ordmarily called "hysteric aphonia.''
Such aphonia is usually preceded by an attack of ordinary acute
laryngitis. It does not come on from purely psychic causes, as a
rule, yet it is not independent of psychic factors. The connection
between the cerebral innervation (what we call the will) and the vocal
cords is temporarily lost as the result of the laryngitis.
This is the first step in the process. Now, if there is any con-
genital tendency to a pathologic forgetfulness or splitting up of the
mind into mutually imconscious parts, if, in" other words, there is any
tendency to hysteria, there may be considerable difficulty in re-
establishing the patient's memory of how to talk. When this diffi-
cidty occurs and prolongs the aphonia after the laryngitis has disap-
J>eared we call it, very naturally, hysteria, but we should bear in mind
that such an attack may occur in a person who is not hysteric, in the
Sense of showing any other manifestation of that disease. In other
'vvords, there is probably enough tendency to hysteria in a great
-*-Kiany of us to result in a hysteric aphonia, provided the connection
559
S6o DIFFERENTIAL DIAGNOSIS
between the brain and the vocal cords were once broken up by the
lesion of laryngitis. In men this break does not occur at all frequently;
in all probability this is one of the reasons for the infrequency of
hysteric aphonia in men.
Chronic hoarseness or aphonia is due almost exclusively to organic
disease of the larynx or to a pressure paralysis produced by tumor or
aneurysm of the mediastinum. Occasionally, the pressure of a dilated
heart in mitral stenosis or other cardiac disease may produce the same
effect. Enlargement of the left lobe of the thyroid gland, occasionally
enlarged bronchial lymph -glands, may produce similar pressure.
Tuberculosis at the apex of the lung may also involve the recurrent
(laryngeal) nerve, producing paralysis of one vocal cord.
In the larynx itself tuberculosis, sj-philis, and tumors, benign or
malignant, arc the commonest causes of hoarseness or aphonia.
The diagnosis of these conditions depends, of course, upon an expert
laryngologic examination.
Case 246
A housewife of fifty-two entered the hospital January to,
Two of patient's sisters died of cancer; one sister, of "nerves." Her
4
Fig. 208. — Shape' of
husband died at twenty-nine of "heart disease and paralytic shocks."
She has one child of twenty-four, well. Many years ago she bad
Hoarseness and Aphonia
LARYNGITIS I^HHi^^HH^Hi^HiHHB^HHHHi 1830
PHTHISIS ■■■■■■i^^HlHlH
NEOPLASM OF THEl ^^^^ ^.^
LARYNX OR CORDS i ^^^^
ANEURYSM ■■ 65
HYSTERIC APHONIA Hi 59
m
fi$
imm
HOAESENESS 561
%htheria, very severely. Four years ago she had a partial hysterec-
jomy for uterine tumors at the Baptist Hospital, and a year later the
eft kidney was removed "on account of something which was cut at
iie previous operation." She passes water four to ten times in the
light and has done so for years, the amount varying with the amount
>f water she takes.
For three weeks she has had a cold in her head and a sore throat.
\ week ago she became dizzy and almost lost consciousness upon the
itreet. She staggered, but managed to get home. Since then she has
lad fever, sweating, cough, sore throat, headache, and increasing
loarseness. The cough has been dry until
lo-day, when she began to raise thick, puru-
.ent ^utum. She has been unable to
peak for three days.
Phy^cal examination showed obesity,
lormal pupils and reflexes, a hard, tender
|land at the angle of the left jaw, herpes
m the nose and upper lip. The lungs
ihowed groaning rftles throughout, but
vere otherwise negative, likewise the heart,
rhe tension of the pulse seemed to be in-
reased. The blood-pressure was not meas-
red. Physical examination was other-
ase negative. The shape of the nose is
bown in Fig. 208. A laryngologist found
larked chronic atrophic rhinitis, also
cute pharyngitis, and laryngitis. The
lood showed 11,000 white cells, 85 per Fig. 209.-Chart of Case 146.
ent. hemoglobin. The urine was nonnal.
Tie temperature was as shown in Fig.
:C?*5?5i:
Wv^>
Z-j.'^Z'^'^
During the first few
ights of her stay the patient had severe attacks of laryngeal dyspnea
nth croupy cough. An intubation outfit was kept at hand, but was not
eeded. By the 15th these attacks ceased, but the lungs were full of
ry and moist riles. The palatal reflexes were at this time noticed to
•e absent, perhaps owing to her former attack of diphtheria.
Discussion. — ^At first sight of this patient there is every reason
o think that we are dealing with an acute laryngitis. The three
/eeks' sore throat, cough, headache, and gradually increasing
lOarseness are fairly typical of that lesion. The herpes and gland-
ilar enlargement in the neck are wholly in keeping with such a
lia^o^.
Vol- 11—36
562 DIFFERENTIAL DIAGNOSIS
On the other hand, the suggestion of syphilis in the husband, the
patient's habit of nocturia, and the absence of palatal reflexes should
make us pause for a moment to consider whether some more serious dis-
ease, or, in particular, whether syphilis may not be in the background.
In a case of this sort the services of a laryngologist are essential
if diagnosis is to be prompt and sure. Without such help one may
make a successful guess, but nothing more. In view of the laryngo-
scopic finding in the present case, there seems no reason to doubt
that the acute infection of the upper air-passages is all that ails the
patient.
Outcome. — On the 30th of January she was sitting up and her
voice had returned. On the 5th of February she seemed to be entirely
well and left the hospital. The treatment consisted of potassium iodid,
10 gr., three times a day, hot Dobell's solution as a gargle, twice
a day, codein, i gr., every two hours when needed for cough, inhala-
tion from steam, from water containing i dram of compoimd tincture
of benzoin to the pint.
Case 247
A nurse of twenty-four, newly arrived at the Massachusetts
General Hospital, and previously employed for two years in a hospital
for the insane, entered the hospital April 8, 1901. She said she had
felt perfectly well until three days ago; then, while on duty, she began
to have headache, general muscular pains, chilliness, fever, sweating,
nausea, and loss of appetite. Her voice from the first has been more
and more hoarse, and yesterday she lost it altogether. At the be
ginning of her illness there was a little cough, without sputum, and a
slight sore throat, with stiffness of the neck. She worked until
yesterday, but took to bed in the evening.
Physical examination showed good nutrition, herpes of the lower
lip, reddening of the tonsils and pharynx, tender glands in both sides
of the neck. A soft systolic murmur at the apex of the heart, with-
out any other abnormality. Lungs, abdomen, and nervous system
normal. Blood and urine normal. While in the ward the patient
was apathetic much of the time, waking from time to time with a
start. She had no cough. Examination of the larynx, by Dr. Alger-
non Coolidge, showed no disease.
Discussion. — Clearly the case began with an acute infection.
Everything in the history and physical signs points to this. An
aphonia persisting after such an infection is usually of the ^pe called
hysteric, and discussed in the introductory paragraidis ci this dbsfM*
HOARSENESS 563
Outcome. — Dr. Coolidge's diagnosis was hysteric aphonia. By
the 14th her voice was normal. It appeared that she had had a pre-
vious hysteric attack in the winter before. On the iStli she left the
ward well.
Case 248
A jeweler of forty-five, born in Turkey, entered the hospital October
5. 1906. The patient has a negative family history and has had no
other illness. He denies venereal disease.
Three years ago he began to have a shooting pain in the right
hand and (oreann. Later a similar pain came in tJie other side, and
Rg. aio.— Shape of hi
iIrc in Case 248.
later still the pain extended to the shoulders and neck, even to the
head. This pain has continued and has grown steadily worse. It
has been treated by many doctors for rheumatism, without relief, and
has prevented work for the past three years. It has never extended
below the level of the shoulders.
The patient had absolutely no other symptom until the fall of
t9o6, when there appeared hoarseness and a severe cough, often dry,
sometimes with foamy sputa, which cough has continued up to the
present time, except for a slight remission during the past summer.
564 DIFFERENTIAL DIAGNOSIS
With this cough there came dyspnea on exertion. Five months igp j
he began to have orthopnea at night.
Physical examination showed a remarkable Battening of the ]
back of the head (Figs. 210, 211). The mucous membranes were ]
cyanotic. Pupils normal. The voice was hoarse, and there was a
frequent ringing cough. At the top of the sternum was a round, pul-
sating tumor, extending down to within 1 inch of the angle of Louis '
and as high as the larynx. It was 3^ inches wide and 2 inches high.
It was tender to touch. The heart's apex extended j inch outside the
Fig.:
-Sh^)e of head and suprasternal bulge in Case 348.
nipple, in the fifth space; no enlargement to the right. At the apex
there was a harsh systolic murmur, transmitted to the axilla. Over
the tumor a harsh systoUc was also heard. About the tumor there
was an area of dulncss, as shown in Fig. 212. The left pulse seemed
a little larger than the right. The artery walls were easily felt.
The lungs and abdomen were negative save for double inguinal hernia,
A laryngologic examination showed paralysis of the recurrent
laryngeal nerve. Systolic blood-pressure at entrance was 155. It
soon fell to 130 mm. Hg.. and remained there during the nine months
of his stay in the hospital. Blood and urine showed nothing abnormal.
HOARSENESS 565
There was no fever. The cough was controlled only by 4-gr. doses of
codein or morphin. X-ray showed a shadow corresponding with the
ascending and transverse arch of the aorta. A diastolic murmur was
audible from time to time, usually best heard at the apex, but also in
the third and fourth left interspaces, near the sternum. Dr. R. H.
Fitz considered it due to mitral stenosis. It could be heard indis-
tinctly as far back as the posterior axillary line. It was a long, early
diastolic sound and replaced the aortic second sound at the apex.
On the 30th of January 250 c.c. of a i per cent, solution of gelatin
in 0.6 per cent, sodium chlorid solution were injected under the skin,
on the left side of the abdomen. This caused severe pain and two
hours later a chill, with rise of temperature to ioz° F., subsiding in
about thirty-six hours. An area of tenderness and redness sur-
roimded the site of the injection and extended round to the back.
This was still present February 5th. On that date the diastolic mur-
mur in the left anterior axillary line was louder than the systolic.
566 DIFFERENTIAL DIAGNOSIS
By the 9th of February the local reaction about the site of the gelatin
injection was gone, and on the 12th of February a second injection,
similar to the first, was given. The reaction was like that after the
previous injection, but somewhat milder. There was no eflFect per-
ceived in the condition of the tumor.
Discussion. — ^When hoarseness and cough appear in a middle-
aged man, without any evidence of acute infection and immediately
following an attack of pain about the upper chest and shoulders or
in the arms, one should always suspect that aneurysm is the cause.
When a pulsating tumor appears at the root of the neck in front, we
can have very little doubt of the diagnosis. Such a tumor might
conceivably be a pulsating vascular thyroid, but such a lesion would
certainly have been of much longer duration, and would, in all prob-
ability, be associated with other manifestations of thyrotoxicosis.
If the patient has aneurysm, as there is every reason to believe,
the diastolic murmur is naturally to be explained as a result of widen-
ing in the aortic arch at the base of the aortic cusps. There seems no
good sense in calling it mitral stenosis. The fact that the patient has
been treated by many doctors for what was called rheumatism is no
reason for supposing that he has ever had rheumatism, in view of the
fact that pains often mistaken for that disease are especially common
in aneurysm.
The a;-ray, as is usual in such cases, showed a much more ex-
tensive growth within the thorax than would have been predicted
from what we would discover on direct physical examination. The
effects of gelatin injections in this case were similar to what I
have seen in a good many others during the luckily short-lived
vogue of that treatment. It causes a great deal of pain, but no good
effect.
Outcome. — The patient's general condition had improved very
much and he was active in helping about the ward. On the 24th of
February he left the hospital.
Case 249
An Italian schoolboy of nine entered the hospital March i, 1909.
Since the 4th of July the boy has been hoarse. In January he choked
on a peanut. Last month he had his tonsils removed. Except for
hoarseness he is now all right. Family history and past history nega-
tive save that he has had scabies.
Physical examination showed a healthy boy with inspiratory and
expiratory dyspnea, involving movements of the accessory muscles of
HOARSENESS 567
respiration. Physical examination was negative save as relates to
the laiynx and the fingers. His nails were somewhat incurved.
Discussion. — Probably the history of choking on a peanut and the
tonsillectomy have nothing to do with this case, as six months have
elapsed since the choking and a month since the tonsillectomy. Or-
ganic disease of the larynx is not common at this boy's age, but his
clubbed fingers suggest that some congenital cause may have been at
work. What this is only the laryngoscope can determine.
It is of some interest to note that although the cause of dyspnea
is high up in the respiratory passages, the dyspnea is not exclusively
of the inspiratory type, but involves expiration as well. We are
usually taught that trouble of this sort should produce inspiratory,
not mixed, dyspnea.
Outcome. — ^Laryngoscopic examination showed a papilloma of the
larynx. On the 4th of March he was transferred to ward G for
operation. On the 5th of March the papilloma was removed. By
the 8th the child was out of bed, although there was a large piece of
the growth still remaining. He left the hospital on the nth.
Case 250
A salesman of fifty-six entered the hospital May 23, 1910. Family
history not remarkable. The patient has always been well, but
seven years ago he had to give up playing baseball because he could
not run the bases. Five years ago he began to get somewhat more
short of breath. Three years ago he was taken rather suddenly with
hoarseness and a chill and pain in his right side and fever. The illness
was called grip, but he has never recovered his strength and has never
been able to work since that time. He lost 25 pounds in weight at the
time of that illness and 25 pounds more since that time. Any at-
tempt to work and exert himself in any way causes a choking sense of
pressure beneath the sternum, a short dry cough, and difl&culty in
getting his breath. He has had no sputum and no pain, no wheez-
iness, and no paroxysms of dyspnea.
For three years he has had left trifacial neuralgia, the pain coming
in quick flashes and going from the left temple to the comer of the
mouth. Throughout the three years he has continued to be hoarse.
The patient is well nourished and lies comfortably without pil-
lows. Pupils negative. Kjiee-jerks and Achilles' jerks not obtained.
Babinski's reaction is present on the left. The right plantar is not
satisfactorily obtained. There is no glandular enlargement. The
heart is negative. Lungs as in Figs. 2 13, 214. The breathing seems to
I
i(ft)I DIFFERENTIAL DMGNOSIS
lie ()( (lijiiinlitlicd inlcnftity over the whole left side. The right pulse is
ulroiiKcr lliiiii ihc Icfl. Abdomtn negative. The laryngoscope shows
ihul thr luwtT piirl of the trarhca is pushed forward so that the tube
U iMl MlniiKhl. Hloud ulid urine are normal, likewise Wassennann
rnicllKii.
Dlicuailon. Tuberculosis, syphilis, and tumor must be con-
HiitiTctl. The lung signs and the hoarseness are familiar tuberculous
HymptumH. I,omh of weight would be a natural accompanimenl,
AftlUnat thifi iilcii, however, is the fact that his illness began with
4
HOARSENESS 569
and the pain which the patient has suffered is not like that generally
seen in aneurysm. The diminution of the left pulse and the respira-
tion in the left lung could be explained either by aneurysm or by some
other cause of pressure. If the statement of a displacement from
behind forward is correct, we must recognize that this is not the usual
direction in which aneurysm exerts its pressure upon the trachea.
Aneurysm generally presses upon the front or side of the windpipe.
Further evidence in the difficult distinction between mediastinal
tumor and aneurysm must be sought in a:-ray examination.
Outcome. — During a month's stay in the hospital the patient lost
10 pounds in weight, but had no fever. Systolic blood-pressure, laa.
X-ray showed large indefinite shadow in the mediastinum, believed by
Dr. Dodd to show definite evidence of mediastinal pressure, especially
on the right of the sternum. Skin tuberculin test was negative, and
Subcutaneous tuberculin, gradually increased i to 10 mg., also gave no
reaction. On the i ith of June the lung signs were less marked behind,
but the crackles in the upper fronts persisted. He was given treat-
ments by x-ray, and left the hospital on the i6th of June. He died
October 9, 1912. The death certificate was signed "Heart trouble."
UUILUU-rtM. DLtcsn^
afl tbc UrtoiT that CDoU be obtancd was ikat k i
Ins aakks, dwvUen, dbtvai. and vints tkm flualj
Cor the post noBtk he had been Toy hooiw; bat had h
FhTskal esmnoatiin dtowol good i
rrilriif ^, BO ^mdnbr cnbrpaBoit. Tbe brarr'-
fdt in tbe azth tpaa, 3 cm. ootsde the mpfk Sdc, n^t bcMder ^ I
cm. from midsXeniuni. Tbexc was a r*^*** ^'sMfic thai at the
apex and - i^y— i^g ly^^^ nniiimii I'mrgMTtml 1r1^ aiWa anri faniic.
A rou^ diastotic nmnnur was beard best m die anBa and at tbe apex.
faintly along tbe left edge of tbe stennnn. not at all on tike ri^t
side. Tbe aortic second was faint: pubnanic second, knd. The pulses
bad a maiked Corrigan quality and tbere was a tapfflan' pulse visible
in ibe fingers. Dnro^ez's sign was presoit and all the peripheral
arteries pulsated ^'isibly. The abdomoi was n^ative. sa\~e that the
edge of the liver could be distincth- felt 2 cm. bdow tbe costal margin.
Tbe blood and urine show^ nothing aboonnaL Blood-prcsstne, |
HOARSENESS 57 1
I20 mm. Hg., systolic; 40 mm. Hg., diastolic. Wassermami reac-
tion negative. Skin tuberculin reaction slightly positive.
Laryngoscopic examination showed the left vocal cord in the
cadaveric position, both in respiration and phonation. By the 13th
his bronchitis had practically cleared up. X-ray on the i8th showed a
shadow about the roots of both lungs, especially on the right. Tuber-
culous glands and malignant disease were suggested (Fig. 215). The
heart by a:-ray was huge. The patient did not react to 10 mg. of old
tuberculin, subcutaneously. On the 4th of September the right border
extended 4 cm. beyond the right edge of the sternum, in the third space.
Discussion. — ^Everything points toward aneurysm here except
the negative a:-ray examination and the negative Wassermann.
It is, however, possible that a rheumatic endocarditis may produce
sufficient dilatation of the left auricle to compress or injure the recur-
rent laryngeal nerve.
The cardiac signs do not indicate anything of this sort, but these
signs may well be wrongly observed or wrongly interpreted.
Despite the slightly positive skin reaction from tuberculin and
the shadows about the roots of both lungs, there seems to me no
good reason to imagine that tuberculosis is the cause of any symptoms
in this case. The negative reaction to 10 minims of old tuberculin
subcutaneously is important negative evidence in this connection.
I do not see how a positive diagnosis can be made. On the whole, I
am inclined to believe that syphilis is at the bottom of the whole
trouble. So large a heart as the or-ray shows could hardly have been
produced by a rheumatic endocarditis within three months and
without more evidence of decompensation. It seems unreasonable to
suppose that a dilated left auricle has produced the laryngeal paralysis.
I believe that later evidence will be more conclusive in favor of the
diagnosis of aneurysm.
Outcome. — ^Under mercurial inunction and iodid of potash the
patient improved very much, and left the hospital on the 9th of
September, having gained 4 pounds during his month^s stay.
Case 252
An engineer of twenty-eight entered the hospital August 27, 1910.
The patient's family history is negative. For two years he has had
gaseous indigestion after eating, immediately relieved by soda or any
simple remedy. During this period his bowels have been rather con-
stii>ated. He denies venereal disease and has always considered him-
self weiL He has been married twelve years. He has no children.
572 DIFFERENTIAL DIAGNOSIS
In January, 1908, he noticed that he was short of breath on exer-
tion. This trouble has steadily and slowly increased since. Shortly
after this he noticed a pain in the left axilla — sharp, stinging, contin-
uous— often keeping him awake at night during the six months of its
duration. It then passed oflF spontaneously and did not recur. For a
year, however, he has had another pain, which he says is around his
heart, passing from the left to the right side, sharp; steady, and often
preventing sleep. For a month he has had dry cough and for two
weeks orthopnea.
Six days ago he suddenly became hoarse, and has been unable to
speak above a whisper ever since. He gave up work ten days ago
and has lost much in weight and strength. His main complaints are
dyspnea, pain, and hoarseness.
Physical examination showed good nutrition, pupils, glands, and
reflexes normal. The whole chest, especially the left chest, heaved
with each systole. The heart's apex reached 2§ cm. outside the nii^le
line and its dulness 4§ cm. to the right of midstemum. The quality
of the impulse was forcible, and the first sound was followed by a blow-
ing systolic murmur, loudest in the pulmonary area. The pulmonic
second sound was palpable as a shock and very loud. There was no
thrill. The pulses were normal. The entire left lung showed broncho-
vesicular breathing and increased whisper and was nearly flat on per-
cussion. The right lung was normal, likewise the abdomen. SystoKc
blood-pressure was 100 mm. Hg. in the right arm, 90 in the left. The
blood was normal. The Wassermann reaction was negative. Urine
was normal. A laryngologist found the left vocal cord motionless in
the cadaveric position. X-ray showed a diffuse shadow through the
entire left chest, suggesting fluid or thickened pleura. No evidence of
aneurysm. On the ist of September the pupils were foimd to be
imequal, and small, hard, epitrochlear glands were felt.
Discussion. — I am driven to a similar course of reasoning in thb
case as in the previous one. If the patient has no syphilis, why should
his heart be so large? He has nothing else in his history or in his
physical examination to produce a cor bovinum capable of lifting
the whole chest at each beat. The negative jc-ray does not disprove
aneurysm, for the extensive shadow in the left chest might cover up
the outline of the aorta. Just what is going on in the left chest it is
difficult to say, but it is certainly possible that aneursymal pressure
could produce such appearances and signs. Conceivably a chronic
pleurisy might involve the recurrent laryngeal nerve and produce
hoarseness; or s)T)hilis of the lung might do the same thing, but
HOARSENESS 573
neither of these diseases can account for so large and forcible a heart,
nor for two weeks of orthopnea, though either of them would explain
the left axillary pain. The differences in the pulses and pupils and
the small, hard epitrochlear gland furnish a certain amount of evidence
confirmatory of the diagnosis of syphilis and, therefore, of aneurysm.
Outcome. — On September ist the left chest was tapped, but no
fluid obtained, the needle evidently entering the lung. Under rest
in bed, with potassiiun iodid, 20 gr. after meals, and an occasional
dose of morphin, the patient's pain practically disappeared and he had
good nights. On the 7th he left the hospital.
Case 253
A housewife of thirty-seven entered the hospital January 9, 1912.
The patient's family history was negative. She had a peritonsillar
abscess seven years ago. Two years ago she was struck in the right
breast and on the head in a street-car accident. After that she had
nausea and fainting spells in the morning, at first three or four times
a week, less frequently after that, but she still has them every month
or two. In August, 191 1, she became hoarse and this symptom has
persisted ever since. Three months ago she caught cold, but both this
and the hoarseness cleared up after a two weeks' vacation. Two and
a half months ago the hoarseness returned, and she has had much
treatment for her throat without relief. When asleep her breathing
is noisy and often wakes her. She has no sore throat and no cough.
A month ago her breathing became labored on exertion, though she
could still lie flat. A week ago she took to her bed from exhaustion.
Three days ago she awoke at 3 o'clock in the morning with extreme
dyspnea, which lasted several hours. Since that time she has never
been free from dyspnea of some degree, and has had recurring attacks
in which she had to fight for breath. These attacks come more fre-
quently at night, and last from one-half to three hours. She has lost
much sleep and much weight in the last week.
Physical examination showed good nutrition, marked expiratory
dyspnea, and moderate inspiratory dyspnea. Pupils and reflexes
negative. No enlarged glands, tongue clean. Wassermann reaction
moderately positive. Larynx showed slight swelling of the glottis
with reddening. On the inside of the larynx the tissues on both sides
showed swelling, which ran up upon the two vocal cords. The cords
were almost approximated, were motionless, and their edges showed
ragged ulcers. On the loth tracheotomy had to be done. The patient
was given "606," mercury, and iodid of potash, but the mercury was
574
DIFFERENTIAL DIAGNOSIS
omitted after a few days because of stomatitis. The patient rapidly
and steadily improved and by the i8th could speak aloud. On the
29th she got her second dose of "606," and on the 5th of February the
tube was removed. The course of the temperature is shown in Fig. 216.
The leukocytes at entrance were 14,500; on the 17th, i3,cxx); on the
24th, 10,000. The blood-pressure was 160 mm, Hg., systolic.
Discussion.— When hoarseness has lasted for six months, although
with a slight intermission in the middle of that period, we may be sure
that some serious organic disease is present. We have no evidence of
a mediastinal pressure, and attention is, therefore, naturally conceo-
Rg. 116.
of Case 253.
trated upon the local condition of the larynx itself. With a posiUve
Wassermann reaction we may certainly expect that syphilitic changes
will be found there, especially as acute suffocative attacks are par-
ticularly common in laryngeal syphilis. In this, as in one previous
case, I am interested to note that the dyspnea was not of the in£am-
matory but of the mixed type, contrary to tradition.
The brilliant effects of salvarsan have seldom been more impressed
upon me than in this case. A patient whose life was in serious danger
was almost well in a week after its use.
Outcome. — February 6, 1912, she went home, apparently cured.
In January, 1913, she reported herself as well, except for some dy^
nea on exertion. No hoarseness.
CHAPTER XIV
PALLOR
As a rule, pallor is not due to anemia. Pale people are common;
anemia is rare. The majority of cases of non-anemic pallor are due
to living indoors, to continuous exposure to high temperatures, as in
industry or in the tropics, or to congenital causes.
Tuberculous patients are usually pale, but seldom anemic. Even
extreme and ghastly pallor in consmnption may be accompanied by
a normal blood.
What the Germans call the "cachexia of old age** is a state in which
pallor as well as emaciation forms a part. It is reasonable to suppose
that such pallor is due to changes in the cutaneous circulation. Pre-
simiably the same is true of the pallor resulting from exposure to heat
or from Uving mdoors.
Pallor of the lips is much more significant than pallor of the face,
much more apt to mean anemia, yet even this site is by no means proof
of anemia. Any one who is in the habit of basing his judgment upon
the looks of the skin and mucous membrane has violent surprises
awaiting him.
Edematous or myxedematous skin is usually pale, whether there is
anemia behind it or not.
A yellow pallor is probably more common in pernicious anemia
than in any other single disease, but it is especially the combination
of such a tint with good nutrition that is properly suggestive of perni-
cious anemia. When accompanied by emaciation, precisely the same
yellow tint results from secondary anemias, however produced. On
the other hand, it must never be forgotten that pernicious anemia may
cause no pallor at all.
Case 254
A housewife of fifty-one entered the hospital May 31, 1912. Her
family history and past history are not of importance. The patient
passed the menopause eleven years ago. For three years she has been
troubled by gas in the stomach and slight discomfort when the organ
is empty. She is always relieved by food. Her appetite and digestion
seem to be good.
576 DIFFERENTIAL DIAGNOSIS
Except for this trouble she has called herself well untfl five months
ago, when she began to notice pallor and loss of weight and strength.
The hunger pain became worse, sharp and burning in character.
The epigastrium was tender. The pain was aggravated by soda,
relieved by food or by vomiting. The vomitus has never been bloody
nor resembled coffee-grounds. She was in the Boston City Hospital
from March 27th to April 18, 191 2. She was fed on milk and lime-
water and told that she had gastric ulcer. For several weeks previous
to this time she was treated there as an out-patient. She was much
relieved by this stay in the Boston City Hospital, and on discharge
went back to work and resumed her ordinary diet, but continued to
lose ground slowly, and for the last two weeks has been much worse,
though she has kept at work. Last night she vomited many times,
though she has not previously done so since leaving the Boston City
Hospital. Her appetite is notably good; her bowels move three or
four times a day. She has noticed slight swelling of her feet and
imder her eyes. She has no nocturia or jaundice. Any kind of
food relieves the pain for a time, but it always returns, regardless
of diet.
On physical examination, she is well nourished, does not look
sick, except that her skin is very pale with a slightly yellowish tinge.
Pupils, glands, and reflexes normal. Heart's impulse extends 2 cm.
outside the nipple line, and is accompanied by a systolic muraiur
audible all over the precordia and transmitted to the axilla, but not
replacing the first sound. Pulmonic second is accentuated. Blood-
pressure, 115 mm. Hg., systolic; 60 mm. Hg., diastolic. Abdomen is
negative. There is no edema. The urine is negative. Weight, 109J
pounds, without clothes. Stomach-tube examination shows small
amount of food in the fasting stomach. After a test-meal HCl was
absent. On the 5 th of June slow rhythmic peristalsis, from left to
right, corresponding in time to that of a normal stomach, was obser\^ed
in the epigastrium. She complained of no pain and practically of no
digestive disturbance. The guaiac test in the stools was positive June
4th, 6th, 7th, 13th, i8th, and 22d. The amount of blood in the feces
seemed to be considerable. June loth the left leg became swollen
and tender, and a hard, cordy vein was felt in the region of the internal
saphenous. On the 22d a hard, smooth lump, movable laterally and
with respiration, not tender, was felt midway between the ensiforai
and the navel.
Up to the time of her discharge, July 8th, there was almost no
change in her condition. The phlebitis subsided in the left leg and
PALLOR 577
was followed by a similar infection in tiie right. Loss of appetite
and moderate distress after meals were not present after June loth,
when we began to give her a dilute hydrochloric acid, lo drops after
meals. The improvement was prompt and striking. On the other hand,
the blood showed littie improvement. Red cells at entrance, 2,500,000;
July 5th they were still below 3,000,000, though the hemoglobin had
risen from 40 per cent. June 7th to 50 per cent. July sth. The leuko-
cytes ranged from 6000 to 10,000. The differential coimt was normal.
The stained smear showed always very marked achromia, great varia-
tions in size and shape, no stippling or nucleated red cells, a dimin-
ished nimaber of blood-plates, and some • macrocytosis. Bismuth
x-x^.y of the stomach showed in all the plates a defect in the outline
of greater curvature.
She re-entered September 4th, having been fairly comfortable
and able to do her work since leaving in July. She has now a good
appetite and has gained in weight and color. She has no pain, but
constant eructations of gas and constant nausea. Diet makes no
difference. When she lies on her right side she is troubled by a drag-
ging sensation in the epigastrium. The past two weeks her wrists and
some of the joints have been swollen and painful. The mass was
made out as before in the abdomen.
She refused operation and left the hospital on the 7th of Septem-
ber, but entered for the third time, September 24th. This time the
curved edge of a mass, firm, not fluctuant and not moving with
respiration, was felt in the lower epigastric region, a little to the left
of the median line. Last December she weighed 129 pounds. Be-
tween this and the following May she lost 21 pounds; since then she
has held her weight.
Discussion. — Three years of stomach trouble of the type that is
relieved by food, and accompanied by good appetite, strongly in-
clines us to make a snap diagnosis of peptic ulcer, gastric or duodenal.
The present condition of good nutrition, despite some marked pallor,
supports this idea.
On the other hand, the presence of stasis, achylia, and especially
the visible peristalsis in the epigastrium, inclines us to interpret the
lump which later appeared as cancer rather than as perigastric exudate
surroimding an ulcer.
When the patient gained so markedly after leaving the hospital
we were again in doubt, but the mass felt at the time of the second
entrance was strongly like that produced by gastric cancer.
Pernicious anemia was at the time seriously considered, but this
Vol. U— 37
578 - DIFFERENTIAL DIAGNOSIS
was a blunder, for the very matked achromia should have |wevaited
our wasting any time in the consideration of that disease.
Ontcome.— On the 37th of September Sr. F. T. Lord thou|^t the
diagnosis to be carcinoma of the lesser curvature of the stomach,
but thought there was a reasonable doubt in favor of gastric ukcr.
Accordingly, on the 38th, Dr. Scudder (q>ened the abdomen and found
a hard mass, ^ze of the fist, involving the greater curvature and an-
terior wall of the stomach. No metastases palpable. Nothing done.
The patient recovered promptly frmn the <q)eration and left the hos-
pital on the 9th of October, igta. She reported Febriiaiy 17, 1913,
that she was losing grotmd steadily and could take only milk.
Case 255
A blacksmith of fifty-one entered the ho^ital October 8, 1907.
For the past six months the patient has noticed pallor, dj'^Hiea on
ezertioa, gradual loss of weight and strength. He has lost 30 pounds
in six months. For three months he has
been unable to work. During the past
two weeks he has had for the fiist time
some vomiting ^lells, three in number,
food only bdng rejected. There is some
dull pain in the right hj-pochonditam, no
jaundice, no cough or edema. Ss family
bistort', pre\'iou5 histon', and habits are
excellent, except that he takes sn excess-
ive amount of tobacco. He denies \'ene-
real disease.
Ph>'sical examination shows poor nutri-
tion, maiked paUor. The heart's "np"^*'
is in the fourth interspace. i\ inch outside
the left nif^le, do enlargement to the lig^t.
Just inside the apex thoe is a rou^ pre-
^stolic murmur and thriD. ending in a
short, sharp first sound; on the left border
of the sternum a bint diashdic murmiu';
at that situation and at the ^lex ■ rou^, kwd s>'st(dic murmur.
The pulse has a Corrigan quality. The tun^ are nonnal save for a
few crackles at the bases. Abdtnnen and extremities n^ative.
Tenq)eiature as seen in fig. 217. Urine negati^-e. Hie blood shows
red cells, 1,316,000; whitecdls. 7aoo;hemogkibin,35[iercetit. Stained
q>edmen shows [K4)-iiuclears, 58.5 per cent.; lyn^ihocytes, 41.5 per
z\^:^
-^^
n^ 117.— dart «( Cue 155.
PALLOR 579
cent.; slight achromia and deformities, no abnormal staining, no
blasts. Blood-plates diminished. Systolic blood-pressure, 128. On
the isth the blood showed red cells, 800,000; white, 12,900; poly-
nudears, 56 per cent.; lymphocytes, 44 per cent., many of them of
the large type with azur granules. On the 17 th the white cells were
29,000; polynuclears, 36 per cent.; large lymphocytes, 59 per cent.;
small lymphocjrtes, 5 per cent.; 12 normoblasts and 3 megaloblasts
were seen while counting 200 cells.
Discussion. — ^The history gives us no inkling of what the patient's
pallor may be due to. His excess in tobacco has certainly no par-
ticular significance, and I may here confess that I have seldom if
ever been convinced that excess in tobacco is in itself the cause of any
serious symptom, whether cardiac, digestive, or nervous. Excess is
as apt to be a result of nervous conditions as their cause. Doubt-
less it does some harm to some people, but I find it difficult to formu-
late any definite beliefs as to its injurious action on the majority of
smokers, even of excessive smokers.
The present condition of the heart might be due either to syphilitic
or to rheimiatic disease of that organ. In the absence of any rheimiatic
history, syphilis is perhaps more probable, but, in view of the very
grave anemia shown by the blood examination, it is our first business
to determine, if possible, what can be inferred from the blood itself.
Could syphilis produce this condition? Very grave anemias have
often been attributed to syphilis, doubtless rightly in some cases,
but such anemias have been, so far as I know, invariably consequent
upon long-standing, obvious, and virulent syphilitic lesions. We have
nothing of the kind here. Moreover, we have a fever of a type not
often seen in the later stages of syphilis when grave anemias may
develop. A close study of the leukocytes leaves me entirely con-
vinced that the patient suffered from an acute lymphoblastoma with
lymphemia. The excess of white cells is not great, but I know of no
disease other than that just mentioned which can produce such a
differential count in connection with such a total leukocyte count.
Moreover, the insidious development of anemia is especially charac-
teristic of the lymphoblastomous lesions of this type. Pallor and the
general symptoms of anemia are often the patient's first complaint.
This means that the red cells and the red cell-forming tissue of the
marrow have been crowded out by the overgrowth of marrow lympho-
cytes, and that the anemia is of the myelophthisic type.
Outcome. — The patient lost steadily in strength, and died on the
19th of October. No autopsy.
580 DIFFERENTIAL DIAGNOSIS
Case 256
A maid of twenty-three entered the hospital January 11, 1910.
The patient's family history and past history are good, except that
she had rheimiatic fever at fourteen and a year ago "used to vomit
blood." Her menstruation is not regular, a month or more being
often omitted.
For two months she has been getting pale and weak. Two or
three times a week she has severe headaches and is very nervous.
For the last four days she has had a smothering sensation in her
upper chest, and for two months has been short of breath on ex-
ertion. In all her attacks she has vomited but once and has had almost
no pain. Appetite, bowels, and sleep are normal. She thinks she has
lost a good deal of weight.
Physical examination shows good nutrition, pallor, and slight yel-
lowness of the skin and mucous membranes. Chest negative, save
for a slight systolic murmur, limited to the apex of the heart and the
region of the left third costal cartilage. Abdomen and extremities
negative. Two examinations of stools showed nothing abnormal.
Red cells numbered 4,280,000 and continued near that point during
her three weeks' stay in the hospital. Hemoglobin at entrance was
45 per cent. ; it never rose above 50 per cent, during the period of ob-
servation. The leukocytes showed nothing abnormal. In the stained
specimen there was marked achromia, slight variations in size and
shape. No abnormal staining, no nucleated red cells. The patient
had no fever and a negative urine during her three weeks' stay.
She was given at first Blaud's pills, 10 gr., three times a day.
Later, 15 minims of the green citrate of iron was given her subcu-
taneously every other day. She improved markedly in looks and
feelings despite the absence of much change in the blood.
Discussion. — I have to drop out of account altogether, in the
diagnosis of this case, the rheimiatic fever and the statement that
she "used to vomit blood." Both may be true, but I can make noth-
ing of them and find no present results of them in the patient.
What we now see is that she has shown the general sjrmptoms of
anemia for two months, and has now a yellow pallor and a notably
low hemoglobin. With a history of rheumatic fever one looks, of
course, for evidence of endocarditis, for that infection often accom-
panies or causes anemia; but, with no fever and no more definite
cardiac signs, I cannot believe that there is any active endocarditis
in this case. Pretty much everybody has sooner or later a slight
PALLOR 581
systolic murmur like that here described. The more often one listens
for it and the more carefully, the more frequently it appears upon our
records. Its absence is surprising in careful bedside notes of any
patient who is sick enough to call a doctor.
Insidious symptoms of this type in a girl of twenty-three always
makes us look with special care for evidence of pulmonary tubercu-
losis. I cannot positively deny the possibility of tuberculosis in this
case, but, despite painstaking search, no evidence of it could be found.
The remaining probability, chlorosis, has of late years become a
rarity in our clinics, so that one hesitates much more than formerly
to make such a diagnosis. Nevertheless, it will account for all the
facts here presented and is the best working hypothesis in sight.
Outcome. — On the 30th of January, 19 10, she left the hospital.
May I, 1 913, she reported herself well and at work.
Case 257
A waist maker of forty, bom in Russia, entered the hospital
February 12, 1910. The patient was sent in from the Out-patient
Department on account of excessive uterine flowing. Her father was
killed in the Odessa massacre. Her family history is not otherwise
remarkable. She has had no previous illness of note. Her menstrua-
tion has been regular, but always excessive. It has been no more so
of late. Late in December, 1909, she got pale and lost her appetite;
in consequence she ate very irregularly and meagerly. At this time
she began to have pain in her chest and between her shoulders. For
the past two weeks she has had palpitation. She stopped work
five days ago on account of increasing weakness. Yesterday her
menstruation began, a week ahead of time, accompanied by headache.
She has constant pain in the middle and right side of her chest. In
the last two years she has lost 17 pounds. Her bowels are regular
and she sleeps well.
Physical examination showed good nutrition, marked pallor, nor-
mal pupils, glands, and reflexes. Chest was negative, save for a
systolic murmur, heard best at the apex of the heart, but audible
also over the whole precordia. Abdomen and extremities negative.
Blood normal. Slight fever, ranging between 99° and 100° F. for the
first three weeks of her stay in the hospital, after that usually below
99° F. There was no elevation of pulse or respiration. Menstruation
ceased on the third day after her entrance to the hospital, but began
again two weeks later and lasted four days. The blood examination
showed the following: Red cells, 1,500,000, at which point they
582 DIFFERENTIAL DIAGNOSIS
remained with very littie change during the five weeks of her stay
in the hospital; hemoglobin, 50 per cent., gradually rising to 60 per
cent.; white corpuscles, 7500, later rising to 10,000; i>oIynuclear
leukocytes, 72 per cent, at entrance, 80 per cent, five weeks later.
The stained smear showed great variations in size and shape; no
achromia. No stippling, marked abnormal staining. At the first ex-
amination no nucleated forms were seen; three weeks later, 4 normo-
blasts were found. Blood-plates, 280,000 at entrance; 490,000 five
weeks later. The feces were negative to guaiac on three successive
examinations. Pelvic examination showed no disease. The Wasser-
mann examination was positive.
Discussion. — The chief impression made by the history is that
we are dealing with a secondary anemia due to excessive uterine
hemorrhage; yet it is almost unprecedented to meet with anemia
of this degree in a patient who has had no very recent or colossal
bleeding and who has been able to work imtil five days before her
entrance.
Posthemorrhagic anemia disables a patient far more quickly
and completely than the slowly developing primary or secondary
type. In these the patient's system becomes accustomed to the
bloodlessness. Some sort of compensation presumably takes place,
and the patient gets along surprisingly well with half or a quarter,
or even a fifth, of his normal quantity of red cells.
Since neither the history nor the general physical examination
reveals any obvious cause for the anemia, we must scrutinize the blood-
picture closely. Everything in it points toward pernicious anemia,
and the presence of a positive Wassermann reaction should not, as it
seems to me, weigh at all against this diagnosis. A person with
syphilis is not thereby immime against the possibility of developing
pernicious anemia, and surely patients with the latter disease may
acquire syphilis. Grave anemias do occur as the result of syphilis,
but not without more obvious lesions than have occurred in this case.
Outcome. — At the end of five weeks the patient showed con-
siderable improvement in her blood and some in her general condition.
She thought she would be as comfortable at home as in the hospital,
and was accordingly discharged March 8th. The treatment through-
out was Fowler's solution with tonics and laxatives.
Case 258
A painter of forty, bom in Russia, entered the hospital November
23, 1910. For the past three months the patient has noticed paDor
PALXOR 583
and pain in the left flank, worse when he urinates. The twenty-four-
hour amount is from 2 to 3 pints, reddish-brown in color, and con-
tains a white sediment. Appetite, bowels, and sleep are normal. The
patioit has lost no weight and worked until entrance. His family
history and past history are otherwise negative; habits excellent.
Physical examination showed fair nutrition, marked pallor. On
the lower forearms, above the inner condyles, were two moderately
tender, firm masses as large as walnuts. Pupils and reflexes were
normal. The heart was negative save for a soft systolic murmur,
replacing the first soimd at the apex and audible all over the pre-
cordia. The aortic second sound was accentuated. The brachial
Fig. 118.— Chart of Case Js8.
arteries pulsated visibly. The lungs showed, at the right apex behind,
a few crackling r&les and all the signs of slight solidification.
Thepatient entered the hospital with a diagnosis of "nephritis," but
Mamination of the urine showed an average of 40 ounces in twenty-
four hours, specific gravity 1015, no albumin, and no casts. On the
25th of November a sterile specimen showed a sediment consisting
of pus in small clumps. This state of things continued thereafter,
and the amount of sediment varied from z to 5 per cent, of pure pus.
This was rej>eatedly stained for tubercle bacilli, with negative results.
Four amilar examinations of the sputum were abo negative. The
blood showed 3,600,000 red cells, and this anemia stayed without
584 DIFFERENTIAL DIAGNOSIS
much change during the four weeks of his stay in the medical wards.
The white cells varied from 9000 to 13,000; hemoglobin, 60 to 70 per
cent. The stained smear showed moderate polynuclear leukocytosis
and slight achromia. The course of the temperature is seen in Fig.
218. Blood-pressure, 115 mm. Hg., systolic.
Cystoscopy, December 4th, showed a normal bladder, but, about
the left ureteral orifice, marked ulceration. Practically no urine
came from this ureter, but only thin pus. From the right ureter normal
urine was obtained. Dr. Hugh Cabot stated that in his opinion the
left kidney was largely destroyed, probably by tuberculosis. The
right kidney competent.
November 28th 20 minims of the urinary sediment were in-
jected into a guinea-pig. January 14th the pig was killed. Autopsy
showed tuberculous lesions of the glands, spleen, and liver. Cul-
tures from the urine always showed streptococci, but nothing else.
Two negative x-rays were taken. The skin tuberculin test was
negative.
Discussion. — The history points toward some disease in or near
the kidney. The physical examination, with its evidence of pyuria,
fever, and anemia, supports this conjecture and the cystoscopy con-
firms it. The only remaining question is as to the etiology of the
renal suppuration. The signs at the apex of the right lung naturally
lead us to assume tuberculosis, both there and in the kidney. The
negative examination of the urinary sediment and of the sputa for
tubercle bacilli incline us against tuberculosis, but do not rule it out
Our only decisive test in a case of this sort is animal inoculation.
The anemia, of course, is secondary to renal infection, whatever its
bacteriologic cause.
Outcome. — On the 20th of December incision was made over the
left kidney, which was found everywhere adherent, as if plastered
into its bed, and surroimded by a markedly thickened inflammatory
capsule. At the lower pole an abscess outside the kidney was broken
into and about 4 ounces of very foul-smelling pus evacuated. The
kidney was removed; the ureter found greatly thickened, as large
as the forefinger. It was removed, together with the kidney, micro-
scopic examination of which showed that its substance was largely
replaced by fibrous tissue, its pelvis and calyces dilated and full of
pus. The patient did not rally well after the operation, and died on
the 2 2d of December. Autopsy showed an evacuated subdiaphrag-
matic abscess in the retroperitoneal tissues about the kidney, with
gangrene of these tissues extending up to the diaphragm, posteriorly;
PALLOR 585
abscess of the spleen, thrombosis of the left external iliac and femoral
veins; obsolete tuberculosis at the apices of both lungs and in the
bronchial lymphatic glands.
Case 259
A housekeeper of forty-four entered the hospital February 23, 191 1.
The patient's father died of cancer of the stomach at fifty-five; mother,
of some chronic stomach and intestinal trouble at fifty-seven. One
brother has nervous dyspepsia, one sister has the same trouble, and
another sister has had stomach trouble for four years, but has recently
recovered.
The patient's general health has always been poor. For years,
she says, she has been as pale as she now is. At twenty-nine she had a
nervous breakdown, with general tremor, weakness, and inability to
use her eyes. She did nothing for six years, during which time
she was several times in hospitals for operations on eye muscles,
for curettage, and other troubles. Twelve years ago the right ovary
was removed. Most of the time since she has been working as a
governess and housekeeper, with only one breakdown, although
she has had constant trouble with sour stomach, gaseous eructations,
epigastric tenderness, and constipation. Her menstruation began at
fourteen and was regular until June, 19 10, since when she has had but
one period, six weeks ago.
A year ago she began to be troubled by sore tongue, and at in-
tervals it has been sore ever since. In September, 1910, she began to
have what she calls "bilious attacks," i. e., nausea and vomiting at
irregular intervals, without relation to meals, associated with anorexia
and constipation, but without pain or jaundice. For the past week she
has vomited once or twice a day. Since January, 191 1 , she has noticed
dyspnea on exertion, associated with some pain in the chest. She
sleeps well with one pillow and has lost no weight. She knows of no
fever.
Physical examination showed marked sallow pallor. Pupils,
glands, and reflexes normal. Mouth and throat negative. Heart
soimds somewhat irregular, distant, and of poor quality. Soft, blow-
ing, systolic murmur, audible all over the precordia and in the left
axilla, loudest at the apex. No evidence of cardiac enlargement, no
accentuation of any sound. Lungs and abdomen negative, except
that the liver dulness extended 3 cm. below the ribs, where the edge
of the prgan was doubtfully felt. There was intermittent coarse
tremor of both hands, especially the right. The urine averaged 45
586 DIFFEKENTIAL DIAGNOSIS
ounces in twenty-four hours; specific gravity, 1004 to loio; albumin
sometimes absent, sometimes present, slightest possible trace. Sedi-
ment negative. Five examinations of the stools were negative.
Examination of the fundi showed patches of exudate and small hem-
orrhages in the left retina.
The condition of the blood is shown in Fig. 219. The red cells
were mostly of the large type and well stained, though a few of them
1 'Saj5|.!]ih|.luW. .|;itj,|.l|,|ll|,l 1 1 1 1
i !-,„
',„„.;:: ; _.-': : :
! Z^'-,"-.Ai 55^ :
1 -5 2i' • ■ -y 'V
1 "f -;»■ - f* ^
'.Z I
\Z :: :: ::: ::: :
"" I"
i ;i "
! ';: c
1 .« f " ""^" ^ "
Fig. 219. — QuiTt showing a
e of red cells, white cells, ajid hemoglobin in Cue iS9'
were very achromic. Occasionally very large purplish or st^^^
cells were seen. Blood-plates seemed to be very much diminished
and there was much defonnity in the shape of the red cells. At
entrance no nucleated forms were seen. On March 7th a few normo-
blasts appeared; on the 14th, 2 megaloblasts were seen while counting
200 white celb; on the 32d, 2 normoblasts and 2 megaloblasts; on
March 28th, 2 megaloblasts only. On the 3d and 8th of April normo-
PALLOR 587
blasts became very abundant, 30, and 18 megaloblasts. After that
the nucleated cells became rare and at times could not be foimd
at aU. The leukocytes at entrance niunbered 5000, sagged in two
weeks to 2500, then gradually rose with the increasing red cells to
15,000; the polynuclear varieties meantime rising from 6c to 83 per
cent. Throughout the whole course the blood-plates were diminished.
April sth 0.6 gm. of salvarsan was injected deep in the left
gluteal region, and the improvement in the patient's blood dated
from this time. Up to the 27th of April she seemed to be decidedly
improving, though there was at times a little edema of the face. On
the sth of May she complained of headache and had slight coryza.
This steadily increased, and at midnight on the 6th she became im-
consdous. Soon after she had a generalized clonic convulsion and
bit her tongue. The radial pulse showed alternation. The face
seemed more edematous than before. There were many crackling
r&les at the base of the right lung; otherwise physical examination
was negative. On the gth Dr. Brewster removed the area of fat and
muscle about the site where "606*' had been injected. The specimen
examined microscopically showed necrosis of fat and muscle and a
small amount of arsenic was detected on chemical examination.
Throughout the three months of her stay in the hospital she
maintained her weight, but had most of the time a slight tempera-
ture in the evening, the highest point reached varying between 99.5°
and 100.5° ^'
Discussion. — This patient seems to be predisposed by inheritance
to stomach trouble and possibly to cancer. She has also suffered
many things from many physicians, as nervous sufferers are un-
fortimately so apt to do. The operations upon her eyes and her
pelvic organs are of the type so often done, especially in the last
decade, because of the utterly false surgical dogma that all nervous
symptoms must have *'a cause,'' by which they mean a cause open
to surgical treatment.
The history of sore tongue accompanying a marked anemia
makes it incumbent upon us to look with special care for evidence
of pernicious anemia, since many cases of that disease begin each one
of the successive waves of illness with a sore mouth. Such a suspi-
cion is here strengthened by the finding of retinal hemorrhages,
hepatic enlargement, and a high color index. Further study of the
blood leaves no considerable doubt of the diagnosis.
A few words may here be said regarding the salvarsan treatment
for pernicious anemia. Certainly a single dose is often devoid of any
588 DIFFERENTIAL DIAGNOSIS
good effect whatever. On the other hand, the recent cases reported
from Dr. Mumford's clmic at Clifton Springs by Dr. Brotherhood
arouse the hope that by giving small and repeated doses of salvar-
san we may produce at any rate a longer and prompter remissioD
of the symptoms than can be expected from the activities of nature
unaided, or from the ordinary methods of treatment. That salvarsan
can cure the disease I do not for a moment believe. It is a palliative,
not an etiologic, treatment, for, although there are certain scn^ of
evidence pointing toward an infectious etiology for pemidous anemia,^
these hints are by no means conclusive. What other infectious dis-
ease begins so regularly at the arteriosclerotic age?
Outcome. — On the isth of May the clinical note is "still doing
well," but on the i8th she died, rather suddenly. Autopsy No. 2854,
May 19th, showed arteriosclerotic nephritis with foci of suppura-
tion; hyperplasia of the bone-marrow; slight hypertrophy of the
heart; streptococcic septicemia; chronic pleuritis; general anemia.
Remarks. — The fact that the kidneys were markedly diseased
would lead some incautious observers to believe that this case sup-
ports the theory often advanced on similar equivocal evidence that
nephritis can cause pernicious anemia. When two diseases occur so
frequently without any known connection with one another, one
needs a good deal more than the fact of their simultaneous occur-
rence within a single body to constitute evidence of an etiologic con-
nection. Whether arsenic-poisoning played any part in this patient's
demise I cannot definitely state. I see no good reason to believe so,
though it is possible that the end may have been hurried by the un-
fortunate accident resulting from the way in which salvarsan was
at that period not infrequently given.
Case 260
A schoolgirl of eight years entered the hospital March 13, 1911.
The little girl's mother has had ten other children and four mis-
carriages. Eight children are living and well. The patient herself
has had measles and whooping-cough, and when four years old was
treated in the Neurologic Department and at the City Hospital for
multiple joint pains, with tenderness, but no swelling. A diagnosis of
multiple neuritis was made. She was in bed three weeks and could
not walk for five weeks from the onset.
After that she was in vigorous health imtil December 10, 1910,
^ Herbert C. Moffitt, TransactioDs of the Association of American Physicians, 1911,
p. 288.
PALLOR 589
when she had a sore throat and an attack of pain in many joints,
though without swelling. She was in bed a week, but has never been
really well since. For an hour on the isth of December she was said
to have been temporarily blind, and for several months past she had
now been troubled with frontal headache. Nevertheless, until four
days ago the parents considered her fairly well.
Four days ago her mother noticed pallor and puffiness of the face.
The child had a good appetite, but vomited most of her food soon
after eating.
Physical examination showed marked pallor and edema of the
face and extremities. Pupils, glands, and reflexes negative. The
chest showed a slight rachitic rosary. The cardiac dulness reached
2 cm. to the right of midstemimi and 7 cm. to the left of the nipple
line. There were no murmurs or accentuations. In the lungs abim-
dant bubbling r&les were heard throughout both chests. There was
soft edema of the extremities; otherwise physical examination was
negative. Blood-pressure, 125 to 135 mm. Hg.j systolic. Stained
smear showed moderate achromia; hemoglobin, 80 per cent.; white
cells, 14,000 to 16,000. The urine averaged 35 ounces in twenty-four
hours, with a slight trace of albumin; specific gravity usually in the
vicinity of loio, occasionally rising to 1020. Granular, cellular, and
bloody casts, with some pus, were present throughout most of her
stay, though after the ist of April the amoimt of blood rapidly di-
minished and soon disappeared. There was no fever during the five
weeks of her stay in the hospital Under daily hot tub baths of fifteen
minutes, at temperature of 100° F., gradually raised to 112° F., fol-
lowed by wrapping in warm blankets, the child steadily improved.
She was given a diet from which meat was omitted and salt limited.
The bowels were moved by 2 drams of sodium sulphate every morn-
ing. The edema was gone by the ist of April and the baths were
then omitted.
Discussion. — Can this patient have had a multiple neuritis at
the age of four? I never heard of any such diagnosis or read of any
such cause. Does it not seem more probable that she had a rheu-
matic infection, similar to that which occurred in 1910? I am in-
clined to believe so. Blindness and frontal headache, following im-
mediately upon an attack of tonsillitis and arthritis, make us con-
fident that the urine will show clear evidence of nephritis, especially
when pallor and puffiness of the face ensue. A systolic blood-pressure
of 135 mm. Hg. constitute hypertension in a girl of eight years and
further supports the diagnosis of nephritis.
SQO DIFFERENTIAL DIAGNOSIS
The case is of interest as an example of posttonsillar or strq)to-
coccic nephritis. In my opinion, there is no other cause for acute
nephritis so common as this. It is impossible to say that many cases
of the so-called scarlatinalnephritis are not, in fact, streptococcic in
origin. Those following tonsillitis are not so often discovered, be-
cause we have not yet become accustomed to expect nephritis as a
complication of that disease.
Outcome. — By the 9th she seemed nearly well, and on the isth
was discharged. In April, 1913, she reported herself entirely weL
The urine was not obtained.
Case 261
A farmer of sixty-two entered the hospital March 24, 19 11. The
patient has had stomach trouble for the past fifteen years, but it has
never prevented his working. He has epigastric pain beneath the
left costal margin occurring with great definiteness, two and a half
hours after meals, especially after breakfast and limch. He says the
pain is like hungry kittens. It is immediately relieved by food, and
for years he has carried crackers or doughnuts in his pocket to take
when the pain comes. He also gets relief from pressure, and often
throws himself across a bag of wool or bale of hay for comfort.
This condition has shown no marked change imtil five weeks ago.
There have often been remissions, lasting several weeks or months.
Five weeks ago he noticed that he was getting pale, and shortly after
had an attack of diarrhea and vomiting, lasting three days. Since
then he has felt weak, though he has been up and about the house.
Two weeks ago he rose from a chair to get a drink of water and fell,
without losing consciousness. There was no vertigo, and he got up
without assistance. A week ago he had a similar experience. He
thinks he may have lost weight. He is quite sure he has lost strength,
though he feels able and willing to work to-day. His family history
and habits are good. He denies venereal disease. His bowels moved
daily imtil within a few weeks. He has always led the vigorous,
out-of-door life of a fanner.
Physical examination showed marked pallor, good nutrition;
pupils slightly irregular, otherwise normal. Glands and reflexes
negative. Chest and abdomen negative. The course of the tem-
perature is shown in Fig. 220. Urine was negative. The patient
weighed 142 pounds, without clothes. The stools, examined six
times, showed a marked reaction to guaiac, but no other abnormality.
The blood showed red cells, 1,800,000; white cells, 14,000; hemoglobin,
35 per cent. There was no marked change from these figures in four
examinations, at weekly intervals. The stained specimen showed
almost no achromia, slight defonnities, the red cells often oversized,
and many of them off-color, even blue. There was a marked poly-
nuclear leukocytosis. Altogether, an equivocal blood, but, when taken
in connection with the history, probably due to secondary anemia.
In the fasting stomach 70 c.c. of turbid, coffee-colored fluid was
found, reacting strongly to guaiac. No further examination was
made.
The first fout days after his entrance to the hospital he had a
persistent hiccup, which was checked, however, by a small dose of
Fig. ito. — Chart of Cue i6i.
morphin and did not recur. Most of the time the patient lay in a
semicomatose condition, occasionally irrational, but able to answer
questions. An attempt was made to secure a donor of blood for
transfusion, but unsuccessfully. April nth and i3tb he complained
in the night of pain in the chest, but during most of the time lay as if
asleep. The fundus oculi was normal.
Discussion. — The only organic disease of the stomach that lasts
fifteen years is peptic ulcer and its results. If this patient has had but
one trouble throughout the whole of his illness, it is inevitable for us
to call it ulcer. His recent pallor and weakness are then explainable
592 DIFFERENTIAL DIAGNOSIS
as the result of hemorrhage, which may have passed out through the
bowel without his knowing anything about it. Some features of the
blood examination pajrallel those of pernicious anemia, but the well-
marked polynuclear leukocytosis, taken in connection with the typical
gastric history, should leave us no doubt that the anemia is, in reality,
of the secondary type.
The latter symptoms in this case present an excellent type of those
which are usually explained by saying that a peptic ulcer has become
cancerous. Like many better men, I was misled into making such a
diagnosis in this case.
Outcome. — On the 15th of April he died. Autopsy showed a per-
forated ulcer of the stomach with localized peritonitis. Cancer had
been considered the most likely diagnosis before death.
Case 262
A housekeeper of thirty-six entered the hospital January i, 1912.
The patient's father died of Bright's disease; in other respects her
family history is excellent. She has never been sick before, but for
the past three months has had a great deal of flowing at irregular in-
tervals. Three years ago, when walking home one cold evening, she
left her coat unbuttoned and thinks she caught cold. For two weeks
after this she had very frequent and painful micturition, whidi,
however, got well without any further complications. Soon after
this, without any known cause, she rapidly lost strength and became
very pale. A vacation in Baltimore benefited her a good deal, and
she went back to work on her return. She has worked for a greater
part of the time since then up to last Thanksgiving, six weeks ago,
though she has remained pale all this time and has never felt very
strong. Since Thanksgiving she has been in bed, though she com-
plains of nothing whatever except weakness. It is hard work for her
now even to think. She absolutely denies any shortness of breath,
any edema, vomiting, headache, or diarrhea. She has an occasional
slight hacking cough, without sputum. She has had no fever, chills,
or sweats, no fainting or vertigo, and no pain in any part of the body.
Her weight, she believes, has remained about the same.
Physical examination shows fair nutrition and considerable pallor.
No jaundice. The pupils are small, slightly irregular in shape, react
normally to light and well to distance. Knee-jerks are present and
equal. All the other reflexes are normal. There are many small,
firm, non-tender, discrete glands in the neck, axillae, and groins. The
tongue shows a thick, brown coat. The mouth and throat are nega-
PALLOR 593
tive. The heart's apex is seen and felt in the fifth interspace, 7 cm.
outside the nipple. Its dulness extends 4 cm. beyond the midstemal
line. At the apex is a harsh, long, systolic murmur, transmitted to
the axilla. The pulmonic second sound is moderately accentuated.
The Ixmgs are negative. The liver dulness extends 7 J cm. below. the
ribs and as high as the fifth interspace in the nipple line. A rounded,
slightly tender edge is felt. The spleen is enlarged by percussion and
its edge is felt just above the level of the navel. It is not tender.
The extremities are negative. Systolic blood-pressure, 140. The
urine 20 to 40 ounces in twenty-four hours, 1012 to 1019 in specific
gravity, slight trace of albimiin, rare granular and hyaline casts with
cells adherent. The blood shows red cells 2,600,000; white, 21,000 to
23,000; hemoglobin, 65 per cent.; polynuclear cells, 75 per cent.
Stained smear shows slight variations in size and shape, but no
achromia or abnormal staining; i normoblast. The Wassermann
reaction is negative.
The patient's family physician later told us that on examination
three weeks ago he found a large dilated heart with a mitral murmur
and a weak, rapid pulse. Under digitalis and rest she improved very
much. After her return from Baltimore, although she worked as a
milliner, she was treated twice for attacks of broken compensation.
Her physician also states that since Thanksgiving she has had several
chills followed by fever, and has complained of pain along the lines
of the ureters.
On the 2d of January a diastolic murmur was heard in the second
right interspace and along the right sternal margin. Corrigan pulse,
capillary pulse, and other vascular phenomena therewith associated
were detected at the same time. The same afternoon she had a chill,
followed by a sharp rise in temperature; the next day another chill,
with slight spasm and moderate tenderness in the region of the spleen;
also crops of petechiae on each arm. Blood-culture gave a Gram-
positive diplococcus, interpreted as a contamination. The patient's
condition was very poor. On the 4th crops of petechiae spread over
the entire body. The heart became very rapid, and there were
several attacks of marked cyanosis and pectoral oppression, lasting
ten to twenty minutes.
Discussion. — So much weakness, unexplained and associated with
extreme pallor, cannot but alarm us with its likeness to the onset of
many a case of pernicious anemia, but the condition of the blood
reassures us.
The heart lesions lead us to look in that direction for an explana-
VoL. 11—38
594 DIFFERENTIAL DIAGNOSIS
tion of the patient's anemia and other symptoms. Here we have a
**causeless" cardiac weakness, with marked enlargement and normal
blood-pressure. We have also an enlargement of the spleen and
liver. Cardiac disease does not enlarge the spleen, hence we must
look elsewhere for an explanation. The general glandular enlarge-
ment prepares our mind for the appearance, late in the case, of a
diastolic murmur which points very directly to syphilis, and gives us
a diagnosis which can explain the "causeless" cardiac weakness and the
splenic tumor, as well as the anemia.
On the other hand, the crops of purpuric spots which marked
the latter days of the patient's life are such as one most often sees in
connection with the rheumatic or streptococcic type of heart disease.
Except for this, however, everything points in the other direction,
that is, everything except the negative Wassermann, which cannot
be ignored, but which need not upset the diagnosis otherwise well
supported.
Outcome. — On the 5th of January the patient died. Autopsy
showed syphilitic aortitis; aneurysm of the celiac axis; fibrous de-
generation of the aortic valve and a slight degree of the same condi-
tion of the mitral valve; hypertrophy and dilatation of the heart;
acute glomerulonephritis; slight chronic perihepatitis and perispleni-
tis; chronic salpingitis; chronic tuberculous pleuritis. No evidence
of emboli.
Remarks. — I was wholly unprepared to find the acute glomerulo-
nephritis shown at autopsy. Possibly it may have been due to a
terminal infection which no one could predict. Certainly the urinary
examination made at the time of the patient's entrance would not
warrant any such diagnosis, though the conditions foimd were not
those of health.
The frequency of chronic perihepatitis and perisplenitis at autops)'
in cases of syphilis tempts one to regard such lesions as of syphilitic
origin, even in cases where the latter disease is by no means clearly
shown.
Case 263
The patient was a Finlander, thirty years old, and has worked in a
stone quarry. He entered the hospital June 19, 191 2, complaining
that for a month he has been getting yellow. He has worked until
nine days ago, though for two months he has noticed that his legs arc
somewhat weak. His family history, past history, and habits are
excellent. Since he stopped work he has noticed vertigo, headache,
PALLOR 595
and tinnitus, with slight shortness of breath. As he lies in bed he
feels perfectly well, has a good appetite, and no pain. He has lost a
few pounds in weight, but thinks he is now regaining them.
Physical examination shows good nutrition and marked yellowish
pallor, normal pupils, glands, and reflexes. The chest is negative, save
for a few moist riles heard below the angle of the left scapula and at
the bottom of the left axilla, not associated with any other phys-
ical signs of disease. The abdomen and extremities are negative.
Urine negative. Systolic blood-pressure, 115. The temperature
occasionally rose to 99.5° F. in the afternoon during the first week of
his stay; after that normal or subnormal. The blood showed red
cells 1,000,000; white cells, 6000; hemoglobin, 40 per cent. The
stained smear showed no achromia, many large, deeply staining red
cells. Marked variations in size and shape and many abnormally
stained cells, but no stippling. Blood-plates decreased. Three
normoblasts and 4 megaloblasts ^were seen while counting 200 white
cells.
Discussion. — Pernicious anemia was the house officer's diagnosis
in this case, and there was certainly much to justify it, for the blood
was absolutely typical and the ordinary physical examination showed
no cause for the anemia. But the patient's youth should lead one
to scrutinize such a diagnosis carefully and to look for every other
possible explanation. Certainly not more than once in a hundred
times does true pernicious anemia occur in a man of this age. In a
young woman it is not so rare.
Still more significant, however, is the patient's nationality, for
we know that of all places in the world Finland is the one most notor-
iously associated with fish tapeworm anemia, whose striking resem-
blance to pernicious anemia was first made clear by Schaumann's
classical monograph.*
This is one of the very few cases in which I have been able to
believe that I have saved a patient's life. Had not the eggs of fish
tapeworm been looked for under my direction, and the appropriate
treatment for the expulsion of the worm given, this patient might
have been allowed to die with the diagnosis of pernicious anemia.
Outcome. — The patient's youth and his race at once suggested
the possibility of a fish tapeworm as the cause of his anemia. Ex-
amination of the stools showed the eggs of that tapeworm. The
patient was accordingly given a milk diet for twenty-four hours with
very free purgation; after that pelletierin tannate, i gr., together
* Berlin, 1904, Hirschwald.
59^ DIFFERENTIAL DIAGNOSIS
with oleoresin of aspidiiim, 15 gr. in capsule, one every two min-
utes for eight doses. The next day the patient passed practically the
whole of a full-grown fish tapeworm. The head was not found.
During the ten days following the expulsion of the tapeworm his
hemoglobin rose 10 per cent, and his blood Improved proportionately
in other respects. Thereafter he rapidly unproved, and went home
on the ist of July to finish his convalescence.
CHAPTER XV
SWELLING OF THE ARH
The symptom is rare, if we except the cases whose diagnosis is
obvious. Swelling of an arm as the result of septic processes in the
hand or higher up is, of course, not uncommon, but needs no discus-
sion or conmient. It is the cases without any such obvious explana-
tion that I have called rare. They occur, now and then, in the course
of cardiac disease, apparently because the dropsical patient has lain
persistently upon one side so that the edematous fluid has settled
there by gravitation.
Aside from this, a phlebitis may occur in the course of heart
disease as well as in other conditions, but in the arm a phlebitis often
presents no obvious tender cord, such as we can palpate on the inside
of a leg similarly affected. Hence, the diagnosis of phlebitis in the
arm has often to be made wholly by exclusion of other causes for the
swelling that we find. One settles down upon that diagnosis in cases
when they find no evidence of cervical or mediastinal pressure {cervical
rib, glandular swellings, malignant disease, aneurysm).
Among the mediastinal tumors which cause an arm to swell, lym-
phoblastoma (Hodgkin's disease) is by far the most common.
Cancerous metastases in the axillary glands after tumor of the breast
usually leave us in no doubt of the cause of the resulting edema in the
arm. On the other hand, axillary abscess may obstruct the venous
circulation and produce a swollen arm without giving us any clear
evidence of its presence, for such an abscess often arises very deep in the
tissues. The pr^ence of slight unexplained fever and leukocytosis in
connection with what is supposed to be a glandular tumor of the axilla
gives us ground for suspecting an abscess behind it.
Case 264
A housewife of thirty-eight entered the hospital July 15, 1906.
For the past three years she has had dyspnea and palpitation on exer-
tion, with swelling of the feet at times. For eight months she has been
in bed a good deal of the time with partial orthopnea. Nocturia, 2.
She has had headaches all her life, but less of late. Appetite and
bowels normal.
597
598 DIFFERENTIAL DIAGNOSIS
Four days ago the right arm swelled and the edema disappeared
from other parts of the body. The whole arm was at first much
enlarged and purple in color. It is now slightly smaller.
Physical examination shows fair nutrition, nervous, quick, and
tremulous movements, prominent eyeballs, no goiter. The heart's
impulse extends to the anterior axillary line, in the fifth and sixth
spaces. Its action is rapid and irregular. The sounds are faint but
clear. The aortic second is accentuated. No murmur. The lungs
show coarse crackles at the bases, otherwise normal. There is dubiess
in the flanks, not shifting with change of position. Abdomen other-
wise negative. The right knee-jerk not obtained, the other normal.
The right arm is greatly swollen throughout and
pits on' pressure. The right leg is also very
edematous, and there is considerable edema of
the right side of the trunk, front and back.
\Z---^4it\LZ There is also slight edema of the left side of the
ll'^T-fl rnTT H ' body, especially the left leg. The white cells
number 33,200; hemoglobin, 95 per cent. The
temperature is as seen in Fig. 221. The urine b
negative save for a shght trace of alhumio.
Under poulticing, purgatives, digitalis, and rest
the edema rapidly diminished. The day after
entrance an apex systolic murmur appeared, and
the first sound was noticed to be sharp and short.
Discussion. — A history of three years' dysp-
nea on exertion and eight months' orthopnea
makes us naturally prone to believe that a
swollen right arm like that here descrihed is
connected with heart disease. The heart lesion
from which this patient suffers seems to me
most like mitral stenosis. In favor of this we have the marked lateral
enlargement of the heart, its rapid, irregular action, and the shaip.
short first sound at the apex. Even without a rheumatic histoo'' *
presystolic murmur, or an accentuated pulmonic second sound, such
physical signs make mitral stenosis the best diagnosis in sight, espe-
cially as there are some points in the case suggesting a left-sided hemi-
plegia, for the combination of valvular heart disease with hemiplegia
occurs most often m mitral stenosis. On this hypothesis, the leukt^
cytosis will be explained as the result of one of those recrudescences ol
fresh infections to which the heart of mitral stenosis is strikingly
subject.
Swollen Arm
CANCER OF THE BREAST ^^H^^^^ 72
LYMPHANGITIS ■■■^■B 39
THROMBOSIS AND PHLE-1 ^^^^^ 2g
BITIS / ^^^^
MEDIASTINAL NEOPLASM ■ 4
SWELLING OF THE ARM 599
That no arterial embolism of the arm has taken place seems clear
from the course of the case. The obstruction, if there be any, seems
to be in the venous trunks. Since no mediastinal pressure has made
itself manifest, a phlebitis of the arm confronts is; on the whole, our
best explanation of the fact.
Outcome. — On the 21st the white cells were 36,500. The arm was
nearly normal in size and the tenderness was very slight. The general
edema persisted after the arm had cleared up.
Case 265
A master mariner of thirty-eight entered the hospital May i, 1900.
About three years before entrance the patient noticed a lump on the
outer side of the right arm near the shoulder. After a few weeks it
began to discharge pus and two or three months later healed up. A
year ago the discharge again appeared, and the bunch was operated
upon by Dr. Maurice H. Richardson. The wound healed very
quickly this time, but had to be opened again in three weeks and has
never completely healed since that time. The last operation was three
months ago. Just before it two lumps appeared upon the left leg, one
on the outer side of it, above the knee, and one in the popliteal space.
These Imnps were opened, but the latter has never healed and is very
tender.
Physical examination showed fine development and nutrition.
There was a small discharging sinus in the region of the right deltoid,
at the bottom of which, 2 inches from the surface, ho sequestrum could
be discovered. The function of the arm was apparently excellent.
The left leg was considerably swollen. The patient says that at times
it has been 3 inches larger in circumference than the other, just above
the knee. There was a small scar on the outer side of the leg, just above
the knee, where the patient says the bunch was opened, and several
old white circular scars about the knee and on the lower leg. There
was marked edema below the knee, and on the inner side of it a brawny
tender swelling connecting with the popliteal space, where a shallow,
unhealthy looking ulcer, very sensitive to touch, was discovered. The
motion of the knee was good.
The leg was raised on pillows and the swelling gradually de-
clined. No operation was done either on the leg or on the arm. The
patient left the hospital on the i8th of May and re-entered October
26, 191 1, stating that he had been operated upon in this hospital thir-
teen years ago, but had been well and strong, with no discomfort, up
to the time of the present iUness, two weeks ago, when he began to have
6oO DIFFERENTIAL DIAGNOSIS
pain in the outside of the upper right arm, near the seat of the old
operation. It all came in one night and now causes much discomfort
Three days ago 'the whole arm became much swollen and tender and
the patient took to bed.
Physical examination shows in the upper part of the right humerus
a dense tiunor, red and very tender, the size of half an orange; other-
wise the examination was negative.
Discussion. — Everything here points toward a local rather than a
circulatory or mediastinal cause for the edema. In all probability
the lump and purulent discharge of three years ago was due to an osteo-
myelitis of the hmnerus. The relapse and discouraging course of the
lesion is characteristic of osteomyelitis. The edema which occurred
in the leg at the same time was doubtless connected with the scar
formation and the ulcer in the popliteal space.
When eleven years later we have a swelling of the arm and a local
tumor over the humerus, we have every reason to connect the two facts
with the old history. Surely we must be dealing with an osteomyelitis
and a septic edema of the arm.
Outcome. — The tumor was opened and 4 ounces of pus evacuated.
The cavity was found to lead to the bone, which was cureted. Four
days later the patient was discharged to the Out-patient Department
The pus contained numerous colonies of streptococci and staphylococci.
Case 266
A candy maker of fifty-five entered the hospital January 31, 1911.
The patient's father died of gastric cancer at seventy-two. His wife
now has consumption, otherwise family history is good. General
health excellent. He had typhoid fever twenty years ago. Denies
venereal disease. Eight weeks ago his left wrist swelled. This con-
tinued for about forty days. Then he gave up work and the sjmp-
toms disappeared. Three days ago his wrist again became swollen,
and later in the same day the entire arm became blue and considerably
enlarged, with itching at the shoulder. He has no fever symptoms and
feels well in all respects.
The patient did not look sick and was well nourished. In the left
front there were soft, high-pitched, interrupted squeaks and twittering
sounds, otherwise the chest was negative; likewise the abdomen. The
left arm and adjacent pectoral region were moderately swollen and
the veins over the shoulder dilated. X-ray showed nothing abnormal.
Wassermann reaction negative. Blood and urine negative. S>'stolic
blood-pressure, 135. No fever in four days' observation. He felt so
SWELLING OF THE ARM 6oi
weQ that at the end of this period he left the hospital, though his arm
was as much swollen as at entrance.
Discussion. — There has been no great pain and no local lesion sug-
gesting sepsis. The general condition is excellent. Careful search for
mediastinal growths and sources of local sepsis is negative. Nothing
is left but phlebitis, and, although we have no idea why this should
occur, we need not expect to have any such idea, for many cases of
phlebitis decline to furnish us with any explanation of their cause.
It may be that some deeper-lying malady may show itself in the later
course of the disease, but at the present time we have no reason to
suspect such nor to connect the patient's symptoms with his old typhoid
fever. The pulmonary signs would make it seem that the lung, as
well as the arm, is congested, and point to a deep-seated cause such as
we have been searching for unsuccessfully in the mediastinum. Until
these lung signs clear up there must be some anxiety regarding a medi-
astinal growth or aneurysm.
Outcome. — On February ii, 191 1, the left upper arm was still 2
inches larger in circumference than the right, the forearm i inch larger
than the right. March 23, 191 1, he felt perfectly well. The arm was
unchanged.
Case 267
A housewife of fifty entered the hospital June 23, 191 1. The
patient's father died of heart trouble at sixty-nine. Her mother is
now living, but has heart trouble, otherwise the family history is
good. The patient has never had rheumatic fever and for thirty
years has had no tonsillitis. Thirteen years ago, after the delivery of
her second child, she was told by Dr. Edward Reynolds that she had
heart trouble, but suffered only occasional dyspnea on exertion until
three years ago, when the dyspnea became more marked and she
began to have precordial pain on exertion or emotional strain. She
was told at that time that her heart was very irregular, and she re-
members swelling of the ankles at night for at least three years.
Four weeks ago she noticed swelling of the left forearm, which
began suddenly without other symptoms. This was coincident with
the stopping of medicine for her heart, which she had been taking for
three years. On account of the arm she consulted Dr. Maurice H.
Richardson, who advised jc-ray and sent her to a medical man. Her
best weight, twenty years ago, was 192 pounds. Her usual weight
now is 180 pounds. For three years she has been losing weight, and
now weighs 143 pounds, without clothes.
DIFFERENTIAL DIAGNOSIS
hudUi-lue.
Physical examination showed on the bard palate a ridge 5 cm. \oag,
15 cm, wide, and J cm. high in the median line, apparently bony. She
says her father had the same thing. Heart's apex was in the sixth
space, anterior axillary line, where a systolic and presystolic munnur
could be heard. At the base there was a high-pitched systolic and a
long diastolic. The aortic second was not audible. The pulse was of
the plateau type. There was no thrill. The vessels of the neck pul-
sated strongly and the pulse could be felt even in the &nger-tips, where
capillary pulsation was visible under the nails. There was marked
edema of the left upper arm and hard edema of the forearm. Both
legs were also much swollen. The ar-ray, diagram of which is here re-
produced (Fig. 322), showed dilatation of the aorta along its left
border. Wassermann reaction was
negative. Blood negative. Blood-
pressure, 320 mm. Hg., systolic;
no mm. Hg., diastolic. Urine,30
ounces in twenty-four hours, with
a specific gravity of 1014, a voy
slight trace of albumin, no casts.
Discussion. — The history
sounds rheumatic, despite the pa-
tient's statement to the contraiy.
By this I mean that it is unusual
for a patient to have a recognized
cardiac lesion for thirteen yeais
unless that lesion is of rhexunatic
origin. Nevertheless, there is
much in the examination of the
heart and aorta pointing toward
syphilitic disease. Aortic regurp-
tation and enlarged aortic arch may, it is true, result merely from
rheumatic trouble, but in the vast majority of cases they are syphilitic
in origin.
Granting that the aorta is dilated and capable of exerting pressure
upon the venous trunk, we have a good reason for phlebitis and swolhn
arm. On the other hand, the phlebitis may have originated simply
by infection within a stagnating venous current and without any IcNal
pressure. Nothing in the case tells how to decide this question. The
prognosis is, in all probability, good.
Outcome. — The cause of the edema was not discovered, and on
July 6th was still present, though much less. She left the ho^ital
July loth.
Fig. 222. — Sketch of jr-ray plate showing
dilated aorta in Case 267.
SWELLING OF THE ABM
603
Case 268
A laborer of thirty-seven entered the hospital May 33, 1912.
Family history negative. Two years ago he had left-sided pneumonia
followed by dry pleurisy. He was sick ten days, and thinks he has not
regained his strength since. He had bronchitis six months ago, but
did not stop work. He has had no cough this winter. Takes one to
three whiskies a day. Denies venereal disease. Seven weeks ago,
while at work, he was seized suddenly with dyspnea, vertigo, and
weakness. After a drink of whisky and an hour's rest he managed
to finish the day's work, but gave up next day. The next few weeks
Fig. 333. — Chart
he was up and about the house, but felt poorly and did no work. He
thinks he had fever at this time, but noticed no shortness of breath.
Three weeks ago he took to bed with pain in both axilla, so severe
that he could only lie upon the "broad of his back." This pain has
been less severe of late, but has been followed by shortness of breath
and orthopnea, with constant cough, but very little sputa. There have
been no digestive symptoms except poor appetite. He thinks he has
lost considerably in weight and strength.
Physical examination showed good nutrition, deep rapid breathing,
severe paroxysms of coughing. He lay only on his left side. Moderate
cyanosis and marked sweating. No glandular enlargement. Pupils
6o4
DIFFERENTIAL DIAGNOSIS
and reflexes normal. Abdomen negative. The heart-rate was
between 120 and 130 for the first three days in the hospital (Fig.
223).' The heart sounds were feeble, and during inspiration many
beats were nearly or completely obliterated at the wrist. The whole
left side was dull, especially in the upper half, and there were many
coarse r&les over it and over the precordia as well. Fremitus was
generally diminished in the lower half, increased in the upper half.
There was amphoric breathing under the left clavicle. The right
border of cardiac dulness extended 7 cm. beyond the median line.
White cells were 11,500 at entrance and remained in that vicinity for
the next month. The urine showed nothing abnormal except at
Fig. 224. — Sketch from x-ray plate June 4th.
times a slight trace of albumin. The sputa was examined repeatedly
for tubercle bacilli, but they were never found. Among the various
organisms seen pneumococci predominated. Dr. F. T. Lord con-
sidered the case one of mediastinal new growth, but later inclined
toward pericardial effusion. Dr. W. H. Smith considered it medias-
tinal tumor. Within a couple of days of entrance a very marked
edema appeared on both sides of the neck, also a massive soft edema of
the tissues in the region of the left breast. The right arm was enor-
mously swollen, and there was a network of dilated veins over the
front of the right shoulder. The arm was also tender and red, so that
a lymphangitis was suspected, but this swelling gradually went down
SWELLING OF THE ASM
60s
without interference. On the 28th I noted that the duhiess in the left
ches.t was nowhere extreme, but moderate, with a shade of tympany.
The breathing was bronchovesicular, not bronchial. R&les innumer-
able, sharply crackling. The patient seemed at that time better.
June ist, the heart soimds were clear but feeble, the arm much less
swollen; he was stronger and could turn in bed better. The cardio-
hepatic angle was still markedly obtuse. In the left back, near the
angle of the scapula, and in the lower left axilla there was broncho-
vesicular breathing with diminished fremitus. Above that point the
breathing was nearly normal. June 2d, additional history was ob-
Fig. 225. — Sketch from A;-ray plate June sth.*
tained from the patient's physician, who stated that the patient
had been drinking heavily before the onset of his illness and that there
was marked precordial pain at that time; that three weeks ago his
present dyspneic condition came on, together with pain in the lower
thorax. At that time signs of solidification were found at the left base,
together with a mitral systolic murmur. Under the physician's obser-
vation the heart sounds changed from loud and strong to distant, rapid,
and weak in the course of seven days. X-ray (Figs. 224, 225) showed
an immense shadow filling the mediastinum, much wider at the bottom
than at the top. The right border of this shadow was believed to be
dufe to the heart and great vessels. The cardiohepatic angle was
6o6
DIFFERENTIAL DIAGNOSIS
obliterated. The left border of shadow was less distinct, but suggest*
a cardiac outline more than anything else. Diagnosis, probably peri-
cardial effusion, possibly dilated heart. June tath the heart showed no
murmur and had a feeble tick-tack quality. Sounds loudest near the
ensiform. The edema of the neck had then disappeared, but was still
very marked in the tissues about the left nipple and axilla and in the
abdominal wall. June 14th the precordial dulness extended 18 cm.
to the left of the median line and 8 cm. to the right (Fig. 3j6).
The diagnosis at this time lay between pericardia! effusion and a
dilated heart, with intracardiac thrombosis. I inclined to the latter,
—Percussion outlines in Case *68.
but as the man was getting worse, and we desired to exclude the
possibility that his decline was due to a removable pressure about the
heart, a needle was injected in the fifth left interspace, i cm. inside the
nipple line at right angles to the chest wall. No fluid was obtained
until the needle had passed 4^ cm. and had traversed a fimi
ant tissue. Then 1400 c.c. were withdrawn before the flow stoj
Toward the end there was a marked improvement in the patient'
pulse and a faint impulse palpable upon the cannula with each heart-
beat. The last 500 c.c. of the fluid showed a slightly reddish tinge,
the rest of the fluid dark straw color. The specific gravity was loi
tained^H
resistf^l
SWELLING OF THE ABM 607
albumin, 3^ per cent.; sediment: polynuclears, 54 per cent; lympho-
cytes, 46 per cent. Culture showed no growth. Twenty minims of
the sediment injected into a guinea-pig June 14th. July iQth the pig
was killed. Autopsy showed tuberculous lesions of the glands, liver,
and spleen. In reaching this fluid the needle entered at a point 15 cm.
from the median line, though it was inside the much displaced left
nipple. The needle-point was directed toward the median line, and
entered first an inch of solid tissue, then went more easily, then pene-
trated a resisting wall and reached the fluid. During the tapping the
Fig, IJ7. — Percussion outlines and other signs in Case
right border of cardiac dulness moved considerably toward the median
line and the paradoxic pulse disappeared. Next day the right border
of dulness was 3 cm. nearer the middle line than before tapping. The
paradoxic pulse returned soon afterward and the patient was much
distressed by cough. On June 226 the bronchial element had disap-
peared from the left chest and the edema was gone. He moved
strongly in bed, his pulse was slower and no longer paradoxic, he slept
without drugs, had a nearly normal temperature, a pulse of So. and was
anxious to get up. On June 29th the pericardium seemed to be re-
tilling. The outline of dubiess is shown in Fig. 227. July 3d there
6o8 DIFFERENTIAL DIAGNOSIS
was a sharp pain in the right chest and a friction rub was heard over
the upper part of the liver duhiess. The liver now reached to the level
of the umbilicus. The heart soimds were again distant. X-ray was
interpreted as pericardial effusion. On the 3d of July he had a sudden
attack of collapse, with cold extremities and almost imperceptible
pulse. The next day his pericardium was tapped at the same part
as before and a cavity reached, but only a few cubic centimeters of
bloody fluid obtained. There was no flow of air through the cannula
with respiration. The needle was believed to be in the pericardium.
On the 7th he began to have bloody sputa, increasing weakness, and
mental confusion, and on the nth he died.
Discussion. — ^Although we were long in doubt as to the correct
diagnosis in this case, we finally settled down upon the belief that peri-
cardial effusion was the most important element in it, and the results
of paracentesis confirmed this. Animal inoculation showed that the
pericarditis was of tuberculous origin. Although he had been so
desperately ill throughout the whole of Jime, it seemed toward the end
of that month as if he were going to get well. At that time we did not
know the result of the animal inoculation. Presumably he had tuber-
culosis, not only in his pericardium, but elsewhere, and his death was
due not only to cardiac weakness, but to infection.
Edema of an arm in connection with large pericardial effusions has
been repeatedly observed. Presumably in this case it was due to
thrombosis with a large venous trunk. I will call attention to the
enormous amount of fluid withdrawn from his pericardium, which cer-
tainly must have been gradually distended for a long period in order
to contain so much.
Case 269
An Italian housewife of fifty-three entered the hospital April 25,
191 2. The patient has six healthy children and has had no miscar-
riages. For a long time she has noticed dyspnea on exertion and can-
not climb stairs. Otherwise she has been well. She takes a little
wine, but not every day, and no hard liquor. For the past month,
since she has been in this country, she has been in bed with increased
dyspnea, swelling of the feet, of the left arm, and of the abdomen.
Her appetite remains good and she feels well in other respects.
Physical examination showed emaciation and enormous enlarge-
ment of the abdomen. Pupils and reflexes normal. Heart's impulse
in the fifth space in the nipple line. Sounds rapid and irregular;
no murmur. Pulmonic second accentuated. Artery walls palpable.
SWELLING OF THE ASM 609
Lungs show coarse riles throughout. Abdomen showed shifting
duhiess in the flanks and the suggestion of a mass in the right upper
quadrant. Very marked edema of the legs. Urine, 25 oimces in
twenty-four hours, with a specific gravity of 1020 and occasional hya-
line casts. Blood normal. Blood-pressure was essentially normal.
Wassermann reaction negative. The feces contained an 8-inch roimd
worm, otherwise not remarkable. The abdomen was tapped and
46 oimces of pale yellow fluid obtained, with a specific gravity of 1009,
and the sediment containing 46 per cent, endothelial cells and the
remainder lymphocytes. On account of the low gravity of the fluid,
without evidence of cardiac or renal disease, a diagnosis of cirrhosis of
the liver was made, but within four days the liver edge could be easily
felt. After tapping, it receded rapidly and the heart continued to be
irregular in force and rhythm. Mitral stenosis was, therefore, sug-
gested. May 5th the arhythmia continued absolute. The pulmonic
second accentuated, the first sound sharp. The disproportionate
ascites, in comparison with the edema elsewhere, suggested adherent
pericardium. Calomel, 3 gr. every four hours, was given May 8th,
after digipuratum, diuretin and purgation, and salt-free diet had
failed to increase the output of urine. After the calomel had been con-
tinued for three days it was omitted. On the next day 40 ounces of
urine were passed and the dropsy rapidly subsided. May 27th there
was no ascites or edema. The heart was slow and regular, the first
sound doubled, and a slight presystolic murmur was heard at the apex.
The edge of the liver was still palpable, but smooth, and even at the time
of discharge, June 3d, the organ extended to the level of the umbilicus,
but its dulness began at the costal margin. She left the hospital June
3d, but re-entered June 12th, with a return of all the symptoms. The
day after this second entry she was exceedingly nauseated. Every
other beat of the heart was strong, the intermediary beat not reaching
the wrist and being followed by a compensatory pause.
Discussion. — No one could be blamed for making, as we did, a
diagnosis of cirrhosis during the early stage of this patient's illness,
although we were quite aware that some cardiac disease existed in addi-
tion to the liver trouble. With the prompt recession of the liver edge,
this diagnosis began to seem very improbable.
What causes for ascites remain? The tap-fluid was obviously a
transudate or dropsical effusion. It could not be explained by tuber-
culous peritonitis or neoplasm of the peritoneum. The kidneys showed
too little disease to explain it. We must fall back, therefore, upon the
heart as the cause of ascites. Now, the one cardiac lesion which we
Vol. 11—39
6lO DIFFERENTIAL DIAGNOSIS
have grown to recognize as a cause of ascites without any proportionate
degree of edema in the legs is adherent pericardium. This disease
ultimately becomes associated with a capsular liver cirrhosis and leads
to many a mistaken diagnosis in interstitial hepatitis.
The presystolic murmur and cardiac irregularity may well have been
due, as we supposed, to mitral stenosis, a lesion not infrequently com-
bined with pericardial adhesions.
So far I have said nothing whatever regarding the swollen arm.
Presumably, it is due to phlebitis.
Outcome. — The patient began to be much disturbed mentally,
refused medicines with violence, and could not be quieted. She left
the hospital on the i6th.
Case 270
With an uneventful history and inheritance a clerk of forty-six
entered the hospital June lo, 1912, complaining that about two months
ago both hands became rather suddenly swollen, the skin red, rough,
and covered with cracks and scales. There was only slight itching and
no known exposure to local irritants. He felt otherwise well, but had
to stop work because of the appearance of his hands, and since that has
been steadily losing weight and strength. His appetite is gone, and
he lives on eggs, milk, and bread. He has a constant dull pain in the
upper abdomen, without relation to food. His bowels are slightly loose,
moving twice a day. His flow of saliva is increased, especially at
night, and he has a bad taste in his mouth. On exertion he is short of
breath and his feet swell during the day. His head feels dizzy and his
eyesight is poor. He passes urine once or twice in the night.
Physical examination shows poor nutrition, swelling of both hands
and wrists, with a patchy deep red coloration and some small whitish
areas where the epidermis has come off, leaving a clear surface beneath.
Small exfoliating areas are seen near the nasal fold on each side. The
abdomen shows slight tenderness and spasm, especially in the epigas-
trium. Physical examination, including blood and urine, otherwise
normal. Systolic blood-pressure, no. No fever in two weeks' ob-
servation. Stomach-tube shows no contents in the fasting stomach
and no free HCl after a test-meal. The patient states that for several
years he has had attacks of indigestion in the springtime, lasting a day
or two, but never severe enough to be remembered without cross-
questioning. With the onset of his present skin lesions there was
loss of appetite, soreness of the mouth, and a mild diarrhea. He has
also had tingling sensations in his legs and feet, relieved by rubbing.
SWELLING OF THE ASM 6ll
When seen in the Out-patient Department there seemed to be a
noticeable disturbance in mentality: excitement, emotionalism, and
weakness. The skin lesion consists of a dry, cool eczema of the hands
and wrists, i to 4 cm. above the wrist-joint. Underneath a ring, re-
moved by the patient July 13th, the skin is fresh and soft.
Discussion. — ^Although both arms were involved in this case, I have
included it because of its unusual diagnostic interest. Clearly the
edema is to be attributed not to intravascular or mediastinal causes,
but to the local lesion. The association of this with diarrhea, indi-
gestion, and mental symptoms strongly suggests pellagra. Indeed, I
know of no other diagnosis which can be called upon to explain such a
clinical picture. If any other diagnosis is made, we have to suppose
that there are two or more separate diseases, such as eczema and
dementia paralytica. We have no evidence of this, and should en-
deavor, if possible, to bring all the facts under a single explanation.
Outcome. — The patient was seen by Dr. C. P. Ward, of Atlanta,
who foimd no doubt of the diagnosis of pellagra. Investigation of the
patient's home conditions showed that he was peculiar, and could
not get along with his neighbors or employers. He says that he is
always trying to spit poison out of his mouth. There was nothing pe-
culiar about his diet, and no reason to believe that he had partaken
of any spoiled cereals. He was discharged on the 24th of July.
CHAPTER XVI
DELIRIUH
It is hard to define delirium. Ordinarily, we are content to say
that it is the sort of rambling, incoherent talk which patients have
during the height of pneumom'a or in acute alcohoUsm; but we also
recognize that in insanity the same phenomena occur without any
infection or fever. We distinguish delirium from the irrational, in-
coherent talk of the psychoneurotic or the hysteric. The latter pa-
tients put more of will and intention into what they say. The truly
delirious patient is thought of as entirely unaware of what he is say-
ing. Whether these distinctions can be strictly maintained or not,
the foregoing is probably as definite a statement of our present usage
of the word delirium as can easily be made.
Using the word in this sense, we must note, first of all, that children
become delirious on very slight provocation, as the result of a cold
or even a digestive upset. In them the phenomenon is doubtless in
some way connected with their greater liability to sleep walking
and to talking in their sleep. Their mental stability and balance is
more easily disturbed than that of the adult.
Next to the transitory deliria of the slight childhood illnesses,
alcoholic delirium, or delirium tremens, is probably the most com-
mon. This is often characterized by hallucinations of sight. Animals,
and especially black animals, are more frequently seen than other
objects.
Among infectious diseases, pneumo^iia is most often assodated
with delirium of an active type. In typhoid the deUrium is quieter
and the patient is easily roused from it.
Of special interest are the postinfectious deliria and psychoses,
which are to be differentiated from most other acute psychoses by
their better prognosis. Doubtless these are closely akin to the
psychoses of the exhaustion type seen after surgical oj>erations, and
often called postoperative psychoses.
In uremic states and in cerebral arteriosclerosis one sees various
types of mental disturbance, and in the acuter and more serious forms
typical delirium may be present.
612
DELIRIUM 613
During the treatment of a case of acute rheumatism, and in any
other disease which involves the free exhibition of salicylates, one
must remember that these salts are capable of exciting an active
deliriimi, the source of which is often not recognized. Next to sali-
cylates, belladonna is the commonest source of a drug delirium.
In acute anemia, after hemorrhage and shock, periods of delirium
are often seen, not only in fatal cases, but in many that recover.
All of the above types of delirium are to be distinguished from
those which occur in the course of those chronic psychoses to which
we give collectively the name of ** insanity " and of which I shall not
attempt to speak. For practical purposes, it seems to me that it is
especially important that the physician should be able to distinguish
true delirium from the manifestations of hysteria. This distinction
is aided by every observation which helps us to recognize the other
features of hysteria: the cause and mode of onset, the previously
recognized characteristics of the patient, the association with con-
vulsive or pseudocomatose states, the presence of hemianesthesia,
and other stigmata of hysteria. So far as the delirium itself is con-
cerned, it is distinguished from the incoherence of the hysteric in
that the latter has usually a predominance of emotion, and especially
of rapidly shifting emotion. The hysteric can usually be aroused,
that is, made to talk with comparative rationality if the appropriate
stimulus can be applied. The older and more brutal way of applying
this stimulus was to throw a bucket of water over the sufferer. Often,
however, the right appeal to the patient's central or true personality
can be found and used by one intimate with the patient. In true
deliriimi this is impossible, and nothing that we say makes any special
difference.
Case 271
An Italian laborer of twenty-one entered the hospital November
16, 1912, in delirium; no history was obtained. The patient was
poorly nourished, and had a curious contraction of his facial muscles,
suggesting risus sardonicus. The left pupil was much larger than
the right. Both were circular, but reacted only slightly to light.
Accommodation could not be tried. The tongue was not seen on
account of trismus, possibly voluntary. The epitrochlear glands
were felt, but there was no demonstrable enlargement of any gland.
The heart was negative, the pulse not dicrotic. The lungs negative.
The abdomen level, tympanitic, held somewhat rigidly; no other
abnormality. The spleen was definitely enlarged to percussion, but
mw
1^
614 DIFFESENTIAL DIAGNOSIS
its edge not felt, perhaps on account of muscular spasm. The lower
end of the right kidney was palpable, but not tender. There was no
costovertebral tenderness. Knee-jerks were not obtained. There
was no ankle-clonus or Babinski. Kemig's s^ was questionable
on both sides; the neck was not stiff. There was no bone or muscle
tenderness.
The Widal reaction was suggestive, but not positive. Blood-
culture negative. Wassennann reaction negative. Leukocytes, 6900;
polynuclears, 88 per cent.; lymphocytes, 12 per cent. Temperature
as in Fig. 228. The amount of urine could not be
determined, as it was passed involuntarily. The
specific gravity was ro24; albumin, slight trace. A
few granular casts and red blood-corpuscles were
found in the sediment. The spinal cord was tapped
and 10 c.c. of blood-tinged fluid withdrawn under
slight pressure. On account of the admixture of
blood, examination of the sediment was unsatis-
factory. Fundus oculi was normal, the cornea
coated with a film of mucous secretion. A slight
amount of bloody and purulent sputum was ob-
tained which, on examination, showed nothing »g-
nificant. No diagnosis as yet.
November i8th a sister-in-law was communicated
with, who stated that the onset of the dsease had
been sudden, with pains all over the body, especially
in the back of the neck, elbow-joints, and knee-
joints. These symptoms began with a chill nine
Case 171. days ago. The patient is unmarried and has been
in this country two years.
The cultures from the spinal fluid were negative. A second
attempt at spinal pimcture was imsuccessful. The needle seemed
to be in the spinal canal, but no fluid was obtained.
Discussion. — Clearly, this is the delirium of an infectious disease.
The only question is, what infection? The curious contraction of
facial muscles made us fear tetanus, but as time went on this disap-
peared and nothing else appeared to suggest that disease. Had the
Widal reaction been positive, one would have no hesitation in calling
the case one of typhoid fever, although the increased percentage of
polynuclear cells and the absence of any leukopenia are atypical for
typhoid. Nothing in the examination of the nervous system sup-
ports the idea of meningitis.
DELIRIUM 615
The sudden onset with chill might have occurred in malaria, but
we searched without success for any parasites. Up to the 19th of
November our diagnosis was wholly imcertain.
Outcome. — On the 19th a number of red macules and papules,
about 2 mm. in diameter, appeared upon the trunk and abdomen and
the Widal reaction in the blood was positive. The patient was con-
stantly delirious and noisy. On the 21st a third attempt was made
at spinal puncture without success. The patient died the same night.
Autopsy showed the lesions of typhoid fever with double otitis media
and focal pneumonia of the left lung. In the pelvis of the left kid-
ney was a stone occluding the ureter and producing hydronephrosis.
The other kidney was normal. Chronic perihepatitis and perisplenitis.
Case 272
A merchant of fifty-five was seen in consultation December 11,1912.
He had always been well, although nervous, until ten days ago, when
he had chill and fever, rusty sputum, and the ordinary signs of solidi-
fication at the right base. For five days he continued desperately ill,
then his temperature dropped to normal, but, to the surprise of all con-
cerned, he began then to be delirious, and has continued so ever since
despite a persistent normal temperature. The pulse has ranged be-
tween 100 and 1 20, and has at times been very irregular. He has taken
food well, but has had moderate abdominal distention throughout
the illness.
At the onset of his delirium he had incontinence of feces. He
has now regained control of the sphincter. The attending physicians
are in doubt as to the condition present at the bottom of the right
lung.
On examination the patient is drowsy and has respirations still,
40 per minute, formerly 48. He looks more than his age, but at the
time of the examination was rational when aroused from his nap.
He moves with difficulty and seems greatly prostrated. At the top
of the right lung, as low as the level of the second rib, there is flatness
on percussion, with distant bronchial breathing. In the back this is
accompanied by coarse crackling r&les, which are more numerous in
the lower half of the lung. Below the level of the second rib in front
the percussion note is short, but low pitched, with a shade of tym-
pany. The left lung showed nothing but a few scattered r⩽ the
pulse is 100 and regular. The heart is negative. The blood-pressure
is not measured. Save for moderate abdominal distention the phys-
ical examination is otherwise negative.
6l6 DIFFERENTIAL DIAGNOSIS
Discussion. — Meningitis had been seriously considered by the
attending physicians, but against this was the absence of any stiff neck,
Kemig's sign, or ocular changes. The absence of headache and fever,
at the time when cerebral symptoms were most marked, suffices, with
the other data just mentioned, to exclude meningitis.
Were he an alcoholic, one might have interpreted the delirium
as delirium tremens, even though no trembling was present to sub-
stantiate the title; but the history was reliable and excluded this
possibility. The condition was clearly not a hysteric one. At his
age such things do not arise de novo.
The ordinary psychoses are not apt to arise in such close connec-
tion with an infectious disease. Hence, the remaining possibility—
postinfectious delirium — seemed the most reasonable diagnosis. This
was explained to the family and a good prognosis was given.
Outcome. — February 25, 1913, the patient writes that he is
perfectly well in essential respects, although he has been somewhat
slow in recovering his strength. The attending physician tells me
that the delirium cleared up about a week after I saw him.
Case 273
A farm laborer of advanced years consulted his dentist early in
March for a supposed toothache on the left side of the upper jaw.
The dentist pulled two teeth without relieving the pain, which later
spread over the left side of the head and was specially severe at the
vertex. At this time the patient had no other symptom except an
increasing weakness and confusion, which did not prevent him, how-
ever, from continuing to do his work upon a farm, though many of his
days were short ones. About six weeks after the onset of headache he
returned one day from his work in a state of mind which alarmed his
wife. He did not seem to recognize her and talked wildly and inco-
herently. He was removed to the nearest hospital the same night,
where I saw him next day.
He was mumbling and rambling in his talk as I approached his
bedside. As he was an old friend of mine, I spoke his name sharply,
at which he roused, recognized me, and burst into tears, evidently
affected by the contrast between his present condition and the ruddy
health in which I had always met him before. The left pupil was much
larger than the right; the tongue was protruded somewhat toward
the right side of the mouth. The right knee-jerk was increased,
and there was a Babinski reaction in the right foot. During a week's
observation there was no fever or leukocytosis. Wassermann reac-
DELDOUM 617
tion was not tried. His speech, as he responded to my questions,
was slow and difficult to understand. Single words were repeated
monotonously, and before I left him he drifted off again into inco-
herent talk. The systolic blood-pressure was 180. The heart was
somewhat enlarged, but not otherwise remarkable. There were many
crackling r^es scattered in both backs. The fimdus oculi, examined
by an expert on the previous night, showed no important changes,
though the arteries were markedly sclerosed, as were those in the arm
and groin. He no longer complained of headache, but became more
and more helpless and hemiplegic. Three days later his sphincters
became relaxed, and on the fourth day he died. There was no
autopsy.
Discussion. — ^At this patient's advanced age it is natural to at-
tribute almost any cerebral symptoms to arteriosclerosis. Brain
tumor is almost the only plausible alternative. The absence of more
distinct focal changes and of optic neuritis and the presence of hemi-
plegia are more characteristic of arteriosclerotic brain trouble than
of tumor.
The chief point of interest in the case is the onset with delirium,
rather than with aphasia or coma. Just what went on within his
brain we never shall know. It seems to me probable that throm-
bosis and softening were the cause both of his initial headache and of
his subsequent delirium.
Case 274
On the i8th of February, 1913, I saw in consultation a married
woman of thirty, who had always been perfectly well except for an
attack of typhoid fever twelve years before.
For the past two months she has been somewhat run down. Febru-
ary 12 th she was taken with sore throat and pain in the left side of the
chest, a temperature of 103.5° F., pulse 160. The tonsils showed the
ordinary appearance of follicular tonsillitis, but the amount of pain
was unusual. By the 15th the throat was much better, temperature
loi*^ F., but the doctor noticed at this time a peculiar odor, suggesting
that of the postmortem room.
Next morning, February i6th, she woke in active delirium, with
religious delusions, with bad pulse, a scanty urine, yet with a tempera-
ture of only 99.5*^ F. During the next twelve hours only 10 ounces of
urine were passed, although she was taking food very fairly and com-
plaining of no headache or other form of distress. No atropin or bella-
donna had been given her. She had received aspirin, 5 gr., three times
6i8
DIFFERENTIAL DIAGNOSIS
a day, and infusions of digitalis, ^ ounce, every four hours for the past
three days, with strychnin, ^ gr., four times a day.
On examination she showed good color and nutrition. Teeth and
chin like those of a rabbit. She lay upon her back with closed eyes,
twitching eyelids, and hands tightly clasped across her chest. Her
breathing was slow and regular, her heart-beats 60 to the minute, with
a slight irregularity apparently of the sinus type. Save for a systolic
munnur at the apex the heart was otherwise negative, likewise the
lungs and abdomen. The neck was not
stiff. The reflexes were excellent. The
pupils were large, equal, and reacted
normally.
When I saw her the patient was con-
scious and would put out her tongue
and answer simple questions, but showed
no initiative. Her temperature and
pulse ranged as in Fig. 329. Subse-
quent conversation with her husband
ehcited the fact that in the previous
summer, while away from home and her
two children, she had become acutely
homesick, and after her return remained
still morbid and not as bright as before.
Just before the present illness there had
been some question of her going away
from home a second time. About this
time she had been greatly ups^t.
Discussion. — Meningitis can be easily excluded by the absence
of physical signs ordinarily associated with it. Uremia had been
seriously considered by the attending physician, but when I saw her
the urine was normal in quality though diminished in amoimt, and
warranted no such diagnosis. There was a good deal in the physical
state when I first saw her to suggest hysteria. The character of her
previous delirium, and the immediate sequence of her mental symp-
toms upon the fall of temperature during an acute infection, seemed to
me to warrant the diagnosis of a postfebrile psychosis.
Suspicion of more serious mental derangement, based upon her
previous attack of homesickness and morbidity, did not seem to me
well founded.
Outcome. — On February 27th her phyddan reported that she had
steadily improved since the iSth and was now in excellent 0
Fig. 139, — Chart of Case ^74.
DELERIXJM 619
Case 275
On the 27th of February, 1913, a girl of nineteen was seen in con-
sultation with her attending physician. Although always anemic and
irregular in her menstruation, she had been considered a healthy, bright
girl until two weeks ago. Her family history was excellent.
Two weeks ago she had a normal appendix removed. The con-
valescence seemed, for the first ten days, perfect. There was no fever
or other imtoward symptom. Then appeared what the doctor called
"insanity" and headache. Her motions were largely resistive and ster-
eotyped, a favorite action being to start up with the remark, "IVe got
to go and meet the doctor." She was disoriented and recognized no
one. At times she seemed to be Uving over again the experiences of
the etherization. Thus she would say, "They make you lie still and
tell you to breathe deep," etc. At other times she would say, "Sh-sh-
sh," with a semistammering articulation, as if trying to form words.
Again she was tearful and anxious, grasping the doctor's hand and
asking, "Are you mad with me? You are not mad with me, are you?"
The words and motions just referred to had been repeated again and
again, day and night, for the past five days.
Physical examination showed pallor; hemoglobin, 65 per cent.; a
negative chest and abdomen, save for some tympany in the latter.
The legs were spastic, and showed at times a coarse tremor approaching
clonus. The eyes and neck seemed normal and there was no paralysis.
The fimdus examination had previously been made and was negative.
The chart showed absolutely no fever and the leukocytes were not
elevated. Her only complaint was the pounding sensation at the
base of her skull on the left side, and it was remembered that she had
had trouble with her ear for a long time, and had complained at times of
deafness, although at other times this was wholly absent, and she said
only that she felt as if something were growing in her ear.
During the five days that have passed since the abnormal mental
condition first showed itself she has slept hardly at all and eaten but
little, refusing food for the most part. The systematization of her de-
lusions, as above described, has been most marked in the last two days;
ofiF and on she seems quite normal, but if she chances to sleep a little
she always wakes "insane." To speak sharply to her often rouses
her and makes her for the time being quite normal.
From time to time throughout these five days she has breathed
with great rapidity, but has had no cough or true dyspnea. She moves
easily and strongly in bed and has had no incontinence of urine or feces.
The urine is normal.
620 DIFFERENTIAL DIAGNOSIS
Discussion. — Meningitis can be ruled out by the absence of fever
and leukocytosis. The tendency to resistance and stereotypy makes
it necessary to consider dementia praecox, but no such diagnosis is
warranted until a longer time has elapsed. This is something to fear,
and not yet to exclude. The onset of the symptoms immediately after
the operation gives groimd for doubting whether anything so serious is
present.
The tendency to live over again the experiences of etherization is
what one might expect in hysteria, and the physical condition is quite
consistent with that idea; but, if it is true that she has previously been
a perfectly normal girl and these symptoms never appeared until after
the operation, it seems to me more reasonable to make some diagnosis
which can be connected directly or indirectly with the operation itself.
Two possibilities suggest themselves: since she is a chlorotic she is more
than ordinarily liable to cerebral thrombosis (sinus- thrombosis), and
since any type of thrombosis is more apt to happen after an opera-
tion, such a lesion might conceivably have occurred. Against this,
however, are the absence of all focal symptoms, unless the sense of
pounding in the back of the head is taken as such, which would be, I
think, a mistake. \
On the whole, the most reasonable diagnosis seems to me that ol an
exhaustion psychosis or postoperative psychosis, such as is the terror of
all surgeons who remember its possibility. Nevertheless, the majority
of such psychoses entirely clear up, and a good prognosis may, therefore,
be given in such cases.
Outcome. — A letter received from her doctor states that "on the
loth of March, at ii p. m., she said she felt something wind up in her
head and then break, and immediately her reason came back and she
recognized every one who came into the room. After that she com-
plained of headache, especially at the back of the head, and would often
throw her head back with a jerk and arch her back. I gave her a good
talking to, told her she must stop it, which she did, although her neck
was quite lame for some time after that. She is now perfectly well
mentally. She gets up each day and practices walking, although her
legs are so weak that she can scarcely use them. She looks finely and
has no temperature."
Remarks. — This outcome seems to suggest that hysteria was the
correct diagnosis — hysteria of the postoperative type — but I should
still be doubtful of it unless some history of previous attacks or mani-
festations can be obtained.
DELIRIUM 621
Case 276
In the spring of 1893 ^ patient was brought in a cab to the Massa-
chusetts General Hospital, fighting maniacally with his companion.
This was about 5 p. m. His companion stated that the patient had
been apparently perfectly well and at work as a day laborer that same
day at noon, when, without rhyme or reason, he suddenly went crazy,
and after some delay was conveyed to the hospital. After being put
to bed he soon became manageable, and slept a good deal of the evening
as well as the night. His temperature was 103.5° F. at entrance. His
pulse was not elevated, respiration normal. His leukocytes were not
increased. The only abnormal feature of the physical examination
was a palpable spleen. A preliminary diagnosis of typhoid fever was
niade. No Widal reaction was done, because in 1893 Widal had not as
yet done his epoch-making work. The next morning the temperature
was normal and the patient seemed dazed, otherwise almost well. This
sudden transition set us to hunting for malarial organisms in the blood,
and after an hour's search I was able to find a pigmented parasite in
violent motion. Quinin was at once administered in large doses, and
the patient was able to leave the hospital twenty-four hours later.
Discussion.— rThe case illustrates the clinical manifestations of that
overcrowding of the cerebral capillaries with malarial parasites which is
so familiar to students of tropical medicine who see autopsies in the per-
nicious forms of the disease. Almost any type of cerebral or mental dis-
ease, such as meningitis, apoplexy, or insanity, may thus be simulated
by a malarial infection, and whenever the temperature is high and the
leukocytes low in such a case one should do one's best to find a malarial
parasite.
CHAPTER XVII
PALPITATION AND ARHYTIDBIA
A NORMAL man is unconscious of his heart-beat except after violent
exertion or in periods of emotional strain. If he becomes oppressively
conscious of it at other times he has palpitation. The heart's action
may be irregular or simply forcible and rapid.
Usually palpitation and arhythmia go together, that is to say, the
heart-beat is especially noticed by the patient when it becomes irregular.
Mere force in the heart-beat, especially if it has been worked up to
gradually during the development of cardiac hypertrophy, is not often
noticed by the patient. What is distressing is a sudden change in
force or in rhythm, which is forced upon the patient's attention and in
greater or less degree alarms him. When a patient comes to us for
palpitation he usually has one of the following diseases:
(i) Thyrotoxicosis y in which the violence as well as the rapidity of
the heart's action attracts the patient's attention and causes alarm.
There is probably no disease in which we see such violent, noisy, and
spectacular heart action as in the thyroid intoxications with which
Graves' name is ordinarily associated.
I recently saw a patient who, in answer to my preliminary ques-
tions as to what ailed her, simply pointed to her violently jump-
ing carotids and said, "Don't you see?" That was her malady, so
far as she knew. Examination showed the ordinary signs of a
thyroid intoxication.
(2) Hypertension, due to arteriosclerosis or to chronic nephritis.
Sooner or later in this condition the patient is aware of violent beating
and throbbing, especially at night, when his attention is not otherwise
occupied, or when he stoops and then rapidly recovers his balance, or
after meals.
(3) Valvular heart disease, without hypertension, but with arhyth-
mia.
(4) Arhythmia, with or without gross cardiac disease.
Of the irregularities seen clinically in patients with obvious cardiac
failure, 60 per cent, are due to auricular fibrilkUion, and have the
characteristics ordinarily described as absolute or perpetual aihyth-
622
PALPITATION AND ARHYTHMIA 623
mia (Thomas Lewis). Taking all varieties of irregular heart, with
or without cardiac failure, Lewis gives the following figures:
Auricular fibrillation 40 per cent.
Premature contractions 35 **
Paroxysmal tachycardia, sinus arhythmia, heart-block, flutter,
and alternation 15 "
The most serious types of arhythmia are due to auricular fibrilla-
tion. The premature contractions are much less often of ominous
significance. The latter typ)e corresponds to the occasional skipping
of a beat, either at regular intervals or as an isolated phenomenon.
It may continue through life and give little or no trouble. The arhyth-
mia caused by auricular fibrillation produces a pulse in which no two
successive beats are alike. When it once begins it usually continues
during the rest of the patient's life, though that is not always the
case.
Sinus arhythmia means ordinarily the physiologic variation of the
heart's rate in connection with the act of breathing. The heart goes
more slowly during inspiration and more rapidly during expiration.
Li adolescence and in the nervous, this psychologic variation may be
exaggerated, but it does not usually trouble the patient or lead him
to consult a physician.
Most premature contractions can be recognized clinically by the
fact that they are followed by a pause of such a length that the pre-
mature contraction plus the pause is almost exactly equal in time to
two normal contractions.
Heart-block is to be suspected clinically in cases of very slow
pulse — 25 to 30 or thereabouts — whether or not this is associated
with apoplectic seizures. A certain diagnosis cannot be made with-
out tracings from the jugular bulb and from the radial simultaneously.
Paroxysmal tachycardia can usually be recognized by the extremely
rapid rate of the heart — 200 or thereabouts — without any disturbances
of rhythm and without any serious interference with circulation.
When the rate is much above 200 the name of **auricular flutter" is
given to it.
Alternation means the interposition of a small wave between each
two larger ones, with or without a disturbance of rhythm. It is to
be distinguished from coupling of the heart-beats, in which there is a
pause between each pair of cardiac contractions. Alternation can
lardy be recognized without a radial pulse tracing.
624 DIFFERENTIAL DIAGNOSIS
ETIOLOGY
Among the causes of arhythmia we may mention: (a) A failing
heart of any type, rheumatic, syphilitic, arteriosclerotic, or nephritic;
(6) the presence of any of the above diseases in the heart, without
cardiac failure; {c) drugs, especially tobacco; {d) nervous influences.
Of the four well-recognized types of arhythmia, only two are
often noticed by the patient — ^namely, the premature contraction or
extra systole and the absolute or perpetual type of arhythmia. The
sinus irregularities of adolescence are seldom noticed unless they are
greatly exaggerated by some neurotic condition or by bad hygiene.
The most marked cases of this kind are usually in those who have
subjected themselves to sexual excesses without venereal disease.
Tobacco and alcohol and coffee play a much smaller part in rendering
the heart and the patient so irritable that sinus irregularities — that is,
the variations in rate which are associated with respiration — ^become
troublesome. Heart-block is so rare an affection that it need not be
further mentioned here.
SUMMARY
For practical purposes, then, we may say that a person who com-
plains of palpitation suffers in the vast majority of cases either from
thyrotoxicosis, from hypertension, chronic valvular disease, from
an absolute ar^iythmia, however produced, or from frequent pre-
mature contractions of the heart.
The pause following the latter type of irregularity is usually the
thing which most alarms the patient. It often awakens him from
sleep with a sense of falling or of great apprehension, sometimes of
suffocation, although the circulation is perfectly well performed in the
vast majority of such cases.
In the types of palpitation associated with valvular disease this
particular symptom is usually overshadowed by dyspnea, insomnia,
and other manifestations of the same lesions; hence, there are really
but three conditions in which the patient often consults us for palpi-
tation: thyrotoxicosis, hypertension, and nervous states.
Case 277
A Russian housewife of fifty-two entered the hospital April 2i»
1906. Last winter the patient began to notice attacks of palpita-
tion of short duration, occurring every week or two. Lately the
attacks have been more frequent; otherwise she has always been well
and has an excellent family history.
Types of Cardiac Disease
BOTH SEXE5
RHEUMATIC a^^B^^l^^^H
NEPHRITIC ^^^^^^^^^HH
ARTERIOSCLEROTIC Mi^i^ai^^^^^
SYPHILITIC
DOUBTFUL CASES
GOITER HEART
RHEUMATIC
NEPHRITIC
ARTERIOSCLEROTIC I
SYPHILITIC
DOUBTFUL CASES I
GOITER HEART I
RHEUMATIC J
NEPHRITIC I
ARTERIOSCLEROTIC |
8YPHIUTIC I
DOUBTFUL CASES I
GOITER HEART I
PALPITATION AND ARHYTHMIA 625
Physical examination, save as relates to the heart, was negative.
The heart's dulness extended ^ inch outside the nipple line in the fifth
si>ace. Its action was irregular and intermittent. A soft systolic
murmur was occasionally heard at the apex. Blood and urine nega-
tive. It was later learned that she had been taking six to ten cups
of tea a day. After a week's observation, the pulse ranging most of
the time between 80 and 90, she was allowed to leave the ward, al-
though the heart was still slightly irregular.
Discussion. — I have searched the best I can through hospital records
and private records for a case illustrating a cardiac neurosis with pal-
pitation as a result of excessive tea-drinking. This is the best case
that I can find, yet it does not seem to me that it will bear criticism.
It is notable that no blood-pressure measurement is recorded, but
my impression is that it would have been found to be elevated. The
persistence of the irregularity after a week's separation between the
patient and her tea seems to me to make it improbable that the tea
was really the cause of her heart trouble. It is not at all likely that
she has but recently begun to drink an excess of tea, yet at the age
of fifty-two she is able to say that her troubles have lasted less than a
year. A cardiac trouble, showing itself for the first time at the
age of fifty-two and associated with enlargement, intermittance,
and irregularity, seems to me, in all probability, due to some organic
disease, of which, in the present instance, arteriosclerosis or nephritis
seem the most probable causes. The Wassermann reaction should,
of course, be done.
Case 278
A Swedish musician of twenty-one entered the hospital Jime 10,
191 1. The patient's family history is excellent, previous history
also good, save for an occasional attack of tonsillitis, the last one
February, 191 1. Once or twice in the past summer- she spat up a
mouthful of pink sputa; no cough before or after. She now comes
to the hospital on account of rapid heart which she has noticed for
two months, at first only on exertion, but now even when she is quiet.
She also feels weak and cannot walk as she did. She has to lie down
in the afternoon. Her appetite, bowels, and sleep are normal and she
has lost no weight. Her eyes have not become more prominent, and
her odlais have grown too large rather than too small. She is very
fond at nuMic^ liJjgmac of expense has not been able to continue
"*^t year, and this has been a source
626
DIFFERENTIAI. DIAGNOSIS
Physical examination showed good nutrition, no tremor of the
hands, thyroid nonnal, systolic blood-pressure no, heart negative,
except for a rapid rate, 130 per minute, lungs and abdomen negative.
Reflexes normal. Blood and urine normal. No fever in three weeks'
observation. With rest and reassurance, an occasional hypnotic or
laxative, the patient gradually improved. Subcutaneous injections
of tuberculin, in doses increased i to 5 mg., were not followed by any
characteristic reaction. The pulse gradually diminished in rate
(Fig. 230). On the 26th she was allowed to go home.
Discussion. — Save for the rs^d
gain under treatment and the rapid
diminution in the rate of the pulse,
one might easily believe this
woman to be suffering from
Graves' disease, which sometimes
begins with tachycardia and no
other symptoms except nervous-
But it does not seem to me
at all probable that any such
trouble would quiet down within
a week. As a rule, months of rest
are necessary before much change
is to be seen.
Since the heart at present
shows nothing abnormal except
its rate, and since it settles down
with rest, one cannot well assume
that any of the four types <rf
cardiac disease — rheumatic, syphilitic, arteriosclerotic, or nephritic—
is present. The tonsillitis of February, 1911, and the pink sputa of
the past summer may indicate some more serious trouble, but at the
present time I do not see that we have any proof of it.
In all probability, therefore, we must attribute the heart-hurry to
nervous or moral causes, and continue in this belief until more can-
vincing evidence of organic disease ap[}ears.
Case 279
A maid of twenty-five entered the hospital October 30, 1911. The
patient has always been well except for acute indigestion, whidi
troubled her three years ago for a short time. During the past sum-
mer she was again nauseated in the hot ni^ts and vomited a few
FBfSSaS
-■-D^;-l
zi\y/t^
■i ■.^! i/t -.H-^i .z ^^
- i - ^7- -
\:h''^W----
-* ■ 5 —
Fig. 330.— Chart of Case 278.
PALPITATION AND ARHYTHMIA 627
times. She has always been strong and cheerful and has liked her
work. Her menstruation has been normal, her habits good.
A week ago she felt a queer sensation of pressure over the heart
during the afternoon. At one o'clock the next morning she awoke
with slight nausea and heaviness in the precordia. She vomited
almost at once, and was immediately relieved "of a load of sickness
around the heart," but at the same time noticed that the heart began
to beat with great rapidity, and this continued the rest of the night
and all the next day, the pumping distressing her very much. Dur-
ing this time she had brief spells of nausea, relieved by vomiting,
about every hour. The next night she slept and did not notice the
rapid heart action. The day after that she felt weak but comfortable,
and on the third day was up and felt well. That night (two nights
ago) the heart began to pound again, and has continued at top speed
ever since. She has remained in bed, feeling weak, sleeping Uttle,
but otherwise not imcomfortable. If she sits up she feels faint and
dizzy. Apparently there was no emotional stress of any kind at the
time of the onset of these symptoms.
Physical examination showed a healthy, well-nourished girl, in
profuse perspiration, with slight general tremor. Pupils and reflexes
negative, except the left knee-jerk was more lively than the right.
The rate of the heart when counted at the apex was about 200. At
the wrist it could not be accurately coimted. The apex impulse
was in the fifth space, i cm. inside the nipple line. The soimds were
very sUghtly irregular in force and rhythm. There were no murmurs.
Physical examination, including the urine, was otherwise negative.
Blood at entrance showed 15,500 white cells, 60 per cent, of which
were lymphocytes. Systolic blood-pressure, 105 mm. Hg.
Discussion. — There is nothing distinctive or definite about the
case until we come to recognize the degree of tachycardia. A pulse-
rate of 200, without considerable arhythmiaor signsof decompensation,
rarely means anything else than paroxysmal tachycardia. A heart
seriously weakened by any of the ordinary causes of heart disease or by
the toxins of infection never goes at such a rate in an adult. Its ra-
pidity, therefore, is really an encouraging sign. The diagnosis can be
clinched beyond reasonable doubt only in case the tachycardia ceases
as suddenly as it began and leaves the patient in fairly good health.
A case of thjn-otoxicosis with a heart of anything like this rapidity
would be in extremis. This patient is far too comfortable. The ner-
vous and organic types of cardiac malady practically never send the
Jbeart-rate beyond 160. Paroxysmal tachycardia may come on in full
628 DIFFERENTIAL DIAGNOSIS
health as the result of some trifling, often quite unrecognizable, cause;
thus, I have seen it in a young girl at the time of menstruation without
any important consequences beyond a few hours' discomfort.
It may also appear in a heart previously weakened by disease, but
only under these conditions has it any grave significance. Even then
the patient never dies during such an attack, and often enjoys many
years of good health thereafter.
Outcome. — Two hours after entrance the pulse was found to be 90,
and continued slow during the four ciays of her stay in the ho^ital.
Most of the time its rate was between 65 and 75. She was entirely
free from symptoms; her blood was normal, and she was accordingly
allowed to go home.
Case 280
A bookkeeper of twenty-three entered the hospital October 10, 1911.
For two years he has been troubled with attacks of palpitation and
nervousness. He has never been sick before. His habits are excellent.
His family histor>' is good. At first the palpitation came after meals or
during excitement, but the attacks have growTi steadily more frequent
and longer. During his worst attacks he feels weak and unsteady upcHi
his logs, but has no dyspnea. A year ago an attack took him just as he
was starting for a quarter-mile race, but he ran the quarter in fifty-four
sca>nds. He has a a^nstant N'ague sense of uneasiness and restlessness.
Small incidents often cause much emotional reaction, and when alone
in a cn>wd he has a curious sense of fear. Before the present illness he
is quite sure that ho was a mattor-of-fact person, never nervous or self-
c\>nsvnous. Ho has had several long vacations without benefit, but
usually fot^ls iHntor on Mondays, His appetite, bowels, and sleep are
normal. Ho has no fatigue and dix* his work as well as ever, although
for I ho jvist year thoro have Ixx^n brief sensations of hotness followed by
chillinoss and he has noticoil a trembling of his fingers.
rh\-sioal oxamination showovi a slight s\-mmetric enlargement of the
thyrvMd. iw^rso trt^mor of the nngors, normal \TScera, no exophthalmos.
Noninal Mixxl and urino. Weight , 1 40 poimds. I\ilse at entrance 1 10,
but alter that it rangc^i Knwcen 70 and 00, although he was not kept
in lH\i.
Discussion* Kvivicnily there is a stix^ng ner\*ous element in this
iaM\ hut the prosonoe of enlan^xl thxiv^d and tremor of the nngeis
makv's it 1 Icar that the nen\>u>ncss is of th\Toid origin and the pai)i-
tation iror.i the NAr.-jo Sv^ura^ I'^n^umaWv, there was a. time in the
pi\\vrTi"ss of this case x^hcr. rapid hc^n action and ner>*ousnes5 wt-re its
PALPITATION AND ABHYTHMIA 629
only symptoms, i. e., when no tremor or goiter were visible. At such a
time one could only make the diagnosis by the exclusion of all other
possibilities. In nervous people this is sometimes impossible.
Outcome. — Operation was considered, but decided against. He left
the hospital October 14th. In the spring of 1913 the patient reported
that he was a little better, but still unable to do his regular work. Ner-
vous tension, especially in cities or crowds, bothers him so much he says
he would walk a mile to avoid it. In the country he is practically all
right unless upset by some unusual excitement. When at rest he feels
fine, but during periods of heart-hurry may get into a panicky state,
especially if alone at night. His pulse is now 84, hands warm and moist.
His weight is 140 pounds, as it has been for the past four years.
Case 281
An Italian housewife of thirty-one entered the hospital October
21, 1911. The patient's illness dates from four months previously.
She has never been sick before this and has an excellent family history.
Four months ago she began to be troubled with ptUpitation and weak-
ness, and these symptoms have persisted since. Shortness of breath is
scarcely, if at all, present, but during the first three months of this pe-
riod die had much headache and ahnost daily vomiting, immediately
after meals. She had no edema at any time. A month ago she was
delivered of a gj-pound baby by an easy labor, but immediately after
it had urgent dyspnea and much aggravated palpitation. The baby
died a week later. The patient remained in bed ten days, then was up
imtil the past week, when she has again remained in bed, still vomiting
occasionally, but nearly free from headache. A week ago, and again
last night, she had an attack of violent palpitation and could not get
her breath. She has had no dizziness or fainting, no cough or edema.
Physical examination showed poor nutrition, rapid breathing, slight
cyanosis, normal pupils and reflexes, slight glandular enlargement in the
neck, axillae, and groins.
The heart's impulse was forcible and diffuse, extending 4 cm. out-
side the nipple, in the fifth space. There was no demonstrable enlarge-
ment to the right and no thrill palpable. A rough, loud, systolic mur-
mur was heard over the whole precordia, loudest at the apex, trans-
mitted to the axilla and back, A faint diastolic whiif was also occa-
sionally heard along the left border of the sternum. The pubnonic
second sound was moderately accentuated. Systolic blood-pressure
varied between 105 and 125 mm. Hg; diastolic between 80 and 95 mm.
I^. Blood and urine were normal. Lungs and abdomen negative.
630 DIFFERENTIAL DIAGNOSIS
No temperature during a week's observation. At times a low-pitched
presystolic murmur was heard at the apex and there was an occasional
complaint of precordial pain, but in most respects compensation seemed
to be excellent. No digitalis was given, and the patient went home on
the 27th. No Wassermaim test was made.
Discussion. — Physical signs point strongly toward valvular dis-
ease, and probably toward mitral stenosis. The patient is too young
for arteriosclerosis, shows no signs of nephritis or thyrotoxicosis, and
has never had a heart suiEciently rapid to be called paroxysmal tachy-
cardia. The unusual feature about the case is that she should have
been troubled first and chiefly by palpitation instead of by dyspnea.
The prognosis in such a case is good, as she has got by the dangerous
years for rheumatic heart. With moderately good care she ought to
live for many years, provided her heart trouble is, as I have assumed,
rheumatic and not syphilitic. A Wassermaim test would help to
determine the prognosis.
Case 282
A woman of fifty-five entered the hospital January 16, 1912. The
patient's mother died of shock, one sister at sixty of apoplexy, and
another sister at forty of shock. Two brothers died of consumption.
The patient's husband had a tuberculous throat, and died of a com-
bination of this and what was called typhoid fever. She has three
children living and well and has had one miscarriage. Twenty years
ago she had sciatica, which was obstinate and painful for two years,
but entirely left her after that time.
For the past six years she has had occasional pains in her knees and
hands, accompanied in the latter site by swelling and redness. For
the past two years there have been no acute symptoms in the fingers,
but stiffness and bony enlargement have been noticed. She had ner-
vous prostration twenty years ago. She passed the menopause thirteen
years ago without incident. One year ago she had a bad cough, lasting
six weeks, but without hemoptysis, night-sweats, or loss of weight.
For the past eight months she has been troubled by palpitation
and oppression in the chest, accompanying sensations of dyspnea.
Swelling of the legs and puffiness of the eyes have been present off and
on for four months. Her appetite has been increasingly poor and her
bowels obstinately constipated. She has become weak and indifferent.
She sleeps well with one pillow. Eight months ago she weighed 172
pounds, with clothes; now, 166 pounds, without clothes.
Physical examination showed good nutrition, flushed cheeks, puffy
PALPITATION AND ASHYTHMIA
631
1 NaIne___
i •* ^ -w
1 1 «« : II
[ I »» :
i~~'~~''t.
|trr
1":::::!:
:::::::
_Wari HosfNa-
^t^!&V*^'
rWt4bJ V^ Vac
Fig. 131. — Blood chart oi Case 1S2.
632 DIFFERENTIAL DIAGNOSIS
eyelids, a few urticarial wheals in the left upper chest. Pupils slightly
irregular, equal, and reacting normally. Heart's apex extends i cm.
outside the nipple. There was a soft systolic murmur over the entire
precordia, transmitted to the axilla. The puhnonic second soimd was
accentuated. Systolic blood-pressure, 140 mm. Hg. at entrance, de-
clining after a week to 120, where it stayed. Limgs were negative,
except for a few fine r&les at the right base behind. Liver dulness
extended from the fifth space to a point 3 cm. below the costal margin
in the mammary line, where a smooth non- tender edge was felt; other-
wise the abdomen was negative. There was edema of ankles and
over the sacrum. Knee-jerks present and equal. Heberden's nodes
were well marked. Temperature, pulse, and respiration were practi-
cally normal during the eight weeks of her stay in the hospital, except
for a flare-up in the last of February following injections of cacodylate
of iron. The data concerning the blood are shown in Fig. 231. In the
stained smear the red cells always showed a large amount of hemoglobin
and large size, with an occasional stippled or off-color cell. Glycosuria
was present for the first month of her stay, the output of sugar averag-
ing 10 gm. per day. There was no acidosis or polyuria. A slight trace
of albumin was usually present, with a few hyaline and granular casts.
Discussion. — The family history shows strong tendencies to arterio-
sclerosis and to tuberculosis, but neither of these diseases can be
predicted in view of the facts indicated. To make a diagnosis of
mitral regurgitation would be the ordinary procedure in such a case,
but such a diagnosis would never be justified. There must be some-
thing behind it — the ^'something'' of which the regurgitation, if it
exists, is symptomatic. The same is true of myocarditis, the tra-
ditional term on which we often fall back for the lack of any better.
I cannot see that the case fits into any of the known types of heart
disease; neither am I content to call it merely functional. Probably
the state of the blood is enough to account for everything. The
diagnosis is clearly pernicious anemia. Without a blood examination
I should be utterly at sea in such a case, and could only speculate
and investigate regarding the possibility of alcoholism, cocaine habit,
or some psychosis in the background. The patient's flushed, flabby
cheeks and the absence of any obvious anemia might easily mislead
one in a case of this kind, unless a blood examination were a matter of
cast-iron routine in every case.
Outcome. — The patient felt stronger and happier in the middle of
February, walked about a little each day, and ate fairly well. On the
loth of March she was sent to the Samaritan Hospital.
PALPITATION AND ARHYTHMIA 633
Case 283
A Scotch mill-worker of forty- two entered the hospital August 15,
1912. About a year ago the patient noticed that her heart was beating
hard. She also had spells, when she felt as if "something comes over
my head, darkness across my eyes, and I can't go out into the open air
quick enough." These symptoms have progressed and been accom-
panied by shortness of breath on exertion, resulting finally in weakness
so marked that nine months ago she took to bed for six months. Three
months ago she felt better and has been about since. Has noticed no
increased sweating, but has been growing very nervous for nearly a
year.
On physical examination the heart's dulness extended 9 cm. to the
left of midstemum and 4 cm. to the right. Apex impulse felt in the
fourth space corresponding with the dulness. The sounds were rapid,
irregular, and nearly one-third of the beats do not reach the wrist.
There were no murmurs. Blood-pressure, 120 mm. Hg., systolic;
72 mm. Hg., diastoUc. There was no exophthalmos and no goiter, but
the fingers showed a fine tremor when extended. Pupils and reflexes
were negative and there was no edema. Abdomen and lungs negative.
The urine averaged 60 ounces in twenty-four hours, with a specific
gravity of loio, no albumin or casts. White corpuscles, 8000, with
47 per cent, polynuclears, and the remainder lymphocytes. Her past
history and family history showed nothing of importance.
Under rest and neutral bromid of quinin, 5 gr., three times a day,
the pulse rapidly improved, and by the 21st all the beats reached the
wrist. The rhythm at that time suggested the fetal type. It later
appeared that she had been given a good deal of thyroid extract and it
was suspected that her symptoms might be due to that cause. Her
husband deserted her several years ago, and she has been much tired
and worried since. She left the hospital much improved on the 4th of
September.
Discussion. — Here is a middle-aged woman with absolute arhyth-
mia and tachycardia, with fine tremor of the fingers, but no other
evidences of Graves' disease. Obviously, worry and fatigue have
something to do with her condition, but it is not likely that they
accoimt for the whole of it. The condition of the heart does not
suggest a rheumatic, syphilitic, arteriosclerotic, or renal type of heart
disease. Probably the administration of thyroid extract may have
GOQtributed to produce her symptoms. But it does not seem to me
likely that this is sufl^cient explanation. In a normal person the
634 DIFFERENTIAL DIAGNOSIS
amount of thyroid extract which she could have taken without entirely
prostrating herself would not be apt to produce such marked symp-
toms. I believe there is something else in the background — ^namely,
thyrotoxicosis.
Outcome. — September 24th she reported at the Out-patient De-
partment feeling pretty well, weighing 1 23^ pounds, but with a pulse
of 128. After she had sat still for half an hour the pulse was 90.
She is less nervous, but still trembles at times. The largest circum-
ference of the neck was 35^ cm. The heart's apex was in the fifth
space, just outside the nipple line. Its action was rapid and the
sounds of tick-tack quality. October 8th the neck measured 34 cm.;
there was considerable tremor of the hands; the pulse was 96. No-
vember 29th she weighed 131 pounds, the neck was 34 J cm., and
the pulse 1 14.
A letter received from the patient December 11, 1912, says there
is now a lump in the front of her neck above the breast-bone. In
other respects she is improving in health.
Case 284
A Russian rag-picker of twenty-nine entered the ho^ital March 21,
iQio, for palpitation, with indefinite pain in the r^on of the left
nipple and in the lower back. His family history and |>ast hisUHy
were not remarkable. He smokes from 25 to 60 cigarettes a day. He
has no dN-^nea, a>ugh, or palpitation, but feels weak and ti^t across
his chest. These sensations are not increased bv exertion or bv food,
but are worse when he has headaches or when doctors are about
him. They are sometimes associated with dizz>' spells. He has
worked steadily ;md has lost no weight.
Ph\*daU examination shows a marked tremor of the evdids and
an old puckertvl white scar under the ramus of the left jaw. The
carvliao ajx^x extends ^ cm. outside the nipple, as estimated by a^t
and touch. The right border extends 5 cm. from the midst^nal fine.
Bel ween the iirst ^md the secc®d sound of e\'er\* alternate cardiac
cycle iwv> taint shc^rt sounds are interposed. In this cycle there is
Hv^ n^^um^ur. but in the nv^rmal alternate cvde a svstolic murmur is
hcarvi aKh:: :ho rx^v^i iM ihe apex-beat. Blood-pressure normaL
The pulses an." equal. ^ukI the extra beat heard at the apex rardy
rxMvht^ the wris:. so thai the rhxthm is usually regular there. In
v^xher Tx^sjwts :^h\^v^5! exanunaiioa, including the urine, is negative.
Ver,v>u> trsvir.^ sijv>wi^i this beat to be an auricular extras\^ole.
The ^vj^:k£::V v:J^l^iuc cvYKiiiion ciuses him actually no sx-mptoms.
PALPITATION AND ASHYTHMIA 635
and the close observation seemed to be tending to make him neu-
rasthenic. He was, accordingly, sent home on the 24th.
Discussion. — This case represents the best that I have been able
to do to find a marked heart trouble attributed to tobacco, and I do
not feel at all sure that the tobacco is the main cause of his troubles,
for when the drug was taken away from him his cardiac condition
was not much different from that which troubled him at the beginning.
Presimiably, the heart has been treated by the administration of digi-
talis. The alternation of strong and weak beats is what we expect
to see under these conditions. We have no evidence of organic dis-
ease in the heart beyond a certain amount of enlargement; possibly
a neurasthenia accounts for the whole thing. The lack of any in-
crease in his symptoms after exertion, and their aggravation by close
observation, seem to indicate that nervous causes are the most im-
portant part of his trouble. Such a patient should be told to keep
clear of doctors and go about his business; if he has any organic disease,
he is not likely to mind the advice long. If he has not, it will do him
good, more good than anything else that we can do.
Case 285
A clerk of nineteen entered the hospital April 11, 19 10. The
patient's family history was excellent. With ordinary colds he has
often had asthmatic attacks, and, although he has played football
without difficulty, he believes that his heart has always been weak.
He uses no tobacco or alcohol, and takes only one cup of tea and one
cup of coffee daily. About the ist of February, 1910, he began to
have attacks of palpitation with sharp, needle-like pains in the pre-
cordia, coming fifteen to twenty times a day and lasting ten to twelve
minutes, not influenced by food or by exertion. There has been no
dyspnea, palpitation, cough, or other symptoms, except loss of strength,
which has been noticed for about four months.
Physical examination showed good nutrition, negative pupils
and reflexes. The heart's apex seen and felt in the fifth space, ii| cm.
from midstemum, 2 cm. outside the nipple line, the right border i§ cm.
from midstemum. The heart's action was irregular. During five
minutes of auscultation the heart would be regular for thirty to forty
beats, then would follow a succession of rapid strokes, irregular, both
in force and frequency, the first sound apparently reduplicated at
times. No murmurs were heard. Pulmonic second sound seemed to
be accentuated. The pulses and radials were not abnormal, and
visceral examination, including urine, was otherwise negative. Blood-
636 DIFFERENTIAL DIAGNOSIS
pressure normal. The blood showed a slight achromia and a poly-
nuclear leukocytosis of 15,000. Venous tracings showed no defect
in conduction. After exercise the heart was always much more
regular than when he was sitting still. The Wassermann reaction
was negative, and nothing further of interest was observed during
ten days of his stay in the hospital. At times the radial pulse and
the aortic second sound would be quite regular, even when the apex
sounds seemed to be decidedly mixed up, owing to doubling of the
first or the second. The precordial pain, of which he complained at
entrance, was not relieved.
Discussion. — ^All the signs in this case seem to me to point toward
a neurotic type of prostration. Of special importance is the fact that
his heart is more regular after exercise than on sitting still. This is a
test of great value and should always be applied in doubtful cases.
Although he states that his heart has always been weak, he seems
to have had no functional difficulties, and one can place but little
importance upon his statement, since he has played football without
difficulty.
The needle-like precordial pains accompanying his palpitation
are such as we have all frequently seen in cardiac neuroses; often
they seem to be connected with gastric flatulency. The doubling of
heart sounds which the record shows is probably of no importance in
an otherwise healthy boy of this age.
Perhaps it is incorrect to call him sound, since his heart's apex
is somewhat outside the nipple line. Without any x-ray control of
this, however, I should not consider it of much significance. The
type of arhythmia is probably respiratory, a so-called sinus arhyth-
mia.
Outcome. — December 22, 191 2, the patient's physician writes
that he has been at work steadily except for the first month after he
left the hospital, that he has not lost a single day since then, and
appears to be in very good health.
^
Case 286
An engineer of thirty-three entered the hospital February 5, 1912.
The patient's family history is excellent and past history not remark-
able. Eight years ago, while working in a chair factory, he noticed
very profuse sweating on slight provocation, and at the same time
he lost much weight. After two months he saw a doctor, who said
that he had ^'enlargement of the heart and trouble in the gland."
After a vacation he felt much better and returned to work, where he
PALPITATION AND A&HYTHHIA 637
felt well enough for five years. Three years ago he began again to
lose weight and bis neck became swollen. The local physician at
that time thought his condition serious and made him give up work.
He then stayed upon a farm for a year and a half, during which time
he improved much and noted considerable reduction in the size of his
neck. For the past year and a half he has been working hard as an
engineer and has felt fairly well until six months ago, when his neck
again began to swell intermittently. Profuse sweating also returned,
and his pulse has been very rapid. He has noticed no prominence
of the eyes.
On physical examination the heart's apex extended ij cm. to the
left of the nipple, in the fifth space. The sounds were clear, between
I^Itj^ppUL
;-""--
m .-
J
m ■ ■
-=^?' i J
:::::;:: ::: ::
::i.:i ; ;:
. . :
^:i^®
: :j^fc
■iS:-l: -13:1--
- 'M'-i
::!::i::i::§::
Fig. J31.— Chart of Case 2I
while in medical wards.
roo and r I'o, but there was a systolic murmur and presystoUc thrill
at the apex. The thyroid gland was moderately enlarged on each
side, and there was slight exophthalmos, slight tremor, and consider-
able moisture of the hands. Physical examination, including the
urine, was otherwise negative. The patient was seen in consulta-
tion by Dr. F. C. Shattuck, who diagnosed a long-standing, well-com-
pensated mitral stenosis, and was doubtful as to whether hyper-
thyroidism played any part. He thought the heart needed no treat-
ment, but advised regulation of hygiene. As the patient had a hernia,
a radical operation for this lesion and an appendectomy were done.
638 DIFFERENTIAL DIAGNOSIS
The appendix showed scar tissue with obliteration of the lumen. It
was adherent to the hernial sac and formed a part of it. The whole
operation was done imder local anesthesia and caused at the time
no considerable shock. About six hours later the patient vomited
and the pulse began to rise, so that next day it reached 140. No
cause for temperature was foimd, but the amount of exophthalmos
was slightly increased for about a week after the operation. On the
5 th of February he was transferred to the medical service, where his
systolic blood-pressure was foimd to be 160 mm. Hg.; diastolic, 85
nmi. Hg. (Fig. 232).
Despite careful questioning, no evidence of any cause for endo-
carditis could be found, and it was learned that palpitation on exer-
tion and emotion had been noticed for at least twelve years. The
palpitation has at times been so great as to shake his bed at night,
and was accompanied by great nervousness and sweating. At no
time has he had any edema or cough. An occasional short presystolic
roll was at this time heard. The apex was 2 cm. outside the nipple
line, in the fifth space. The aortic second greater than the pulmonic
second. Pulse tracings showed an absolute arhythmia, but no evi-
dence of tricuspid insufficiency. This arhythmia persisted after
atropin, subcutaneously, j^ gr., repeated in six hours. He had occa-
sional spells of tachycardia, in which the heart's rate would rise to 130
to 160.
Discussion. — I should not have inserted this case but for tne
fact that a distinguished clinician differed strongly from the diagnosis
of goiter heart or thyrotoxicosis, which seemed to me clearly war-
ranted by the facts. I have never seen a case of pure mitral stenosis
in a man of thirty- three which produced a systolic blood-pressure of
160 mm. Hg. The presence of goiter tumor, unusual sweating, and
slight exophthalmos seem to me to leave no considerable doubt as
to the diagnosis. Whether or not he had mitral stenosis in addition
to thyrotoxicosis I do not know. I am convinced that a presystolic
murmur may exist in any type of enlarged heart, and not merely
with aortic regurgitation, as described by Flint. That the murmur
disappeared when the heart was slow does not furnish evidence eithef
for or against mitral stenosis. Neither does the existence of absolute
arhythmia exclude thyroid disease.
Outcome. — When the heart was slow no presystolic roll could be
heard, and on the 24th of February he was discharged. A year later
the patient reported that he still had tachycardia, but had been work-
ing steadily and holding his weight since June i, 191 2.
CHAPTER XVIII
TREMOR
Tremors are classified as coarse and fine, the latter particularly
characteristic of thyrotoxicosis. Coarse tremors are common to a
great many states presently to be mentioned.
The commonest of all causes for tremor are cold, nervousness, and
fatigue. After hard muscular work the hand shakes. In difficult
situations the knees knock together. The only importance of such
types is that we should take sufficient pains to exclude them when
considering diseases in which tremor forms an essential element.
One does not want to condemn a person as alcoholic or burdened with
thyroid disease merely because the hand shakes from apprehension or
tire. One must be sure that the psychic conditions are understood
and that we are getting a fair sample of the patient's muscular condi-
tion.
In old age there is a tremor, especially of the head, which does not
connect itself with any known pathology and must be distinguished
from the much more serious conditions of the nervous system to be
mentioned below. The diagnosis of senile tremor depends on the ex-
clusion of all causes except senility and the absence of the associated
symptoms of paralysis agitans. It is often seen in arteriosclerosis, but
there is no proof of an etiologic connection.
The tremor of alcoholism is coarse and irregular. It appears espe-
cially in the morning hours, when alcohol is suddenly taken away or
when the person is sobering up; in other words, under the same condi-
tions which produce alcoholic delirium or the trembling deliriima
(delirimn tremens). It sometimes has the characteristics of an inten-
tion tremor, but can be controlled to some extent by the will.
In Graves' disease (thyrotoxicosis) the tremor is more rapid and of
shorter excursion than in any other condition that I know. It is
often to be recognized only when the fingers are extended and spread
apart. It is present constantly, although it may be accentuated by
temporary causes of nervousness. It is seldom bad enough to inter-
fere with the ordinary use of the hands. It may be an early or a late
symptom of the disease, but should always be looked for in doubtful
639
640 DIFFERENTIAL DIAGNOSIS
Parkinson^ s disease, or paralysis agitans, is the next most common
cause of tremor. It usually appears first in the hands and produces
peculiar movements of the thumb and first two fingers, which have been
compared to pill rolling or bread crumbling. It is a relatively slow and
coarse tremor, and although it begins in the hand, may spread up-
ward, in the course of time, to involve the arms, head, and even the
legs. It is increased by excitement, but can generally be lessened by
volimtary effort. Its diagnosis depends upon the presence of the
associated symptoms of the disease, especially the muscular rigidity,
the bent and rigid carriage, the mask-like, expressionless face, and gen-
eral muscular weakness.
Lead-poisoning occasionally produces tremor, in connection with
other evidences of neuritis. The same is true of mercurial-poisoning
and of most of the drug habits, such as morphinism, cocainism, etc.
In multiple sclerosis and other cerebral, as well as spinal, lesions
we have an intention tremor, that is, one which is more marked when
the patient tries to use the muscles or is made worse by voluntary effort.
In multiple sclerosis such a tremor is often associated with nystagmus
and disturbances of speech, which render it slow, segmented, or stac-
cato; also a spastic type of paralysis. The disease presents a great
variety of types depending on the varying distribution of the lesions.
Case 287
A choreman of fifty-three entered the hospital February 22, 191a
The patient's family history is negative. He had "pleurisy and
pneumonia^' on the left side eight years ago. He takes "two glasses
of beer a day and an occasional whisky." Four weeks ago a freight
elevator fell on him, striking his head, but not injuring him in any other
way. The scalp wound healed in ten days, but since the injury he has
had a dull pain running from the nape of the neck along the shoulders,
intensified by any sudden movement of the head. The appetite has
been poor for a long time and he has not worked since the accident
His sleep has been very poor.
Physical examination showed good nutrition, subnormal tem-
perature (Fig. 233), and a marked coarse tremor of the hands. The
heart's apex extended i cm. outside the nipple. The pulmonic sec-
ond sound was accentuated. There were no murmurs. The brachial
arteries were tortuous and pulsated visibly. Systolic blood-pressure,
165. Urine negative. White cells, 20,000, with a polynuclear leuko-
cytosis; hemoglobin, 90 per cent. There was slight dulness and
decreased breathing at the left apex, posteriorly. Abdomen showed
Tremor
SENILITY
COLD
NERVOUSNESS
EXHAUSTION ^
ALCOHOLISM
EXOPHTHALMIC GOITER
MORPHINISM
MULTIPLE SCLEROSIS
GENERAL PARESIS
PARKINSON'S DISEASE
CASES TOO MANY AND TOO VAGUELY ENUMERABLE FOR GRAPHIC REP-
RESENTATION
830
290
100
82
26
26
Vol. 11—41
641
642
DIFFEKENTIAL DIAGNOSIS
nothing abnormal. The ni^t after entrance he became belligerent
and thought he had been wronged by another patient.
Discussion. — The fact that the patient has not worked since his
accident and has not been able to sleep well should make us very suspi-
cious of alcoholism, no matter what the patient
himself says on the subject. Workingmen of
fifty-three do not suddenly acquire insomnia
from the ordinary causes affecting nervous and
highly civilized people.
The behavior of the patient in the hospital,
the appearance of cerebral symptoms in the
evening, gives the support to the suspicion of
alcoholism, and makes us pretty certain that he
has taken a good deal more than two glasses of
beer a day and an occasional whisky.
There may be a certain element of traumatic
neurosis in the case. In such conditions tremor
is frequent, but it is more probable that the alco-
holism is the dominant factor.
Obviously, the patient has some arterioscle-
rosis, but this has probably no relation to the
tremor.
Outcome.— -The next morning he was af^wi-
III
Kg- 333— Chart
Case 387.
ently rational. X-ray examination of his neck was negative. He left
the hospital on the 28th, after a negative examination by an alienist.
Case 288
A housewife of fifty-one entered the hospital July 23, igio. The
patient was recommended from the Out-patient Department for
tremor, edema of the legs, and slight chronic arthritis. Ten years ago
she was in bed four weeks with intense jaundice, butno[>ain. During
the two years following this she suffered from frequent attacks of epi-
gastric pain, lasting several hours. Five years ago she had t>'phoid
fever and was in bed four months. She passed the menopause seven
years ago.
Sixteen months ago she woke too weak to get up, and remained
ten weeks in bed with what the doctor called "nervous prostration."
Since that time she has been about the house daily, but has suffered
much pain in both hips. During the last few months her hands have
trembled.
The pain has prevented good sleep, and she has taken always J
TKEUOR 643
gr. codein, which produces about two hours' sleep. The appetite is
fair- The boweb move every other day. She has lost no weight.
On physical examination, the patient is very poorly nourished and
sallow. Pupils normal. Internal viscera normal. Knee-jerks and
pUntars normal. Achilles reflexes not obtained. Marked Kemig's
sign bilateral. The neck is held stiffly, bent markedly forward and to
the right. All the muscles are spastic. The hip-joints are sore on
motion, the knees slightly so. There is well-marked
intention tremor of the hands and considerable
tremor of the legs when attention is directed to
them. The back is stiff and shows a lateral curv-
ature, most marked in the lower thoracic region,
with a convexity to the left. The range of the
temperature is shown in Fig. 234. The urine
averaged 35 ounces in twenty-four hours. It was
always turbid and acid, with a specific gravity of
1023. Negative sediment. The blood was nor-
mal. Systolic blood-pressure, 105. The patient
went home on the 28th.
Discussion. — The case is obviously one of Par-
kinson's disease, and is here introduced to call at-
tention to the fact that pain and other joint symp-
toms may be very prominent in the clinical picture
of paralysis agitans. At the time of this patient's
examination in the hospital there was actually no
tremor at all, and one must be prepared to recog- '*j CMe^s"'
nize the disease in the absence of this symptom, ■
paying especial attention to the expression of the face, the stifTness of
the neck and back, and the peculiarities of the gait.
Note that the doctor made a diagnosis of nervous prostration only
sixteen months ago, a diagnosis which, of course, is never correct when
its symptoms originate in a person of forty-nine.
Case 289
A foreman in a hay and grain house, forty-four years old, entered
the hospital July 28, 1910. The patient's family history is negative.
Nineteen years ago he had "sciatic rheumatism" for three weeks;
otherwise was well and strong until the present illness. March i, 1909,
he had a severe sore throat with a peritonsillar abscess. Just after
this he ate some well-done pork at a restaurant. Seven hours later he
felt dopy. Twenty hours later he noticed a rash all over his body.
644 DIFFERENTIAL DIAGNOSIS
This rash lasted ten days and was accompanied by a tough swelling
of the skin, suggesting myxedema to his physician. He desquamated
in large pieces, but did not feel sick, and March isth went back to work.
April 2oth he began to feel pain and tenderness in his elbows and his
groins, and his doctor found tenderness along the ubiar side of each
arm. April 24th his hands began to shake y so that on the 27th he had
to quit work and has not been able to resume it since.
Gradually numbness crept up his arms until they were p>aralyzed.
Then the legs became powerless. There was much paresthesia, but no
anesthesia and no involvement of sphincters, speech, or swallowing.
The iHnver has gradually returned in his arms and partially in his legs,
but he cannot straighten his knees.
In other respects his health is good, but he has lost about 20 poimds.
He knows of no exjH)sure to lead.
Phj'sical examination showed a rather obese patient, with normal
pupils, and nothing remarkable about his internal \iscera. Knee-
jerks, imkle-jerks, and plantars were absent. Cremasterics present on
bi>th sides. Alxlominal reflexes not obtained. There was practically
no motion below the knees and a moderate contraction of the hamstring
muscle. No tiXMln^p. Motions of the left hand were fair, but rather
weak. The little tmger nuxlerately contracted. The right hand was
nuxlerately alxlucteil from the forearm and the fingers were in the
jx^sition of a typical claw-hand. The grasp was weak, and there was
amsiderable atn^phy in this and in the other hand, especially at the
Ixise of the thumb. Sens;ition of touch was delaved and inaccurate
in the foot, fair in the legs and hands, good in the rest of the body.
The extensk^r muscles of the arms and hands reacted to galN'anism. but
a strvmg faradic current w;is necessar)* lo produce any reaction. Ail
elcvtric rt^actions wort^ absent in the perineal muscles. The Wass^-
mann nwciion was jxxsilive.
The jxiticnl was given Ziuider exercises, electric-light baths, and
mass^\i^\ and by .\ugust oih couM stand on his feet. August ij;ih he
ivuld lake a few slo^xs with help. An orthopedic consultant ad\'i>ed
lenvnotv.y of the hamstrings, but under Zander treatment his legs we«
\\>nsivioraMy siraighieneil by the ;cth. By September 7th the patient
had shv^vn ven- markevl improvemeni and was transferred to the
nouTv^U>5:ic wurvis. where a slight edema, duskiness, and coolness oc :be
fee; wvrx^ :our.vi.
DiscossioQ* - la \-iew okt the {x>siii\"e Wasssermann reaction in lii?
v-As^. h s^x^nxs :v^ r.:e that the d^aiXvtsis 01 periphenl neuritis, maoe ii
the :r,v,c o.: his stay ir. she hvxsj^tju, is a \>ef>~ doubtful one. It must be
TREMOR 64s
admitted that the physical signs and condition of the reflexes support
the diagnosis of a neuritis, but, in the absence of any of the known
causes of such a lesion and the presence of a Wassermann reaction, it
seems to me doubtful whether the disease is confined to the peripheral
nerves.
At the beginning of the illness there were some etiologic suggestions
which deserve a moment's conmient. Peritonsillar abscess is a cause
of many other manifestations of infection and toxemia, but I know of
no good evidence for connecting it with nervous symptoms of this
type. The same may be said of his initial rash and dull mental state
following the eating of pork. What this illness was I have no idea.
It surely cannot have been beriberi or myxedema.
On the whole, I must admit that the condition is by no means a
clear one, though I incline to the opinion that syphilis is at the bottom
of it.
Outcome. — September 26th he was able to walk alone and had
moderate strength in his left hand. December 2, 191 2, the patient's
physician writes that he can now walk without cane or crutches, though
he still has toe-drop and some deformity and weakness in the hands.
Case 290
A chair-caner of seventeen entered the hospital December 6, 1910.
The patient came in because of a twitching of the left arm. While
waiting in the anteroom for examination she was heard screaming and
was brought in in the arms of the nurse, apparently comatose, with
face bluish, foam on the lips, and irregular jerking motions of the arms
and legs. The pupils and knee-jerks responded normally.
She remained unconscious about fifteen minutes, though opening
her eyes occasionally without looking round. The subcutaneous in-
jection of ijV-gr- apomorphin caused slight nausea and a renewal of
consciousness.
The patient says that she has had similar attacks at irregular inter-
vals for the last four years, though sometimes she has gone a year with-
out any, and again she would have them every week or two. They last
fifteen or twenty minutes, begin with vertigo, then headache, then loss
of consciousness. After such an attack she has to lie down for an hour
or more and feels very weak. A year ago last November she had an
attack on an electric car, and stayed a week in the City Hospital there-
after.
Two weeks ago blood was taken from her left arm for examination.
The next morning the arm was twitching when she awakened, and ever
646 DIFFERENTIAL DIAGNOSIS
since then, as she sits in a chair, the left arm and shoulder are agitated
by a constant tremor, which slightly shakes the whole body, while the
left shoulder is drawn down. There is a slight limp in the left foot.
Physical examination shows well-marked left hemianesthesia. The
tremor involves chiefly the latissimus dorsi. The anesthesia is not
marked upon the trunk or face, but is most striking in the foot and arm.
The grip of the left hand is very feeble. Both knee-jerks are exag-
gerated, the left more than the right. No plantar reflexes obtained
upon the left. The left ankle- jerk is exaggerated.
No notes of treatment were made during the five weeks of the
patient's stay in the hospital, during which she passed through an
attack of acute tonsillitis and two menstrual periods. The bowels
were decidedly constipated, several days often passing without any
movement.
Discussion. — The initial attack, as described, might be either
hysteric or epileptic, although the fact that she opened her eyes
occasionally and that apomorphin brought her to consciousness
are items strongly in favor of hysteria.
It is easier to interpret the attack when we study the later phases
of her trouble and the physical examination. Hemianesthesia with
exaggeration of both knee-jerks and a tremor of the arm following
immediately upon the extraction of blood for examination makes a
clinical picture strongly confirming the previous suspicion of hysteria.
Weir Mitchell has described similar cases, especially one classical and
spectacular instance in which later a careful autopsy showed abso-
lutely no lesion — macroscopic or microscopic*
Case 291
A man with no occupation, thirty-three years of age, entered the
hospital June 29, 191 2. The patient's family history is excellent.
He had the ordinary children's diseases, and beginning at seven years
old had five severe attacks of rheumatic fever, the last one four years
ago. Since that time he has noticed palpitation on exertion or excite-
ment, and occasionally slight dyspnea. He denies venereal disease
and alcohol.
Four years ago, after being in bed three months with rheumatic
fever, he noticed that his hands trembled and made imcertain irregu-
lar motions when he used them, though there was no paralysis or dis-
turbance of sensation. He also finds himself weak and unsteady on
his feet and can get about only with crutches. Four years ago his
* Transactions of the Association of American Physicians, 1904, p. 433.
TREMOR 647
speech was very thick and unintelligible. He knew what he wanted
to say, but could not pronounce the words correctly. For the last
two years he has been training himself in speech, with considerable
improvement as a result. He can now also write, paint, and do
basket-work, and has no trouble in dressing himself. He still has to •
use crutches. He has no pain, no vertigo, and no ocular disturbance.
For a short time, three years ago, he had slight incontinence of urine,
but that soon passed off and has not recurred.
Physical examination showed good nutrition, slight cyanosis,
normal pupils, knee-jerks equal and Uvely, plan tars and cremasterics
normal. Superficial abdominal reflexes not obtained. All motions
of the tnmk and arms are awkward and uncertain and accompanied
by a coarse, irregular tremor, not fibrillary in character. No wasting.
Grips strong and equal. Head held to the left, mouth slightly drawn
to the right. Tongue protruded slightly to the right. Speech
slightly thick, but not scanning. No nystagmus. The fundus oculi
normal. A neurologic consultant was in doubt between hysteria
and multiple sclerosis. Wassermann reaction negative. Blood and
urine negative. No fever in ten days' observation. Systolic blood-
pressure, 180 nmi. Hg.; diastolic, 60 mm. Hg. By lumbar puncture
a few cubic centimeters of clear fluid were obtained, not imder
pressure.
The cell-count was 3 per centimeter.
The heart's apex was seen and felt in the sixth space, 5 cm. out-
side the nipple line. There is a sUght presystolic thrill at this point
and a faint presystolic murmur, ending in a loud first sound and a loud
systolic murmur. At the aortic area and along the left sternal border
a diastolic murmur is heard. The pulmonic second is greater than the
aortic second, which is very faint.
Pulses markedly Corrigan in quality. Capillary pulse present.
Lungs, abdomen, and extremities normal. The patient remained in
the hospital ten days and left without any considerable change in his
condition.
Discussion. — The patient has all the evidences of rheumatic or
streptococcic endocarditis, with mitral stenosis and probably aortic
regurgitation and stenosis. It is not probable, however, that the
present condition of the hands has any direct connection with the
rheimfiatic infection. We note that the ataxia and tremor of the
hands is associated with disturbances of speech and of gait. The
spasticity often seen in multiple sclerosis is not present.
As in many cases, the diagnosis is in doubt between hysteria and
648 DIFFERENTIAL DIAGNOSIS
multiple sclerosis. Some of the most classical and disastrous diag-
nostic mistakes that I have known have been those in which the
physician called the case hysteria and treated it accordingly, when
the march of time demonstrated the presence of an incurable organic
disease, multiple sclerosis. In this case the nature and duration
of the trouble with speech, the transitory attack of urinary incon-
tinence, the muscular abnormalities in the head, face, and tongue,
incline us to believe that organic disease is present. It is very im-
probable that a man would begin to be hysteric at twenty-nine.
Paresis and other postsyphilitic diseases of the nervous system
may be excluded by the negative Wassermann reaction and the low
cell-count in the spinal fluid.
We have no grounds for suspecting multiple neuritis. Under
these conditions the diagnosis of multiple sclerosis seems to be the
most defensible
CHAPTER XIX
ASCITES AND ABDOMINAL ENLARGEMENT
I RECENTLY made a series of wrong diagnoses in cases of ascites.
These failures, which were shared by some of the best diagnosti-
cians in the country, suggested to me a study of the causes of this
symptom. Until recently I had supposed that the diagnosis of the
causes of ascites was one of the easiest in medicine. I was amazed
to hear Dr. RoUeston say, in 1909, that he considered the diagnosis
of cirrhosis a very difficult one; but in the light of recent events I
have come to agree with him. To minimize the number of future
mistakes, I have in this chapter endeavored:
1. To tabulate from the autopsy records of the Massachusetts
General Hospital the actual causes of ascites as foimd postmortem
in 2217 autopsies (Chart I).
2. To tabulate the clinical diagnoses of ascites made at this
hospital in the last forty years. Some of these diagnoses have been
verified by operation or autopsy. A larger number rest on clinical
evidence alone, but in most of the more dubious and more interesting
cases we have operative or postmortem knowledge of the actual
condition (Chart II).
3. To tabulate the rates at which ascites accumulates in different
diseases. Possibly these latter facts may be of some assistance in
identifying through its more or less characteristic tempo of accumu-
lation the ascites of tuberculous peritonitis (Chart V).
4. To relate some of my failures and discuss the possibilities of
better success in the future.
Chart I shows the causes of fluid as found in the peritoneum in
2217 cases at autopsy. A quart or more of fluid was present in all
these cases. Cases of septic peritonitis and hemoperitoneum are
omitted; 88 per cent, of the remaining cases are due, as was anti-
cipated, to one of five causes: Cardiac weakness y nephritis y abdominal
neoplasms, cirrhotic liver, and tuberculous peritonitis.
I am uncertain whether the cases of adherent pericardium (all
of which were associated with extensive peritoneal thickening) should
be classed with the cases of cardiac weakness or with those of chronic
649
Causes of Ascites as Found Postmortem in
2217 Autopsies
CARDIAC WEAKNESS
NEOPLASMIC PERITONITIS
RENAL DISEASE
CIRRHOSIS OF LIVER
PERITONEAL TUBERCULOSIS
ADHERENT PERICARDIUM
ECLAMPSIA
THROMBOSIS, CAVAL, MES-)
ENTERIC, OR PORTAL
CHRONIC FIBROUS PERI-
TONITIS
UTERINE FIBROMYOMA
INTESTINAL OBSTRUCTION
PANCREATITIS
OVARIAN CYST
}
I
ACUTE YELLOW ATROPHY 1
OF LIVER )
STATUS LYMPHATICUS
I
TOTAL
89
^ 197,
26 > or
23
15 J
9
3
88*^-
/«
3
2
1
1
1
1
224
Chart I.
050
Relative Frequency of the Common Causes of
Ascites
FROM the clinical RECORDS OF THE MASSACHUSETTS
GENERAL HOSPITAL, 1870-1910
CARDIAC WEAKNESS ^■i^lHHII^^l^^HBHI^^HHi 1397
RENAL DISEASE ■■■■■^^^1^ 665
HEPATIC CIRRHOSIS HlHHi 325
PERITONEAL TUBERCULOSIS HH^H 263
INTESTINAL OBSTRUCTION ^ 86
OVARIAN TUMORS ^ 63
INTESTINAL CANCER' ■§ 56
UTERINE FIBROMYOMA ■ 55
PERITONEAL CARCINOSIS ■ 53
PERICARDIAL ADHESIONS ■ 36
HEPATIC CANCERS ■ 30
PERNICIOUS ANEMIA I 15
LEUKEMIA I 11
MESENTERIC THROMBOSIS I 8
ABDOMINAL LYMPHOMA I 5
VISCERAL SYPHILIS* I 4
CAVAL AND PORTAL 1
THROMBOSIS i
I
TOTAL 3074
^ With glandular metastases.
' Hepatic, splenic, etc.
Chart II.
6si
Percentage of Cases of Ascites Found in SOO\
Cardiac Cases Observed Clinically
MASSACHUSETTS GENERAL HOSPITAL, 187CH1910
MITRAL AND TRICUSPID
REGURGITATION
}
AORTIC STENOSIS AND
REGURGITATION
}
MITRAL STENOSIS AND^
REGURGITATION i
MITRAL AND AORTIC RE-
GURGITATION
}
Chart III.
652
100%
ADHERENT PERICARDIUM Hi^H^lHiH^ii^HJHiHH 76%
MITRAL AND AORTIC)
STENOSIS AND REGUR- \ ^i^lHI^IHHB 42%
GITATION )
"MYOCARDIAL WEAKNESS'' ■■^^^H 37
35
AORTIC REGURGITATION ■■§■■■ 29
24
"MITRAL REGURGTIATION'' ■■■1^ 22
20
MITRAL STENOSIS ■■§ 8
Percentage of Ascites Found Among 10,19?
Cases of the Diseases Which Produce This
Symptom
massachusetts general hospital. 1870-1910
THnOMBOSIS iVENA CAVAi ^^^^^^^^^^^^^^^^^^^ 100
THROMBOSIS (PORTAU Ml^H^^^^^^^^^^^l^^^^^B 100
CIRRHOSIS OF THE LIVER ^H^^^^^^^^^^^^^B^^B 88
TUBERCULOUS PERITONITIS M^B^^^^^i^^^^^^^^H 82
NEOPLASMIC PERITONITIS ^^^^^^^i^^^^^^^^^^B 82
THROMBOSIS (MESENTERY) ^^^^^^^^^^^IH^^^H 80
OVARIAN FIBROMA ^^^^^^^^^^^^^^ 50
MALIGNANT LYMPHOMA^
(THORACIC AND ABOOM- [ ^i^^^^^^^^^^^^B 50
INTESTINAL OBSTRUCTION ^^^^^^^B^^^ 43
RENAL AND CARDIORENAL
OVARIAN SARCOMA
LEUKEMIA
PERNICIOUS ANEMIA
OVARIAN CVST, MULTI-
UTERINE FIBROMA
i
654 DIFFERENTIAL DIAGNOSIS
peritonitis. Of the other items in the list, the one most surprising
to me is puerperal eclampsia.
CLINICAL STATISTICS OF ASCITES
In some of the cases arranged in Chart II the diagnosis was veri-
fied by operation or autopsy. This was the case with all the neo-
plasms and thromboses, and with most of the cases of intestinal
obstruction and tuberculous peritonitis; but in the cardiac, renal,
and hepatic cases, and most of the blood diseases, the evidence is
wholly clinical.
Points of interest in this column are: (a) The frequency of ascites
with ovarian cysts and tumors (see below. Chart VI), and (b) the
large figures obtained in intestinal obstruction. Probably in a con-
siderable number of these cases the fluid may have been due to actual
peritonitis associated with the obstruction.
In this chart all the unstarred items represent cases actually
studied in the. original clinical record. The items which are starred
were calculated as follows:
Throughout an eight year period I determined, by study of the
clinical records, the percentage of ascitic cases among all the cases
of cardiac and renal disease. These positive percentages were then
applied to the total number of cases of each disease, as shown by a
count of the cards in the card catalogue (1870-1910). The starred
items are, therefore, only approximately accurate.
Chart V
Rate of ascitic
No. of accumulation.
Disease. cases. Ounces per day.
1. Cardiac weakness 2 3^54
2. Cirrhosis of the liver 16 20
3. Chronic nephritis 5 13
4. Solid tumors of ovary 2 12
5. Neoplasms of the abdominal organs and glands 4 11
6. Adherent pericardium (before cardiolysis) 2 11
Adherent pericardium (after cardiolysis) i 2
7. Uterine fibroid 2 8-11
8. Tuberculous peritonitis 15 5-6
Chart V requires little explanation. The number of ounces of
fluid between two exhaustive tappings is divided by the number of
days intervening. There is a chance for error here, in that the tappings,
which were supposed to empty the peritoneal cavity, may, in fact,
have left some fluid behind; but I do not think that this error is
suflBciently serious to interfere with my r-
ASaXES AND ABDOMINAL ENLARGEMENT 655
ASQTES WITH SOLID TUMORS OF THE OVARY
1. Cancer of the Ovary. — Fifty-four cases are on record at the
Massachusetts General Hospital between 1870 and 19 10. In 6 of
these there was no operation or autopsy. Of the remaining 48, there
were 19 cases (40 per cent.) in which a considerable amount of ascites
was found.
2. Fibroma of the Ovary. — Twenty well-recorded cases are to be
foimd in our records. In 10 of these (50 per cent.) ascites was well
marked at the time of operation.
3. Sarcoma of the Ovary. — Five cases, i with ascites.
ASCITES WITH CYSTIC TUMORS OF THE OVARY
There were 391 cases operated upon at the Massachusetts General
Hospital (1870-1910) for multilocular ovarian cyst. In 31 of these
(7.9 per cent.) ascites was well marked at the time of operation.
In 8 of these 31 the fluid was bloody or chocolate colored. In i the
amoimt of serum was measured at 17 quarts.
ASCITES WITH UTERINE FIBROMYOMA
Among 723 cases operated upon for fibroid of the uterus, 55
cases (7 per cent.) showed ascites. This was of small amoimt in
18 cases (2.4 per cent.); of large amoimt in the remaining 37 (4.6
per cent.).
In 10 of the 55 cases the fluid was bloody, in 2 others it was purulent.
In Chart VI the relation of ascites to the different varieties of
ovarian tumor is demonstrated. All these cases were operated on.
I think many persons will be surprised, as I was, to learn how fre-
quent is the association of ascites with benign ovarian growths such
as fibroma and multilocular cyst. I have no idea why a small ovarian
fibroma without metastases should produce extensive ascites so
frequently.
Why should a small percentage (7.9 per cent.) of cystic tumors
produce ascites? One would expect to find it in all cases or in none.
Chart VI. — Percentage of Ascites Occurring in the Dijfferent Varieties of Ovarian Tumor.
No. of Ascites found at
Diagnosis. cases. operation in —
Chrarian fibroma 20 50 per cent.
Ovarian cancer 54 4© **
Ovarian sarcoma 5 20 **
Ovarian cyBtoma 39^ 79 "
Among 14 cases operated upon for parovarian cyst no ascites was
656 DIFFERENTIAL DIAGNOSIS
Case 292
A housekeeper of forty-eight entered the hospital July 17, 1909.
She entered with a diagnosis from the Out-patient Department of
'^ascites, cause unknown." Nephritis, malignant disease, tuberculosis,
and adherent pericardiimi were suggested. Family history negative.
The patient has always been delicate, and when six years old was pro-
nounced tuberculous and sent to the country, with great benefit
Fifteen years ago she had a bad cough, with "ulcer in her throat" and
loss of weight. She went to Vermont for two months, improved very
much, and has been better ever since, though eight years ago she had a
"nervous breakdown," and six years ago the glands in her neck became
large and inflamed. They were opened and drained at the Homeo-
pathic Hospital. Following this operation the left arm became stiff
and paralyzed, though the power gradually returned afterward. She
has never been strong since then.
When first married she had two miscarriages, no children. Four-
teen months ago she passed the menopause without incident. A year
ago her face began to be swollen, and soon after that a swelling was noticed
in the abdomen. Four months ago the legs became swollen, but the
feet did not swell until two months ago. Five weeks ago she had to
take to bed. She has had no pain, save an occasional "catch" in the
lower right chest, which she has had on and off for years. She is
gaining in weight, but thinks she has lost flesh. She has had no
cough.
Physical examination showed poor nutrition, pupils slightly irregu-
lar, otherwise normal. Heart negative, impulse shifting i cm. A\'ith
change of position. All the evidences of fluid in the abdomen. Nor-
mal reflexes. On the i8th the abdomen was tapped. Five pints of
fluid were obtained, pale, opalescent, 1008 in specific gravity, with a
sediment containing 85 per cent, small lymphocytes. After tapping
the edge of the liver could be plainly felt, sharp, hard, and apparently
not irregular. The blood, urine, and blood-pressure were all normal.
The patient had no fever in two weeks' observation. The Wasser-
mann reaction was negative. Tlie fluid rapidly re-accumulated.
Examination of the stomach with a stomach-tube showed nothing
abnormal.
Discussion. — On the 25th of July I summed up the evidence as
follows: "Neoplasm seems the most probable diagnosis, although there
are no masses or pressure symptoms nor any organ markedly depressed
in function. The urine is not characteristic of any type of nephritiSi
ASCITES AND ABDOMINAL ENLARGEMENT 657
and the absence of cardiac enlargement, high blood-pressure, and
uremic symptoms make nephritis unlikely as a cause of the ascites.
Tuberculous peritonitis seems unlikely, since there is no fever, no
local tenderness or spasm, and since the fluid has re-acciunulated so
rapidly. Cirrhosis is possible, but improbable, on account of the ab-
sence of alcoholic history, the rapidity of the re-accimiulation, and
absence of toxemia. The patient certainly looks cancerous."
On the 27 th the patient was transferred to the surgical service and
the abdomen opened. A large amoimt of ascitic fluid was evacuated,
but the exploration showed nothing abnormal in any part of the
abdomen except a few hard white nodules, the size of peas, in the
liver. One of these was excised and examined by Dr. Maurice H.
Richardson, who made a diagnosis of ^'cirrhosis of the liver." There
were contracted places in the liver, suggesting scars. The diagnosis
recorded on the surgical history is "syphilis of the liver." The patient
was transferred to the medical side and was given mercurial inimctions
and iodid of potash. Nevertheless the abdomen rapidly refilled;
6 quarts were removed on the 19th and 5 quarts on the 23d. The
character of the fluid was essentially that previously reported.
Outcome. — She left the hospital September ist and died September
4th. Hepatic cirrhosis of syphilitic origin seems, on the whole, the
most reasonable diagnosis.
Case 293
A housewife of twenty-seven entered the hospital November 15,
1909. Five months ago the patient began to notice soreness in the
lower abdomen, which soon after swelled, and has since grown steadily
and rapidly in size. Except for this she has had practically no symp-
toms, though occasionally she vomits. Her appetite is good and her
bowels regular. Her menstruation is normal, but she has lost consider-
ably in weight and strength. Five months ago she weighed 1 58 poun4s ;
now, 132 pounds. Nevertheless, she is not emaciated even now. Her
family history and past history are excellent.
Physical examination was negative except as relates to the ab-
domen, which showed shifting dulness in the flanks. Blood showed 75
per cent, hemoglobin and slight achromia in the smear. Urine nega-
tive. No fever. On the 17 th 9I quarts were removed from the abdo-
men, and after this tapping a mass the size of an orange could be felt
low down on the right side of the abdomen. It was not tender, and
suggested the feel of a closely packed bunch of grapes. A similar but
smaller mass was felt on the left. The mass was easily felt bimanually
yoi..n-42
658 DIFFERENTIAL DIAGNOSIS
on each side of the uterus, which itself seemed normal. The tap fluid
was greenish yellow, opalescent, alkaline, 1019 in specific gravity, 4.4
per cent, albumin, with 63 per cent, endothelial cells, 33 per cent.
lymphocytes, and 4 per cent, polynuclears in the sediment.
Discussion. — The clinical picture is of slight anemia and ascites in
a woman of twenty-seven. Nothing definite could be said until after
tapping, which showed a high gravity fluid such as we should expect
in neoplastic peritonitis or tuberculosis of the peritoneum. Between
these two diseases the mass felt low down near the pelvis should make
us strongly favor neoplasm. It is true that tuberculous peritonitis
may produce abdominal masses, but they are rarely in this situation.
Moreover, we have no fever and nothing in the family history or pre-
vious history to suggest tuberculosis. The diagnosis, therefore, should
be of a pelvic neoplasm, which in this situation is almost certainly of
ovarian origin. Whether it is benign or malignant only histologic
examination can decide.
Outcome. — ^At operation, November 20th, the uterus and ap-
pendages were found bound up in one large mass of tissue, resembling
that of a papillary cyst adenoma. The whole mass, including the
uterus, was removed. Examination showed both ovaries cystic, with
numerous papillary outgrowths, some of which are growing freely from
the peritoneal surfaces. Microscopic examination showed a fibrous
structure in papillary form, the surface of which was covered by a
single layer of rather long cylindric epithelial cells. Diagnosis, papil-
lary cyst adenoma. The patient did well after operation, left the
hospital December 9th, and a year later, December 13, 1910, seemed to
be entirely well.
Case 294
A barber of forty-nine entered the hospital April 18, 1910. The
patient's father died of paresis at forty-seven, after an illness of
three years. His mother died of cancer of the breast. His wife
has had tuberculosis and has been in a sanitarium fifteen months
for it.
The patient himself has never had a sick day until February 5, 1910,
when he had a chill, followed by severe pains in his neck and breast-
bone, with slight cough and fever. He was in bed four weeks, and
after he had been up a few days his feet and legs began to swell and be
began to be short of breath. Both these symptoms have steadily
increased since, and he has had to sleep in a steamer chair formore tlx^
a month. For two weeks he has had a slight cough, but he no ^^^^^
ASCITES AND ABDOMINAL ENLARGEMENT 659
has any pain. Three weeks ago he began to notice enlargement of his
abdomen.
On physical examination, the patient was obese, skin pale and
cyanotic. Heart's impulse fell in the fifth space, 3 cm. outside the
nipple line, the right border dubiess 4 cm. from midstemum. Sounds
feeble, rapid, regular, no murmurs or accentuations. Systolic blood-
pressure, 155 to 180 during the week of his stay in the hospital. The
lungs and abdomen as shown in Figs. 235, 236. Spleen never felt. The
whole body is more or less edematous, the legs especially showing a
'B -J5> — Physical signs in Cose 194.
hard, brawny swelling. The abdomen was tapped on the 18th and
1600 c.c. of canary-yellow turbid fluid obtained. Specific gravity was
1017; albumin, i per cent. Sediment contained 90 per cent, of small
mononuclears, 2 per cent, polynuclears, the remainder of the endo-
thelial type. On the 20th there was intense bronchial breathing in the
left back, suggesting a pressure area as in pericarditis or hydropericar-
dium. The whispered voice was much increased and there was
^^ egophony.
^H The patient remained afebrile and fairly comfortable during the day,
66o
DIFFERENTIAL DIAGNOSIS
but was very dyspneic and a little delirious at night, especially when J
he slipped down off his bed-rest. The urine examined at entrance 1
showed about 6 per cent, of sugar and o.i per cent, of albumin. The |
amount was not increased and averaged 35 to 45 ounces, and the sedi-
ment showed only an occasional hyaline or granular cast. The blood
showed 13,500 leukocytes. The sugar output per day varied between
30 and 50 gm. The Wassermann reaction was positive. A culture
from the ascitic fluid was negative. I
On the 23d he had a fairly comfortable day, though he dozed a n
good deal. On the night of the 24th he suddenly became cyanotic and
pulseless, and within an hour was dead. There was no autopsy.
Fig. 236. — PhysioJ siigns in Case 304.
Discussion. — The family history is variegated and interesting, but
not of special significance, so far as I see, in connection with the
present symptoms of the patient, which point to a postinfectious car-
diac trouble associated with hypertension. J
The specific gravity of the tap-fluid is not like that of an ordinaty^a
dropsy. On the other hand, the amount of albumin is smaller thaa^
that which we expect in fluid of any other kind. With a positive
Wassermann reaction any such cardiac weakness should be regarded as
very possibly syphilitic, especially as we have no conclu^ve evidence
of any other type of heart trouble.
ASaXES AND ABDOMINAL ENLARGEMENT 66l
The condition of the urine is perfectly consistent with this hypoth-
esb. We may suppose, then, that he has a syphilitic nephritis and
myocarditis; possibly also a syphilitic hepatitis. A similar affection
of the pancreas might be conjectured as a reason for the glycosuria.
Yet surely he did not die of diabetes. The glycosuria was only a minor
item in his trouble.
I am also quite sure that he did not die of tuberculosis. The course
of the illness is far too short and afebrile.
Malignant disease, too, may be clearly excluded. Just how far the
lesions of the heart, kidney, and liver may have separately contributed
to the acomiulation of ascites it is impossible to say.
Case 295
A bricklayer of twenty-three entered the hospital November 30,
1910. Three of the patient's brothers died of Bright's disease, one
sister of congenital heart trouble; otherwise the family history is good.
The patient had a hard chancre last February, and was treated by in-
imctions of mercury, mercurial pills, and iodid of potash from April to
October of the present year. In April he had a sore throat, loss of
hair, swelling and tenderness of the cervical lymph-glands, and severe
liunbar pains, the latter lasting two weeks and disabling him for that
period from work.
Five weeks ago he noticed that his trousers were getting tight and
his legs beginning to swell. In a week he could hardly walk because of
the swelling. He gave up work and went to bed for a week, after which
the swelling was reduced on a milk diet. He got up and the swelling
then reappeared within a few days. Since then he has been in bed, off
and on, without any permanent benefit. He never passes urine at
night and, aside from the edema, has no symptoms, except three slight
headaches within the past month and some dimness of vision in the last
two days.
Physical examination showed normal pupils and reflexes, notable en-
largement of the cervical, axillary, and epitrochlear lymph-nodes, which
were hard, the smallest the size of a pea. The heart was negative and
the lungs as in Fig. 237. Abdomen showed dulness in the flanks, shift-
ing with change of position. The fundus oculi was normal. Urine dur-
ing his eight weeks' stay in the hospital averaged 50 ounces in twenty-
four hours, with a specific gravity of 1022. The amount of albumin
varied between a large trace and 0.6 per cent. The sediment showed
veiy large granular casts and a few hyalines. Systolic blood-pressure
above 125 mm. Hg., usually 120 nmi. Hg. or lower; at en-
662
DIFFERENTIAL DIAGNOSIS
trance, no mm. Hg. Blood was normal. Toward the latter part of I
his stay the number of casts in his urine decreased somewhat, but the
albumin ranged between 0.4 and 0.7 per cent, Wassermann reaction
was negative on the 7th and 13th of January. Dally hot-air baths and
purgation with magnesium sulphate had, for the first ten days, no con-
siderable effect upon the edema and ascites. No cardiac hypertrophy
could be made out. By the 12th of December, 1910, the edema and
ascites began to go down. The girth at the navel was then 87 cm.;
on the 24th of December, girth 84 cm.; January 5th, 1911, girth 81 an.
Fig. 237. — Physical rr.T,- >i ( i ■ ...■
January 8th no demonstrable fluid in the abdomen. He noticed that]
he passed more urine whenever he stayed in bed.
Discussion. — When I studied this patient in the hospital I \
amazed at the combination of low blood-pressure with obvious urinary 1
evidence of nephritis. I did not at that time realize that the degen- I
erative tubular lesions often associated with syphilis may produce just
this combination of s>Tnptoms, the type of lesion classified by Volhard'
as a nephrosis. As in the previous case, we may be In some doubt how
D F. Volhard undTb. Fahr. von Julius Sprioger,
ASaiES AND ABDOMINAL ENLARGEMENT 663
much was contributed by the kidney and how much by the liver to the
accumulation of ascites in this case.
Outcome. — January 17, 1910, girth 78 cm. January 22d, practi-
cally no edema, even when he is up and about. Is feeling considerably
better and wants to go home. Accordingly he is discharged.
Two years later, January 2, 1913, he writes: "I have been steadily
improving since I left the hospital. Last August when I took neosal-
varsan I had my urine tested and there was a faint trace of albumin.
Last week I had it tested again and there wasn't any albumin. I have
taken salvarsan four times and seem to feel better after taking it."
The nephrosis may have cleared up or it may have reached the
stage of "contracted kidney," which (according to Volhard) follows
in some cases of this type, as well as in the glomerular and vascular
types of disease.
Case 296
A woman of twenty-one entered the hospital Jime 15, 191 1. The
patient's father died of cancer of the stomach at sixty-two, otherwise
the family history is excellent. She has had no previous illnesses until
May, 1903, when she was much pulled down by an attack of mimips
and whooping-cough, her cough lasting imtil July. Then she was well
until September, when she noticed a painless enlargement of the abdo-
men, and three weeks later was tapped, 8 quarts being withdrawn.
She was tapped three times more before March, 1904, when she went to
the Boston City Hospital and had two operations, preceded by measles.
The second operation was said to have been on the liver. The nature
of the first one was not known. After that time she was tapped only
about once a year, 12 to 15 quarts of clear yellow fluid being with-
drawn each time. She has had at no time any pain and her bowels
have been regular. She has lost no weight and has felt strong and well
most of the time, though just before each tapping she has had some
dyspnea and edema of the legs.
Physical examination showed good nutrition, very dry skin, marked
dulness in the flanks, shifting with change of position, soft edema of the
legs, flatness below the angles of the scapulae, with diminished breath
sounds and voice sounds. The apex impulse of the heart not made out,
apparently displaced to the left and upward. A blowing systolic
murmur was heard at the apex and transmitted over the precordia.
The pulmonic second was accentuated. Knee-jerks were not ob-
tained. Pupils normal. Urine normal at entrance and most of the
time thereafter, though occasionally it contained a very slight trace
664 DnTERENTUL DUGNOSIS
of albumin. Blood normal. Systolic blood-pressure, i30. Weight I
at entrance, 155 pounds; at discharge, six weeks later, 156 poimds. ]
A letter received from the Boston City Hospital stated that she J
was admitted there June 28, 1904, with a diagnosis of tuberculous I
peritonitis and operated upon June 29th, when considerable ascites I
was found, with a normal liver and spleen. Tubercles were found!
on the sigmoid flexure. The second operation, August 4th, showed J
nothing but a considerable amount of ascites.
Fig. 338.— Signs in Case 296.
The abdomen was tapped at the Massachusetts General Hospital
on the 2ist of June and 17 quarts of fluid withdrawn. Specific gravity.
1007 ; albumin, i per cent. ; sediment, endothelial cells; culture negative.
After I mg. of tuberculin she had a typical temperature reaction, with
considerable cyanosis. On the 26th she was given 100 gm. levulose in
oatmeal, but the urine showed no sugar thereafter. ,V-ray of the
shins, June 25th, showed nothing abnormal. Wassermann reaction
was negative June i6th. Dr. F. G. Balch advised no surgical inter-
ference. At entrance, June i6th, I made the diagnosis of cirrhosis of
the liver; later chronic fibrous peritonitis seemed more probable.
ASCITES AND ABDOMINAL ENLARGEMENT 665
She was discharged the 27th of July and re-admitted February ag,
1912, after being tapped meantime every eight or nine weeks at first,
later ever>- four weeks, and, later still, every three weeks. For the
past month she has complained of much gas in her stomach, with loss
of appetite, vomiting and dyspnea, especially at night. For a month she
has remained in bed and has lost weight. Two days ago, at g p. M.,
she had sudden intense pain in the left lower back and began to cough,
raising bright blood.
Physical examination showed marked cyanosis, lungs and abdomen
as in Figs. 238, 239. The abdomen obviously contained much fluid.
I
Case iqfi.
Knee-jerks were present and equal. There was marked systolic re-
traction of the lower precordial spaces, suggesting mediastinitis.
There was also a paradoxic pulse.
Discussion. — The insidious onset of ascites in an afebrile patient of
fourteen, and in quantity sufficient to require repeated tappings, with-
out any marked impairment of the general health, is an unusual clinical
picture. There is, however, one well-recognized cause to which it may
be due — namely, adhesive pericarditis.
Although the records of the Boston City Hospital state that the
patient had tuberculous peritonitis, the details of the record are not at
666 DIFFERENTIAL DIAGNOSIS
all convincing. One does not exf)ect to find any such process confined
to the sigmoid flexure or to any other one part of the intestine.
When at the Massachusetts General Hospital the characteristics of
the tap-fluid were clearly those of a transudate, not of a peritonitis.
The positive tuberculin reaction obtained at this time is not of impor-
tance in a patient of twenty-one. Mitral regurgitation would have
been the diagnosis made by many, in view of the physical signs at this
period. I wish, however, to insist strongly that such a diagnosis is
never justified as the chief or main explanation of any set of symptoms
whatever. Mitral regurgitation may often be a subordinate item in a
pathologic state, an item like pulmonary congestion or ulcer of the leg,
but it is never a sufficient or primary cause for other symptoms.
At the time of the second entrance the patient had evidently had a
period of failing compensation and a recent limg infarct.
The evidence presented at the time would lead any unprejudiced
observer straight to the diagnosis of adhesive pericarditis. The only
missing link is the lack of any rheumatic history.
Outcome. — She did not improve at all, and died March ist
Autopsy showed chronic adhesive pericarditis, chronic perihepatitis,
perisplenitis, chronic peritonitis, hypertrophy and dilatation of the
heart, infarct of the left lung, infarcts of the kidneys, chronic pleuritis.
Case 297
A married woman of forty entered the hospital August 26, 1911.
Her family history is negative, and she remembers no serious illness
since childhood. She has been married fifteen years and has one child
living and well. Has had no miscarriages. Her habits are excellent
She has never taken alcohol.
One year ago she had what she calls "gastritis" for a week, and for
four or five days afterward her skin was yellow, but there was no itching.
She was not in bed, but since then has not felt quite so strong as before,
and her abdomen has often been "bloated" for a day or two. The
swelling has disappeared after a cathartic.
Two months ago the swelling in the abdomen became more marked
than before and steadily increased until three weeks ago, when she
began taking salts steadily. Since then it has decreased much, but a
shortness of breath, which began two months ago, has meantime c<m-
stantly increased. For the past month she has had a dry cough, and
finds it distressing to lie upon the right side at night. There has been
no pain in the chest, no chills or fever, no return of the jaundice, no
edema. She does not think that she has lost any weight and says she
ASCITES AND ABDOMINAL ENLARGEMENT 667
has always been thin. For years it has been her habit to pass urine
four or live times in the night.
Physical examination showed poor nutrition, slight dyspnea,
moderate pallor, and cyanosis. Pupils and reflexes normal. No
enlarged glands. Chest and abdomen as shown in Figs. 240-243.
Urine normal. Blood likewise normal. Wassemiann reaction, Sep-
tember 14th, was slightly positive, and that done with the chest fluid
moderately positive. The right chest was tapped August 26th, August
30th, September ist, 9th, 14th, 18th,. 23d, and 3olh. It did not need
to be tapped again until the rjth of October, and not after that until
some months later. During most of her two months* stay in the hos-
Fift. 340. — Physical signa in Case 297
pital her temperature reached 99.3° F., or slightly higher, each after-
noon. The pulse ranged in the neighborhood of no for the first month,
after that lower, and for the last two weeks of her stay it was about 80.
Her weight was 124 pounds at entrance, 104 pounds on the 15th
of September and at the time of her discharge, October 20th. At
all of these tappings of the chest, referred to above, the specific gravity
of the fluid varied from 1004 to 1007. Amount of albumin was i per
cent, or less; the sediment mostly of endothelial cells. The amount
drawn at each tapping varied from 2 to 4 quarts. A'-ray examination
added no new evidence, but its results were strongly against thepres-
; of any mediastinal tumor or any primary disease of the lungs.
Fig. 243. — Diagram of i-riy shadows.
Plate taken with patient prone.
Fig. 143.— Diagram of i-ray plale tjkoi
with patient sitting up and tminediilcljr
after Ihc Aithdiavra.! til i\ quarts of A
from the right chesl.
The spleen was always felt when the abdomen was moderately r
In early September there was at one time a trifling sug"^
ASaTES AND ABDOMINAL ENLAKGEMENT 669
thalmos, and the rapid unsatisfactory beat of the heart slightly sug-
gested the action of a goiter heart.
On the 20th of September the abdomen was thought to contain a
Ettle fluid, although no absolute flatness could be obtained in the
flanks. It was accordingly tapped, but only 40 c.c. of fluid obtained,
the characteristics being practically the same as those of the chest fluid.
Even after 21 quarts of fluid had been removed from her chest within
four weeks — to September 23d — ^(Figs. 244, 245) her nutrition was
extraordinarily well maintained.
About the first of October she was put upon a salt-free diet and began
to improve at once At the tapping, October 14th, only 2 quarts of
I, 145. — Condition of chest September i%d in Case ig?. Anterior and posterior
fluid were obtained. She left the hospital October 21, 1911, and re-
ported regularly thereafter. January 13, 1912, three months after the
last tapping, there was no evidence of any considerable amount of fluid
in the right chest, but the abdomen contained a moderate amount of
fluid. Her only complaint now was a moderate degree of prolapse of the
vaginal waU. She notices that she is rapidly gaining weight and now
weighs III pounds. She feels excellently well.
Dr. R.B. Greenough suggested the possibility of ovarian tumor, and
thought this possibility would justify exploratory incision. Dr. W. H.
Smith thought the fluid due to pressure of glands, either syphilitic or of
the Hodgkin's type. As an alternate diagnosis, he suggested primary
;nant disease of the abdomen, possibly of the ovary, with metas-
670 DIFFEBNETIAL DIAGNOSIS
tases in the right lung. Dr. C. H. Lawrence suggested chronic adhesive
peritonitis or pleuritis, syphilitic in origin, but could not rule out solid
tumor of the ovary. Dr. G. C. Shattuck suggested mediastinal ob-
struction due to old polyserositis, perhaps sjphilitic or tuberculous in
origin. Dr. F. T. Lord suggested perihepatitis, with peritonitis and
involvement of the gastrohepatic omentum and partial occlusion of the
portal vein, and a similar process in the mediastinum and pleura with
occlusion of the right azygos vein. Dr. James H. Wright thought the
hydrothorax due to a lesion of the mitral valve, with the dilated right
heart pressing on the right azygos vein. The ascites, he said, was due J
to cirrhosis of the liver.
The patient re-entered the hospital March i. 1912, complaining
chiefly of vaginal prolapse, with bloating of the abdomen. Three weeks
ago her abdomen became especially swollen. She took an active purge,
had severe watery catharsis, and the abdomen became flat, but she was
much weakened. She was in bed a week thereafter and has not
recovered strength since, although the abdomen has again become
swollen. The condition of the chest and abdomen are shown in Figs.
246, 247. Three and a half quarts of fluid were withdrawn from
the chest, the properties of the fluid being essentially as before; ij
quarts were also withdrawn from the abdomen on the 4th of March
and I f quarts three days after. The chest was tapped thereafter oa
the 1 2th, 20th, and 29th of March and on the 5th and 14th of Aptii
ASaXES AND ABDOMINAL ENLARGEMENT 67 1
the amoxint drawn varying from 3 to 4 quarts. The abdomen was
tapped on the 21st of March and i quart withdrawn; on the 28th 2
quarts were withdrawn.
On the 13th of March she had a well-marked temperature reaction
following the subcutaneous injection of i mg. of tuberculin. Salt-
free diet, which helped her so much before, had now no effect. On the
1 6th of April she developed an erysipelas around the last tap-hole in
the back. Thereafter she lost her flesh rapidly, though the erysipelas
cleared up. On the 24th of April, 191 2, she died.
Discussion. — The multitude of conflicting diagnoses which I have
recorded in this case shows that it was one of great interest and diffi-
cxilty. Throughout the whole case our attention was concentrated
upon the problem of explaining the rapid re-accumulation of dropsical
fluid in the right chest. It was clearly not a pleuritic effusion, for its
specific gravity was far too low. In the heart we could find no sufficient
cause for it. The x-ray evidence was strongly against any neoplasm
such as lymphoblastoma. No nephritis and no pelvic tumor could be
foimd. (It will be remembered that some pelvic tumors are associated
with bydrothorax as well as with ascites.)
Insufficient attention was paid to the history of jaundice and to
the splenic enlargement. In view of the positive Wassermann reaction,
my attention was thrown off the possibility of liver cirrhosis, though, in
fact, that reaction should have acted rather to strengthen such a possi-
bility. As a matter of fact, very little attention was paid to the
abdomen, either by the patient or her physicians, for the thoracic symp-
toms were much more prominent.
When it seemed clear that we could exclude the heart, the kidney,
tuberculous peritonitis, and any possible neoplastic source of pressure,
I skipped over the fourth common cause of ascites, namely, hepatic
cirrhosis, and alighted on a much more uncommon possibility, namely,
multiple serositis. Looking back with the knowledge of hindsight, it
is easy to see that this was foolish; yet, even after the autopsy, the
mystery of recurrent hydrothorax was never cleared up.
Outcome. — Autopsy showed cirrhosis of the liver, enlargement of
the spleen, right seropurulent pleuritis, obsolete tuberculosis of the
bronchial lymphatic glands, streptococcic septicemia.
Case 298
An Italian barber of thirty-six entered the hospital October 27,
191 1. The patient has lost one brother of tuberculosis, but was
not, so far as he knows, exposed to infection; otherwise his family
672 DIFFERENTIAL DIAGNOSIS
history and past history are excellent. For fifteen years he has
taken four or five whiskies and three or four beers a day. He had
gonorrhea ten years ago, but no syphilis.
Until six weeks ago he has felt entirely well. Then he
was seized in the night with vomiting and diarrhea. Next day he
went to work and felt as well as usual for two weeks, when he had a
second similar attack without known cause. He returned to work,
but at the end of a week's work, three weeks ago, he noticed vague
abdominal discomfort and an uncomfortable sense of fulness after
eating or drinking, even in moderation. A few days later he noticed
that his abdomen was enlarged, and he felt so weak and tired that
he gave up work. The abdominal enlargement has steadily in-
creased, and within a few days he has noticed some puflSiness of the
ankles.
His bowels have been constipated and have required cathartics.
In each of the above vomiting spells he noticed black stools; at
other times there has been nothing abnormal about them. He has
never vomited blood and has had no stomach symptoms save after a
drinking bout. His appetite is still fair.
Physical examination showed poor nutrition, normal pupils and
reflexes, normal chest save for a few fine crackles at each base. Ab-
domen showed shifting dulness in the flanks with slight edema of the
ankles. Over the shins were many large areas of brownish pigmenta-
tion. Blood-pressure, 130 mm. Hg., systolic; 85 mm. Hg., diastolic.
Wassermann reaction was suspicious. Urine normal. White count
at entrance, 11,000; November ist, 19,000; November 2d, 20,000;
November 3d, 25,000; November 6th, 22,000; November 7th, 18,000;
November 9th, 15,000; November nth, 13,000; November 14th,
10,500. Through the ascitic accumulation a hard, apparently smooth
Uver could be felt by ^^dipping'' at the level of the umbilicus. Spleen
not felt. In the fasting stomach there was a good deal of blood-
stained material, with a positive reaction to guaiac.
The tap-fluid at entrance was 3800 c.c, amber color, with a specific
gravity of 1012, albumin, 2.4 per cent., smear chiefly large endothelial
cells, culture negative. Another tapping, November 3d, showed 3300
c.c. ; specific gravity, loio; albumin, 3 per cent. ; sediment, 70 per cent
of small lymphocytes, 20 per cent, of polynuclears, 10 per cent, endo-
thelial cells, no growth on culture-media. The results of blood-cul-
ture during the febrile attack are shown in Fig. 248. It was n^ative
November 2d and November 9th. Weight, November i6th, 127
pounds; November 2 2d, after three tappings^ the fluid seemed to be
ASaTES Am> ABDOMINAL ZNLARGEUENT 673
accumulating more slowly. Operation was advised, but postponed.
The patient left the hospital November 22d.
He came back again December 26th in about the same condition.
Discu88ion.^When an Italian of thirty-six admits alcoholism
and gonorrhea, his denial of syphilis is of no special importancei and,
joining this history to the attacks of vomiting and black stools
and the four weeks of swollen abdomen, which examination shows
to be full of fluid, we naturally think, first of all, of hepatic cirrhosis.
The cardiac, renal, neoplastic, and tuberculous causes of ascites are
less apt to be associated with black stools.
The tap-fluid is of medium weight, but, on the whole, nearer to
that of a transudate than that of an inflammatory fluid. The only
discussable question relates to the origin of the cirrhosis. The suspi-
cious Wassermann reaction and the brown scars upon the shin rather
incline us to believe that the trouble is syphiUtic. The fever points
in the same direction. Alcoholic drrhosb is less likely to produce
such a pyrexia. None of the other causes of ascites, except tuber-
culous peritonitis, produce fever. Against the latter are the condi-
tion of the liver edge and the specific gravity of the fluid, as well as
the ne^tive past history and family history.
B. — Operation on the 30th showed a small hob-nailed
'. n— «8
674 DIFFESENTIAL DIAGNOSIS
liver. Its surface and that of the peritoneum near it was scnq>ed
until it bled and the two surfaces brought into apposition. January
4th the patient's temperature began to rise and continued elevated,
as shown in Fig. 249. There were many r&Ies in both chests and he
raised a large amount of thick sputa, but showed no signs of limg
consolidation. On the nth he had to be tapped; 118 ounces were
removed. On the 25th he was tapped again and 32 ounces removed.
After that the abdomen did not refill and the patient felt much better.
On the 6th of February, 1912, he left the hospital in good condition.
H
'M\
nil
SBS
UAlUllllUliulViii
^
MiSjf
Fig. 249. — Chart oi Case 398, after Talma's operation.
Remarks.— Apparently, after the operation he suffered a pul-
monary thrombosis. His subsequent history was that of an alcoholic
loafer. From a physical point of view the operation was a success;
from a community standpoint we can hardly say so. On the 3d of
May he still had moderate ascites, but was greatly improved in
general appearance and had gained in flesh and strength. On the
31st of May the amount of fluid in the abdomen was small, but Ai^ust
3ist there was still shifting dulness in the flanks. October 14, 1913,
he had not gone to work; he evidently enjoyed his leisurely life far
too well.
Case 299
A clerk of twenty-four entered the hospital March 28, 1912, Tie
patient's father died of Bright's disease. Family history otherwise
ASaTES AND ABDOMINAL ENLARGEMENT 675
excellent. Three years ago she had a swelling on the right side of the
neck which lasted for some weeks. Her menstruation has been rather
profuse for the past year.
For five months she has been gradually getting weaker and losing
appetite, but has had no more definite symptoms than these until
two months ago, when she began to have a pain between her shoulders
and down both arms. In the course of another month this gradually
wore oflf. Four weeks ago she noticed swelling of the abdomen,
which, especially in the last two weeks, has much increased, although
for the same period she has had three or four watery stools a day and
has been obliged to remain in bed. She has considerable pain about
her heart after meals, relieved by belching; she is somewhat short of
breath on exertion and when attempting to lie flat.
Physical examination showed considerable wasting, marked sweat-
ing, normal pupils and reflexes, normal chest, save for the evidences of a
high diaphragm, shifting dulness in the flanks, blood-pressure 120 mm.
Hg., blood and urine normal. On the 29th the abdomen was tapped
and 5^ quarts of fluid, greenish yellow in color, withdrawn. Specific
gravity, 1018, albumin over 3 per cent. Smear of sediment showed 45
per cent, polynuclears, 55 per cent, large and small mononuclears, a
few red blood-cells, no tubercle bacilli; 20 minims of this sediment
were injected into a guinea-pig March 29th. On the 6th of May the
animal was killed, and the autopsy showed tuberculous lesions of the
glands, liver, and spleen. After tapping there was still slight general
spasm of the abdomen and a moderate dull pain there. Throughout
her three weeks in the medical wards the temperature continued much
elevated. The cutaneous tuberculin test was positive. On the 1 7th of
April she was transferred to the surgical wards.
Discussion. — Here we have a clinical picture of an ascites with-
out any evidence of renal, cardiac, hepatic, or neoplastic origin.
The fluid is of high specific gravity and produces tuberculosis in
a guinea-pig. There are no further evidences needed. We may
be as certain of tuberculous peritonitis as if an autopsy had been
done.
Looking back from this standpoint of certainty, it is of interest that
the patient had, three years before, a swelling in the neck, which we
may reasonably interpret as a tuberculous gland. This followed five
months of the sort of symptoms ordinarily known as general debiUty
or attributed to stomach trouble. Diagnosis would probably have been
impossible at that time, but the lesson to be learned is this: when
people become debilitated without any good reason and without any
676 DIFFERENTIAL DIAGNOSIS
demonstrable physical sign, tuberculosis is always a plausible cause and
should be watched for sedulously.
Outcome. — ^At operation the peritoneum was lusterless, but very
few tubercles could be seen. There were a moderate nimiber of ad-
hesions and several pockets of fluid, which were not opened. Both
Fallopian tubes were foimd to be tuberculous and were removed. In
the surgical wards she continued to run a fever from April 17 th to her
discharge, May 9th. Microscopic examination of the excised tubes
showed tuberculosis. Her general condition improved somewhat.
January 20, 19 13, a letter from her sister states that she died
Jxme 30, 191 2.
Case 300
A housepainter, aged fifty-six years, who had taken alcohol only
occasionally and in moderate amoimts, noticed edema of his ankles
seven weeks ago. A week later his belly swelled up, and he needed
three tappings in six weeks, 8 or 9 quarts being withdrawn each
time. Has lost 30 poimds in four months.
Examination. — The right lower lid contained a small nodule
showing all the characteristics of epithelioma. The heart was dis-
placed so that its apex was in the anterior axillary line, while the
right border of dulness was at the left sternal margin. There was a
soft systolic murmur at the apex. The pulmonic second soxmd was
not accentuated.
There was evidence of edema at the bases of the limgs. The belly
contained a large amount of serous fluid, 250 ounces accumulating
between two tappings sixteen days apart — an average of over 15
oimces a day. The fluids were 1006 and 1008 in gravity, and showed
80 and 90 per cent, of lymphocytes respectively in their sediments.
Culture and animal inoculation negative. Fever was absent, and
there was no reaction after the subcutaneous injection of 10 mg. of
tuberculin.
There was some excess of neutral fat in the stools, suggesting to
Dr. H. F. Hewes the stools of tuberculous peritonitis.
In diagnosis we considered cirrhosis of the liver, tuberculous
peritonitis, and also the possibility that misplacement of the heart,
owing to pleural adhesions, might have kinked some one of the great
abdominal veins so as to produce stasis and ascites.
Against cirrhosis was the early appearance of swelling in the legs
and the moderate amount of alcohol ingested. Against tuberculosis
was the negative tuberculin reaction and the low gravity of the
ASCITES AND ABDOMINAL ENLARGEMENT 677
fluid obtained by tapping. On the other hand, the cell-count in the
fluid, the appearance of the stools, as well as the old history of pleurisy,
made tuberculous peritonitis a possibility. On the whole, cirrhosis
seemed the more probable, and on operation, September i8th, this
was found.
Outcome. — ^The patient died September 29th, and autopsy showed
the ordinary lesions of cirrhosis of the liver and, in addition, a thrombo-
sis of the portal vein and a chronic peritonitis. There was also slight
fibrous endocarditis of the aortic and mitral valves and slight hyper-
trophy and dilatation of the heart. There was obsolete tuberculosis
of a tracheal lymph-gland, which is interesting in view of the negative
tuberculin reaction.
Case 301
A married woman, aged thirty-eight years, entered the hospital
October 9, 1908. She has previously been well except that she has
had a cough since she was a girl, and had typhoid fever ten years
ago. For two or three years she has felt something wrong in the
pelvis, and a year ago her doctor foimd a uterine j&broid there. The
patient thinks this timior has been present for four years.
Seven months ago she consulted a physician for pain in her left
chest. He found pleural effusion, and withdrew 2 quarts of fluid
by tapping. The same amount was withdrawn four weeks later,
but the fluid again recurred.
A month ago the abdomen was noticed to be swelling, and this
has increased up to the present time. She has had dypsnea on
exertion for many years, but this has been worse within the last
seven months, and now she cannot lie down flat. For the last two
days the feet and legs have been swelling. The bowels move five
to eight times a day during the last few weeks. Several examina-
tions of the urine and several of the sputa have been negative.
Physical examination verified the findings of fluid in the left
chest and in the abdomen. October loth the abdomen was tapped
and 18 pints of serum withdrawn. The specific gravity was 1018,
and the cell-count showed 63 per cent, of lymphocytes.
After tapping, a rounded solid tumor, hard and painless, could be
felt in the median line, apparently connected with the uterus. The
diagnosis was believed to be tuberculous peritonitis, and the experiment
was tried of withdrawing 8 oimces of fluid from the chest every two
or three days, in order to prevent recurrence such as was thought
likely to follow if the whole amount was removed at once.
678 DrFFERENTIAL DIAGNOSIS
On November 21st the abdomen was again tapped and 18 pints
again removed. This amount had accumulated in forty-two days,
being at the rate of 7 oimces a day. After this tapping, pelvic ex-
amination showed a mass filling the pelvis, pushing the cervix up behind
the pubes, very hard, irregular, non-elastic, and continuous with the
suprapubic tumor. Dr. M. H. Richardson believed the condition to
be one of tuberculous peritonitis with a concomitant uterine tumor,
benign or malignant.
The association of fluid in the abdomen with fluid in the chest,
and the history of a chronic cough, together with the high gravity
of the fluid, made us confident of the diagnosis of tuberculous peri-
tonitis, although in the two and one-half months of her stay in the
medical wards there was never any fever. The blood and urine were
throughout negative, as was the rest of the visceral examination.
Outcome. — Operation, December 12th, showed no peritonitis, but a
fibroma of the ovary; after the removal of this the patient convalesced
rapidly, and when I saw her a year later she was in perfect health, as
she had been for the last eleven months since leaving the hospital.
Case 302
An unmarried Italian girl, aged seventeen years, entered the hos-
pital October 17, 1908, for enlargement of the abdomen, with fever
and general abdominal pain. These symptoms had been present for
the last two weeks and had been accompanied by a dry cough.
On examination there were dulness and harsh breathing through-
out the left lung except at the bottom of the axilla and the base
posteriorly, where breathing was much diminished and resonance
almost absent. Below the second left interspace were fine and
medium crackling r^les in front, and the same riles were heard below
the angle of the scapula behind. The abdomen showed all the evi-
dences of free fluid. Otherwise, physical examination was negative,
and the blood and urine showed nothing abnormal.
After the first five days the patient had practically no fever through-
out her two months' stay in the hospital. The abdomen showed
general tenderness, but was otherwise negative, save for the evidences
of free fluid above referred to. The abdomen was tapped on the 21st,
but only a few ounces of clear serous fluid were obtained; 5 mg. tu-
berculin were injected subcutaneously on the 30th, after which the
temperature rose from normal to 103.2° F. within six hours, returning
to normal within twelve hours more. The cutaneous reaction for
tuberculosis was also positive.
ASaXES AND ABDOMINAL ENLARGEMENT 679
She gained weight, although there was no increase in the amount
of fluid, and on November 12th was allowed to go home.
Outcome. — ^Af ter this she slept out of doors and lived out of doors
continuously, but by January the abdomen began to enlarge again,
and January i6th she was operated on and diffuse tuberculosis of the
peritoneum found. Diagnosis was verified by microscopic examina-
tion of an excised piece. The Fallopian tubes were also tuberculous
and were removed. Convalescence was uneventful.
The resemblance between this case and that last described is
striking. Indeed, but for the presence of the tumor in the first case,
the abdominal tenderness and the scantiness of the ascites in the
second, they are almost identical from a clinical standpoint, despite
the entire difference of the actual pathologic condition present.
A relatively slow accumulation of fluid and a slight general rigid-
ity and tenderness of the belly help to distinguish the ascites of
tuberculous peritonitis from that produced by other diseases.
Case 303
A boy, aged, six years, entered the hospital October 19, 1908.
His history was not of significance up to five months previously,
when his abdomen began to swell; there was also some puffiness of
the face, but no other symptoms, and within a few weeks he was
able to be up and about. Later he relapsed, and two months ago
the abdomen was tapped, 4 quarts of dark yellow, turbid fluid being
withdrawn.
Since this there has been considerable vomiting, and at one time
he had convulsions and was considered moribund. He was tapped
again three weeks ago and 3 quarts of fluid withdrawn. Since then
the abdomen has rapidly refilled.
On examination the cardiac impulse was in the nipple line, fourth
space. The cardiac examination was otherwise not remarkable.
Blood-pressure not measured. The lungs were negative, the abdo-
men very prominent, showing all the evidences of free fluid. Con-
siderable soft edema of the legs and feet.
The urine averaged between 5 and 10 ounces in twenty-four hours
during his stay in the hospital. The specific gravity was between
1020 and 1022; the amount of albumin from 0.5 to 0.9 per cent. In
the sediment were many hyaline, granular, and fatty casts.
The abdomen was tapped on October 21st and 5 quarts 6 ounces
of chylous fluid withdrawn; specific gravity, 1009. In the sediment,
lymphocytes, 37 per cent.; epithelial cells, 63 per cent.
68o DEFFEKENTIAL DIAGNOSIS
Outcome. — The boy left the hospital on November 2, 1908, in very
poor condition, and remained so until February, 1909, when, after
tapping, his abdomen did not refill, and this improved condition per-
sisted for three months. Since then he has had to be tapped every two
weeks, fifteen times in all, up to September 27th. (An average accu-
mulation of about 12 ounces a day.)
His condition in September, 1909, was in all respects essentially
the same as it had been a year before, except that the heart was 1.5
cm. farther to the left. He was tapped on the 28th and 5 quarts
(5800 c.c.) of opalescent fluid removed; specific gravity, 1006. After
this the fluid re-accumulated very slowly, and he was allowed to go
home on October 9th.
Case 304
A dentist, aged thirty-nine years, entered the hospital October
20, 1908. He had been in the habit of taking a pint and a half of
whisky a day for the last two years, and an imknown amoimt for
eight years previously. Two and one-half months ago he noticed
that his trousers were tight around the waist. This increased so
rapidly that four weeks later the abdomen had to be tapped, and
5 quarts of serous fluid were withdrawn. Since then he has been
tapped four times, the amount being about the same each time.
This means an acciunulation of about 16 ounces a day. His feet
have never been swollen, his appetite has been good, there has been no
pain or other symptoms of any kind. The last tapping was a week ago.
Physical examination was essentially negative except for the
evidences of ascites. The blood and urine showed nothing abnormal.
Temperature, pulse, and respiration were normal. October 27th, 14
pints 7 ounces of turbid yellow fluid were withdrawn. After tapping,
the edge of the liver could not be felt below the ribs, but could be
touched by reaching up behind the costal margin. The specific
gravity of the fluid was 1008.
Outcome. — On October 28th the abdomen was opened, the liver
found to be shrunken and irregularly nodular. Omentopexy was done,
but by November 9th the patient had to be tapped again, and 9 pints
of fluid were removed. (Rate of accumulation, 12 oimces a day.)
He left the hospital November 22, 1908. November 29, 1909,
the patient was- seen and seemed to be in excellent condition. There
was no return of fluid in the abdomen. The abdomen was tapped
within a few days after leaving the hospital in November, 1908, but
tapping has not been required since. He now eats well, sleeps well,
and looks well.
ASaTES AND ABDOMINAL ENLARGEMENT 68l
Case 305
A salesman, aged thirty-four years, entered the hospital Novem-
ber 13, 1908. His family history and past history not remarkable,
habits good. For four or five years he has been gaining weight and
has noticed that his trousers were tight about the waist. His usual
weight is 150 pounds; now, 158 poimds. The increase of his girth has
been especially marked in the last year, and has been accompanied
by dyspnea on exertion. During the last ten months his appetite has
also failed; he has had a good deal of vomiting soon after meals,
also troublesome constipation. He worked imtil nine months ago.
Eight months ago he was tapped and 6^ quarts of clear fluid removed.
After a month he began to refill. He has been treated during the last
four months in the Out-patient Department.
Physical Examination. — The heart's impulse extended 2 cm.
outside the nipple line in the fifth space. The heart sounds were
clear and there was nothing else of interest in the cardiac condition.
The position of the apex shifted outward 2.5 cm. when he lay on the
left side. The peripheral arteries were normal and the lungs nega-
tive. The abdomen showed all the evidences of free fluid, and the
edge of the liver could be felt 7 cm. below the costal margin in the
mammary line.
He was tapped November 20th; 202 ounces of yellow turbid fluid
removed; specific gravity, 1020. In the sediment 85 per cent, of
small lymphocytes, 15 per cent, of large lymphocytes. Nothing
more felt after tapping. After an injection of 0.005 tuberculin sub-
cutaneously there was a positive temperature reaction. The a:-rays
showed no evidences of tuberculosis in the lungs. At this time the
spleen was easily palpable when the patient lay upon his right side,
and it was noticed that there was a systolic retraction of the apical
and precordial region. Adherent pericardium, tuberculous perito-
nitis, and cirrhosis were considered, but laparotomy, December 5th,
showed no tuberculosis and no evidence of disease in the liver so far
as the surgeon's hand could discover. Dr. M. H. Richardson and
Dr. Hugh Cabot considered the case to be probably one of pericar-
ditis with adhesions and secondary ascites.
After that he got along imtil January 9, 1909, with two tappings,
but was then operated on again, January loth, for the relief of adherent
pericardium. Parts of the third, fourth, and fifth ribs were resected
from their sternal attachments to a point 4 inches to the left. This
seemed to allow the free retraction of the heart, and was deemed
sufl&cient.
682 DIFFERENTIAL DIAGNOSIS
He returned to the medical wards on January 26, 1909, and under
calomel diuresis the urine rose to 68 oimces and the amoimt of ascites
was considerably decreased. This calomel diuresis was rep)eated
ten days later, with success as before. On March 4th he was tapi>ed,
but only 4 quarts removed. The h'ver edge was then felt 5 cm. below
the ribs. The specific gravity of the ascitic fluid was 1017. March
loth he was tapped again, but only 6 pints foimd. A calomel diuresis
was attempted on March 15 th, but was unsuccessful. It was
evident that after the operation for cardiolysis the accumulation
of ascites was slower, though this may have been due to the per-
sistent administration of diuretics and cathartics. He was last seen
March 27, 1909.
Case 306
A Russian Jewish millgirl, aged eighteen years, entered the hospital
December 2, 1908, with a diagnosis of "tuberculous peritonitis" made in
the Out-patient Department by Dr. W. H. Smith (O. P. D., No.
118,422). Her family history and past history were uneventful.
Menstruation began at twelve and has been regular until within the last
year, when it has become more frequent, and lately has come every two
weeks and lasted four days each time. For three months she has no-
ticed enlargement of the abdomen, and thinks she has been losing
weight. Within the last month she has had some abdominal pain,
paroxysmal and griping. Her appetite has been good and there has
been no cough or other symptoms. Pulse, temperature, and respira-
tion were moderately and irregularly elevated. The urine showed
nothing abnormal. In the blood were 17,900 leukocytes j>er cubic
millimeter December 3d; 16,800 leukocytes December 7th.
Physical examination was negative except as relates to the abdo-
men, which was prominent, tense, flat on percussion throughout, sym-
metric, and gave a fluid wave. Girth at the umbilicus, 86.5 cm. The
edge of the liver was not felt. No edema.
Tuberculous peritonitis was considered, but the leukocytosis and
the extreme tightness of the belly made the diagnosis doubtful.
Outcome. — December 4th the abdomen was tapped above the
pubes and 96 ounces of muddy, thick, viscid, ropy, alkaline fluid
obtained; gravity, 1025. The fluid resembled very thick maple sjrrup
and formed a jelly-like mass after heating. When diluted there was
no precipitate or clot obtained by heat or by the addition of acetic
acid. Biuret reaction negative. The addition of alcohol produced
a heavy, ropy, tenacious precipitate (pseudomucin and paramucin).
ASCITES AND ABDOMINAL ENLARGEMENT 683
This precipitate, when boiled with acid, broke up into two bodies,
one of which reduced Fehling's, while the other gave the Biuret reac-
tion. In the sediment there was nothing distinctive. The fluid was
obviously characteristic of the contents of an ovarian cyst. By lapar-
otomy a large multilocular cyst of the right ovary was removed with-
out incident.
Case 307
A housewife, aged thirty-seven years, entered the hospital February
15, 1909. She had had a miscarriage seven and one-half years ago,
purposely induced; one living child five years old. Two threatened
miscarriages in the course of this pregnancy. The baby was anemic
for the first three weeks, but otherwise has been well. The patient
had diphtheria twelve years ago, and the throat was sore for six weeks
at that time. Three years ago began to have pains in her lower legs,
especially along the shins. The pains came at night, were very severe,
and prevented sleep. There were no enlarged veins or other noticeable
changes, but the bones were sore to the touch. A year later some ulcers
appeared; the last one healed three months ago. Four months ago she
had severe pain in the occiput, worse at night, and at this time three
lumps appeared on her head about i inch in diameter, sore to the touch.
One of them still remains.
Since her last pregnancy has had trouble with her nose, causing
difficulty in breathing. At this time also, about five years ago, her
hair came out profusely for a time. Two or three years ago she noticed
a tiunor in her left hypochondrium, which caused no symptoms, but
bothered her in putting on her corsets. Last October she was operated
on for hemorrhoids, and at that time the doctor said that her spleen
was enlarged.
Two and one-half months ago the belly began to enlarge, and she
has been tapped twice, six weeks ago and three weeks ago. On
examination there were many pea-sized cervical glands. The chest
was negative; systolic blood-pressure, 135. The upper border of the
liver showed on percussion a median elevation just above the nipple
line. The edge of the spleen was felt 12 cm. below the ribs. There
was evidence of free fluid in the abdomen, and the girth at the umbili-
cus was 109 cm. Considerable soft edema of the ankles, and dark
brown scars over the ankles and shins. On the forehead near the hair
line was a straight periosteal thickening, and another higher up in
the hair on the frontal bone. X-ray plates showed specific changes
in the tibiae.
684 DIFFERENTIAL DIAGNOSIS
Outcome. — ^Under antisyphilitic treatment and diuretin the
patient improved rapidly. The fluid diminished in amount, but on
March 2d 6 quarts were withdrawn, after which the edge of the liver
could be easily felt 2 cm. below the ribs in the nipple Une. The ascitic
fluid was 1009 in specific gravity and showed 90 per cent, of mononu-
clear cells, about one-half of them large and one-half small. She left
the hospital March 6, 1909, and up to date, May i, 1914, has remained
well.
Case 308
A shoemaker, aged fifty-three years, entered the hospital Novem-
ber 12, 1908. Family history and past history not remarkable. Elight
years ago lumps appeared in the kf t side of his neck, and have not
changed since then until a year ago, when additional and larger lumps
made their appearance near those previously felt. Also similar lumps
in the axillae and groins. Nine months ago lumps were noticed in the
abdomen. Three weeks ago the belly and legs began to swell, and a
week ago he was tapj)ed in the Out-patient Department and 2200 c.c
removed; specific gravity, loii; sediment Ijrmphocytic. Eighteen
months ago he weighed 180 pounds; a month ago, 160 ix>imds. A
gland was removed in the Out-patient Department, and a diagnosis of
lymphosarcoma or lymphoblastoma (Mallory) made.
On physical examination there was a mass of glands, roughly
10 by 8 cm., in the left side of the neck, not adherent to the skin, and
fairly movable. Elsewhere in the neck, axillae, and groins there were
glands from the size of a bean to that of a hickory nut. The right
pupil slightly larger than the left. Heart's apex, 1.5 cm. outside the
nipple line. Cardiac examination otherwise not significant; lungs
negative. The abdomen showed evidences of free fluid and large ir-
regular tumors. The spleen and liver not made out. On the f)osterior
rectal wall a mass half the size of the fist, hard and nodlilar, was
palpable.
He was tapped on November 25 th and 82 ounces of brownish-red
fluid obtained. On December 4th, 86 ounces more were removed.
Specific gra\nty, 1015; sediment mostly epithelial cells. December
8th, 115 ounces more were withdrawn. December 20th, only 12
ounces. December 24th, 17 ounces more. December 28th, x-rays
showed a shadow over the whole left side of the chest.
Outcome. — Under diuretin, started December 26th, urine rose on
the 30th to 62 ounces, and several times subsequently 60 to 80 ounces
were obtained as the result of diuretin. He was tapped December 28th
ASCITES AND ABDOMINAL ENLARGEMENT 685
and 7 pints obtained. On January 3d, 50 ounces; January 9th, 6
pints; January isth, 106 ounces; January 19th, 96 oimces. He left
the hospital January 21st, and died soon after at home.
Case 309
A stage-manager of thirty-one entered the hospital June 29, 1907.
The patient has been well, so far as he knows, until three and one-half
weeks ago, when he began to feel rather poorly, and three weeks ago
gave up work on account of spells of colicky pain in the abdomen, espe-
cially after a heavy meal. The pain always shifted from one point to
another in the abdomen and was not accompanied by any tenderness.
The attacks lasted two or three days, with intervals of entire comfort
between times, during which intervals, however, he has felt weak,
feverish, thirsty, and has been unable to take solid food.
Six days ago he felt fine and went on a visit to Lexington, where he
ate ice-cream and cake and took two glasses of champagne. That
night he had chills, fever, and nausea. The next morning he was weak
and had headache, but went to work and kept at it through the day.
That night he had epigastric pain and vomiting, and has since then
remained in bed, feverish and sleepless. Three days ago the abdomen
swelled and became generally sore. For twenty-four hours he has
had much hiccup and belching of gas.
On physical examination the patient is mentally alert, but looks
very sick. The head, chest, and extremities are negative. The abdo-
men is distended, the navel flushed, general tenderness throughout,
marked in the epigastrium, but not in the right ili^-c region. Shifting
dulness in the flanks. Spleen enlarged on percussion. One typical
rose spot on the back. The white cells are 10,800; hemoglobin, 80 per
cent.; Widal reaction negative. The temperature is 101° F.; pulse,
100. The urine is 35 ounces in twenty-four hours; specific gravity,
1030; slightest possible trace of albmnin; rare granular cast. The
vomitus consists of greenish fluid, mucus and undigested food. Guaiac
always negative. HCl absent.
Discussion. — Three weeks' colic with fever in attacks lasting two or
three days at a time, then three days of a sore and swollen belly, fol-
lowed by twenty-four hours of hiccuping, leads us straight to the diag-
nosis of general peritonitis, dependent upon some focus of inflamma-
tion within the abdomen. The physical examination shows evidence
of free fluid and of general tenderness, such as is produced by perito-
nitis. The amount of fever and leukocytosis is not great, and must
be accounted for, if we stick to the theory of peritonitis, by saying
686 DIFFERENTIAL DIAGNOSIS
that the patient is overwhehned by his infection and cannot react
against it.
Is the spleen enlarged? I see no evidence of it. A spleen that we
cannot feel should never be considered enlarged, no matter what the
percussion outlines are. This is not to say that such enlargement can-
not exist, but only that we cannot feel sure of it, and that an enlarged
area of dulness in the splenic region frequently exists without any
enlargement of the spleen or any other local cause of importance.
Among the diagnoses likely to be made in this case we will take first
the inevitable ptomain-poisoning. Any abdominal pain which the
patient connects with a supposedly poisonous material is very apt to
be called ptomain-poisoning by the patient himself and by his doctor.
Such a diagnosis has an impressive sound and pleases the patient, yet
it is almost inevitably a blunder. True food-poisoning is rare, and,
even if poisons from food are actually the cause of the patient's troubles,
we have no reason to assume that these poisons are really ptomains.
In the vast majority of cases, the term "ptomain-poisoning" is only a
blind to cover up our ignorance of what the actual diagnosis is. Within
the past year or two I have known the following diseases miscalled
ptomain-poisoning: tabes dorsaUs with gastric crisis, lead-ix>isoning,
appendicitis, gall-stones, cancer of the colon, and uremia. Without
much trouble the list might be greatly extended.
The commonest cause of an otherwise general peritonitis is inflam-
mation of the appendix. I cannot rule out this diagnosis here, but
there are no local physical signs to support it.
Some cases of tuberculous peritonitis remain entirely latent for a
long time and then suddenly manifest themselves by acute symptoms,
due to local peritonitis or obstruction by adhesions. The presence of
shifting dulness in the flanks might be interpreted as supporting this
conjecture. As a rule, however, the patient is not nearly as sick as this
patient seems to be. In the acute complications of tuberculous peri-
tonitis, the general condition of the patient remains surprisingly good.
Such a feature as a twenty-four-hour hiccup would not be exi>ected.
Acute intestinal obstruction of unknown origin might produce all
the symptoms here described. At this patient's age, however, intes-
tinal obstruction is rare, unless there has been a previous peritonitis
or laparotomy.
Acute gall-bladder disease is certainly a possibility, although we
have no jaundice, no demonstrable enlargement of the gall-bladder,
and no local tenderness. Had the gall-bladder actually j>erforated,
the patient's condition would be even more grave than it is. The
ASCITES AND ABDOMINAL ENLARGEMENT 687
shifting of the colicky pain from point to point is not what one expects
in gall-bladder disease.
Peptic ulcer usually shows a longer history of gastric sjrmptoms
and less shifting colic. Nevertheless, it is impossible to exclude a
perforation of such an ulcer with general peritonitis as a result.
On the whole, then, I am unable to reach a definite diagnosis of the
cause of this patient's general peritonitis. Intestinal obstruction
seems as probable as anything, with appendicitis a close second.
Outcome. — Operation, July 2d, showed 2 quarts of dear fluid in
the abdomen, the small intestine greatly distended, no cause for ob-
struction found. Incision was then enlarged downward and a coil
of intestine, apparently from the upper ileum, found thickened, blue,
and covered with a fibrous exudate. The mesentery corresponding
with this loop was thick and porky. Above this point the intestine
was distended; below it, contracted. The diseased loop was clamped
and cut away. The patient died the next day. Autopsy showed
chronic appendicitis with abscess formation; suppurative thrombosis
of the portal vein, inferior and superior mesenteric veins and their
radicles; general peritonitis.
Case 310
A rubber worker of forty-nine, bom in Austria, entered the hospital
January 26, 1910. The patient has noticed enlargement of the ab-
domen for five weeks; previously to that he has been well. His father
died of lung trouble at fifty-four. He had three brothers and one sister
who died of unknown cause. One living brother has stomach trouble.
The patient's wife and nine children are well. He drinks half a pint of
whisky a day. He has done this for thirty-five years, with a little
beer and wine occasionally. He spends thirty-five cents a week for
tobacco.
Abdominal swelling compelled him a month ago to give up work,
though he has no considerable pain and rarely vomits. At the same
time his skin became yellow, his stools light colored, his urine dark,
his feet swelled, and a cough appeared, which has since become worse.
Appetite and sleep are good, and, so far as he knows, he has lost no
weight.
Physical examination showed fair nutrition and was generally
negative, except as relates to the abdomen, the general yellow discolor-
ations of skin and mucous membranes, and the absence of knee-jerks.
The abdomen showed shifting dulness in the flanks and elsewhere,
except for a small area of tympany about the navel. No tenderness or
688 DIFFERENTIAL DIAGNOSIS
masses could be detected. The knee-jerks were not obtained. Plantar
reflexes normal. Save for the presence of bile the urine showed noth-
ing remarkable and the blood was normal. The evening temperature
ranged in the neighborhood of ioo° F. during two weeks* observation.
The temperature was usually normal in the morning. The stools
were of normal color and contained bile. They were negative to
guaiac and showed no special abnormalities.
Two and one-half quarts of fluid were removed from the abdomen
on the 29th. After tapping the surface of the liver it seemed coarsely
nodular. The abdominal fluid had a gravity of 1008, contained i
per cent, albumin, and a sediment with 88 per cent, of small lympho-
cytes.
Discussion. — Lead-poisoning, which is brought to our attention by
this patient's occupation (since litharge is used in the manufacture of
rubber), does not ordinarily produce abdominal enlargement as the
most noticeable sxnnptom, and without pain. The abdominal enlarge-
ment which we sometimes see in lead-poisoning is due to gas and is
associated with pain and constipation. If this patient has plumbism,
his abdominal SNuiptoms are not at all characteristic of it.
The family histor>- of tuberculosis leads us to ^)eculate on the
possibility of tuberculous peritonitis, which might quite possibly come
on in this way, though rarely in a patient of fort>--nine. The presence
of jaundice, absent knee-jerks, and swelled feet cannot be easily ac-
counted for in this way. and the cough is much more likely to be due to
a high diaphragm than to tuberculosis. On the other hand, tubercu-
k>sis would oasilv accv^unt for the condition of the abdomen and for the
fe\"er.
The iUvx^hoUc hisior\- leads strais^ht to drrhosb of the liver as a
plausible oxj^Umaiion of his SNTiiptoms, I see nothing in the case to
exclude this diagnosis, though ie\-er is not the rule in cirrhosis, and me
cannot thus acxvunt for the loss of knee-jertLS. Moreover, the snuJl
mxlulos v>f the oirrhotio liver surface are rarely, if ever, palpable
lhn>ugh the Ix^Uy wail.
It. howvwr. wo suppose a drrhosis of the syi^iilitic type, we can
expLun the lv>>5 v^i ki^ct^Sorks as manifestations of the same
The aoxnic fluivi v^biAincxi by tapping has the characteristics
seoii in drrhvXfcss, whcihor of the alcoholic cv syphilitic t>pe, and :is
low >ax\ ir.c cTAx-ity rivl-iuics against a diagnosis of cancexous per:i4>
r.iiis or :v,Scro**:k>jc>.
S\;>V:r,i< is the N:^: workin*: hxToihcas.
Outcome. Vigv^rvV^^ anii>\"phi!;iic treaUDcnt caused no inQprc«ve-
ASCITES AND ABDOMINAL ENLARGEMENT 689
ment. On the 5th of February he had to be tapped again, and about
the same amount of fluid of the same character was withdrawn. This
had to be repeated once more on the 9th of February, when 3 quarts
were withdrawn. The tube of the trocar, when moved about, seemed
to encounter either adhesions or glands, and the fluid did not seem to be
entirely free in the abdominal cavity. The patient went home on the
loth, and died March 17, 1910.
Case 311
A laborer of twenty-eight entered the hospital April i, 1910. The
patient comes to the hospital because, as he says, his stomach has been
markedly enlarged for the past two weeks. This has been accom-
panied by considerable pain, which compelled him to give up work
three weeks ago. Later, he remembered that fluid had been removed
from his left chest five months previously. Nevertheless, he had been
steadily at work since that time until the present illness. His family
history, past history, and habits are excellent. He thinks he has lost
some weight and strength, and his appetite has been poor. He has a
slight cough, with yellowish sputum. He entered the hospital with a
diagnosis of "cancer of the stomach."
Physical examination showed a sallow, pale skin, although the
blood-smear showed only slight achromia; hemoglobin, 75 per cent.
There was harsh breathing at the left apex, otherwise no pulmonary
lesions, save such as could be explained by the abdominal enlargement.
There was shifting dulness in the flanks, with tympany in the distended
region about the navel. The spleen was not felt; the abdomen and
extremities wholly negative. The blood and urine were negative, the
temperature slightly elevated at night during the first ten days of
his stay in the hospital, usually reaching 99.5° to 100° F. After that it
did not go above 99° F. during a month's observation. The sputum,
four times examined, showed nothing of interest. His abdomen re-
*mained always distended with gas, even when fluid could no longer be
demonstrated there. Enemata had no considerable effect on this gas.
The skin tuberculin test was slightly positive. There was always
dulness and diminished respiration at the bases of the lungs, sometimes
with fine crackles, but the high position of the diaphragm made it diflS-
cult to be sure that any independent disease existed in the pleural
cavity.
Discussion. — When we know that fluid has been recently removed
from the chest of a patient free from cardiac and renal disease, we can
have little doubt that he has had pleurisy; that is, a tuberculosis. Any
Vol. 11—44
690 DIFFERENTIAL DIAGNOSIS
other s3miptoms which may appear will, therefore, be naturally inter-
preted in the light of this earlier disease.
When a patient with such a history shows fluid in the abdomen,
with anemia, sUght fever, and questionable signs at the apex of the left
lung, tuberculous peritonitis is by far the most probable diagnosis.
The diagnosis could be further supported were the abdomen to be
tapped and a high-gravity fluid obtained. This would help us to
exclude cirrhosis and syphilis of the liver.
Malignant disease as a cause of ascites should always be remembered
in a case of this kind, although we cannot take the idea very seriously
in view of the patient's age, his lack of stomach or bowel symptoms^
and the absence of any palpable tumor.
A point of interest in this case is the very marked gaseous disten-
tion which persisted after the evidences of fluid had disappeared. It
should always be remembered that in cases of ascites, from any cause,
gaseous distention of the intestinal coils is for some reason or other a
very frequent concomitant. At times it is so extreme as to mask the
existence of fluid beneath or behind it. Sometimes the obvious gaseous
distention weighs far too strongly in our minds and leads us to sup-
pose that if there is so much gas, no disease-producing ascites is likely
to be present. But the truth is just the opposite. A belly which is
chronically and obstinately distended with gas should be especially
suspected of containing free fluid as well.
Outcome. — By the 27th he was up and about the ward and seemed
quite strong, though his abdomen was still distended with gas and his
bowels difficult to move. His weight had risen from 122 to 127 J.
pounds. He left the hospital April 30, 1910.
February 12, 191 1, his physician reports that he has been at work
and had a splendid appetite until February nth, although for two
weeks he has had a cough and night-sweats. The sputa showed many
tubercle bacilli. The belly was tense, tympanitic, and showed no evi-
dence of fluid. Weight, 1 25^ pounds. Both lungs showed coarse moist
riles.
Case 312
A salesman of thirty-five entered the hospital May 9, 19 10. His
family history was unimportant. The patient had measles, whooping-
cough, scarlet fever, and diphtheria when young, also several mild
attacks of ''inflammatory rheumatism," but has never been laid up.
Eleven years ago he had typhoid fever and was sick four weeks. He
has had occasional sore throats and one attack of influenza. He has
ASaTES AND ABDOMINAL ENLARGEMENT 69I
been said to have a weak spot in one lung, and two years ago was sent
to Saranac Lake by Dr. E. G. Janeway. He was treated there for
several months for tuberculosis. Since then he has worked each winter
and rested each summer. He denies venereal disease and takes no
alcohol, but imtil of late has smoked thirty to forty cigarettes daily.
He has been able to attend to business up to January, 1910, when
his stomach began to trouble him, distress after eating, abdominal
distention, gas, and abdominal pain being the principal troubles. His
habitual cough has become more severe, though it is still dry. In con-
nection with his gastric distress he has times of what he calls being
"choked up," when he vomits and gets very short of breath. In
February he was in a hospital in California for seven weeks, and was
treated for stomach trouble without relief. For the past two months
his feet have been swollen at night and his eyesight has been getting
poor. In spite of all these troubles, his appetite has been good and his
bowels have moved daily. His sleep has been disturbed by severe gen-
eralized headache. He passes urine twice or thrice at night. He has
lost 24 pounds in two years and now weighs no pounds.
Physical examination showed a well-nourished man, pupils and
reflexes normal, glands the size of beans in the neck, axillae, and groins.
Heart's impulse in the nipple line, fifth space, no enlargement to the
right. The aortic second sound slightly accentuated. No murmur.
Blood-pressure, 225 mm. Hg., systolic. Lungs hyperresonant with
squeaks scattered throughout. At the right base, dulness with feeble
breathing and distant voice sounds. Abdomen full, tympanitic
throughout, and slightly tender. The liver dulness extended almost to
the navel, but the edge of the organ was not felt and the abdomen was
otherwise negative. The fundus oculi showed great indistinctness at
the edges of the disk, but numerous large hemorrhages and patches of
exudate throughout. Throughout most of the patient's six months'
stay in the hospital the urine averaged 45 ounces in twenty-four hours,
with a specific gravity from 1006 to 1014 and albiunin from a slight
trace to 0.7 per cent.; sediment a rare hyaline cast, sometimes with a
few cells or fat drops adherent. Leukocytes 14,000, 87 per cent, of
which were polynuclear; hemoglobin, 90 per cent.
At entrance the patient seemed perfectly comfortable, except for
a respiration of 37 and considerable headache. About 7 p. m. he began
to vomit, his respirations increased, and he became very nervous. A
hot tub bath with a hot pack was given, but the exertion was too much
for the patient and he had terrible dyspnea, though the sweating after
the bath was satisfactorily profuse. With morphin he had a fair
692 DIFFERENTIAL DIAGNOSIS
night, but early the next morning he had an agonizing headache, per-
sistent vomiting, and Cheyne-Stokes breathing, with slight generalized
spasms during the period of apnea. Accordingly, 15 ounces of blood
were withdrawn and i pint of salt solution given under the skin. The
systolic blood-pressure fell 55 points, but soon regained its former high
level. The patient was somewhat relieved, and thereafter improved
imder daily hot-air baths with pilocarpin. Although the headache
persisted and he rejected almost all food, he had no real convulsion.
On the 12th dyspnea was still troublesome and he complained of
faintness. There was marked reduplication of the second sound in
the third left interspace and an occasional prematiure beat. Sj'stolic
blood-pressure, 215. There were no r4les in the lungs and no edema.
Twenty-four ounces of normal saline solution were given under the
skin and no rise of blood-pressure followed. At this time the left
border of cardiac dulness was 14 cm. from the median line. On the
14th, headache and vomiting continuing, 12 oimces of blood were with-
drawn and I pint of saline solution injected. He was then given J gr.
of cocain by mouth and a little food. He retained this, fell asleep, and
next morning seemed much better. Thereafter he steadily improved,
and by the 21st his d>-spnea was gone. He then took food regularij-
(though in small quantities) and slept fairly. His headache still per-
sisted and he occasionally vomited. Various diuretics, such as sodium
theocin acetate, were given without relief. Aq)irin, 10 gr., everj-hour
for three daj-s, gave some relief to headache, but J to | gr. of moiphin
was needed almost dailv to control headache.
On the 31st of May he was doing verj' well, at times quite free from
headache. There had been no return of edema or convulsive move-
ments. Hot-air baths without pilocarpin did not seem to act favorably.
Blood-pressure gradually declined to the neighborhood of 150, where it
persisted imtil the second week in June; then it ranged at 170 for two
weeks. Any attempts to sit up straight, to stop the hot-air baths, or to
bear any excitement produced vomiting and headache at once. June
9th he could read a postal card, though at entrance he could scarcely
see people about his bed. It was found an ad\'antage to add lactose to
his liquid food in order to increase its \'alue. After the 20th of Jime
his blood-pressure ranged for a month in the nei^borhood of 200. but
despite this he improved steadily and by the middle of July was in
better condition than at any time. He was able to sit up in bed. to
read to himself, and he hardly seemed like the same patient. The eye
fundus, however, showed no notable change.
On the iSth of July he ¥ras able to sit up in a chair without headadie
ASCITES AND ABDOMINAL ENLARGEMENT 693
or any other ill effects and was eating ordinary meals without distress.
The blood-pressure meantime was ranging higher than at any time,
230 to 250. July 19th he could stand alone, though he could not walk.
His abdomen was always markedly prominent, but showed no evident
fluid, and his limgs were clear. Shortly after this he became more im-
comfortable. During the early part of August all his bad symptoms
returned, and on the 1 2th of August the slightest noise caused twitching.
Thereafter his blood-pressure ranged a little lower, in the neighborhood
of 200 for the next month, but the urinary output increased and the
pulse somewhat improved. About the i6th of August a harsh systolic
murmur developed, loudest in the pulmonary area, but audible over the
whole precordia. The pulmonic second soimd was now greater than
the aortic second, the latter sharp but distant. R&les appeared in the
lungs and edema over the sacrum. One-eighth grain of morphin with
2^ gr. of cocain gave him good nights, but he began at this time to be
incontinent. His headaches were more or less relieved by the doses of
aspirin, previously mentioned.
On the 24th of August he was almost unconscious. His tempera-
ture remained elevated for several days without obvious cause. On
the 26th the left border of cardiac dulness was 15 cm. from the median
line; the second sound to the left of the sternum was very loud, and a
systolic murmur replaced the first sound all over the precordia.
Sloughing hemorrhoids were discovered at this time and may have
accoimted for the temperature. At this time the blood-pressure came
down to 160 for a few days, but soon rose again, and on the 14th of
September was 220. He lost flesh steadily at this time, though he was
able to eat fairly well, and his heart remained strong. Mentally he
was very dull. After the 7th of September he had a good deal of
mild delirium, chiefly of a happy type.
On the 20th he was a living skeleton, with a large heart beating
tirelessly and no evidence of cardiac failure. Two small bed-sores
developed at this time. He still ate and slept well. September 2 2d
he became worse and passed almost no urine for forty-eight hours.
The blood-pressure was now 150, having been dropping steadily since
the 14th; pulse very slow, 45 to 60, regular. There was no marked
edema of the legs. The steady decline of temperature, pulse, and
blood-pressure during the last two weeks of his life is shown in Fig.
250. He died on the 27th.
Discussion. — ^A very important group of symptoms points straight
toward the diagnosis of tuberculosis in this case; we have, first of all,
the dictum of an almost infallible diagnostician, then the habitual
694 DIFFEItENTIAL DIAGNOSIS
dry cough, the dyspeptic symptoms, and the slight glandular enlarge-
ment. There is another point favoring tuberculosis, viz., that the
patient has many symptoms in many places, so that we must look for
some disease capable of attacking many organs simultaneously. Such
diseases are especially tuberculosis, syphilis, streptococcic sepsis, and
the malignant neoplasms.
But there is a second group of symptoms not easily explained as
part of a tuberculous process. The dyspneic attacks, the swollen feet,
the headaches with poor sight,
Si
m
m
&%
w
rrj3)3!^j55y5 T
a
and, above all, the high blood-
pressure, retinitis, Cheyne-Stokes'
breathing, and convulsions, make
it almost certain that we are deal-
ing with a chronic nephritis, and
at this patient's age, in all proba-
bility, a chronic glomerular nq>h-
ritis. Amyloid disease of the
kidney, such as might be second-
ary to tuberculosis, would not be
at all likely to give us such a
group of symptoms as this. TTie
striking thing about amyloid dis-
ease, as a rule, is its latency,
its colorless, often symptomless,
course.
Is there anything in the case
not to be explained by glomerular
nephritis? I see nothing. Syph-
ilis and malignant disease, which
I mentioned in former paragraphs, cannot of themselves produce any
such clinical picture, although it is, of course, possible that the neph-
ritis may have been of syphilitic origin.
Outcome. — Autopsy showed chronic glomerulonephritis, arterio-
sclerosis, hypertrophy and dilatation of the heart, myomalacia of the
heart's wall near the apex, with mural thrombi in this region and each
side of the septum. Also thrombi in the right and left auricular ap-
pendages. There were infarcts in the lower lobes of the lungs and
tliromhoses of small branches of pulmonary arteries; acute terminal
poriiarditis and pleuritis; obsolete tuberculosis of a tracheal lym-
pluitii" Kill"''; small papillary adenoma of the kidney. The absence
of liny loiisiderable evidence of tuberculosis is striking; also the ab-
semc of any infection of the circulating blood.
Fig. »sO' — Blood-pressure (starred line),
temperattve, pulse, and respiration during
the last two weeks ot life in Case 312.
ASCITES AND ABDOMINAL ENLARGEMENT
69s
Case 313
A housewife of forty-seven entered the hospital January 6, 1911.
The patient has noticed enlargement of the abdomen for about eight
years. At first it was larger than it now is. The present size has been
maintained for about five years. Otherwise she has always been well,
though formerly subject to tonsillitis and troubled for a few days, eight
years ago, by an attack of "malaria," in Nashua, N. H. She was in
bed four days with chills and fever. Family history and habits are
excellent. Menstrual flow has been excessive for seven years, and she
felt in Case 313.
has grown increasingly pale and weak during this period. She worked
until to-day, taking care of her house and doing all the cooking and
sewing for her husband and six children, but not washing. Five
months ago she weighed 190 pounds; a week ago, 176 pounds. Her
appetite is good, bowels costive, urination not remarkable. She suffers
no pain whatever.
Physical examination showed good nutrition, ivory-colored skin,
marked pallor of the mucous membranes. No glandular enlargement,
pupils and reflexes normal. Chest negative. Abdomen was generally
696 DIFFERENTIAL DIAGNOSIS
enlarged; also a mass as in Fig. 251. The mass there shown filled
two-thirds of the abdomen, was firm, freely movable, elastic, and not
tender. Otherwise the abdomen was not remarkable. There was con-
siderable edema of both legs and marked varicose veins in the same
area. At entrance red cells nimibered 1,900,000; white cells, 5000;
hemoglobin, 25 per cent. The stained smear showed marked achromia,
with considerable variations in size and shape, no abnormal staining
reaction or nucleated cells. Blood-platelets, 160,000. In twenty days
the red cells rose to 4,500,000, hemoglobin to 70 per cent., white cor-
puscles to 8000. The urine averaged 45 oimces in twenty-four hours,
with a specific gravity of 1015, a trace of albumin, and no casts.
Systolic blood-pressure, 125. Feces normal. During this time she
took Blaud's mass, 20 gr., three times a day. After the first two days
there was no flowing. Vaginal examination showed her cervix high in
the median line behind the pubes, but continuous with the abdominal
tiunor. The diagnosis in the medical wards was in doubt as between
ovarian cyst and uterine fibroid. Dr. W. J. Mayo saw the patient
and considered it fibroid. Dr. Farrar Cobb made the same diagnosis.
Discussion. — There are not many causes for an abdominal enlarge-
ment lasting eight years in a woman of forty-seven. Aside from obesity
and gaseous distention, there is hardly anything but uterine fibroid
and ovarian tumor. The fact that she has been steadily and vigor-
ously at work, and that she is still well-nourished, makes any malignant
type of disease improbable. Between fibroid and ovarian cyst, the
amenorrhea and the uterine hemorrhages strongly favor the diagnosis
of fibroid. The elasticity and free mobility of the mass is slightly in
favor of cyst, though I have learned to distrust all inferences based
chiefly upon such characteristics of a pelvic tumor. The position of
the cervix uteri is a further point in favor of fibroid.
Outcome. — On the 2d of February the abdomen was opened, show-
ing a small amount of free fluid and a tumor of soft gelatinous consist-
ency, rather tense, but showing no large firm parts anywhere. H>'s-
terectomy was done. Examination of the growth by Dr. W. F. WTiit-
ney showed the uterus greatly enlarged by a single growth weighing
4450 gm. The uterine cavity was enlarged, measuring 14 cm. On
section the growth was fasciculated, its meshes being filled with serous
fluid. These meshes were shown under the microscope to be formed of
interlacing bunches of fibrous and muscular tissue. Diagnosis, fibro-
myoma with lymphatic dilatation, so-called cystic fibroid. The patient
made an excellent recovery. On November i, 1912, she seemed
entirely well and had gained 60 pounds.
ASaTES AND ABDOMINAL ENLARGEMENT 697
Remarks. — That a patient who has but 1,900,000 red cells shoxild
patiently continue to do the whole work for her husband and six
children is a type of familiar heroism to which, despite its familiarity,
I cannot forbear to allude.
Case 314
An imoccupied woman of thirty-five entered the hospital May 13,
191 1. The patient has always beeni well, though she had scarlet fever
and measles as a child. As the oldest of twelve children she did all sorts
of work until ten years ago. Then she had a sudden swelling of the
abdomen, accompanied by severe general abdominal pain, which con-
fined her to bed for several weeks. She had no vomiting, but has never
felt really well since that time. Any excitement or strain produces
severe headaches and general aching all over the body. She passes at
times large quantities of very pale urine, often getting up five to ten
times at night, but she is able to pass it only when she is calm. Her
bowels always move with difficulty, and there is a dull ache in that
region most of the time. Distention of the abdomen is present off and
on in varying amounts. It is always greater at night and her sleep is
very poor. For a year she has had a slight cough without any sputa.
Moderate exertion makes her tired and short of breath, but she has
never had orthopnea or edema. She is now at her maximum weight,
no pounds. Appetite is fair, but she has little ambition for food.
Menstruation is regular, but scanty.
Physical examination shows good nutrition, normal pupils and
reflexes, no glandular enlargement, chest negative. Abdomen full and
very prominent, tympanitic everywhere, no^ tenderness. SUght gen-
eral rigidity. Liver and spleen apparently not enlarged. Navel not
flushed. A slight degree of ankle-clonus on each side, perhaps vol-
imtary. Rectal examination negative. Blood, urine, and blood-press-
ure normal. No temperature in one week's observation . Calomel and
sodiiun sulphate produced fourteen movements in two days, but the
size of the abdomen did not change. It was imaffected by turpentine
stupes or by the rectal tube. On the 19th she went home.
Discussion. — The long duration of this case is its most interesting
feature. It has lasted ten years. The abdominal enlargement which
she now complains of was her first symptom and she has it still. She
also has symptoms in various other parts of her body and one group
of urinary symptoms suggesting the vasomotor instability of the neu-
rotic. The anorexia, insonmia, and headaches from any strain point
in the same direction.
698 DIFFERENTIAL DIAGNOSIS
There is, however, a small group of symptoms pointing in another
direction; that is, her year of slight cough with dyspnea and distention
of the abdomen, which might mean tuberculous peritonitis^ eq>ecially
as physical examination shows slight general rigidity, the precise char-
acteristic of the tuberculous abdomen.
Yet the other and larger group of symptoms is, on the whole, the
more important, for she has had the abdominal trouble throughout, and
it is exceedingly improbable that tuberculous peritonitis should last ten
years without producing any loss of weight. The fact that she is now
at her maximum weight is almost sufficient to exclude organic disease.
If, then, we exclude organic disease, can a neurosis account for her
abdominal enlargement? It is well known that gaseous distention
often accompanies and sometimes conceals ascites. It is, therefore,
conceivable that there may be some organic trouble in the background,
but we can only say that we have done our best to find such and failed.
Outcome. — July 25, 1914, a friend of the patient writes that since
leaving the hospital she has been quite well when quiet, but under any
mental strain or worr\^ her bowels almost immediately become dis-
tended to an enormous size, causing great distress and pain and stc^
ping the action of the bladder and bowels. Rest and sleep di^>el these
symptoms, but anything that happens out of the ordinary, causes the
abdomen to swell up almost immediately. She is physically well and
contented.
Case 315
An unoccupied woman of fifty-eight entered the ho^ital October
31, 191 1. A year ago the patient began to have sharp attacks of pain
in the lower abdominal region, rather more to the right. The pain was
not definitely related to the taking of food. At the same time the
abdomen became somewhat enlarged, and after a week she began to
vomit frequently, so that for the next ten dav-s she kept almost no food
in her stomach. After that she was better, but her s>'mptoms have
recurred ever>' few weeks, lasting from three to seven days. For six
months she has vomited once or twice almost daily. Her i>ain has
become more frequent, but less sharp. The abdominal enlargement
has steadily increased during the last six months, but the rest of her
body, she thinks, has emaciated. Her l^s are swollen somewhat in
the da\'time, but not more than thev have alwa\'s been, as she has
always had varicose veins. She has tried to keep at work during the
year, but has often had to give up for days or weeks and for the last
fortnight has done nothing. Her bowels often do not move for three
or four da\'s. She has no jaundice.
ASCITES AND ABDOMINAL ENLARGEMENT 699
Physical examination shows marked emaciation, good color, pupils
and reflexes normal, no glandular enlargement. Chest negative.
Abdomen dome shaped, much distended, with an elastic feel, and a
marked fluid wave transmitted to the top as well as to the sides of the
abdomen. The abdomen does not sag into the flanks; it is everywhere
dull and nowhere tender. Liver and spleen are not felt. The legs
show slight edema and marked varicosity of the veins. The cervix
uteri is high, not otherwise remarkable. There is no drag upon the
cervix when the abdomen is manipulated. The fundus not made out.
In the median line, just below the navel, is a hard, smooth, almost
immovable mass, the size of an egg. Blood and urine normal. No
temperature in two weeks' observation. Systolic blood-pressure,
156 mm. Hg.; diastolic, 80 mm. Hg.; weight, 91 pounds.
Discussion. — ^A year of abdominal symptoms in a woman of fifty-
eight, previously well, are always ominous symptoms. One always
fears malignant disease, especially when, as in this patient, there has
been vomiting and swelling of the legs. The latter symptom, how-
ever, need not alarm us, as it is, in all probability, due to her varicose
veins and is by no means a new symptom.
Much more serious is the marked emaciation, as shown on physical
examination, and the apparent presence of an ascites. We cannot at-
tribute such an ascites to the heart or to the kidney. It is not likely
to be of liver origin at her age and with her history. It does not pre-
sent the picture of tuberculous peritonitis. The only common cause
for ascites that remains is tumor, usually a malignant tiunor in some
part of the abdomen. The hard, smooth mass below the imibilicus is,
in all probability, part of such a tumor. It is possible that the ascites
may be associated with a benign timior, such as an ovarian fibroma,
ovarian cystoma, or a fibroid uterus, but no one of these is a frequent
cause of ascites. On the whole, we have reason to fear malignant dis-
ease. In any case the abdomen must be opened.
Outcome. — On the 7th of November, 1911, an ovarian cyst about
15 inches in diameter was removed. It contained about 6 quarts of
fluid and was not adherent. It apparently originated from the left
ovary. The patient did well after operation, and December 3, 191 2,
reported at the hospital in perfect condition.
Remarks. — This case was sent to the hospital as one of ascites, but
this diagnosis was never seriously considered. The shape of the ab-
dominal enlargement was wholly unlike ascites, and the ordinary causes
of ascites could with reasonable probability be excluded.
700
DIFFERENTL41 DIAGNOSIS
Case 316
A housewife of forty-eight, born in Russia, entered the hospital!
January 19, 1912. Ten years ago the patient fell, striking her rigfatl
side. Since then she has noticed pain in the right flank and back^l
gradually growing more severe. For five weeks she has noticed)
abdominal enlargement, and her sleep has been disturbed at night t
the pain above described. For a month her urine has been :
and painful in passing. She has no appetite and food causes discom
fort or nausea. At the onset of her troubles she vomited occasionally,^
but has not done so now for some weeks. She has been in bed for the
past month on account of pain and weakness. She thinks she has lost
flesh. Three days ago her feet became swollen. J
Physical examination shows much emaciation. Shght generall
brownish pigmentation of the skin. Pupils, glands, and reflexes j
normal. Chest negative save for moist riles at the right base behind.
The abdomen was greatly enlarged and tense, the right side in the re-
gion of the liver especiaUy prominent. In the right flank and e
trium a mass can easily be felt, as shown in Figs. 252-354. Impul
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