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Presented  to  the 

LIBRARY  oj  the 

UNIVERSITY  OF  TORONTO 

by 

Mrs.    Cyril  Allen 


MEDICAL  DIAGNOSIS 


WITH 


SPECIAL  REFERENCE  TO  PRACTICAL  MEDICINE. 


GUIDE  TO  THE  KNOWLEDGE  AND  DISCRIMINATION 

OF  DISEASES. 


BY 


J.  M.  DA   COSTA,  M.D., 


LECTDRER    ON    CLINICAL    MEDICINE,    AND    PHYSICIAN    TO    THE    PENNSYLVANIA    HOSPITAL;     PELLCW    OF    TFIE 
COLLEGE   OF   PHYSICIANS   OP    PHILADELPHIA;    MEMBER   OF   THE   AMERICAN    PHILOSOPHICAL  SOCIETY; 
OP    THE    PATHOLOGICAL    SOCIETY    OF    PHILADELPHIA;    FORMERLY    PHYSICIAN    TO    THE    PHILA- 
DELPHIA   HOSPITAL;    CORRESPONDING    MEMBER    OF    THE    NEW   YORK    PATHOLOGICAL 

SOCIETY,  ETC.  ETC. 


Illustrattb  \axi\  inpaliings  0n  Mo0ir. 


THIRD  EDITION,  REVISED. 


PHILADELPHIA : 

J.   B.   LIPPINCOTT    &    CO. 

1870. 


Entered  according  to  Act  of  Congress,  in  the  year  1870,  by 

J.  M.  DA   COSTA,  IM.D., 
In  the  Office  of  the  Librarian  of  Congress,  at  Washington. 


PREFACE  TO  THE  THIRD  EDITION. 


Another  edition  of  this  work  having  been  called  for,  I  have 
revised  it,  and  in  some  parts  extended  it ;  I  trust,  in  all,  improved 
it.  In  submitting  it  again  to  the  profession,  I  indulge  the  hope 
that  this  edition  may  meet  with  the  same  favor  as  its  predecessors. 

1609  Walnut  Street, 

Philadelphia,  July,  1870. 


(iii) 


PREFACE  TO  THE  FIRST  EDITION. 


My  chief  aira  in  writing  this  work  has  been  to  furnish  advanced 
students  and  young  graduates  of  medicine  with  a  guide  that  might 
be  of  service  to  them  in  their  endeavors  to  discriminate  disease.  I 
have  sought  to  offer  to  those  members  of  the  profession  who  are 
about  to  enter  on  its  practical  duties  a  book  on  Diagnosis  of  an 
essentially  practical  character, — one  neither  so  meagre  in  detail  as 
to  be  next  to  useless  when  they  encounter  the  manifold  and  varying 
features  of  disease,  nor  so  overladen  with  unnecessary  detail  as  to  be 
unwieldy  and  lacking  in  precise  and  readily-applicable  knowledge. 

In  executing  my  undertaking,  two  plans  offered  themselves:  either 
to  describe  morbid  states  in  compliance  with  the  usual  pathological 
classification  followed  in  treatises  on  the  Practice  of  Medicine,  or  to 
group  them  according  to  their  marked  symptoms.  The  former  plan 
would  have  been  far  the  easier,  but  the  latter  seemed  to  me  the  more 
suitable  for  a  volume  of  this  kind;  and  although  it  has  involved 
much  labor,  and  has  rendered  the  task  much  more  difficult  of  accom- 
plishment, its  advantages  appeared  to  me  so  great  that  I  have 
adopted  it  throughout.  That  this  attempt  at  a  purely  clinical  classi- 
fication is  not  perfect,  I  am  fully  aware.  But  with  all  its  short- 
comings, I  venture  to  hope  that  it  will  not  be  devoid  of  value  as  an 
aid  in  their  studies  to  those  for  whom  it  is  intended. 

Some  of  the  statements  made  may  appear  too  absolute,  and  as  not 
taking  sufficient  notice  of  the  many  exceptions  which  may  arise  ;  but 
it  was  impossible  to  avoid  this  without  very  lengthy  discussion  :  and 
even  in  the  lengthiest  discussion  all  exceptions  and  all  possible  points 
of  fallacy  would  not  have  been  mentioned:  for  Nature  does  not  limit 
herself  in  her  irregularities  any  more  than  in  her  rules.     The  text 

(V) 


Vl  PREFACE    TO    THE    FIRST    EDITION. 

roust,  therefore,  be  looked  upon  as  treating  only  of  general  laws  and 
of  tlieir  most  notable  infractions  ;  in  fact,  but  as  a  series  of  etchings, 
with  here  and  there  a  prominent  figure  shaded,  but  not  as  an  attempt 
to  reproduce  the  colors  of  an  original  whose  varied  hues  could  not 
be  closely  copied,  even  by  the  hand  of  a  master. 

The  main  object  of  this  work  is,  what  its  title  implies,  the  con- 
sideration of  Medical  Diagnosis.  In  connection  with  this,  however, 
I  have  endeavored  to  take  cognizance  of  the  prognosis  of  individual 
affections,  and,  where  it  could  be  done  without  interfering  with  the 
plan  of  the  book,  to  give  a  summary  of  the  indications  for  their  treat- 
ment. Occasionally  the  record  of  cases  has  been  introduced  by  way 
of  elucidation.  To  have  done  this  to  a  much  greater  extent,  though 
in  some  respects  desirable,  would  have  swelled  the  work  to  an  inor- 
dinate size. 

The  wood-cuts  employed  as  illustrations  are  all  original.  Many 
are  from  sketches,  or  at  least  are  based  on  sketches,  taken  directly 
from  cases  of  interest,  and  improved  either  by  the  skilful  hand  of 
Dr.  Packard,  or  by  Mr.  Wilhelm,  the  artist  who  has  so  faithfully 
engraved  them.  While  acknowledging  my  obligations  to  them,  I 
must  also  express  ray  indebtedness  to  Dr.  Richard  J..  Dunglison  for 
his  valuable  assistance  in  making  the  index  to  this  volume. 

Philadelphia,  Apj-U,  1864. 


CONTENTS. 


INTRODUCTION. 

PAOE 

General  Considerations 17 

CHAPTER  I. 

EXAMINATION  OF  PATIENTS,  AND  SOME  SYMPTOMS  OF  GENERAL  IMPORT 

General  Considerations 28 

Position  of  the  Body 31 

General  Aspect — Expression  of  Countenance 32 

Sldn 34 

Pulse 35 

Tongue 41 

Sensations  of  Patients 44 

Temperature  of  the  Body 45 

CHAPTER  II. 

DISEASES   OF    THE   BRAIN,    SPINAL   CORD,    AND    THEIR    NERVES. 

General  Considerations 50 

Deranged  Intellection 50 

Delirium 51 

Stupor 54 

Coma 54 

Insomnia 55 

Deranged  Sensation 55 

Hyperesthesia 56 

Anaesthesia 57 

Headache 61 

Vertigo 63 

Derangement  of  Special  Senses 64 

Deranged  Motion 70 

Paralysis 70 

(vii) 


viii  CONTENTS. 

Locomotor  Ataxia 95 

Tremor 100 

Spasms — Convulsions 101 

Deranged  Nutrition  and  Secretion 103 

Acute  Aft'ections  of  which  Delirium  is  a  Prominent  Symptom lOfi 

Acute  Meningitis 106 

Tubercular  Meningitis 112 

Cerebro-spinal  Meningitis 116 

Delirium  Tremens 120 

Acute  Mania 123 

Diseases  marked  by  Sudden  Loss  of  Consciousness  and  of  Voluntary 

Motion 124 

Apoplexy 124 

Sun-stroke 136 

Catalepsy 138 

Diseases  marked  by  Convulsions  or  Spasms 139 

Epilepsy 139 

Chorea 144 

Hysteria 147 

Tetanus 150 

Diseases  cbaracterized  by  Gradual  Impairment  of  the  Mental  Faculties 

with  Paralysis 153 

Chronic  Softening I53 

Tumor 15g 

General  Paralysis 1(31 

Diseases  characterized  by  Enlargement  of  the  Head 162 

Chronic  Hydrocephalus  162 

Hypertrophy  of  the  Brain 1(33 

Diseases  characterized  by  Paroxysmal  Pain 164 

Neuralgia  in  General 1(34 

Facial  Neuralgia 1(3(3 

Hemicrania 1(37 

Sciatica Kjg 


CHAPTER   III. 

DISEASES   OF    THE   UPPER   AIR-PASSAGES, 

General  Considerations 1^2 

Examination  of  the  Larynx  by  the  Laryngoscope 174 

Acute  Laryngeal  Affections ]gl 

Acute  Laryngitis jo| 

(Edema  of  the  Glottis Ig3 

Croup j^^ 

Chronic  Laryngeal  Affections 19q 

Chronic  Laryngitis i  q,^ 

Diseases  of  the  Trachea jor 


CONTENTS.  IX 


CHAPTER   IV. 

DISEASES   OF   THE   CREST. 
General  Considerations 190 

SECTION  r. 

DISEASES    OF    THE    LUXGS. 

Difl'erent  Methods  of  Physical  Diagnosis,  and  the  Physical  Signs  of  Pul- 
monary Diseases 198 

Inspection 198 

Mensuration 199 

Palpation 203 

Percussion 204 

Percussion  of  the  healthy  Chest 208 

Auscultation 210 

Sounds  of  Eespiration  in  Health  and  in  Disease 212 

Changes  in  the  Yesicuiar  Murmur 213 

Bronchial  Eespiration 218 

New  or  adventitious  Sounds 220 

Auscultation  of  the  Voice 225 

Combination  of  the  Physical  Signs  and  the  Examination  of  Patients 

affected  with  Disease  of  the  Lungs 220 

Principal  Symptoms  of  Diseases  of  the  Lungs 230 

Dyspnoea 231 

Cough 235 

Haemoptysis 238 

Diseases  in  which  Clearness  on  Percussion  is  met  with 242 

Acute  Bronchitis 242 

Chronic  Bronchitis 246 

Emphysema 249 

Diseases  in  which  Dulness  on  Percussion  occurs 255 

Phthisis : 255 

Acute  Affections  of  the  Lungs 277 

Acute  Phthisis 278 

Acute  Pneumonia 282 

Acute  Pleurisy 292 

Diseases  presenting  Dilatation  of  the  Chest,  Displacement  of  the  Liver  and 

Heart,  and  Dyspna?a 299 

Pneumothorax 299 

Chronic  Pleurisy 304 

Diseases  in  which  Retraction  of  the  Chest  occurs 310 

Chronic  Pleurisj- 310 


CONTENTS. 


SECTION  II. 

DISEASES   OF    THE    HEART. 

General  Considerations 314 

Examination  of  the  Heart  by  the  different  Methods  of  Physical  Diagnosis  317 

Inspection 318 

Palpation 319 

Percussion 320 

Auscultation 322 

General  and  Local  Symptoms  of  Diseases  of  the  Heart 332 

Cardiac  Dropsy 333 

Deransrement  of  the  Circulation 333 

Cardiac  Pain 335 

Palpitation 338 

Punctiunal  Disorders  of  the  Heart 340 

Disorders   characterized   by  Palpitation,  associated   or   not  with 

Change  of  Ehythm 340 

Prganic  Diseases  of  the  Heart 345 

Acute  Diseases  presenting  Pain  in  the  Cardiac  Region  ;  Symptoms 
of  a  Disturbed  Circulation  ;  and  a  Change  in  the  Sounds  of 

the  Heart,  or  their  Replacement  by  Murmurs 345 

Acute  Endocarditis 346 

Acute  Pericarditis 352 

Carditis 360 

Chronic  Diseases  attended  with  Increased  Extent  of  Percussion  Dul- 

ness,  but  with  Normal  or  almost  Normal  Heart  Sounds 361 

Hypertrophy 361 

Dilatation 364 

Diseases  of  the  Heart  exhibiting  more  or  less  of  the  Signs  and 
Symptoms  of  Enlargement  of  the  Organ,  and  accompanied 

by  Endocardial  Murmurs 370 

Valvular  Affections 370 

Displacements  of  the  Heart 384 


SECTION  III. 
Thoracic  Aneurism 385 

CHAPTER   Y. 

DISEASES   OF   THE    MOUTH,    PHARYNX,    AND    (ESOPHAGUS. 

Mouth 396 

Stomatitis 396 

Glossitis 398 


CONTENTS.  XI 

Fauces ; 399 

Acute  Sore  Throat 399 

Tonsillitis 400 

Diphtheria 401 

Chronic  Sore  Throat 407 

Pharynx  and  (Esophagus 409 

Ketropharyngeal  Abscesses 409 

Oesophagitis 410 

Stricture  of  Qj^sophagus 410 


CHAPTER  VI. 

DISEASES    OF    THE    ABDOMEN. 

General  Considerations 412 

Methods  and  General  Results  of  Physical  Examination  of  the  Abdomen..  413 

Inspection 413 

Palpation 415 

Percussion 416 

Auscultation 421 

SECTION  I. 

DISEASES    OF    THE   STOMACH. 

General  Considerations 421 

Loss  of  Appetite 422 

Excessive  Aciditj  of  the  Stomach 423 

Flatulency 424 

Nausea  and  Vomiting 425 

Pain 433 

Diseases  of  the  Stomach  with  Pain  and  Soreness  at  the  Epigastrium,  and 

Vomiting 440 

Acute  Gastritis 440 

Chronic  Diseases  of  the  Stomach 445 

Chronic  Gastritis 445 

Gastric  Ulcer 447 

Gastric  Cancer 451 

SECTION  II. 

DISEASES    OF    THE    INTESTINES    AND    PERITONEUM. 

General  Considerations 457 

Alvine  Discharges 458 

Diseases  attended  with  Paroxysms  of  Pain  referred  chiefly  to  the  Middle  or 

Lower  Part  of  the  Abdomen,  without  marked  Tenderness,  etc..  460 
Colic 460 


XI 1  CONTENTS. 

Diseases  attended  with  Piiin  iuul  marked  Tenderness  in  the  Umbilical 

Region  or  diffused  over  the  Abdomen 472 

Acute  Enteritis 472 

Acute  Peritonitis 474 

Chronic  Peritonitis 487 

Diseases  attended  with  Pain  and  Tenderness  in  the  Right  Iliac  Fossa 488 

Ati'eetions  of  the  Caecum  and  its  Appendix 488 

Diseases  attended  with  Constipation,  and  of  which  it  is  a  Prominent  Symp- 
tom   494 

Intestinal  Obstruction 495 

Habitual  Constipation 505 

Disorders  in  which  Morbid  Discharges  from  the  Bowels  occur 508 

Diarrhoea 508 

Dysentery 5I3 

Intestinal  Uemorrhage  or  Mel^na 515 

Fatty  Diarrhcea 516 

Diseases  attended  with  Vomiting  and  Purging 517 

Cholera  Infantum 5I7 

Cholera  Morbus 5I8 

Cholera 5I9 


SECTION  III. 

DISEASES    OF    THE    LIVER. 

General  Considerations 524 

Jaundice 524 

Acute  Diseases  of  the  Liver,  attended  generally  with  Slight  Enlargement 

of  the  Organ,  and  more  or  less  Jaundice 530 

Acute  Congestion 53O 

Acute  Hepatitis 53O 

InHammation  of  the  Gall-bladder  and  Gall-ducts 535 

Acute  Diseases  characterized  by  Decrease  in  the  Size  of  the  Liver,  and 

by  Deep  Jaundice 537 

Acute  Yellow  Atrophy 537 

Chronic  Diseases  attended  with  Enlargement  of  the  Liver,  and  with  Slight 

or  no  Jaundice 530 

Chronic  Congestion 53g 

Chronic  Hepatitis 54^ 

Abscess  of  the  Liver c^i 

Fatty  Liver "*  g^g 

Waxy  Liver g^- 

Cancer  of  the  Liver ^ -4-- 

Hj-datids  of  the  Liver 5-3 

Chronic  Diseases  attended  with  Decreased  Size  of  the  Liver  and  with  Ab- 
dominal Dropsv r^- 

Cirrhosis 

,,,         .      .  oo( 

Chronic  Atrophy  of  the  Liver 5(32 


CONTENTS.  Xin 

SECTION  IV. 

ABDOMINAL    ENLARGEMENT. 

General  Abdominal  Enlargement .562 

Ascites .562 

Chronic  Tympanites .568 

Partial  Abdominal  Enlargement 569 

Abdominal  Tumors 569 

SECTION  V. 
ABDOMINAL  PULSATION. 

Aortic  Pulsation 581 

Abdominal  Aneurism -581 


CHAPTER  VII. 

ON   THE    URINE,    AND   ON   DISEASES   OF    THE    URINARY    ORGANS. 

Urine ,586 

Color 590 

Specific  Gravity 593 

Reaction 595 

Changes  in  the  Quantity  of  the  more  Important  Constituents 597 

Presence  of  Abnormal  Substances  in  the  Urine 612 

Sediments 6.33 

Urinary  Organs 635 

Diseases  of  the  Kidney  of  which  Pain  is  a  Prominent  Symptom...  635 

Nephritis 635 

Nephralgia 637 

Diseases  marked  by  an  Albuminxsus  Condition  of  the  Urine,  with 

more  or  less  Dropsy 641 

Acute  Bright's  Disease 642 

Chronic  Bright's  Disease 649 

Diseases  associated  with  Purulent  Urine 661 

Acute  Cystitis 661 

Chronic  Cystitis 662 

Abscess  of  the  Kidney 663 

Pyelitis 665 

Disorders  in  which  a  very  Large  Amount  of  Urine  is  discharged..  668 

Diabetes 668 

Chronic  Diuresis 669 

Disorders  in  which  Little  or  no  Urine  is  discharged 671 

Suppression  of  Urine 671 

Eetention  of  Urine 672 


XIV  CONTENTS. 

CHAPTER  VIII. 

DROPSY. 

Dropsy,  according  to  its  Seat  and  Extent 674 

Dropsy,  according  to  its  Cause 676 

Dropsy,  according  to  the  Kapidity  of  its  Development 678 

CHAPTER  IX. 

DISEASES    OF    THE    BLOOD. 

Anaemia 680 

Leucopythaemia 683 

Pyajmia 685 

Septfemia 688 

Thrombosis  and  Embolism 688 

Scurvy 695 

Purpura 696 

CHAPTER  X. 

RHEUMATISM   AND    GOUT. 

Acute  Eheumatism 699 

Chronic  PJieumatism 703 

Gout 707 

Kheumatic  Arthritis 709 

CHAPTER  XI. 

FEVERS. 

General  Consideration? 711 

Continued  Fevers 713 

Simple  Continued  Fever .' 714 

Catarrhal  Fever 715 

Typhoid  Fever 716 

Typhus  Fever 727 

Eelapsing  Fever 738 

Periodical  Fevers 742 

Intermittent  Fever 742 

Eemittent  Fever 746 

Congestive  Fever 753 

Yellow  Fever 759 

Eruptive  Fevers 764 

Scarlet  Fever 765 

Measles 770 

Small-pox 773 

Dengue 778 

Erysipelas 779 


LIST    OF   ILLUSTRATIONS.  XV 

CHAPTER  XII. 

DISEASES   OP   THE   SKIN. 

General  Considerations 782 

Exanthematous  Diseases 784 

Papular  Diseases 785 

Vesicular  Diseases 786 

Pustular  Diseases 788 

Squanjous  Diseases 789 

Tuberculated  Diseases 790 

Parasitic  Diseases 792 

CHAPTER  XIII. 

POISONS   AND   PARASITES. 

Poisons 790 

Acute  Poisoning 797 

Irritant  Poisons 797 

Narcotic  Poisoning 799 

Chronic  Poisoning 802 

Parasites 810 

Vegetable  Parasites 810 

Animal  Parasites 811 

Index 829 


LIST  OF  ILLUSTRATIONS. 


Fig.  1.  Sphygmograph  of  Marey 39 

2.  Thermometer  for  Clinical  Purposes 45 

3.  The  .iiEsthesiometer 59 

4.  Laryngoscopes 174 

5.  Laryngoscopic  Examination 176 

6.  Laryngeal  Image,  as  seen  in  the  Laryngoscope 177 

7.  The  Stethometer 200 

8.  The  Stetho-goniometer 201 

9.  Hutchinson's  Spirometer 202 

10.  The  Hsemadynamometer 203 

11.  The  Pleximeter 204 

12.  Percussion  Hammer 205 

13.  The  Ordinary  Stethoscope 210 


xvi  LIST    OF   ILLUSTRATIONS. 

Fio.  14.  The  Double  Stethoscope 211 

15.  The  Differential  Stethoscope 211 

l(j.  Dia<iriim  illustrative  of  the  Main  Forms  of  Feeble  Kespiration..  215 

17.  Diagram  illustrative  of  Kales 221 

18.  Appearance  of  the  Chest  in  Emphysema 250 

19.  Commencing  Infiltration  in  Phthisis 259 

20.  Cavities  in  the  Lung  in  Phthisis 261 

21.  Diacram  illustrative  of  Perfect  Pulmonary  Consolidation,  such 

as  occurs  in  the  Second  Stage  of  Pneumonia 284 

22.  Roughening  of  the  Pleura  from  Inflammation 293 

23.  Examination  of  Posterior  Portion  of  Chest,  a  Large  Effusion 

occupying  the  Left  Pleural  Cavity 294 

24.  Physical  Signs  in  Pneumothorax 302 

25.  Topography  of  the  Heart 315 

26.  Diagram  showing  the  Points  at  which  the  Separate  Valves  may 

be  listened  to 323 

27.  Position  of  the  Heart,  and  Distention  of  the  Pericardium  with 

Fluid  in  Pericarditis 354 

28.  Hypertrophied  Heart  lying  in  its  Position  in  the  Chest 368 

29.  Dilated  Heart,  the  Eight  Ventricle  opened 365 

30.  Narrowing  of  the  Aortic  Orifice  by  Vegetations  springing  from 

the  Valves 373 

31.  InsuflBcient  Mitral  Valves  permitting  Eegurgitation  of  the  Blood  375 

32.  Sphygmogram  of  Aortic  Insufficiency 378 

33.  Sphymogram  of  Mitral  Insufficiency 378 

34.  Results  of  Abdominal  Percussion 420 

35.  Sarcinae  Ventriculi 427 

36.  Crystals  of  Uric  Acid 603 

37.  Mixed  Urates 605 

38.  Earthy  Phosphates  in  the  Urine 606 

39.  Crj'stals  of  Oxalate  of  Lime 613 

40.  Pus  Corpuscles 631 

41.  Epithelial  Casts  and  Cells  from  the  Kidneys"  in  a  Case  of  Acute 

Bright's  Disease 643 

42.  Fatty  Casts  and   Epithelial  Cells  filled  with   Fat,  as  seen   in 

Discharge  from  a  Fatty  Kidney 656 

48.  Hyaline  or  Waxy  Casts  from  the  Urine 658 

44.  Granular  Casts,  or  Casts  covered  with  Disintegrating  Epithe- 
lium and  Granules 658 

4-5.  Pigment  in  the  Blood  in  Malarial  Cachexia 752 

46.  Tffinia  Solium gl4 

47.  Trichina  in  Recent  Human  Muscle 819 

48.  Trichina  Capsule  with  Scalelike  Calcareous  Deposits 820 

49.  Encapsuled  Chalky  Concretions  in  Muscle  due  to  Trichina 821 

50.  Trichina  Spiralis.     Magnified  300  Diameters 822 


MEDICAL   DIAGNOSIS. 


INTRODUCTION. 

GENERAL    CONSIDERATIONS. 

The  study  of  any  complicated  subject  leads  of  necessit}-  to 
its  arrangement  into  branches.  Closely  connected  as  these 
are,  and  forming  always  parts  of  a  whole,  they  are  not  only 
capable  of  distinct  treatment,  but  frequently  become  more 
intelligible  as  they  are  so  treated.  This  is  made  very  mani- 
fest in  investigating  disease.  The  extent  of  ground  the  in- 
quiry covers  has  rendered  it  imperative  to  map  it  out  into 
various  provinces,  which,  however  intimately  united,  may  be 
with  convenience  separately  surveyed.  One  comprises  the 
laws  and  facts  common  to  individual  afi'ections;  in  another 
are  gathered  together  all  relating  to  their  causes ;  another 
embraces  the  consideration  of  their  detection  and  the  full 
recognition  of  their  nature.  It  is  the  purpose  of  these  pages 
to  examine  this  department  somewhat  minutely,  and  espe- 
cially that  portion  of  it  coming  within  the  range  of  the 
practitioner  of  medicine.  In  so  doing  it  will  become  ap- 
parent how  diagnosis,  for  such  the  distinction  of  disease  is 
technically  called,  is  partly  a  science,  partly  an  art :  a  sci- 
ence, because  it  comprehensively  takes  account  of  general 
facts,  and  of  principles  based  on  those  facts;  an  art,  because 
it  demands  a  cognizance  of  the  means,  and  their  application 
to  arrive  at  the  desired  result. 

To  consider,  then,  medical  diagnosis  in  all  its  bearings,  it 
will  be  necessary  not  only  to  hold  up  to  view  the  morbid 
states  met  with  in  the  examination  of  the  sick,  but  to  inquire 

2  (17) 


IS  MEDICAL   DIAGNOSIS. 

ill  wliat  manner  tliey  may  be  most  readily  recognized  and 
explored,  and  how  their  differences  may  be  made  available 
in  the  discrimination  of  one  ailment  from  another.  In  a 
stntly  of  this  kind,  an  investigation  of  symptoms  plays  un- 
avoidably a  prominent  part.  In  truth,  the  detection  of  dis- 
ease is  the  product  of  close  observation  of  symptoms,  and  of 
correct  deduction  from  these  symptoms. 

The  first  requirement  therefore  for  an  accurate  diagnosis 
is  to  learn  to  recos-nize  morbid  signs.  But  the  art  of  ob- 
servation  this  implies  is  not  easy,  and  cannot  be  thoroughly 
acquired  except  by  practice.  No  one  aspiring  to  become  a 
skilful  observer  can  trust  exclusively  to  the  light  reflected 
from  the  writings  of  others ;  he  must  carry  the  torch  in  his 
own  hands,  and  himself  look  into  every  recess.  The  knowl- 
edge obtained  from  reading  is,  however,  serviceable  in  this 
way.  It  aids  in  overcoming  one  of  the  main  difliculties  at 
first  experienced, — to  know  where  to  look  and  what  to  look 
for.  There  are  in  almost  every  affection  some  symptoms 
which  can  hardly  escape  the  merest  beginner;  but  also  some 
which  do  not  appear  on  the  surface,  and  which  to  find  tax 
the  skill  of  the  experienced  physician.  And  it  is  especially 
in  this  search  after  hidden  signs  that  medical  information  as 
well  as  cultivated  tact  is  demanded. 

Now,  to  recognize  the  manifestations  of  disease,  whether 
they  are  or  are  not  readily  perceptible,  we  have  to  employ  our 
eyes  and  ears,  our  sense  of  touch  and  of  smell.  Formerly 
we  could  go  no  further  than  these  senses  unassisted  would 
carry  us.  But  science  has  lent  its  aid,  and  furnished  means 
by  the  help  of  which  we  can  detect  clearly  what  before  we 
could  not  detect  at  all,  or  of  what  at  best  we  only  caught  a 
glimpse.  We  now  possess  instruments  by  which  we  ascer- 
tain Avith  accuracy  the  size  of  organs  and  their  play.  With 
thermometers  we  tell  the  beat  of  various  parts  of  the  body  to 
a  fraction  of  a  degree.  Specific-gravity  bottles,  and  other 
measures  devised  for  the  purpose,  inform  us  of  the  relative 
gravity  of  fluids.  The  microscope  gives  at  a  glance  insight 
into  matters  which  the  naked  eye  fiiils  even  to  perceive.  And 
chemistry,  with  its  marvellous  teachings,  is  rendering  our 
knowledge  of  many  morbid  states  admirably  and  amazingly 


GENERAL    CONSIDERATIONS.  19 

complete.  Then  the  sagacity  of  modern  times  has  taught  ns 
to  enlist  the  sense  of  hearing,  and  demonstrated  how  a  dis- 
ciplined ear  may  detect  the  workings  of  disease  in  cavities 
into  which  the  eye  cannot  penetrate.  The  eft'ect  of  all  these 
improved  methods  of  study  has  been  to  give  an  immense 
impetus  to  clinical  research,  and  in  this  manner  to  lead  to 
the  construction  of  a  solid  groundwork  of  experience  in 
striking  contrast  with  the  looseness  and  wild  vagaries  of 
former  times.  The  advance  in  diagnosis  thus  attained 
forms  indeed  one  of  the  most  pleasing  portions  of  medical 
history. 

When,  by  means  of  the  aided  or  unaided  senses,  the  symp- 
toms of  the  malad}'  have  been  discovered,  the  next  step 
toward  a  diagnosis  is  a  proper  appreciation  of  their  signifi- 
cance and  of  their  relation  toward  each  other.  Knowledge, 
and,  above  all,  the  exercise  of  the  reasoning  fiiculties,  are 
now  indispensable.  The  daily  habit  of  investigating  disease; 
a  scrutinizing  study  of  the  anatomical  lesions ;  chemistry, 
with  its  most  searching  analyses ;  the  microscope,  with  the 
wonders  it  reveals, — are  all  of  little  use,  unless  we  have  been 
taught  the  necessity  of  placing  the  morbid  signs  they  lay  bare 
in  connection  with  each  other,  and  of  considering  in  individual 
cases  their  respective  value.  Were  it  otherwise,  the  science 
of  diagnosis  would  be  simply  a  matter  of  memory.  It  is, 
however,  this  very  analysis  of  symptoms,  and  the  lengthy 
process  of  induction  attending  it,  which  make  medical  diag- 
nosis so  difficult  and  so  unattractive  to  the  beginner.  He 
sees  that  by  reflection  and  reasoning  on  what  are  frequently 
but  indirect  manifestations,  he  must  find  the  seat  and  nature 
of  disorders  hidden  from  his  view.  Nor  is  it  reasoning  on 
the  ascertained  facts  alone  that  is  required:  the  premises 
may  be  but  probabilities ;  for,  in  truth,  diagnosis  deals  at 
times  with  the  logic  of  probabilities  as  much  as  with  the 
logic  of  patent  facts. 

Now  we  are  greatly  aided  in  appreciating  the  import  of 
morbid  signs,  and  in  interpreting  them  correctly,  by  already 
existing  knowledge.  We  look  to  landmarks  which  our  pre- 
decessors have  erected,  and  the  o-raduallv  accumulated  science 
of  semeiology,  rightly  employed,  furnishes  the  clue  to  the 


20  MEDICAL   DIAGNOSIS. 

discovery  of  the  disease.  Thus  the  stores  which  medicine 
has  laboriously  collected  during  centuries  can  be  used  with 
advantage  by  all,  and  exist  for  the  good  of  all. 

But  an  acquaintance  with  semeiology  is  far  from  being  the 
sole  guide  to  diagnosis,  nor  does  it  at  once  help  to  a  recog- 
nition of  the  malady.  There  are  few  symptoms  in  them- 
selves distinctive;  and  often  a  symptom  may  be  due  to  one 
of  several  causes.  Semeiology  informs  us  of  these  different 
causes;  but  to  find  out  the  precise  meaning  of  the  abnormal 
manifestation  in  an  individual  case,  we  have  to  draw  our 
inference  from  all  the  signs  encountered — to  compare  them 
with  each  other;  to  seek  out  those  that  are  in  the  background. 
We  are  thus  arriving,  step  by  step,  at  the  explanation  of  the 
morbid  appearances,  the  starting-point  in  deduction  always 
being  what  is  known  of  the  affection  whose  presence  is  sus- 
pected, and  whose  symptoms  we  are  contrasting  with  those 
before  us.  For  the  conclusion  to  be  valid  and  exact,  it  is  of 
course  requisite  that  each  part  of  the  testimony  have  the 
proper  position  assigned  to  it.  In  reasoning  correctly  on 
symptoms,  the  same  laws  apply  as  in  reasoning  correctly  on 
any  other  class  of  phenomena :  the  mental  process  is  the 
same;  the  facts  have  to  be  sifted  and  weighed,  not  merely 
indiscriminatelj'  collected.  And  while  the  intellectual  act  is 
being  performed,  much  collateral  evidence  is  to  be  sought 
for  before  a  final  judgment  is  given;  especially  is  it  necessarj^ 
to  view  the  symptoms  with  constant  reference  to  the  age,  sex, 
and  habits  of  the  patient,  and  to  the  circumstances  amid  which 
the  disorder  develops  itself. 

To  accomplish  all  this  effectually,  the  physician  has  need 
of  much  and  varied  knowledge.  He  must  be  master  of 
something  more  than  of  that  information  supplied  to  him  by 
semeiology.  lie  must  be  an  anatomist  to  pronounce  with 
certainty  on  the  seat  of  the  malady;  a  physiologist  to  appre- 
ciate the  aberration  of  functions.  Above  all,  he  must  be  a 
pathologist  in  the  full  sense  of  the  term:  he  must  understand 
the  antagonism  between  diseases;  the  frequency  with  which 
they  coexist;  the  influence  of  remedial  agents  on  them;  and 
be  cognizant  of  their  natural  history  and  of  the  general  laws 
governing  them,— for  how  else  can  he  form  an  estimate  of 


GENERAL    CONSIDERATIONS.  21 

morbid  action  while  it  is  in  progress?  Then  it  is  desirable 
that  he  sliould  be  aware  of  what  are  their  current  divisions 
and  classifications.  From  what  has  already  been  represented, 
it  is  evident  that  he  must  also  be  a  correct  reasoner ;  for  even 
a  good  observer  will,  by  bad  reasoning,  arrive  at  a  faulty 
diagnosis,  just  as  sometimes  a  bad  observer  may,  by  the  same 
process,  blunder  into  the  truth.  There  is,  indeed,  no  end  to 
the  extent  of  knowledge  which  may  be  brought  to  bear  in 
working  out  a  conclusion  regarding  the  character  and  seat  of 
a  malady.  The  habit  of  observation  once  acquired,  informa- 
tion of  the  most  varied  kind  will,  by  an  accurate  reasoner,  be 
made  tributary  to  the  completeness  of  the  diagnosis.  Every 
fresh  acquirement  tends  to  enlarge  our  powers  of  insight. 
Just  as  in  nature,  the  higher  we  ascend,  the  more  fully  lies 
the  view  before  us. 

Having  thus  indicated  the  elements  of  an  accurate  and 
thorough  diagnosis,  we  may  next  inquire  in  what  way  it  is 
most  speedily  and  conveniently  arrived  at  when  at  the  bed- 
side. Tlie  main  facts  of  the  case  on  which  the  deductions 
are  to  be  based  are  of  course  first  elicited;  and  we  shall  pres- 
eniiy  see  how  this  may  be  most  effectually  done.  We  lay 
hold  of  the  main  facts,  and  especially  of  those  which  are  the 
most  direct  signs  of  the  morbid  action.  They  are  coupled 
together,  and  the  inquiry  started  as  to  what  organ  they  point 
as  the  seat  of  the  malady.  This  often  has  been  already  de- 
termined by  the  very  method  of  the  examination,  and  we 
therefore  proceed  at  once  to  investigate  the  precise  nature  of 
the  disorder  by  analyzing  the  symptoms  and  the  previous 
history.  Sometimes,  however,  the  site  of  the  disease  does 
not  admit  of  being  definitely  fixed  upon,  or  we  can  only  in  a 
general  manner  decide  upon  the  function  impaired.  Again, 
as  in  idiopathic  fevers,  we  may  find  no  signs  of  local  disease, 
— merely  those  of  a  general  disturbance.  In  any  of  these  in- 
stances clinical  experience  steps  in  to  explain  the  phenomena 
as  fixr  as  possible,  and  to  inform  us  in  what  affections  they 
occur.  It  may  be  only  in  one,  then  the  desired  goal  is  at 
once  attained.  But,  as  above  stated,  there  are  few  signs  in 
themselves  pathognomonic.  It  is  therefore  to  be  ascertained 
which  one  of  the  disorders  is  before  us  that  special  pathology 


o.-) 


MEDICAL   DIAGNOSIS. 


teaches  nuiy  yield  the  symptoms  encountered.  One  of  these 
is  taken  up.  Its  symptoms  are  pLaced  side  by  side  with 
those  present.  They  accord  in  some  respects,  but  not  in  alL 
Moreover,  in  searching  for  some  of  the  phenomena  which 
the  supposed  mahidy  gives  rise  to,  these  are  not  found.  The 
view  is  abandoned,  and  another  taken  up.  It  agrees  in  all 
particuUirs.  The  diagnosis  is  made.  Yet  when  the  diagnosis 
is  thus  arrived  at,  we  have,  before  it  can  be  considered  as 
complete  and  be  acted  upon,  still  to  determine  whether  or 
not  any  other  morbid  state  exists,  and  to  take  into  account 
the  patient's  general  condition  and  his  individuality. 

To  cite  a  case  in  illustration.  A  person  consults  us  for  a 
cough  brought  on  by  exposure.  He  has  been  sick  for  four 
or  five  days,  having  been  previously  in  good  health.  We 
notice,  on  examining  hira,  that  his  breathing  is  hurried,  and 
that  he  has  fever;  the  lower  portion  of  one  side  of  the  chest 
is  dull  on  percussion,  and  the  respiration  there  is  wanting ; 
the  action  and  sounds  of  the  heart  are  normal.  Tlie  facts 
point  to  the  lung  or  its  covering  as  tlie  seat  of  the  disorder. 
We  know,  furthermore,  from  the  history  and  the  febrile 
symptoms,  that  we  have  to  deal  with  an  acute  affection. 
AYhat  are  the  acute  pulmonary  aff'ections?  Acute  bronchitis; 
acute  phthisis;  acute  pleurisy;  acute  pneumonia.  In  all 
occur  fever,  cough,  and  impaired  breathing.  Is  it  acute 
pneumonia?  Xo ;  for,  notwithstanding  there  is  in  this  com- 
plaint, in  addition  to  the  general  symptoms  mentioned,  dul- 
ness  on  percussion,  such  as  we  have  here,  the  duluess  is 
associated  with  a  blowing  respiration;  whereas  in  the  case 
before  us  no  respiration  is  heard.  Let  us  look  at  the  sputum, 
and  see  if  it  is  tenacious  and  rusty  colored.  It  is  not;  it 
is  thin  and  frothy.  Moreover,  the  breathing,  although  hur- 
ried, is  less  hurried  than  it  is  apt  to  be  in  inflammation  of 
the  lung.  But  acute  pleurisy  may  explain  all  the  signs.  The 
patient,  too,  when  questioned,  states  that  he  had  at  the  onset 
a  sharp  pain  in  his  side ;  and  this,  we  are  aware,  takes  place 
in  pleurisy.  The  vocal  vibrations,  likewise,  are  noticed  to 
be  absent  on  one  side  of  the  chest,  which,  when  measured,  is 
found  to  be  enlarged.  This  corresponds  in  all  points  with 
what  happens  in  pleurisy  in  the  stage  of  effusion.  The  disease 


GENERAL    CONSIDERATIONS.  23 

is,  therefore,  acute  pleurisy  in  the  stage  of  effusion.  We  finish 
the  diagnosis  by  ascertaining  the  existence  or  non-existence 
of  other  maladies,  and  by  taking  note  of  the  severity  of  the 
complaint;  that  it  has  occurred  in  a  young  and  robust  person 
of  good  habits;  and  that  the  symptomatic  fever  is  very  active. 

This  process  of  arriving  at  an  opinion  is  the  simplest.  It 
is  one  in  which  the  investigation  of  the  case  is  to  some  ex- 
tent carried  on  while  the  deductions  are  being  made.  And 
by  habit  it  is  astonishing  how  rapidly  it  may  be  performed. 
The  mind  works  unconsciously,  and  a  decision  is,  to  all  ap- 
pearance, formed  intuitivel}',  which  surprises  the  inexperi- 
enced by  its  readiness  and  precision.  This  method  aims,  so 
far  as  the  symptoms  permit,  at  a  direct  diagnosis.  But,  in 
truth,  it  is  often  what  is  called  differeniial:  that  is,  it  takes 
cognizance  of  and  dwells  on  the  essential  signs  by  which  one 
disease  can  be  discriminated  from  another  whicli  it  resembles. 

Sometimes,  instead  of  attaining  the  desired  result  in  the 
manner  proposed,  we  are  obliged  to  judge  of  the  nature  of 
the  malady  entirely  by  finding  out  what  it  is  not.  The 
various  diseases  capable  of  producing  all,  or  even  some,  of 
the  striking  symptoms  observed,  are  enumerated.  They  are 
one  by  one  considered  and  set  aside,  until  by  this  process  of 
pure  exclusion  the  mischief  is  brought  to  light.  Thus,  to  use 
again  the  example  just  given,  we  should  have  to  assign  rea- 
sons why  the  disease  is  neither  acute  pneumonia,  nor  bron- 
chitis, nor  acute  phthisis,  and  in  this  way  determine  it  to  be 
acute  pleurisy.  But  to  prove  what  a  thing  is,  by  proving  all 
that  it  is  not,  is  a  very  tedious  process;  and  we  must  be  quite 
certain  that  really  all  morbid  states  which  may  give  rise  to 
the  symptoms  encountered  are  thought  of  and  inquired  into, 
otherwise  our  conclusion  may  be  fallacious,  though  reasoned 
out  in  the  most  logical  manner.  Moreover,  our  knowledge 
of  many  pathological  conditions  is  so  imperfect  that  we  are 
not  fully  cognizant  of,  or  able  at  once  to  discern  the  more 
characteristic  signs ;  nor  can  the  symptoms  be  taken  hold  of 
and  arranged  in  such  a  way  as  shall  permit  us  to  make  nice 
distinctions  without  a  lengthy  and  laborious  plan  of  proce- 
dure. Owing  to  these  drawbacks,  diagnosis  by  exclusion  is 
not,  on  ordinary  occasions,  much  employed,  nor,  indeed,  is 


•2-1  MEDICAL    DIAGNOSIS. 

it  to  be  roconimeiulecl.  Yet  in  difficult  and  obscure  cases, 
wliere  tbe  accustomed  pathway  is  blocked  up,  it  may  enable 
us  to  pass  by  obstacles  otherwise  insurmountable. 

But  can  we  by  this,  or  by  any  other  road,  always  reach  a 
certain  diasrnosis?  We  cannot,  and  for  several  reasons:  The 
patient  may  deceive  us,  wilfully  or  unintentionally.  It  may 
be  necessary,  for  the  confirmation  of  the  opinion  formed,  to 
obtain  an  accurate  history  of  the  case,  and  circumstances 
may  render  this  impossible.  The  disorder  may  be  so  rare 
that  its  symptoms  are  not  understood.  There  may  be  sev- 
eral lesions  present,  the  signs  of  one  masking  or  neutralizing 
the  si£i:ns  of  the  other. 

The  first  of  the  causes  mentioned  is  a  source  of  error  diffi- 
cult to  guard  against.  To  escape  punishment,  to  avoid  disa- 
greeable duty,  to  excite  compassion,  to  obtain  a  compliance 
with  unreasonable  wishes,  or  sometimes  from  the  mere  love 
of  deception,  symptoms  may  be  stated  to  exist  which  do  not 
exist,  or  may  be  imitated  and  artificially  produced.  Persons 
who  thus  feign  disease  are  numerous.  They  are  found  in  all 
occupations  and  all  classes  of  society.  They  abound  in  the 
army  and  navy.  Hysterical  women  and  hypochondriacs  go 
to  swell  the  list.  These,  indeed,  suffer  mostly  some  incon- 
venience, but  exaggerate  it  immensely,  and,  by  deceiving 
themselves,  end  by  deceiving,  unless  he  be  on  his  guard, 
their  physician.  On  the  other  hand,  disease  actually  in 
progress  may  be  carefully  concealed  from  motives  of  deli- 
cacy or  from  fear  of  the  consequences. 

An  incorrect  diagnosis  from  want  of  a  proper  history-  does 
not,  on  the  whole,  often  occur.  Patients  are  generally  very 
willing  to  give  a  full  account  of  themselves  and  of  their  dis- 
tresses. Sometimes,  however,  the  reverse  happens.  Mental 
anxiety  or  sorrow  may  be  wearing  the  body  out  while  the 
suflerer  obstinately  persists  in  hiding  the  cause  of  his  weaning 
health.  We  meet  also  with  individuals  so  stupid  that  the 
most  elaborate  cross-examination  fails  to  elicit  anything  like 
a  connected  history.  Again,  we  may  be  unable  to  do  so  from 
the  patient  having  lost  the  power  of  speech.  A  man  is  brought 
into  a  hospital  unconscious.  It  is  of  the  utmost  importance 
to  know  how  long   he  has  been   in   this  state,   and  what 


GENERAL    CONSIDERATIONS.  25 

were  his  prior  symptoms ;  unless  some  friend  can  supply  the 
information,  the  most  valuable  diagnostic  data  are  wanting. 

In  the  rarity  of  a  disease  we  have  a  serious  drawback  to 
its  recognition.  This  may  occasion  an  error  of  diagnosis  in 
a  twofold  manner.  The  more  distinctive  symptoms  may  be 
so  little  understood,  and  the  prominent  features  so  nearly 
identical  with  those  of  a  malady  with  the  manifestations  of 
which  we  are  well  acquainted,  that  a  conclusion  of  the  pres- 
ence of  the  latter  forces  itself  almost  immediately  on  the 
mind.  Or,  the  disorder  may  give  rise  to  phenomena  wholly 
unknown,  nothing  but  the  autopsy  revealing  their  true  mean- 
ing. Every  physician  encounters  such  cases.  It  is  true  that 
the  progress  of  science  and  the  aggregation  of  clinical  facts 
are  from  year  to  year  bringing  them  into  a  narrower  circle. 
But  is,  for  instance,  our  knowledge  of  aftections  of  the 
nervous  centres  anything  like  complete?  Are  there  not  still 
diseases,  nay,  groups  of  diseases,  that  have  eluded  discovery 
to  the  manifold  means  of  research  of  the  present  day,  as  they 
have  to  the  accumulated  experience  of  the  past? 

But  the  most  serious  obstacle  to  a  precise  diagnosis  lies  in 
the  fact  that  frequently  several  lesions  coexist.  Disease  is  a 
very  complex  state,  and  when  one  portion  of  the  economy 
gets  out  of  order,  another  is  apt  to  follow.  How  close,  for 
example,  the  connection  between  affections  of  the  heart  and 
of  the  kidney !  Here  it  is  easy  to  arrive  at  a  conclusion,  since 
we  have  the  means  of  judging  accurately  of  the  condition  of 
both  organs.  But  there  are  instances  in  which  it  is  very  diffi- 
cult, especially  when  a  part  contiguous  to  one  chronically 
affected  is  attacked  with  acute  disease.  A  person  applies  for 
relief,  presenting  all  the  symptoms  of  a  severe  local  peritonitis. 
The  inflammation  spreads;  death  results.  The  exciting  cause 
of  the  inflammation  is  discovered  to  be  a  structural  alteration 
of  one  of  the  abdominal  viscera,  the  signs  of  which  were  com- 
pletely merged  in  the  more  marked  signs  of  the  recent  in- 
flammation. And  this  disguisement  is  effected  not  only  by 
the  supervention  of  another  and  more  acute  complaint,  but 
also  sometimes  by  the  prominence  of  those  remote  sympa- 
thetic derangements  which  an  affection  of  any  viscus  may 
produce.    Thus,  the  disturbed  action  of  the  heart  in  dj'spep- 


26  MEDICAL    DIAGNOSIS. 

tic  persons  tlirows  at  times  the  symptoms  of  the  gastric 
mahuly  into  the  sliade.  Yet  it  must  be  admitted  that  errors 
of  diagnosis  from  this  source  are  not  apt  to  occur  to  the 
careful  practitioner.  A  thorough  examination  of  the  case 
is  a  safeguard  against  them. 

These,  then,  are  the  various  causes  rendering  a  diagnosis 
uncertain,  or  wholly  unattainable.  Let  us  add  to  them  one 
that  does  so  temporarily.  There  are  disorders  the  early 
manifestations  of  which  are  so  much  alike,  that  it  is  next  to 
impossible  to  tell  with  which  of  several  we  have  to  deal.  In 
fevers  this  often  happens.  Here,  however,  a  few  days,  or 
even  less,  will  almost  always  solve  the  difficulty.  But  not  so 
in  other  diseases.  It  is  only  after  a  much  longer  time,  and 
b}^  careful  watching  of  the  patient,  that  the  appearance  or 
disappearance  of  a  striking  symptom,  or  the  greater  promi- 
nence a  hitherto  indistinct  sign  assumes,  inclines  the  scales 
toward  one  or  the  other  of  the  aflections  between  which 
judgment  has  been  kept  in  suspense. 

In  some  such  instances,  the  treatment  becomes  the  touch- 
stone of  the  diagnosis.  JS^ow  it  may  be  asked,  Does  this 
demonstrate  that  the  diagnosis  of  a  case  is  not  necessary  for 
its  treatment?  jSTot  at  all.  It  simply  proves  that  we  are 
sometimes  obliged  to  aim  at  removing  symptoms  without 
understanding  their  source.  But  it  does  not  prove  that  if 
we  understood  their  source,  we  should  not  be  better  able  to 
remove  the  symptoms.  The  practitioner  who  undertakes  to 
relieve  disease  simply  by  attempting  to  allay  its  symptoms, 
regardless  of  their  cause,  and  without  understanding  their 
true  relation  and  signiticance,  is  groping  in  the  dark.  His 
treatment  is  vacillating;  drug  replaces  drug;  alleviation  is 
taken  for  a  cure;  and  the  experience  obtained  is  utterly  un- 
trustworthy. One  great  advantage,  indeed,  of  attending 
carefully  to  diagnosis  is,  that  it  enables  us  to  use  remedies 
knowingly,  and  with  decision;  to  appreciate  what  they  are 
effecting;  to  abstain  from  such  as  must  be  injurious.  There 
is  less  needless  meddhng,  more  calmness;  the  treatment 
rises  above  the  consideration  of  the  moment,  and  takes  into 
account  what  is  for  the  patient's  ultimate  good.  It  is  some- 
times urged  that  the  accurate  detection  of  disease  makes 


GENERAL    CONSIDERATIOISrS.  27 

timid  practitioners,  and  deprives  them  of  confidence  in  med- 
icines. More  just  is  it  to  say,  that  it  shows  how  wide  is  the 
chasm  between  onr  acquaintance  with  morbid  conditions 
and  with  remedies;  how  far,  unfortunately,  our  skill  to 
detect  disease  outruns  our  power  to  cure  it. 

There  is  undoubtedly,  however,  a  danger  which  may  arise 
from  paying  very  minute  attention  to  diagnosis.  The  study 
of  it  is  so  interesting,  and  capable  of  being  conducted  so 
entirely  without  reference  to  other  points,  and  especially  to 
the  treatment  of  the  complaint,  that  some  minds  are  carried 
away,  and,  lost  in  the  pursuit  of  diagnostic  knowledge,  forget 
for  what  purposes  chiefly  that  knowledge  is  profitable.  Its 
main  use  is  to  enable  us  to  foretell  the  course  and  probable 
issue  of  a  malady,  and  to  frame,  with  understanding,  plans 
to  relieve  the  sufferings  and  disorders  of  those  who  have  en- 
trusted their  health  and  their  lives  into  our  hands.  Nor 
ought  we  ever  to  be  unmindful  how  important  it  is,  in  basing 
the  management  of  a  disease  on  its  diagnosis,  to  found  that 
diagnosis  on  a  general  survey  of  all  the  circumstances;  how 
necessary  not  to  assign  prominence  to  minor  points  ;  and  how 
the  extent  of  the  disorder,  the  circumstances  under  which  it 
has  occurred,  the  sympathetic  disturbances  produced,  and  the 
vital  state  of  the  patient,  belong,  rightly  considered,  quite  as 
much  to  the  diagnosis  as  the  recognition  of  the  precise  seat 
and  exact  anatomical  character  of  the  malady,  and  are,  in 
truth,  frequently  its  more  important  part. 


CHAPTER  I. 

THE    EXAMINATION    OF    PATIENTS,    AND    SOME     SYMPTOMS    OF 

GENERAL    IMPORT. 

To  elicit  the  facts  of  a  case  by  a  careful  examination  is, 
as  has  been  stated,  the  first  requisite  for  diagnosis.  To  con- 
duct, however,  a  clinical  inquiry  with  precision  and  fticility, 
requires  continual  practice,  and  is  rendered  easier  by  following 
some  well-digested  plan.  The  advantage  of  adopting  a  method 
is  clearly  seen,  if  the  attempts  of  a  beginner  be  watched.  He 
wanders  in  his  search  from  one  part  of  the  body  to  another, 
attracted  by  different  symptoms  in  turn ;  pointless  question 
succeeds  to  pointless  question;  and  a  conclusion,  almost  cer- 
tainly erroneous,  is  finally  jumped  at,  or  an  acknowledgment 
made  of  inability  to  arrive  at  any. 

Xow  there  are  several  ways  which  have  been  proposed  to 
overcome  this  embarrassment.  One  of  the  principal  consists 
in  first  questioning  the  patient  with  regard  to  his  history. 
His  age;  his  occupation;  the  diseases  from  his  childhood  up; 
his  habits;  his  constitution;  the  affections  hereditary  in  his 
family, — are  all  minutely  inquired  into.  After  this  are  traced 
the  origin  and  progress  of  the  existing  disorder,  and  the 
remedies  ascertained  that  have  been  used  against  it.  The 
present  condition  is  then  explored ;  each  organ  or  each  sys- 
tem being  in  turn  interrogated.  The  investigation  is  now 
regarded  as  complete;  the  facts  are  considered,  and  the  diag- 
nosis, prognosis,  and  treatment  determined.  This  method  of 
examining  is  termed  the  synthetical  or  historical;  another,  the 
analytical,  reverses  the  order.  The  present  condition  is  first 
ascertained,  and.  subsequently  the  patient's  history  or  anam- 
nesis. Both  of  these  courses  have  something  to  recommend 
them,  and  some  strong  objections.  The  synthetical  method  is 
the  more  purely  scientific;  but  it  is  too  full,  and  calls  for  too 
(28) 


EXAMINATIOX    OF    PATIENTS,  ETC.  29 

much  labor,  to  meet  the  requirements  of  ordinary  profes- 
sional life.  It  is  much  better  adapted  for  recording  cases  in 
the  pursuit  simply  of  pathological  knowledge,  and  decidedly 
the  best  where  the  history  is  obscure  and  the  symptoms  ill- 
defined.  The  plan  which  I  habitually  prefer  is  to  take  a 
general  survey  of  the  history  and  of  the  prominent  symp- 
toms, and  having  thus  obtained  some  clue  to  the  part  most 
likely  to  be  affected,  to  explore  that  with  care.  For  instance: 
we  are  brought  to  the  bedside  of  a  patient  for  the  first  time; 
we  inquire  how  long  he  has  been  sick ;  how  that  sickness 
began  ;  in  what  way  he  is  now  troubled, — whether  he  has 
pain,  or  what  is  the  main  source  of  his  annoyance.  Wliile 
questioning  him,  we  are  scanning  his  appearance,  the  position 
of  the  body,  his  movements,  his  manner  of  breathing.  The 
hand  is  applied  to  the  skin ;  the  pulse  is  felt.  Partly  from 
this  examination  and  partly  from  the  history,  some  organ  is 
fixed  upon  to  be  specially  investigated :  say  pain  in  the  epi- 
gastric region  and  vomiting  are  complained  of — our  atten- 
tion is  directed  to  the  stomach.  We  explore  this  organ,  its 
physical  state  and  its  functions.  Then  we  look  to  the  parts 
that  are  anatomically  or  physiologically  nearest  related  to  it, 
which  are,  in  the  case  cited,  the  intestines  and  liver.  The 
examination  is  completed  by  taking  heed  of  the  condition  of 
other  portions  of  the  body;  by  reviewing  the  history  of  the 
case;  and  bj'  endeavoring  to  elicit  fully  such  points  as  bear 
upon  the  diagnosis,  which  the  mind,  consciously  or  uncon- 
sciously, has  already  commenced  to  frame.  Then  the  bal- 
ance between  the  symptoms  is  struck,  the  diagnosis  recast, 
modified,  or  extended,  and  the  treatment  decided  uj^on. 

There  is  some  repetition  in  this  plan,  but  it  is  the  one 
which  appears  practically  the  most  suitable.  It  has  the  ad- 
vantage of  bringing  together  the  marked  features  of  a  case, 
and  especially  those  most  clearly  indicative  of  the  general  or 
vital  condition.  But  whatever  scheme  be  chosen,  it  should, 
for  us  to  become  proficient  in  it,  be  as  constantly  and  closely 
adhered  to  as  the  varying  circumstances  of  disease  will  per- 
mit. Yet  thoroughly  to  acquire  the  habit  of  examining  with 
accuracy  and  care,  and  also  to  obtain  the  full  fruits  of  expe- 
rience, it  is  indispensable  to  keep  written  records.    This,  too, 


30  MEDICAL   DIAGNOSIS. 

ssliould,  SO  far  as  possible,  be  done  according  to  a  uniform 
design,  since  it  both  prevents  us  from  overlooking  important 
symptoms,  and  enables  cases  to  be  more  readily  compared. 
I  subjoin  a  schedule  which  I  have  used  for  some  time,  and 
which  is  based,  as  closely  as  practicable,  on  the  plan  of  ex- 
amination just  mentioned. 

Date  of  Examination  ;  Name  ;  Age  ;  Color  ;  Place  of 
Birth;  Present  abode;  Occupation  or  social  state;  In 
females,  whether  married  or  not,  number  of  children  and 
date  of  last  confinement. 

History. 

1.  JUstory  antecedent  to  2)resent  disease :  Constitution  and 

General  Health  —  Hereditary  predisposition  — 
Previous  Diseases  or  Injuries — Habits  and  mode 
of  life;  hygienic  influences  to  which  exposed,  etc. 

2.  History   of  present  disease:    Its   supposed   exciting 

cause — Date  of  seizure — Mode  of  invasion  ;  sub- 
sequent symptoms  in  order  of  succession — Pre- 
vious treatment. 
Present  Condition  of  Patient. 

1.  General  Sym-ptoms : 

Position  /  "^  bed-mode  of  lying ; 
{  out  of  bed — movements; 

Aspect/ ^^b^*^^^'' 

I  of  countenance ; 

Skin ; 

Pulse ; 

Respiration — as  to  frequency,  etc.; 

Tongue; 

f  appetite ; 
General  state  of  Digestion  I  thirst ; 

(condition  of  bowels; 
General  state  of  Urinary  Secretion  ; 
Sensations  of  patient:  })ain,  etc. 

2.  Examination  of  sjjecial  regio7is  or  functions,  commenc- 

ing with  the  one  presumably  the  most  affected. 
Diagnosis. 
Treatment. 
Remarks. 


EXAMINATION    OF    PATIENTS,  ETC.  31 


The  history  is  here  placed  first ;  then  the  symptoms  of 
general  import,  such  as  those  furnished  by  the  pulse  and 
tongue,  are  made  to  precede  the  examination  of  special  re- 
gions. These  general  symptoms  are  of  great  value  in  the 
recognition  of  disease,  and  of  yet  greater  value  in  determin- 
ing its  treatment.  They  are  something  more  than  the  mere 
physical  signs  of  textural  affections ;  they  indicate  vital  con- 
ditions, and  partly  from  their  value,  and  partly  from  their 
not  being  linked  to  a  disease  of  any  organ  in  particular,  they 
demand  a  separate  and  detailed  consideration. 

Position  of  the  Body. — By  noting  whether  the  patient  is 
in  bed  or  out  of  bed — how  he  lies,  or  how  he  walks — a  gen- 
eral idea  may  be  formed  as  to  the  acuteness  of  an  attack, 
the  impairment  of  strength  it  has  produced,  and  sometimes 
even  as  to  its  nature.  Let  a  person  who  has  been  actively 
attending  to  his  usual  occupation  be  suddenly  confined  to  his 
bed,  and  the  inference  that  the  disease,  if  not  dangerous,  is 
at  all  events  a  severe  and  acute  one,  will  be  commonly  cor- 
rect ;  certainly  so,  if  no  mishap  to  the  organs  of  locomotion 
has  necessitated  a  resort  to  the  recumbent  position.  When 
the  patient  lies  for  a  long  time  on  his  back,  it  is  generally 
from  exhaustion,  or  from  paralysis,  or  it  is  owing  to  tlie  pain 
which  pressure  or  motion  of  any  kind  occasions.  Such  is 
the  cause  of  the  dorsal  decubitus  in  peritonitis,  and  in  rheu- 
matism. Lying  fixedly  upon  one  side  may  be  looked  upon 
as  an  indication  that  the  action  of  the  lung  of  this  side  is 
impeded,  and  that  the  respiration  has  to  be  carried  on  with 
the  other.  There  are  exceptions  to  this  rule,  but  not  enough 
to  destroy  its  value.  The  patient  may  be  confined  to  bed, 
and  yet  unable  to  lie  down  in  it,  on  account  of  the  distress  in 
breathing  to  which  the  recumbent  posture  gives  rise :  he 
leans  forward,  or  sits  erect.  This  necessity  of  breathing  in 
the  upright  position,  or  "  orthopnoea,"  is  a  form  of  dyspncea 
encountered  especially  in  diseases  of  the  heart,  or  where 
fluid  is  effused  into  the  air-cells  or  into  both  pleural  cavities. 

If  a  person  is  able  to  be  about,  his  posture  and  movements 
become  important  manifestations  of  his  condition.  The 
young  and  the  strong  walk  erectly,  quickly,  and  firmly ;  the 
aged  and  weak,  stoopingly,  slowly,  and  with  difficulty.     In 


32  MEDICAL    DIAGNOSIS. 

discaf=iet5  of  the  spine  the  body  is  bent:  so,  too,  in  afleetions 
of  the  lars^rcr  joints  of  the  lower  extremities. 

When,  after  a  fever,  or  any  other  prostrating  malady,  the 
patient  leaves  his  bed,  he  totters,  moves  slowly,  and  is  soon 
obliged  to  rest:  returning  strength  brings  with  it  a  quicker 
and  steadier  salt.  In  some  diseases  of  the  brain  the  move- 
ments  are  staggering;  in  one-sided  palsy  they  are  uncertain, 
and  the  affected  side  lags,  or  its  motions,  if  it  can  be  moved 
at  all,  are  laborious.  Excessive  and  uncontrollable  move- 
ments are  observed  in  mania  and  in  chorea;  trembling 
motions  in  states  of  extreme  debility,  in  shaking  palsies, 
and  in  the  delirium  of  drunkards. 

General  Aspect— Expression  of  Countenance. — The 
eye  of  an  experienced  observer  notices  rapidly  whether  the 
body  is  bulky  or  wasted,  and  whether  the  surface  is  discol- 
ored or  otherwise  changed.  The  indications  afforded  by  the 
latter  appearances  will  be  more  conveniently  spoken  of  in 
connection  with  the  morbid  states  of  the  skin;  but  to  those 
furnished  by  the  former  a  few  lines  may  be  here  devoted.  A 
bulky  aspect  of  the  whole  body  is  the  result  of  corpulency,  or 
arises  from  universal  anasarca.  In  some  acute  diseases,  too, 
a  general  tumefaction  may  take  place — for  example,  in  the 
exanthemata.  A  partial  increase,  or  a  swelling,  arises  from 
the  local  extravasation  of  fluid  or  air  into  the  cellular  tissues. 
If  air,  the  tissues  crepitate  under  the  finger ;  if  fluid,  the  skin 
pits.  A  swelling  may,  further,  proceed  from  an  inflammatory 
thickening,  or  from  a  tumor  or  any  morbid  growth. 

A  diminution  in  bulk  is  a  more  frequent  and  a  more 
striking  symptom  than  an  augmentation.  It  may  take  place 
very  rapidly,  as  witnessed  in  Asiatic  cholera.  More  generally 
the  wasting  is  gradual,  and  is  a  sure  indication  of  the  nutri- 
tion of  the  body  not  being  properly  carried  on.  It  occurs  in 
the  course  of  protracted  fevers,  and  in  most  chronic  diseases. 
In  dangerous  and  slowly  fatal  maladies,  and  in  those  attended 
with  constant  discharges — for  instance,  in  chronic  diarrhea 
— the  loss  of  flesh  reaches  its  highest  point. 

Emaciation  is  most  readily  recognized  in  the  face.  It  gives 
rise  to  that  significant  change  in  the  features  which  at  once 
reveals  the  existence  of  disease.     N"ot  that  emaciation  is  the 


EXAMINATION    OF    PATIENTS,  ETC.  33 

only  striking  alteration  observable  in  the  countenance  when 
health  has  failed.  There  may  be  pallor,  sallowness,  a  livid 
hue  of  the  lips,  a  pufty  appearance  of  the  eyelids,  a  flush  on 
the  cheeks.  Now  these  changes  in  the  features,  added  to  the 
expression  which  pain  or  special  trains  of  thought  produce, 
make  up  that  peculiar  physiognomy  of  disease  so  pregnant 
with  meaning.  But  I  shall  not  attempt  to  describe  in  detail 
the  cast  or  the  play  of  features  in  the  sick.  The  shades  of 
expression  are  so  numerous  that  they  baffle  description,  and 
are  only  to  be  learned  by  continuous  bedside  experience.  I 
will  merely  set  down  a  few  broad  facts  which  this  experience 
teaches. 

Among  the  countenances  most  frequently  met  with,  is  that 
of  apathy  and  stupor.  The  eye  is  dull  and  listless;  the  face 
pale,  or  flushed  with  fever.  This  look  is  very  common  in 
fevers  of  a  low  type,  and  is  often  combined  with  blackish 
accumulations  on  the  lips,  gums,  and  teeth. 

Unnatural  fulness  and  congestion  of  the  features  are  some- 
times observed  in  hypertrophy  of  the  heart,  and  oftener  still 
in  habitual  drunkards.  The  same  aspect  is  seen  in  apoplexy 
and  in  typhus  fever. 

A  pinched  expression  is  found  when  there  is  intense  anx- 
iety or  pain,  or  a  wasting  malady  attended  with  constant 
suffering.  It  is  specially  observed  in  acute  peritoneal  inflam- 
mation. When  very  marked,  and  accompanied  by  change 
of  hue,  it  is  the  face  which  Hippocrates  has  so  graphically 
described.  In  the  great  master's  own  words,  "a  sharp  nose, 
hollow  eyes,  collapsed  temples  ;  the  ears  cold,  contracted, 
and  their  lobes  turned  out;  the  skin  about  the  forehead 
rough,  distended, 'and  parched;  the  color  of  the  whole  face 
green,  black,  livid,  or  lead  colored."  This  is  the  physiog- 
nomy of  approaching  death,  and  generally  its  speedy  fore- 
runner, excepting  in  those  cases  in  which  it  proceeds  from 
want  of  food,  from  protracted  vigils,  or  from  excessive  dis- 
charge from  the  bowels. 

The  face  of  shock,  with  its  great  pallor,  its  anxious  or 
frightened  look,  and  its  fixed  or  oscillating  eye,  often  with  a 
contracting  pupil,  is  a  face  seen  after  severe  injuries,  and  as 
such  familiar  to  the  suro;eon.    But  in  raanv  of  its  main  traits 


34  MEDICAL    DIAGNOSIS. 

it  may  be  also  met  with  in  diseases  that  make  a  sudden  and 
overwhehning  impression  on  the  nervous  system;  for  in- 
stance, it  is  at  times  encountered  in  cerebro-spinal  fever  and 
in  cholera. 

An  aspect  serious  and  dull  on  one  side,  while  the  other 
side  is  in  full  play,  is  witnessed  in  hemiplegia,  or  in  paralysis 
of  the  facial  branch  of  the  seventh  nerve.  The  difference  in 
the  cast  of  the  features  may  escape  observation  when  the  face 
is  in  repose,  but  as  soon  as  an  attempt  is  made  to  laugh,  it 
shows  itself  plainly. 

Independently  of  these  lineaments  which  may  be  said  to 
be  common  to  several  diseases,  we  read  frequently  in  the 
countenance  the  signs  of  special  disorders.  A  dusky  flush 
on  the  face,  if  associated  with  rapid  breathing,  is  almost  a 
certain  indication  of  inflammation  of  the  lung.  Puffiness  of 
the  eyelids  in  a  pallid  person  is  very  apt  to  be  expressive  of 
Bright' s  disease.  A  bluish  color  of  the  lips  shows  plainly 
that  the  venous  circulation  is  interfered  with,  or  that  the 
blood  is  but  imperfectly  aerated.  Then  there  is  the  straw- 
colored,  anemic  hue  of  malignant  disease;  the  jaundiced, 
melancholy  look  of  a  hepatic  affection ;  the  downcast  expres- 
sion and  mobility  of  the  features  in  hysteria;  the  thickened 
upper  lip,  delicate  skin,  and  fair  complexion  of  scrofula,  and 
the  various  traits  which  tend  to  mark  not  onl}-  the  special 
diathesis,  but  also  the  peculiar  temperament  with  the  mor- 
bid tendencies  that  belong  to  it.  But  this  is  not  a  subject  to 
be  pursued  here  any  further ;  it  was  merely  touched  upon 
to  exhibit  the  diagnostic  importance  of  a  study  of  the  coun- 
tenance.* 

Skin.— By  the  state  of  the  skin  we  can,'  to  a  great  extent, 
judge  of  the  activity  of  the  circulation  and  of  the  character 


*  For  fuller  information  on  the  Physiognomy  of  Disease,  and  especially  on 
the  physiognomical  value  in  diagnosis  of  special  features,  as  the  jaws,  palate, 
teeth,  ears,  hair,  the  reader  is  referred  to  Laycock's  Lectures,  Med.  Times 
and  Gazette,  vol.  i.  1862;  also  to  a  paper,  ib.  Sept.  1867.  The  individual 
muscles  concerned  in  physiognomical  expression  have  been  made  the  subjeot 
of  careful  study  by  Duchenne:  Proceedings  of  French  Academy,  Arch. 
Gener.  de  Med.,  1862,  et  seq.;  also  in  Physiologie  des  Mouvements,  Paris, 
1867. 


EXAMINATION    OF    PATIENTS,  ETC.  35 

of  the  blood.  Moreover,  it  is  a  fair  index  of  the  secretions, 
and  of  the  condition  of  the  system  at  large.  In  fevers,  along 
with  the  quickened  circulation,  the  temperature  of  the  skin 
is  increased ;  the  attending  dr3'ness  is  produced  by  defective 
perspiration.  Coldness  of  the  surface  indicates  a  weakened 
capillary  circulation,  and  is  met  with  at  the  invasion  of  acute 
diseases,  and  when  the  nervous  power  is  under  the  sway  of 
some  highlj^  deleterious  influence.  If  heat  of  surface  succeed 
a  cold  skin,  we  know  that  reaction  has  taken  place,  that  the 
circulation  has  again  become  active.  Protracted  coldness, 
whether  attended  with  dryness  or  with  clamminess,  is  of  evil 
augury ;  it  implies  a  seriously  diminis?ied  vital  force. 

The  cutaneous  covering  is  pale  whenever  the  blood  is 
poor  and  watery.  If  it  be  seriously  vitiated  and  deprived  of 
its  tibrin,  as  in  putrid  fevers,  black  spots  are  seen,  due  to  ex- 
travasation. Ofttimes  the  surface  is  overspread  with  erup- 
tions, some  of  which  bear  a  close  relation  to  disorders  of 
internal  organs,  while  others  are  connected  with  febrile  or 
general  maladies;  and  others,  again,  are  owing  to  a  disease 
of  the  texture  itself. 

Tension  of  the  skin  is  met  with  in  acute  aft'ections  accom- 
panied by  active  excitement.  In  wasting  and  prostrating 
ailments,  on  the  other  hand,  the  skin  feels  very  relaxed  and 
soft;  and  in  those  producing  rapid  emaciation,  it  is  inelastic 
and  lies  in  folds. 

Pulse. — The  study  of  the  pulse,  elevated  into  a  science  by 
Galen  and  his  disciples,  has  come  down  to  us  with  the  sanc- 
tion of  centuries;  and  to  feel  the  beat  at  the  wrist  is  still,  in 
the  opinion  of  many,  as  indispensable  to  the  understanding 
of  a  case  as  it  was  thought  to  be  by  the  Arabs,  and  in  the 
Middle  Ages.  Yet  the  advance  of  science  has  shaken  the 
belief  in  the  paramount  importance  of  the  pulse.  It  has 
shown  that,  although  a  most  valuable  means  of  information, 
it  is  not  exclusively  to  be  relied  upon,  and  has  proved  the 
many  divisions  and  refinements  of  the  physicians  of  by-gone 
days — who  endeavored  by  the  pulse  to  judge  of  every  con- 
ceivable morbid  condition — to  be  practically  useless.  In- 
deed, were  even  all  their  distinctions  founded  in  fact,  we 
have  now  better  ways  of  judging  of  lesions  than  by  feeling 


36  MEDICAL    DIAGNOSIS. 

tlio  radial  aitory.  The  same  may  be  said  of  the  prognostic 
indications  drawn  from  the  pulse.  It  aftbrds  us  in  this  re- 
spect unu-li  instruction  ;  but  any  attempt  to  revive  the 
various  critical  pulses,  as  taught  by  Solano  or  Bordeu,  would 
be  received  with  the  same  derision  as  we  do  the  pretensions 
of  our  Chinese  brethren  to  distinguish  diseases  by  feeling 
the  pulse  of  the  right  or  the  left  side,  or  to  determine,  by  its 
aid,  the  sex  of  the  child  in  a  pregnant  w^oman. 

The  pulse  enlightens  us  on  the  action  of  the  heart,  and  on 
something  more — on  the  state  of  the  artery  itself  and  of  the 
blood.  In  a  healthy  adult  a  beat  of  some  resistance  is  felt, 
recurring  from  sixty-five  to  seventy-five  times  in  a  minute. 
It  becomes  slower  with  advancing  years,  though  it  may  rise 
in  the  very  aged.  The  pulse  of  infancy  is  one  hundred  and 
ten  to  one  hundred  and  twenty ;  and.  of  a  child  three  years 
old,  from  ninety  to  ninety-five.  Warmth  quickens  the  pulse, 
so  do  rapid  breathing,  forced  expiration,  and  the  process  of 
digestion.  In  the  recumbent  position  and  during  sleep  it 
fails. 

At  the  bedside  we  study  in  the  pulse  its  frequency,  its 
rhythm,  its  volume  and  strength,  and  its  resistance. 

Increased  frequency  of  the  beat  denotes  increased,  frequency 
of  the  heart's  action,  and  arises  from  anv  cause  which  excites 
the  heart.  Hence  exercise,  rapid  breathing,  mental  emotion, 
or  restlessness,  will  occasion  the  number  of  beats  to  exceed 
the  average  of  health  as  readily  as  fevers  or  acute  inflamma- 
tory diseases.  In  great  debility,  too,  the  pulse  rises ;  and 
the  more  depressed  the  vital  condition,  the  higher  the  pulse 
becomes.  The  heart  may  thus  quicken  from  so  many  and 
such  varied  causes  acting  temporarily  or  permanently,  that 
increased  frequency  of  pulse,  taken  by  itself,  has  no  signifi- 
cant diagnostic  meaning. 

A  slow  pulse,  too,  happens  in  many  difterent  states— from 
cold,  exposure  to  wet,  in  icterus.  It  is  also  produced  by  an 
intense  and  prostrating  shock,  or  is  found  coexisting  with 
pressure  on  the  brain.  In  some  persons  the  pulse  is  naturally 
very  slow. 

The  rhythm  of  the  pulse  is  often  perverted.  Instead  of 
the  beats  following  each  other  in  regular  succession,  they 


EXAMINATION    OF    PATIENTS,  ETC.  37 

are  unequal,  or  one  or  two  intermit.  An  irregular  pulse 
occurs  from  digestive  troubles  or  from  debility;  but  it  is 
more  frequently  the  indication  of  a  cerebral  or  cardiac 
lesion.  It  is  sometimes  a  difficult  beat  to  count;  and  we 
must  be  careful  not  to  regard  at  once  a  pulse  as  irregular 
because  it  appears  to  intermit.  The  seeming  irregularity 
may  be  caused  by  a  slipping  of  the  fingers  from  the  artery, 
which  they  are  very  apt  to  do  after  they  have  been  on  the 
vessel  for  some  time. 

The  volume  and  strength  of  the  pulse  are  of  much  more  im- 
portance than  either  its  rhythm  or  its  frequency.  Volume 
and  strength  are  often  associated,  and  are  much  alike;  but 
they  are  not  identical.  When  the  beat  of  the  artery  is  large, 
we  call  it  dbfull  pulse.  This  is  owing  to  the  distention  of  the 
vessel  with  blood — its  complete  expansion  with  every  beat 
of  the  heart.  A  full  pulse  is,  therefore,  the  pulse  of  plethora ; 
the  pulse  of  the  young  and  robust  in  health,  or  in  inflamma- 
tory diseases;  the  pulse  in  the  early  stages  of  fevers,  or  in 
obstruction  of  the  capillaries.  It  is  usually  a  pulse  of  power, 
just  as  its  opposite,  a  small  pulse,  is  usually  the  pulse  of  de- 
bility. Yet  a  full  pulse  may  be  produced  by  the  distention 
of  an  artery  which  has  lost  its  tone,  and  which  the  finger 
easily  compresses.  Such  a  pulse,  the  "  gaseous  pulse,"  de- 
notes exhaustion,  and  proves  that  a  full  pulse  and  a  strong 
pulse  are  not  always  synonymous.  Indeed,  into  the  idea  of 
strength  enters  something  more  than  mere  fulness.  A  strong- 
pulse  is  a  natural  pulse  heightened  in  all  its  characters.  It 
has  more  fulness,  but,  in  addition,  more  impulse,  and  less 
compressibility  than  an  ordinary  pulse.  A  strong  pulse, 
therefore,  indicates  activity  of  the  contraction  of  the  heart, 
and  a  normal,  perhaps  increased  tonicity  of  the  arterial  coats. 
It  is  found  in  active  inflammations;  also  in  Iwpertrophy  of 
the  heart.  Its  opposite,  a  weak  pulse,  betokens  want  of 
force,  often  want  of  healthy  blood.  It  is  generally  small  as 
well  as  weak.  But  as  little  as  the  full  pulse  is  always  strong, 
is  the  small  pulse  always  weak.  The  small,  choked  pulse 
of  peritoneal  inflammation  may  be  tine  and  wiry;  but  who 
would  call  it  a  weak  pulse? 

The  resistance  or  tension  of  the  pulse  is  another  valuable 


38  MEDICAL   DIAGNOSIS. 

guide  in  the  appreciation  of  morbid  action.  Is  the  pulse 
hard  aiitl  resisting?  is  it  soft  and  compressible?  are  questions 
on  the  solution  of  which  the  application  of  remedies  maj 
hang.  A  hard,  tense  pulse  denotes  increased  contractility 
of  the  arteries,  and  high-wrought  power.  Be  the  beat  full  or 
small,  slow  or  frequent,  it  tells  us  that  the  blood  is  being 
driven  with  force  along  the  arterial  system.  But  it  also  tells 
us  that  the  irritation  has  implicated  the  coats  of  the  arteries 
themselves,  as  their  extreme  resistance  to  the  finger  plainlj- 
shows.  A  tense  pulse  is  met  with  in  active,  violent  inflam- 
mations, or  sometimes,  though  not  often,  in  states  of  ex- 
treme and  continued  excitement  without  inflammation.  It 
is  almost  needless  to  add  that  changes  in  the  coats  of  the 
arteries  may  also  be  a  cause  of  a  hard  and  resistant  beat. 
Where  no  local  alterations  are  present,  and  where  no  acute 
symptoms  explain  the  sympathetic  disturbance  of  the  heart 
and  arterial  system,  a  tense  pulse  will  be  commonly  found  to 
be  associated  with  hypertrophy  of  the  left  ventricle. 

The  opposite  of  the  hard  pulse  is  the  soft  or  compressible 
pulse.  This  implies  deficient  impulsion,  loss  of  tone  in  the 
vessel,  and  is  the  pulse  of  low  fevers  and  of  debility.  But  it 
is  also,  when  following  a  tense  state  of  the  artery,  the  pulse 
which  denotes  returning  health,  and  imminent  danger  passed. 

Such  are  the  meanings  attached  to  the  various  characters 
of  the  pulse.  Yet  they  do  not  often  present  themselves  thus 
isolated.  The  following  are  usually  combined,  and  bear  this 
explanation: 

A  hard,  full,  frequent  pulse  occurs  in  active  inflammations, 
and  in  most  of  the  acute  diseases  of  robust  persons. 

A  hard  pulse,  full  or  small,  bounding  or  not,  if  unconnected 
with  acute  symptoms,  leads  to  the  suspicion  of  cardiac  disease, 
or  of  an  affection  of  the  artery  itself. 

A  tense,  contracted,  and  frequent  pulse  is  met  with  in  a 
large  group  of  inflammations  below^  the  diaphragm,  as  iu 
enteritis,  peritonitis,  gastritis. 

A  frequent  pulse,  full  or  small,  but  rarely  tense,  is  the  pulse 
of  most  idiopathic  fevers. 

A  very  frequent  pulse,  but  very  feeble  and  compressible,  is 
the  pulse  of  marked  debility,  of  prostration,  of  collapse. 


EXAxMINATION    OF    PATIENTS,  ETC. 


39 


A  pulse  frequent,  and  changeable  in  its  rhythm,  is  pro- 
duced, for  the  most  part,  either  by  disease  of  the  heart  or 
of  the  brain. 

The  appreciation  of  these  different  kinds  of  pulses  requires 
considerable  practice.  But  even  this  scarcely  teaches  us  to 
estimate  the  exact  degree  of  the  alteration  of  the  beat,  cer- 
tainly not  with  sufficient  distinctness  to  convey  to  others  an 
accurate  idea,  or  even  to  be  able  ourselves  to  compare  one 
observation  with  another.  To  attain  these  desirable  re- 
sults, physiologists  have  sought  for  instruments  by  means  of 
which  the  pulse  might  be  examined  with  precision,  its  finer 
shades  of  difference  recognized,  and  its  movements  recorded. 
The  best  instrument  as  yet  invented  is  the  sphygmograjyh  of 
Marey,*  which  registers  with  correctness  not  only  the  fre- 
quency and  regularity,  but  also  the  form  of  pulsation,  and  may 
be  applied  almost  as  readily  to  the  study  of  the  cardiac  impulse 
and  of  pulsatile  tumors  as  toward  gaining  a  knowledge  of  the 
pulse  wave.  Slight  irregularities  which  wholly  escape  the  fin- 
ger may  be,  through  its  aid,  discerned  with  facility,  and  we 
can  tell  at  once  in  how  far  these  irregularities  belong  to  one  or 
to  a  succession  of  beats.     Double  beats,  too,  not  appreciable 

Fig.  1. 


The  sphygmograph  attached  to  the  wrist.    Its  tracings  are  seen  by  the  white  lines  ou  the  bhick 

background. 

to  the  hand,  are  easily  detected.  Indeed,  one  of  the  most 
valuable  results  arrived  at  by  the  sphygmograph  concerns 
the  type  of  pulse  in  which  a  double  beat  is  perceived  to  each 
contraction  of  the  heart.  This,  the  "dicrotic"  pulse,  or  the 
pulsus  biferiens  of  the  older  authors,  is  most  commonly  met 
with  in  fevers  of  a  tvphoid  form,  and  preceding  or  during  the 


■•••  Phj'siologio  Medicale  de  la  Circulation  du  Sang.     Paris,  1863. 


40  MEDICAL    DIAGNOSIS. 

continuance  of  hemorrhages.  Yet  the  phenomenon  of  di- 
crotism  may  be  stated  to  be  really  a  physiological  one,  since 
the  sphygmogra})h  proves  it  to  exist  in  almost  every  person. 
The  rebound  is  chiefly  due  to  the  oscillation  of  the  column 
of  blood  in  the  arteries,  and  is  very  much  influenced  by  their 
elasticity.  It  is  rarel}'  suflicient  to  be  determined  by  the 
touch,  except  when  the  arterial  tension  or  contractility  is 
lessened  and  the  elasticity  of  the  tubes  increased,  as  happens 
in  the  disorders  in  which  the  dicrotic  pulse  is  encountered. 
In  old  persons,  in  whom  the  coats  of  the  arteries  are  in- 
elastic, dicrotism  is  but  feebly  marked.  A  rapid  circulation 
renders  the  pulse  more  obviously  dicrotic.  The  rebound 
may  occur  during  the  systole  or  diastole  of  the  vessel ;  and 
instead  of  one,  there  may  be  four  or  five  of  the  secondary 
pulsations. 

When  we  apply  the  sphygmograph  for  clinical  purposes, 
we  study  chiefly  in  its  tracings,  the  line  of  ascent,  the  summit, 
and  the  line  of  descent.  Each  pulsation  is  composed  of  these 
three  parts.  The  line  of  ascent  tells  us  the  manner  in  which 
the  blood  enters  the  vessels.  The  more  rapid  the  flow^,  and 
the  more  quickly  the  artery  distends,  the  more  vertical  the 
line.  The  force,  too,  is  indicated  by  this  line,  or  rather  by 
its  height;  though  here  we  find  that  the  strength  of  the  ven- 
tricular contraction  is  far  from  being  the  only  cause  influ- 
encing the  amplitude  of  the  tracing.  Indeed,  as  we  may 
note  in  old  persons,  a  large  volume  of  the  artery  gives  very 
considerable  height  to  the  lines  of  ascent,  so  does  a  long  in- 
terval between  the  pulsation,  or  the  obstruction  of  the  vessel 
below  the  point  where  the  observation  is  made.  A  state  of 
feeble  tension  in  the  capillary  system,  further,  has  the  same 
efiect,  whereas  when  the  passage  in  the  ultimate  ramiticatiou 
of  the  vesicular  system  is  difficult,  the  lever  descends  slowly 
by  a  line  convex  upward,  and  is  soon  again  raised  by  the 
next  pulsation.  The  line  joining  the  summit  of  a  series  of 
pulsations,  or  the  maxima  of  tension,  is  generally  a  straight 
hue;  a  similar  imaginary  line  connecting  the  bases,  or  the 
minima,  is  apt  to  run  parallel  to  it;  but  irregularity  of  pulsa- 
tion leads  to  irregular  lines,  and  the  lower  line  may  be  irreg- 
ular while  the  upper  is  straight. 


EXAMINATION    OF    PATIENTS,  ETC.  41 

The  summit  of  the  pulsation  informs  us  of  the  time  during 
which  the  entrance  of  blood  balances  the  onward  flow.  This 
summit  may  be  a  horizontal  line  of  some  length,  and  an  ex- 
tended plateau  of  the  kind  is  very  apt  to  happen  in  indura- 
tion or  ossitication  of  the  arteries.  In  some  instances  we 
find  a  little  hooked  point  preceding  the  usually  transverse 
mark  of  the  summit.  This  occurs  by  the  rapid  movement 
of  the  lever,  and  is  a  valuable  si^n  of  reg-uro-itation  through 
the  aortic  valves. 

The  line  of  descent  follows  the  closure  of  the  semilunar 
valves.  It  is  sometimes  purely  oblique,  and  the  more  rapidly 
the  pressure  is  lessened  in  the  arterial  system,  the  more 
oblique  is  the  line.  It  often  shows  a  series  of  undulations, 
giving  rise  to  the  dicrotism  in  the  pulse  which  has  been  above 
mentioned. 

These  points  must  all  be  attended  to  in  examining  sphygmo- 
graphic  tracings;  but,  unfortunately,  the  mode  of  adjusting 
the  instrument,  and  of  proportioning  the  pressure  of  the 
spring,  has  something  to  do  with  the  kind  of  delineation 
obtained.  To  secure  greater  accuracy,  Anstie*  and  San- 
derson have  made  improvements  in  the  instrument.  San- 
derson, especially,  has  fixed  the  centre  button  at  a  definite 
pressure,  thus  insuring  an  arrangement  very  useful  for  pur- 
poses of  comparison.  Still,  with  all  its  perfection,  the  precise 
value  of  the  instrument  for  clinical  research  is  yet  to  be  fixed. 
After  using  it  considerably,  I  think  it  much  more  likely  to 
be  of  avail  in  investigations  on  the  exact  action  of  medicines 
than  in  aiding  us  very  materially  either  in  questions  of  diag- 
nosis or  in  decisions  on  treatment.  At  all  events,  I  do  not 
think  it  has  been  shown  that  it  supersedes  the  older  and 
more  usual  means  of  research. 

Tongue. — When  a  patient  is  told  to  put  out  his  tongue, 
it  is  not  because  the  physician  thinks  it  obligatory  to  see 
whether  or  not  this  organ  is  the  seat  of  a  disease,  but 
because  experience  has  taught  him  that  the  tongue  is  a 
mirror,  more  or  less  perfect,  of  the  condition  of  the  digestive 
functions,  and  that  it  refiects  the  complexion  of  the  nervous 

*  Lancet,  No.  35,  1868. 


42  MEDICAL    DIAGNOSIS. 

power  and  of  the  blood,  and  the  state  of  the  secretions.  To 
judge  of  these  varied  circumstances,  we  have  to  examine  the 
tongue  in  regard  to  its  movements,  its  vohime,  its  dryness  or 
its  humidity,  its  color,  and  its  coating. 

The  movements  of  the  tongue  are  impeded  and  tremulous 
in  all  conditions  of  the  system  attended  with  exhaustion.  It 
is  protruded  slowly  and  with  difficulty  in  fevers  of  a  low  type, 
and  in  nervous  disorders  which  are  accompanied  by  marked 
debility.  The  action  of  the  muscles  is  seriously  impaired  in 
paralysis.  In  hemiplegia  one  side  is  crippled,  and  the  tongue 
turns  toward  one  of  the  corners  of  the  mouth.  When  im- 
perfect articulation  is  associated  with  difficulty  in  moving  the 
organ,  it  commonly  announces  a  serious  cerebral  lesion. 

The  volume  of  the  tongue  is  changed  by  its  own  diseases ; 
more  rarely  by  the  condition  of  the  sj^stem  at  large,  or  by 
disturbances  of  the  abdominal  viscera.  Yet  a  swollen  or  a 
broad  and  flabby  tongue,  on  the  sides  of  which  the  teeth 
leave  their  marks,  is  sometimes  found  in  chronic  ailments  of 
the  digestive  organs,  and  as  the  result  of  the  action  of  mer- 
cury, and  of  certain  poisons.  It  is  further  observed  in  some 
affections  of  the  brain,  or  as  a  consequence  of  the  disturbed 
circulation  attending  diseases  of  the  heart,  and  in  distempers, 
like  the  plague,  typhus,  or  scurvy,  in  which  the  blood  is 
much  altered. 

Dryness  of  the  tongue  indicates  deficient  secretion.  In 
acute  visceral  inflammations,  and  still  more  frequently  in 
the  exanthemata  and  in  typhoid  fever,  the  tongue  is  dry ;  it 
may  be  so  dry  as  to  cause  the  papillae  to  become  prominent 
and  the  whole  organ  to  appear  roughened.  This  condition 
is  one  which,  in  acute  diseases,  is  always  to  be  dreaded, 
especially  if  the  tongue  be,  in  addition,  of  a  dark  color,  or 
furred  or  fissured ;  for  it  is  then  a  proof  not  only  of  arrested 
secretions,  but  of  depraved  blood  and  of  ebbing  life  force. 
Yet  a  fissured  tongue  is  not,  by  itself,  indicative  of  great  and 
imminent  danger;  it  may  occur  in  chronic  afiections  of  the 
liver,  or  in  chronic  inflammation  of  the  intestines;  and  in 
some  persons  it  is  congenital.  The  opposite  of  dryness,  hu- 
midity,  is,  unless  excessive,  a  favorable  sign.  It  is  extremely 
so,  if  it  succeed  to  dryness,  because  it  is  a  proof  that  the 
secretions  are  being  re-established. 


EXAMINATION    OF    PATIENTS,  ETC.  43 

The  color  of  the  tongue  is  subject  to  many  variations.  It 
is  remarkably  pale  whenever  the  blood  is  watery  and  defi- 
cient in  red  globules.  It  is  exceedingly  red  and  shining  in 
the  exanthemata,  especially  in  scarlet  fever.  The  tongue  is 
also  very  red,  if  inflammation  have  attacked  its  substance,  or 
the  fauces,  or  the  pharynx.  It  is  bluish  and  livid  when  there 
is  an  obstruction  to  the  flow  of  the  venous  blood  or  deficient 
aeration,  as  in  some  structural  diseases  of  the  heart  and  in 
dangerous  cases  of  pneumonia  or  bronchitis. 

Equally  as  important  as  the  color  of  the  organ  are  the  color 
and  form  of  its  coating.  In  health  the  tongue  has  hardly  a 
discernible  lining;  disease  quickly  gives  it  one.  In  inflam- 
mation of  the  respiratory  textures,  at  the  commencement  of 
fevers,  in  disorders  of  large  portions  of  the  abdominal 
raucous  tract,  the  epithelium  accumulates,  and  the  tongue 
has  a  loaded,  whitish  appearance.  The  coat  is  apt  to  be  yel- 
lowish in  disturbances  of  the  liver,  and  of  a  brown  or  very 
dark  hue  when  the  blood  is  contaminated.  But  we  must  be 
sure,  in  drawing  our  inferences,  that  the  abnormal  aspect  be 
not  due  to  the  food  partaken  of  or  to  medicine.  Its  color 
is  also  modified  by  the  character  of  the  occupation.  Thus, 
as  Chambers  tell  us,  there  is  a  curious,  smooth,  orange-tinted 
coating  on  the  tongues  of  tea-tasters.  A  local  cause  some- 
times gives  rise  to  a  thick,  opaque  coat.  For  instance, 
decayed  teeth  may  produce  a  yellow  sheathing  on  one  side. 
Aftections  of  the  fauces  also  occasion  a  deep-yellow  hue. 
Again,  some  persons,  even  in  health,  wake  up  every  morn- 
ing with  their  tongues  covered  at  the  back  with  a  heavy 
coating  which  wears  oft'  during  the  day. 

In  some  diseases  the  epithelium,  which  is  either  formed  in 
excessive  quantities  or  not  thrown  oft",  collects  between  the 
papillffi,  leaving  these  uncovered  and  prominent.  This  is 
especially  noticed  in  scrofulous  children.  When  the  epithe- 
lium is  sticky  and  adherent,  it  winds  itself  chiefly  around 
the  filiform  papillae,  giving  to  the  surface  of  the  organ  a 
furred  appearance.  Although  this  kind  of  tongue,  as  almost 
every  other  variety,  is  met  with  now  and  then  in  persons  who 
are  not  sick,  yet  it  may  generally  be  looked  upon  as  denoting 
serious  trouble.     It  occurs  sometimes  in  chronic  diseases  of 


44  MEDICAL    DIAGNOSIS. 

tlie   abdominal  viscera,  but  much  oftener  in   grave  acute 
maladies. 

To  sum  up,  before  leaving  the  subject,  the  manifestations 
afforded  by  the  tongue  which  are  indicative  of  danger.  They 
are,  tremulous  action;  dryness:  a  livid  color;  a  very  red, 
shining,  or  raw  aspect ;  a  marked  fur,  or  a  heavy  coating  of 
a  dark  or  black  hue.  Any  change  from  these  to  a  more 
natural  look  bears  a  favorable  interpretation ;  so,  too,  when 
the  red,  glazed  tongue  becomes  covered  with  a  distinct  coat. 

The  state  of  the  digestion  and  the  character  of  the  dis- 
charges have  so  close  a  connection  with  the  nutrition  of  the 
body,  that  they  become  important  general  symptoms.  But 
for  sake  of  convenience,  their  value  will  be  inquired  into 
while  discussing  the  diseases  in  the  recognition  of  which 
they  occupy  the  foremost  place.  A  few  words  here,  how- 
ever, on  the  sensations  of  patients. 

Sensations  of  Patients.— Sick  persons  are  subject  to 
many  disagreeable  feelings.  They  complain  of  chills,  of 
heat,  of  languor,  of  restlessness,  and  of  uneasiness;  but  their 
most  constant  complaint  is  of  pain.  Now  jmin  may  be  of 
various  kinds :  it  may  be  dull  or  gnawing ;  it  may  be  acute 
and  lancinating.  In  its  duration  it  may  be  permanent  or 
remittent.  A  dull  pain  is  generally  persistent.  It  is  most 
often  present  in  congestions,  in  subacute  and  chronic  inflam- 
mations, and  where  gradual  changes  of  tissue  are  taking 
place.  It  is  the  pain  of  chronic  rheumatism,  and  shades  off 
into  the  innumerable  aches  of  this  maladv.  The  onlv  acute 
affections  in  which  it  is  apt  to  exist  are  inflammations  of  the 
parenchymatous  viscera  and  of  mucous  membranes. 

Acute  pain  is  in  every  respect  the  reverse  of  dull  pain.  It 
is  usually  remittent,  and  not  so  fixed  to  one  spot.  It  is  met 
with  in  spasmodic  affections,  in  neuralgia,  and,  with  ex- 
tremely sharp  and  lancinating  pangs,  in  malignant  disease. 

Pain  varies  much  in  intensity ;  it  is  sometimes  so  extreme 
as  to  cause  death.  We  have  to  judge  of  its  severity  partly 
on  the  testimony  of  the  sufferer,  partly  by  the  countenance, 
and  partly  by  the  attending  functional  disturbances.  The 
latter  are  not  to  be  overlooked,  for  they  enable  us,  to  some 
extent,  to  appreciate  whether  the  torments  are  as  great  as 
they  are  represented  to  be. 


EXAMINATION    OF    PATIENTS,  ETC. 


45 


The  seat  to  which  the  paiu  is  referred  is  far 
from  being  always  the  seat  of  the  disease.  A 
calculus  in  the  bladder  may  produce  dragging 
sensations  extending  down  the  thighs  ;  inflam- 
mation of  the  hip-joint  gives  rise  to  pain  in  the 
knee  ;  disorders  of  the  liver  occasion  pain  in  the 
right  shoulder.  Pain  felt  at  some  part  remote 
from  that  aflected,  is  either  transmitted  in  the 
course  of  a  nerve  involved,  or  is  sympathetic. 

The  same  abnormal  action  does  not  always 
create  the  same  kind  of  pain.  Inflammation, 
for  instance,  causes  difterent  pain  as  it  involves 
different  structures ;  the  pain  from  an  inflamed 
pleura  is  not  the  same  as  that  from  an  inflamed 
muscle.  Speaking  generally,  the  tissues  them- 
selves seem  to  determine  the  form  of  pain  more 
certainly  than  the  precise  character  of  the  mor- 
bid process  does.  Thus,  pain  in  diseases  of  the 
periosteum  and  bones,  no  matter  what  may  be 
the  exact  nature  of  the  malady,  is  mostly  boring 
and  constant;  in  the  serous  membranes,  sharp; 
in  the  mucous  membranes,  dull;  and  in  the 
skin,  burning  or  itching. 

Pain  produced  by  pressure  is  called  tenderness. 
It  indicates  increased  sensibility,  and  is  most 
constantly  associated  wdth  inflammation.  Yet 
tenderness  may  be  present  without  inflamma- 
tion ;  the  tenderness,  for  example,  of  the  skin  in 
hysteria.  Commonly  it  is  combined  with  pain 
occurring  independently  of  pressure  ;  but  a  part 
may  be  tender  and  not  painful. 

Temperature  of  the  Body. — There  is 
one  more  symptom  having  a  general  sig- 
nificance which  must  be  men- 
tioned, namely,  that  connected 
with  the  function  of  calorification, 
and  based  on  the  determination 
of  the  heat  of  the  body.  To 
measure  this  a  thermometer  is 
necessary;    and  the  thermometry 


Fig.  2. 


so 


Tliermomotcr  for  clinical  purposes. 
Nearly  natural  size. 


46  MEDICAL    DIAGNOSIS. 

of  iliseasc  bus  been  of  late  very  carefully  studied,  and  has 
been  found  to  aflbrd  much  aid  in  the  recognition  of  morbid 
states,  particularly  of  febrile  conditions,  and  of  aflections 
attended  with  marked  tissue  changes. 

The  thermometer  used  for  clinical  purposes  should  be  very 
sensitive.     A  convenient  form  is  to  have  it  curved,  and  with 
an  elongated  bulb.     The  scale,  extending  from  about  75° 
Fahr.  to  115°,  ought  to  be  very  correctly  and  uniformly  grad- 
uated.    For  minute  investigations  it  should  be  divided  so  as 
to  exhibit  fifths  or  tenths  of  a  degree ;  but  for  ordinary  pur- 
poses one  registering  half  of  a  degree  is  sufficiently  accurate. 
It  is  a  matter  of  some  dispute  as  to  which  is  the  most  ap- 
propriate part  to  place  the  thermometer.     To  put  it  under 
the  tongue  or  in  the  rectum  has  heen  strongly  recommended. 
But  the"  most  suitable  site  seems  to  be  the  axilla.     The  bulb 
is  pressed  into  the  armpit  and  kept  in  close  contact  with  the 
skin  for  from  three  to  five  minutes,*  and  the  degrees  marked 
are  read  off  while  the  tbermometer  is  still  in  position.     The 
instrument  may  be  conveniently  introduced  just  below  the 
skin  covering  the  edge  of  the  pectoralis  major  muscle ;  and 
to  insure  exactness,  the  patient  should  be  kept  in  bed  for  at 
least  one  hour  before  the  examination,  and  the  axilla  be  w^ell 
covered.    The  best  posture  is  found  to  be  neither  completely 
on  the  back  nor  side,  but  diagonally  on  the  right  or  left  side.f 
In  all  cases  of  any  importance,  not  less  than  two  observations 
should  be  made  daily,  and  every  day  at  tbe  same  hour.     Be- 
tween seven  and  nine  o'clock  in  the  morning,  and  about  seven 
o'clock,  or  somewhat  earlier,  in  the  evening,  are  regarded 
as  the  most  appropriate  periods.     If  only  a  single  observa- 
tion be  taken,  it  is  best  done  in  the  afternoon  or  evening. 
Before  fitting  the  thermometer  into   the  armpit,  it  should 
be  warmed  in  the  hand  or  slightly  heated  in  water;  and  in 
every  record  of  the  temperature,  the  pulse  and  the  respira- 
tions must  be  also  noted. 

*  Yet,  even  after  this,  the  thermometer  may  go  on  rising.  Indeed,  the  vari- 
ations may  extend  over  an  hour.  (See  the  observations  of  Goodhavt  in  Guy's 
Hospital  Reports,  vol.  xv.)  I  think,  however,  that  for  practical  purposes 
the  statement  in  the  text  is  correct. 

f  Kinger  on  the  Temperature  of  the  Body.     London,  1865. 


EXAMINATION    OF    PATIENTS,  ETC.  47 

The  average  lieat  of  the  bod}-  in  temperate  climes  is 
estimated  by  Wunderlich  as  37°  centigrade  in  the  axilla ; 
that  of  freshly  voided  urine  is  about  the  same.*  Expressed 
in  the  scale  used  in  this  country  and  in  England,  it  may  be 
stated  that  the  average  heat  of  sheltered  and  internal  parts 
of  the  body  is  98'Q°  Fahr.f  It  rises  with  the  temperature 
of  the  air,  and  fluctuates  during  the  day,  being  in  temperate 
climates  greatest  early  in  the  morning.  It  is  heightened  by 
exercise,  and  reduced  by  sustained  mental  exertion,  and 
changes  even  when  we  are  at  rest.^  But  no  cause,  as  a  rule, 
except  disease  induces  a  variation  of  much  more  than  1° ;  and 
even  in  the  extreme  heat  of  tropical  climates,  the  animal 
heat  does  not  surpass  99*5°.  Thus  a  temperature  above  this, 
or  more  than  a  degree  below  the  average  stated,  when  per- 
sistent, indicates  some  morbid  action  in  the  economy.  At 
all  events,  it  does  so  in  adults;  in  very  aged  persons,  a  tem- 
perature of  97°  may  still  be  normal ;  and  we  must  bear  in 
mind  that  in  children  the  daily  range  is  much  greater  than 
in  adults.  There  may  be  a  fall  in  the  evening  amounting  to 
between  2°  and  3°  Fahr.§  A  further  point,  too,  to  be  taken 
into  account  in  those  of  all  ages  is,  that  the  temperature  is 
influenced  by  food  and  stimulants.  And  these  are  elements 
apt  to  be  overlooked,  and  which  make  deductions  from 
single  observations  or  comparatively  slight  changes  untrust- 
worthy. 

In  ordinary  cases  tbe  pulse  and  temperature  rise  synchro- 
nously, and  every  degree  above  98°  Fahr.  corresponds  with 
an  increase  of  ten  beats  of  the  pulse.  The  fever  temper- 
ature ranges  from  100°  to  106°.     When  it  exceeds  this,  the 

*  Die  Eigenwiirme  in  Krankheiten.     1868. 

f  It  may  be  useful,  for  the  sake  of  comparing  the  results  of  observers  in 
diiferent  countries,  to  recall  the  fact  that  one  degree  of  Fahrenheit  is  equal 
to  |th  of  a  degree  of  the  centigrade  thermometer,  and  ^th  of  a  degree  of 
Eeaumur ;  and  also  that  the  freezing  point  of  the  first  is  placed  at  32°; 
that  of  the  others  at  zero.  To  convert  centigrade  into  Fahrenheit,  we  mul- 
tiply by  9  and  divide  by  5;  to  convert  Eeaumur,  we  multiply  by  9  and  divide 
by  4,  and  when  above  zero,  in  either  case,  add  32. 

X  See  an  instructive  paper  by  Garrod,  on  the  Minor  Fluctuations  of  the 
Temperature  of  the  Human  Body,  Proceedings  of  Koyal  Society,  May,  1869. 

§  Finlayson,  Glasgow  Med.  Journal,  Feb.  1869. 


48  MEDICAL    DIAGNOSIS. 

patient  may  be  looked  iiiton  as  in  clanger,  except  the  rise  be 
due  to  malarial  fever.  Under  these  circumstances  it  is  rapid, 
occurring  in  a  person  who  but  yesterday  was  healthy.  In 
typhoid  fever,  the  thermometer  during  the  earlier  stages 
docs  not  rise  to  more  than  103-5°  Fahr.  in  the  evening,  and 
is  lower  in  the  morning;  at  any  period  of  its  course,  a  tem- 
perature of  105°  is  a  proof  of  a  grave  disease.  A  temperature 
of  101°  to  103°  shows  a  mild  attack.  In  severe  cases  of 
yellow  fever,  the  heat  in  the  armpit  has  been  noted  as  108°.* 
In  pneumonia,  a  temperature  above  104°  Fahr.  is  stated  to 
be  a  symptom  of  a  very  serious  seizure;  so,  too,  is  it  in  acute 
rheumatism  a  symptom  either  of  danger  or  of  some  com- 
plication. "  Stability  of  temperature,"  says  Aitken,t  "from 
morning  to  evening,  is  a  good  sign;  on  the  other  hand,  if 
the  temperature  remains  stable  from  evening  till  the  morn- 
ing, it  is  a  sign  that  the  patient  is  getting  or  will  get  worse." 
In  convalescence  the  temperature  declines  until  it  attains 
its  norm,  or  even  falls  somewhat  below  this.  If  the  ther- 
mometer again  indicate  a  decided  rise,  it  shows  a  return  of 
the  malady,  or  the  supervention  of  some  complication  or 
new  disorder;  and  the  persistence  of  even  a  slight  degree 
of  abnormal  heat  after  apparent  convalescence,  is  a  sign  of 
imperfect  recovery,  or  of  the  existence  of  some  lingering 
secondary  complaint.  Further,  in  cases  of  low  fevers,  the 
skin,  particularly  of  the  hands  and  feet,  may  feel  cool,  while 
the  instrument  in  the  axilla  marks  104°. 

Specific  forms  of  febrile  diseases  have  their  character- 
istic variations  of  temperature.  In  measles,  for  instance, 
the  temperature  rises  toward  the  breaking  out  of  the  rash, 
reaches  its  height  with  the  period  of  eruption,  and  in  the 
twenty-four  hours  succeeding  it  falls  rapidly.  If  it  remain 
elevated,  104°  to  105°,  particularly  after  the  rash  has  faded, 
it  is  due  to  the  presence  of  some  complication.  In  scarlet 
fever  the  thermometer  marks  105°  or  106°,  or  upwards,  until 
about  the  third  day.  From  the  third  to  the  ninth  day  it 
ranges  from  a  fraction  below  104°  to  somewhat  under  103°, 
and  then  gradually  subsides. 


*  Wragg,  Charl.  Med.  Journ.,  vol.  x. 
t  Science  and  Practice  of  Medicine. 


EXAMINATION    OF    PATIENTS,  ETC.  49 

111  other  than  febrile  states,  too,  the  thermometer  may 
assist  materially  in  diagnosis  and  prognosis.  Thus  it  en- 
ables us  to  judge  between  increased  frequency  of  pulse  due 
to  fever  and  to  debility;  it  indicates  that  sweating  which  is 
not  preceded  by  a  previous  elevation  of  temperature,  and 
caused  by  it,  is  the  result  and  not  the  source  of  exhaustion ; 
and  according  to  recent  observations,  there  is  probably  a 
continuous  rise  of  the  heat  of  the  body  in  all  cases  in  which 
a  deposition  of  tubercle  is  taking  place  in  any  of  its  organs, 
and  more  especially  in  the  lungs;  while,  on  the  other  hand, 
I  have  noticed  that  in  cancerous  aiiections  the  heat  of  the 
body  is  but  little  influenced,  and  is  sometimes  even  below 
the  normal  standard. 

Such  are  some  of  the  main  facts  connected  with  the  ther- 
mometry of  disease,  and  in  the  course  of  this  volume  there 
will  often  be  occasion  to  refer  to  others.  But  even  those 
here  mentioned  are  sufficient  to  show  that  the  accurate 
study  of  the  temperature  may  be  of  much  service  in  the 
recognition  of  a  malady  and  in  foretelling  its  issue.  But  to 
make  it  so  we  must  look  to  connected  observations,  and  par- 
ticularly must  we  avoid  laying  too  much  stress  on  fluctua- 
tions comparatively  slight,  and  which  may  be  due  to  other 
causes  than  to  disease. 


CHAPTER  II. 

DISEASES  OF  THE    BRAIN,  SPINAL  CORD,  AND  THEIR  NERVES. 

The  study  of  the  disorders  of  the  brain,  and,  in  truth,  of 
those  of  the  entire  nervous  system,  is  very  difficult.  Nor, 
owing  to  our  deficient  knowledge  of  the  physiology  of  these 
vital  parts,  and  to  our  inability  to  appreciate  the  minute 
structural  changes  of  nerve  tissue,  does  it  yield  as  precise 
and  accurate  results  as  the  importance  of  the  subject  renders 
desirable,  and  as  our  improved  means  of  research  have  at- 
tained in  affections  of  most  other  portions  of  the  economy. 
Yet  considerable  advance  has  been  made  of  late  years  in 
untangling  many  knotty  problems;  and  at  least  the  more 
tangible  evidences  of  nervous  disease  are  much  more  clearly 
recoo-nized.  It  is  these  with  which  this  sketch  is  intended 
to  deal. 

But  first,  of  a  few  symptoms  and  morbid  states  having  a 
general  significance  rather  than  a  specific  connection  with 
any  malady. 

DERANGED    INTELLECTION. 

The  great  instrument  of  the  intelligence,  the  brain,  mani- 
fests its  ailings,  whether  primary  or  merely  sympathetic,  by 
derangement  of  thought  of  every  conceivable  degree  and 
kind — from  dulness  and  confusion  of  the  intellect  to  its 
utter  perversion  and  absolute  prostration.  When  one  intel- 
lectual function  is  disturbed,  generally  all  are,  or  soon  become 
so;  yet  we  may  find  impairment  of  judgment  and  of  imagi- 
nation without  deterioration  of  memory  or  of  the  powers  of 
attention.  One  of  the  most  marked  signs  of  mental  infirmity 
is  a  disordered  memor}'.  This  is  especially  encountered  in 
chronic  cerebral  diseases,  or  in  such  nervous  affections  of 
uncertain  seat  as  epilepsv.  Another  signal  of  mental  de- 
(50) 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  51 

rangement  is  loss  of  jiulgraent,  or  rather  loss  of  power  to 
appreciate  the  logical  sequence  of  ideas ;  yet  another  is  de- 
pression of  mind,  or  its  opposite,  exaltation.  All  these  ab- 
normal conditions  may  happen  in  acute  as  well  as  in  chronic 
maladies,  but  they  are  more  striking  and  become  of  more 
aid  in  the  diagnosis  of  the  latter  than  of  the  former;  and 
they  may  or  may  not  be  joined  to  appreciable  textural 
changes.  To  the  psychologist  their  significance  is  very 
great,  as  they  are  often  the  only  premonitory  symptoms  of 
that  departure  from  mental  health  which  terminates  in  con- 
firmed insanity. 

In  acute  disturbances  of  the  brain,  whether  functional  or 
organic,  we  meet  with  these  striking  phenomena  connected 
with  disordered  intellection :  delirium,  stupor,  coma,  in- 
somnia. 

Delirium. — This  is  a  wandering  of  the  mind,  manifesting 
itself  by  the  expression  of  ill-associated  thoughts,  of  the  in- 
congruity of  which  the  patient  is  not  conscious.  It  most 
frequently  occurs  in  those  of  susceptible  nervous  system, 
and  is,  in  consequence,  more  common  in  the  young  than  in 
the  old.  It  is  almost  invariably  united  with  restlessness, 
and  rises  as  night  approaches. 

The  character  of  the  delirium  is  very  various.  There  is 
first  the  quiet  delirium,  of  a  low  or  passive  type.  The  patient 
mutters  incoherent  words,  moans  without  any  assignable 
reason,  or  lies  silent,  with  his  eyes  open,  his  thoughts  pre- 
occupied with  his  vague  illusions.  If  strongly  aroused,  he 
gives  a  rational  answer,  but  not  a  long  or  a  connected  one, 
for  he  soon  returns  to  his  dreams  and  his  ever-changing  hal- 
lucinations. He  picks  at  his  bedclothes,  moves  in  bed,  and 
may  even  occasionally  try  to  leave  it,  although  he  is  very 
easily  prevented  from  so  doing. 

Then  there  is  a  delirium  of  somewhat  more  active  type, 
but  still,  on  the  whole,  quiet;  the  patient  wanders,  yet  not 
boisterously.  He  is  irritable,  and  often  does  not  show  that 
his  mind  is  disturbed,  excepting  in  some  one  particular:  in 
irascibility  about  trifles,  or  in  expressions  and  modes  of 
thought  quite  foreign  to  his  nature. 

An  active,  j^erce  delirium  presents  diflferent  characteristics. 


52  MEDICAL   DIAGNOSIS. 

The  patuiit  is  wild,  noisy;  he  sings,  screams,  gets  out  of  bed ; 
his  t;u-o  during  the  excitement  becomes  congested;  the  eye  is 
bright,  often  liery. 

Now  all  these  forms  of  delirium  occur  in  many  different 
maladies,  and  are  very  far  from  being  of  necessity  linked  to 
an  organic  cerebral  affection.  Nay,  not  even  the  most  vio- 
lent kind  of  mental  wandering  is  positively  indicative  of  a 
lesion  of  the  brain  ;  at  least,  not  of  such  a  lesion  as  can  be 
determined  by  the  aid  of  the  scalpel,  or  indeed  by  any  of 
our  present  means  of  investigation.  As  a  rule,  we  find  the 
low,  quiet  delirium  in  conditions  of  vital  exhaustion,  particu- 
larly in  those  depressed  states  of  the  nervous  system  whicb 
are  connected  with  quickened  vascular  action,  and  with  a 
deterioration  of  the  blood,  as,  for  instance,  in  the  low  fevers. 
The  tierce  delirium  may,  however,  be  associated  wdth  pros- 
tration or  depraved  blood.  Thus  the  delirium  of  pneumonia 
is  sometimes  of  a  violent  kind,  owing  to  the  maddening 
effect  of  the  ill-oxygenated  vital  fluid  on  the  brain.  In  most 
of  the  ordinary  fevers  the  delirium  is  of  a  moderate  type;  in 
inflammatory  diseases  of  the  brain  and  in  acute  mania  it  is 
tierce. 

Delirium  is  not  difficult  of  recognition  :  yet  we  must  be 
very  careful  not  to  confound  with  it  the  troubled  dreams  to 
which  ailing  children  are  so  liable,  and  which  occasion  con- 
fusion of  thought  on  tirst  awaking  and  until  consciousness 
is  fully  aroused.  Delirium  is  most  likely  to  be  mistaken  for 
insanity.  There  is,  however,  this  palpable  difference:  an 
insane  person  is  commonly  in  good  health  in  all  save  his 
intellect ;  a  delirious  person  is  sick,  and  exhibits  other  evi- 
dences of  his  sickness  in  much  besides  his  delirium.  It  is 
true  that,  when  the  patient  is  tirst  seen,  doubt  may  arise; 
but  it  is  not  generally  of  long  duration.  The  most  perplex- 
ing cases  are  those  in  which  insanity  follows  or  attends  in- 
ordinate drinking.  But  this  is  a  subject  we  shall  discuss  in 
reviewing  the  clinical  phenomena  of  mania  a  potu. 

Another  perplexing  group  of  cases  is  furnished  by  the  oc- 
currence of  that  singular  form  of  delirium  which  is  met  with 
at  times  in  acute  diseases,  especially  in  fevers,  and  which,  as 
it  is  apt  to  be  associated  with  insufficient  nutrition,  has  been 


DISEASES    OF   THE   BRAIN,  SPINAL    CORD,  ETC.  53 

called  the  delirium  of  inanition,  or  of  collapse.*  Its  outbreak 
is  sudden,  like  an  attack  of  mania,  but  it  is  found  to  be  com- 
bined with  a  feeble  pulse,  a  skin  bathed  in  perspiration,  cold 
hands  and  feet, — in  one  word,  with  the  signs  of  great  pros- 
tration or  of  collapse.  The  seizure  happens  usually  early 
in  the  morning,  and  is  quite  unexpected,  for  it  occurs  very 
commonly  at  the  end  of  the  febrile  state,  and  when  the  con- 
dition of  the  skin  and  pulse  bespeaks  convalescence.  The 
exhausted  nervous  centre  betrays  itself  in  the  sudden  men- 
tal wandering,  which  has  generally  this  characteristic,  that 
there  is  but  one  fixed  delusion,  and  this  ordinarily  one  con- 
nected with  the  subjects  which  have  most  engrossed  the  mind 
before  the  illness.  The  seizure  lasts  from  six  to  forty-eight 
hours,  and  at  its  termination  the  patient  is  apt  to  awake  out  of 
a  sleep  with  a  calm  mind,  remembering,  perhaps,  his  hallu- 
cination as  a  vivid  dream.  There  may  be  more  than  one 
attack,  but  this  is  not  common ;  and  the  duration  is  mate- 
rially abridged  by  opium  and  the  employment  of  stimulants 
and  nourishment.  The  form  of  delirium  under  considera- 
tion has  been  spoken  of  as  linked  to,  or  rather  as  a  sequel 
of,  febrile  conditions.  But  it  may  also  succeed  exhausting- 
discharges  and  drains  from  the  system,  or  inability  to  obtain 
the  proper  amount  of  food  or  to  digest  it.  Thus  it  may 
happen  in  malignant  diseases  of  the  stomach  ;  also  in  mere 
gastric  irritability  and  persistent  vomiting.  The  most  marked 
instance  of  this  kind  of  mental  wandering  I  have  encountered 
was  associated  with  functional  gastric  disorder,  which  pre- 
vented enough  food  from  being  retained.  In  this  patient  the 
hallucination  was  on  one  subject — a  business  matter  which 
had  been  annoying  him  greatly  just  before  his  illness  assumed 
a  decided  character. 

Delirium  is  sometimes  simulated.  I  saw  not  very  long 
since  an  instance  of  the  kind.  It  differed  from  real  delirium 
by  the  absence  of  all  other  signs  of  sickness,  and  by  the 
sameness  of  the  mental  wanderino^.  The  man  whined  when 
spoken  to,  and  pretended  to  rave;  but  his  ideas  always  ran 


*  See  "Weber,  Medico-Chirurg.  Transact.,  1865;  Becquet,  Archiv.  Gener. 
de  Medecine,  1866 ;  also  the  Clinical  Lectures  of  Chomel  and  of  Trousseau. 


54  MEDICAL    DIAGNOSIS. 

on  the  same  subject,  aiul  he  was  very  solicitous  about  his 
food,  ami  about  other  matters  of  which  a  delirious  person 
takes  uo  notice,  and  for  which  he  cares  nothing.  Delirium 
is  more  or  less  continuous;  once  delirious,  a  patient  remains 
so  for  some  time,  and  until  the  exciting  cause  subsides.  In 
this  respect  hysterical  delirium  is  exceptional  ;  it  does  not 
last  long,  or  it  intermits  aud  then  reappears. 

Stupor.— A  blunted  state  of  mind,  a  partial  drowsy  un- 
consciousness, constitutes  the  phenomenon  called  stupor. 
The  patient  lies  in  a  deep  slumber,  from  which  he  cannot 
be  roused  save  with  great  difficulty,  and  when  roused  he 
answers  reluctantly  and  briefly,  and  soon  resumes  his  heavy 
sleep.  The  expression  of  his  face  is  dull,  yet  now  and  then 
a  ray  of  intelligence,  excited  by  some  object  which  attracts 
his  attention  or  by  some  pleasant  reverie,  flits  across  his 
features. 

Stupor  is  met  with  in  several  cerebral  affections,  and 
seems  to  be  chiefly  owing  to  a  congestion  of  the  brain.  It 
is  frequently  seen  in  typhoid  fever,  immediately  after  an  epi- 
leptic fit,  or  as  the  result  of  narcotic  poisons;  and  is,  in  these 
states,  also  probably  due  to  cerebral  congestion.  But  there 
is  nothing  pathognomonic  about  it  in  these  various  condi- 
tions, nothing  by  which  we  can  judge  positively  of  its  origin. 

Coma. — Coma  is  complete  loss  of  consciousness:  percep- 
tion and  volition  are  alike  suspended,  and  there  is  an  appear- 
ance of  the  profoundest  sleep.  The  face  wears  a  confused 
look;  the  pupils  are  sluggish,  often  dilated.  Sensation  may 
be  blunted,  but  is  not  destroyed;  neither  is  motion,  for  the 
patient  moves  when  his  skin  is  pinched  or  tickled.  Coma  is 
always  of  grave  augury :  it  betokens  a  very  serious  disturb- 
ance of  the  functions  of  the  brain. 

The  most  thorough  coma  is  seen  in  apoplexy ;  it  comes  on 
very  quickly,  and  is  attended  with  a  noisy  respiration  and  a 
slow  pulse.  Another  form  of  coma,  scarcely  less  complete, 
is  caused  by  narcotic  poisoning;  it,  however,  does  not  appear 
suddenly,  and  when  from  opium  is  associated  with  contrac- 
tion of  the  pupils.  The  coma  of  fevers  and  of  acute  diseases, 
whether  cerebral  or  not,  is  also  gradually  produced,  but,  un- 
like that  due  to  the  toxical  effect  of  opium,  is  ordinarily  pre- 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  55 

ceded  for  days  by  insomnia,  by  delirium,  and  by  other  signs 
of  cerebral  disturbance.  The  coma  of  epilepsy  is  recognized 
by  its  following  epileptic  seizures.  In  Bright's  disease, 
among  the  nervous  phenomena  of  which  coma  as  well  as 
stupor  and  delirium  may  happen,  the  loss  of  consciousness 
is  apt  to  occur  subsequently  to  either  of  the  two  other  mor- 
bid phenomena,  and  its  cause  is  made  evident,  as  is  further 
on  more  particularly  explained,  by  the  coexistence  of  albu- 
men and  tube-casts  in  the  urine. 

Sometimes  a  person  may  appear  to  be  comatose  when  his 
intellect  is  reall}^  but  little  disordered.  He  may  be  paralyzed, 
and  not  have  the  power  to  communicate  his  ideas.  This 
state  is  distinguished  from  coma  by  noting  that  the  patient's 
attention  is  always  directed  to  the  questions  asked  him,  nay, 
that  he  strives  to  answer  them,  but  cannot;  and  that  he  has 
lost  all  control  over  the  muscular  movements  of  one  or  of 
both  sides  of  the  body. 

Insomnia. — The  deprivation  of  sleep  is  a  frequent  con- 
comitant of  cerebral  congestion  and  of  the  earlier  stages  of 
cerebral  inflammation.  But  a  person  may  be  sleepless  from 
excessive  pain,  from  exhaustion,  from  grief,  or  from  mental 
excitement  or  fatigue;  and  sometimes  insomnia  is  engen- 
dered by  habitual  working  late  at  night.  However,  in  sev- 
eral of  these  states  congestion,  though  of  a  passive  character, 
is,  in  all  likelihood,  the  immediate  cause  of  the  wakefulness. 

Insomnia  often  precedes  or  attends  delirium,  as  appears  in 
typhoid  fever.  Among  purely  nervous  affections  it  is  most 
marked  in  delirium  tremens.  It  is  a  very  troublesome  symp- 
tom; but,  occurring  in  so  many  abnormal  conditions,  it  can- 
not be  looked  upon  as  having  a  distinct  and  specific  diag- 
nostic value. 

DERANGED    SENSATION. 

The  signs  of  perverted  or  impaired  sensation  are  very 
numerous.  They  may  be  either  those  due  to  an  alteration 
of  the  general  sensibility,  or  be  the  signals  of  a  derange- 
ment of  a  nerve  of  special  sense.  Let  us  look  at  a  few  in 
detail. 


oG  MEDICAL    DIAGNOSIS. 

Hypersesthesia.— An  exalted  irritability  of  the  sensitive 
snrfave  norvos — of  those  of  the  skin,  the  mucous  membranes, 
or  even  of  those  of  deeper  seated  structures — in  other  words, 
a  hyperesthesia  of  these  parts,  is  a  symptom  of  much  diagnos- 
tic importance;  not  so  much,  perhaps,  on  account  of  the  light 
tlirown  on  any  particular  disease  by  the  increased  sensibility, 
as  because  its  presence  makes  it  requisite  to  determine  its 
origin  and  to  separate  its  phenomena  from  those  of  inflam- 
mation. And  in  truth  the  distinct  acknowledgment  that 
acute  sensibility  is  not  of  necessity  inflammatory,  is  one  of 
the  triumphs  of  modern  pathology.  How  many  cases,  for 
example,  of  abdominal  tenderness,  which  would  formerly 
have  been  supposed  to  be  indicative  of  peritoneal  inflamma- 
tion, are  now  known  to  be  merely  instances  of  hyperses- 
thesia! We  may,  as  a  rule,  distinguish  the  peripheral  sensi- 
bility from  the  tenderness  of  subjacent  inflammation,  by  its 
extension  over  a  larger  surface;  by  deep  pressure  producing 
no  more  pain  than  a  very  light  touch;  by  the  absence  of  signs 
of  functional  disturbance  of  the  part  apparently  involved  in 
inflammatory  disease ;  by  the  uniformity  of  the  symptoms, 
no  matter  hoAv  long  the  duration  of  the  disorder;  and  by  the 
sensitiveness  exhibiting  distinct  intermissions  and  exacerba- 
tions. 

But  in  what  affections  do  we  encounter  hypersesthesia  ?  ,  Is 
it  only  in  those  of  the  brain  or  spinal  cord?  By  no  means; 
indeed  we  may  say  that,  in  organic  diseases  of  these  structures, 
such  at  least  as  we  can  detect,  it  is  not  common,  and  rarely 
reaches  a  high  degree  of  development,  with  the  exception  of 
tumors  pressing  upon  the  pons  varolii  and  corpora  quadrige- 
mina,  and  of  alteration  of  the  posterior  columns  of  the  cord, 
or  in  some  cases  of  meningitis,  or  in  injuries  dividing  trans- 
versely and  completely  a  lateral  half  of  the  spinal  cord.  By 
far  the  most  usual  causes  of  hypersesthesia  are  impoverished 
blood  and  that  mysterious  malady  called  hysteria.  Sometimes 
it  is  produced  by  rheumatism  or  gout,  or  by  disturbance  of  the 
function  of  the  kidney.  It  is  further  met  with  in  hydrophobia ; 
in  inflammations  in  internal  cavities  involving  the  ganglia  of 
the  great  sympathetic :  after  the  use  of  ergot  and  of  opium ; 
and  in  some  of  the  diseases  of  the  skin.     It  also  attends 


DISEASES  OF  THE  BRAIN,  SPINAL  CORD,  ETC.        57 

paroxysms  of  neuralgia,  as  witnessed  in  the  exquisite  sensi- 
tiveness of  the  skin  during  an  attack  of  tic  douloureux ;  the 
painful  spots,  too,  in  the  course  of  local  neuralgias,  are 
thought  to  be  hypereesthetical. 

The  exaltation  of  sensation  may  disclose  itself  in  other 
signs  besides  pain  and  tenderness;  in  a  general  irritability 
of  the  surface,  in  itching,  and  in  unnatural  feelings  of  various 
kinds.  Its  seat  is  ordinarily  the  skin,  and  commonly  the 
cutaneous  nerves  near  the  point  of  irritation  which  causes 
the  heightened  sensibility. 

Hyperfesthesia  may  atiect  the  nerves  of  the  special  senses, 
manifesting  itself,  for  instance,  by  intolerance  of  light,  or  of 
sound.  But  this  variety  of  hyperissthesia  need  here  be  but 
alluded  to,  as  we  shall  presently  look  more  fully  at  the  signs 
of  disturbance  of  these  nerves. 

Of  the  minute  anatomical  changes  in  hyper?esthesia  we 
know  nothing;  our  present  means  of  research  are  insuffi- 
cient for  investigations  of  this  character.  Physiologically 
speaking,  the  phenomenon  belongs,  for  the  most  part,  to  the 
reflex  order — a  term  under  which  we  conveniently  hide  much 
ignorance. 

Anaesthesia. — Loss  of  sensation,  or  anaesthesia,  is  of 
various  degrees.  It  may  be  complete  or  partial:  a  perfect 
absence  of  sensibility  or  its  mere  benumbing.  Not  to  speak 
of  its  meaning  when  displaying  itself  only  in  the  organs  of 
the  special  senses,  we  find  it  in  diseases  of  the  brain ;  in 
several  of  the  neuroses ;  after  the  use  of  large  doses  of  In- 
dian hemp,  of  lead,  of  arsenic:  we  see  it  accompanying  or 
preceding  cutaneous  eruptions,  such  as  elephantiasis  or  pem- 
phigus; and  as  the  result  of  abnormal  conditions  of  the  blood. 
In  the  mucous  membranes,  too,  it  may  exist,  either  in  con- 
sequence of  the  general  causes  just  mentioned,  or  of  some 
purely  local  irritation.  But  it  does  not  attack  these  struc- 
tures nearly  as  often  as  it  does  the  skin ;  indeed  this  is  so 
well  understood  that,  when  we  speak  of  anoesthcsia  without 
qualifying  it,  we  mean  that  of  the  cutaneous  nerves.  In  the 
parts  affected  with  ansesthesia  the  nutrition  is  less  active, 
and  there  is  a  feeling  of  numbness.  The  temperature  is  di- 
minished, and,  if  the  impaired  sensibility  be  at  all  general. 


58  MEDICAL    DIAGNOSIS. 

the  patient  is  not  susceptible  to  alternations  of  heat  and  cold. 
Frequenth'the  circulation  in  the  skin  is  retarded,  occasioning 
a  perceptible  lividity  and  discoloration  of  the  surface. 

Loss  of  sensation  has  a  much  more  constant  connection 
with  orsfanic  affections  of  the  nervous  centres  than  increased 
sensibility.  It  may  precede  acute  attacks  of  cerebral  dis- 
ease, and  indeed  sometimes  exists  for  years  before  any  marked 
cerebral  symptoms  are  perceived.  Thus,  a  case  of  apoplexy 
was  observed  by  Andral*  in  which  deficient  sensation  was 
noticed  at  various  portions  of  the  thorax  for  a  long  time  pre- 
vious to  the  loss  of  consciousness;  another  in  which  the  tips 
of  the  fingers  were  benumbed,  and  felt  continually  as  if  they 
had  been  subjected  to  intense  cold.  Forbes  Winslowf  men- 
tions instances  in  which  circumscribed  conditions  of  impaired 
sensation  were  the  premonitory  symptoms  of  softening  of  the 
brain ;  the  defective  feeling  being  manifested  in  some  cases 
in  the  skin,  in  others  in  the  tongue  and  fauces.  In  the  in- 
sane, especially  in  monomaniacs,  anaesthesia  is  very  common, 
and  ordinarily  very  extended ;  so,  too,  in  general  paral3'sis. 
Indeed,  with  few  exceptions,  an  extended  anaesthesia  points  to 
an  affection  of  the  nervous  centres.  Loss  of  sensation  from 
this  source  has,  moreover,  the  significant  feature  of  being 
associated  with  motor  disturbances. 

If  the  defective  sensibility  be  owing  to  a  spinal  malady,  it 
is  generally  found  in  the  lower  extremities,  and  coexists  with 
paralysis;  for  anaesthesia  without  paralysis  of  motion  is  not 
met  with  in  the  ordinary  diseases  of  the  spinal  cord.  Im- 
paired sensibility  of  spinal  origin  is  usually  indicative  of  the 
gray  matter  of  the  cord  having  been  disturbed  or  altered ;  in 
the  aflfection  known  as  sclerosis  of  the  cord  the  sensation  is 
retarded  rather  than  lost.| 

Anaesthesia  is  sometimes  the  result  of  reflex  action.  It 
may  thus  arise  in  disorders  of  any  of  the  viscera,  and  from 
an  irritation  of  any  sensitive  nerve.  It  has,  for  instance,  been 
observed  in  both  lower  limbs  in  sciatica.  § 


*  Clinique  Medicale,  tome  v.       f  Obscure  Diseases  of  the  Brain,  page  549. 
X  Vulpian,  Arch,  de  Phys.,  i.  No.  3. 

I  For  some  striking  observations  on  this  subject,  the  reader  is  referred  to 
the  tenth  lecture  of  Brown-Sequard's  work  on  the  Central  Nervous  System. 


DISEASES    OF    THE    BKAIN,  SPINAL    CORD,  ETC. 


59 


A  localized  and  curious  form  of  anfestliesia  happens  now 
and  then  in  consequence  of  an  affection  of  the  fifth  nerve. 
Tlie  extent  of  loss  of  sensation  depends  very  much  upon  the 
part  of  the  nerve  at  wliich  the  cause  of  disturbance  is  seated. 
The  skin  of  the  nose  and  cheek  may  become  devoid  of  sen- 
sation ;  the  reflex  movements  of  the  muscles  of  the  face  may 
cease;  the  conjunctiva,  or  the  whole  surface  of  the  eye,  or 
one-half  of  the  tongue  be  deprived  of  sensibility.  Only  one, 
or  all  of  these  phenomena  may  be  conjointly  encountered, 
according  as  part  of  one,  or  one,  or  all  of  the  branches  of  the 
fifth  nerve  are  aflected.  Sometimes,  as  Romberg  proves, 
trigeminal  anesthesia  is  of  rheumatic  origin.  When  it  is  com- 
plicated with  disturbed  functions  of  adjoining  cerebral  nerves, 
it  may  be  assumed,  says  the  same  distinguished  observer, 
that  tlie  cause  is  seated  at  the  base  of  the  brain. 

In  endeavoring  to  form  a  correct  opinion  of  the  complete- 


FiG.  3. 


Tll(_'   a■.■^tlH■si<llllrt('l■. 


ness  of  antesthesia,  it  will  not  do  to  trust  entirely  to  the 
patient's  statements.  We  must  resort  to  means  by  which 
we  can  make  accurate  comparisons;  and  one  of  the  best  is 
to  pursue  the  method  used  by  Weber  in  his  researches  on 
the  tactile  properties  of  the  skin.  It  consists  in  determining 
how  closely  the  points  of  a  pair  of  compasses  sheathed  with 
cork  may  be  approximated  on  the  skin,  and  yet  be  felt  as 
two  distinct  points.  An  instrument  for  the  same  purpose, 
called  the  "  sestliesiometer,"  was  invented  by  Dr.  Sieveking, 
and  can  be  applied  in  paralysis  to  ascertain  the  amount  and 
extent  of  sensational  impairment,  as  a  means  of  diagnosis 


60  MEDICAL    DIAGNOSIS. 

between  actual  paralysis  of  sensation  and  mere  subjective 
anaesthesia  in  which  the  tactile  powers  are  unaltered,  and  as 
affording  us  assistance  in  determining  the  progress  of  a 
case  of  pals}^  for  better  or  for  worse.  A  similar  instrument, 
though  differing  in  having  a  larger  handle,  is  used  by  Brown- 
Sequard;*  and  yet  another,  combining  the  principle  of  the 
beam  compass  with  that  of  the  mathematical  one,  has  been 
contrived  by  Dr.  Ogle.f 

To  understand,  however,  any  results  obtained  regarding 
the  tactile  sense,  it  is  absolutely  necessary  that  we  should  be 
aware  how  this  differs  in  some  parts  of  the  body.  Most 
works  on  physiology  contain  an  account  of  the  researches 
of  Weber  and  of  those  who  have  prosecuted  the  inquiry  he 
started.;}:  It  would  therefore  be  useless  to  quote  them  here 
at  any  length,  yet  a  few  of  the  conclusions  arrived  at  may  be 
advantageously  mentioned.  At  the  tip  of  the  tongue  two 
points  can  be  readily  distinguished  when  only  separate  from 
each  other  about  the  Jj  of  an  inch,  or  half  a  Paris  line;  at 
the  palmar  surface  of  the  third  phalanx  the  limit  is  one  line; 
on  the  palm  of  the  hand,  the  cheek,  and  extremity  of  great 
toe,  five  lines ;  on  the  back  of  the  hand,  fourteen  lines ;  on 
the  skin  over  the  patella  and  dorsum  of  the  foot,  eighteen 
lines ;  over  the  middle  of  the  arm,  thigh,  and  over  the  spine, 
thirty  lines.  But  these  observations  are  found  to  vary  some- 
what even  in  perfectly  healthy  persons,  some  being  able  to 
distinguish  at  a  much  shorter  distance  than  others. 

Besides  the  impairment  or  loss  of  tactile  discrimination,  the 
altered  sensibility  may  show  itself  in  the  loss  of  the  faculty  of 
feeling  pinching,  pricking,  and  other  acts  which  excite  pain  ; 
or  in  insensibility  to  tickling;  or  in  the  want  of  appreciation 
of  heat  and  cold;  or  of  the  sensation  which  attends  muscular 
contraction,  w^hether  produced  by  the  will  or  by  a  galvanic 
current,  i^ow,  it  is  of  interest  in  individual  cases  to  note 
which  particular  kind  of  sensibility  is  affected,  though,  as  yet, 
we  are  not  in  possession  of  sufficient  facts  to  draw,  from  the 

*  Journal  de  Physiologie,  tome  i.,  1858. 
t  Beale's  Archives  of  Medicine,  vol.  i. 

X  See  especially  Carpenter's  article,  "Touch,"  in  Cyclopedia  of  Anatomy 
and  Physiology  ;  also  Valentin's  "  Lehrbnch  der  Physiologie." 


DISEASES    OF    THE    BRAIN,  SPINAL   CORD,  ETC.  61 

absence  of  oue  form  of  sensibility  or  the  other,  any  positive 
conclusions  as  to  the  seat  or  character  of  the  disease. 

In  afl'ections  of  the  base  of  the  brain,  we  have  been  recently 
told  there  is  this  peculiar  modification  of  tactile  impression, 
that  the  patient  feels  three  points  instead  of  the  two  of  the 
festhesiometer.* 

Anaesthesia  may  be  limited  to  one-half  of  the  body.  In 
diseases  of  the  spinal  cord  this  is  a  symptom  of  the  gray 
matter  in  the  opposite  half  of  the  cord  being  altered. 

Anffisthesia  and  hypersesthesia  follow,  or,  to  speak  more 
accurately,  manifest  themselves  only  in  connection  with  ex- 
ternal impressions.  Let  us  now  look  at  some  abnormal  sen- 
sations which  are  not  objective,  but  subjective, — arising,  so 
far  as  we  can  judge,  independently  of  external  impressions. 
Headache  and  vertigo  are  of  this  character. 

Headache. — In  every  case  of  headache  we  must  first  as- 
certain that  the  pain  really  originates  within  the  cranium, 
and  that  it  is  not  owing  to  supra-orbital  neuralgia ;  to 
rheumatism  of  the  scalp;  to  disease  of  the  bones;  to  perios- 
titis, syphilitic  or  otherwise;  to  affections  of  the  ear;  in  fact, 
to  those  numerous  causes  which  occasion  cephalic  pain.  To 
accomplish  this  is  generally  not  difficult.  An  inquiry  into 
the  history  of  the  case,  the  particular  locality  of  the  pain,  and 
its  augmentation  on  pressure  in  most  of  the  disorders  named, 
furnish  evidence  which,  rightly  used,  decides  the  source  of 
the  cephalalgia  to  be  external  to  the  cranium. 

Having  settled  this  point,  we  have  next  to  determine  the 
probable  cause  of  the  headache — a  question  the  solution  of 
which  depends  frequently  more  upon  the  symptoms  attend- 
ing the  pain  than  upon  its  character.  But  let  us  glance  at 
some  of  the  more  common  causes  and  characteristics  of 
intra-crauial  headache. 

Headache  is  an  important,  and,  on  the  whole,  rarely  ab- 
sent symptom  of  diseases  of  the  broin.  In  inflammation  of 
that  organ  it  is  generally  agonizing,  and,  although  subject 
to  exacerbations,  continuous;  it  is  associated  with  fever,  with 
vomiting,  and  with  delirium.     In  abscesses  of  the  brain,  in 

*  Brown-Sequard,  Archive  de  Physiologie,  i.  No.  3. 


62  MEDICAL   DIAGNOSIS. 

tumors,  softenins:,  and  similar  aftections  which  run  a  chronic 
course,  the  headache  is  also  persistent,  but  less  violent,  and 
only  occasionally  paroxysmal ;  it  is  usually  accompanied  by 
siffns  of  disturbed  intellection  and  of  deranj^ed  motion.  In 
congestion  of  the  brain  the  pain  is  dull,  increased  by  stoop- 
ing or  lying  down,  by  long  sleep,  and  by  bodily  or  mental 
fatigue;  its  concomitants  are  a  flushed  face,  throbbing  of  the 
arteries  of  the  neck,  and  a  heated  head.  In  diseases  of  the 
meninges,  especially  those  of  a  chronic  character,  the  pain  is 
constant  and  flxed,  and  sometimes  very  sharp.  The  latter 
kind  of  pain  when  persistent  is  very  significant  either  of  dis- 
ease of  the  membranes,  or,  at  least,  of  parts  of  the  superficial 
structure  in  contact  with  them,  and  is  usually  felt  at  the  place 
on  the  head  which  corresponds  to  the  lesion  within  the  skull. 
There  is  generally  in  meningeal  affections  coexisting  heat  of 
forehead,  with  signs  of  local  vascular  excitement. 

Nervous  or  neuralgic  headache  is  most  common  in  women, 
especially  in  anemic  women.  It  is  unremitting  and  very 
severe,  yet  of  short  duration ;  but  after  it  is  over  there  is  a 
great  lassitude,  and  even  some  local  soreness.  It  is  not  at- 
tended with  fever,  nor  with  any  signs  of  disturbance  of  the 
brain,  excepting  at  times  with  a  confusion  of  vision  and  an 
inability  to  carry  on  a  connected  train  of  thought.  Anything 
that  agitates  the  nervous  system  produces  an  attack;  stimu- 
lants and  food  often  relieve  it. 

Si/mpatheiic  headache  is  of  kindred  nature.  It  is  found 
mainly  in  connection  with  disorders  of  the  alimentary  tube 
and  of  the  uterus,  and  is  often  worse  in  the  morning,  before 
food  has  been  taken. 

Headache  may  be  dependent  upon  various  jmsons,  whether 
generated  in  the  system  or  introduced  from  without ;  for  in- 
stance, in  organic  diseases  of  the  kidney  the  retention  of  a 
large  quantity  of  urea  in  the  blood  becomes  the  source  of  con- 
stant pain  in  the  head.  In  lead  poisoning,  in  opium  eaters, 
in  drunkards,  and  after  the  use  of  strychnia  or  of  large 
quantities  of  quinia,  headache  is  a  common  phenomenon. 

In  studying  headache  as  a  symptom,  we  must  always  note 
what  influence  position  and  movements  of  the  head  have  on 
the  pain  :  whether,  for  instance,  stooping,  swinging  the  head 


DISEASES    OF    THE    BRAIN,   SPINAL    CORD,  ETC.  63 

from  side  to  side,  or  rising  rapidly  from  the  horizontal  to  the 
erect  posture  aft'ect  it,  and  canse  it  to  be  combined  with  verti- 
ginous or  other  abnormal  sensations. 

Vertigo. — This  is  a  transitory  feeling  of  swimming  of  the 
head,  a  sense  of  falling,  or  illusory  movements  of  external 
objects.  The  curious  sensation  is  apt  to  occur  whenever 
the  circulation  within  the  cranium  is  disturbed,  and  is  often 
symptomatic  of  a  disease  of  the  heart,  liver,  kidneys,  stom- 
ach, or  blood,  or  it  follows  long-continued  and  exhausting 
discharges.  Vertigo  may  attend  any  disorder  of  the  brain. 
The  cerebral  form  is  recognized,  in  part,  by  the  absence  of 
those  affections  of  other  organs  which  would  induce  the 
dizziness ;  in  part,  by  its  being  joined  to  headache,  and  to 
further  signs  of  an  encephalic  malady.  Moreover,  it  is  most 
usually  objective  in  character:  surrounding  objects  appear 
to  the  patient  to  move,  not  he  himself;  and  unlike  the  sub- 
jective vertigo,  so  common  in  mere  sympathetic  disturbance 
of  the  brain,  closing  the  eyes  relieves  it. 

There  is  a  kind  of  vertigo  to  which  Trousseau  especially 
has  called  attention.  The  abnormal  sensation  is  very  short 
in  its  duration,  but  severe;  the  patient  momentarily  loses  all 
consciousness.  The  vertigo  recurs  at  uncertain  times:  while 
actively  engaged,  sometimes  while  in  bed  and  half  asleep. 
The  head  feels  heavy  after  an  attack,  and  the  mind  is  tem- 
porarily stupefied  ;  otherwise  the  health  is  good.  This  type 
of  vertigo  is  dangerous.  It  is  often  the  precursor  of  epilepsy, 
and  after  a  time  becomes  associated  with  convulsions. 

Another  kind  of  vertigo  is  that  which  arises  from  overwork 
of  the  brain,  and  which,  when  at  all  persistent,  must  make  us 
fear  that  the  organ  has  begun  to  soften.  Yet  another  is  found 
to  be  associated  with  partial  deafness,  or  with  irritation  of 
the  auditory  nerve.  In  some  instances  the  giddiness  is  the 
only  symptom  of  disorder,  and  is  present  for  many  years, 
the  patient  enjoying  otherwise  excellent  health.  I  have 
known  a  number  of  such  instances  in  which  this  tendency 
appeared  to  have  been  inherited. 

Besides  headache  and  vertisro,  there  are  various  unnatural 
sensations,  such  as  a  feeling  of  momentary  unconsciousness 
without  giddiness;  a  feeling  within  the  cranium  of  weight, 


64  MEDICAL    DIAGNOSIS. 

of  constriction ;  the  feeling  described  as  a  rush  of  blood  to 
the  head;  ocular  spectra,  and  other  false  perceptions  of  many 
kinds  and  of  every  gradation.  But  I  shall  do  no  more  than 
advert  to  this  subject,  and  will  merely,  in  concluding  the 
examination  of  the  evidences  of  deranged  sensation,  con- 
sider some  of  the  morbid  phenomena  of  the  special  senses, 
and  particularly  of  the  sense  of  sight  and  of  hearing. 

Derangement  of  Special  Senses.— The  sense  of  vismi 
may  be  exalted,  impaired,  or  perverted,  in  disorders  of  the 
brain,  whether  organic  or  functional.  It  is  exalted  in  in- 
flammation ;  impaired,  even  totally  lost,  in  softening,  in 
tumors,  in  apoplexy,  and  during  violent  hysterical  attacks 
simulating  apoplexy.  Perversions  of  the  sense  of  vision 
are  more  frequent  than  its  abolition,  and  probably  more 
peculiar  to  cerebral  affections.  They  are  of  all  kinds — some 
of  great  consequence,  others  of  but  little.  Iluscse  volitantes, 
or  the  delusion  of  spots  and  various  small  objects  floating 
before  the  eye,  have  the  latter  significance ;  for  they  may 
happen  in  almost  any  form  of  cerebral  disturbance,  also  in 
anaemia,  in  cardiac  maladies,  in  the  neuroses,  and  in  states 
of  nervous  exhaustion.  Some  persons  see  but  half  an  ob- 
ject. This  may  be  dependent  upon  an  injury  to  the  brain, 
or  be  owing  to  some  purely  local  affection  of  the  eye.  In 
the  former  case  there  is  coexisting  headache,  and  the  mind 
generally  shows  signs  of  disorder.  Double  vision,  unless 
connected  with  strabismus,  is  almost  always  the  result  of 
cerebral  disease.  Of  other  manifestations  of  deranged  sight, 
such  as  illusions,  ocular  spectra,  and  phantasms,  I  cannot 
here  take  cognizance:  I  shall  only  state  that  they  are  more 
common  in  derangement  of  the  mind,  temporary  or  perma- 
nent, than  in  recognizable  organic  disease  of  the  brain. 

The  appearance  of  the  eye  is  often  of  as  much  significance 
as  the  derangement  of  sight.  There,  for  instance,  is  strabis- 
mus, which  is  of  very  usual  occurrence  in  cerebral  ailments. 
"We  find  it  during  an  attack  of  convulsions;  in  meningitis; 
in  tumors  of  the  base  of  the  brain  ;  in  effusion  into  the  ven- 
tricles; and  previous  to  an  attack  of  apoplexy.  In  some 
cerebral  maladies  the  eye  has  a  fixed  stare ;  in  others  the 
eyelids  are  constantly  moving :  but  the  latter  is  a  sign  more 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  65 

frequent  in  cliorea  or  hysteria.     Great  brilliancy  of  the  eye 
is  often  noticed  in  meningitis  and  in  insanity. 

The  pupils  are  very  variously  affected  by  cerebral  disorders. 
"We  find  them  dilated  or  contracted,  slnggish  or  rapidly  alter- 
ing, on  the  admission  or  exclusion  of  light.  We  observe  a 
difference  in  the  size  of  the  two  pupils,  and  in  their  relative 
irritability.  A  dilatation  of  both  pupils  is  found  in  compres- 
sion of  the  brain,  whatever  its  immediate  cause,  but  especi- 
all}'  in  compression  from  a  collection  of  fluid  in  the  ventricles 
and  in  the  subarachnoid  spaces;  the  pupils  likewise  react 
very  sluggishly,  sometimes  hardly  at  all,  under  the  stimulus 
of  light,  and  the  retina  appears  insensible.  A  similar  state, 
although  not  carried  to  the  same  degree,  is  met  with  in  the 
congestion  of  the  brain  accompanying  low  fevers.  We  also 
find  dilatation  of  both  pupils  in  chlorosis,  and  when  the 
system  is  under  the  influence  of  belladonna. 

Contraction  of  the  pupils  exists  in  the  earlier  stages  of 
cerebral  inflammation.  It  is  then  associated  with  intoler- 
ance of  light,  which  does  not  occur  if  the  contraction  be 
produced  by  narcotism  or  by  coma.  Contraction  of  the 
pupils  happens  also  in  spinal  diseases.*  One-sided  contrac- 
tion, like  one-sided  dilatation  of  the  pupil,  is  ordinarily  the 
result  of  a  one-sided  lesion  of  the  brain  ;  yet  it  may  also  be 
owing  to  tumors  at  the  root  of  the  neck. 

But  in  estimating  the  value  of  any  morbid  evidences  fur- 
nished by  the  state  of  vision  or  the  appearance  of  the  eye, 
we  must  make  allowance  for  the  purely  local  diseases  of  the 
organ,  and  exclude  them  from  consideration  before  we  draw 
conclusions  as  to  the  condition  of  the  brain.  We  are  greatlv 
aided  in  this  by  the  use  of  the  ophthalmoscope,  which  gives 
not  only  information  as  to  many  of  the  mere  visual  disturb- 
ances, but  as  to  the  changes  brought  about  in  the  eye  by 
cerebral  afl'ections. 

The  fundus  oculi,  as  revealed  by  the  ojjhthalmoscope,  pre- 
sents various  lesions,  which,  although  not  pathognomonic  of 
any  one  condition,  furnish  additional  information  of  value  in 
locating  more  definitely  the  particular  disease.    These  lesions 

*  See  Cases,  Edinb.  3Ied.  Journal,  Dec.  1869. 


66  MEDICAL   DIAGNOSIS. 

depend  either  on  an  extension  of  inflammation  of  the  brain 
to  the  internal  structures  of  the  eye,  or  on  the  amount  of 
resistance  offered  to  tlie  circulation  within  the  cranium. 
This  resistance  may  arise  either  from  a  marked  "coarse" 
lesion,  or  it  may  be  exerted  through  the  sympathetic  nervous 
system. 

We  should  invariably  examine  with  the  ophthalmoscope 
the  eyes  of  patients  suspected  of  having  disease  of  any  part 
of  the  cerebro-spinal  nervous  system,  and  not  wait  for  the 
development  of  symptoms  which  belong  to  a  later  stage  to 
elucidate  the  diagnosis.  Changes  in  the  eye,  indeed,  often 
occur  early  enough  to  be  the  first  certain  sign  of  the  disease, 
and  this,  too,  without  any  impairment  of  sight;  on  the  other 
hand,  lesions  indicating  cerebral  or  other  organic  trouble 
have  been  found  in  cases  in  which  failure  of  sight  only  was 
complained  of,  the  ultimate  cause  being  imsuspected  by  the 
patient.  But  particularly  is  the  ophthalmoscope  valuable  in 
enabling  us  to  diagnosticate,  oftentimes  at  once  and  with 
certaint}',  organic  from  functional  disorder. 

The  chancres  in  connection  with  orijanic  disease  have  been 
observed  chiefly  in  the  retina,  the  optic  disk,  and  the  choroid, 
and  for  the  most  part  indiflferently  in  both  eyes,  even  when 
the  causative  disease  is  limited  to  one  hemisphere. 

Betimtis  occurs  most  frequently  in  connection  with  inh*a- 
cranial  lesions,  constitutional  syphilis,  and  Bright's  disease. 
It  is  characterized  by  a  reddish-gra}^  opaque,  swollen,  and 
somewhat  hyperemic  optic  disk,  with  an  irregular  and  indis- 
tinct outline,  which  passes  into  the  retina  without  any  clear 
line  of  demarcation.  The  retina  presents  a  hazy  appearance, 
particularly  marked  in  the  vicinity  of  the  optic  papilla  and 
macula  lutea ;  its  arteries  are  but  slightly  changed  in  appear- 
ance, but  the  veins  are  enlarged,  dark  in  color,  and  very  tor- 
tuous.    Hemorrhagic  extravasations  are  common. 

In  sy2)hUitic  retinitis  the  disk  and  retina  are  veiled  by  a  faint, 
bluish-gray  film,  due  to  serous  transudation,  most  marked 
along  the  course  of  the  vessels,  and  which  shades  oft'  imper- 
ceptibly into  the  healthy  retina.  Minute  puuctiform  opaci- 
ties are  strewn  irregularly  over  the  retina,  and  they  undergo 
rapid  changes,  appearing  and  disappearing  in  the  course  of  a 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  67 


few  days.  Galezowski  has  found  syphilitic  retinitis  and 
neuritis  to  be  alwaj's  accompanied  by  color-blindness.  In 
patients  who  were  the  victims  of  hereditary  syphilis,  Mr. 
Hutchinson  has  frequently  observed  pigmentary  retinitis. 

The  syphilitic  form  of  retinitis  should  not  be  confounded 
with  that  which  accompanies  disease  of  the  kidney,  and  which 
is  characterized  by  the  formation  on  the  retina  of  brilliant 
white  stellated  spots  in  the  region  of  the  macula  lutea,  and 
of  a  broad,  glistening,  white  mound  encircling  the  optic 
disk.  These  spots  are  constant,  and  are  due  to  a  fatty  de- 
generation of  the  connective  tissue  element  and  sclerosis  of 
the  optic  nerve  fibres.  Retinal  hemorrhage  is  also  of  fre- 
quent occurrence. 

A  peculiar  form  of  retinitis  has  been  observed,  in  some 
rare  cases,  to  accompany  diabetes.* 

Ojyiic  neuritis  always  results  directly  —  so,  at  least,''we  are 
told  by  Dr.  Allbutt  —  from  meningitis  or  cerebritic  soften- 
ing, whatever  may  be  the  indirect  cause.  Yet  it  has  been 
observed  in  cases  of  phlebitis  of  the  sinuses,  acute  and 
chronic  meningitis,  chronic  encephalitis,  cerebral  hemor- 
rhage, tumors  of  the  brain,  particularly  when  situated  near 
the  optic  tract  or  chiasm,  cerebral  compression,  chronic  hy- 
drocephalus, abscess  of  the  brain,  syphilitic  deposit,  hydatid 
cyst,  acute  myelitis,  locomotor  ataxia,  certain  forms  of  epi- 
lepsy, paralysis  or  neurosis  connected  with  organic  disease 
of  the  nervous  system,  and  in  diphtheria,  rheumatic  fever, 
etc.  Being  found  in  so  many  states,  its  exact  value  in  each 
is  still  to  be  settled.  In  cases  of  hemiplegia.  Dr.  Hughlings 
Jackson  has  noted  its  greater  frequency  in  connection  with 
left-sided  paralysis.  In  lesions  of  the  encephalon  or  me- 
ninges, Bouchut  thinks  it  is  in  general  more  marked  in  the 
eye  corresponding  to  the  hemisphere  which  is  more  seriously 
aiiected;  Hughlings  Jackson,  however,  denies  the  existence 
of  any  relation  between  the  side  of  the  brain  diseased  and 
the  eye  aftected. 

The  essential  ophthalmoscopic  sign  of  optic  neuritis  is 
serous   infiltration  and   prominence  of  the  papilla,  accom- 

*  Vide  Compte  Rendu  du  Congres  Oplith.  de  Taris,  18G2,  p.  110. 


gg  MEDICAL    DIAGNOSIS. 

panied  by  vascular  turgescence.  The  disk,  owing  to  its  in- 
liltration,  presents  a  woolly  appearance.  As  the  walls  of  the 
vessels  are  mostly  healthy,  the  extravasations  which  are  seen 
in  the  retinitis  of  albuminuria  do  not  frequently  occur  in 

optic  neuritis. 

Perineuritis  is  the  name  given  by  Galezowski  to  inflamma- 
tion w^hich  seems  chiefly  to  aflect  the  outer  neurilemma. 
The  papilla  is  enlarged  and  prominent,  but  the  exudation 
appears  to  be  confined  to  the  margin  of  the  papilla,  the  out- 
lines of  which  are  veiled,  while  the  centre  is  transparent,  and 
resembles  the  normal  state.  This  condition  is  very  sug- 
gestive of  meningitis. 

Simple  hyperemia  of  the  disk  may  be  due  to  encephalic  dis- 
ease, to  meningitis,  or  to  Bright's  disease.  A  transient  form 
of  hyperemia  may  be  seen  in  the  changes  of  cerebral  vascu- 
larity attended  with  convulsions,  in  affections  of  the  heart, 
such  as  aortic  regurgitation,  and  in  Graves'  disease. 

Diseases  of  the  spinal  cord,  as  acute  myelitis,  spinal  scle- 
rosis, locomotor  ataxia,  frequently  induce  a  congestive  lesion 
of  the  optic  papilla,  which,  at  a  later  period,  becomes 
atrophic.  These  changes  do  not  become  established  in  cases 
of  spinal  disease  which  run  a  short  course,  but  they  slowly 
supervene  in  more  chronic  cases. 

Dr.  Ilughlings  Jackson  has  described*  a  peculiar  con- 
dition of  the  retina,  which  he  observed  in  a  patient  with 
epileptiform  convulsions,  and  which  he  calls  epilepsy  of  the 
retina.  The  retina  is  entirely  anemic,  a  condition  dependent 
in  all  probability  upon  a  contraction  of  the  retinal  vessels 
similar  to  that  which  occurs  in  the  vessels  of  the  brain 
during  an  epileptic  fit. 

Atrophy  of  the  optic  nerve  is  met  with  in  cases  of  cerebral 
tumor,  in  meningitis,  hydrocephalus,  constitutional  syphilis, 
sun-stroke,  after  typhoid  fever,  and  in  paralysis  and  symp- 
tomatic epilepsy.  Allbutt  has  foundf  that  atrophy  of  the 
optic  disk  happens  in  nearly  every  case  of  general  paralysis 
of  the  insane,  beginning  as  a  pink  suflusion  of  the  nerve, 
without   much    stasis  or  exudation,   and   ending  as  simple 

*  Royal  Ophthal.  Hosp.  Rep.,  vol.  iv.  p.  14. 
t  Brit.  Med.  .lour.,  March  14,  1868. 


DISEASES    OF    THE    BRAIN,   SPINAL    CORD,  ETC.  69 

white  atrophy — a  process  which  he  likens  to  "red  and  white 
softening"  of  the  brain.  Atrophy  freqiientl}'  occurs  in  loco- 
motor ataxia,  and  has  been  observed  in  some  cases  of  chronic 
myelitis,  etc.  It  may  occur  as  a  secondary  effect  of  cerebral 
hemorrhage.  According  to  Bouchut,*  it  is  never  seen  in 
cases  of  meningitis,  except  w^hen  this  is  a  complication  of 
chronic  meningitis,  an  old  encephalitis,  or  an  old  tumor  of 
the  brain.  It  is  never  found  as  a  result  of  spinal  injuries; 
and  repeated  scrutiny  has  convinced  Bouchut  that  the  fundus 
is  entirely  unaffected  iu  rachitis. 

The  causes  of  choroiditis,  with  the  exception  of  the  syphi- 
litic form,  are  very  obscure.  It  appears  most  frequently  as 
circumscribed  white  patches  in  the  choroid,  over  which  the 
retinal  vessels  may  be  seen  coursing.  It,  however,  occa- 
sionally assumes  most  varying  appearances.  The  syphilitic 
form  is  by  far  the  most  common,  and  is  distinguished  by  the 
presence  of  patches  of  many  colors  at  the  back  of  the  eye, 
some  being  of  a  brilliant  white,  others  of  darker  tints,  such 
as  red  or  brown. 

Tubercles  of  the  choroid  are  a  manifestation  of  the  tuber- 
cular diathesis,  and  one,  too,  which  is  probably  of  more 
frequent  occurrence  in  miliary  tuberculosis  than  is  generally 
supposed.  In  eighteen  cases  of  miliary  tuberculosis  which 
were  examined  in  the  Berlin  Pathological  Institution,  Cohn- 
heim  found  tubercles  iu  the  choroid  of  one  or  both  eyes  in 
every  instance.  They  appear,  ophthalraoscopically,  in  the 
form  of  small  circumscribed  spots,  of  a  pale  rose-red  color, 
or  grayish-white  tint,  and  vary  in  size,  according  to  Wells, 
from  one-third  to  two  and  five-tenths  of  a  millimetre.  They 
are  chiefly  situated  in  the  vicinity  of  the  optic  disk.  The 
sight  may  remain  unimpaired.  In  the  retina  and  choroid,  the 
existence  of  tubercles  indicates  either  tubercular  meningitis 
or  general  tuberculosis.  If,  with  tubercular  granulations  of 
the  choroid,  fever  and  disturbances  of  intellect,  of  movement 
and  sensation  be  present,  the  existence  of  tubercular  menin- 
gitis may  be  determined. 

As  regards  the  sense  of  hearing,  the  same  may  be  said  as 

*  Diagnostic  cles  Maladies  Nerveux  par  rOphthalmoscopie. 


70  MEDICAL    DIAGNOSIS. 

of  vision.  It,  too,  is  perverted  and  impaired  in  various 
cerebral  aifeetions;  yet  to  be  certain  that  the  cause  of  the 
trouble  is  cerebral,  the  ear  must  first  be  carefully  examined 
with  reference  to  any  physical  imperfection. 

Great  acuteness  of  hearing  and  intolerance  of  sound  are 
generally  symptoms  of  extreme  nervous  irritability,  or  of 
commencing  cerebral  inflammation.  Deafness  may  be  owing 
to  softening  of  portions  of  the  brain  ;  but  it  is  also  found  as 
a  temporary,  and  by  no  means  unfavorable  symptom  in  the 
continued  fevers.  Imaginar}^  sounds  and  ringing  noises  in 
the  ear,  or  tinnitus  aurium,  are  frequent  accompaniments  of 
cerebral  disorders.  But  the  latter  is  encountered  in  so  many 
different  conditions — in  diseases  of  the  cerebral  vessels,  in 
congestion  of  the  brain,  in  affections  of  the  heart,  in  anaemia 
— that  it  is  a  sign  of  but  little  moment;  and,  in  truth,  its 
most  usual  cause  is  local,  namely,  an  accumulation  of  wax 
in  the  meatus. 

DERANGED    MOTION. 

The  chief  manifestations  of  deranged  motion  resolve  them- 
selves into  the  phenomena  called  paralysis,  tremor,  ataxia, 
spasms,  and  convulsions. 

Paralysis. — When  we  speak  of  paralysis,  we  mean  a  loss 
of  muscular  contractility,  and,  as  a  consequence,  of  the  power 
of  motion.  It  is  true,  there  is  also  a  paralysis  of  sensation, 
which  may  be  conjoined  with  the  paralysis  of  motion ;  but 
the  latter  often  happens  alone,  and  is  the  morbid  state 
alluded  to  when  we  use  the  term  paralysis  without  qualify- 
ing whether  of  sensation  or  of  motion. 

Paralysis  may  be  general,  or  it  may  be  partial.  It  may 
aliect  the  majority  of  the  muscles  of  the  frame,  or  be  limited 
to  one  muscle.  It  may  be  strictly  confined  to  one  side,  or 
exist  solely  in  the  lower  half  of  the  body.  It  may  come  on 
rapidly,  or  appear  slowly.  But  under  any  circumstance  it  is 
not  a  disease,  but  a  symptom.  We  must,  in  individual  cases, 
therefore,  aim  at  determining,  so  far  as  possible,  its  cause, 
before  we  attempt  to  remedy  the  palsy.  The  causes  which 
give  rise  to  paralysis  may  be  thus  summed  up : 


DISEASES    OF   THE    BRAIN,  SPINAL    CORD,  ETC.  71 

Paralysis  dm  to  a  lesion,  or  any  morbid  condition  of  the  nervous 
centres. — Softening  of  the  central  nervous  textures,  or  any 
process  which  materially  alters  them,  occasions  loss  of  power 
in  the  part  over  which  their  influence  in  health  extends.  The 
complete  paralysis  attending  most  of  the  diseases  of  the  brain 
or  of  the  spinal  cord  belongs,  therefore,  to  this  category. 

But  besides  these  palsies  of  organic  origin,  there  are  pal- 
sies dependent  upon  what,  so  far  as  we  are  aware,  is  simply 
a  functional  derangement  of  the  great  centres  of  innervation. 
How  else  explain  a  hysterical  paralysis,  or  the  transitory 
palsy  sometimes  seen  to  follow  low  fevers,  or  that  occurring 
after  overwork  or  excesses,  and  so  evidently  from  nervous 
exhaustion  ? 

Paralysis  due  to  a  lesion  in  the  course  of  a  nerve. — The  nervous 
force  may  be  properly  generated,  but  the  nerve  fibres  may 
be  incapable  of  conducting  it.  For  instance,  if  a  nerve  be 
wounded,  or  lacerated,  or  compressed,  paralysis  of  the  muscles 
which  it  supplies  takes  place.    Palsy  from  this  cause  is  local. 

Paralysis  due  to  an  affection  of  the  nerves  at  their  extremities. — 
A  paralysis  originating  at  the  periphery  of  a  nerve  is  a  rare 
complaint.  But  we  meet  every  now  and  then  with  undoubted 
illustrations  of  such  a  disorder:  for  example,  the  palsy  result- 
ing from  exposure  to  cold.  Peripheral  palsies  lead  quickly 
to  atrophy  of  the  muscles.  They  are,  from  their  very  nature, 
local,  and  commonly  remain  so.  But  there  is  a  notable  ex- 
ception to  this  in  the  so-called  creeping  palsy;  a  disease 
which  commences  with  a  feeling  of  numbness  and  a  slight 
loss  of  muscular  power  in  one  arm  or  leg,  but  which  grad- 
ually spreads  to  other  portions  of  the  body. 

Paralysis  due  to  reflex  action. — Here  the  paralysis  is  produced 
through  the  medium  of  the  great  seat  of  the  reflex  system,  the 
spinal  cord,  which  reflects  the  irritation  communicated  to  it 
to  parts  healthy  in  themselves.  At  all  events,  cases  are  from 
time  to  time  met  with  which  admit  of  no  other  explanation. 
How  else  can  excitation  of  the  dental  nerves  in  teething  chil- 
dren, or  disorders  of  the  intestines  both  in  adults  and  children, 
or  disease  of  the  bladder,  urethra,  uterus,  lungs  or  pleura,  or 
irritation  of  the  nerves  of  the  skin,  occasion  paralysis  ?  or 
how  else  can  a  wound  of  a  nerve  on  one  side  of  the  body  lead 
to  palsy  on  the  other  ? 


/ 


72  MEDICAL    DIAGNOSIS. 

Paralysis  brought  on  by  reflex  action  is  rarely  of  long  du- 
ration. It  is  increased  or  diminished  as  the  causes  which 
produce  it  increase  or  diminish,  and,  as  a  rule,  soon  disap- 
pears after  the  source  of  irritation  is  removed.  It  may  aflfect 
almost  any  part  of  the  body,  and  even  assume  the  paraplegic 
form. 

Paralysis  due  to  serious  interference  with  the  circulation. — This 
kind  of  palsy  is  observed  if  the  principal  artery  of  a  part  be 
obliterated.  But  it  is  not  often  encountered  ;  and  when  met 
with,  is  not  unusually  found  to  be  connected  with  gangrene 
of  the  paralyzed  part.  It  is  sometimes  noticed  as  a  transient 
phenomenon  after  the  ligature  of  a  large  artery;  in  a  more 
permanent  form  it  is  apt  to  be  caused  by  a  plug  of  fibrin 
impacted  in  a  vessel. 

Paralysis  due  to  a  morbid  state  of  the  muscles. — Any  process 
which  materially  impairs  the  normal  structure  of  muscular 
tissue  Avill  entail  loss  of  muscular  power ;  but  in  point  of 
fact,  the  disease  which  commonly  occasions  this  form  of  pa- 
ralysis (if  it  be  correct  to  call  that  paralysis  in  which  the 
nervous  system  is  not  to  appearance  particularly  concerned) 
is  muscular  atrophy,  and  especially  the  progressive  musculnr 
atrophy  connected  with  fatty  degeneration. 

Paralysis  due  to  the  j)resence  of  imsons  in  the  system. — The 
toxical  effects  of  lead,  arsenic,  mercury,  of  alcohol,  and  of 
sulphuret  of  carbon,  may  exhibit  themselves  by  producing 
palsy.  Malarial  poisons,  and  poisons  formed  in  the  system, 
such  as  that  of  rheumatism  or  of  gout,  may  act  in  the  same 
way.  The  former  occasion  that  singular  "  intermittent  paraly- 
sis" which  may  come  on  either  as  one  of  the  phenomena  of 
a  fit  of  ague,  or  as  an  apparently  independent  complaint ; 
which  assumes  either  the  quotidian  or  tertian  type,  and  in 
which  both  sensation  and  motion  may  be  affected.  How 
any  of  these  poisons  operate,  whether  by  interfering  with  the 
nutrition  of  the  nervous  centres  and  weakening  their  gener- 
ating force,  or  by  enfeebling  the  conducting  power  of  the 
nerves,  is  unknown.  The  palsies  coming  under  this  head 
being,  as  it  were,  functional,  are  not  ordinarily  intractable. 
Those  due  to  malaria  yield  speedily  to  decided  doses  of 
quinine. 


DISEASES    OF   THE    BRAIN,  SPINAL    CORD,  ETC.  73 

In  the  parts  affected  with  paralysis,  the  nutrition  and  secre- 
tion are  disturbed  and  tlie  circulation  is  sluggish.  They  are 
frequently  swollen  and  edematous,  the  pulse  is  weaker  than 
in  the  sound  members,  and  the  sensation  is  impaired.  The 
nails  grow  slowly;  the  perspiration  is  defective;  the  skin 
feels  cold,  is  prone  to  break  from  the  effect  of  pressure,  and 
the  ulcers  heal  but  tardily.  The  condition  of  the  muscles 
is  very  various.  In  some  cases  they  are  completely  relaxed, 
in  others  rigid ;  at  times  they  become  agitated  with  convulsive 
movements.  These  phenomena  are  apt  to  be  most  evident 
in  palsies  of  organic  origin,  especially  in  those  dependent 
upon  a  brain  lesion,  and  in  those  due  to  disease  of  the  spinal 
cord  in  which  anesthesia  is  present.  Where  hyperesthesia 
occurs,  the  increased  sensibility  is  attended  with  a  larger 
supply  of  blood  and  a  higher  temperature  than  normal. 

Having  thus  briefly  alluded  to  some  of  the  general  traits 
and  to  the  causes  of  paralysis,  let  us  now  examine  its  chief 
varieties  with  reference  to  their  clinical  significance  and 
their  diagnosis.  In  so  doing,  it  will  be  convenient  to  be 
guided  by  their  marked  coarse  features  rather  than  by  their 
presumed  origin. 

Hemiplegia. — And  first,  of  hemiplegia,  or  one-sided  palsy. 
This  state  of  things  may  affect  all  the  voluntary  muscles  on 
one  side  of  the  body;  but  it  generally  exists  only  in  those  of 
the  limbs  and  face.  Neither  the  legs  nor  arras  can  move, 
and  the  muscles  of  the  face  on  the  side  corresponding  to  the 
paralyzed  limbs  are  motionless.  The  cheek  hangs ;  the 
mouth  is  drawn  toward  the  healthy  side,  because  the  muscles 
on  the  other  are  powerless  to  resist ;  the  tongue,  when  pro- 
truded,, is  ordinarily  slowly  pushed  out  toward  the  palsied 
side ;  the  articulation  is  imperfect. 

But  the  rule  with  respect  to  the  face  being  paralyzed  on 
the  same  side  as  the  rest  of  the  body  has  its  exceptions. 
Indeed,  when  we  reflect  that  the  nerves  which  supply  the 
facial  muscles  are  given  off  above  the  pyramids,  therefore 
above  the  point  of  decussation  of  the  nervous  fibres  in  the 
cord,  it  is  perplexing  that  it  should  be  a  rule  at  all.  The 
solution  of  the  question  has  been  attempted  by  assuming, 
in  accordance  with  the  physiological  researches  of  Stilling 


74  MEDICAL    DIAGNOSIS. 

aiul  Phillipeaux,  a  crossing  of  the  facial  nerves.  Should, 
then,  the  lesion  be  seated  in  the  brain  above  this  crossing, 
both  face  and  body  are  paralyzed  on  the  side  opposite  to  the 
diseased  spot.  Should,  however,  the  lesion  involve  the  facial 
nerve  fibres  at  a  point  below  or  after  the  crossing,  there  will 
be  paralysis  of  the  face  on  one  side,  and  of  the  limbs  on  the 
other,  the  facial  palsy  being  direct,  and  that  of  the  body, 
crossed. 

ISTow  according  to  Gubler,*  who  has  investigated  the  intri- 
cate subject  with  much  skill,  this  form  of  paralysis  is  always 
indicative  of  a  lesion  of  the  pons  varolii,  close  to  which  the 
facial  nerves  originate,  and  through  which  the  nerve  fibres 
for  the  limbs  pass  before  they  decussate  lower  down.  But 
in  adopting  this  conclusion,  we  must  always  remember  that 
there  are  rare  cases  of  "  alternating  paralysis"  due  to  a  com- 
bination of  several  lesions,  one  affecting  a  cerebral  lobe  on 
one  side  and  the  facial  nerve  on  the  other.  And  even  when 
the  lesion  is  unilateral,  we  may  meet  with  exceptional  cases ; 
so  that  the  whole  matter  cannot  as  yet  be  regarded  as  fully 
settled.  With  reference  to  the  other  cerebral  nerves,  should 
we  find  any  of  them  paralyzed  on  one  side  and  the  body  on 
the  other,  we  shall  very  generally  be  correct  in  assuming 
that  the  palsy  is  not  due  to  disease  on  both  sides  of  the 
brain,  but  is  rather  a  disturbance  of  the  aftected  nerve  near 
its  origin  or  in  its  course,  and  on  the  side  on  which  the 
brain  is  injured,  while  the  paralysis  of  the  limbs  is  on  the 
opposite  side.f 

Hemiplegia  results,  in  the  vast  majority  of  instances,  from 
cerebral  disease.  Hence  we  find  it  commonly  associated 
with  disordered  mental  powers,  and  other  signs  of  a  brain 
lesion.     Hemiplegia  caused  by  an  aflfection  of  one-half  of  the 


*  De  I'emiplegie  alterne  envisagee  comme  signe  de  lesion  dc  la  protuber- 
ance annulaire.     Gaz.  Hebdora.,  1856,  1859. 

f  Minute  anatomical  researches,  particularly  those  of  Lockhart  Clarke,  on 
the  internal  structure  of  the  brain,  are  beginning  to  remove  much  of  the  ob- 
scurity in  attempting  to  explain  these  double  palsies,  as  well  as  the  dissimilar 
manner  in  which  the  facial  nerve  is  affected.  Connecting  nuclei  on  the  floor 
of  the  fourth  ventricle  and  elsewhere  are  traced.  (Sec  riiilosuphioal  Trans- 
actions, Part  I.  1868. 


DISEASES    OF   THE    BRAIN,  SPINAL    CORD,  ETC.  75 


spinal  cord,  near  its  commencement,  is  not  combined  with  a 
decay  of  the  mental  faculties,  and  the  muscles  of  the  chest 
and  abdomen  are  involved  in  the  paralysis,  which  they  are 
not  in  cerebral  hemiplegia,  unless  the  lesion  be  very  exten- 
sive. Then  in  spinal  hemiplegia  there  is  apt  to  be  coexisting 
anaesthesia;  and  the  umbilicus  is  with  every  act  of  inspira- 
tion drawn  toward  the  sound  side;  and  according  to  the 
statement  of  Romberg,  spinal  hemiplegia  is  more  persistent 
in  the  leg  than  it  is  in  the  arm.  We  possess  a  further  test 
in  electricity.  Marshall  Hall  long  since  enunciated  the  doc- 
trine that  the  irritability  of  the  muscles,  Avhen  the  influence 
of  the  brain  is  withdrawn,  is  increased ;  and  that,  therefore, 
in  cerebral  paralysis  the  palsied  limbs  are  more  excitable  by 
electricity.  This  statement  is  qualified  by  Duchenne,  who 
asserts  that  in  cerebral  hemiplegia  the  electro-muscular  con- 
tractilitv  remains  as  in  health,  while  it  is  diminished  or  abol- 
ished  in  spinal  disease.  Unfortunately,  this  admirable  and 
easy  test  is  liable  to  certain  drawbacks,  and  its  accuracy  de- 
pends greatl}'  upon  the  state  of  resolution  or  of  rigidity  of 
the  muscles  of  the  unsound  limb.  At  least  such  is  the  con- 
clusion to  be  drawn  from  the  experiments  of  Todd;*  and  the 
observations  of  Althaus,  also,  lead  to  a  similar  inference. f 
The  results  obtained  by  him  would  seem  to  show  that  in  a 
certain  number  of  cases  of  cerebral  paralysis,  the  muscles  are 
flaccid,  and  the  contractility  is  diminished;  while  in  another 
class  of  cases  no  diflference  in  contractility  can  be  discerned 
between  the  healthy  and  the  palsied  limb;  but  in  a  third  class 
the  afiected  muscles  are,  by  a  current  of  the  same  intensity, 
more  powerfully  convulsed  than  those  of  the  sound  side,  and 
then  we  may  infer  that  the  paralysis  is  due  to  brain  disease 
of  an  irritative  character.^ 

*  Clinical  Lectures  on  the  Nervous  System,  page  39 ;  and  Med.-Chirurg. 
Transact.,  vol.  xxxvi. 

f  On  Paralysis,  Neuralgia,  etc.,  3d  edition,  1864;  also  Medical  Electricity, 
2d  edition,  1870.  As  in  the  cases  of  Kosenthal,  quoted  Kctrospect  of  Syden- 
ham Society,  1868 ;  also  cases  of  Brown-Sequard. 

X  These  remarks  apply  to  the  effects  obtained  by  the  induced  current,  or  to 
faradisation  of  the  muscles.  A  continuous  current  maj',  however,  in  cases  of 
palsy,  give  different  results.  The  muscles  of  a  palsied  part  may  respond 
actively  to  galvanisation  and  not  at  all  to  faradisation.     How  far  these  dif- 


76  MEDICAL    DIAGNOSIS. 

But  supposing  that  we  have  satisfactorily  settled  the  hemi- 
plegia to  be  cerebral,  the  points  next  to  be  investigated  are, 
where  is  the  lesion  situated?  and  what  is  its  probable  nature? 
Now  the  former  question  may  be  answered  in  a  general  way 
by  stating  that  it  is  on  the  side  opposite  to  the  palsy,  if  the 
lesion,  which  it  almost  always  is,  be  seated  above  the  point 
of  decussation  of  the  pyramidal   columns  of  the  medulla 
oblongata ;  for  a  lesion  below  the  decussation  gives  rise  to 
palsy  on  the  same  side,  and  a  lesion  on  a  level  with  the 
decussation,  to  double-sided  palsy.     Furthermore,  we  may 
reasonably  conclude  the  morbid  process  to  have  affected  the 
corpus  striatum,  if  motion  be  seriously  impaired,  or  to  have 
attacked  the  optic  thalamus,  if  there  be  paralysis  of  sensa- 
tion ;  yet  in  point  of  fact,  so  intimate  is  the  union  between 
these  two  bodies,  that  one  is  hardly  ever  much  disorganized 
without  the  other  being  drawn  into  the  disease.     The  more 
superficial  the  lesion,  and  the  nearer  therefore  to  the  surface, 
the  more  incomplete  the  palsy,  and  the  more  the  disease  ex- 
tends toward  the  corpus  striatum,  the  more  thorough  does 
the  paralysis  of  motion  become.    We  may  further  distinguish 
the  palsy  which  ensues  from  that  caused  by  an  affection  lower 
down,  as  of  the  pons  varolii,  by  observing  that,  besides  the 
peculiar  crossed  paralysis  of  the  fiice  and   limbs  which  so 
often  happens  in  this,  and  which  has  been  above  described, 
we  find  extreme  coldness  of  that  side  of  the  body  which  is 
to  become  paralyzed  after  a  time;  also  giddiness  and  a  tend- 
ency to  vomit;  jerkings  of  the  muscles  of  the  face,  on  the 
side  opposite  to  the  injury;  sensations  of  tickling  in  the  face; 
and  one-sided  facial  ansesthesia,  with  a  loss  of  sense  of  taste 
on  the  corresponding  side,  though  with  unimpaired  motion 
of  the  tongue.     Should  we  encounter  paralysis  of  sensibility 
and  motion  on  one  side  of  the  body,  and  both  sides  of  the 
face  be  palsied  as  to  motion  and  sensation,  the  recti  muscles 


ferences  may  be  made  available  for  diagnostic  purposes  is  undetermined.  In 
accordance  with  the  recent  researches  of  Erb  (Archiv  fiir  Klinisohe  Medi- 
cm,  Bd.  ii.),  the  alterations  of  excitability  only  affect  the  muscles,  since,  when 
there  has  been  an  injury  to  the  motor  nerves,  there  is  loss  of  excitabilitv 
alike  to  the  induced  and  continuous  current.  (See  Erb  ;  also  Mover's  work  on 
Electricity,  translated  by  Hammond,  and  Althaus  on  Medical  Electricity.) 


DISEASES    OF    THE    BRAIN,  SPINAL    COllD,  ETC.  77 

of  the  eye  be  paralyzed,  and  taste  lost  over  the  anterior  part 
of  the  tongue,  we  may  infer  that  the  injury  is  seated  rather 
above  the  lower  portions  of  the  pons,  and  affects  the  spot 
where  the  facial  nerve  and  part  of  the  trigeminal  cross.* 

The  nature  of  the  paralyzing  lesion  can  only  be  arrived  at 
by  a  careful  scrutiny  of  all  the  facts  of  the  case.  A  sudden 
paralysis  occurring  simultaneously  with  coma  almost  always 
has  its  origin  in  an  apoplectic  eifusion ;  a  sudden  paralysis 
without  coma  is  generally  due  to  a  rapid  giving  way  of  a 
softened  brain.  A  gradual  development  of  palsy  indicates 
some  chronic  cerebral  disorder,  such  as  softening,  or  a  tumor, 
or  any  affection  compressing  the  nervous  substance.  We 
may  also  gain  much  knowledge  by  carefully  exploring  the 
organs  of  circulation  and  the  kidneys.  Thus,  a  paralysis 
found  to  be  conjoined  to  a  cardiac  malady  or  to  a  diseased 
state  of  the  arteries,  is,  in  all  likelihood,  owing  to  softening, 
to  an  apoplectic  effusion  into  the  brain,  or,  as  happens  in 
rare  cases,  to  a  stopping  up  of  one  of  the  cerebral  arteries 
with  a  mass  of  coagulated  fibrin.  When  the  kidneys  are 
seriously  disordered,  it  is  not  unreasonable  to  suppose  that 
the  hemiplegia  has  been  caused  by  some  chronic  disease  of 
the  brain,  the  result  of  the  altered  nutrition  produced  by  the 
ill-purified  blood. 

A  further  clue  to  the  character  of  the  cerebral  lesion  is 
obtained  by  examining  the  palsied  muscles.  Todd,  who  has 
most  clearly  and  forcibly  directed  attention  to  this  subject, 
declares  that  when  the  paralyzed  limbs  exhibit  a  rigid  state 
of  the  muscles  from  the  moment  of,  or  soon  after  the  attack, 
we  may  assume  the  lesion  to  be  of  an  irritative  nature,  such 
as  an  inflammation,  or  a  compression  of  healthy  brain  tissue 
by  an  apoplectic  clot  or  by  an  accumulation  of  puriform  fluid 
in  the  subarachnoid  spaces.  When  the  muscular  contraction 
does  not  take  place  until  late  in  the  complaint,  and  becomes 
associated  with  wasting  of  the  muscles,  it  may  be  presumed 
to  be  caused  by  an  irritation  from  an  attempt  at  cicatrization. 
When  the  muscles  are  flaccid  and  relaxed,  and  there  is,  for 
instance,  no  resistance  in  the  flexing  of  the  forearm  upon  the 

*  Brown-Sequard,  Dublin  Quart.  Journ.,  May,  1805. 


78  MEDICAL   DIAGNOSIS. 

arm,  or  the  leg  ii}>oii  the  thigh,  we  may  conclude  the  lesion  to 
be  of  a  depressing  kind,  such  as  white  softening  of  the  brain, 
with  or  without  rupture  of  the  blood-vessels.  In  paralysis 
with  resolution  of  the  muscles,  as  before  stated,  the  electric 
excitability  of  the  unsound  limb  is  far  less  than  that  of  the 
sound  one,  while  in  early  rigidity  it  is  much  increased. 

A  curious  phenomenon  connected  with  paralysis  is,  that 
reHex  actions  can  be  excited  in  the  apparently  lifeless  limb. 
The  application  of  a  hot  iron,  or  the  tickling  of  the  sole  of 
the  foot,  will  often  give  rise  to  violent  movements. 

Paraplegia. — This  differs  from  hemiplegia  in  the  palsy  oc- 
curring on  both  sides,  yet  being  limited  to  the  lower  extrem- 
ities. It  almost  never  depends  on  disease  of  the  brain,  its 
most  frequent  cause  being  a  lesion  of  the  spinal  cord.  There 
are,  however,  cases  in  which  it  results  from  poisons,  from 
fatigue,  from  excesses,  and  in  which  it  exists  independently 
of  any  recognizable  structural  change. 

The  disorder  generally  comes  on  slowly.  At  first  the 
patient  only  loses  the  steadiness  of  his  gait;  gradually  he  is 
deprived  of  all  power  of  motion,  but  the  intellect  and  the 
nerves  of  special  sense  remain  unaffected.  If  the  lesion  be 
in  the  lumbar  part  of  the  cord,  the  paralysis  is  confined  to 
the  lower  extremities  and  to  the  pelvic  muscles ;  if  the  dorsal 
portion  be  attacked,  we  find,  in  addition,  signs  of  paralysis 
of  the  abdominal  walls  and  of  the  sphincters,  tympanites, 
and  a  somewhat  impeded  breathing.  In  diseases  of  the  upper 
section  of  the  cord  there  is  coexisting  palsy  of  the  upper  ex- 
tremities, with  difiiculty  in  deglutition  and  in  respiration. 
In  the  muscles  supplied  by  the  nerves  which  originate  in 
healthy  marrow,  involuntary  retractions  or  reflex  phenomena 
may  be  induced,  and  the  striking  effects  of  strychnia,  when 
given  in  doses  sufficient  to  produce  its  peculiar  muscular 
spasms,  are  manifested.  To  the  effects  of  electricity  we  have 
already  alluded.  The  palsied  muscles  do  not  respond  to  the 
electrical  stimulus ;  at  least  they  do  not  after  their  nutrition 
has  become  impaired. 

Paraplegia  is  generally  more  marked  on  one  side  than  on 
the  other,  and  the  paralysis  of  motion  is  apt  to  be  associated 
Avith  very  complete  and  permanent  anossthesia.     When,  as 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  79 

sometimes  happens,  the  mischief  is  limited  to  a  lateral  seg- 
ment of  any  part  of  the  cord,  there  is  paralysis  of  motion  on 
the  same  side  of  the  body,  and  of  sensation  on  the  other.* 

Preceding,  or  even  attending  many  cases  of  paraplegia,  is 
a  very  curious  symptom  which  belongs  exclusively  to  atfec- 
tions  of  the  cord  :  a  spasm  of  the  flexor  muscles  of  the  lower 
limbs,  so  powerful  that  the  anterior  parts  of  the  thighs  come 
almost  in  contact  with  the  abdomen,  while  the  heels  are 
drawn  up  so  as  to  touch  the  back  of  the  thighs, f 

Let  us  now  take  a  cursory  view  of  the  diflerent  forms  of 
spinal  paraplegia. 

Sometimes  the  paralysis  occurs  suddenly,  and  in  conse- 
quence of  an  injury  to  the  spine,  of  a  displacement  subse- 
quent to  a  disease  of  the  bones,  of  blood  extravasated  into 
the  canal,  or  of  poisons,  as  the  lathyrus  sativus.|  When 
either  of  the  former  two  causes  has  led  to  the  sudden  palsy, 
the  diagnosis  is  materially  aided  by  the  history  of  the  case, 
and  by  a  close  examination  of  the  vertebral  column.  But  if 
there  be  no  history  of  an  injury,  if  no  signs  of  a  disease  of 
the  bones  or  the  intervertebral  cartilages  can  be  detected,  we 
may  suspect  a  spinal  hemorrhage  to  have  produced  the  sudden 
paraplegia;  and  this  suspicion  becomes  much  strengthened 
if  violent  pain  in  the  back  exist,  if  the  patient  be  unable  to 
retain  his  urine  or  feces,  and  if  the  affected  limbs  become 
rigid.  And  we  are  not  kept  in  doubt  long,  for  spinal  apo- 
plexy has  generally  a  speedily  fatal  termination. 

But  besides  these  causes,  others  lead  rapidly  to  paraplegia. 
Softening  of  the  cord  may  have  progressed  latently  until  the 
degeneration  destroys  the  continuity  of  the  conducting 
tubules,  when  palsy  at  once  takes  place.  Then  there  are 
cases  following  sexual  excesses,  cases  for  which  neither  dur- 
ing life  nor  after  death  any  organic  causes  can  be  assigned, § 
and  which  must  therefore  be  viewed  as  due  to  enfeebleraent 


*  Brown-Sequard's  Lectures  on  the  Nervous  Centres. 

f  Ibid.,  page  114. 

X  Irving,  Indian  Annals,  No.  12,  referred  to  in  Brit,  and  For.  Med.-Chirurg. 
Eev.,  Oct.  1860. 

I  For  instance,  Case  XVIII.  in  Gull's  admirable  Series  of  Cases  of  Para- 
plegia, in  vol.  iv.  Guy's  Hosp.  Eep.,  3d  series. 


80  MEDICAL    DIAGNOSIS. 

of  functional  power.  Similar  cases  of  spinal  paralysis,  more 
or  less  complete,  may  occur  after  fatigue  and  violent  exercise, 
and  would  even  seem  to  have  been  induced  by  exposure  to 
cold  and  wet.  In  all  instances  of  spinal  palsy  due  to  im- 
paired nerve  power,  the  disorder  is  much  more  apt  to  come 
on  quickly  than  gradually,  and  a  tonic  treatment  is  likely  to 
be  followed  by  decidedly  good  effects. 

Yet  another  variety  of  paraplegia  which  may  happen 
rapidly,  is  that  form  which  has  been  described  as  acute  ascend- 
ing paralysis,  and  to  which  evidently  many  of  the  cases  of 
creeping  palsy  that  have  been  reported  belong.  It  may  come 
on  after  fatigue  and  exposure  in  persons  in  perfect  health. 
Numbness  and  pain  in  the  lower  extremities  are  soon  fol- 
lowed by  loss  of  muscular  power,  which,  in  turn,  goes  on 
rapidly  to  complete  paraplegia.  The  upper  extremities  now 
may  become  implicated,  and  sensation,  which  at  first  was 
normal,  is  enfeebled.  The  patient  is  restless,  sleepless,  but 
his  intelligence  is  unimpaired.  The  respiration  and  circu- 
lation are  then  apt  to  become  embarrassed,  and  sudden  death 
ensues  within  a  month  from  the  time  of  the  seizure.*  But 
all  cases  do  not  run  so  rapid  a  course;  and,  in  truth,  we 
meet  with  instances  in  which  the  disorder  is  rather  chronic 
than  acute.  The  muscles  in  any  case  atrophy;  and  in  those 
involved,  the  electro-muscular  contractility  is  diminished  or 
abolished,  and,  as  Jaccoudf  tells  us  in  the  cases  he  observed, 
there  is  anaesthesia  localized  over  the  affected  parts,  and  the 
reflex  movements  are  abolished.  Whether  the  primary  lesion 
be  in  the  peripheral  nerves  or  in  their  spinal  centre  is  as  yet 
an  undecided  question. 

Gradual  paraplegia  occurs  in  congestion,  in  acute  and 
chronic  inflammation  of  the  meninges,  in  myelitis,  in  soft- 
ening, in  atrophy,  in  compression  of  the  cord,  and  from 
reflex  irritation.  It  is  very  difficult  to  determine  the  feat- 
ures by  which  these  different  morbid  conditions  may  be 
distinguished  from  each  other;  indeed,  a  distinction  is  not 


*  As  in  the  case  reported  by  Haycm.     Truvaux  de  la  Societe  Medicalc 
d'Observation,  tome  ii.  1867. 
f  Clinique  Medicale. 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  81 

always  possible.  These  are  some  of  the  marks  of  discrimi- 
nation : 

lu  congestion  of  the  cord  there  is  dull  pain,  generally  con- 
fined to  the  lumbar  and  sacral  regions;  the  palsy  progresses 
slowl}^  from  below  upward,  is  preceded  by  a  feeling  of  numb- 
ness, is  almost  always  incomplete,  and  rarely  combined  with 
paralysis  of  the  sphincters.  Moreover,  the  difficulty  in  walk- 
ing is  much  greater  on  arising  after  a  night's  rest,  or  indeed 
whenever  tlie  patient  has  been  for  any  length  of  time  in  the 
recumbent  posture.  We  may  often,  too,  trace  the  conges- 
tion to  some  disturbance  of  the  circulation,  especially  of  the 
abdominal  circulation ;  or  to  alterations  in  the  composition 
of  the  blood,  as  in  rheumatism,  small-pox,  or  typhus;  or  we 
find  it  as  a  result  of  exposure  to  cold  and  wet. 

In  inflammation  oi the  meninges  we  encounter  severe  pain  in 
the  back,  but  little  influenced  by  pressure  upon  the  spine,  yet 
aggravated  by  movement,  even  by  the  acts  of  defecation  and 
of  urination  ;  sometimes  a  sensation  as  if  a  cord  had  been 
drawn  around  the  belly;  pains  in  the  limbs  similar  to  those 
of  rheumatism ;  cutaneous  hypereesthesia ;  muscular  contrac- 
tions, more  or  less  permanent  and  painful;  still  only  very 
incomplete  paralysis,  or,  indeed,  none  at  all.  When  marked 
paraplegia  follows  the  symptoms  mentioned,  we  may  suspect 
that  an  effusion  has  taken  place  which  compresses  the  spinal 
cord.  Cases  of  spinal  meningitis  are  not  unusual  among  sol- 
diers w'ho  have  slept  on  damp  ground. 

Myelitis  presents  many  of  the  same  symptoms.  But  they 
generally  come  on  by  slow  degrees,  and  the  paraj^lcgia 
becomes  very  complete.  Contractions  of  the  muscles  are 
uncommon,  and  certainly  not  permanent,  the  muscles  are 
usually  limber;  there  is  comparative!}^  little  pain,  none  on 
pressure  at  any  part  of  the  spine,  or  on  motion,  and  anaes- 
thesia is  apt,  sooner  or  later,  to  show  itself.  Further,  we 
generally,  though  not  constantly,  find  the  urine  allcaline,  and, 
as  a  rule,  a  want  of  control  over  the  bladder  and  rectum  exists. 
In  acute  cases  there  are,  as  in  acute  spinal  meningitis  (with 
■which,  indeed,  myelitis  may  be  complicated),  heat  of  skin 
and  a  frequent  pulse.  In  many  instances  w^e  notice  erection 
of  the  penis.     Reflex  movements  are  gradually  abolished  in 

6 


82  MEDICAL   DIAGNOSIS. 

the  palsied  limbs,  and  involuntary  contractions  can  no  longer 
be  excited  in  them.* 

Softening  of  the  cord  cannot,  with  any  certainty,  be  distin- 
guished from  chronic  inflammation,  often,  in  truth,  a  cause 
of  the  softening.  Nor  can  the  paraplegia  consequent  upon 
atrophy  of  the  cord  be  clearly  separated.  Indeed,  although 
it  i3  stated  that  we  may  infer  its  presence,  if  the  history  of 
the  patient  prove  him  to  have  been  subject  to  tremulous 
movements,  and  an  unsteady  gait ;  if  difficulty  in  urination, 
spasmodic  muscular  contractions,  or  sudden  muscular  jerks 
have  preceded,  or  accompany  the  failing  sensation  and  the 
loss  of  motion  ;  yet  of  atrophy,  excepting  when  in  connection 
with  locomotor  ataxia,  we  have  no  trustworthy  knowledge. 
In  the  form  of  atrophy  with  hardening,  the  so-called  sclerosis 
of  the  cord,  we  find  chiefly  the  symptoms  of  atrophy  just 
alluded  to.  But  a  great  deal  depends  on  the  seat  of  the 
lesion.  Thus,  when  limited  to  the  posterior  column,  the 
symptoms  are  those  of  locomotor  ataxia ;  when  to  the  anterior 
lateral,  we  meet  with  a  paraplegia  of  slow  development  and 
with  coexisting  derangement  of  the  bladder  and  rectum;  in 
more  general  sclerosis,  or  when  difi:used  and  in  patches,  at- 
tacks of  severe  pain,  cramps,  or  permanent  contractions  are 
apt  to  accompany  the  gradually  extending  and  very  general 
palsy.f  In  tumors  pressing  upon  the  spinal  cord  or  seated  in 
its  substance,  especially  those  of  a  cancerous  nature,  there  is 
much  pain  over  the  seat  of  the  tumor,  with  very  gradual  paraly- 
sis, which  is  conjoined  to  impaired  sensation  manifest  from 
the  very  beginning  of  the  disease,  and  in  some  instances  to 
priapism  ;  and  emaciation  and  signs  of  a  grave  constitutional 
disease  often  attend  the  palsy. 

But  what  of  the  re/?ex  paraplegia,  to  which  Brown-Sequard 
has  of  late  years  so  cogently  called  attention,  and  which  is 

*  An  altered  sensibility  to  lieat  and  cold  when,  for  instance,  a  sponge  soaked 
in  warm  water  or  a  piece  of  ice  is  applied  to  the  spine  over  the  inflamed  spot, 
has  been  spoken  of  as  a  diagnostic  test.  In  either  case  the  sensation,  when 
the  diseased  part  is  reached,  changes  to  a  burning  sensation.  Tliis  symptom 
is.  however,  far  from  constant,  and  cannot  be  accepted  as  conclusive. 

f  See,  for  instance,  the  cases  referred  to  in  Jaccoud's  Clinique  Medicale ; 
also  in  an  elaborate  article  by  Meredith  Clymer,  New  York  Medical  Journal, 
May,  1870. 


DISEASES    OF    THE   BRAIN,  SPINAL    CORD,  ETC.  83 

caused  "by  the  most  varied  irritations  of  the  skin,  the  rau- 
cous and  serous  membranes,  the  abdominal  or  thoracic  vis- 
cera, as  well  as  of  the  genital  organs  or  the  trunks  of  the 
spinal  nerves  ?"  Can  we  isolate  it  from  the  paraplegia  of 
organic  spinal  origin  ?  N'ot  with  any  certainty,  unless  we 
can  discern  the  source  of  the  irritation,  obtain  a  clear  history 
of  the  case,  and  satisfy  ourselves  of  the  absence  of  the  spe- 
cial symptoms  of  an  organic  disease  of  the  spine  or  its  con- 
tents. Some  distinctive  features  are,  that  the  muscles  do  not 
become  atrophied ;  that  their  reflex  power  is  comparatively 
unimpaired ;  that  anaesthesia  is  exceptional ;  that  the  palsy 
is  seldom  complete ;  that  some  muscles  are  much  more 
afi'ected  than  others;  that  spasms  in  the  paralyzed  muscles 
are  extremely  uncommon  ;  that  there  are  very  rarely  pains 
in  the  spine,  either  spontaneously,  or  on  pressure,  or  by  per- 
cussion, or  by  applying  ice,  or  a  hot  moist  sponge.  Then  it 
is  stated  that  "  in  a  short  time  a  much  greater  probability  of 
the  accuracy  of  the  diagnosis  will  spring  from  the  corre- 
spondence between  changes  in  the  degree  of  the  paralysis 
with  changes  in  the  visceral  disease  or  external  irritation 
that  is  supposed  to  have  produced  the  paraplegia,"* 

So  much  for  paraplegia.  We  shall  now  examine  some  of 
the  other  clinical  varieties  of  paralysis ;  and  first,  that  con- 
nected with  hysteria. 

In  hysterical  jparalysis  there  is  no  structural  affection  of  the 
brain,  and  yet  all  looks  as  if  this  were  the  case.  What  dis- 
tinguishes this  paralysis  from  that  of  organic  cerebral  disease, 
is  its  occurrence  in  markedly  hysterical  persons ;  its  sudden 
appearance,  and  frequently  its  just  as  sudden  disappearance  ; 
its  coming  on  generally  under  the  influence  of  some  power- 
ful emotion ;  the  usual  absence  of  any  signs  of  a  lesion  of 
the  nervous  centres,  excepting  the  paralysis ;  the  incomplete 
character  of  the  palsy,  the  patient  being  sometimes  able  to 
move  while  under  strong  excitement;  the  unimpaired  mo- 
tion of  the  muscles  of  the  face  and  of  the  tongue ;  and  the 
ease  with  which  reflex  movements  are  brought  on  in  the 

*  Brown-Sequard,  Lectures  on  the  Diagnosis  and  Treatment  of  the  Princi- 
pal Forms  of  Paralysis  of  the  Lower  Extremities.  186L  See  also  G.  Eche- 
verria  on  Pieflex  Paralysis.    New  York,  1866. 


84  MEDICAL    DIAGNOSIS. 

liolpless  limb.  Moreover,  we  have  a  valuable  diflerential 
test  in  electricity.  The  muscles,  except  in  cases  of  very 
long  standing,  respond  perfectly  to  its  stimulus,  although, 
as  we  are  told  by  Duchenne,  the  electro-muscular  sensibility 
—the  sensation  produced  by  the  contractions  caused  by  the 
current — i^  either  diminished  or  abolished,  while  in  cerebral 
paralysis  it  is  intact. 

Hysterical  paralysis  may  seize  only  upon  one  limb,  or  part 
of  one  limb,  or  it  may,  although  it  rarely  does,  assume  a 
hemiplegic  or  paraplegic  form.  Hysterical  hemiplegia  pre- 
sents a  peculiarity  in  the  gait,  on  which  Todd*  lays  great 
stress.  "  In  walking,  when  the  palsy  is  pretty  complete,  the 
leg  is  drawn  along  as  if  lifeless,  sweeping  the  ground."  It 
is  not  swung  round,  describing  the  arc  of  a  circle,  as  it  is  in 
ordinary  hemiplegia.  The  palsy  is  almost  invariably  left- 
sided.  It  may  be  conjoined  to  very  decided  anresthesia, 
which  passes  beyond  the  paralyzed  part  to  the  nearest  por- 
tion of  skin  and  mucous  membrane,  though,  as  a  rule,  still 
limited  to  the  same  side.  Thus  we  find  the  pituitary  mem- 
brane of  one  nostril  rendered  insensible,  if  the  loss  of  feeling 
should  affect  the  face. 

Rheumatic  j)aTalysis  resembles  hysterical  paralysis  in  being 
ordinarily  very  limited.  It  may  affect  any  muscle,  or  any 
group  of  muscles  in  the  body ;  sometimes  the  rheumatic 
poison  disorders  the  portio  dura,  and  we  observe,  in  con- 
sequence, facial  palsy.  Rheumatic  paralysis  is  recognized 
by  the  history  of  the  case;  by  the  evidences  of  a  rheumatic 
attack ;  by  the  rapid  development  of  the  p)alsy ;  by  the  pain 
that  attends  it ;  and  by  its  being  unaccompanied  by  symp- 
toms strictly  referable  to  a  disease  of  the  brain.  The  mus- 
cles themselves  are  readily  acted  upon  by  electricity,  unless 
their  structure  be  altered. 

Faralysis  from  lead  jJoisoning  occurs  primarily,  and  some- 
times only,  in  the  extensor  muscles  of  the  arm,  occasioning 
the  well-known  wrist-drop.  Gradually  other  muscles  be- 
come involved :    there  is  loss  of  power  in  the  ball  of  the 


*  Clinical  Lectures  on  Paralysis  and  other  Affections  of  the  Nervous  Sys- 
tem.    Lecture  XIII. 


DISEASES    OF   THE    BRAIN,  SPINAL    CORD,  ETC.  85 

thumb,  in  the  deltoid,  and  in  the  triceps ;  but  not  in  the  in- 
tercostal muscles,  or  in  those  of  the  lower  extremities.  The 
disturbed  muscles  on  both  sides  of  the  body  waste,  and  en- 
tirely lose  their  irritability  to  electricity.  The  patient  is 
"sveak,  his  movements  tremulous;  he  has  the  peculiar  blue 
line  on  the  gums;  is  obstinately  constipated,  and  subject  to 
colic.  Sometimes  the  poison  seizes  upon  the  brain,  and  epi- 
leptic convulsions  and  other  signs  of  a  serious  cerebral 
trouble  appear.  From  the  locality  of  the  palsy,  in  addition  to 
the  accompanying  symptoms  and  the  knowledge  of  the  man's 
employment,  the  diagnosis  is  usually  arrived  at  with  ease. 

Diphtheritic  paralysis  is  a  remarkable  sequel  of  diphtheria. 
It  follows  an  attack  of  that  disease  within  a  fortnight  or  two 
months,  and,  therefore,  after  the  patient  is  apparently  fully 
convalescent.  It  may  be  very  localized,  merely  affecting  the 
palate  or  the  phaiynx;  or  ver}^  general,  fastening  upon  both 
of  the  lower,  and  even  upon  the  upper  extremities.  When 
extensive,  it  is  always  ushered  in  by  a  throat  palsy.  It 
ensues  gradually, — day  by  day  the  muscular  power  is  more 
and  more  enfeebled.  The  loss  of  motion  is  often  preceded 
by  numbness  and  formication.  The  palsy  mends  as  slowly 
as  it  comes  on,  yet  most  cases  fully  recover.  How  it  is  pro- 
duced is  difficult  to  determine.  It  may  be  that  the  poison 
acts  directly  by  enfeebling  the  nervous  force,  or  that  the 
paralysis,  like  that  sometimes  attending  extreme  ansemia,  is 
primarily  due  to  the  marked  impoverishment  of  the  blood, 
by  which  means  ultimately  the  nutrition  of  the  nervous  cen- 
tres is  deteriorated.  The  brain  itself  shows  no  signs  of  dis- 
ease ;  at  least  there  were  no  symptoms  of  cerebral  mischief 
in  the  cases  which  have  come  under  my  observation. 

Paralysis  from  syphilis  we  ffnd  in  persons  presenting  signs 
of  constitutional  syphilis,  and  in  whom  any  serious  nervous 
disturbance  may  be  looked  upon  as  pointing  to  a  local  mani- 
festation of  syphilis  in  the  nervous  centres.  Not  unusually 
the  syphilitic  exudation  is  localized  in  the  course  of  one  or 
several  nerves,  and  we  have,  for  instance,  paralysis  of  one  of 
the  sixth  pair,  or  paralysis  of  the  fifth  with  or  without  paral- 
ysis of  some  other  cerebral  nerve.  But  as  syphilis  attacking 
the  nervous  system  is  chiefly  characterized  by  a  want  of  uni- 


86  MEDICAL   DIAGNOSIS. 

forniity  in  the  lesions  it  produces,  so  we  find  very  dissimilar 
phenomena  preceding  or  attending  the  palsies.  Thus  we 
may  or  may  not,  though,  in  point  of  fact,  we  most  usually 
do,  find  them  associated  with  pain  in  the  head,  with  optic 
neuritis,  with  vertigo,  and  sickness  at  the  stomach.  Decided 
vertigo  is  prone  to  occur  where  the  syphilitic  trouble  has  led 
to  a  disease  of  the  vessels,  and  is  apt  to  be  the  forerunner 
of  local  softenings,  and  of  a  rather  extended  hemiplegia. 
When  disease  of  the  membranes  has  happened,  headache 
is  generally  very  severe,  and  convulsions  occur;  the  same 
symptoms  are  encountered  when  there  is  a  mass  in  the 
hemisphere ;  though  here  again  this  form  of  mischief  may 
be  comparatively  latent,  the  patient  have  only  occasionally 
convulsions,  the  paralysis  be  slight  or  improving,  and  yet  a 
fatal  coma  follow  a  few  convulsions.  Instances  of  this  kind 
have  lately  come  under  my  observation. 

But,  as  a  rule,  syphilitic  paralysis  does  not  terminate  fatally. 
In  truth,  the  ease  with  which  the  palsy  and  its  attending 
phenomena  yield  to  treatment,  if  we  except  marked  in- 
stances of  hard  nodules,  the  result  of  the  poison,  forms  one 
of  the  traits  of  the  malady.  Other  common  traits,  to  speak 
in  general  terms,  and  guarded  by  what  has  been  said  of  the 
dissimilar  character  of  the  lesions,  are — that  it  commonly 
affects  persons  younger  than  those  in  whom  we  find  paral- 
ysis dependent  upon  disease  of  the  nervous  centres,  and 
chiefly  of  the  brain ;  and  that  its  manifestations  are  very 
shifting  and  capricious.  These  same  traits  characterize 
syphilitic  diseases  of  the  nervous  system  hi  which  paralj'sis 
is  not  among  the  symptoms. 

The  mischief  to  the  nervous  system  may  not  happen  for 
years  after  the  infection.  It  may  be  the  result  of  an  inher- 
ited trait.  But  such  cases  cannot  be  recognized  with  any 
certainty  unless  there  are  other  signs  of  syphilis  than  the 
suspected  nervous  symptoms ;  and  chief  among  these  signs 
is  that  valuable  test  of  congenital  syphilis  discovered  by  Mr. 
Hutchinson — a  malformation  of  the  two  upper  central  per- 
manent incisors,  which  consists  in  their  beiuof  narrower  at 
their  cutting  edges  than  at  their  insertions,  and  often 
notched. 


DISEASES    OF   THE   BRAIN,  SPINAL    CORD,  ETC.  87 

The  forms  of  paralysis  which  have  just  been  noticed  are 
mainly  such  as  are  designated  as  partial.  When  the  loss  of 
power  is  very  limited,  the  palsy  is  commonly  spoken  of  as 
local.  Several  of  these  local  paralyses  are  of  very  great  in- 
terest ;  the  one,  however — from  its  comparative  frequency, 
and  on  account  of  its  being  often  mistaken  for  a  sign  of 
intra-cranial  disease — of  particular  importance,  is  the  facial, 
or  BelVs  palsy.  The  disease  consists  in  an  affection  of  one 
of  those  facial  nerves  the  course  and  functions  of  which  Sir 
Charles  Bell  did  so  much  to  determine,  namely,  the  portio 
dura  of  the  seventh  pair.  In  consequence  of  the  derange- 
ment of  this  motor  nerve,  nearly  all  the  muscles  of  the  face 
lose  their  faculty  of  motion,  and  as  it  is  their  play  which 
gives  expression  to  the  countenance,  the  appearance  of  the 
face  is  extraordinary.  The  eyelids  are  open  and  lixed;  the 
features  rigidly  composed  on  one  side  of  the  face — for  the 
disease  is  a  one-sided  one — and  reflecting  every  change  of 
feeling  on  the  other.  In  some  cases  the  velum  palati  is  in- 
volved in  the  paralysis.  But  sensation  remains  unimpaired 
so  long  as  the  fifth  nerve  is  not  disturbed. 

The  causes  of  this  palsy  are  such  as  influence  the  dis- 
tressed nerve  in  its  course  or  at  its  periphery :  a  wound ; 
mumps;  otitis;  exposure  to  cold.  Not  being  due  to  a  cere- 
bral malady,  it  is  not  a  sign  of  serious  danger.  It  is  easily 
discriminated  from  the  facial  palsy  of  disease  of  the  brain 
by  the  inability  to  close  the  eyelids,  owing  to  the  paralysis 
of  the  orbicularis  palpebrarum;  by  the  absence  of  impaired 
sensation,  of  headache,  vertigo,  mental  confusion,  of  loss  of 
memory ;  by  the  much  more  complete,  though  strictly  local 
character  of  the  paralysis,  and,  ordinarily,  by  the  lost  electro- 
muscular  contractility.* 

In  rare  instances  the  facial  palsy  is  seen  on  both  sides. 


*  But  here  again  we  must  remember  that  the  continuous  current  may  give 
different  results  from  faradisation.  Meyer,  op.  cit,  tells  us  that  those  facial 
palsies  in  which,  a  week  after  their  appearance,  faradisation  produces  no 
muscular  movement,  while  a  feeble,  continuous  current  causes  vigorous 
contractions  in  the  muscles,  furnish  a  much  more  unfavorable  prognosis,  and 
recover  slowly  and  imperfectly.  He  supposes  the  lesion  to  be  in  the  facial 
nerve  while  in  transit  through  the  petrous  portion  of  the  temporal  bone. 


88  MEDICAL   DIAGNOSIS. 

Now  tlio  disorder  may  be  within  the  cranium  or  aiFect  the 
nerves  in  their  course.  When  dependent  simplj'  on  a  local 
atlection,  and  therefore  limited  to  the  manifestations  of 
paralysis  of  the  portio  dura,  we  find  the  same  causes  at  work 
which  give  rise  to  the  more  usual  one-sided  disease.  Ex- 
posure to  cold  and  rheumatism  are  most  frequently  men- 
tioned in  the  recorded  cases;  but  syphilis  is  also  cited  among 
the  causing  elements.  In  an  instance  detailed  bj^  Todd,  in 
his  clinical  lectures,  there  was  disease  of  the  temporal  bone, 
and  the  portio  mollis  was  also  implicated.  The  face  is  im- 
movable, or  nearly  so,  and  the  palsy  is  generally  more  com- 
plete on  the  left  side  than  on  the  right.  The  muscles  do 
not  respond  to  electricity,  or  respond  but  imperfectly,  and 
we- notice,  as  in  the  one-sided  malady,  that  a  continuous  cur- 
rent may  excite  their  action,  while  faradisation  does  not. 
Nay,  the  two  sides  may  give  different  results  in  this  respect.* 
About  other  local  palsies,  such  as  of  the  pharynx  and 
oesophagus,  of  the  larynx,  of  the  tongue,  of  the  muscles  of 
the  eye,  of  the  diaphragm,  of  isolated  muscles  of  the  trunk 
or  of  the  extremities,  it  is  impossible  here  to  enter  into  par- 
ticulars. But  there  are  some  forms  of  local  palsy  which, 
from  their  striking  interest,  it  is  necessary  to  describe.  One 
is  the  loss  of  power  in  the  wrists,  arising  from  atrophy  of  the 
muscles  in  the  overworked  parts  of  persons  whose  stomachs 
do  not  take  in  a  sutficient  supply  of  nutriment,  as  in  poorly- 
fed  and  hard-worked  shoemakers;!  another,  the  paralysis  of 
the  tongue  and  parts  concerned  in  deglutition,  to  which 
attention  has  been  chiefly  called  by  Trousseau.J     In  this 


*  Case  of  Baerwinkel,  Schmidt's  Jahrb.,  Bd.  cxxxvi.,  No.  1.  Baerwinkel 
suggests  that  the  dissimilar  reaction  is  always  owing  to  different  exudation 
and  condition  of  pressure  on  the  affected  nerve.  Thus,  in  any  case,  whether 
single  or  double,  where  galvanization  produces  contraction,  and  the  induced 
current  fails  to  do  so,  he  thinks  that  a  firm  and  extensive  exudation  com- 
presses the  nerve,  whereas  in  slight  or  serous  exudations,  faradisation  acts, 
and  a  speedy  recovery  may  be  anticipated. 

Tor  other  cases  of  double  facial  palsy,  see  Gairdner,  Lancet,  May  18,  1861 ; 
Pellet,  Travaux  de  la  Societe  Medicale,  1867  ;  Wright,  British  Medical  Jour- 
nal, Feb.  1869. 

t  Chambers  on  the  Indigestions,  p.  101,  Am.  edition. 

X  Clinique  Medicale. 


DISEASES    OF   THE    BRAIN,  SPINAL    CORD,  ETC.  89 


glossopharyngeal  paralysis,  the  first  symptoms  which  are  likely 
to  attract  attention  are,  that  the  tongue  seems  less  supple 
and  the  utterance  becomes  thick;  the  food  lodges  between 
the  teeth  and  cheek,  and  the  saliva  is  apt  to  dribble  from 
the  lips  and  corners  of  the  mouth.  As  the  paralysis  pro- 
gresses, the  shape  of  the  tongue  is  altered — it  lies  motionless 
in  the  mouth ;  the  posterior  nares  can  no  longer  be  closed 
by  the  velum  and  muscles  of  the  posterior  palatine  arch ; 
deglutition  becomes  very  difiicult,  and  the  patient  is  tor- 
mented with  hunger.  The  mucous  membrane  of  the  larynx 
is  frequently  insensible,  the  respiratory  movements  are 
unusually  weak,  and  fits  of  suffocation  ensue.  Thus  gen- 
eral debility  becomes  extreme,  and  the  patient  is  apt  to 
perish  by  the  sudden  stoppage  of  the  heart's  action.  The 
disease  is  an  unmistakable  one ;  the  only  affection  at  all  re- 
sembling it  is  double  facial  palsy  ;  but  here  the  tongue  is 
not  involved,  and,  on  the  other  hand,  in  glossopharyngeal 
paralysis  only  the  lower  part  of  the  face  is  motionless.  This 
curious  disease  may  have  an  acute  beginning.*  It  is  some- 
times complicated  with  weakness  of  the  muscles  of  one  side 
of  the  body.  Of  its  morbid  anatomy  nothing  positive  is 
known.  In  a  case  described  by  Trousseau  the  roots  of  the 
vagus,  of  the  right  hypoglossal,  and  several  of  the  anterior 
spinal  roots  were  atrophied.  It  may  be  that  the  lesion 
is  in  the  nuclei  at  the  floor  of  the  fourth  ventricle,  from 
which,  as  Lockhart  Clarke  has  shown,  the  hypoglossal,  the 
spinal  accessory,  the  vagus,  and  the  facial  are  connected. 

Now,  before  passing  on  to  other  matters,  we  shall  here  dis- 
cuss a  few  points  of  general  clinical  interest.  "We  are  some- 
times much  perplexed  to  know  if  a  palsy  is  the  result  of 
commencing  disease  of  the  brain  or  spinal  cord,  or  if  it  is 
purely  local.  To  speak  first  of  the  brain :  the  cerebral 
symptoms  may  not  be  very  marked,  or  they  may  be  so  con- 
tradictory as  to  afford  no  real  help  in  diagnosis.  We  may 
have  nothing  to  fall  back  upon  but  our  knowledge  of  the 
anatomy  and  physiology  of  the  nervous  system;  and  if  we 
discover  that  the  palsy  affects  muscles  that  are  supplied  by 

*  Herard,  I'Union  Med.,  Xo.  3-3,  1868. 


90  MEDICAL    DIAGNOSIS. 

difterent  nerves,  and  sucli  as  have  uo  communication  with 
each  other,  we  may  set  down  the  complaint  as  having  a  cen- 
tral origin. 

Another  most  important  question  which  may  arise — and  not 
only  with  reference  to  limited,  but  also  to  extended  palsies — 
is,  whether  the  loss  of  muscular  power  be  not  in  reality  de- 
pendent upon  changes  in  the  muscular  tissue,  and  especially 
upon  that  change  found  in  the  disorder  known  as  "  wasting 
palsy,"  or  progressive  muscular  atrophy.  Of  the  nature  of  this 
strange  affection  we  are  as  yet  in  doubt.  It  was  once  thought 
to  be  owing  to  a  disease  of  the  anterior  roots  of  the  spinal 
nerves;  but  the  researches  of  Aran  and  of  Duchenne  have 
led  to  the  opinion  that  it  consists  in  an  atrophy  connected 
with  fatty  transformation  of  the  muscular  fibres,  due  pri- 
marily to  changes  of  these  structures.  Still,  though  this 
view  is  perhaps  the  one  most  generally  adopted,  and  w^ould 
seem  to  be  favored  by  the  cases  brought  together  and  ana- 
lyzed by  Dr.  Roberts,  in  his  Essay  on  "Wasting  Palsy,  it  is 
very  possible  that,  by  patient  and  careful  examinations  of  the 
spinal  cord,  we  shall  find  minute  structural  changes  in  its 
substance  confined  to  isolated  spots,  and  sufiicient  to  account 
for  the  disease  in  the  muscles.  This  was  done  by  Lockhart 
•  Clarke,  in  a  case  recorded  in  Beale's  Archives  for  1861.  The 
sympathetic  has  been  found  diseased  in  its  cervical  ganglions 
by  Schneevogt  and  by  Jaccoud;*  and,  on  the  whole,  the  con 
nection  with  some  nervous  lesion  is  too  constant  for  us  to  look 
upon  it  as  a  coincidence. 

The  main,  and  always  the  most  striking  sign  of  progressive 
muscular  atrophy  is  a  constantly  increasing  inability  to  per- 
form certain  movements.  When  the  muscle  chiefly  concerned 
in  the  attempted  motion  is  examined,  it  is  found  to  have  dwin- 
dled. Soon  other  muscles  follow;  and  their  w^asting,  too,  is 
accompanied  by  still  further  impaired  motion.  Portions  of 
the  disorganizing  muscles  sometimes  twitch,  much  to  the 
annoyance  of  the  patient.  The  circulation  in  the  affected 
part  becomes  languid;  it  is  also  very  susceptible  to  cold,  and 
indeed  its  temperature  is  lowered,  there  is  a  feeling  of  numb- 


*Clinique  Medicale ;  also  Simon,  Nouveau  Diction,  do  Med.,  1866. 


DISEASES    OF   THE    BRAIN,  SPINAL    CORD,  ETC.  91 

ness  iu  it,  but  very  rarely  neuralgic  pains;  to  pressure  it  is 
soft  and  yielding.  The  muscles  most  frequently  attacked  are 
those  of  the  hand ;  the  flexors  and  supinators  of  the  fore- 
arm ;  the  biceps,  the  deltoid,  and  the  other  muscles  of  the 
shoulder;  sometimes  the  disease  commences  in  the  trunk 
and  lower  extremities.  The  decrease  of  the  muscular  fibres 
gives  rise  to  strange  and  palpable  deformities,  and  when  the 
muscles  of  the  trunk  are  involved,  to  extraordinary  positions 
of  the  body,  in  consequence  of  all  antagonism  to  the  healthy 
muscles  having  been  removed. 

"When  we  contrast  this  curious  malady  with  the  forms  of 
paralysis  with  which  it  may  be  confounded,  we  find  several 
features  at  variance.  From  cerebral  hemiplegia  it  differs  by 
its  much  more  gradual  invasion,  by  the  rapidity  but  want  of 
uniformity  with  which  the  muscular  atrophy  takes  place, 
and  by  the  absence  of  disordered  intellect  and  of  other  signs 
of  disease  of  the  brain.  From  extended  general  paralysis 
of  cerebral  origin  it  is  separated  by  the  non-existence  of 
cerebral  phenomena,  and  by  the  capricious  and  unequal 
manner  in  which  the  atrophy  seizes  upon  the  muscles.  Dif- 
ficulty in  articulation  and  in  deglutition  may  occur  in  either ; 
but  in  the  one  case  they  are  associated  with  disturbed  men- 
tal faculties,  in  the  other  they  are  not.  From  general  spinal 
paralysis  it  is  mainly  diagnosticated  by  the  spinal  malady 
affecting  primarily  all  the  muscles  of  the  lower  extremities 
before  those  of  the  upper  become  involved. 

Another  means  of  distinguishing  the  muscular  atrophy 
from  the  diseases  just  considered,  is  by  means  of  instruments 
by  which  portions  of  the  affected  textures  can  be  removed 
and  subjected  to  microscopical  examination.  Duchenne  has 
invented  a  trocar  for  the  purpose,  and  so  have  other  patholo- 
gists.* 

Then  we  possess  a  touchstone  in  the  use  of  electricity.  In 
progressive  muscular  atrophy  the  muscles  respond  feebly, 
still  they  respond;  and  in  portions  where  there  are  many 
sound  fibres  they  contract  energetically.     In  general  paral- 


*  For  an  exact  description  of  these  different  instruments,  see  Amer.  Jour, 
of  Med.  Sciences,  Oct.  1869,  p.  434. 


92  MEDICAL    DIAGNOSIS. 

ysis  of  spinal  origin  their  contractile  power  is  lost ;  no  ef- 
fort of  the  patient,  no  current,  whatever  its  strength,  causes 
them  to  move.     In  general  cerebral  paralysis,  on  the  other 
hand,  their  electrical  contractility  is  intact.     The  difficulty 
of  distinguishing  cases  of  local  paralysis  from  progressive 
muscular  atrophy  is  at  times  very  great.     Yet  generally  we 
may  separate  the  latter,  say,  for  instance,  from  rheumatic 
paralysis,  by  noticing  that  this  affects  a  group  of  muscles 
rather  than  one  muscle,  or  than  one  muscle  here  and  another 
there.     Further,  the  atrophied  muscle  in  the  rheumatic  dis- 
order is  the  seat  of  pain  intensified  by  movement,  and  it  con- 
tracts  well   under  the   electric  stimulus, — phenomena   the 
reverse  of  those  presented  by  fatty  transformation  of  the 
muscular  textures.     The  same  test  by  the  electric  current  is 
of  service  in  discriminating  the  muscular  disease  from  hys- 
terical paralysis,  from  paralysis  consequent  upon  injuries  to 
nervous  trunks,  and  upon  lead  poisoning.     In  the  first  of 
these  palsies  the  electrical  contractility  is  intact,  in  the  others 
it  is  abolished ;  while  in  progressive  muscular  atrophy  it  is 
simply  enfeebled.* 

Paralyzed  muscles  atrophy,  and,  as  especially  happens  in 
children,  may  subsequently  undergo  a  fatty  change.  To 
distinguish  such  a  condition  from  progressive  muscular 
atrophy  is  difficult.  We  have  to  lay  great  stress  on  the 
symptoms  which  ushered  in  the  paralytic  state.  This  is 
particularly  important  in  attempting  to  discriminate  with 
reference  to  the  so-called  essential  iMralysis  from  which  chil- 
dren sufier ;  for  we  attach  great  weight  to  the  fever  and  the 
cerebral  symptoms  so  commonly  preceding  the  palsy,  or  to  its 
occurring  suddenly  during  teething.    Besides,  an  entire  limb, 

*  These  remarks  are  based  on  the  results  obtained  by  Duchenne  by  means 
of  faradisation  [De  V electrisation  localisce,  Paris,  1861) ;  and  are,  I  think,  in 
the  main,  correct.  But,  as  above  mentioned,  the  condition  of  the  muscles 
influences  somewhat  the  electro-muscular  contractility ;  some  of  the  state- 
ments may  be,  therefore,  too  absolute,  and  cannot  be  solely  relied  upon  in 
forming  a  differential  diagnosis.  The  modifying  circumstances  alluded  to,  as 
I  repeatedly  have  had  opportunities  of  observing,  show  themselves  chiefly  in 
some  old-standing  cases  of  cerebral,  of  rheumatic,  and,  though  this  is  less 
certain,  of  hysterical,  paralysis,  in  all  vf  which  the  excitability  of  the  muscles 
may  be  very  much  impaired,  or  even  temporarily  lost. 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  93 

or  even  both  legs  and  arms,  may  from  the  onset  be  affected. 
The  subsequent  history,  too,  is  dissimilar.  There  is  often 
a  steadily  progressing  recovery  within  six  months  or  sooner; 
though  the  disorder  may  last  for  three  or  four  years,  or 
even  much  longer.  The  affected  muscles  are  apt  to  begin 
to  atrophy  after  the  paralysis  has  lasted  a  month,  and  when 
their  wasting  is  marked  they  no  longer  respond  to  the  in- 
duced electrical  current,  though  they  may  still  react  strongly 
under  the  constant  galvanic  current.*  In  protracted  cases, 
contractions  of  the  joints  take  place,  and  atrophy  of  portions 
of  the  osseous  system  occurs,  or  rather  a  want  of  its  develop- 
ment in  the  blighted  parts.  Then  in  forming  a  diagnosis  we 
may  take  into  account  the  extreme  rarity  with  which  chil- 
dren are  attacked  with  progressive  fatty  atrophy — a  disease 
of  adults,  and  pre-eminently  of  those  of  the  male  sex  who  use 
their  muscles  continuously  and  violently. 

The  same  difference  in  age  helps  us  also  to  distinguish 
that  curious  disorder,  chiefly  described  by  Duchenne,  and 
which  he  names  pseudo-hi/pertrojjhic  muscular  jmralysis.  A 
disease  exclusively  of  childhood,  it  is  characterized  b}'  weak- 
ness in  the  lower  limbs  primarily,  the  muscles  of  which,  and 
particularly  the  gastrocnemii,  increase  greatly  in  size.  Yet, 
notwithstanding  this  apparent  hypertrophy,  there  is  debility, 
with  a  waddling  gait,  and  as  the  disease  progresses  and  be- 
comes more  general,  complete  paralysis  may  ensue,  with 
rapid  dwindling  of  the  affected  muscles.  These,  when  exam- 
ined microscopically,  show,  in  the  stage  of  increase,  large 
masses  of  interstitial  fatty  matter  and  an  augmentation  of 
the  interstitial  connective  tissue. f 

The  iwognosis  of  paralj^sis,  viewed  in  a  general  manner,  is 
unfavorable;  but  to  this  general  view  there  are  many  and 
palpable  exceptions.  The  cause  of  the  palsy  materially  in- 
fluences its  probable  termination.  Palsies  produced  by  poi- 
sons usually  end  in  recovery;  so  do  those  owing  to  cachexias, 
to  alterations  in  the  blood,  to  syphilis,  to  hysteria,  and  to 
wounds  of  nerves.    Rheumatic  paralysis  is  frequently  very  ob- 

*  Hammond,  Jnurn.  of  Psychology,  vols.  i.  and  ii. 
f  Archives  Gener.,  tome  i.,  1868. 


94 


MEDICAL    DIAGNOSIS. 


stiuate,  as  is  also  tlie  paralysis  which  has  its  origin  in  nervous 
exhaustion  occasioned  by  excesses.  The  palsy  resulting  from 
a  chronic  cerebral  or  spinal  lesion  yields  a  grave  prognosis. 

In  the  treatment  applicable  to  paralysis  two  main  indica- 
tions arise.  The  first  is,  to  treat  the  palsy  as  much  as  pos- 
sible— and  the  more  recent  it  is,  the  more  this  is  possible — 
according  to  its  cause.  The  second  is,  to  keep  up  so  far  as 
it  can  be  kept  up,  the  nutrition  of  the  paralyzed  parts  and 
to  stimulate  them  to  action.  The  former  indication  is  best 
fulfilled  by  constitutional,  the  second  by  local  means. 

Before  proceeding,  we  will  examine  the  main  forms  of 
paralysis  which  we  have  been  studying,  arranged  in  a  tabular 
form,  and  chiefly  with  the  view  of  ascertaining  its  seat,  pre- 
mising that  the  statements  must  be  received  rather  as  gen- 
erally true  than  as  statements  which  are  absolutely  so. 


TABULAE  VIEW  OF  PAEALYSIS. 


Symptoms. 
Inability  to  move  leg  and  arm  of 
one  side.  Sensation  unimpaired, 
or  slightly  impaired.  Incomplete 
paralysis  of  muscles  of  face ;  mouth 
drawn  toward  healthy  side.  Elec- 
tro-muscular contractility,  as  a  rule, 
preserved  ;  may  be  increased. 


Seat  of  Lesion. 

Corpus  striatum  chiefly,  less  markedly 
optic  thalamus,  both  on  side  oppo- 
site to  the  palsy. 


Same  symptoms,  but  paralysis  of 
face  on  opposite  side  to  that  of  arm 
and  leg,  and  usually  marked  facial 
palsy ;  loss  of  sensation  on  one  side 
of  face;  giddiness;  nausea,  etc. 


Pons  Varolii,  on  side  opposite  to  palsy 
of  limbs.  The  part  atFected  is  be- 
low decussation  of  facial  nerve. 


Same  symptoms,  but  face  paralyzed     Pons  Varolii,  and  at  level  of  decussa- 
on  both  sides.  tion  of  facial  nerve. 


Paralysis  of  arm  and  leg  on  one  side ;     Crus  cerebri  on  side  corresponding  to 
slight  paralysis  efface;  third  nerve         paralysis  of  third, 
paralyzed  on  other  side. 


Motion  more  or  less  completely 
affected  on  both  sides  of  body; 
sensibility  diminished  or  lost  on 
one  side;  increased  on  the  other; 
the  same  with  temperature. 


Medulla  oblongata  on  side  of  in- 
creased sensibility  and  temperature, 
and  at  level  of  decussation  of  ante- 
rior pyramids. 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  95 

Symptoms.  Seat  of  Lesion. 

Both  legs  paralyzed  as  to  motion  and     In  the  cord  at  npper  limit  of  lumbar 
sensation.     Paralysis  of  muscles  of         region,  or  higher  up. 
respiration  ;  loss  of  power  over  blad- 
der and  rectum  ;    electro-muscular 
contractility  diminished  or  lost. 

Both   legs  paralyzed  as  to  sensation     In  the  cord  at  upper  limit  of  sacral 
and  motion,  except  muscles  supplied         region, 
by  anterior   crural   and   obturator 
nerves;  loss  of  power  over  bladder 
and  rectum.     . 

Locomotor  Ataxia. — In  this  disorder  we  have  uncertainty 
of  motion  and  apparent  palsy;  or,  in  the  words  of  Duchenue, 
who  gave  it  the  name  of  progressive  disorder  of  locomotion 
— aiaxie  locomotrice  progressive — it  consists  in  "a  progressive 
abolition  of  the  co-ordination  of  movement  with  apparent 
paralysis  contrasting  with  the  integrity  of  muscular  force." 
The  patient  is  not  deprived  of  the  power  of  motion,  but 
of  the  power  of  controlling  his  motion  :  hence  he  staggers  in 
his  walk,  or  cannot  walk  at  all  without  support;  it  is  evident 
that  the  muscles  do  not  obey  the  will. 

"  The  affected  individuals,"  says  Duchenne,  in  summing 
up  the  main  signs  of  the  malady,  "present  a  group  of  identical 
phenomena:  the  same  commencement,  same  symptoms,  same 
progress,  same  termination.  Thus,  in  the  majority,  paralysis 
of  the  sixth  pair  or  of  the  third  pair,  a  weakening  or  even  a 
loss  of  vision,  attended  with  inequality  of  the  pupils,  are  the 
phenomena  present  either  at  the  onset,  or  are  precursory  to 
the  disturbance  of  the  co-ordination  of  movement.  Very 
characteristic  piercing  pains,  wandering,  erratic,  of  short 
duration,  rapid  as  lightning,  or  similar  to  electric  discharges, 
returning  in  paroxysms,  and  attacking  all  the  regions  of  the 
body,  accompany  or  follow  these  local  paralyses.  These 
phenomena  constitute  the  first  stage.  Subsequently,  after 
a  time  varying  from  several  months  to  several  years,  there 
appear  in  the  second  stage :  vertigo ;  difliculty  in  maintain- 
ing the  equilibrium  of  the  body  and  in  co-ordinating  move- 
ments ;  soon  afterward,  or  sometimes  simultaneously,  a 
diminution,  or  a  loss  of  tactile  sensibility  or  of  sensibility 
to  pain  (analgesia  and  anaesthesia),  at  first  in  the  inferior. 


96  MEDICAL    DIAGNOSIS. 

more  rarely  in  the  superior  extremities.    Finally,  in  the  third 
stage  the  disease  becomes  general. 

"During  the  course  of  the  malady  occur  frequently  dis- 
orders of  tlie  functions  of  the  rectum  and  of  the  bladder, 
without  sugar  or  albumen  being  present  in  the  urine.  The 
intellect  remains  unimpaired ;  speech  is  neither  hesitating 
nor  embarrassed;  the  electro-muscular  contractility  is  intact; 
and  the  muscles  undergo  no  alteration  of  nutrition  or  of  their 
tissue.  Ordinarily,  too,  the  malady  is  'progressive  in  the  strained 
sense  which  Requin  has  given  to  the  term,  namely,  that  the 
disease  has  not  merely  a  tendency  to  become  general,  but  it 
often  has  also  a  fatal  termination."* 

Trousseau,  in  his  Clinical  Lectures,  points  out,  as  a  diag- 
nostic sign,  of  value  even  in  the  early  stages  of  ataxia,  the 
strange  eflect  of  closing  the  eyes :  this  gives  rise  to  an  in- 
crease of  the  uncertainty  of  the  patient's  gait  to  such  an  ex- 
tent that  he  is  incapable  of  taking  a  single  step  without 
falling,  or  to  an  utter  inability  to  stand  erect  with  his  feet  in 
juxtaposition  without  instantly  losing  his  balance.  But  the 
same  sign  is  occasionally  observed  in  beginning  paraplegia  and 
other  forms  of  palsy,  and  is  thus  not  strictly  pathognomonic. 
And  as  regards  some  of  the  other  symptoms,  admitting  now, 
as  beyond  doubt,  that  the  so-called  Duchenne's  disease  is, 
in  its  essential  features,  identical  with  a  form  of  palsy  clearly 
recognized  by  Todd,  and  with  the  malady  described  byEom- 
berg  and  several  German  pathologists  under  the  name  of 
tabes  dorsalis,  it  may  well  be  a  question  whether  we  can  take 
as  distinctive,  that  in  the  affection  described  by  Duchenne 
the  disturbance  of  the  cranial  nerves  precedes  the  uncer- 
tainty of  movement  of  the  muscles  of  the  lower  extremities; 
whether  we  can  consider  that  the  early  symptom,  accounted 
by  him  as  the  most  pathognomonic — the  violent  pains  (and 
which  he  declares  not  to  have  met  with  only  once  in  one 
hundred  cases) — is  so  characteristic  that  we  are  justified  in 
regarding  as  belonging  to  a  separate  disease  those  instances 
of  apparent  paralysis,  which  exhibit,  on  close  examination, 
an  imperfect  power  of  co-ordination  of  the  muscles,  and  par- 


*  Electrisation  Localis^e.     Paris,  1861. 


DISEASES    OF    THE    BKAIN,  SPINAL    CORD,  ETC.  97 

ticalarlj  of  those  of  the  lower  limbs,  but  in  which  the  signs 
just  alluded  to  are  absent.  If,  then,  we  admit  the  identity 
of  tabes  dorsalis  and  of  progressive  muscular  ataxia,  and  do 
not  even  view  the  latter  as  a  distinct  variety  of  the  former, 
we  must  also  admit,  in  accordance  with  other  observations 
than  those  of  Duchenne,  that  the  first  symptom  of  the  affec- 
tion often  consists  of  a  sense  of  weakness  and  weariness  in 
both  legs,  or  only  in  one,  and  that  the  darting  pains  in  the 
lower  extremities  are  not  constant.  The  dwindling  of  the 
muscles,  especially  of  those  of  the  nates,  legs,  and  back,  and 
their  weakened  or  lost  contractility  when  subjected  to  a  gal- 
vanic current,  which  Romberg*  notices,  may  be  due  to  coex- 
isting chronic  myelitis.  It  is  indeed  undoubted  that  some 
of  the  phenomena  which  have  been  ascribed  to  tabes  dor- 
salis more  strictly  appertain  to  concurring  complaints,  and 
thus  there  is  some  confusion  in  determining  its  exact  clinical 
historv. 

But  summing  up  the  truly  significant  features  of  locomotor 
ataxia,  we  find  a  peculiar  gait,  stumbling,  staggering,  with- 
out true  paralysis;  shooting,  neuralgic  pains;  numbness  in 
the  feet  and  legs,  with  sensibility  defective,  excepting  to  tem- 
perature ;  frequent,  but  by  no  means  invariable  impairment 
of  siofht  or  hearina;', — all  coexistinsr  with  undisordered  mental 
faculties,  with  well-nourished,  vigorously  contracting  mus- 
cles, and  with  an  absence  of  tremor  or  spasm.  Moreover, 
thougli  there  may  be  some  want  of  perfect  action  in  the 
muscles  of  the  upper  extremities,  the  real  features  of  ataxia 
are  met  with  in  the  lower. 

This  curious  atiection  is  probably  due  to  a  peculiar  de- 
generation and  atrophy  of  the  posterior  column  of  the  cord, 
bearinnino-  or  havins;  its  chief  seat  in  the  lumbar  region.  Yet 
it  is  not  certain  that  this  is  the  invariable  anatomical  change, 
or  that  the  group  of  symptoms  constituting  muscular  ataxia 
may  not  be  linked  to  various  diseases  of  the  cord  and  brain. 

But  to  return  to  a  consideration  of  the  diagnosis  of  the 
malady  under  discussion.  Let  us  first  examine  how  it  differs 
from  the  general  jiaralysis  of  the  insane.     Both  maladies  are 


*  Nervous  Diseases.     Sydenham  Sue.  Transla.,  vol.  ii. 

7 


98  MEDICAL    DIAGNOSIS. 

very  chronic  in  tlieir  course,  and  in  both  there  is  loss,  or 
certainly  impairment  of  the  faculty  by  which  we  co-ordinate 
the  action  of  the  muscles.  In  the  one  case,  however,  it  exists 
with  tremors,  Avith  thickness  of  speech,  with  dementia,  and, 
at  least  in  its  earlier  stages,  with  a  certain  amount  of  force 
in  the  irregular  muscular  movements;  but  without  strabis- 
mus, Avithout  amaurosis,  and  witliont  the  sharp,  peculiar 
pains  of  ataxia.  Then,  in  this  malady,  the  upper  extremities 
share  far  less  frequently  in  the  disorder,  and  when  they  do, 
there  is  in  them  rather  cutaneous  anaesthesia,  with  some 
trembling  and  incomplete  paralysis,  than  an  obvious  failure 
of  co-ordinating  power. 

"With  reference  to  the  distinction  of  progressive  locomotor 
ataxia  from  most  of  the  diseases  of  the  spinal  cord,  it  is  only 
necessary  to  remark  on  the  extreme  rarity  of  real  muscular 
spasm  in  ataxia;  from  the  ordinary  spinal  paraplegia  the 
result  of  myelitis,  it  difiers  in  the  fact  that  the  muscles  act 
with  strength,  the  patient  can  flex  and  extend  his  legs  and 
kick  vigorously,  while  in  paralysis  the  affected  limbs  cannot 
move. 

A  dimimdion  or  loss  of  the  muscular  sense — that  guiding  sense 
by  which  we  judge  of  the  position  of  the  limbs,  of  the  degree 
of  resistance  opposed  to  muscular  movements,  and  are  con- 
scious of  these  movements,  and  which,  particularly  in  hys- 
terical patients,  may  become  very  much  disturbed— is  apt  to 
occasion  some  difficultv  in  dias-nosis,  since  in  locomotor 
ataxia  the  muscular  sense  may  be  also  deficient,  and,  on  the 
other  hand,  in  the  former  morbid  state  the  muscular  motions 
be  somewhat  impaired,  and,  as  in  ataxia,  the  feet  feel  numb 
in  standing  and  in  walking,  and  the  patient  be  unable  to 
walk  in  the  dark.  But  there  is  this  difference  :  where  merely, 
the  muscular  sense  is  affected,  he  can  walk  and  perform  all 
movements,  even  those  of  a  complex  nature,  without  vacilla- 
tion, so  long  as  his  eye  is  fixed  on  them  and  superintends  and 
gives  them  direction  ;  while,  in  ataxia,  the  derangement  of 
muscular  co-ordination  renders,  even  with  the  aid  of  sight, 
the  movements  uncertain  and  irregular.  Then  cutaneous 
anaesthesia  is  apt  to  coexist  with  this  malady;  and  the  treat- 
ment will  throw  light  on  a  doubtful  case,— the  local  use  of 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  90 

electricity  will  usually  cure  the  loss  of  muscular  sense  in  hys- 
terical paralysis,  but  it  has  no  curative  effect  in  ataxia. 

Diseases  of  the  cerebellum  produce  many  of  the  phenomena 
regarded  as  peculiar  to  locomotor  ataxia.  But  the  gait  of 
the  patient  in  cerebellar  disorders  is  precisely  that  of  a 
drunken  man :  when  attempting  to  Avalk,  he  leans  to  one 
side,  moves  in  the  arcs  of  a  circle,  or  describes  zigzags;  and 
when  standing  erect,  his  body  swings  backward  and  forward, 
or  from  side  to  side,  though  his  feet  remain  quietly  fixed  on  the 
ground.  In  ataxia,  on  the  other  hand,  the  muscular  contrac- 
tions in  the  erect  position  or  during  attempts  at  walking  are 
strong  and  sudden,  more  like  spasms,  ^^et  not  spasmodic,  and 
have  as  their  object  to  keep  the  body  in  the  line  of  gravity, 
and  the  walk,  though  accomplished  with  difficulty,  is  straight, 
not  reeling ;  the  affected  person,  too,  while  he  is  walking, 
does  not  take  his  eyes  off'  the  ground  or  from  his  feet  for  fear 
of  falling,  but  he  is  not  giddy.  Moreover,  in  diseases  of  the 
cerebellum  we  find  marked  vertiginous  sensations,  especially 
daring  attempts  at  locomotion;  vomiting,  particularly  at  the 
onset  of  the  complaint,  and  aggravated  or  brought  on  by  the 
erect  posture;  frontal  pain  when  the  head  is  bent;  defective 
vision,  becoming  very  much  so  when  an  object  is  looked  at 
for  any  time,  or  double  vision  ;  no  diminution  either  of  power 
of  motion  or  of  sensibility;*  and  in  some  instances  rotary 
movements. 

Chronic  alcoholism,  gives  rise  to  extended  hypersesthesia  and 
neuralgic  pains,  and  motor  disturbances  which  may  be  like 
those  of  ataxia. t  But  in  the  history  and  the  other  evidences 
of  the  ravages  of  alcohol  we  find  the  distinguishing  traits. 
In  chorea  the  irregular  muscular  movements  are  very  dissim- 
ilar from  those  of  locomotor  ataxia.  Moreover,  there  is  an 
absence  of  the  neuralgic  pains,  and  chorea  is  a  disease  of 
childhood;  locomotor  ataxia  of  adults.  The  closest  simi- 
larity to  locomotor  ataxia  I  have  seen  has  been  in  several 
cases  of  hysteria.  One  in  particular,  in  a  very  anemic 
woman,    similated   it   closely;    and   it   may    be    a  question 


*  Duchenne,  G:iz.  Hebdomad.,  1864. 
f  Leudet,  Arch.  G6ner.,  Jan.  1867. 


100  MEDICA].    DIAGNOSIS. 

whether  the  nutrition  of  the  parts  affected  in  ataxia  were 
not  disordered,  and  the  nervous  structures  functionally  dis- 
tnrhed,  T  desire  particularly  to  call  attention  to  these  cases, 
which  can  be  distinofuished  bj'  their  history,  the  usual  coex- 
istence of  ana?mia,  and  the  absence  of  severe  darting  pains. 
Moreover,  the  apparent  want  of  muscular  co-ordination  is 
more  irregular  in  its  manifestations ;  and  the  cases  recover. 
So  I  think  may  other  cases  of  locomotor  ataxia  due  to  special 
causes.  For  I  have  seen  cases  in  syphilitic,  patients,  typical 
in  everything  excepting  perhaps  the  severity  of  the  neuralgic 
pain,  essentially  typical  in  the  muscular  phenomena,  and  in 
the  inability  to  walk  with  closed  eyes,  in  whom  a  gradual  and 
nearly  complete  recovery  took  place.  Here  the  lesion  was 
probably  removed  or  greatly  influenced  by  the  antisyphilitic 
treatment. 

Tremor. — An}-  involuntary  agitation  of  the  body,  or  of 
part  of  it,  without  marked  muscular  contraction  or  impedi- 
ment to  voluntary  movement,  is  called  tremor.  The  trem- 
bling depends  upon  a  weakening  of  the  muscular  and  nervous 
systems.  It  is  common  in  old  age,  in  convalescence  from 
debilitating  diseases,  and  during  chills.  We  also  tind  it  in 
workers  in  mercury  and  lead,  and  in  those  who  abuse  alco- 
holic stimulants  or  coffee,  or  are  addicted  to  the  use  of 
opium.  In  some  cases  it  seems  to  be  connected  with  an 
organic  disease  of  the  nervous  centres.  It  constitutes  the 
main  symptom  of  the  singular  disorder  known  as  shaking 
palsy,  or  paralysis  agitans;  an  affection  thought  to  depend 
upon  a  lesion  of  the  tubercula  quadrigemina,  or  the  upper 
portion  of  the  spinal  cord. 

Tremor  is  easily  recognized.  Yet  it  mav  be  confounded  ' 
with  muscular  twitchings,  which,  like  it,  spring  from  a  de- 
ranged innervation  rather  than  from  organic  disease.  But 
it  differs  from  these  spasmodic  movements  by  being  more 
incessant,  and  unconnected  with  decided  muscular  contrac- 
tions. In  nervous  susceptible  persons  laboring  under  an 
acute  attack  of  disease,  it  is  at  times  combined  with  great 
restlessness,  and  is  apt  to  be  mistaken  for  a  convulsive  state. 
Again,  it  may  be  distinguished  by  the  absence  of  muscular 
contractions,  and  by  the  unintermitting,  irregular  motions. 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,   ETC.  101 

Spasms— Convulsions. — Both  these  terms  are  applied  to 
involuntary  muscular  contractions,  with,  perhaps,  this  differ- 
ence :  the  word  spasm  is  used  when  we  wish  to  express  the 
idea  of  less  universal  muscular  derangement,  but  especially 
when  the  muscles  of  organic  life  are  believed  to  be  involved; 
and  convulsions,  when  the  disorder  affects  the  muscles  of  the 
whole  body,  or  at  least  many  muscles  at  once,  and  chiefly 
those  of  volition.  Yet  these  are  not  distinctions  that  can, 
or  indeed  ought  to  be,  very  strictly  carried  out,  for  the  two 
phenomena  often  coexist;  and  being  produced  by  the  same 
causes,  and  obedient  to  the  same  laws,  can  hardly  be  sepa- 
rated. 

Spasms  may  be  clonic  or  tonic.  In  clonic  spasms  the 
muscles  are  agitated  by  successive  contractions  and  relaxa- 
tions of  their  fibres.  Clonic  spasms  are  very  extensive ;  in 
truth,  so  generally  is  this  is  the  case,  that,  if  we  make  any 
distinction  between  spasms  and  convulsions,  we  are  bound 
to  contemplate  clonic  spasms  as  convulsions  rather  than  as 
spasms.  In  tonic  spasms  the  muscles  are  rigidly  set,  and 
retain  for  a  time  their  contraction,  in  spite  of  every  effort 
on  our  part,  or  on  the  part  of  the  patient,  to  relax  them. 
The  most  marked  type  of  this  disorder  is  seen  in  tetanus ; 
the  most  perfect  illustration  of  clonic  spasms  is  furnished  in 
hysteria. 

Convulsions  may  be  accompanied  by  a  loss  of  conscious- 
ness, and  by  impaired  or  abolished  sensibility,  as  in  epi- 
lepsy, or  they  may  coexist  with  unclouded  thought  and 
unaltered  sensibility,  as  in  tetanus.  What  their  immediate 
cause,  is  very  difficult  to  determine,  for  as  yet  we  possess 
little  positive  knowledge;  and  as  to  the  portion  of  the  nerv- 
ous centres  where  they  arise,  or  the  structural  changes  that 
attend  an  attack,  we  know  next  to  nothing.  The  seat  of 
the  disturbance  is  in  some  cases  evidently  the  cerebro-spinal 
system,  but  many  convulsions  have  their  origin  in  a  pertur- 
bation of  the  reflex  system.  Of  their  exciting  cause  we  may 
say  that,  in  those  of  susceptible  nervous  organizations,  any 
extrinsic  irritation,  such  as  teething  or  disordered  digestion, 
leads  to  a  fit.  Further  causes  are  diseases  of  the  brain ; 
sudden  interference  with   the  circulation ;   profuse  hemor- 


102  MEDICAL    DIAGNOSIS. 

rhai!:es;  a  contaminiited  blood.  Children,  who  are  partic- 
ularly liable  to  oouvulsions,  often  have  them  as  the  precursors 
of  febrile  diseases.  In  point  of  diagnosis  it  is  of  great  im- 
portance to  distinguish  whether  their  inroad  is  or  is  not 
symptomatic  of  a  cerebral  lesion.  If  there  have  been  a 
previous  disorder  of  the  intellectual  functions,  or  any  other 
manifestation  of  a  brain  trouble,  we  may  assume  the  con- 
vulsions to  be  the  signal  of  cerebral  mischief.  But  when 
no  such  phenomena  are  met  with,  we  are  likely  to  tind  the 
source  of  irritation  in  some  other  portion  of  the  body. 
Practically  speakins;,  when  convulsions  are  amono-  the  first 
signs  of  a  malady,  they  are  not  apt  to  depend  upon  a  disease 
of  the  brain;  and  even  if  recognized  to  form  part  of  the 
symptoms  of  a  cerebral  lesion,  we  may  conclude  that  the 
lesion  has  not  reached  its  highest  degree  of  development, 
but  is  still,  as  it  were,  irritative,  and  has  not  led  to  cerebral 
disorganization. 

Besides  separating  convulsions  or  spasms  in  conformity 
with  their  eccentric  or  their  centric  origin,  we  must  always 
attempt  to  ascertain  the  particular  nature  of  the  cause.  If 
centric,  is  it  congestion,  or  inflammation,  a  tumor,  or  cere- 
bral hypertrophy;  or  is  the  convulsion  essential  and  idio- 
pathic, due  to  influences  the  cognizance  of  which  is  not 
within  our  narrowl^^-bounded  horizon  ?  If  eccentric,  is  it 
owing  to  an  impure  or  impoverished  blood,  to  retained  poi- 
sons, to  intestinal  or  other  visceral  irritation,  and  what  is  the 
probable  share  the  reflex  system  has  in  the  visible  disturb- 
ance of  the  muscles?  To  solve  these  questions  is  often  a 
very  difiicult  matter,  and  nothing  but  a  careful  analysis  of 
all  the  phenomena  of  the  case  enables  us  even  to  approxi- 
mate the  truth. 

Closely  connected  with  spasms  and  convulsions,  and  in- 
deed, in  a  certain  sense,  not  separable  from  them,  are  other 
kinds  of  irregular  muscular  movements,  such  as  cramps — 
a  short  contraction  of  one  or  several  muscles  occurring  in 
paroxysms,  and  attended  with  severe  pain;  rigidity — a  per- 
manent tonic  contraction  of  the  muscles,  often  encountered 
in  diseases  of  the  brain,  especially  in  cerebral  softening ;  and 
the  jerking  movements  of  chorea. 


I 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  103 

DERANGED    NUTRITION    AND    SECRETION. 

Among  the  subjects  connected  with  the  nervous  system 
which  have  of  late  years  received  most  attention,  there  is 
none  of  more  interest  than  the  association  of  its  disorders 
with  derangements  of  nutrition  and  secretion.  Now  such 
are  very  manifest  in  paralyzed  limbs  or  after  nerve  wounds. 
But  these  obvious  alterations  need  here  but  be  referred  to. 
It  is  rather  my  intention  to  speak  of  the  less  palpable  phe- 
nomena, and  those  in  which,  at  first  sight,  the  nervous  sys- 
tem is  not  so  distinctl}'  concerned.  For  instance,  the  skin 
may  become  the  seat  of  diverse  eruptions,  undergo  modifica- 
tions of  color  and  structure,  the  secretions  may  be  aug- 
mented or  diminished,  the  muscles  and  joints  show  textural 
changes,  swellings  may  happen  aft'ecting  various  portions  of 
the  body,  either  external  or  internal, — yet  all  be  due  to  dis- 
turbed nervous  influence,  and  the  real  disorder,  therefore,  be 
in  parts  very  difl:erent  from  where  it  appears. 

To  particularize  with  reference  to  a  few  of  the  derange- 
ments alluded  to.  There  is  the  aftectiou  known  as  herpes 
zoster,  of  which  there  can  be  no  longer  anv  doubt  that  the 
vesicles  encircling  half  the  circumference  of  the  trunk  are 
uot  a  primary  skin  affection,  but  the  local  expression  of  irri- 
tation of  a  nerve.  They  closely  follow  the  distribution  of 
some  superficial  sensory  nerve,  and  this  unilateral  herpes  is 
really  but  a  sign  of  localized  neuralgia, — from  its  seat,  most 
generally  of  a  dorso-intercostal  neuralgia.  Then  again  we 
encounter  instances  of  large  vesicles  or  buUje  accompanying 
other  neuralgias,  as  of  the  sciatic  ;  and  attacks  of  erysipelas 
having  their  origin  in  facial  neuralgia,  as  has  been  ably 
demonstrated  by  Anstie.  Furthermore,  the  most  various 
kinds  of  spots  and  blotches,  and  thickenings  of  the  skin 
have  been  noticed,  by  different  observers,  after  this  and 
other  forms  of  neuralo-ia. 

Oftentimes,  too,  these  morbid  appearances  on  the  skin  are 
combined  with  evidences  of  altered  secretion.  Thus,  in  a 
case  related  by  Parrot,*  in  addition  to  the  neuralgic  parox- 

*  Gaz.  Hebdom.,   1859;    quoted  in  Handlield  Jones  on   Funct.  Nervous 
Disorders. 


104  MEDICAL    DIAGNOSIS. 

vsms  attended  with  sanofuineons  exudations  at  the  painful 
parts,  there  occurred,  at  times,  bloody  sweating  on  the 
knees,  thighs,  hands,  and  face.  Lachrymation  was  noticed 
in  nearly  half  tJie  cases  of  trigeminal  neuralgia  analyzed  by 
Notta;*  and  one-sided  furring  of  the  tongue  is  a  not  un- 
common phenomenon  in  this  complaint.  Associated  WMth 
tliese  evidences  of  altered  secretion  may  be  signs  of  altered 
nutrition,  such  as  iritis,  corneal  clouding,  and  inflamma- 
tion of  the  fascia  or  of  the  periosteum  in  contact  wnth  the 
achins  nerve.  And  let  us  here  add  that  these  evidences 
of  perverted  nutrition  are  not  confined  to  neuralgic  disor- 
ders. They  occur  also  in  diseases  of  the  central  nervous 
system.  Thus  aftections  of  the  joints  have  been  observed 
to  follow  cerebral  hemorrhages,  and  various  spinal  disorders; 
and  a  form  of  joint-mischief,  of  hydrarthrosis,  has  been,  of 
late,  specially  described  by  Charcotf  in  locomotor  ataxia. 

Among  the  phenomena  of  altered  secretion,  connected 
with  nervous  affections,  one  of  the  most  striking  is  excessive 
sv:eaimg.  In  lesions  of  the  cervical  sympathetic  on  one  side, 
we  may  have  strictly  unilateral  sweating  of  the  face  and 
neck,  the  other  side  remaining  perfectly  dry  •,%  ^i^d  greater 
vascularity  and  increased  temperature  are  concomitants.  In 
lesions  of  the  abdominal  ganglia  profuse  sweating  also  hap- 
pens, and  is  apt  to  be  combined  with  impeded  secretion 
from  the  mucous  coats  of  the  bowels,  as  we  occasionally  find 
in  instances  of  abdominal  aneurism.  jS'ot  that  excessive 
sweating,  whether  localized  or  general,  is  always  linked  to 
an  affection  of  the  great  sympathetic  ganglia.  We  find,  in- 
deed, local  sweatings  limited  to  the  hands  and  feet  without 
any  signs  of  other  trouble.  And  general  sweatings,  irre- 
spective of  those  of  colloquative  character  attending  phthisis, 
or  those  of  malarial  diseases,  happen  after  low  fevers,  in  in- 
active states  of  the  liver,  and  in  some  persons  go  on  for 
years  without  any  obvious  cause.  It  may  be,  however,  that 
in  most,  if  not  all  these  cases,  the  sympathetic  system  is 
really  at  fault,  at  least  in  so  far  that  there  is  a  reflex  de- 


*  Archiv.  Gen.,  1854.  f  Archives  de  Physiologie,  1868. 

+  As  in  the  case  recorded  by  W.  Ogle,  Med.-Ch.  Transact.,  vol.  lii. 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  105 

rangement  of  the  vaso-iiiotor  nerves,  and  of  course,  then,  of 
the  subcutaneous  blood-vessels  and  the  glands  they  supply. 

But  these  are  not  questions  which  we  can  here  consider. 
Indeed,  the  whi/  and  the  how  of  all  these  changes  of  secre- 
tion and  nutrition  attending  nervous  affections  are  very  un- 
certain, and  such  a  consideration  touches  on  the  question 
whether  or  not  there  are  special  trophic  nerves,  and  on  other 
unsettled  points  of  physiology. 

To  return  to  the  clinical  phenomena.  Besides  the  exter- 
nal manifestations  of  altered  secretion  and  nutrition,  there 
are  certain  changes  in  internal  organs,  the  expression  of 
nervous  derangements.  Modern  research  has  rendered  it 
most  probable  that  the  triple  lesion  known  as  exophthalmic 
goitre  is  of  this  kind,  and  due  to  disease  of  the  sympathetic 
nerve.  And  the  Medicine  of  the  Future  will  most  likely  ac- 
quaint us  with  many  more  disorders  of  glands  and  viscera 
which  originate  in  altered  nerve-structure  and  perverted 
power. 

So  much  for  the  chief  manifestations  of  nervous  com- 
plaints. From  the  preceding  pages  it  will  liave  become 
apparent  how  many  of  them  are  functional,  or  are  at  least 
of  necessity  so  regarded,  and  how  these  functional  disorders 
may  be  attended  with  the  signs  of  quite  as  great,  or  even 
greater,  disturbance  than  the  organic  maladies.  And  nothing 
is  more  difficult  than  to  fix  their  seat;  for  after  death  not  the 
slightest  structural  alteration  may  be  discernible,  or  it  may 
be  of  a  character  insufficient  to  account  for  the  phenomena 
during  life.  In  consequence,  there  is  very  great  confusion, 
and  much  doubt  is  thrown  over  any  anatomical  or  pathologi- 
cal classification  of  nervous  diseases.  I  subjoin  a  table  of  the 
main  aftections,  arranged  according  to  their  supposed  sites. 
It  may  not  suit  a  strict  critic,  since,  in  several  of  the  disor- 
ders regarded  as  functional,  modern  research  has  indicated 
the  probable  organic  cause.  But  from  the  stand-point  of  the 
physician  it  would  be  as  3'et  premature  to  recognize  a  fixed  or- 
ganic nature,  and  I  contend  rather  for  the  classification  being 
clinically  than  pathologically  unimpeachable.  Nor  will  it  be 
adhered  to  in  the  description  of  nervous  disorders  about  to 


loa 


MEDICAL   DIAGNOSIS. 


Cerebral. 


Orqfinic. 


follow;  which  will  be  traced  according  to  divisions  formed 
by  iTi'onps  of  symptoms  rather  in  obedience  to  a  pathological 
classiiication. 

TABLE  OF  THE  D160HDEKS  OF  THE  BRAIN  AND  SPINAL  CORU. 

r  Congestion. 

Meningitis,  in  its  various  forms. 
Hydrocephalus. 
Abscess. 
Softening. 

Hemorrhage  (Apoplexy). 
Tumoi's,  etc. 
Delirium. 
Insanity? 
Finictional.  J    Headache. 
I   Trance. 
[  Ecstasy. 

On/ainc i   Cerebro-spinal  meningitis. 

f  Epilepsy. 
Functional.  \   Catalepsy. 
I   Hysteria? 

Hyperjemia 

Spinal  meningitis. 

Myelitis. 

Softening.    . 

Atroj)hy. 

Sclerosis. 

Spinal  apoplexy. 

Tumors,  etc. 

"Wasting  palsy  ? 

Locomotor  ataxia  ? 
'  Spinal  irritation. 

Chorea. 

Paralysis  agitans. 

Tetanus. 

Hydrophobia. 
,  Reflex  spasms  due  to  irritation  of  the  cord. 


Cerebro-Spinal 


r 


Organic. 


Spinal J 


Funciional.   -j 


Acute  Affections  of  which  Delirium  is  a  Prominent  Symptom. 

This  clinical  group  embraces  the  different  forms  of  me- 
ningeal inflammation,  delirium  tremens,  and  acute  mania — 
affections  in  all  of  which  the  brain  is  the  seat  of  the  dis- 
turbance. 

Acute  Meningitis. — By  this  term  is  now  understood  an 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  107 

inflammation  of  the  membranes  of  the  brain,  especially  of 
the  arachnoid  and  pia  mater.  The  dura  mater  is  far  less 
frequently  attacked ;  very  rarely,  unless  the  morbid  action 
be  of  syphilitic  origin,  or  have  extended  from  the  bones  of 
the  cranium. 

The  disease  generally  presents  two  well-marked  stages. 
The  first,  or  the  stage  of  excitement,  is  characterized  by  in- 
tense headache,  great  restlessness,  vomiting,  a  hard,  frequent 
pulse,  fever,  injected  eye,  often  with  a  contracted  pupil,  an 
increased  sensibility  to  light  and  sounds,  obstinate  constipa- 
tion, irregular  respiration,  and  soon  by  active  delirium,  and 
convulsions ;  the  second  stage  is  marked  by  an  evident  ebb- 
ing of  the  life  forces  :  the  extremities  are  cold,  the  pupils 
dilated,  the  pulse  is  feeble  and  much  slower,  and  intermitting, 
or  it  becomes  extremely  rapid  and  threadlike ;  involuntary 
passages  occur,  there  is  utter  loss  of  mind  and  of  sensibility 
— in  one  word,  coma  or  collapse. 

Not  every  case,  however,  has  all  these  symptoms,  or  goes 
at  once  from  the  stage  of  excitement  to  that  of  collapse. 
There  may  be  a  well-defined  period  of  transition,  during 
which  the  heat  of  skin,  excepting  of  the  head,  diminishes, 
drowsiness  appears,  and  the  pulse  sinks  somewhat  in  fre- 
quency. Again,  the  disease  may  be  arrested  before  the 
signs  of  prostration  are  very  evident. 

The  attack  may  be  preceded  by  sick  stomach,  buzzing  in 
the  ears  and  vertigo,  or  set  in  with  severe  pain  lixed  to  the 
forehead,  and  increased  b}^  movements.  In  some  cases  it 
begins  with  delirium  or  convulsions.*  And  among  its  symp- 
toms, even  in  the  earliest  stages,  a  persistent  pain,  attacking 
one  or  both  knees,  violent,  intensified  on  motion,  unrelieved 
by  local  means,  and  connected  neither  with  swelling  nor  with 
any  other  change  in  the  form  or  appearance  of  the  joint,  has 
been  particularly  noticed. f 

The  malady  may  pass  rapidly  through  its  stages,  so  rap- 
idly that   their  distinctive   features   become    confused    and 

*  On  the  other  hand,  these  symptoms  may  bo  absent.  In  a  paper  by 
Churcli,  in  St.  Bartholomew's  Ho.spital  Reports,  vol.  iv.,  are  several  cases 
without  delirium. 

t  Lund,  quoted  in  Amer.  Jour,  of  Med.  Sciences,  Oct.  1864. 


108  MEDICAL    DIAGNOSIS. 

blended.     Generally  it  does  not  last  less,  nor  much  more, 
than  a  week. 

Acute  meningitis  is  brought  on  by  exposure,  by  depressing 
cares,  by  intense  application  to  study,  by  a  blow  or  fiill  upon 
the  head,  by  disease  of  adjacent  structures,  or  by  syphilis. 
It  sometimes  affects  mainly,  or  wholly,  the  coverings  of  the 
convex  portion  of  the  brain;  at  other  times  the  inilanjmation 
is  limited  to  the  base.  According  to  Duchatelet,*  meningitis 
of  the  base  may  be  discriminated  by  remissions  in  the  deli- 
rium, and  by  the  coexistence  of  spasmodic  symptoms  with 
profound  and  early  coma.  These  signs,  at  all  events,  are 
said  to  be  distinctive  in  children,  who,  more  than  adults,  are 
disposed  to  this  form  of  the  complaint. 

Acute  meningitis  is  not  always  easy  of  diagnosis.  Leav- 
ing out  for  the  present  the  other  disorders  belonging  to  the 
same  group,  such  as  acute  mania  and  delirium  tremens,  it 
may  be  confounded  with 

Cerebritis  ; 

Acute  Softening; 

Head  Symptoms  of  Continued  Fevers  ; 

Head  Symptoms  of  Acute  Rheumatism  ; 

Head  Symptoms  of  Pneumonia  ;  of  Pericarditis. 

Cerebritis. — There  is  very  little  appreciable  difference  be- 
tween inflammation  of  the  brain  tissue  and  inflammation  of 
the  meninges.  In  truth,  what  we  commonly  call  meningitis 
(because  the  evidences  of  the  morbid  action  are  most  dis- 
tinct in  the  meninges)  is  often  also  cerebritis;  since  the  dis- 
eased process  extends  very  readily  from  the  tunics  of  the 
brain  to  the  adjacent  cerebral  substance.  We  may  suspect 
this  structure  to  have  become  involved,  if  the  sense  of  vision 
or  of  hearing  be  suddenly  perverted;  if  the  convulsions,  the 
agitation  of  the  limbs,  and  the  tremors  be  very  marked ;  if 
they  occur  chiefly  upon  one  side;  and  if  coma  succeed  rap- 
idly to  the  period  of  excitement,  and  be  accompanied  or 
preceded  by  one-sided  palsy. 

Acute  Softening. — The  form  of  acute  softening  which  simi- 
lates  meningitis  is  that  associated   with   delirium.     But  it 


*  Inflammation  de  rAraclmoide,  page  230. 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  10l> 

occurs  only  in  veiy  old  persons,  is  apt  to  be  preceded  by 
restlessness,  some  mental  confusion,  and  signs  of  a  general 
breaking  up  of  nervous  force,  is  soon  associated  with  dis- 
turbances of  the  bladder  and  rectum,  and  the  patient  gradu- 
ally passes  into  a  comatose  state.  In  the  cases  which  I  have 
seen  there  was  neither  much  headache  nor  febrile  disorder. 

Head  Si/mptoms  of  CoMinued  Fevers. — In  all  the  varieties  of 
continued  fever,  but  especially  in  typhoid  and  typhus,  cere- 
bral symptoms  at  times  arise  which  bear  a  very  strong  resem- 
blance to  those  of  idiopathic  meningitis;  and  such  symptoms, 
it  has  been  fully  proved,  may  appear  without  the  examina- 
tion of  the  dead  body  revealing  even  traces  of  inflammation. 
How,  then,  are  we  to  distinguish  these  fever  cases  from  me- 
ningitis; or  how  ascertain,  if  inflammation  of  the  brain  be 
really  before  us  as  a  complication  and  product,  if  thus  it 
may  be  called,  of  the  fever?  Unfortunately,  there  is  no 
sign  absolutely  diagnostic.  Perhaps  future  researches  may 
determine  that  the  increase  of  phosphates  in  the  urine,  found 
by  Bence  Jones  to  occur  in  inflammatory  afl:ections  of  the 
nervous  textures,  is  a  valuable  source  of  distinction.  But 
we  know  that  this  increase  may  also  be  due  to  other  causes, 
and  as  yet  we  are  too  little  cognizant  of  the  exact  chemistry 
of  the  secretions  in  the  maladies  under  discussion  to  make 
the  urine  the  difl'erential  test.  jSTor  does  cerebral  ausculta- 
tion aftbrd  us  any  help;  for  the  few  authors,  like  Fisher,* 
Whitney,t  or  Roger,J  who  have  at  all  investigated  the  sub- 
ject, are  not  even  agreed  whether  the  souffle  that  is  perceived 
is  constantly  present  in  meningitis,  whether  it  may  not  exist 
in  any  cerebral  disturbance,  nay,  whether  it  may  not  be  heard 
in  health.  As  matters  stand,  a  diagnosis  can  only  be  estab- 
lished by  a  careful  consideration  of  all  the  symptoms,  and  of 
the  history  of  our  patient:  by  searching  for  the  eruption  of 
typhus  or  typhoid  fever;  by  taking  note  of  the  expression 
of  the  countenance;  of  the  character  of  the  delirium,  ordi- 
narily so  much  more  active  when  the  brain  or  its  membranes 
are  inflamed,  and  attended  with  much  more  intense  head- 


*  Am.  Journ.  of  Med   Sciences,  Aug.  1838. 
t  Il.id.,  Oct.  1843.  X  Il-'i<^l-!  <Jct.  1862. 


110  MEDICAL    DIAGNOSIS. 

jR-lie,  witli  throbbing  of  the  arteries  of  the  neck  and  face,* 
and  not  nnfrequently  with  convulsions.  But  how  difficult  it 
may  be  to  arrive  at  a  correct  conclusion,  unless  we  possess  a 
full  knowledije  of  all  the  circumstances,  is  shown  by  this 

case : 

A  man,  about  thirty-five  years  of  age,  was  admitted  into 
the  Philadelphia  Hospital  on  February  8th,  1861,  with  a  cer- 
tificate that  he  was  laboring  under  typhoid  fever.     No  clue 
could  be  obtained  to  the  history  of  the  malady.     The  man 
liimself  was  unable  to  afford  any  information,  as  he  was  not 
in  a  state  to  answer  any  questions.     His  pulse  was  excess- 
ively feeble,  and  somewhat  irregular;   the  eye  was  not  in- 
jected, but  suffused  and  watery;  the  pupils  sluggish  and  the 
eyeballs  in  constant  motion  ;  the  tongue  was  dark,  dry,  and 
fissured ;  the  breath  offensive.     There  appeared  to  be  pain 
on  pressure   in  the  right   iliac  fossa,  but  the  bowels  were 
constipated,  and  no  eruption  could  be  detected.     The  most 
striking  feature  of  the  case  was  the  delirium,  which  was 
noisy  and  violent,  and  accompanied  by  great  restlessness; 
the  man  sang,  screamed,  was  constantly  attempting  to  get 
out  of  bed  and  to  upset  his  medicine  bottle.     What  Avas  the 
nature  of  the  malady?     It  did  not  seem  to  me  to  be  typhoid 
fever :  the  symptoms  belonged  more  to  inflammation  of  the 
brain,  but,  knowing  neither  how  nor  when  the  delirium  had 
commenced,  I  could  not  be  positive  that  such  was  the  lesion. 
The  bowels  were  opened  by  a  turpentine  injection,  and  as 
the  patient  was  evidently  sinking,  he  was  stimulated;  but  to 
no  purpose — he  died  the  day  after  his  admission  into  the 
hospital.     The  autopsy  showed  the  intestines  to  be  sound. 
The  membranes  of  the  brain,  after  the  dura  mater  was  re- 
moved, were  found  to  be  opaque,  and  between  the  convolu- 
tions were  shreds  of  lymph  and  a  puriform  liquid.     There 
Avere  but  traces  of  inflammation  at  the  base,  excepting  in 
the  neighborhood  of  the  pons  varolii,  where  some  lymphy 
effusion  was  discerned.    The  ventricles  were  tilled  with  fluid, 
and  the  nervous  structure  in  the  neighborhood  of  the  thalami 
and  corpora  striata  was  softened. 


*  Still,  even  this  symptom  is  not  certain,  for  I  have  repeatedly  noticed 
throbbing  of  the  vessels  of  the  neck  in  low  fevers. 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  Ill 

Subsequently  to  the  man's  death  it  was  ascertained  that 
he  had  been  sick  for  only  four  days  before  he  entered  the 
ward;  which  fact,  had  it  been  previously  known,  would  have 
materially  assisted  the  diagnosis.  Irrespective  of  the  diffi- 
culty of  its  recognition,  this  case  is  of  peculiar  interest.  It 
illustrates  the  possibility  of  the  absence  of  convulsions  and 
of  paralysis,  notwithstanding  the  most  evident  cerebral  dis- 
organization. 

Head  Spnptoms  of  Acute  Rheumatism. — In  rheumatic  fever 
cerebral  symptoms  occasionally  arise  which  may  be  referred 
to  inflammation  of  the  brain,  or  which,  by  their  prominence, 
may  mislead  the  practitioner,  causing  him  to  regard  the 
signs  of  the  rheumatism  as  of  little  importance,  if  indeed  he 
does  not  whollv  overlook  them.  And  the  morbid  manifesta- 
lions  are  very  much  like  those  of  acute  meningitis :  restless- 
ness, headache,  and  violent  delirium,  succeeded  by  coma. 
The  delirium  is  commonly  of  gradual  approach,  but  it  may 
come  on  suddenly.  Generally  it  does  not  appear  until  the 
patient  has  been  suffering  for  at  least  a  week  with  acute 
rheumatism  ;  and  the  heavy  sweats  and  swollen  joints  point 
out  the  malady  w^ith  which  it  is  combined. 

Formerly  the  cerebral  phenomena  were  looked  upon  as 
due  to  metastasis  of  the  rheumatic  inflammation  to  the  brain. 
But  this  view  is  now  abandoned ;  for  examinations  of  the 
head,  in  cases  which  proved  rapidly  fatal,  have  failed  to  de- 
tect, save  in  rare  instances,  an}'  evidences  of  inflammatory 
action  within  the  cranium.  The  abnormal  signs  are,  as  a 
rule,  much  more  probably  attributable  to  the  altered  con- 
dition of  the  blood,  and  are  often  found  to  be  connected 
with  the  setting  in  of  pneumonia  or  of  inflammation  of  the 
membranes  of  the  heart,  or  to  plugs  of  fibrin  in  the  capil- 
laries of  the  brain,  and  are  apt  to  be  associated  with  a  very 
high  temperature. 

Head  Symptoms  of  Pneumonia  ;  of  Pericarditis. — In  both  these 
maladies  delirium  may  be  met  with  of  a  character  so  violent 
as  to  lead  to  the  belief  that  the  brain  or  its  membranes  are  in- 
volved in  an  inflammatory  disease.  The  diagnosis  is  cleared 
up  by  a  careful  examination  of  the  chest.  Then  we  may  lay 
stress  on  the  furious  delirium,  being  unattended  with  spas- 


llli  MEDICAL    DIAGNOSIS. 

modie  movements  or  with  paralysis.  The  form  of  pneumonia 
which  is  mostly  associated  with  delirium,  is  inflammation  of 
the  upper  lobes. 

Tubercular  Meningitis.— This  is  a  rare  disease  in  adults; 
not  a  rare  disease  in  children.  Its  distinct  recognition  be- 
longs to  the  present  generation  of  physicians;  and  nearly  all 
of  the  cases  of  so-called  acute  hydrocephalus,  and  most  of 
those  of  meningitis  of  the  base,  have  now  been  ascertained 
to  be  instances  of  tubercular  meningitis,  or,  to  define  the 
morbid  state,  of  an  inflammation  of  the  meninges  occurring 
in  tubercular  patients,  and  ordinarily  accompanied  by  the 
deposition  of  tubercles  at  the  base  of  the  brain. 

The  premonitory  signs  of  the  malady  are  of  great  impor- 
tance. The  child  has  generally  been  ailing  for  some  time; 
is  restless,  peevish,  sleeps  ill,  complains  of  headache,  and  is 
troubled  with  a  frequent,  short  cough,  and  with  constipation. 
To  these  symptoms  are  soon  superadded  thirst,  a  coated 
tongue,  vomiting,  a  dry  skin,  and  generally  an  accelerated 
pulse  and  grinding  of  the  teeth,  constituting  the  most  promi- 
nent features  of  the  first  stage  of  the  affection.  After  four 
or  five  days  the  second  stage  is  reached,  and  the  brain  symp- 
toms become  much  more  clearly  developed.  The  child  shuns 
the  light,  puts  its  hand  frequently  to  its  head,  and  utters 
every  now  and  then  a  peculiar,  sharp,  distressing  cry.  At 
night  the  headache  exacerbates,  and  is  attended  with  fleet- 
insr  delirium.  A  slis-ht  strabismus  is  observable,  and  the 
eyeballs  oscillate.  The  pulse  is  very  irregular  in  its  rhythm, 
sometimes  rapid  and  intermitting,  then  suddenly  falling  and 
becoming  quite  slow.  The  vomiting  ceases,  and  there  may 
be  a  remission  in  the  symptoms  with  restored  intelligence ; 
but  the  pulse  remains  irregular,  the  bowels  are  even  more 
constipated  than  before,  and  the  abdomen  appears  retracted. 
The  third  stage  is  one  of  complete  stupor,  accompanied  or 
preceded  by  convulsions.  The  expression  of  the  face  is 
idiotic;  the  pupils  are  dilated;  there  is  subsultus,  and  one 
side  of  the  body  is  paralyzed.  Deglutition  is  very  difficult: 
the  surface  is  covered  with  cold  sweats.  This  condition,  so 
painful  to  behold,  may  last  for  days;  repeated  conviilsions 
hasten  its  termination. 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  113 

Can  wo  distinguisli  this  formidable  complaint  from  ordi- 
nary meningitis?  Seldom  from  meningitis  of  the  base;  gen- 
erally from  meningitis  of  the  convexities.  As  regards  the 
discrimination  from  the  former  malady,  we  are,  it  is  true, 
sometimes  enabled  to  pronounce  the  affection  to  be  tuber- 
cular meningitis,  if  we  are  familiar  with  the  patient's  ante- 
cedents, and  are  cognizant,  previous  to  the  seizure,  of  the 
presence  of  tubercle  in  any  of  the  internal  organs,  or  a.re 
able  at  the  time  to  detect  the  signs  of  phthisis.  But  without 
knowledge  of  this  kind,  a  positive  diagnosis  is  impossible; 
we  have  nothing  to  direct  us  excepting  the  probability  that 
the  case  is  tubercular,  because  most  instances  of  meningitis 
of  the  base  are  of  that  nature.  This  uncertainty  does  not 
exist  with  reference  to  the  usual  form  of  simple  meningeal 
inflammation.  We  may  generally  distinguish  the  tubercular 
malady  by  its  occurrence  in  an  unhealthy  person ;  by  its 
insidious  approach;  by  the  absence  of  violent  delirium;  by 
the  appearance  of  convulsions,  not  early,  but  late  in  the 
disease ;  by  the  far  less  violent  headache,  and  less  degree  of 
febrile  excitement;  by  the  notable  remissions  in  several  of 
the  cerebral  signs ;  by  the  chest  symptoms,  and  the  long 
duration  of  the  affection. 

Tubercular  meningitis  is  ordinarily  attended  with  an  effu- 
sion of  serum  into  the  ventricles,  and  it  is  very  plain  that 
many  of  the  symptoms  are  attributable  to  pressure  of  the 
fluid  on  portions  of  the  brain.  Now,  how  can  we  separate 
the  malady,  acute  hydrocephalus,  as  many  still  call  it,  from 
dropsy  of  the  brain,  or  chronic  hydrocephalus?  Partly  by 
the  history  of  the  case,  and  partly  by  the  normal  size  of  the 
head;  for  the  water  on  the  brain  is  not  sufficient  in  amount, 
nor  is  it  there  long  enough,  to  produce  an  appreciable  aug- 
mentation of  the  cranium.  Then,  in  chronic  hydrocephalus 
the  symptoms  manifest  themselves  for  years,  from  childhood 
even  to  adult  life.  The  signs  of  a  profound  cerebral  lesion 
appear  gradually,  the  special  senses  are  by  degrees  enfeebled, 
but  it  is  a  long  time  before  they  are  wholly  abolished,  or 
before  complete  loss  of  consciousness  takes  place. 

As  regards  the  diagnosis  between  tubercular  meningitis 
and   acute   hydrocephalus,   it  need   only  be    stated    that    this 

8 


114  MEDICAL    DIAGNOSIS. 

attection  is  in  the  vast  majority  of  cases  a  syiiouyme  for  the 
former.  Yet  we  occasionally  meet  with  instances  in  which 
acute  hydrocephalus  occurs  unconnected  with  tubercle.  It 
then  runs  either  a  latent  course,  or  appears  as  an  acute 
malady  with  symptoms  similar  to  those  of  acute  meningitis, 
commencino;  either  with  fever  or  with  convulsions,  and 
often  attended  with  intense  restlessness,  succeeded  by  drow- 
siness, and  having  periods  of  intermission  of  the  symptoms 
and  of  apparent  improvement.  Toward  the  end  convul- 
sions are  very  common.  The  complaint,  unlike  tubercular 
meningitis,  happens  in  previously  healthy  children,  begins 
suddenly,  and  is  of  shorter  duration.  But  the  eiiusion  may 
remain,  and  the  disorder  lead  to  chronic  hydrocephalus. 

There  is  a  functional  disturbance  of  the  brain  which  it  is 
of  great  importance  to  discriminate  from  tubercular  menin- 
gitis— the  hydrocephaloid  disease  described  by  Marshall  Hall. 
It  has  a  stage  of  irritability,  and  a  stage  of  torpor :  a  stage 
in  which  the  little  patient  is  restless,  feverish,  irritable ;  and 
a  stage  in  which  the  countenance  becomes  pale,  the  breath- 
ing irregular,  the  voice  husky,  the  pupils  uninfluenced  by 
light.  These  symptoms  indicate  nervous  exhaustion.  They 
generally  come  on  after  an  enfeebling  attack  of  illness,  espe- 
cially subsequent  to  protracted  diarrhoea;  sometimes  they 
follow  premature  weaning.  In  the  history  of  the  case;  the 
less  tendenc}^  to  vomiting;  in  the  regularit}'  of  the  pulse;  in 
the  flaccid  and  hollow  state  of  the  fontanelle,  so  dissimilar  to 
its  prominent  and  tense  condition  in  inflammation;  and  in  the 
arrest  of  the  threatening  signs  by  stimulants  and  by  tonics,  we 
iind  the  guides  which  enable  us  to  decide  against  the  exist- 
ence of  an  organic  disease  of  the  brain  or  its  membranes. 

But  other  aft'ections  besides  those  of  the  brain  may  be 
confounded  with  tubercular  meningitis,  such  as  typhoid  and 
remittent  fevers.  From  typhoid  fever  tubercular  meningitis 
may  be  distinguished  by  the  frequent  vomiting ;  by  the 
retracted  abdomen,  so  unlike  the  swollen,  tender  belly  of 
enteric  fever;  by  the  constipation  instead  of  the  diarrlnija; 
by  the  absence  of  an  eruption,*  and  of  enlargement  of  the 

*  Fox,  Clinical  Observations  on  Acute  Tubercle  St.  George  Hosp.  Rep., 
1869. 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  115 

spleen ;  by  the  irregularity'  of  the  pulse  ;  by  the  occurrence 
of  convulsions  and  anesthesia,  and  other  signs  of  profound 
motor  and  sensorial  disturbance,  and  by  the  lower  heat,  the 
thermometer  seldom  rising  above  102°.*  The  duration  of 
the  two  complaints  affords  no  help  in  diagnosis,  since  the 
one  may  last  as  long  as  the  other. 

Tubercular  meningitis  is  very  often  mistaken  for  infan- 
iile  remittent^  and  indeed  there  are  many  points  of  close 
resemblance  between  them.  Without  mooting  the  question 
whetlier  the  remittent  fever  of  children  be  really  a  distinct 
disease,  we  may  here  accept  the  group  of  clinical  phenomena 
supposed  to  be  characteristic,  and  point  out  the  differences 
between  them  and  those  of  tubercular  or  scrofulous  inflam- 
mation of  the  brain.  In  the  ffrst  place,  excepting  in  those 
rare  cases  of  coexisting  acute  tubercularization  of  the  intes- 
tines, we  do  not  perceive  in  the  cerebral  disorder  a  tongue 
red  at  the  edges,  diarrhoea,  and  other  manifestations  of  in- 
testinal irritation  ;  and  vomiting  and  nausea  are  more  prom- 
inent and  protracted  symptoms  than  in  remittent  fever.  But 
in  this  complaint  the  heat  of  skin  is  much  greater;  the  pulse 
quicker,  yet  not  unequal  and  subject  to  such  decided  varia- 
tions;  delirium  occurs  much  earlier,  and  is  much  more 
marked, — indeed,  tubercular  meningitis  may  run  through 
all  its  stages  without  mental  wandering. 

In  reviewing  the  maladies  with  which  tubercular  menin- 
gitis may  be  confounded,  it  is  incumbent  upon  us  to  bear 
in  mind  the  inflammatory  afl'ections  of  the  lungs,  which,  in  chil- 
dren especially,  are  not  uncommonly  associated  with  deli- 
rium and  other  symptoms  of  a  deranged  nervous  system. 
But  the  cerebral  phenomena  take  a  different  course ;  the 
febrile  excitement  is  more  intense;  and  an  examination  of 
the  chest  reveals  the  cause  of  the  disturbance  of  the  brain. 
Yet  we  must  not  overlook  the  fact  that  the  signs  of  acute 
phthisis  may  be  like  those  of  acute  bronchitis  or  of  acute 
pneumonia ;  that  hence  it  may  become  a  very  perplexing 
subject  to  determine  the  precise  cause  of  the  disordered  res- 


*  I  have  never  seen  an  eruption  in  tuborcular  meningitis  ;  but  Barthez 
and  Killiet  speak  of  fugitive  imperfectly-formed  rose-spots  being  present  in 
rare  cases. 


11»]  MEDICAL    DIAGNOSIS. 

piratioii,  and  the  presence  or  absence  of  tubercular  disease 
in  the  luug-s.  Indeed,  if  the  explanation  of  the  brain  symp- 
toms depend  solely  on  the  elucidation  of  this  point,  the 
diasrnosis  at  times  remains  uncertain.  In  adults  the  diffi- 
culty  is  far  less,  because  the  demonstration  of  the  existence 
or  non-existence  of  pulmonary  tubercle  is  much  easier. 

Tubercular  meningitis  is  a  very  fatal  disease.  Whether 
it  be  invariably  fatal,  is  as  yet  an  undecided  matter.  But, 
notwithstanding-  the  observations  of  Rilliet,  the  weight  of 
evidence  tends  in  that  direction.  Cures  are  said  to  have 
been  etfected  by  the  free  use  of  iodide  or  of  bromide  of 
potasshnn,  and  by  counter-irritation  to  the  scalp. 

Cerebro-spinal  Meningitis. — Now  and  then  cases  of  me- 
ningitis are  encountered  in  which  the  inflammation  affects 
simultaneously  the  membranes  of  the  brain  and  of  the  spine, 
and  in  which  the  s3'mptoms  of  the  cerebral  malady  are  found 
to  be  blended  with  severe  pain  along  the  vertebral  column, 
with  convulsions,  with  rigidity  of  the  muscles,  with  perverted 
cutaneous  sensibility — in  short,  with  the  phenomena  denoting 
spinal  meningitis.  But  such  sporadic  cases  are  of  rare  oc- 
currence. Generally  cerebro-spinal  meningitis  is  not  met 
wath  save  as  an  epidemic  disease  which  presents  itself  at  dif- 
ferent times  in  somewhat  dissimilar  forms,  changing  mainl}' 
as  the  cerebral  or  the  spinal  disturbance  prevails,  and  vary- 
ing, moreover,  according  to  the  predominance  of  the  consti- 
tutional or  local  phenomena. 

Let  us  look  at  its  most  common  characters.  The  disease 
is  either  gradual  in  its  approach — a  feeling  of  chilliness, 
succeeded  by  headache,  by  pain  in  the  back  and  joints,  and 
stiifness  of  the  muscles  of  the  neck,  preceding  its  full  devel- 
opment; or  it  begins  with  a  chill,  quickly  followed  by  vom- 
iting, by  headache,  by  delirium  or  stupor,  and  extraordinary 
prostration.  When  the  complaint  has  fairly  set  in,  the  head- 
ache is  intense,  and  often  accompanied  by  vertigo.  The 
face  has  a  iixed  expression,  or  bears  a  look  of  suffering;  the 
head  is  thrown  backward  and  rigidly  fixed.  There  is  pain 
at  the  nape  of  the  neck  and  along  the  spinal  column,  not 
increased  by  pressure,  but  much  augmented  by  movements 
of  any  kind,  felt  also  in  the  loins,  and  shootins;  into  the  ex- 


i 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  11 


T 


tremities.  The  patient  is  restless  ;  he  trembles  ;  talks  inco- 
herently; and  when  spoken  to  does  not  appear  to  hear;  his 
pupils  are  generally  dilated,  and  there  may  be  dimness  of 
sight,  or  double  vision.  The  skin  is  dry,  often  very  sensi- 
tive, or  in  some  parts  the  sensibility  is  increased,  in  others 
diminished,  and  the  cutaneous  surface  is  frequently  spotted 
with  a  red  or  a  brown  eruption,  which  becomes  rapidly 
petechial,  and  wholly  uninfluenced  by  pressure;  vesicles,  too, 
are  apt  to  appear  on  the  lips.  They  show  themselves  from 
the  third  to  the  sixth  day  of  the  disease,  while  the  eruption 
is  seen  either  on  the  first  day,  or  may  at  all  events  be  de- 
tected by  the  third  or  fourth  day.  The  pulse  at  first  is  gen- 
erally either  natural  or  slow;  but  it  becomes  rather  frequent 
and  irregular,  and  commonly  remains  accelerated  through- 
out the  disease.  The  tongue  is  moist  or  dry,  and  brown; 
the  breathing  often  hurried  and  shallow,  and  the  urine 
slightly  albuminous.  The  bowels  are  at  the  outset  consti- 
pated, but  as  the  malady  advances  they  become  relaxed. 
There  is  very  usually  persistent  irritability  of  the  stomach, 
with  great  thirst,  and  spasmodic  contractions  or  convulsive 
movements  in  the  muscles  of  the  extremities.  With  these 
symptoms,  to  which  those  of  exhaustion  become  plainly 
added,  the  disorder  progresses  to  its  close,  presenting  in 
some  cases  now  and  then  strange  and  delusive  remissions, 
soon  followed  by  distinct  exacerbations.  In  fortunate  in- 
stances the  morbid  phenomena  gradually  lose  their  violence, 
and  the  patient  enters  upon  a  tedious  convalescence. 

But  though  these  are  the  symptoms,  which  frequently 
recur  in  epidemics,  yet,  as  already  indicated,  they  cannot 
always  be  taken  as  the  standard  expression  of  the  disease. 
Most  of  them  were  observed  in  the  formidable  examples  of 
the  malady  which  have  but  recently  been  encountered  in 
tliis  country :  and  they  have  also  been  met  with  in  the  epi- 
demic cerebro-spinal  meningitis  not  long  since  prevalent  in 
Germany.  As  regards  this  epidemic,  we  are  told  by  a  dis- 
tinguished observer,*  that  the  spleen,  earl}^  in  the  attection, 
enlarges,  but  does  not  continue  tumefied;  and  that  the  tem- 

*  Wunderlich,  Archiv  der  Heilkunde,  No.  Til.,  1865,  quoted  in  the  Am. 
Journ.  of  Med.  Sciences  for  Oct.  18G5. 


118  MEDICAL   DIAGNOSIS, 

poruture  reaches  106°  to  108°  Falir.,  or  even  higher,  without 
there  beinoj  a  proportionate  rise  in  the  pulse ;  or  this  may 
become  frequent  M'ithout  a  corresponding  increase  in  the 
temperature,  whicli,  moreover,  is  not  sustained  at  the  same 
lieight.  And  whether  the  pulse  be  rapid  or  slow,  the  force 
of  the  heart's  impulse  is  at  times  found  to  be  singularly 
augmented. 

The  duration  of  the  malady  is  very  various.  Patients 
may  become  rapidly  comatose,  and  die  within  twelve  hours, 
before  any  distinctly  febrile  action  has  commenced ;  or  sink 
in  "a  few  days ;  or,  on  the  other  hand,  the  complaint  may 
pursue  a  ver}'  chronic  course,  lasting  for  weeks,  and  during 
this  time  deafness  and  blindness,  convulsions,  retention  of 
urine,  and  partial  palsies — though  this  is  very  unusual — 
may  be  prominent  phenomena.  In  any  case,  the  prognosis 
is  highly  unfavorable;  especially  so  when  the  symptoms 
from  the  onset  are  violent,  or  the  signs  of  spinal  disturbance 
preponderate. 

Of  the  cause  of  the  formidable  disease  we  know  little. 
Many  look  upon  it  as  modified  typhus ;  and  what  tends  to 
support  this  view  is,  that  the  disorder  occurs  epidemically 
under  much  the  same  circumstances  as  typhus.  We  find  it 
in  crowded  jails,  in  poorhouses,  among  ill-clad,  half-nour- 
ished persons.  And  whether  typhus  or  not,  it  is  certainly  a 
general  disease,  not  merely  an  inflammation,  and  the  descrip- 
tion of  this  cerebro-spinal  fever  here  can  only  be  justified  on 
grounds  of  clinical  convenience. 

Cerebro-spinal  meningitis  is  an  aftection  very  familiar  to 
military  surgeons.  It  attacks  recruits  who  have  been  sub- 
jected to  unaccustomed  fatigue,  or  have  been  huddled  to- 
gether in  unhealthy  barracks  or  camps.  Attention  to  clean- 
liness, good  food,  pure  air,  sufficient  clothing,  and,  as  far  as 
possible,  not  overmarching  raw  troops,  are  then  its  surest 
prophylactics. 

To  determine  the  diagnosis  is  ordinarily  not  difficult;  the 
epidemic  character  of  the  malady  is  a  safeguard  against 
error.  The  protracted  cases  simulate  typhoid  fever.  They 
resemble  it  in  its  long  duration,  in  several  of  the  cerebral 
symptoms,  in  the  occurrence  of  an  eruption,  and  sometimes 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  110 

of  cliarrhcea.  They  (lifter  from  it  in  more  sudden  invasion, 
or  ratner  in  the  short  time  in  which  the  disease  reaches  an 
alarming  aspect;  and  in  the  early  stages  the  violent  head- 
ache, the  constipation,  the  constant  vomiting,  the  slow  or 
normal  pulse,  and  the  cool  or  but  slightly  heated  skin,  are 
unlike  the  signs  of  enteric  fever.  In  those  cases  in  which 
an  eruption  appears,  it  is  noticed,  at  latest,  by  the  third  or 
fourth  day,  not  at  the  end  of  a  week,  as  in  typhoid  fever; 
nor  is  the  rash,  save  in  extremely  rare  instances,  rose-colored. 
Later  in  the  malady  the  traits  of  distinction  become  broader 
and  broader.  The  prominence  of  the  abdominal  symptoms 
in  the  one  disorder;  the  continued  violent  headache,  the 
fixed  spinal  pain,  the  severe  twitchings,  or  the  tetanic 
rigidity  of  the  muscles  in  the  other,  are  signs  the  import  of 
which  are  not  easily  overlooked. 

The  suddenness  with  which  the  morbid  phenomena  occa- 
sionally develop  themselves,  and  the  lulls  that  take  place  in 
the  course  of  the  aft'ection,  may  cause  it  to  be  mistaken  for 
the  cerebral  variety  of  congestive  fever.  But  the  remissions 
are  not  so  marked  as  in  this  pernicious  malady,  nor  are  the 
exacerbations  preceded  by  a  long,  violent  chill.  Moreover, 
congestive  fever  does  not  begin  with  congestive  symptoms, 
but  the  first  attack  is  like  that  of  an  ordinary  intermittent 
or  remittent;  hence  we  have  the  history  of  the  case  to  in- 
struct us. 

From  tetanus  cerebro-spinal  meningitis  may  be  distin- 
guished by  its  epidemic  prevalence,  and  by  the  signs  of 
mental  disturbance,  which  are  very  slight  or  wholly  wanting 
in  the  former  disorder.  Generally,  too,  the  cognizance  of 
the  exciting  cause  of  the  tetanic  convulsions,  such  as  their 
following  wounds  or  punctures,  aids  in  interpreting  their 
meaning. 

How  can  we  discriminate  between  mflammaiioii  of  the  cord 
and  of  the  cerebro-spinal  meninges?  Thus:  in  myelitis,  as 
in  pure  spinal  meningitis,  mental  symptoms  are  absent ;  their 
presence  in  cerebro-spinal  meningitis  constitutes  one  of  the 
marked  features  of  the  disease.  In  myelitis  there  is  an  utter 
absence  of  convulsions  or  spasms,  or  should  these  happen, 
they  occur  in   the  shape  of  clonic  spasms;   but  tonic  con- 


1:20  MEDICAL    DIAGNOSIS. 

tractions  of  muscles  do  not  occur  unless  there  be  coexisting 
meningeal  inHammation  ;  in  cerebro-spinal  meningitis,  on 
the  other  hand,  rigidity  of  the  muscles  is  one  of  the  most 
striking  peculiarities.  In  myelitis  priapism  is  a  frequent 
symptom  ;  it  is  scarcely  met  with  in  cerebro-spinal  menin- 
gitis. Myelitis  is  usually  accompanied  or  followed  by  paral- 
ysis ;  paralysis  is  a  very  rare  sequel  of  cerebro-spinal  in- 
flammation, and  when  it  happens,  is  limited  in  extent.  A 
complete  palsy  always  justifies  the  conclusion  of  myelitis, 
or,  at  all  events,  of  considerable  pressure  on  the  cord  from 
an  effusion. 

The  ordinary  form  of  cerebral  meningitis^  as  well  as  fuhercular 
meningitis,  diiiers  from  the  cerebro-spinal  atfection  by  the 
presence  in  this  of  marked  spinal  symptoms  and  commonly 
of  an  eruption,  and  by  the  dissimilar  origin  and  progress  of 
the  cases.  The  likeness  of  the  malady  to  typhus  fever,  and 
the  relation  it  bears  to  it,  we  shall  elsewhere  discuss. 

Delirium  Tremens. — The  prominent  trait  of  this  com- 
plaint is  delirium,  associated  with  trembling  and  with  sleep- 
lessness. It  occurs  in  intemperate  persons;  yet  such  is  not 
always  the  case,  for  we  may  iind  an  affection  identical  with 
mania  a  potu  in  those  who  are  not  intemperate  in  the  ordi- 
nary acceptance  of  the  word,  but  whose  nervous  systems 
have  been  racked  by  persistent  mental  anxiety,  or  by  tiie 
use  of  other  than  alcoholic  stimulants. 

Generally,  however,  delirium  tremens  is  brought  on  by  the 
abuse  of  intoxicating  liquors.  It  is  a  current  belief,  and  one 
which  has  found  much  favor  among  habitual  drinkers,  that  a 
diminution  or  a  sudden  discontinuance  of  the  accustomed 
beverage  is  followed  by  an  onset  of  delirium.  Tiiis  may 
perhaps  happen  ;  but,  if  I  am  to  take  as  a  standard  the  large 
number  of  cases  of  the  disorder  that  have  come  under  my 
care  at  the  Philadelphia  and  Pennsylvania  Hospitals,  I  should 
say  that  its  appearance  is  most  commonly  preceded  by  a  long- 
continued  and  unusually  severe  debauch,  which  linds  its 
winding  up  in  an  attack  of  mania  ;  and  hence  that  this  occurs 
in  consequence  of  an  excess,  rather  than  of  a  diminution  of 
the  habitual  stimulus. 

Let  us  look  a  little  more  closely  at  the  mental  wandering. 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  121 


5      MXX^IXIXJ        ^KJLV^, 


It  is  veiy  rarely  fierce ;  nor  is  the  patient  taken  up  wholly 
with  his  delusions.  He  pays  a  certain  amount  of  actention 
to  surrounding  objects,  answers,  perhaps  in  a  rambling  man- 
ner, the  questions  put  to  him,  but  fancies  that  animals  are 
running  around  on  his  bed,  or  are  crawling  on  the  walls,  and 
is  thereby,  or  by  some  equall}-  distressing  illusion,  kept  in 
horror  and  dread.  Or  he  imao-ines  himself  to  be  eno-ao-ed  in 
his  ordinary  occupations,  and  gives  minute  directions  as  to 
what  he  wishes  done;  tries  to  get  out  of  bed,  yet  is  quite 
tractable  when  thwarted  in  his  eftbrts.  His  hands  are  con- 
stantly moving,  and  his  delirium,  to  use  the  graphic  epithet 
of  Dr.  Watson,  is  a  busy  one.  With  it  are  associated  great 
sleeplessness,  a  frequent,  soft  pulse,  a  moist,  coated  tongue, 
and  a  clammy  skin. 

How  are  we  to  distinguish  the  malady  from  one  to  which 
it  bears  a  certain  resemblance — acute  meningitis  ?  Taking 
clearly  expressed  examples  of  each,  we  find  tlie  following 
marks  of  distinction:  the  pulse  is  different;  tense  and  hard 
in  meningeal  infiammation,  it  is  yielding  and  soft  in  delirium 
tremens.  The  skin  and  tongue  are  dry  and  feverish  in  the 
former  affection,  moist  in  the  latter.  Then  the  characteris- 
tics of  the  delirium  are  dissimilar:  and  in  the  one  disease 
the  mental  wandering  is  combined  with  severe  headache,  but 
not  with  tremors;  in  the  other,  with  tremors,  but  not  with 
headache. 

Yet  in  actual  practice  the  diagnosis  is  not  always  so  easy 
as  it  might  appear  to  be  at  first  sight,  and  we  meet  here  and 
there  with  cases  presenting  symptoms  the  exact  meaning  of 
which  it  is  puzzling  to  determine.  The  difficulty  is  mainly 
occasioned  by  extreme  cerebral  congestion,  or  by  infiamma- 
tory  action,  having  been  produced  by  the  same  exciting  cause 
that  has  brought  on  delirium  tremens.  In  tiiis  blending  of 
two  morbid  states,  the  pulse  is,  or  soon  becomes,  tenser  than 
in  pure  mania  a  potu  ;  the  skin  is  hotter;  and  I  believe  the 
irritability  of  the  stomach  is  more  marked  and  more  per- 
sistent. In  some  instances,  convulsions,  strabismus,  and 
deep  stupor  (carefully  to  be  distinguished  from  the  sleep 
which  announces  the  termination  of  mania  a  potu)  set  all 
doubt  at  rest.     But  when  these  signs  are  not  present,  we 


122  iMEDICAL    DIAGNOSIS.  / 

have  to  jiulge  chiefly  by  the  vascular  excitement,  and  by  the 
activity  of  the  fever,  of  the  mischief  that  is  going  on  within 
the  cranium.  Yet  caution  is  necessary  in  accepting  as  evi- 
dence phenomena  which  may  be  of  diverse  origin;  the  fever 
may  be  the  result  of  an  intercurrent  or  coexisting  pneumonia, 
of  a  gastritis,  of  a  pulmonary  apoplexy.*  Only  after  a  thor- 
ough exploration  of  the  condition  of  the  internal  viscera 
can  we  accord  to  heat  of  skin  and  bounding  pulse  their  full 
value. 

There  is  another  point  connected  with  the  diagnosis  of  the 
malady  which  it  is  necessary  to  mention,  and  chiefly  for  the 
purpose  of  calling  attention  to  a  very  common  error.  The  fact 
that  a  person  known  to  be  of  bad  habits  is  affected  with  deli- 
rium, is  often  received  as  a  sure  indication  that  the  mental 
delusions  have  been  produced  by  the  abuse  of  ardent  spirits. 
But  they  may  be  in  reality  owing  to  other  causes :  to  fever; 
to  a  visceral  inflammation  ;  to  acute  mania.  To  avoid  being 
deceived,  we  must  lay  stress  rather  on  the  special  character 
of  the  delirium,  and  on  the  symptoms  with  which  it  is  com- 
bined, than  on  its  mere  presence.  In  other  words,  delirium 
in  intemperates  is  not  of  necessity  the  fruit  of  intemperance. 
In  discussing  acute  mania  we  shall  return  to  this  subject. 

The  prognosis  of  delirium  tremens  is  not  unfavorable;  at 
all  events,  not  untavorable  in  the  first  attack.  Indeed,  if  the 
patient  possess  sufficient  strength  of  will  to  reverse  his  habits, 
and  be  disposed  to  take  his  first  punishment  as  a  warning,  it 
is  powerful  for  good,  instead  of  for  evil.  But,  unfortunately, 
most  attempts  at  reform  do  not  last  long,  and  sooner  or  later 
the  drunkard  dies  a  drunkard's  death.  The  fatal  issue  is 
occasionally  brought  on  by  an  intercurrent  inflammation, 
especially  of  the  lung;  sometimes,  after  the  subsidence  of 
the  urgent  cerebral  symptoms,  the  patient  dies  very  unex- 
pectedly, and  no  morbid  appearances  in  the  brain  or  its  mem- 
branes account  for  the  abrupt  extinction  of  life.  In  many 
instances,  however,  of  these  sudden  deaths,  a  large  amount 
of  serum  is  found  in  the  ventricles,  or  in  the  subarachnoid 
spaces. 


*  Case  at  the  Philadelphia  Hospital,  July,  1860. 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD.  ETC,  123 

Acute  Mania. — It  would  he  obviouslj  ont  of  place  to 
attempt  to  give,  in  a  work  on  medical  diagnosis,  a  detailed 
account  of  an}'  of  the  forms  of  insanity;  bur,  in  its  acute 
variety  especially,  it  resembles  other  affections  of  the  nerv- 
ous system  so  closely,  that  it  cannot  be  wholly  passed 
over. 

There  are  mainly  two  disorders  with  which  acute  mania  is 
liable  to  be  confounded — acute  meningitis  and  delirium  tre- 
mens; and  we  shall  for  our  purposes  best  learn  the  manifest- 
ations of  acute  mania  by  contrasting  it  with  these  maladies. 

From  acute  meninoitis  mania  differs  in  these  essential 
particulars :  the  premonitory  symptoms  of  the  former  are 
headache,  drowsiness,  and  often  a  sense  of  tingling  and  of 
numbness  in  the  extremities;  these  signs  are,  however,  soon 
succeeded  by  the  severer  headache,  tense  pulse,  high  fever, 
and  optical  illusions  of  the  developed  disease.  The  pre- 
monitory symptoms  of  acute  mania,  on  the  other  liand,  have 
generally  existed  for  a  longer  time  before  the  marked  out- 
break; some  singular  change  of  manner  or  of  mode  of 
thought  commonly  precedes  the  first  violent  attack  of  in- 
sanity, excepting  in  those  cases  in  which  the  overthrow  of 
reason  results  from  a  sudden  e-reat  o-rief  or  a  violent  shock 
to  the  nervous  system.  Further,  when  the  delusions  have 
taken  full  possession  of  the  mind,  the  patient  attempts  to 
act  up  to  theni,  and  his  bodily  strength  enables  him  to  do 
so.  He  has  little  if  any  fever;  no  spasms;  Ins  pupils  are 
not  contracted;  his  stomach  is  not  irritable;  he  does  not 
suffer  from  headache,  or  at  least  does  not  in  any  way  com- 
plain of  his  head.  It  is  needless  to  point  out  how  all  this 
differs  from  acute  inflammation  of  the  brain. 

There  is  but  little  difficulty  in  discriminating  between 
typical  cases  of  delirium  tremens  and  of  acute  mania.  The 
anxious  and  distressed  countenance,  the  alarm,  the  good- 
natured  loquacity  and  restlessness  of  the  patient,  his  moist 
skin,  compressible  pulse,  and  creamy  tongue,  —  are  phe- 
nomena very  different  from  the  ravings  and  excitement,  or 
stubborn  silence  alternating  with  the  Avildly  expressed  hal- 
lucinations of  insanity.  Yet  there  are  cases  in  which  it  is 
not  easy  to  tell  if  the  delusions  are  really  due  to  intemper- 


124  AIEDICAL    DIAGNOSIS. 

ance:  cases  of  iiisaiiity  excited  by  drink  iu  persons  predis- 
posed to  mania.  It  may,  indeed,  at  first  be  impossible  to 
decide  upon  their  nature,  and  upon  the  share  the  drinking 
has  in  tlieir  production.  A  few  days,  however,  ordinarily 
remove  nil  uncertainty;  the  person  who  is  thought  to  be 
merely  delirious  is  seen  to  become  frantic  after  an  intermis- 
sion of  quiet,  or,  entirely  unlike  wliat  happens  in  mania  a 
potu,  to  be  still  out  of  his  mind  after  he  has  had  a  good, 
sound  sleep.  In  one  instance,  in  which  much  doubt  existed 
as  to  the  diagnosis,  the  patient  solved  the  doubt  by  jumping 
out  of  bed  after  having  been  quietly  sleeping  for  hours,  and 
in  a  state  of  wild  excitement  knocked  down  the  nurse  who 
tried  to  prevent  her  from  leaving  the  room.* 

Diseases  marked  by  Sudden  Loss  of  Consciousness  and  of 

Voluntary  Motion. 

The  chief  diseases  of  this  class  are  apoplex}',  sun-stroke, 
and  catalepsy.  Epileps}-,  too,  might  assert  its  claims  to  be 
here  regarded;  but  it  is  more  convenient  to  consider  it  with 
the  convulsive  affections. 

Apoplexy. — This  is  coma  coming  on  rapidly,  in  conse- 
quence of  the  compression  of  the  brain  by  extravasated 
blood.  At  all  events,  hemorrha^ce  is  the  condition  bv  far 
the  most  commonly  linked  to  the  comatose  symptoms;  in 
comparatively  rare  cases  only  does  the  pressure  upon  the 
brain  result  from  turgescence  of  the  vessels,  or  from  an  effu- 
sion of  serum. 

The  malady  has  sometimes  no  prodromata ;  but  not  un- 
frequently  it  is  preceded  by  great  depression  of  spirits,  by 
attacks  of  loss  of  memory,  by  illusions,  by  vitiated  percep- 
tions, by  vertigo,  or  by  odd  sensations  in  the  head. 

The  seizure  is  generally  very  sudden,  and  the  coma 
quickly  developed.  The  patient  falls  to  the  ground,  bereft 
of  all  consciousness.  In  other  instances,  before  he  sinks 
into  the  comatose  sleep,  there  will  be  more  or  less  pain  in 


*  For  fuller  information  on  the  diagnosis  of  acute  mania,  see  particularly 
Dr.  Henry  Maudsley's  work. 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC  125 

tlie  head,  sickness  at  the  stomach,  heaviness  and  confusion 
of  thonglit,  or  even  slight  convulsions.  Such  gradual  eases, 
Abercrombie  tells  us,  are  more  dangerous  than  those  of 
abrupt  origin. 

When,  whatever  its  commencement,  the  attack  has  reached 
its  height,  it  presents  these  well-known  features :  the  patient 
lies  as  if  in  a  deep  sleep,  breathing  laboriously  and  noisily, 
and  each  snoring  inspiration  followed  by  a  flapping  of  the 
cheeks  in  expiration.  The  pulse  is  slow,  full,  at  times  irreg- 
ular; the  carotids  throb  violently,  and  the  increased  pulsa- 
tion is  particularly  noticed  in  large  effusions,  whether  of 
blood  or  of  serum  ;  there  is  dithculty  of  deglutition  ;  the 
pupils  are  immovable,  and  either  contracted  or  dilated;  the 
eye  half  open.  All  thought,  all  sensation,  all  volition  is  sus- 
pended; the  limbs  are  motionless,  flaccid,  and  when  lifted 
fall  passively  and  to  all  appearance  lifeless  to  the  ground. 
Occasionally,  not  often,  their  muscles  are  rigid;  but,  save 
when  the  apoplexy  is  very  extensive,  reflex  contractions  can 
be  excited  in  them. 

If  the  patient  recover  from  the  comatose  state,  he  does  so 
generall}'  in  a  short  time ;  in  a  few  hours,  unless  the  lesion 
be  very  great,  the  intellectual  faculties  begin  to  resume  their 
sway,  and  all  the  functions  of  the  body  are  slowly  restored  to 
their  natural  condition.  Yet  there  is  a  palpable  exception  to 
this  in  the  muscular  system.  Paralysis  of  one  side  is  very 
apt  to  remain  long  after  everything  else  presents  a  normal 
look ;  nay,  it  may  be  a  sequel  lasting  for  years,  or  even  per- 
manently. 

One  attack  of  apoplexy  is  likely,  sooner  or  later,  to  be 
followed  by  another,  and  the  reason  of  this  is,  that  the  pre- 
disposing cause  is  generally  of  a  persistent  character — an 
organic  cardiac  malady,  especially  hypertrophy  of  the  left 
ventricle  or  tricuspid  regurgitation;  a  disease  of  the  cerebral 
arteries;  or  softening  of  the  brain.* 

Now,  is  there  anything  at  the  time  of  the  apoplexy,  or 


*  The  most  recent  researches  have  rendered  it  likely  that  the  extravasation 
of  blood  is  always  due  to  the  same  immediate  cause,  to  rupture  of  miliary 
aneurisms  on  the  minute  arteries.  See  Charcot  and  Bouchard,  Archiv.  de 
Physiol.,  1868;  also  Charcot,  Maladies  des  Vieillards. 


Ilji;  MEDICAL    DIAGNOSIS. 

after  its  most  urgent  syinptoins  huve  passed  away,  by  wliioh 
we  eini  recognize  whether  the  pressure  on  tlic  hrain  ror^nlts 
from  a  (•h>t,  a  serous  etl'iision,  or  from  a  tnrgescence  of  the 
eerehral  vessels?  And,  ngain,  do  the  morbid  manifestations 
furnisli  any  chie  to  tlie  seat  of  the  hemorrhage?  Witli  refer- 
ence to  the  former  (piestion,  all  clinical  experience  forces  us 
to  admit  that,  in  any  of  the  states  mentioned,  the  actual 
sii,nis  may  he  the  same;  and  that  we  never  can  be  quite  cer- 
tain of  tlie  non-existenct!  of  a  elot.  It  is  true  that  when  the 
apoplectic  symiitMiiis  abate  I'aiiidly;  when  thought,  however 
confused,  soon  i-ettirns;  when  the  limbs  ari"  not  paralyzed, 
(U'  are  so  but  imperfectly  and  tor  a  >liort  time, — we  have 
stroni'' reason  t'or  belic\iiiu-  tliat  con^-e.-tion  ^imiih'  lies  at  the 
njot  of  tlie  disturbance;  that,  in  other  words,  the  case  is  one 
of  those  called  simple  apoplexy.  \)\\\  it  is  never  possible  to 
give  a  positive  opinion,  since  a  clot  near  tlu'  ju'riphery  of 
tlie  brain  ma\'  occasion  the  same  phenomena  as  those 
specified. 

And  with  reu'ai'd  to  a  rapiil  eirn>ion  ot'  serum,  tlie  diili- 
culty  of  di^tinelion  i>  unite  as  great,  or  i'\'en  greati'r.  In 
fact,  the  oidy  ditfei'ent la  1  sigii>  which  wvvv  formerly  claimed 
for  serous  apoplexy,  namely,  pallor  ot'  face  ami  t"etd)leness  of 
pulse,  are  now  known  to  be  \-ei'y  eomnion  in  large  sanguine- 
ous effusions;  and  wlien  we  anaK/.e  llie  svuiptonis  ot'  the 
eases  recorded  by  Abererombie,  by  Morgagni,  by  Andral, — 
for  the  desciMplion^  of  nlilci'  autlnu's  respi'cting  thi>  affection 
ai'e  not  to  be  trusted,  and  nmsi  nnMleni  authorities  .seem  to 
pas.s  it  by  as  whollv  un\\Mitli_\  ol'  noiiee, — we  liiiil  al)solutely 
nothing  tluit  can  hi-  looked  u|mui  as  e\'en  pointing  to  a  diag- 
nosis. In  a  case  which  came  uniler  my  obsi'i'vation  some 
years  since,*  the  I'cspiration  \vas  not  noisy,  noi-  was  there 
fhipping  of  the  cheeks,  ov  the  least  diseernibh'  mo\ement  ot' 
any  i)ortion  ot'  the  body;  yet  1  am  not  aware  that  any  of 
thes^'  points  can  be  I'cgarded  as  diagnt>stie. 

riie  s,i(/  nt  llie  lieniorrliage  can  ordinaril\'  be  ih-teeted 
with  somewhat  more  eertaintx  than  the  eaiise  of  the  cerebral 
pressure;    it  could    be   detected   with  yet   greater  certainty, 

*  Charlotiton  Medicul  Juuriml  iiiul  Ucview,  .Miinli,  18.V.>. 


inSK\SKS    OV    TUK    BRAtX,  SPIXAL    OORl\  KtO.  IHI 

wore  it  not  that  the  oxtnivasAtion  i^o  otYou  take*  plaoo  into 
an  alroadv  dis^eassed  bi^in.  In  the  vAst  majority  of  in5<tanot>$, 
tho  bUW  is  ottuscHl  into  one  of  the  corpoi-u  striatic  and  optic 
thaUvnii,  and  wo  tind,  in  eonsoquonoo,  only  ono-sided  ^viraU 
Ysis,  If  the  Icjsion  bo  in  both  honnssphoros,  tho  jvilsy  is  on 
both  sides  of  the  bodv,  althonsili  almost  invariably  moi'^ 
complete  on  one  side  than  on  tho  other.  Yet  a  double-sided 
palsy  does  not  justity  an  alvsolnto  opinion  that  the  e^xtravu- 
sation  of  blo«.Hi  into  the  brain  substance  is  double-sided.  It 
betokens  also  an  ettusion  into  the  ventrioles.  But  ventricu- 
lar homorrhaiTO  is,  besides,  distinjjnished  by  pivfound  con\a 
and  by  tonic  contraction  of  tho  muscles, 

llomorrhasiv  into  the  corpoDi  quadris^omina  presents  most 
frequently  this  combination  of  symptoms:  mnscular  tjvm- 
blinji-s,  convulsions,  impairment  of  sight  and  alter:uiou  of 
the  pupils.  Coivbollar  hemorrhasJ^^  ijives  rise  to  very  tern* 
porary  loss  of  consciousness;  to  ivlaxation  vvf  the  muscles 
of  the  limbs  without  paralysis  or  impaiixnl  sensibility ;  and 
to  fivquent  voniitiuii.*  In  hen\orrh;kiV  into  one-half  of  the 
pons,  thoiv  is  palsy  of  the  oxtixMuities  on  one  side,  auvi  of 
the  face  on  tho  othei\t  Theix^  may  also  be  hyponvsthosia  in 
some  parts  of  tho  Kviy,  and  anuiui»sis.J 

Ucmorrh,\iiO  limited  to  the  arachnoid,  with  the  bkHnl 
pouivvl  into  the  subaraclmoid  s^vices,  invasions  oixlinarily 
\v*in  in  the  head,  somnolenoy,  and  pivfound  «.\Mua  without 
\>;ualysis,  and  without  anax^thosia  or  slow  pulse,  but  with  ixs 
laxation  of  tho  muscKxs  and  son\otimes  with  ^xMwulsions: 
and  now  and  then  tho  symptoms  assume,  to  all  appeiu-anv.v,  a 
ivmittont  vx>ui^!»e.  It  is  a  very  fatal  form  of  apoplexy,  v>ccu»^ 
riuij  chictlv  in  now-born  childixMi,  and  at\or  injuries  to  the 
head,  or  fivn>  tho  sjivinjj  wav  of  a  disoasovl  and  wideuvHi 
artery,  v>r  in  consequence  of  a  ruptuix^  of  one  of  tho  sinuses 
of  tho  dura  nuitor. 

When  tho  ctfusion  of  bUxnl  takes  place  botwvvn  tlio  dura 
mater  and  the  arachnoid,  it  is,  as  Viix'how  has  of  late  yeai-s 
pivvcd,  iixmerally  tho  ultimate  ix^sult  of  an  intlan\mation  and 

*  UiUsuvt,  Aivh.  i,«^x.  \lo  Mi\i.,  IS:»^,  tvnuo  \i. 


1:28  MEDICAL    DIAGNOSIS. 

ofsiibsoquent  changes  of  the  inner  surface  of  the  dura  mater. 
On  eh)sc  inquiry,  the  precursory  symptoms  of  a  disease  of 
the  membrane  may,  perhaps,  be  traced  by  the  constant  and 
localized  pain. 

Let  us  now  examine  how  the  diagnosis  of  apoplexy  can  be 
determined,  and  how  this  malady  maybe  distinguished  from 
other  states  which  produce  rapid  loss  of  consciousness,  or 
sudden  paralysis.  Not  to  mention  epilepsy — the  phenomena 
of  whicli  we  shall  further  on  contrast  with  those  of  apoplexy, 
and  shall  observe  to  differ  chiefly  in  the  prominence  of  the 
convulsions;  or  meningitis — in  which  fever,  headache,  and 
other  signs  of  an  acute  cerebral  disease  precede  insensibility; 
or  a  tumor — which,  save  in  the  rarest  instances,  leads  only 
very  graduall}'  to  a  comatose  condition  ;  or  uremic  coma — 
marked  by  peculiar  prodromata  and  peculiar  stertor ;  or  sun- 
stroke— belonging  to  the  same  group  as  cerebral  hemorrhage, 
yet  presenting  points  of  contrast,  which  will  shortly  engage 
our  attention, — we  find  these  morbid  states  liable  to  be  mis- 
taken tor  apoplexy : 

Insensibility  from  Drink,  or  from  Narcotic  Poisons  ; 

Syncope; 

Asphyxia  ; 

Acute  Softening  ; 

Sudden  Extensive  Paralysis  ; 

Obstructions  of  Cerebral  Arteries  ; 

Protracted  Sleep  ; 

Cerebral  Hysteria  ; 

Aphasia. 

Insensibility  from  Drink,  or  from  Narcotic  Poisons.  —  Both 
these  conditions  are  sometimes  difiicult  to  distinguish  from 
the  coma  of  apoplexy;  and  if  we  are  not  cognizant  of  the 
circumstances  preceding  their  development,  we  have  only 
these  points  to  guide  us:  in  intoxication  there  is  a  strong- 
smell  of  whisky,  gin,  or  whatever  liquor  has  produced  it, 
emanating  from  the  mouth,  and  the  man,  although  uncon- 
scious, is  not  often  entirely  bereft  of  all  power  of  motion — he 
is  certainly  not  paralyzed.  Moreover,  the  pulse  is  not  slow, 
it  is  frequent;  the  eye  is  injected,  and  the  symptoms  become 
suddenly  much  ameliorated  after  the  inhalation  of  ammonia, 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  129 

or  after  the  stomach  has  been  emptied  of  its  contents.  In 
narcotic  poisoning,  especiallj^  if  from  opium,  the  pupils  are 
very  much  contracted ;  and  we  are  likely  to  encounter  re- 
peated vomiting,  and  a  gradual  intensification  of  the  coma. 
The  patient,  however,  unless  death  be  very  close  at  hand, 
can  be  momentarily  roused  from  his  deep  sleep;  and  his 
calm  breathing  is  unlike  the  stertor  of  apoplexy.  But  when 
the  hemorrhage  has  taken  place  into  the  pons  varolii,  the 
diagnosis  is  very  difficult,  especially  if  the  bleeding  be  ex- 
tensive, for  we  then  are  apt  to  have  a  contraction  of  both 
pupils,  and  the  respiration  may  not  be  stertorous;  nor  is 
there  always  at  first  paralysis.  Yet  this  subsequently  ap- 
pears, and  thus  the  detection  of  the  cause  of  the  insensibility 
is  rendered  easier.* 

Nitrobenzole,  which  operates  as  a  narcotic  poison  in  vapor 
as  well  as  in  a  liquid  state,  may,  in  the  rapidly  fatal  cases, 
produce  coma,  which  may  be  mistaken  for  the  insensibility 
of  apoplexy.  But  the  poison  leads  quickly  to  death  when 
coma  has  been  induced,  and  is  detected  by  its  strong  odor, 
resembling  that  of  bitter  almonds. f  Poisoning  by  drinking 
chloroform,  and  which  gives  rise  to  many  of  the  symptoms 
of  apoplexy,  is  also  discerned  by  the  odor,  and  by  the  quick 
and  tumultuous  action  of  the  heart  which  accompanies  the 
stertorous  breathing,  by  the  relaxation  of  the  limbs,  the 
deathlike  aspect  of  the  face,  the  widely  dilated  pupils,  and 
the  complete  general  angesthesia.J 

Syncope — Asphyxia. — The  loss  of  consciousness  in  either  of 
these  states  is  as  striking  as  that  of  apoplexy.  But  there  is 
this  decided  difterence :  the  suspension  of  thought  and  of 
volition  in  a  fainting  fit  is  due  to  failure  of  the  circulation  ; 
hence  the  pulse  is  hardly,  or  not  at  all  felt,  instead  of  being 
full,  as  it  is  in  apoplexy.  Further,  the  pallor  of  the  face,  the 
quiet  respiration,  the  short  duration  of  the  syncope  mark 
plainly  the  one  ati:ection  from  the  other.  And  with  refer- 
ence to  asphyxia :  the  turgid  and  livid  face,  the  bluish  lip, 

*  See  an  interesting  case  mentioned  by  Dr.  J.  H.  Jackson,  London  Hos- 
pital Kepurts,  vol.  i.,  1864. 

f  Taylor,  Oruys  Hospital  Reports,  vol.  x.,  3d  series. 

%  As  in  the  case  reported  in  I'Union  Medicale,  October,  1864. 

9 


130  MEDICAL   DIAGNOSIS. 

tlio  distressed  and  embarrassed  breatliing-  preceding  the  con- 
vulsions, and  the  loss  of  consciousness,  show  clearly  that  the 
disturbance  afi'ects  primarily  the  lungs,  and  does  not  reside 
in  the  brain. 

Acute  Softening. — This  may  give  rise  to  symptoms  so  simi- 
lar to  those  of  cerebral  hemorrhage,  that  a  differential  diag- 
nosis is  impossible.  Especially  does  this  happen  if  the  dis- 
ease manifests  itself  suddenly,  which  Rostan  informs  us 
occurred  in  one-half  of  the  cases  he  noted.  In  those  of 
more  gradual  origin,  a  feeling  of  numbness,  deterioration 
of  memory,  irritability  of  the  temper,  slight  impairment  of 
motion,  and  a  vacant,  dull  look,  are  noticed  for  some  time 
before  the  attack.  Occasionally  delirium  immediately  pre- 
cedes the  loss  of  consciousness.  Now  this  may  be  very  per- 
fect, or  imperfect,  or  even  Avholly  Avanting, — for  the  patient 
may  become  paralyzed,  after  being  merely  confused  or  feel- 
ing distressed,  but  without  losing  his  consciousness.  The 
palsy  is  at  times  attended  with  hyperaesthesia  and  with  rigidity 
of  the  limbs. 

But  it  is  by  the  after-symptoms  that  we  most  easil}^  sepa- 
rate acute  softening  from  apoplexy.  In  the  latter,  after  the 
shock  is  over,  a  gradual  improvement  takes  place,  very 
obvious  as  regards  the  mental  faculties  and  the  power  of 
articulation ;  in  the  former,  the  mind  remains  obtuse,  or 
greatly  impaired,  and  there  is  otherwise  but  slight  ameliora- 
tion ;  defects  of  sensibility  are  particularly  apt  to  be  noticed. 
A  significant  sign,  too,  of  acute  softening  is  an  increased 
secretion  from  the  mouth  and  eye.* 

Sudden  Extensive  Paralysis  without  Coma. — This  is  not  a  trait 
of  apoplexy,  although  it  is  a  common  error  to  suppose  that 
a  sudden  palsy  is  produced  by  hemorrhage  into  the  brain. 
Sudden  extensive  paralysis  without  coma  is  ordinarily  owing 
to  softening  of  the  brain;  but  it  may  be  due  to  hemorrhage 
into  the  spinal  column.  Palsy  from  this  source,  unlike  that 
caused  by  cerebral  hemorrhage,  is  almost  invariably  double- 
sided,  is  accompanied  by  severe  spinal  pain,  and,  if  the  ex- 
travasation have  taken  place  into  the  meninges,  by  tonic 
spasms,  like  those  of  tetanus. 


*  Durand  Fardel,  Maladies  des  Vieillurds. 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  131 

Obstruction  of  the  Cerebral  Arteries. — If  a  cerebral  artery  be 
suddenly  closed  by  a  tibriiioid  vegetation  being  washed  into 
it,  apoplectic  symptoms  arise.  We  may  suspect,  for  we  never 
can  be  quite  certain,  that  an  arterial  obstruction  is  the  cause 
of  the  disturbance  of  the  brain,  if  the  patient  be  laboring  under 
an  acute  or  subacute  endocardial  inflammation,  or  a  chronic 
valvular  trouble  in  which  fragments  of  vegetations  may  be 
broken  off;  and  if  witliin  a  brief  period  of  each  other  several 
incomplete  attacks  have  occurred  before  a  perfect  (and  gen- 
erally fatal)  comatose  condition  sets  in.  The  usual  locality 
of  the  impaction  is,  according  to  Virchow,  in  the  arterj^  of 
the  fossa  of  Sylvius  ;  and  the  consequences  of  the  interrupted 
circulation  are  at  once  perceived  in  the  adjacent  centre  of 
motion — the  corpus  striatum.  The  palsy  which  ensues  in 
connection  with  the  apparently  apoplectic  phenomena  is  one- 
sided ;  and  the  facial  paralysis  is  on  the  same  side  with  that 
of  the  limbs.  Other  peculiarities  of  the  hemiplegia  are, 
that  its  onset  is  not  of  necessity  attended  with  loss  of  con- 
sciousness, or  that  this  is  slight  and  of  short  duration ;  that 
the  palsy  is  often  quickly  followed  by  gangrene  of  the  ex- 
tremities; or  is  associated  with  disturbance  of  the  kidneys, 
or  with  enlargement  of  the  spleen  and  tenderness  in  the 
splenic  region,  due  to  changes  in  the  organs,  produced  by  an 
impaction  of  fibrin.  Just  as  in  apoplexy,  we  may  find  in  ob- 
structions of  the  vessels,  softening  as  a  result  of  the  accident; 
nor  are  the  symptoms  of  this  sequel  different  from  what  the}- 
are  when  softening  is  owing  to  more  usual  causes.*  Occa- 
sionally the  clot  is  not  washed  into  the  brain,  but  is  formed 
in  one  of  its  arteries.  The  thrombosis  may  extend  thence  as 
far  as  the  common  carotid.  Hasse,  who  has  placed  two  such 
cases  on  record,  mentions  that,  independently  of  the  cerebral 
symptoms,  they  may  be  recognized  by  the  absence  of  pulsa- 
tion in  the  carotid  of  the  affected  side,  and  its  tense,  cordy 
feel.t 

*  But  it  is  possible  that  we  shall  learn  to  look  upon  thrombosis  and  em- 
boli as  among  the  ordinary  causes  of  softening  of  the  brain.  A  recent 
author,  M.  Lancereaux  ("  De  la  Thrombose  et  de  I'Embolie  Cerebralc"), 
states  that  of  22  cases  he  observed,  16  were  connected  with  arterial  ob- 
struction. 

t  Zeitschr.  fiir  Ration.  Pathol  ,  Band  iv.     There  may  be  other  causes,  too, 


132  MEDICAL    DIAGNOSIS. 

Proti-aded  Sleep. — While  recovering  from  acute  diseases, 
the  sick  often  sleep  profoundly,  and  for  a  long  time.  Yet 
there  is  little  likelihood  of  confounding  this  with  the  sleep 
of  apoplexy;  for  the  antecedent  circumstances  reveal  the 
meaninu-  of  this  restoration  of  nature.  Sometimes,  however, 
persons  sink  into  a  deep  and  prolonged  slumber,  without  any 
previous  ailment.  Medical  literature  furnishes  a  number 
of  such  instances.  In  one  recorded  by  Dr.  Cousins,*  the 
tendency  to  somnolency  has  lasted  for  years.  The  patient 
frequently  sleeps  three,  and  sometimes  five  days  at  a  time. 
When  he  awakes  he  is  well.  In  a  case  which  I  saw  with 
Dr.  S.  Weir  Mitchell,  and  which  is  described  by  him,t  the 
slumberer  was  aroused  several  times  by  the  exciting  influ- 
ence of  electricity;  but  this  finally  lost  its  eitect,  and  she 
relapsed  into  a  sleep  from  which  she  awoke  no  more.  These 
kind  of  cases  ma}^  give  the  impression  of  apoplexy,  yet  they 
do  not  resemble  it  very  strictly.  They  are  unlike  it  in  the 
gentle,  noiseless  breathing,  and  feeble  pulse ;  iu  the  occa- 
sional motion  of  the  body ;  and  in  tlie  protracted  uncon- 
sciousness. 

Cerebral  Hysteria. — The  actual  similitude  and  the  points  of 
contrast  between  this  curious  state  and  apoplexy  may  be 
learned  from  the  following  sketch: 

A  married  lady,  of  a  remarkably  susceptible  and  nervous 
disposition,  had  been  for  many  months  suffering  from  amen- 
orrhcea  and  from  sluggish  action  of  the  bowels.  She  was  at 
the  same  time  troubled  with  a  constant  cough,  evidently  de- 
pendent upon  a  deposition  of  tubercles  in  one  of  the  lungs. 
She  had  been  in  ver}'  bad  health,  but  by  the  steady  employ- 
ment of  tonics,  and  the  beneficial  effects  of  a  sea  voyage,  her 
symptoms  were  much  amended.  Her  appetite  improved,  and 
she  commenced  to  gain  flesh  and  to  take  exercise  without 


of  cerebral  embolism.  For  instance,  a  case  of  carbuncle  ending  in  embolism 
of  the  middle  cerebral  artery,  is  described  in  the  Med.  Times  and  Gazette, 
Feb.  1869.  Cases  of  fat  globules  in  the  smaller  arteries  leading  to  a  fatty 
embolism  have  been  analyzed  by  Busch.  See  Virchow's  Archiv,  as  quoted 
in  Brit,  and  Foreign  Medico-Chirurg.  Rev.,  April,  1869,  p.  551. 

*  iledical  Times  and  Gazette,  April,  1863  ;  see  also  a  somewhat  simihir  case, 
N.  y.  Journ.  of  Med.,  Dec.  1867. 

t  Transact,  of  Phil.  Coll.  of  Physicians,  1856. 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  183 

fatigue.  She  was,  however,  troubled  with  headache,  atid  with 
pain  at  the  lower  part  of  the  abdomen.  On  one  occasion  in 
the  evening  I  ordered  her  some  cathartic  medicine ;  and  in 
the  morning  she  was  better  than  usual  and  in  the  liveliest 
spirits.  A  few  hours  afterward  I  was  sent  for,  and  found  her 
insensible.  She  had  complained  of  a  sudden,  sharp  cramp 
near  the  umbilicus,  and  had  then  ceased  to  speak.  She  re- 
mained unconscious  for  about  twelve  hours;  yet  not  wholly 
so,  for  every  now  and  then  she  opened  her  eyelids,  muttered 
a  word  or  two,  a  pleasant  smile  flitted  over  her  countenance; 
but  she  soon  relapsed  into  her  deep  slumber.  Her  thumbs 
were  drawn  inward ;  she  had  occasionally  convulsive  move- 
ments;  the  breathing  was  rapid,  but  not  noisy;  the  pulse 
feeble — at  first  slow,  then  frequent ;  her  eyes  squinted  in  the 
most  decided  manner.  Stimulants  and  antispasmodics  were 
freely  given,  but  without  much  benefit,  for  she  recovered 
from  her  lethargy  only  with  the  setting  in  of  the  most  vio- 
lent paroxysmal  pains  in  the  abdomen,  shooting  down  the 
thigh,  and  accompanied  by  contractions  of  the  muscles  and 
by  exquisite  local  tenderness.  The  next  day,  without  much 
abatement  of  the  sufl:ering,  she  was  perfectly  conscious;  but 
still  she  squinted — nay,  was  totally  blind,  and  remained  so 
for  two  days.  During  this  time  a  menstrual  discharge  com- 
menced, which  in  part  relieved  the  abdominal  pain.  The 
head  symptoms  were,  if  the  expression  be  admissible,  a 
metastasis  of  hysteria  from  the  ovaries  to  the  brain.  It  is 
needless  to  point  out  how  tnis  display  of  hysteria  differed 
from  apoplexy. 

Aphasia.  —  By  this  term  is  meant  loss  of  the  faculty  of 
expression  of  thought,  either  in  consequence  of  loss  of  the 
faculty  of  speech,  or  of  communicating  thought  by  writing 
or  by  gestures.  The  patient  may  be  deprived  of  the  ability 
of  expressing  himself  in  one  of  these  ways,  or  in  all;  the 
loss  of  speech  is  the  most  common,  and  is  apt  to  be  asso- 
ciated with  a  very  decided  impairment  of  memory  and  an 
enfeeblement  of  intelligence.  The  disorder  is  temporary, 
lasting  but  a  few  hours  or  some  days,  or  it  continues  for 
months  or  years.  And  during  its  course  the  afi'ected  person 
is  incapable  of  recalling  words  to  give  utterance  to  his  ideas; 


134  MEDICAL   DIAGNOSIS. 

or  if  he  eiin  recall  the  words  to  the  mind,  and  thus  think, 
cannot  express  them.  He  has  lost,  to  use  the  language  of 
Trousseau,  to  whom,  more  than  to  any  one  else,  we  are  in- 
debted for  our  knowledge  of  the  subject,  "  at  the  same  time, 
to  a  greater  or  less  degree,  the  memory  of  words,  the  memory 
of  the  acts  by  the  aid  of  which  the  words  are  articulated, 
and  intelligence;  but  all  the  faculties  are  not  equally  lost, 
and,  however  damaged  the  intelligence,  it  is  less  so  than  the 
memory  of  the  acts  of  phonation,  and  this  less  so  than  the 
memory  of  words." 

Very  often  the  patient  has  but  a  few  w^ords  at  his  control ; 
he  says  "yes"  or  "no"  for  everything,  and  appears  angr}?- 
that  he  can  say  no  more ;  or  he  uses  wrong  words,  knowing 
perhaps  that  they  are  wrong,  and  sometimes  only  those  of 
a  profane  kind ;  or  he  confuses  merely  some  syllables  in  the 
words  he  employs;  or  he  may  not  be  able  to  utter  a  w^ord. 
Yet  while  in  this  condition  there  is  no  defect  in  the  tongue, 
or  lips,  or  palate,  to  account  for  the  inability  to  talk;  they 
are  as  healthy  as  usual ;  the  act  of  swallowing  is  easily  per- 
formed ;  and  even  where  the  aphasia  is  complicated  with 
hemiplegia,  it  is  not  difficult  to  discern  that  the  imperfect 
articulation  and  thick  speech  attending  the  palsy — which, 
moreover,  are  very  apt  to  become  greatly  ameliorated,  or 
even  pass  off  within  a  short  period  after  the  seizure — are  not 
the  cause  of  the  singular  disturbance  of  the  faculty  of  ex- 
pression; a  disturbance  which  will  mostly  show  itself  not 
simply  by  the  failure  to  utter  words,  but  also  by  the  in- 
ability to  recollect  them  and  write  them  down.  Indeed,  it 
is  necessary  to  bear  in  mind  that  these  states  may  coexist, 
but  they  also  may  be  present  separately.  Thus,  there  are 
persons  who  can  think,  but  cannot  speak  or  write;  there 
are  those  who  can  think  and  write,  but  cannot  speak ;  and 
there  are  those  who  can  think  and  speak,  but  cannot  write. 
For  the  second  group  the  term  aphemia;  for  the  third, 
that  of  agraphia  has  been  proposed.*  Most  patients  under- 
stand perfectly  well  what  is  said  to  them;  some  can  read  to 
themselves ;  and  unless  the  general  intelligence  is  very  per- 


*  Bastian,  Br.  and  Foreign  Med.-Chir.  Review,  April,  1809. 


DISEASES    OF    THE    BRAIN",  SPINAL    CORD,   ETC.  135 

ceptibly  aftected,  tliey  can  express  themselves  by  signs  and 
gestures.  In  some  cases  there  is  rather  loss  of  memory  and 
forgetfulness  and  confusion ;  but  it  is  very  doubtful  whether 
these  defects  of  niemorv  ous^ht  to  be  included  under  the 
general  head  of  aphasia,  for  when  prompted  the  word  is  at 
once  spoken. 

Aphasia  is  believed  to  be  dependent  upon  disease  situated 
in  the  frontal  convolutions,  and,  by  Broca,  the  lesion  is  even 
located  in  the  supposed  seat  of  articulate  language,  in  the 
posterior  part  of  the  third  frontal  convolution  of  the  left  side 
of  the  cerebrum.  This  view  receives  support  from  the  fact 
that  the  hemiplegia  which  ma}^  accompany  aphasia  is  almost 
invariably  right-sided.*  Still,  even  this  fact  rather  favors 
the  lesion  beine:  on  the  left  side  than  beins'  strictlv  in  the 
convolution  mentioned.  Indeed,  several  cases  have  been  ob- 
seved — I  have  myself  met  with  two — in  which  the  part  in 
question  was  healthy ;  and,  on  the  whole,  I  think  it  rather 
proves  that  the  trouble  is  in  the  left  anterior  portions  of  the 
brain  than  in  a  special  convolution.  As  regards  the  exact 
lesion  in  the  affected  portion  of  the  brain,  it  is  very  various. 
In  cases  of  aphasia  of  short  duration  and  without  palsy, 
there  is  probably  merely  congestion  ;  in  protracted  cases, 
and  those  in  which  we  find  coexisting  hemiplegia,  a  clot  or 
softening  is  likely  to  be  present;  deficient  tone  of  the  blood- 
vessels and  enfeebled  nutrition  will  perhaps  explain  the 
aphasia,  which  may  be  noticed  during  the  convalescence 
from  grave  acute  maladies.  This  form  of  the  complaint  and 
that  consequent  upon  congestions  end  in  more  or  less  rapid 
and  generally  perfect  recover}' ;  in  the  other  forms,  either 
no  improvement  follows,  or  only  a  very  partial  gain  of  words 
takes  place. 

The  suddenness  with  which  the  attack  mav  set    in  will 


*  Troussoau,  in  his  Clinique  Medicale,  records  an  exception,  and  several 
are  mentioned  by  Sanders,  in  the  Edinburgh  Medical  Journal,  June,  18')6, 
and  by  Hughlings  Jackson,  in  a  very  interesting  paper  in  the  London  Hos- 
pital Reports,  vol.  i.  The  same  author  notices  the  concurrence  of  the  loss  of 
speech  and  hemiplegia  with  valvular  disease  of  the  heart,  and  traces  their 
connection,  in  many  cases,  to  embolism  of  the  cerebral  arteries,  particularly 
plugging  of  the  middle  cerebral  artery  on  the  left  side. 


136  MEDICAL    DIAGNOSIS. 

cause  it  to  l>o  nnstakeii  for  an  ordinary  apoplectic  seizure. 
But  we  find  eitlier  not  the  least  deficiency  in  motion  in  any 
part  of  the  bod}',  and  well-preserved  consciousness ;  or  the 
disease  may  become  m*anifest  subsequent  to  attacks  of  ver- 
tigo, or  to  a  paralytic  stroke  preceded  or  not  by  the  ordinary 
signs  of  an  apoplectic  fit.  Under  these  circumstances  the 
diagnosis  cannot  be  definitely  made,  until,  after  fully  re- 
turned consciousness,  we  have  an  opportunity  of  examining 
the  state  of  the  mind,  and  of  the  tongue  and  the  muscles 
concerned  in  articulation,  remembering  that  if  there  is  difii- 
culty  ill  articulation  the  case  is  not  one  of  aphasia. 

Sun-stroke. — Persons  exposed  to  the  scorching  rays  of 
the  sun  in  midsummer  often  become  dizzy,  and  fall  to  the 
ground  insensible — they  have  had  a  sun-stroke.  The  attack 
either  takes  place  while  the  patient  is  still  exposed  to  the 
sun  ;  or,  in  rarer  instances,  he  reaches  his  home  with  a  stag- 
gering gait,  giddy,  faint,  sufi^ering  from  a  dull,  oppressive 
pain  in  the  head,  and  after  some  hours  becomes  unconscious. 
However  the  onset,  the  insensibility  which  occurs  is  generally 
complete,  although  it  may  be  so  but  for  a  few  minutes.  Asso- 
ciated with  it  are  a  frequent,  feeble  pulse,  a  skin  not  deficient 
in  warmth  and  sometimes  very  hot  on  the  forehead,  stertor- 
ous breathing,  difficulty  in  swallowing,  and  relaxation  of  the 
limbs. 

When  we  contrast  these  symptoms  with  those  of  apoplexy, 
we  find  the  following  marks  of  distinction  :  the  pulse  is  not 
slow  and  full,  but  feeble;  there  is  more  difficulty  in  degluti- 
tion, but  a  less  snoring  respiration  ;  the  coma  does  not  ordina- 
rily remain  as  complete  for  so  great  a  length  of  time,  for  soon 
the  patient  may,  temporarily  at  least,  be  partially  roused  from 
his  deep  sleep  ;  and  no  paralysis,  either  of  the  limbs  or  of  the 
cheek,  occurs.  The  after-symptoms,  too,  are  difterent:  in 
cerebral  hemorrhage,  paralysis ;  in  sun-stroke,  feebleness  of 
movement,  but  no  paralysis.  In  the  former,  no  marked, 
persistent  headache;  in  the  latter,  headache,  more  or  less 
chronic,  always  aggravated  by  walking  in  the  sun,  and  often 
for  months  accompanied  by  signs  of  an  exhausted  nervous 
system,  and  in  some  instances  by  epileptic  convulsions. 

The  question  with  regard  to  the  discrimination  of  these 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  137 

morbid  states  is  one  of  great  practical  value,  as  on  the  con- 
clusion arrived  at  depends  our  therapeutic  action.  Are  we 
to  bleed,  and  to  purge  actively?  or  are  we  to  withhold  the 
lancet,  use  purgatives  moderately,  and  trust  to  cold  att'usions, 
sinapisms,  and  stimulants  ?  Are  we,  in  other  words,  to  follow 
out  a  treatment  of  service  in  apoplexy,  or  a  treatment  of  ser- 
vice in  the  majority  of  instances  of  sun-stroke?    * 

These  points  are,  as  a  rule,  readily  determined  by  paying 
attention  to  the  variance  in  the  symptoms  mentioned.  But 
it  must  be  confessed  that  we  sometimes  meet  with  ambiffu- 
ous  cases — cases  in  which  the  signs  of  nervous  exhaustion 
produced  by  exposure  to  heat  are  blended  with  those  of  cere- 
bral congestion  or  hemorrhage  excited  by  the  same  cause, 
and  in  which,  when  they  terminate  fatally,  the  autopsy  shows 
not  simply  a  changed  blood,  or  pulmonary  congestion,  but 
turgescence  of  the  cerebral  vessels,  or  an  extravasation.  The 
management  of  such  yjatients  requires  great  care;  we  must 
stimulate  or  not,  according  to  which  indication  the  weight  of 
the  symptoms  inclines. 

The  remarks  just  made  refer  to  the  most  common  form 
of  sun-stroke — that  attended  with  more  or  less  sudden  loss 
of  consciousness,  and  therefore  simulating  apoplexy.  But 
there  are  cases  in  which  the  abnormal  manifestations  come 
on  gradually,  and  in  which  the  patient  at  no  time  becomes 
insensible.  I  have  seen  a  number  of  the  kind;  they  were 
not  unusual  among  officers  sent  home  from  the  wearing  sum- 
mer campaigns  of  the  late  war.  The  chief  sj'mptoms  are, 
intense  headaclie,  nausea,  prostration,  and  inability  to  per- 
form any  work  requiring  sustained  attention.  All  these 
signs  appear  after  protracted  exposure  to  the  sun;  and  they 
mend  but  very  tardily.  In  truth,  in  the  slowly  developed 
disorder  the  subsequent  nervous  exhaustion  and  the  parox- 
ysms of  headache  seem  to  be  much  more  persistent  than  the 
same  phenomena  following  what  looks  like  the  more  violent 
form  of  the  malady.  Among  the  sequelse  of  these  apparently 
incomplete  attacks  are,  irritability  of  the  bladder,  inconti- 
nence of  urine,  and  irregular  action  of  the  heart.  But  no- 
thing is  as  striking  as  the  loss  of  mental  and  bodily  energy. 

The  symptoms  of  "insulatio,"  or  sun-stroke,  may  be  in- 


138  MEDICAL   DIAGNOSIS. 

duccd  by  prolonged  atmospheric  heat,  while  the  patient  is 
in-doors  and  not  exposed  to  the  rays  of  the  sun.  Such  cases 
of  heat  apoplexy  are  known  to  occur  in  India  even  at  mid- 
nii2:ht.  They  may  be  preceded  by  a  sense  of  extreme  weari- 
ness, by  inability  to  sleep,  by  loss  of  appetite,  by  constipation 
and  frequent  micturition,  and  by  deficient  perspiration  ;  or 
the  signs  of  exhaustion,  followed  by  more  or  less  complete 
insensibility,  appear  without  distinct  prodromes. 

Catalepsy. — This  is  a  sudden  suspension  of  thought,  of 
sensibility,  and  of  voluntary  motion,  during  the  continuance 
of  which  the  muscles  retain  the  exact  position  they  happen 
to  be  placed  in  at  its  onset.  This  strange  and  uncommon 
complaint  occurs  in  paroxysms,  which  may  last  but  a  few 
minutes  or  several  hours,  and  during  which  the  most  con- 
plete  ansesthesia,  not  only  of  the  skin,  but  of  the  deeper  tis- 
sues, may  occur.*  The  disorder  is  met  with  in  females,  espe- 
cially in  hysterical  females,  and  alternates  with  outbreaks  ot 
hysteria.  But  it  may  also  exist  in  the  male  sex,  and  be  in 
either  hereditary.  It  has  been  even  noticed  as  au  epidemic 
in  localities  where  there  are  many  families  closely  connected 
by  intermarriages. t 

Catalepsy  may  be  mistaken  for  apoplexy,  or  even  for  death 
itself.  It  differs  from  apoplexy  by  its  constant  recurrence : 
and  further,  during  an  attack  the  eyes  are  wide  open  ;  the 
pupils,  although  dilated,  are  very  susceptible  to  light ;  and 
there  is  an  absence  of  stertorous  breathing  as  well  as  of  the 
characteristic  relaxation  of  the  muscles  or  of  the  paralysis  of 
apoplexy, — for  the  limbs  are  outstretched,  or  held  in  every 
conceivable  annoying  or  painful  position,  yet  as  soon  as  con- 
sciousness is  restored,  their  power  of  movement  fully  returns. 
The  pulse  is  not  retarded ;  on  the  contrary,  although  feeble, 
it  becomes  very  frequent. 

The  perplexing  affection  varies  from  a  kindred  state, 
ecstasy,  in  this:  in  the  latter  the  loss  of  consciousness  is  not 
complete.  The  patient  is  merely  insensible  to  external  ob- 
jects, because  he  is  intensely  absorbed  in  some  vision  present 

*  As  in  the  case  reported  by  Lasequc,  Arcliiv.  Geiier  de  Medeciiie,  tome 
i.,  1864. 

t  Vogt,  Schmidt's  .Juhrh.,  Bd.  cxx.  )..  301. 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  139 

to  his  imagination,  or  in  the  contemplation  of  some  subject 
to  him  of  all-engrossing  interest.  But  he  is  not  statue-like  ; 
on  the  contrary,  his  countenance  is  animated,  earnest,  and 
he  talks,  declaims,  sings. 

There  is  a  curious  form  of  the  disorder,  which  Sir  Thomas 
Watson  describes.  It  is  an  imperfect  kind  of  catalepsy  called 
daymare,  the  affected  person  being  at  the  time  incapable  of 
moving  or  speaking,  yet  cognizant  of  all  that  goes  on  around 
her.  These  seizures  of  temporary  deprivation  of  muscular 
power,  without  unconsciousness,  were  thought,  by  the  accom- 
plished physician  quoted,  to  have  depended,  in  the  case  he 
cites,  upon  a  diseased  state  of  the  blood-vessels  of  the  brain. 
Were  this  condition  always  present  in  the  complaint,  it  would 
be  a  far  more  serious  one  than  ordinary  catalepsy. 

Diseases  marked  by  Convulsions  or  Spasms. 

Epilepsy. — Epilepsy  is  a  disease  the  chief  manifestation 
of  which  consists  in  recurring  attacks  of  sudden  loss  of  con- 
sciousness, attended  with  convulsive  movements.  The  pa- 
tient falls  to  the  ground  without  thought,  without  feeling, 
without  the  power  of  voluntary  motion.  He  utters  often  a 
short  piercing  cry,  then  a  fearful  muscular  struggle  begins. 
The  legs  are  stiff,  and  turned  inward;  the  head  is  tossed 
backward,  or  from  side  to  side ;  the  mouth  is  distorted,  the 
lips  covered  with  foam ;  the  arms  outstretched  and  rigid,  or 
thrown  about  with  great  force;  the  eyelids  are  half  closed; 
the  teeth  are  ground  together,  and  the  tongue  is  thrust  be- 
tween them,  and  often  severely  bitten.  Gradually  the  con- 
vulsive movements  become  less  violent  and  cease  altogether, 
and  the  patient  passes  into  a  deep  sleep,  from  which  he 
awakes  fatigued  and  exhausted,  and  dull  in  intellect.  But 
these  symptoms  disappear,  and  he  returns  to  his  usual  state 
of  health. 

But  every  paroxysm  does  not  present  the  same  phenom-  ■ 
ena,  or  run  the  same  definite  course.     In  many  the  attack 
is  preceded  by  strange  sensations :    by  a  peculiar  train  of 
thought;    by  retching;  by  the  feeling  of  a  puff  of  air  as- 
cending from    the   extremities  to   the   head.      This  "  aura 


140  MEDICAL    DIAGNOSIS. 

epileptica,"  on  which  so  much  stress  lias  been  Laid,  is,  how- 
ever, very  far  from  constant.  Yet  it  may  exist,  as  Brown- 
Sequard  teaches,  without  hardly  being  perceived:  it  may  be 
an  nnfolt  irritation  starting  from  some  centripetal  nerve  in 
any  part  of  the  skin,  or  from  some  organ  not  deeply  seated, 
as  the  testicle,  and  its  point  of  departure  may  be  detected 
by  observing,  during  the  fit,  in  what  neighborhood  the  first, 
or  the  most  violent,  or  the  most  prolonged  contractions 
occur.  In  very  rare  instances  sudden  spasms  of  the  face  and 
chest  occur  with  arrest  of  respiration,  and  followed  by  a 
clonic  convulsion,  3^et  with  so  little  unconsciousness,  that  it 
remains  doubtful  whether  the  paroxysm  has  been  attended 
by  unconsciousness  at  all. 

Some  seizures  are  very  light, — a  transient  suspension  of 
consciousness,  a  slight  twitching  of  some  of  the  muscles,  a 
fixed  gaze,  perhaps  a  decided  impression  of  vertigo,  and  all 
is  over.  These  abortive  fits,  the  petit  mal  of  the  French,  are 
very  apt  to  precede  by  some  days  a  severe  attack,  or  several 
of  them  may  take  the  place  of  the  more  turbulent  form  of 
the  disorder.  And  they,  too,  like  the  graver  epileptic  convul- 
sion, may  present  strange  irregularities.  They  may  manifest 
themselves,  for  instance,  only  in  bursts  of  unmeaning  laugh- 
ter, as  happened  in  the  extraordinary  case  recorded  by  Dr. 
George  Paget;*  or  in  attacks  of  sudden  and  intense  facial 
neuralgia,  with  or  without  partial  convulsions,  as  in  the  cases 
narrated  by  Trousseau. f 

The  epileptic  paroxysm  does  not  always  pass  o&  without 
leaving  some  trace  of  the  profound  disturbance  it  has  occa- 
sioned. It  may  be  followed  by  hemiplegia,  due,  it  is  ordi- 
narily thought,  to  a  congestion  of  the  brain  during  the  fit. 
Whether  this  be  the  explanation  or  not,  it  is  certain  that  the 
palsy,  like  that  following  cerebral  congestion,  is  very  tran- 
sient and  generally  disappears  in  a  few  da3'8.  Another 
sequel  of  the  attack  is  loss  of  voice;  another,  abdominal 
tenderness. 

In  the  intervals  between  the  seizures  the  patient  is  not 

*  British  Medical  Journal,  Feb.  1859. 
f  Clinique  Medicale,  toino  ii. 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  141 

ill  reality  well.  His  temper  is  irritable,  aod  his  mental 
faculties  slowly  but  certainly  deteriorate.  The  loss  of  mem- 
ory particularly  is  very  marked ;  and  dementia  is  not  an 
unusual  complication  of  long-continued  epilepsy.  In  some 
epileptics,  as  Herpin  so  well  points  out,  there  is  much  mental 
excitement  or  a  curious  mental  state  preceding  the  seizures, 
or  a  violent  and  dangerous  mania  may  follow  the  tit.* 

Epilepsy  is  either  central  or  peripheral :  that  is,  the  ex- 
citing cause  is  seated  in  the  nervous  centres,  especially  in 
the  brain  or  medulla;  or  affects  the  centripetal  nerves,  and 
is  by  them  reflected  to  the  nervous  centres.  It  is  thus  that 
the  malady  originates  in  injuries  of  nerves,  in  diseases  of 
the  skin,  of  the  gastro-intestinal  tract  of  the  uterus,  from  the 
irritation  of  worms,  or  in  consequence  of  congenital  phimo- 
sis.f  Now  with  reference  both  to  the  prognosis  and  the 
treatment,  it  is  very  important  to  discriminate  between 
epilepsy  of  centric  and  of  eccentric  origin  ;  and  to  arrive  at 
this  discrimination  is  only  possible  by  a  thorough  examina- 
tion of  all  the  constitutional  symptoms,  and  by  ascertaining 
the  starting-point  and  tracing  the  course  of  the  aura.  Another 
diagnostic  separation  of  great  practical  value  is  to  determine, 
after  we  have  concluded  the  epilepsy  to  be  central,  if  it  be 
symptomatic  of  a  cerebral  disorder — such  as  of  a  tumor,  of 
cysticerci  lodged  in  the  organ,  of  a  syphilitic  affection  of  the 
membranes,  or  of  a  distui'baiice  of  the  brain  produced  by  dis- 
ease of  the  skull-cap — in  fact,  of  any  of  those  cerebral  mala- 
dies which  are  known  to  engender  epileptic  seizures;  or  if  it 
be  watery  blood,  or  vitiated  blood  full  of  abnormal  ingredi- 
ents, as  in  diseases  of  the  kidneys,  acting  injuriously  on  the 
nutrition  of  the  cerebral  texture;  or  if  it  be  idiopathic,  due  to 
causes  we  do  not  fully  understand,  chief  among  them,  per- 
haps, if  we  may  look  upon  the  observations  of  Kiissmaul  and 
Teuner|  and  of  Schroeder  van  der  Kolk§  as  conclusive,  to 


*  Miiudsley,  Article  "Insanity"  in  Koynolds's  System  of  Medicine,  vol.  ii. 

t  Altliaus,  Lancet,  Feb.  1867. 

X  On  Epileptiform  Convulsions.  Translated  by  New  Sydenham  Society, 
18.59. 

§  Minute  Structure  and  Functions  of  Spinal  Cord  and  Medulla.  Sydenh. 
Soc,  1859. 


142  MEDICAL   DIAGNOSIS. 

a  morbid  excitation  or  an  affection  of  the  medulla  oblongata. 
During  the  paroxysms  it  is  impossible  to  settle  the  matter; 
but  in  the  interval  we  may  often  do  so  by  close  attention  to 
the  history  of  the  case,  and  by  noting  whether  the  patient 
enjoys  the  usual  health  of  epileptic  subjects,  or  presents  signs 
of  a  chronic  cerebral  trouble.  Romberg  tells  us  that  where 
affections  of  the  bones  lie  at  the  root  of  the  complaint,  the 
fits  are  readily  induced  by  pressure  upon  the  skull ;  and  fur- 
ther, that  if  there  be  disease  residing  in  one  of  the  cerebral 
hemispheres,  the  aura  affects  the  opposite  side  of  the  body, 
and  is  generally  confined  to  the  upper  extremity. 

Much  has  been  said  of  the  distinction  between  epilepsy 
and  co7Wulsions.  N'ow  as  regards  the  seizure  itself,  there  is 
no  appreciable  difference ;  the  only  diversity  consists  in  the 
recurrence  of  the  attack  after  intervals  of  comparative  health, 
and  in  the  non-existence  of  any  disturbance  from  which  con- 
vulsions are  likely  to  arise,  such  as  a  recent  injury  to  the 
head,  an  eruptive  fever,  the  parturient  state,  inflammation  of 
the  brain,  aBright's  kidney,  teething,  or  rickets.  In  children, 
who,  as  is  well  known,  are  particularly  subject  to  convul- 
sions, the  diagnosis  maybe  a  difficult  matter;  but  the  fits 
of  epileps}-  are  distinguishable  by  the  dulness  of  intellect, 
and  the  slow  mental  and  bodily  development,  observable 
in  the  intervals.  And  we  are  not  often  called  upon  to  make 
this  differential  diagnosis,  because  of  the  extreme  rarity  with 
which  epilepsy  occurs  in  the  young ;  although  many  insist 
that  it  is  more  frequent  than  is  supposed,  basing  this  assump- 
tion on  the  generally- received  fact  that  the  history  of  epilep- 
tics shows  them  to  have  suffered  greatly  from  convulsions 
during  childhood. 

The  diseases  which  are  most  apt  to  be  confounded  with 
epilepsj'  are  hysteria  and  apoplexy.  The  former — like  all 
the  rest  of  the  group  now  under  discussion,  like  chorea,  like 
tetanus,  like  hydrophobia — is  discriminated  by  the  absence 
of  that  perfect  suspension  of  consciousness  that  takes  phice 
in  epileptic  seizures ;  and  there  are  other  marks  of  distinc- 
tion, to  which  we  shall  presently  refer.  In  apoplexy,  as  iul 
epilepsy,  we  meet  with  loss  of  consciousness,  sometimes  with 
convulsions.     But  these  are,  on  the  whole,  rare,  and  coma 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  143 

precedes  and  does  not  follow  them,  as  happens  in  epilepsy. 
Then,  stertorous  breathing,  and  a  slow,  full  pulse,  are  not 
observed  in  epilepsy;  for  the  breathing,  although  irregular 
and  gasping,  is  not  coarse  and  noisy,  and  the  pulse  is  feeble, 
irregular,  and  frequent.  Epileptic  patients  bite  tlieir  tongue; 
this  does  not  occur  in  apoplexy.  In  epilepsy  the  paroxysm 
seldom  lasts  longer  than  from  ten  to  fifteen  minutes  before 
consciousness  returns,  and  before  the  convulsions  cease ;  in 
apoplexy  the  insensibility  is  of  much  longer  duration.  Epi- 
lepsy is  not  usually  followed  by  paralysis;  apoplexy  is  com- 
monly. 

Epilepsy  is  often  feigned;  yet  impostors  cannot  feign  it 
completely.  They  may  bite  their  tongue ;  they  may  imitate 
the  stertor,  the  foam  at  the  mouth,  the  convulsions,  the 
thumb  drawn  inward  toward  the  palm,  the  confused  air  on 
awakening :  they  may  simulate,  although  they  rarely  do  so, 
the  indifference  to  pain  ;  but  there  is  one  feature  of  the  real 
attack  they  cannot  copy — the  insensibility  of  the  iris.  ]^o 
matter  how  skilful  the  dissembler,  his  pupils  must  contract 
when  exposed  to  a  strong  light;  they  must  dilate  when  the 
stimulus  is  withdrawn. 

But,  unfortunately,  there  are  several  difficulties  in  making 
this  test  an  absolute  one.  In  the  first  place,  the  pupils,  dur- 
ing a  fit,  cannot  always  be  readily  observed.  In  the  second 
place,  not  in  every  case  of  epilepsy  are  they  perfectly  immov- 
able ;  in  some,  though  sluggish,  they  react  to  light.  And 
again,  as  proved  by  Dr.  Keen,  violent  muscular  motion  in- 
stantly dilates  the  pupil,  and  so  long  as  the  movement  con- 
tinues, so  long  will  the  iris  act  dilatorily,  even  when  exposed 
to  a  bright  light.  Thus  muscular  spasms  alone,  even  when 
simulated,  may  cause  the  pupils  to  be  dilated  and  inactive. 
A  test,  said  to  be  more  generally  useful,  is  the  administra- 
tion of  ether.  When  given  to  an  epileptic,  its  first  effect 
is  to  increase  the  violence  of  the  spasm,  but  eventually  the 
patient  passes  into  the  deep  sleep  produced  by  ether,  with- 
out any  of  the  prior  cerebral  excitement ;  while  in  the 
malingerer  this  manifests  itself  by  talking  and  laughing — in 
fact,  in  the  usual  way.* 

*  Keen,  Mitchell,  and  Morehouse,  Am.  Journ.  of  Med.  Sci.,  Oct.  18G4. 


144  MEDICAL    DIAGNOSIS. 

Chorea. — This  spasmodic  affection  is  chie%  met  with  in 
young  persons,  especially  in  girls  approaching  the  age  of 
puberty.  It  is  characterized  by  irregular  clonic  spasms  of 
groups  of  muscles  under  the  influence  of  the  will  and  mainly 
of  those  on  one  side  of  the  body.  But  the  patient  is  not  de- 
prived of  consciousness,  and  with  it  of  all  power  of  voluntary 
motion.  He  knows  what  he  is  about,  and  can  in  part  exe- 
cute the  movements  he  undertakes;  yet  his  limbs  are  not 
completely  under  his  control.  They  obey  only  his  general 
directions,  but  not  entirely  or  at  once;  for  the  muscles  jerk 
and  pull  as  seems  to  them  best,  taking  no  heed  of  the  time  or 
the  manner  in  which  the  will  wishes  any  movement  executed. 
In  some  cases,  not  in  many,  the  muscles  of  deglutition  and  of 
respiration  become  implicated,  and  difficulty  in  swallowing 
and  in  breathing  occurs.  A  dilated  pupil,  too,  acting  very 
sluggishly  in  response  to  light,  may  be  met  with  among  the 
phenomena  of  this  singulm*  malady. 

Chorea  is  essentially  a  functional  disorder  of  the  nervous 
centres — at  least  morbid  anatomy  has  as  yet  failed  to  prove 
its  definite  connection  with  any  organic  lesion.  A  centric 
structural  cause  for  the  irregular  movements  has  sometimes 
been  found  in  cerebral  tubercles,  or  in  the  circumscribed 
softening  of  segments  of  the  spinal  cord  ;  but  these  are  very 
exceptional  instances.*  In  a  large  number  of  persons  the 
malady  is  called  into  existence  by  an  irritation  of  peripheral 


*  In  an  admirable  paper  by  Dr.  .John  W.  Ogle  (British  and  Foreign  Med.- 
Chirurg.  Review,  1868),  congestion  more  or  less  complete  of  the  brain  or 
spinal  cord  was  met  with  in  six  cases  out  of  sixteen ;  in  one  case  there  was 
actual  softening  of  the  cord  ;  in  one  softening  of  certain  portions  of  the  brain. 
In  ten  out  of  the  sixteen  cases  there  existed  more  or  less  fibrinous  deposit  or 
granulations  upon  some  portion  of  the  valves  of  the  heart  or  its  lining  mem- 
brane. A  knowledge  of  this  fact  had  led  several  pathologists  to  the  belief 
that  chorea  is  connected  with  these  vegetations  being  set  free  and  carried 
as  emboli  to  different  organs.  Dr  Tuckwell  (Br.  and  Foreign  Med.-Chir. 
Review,  Oct.  1867)  explains  thus  the  cases  we  sometimes  encounter  in  which 
wild  maniacal  delirium,  with  subsequent  rapid  emaciation,  arises;  and  Dr. 
Hughlings  Jackson  (London  Hospital  Reports,  vol.  ii.,  and  Edinb.  Med. 
Journ.,  Oct.  1868)  believes  that  in  chorea  plugging  of  the  minute  vessels 
supplying  the  corpus  striatum  is  the  immediate  cause  of  the  disease;  a  one- 
sided embolism  giving  rise  to  but  a  one-sided  chorea.  These  ingenious  views 
still  require  substantiation. 


DISEASES    OF    THE    BRAIN,   SPINAL    CORD,   ETC.  145 

portions  of  the  nervous  system.  Thus  a  blow,  a  wound  of  a 
nerve,  disorders  of  the  uterus,  painful  menstruation,  preg- 
nancy, or  gastric  or  intestinal  affections  may  act  as  the  ex- 
citing causes  of  the  perverted  muscular  movements. 

Chorea  is  often  produced  by  strong  mental  emotion,  espe- 
cially by  fright.  It  may  also  be  the  sequence  of  rheumatic 
fever.  Indeed,  it  is  the  opinion  of  many  eminent  patholo- 
gists that  it  usually  arises  from  the  same  diathesis,  that  at- 
tends or  occasions  rheumatism.  The  evidence  adduced  con- 
sists, in  the  proneness  of  those  of  rheumatic  constitution  to 
chorea,  in  the  muscular  pains,  tlie  high-colored,  acid  urine, 
in  the  tendency  of  both  maladies  to  recur,  and  the  frequenc}- 
with  which  in  both  endocardial  affections  are  evoked.  Yet 
this  view  of  the  subject,  although  sanctioned  by  high  au- 
thority, and  now  the  generally-received  one,  cannot  be  ac- 
cepted as  conclusive.  Certainly,  in  a  large  number  of  persons 
affected  with  chorea,  we  fail  to  detect  any  proof  of  a  rheu- 
matic diathesis.  And  as  for  the  cardiac  complication,  the 
presence  of  wdiich  is  chiefly  deduced  from  the  existence  of  a 
murmur,  the  inference  drawn  from  this  sio;n  is  hardlv  a  fair 
one  ;  for  is  it  not  often  due  to  ansemia,  or  dependent  upon 
spasmodic  action  of  the  papillar}-  muscles — the  same  spas- 
modic action  that  is  seen  in  the  striated  muscles  of  the  face 
or  of  the  extremities? 

The  disease  is  rarely  fatal :  but  it  is  not  of  short  duration  ; 
for,  although  it  may  be  acute,  it  commonly  lasts  for  months. 
There  are  no  cerebral  symptoms  attending  it,  yet  the  men- 
tal faculties  are  not  in  a  perfectly  healthy  state.  The  intel- 
lect of  a  choreic  child  develops  slowly,  and  is  evidently 
enfeebled  while  the  disorder  lasts.  In  some  cases  paralysis 
supervenes  ;  but  it  is  not  permanent,  nor  indeed  of  long 
duration.  But  those  who  have  been  choreic  remain  subject 
to  nervous  disorders ;  and  I  have  known  several  instances  in 
which  the  complaint  has  been,  in  after-years,  followed  by 
epilepsy. 

The  diao-nosis  of  chorea  is  ffenerallv  verv  easv.  The  mal- 
ady  differs  from  the  spasms  of  acute  cerebral  disease  by  the 
absence  of  fever,  and  of  delirium  or  of  coma;  from  epilepsy, 
by  its  continuousness,  by  the  non-existence  of  unconscious- 

10 


146  MEDICAL   DIAGNOSIS. 

ness,  and  by  the  rarity  with  which  the  muscles  jerk  at  a 
time  when  epileptic  convulsions  are  most  frequent,  namely, 
at  night ;  from  tetanus,  it  is  chiefly  distinguished  by  not  ex- 
hibiting tonic  spasms. 

Parali/sis  agitans  is,  like  chorea,  attended  with  disturbed 
muscular  movements.  But  we  find  weakness  and  tremor 
rather  than  spasmodic  contraction,  and  w^ant  of  control  over 
muscular  motion.  Then,  as  the  malady  progresses,  the  pro- 
pensity to  lean  forward,  or  to  walk  on  the  fore  part  of  the 
foot,  is  very  characteristic.  The  aifection  is  met  with  chiefly 
in  old  persons;  though  there  are  forms  of  it  which  may  hap- 
pen at  any  age,  and  in  which  the  violent  shaking  movements 
take  place  when  any  muscular  action  is  performed  and  are 
entirely  beyond  the  patient's  control,  but  subside  when  he  is 
at  rest  and  during  sleep.  This  peculiar  kind  of  paralysis 
agitans,  if  such  it  may  be  called,  is  nearly  afliliated  to  chorea. 
Like  it,  too,  it  may  originate  in  fright.  It  differs  chiefly  in 
the  motions  repeating  themselves  rhythmically  and  symmet- 
rically on  the  two  sides  of  the  body,*  and  in  presenting  no- 
thing of  the  irregular  and  rapidly  changing  character  of  the 
true  choreic  movements. 

Convulsive  tremor,  to  adopt  the  name  given  by  Dr.  Ilam- 
mondf  to  a  paroxysmal  affection  in  which  several  times  in 
the  day  severe  muscular  tremor  arises,  differs  from  chorea  in 
not  being  continuous,  as  it  occurs  in  attacks  lasting  from 
fifteen  to  twenty  minutes,  passing  off  gradually,  and  leaving 
the  patient  in  a  profuse  perspiration.  The  seizures,  more- 
over, in  their  sudden  onset  resemble  more  an  attack  of  epi- 
lepsy, and  there  is  slight  headache,  with  vertigo,  and  an  in- 
tense feeling  of  anxiety,  though  not  unconsciousness.  The 
unrestrainable  muscular  tremor  affects  the  face,  the  arms, 
the  trunk,  but  not  the  lower  extremities,  and  is  associated 
with  increased  sensibility  of  the  skin  of  the  disturbed  parts. 

Mercurial  tremor,  another  variety  of  tremor,  is  disci-imi- 
nated  from  chorea  by  observing  that  the  trembling  and  the 
incessant  movements  stop  when    the  shaking  limb  is  sup- 


*  As  in  the  ease  recorded  by  Sanders,  Edin.  Med.  Journ  ,  5Iay,  1865. 
t  New  York  Medical  Journal,  June,  18G7. 


DISEASES    OF   THE    BRAIN,  SPINAL    CORD,  ETC.  147 

ported.  And  the  gradual  manner  in  wliicli  the  disease 
appears,  its  occurrence  among  persons  whose  occupations 
predispose  them  to  the  absorption  of  mercury,  the  wakeful- 
ness, the  disorder  of  the  digestive  organs  and  the  sponginess 
of  the  gums, — form  a  group  of  phenomena  very  dissimiharto 
those  of  chorea. 

Faded  sjx/sm  differs  from  the  spasmodic  contractions  of 
chorea  in  being  always  of  equal  intensity,  and  in  the  grimaces 
being  strictly  confined  to  the  same  group  of  muscles,  and 
generally  existing  only  on  one  side  of  the  face. 

The  iLTiier's  cramj),  a  strange  affection  in  which  every 
attempt  at  writing  at  once  produces  spasmodic  action  of  the 
muscles  of  those  fingers  which  are  brought  into  play,  is  sep- 
arated from  chorea  by  its  occurrence  in  individuals  who 
have  strained  their  muscles  in  using  a  pen  continuously  and 
rapidly  ;  by  the  almost  instant  cessation  of  the  spasm  when 
the  afi[licted  person  ceases  to  write ;  and  by  the  ease  with 
which  the  fingers  perform  other  motions,  and  are  capable  of 
being  used  for  every  other  purpose  excepting  for  the  one 
which  has  brought  on  the  disorder.  A  very  analogous  com- 
plaint is  sometimes  encountered  in  seamstresses. 

There  is  a  form  of  chorea,  or,  if  it  be  a  distinct  disorder, 
one  closely  allied  to  chorea,  which  consists  in  repeated  vio- 
lent bobbings  of  the  head,  lasting  many  minutes  at  a  time. 
These  salaam  convulsions,  as  Sir  Charles  Clarke  calls  them, 
are  a  very  obstinate  complaint.  Although  most  commonly  met 
with  in  children,  they  have  been  known  to  occur  in  adults.* 

Hysteria. — This  description  of  hysteria  will  deal  chiefly 
with  the  symptoms  of  an  hysterical  paroxysm.  Most  of  the 
local  hysterical  affections  have  been,  or  will  be,  considered 
in  connection  with  the  disease  they  ape;  and  to  discuss  any 
questions  relating  to  the  nature  of  this  perplexing  malady, 
or  to  attempt  to  scrutinize  or  to  interpret  all  the  false  and 
contradictory  signals  it  hangs  out,  is,  in  a  work  of  this  kind, 
manifestly  impossible. 

An  hysterical  fit  may  set  in  suddenly,  under  the  influence 
of  some  violent  mental  emotion  ;  but  more  generally  it  is 

*  Levick,  Amer.  Journ.  of  Med.  Sciences,  Jan.  1862. 


148  MEDICAL    DIAGNOSIS. 

preceded  by  altered  spirits,  by  a  sensation  of  pressure,  and 
of  constriction  at  the  pit  of  tlie  stomach,  which  feeling  as- 
cends to  the  throat,  and  is  likened  by  the  patient  to  the 
rising  of  a  ball.  She  becomes  much  agitated,  sobs,  laughs, 
cries,  her  muscles  contract  violently,  or  she  lies  motionless, 
and  apparentl}'  without  the  power  of  motion,  until  her  seem- 
ing insensibility  is  disturbed  by  something  she  disapproves 
of,  or  fears.  The  heart  palpitates  ;  the  breathing  is  irregular 
and  heaving, — on  account,  perhaps,  of  an  affection  of  the 
lar^'nx,  but  not  of  its  temporary  closure,  which,  as  Marshall 
Hall  tells  us,  so  commonly  ensues  in  epilepsy. 

These  hysterical  outbursts  differ  from  the  spasms  of  chorea 
by  their  remissions,  the  patient  remaining  at  times  for  months 
free  from  the  convulsive  movements.  Moreover,  there  is  not 
even  partial  unconsciousness  in  chorea.  It  is  true  that  this 
malady  and  hysteria  are  sometimes  combined,  or  rather  that 
chorea  happens  in  hysterical  subjects;  yet  even  then  it  is  re- 
markable how  rarely  tits  of  hysteria  take  place  in  those 
affected  with  St.  Vitus's  dance. 

It  is  sometimes  very  difficult  to  distinguish  between  par- 
oxysms of  hysteria  and  of  epilepsy;  and  it  becomes  the  more 
difficult  if  the  epileptic  seizures  occur  in  hysterical  patients. 
Yet  there  are  ordinarily  many  well-marked  points  of  distinc- 
tion between  the  two  maladies,  as  will  be  seen  from  this 
table  : 

Epilepsy.  Hysteria. 

Sudden    and   complete   loss    of   con-  Gradual  and  only  partial,  or  appar- 

sciousness.  ent  unconsciousness. 

Livid  face;   escape  of  frothy  saliva  Face   flushed,   or    complexion    unal- 

from  the  mouth  ;  eyelids  half  open  ;  tered  ;    no   froth    on  lips;    eyelids 

eyeballs  rolling;    grinding  of  the  closed;     eyeballs     fixed;     neither 

teeth  ;  biting  of  the  tongue  ;  more  grinding  of  the  teeth  nor  biting  of 

or  less  insensibility  of  the  pupils  the  tongue  ;  pupils  react  readily, 
to  light 

Distortion  of  countenance.  No  distortion  of  countenance. 

Patient  evinces  no  feeling.  Patient  sighs,  or  laughs,  or  sobs. 

Aura  epileptica.  Globus  hystericus. 

Convulsions  often   more  marked  on  No     such     ditlerence  ;     convulsions 

one   side  than    on  the  other ;  and  •  clonic, 
more  tonic  than  clonic 

Paroxysm   generally  of  short  dura-  Paroxysms  generally  of  longer  dura- 
tion, tion. 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  149 

Epilepsy.  Hysteria. 

Paroxysm  followed  by  a  heavy,  half-  Paroxysm  not  followed  specially  by 

comatose  sleep,  by  headache,  and  sleep;    patient   often,   after  attack 

dulness  of  intellect.  terminates,  wakeful  and  depressed 

in  spirits. 

Frequently  occurs  at  night  Rarely  occurs  at  night. 

No  particular  connection  with  uter-  Often    connected    with    disorders   of 

ine  disturbance,  although  a  parox-  the  uterus,  or  of  menstruation, 
ysm  often  takes  place  at  the  men- 
strual period. 

But  hysteria  is  not  an  aftection  merely  of  paroxysms.  In 
the  intervals  between  them  we  tind  peculiar  and  significant 
manifestations  of  the  strange  complaint,  which  should  be 
understood  lest  they  be  taken  as  the  signs  of  other  troubles. 
We  observe  an  extreme  susceptibility  of  the  nervous  system, 
various  hj^persesthesite,  such  as  tenderness  in  the  epigastrium, 
or  in  the  course  of  the  spinal  column  ;  that  peculiar  pain  in 
the  left  side  which  distresses  so  many  hysterical  and  anemic 
women  ;  and  sometimes  local  anesthesia.  Besides  these,  we 
encounter  manifold  local  hysterical  ailments,  such  as  hys- 
terical paralysis,  hysterical  aphonia,  hysterical  peritonitis, 
hysterical  afiections  of  joints,  or  hysterical  pain  in  the  fore- 
head. 

The  distinction  between  these  hysterical  pseudo-maladies 
and  the  diseases  they  simulate,  is  far  from  being  an  easy 
task.  We  have  to  take  into  account  the  patient's  age  and 
sex;  the  existence  of  any  irregularity  in  the  uterine  func- 
tions ;  whether  or  not  she  has  suiiered  from  paroxysms  of 
hysteria;  how  the  pain  is  influenced  by  pressure;  and  the 
signs  of  functional  disorder  of  the  apparently  aftected  part. 
We  may  thus  avoid  mistaking  a  phantom  for  a  true  disease. 
Yet  there  is  another  and  opposite  source  of  error  quite  as 
strenuously  to  be  guarded  against.  The  complaint  may  be 
really  an  organic  one,  occurring  in  an  hysterical  patient,  and 
concealed,  or  exaggerated  and  complicated  by  the  symptoms 
of  hysteria.  In  all  such  doubtful  cases  we  must  accord  great 
weio-ht  to  the  extent  of  functional  and  constitutional  disturb- 
ance  accompanying  the  local  morbid  state. 

Hysteria  is  sometimes  feigned — feigned  to  elicit  sympathy, 
or  to  procure  compliance  with  wishes  or  caprices.     Nor  is 


150  MEDICAL    DIAGNOSIS. 

tlie  simulation  of  the  disorder  an  outgrowth  from  our  civ- 
ilization. The  epigrams  of  Martial  prove  how  common  the 
feigning  of  hysteria  was  among  the  Roman  women. 

Tetanus. — A  disease  of  very  obscure  pathologj-,  but  of 
clearly  defined  and  thoroughly  characteristic  symptoms, 
marked  by  persistent  rigid  contraction  of  the  voluntary 
muscles,  particularly  of  those  of  the  jaw. 

The  distressing  malady,  as  we  see  it,  is  generally  traumatic, 
following  a  wound  or  an  injury;  for  idiopathic  tetanus  is  very 
seldom  met  with  in  temperate  climates.  But  in  hot  coun- 
tries, or  in  those  in  which  sudden  alternations  of  temperature 
are  common,  it  is  not  a  rare  disease,  and  is  indeed  frequent 
among  children.  The  cases  of  idiopathic  tetanus  we  en- 
counter are  almost  always  the  result  of  exposure  to  cold. 

The  muscles  ordinarily  first  affected  are  those  of  the  jaw 
and  neck;  there  is  a  stiffness  about  them  w^hich  the  patient 
is  apt  to  attribute  to  having  caught  cold.  Sometimes,  how- 
ever, the  disorder  exhibits  itself  primarily  in  the  external 
respiratory  muscles.  When  the  malady  is  fully  developed, 
most  of  the  muscles  are  stiff'  and  hard,  the  jaw  cannot  be 
opened, — whence  the  common  name  of  lock-jaw, — and  there 
is  much  ditficulty  in  speaking  and  in  swallowing.  With 
these  symptoms  we  usually  find  rigidity  of  the  muscles  of 
the  abdomen  and  of  the  limbs,  and  a  distressing  pain  at  the 
pit  of  the  stomach,  dependent  upon  spasm  of  the  diaphragm. 
And  besides  the  permanent  contraction  of  the  voluntarv 
fibres,  exacerbations  of  spasm  take  place,  during  which  the 
muscles  become  very  hard.  These  paroxysms  are  accom- 
panied by  intense  pain,  and  recur  with  increased  severity 
and  frequency  as  the  disease  advances  to  a  fatal  termination. 
When  at  their  height,  the  body  becomes  curved,  the  patient 
merely  resting  upon  his  head  and  heels.  This  is  opisthotonos; 
while  the  setting  of  the  jaw,  especially  when  its  muscles  alone 
are  affected,  is  called  trismus. 

Notwithstanding  the  striking  muscular  disorder  and  the 
exhausting  pain,  there  is  little  constitutional  disturbance; 
the  pulse  may  be  quickened,  but  it  preserves  its  volume 
until  the  last  stage  is  reached ;  and  there  is  no  fever,  nor  is 
the  intellect  affected. 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  l")! 

Tetanus  runs  an  acute  or  a  chronic  course.  Some  cases 
last  three  weeks,  and  when  of  such  long  duration  are  apt  to 
recover.  But  generally  the  malady  terminates  fatally  before 
the  eighth  day. 

Few  complaints  are  likely  to  be  confounded  with  tetanus; 
yet  these  few  resemble  it  closely  In  many  respects.  For 
instance,  one  of  the  freaks  of  hysteria  is  to  take  the  appear- 
ance of  tetanus;  and  tonic  spasms  dependent  upon  an  affec- 
tion of  the  spinal  cord  or  medulla  oblongata,  strychnia  poison- 
ing, or  hydrophobia,  may  accurately  simulate  its  symptoms. 

Hysterical  tetanus  is  distinguished  from  the  real  disease  by 
being  preceded  by,  or  attended  with,  fits  of  hysteria;  by  the 
age  and  sex  of  the  patient ;  by  the  absence  of  pain ;  by  the 
occasioual  occurrence  of  clonic  instead  of  tonic  spasms;  and 
the  Intermission  every  now  and  then  of  all  muscular  rigidity. 
Moreover,  the  influence  of  the  mind  upon  the  seeming  teta- 
nus is  very  striking.  If  within  hearing  of  the  patient,  the 
employment  of  cold  to  the  spine,  or  the  application  of  the 
cautery  be  threatened,  or,  better  still,  if  the  latter  instrument 
be  actually  made  ready  for  use  before  her,  an  extraordinary 
subsidence  of  all  stiffening  and  starting  of  the  limbs  takes 
place. 

Tetanic  spasms  symptomatic  of  an  affection  of  the  spinal 
cord  are  separated  from  tetanus  by  the  different  history ;  by 
no  violent  exacerbations  being  brought  on,  as  they  are  In 
tetanus,  by  slight  movements,  or  by  an  attempt  at  speaking, 
or  by  any  reflex  irritation;  by  the  absence  of  marked  remis- 
sions; by  the  rigidity  being  almost  always  limited  to  the  ex- 
tremities (excepting  in  the  case  of  meningeal  apoplexy,  in 
which,  as  in  tetanus,  the  head  is  drawn  backward) ;  and  by 
the  setting  in  of  palsy  before  the  malady  terminates. 

In  the  tetanic  spasms  which  may  occur  in  scarlet  fever,  in 
typhus,  in  small-pox,  or  in  pyemia,  and  which  are  the  result 
of  an  irritation  of  the  cord  produced  by  the  poisoned  blood, 
rather  than  of  a  disease  of  its  membranes  or  Its  structure, 
the  rigidity  runs  so  uncertain  a  course,  appears  so  quickly, 
disappears  so  suddenly,  perhaps  not  to  reappear,  or  only  to 
reappear  after  a  considerable  interval,  that  there  is  little  like- 
lihood of  confounding  the  muscular  disorder  with  tetanus. 


152  MEDICAL    DIAGNOSIS. 

Yet'  another  form  of  symptomatic  rigidity  requires  to  be 
distinguished  from  tetanus  — a  local  rigidity,  owing  to  the 
irritation  of  the  nerve  supplying  the  stiffened  muscles;  as 
for  instance,  a  spasm  from  irritation  of  the  peripheral  or  the 
central  tract  of  the  motor  portion  of  the  lifth,  the  so-called 
"  masticatory  spasm"  of  the  face.  This  curious  ailment  may 
be  of  reflex  origin,  the  exciting  cause  being  a  decayed  tooth, 
a  wound,  exposure  to  cold;  or  it  may  exist  in  connection 
with  apoplexy,  or  with  an  inflammation  of  the  brain.  Its 
main  marks  of  distinction  from  the  trismus  of  tetanus  are, 
that  it  is  purely  local,  is  often  of  long  continuance,  is  not 
painful,  has  no  paroxysms  of  aggravation,  is  not  combined 
with  impaired  deglutition,  and  is  not  dangerous.* 

The  symptoms  of  strychnia  poisoning  are  almost  identical 
with  those  of  tetanus;  yet  there  are  some  characteristic  dif- 
ferences. The  spasms  from  strychnia  do  not  supervene  upon 
exposure  to  cold,  or  upon  a  wound;  but  follow  within  about 
two  hours  or  less  the  taking  of  some  solid  or  liquid.  They 
come  on  suddenly,  and  with  violence ;  and  the  tetanoid  con- 
vulsions affect  simultaneously  nearly  all  the  voluntary  mus- 
cles of  the  body,  but  with  greatest  intensity  those  of  the 
trunk  and  spine,  producing  very  early — within  a  few  min- 
utes, commonly  —  a  marked  opisthotonos,  which  in  tetanus 
does  not  appear,  if  it  appear  at  all,  for  many  hours  or  for 
days  after  the  seizure.  On  the  other  hand,  the  stiffness  of 
the  jaws,  which  is  among  the  very  earliest  signs  of  tetanus, 
is  not  at  first  perceived  in  strychnia  poisoning ;  and  if  it 
occur,  occurs  only  imperfectly.  Further,  we  do  not  see  the 
frightful  tetanic  face,  with  its  knit  brow  and  horrid  grin ; 
we  do  not  observe  intermissions  in  the  convulsions,  or  diffi- 
culty in  swallowing;  and  in  from  ten  minutes  to  two  hours 
after  the  commencement  of  the  attack  the  patient  dies  or 
recovers. t 

Finally,  let  us  contrast  tetanus  with  hydrophobia.     Both 

*  Bright,  in  the  second  volume  of  his  Medical  Ilejiorts,  gives  the  particu- 
lars of  a  case  which  illustrates  many  of  the  difficulties  of  diagnosis  to  which 
the  affection  may  give  rise. 

f  These  statements  are  based  on  the  researches  of  Taylor  (Guy's  Hospital 
Eeports,  3d  Series,  vol.  ii.),  of  Todd,  and  of  Christison. 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  153 

showing  the  reflex  functions  of  the  spinal  cord  to  be  in  an 
exalted  condition ;  both  spasmodic  affections  lasting  ordina- 
rily but  a  few  days ;  both  taking  place,  the  popular  opinion 
to  the  contrary  notwithstanding,  at  all  periods  of  the  year; 
both  presenting  violent  paroxysms  of  convulsions,  which  are 
often  excited  by  the  slightest  touch  or  jar  to  the  body;  both 
frequently  occasioning  torturing  pain  near  the  pit  of  the 
stomach;  both  ensuing  commonly  upon  an  injury;  both 
usually  augmenting  in  intensity  from  hour  to  hour,  and 
scarcely  within  the  reach  of  therapeutic  measures, — these 
ghastly  maladies  are  yet  dissimilar.  In  the  one,  deglutition 
may  be  difficult;  in  the  other  it  is  next  to  impossible,  all  at- 
tempts at  swallowing,  especially  of  fluids,  exciting  the  most 
distressing  spasmodic  dysphagia.  In  the  one,  the  breathing 
may  or  may  not  be  interfered  with ;  in  the  other,  the  spasms 
of  respiration  are  almost  as  marked  a  feature  as  the  spasms 
of  deglutition.  Then  the  irritability  of  temper;  the  fierce 
manner  of  the  patient,  his  rabid,  perhaps  maniacal  parox- 
ysms; the  constant  thirst;  the  accumulation  of  stringy 
mucus  about  the  angles  of  the  mouth ;  the  vomiting ;  the 
acute  sensibility  of  the  surface ;  the  trembling  of  the  mus- 
cles; the  clonic  instead  of  tonic  spasms;  the  strangling 
sensation  in  the  throat, — are  phenomena  too  strikingly  pecu- 
liar to  render  an  error  in  diagnosis  very  likely.* 


Diseases  characterized  by  Gradual  Impairment  of  the  Mental 

Faculties  with  Paralysis. 

Chronic  Softening. — This  subject  displays  even  more  dif- 
ficulties in  its  symptomatic  relations  than  it  does  in  its  patho- 
logical. There  are,  in  truth,  no  pathognomonic  symptoms 
the  presence  of  which  would  enable  us  to  dechxre,  without 
hesitation,  that  w^e  are  dealing  with  softening  of  the  brain,  or 
the  absence  of  which  would  justify  us  in  concluding  that  it 


*  Some  of  the  points  here  referred  to  serve  also  to  distinguish  hydrophobia 
from  acute  mania,  and  from  hysteria.  For  as  in  tetanus,  so  here  we  find  this 
erratic  comphiint  sinuihitini;  the  terrible  disease.  (See,  for  instance,  a  case 
referred  to  in  Guy's  Hospital  Keports,  vol.  xii.  3d  Series,  and  remarks  in 
Gamgee's  article  on  Hydrophobia,  in  Keynolds's  System  of  Medicine.) 


154  MEDICAL   DIAGNOSIS. 

does  not  exist.  Yet  a  kro-e  number  of  cases  exhibit  uniform 
manifestations  which  permit  us  ordinarily  to  recognize  the 
mahady  with  some  degree  of  certainty. 

There  are  two  main  forms  of  softening — the  red  and  the 
white.  The  former  is  inflammatory,  and  runs  an  acute  course, 
with  symptoms,  as  we  have  already  discussed,  often  closely 
simulating  those  of  apoplexy,  but  sometimes  with  signs  like 
those  of  the  chronic  malady,  and  ditfering  in  nothing  but  in 
their  intensity  and  short  duration.  The  second  kind  is  chiefly 
dependent  upon  a  change  in  the  nutrition  of  the  brain,  and 
is  very  often  linked  to  a  diseased  condition  of  the  cerebral 
arteries ;  it  may,  however,  be  caused,  or  at  all  events  accom- 
panied, by  an  inflammatory  exudation  infiltrated  among  the 
nervous  pulp.  These  briefly  are  its  early  symptoms  :  gradual 
impairment  of  intelligence ;  weakening  of  memory ;  head- 
ache; vertigo;  muscular  debility;  cutaneous  hypera^sthesia  or 
anaesthesia;  formication  and  numbness;  and  slight  and  par- 
tial palsies,  particularly  of  the  muscles  of  one  side  of  the 
mouth,  or  of  one  eyelid.  Then  there  is  not  unfrequently  de- 
fective articulation,  with  great  irritability  of  temper,  nausea 
and  vomiting,  extreme  sensitiveness  to  sounds,  and  painful 
feelings  in  various  parts  of  the  body.  As  the  local  mischief 
advances,  the  paralysis  becomes  more  universal,  assuming 
generally  the  hemiplegic  form ;  and  spasms,  either  tonic  or 
clonic,  or  epileptic  convulsions  occur. 

The  mental  decay  proceeds  steadily,  and  sometimes  shows 
itself  in  a  constant  repetition  of  the  same  action  or  the  same 
phrase.  In  an  old  lady  whom  I  attended,  this  was  the  most 
marked  symptom :  she  was  constantly  complaining  of  her 
teeth  needing  attention,  was  perfectly  satisfied  when  assured 
by  the  dentist  that  they  did  not,  but  soon  reiterated  her  com-  ? 
plaint.  Beyond  this,  and  most  painful  sensitiveness  to  sound 
and  to  liglit,  intense  headache,  nausea,  and  a  progressive  de- 
terioration of  memory  and  of  the  faculty  of  thought,  she  pre- 
sented no  signs  of  cerebral  softening.  She  died  without  the  ' 
occurrence  of  paralysis. 

Softening  of  the  brain  may  be  caused  by  a  diseased  state 
of  its  blood-vessels,  or  by  their  obstruction  ;  by  long-continued 
grief;  by  persistent  mental  labor;  by  constitutional  syphilis  ; 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  155 

by  frequently  repeated  epileptic  paroxysms ;  and  by  an  inflam- 
raatory  disease  spreading  from  the  meninges  to  the  brain. 
It  may  also  be  dependent  upon  apoplexy.  At  all  events,  we 
frequently  meet  with  it  in  connection  with  hemorrhage,  and 
associated  sometimes  in  a  manner  to  make  it  a  very  perplexing 
matter  to  ascertain  if  the  softening  has  followed  the  extrava- 
sation of  blood,  or  if  the  extravasation  has  taken  place  into 
an  already  diseased  brain.  We  may  conclude  the  latter  to 
have  occurred,  if  signs  of  deranged  intellection  or  sensation 
have  preceded  the  attack ;  if,  soon  after  reaction  from  the 
shock,  the  patient,  instead  of  mending  in  mind,  exhibit  un- 
mistakable evidences  of  progressing  mental  decay;  and  if 
convulsive  movements  or  rigidity  of  the  limbs  appear. 

And,  indeed,  it  is  by  this  combination  of  signs  alone  that 
we  are  enabled,  whatever  the  relations  of  the  softening  to  the 
hemorrhage,  to  decide  whether,  after  an  apoplectic  seizure, 
softening  is  present  at  all;  an  inquiry  practically  of  much 
more  consequence  than  to  determine  whether  the  cerebral 
disorganization  has  or  has  not  existed  prior  to  the  bleeding. 
And  let  us,  in  passing,  remark  that  a  small  clot  breaking 
down  the  softened  cerebral  mass,  yet  not  extending  beyond 
the  limits  of  the  diseased  texture,  occasions  no  special  signs 
— occasions  only  the  signs  of  a  sudden  giving  way  of  nerve 
pulp  :  paralysis  without  unconsciousness. 

Assuming  now  the  relations  of  hemorrhage  to  softening 
to  have  been  for  our  purpose  settled,  we  shall  next  study 
how  various  other  cerebral  maladies,  such  as  congestion, 
anaemia,  abscess,  and  hardening,  may  be  distinguished  from 
softening. 

Congestion  is  discriminated  by  its  being  very  rarely  a  per- 
sistent state.  An  acute  attack  produces  the  symptoms  of 
apoplexy;  a  more  lasting  congestion  is  recognized  by  tracing 
the  cause  which  has  led  to  the  fulness  of  the  vessels, — such 
as  an  interference  with  the  circulation,  the  result  of  a  disease 
of  the  circulatory  system  itself,  or  of  the  abdominal  viscera, 
—and  by  noting  that,  although  the  patient  suffers  from  dull 
headache,  from  jerking  of  the  muscles,  from  pulsation  of  the 
carotids,  from  vertigo,  these  signs  are  far  from  being  con- 
stant, and  come  and  go  for  a  long  time  without  any  material 


156  MEDICAL   DIAGNOSIS. 

disturbance  of  the  functions  of  the  brain  being  perceptible, 
either  in  reference  to  thought  or  to  voluntary  motion. 

Cerebral  anxmia  is  a  state  in  which  the  supply  of  blood  in 
the  brain  is  diminished,  and  usually  also  altered.  Occurring 
suddenly,  it  produces  unconsciousness,  or  dizziness  or  stupor, 
or,  if  very  general,  and  especially  if  associated  with  venous 
congestion,  it  may  cause  convulsions.  When  more  gradually 
induced,  it  manifests  itself  by  drowsiness,  distressing  head- 
ache, often  more  particularly  referred  to  the  vertex;  by  the 
pale  face  and  uninjected  eye  with  large  pupil ;  by  derange- 
ment of  the  special  senses,  by  the  vertigo  and  the  other 
symptoms  of  cerebral  disorder  being  relieved  in  the  recum- 
bent position ;  and  by  the  feeble  pulse  and  cool  forehead. 
Then  in  tracing  its  history  we  are  apt  to  find  that  it  occurs 
in  those  who  have  been  exhausted  by  debilitating  diseases, 
or  repeated  hemorrhages,  or  by  albuminuria.  The  chief  dis- 
tinction from  softening  lies  in  the  history  of  the  case;  the 
aspect  of  the  patient,  too,  and  the  absence  of  palsies  or  their 
passing  nature  must  be  taken  into  account.  But  we  must 
not  forget  that  if  the  morbid  condition  be  long  continued, 
the  ill-nourished  brain  will  soften. 

Abscess  of  the  brain  diifers  mainly  in  this  from  chronic 
softening:  the  disease  is  of  short  duration.  Some  cases  may 
run  a  very  rapid  course,  others  may  continue  for  months; 
yet  few,  as  Lebert*  informs  us,  last  longer  than  eight  weeks. 
Further,  we  find  in  abscess,  unlike  what  happens  in  soften- 
ing, convulsions  in  the  earlier  period,  and  paralysis  late  in 
the  malady;  and  not  unfrequently  we  discover,  in  analyzing 
the  history,  that  chills  have  occurred,  or  we  can  detect  the 
clue  to  the  cerebral  abscess  in  a  disease  of  the  internal  ear,  or 
in  an  injury  to  the  head,  or  in  the  presence  of  a  suppurative  ' 
process  in  some  distant  part  of  the  body. 

Hardening  of  the  cerebral  substance  is  a  morbid  state 
scarcely  to  be  discerned  during  life.  It  appears  chiefly  in 
children  ;  in  adults  it  is  rarely  seen  excepting  as  the  result 
of  lead  poisoning.     The  comparatively  healthy  condition  of 


*  Archiv  fiir  Path.  Anat.,  Bd.  x.;  see,  also,  Gull's  paper  in  Guy's  Hosp. 
Reports,  3d  Series,  vol.  iii. 


DISEASES    OP    THE    BRAIN,  SPINAL    CORD,  ETC.  157 

the  general  nntrition  of  the  body;  the  pain  in  the  course, 
or  at  the  extremities  of  peripheral  nerves  ;  the  double-sided 
palsy  spreading  from  the  extremities  up  ;  the  frequency  of 
convulsions  and  of  muscular  tremors;  the  remissions  in  the 
symptoms ;  the  want  of  prominence  of  the  evidences  of 
deranged  sensation  or  of  mental  decay, — all  serve  to  distin- 
guish, so  far  as  it  can  be  distinguished,  cerebral  induration 
from  cerebral  softening. 

There  is  yet,  leaving  tumors  out  of  the  question,  another 
affection  of  the  brain  which  may  be  confounded  with  soft- 
ening: an  exhaustio7i  of  brain-power  encountered  among  pro- 
fessional men,  or  those  engaged  in  laborious  literary  under- 
takings. This  sometimes  comes  on  very  suddenly,  with  signs 
like  those  of  a  collapse ;  at  other  times  it  is  slower  in  its  de- 
velopment. Its  manifestations  are,  a  slight  deterioration  of 
memory,  and  an  inability  to  read  or  write,  save  for  a  very 
short  period,  although  the  power  of  thought  and  of  judgment 
is  in  no  way  perverted.  jSTor  is  the  power  of  attention  more 
than  enfeebled  ;  the  sick  man  is  fully  capable  of  giving  heed 
to  any  subject,  but  he  soon  tires  of  it,  and  is  obliged  from 
very  fatigue  to  desist.  lie  passes  sleepless  nights,  is  subject 
to  ringing  in  the  ears,  cannot  bear  much  exercise,  is  troubled 
with  irregular  action  of  the  heart,  with  a  frequent  desire  to 
urinate,  and  with  neuralgic  pains  in  the  face  or  a  feeling  of 
soreness  in  the  head ;  but  he  does  not  lose  flesh,  and  his 
digestion  is  uninjured. 

Many  remain  in  this  condition  for  months,  and  then  slowly 
regain  their  health.  What  the  precise  disturbance  of  the 
brain  consists  in,  I  cannot  say ;  it  is  possible  that  the  nutrition 
of  the  organ  has  been  interfered  with  from  overuse,  and  that 
the  further  continuance  of  mental  toil  and  anxiety  would  have 
led  to  softening.  The  phenomena  dilfer  from  those  of  this 
serious  cerebral  disease,  by  the  absence  of  or  at  least  by  the 
tar  less  permanent  and  marked  headache,  by  the  compara- 
tively unimpaired  intelligence,  and  by  the  non-occurrence  of 
spasms,  or  of  paralysis  of  motion  or  sensation. 

To  consider  now  the  diagnosis  of  the  chief  varieties  of  soft- 
ening. In  how  far  is  it  possible  to  distinguish  the  inflam- 
matory from  the  non-inflammatory  form  ?     The  more  acute 


158  MEDICAL    DIAGNOSIS. 

the  sj'mptoms,  the  greater  is  the  likelihood  of  their  being  due 
to  an  inflammatory  lesion  ;  and  in  young  subjects  this  proba- 
bility becomes  almost  a  certainty.  A  latency  of  the  affection, 
its  slow  and  gradual  manifestation,  its  existence  in  persons 
advanced  in  life,  and  in  whom  we  have  reason  to  suspect  de- 
generation of  the  coats  of  the  arteries,  are  facts  which  justify 
the  conclusion  that  it  is  owing  to  a  depraved  nutrition  of  the 
cerebral  substance,  and  not  to  its  inflammation. 

Tumor. — Tumors  of  the  brain  give  rise  to  a  great  diver- 
sity of  signs,  according  to  their  locality,  their  size,  and  their 
nature.  Let  us  examine  the  peculiar  symptoms,  or  group  of 
symptoms,  by  which  we  may  infer  their  occurrence,  and  then 
see  in  how  far  an  attempt  is  likely  to  succeed  to  distinguish 
their  seat  and  precise  nature. 

The  presence  of  a  tumor  in  the  brain  is  rendered  probable 
if,  in  addition  to  vertigo,  to  vomiting  or  a  disposition  to 
vomit,  to  headache,  violent  but  paroxysmal  and  neuralgic  in 
its  character,  we  find  impairment  or  loss  of  vision,  or  in- 
deed aneesthesia  of  any  special  sense,  and  epileptiform  con- 
vulsions not  followed  by  any  greater  deterioration  of  health 
than  previously  existed  ;  if  with  these  signs  of  cerebral  irrita- 
tion the  intellect  is  not  at  first  markedly  disordered,  nor  the 
articulation  affected ;  and  if  paralyses  do  not  show  them- 
selves until  a  very  long  time  after  the  headache,  and  are 
even  then  limited  to  the  muscles  of  the  eyeball  or  of  the  face, 
or  to  the  muscles  of  the  extremities  of  one  side  of  the  body. 
Yet  before  the  evidence  is  considered  conclusive,  we  must 
exclude  other  chronic  cerebral  troubles,  especially  softening, 
abscesses,  and  chronic  meningitis. 

We  separate  softening  by  noticing  that  the  headache  caused 
b}^  a  tumor  is  much  more  violent  and  paroxysmal,  not  dull 
nor  of  steady  intensity ;  that  the  intelligence  remains  for  a 
long  time  intact  in  all,  save,  perhaps,  a  weakening  of  the 
memory ;  that  motor  and  sensory  disturbances  are  less  fre- 
quent and  prominent,  but  convulsions  far  more  so.  Remis- 
sions, or  intervals  of  apparent  improvement,  occur  in  both 
morbid  states  ;  but  they  are  more  perfect  and  of  longer  dura- 
tion in  tumor  than  in  softening. 

The   differential  diagnosis   between  tumor  and  abscess  is 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  159 

more  difficult.  We  may  conclude  the  latter  to  furnish  the 
explanation  of  the  signs  of  cerebral  pressure  or  disorganiza- 
tion, if  the  cephalalgia  be  sudden  in  its  development,  and 
uniform  and  general,  instead  of  neuralgic  and  limited. 
Then,  convulsions,  drowsiness,  paralysis,  and  coma  succeed 
each  other  much  more  rapidly  and  much  more  constantly  in 
abscess  than  in  tumor — a  malady  running  a  very  chronic 
course,  and  in  which  the  patient  does  not  remain  drowsy  or 
palsied  after  the  epileptiform  seizures.*  If,  moreover,  we 
obtain  the  history  of  a  severe  injury  to  tlie  skull,  or  find  a  dis- 
charge from  the  ear,  or  pain  upon  pressure  over  the  mastoid 
process,  or  a  chronic  disease  about  the  head,  or  albuminous 
urine,  or  protracted  suppuration  in  any  part  of  the  body,  we 
may  safely  infer  that  an  abscess,  not  a  tumor,  is  the  cause  of 
the  evident  cerebral  mischief. 

Chronic  menmgitis,  an  affection  sometimes  complicating 
tumor,  is  discriminated  by  laying  stress  on  its  etiologic  rela- 
tions— such  as  blows  upon  the  head,  diseases  of  the  bones, 
syphilis,  rheumatism  ;  and  by  observing  its  frequent  yet 
irregular  accessions  of  fever,  the  great  irritability  of  temper, 
the  dulness  of  intellect,  the  loss  of  memory,  and  the  noc- 
turnal delirium.  The  pain,  too,  is,  as  a  rule,  somewhat 
duller  and  more  difiused  than  in  tumor,  though  more  fixed 
and  constant,  and  there  is  more  vertigo ;  but  the  convulsions, 
on  the  other  hand,  are  less  distinctly  epileptiform  in  type, 
yet  convulsive  movements  of  some  muscles  are  very  common, 
and  may  be  even  followed  by  incomplete  paralysis. 


*  I  have  mentioned  epileptic  seizures  in  these  affections  because  I  believe 
they  belong  to  them.  But  Brown-Sequard  has  recently  stated  (quoted  in  Am. 
Journ.  of  Med.  Science.-,  April,  1869,  p.  531)  that  diseases  of  the  cerebral 
substance  are  incapable  of  producing  epileptic  symptoms,  and  that  when  these 
occur  they  are  to  be  attributed  to  concomitant  lesions  of  the  meninges. 
However,  whatever  the  cause,  the  epileptic  fits  may  be  absent.  Thus  they 
occurred  in  only  38  cases  of  abscess  of  the  brain  out  of  73  collected  by  Gull 
and  Sutton  (see  article  "Abscess  of  Brain,"  in  Reynolds's  System  of  Medi- 
cine). Again,  it  must  be  borne  in  mind  that  both  affections  may  be  quite 
latent.  Particularly  is  this  the  case  with  cerebral  abscess;  and  the  sudden 
rupture  of  the  abscess  may  give  rise  to  symptoms  undistinguishable  from 
those  of  hemorrhage,  undistinguishable  at  least  unless  from  a  disease  of  the 
bones  of  the  skull,  or  some  points  in  the  history  of  the  case,  we  can  infer  an 
abscess. 


160  MEDICAL    DIAGNOSIS. 

Thromhosh  of  the  sinuses  of  the  brain  may  occasion  partial 
palsies,  and  the  symptoms  of  cerebral  pressure  like  those  of 
tumors,  and  cannot  be  distinguished  excepting  in  those  in- 
stances in  which  we  can  find  distention  of  the  collateral  cir- 
culation and  injection  and  oedema  of  the  forehead  and  eyelids.* 
Convulsions,  further,  are  scarcely  among  the  symptoms. 

The  precise  seat  of  the  tumor,  it  is  impossible  to  determine. 
An  affection  of  the  special  senses  points  to  disease  near  to, 
or  at  the  base  of  the  brain ;  and  the  probability  of  this  view 
is  much  strengthened  if  there  be  paralysis  of  the  face  on  the 
side  opposite  to  that  of  the  extremities,t  and  if  vigorous  in- 
spiration, during  which  the  brain  falls  and  presses  the  morbid 
mass  against  the  walls  of  the  base  of  the  skull,  cause  or  in- 
crease  pain  ;  whereas,  so  says  that  high  authority,  Romberg, 
in  tumors  on  the  upper  surface,  forced  expiration  produces  a 
like  result. 

And  what  of  their  nature — can  we  form  an  opinion  regard- 
ing it  from  any  of  the  signs  referable  to  the  cerebral  disor- 
ganization ?  We  cannot:  the  character  of  the  pain  has  been 
thought  to  be  of  great  significance;  but  the  testimony  to  prove 
that  it  is  so,  is  in  the  highest  degree  unsatisfactory.  We  may 
sometimes,  however,  from  the  history  of  the  case,  or  from  the 
existence  of  some  of  the  manifestations  of  special  cachexias, 
draw  a  correct  inference.  For  instance,  if  we  find  disease  of 
the  lungs,  or  any  evidences  of  scrofula,  and  the  patient  is 
young,  we  shall  probably  be  right  in  conjecturing  the  tumor 
of  the  brain  to  be  a  mass  of  tubercle;  but  if  the  sufferer  is 
advanced  in  years,  and  exhibits  tumors  in  various  parts  of 
the  body,  and  further  signs  of  a  cancerous  diathesis,  we  may 
with  reasonable  certainty  presume  the  tumor  within  the  skull 
to  be  cancerous.  Other  kinds  of  tumors  and  deposits  can 
scarcely  be  said  to  he  within  the  reach  of  diagnosis.  Cysts 
seated  in  the  superficial  portions  of  the  brain  either  occasion 
no  symptoins,  or  they  give  rise  to  headache,  to  attacks  of 
vertigo,  to  vomiting,  and  to  epileptic  seizures,  but  very  rarely 

*  Heubner,  quoted  in  Schmidt's  Jnhrbiicher,  No.  1,  1809. 

f  But  as  rt'giirds  the  palsy  of  the  face  being  on  the  .side  opposite  to  that 
of  the  body,  this  depends  very  mucli  upon  the  exact  position  and  extent  of 
the  lesion,  as  has  been  explained  while  discussing  hemiplegia. 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  161 

to  palsies.  The  symptoms  mentioned  are  far  more  apt  to  be 
present  when  the  cysts  occupy  the  lateral  ventricles  ;  epileptic 
convulsions  especially  are  very  rarely  absent. 

The  symptoms  of  an  aneurism  within  the  cranium  are 
usually  those  of  an  ordinary  tumor,  and  the  afJection  is  not 
distinguishable  excepting  where  we  lind  decided  indications 
of  disease  of  the  vessels  in  other  parts  of  the  system.* 

General  Paralysis.  —  This  fatal  and  obscure  cerebral 
malady  resembles  softening  of  the  brain — nay,  softening  is 
frequently  found  after  death  ;  but  there  may  be  atrophy  with 
hardening,  or  other  morbid  changes,  and  the  aftection  is  now 
recognized  as  a  distinct  disease  by  most  pathologists. 

The  disorder  is,  clinically  speaking,  marked  by  impairment 
of  the  powers  of  locomotion  ;  by  an  inability  to  articulate  dis- 
tinctl}- — a  symptom  which  precedes  the  deranged  locomotion ; 
by  the  peculiar  meaningless  countenance;  and  the  complete 
perversion  of  the  mental  faculties,  amounting  ordinarily,  in 
tact,  to  insanity. 

The  palsy  is  very  peculiar:  indeed.  Dr.  Skae,  who  has  so 
graphically  described  the  aftection, f  says  that,  in  the  usual 
sense  of  the  term,  there  is  no  palsy  in  the  limbs  at  all ;  there 
is  rather  a  want  of  control  over  their  co-ordinate  action,  dis- 
playing itself  in  a  swaying  from  side  to  side  when  the  patient 
attempts  to  walk.  The  impairment  of  the  muscular  move- 
ment gradually  extends:  there  is  a  tremulousness  in  the 
muscles  of  expression  ;  the  speech  becomes  more  inarticu- 
late, until  scarcely  a  word  can  be  distinguished ;  and  the 
patient  cannot  rise  without  being  assisted.  The  cutaneous 
sensibility  is  greatly  diminished  or  is  lost.  The  mental  de- 
rangement is  often  marked  by  an  exaggerated  sense  of  per- 
sonal power  or  importance.  Death  is  often  preceded  by 
convulsive  attacks  and  by  coma,  or  sometimes  by  painful 
contractions  of  the  muscles  of  the  trunk  or  extremities,  or 
by  obstinate  diarrhoea,  or  pulmonary  troubles. | 

The  strange  malady  difters  from  other  forms  of  extensive 


*  See  an  excellent  paper  by  Dr.  James  H.  Hutchinson,  Pennsylvania  Hos- 
pital Keports,  vol.  ii. 

f  Edinburgh  Med.  and  Surg.  Journ.,  April,  1860. 
X  Calmcil,  Traite  des  Malad.  Inflammat.  du  Cerveau.     Paris,  1858. 

11 


162  MEDICAL    DIAGNOSIS. 

general  paralysis  in  being  far  less  of  a  real  palsy.  It  is  cer- 
tainly far  less  complete  than  the  extensive  paralyses  that 
follow  lesions  of  the  npper  portion  of  the  spinal  cord,  or 
which  are  consequent  upon  the  poison  of  lead,  or  of  mala- 
ria, or  of  diphtheria.  Its  association  with  marked  disturb- 
ance of  the  intellect  furnishes,  moreover,  a  diti'erential  test 
of  great  value,  and  not  merely  with  reference  to  the  general 
palsies  just  mentioned,  but  also  as  regards  the  trembling 
movements  of  old  age,  of  progressive  muscular  atrophy,  and 
of  chronic  alcoholism. 

Diseases  characterized  by  Enlargement  of  the  Head. 

Chronic  Hydrocephalus. — The  signs  of  dropsy  of  the 
brain  are,  a  progressive  enlargement  of  the  head,  and  a  per- 
version or  a  gradual  loss  of  one  or  several  of  the  special 
senses,  of  the  mental  faculties,  and  of  the  power  of  voluntary 
motion.  The  child  cannot  bear  the  weight  of  its  head;  the 
gait  is  tottering  and  uncertain.  The  intellect  slowly,  but 
certainly,  becomes  deranged.  As  the  malady  advances,  stra- 
bismus, partial  palsies,  epileptic  convulsions,  vomiting,  cuta- 
neous anaesthesia,  and  loss  of  sight,  smell,  and  of  taste  are 
observable ;  the  bowels  become  very  constipated ;  and  a 
copious  secretion  of  tears  and  of  saliva  is  not  infrequent. 

Before  death  takes  place,  which  sometimes  does  not  hap- 
pen for  years,  the  child  ordinarily  becomes  idiotic.  A  few 
cases  recover :  fewer  reach  adult  age  with  their  brain  com- 
pressed by  the  accumulated  fluid;  in  still  fewer  the  disease 
does  not  develop  itself  until  after  childhood.  If  the  patient 
survive  until  adult  age,  the  size  of  the  skull  is  generally  im- 
mense. I  saw,  a  few  years  since,  a  young  man,  twenty-two 
years  of  age,  whose  head  measured  fully  two  feet  and  a  half 
in  circumference.  He  could  walk  unaided,  but  often  fell. 
He  was  half  idiotic,  and  subject  to  epileptic  tits;  yet  he  had 
suflicient  intelligence  to  understand  what  was  said  to  him, 
and  in  his  childish  way  to  do  as  he  was  told. 

The  skull  is  sometimes  very  large  without  dropsy  of  the 
brain  existing.  The  head  may  be  overgrown,  and  its  bones 
thickened  and  spongy  in  rachitis;  or  it  may  be  large  when 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  163 

there  is  no  disease.  These  states  differ  from  chronic  hvdro- 
cephalus  by  the  absence  of  cerebral  symptoms;  and  in  doubt- 
ful cases  we  may  call  in  the  ophthalmoscope  as  a  means  of 
diagnosis.  The  vessels  of  the  eye,  even  in  the  early  stages 
of  chronic  hydrocephalus,  enlarge,  and,  in  proportion  as  the 
serum  compresses  the  brain,  we  Und  an  increase  of  vascu- 
larity in  the  retina  with  dilatation  of  the  veins,  and  with  an 
increase  of  the  number  of  vessels  in  the  retina ;  its  complete 
or  partial  serous  infiltration ;  and  an  atrophy,  more  or  less 
perceptible,  of  the  optic  nerve.  These  lesions  vary  with  the 
age  of  the  disease  and  the  amount  of  serous  effusion ;  but 
none  of  them  exist  in  rickets.*  The  size  of  the  head  may 
also  be  augmented  in  consequence  of  meningeal  apoplexy, 
or  of  hypertrophy  of  the  brain.  The  former  may  be  sus- 
pected, if  the  distention  of  the  cranium  follow,  at  no  very 
long  interval,  an  attack  of  convulsions  and  of  coma  in  a 
teething  child. 

Hypertrophy  of  the  Brain. — A  strange  complaint,  in 
which  the  brain  develops  with  disproportionate  rapidity  to 
the  growth  of  its  bony  case,  which  thus  becomes  too  small 
for  its  contents. 

The  symptoms  this  morbid  state  occasions,  irrespective  of 
the  enlargement  of  the  head,  are :  headache,  vertigo,  drow- 
siness, and  epileptiform  convulsions.  The  gait  is  very  un- 
steady; the  mind  gradually  gives  way.  After  the  paroxysms 
of  headache  and  of  convulsions  we  often  find  stupor,  which 
may  deepen  into  fatal  coma.  Sometimes  delirium,  and  even 
mania  are  noticed. 

Hypertrophy  of  the  brain  requires  to  be  carefully  distin- 
guished from  the  enlargement  of  the  head  which  takes  place 
when  both  the  brain  and  the  skull  increase  rapidly;  a  hyper- 
trophy, too,  in  a  certain  sense,  but  not  a  hypertrophy  fraught 
with  danger  or  occasioning  any  morbid  manifestations. 

Equally,  or  yet  more  important,  is  it  to  discriminate  be- 
tween the  augmented  brain  and  chronic  hydrocephalus.  And, 
unfortunately,  the  marks  of  distinction  are  not  very  clearly 
traced.     Both  diseases  have  much  the  same  symptoms ;  both 

*  Bouchut,  quoted  in  Br.  Med.  Journ.,  1865,  or  op.  cit. 


164  MEDICAL    DIAGNOSIS. 

are  generally  of  long  duration.  There  is,  however,  in  many 
cases,  this  dissimilitude :  in  hypertrophy  the  convulsions  are 
a  much  more  marked  phenomenon,  and  they  precede,  rather 
than  accompany,  the  signs  of  failing  intellect  and  of  cerebral 
pressure.  The  changes  in  the  special  senses  are  not  so  com- 
mon, nor  so  prominent;  there  is  not,  when  the  foutanelles 
are  touched,  the  sensation  of  a  tense  membrane  filled  with 
water,  but  more  that  of  a  solid  substance ;  and  the  body  does 
not  waste  as  in  dropsy  of  the  brain. 

Dr.  Mauthner*  lays  great  stress  on  the  different  shapes  of 
the  head.  In  chronic  hydrocephalus,  he  states,  the  forehead 
is  the  first  to  enlarge,  and  the  posterior  part  of  the  skull 
does  not  expand  until  long  afterward  ;  in  hypertrophy  the 
reverse  takes  place.  But  this  is  not  a  sign  free  from  doubt ; 
indeed,  it  may  be  looked  upon  as  of  very  questionable  value. 
The  same  may  be  said  with  regard  to  the  observation  of 
West,  that  in  hypertrophy  there  is  no  prominence,  but  an 
actual  depression  of  the  anterior  fontanelle,  and  that  a  simi- 
lar depression  is  observable  at  all  the  sutures. 

Diseases  characterized  by  Paroxysmal  Pain. 

There  is  a  group  of  nervous  disorders  characterized  solely 
by  pain,  which  is  confined  ordinarily  to  one  nerve,  and  is 
seemingly  seated  in  it.  These  nervous  pains,  unconnected, 
so  far  as  we  know,  with  disease  of  structure,  bear  the  ge- 
neric name  of  neuralgia.  They  are  acute,  follow  the  course 
of  a  nervous  branch,  and  come  on  in  paroxysms  having  dis- 
tinct exacerbations,  succeeded  by  distinct  intermissions.  In 
some  cases  these  intermissions  are  long,  in  others  short ;  in 
some  they  are  complete,  in  others  the  pain  is  lasting  and  ' 
becomes  from  time  to  time  exalted — more  remissions,  there- 
fore, than  intermissions.  Save  in  the  rarest  instances,  the 
excruciating  sensations  are  not  complicated  with  heat  and 
swelling.  ISTor  is  there  tenderness,  excepting  when  the  neu- 
ralgia is  of  long  continuance;  at  least  there  is  not  tenderness 
along  the  aching  nerve,  though  we  mav  find  certain  sensitive 


*  Krunkheiten  des  Gehirns,  etc.     Vienna,  1844. 


I 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  165 

spots,  which,  in  the  case  of  the  spinal  nerves,  are  readily  de- 
tected by  pressing  on,  or  to  one  side  of,  the  spinous  process 
of  the  vertebra  near  which  the  affected  nerve  emerges,  and 
by  examining  the  points  of  terminal  expansion.  These  pain- 
ful spots  are  often  looked  upon  as  proving  the  presence  of 
what  is  vaguely  called  "spinal  irritation." 

The  pain  of  neuralgia  is,  then,  of  a  purely  nervous  charac- 
ter, and  exists  independently  of  inflammation,  or  of  any 
recognizable  textural  change  of  the  nervous  centres  or  nerv- 
ous trunks.  This  we  must  always  bear  in  mind  before 
concluding  the  complaint  to  be  neuralgia;  seeking  carefully 
for  the  signs  of  a  disturbance  of  the  nervous  centres  or  of  the 
larger  nervous  trunks  before  the  morbid  excitation  of  sensi- 
bility is  looked  upon  as  forming  the  whole  disorder.  Audit 
is  only  when,  after  a  minute  search,  we  can  detect  no  definite 
organic  cause  for  the  local  pain,  that  we  may  set  down  our 
patient  as  laboring  under  neuralgia. 

From  the  characteristics  of  the  pain  just  mentioned,  it  is 
evident  that  it  is  not  very  likely  to  be  confounded  with  that 
of  local  inflammation.  But  there  is  a  kind  of  local  pain  for 
which  neuralgia  is  often  mistaken  :  the  pain  of  subacute  or 
of  chronic  rheumatism.  Yet  this  is  in  reality  very  dissimi- 
lar. The  rheumatic  pain  is  attended  with  soreness,  is  ag- 
gravated by  movement  or  by  pressure,  is  more  difluse  and 
irregular,  much  more  constant,  much  more  influenced  by 
alternations  of  temperature,  but  not  acute  nor  paroxysmal, 
and,  Anally,  not  limited  anatomically  to  the  course  of  one 
nerve,  but  scattered  over  parts  supplied  by  several. 

The  source  of  the  neuralgia  should  always  be  determined 
as  closely  as  possible,  both  on  account  of  the  prognosis  and 
the  treatment.  In  many  cases  it  will  be  found  to  be  con- 
nected with  ansemia  :  in  others  with  the  poison  of  rheuma- 
tism, of  gout,  of  syphilis,  or  of  uraemia.  It  is  often  reflex, 
the  pain  being  far  away  from  the  seat  of  the  disease,  and 
due  to  irritation  reflected  throuo-h  the  nervous  centres.  For 
instance:  an  affection  of  the  digestive  apparatus,  of  the  liver, 
or  of  the  kidneys,  may  give  rise  to  neuralgia  in  parts  quite 
remote  from  them.  It  is  evident  that  if  such  be  the  origin 
of  the  disorder,  and  if  the  malady  which  lies  at  its  root  and 


16t)  MEDICAL    DIAGNOSIS. 

excites  it  can  be  controlled,  the  neuralgia  will  simultaneously 
disappear.  Yet  it  must  be  confessed  that  we  cannot  always 
detect  the  cause,  whether  or  not  it  be  of  the  nature  just  men- 
tioned, and  we  have  often  to  treat  the  neuralgia  by  employ- 
ing those  agents  which  are  suitable  to  the  greatest  number 
of  cases;  using  local  means  and  anodynes  to  allay  the  pain, 
and  quinine,  iron,  arsenic,  or  aconite,  ta  mitigate  the  severity 
of  the  attacks  and  eradicate  their  tendency  to  retnrn. 

Neuralgia  may  occur  in  any  portion  of  the  body.  It  may 
shift  rapidly  from  one  part  to  another,  as  in  that  peculiar 
neuralgia  described  by  Putegnat,*  excited  by  a  desire  to  pass 
water  and  by  the  act  of  micturition,  beginning  with  numb- 
ness and  acute  burning  or  lancinating  pain  along  the  urinary 
passages,  then  aftecting  particularly  the  nerves  of  the  fore- 
arm, especially  the  ulnar,  and  disappearing  completely  after 
micturition.  The  most  frequent  seat  of  neuralgia  is  perhaps 
about  the  head ;  and  we  shall  here  notice  chiefly  a  few  of  its 
most  common  kinds.  Most  of  the  other  varieties  of  the  dis- 
order, and  especially  intercostal  neuralgia  and  some  of  the 
abdominal  forms,  will  be  elsewhere  alluded  to. 

Facial  Neuralgia. — The  facial  branches  of  the  fifth  pair 
are  very  often  the  site  of  agonizing  pain.  But  all  the 
branches  of  the  nerve  are  not  equally  liable :  the  lowermost 
of  them  is  rarely  aiiected.  When  the  supra-orbital  division 
is  the  seat  of  the  ailment,  the  pain  shoots  to  the  forehead, 
the  eyebrow,  and  the  eyeball.  If  the  infra-orbital  nerve  be 
disturbed,  the  pain  darts  to  the  upper  lip,  the  upper  row  of 
teeth  and  the  posterior  nares,  and  the  cheek  tingles,  or  the 
eyelids  twiteh.  When  the  pain  occurs  in  the  inferior  branch, 
it  radiates  to  the  lips  and  chin,  and  is  frequently  accom- 
panied by  a  flow  of  saliva.^  Generally  the  parts  around  the 
point  where  the  affected  nerve  emerges  are  sensitive  to  the 
slightest  touch.  Sometimes  only  one,  at  other  times  two,  at 
others  all  the  branches  of  the  fifth  are  implicated  in  the 
complaint,  or  they  may  be  seized  upon  alternately. 

The  disease  is  one  of  those  belonging  to  advancing  years. 


*Gaz.  Hebdom.  de  Med.  et  Chir.,  April,  1864;  quoted  iu  llanking's  Ab- 
stract, vol.  xxxix. 


DISEASES    OF    THE    BRAIN,  SPINAL    CORD,  ETC.  167 

It  has  the  same  causes  as  any  other  form  of  neuralgia. 
Sometimes  it  is  associated  with  decayed  teeth,  or  with  an 
abnormal  state  of  the  bones  of  the  head  or  face,  such  as 
thickening  of  the  frontal,  ethmoid,  and  sphenoid  bones. 
Many  of  these  cases  terminate,  after  months  or  years  of  ex- 
cruciating agony,  in  apoplexy.* 

The  intervals  between  the  paroxysms  are  of  very  varying 
length.  They  may  be  of  six  months,  or  even  a  year's  dura- 
tion; but  so  long  an  intermission  is  uncommon.  Seasons 
in  which  sudden  changes  of  weather  are  frequent  generally 
excite  several  attacks  in  those  predisposed  to  them. 

The  maladj^  is  easily  recognized.  It  may  be  mistaken  for, 
or  rather  there  maybe  mistaken  for  it,  a  disease  of  the  bones 
of  the  face.  But  the  local  signs  of  this  are  different,  and  the 
pain  is  not  paroxysmal.  Painful  anaesthesia  of  the  fifth  nerve 
is  discriminated  by  the  insensibility  of  the  painful  portions 
to  the  touch,  or  indeed  to  any  irritation.  Spasm  of  the  face 
is  distinguished  by  the  absence  of  pain,  from  the  convulsive 
twitchings  which  sometimes  take  place  in  tic  douloureux. 

The  epileptiform  neuralgia  described  by  Trousseau  is  dis- 
similar in  these  peculiarities :  whether  simple  or  combined 
with  rapid  convulsive  movements  of  the  muscles  on  one  side 
of  the  face,  it  is  quickly  over;  it  lasts  but  ten  or  twenty 
seconds  at  a  time,  never  more  than  a  minute.  Yet  during 
the  short  duration  of  the  seizures,  the  pain  reaches  an  in- 
tensity greater  even  than  in  ordinary  neuralgia.  Moreover, 
in  some  persons  who  sufier  from  this  terrible  malady — the 
attacks  of  which  may  happen  in  quick  succession  by  day 
as  well  as  by  night,  and  then  perhaps  remit  for  weeks  or 
months — vertiginous  sensations  or  epileptic  fits  occur,  and 
thus  the  diagnosis  is  facilitated  by  the  history  of  the  case. 

Hemicrania. — As  in  the  other  forms  of  neuralgia,  the 
chief  symptoms  of  the  disorder  resolve  themselves  into  one 
symptom — the  symptom  of  pain.  This  is  ordinarily  limited 
to  the  supra  orbital  and  temporal  regions  of  one  side,  but 
it  may  extend  to  the  scalp ;  and  in  very  rare  instances  the 

*  Sir  Henry  Halford's  Essays  and  Orations,  delivered  at  the  Royal  College 
.of  Physicians,  page  37  et  seq. 


168  MEDICAL    DIAGNOSIS. 

cerebral  neuralgia  is  not  one-sided,  but  double-sided.  The 
pain  is  intensified  by  sound  of  any  kind,  and  is  commonly 
accompanied  by  a  sense  of  weight,  and  by  more  or  less 
sickness  of  stomach.  Sometimes,  indeed,  the  nausea  and 
vomiting  are  very  prominent  features  of  the  paroxysm, 
hardly  less  prominent  than  the  pain.  The  attack  lasts  for 
hours  or  days.  At  its  termination,  the  patient  feels  ex- 
hausted, yet  soon  recovers  his  usual  health,  and  may  remain 
free  from  a  seizure  for  a  long  time.  But  as  the  disorder 
most  commonly  occurs  in  women,  and  usually  at  their  men- 
strual periods,  the  interval  is  not  apt  to  extend  beyond  four 
weeks. 

Hemicrania  is  a  very  stubborn  aftection.  It  generally 
argues  a  debilitated  state  of  system,  and  has  of  late  years 
been  explained  as  a  neurosis  of  the  sympathetic.  It  is  a 
disease  the  tendency  to  which  diminishes  after  middle  age. 

Hemicrania  must  be  carefully  separated  from  the  pain  in 
the  head  which  accompanies  an  organic  cerebral  affection. 
The  main  points  of  distinction  are,  that  the  neuralgic  malady 
is  paroxysmal,  is  attended  with  the  same  group  of  symptoms 
during  each  attack,  and  produces  no  nervous  derangement 
in  the  intervals  between  the  seizures;  while  the  other  morbid 
condition  is  more  or  less  constant,  and  yields  persistent  signs 
of  a  cerebral  trouble. 

Rheumatism  of  the  scalp  differs  from  hemicrania  in  the  pain 
being  continuous,  dull,  and  superficial ;  in  occupying  gen- 
erally both  sides  of  the  head  ;  in  being  augmented  by  moving 
the  affected  muscles,  and  relieved  by  warmth.  Moreover, 
there  is  almost  always  other  evidence  of  rheumatism,  and 
the  pain  is  intensified  by  pressure;  whereas  in  hemicrania, 
although  the  hair  may  be  sensitive  to  the  touch,  strong 
pressure  on  the  forehead,  and  even  on  the  hairy  part  of  the 
scalp,  does  not  increase  the  pain,  may  indeed  afford  relief. 

In  periostitis  affecting  the  bones  of  the  head,  particularly 
when  occurring  in  connection  with  constitutional  s^-philis,  we 
may  find  the  same  violent  pain  as  in  hemicrania.  But  there 
is  considerable  tenderness  on  pressure,  and  the  parts  attacked 
are  swollen  and  less  elastic  than  the  healthy  portions,  and  the 
pain  is  especially  severe  at  night. 


DISEASES    OF   THE    BRAIN,  SPINAL    CORD,  ETC.  169 

« 

Sciatica. — This  is  neuralgia  following  the  course  of  the 
sciatic  nerve.  The  seat  of  the  greatest  suffering  is  generally 
the  lateral  surface  of  the  thigh ;  thence  the  pains  extend  to 
the  popliteal  space,  and  in  some  instances  along  the  anterior 
part  of  the  leg.  Often,  too,  the  patient  complains  of  an 
aching  near  the  sciatic  notch  and  in  the  loins.  The  pain  is 
more  or  less  steady,  hut  it  has  its  periods  of  tierce  exacerba- 
tion;  and  damp,  cold,  and  pressure  augment  it. 

The  disease  is  obstinate,  and  lasts  for  weeks  or  months. 
It  interferes  with  locomotion,  on  account  of  the  distress 
which  movements  of  the  leg  and  foot  occasion.  It  is  rare  in 
children,  being  most  frequent  between  the  ages  of  twenty 
and  sixty.*  Generally  it  depends  upon  the  rheumatic  diath- 
esis, or  upon  an  irritation  affecting  the  nerve  before  it  leaves 
the  pelvis,  the  result  not  unusually  of  pressure  from  a  gravid 
womb,  or  from  an  accumulation  of  feces  in  the  colon.  In 
some  instances  it  is  connected  with  gout,  in  others  with 
syphilis ;  and  it  may  be,  although  it  very  rarely  is,  sympto- 
matic of  cerebral  disease.  Occasionally  it  is  due  to  reflex 
excitation  of  the  nerve.  Sometimes  it  occurs  after  forced 
marches  or  long  rides;  probably  in  the  majority  of  these 
cases,  however,  the  sciatica  is  rheumatic. 

It  is  often  a  very  essential  matter  to  determine  whether 
or  not  an  efi'usion  has  taken  place  within  the  sheath  of  the 
nerve,  since  it  becomes  of  the  greatest  importance  to  adopt 
local  and  general  means  by  which  the  fluid  can  be  absorbed 
before  the  pressure  on  the  nerve  causes  an  alteration  of 
structure. 

"  When,"  says  Dr.  Fuller,  who  has  carefully  investigated 
this  subject,  "  a  patient  who  is  sufi'ering  from  sciatica  com- 
plains of  a  dull  aching  and  benumbing  pain  in  the  limb, 
causing  it  to  feel  swollen ;  when  this  sense  of  numbness  and 
increased  bulk  has  succeeded  to  pain  of  greater  intensity, 
accompanied  by  cramps  and  startings  of  the  limbs ;  and 
when,  more  especially,  in  addition  to  these  symptoms,  there 


*  Valleix,  Fuller.     Both  of  these  authors  further  state  it  to  be  more  com- 
mon in  men  than  in  women,  which  is  denied  by  Copland  and  Homberg. 


170  MEDICAL    DIAGNOSIS. 

is  more  or  less  inability  to  move  the  limb, — the  presence 
of  fluid  within  the  sheath  of  the  nerve  may  be  inferred,  and 
steps  should  be  taken  to  obtain  its  evacuation."* 

The  disorders  which  are  most  likely  to  be  confounded  with 
sciatica  are:  rheumatism  of  the  muscles  and  fibrous  sheaths 
around  the  hip  joint;  affections  of  the  joint;  and  pains 
caused  by  irritation  of  the  kidney.  The  former  is  very 
readily  distinguished.  It  is  generally,  what  sciatica  is  rarely, 
double-sided;  and  the  pain  is  dull,  diffuse,  not  paroxysmal, 
not  limited  to  the  course  of  the  sciatic  nerve,  nor  as  much 
increased  on  pressure  as  that  of  sciatica.  But,  practically 
speaking,  this  kind  of  rheumatism  is  seldom  seen  unless 
associated  with  rheumatic  neuralgia  of  the  sciatic  nerve. 

In  affections  of  the  hip-joint  the  suffering  is  increased  by 
standing  with  the  weight  of  the  body  thrown  on  the  diseased 
leg.  Moreover,  the  pain  is  usually  limited  to  the  hip-  and 
knee-joints;  the  aspect  of  the  limb  points  to  the  disorganiza- 
tion that  is  going  on ;  the  leg  shortens.  Yet  before  admit- 
ting this  as  a  mark  of  difference,  it  must  be  ascertained  by 
careful  measurement ;  for,  in  consequence  of  muscular  con- 
tractions, the  affected  limb  in  sciatica  may  appear  to  be 
shorter  than  it  is.  The  main  points  of  distinction  between 
sciatica  and  the  nervous  aflection  of  the  hip-joint,  so  admira- 
bly described  by  Sir  Benjamin  Brodie,  are  the  usual  combina- 
tion of  the  latter  with  hysteria,  the  very  superficial  tender- 
ness, and  the  fact  that  the  pain  is  apt  to  extend  over  the 
whole  thigh. 

Irritation  of  the  kidney  causes  pain  shooting  down  the  thigh. 
The  distress  exists,  however,  in  the  course  of  the  anterior 
crural  nerve,  is  therefore  not  localized  in  the  sciatic,  is  unat- 
tended with  tenderness,  but  is  accompanied  by  a  frequent 
desire  to  pass  water,  and  by  other  signs  of  trouble  of  the 
urinary  functions. 

Sciatica  is  sometimes  feigned,  especially  by  soldiers.  But 
the  copy  is  rarely  a  very  accurate  one.  Impostors  complain 
of  pain  on  pressure  and  on  motion,  but  are  ignorant  that  the 


*  Khcuroatism,  Rheumatic  Gout,  etc. 


I 


DISEASES    OF    THE   BRAIN,  SPINAL    CORD,  ETC.  171 

pain  is  prone  to  exacerbate  after  intervals  of  comparative 
quiet,  and  to  increase  in  violence  as  night  approaches.  Their 
fancied  torment  is  constant,  but  does  not  prevent  them  from 
sleeping;  they  wince  when  the  muscles  of  the  thigh  are 
touched,  yet,  if  their  attention  be  diverted,  the  hand  may  be 
pressed  along  the  sciatic  nerve  without  any  sign  of  tender- 
ness being  manifested. 


CHAPTER  III. 

DISEASES    OF    THE    UPPER    AIR-PASSAGES. 

The  larynx  and  trachea  form  the  main  portion  of  the  upper 
air-passages.  Let  us  inquire  into  their  aifections,  and,  on 
account  of  their  greater  frequency,  especially  into  those  of 
the  larynx. 

There  are  several  symptoms  constantly  met  with  in  laryn- 
geal diseases  which  at  once  direct  attention  to  the  seat  of  the 
malady.  The  larynx  is  the  organ  of  speech  ;  hence  changes 
in  the  voice  constitute  the  most  striking  manifestations  of 
laryngeal  disorders.  These  changes  vary  in  degree.  The 
voice  may  he  merely  hoarse,  or  so  completely  lost  that  the 
patient  is  hardly  able  to  speak  in  an  audible  whisper.  In 
young  children  the  different  tone  of  the  cry  corresponds  to  the 
altered  voice  of  adults.  The  alteration  of  the  voice  depends 
almost  wholly  upon  an  affection  of  the  vocal  cords,  and  this 
may  be  of  organic  origin,  such  as  from  inflammation,  oedema, 
ulceration,  cicatrices,  and  morbid  growths;  or  proceed  from 
perverted  or  impaired  innervation.  To  the  latter  class  be- 
long most  of  the  cases  of  "functional  aphonia."  Ver\'  often 
the  hoarseness  or  loss  of  voice  is  caused  by  diminished  ten- 
sion, and  want  of  certain  and  prompt  action  of  the  vocal  cords, 
whether  connected  with  structural  change  or  not.  The  same 
cause  gives  rise,  for  the  most  part,  to  the  modifications  of  the 
voice  which  show  themselves  as  huskiness  in  speaking,  or  in 
the  loss  of  certain  notes  in  singing. 

Next  to  the  voice  in  diagnostic  importance  stand  the  char- 
acter of  the  breathing  and  the  cough. 

The  breathing  is  labored  and  difficult,  and  is  frequently  per- 
ceived to  be  noisy,  and  coarse  or  shrill — the  so-called  laryn- 
geal stridor:  a  sign  encountered  whenever  the  orifice  through 
which  the  air  has  to  pass  is  narrowed,  either  temporarily  by 
(172) 


DISEASES    OF    THE    UPPER   AIR-PASSAGES.  173 

a  spasm,  or  more  permanently  by  any  state  which  giv^es  rise 
to  a  constriction  of  the  parts;  for  instance,  by  swelling  of  the 
mucous  membrane. 

The  difficult}^  in  breathing  is  in  some  diseases  very  slight; 
in  others  very  great.  One  of  the  peculiarities  of  this  laryn- 
geal dj-spnoea  is  its  tendency  to  recur  in  paroxysms,  during 
which  the  patient  appears  to  be  in  imminent  danger  of  stran- 
gling. These  fits  of  suffocation  are  mostly  produced,  by  a 
spasm  of  the  glottis.  They  occur  in  pure  spasm  of  the  glot- 
tis; in  croup;  in  oedema  of  the  glottis;  in  ulceration,  and  in 
polypi  of  the  larynx. 

The  cough  of  laryngeal  affections  presents  frequently  the 
same  peculiarity  as  the  dyspnoea — it  happens  in  paroxysms. 
Another  peculiarity,  although  not  so  constant  a  one,  is  its 
harsh  and  ringing  tone.  The  cough  is  often  short  and  dry  ; 
but  sometimes  it  is  followed  by  a  muco-purulent  expectora- 
tion of  roundish  shape,  or  by  a  blood-streaked  sputum,  or, 
as  we  may  find  in  pseudomembranous  laryngitis,  by  the 
spitting  up  of  false  membrane.  It  is  readily  excited  by  the 
act  of  swallowing,  and  its  seat  is  referred  by  the  patient 
himself  to  the  windpipe. 

Pain  is  not  so  usual  a  symptom  of  laryngeal  disease  as 
either  cough  or  changed  breathing.  In  some  of  the  chronic 
affections  it  may  be,  indeed,  wantiiig.  It  is  very  rarely 
severe;  often  more  a  sensation  of  tickling,  of  burning,  or 
of  uneasiness  than  actual  pain.  It  is  apt  to  extend  down  the 
trachea  to  the  upper  part  of  the  sternum.  Sometimes  it  is 
increased  on  pressure,  as  in  acute  laryngitis  and  in  ulceration 
of  the  mucous  membrane,  and  it  may  be  also  augmented  by 
the  act  of  swallowing. 

By  the  sj-mptoms,  then,  of  altered  voice,  cough,  dyspnoea, 
and,  in  some  cases,  of  local  pain  and  difficulty  in  deglutition, 
we  recognize  a  laryngeal  affection  ;  and  these  symptoms  re- 
veal more  than  any  physical  examination  of  the  organ  made 
by  the  means  ordinarily  in  use.  The  stethoscope  is  occasion- 
ally of  service;  yet,  on  the  whole,  it  furnishes  little  informa- 
tion. But  of  late  years,  inspection  of  the  larynx  has  been 
rendered  practicable  by  the  aid  of  an  ingenious  instrument, 
the  laryngoscojpe,  and  our  knowledge  of  laryngeal  diseases  has 


174 


MEDICAL   DIAGNOSIS. 


already  been  revolution- 
ized through  its  powerful 
influence.  The  instru- 
ment employed  by  Czer- 
mak* — the  physician  to 
whom  we  are  chiefly  in- 
debted for  the  informa- 
tion gained  by  the  appli- 
cation of  laryngoscopy  to 
disease — is  a  modification 
of  the  one  used  by  Garcia 
in  his  researches  on  the 
human  voice.  It  consists 
of  a  small  mirror  fixed  on  a  long  stem. 

The  mirror  is  best  made  of  glass 
,  backed  with  silver  or  with  amalgam. 
It  may  be  either  circular,  square,  or 
oval.  The  circular  mirror  occasions 
generally  least  irritation.  It  may  vary 
in  size  from  half  an  inch  to  an  inch 
and  a  quarter  in  diameter.  The  larger 
the  mirror  we  can  employ,  the  better 
is  the  image. 

The  mirror  is  in  some  cases  all  that 
is  necessary  to  practise  laryngoscop}'. 
It  is  heated  in  warm  water  or  over  a 
spirit-lamp,  and  then  introduced  into 
the  back  of  the  mouth  in  the  manner 
presently  to  be  described ;  the  person 
to  be  examined  having  been  placed 
with  his  face  toward  the  sunlisrht,  so 
that  its  rays  may  strike  the  laryngeal 
mirror. 

But  examinations  by  direct  light  are 
only  practicable  on  some  days  and  at 
certain  periods  of  the  day.  Usually  we 
require  a  second  mirror  to  illuminate 
the  throat  and  the  laryngoscope.    This 


Fig.  4. 


*  On   the  Laryngoscope,  etc.      Translated   by 
the  New  Sydenham  Society.     1861. 


LarynRoscopps  of  various  shaiw  ; 
not  quite  iiiituial  sizo. 


DISEASES    OF    THE    UPPER    AIR-PASSAGES.  175 

mirror,  when  sunlight  is  employed,  has  a  plane  surface ; 
when  artificial  light  is  used,  it  is  better  that  the  reflector  be 
slightly  concave.  One  of  circular  form,  in  size  about  three 
inches  and  a  half  in  diameter,  and  with  a  focus  of  from  ten 
to  fourteen  inches,  answers  best.  It  may  be  either  attached 
to  the  head  by  means  of  a  band,  or  worn  on  a  pair  of  spec- 
tacle frames,  or  be  placed  on  a  movable  stand  or  affixed  to  a 
lamp,  or  be  fastened  to  a  handle  which  is  held  in  the  mouth. 
The  latter  plan,  that  of  Czermak,  is  the  one  least  employed; 
it  is  far  less  convenient  than  the  spectacle  attachment  intro- 
duced by  Semeleder.*  When  this,  or  the  frontal  band  is 
made  use  of,  the  observer  may  either  place  the  mirror  oppo- 
site to  one  of  his  eyes,  and  look  through  the  central  perfora- 
tion, or  adopt  the  easier  method  of  wearing  the  reflector  on 
his  forehead. 

Yet  another  way  of  obtaining  a  strong  illumination  of  the 
fauces  is  by  means  of  a  globe  of  glass  tilled  with  water,  as 
recommended  by  Stoerck  and  Walker.  The  French,  fol- 
lowing the  lead  of  Moura,t  have  recourse  for  the  most  part 
to  lenses,  and  concentrate  the  light  directly  into  the  throat. 
The  lamp  which  I  often  employ  has  a  concave  reflector  at- 
tached to  it  on  a  movable  arm,  and  by  means  of  a  bull's-eye 
condenser  light  is  first  thrown  on  the  reflector  and  thence 
into  the  mouth.  But  a  yet  better  arrangement  is  obtained 
by  a  combination  of  lenses  attached  to  a  metallic  frame, 
which  can  be  fastened  to  a  lamp,  as  in  the  now  so  generally 
employed  apparatus  of  Tobold. 

Supposing  that  we  wish  to  examine  the  larj'nx  of  a  per- 
son with  the  usual  instruments,  and  by  artificial  light,  we 
should  proceed  thus :  the  patient,  sitting  in  an  upright 
position,  with  his  head  very  slightly  inclined  backward, 
is  placed  near  a  petroleum-  or  gas-lamp,  burning  with  a 
steady  brilliant  light,  and  the  flame  of  which  is  behind  and 
about  on  a  level  with  his  eyes.  He  is  directed  to  open  his 
mouth  widely,  to  put  out  his  tongue,  and  to  hold  it  at 
its  point  between  two  fingers  enveloped  in  a  soft  napkin 


*  Rhinoscopy  and  Laryngoscopy.     Translated,  New  York,  1866. 
f  Traite  Pratique  de  Laryngoscopie.     Pari?,  1864. 


176 


MEDICAL    DIAGNOSIS. 


or  handkerchief.  If  he  cannot  accomplish  this  readily,  the 
observer  must  hold  the  protruded  tongue,  or  a  tongue  de- 
pressor be  employed.  The  observer  now  seats  himself  di- 
rectly in  front  of  the  patient,  and  nearly  a  foot  from  his 
mouth.  Putting  on  his  spectacles  or  frontal  band,  he  throws 
a  disk  of  light  into  the  back  part  of  the  mouth;  he  then 
rapidly  introduces  the  laryngeal  mirror,  previously  heated  in 
warm  water  or  over  a  spirit-lamp,  and  its  temperature  regu- 
lated by  touching  his  own  hand  or  cheek.  The  mirror, 
great  care  being  taken  not  to  bring  it  in  contact  with  the 
tongue,  is  placed  with  its  back  against  the  uvula,  and  it  and 

Fig.  5. 


Laryngoscopic  examinatioD,  as  made  with  the  means  ordinarily  employed. 

the  soft  palate  pressed  backward  and  upward  ;  the  lower  sur- 
face of  the  laryngoscope  should  be  firmly  applied  to,  or  if 
this  occasion  too  much  irritation,  should  be  held  near  the 


DISEASES    OF    THE    UPPER    AIR-PASSAGES. 


177 


Fig.  6. 


posterior  wall  of  the  pharynx.  The  inclination  of  the  mirror 
varies  with  the  position  of  the  patient  and  the  parts  we  wish 
more  particularly  to  explore.  As  a  general  rule,  it  may  rest 
at  an  angle  of  about  45°. 

This  is  the  manner  in  which  an  examination  is  made  where 
the  reflector  is  worn  by  the  examiner.  Where  it  is  stationary, 
as  for  instance  with  the  Tobold  laryngoscopic  lamp, — a  less 
portable  but  far  easier  mode  of  illuminating,  and  well  adapted 
for  office  practice, — the  reflector  is  attached  to  the  lamp  by  a 
flexible  brass  rod,  and  the  light  is  thrown  from  it  into  the 
mouth,  leaving  the  examiner  unembarrassed. 

When  the  mirror  has  been  introduced  in  the  manner  de- 
scribed, the  laryngeal  image  is  readily  perceived.  We  see 
the  epiglottis,  the  glottis,  the  cartilages,  the  true  vocal  cords, 
the  superior  thyro-arytenoid  ligaments  or  false  vocal  cords, 
and  in  some  cases  even  the  rings  of  the  trachea.  We  may 
be  able  to  discern  each  portion  of  the  laryngeal  aperture  with 
distinctness,  or  it  may  take  several  examinations  to  do  so. 

In  health,  the  color  of  the 
various  parts  is  very  dift'erent. 
Stoerck  has  well  described  it 
in  likening  that  of  the  epiglot- 
tis, the  interior  of  the  larynx 
below  the  glottis,  and  of  the 
cricoid  cartilage  to  the  colora- 
tion of  the  conjunctiva  of  the 
eyelid ;  and  the  hue  of  the 
aryepiglottidean  folds  and  the 
prominences  of  the  arytenoid 
cartilages  to  that  of  the  gums. 
The  mucous  membrane  of  the  trachea  between  the  rings  is  of 
a  pale  pink  color ;  the  vocal  cords  have  a  white  glistening  look. 
Mackenzie  takes  special  notice  of  the  whole  of  the  under  sur- 
face of  the  epiglottis  being  in  some  cases  of  a  bright-red  hue; 
and  Gibb  points  out  that  in  negroes  the  cartilages  of  Wris- 
berg  have  a  yellowish  tinge. 

The  laryngeal  image  in  the  mirror  bears  this  relation  to 
the  real  position  of  the  parts :  the  right  vocal  cord  of  the 
person  who  is  examined  is  seen  on  the  left  side  of  the  mirror, 

12 


Laryngeal  image,  as  seen  in  tlio  laryngoscope 
under  favorable  circumstances. 


178  MEDICAL   DIAGNOSIS. 

and  tlie  left  vocal  cord  on  the  right ;  or,  to  state  the  matter 
in  a  form  easily  to  be  remembered,  the  cord  which  corre- 
sponds to  the  right  hand  of  the  patient  is  the  right,  that 
seen  toward  his  left  hand  is  the  left.  The  epiglottis  appears 
in  the  laryngoscope  at  the  upper  portion  and  toward  the  front; 
so  do  the  other  structures  which  lie  in  front.  The  arytenoid 
cartilages  appear  at  its  lower  portion. 

To  judge  of  the  movements  of  the  vocal  cords,  we  tell  the 
patient  alternately  to  inspire  deeply  and  to  sound,  as  a  high 
note,  a  sound  like  "ah."  During  this  the  vocal  cords  are 
closely  approximated  and  stretched,  and  the  epiglottis,  in  fact 
the  whole  larynx,  elevated ;  while  during  a  full  inspiration 
the  cords  are  far  apart,  and  hence  the  glottis  is  wide  open. 
To  obtain  a  satisfactory  sight  of  the  deeper-seated  parts,  we 
must  bear  in  mind  that  the  more  the  surface  of  the  mirror  is 
placed  horizontally,  the  more  distinctly  they  come  into  view. 
For  the  exploration  of  these  structures,  and  particularly  of 
the  trachea,  the  light  must  be  thrown  from  below  upward 
upon  the  laryngoscope. 

In  some  patients  laryngoscopy  is  easy;  the  instrument 
causes  no  irritation,  and  a  conclusive  examination  may  be 
made  at  the  first  attempt.  In  others,  a  course  of  training  is 
required  to  subdue  the  sensibility  of  the  fauces,  which  may 
be  general,  or  be  limited  to  a  very  small  spot.  As  a  means  of 
overcoming  the  difficulty,  sucking  small  pieces  of  ice,  or  the 
previous  administration  of  bromide  of  potassium  has  been 
a-ecommended.  But  the  best  means  is  skill  in  the  use  of  the 
instrument — its  rapid  and  decisive  handling. 

In  some  persons  with  very  irritable  throats,  I  have  ob- 
itained  good  views  by  pressing  the  instrument  against  the 
•roof  of  the  mouth,  instead  of  passing  it  back  into  the  pharynx, 
and  by  altering  the  position  of  the  head  a  little,  tilting  it  more 
■backward.  The  epiglottis,  and  the  structures  at  the  entrance 
•of  the  windpipe,  are  thus  readily  enough  brought  into  view; 
with  the  deeper  parts  we  do  not  succeed  so  well.  But  iu 
many  cases  we  get  sufficient  guide  for  topical  applications. 

There  are  some  further  obstacles,  such  as  a  rising  up  of  the 
tongue,  greatly  enlarged  tonsils,  a  very  long  uvula  or  a  pend- 
ant epiglottis,  all  of  which  at  times  seriously  interfere  with 


DISEASES    OF    THE    UPPER    AIR-PASSAGES.  179 

our  investigations.  But  in  any  case  we  should  not  endeavor 
to  make  the  view  more  satisfactory  by  constantly  altering  the 
position  of  the  mirror.  It  is  always  better  to  introduce  it 
repeatedly,  than  to  shift  it  often  when  introduced,  or  to  keep 
it  for  any  length  of  time  in  the  patient's  mouth. 

To  acquire  dexterity  and  quickness  of  manipulation,  one 
of  the  best  means  in  our  possession  is  auiolaryncjoscopy.  We 
may  readily  inspect  our  own  larynx  by  the  simple  method 
recommended  by  Dr.  George  Johnson,*  by  employing  a 
toilet  glass  and  throwing  the  light,  with  the  reflector  worn 
in  the  ordinary  manner,  on  the  image  of  the  fauces  as  seen 
in  the  toilet  glass ;  the  laryngeal  mirror  is  then  introduced 
into  the  mouth. 

If  the  mirror  is  passed  behind  the  uvula,  and  the  reflecting 
surface  directed  upward,  the  posterior  nares  may  be  exam- 
ined. To  practise,  however,  rhinoscopy,  the  mirror  should  be 
small  and  fixed  to  the  shaft  at  a  right  angle.  The  patient  is 
directed  to  keep  his  head  erect,  or  bend  it  slightly  forward, 
and  while  his  mouth  is  widely  open  a  strong  light  is  thrown 
to  the  back  of  the  throat.  But  before  the  rhinal  mirror  is 
placed  in  position,  a  tongue  spatula  is  applied,  with  which  the 
back  of  the  tongue  is  well  pressed  down.  After  the  spatula 
has  been  suitably  fixed,  it  is  given  to  the  patient  to  hold. 
It  is  very  rarely  we  can  dispense  with  the  use  of  the  spatula, 
though  we  may  do  so  by  employing,  as  recommended  by 
Voltolini,  a  shield  of  gutta-percha,  a  part  of  which  is  raised 
up  to  allow  the  handle  of  the  mirror  to  pass  through.  Yet, 
whether  the  spatula  be  employed  or  not,  a  difficulty  still  re- 
mains, namely,  to  get  the  uvula  out  of  the  way.  This  is  not 
easily  accomplished  without  a  palate  hook,  by  which  means 
the  uvula,  with  a  portion  of  the  soft  palate,  is  gently  drawn  for- 
ward and  upward ;  the  handle  of  the  hook  being  held  to  one 
side  of  the  mouth.  The  mirror,  with  its  reflecting  surface 
toward  the  operator,  is  now  passed  along  the  spatula,  until 
it  reaches  the  posterior  w^all  of  the  pharynx.  By  then  rais- 
ing somewhat  the  handle  of  the  mirror,  we  obtain  a  view 
of  the  septum  ;  and  by  slanting  the  mirror  first  toward  one 

*  Lectures  on  the  Laryngoscope. 


180  MEDICAL   DIAGNOSIS. 

side  and  tlieu  toward  the  other,  the  posterior  nares  and  the 
oritiees  of  the  Eustachian  tubes  may  be  inspected. 

The  art  of  rhinoscopy  is  more  difficult  than  that  of  laryn- 
goscopy, and  demands,  to  acquire  proficiency,  constant  prac- 
tice. And  thouirh  the  rhinal  mirror  aids  us  in  detectins^ 
morbid  appearances  -which  would  otherwise  escape  observa- 
tion, it  neither  does  so  as  readilv  nor  as  completely  as  the 
laryngoscope.  Hy  the  aid  of  this  we  can  discern  inflamma- 
tion of  various  parts  of  the  larynx;  oedema;  ulcers,  simple 
or  specific  ;  cicatrices  :  excrescences  and  morbid  growths ; 
irregularities  in  the  shape  of  the  glottis,  and  in  the  mobility 
of  the  cords ;  abscesses  ;  diseases  of  the  cartilages,  and  other 
abnormal  conditions  which,  without  it,  could  not  be  recog- 
nized, or,  to  say  the  least,  not  be  diagnosticated  with  any 
degree  of  certainty.  Indeed,  any  one  who  attempts  a  diag- 
nosis of  laryngeal  diseases  without  the  laryngoscope,  attempts 
to  do  without  the  onlv  means  which  renders  the  diairnosis  at 
all  trustworthy,  and  is  guilty  of  neglect. 

Let  us  now  look  at  the  chief  diseases  of  the  larynx. 
Grouped  in  accordance  with  their  main  features,  and  without 
classifying  them  in  strict  obedience  to  laryugoscopic  inquiries, 
they  may  be  arranged  as  follows : 

AcDTB  Orgakic  Diseases. 

Inflaimnation  of  the  mucous  membrane  of  larynx — Acute  laryngitis. 
(Edema  of  the  glottis. 


»' 


Acute  affections  of  the  Inrviix  ■> 

and   trachea  as  met  with  I  Spasmodic  and   pseudomembranous 
in  children.  •      laryngitis — False  and  true  croup. 

Chronic  Organic  Diseases. 

Inflammation  of  the  mucous  membrane  in  part,  or  of  the  whole — Chronic 

laryngitis  in  its  various  forms. 
Destruction  of  the  cartilages. 
Growths  and  tumors  of  various  kinds. 
TTlccrs,  simple  and  specific. 

Affections  of  the  Nerves. 
Spasm  of  the  glottis.  (Laryngismus  stridulus.) 
Nervous  aphonia.  |  ^""^'t'onal,  or  purely  nervous  aphonia. 
I  Paralysis  of  the  muscles  of  the  cord. 


DISEASES    OF    THE    UPPER    AIR-PASSAGES.  181 

Acute  Laryngeal  Affections. 

Acute  Laryngitis. — In  its  mild  form,  acute  laryngitis 
is  neither  an  uncommon  nor  a  dangerous  disease.  In  its 
severer  form  it  is  much  more  uncommon,  and  very  much 
more  dangerous.  The  inflammation  attacks,  in  either  case, 
the  mucous  membrane  lining  the  cartilages,  "When  it  is 
slight,  it  occasions  simply  hoarseness ;  a  feeling  of  tickling 
and  irritation  in  or  near  the  larynx ;  a  trifling  though  an- 
noying cough,  or  rather  a  constant  disposition  to  clear  the 
throat,  more  than  a  cough  ;  and,  owing  in  a  great  measure 
to  a  coexisting  inflammation  of  the  fauces,  some  difficulty  in 
swallowincr.  This  is  one  of  the  forms  of  the  "bad  sore- 
throat"  so  frequently  seen  in  winter  and  in  the  early  months 
of  spring,  and  which  passes  off'  in  the  course  of  a  few  days. 

When  the  inflammation  is  violent,  and  especially  when  it 
involves  the  submucous  tissues,  the  symptoms  are  much  ag- 
gravated, and  the  patient's  life  is  in  imminent  peril.  His 
sufterins:  is  verv  grreat :  for  the  swollen  membrane  nearlv 
closes  the  narrow  aperture  through  which  the  air  is  con- 
veved  to  the  lung's.  His  respiration  becomes  seriously  im- 
peded,  he  breathes  often,  and  each  time  he  draws  his  breath 
a  wheezing  or  whistling  noise  is  heard.  He  coughs  fre- 
quently, yet  expectorates  very  little;  and  the  cough  is  dis- 
tressing and  painful,  and  has  a  harsh  sound.  The  voice 
is  hoarse,  or  sinks  into  a  scarcely  audible  whisper.  The 
patient  knows  the  seat  of  his  disease :  he  feels  that  it  lies  in 
the  windpipe,  and  complains  of  this  being  tender  when 
pressed,  and  of  a  feeling  of  constriction  in  the  throat. 
There  is  trouble  in  swallowing,  and  fever,  with  a  full  pulse 
and  flushed  face.  If  the  case  advance  unchecked,  the  coun- 
tenance becomes  distressed  and  pale,  the  lips  bluish,  the 
pulse  irregular,  and  death  sets  in  with  all  the  signs  of  defi- 
cient aeration  of  blood  and  of  strangulation. 

The  disease  in  its  graver  form  runs  a  very  rapid  course. 
If,  in  a  few  days  after  its  commencement,  no  improvement 
show  itself,  life  does  not  last  long.  Sometimes  death  takes 
place  on  the  first  day  of  the  attack.  It  rarely  waits  for  the 
sixth. 


182  MEDICAL    DIAGNOSIS. 

Acute  idiopathic  laryngitis  is  very  seldom  met  with  save 
in  adults.  Children  sutler  from  an  analogous  but  not  an 
identical  disease,  croup.  Occasionally,  however,  we  do  see 
acute  laryngitis  in  children,  and  exhibiting  the  same  feat- 
ures as  in  the  adult;  but  then  it  has  almost  always  arisen  as 
the  consequence  of  swallowing  irritating  substances,  and  not 
as  the  result  of  exposure  to  cold  or  wet. 

The  marked  symptoms  of  the  perilous  complaint  prevent 
it  from  being  overlooked,  and  render  its  discrimination  easy. 
There  is  fever  with  dyspnoea  in  the  acute  pulmonary  affec- 
tions; but  the  voice  remains  unaltered,  and  they  exhibit 
physical  signs  which  acute  laryngitis  does  not :  they  show 
rales,  or  abnormal  respiration  sounds  ;  while  in  laryngitis 
the  murmur  of  the  lungs  is  that  of  health,  although  it  is 
sometimes  enfeebled  by  the  impediment  in  breathing,  or 
obscured  by  the  shrill  sound  which  issues  from  the  larynx. 
We  find  difficulty  in  swallowing  and  some  hinderance  in 
breathing  in  tonsillitis ;  but  inspection  of  the  oral  cavity 
immediately  detects  the  source  of  the  trouble.  There  is 
difficulty  in  swallowing  in  pharyngitis,  but  there  is  not  em- 
barrassed breathing,  nor  a  peculiar  voice,  nor  cough,  and 
the  fauces  appear  dusky  and  injected,  while  they  are  but 
slightly  aflrected  in  laryngitis,  unless  the  inflammation  of  the 
larynx  have  supervened  upon  that  of  the  throat.  Croup  re- 
sembles acute  idiopathic  laryngitis  most  nearly ;  but  it  is  as 
rare  in  the  adult  as  acute  laryngitis  is  in  the  child,  and,  as  we 
shall  presently  see,  obvious  differences  in  the  symptoms  exist. 

There  is  a  peculiar  form  of  inflammation  of  the  larynx, 
a  diffuse  i-nflammation  of  the  cellular  tissue,  with  lymph  or  pus 
infiltrated  in  the  submucous  tissue,  to  which  attention  has 
been  called  by  Mr.  Henry  Gray.*  It  is  a  very  formidable 
aficction,  which  bears  a  strong  likeness  to  erysipelatous 
laryngitis,  but,  what  is  not  by  any  means  constantly  the 
case  in  this  disorder,  the  symptoms  commence  in  the  fauces 
and  larynx;  and,  wholly  unlike  erysipelatous  laryngitis,  the 
neck  becomes  greatly  swollen  from  the  eft'used  products 
around  the  larynx,  trachea,  and  oesophagus,  filling  its  cellular 


*  Holmes's  System  of  Surgery,  vol.  iii. 


DISEASES    OF    THE    UPPER    AIR-PASSAGES.  183 

tissue.  The  disease  begins  with  chills,  soreness  of  throat,  and 
fever,  soon  succeeded  by  a  hacking  cough,  by  dyspnoea,  by  a 
dusky  hue  of  the  fauces,  by  enlargement  of  the  tonsils  and 
of  the  glands  in  the  neighborhood  of  the  jaw,  and  by  very 
great  difficulty  in  swallowing.  As  the  complaint  proceeds, 
the  neck  increases  greatly  in  size,  the  fever  assumes  a  low 
type,  and  the  patient  either  sinks  gradually,  or  dies  asphyx- 
iated. 

(Edema  of  the  Glottis.— The  danger  of  acute  laryngitis  of 
any  kind  is  very  much  aggravated  by  the  precise  seat  of  the 
disease.  When  the  inflammation  takes  place  immediately 
around  the  glottis,  and  causes  a  serous  fluid  to  transude,  the 
peril  is  greatly  increased.  The  inspiration  is  audible,  noisy, 
hissing;  there  is  a  most  distressing  sensation  of  constriction 
or  obstruction  in  the  windpipe,  and  the  patient  makes  re- 
peated efl:brts,  by  swallowing  or  by  hawking,  to  clear  his 
throat  of  the  substance  which  seems  to  him  to  be  clogging  it. 
His  difiiculty  of  breathing  is  intense,  and  occurs  in  frightful 
paroxysms,  sometimes  of  a  quarter  of  an  hour  in  duration, 
during  the  whole  of  which  time  strangulation  appears  to  be 
imminent,  and  often  he  does  perish  by  strangulation.  This 
grave  form  of  oedema  of  the  glottis  sometimes  follows  an  ex- 
tension of  the  peculiar  inflammation  of  the  throat  in  the  ex- 
anthemata, or  is  of  erysipelatous  origin,  and  it  occasions 
death  quickly,  and  amid  great  sufl:ering.  But  the  oedema 
may  arise  without  preceding  acute  inflammation,  whether 
this  be  specific  or  not.  It  may  result  from  long-continued 
pressure  on  the  trachea  or  larynx,  or  occur  in  connection 
with  the  external  oedema  of  Bright's  disease.  Again,  an 
effusion  of  serum  may  cause  death  most  suddenly  and  un- 
expectedly in  a  person  who  has  been  laboring  under  a 
chronic  laryngeal  disorder.  Such  cases  of  oedema  of  the 
glottis  are  distinguished  from  those  produced  by  active 
laryngeal  inflammation  by  the  absence  of  fever,  of  local 
tenderness,  and  of  marked  difiiculty  of  deglutition.  It  is 
true  that,  if  the  edematous  aftection  ensue  upon  a  chronic 
inflammation  of  the  larynx,  tenderness  and  an  impediment 
in  swallowing  may  be  observed.  But  the  history  of  the 
malady  and  the  non-existence  of  fever  leave  little  room  for 
error. 


184  MEDICAL    DIAGNOSIS. 

The  diagnostic  sign  which  some  have  proposed  as  the 
proof  of  the  presence  of  oedema  of  the  glottis — the  swelling 
of  the  epiglottis,  as  ascertained  by  the  touch — cannot  be  re- 
lied upon,  because  this  swelling  does  not  always  exist  to  an 
obvious  degree,  and  even  when  it  does  exist,  is  not  readily 
determined  by  the  finger. 

Croup. — Croup  is  inflammation  of  the  larynx  and  trachea; 
but  it  is  something  more.  It  is  a  spasmodic  action  of  the 
muscles  of  the  larynx,  which  spasmodic  action  gives  rise  to 
much  of  the  peculiar  cough,  the  stridor,  and  the  paroxysms 
of  dj'spnoea,  so  characteristic  of  the  disease.  As  croup  is 
thus  an  aftection  composed,  as  it  were,  of  several  distinct 
elements,  it  differs  somewhat  according  as  one  or  the  other 
of  these  elements  preponderates.  Thus  the  inflammation 
may  be  comparatively  slight,  yet  the  spasm  play  a  very 
prominent  part;  or  the  inflammation  may  be  very  severe, 
and  result  in  the  formation  of  a  false  membrane.  To  the 
first  class  belongs  the  disorder  known  as  false  croup,  catar- 
rhal croup,  stridulous  laryngitis,  spasmodic  laryngitis;  to  the 
second,  the  true  croup,  or  pseudomembranous  laryngitis. 

False  croup. — This  is  one  of  the  most  common  diseases  of 
childhood.  Its  seizures  happen  chiefly  at  night;  and  the 
child  that  has  gone  to  bed  well,  or  perhaps  a  little  fretful 
from  teething,  or  with  a  slight  catarrh,  wakes  up  suddenly 
in  a  great  state  of  alarm,  breathing  with  much  difficulty.  It 
coughs  with  violence  and  at  short  intervals,  and  the  cough  is 
noticed  to  be  loud  and  ringing  and  hoarse;  and  so  are  the 
voice  and  the  cry.  Each  inspiration  is  attended  with  that 
shrill,  "croupy"  sound,  which,  once  heard,  is  never  for- 
gotten. The  face  is  flushed,  the  pulse  frequent,  and  the 
skin  hot,  or,  to  speak  more  accurately,  heated,  for,  in  the 
majority  of  cases,  the  fever  is  not  of  a  very  active  character. 
The  paroxysm  continues  in  this  manner  for  about  an  hour ; 
the  breathing  then  becomes  quiet,  the  child  falls  asleep,  and 
rests  well  until  toward  morning,  when  the  attack  is  apt  to  be 
renewed.  The  little  patient  may,  however,  escape  this  alto- 
gether, and  keep  well ;  or  else  the  paroxysm  recurs  the  next 
night,  or  for  several  nights  in  succession.  In  the  intervals 
the  voice  and  respiration  are  natural,  there  is  little  or  no 


DISEASES    OF    THE    UPPER    AIR-PASSAGES.  185 

fever,  little  or  no  cough.  Yet  sometimes  a  cough  remains, 
which  has  every  now  and  then  a  croupal  sound;  and  the 
voice,  too,  is  slightly  hoarse,  but  not  smothered  or  extinct, 
as  in  true  croup. 

False  croup  most  frequently  follows  exposure.  It  is  very 
rarely  fatal ;  hence  we  are  not  conversant  with  its  morbid 
anatomy.  The  few  cases  which  have  been  examined,  pre- 
sented signs  of  inflammation  in  the  larynx  and  trachea, 
inadequate,  however,  in  themselves  to  account  for  death. 
Yet  such  inflammation  probably  always  exists  to  a  greater 
or  less  degree.  Cases  in  which  it  is  extensive  and  severe, 
without  having  led  to  a  plastic  exudation,  approach  in  their 
persistency  and  in  the  character  of  their  symptoms  closely 
to  true  croup.  Indeed,  one  form  of  the  complaint  may  run 
into  the  other,  which  is  far  from  astonishing,  since  they  are 
not  two  diseases,  but  only  two  forms  of  the  same  disease. 

The  main  element  in  the  production  of  the  symptoms  of 
false  croup  is  undoubtedly  spasm  of  the  glottis,  and  this  is  the 
reason  why  this  aftection  is  so  frequently  described  by  au- 
thors as  identical  with  the  first-named  malady.  But  without 
entering  into  the  much-vexed  question  of  pathology;  without 
discussing  whether  or  not  the  laryngismus  stridulus,  as  spasm 
of  the  glottis  is  called  by  many,  is  due  to  enlargement  of  the 
thymus  gland,  or  of  the  cervical  and  bronchial  glands ; 
whether  or  not  it  is  caused  by  an  organic  disease  of  the 
cerebro-spinal  axis,  or  is  simply  a  reflex  phenomenon,  —  it 
seems  undoubted  that  the  spasm,  while  it  may  complicate 
any  aftection  of  the  larynx  and  trachea,  may  also  exist  inde- 
pendently. It  may,  therefore,  form  a  distinct  disorder,  which 
difters  from  false  croup  by  the  absence  of  all  inflammation 
and  by  several  circumstances  which  unmistakably  proclaim 
its  non-identity,  such  as  its  occurrence  in  adults  as  well  as  in 
children,  and  especially  its  frequent  association  with  other 
convulsive  symptoms — with  distortion  of  the  face,  spasmodic 
contraction  of  the  hands  and  feet,  and  general  convulsions. 

As  in  croup,  the  seizures  are  most  apt  to  take  place  at 
night.  Generally  the  child  has  been  fretful  from  teething, 
or  from  gastric  or  intestinal  irritation,  when  suddenly  an 
attack  of  difficult  breathing  occurs,  accompanied  by  several 


186  MEDICAL    DIAGNOSIS. 

loud,  crowing  inspirations,  and  by  an  appearance  of  the  most 
manifest  distress  and  of  threatening  suffocation ;  yet  the  par- 
oxysm is  not  associated  either  with  cough,  or  with  fever,  or 
with  an  altered  voice  or  a  materially  changed  cry.  A  fit  of 
this  kind  may  be  repeated  twenty  or  thirty  times  a  day.  It 
may  terminate  fatally  in  a  short  time;  usually,  however,  the 
paroxysms  are  spread  over  weeks,  or  even  over  a  longer 
period.  Thus,  in  addition  to  the  frequent  combinations  with 
other  convulsive  symptoms,  the  protracted  duration  of  the 
disease,  and  the  absence  of  febrile  disturbance,  of  hoarseness, 
and  of  cough,  point  out  the  distinction  between  spasm  of  the 
glottis  and  spasmodic  laryngitis. 

True  croup. — True  croup  is  a  formidable  affection,  in  which 
there  is  not  only  inflammation,  but  inflammation  which  re- 
sults in  the  formation  of  a  false  membrane.  The  plastic 
exudation  is  found  lining  the  larynx,  extending  into  the 
trachea  or  down  into  the  bronchial  tubes,  and  is  seen  in  the 
fauces  and  on  the  tonsils. 

The  symptoms  of  this  dangerous  malady  are :  the  same 
brazen  cough,  the  same  stridulous  breathing  as  in  false 
croup ;  and  a  decided  change  in  the  voice,  dyspnoea,  and 
fever.  But  all  these  symptoms  do  not  show  themselves  at 
once.  The  disease  usually  begins  with,  or  rather  is  preceded 
by,  slight  fever  and  catarrh,  and  some  hoarseness.  This  may 
last  for  a  few  days,  when  the  sj^mptoms  peculiar  to  croup 
manifest  themselves.  The  cough  attracts  attention  by  its 
ringing  sound,  and  at  the  same  time,  or  shortly  after,  the 
characteristic  croupal  respiration  is  perceived.  High  fever 
and  difliculty  in  breathing  soon  set  in,  and,  although  ex- 
hibiting exacerbations  and  remissions,  only  cease  when  the 
disease  ceases.  There  is  much  thirst,  no  appetite ;  but  what 
is  taken  is  readily  enough  swallowed.  The  voice  is  changed 
almost  from  the  onset.  It  is  hoarse  and  whispering,  and  as 
the  disease  advances,  often  becomes  totally  suppressed. 

The  child  remains  in  this  condition  for  several  days  :  rest- 
less, with  its  head  thrown  back,  its  respiration  labored,  and 
the  croupal  sound  never  completely  disappearing.  Some- 
times, but  far  from  always,  solid  masses  of  membrane  are 
coughed  up.     Finally,  the  cough  may  stop  altogether  ;  the 


DISEASES    OF    THE    UPPER    AIR-PASSAGES.  187 

intervals  between  the  paroxysms  of  dyspnoea  are  effaced  ;  the 
face  becomes  livid ;  the  skin  loses  its  sensibility ;  the  ex- 
tremities grow  cold  ;  and,  unless  relief  be  afforded,  either  by 
medicinal  means  or  by  an  operation,  the  little  sufferer  dies 
comatose  or  suffocated.  The  fatal  termination  is  not  unfre- 
quently  hastened  by  an  intervening  attack  of  bronchitis  or 
pneumonia — a  fact  which  teaches  us  not  to  neglect  examin- 
ing the  lungs  in  cases  of  croup,  so  as  to  be  sure  that  no  dis- 
ease is  there  silently  running  its  course  with  its  symptoms 
masked  by  the  tracheal  malady.  In  this  respect,  auscultation 
affords  us  important  information,  much  more  important  than 
any  it  yields  as  to  the  exact  seat  and  the  extent  of  the  affec- 
tion of  the  windpipe. 

Still  the  application  of  a  stethoscope  to  the  larynx  or  tra- 
chea is  not  without  value.  It  may  enable  us  to  judge  of  the 
position  of  the  exudation,  for  we  may  occasionally  hear  a 
vibrating  sound,  as  if  a  membrane  were  being  tossed  to  and 
fro  by  a  current  of  air.  In  a  case  that  came  under  my  notice 
several  3'ears  ago,  this  sign  was  perceived  with  great  distinct- 
ness at  the  lower  part  of  the  trachea,  and  toward  the  com- 
mencement of  the  left  bronchial  tube ;  and  at  the  autopsy, 
at  exactly  this  point  was  found  a  thick  layer  of  membrane 
lying  unattached  in  the  tube. 

Croup  is  a  disease  not  apt  to  be  mistaken.  Yet  we  must 
be  cautious  not  to  attach  too  much  weight  to  any  one  of  the 
symptoms;  we  ought  rather  to  judge  of  the  existence  of  the 
disorder  by  their  grouping.  Thus  the  ringing  cough  is  in 
itself  by  no  means  diagnostic,  for  it  may  occur  in  some 
chronic  laryngeal  affections,  and  it  is  met  with  in  children 
suffering  from  intestinal  irritation.  The  stridulous  respira- 
tion is  also  heard,  or  at  all  events  there  is  a  tolerably  close 
copy  of  it,  in  simple  spasm  of  the  glottis,  and  sometimes 
when  foreign  bodies  have  found  their  way  into  the  larynx. 
The  paroxysms  of  apparent  suflbcation  happen  equally  in 
oedema  of  the  glottis.  Not  even  the  symptom  considered  of 
all  the  most  pathognomonic — the  expectoration  of  false  mem- 
brane— is  strictly  so,  since  this  may  come  from  the  bronchial 
tubes  or  from  the  throat.  But  when  we  take  the  symptoms 
collectively:  the  ringing  cough,  the  peculiar  respiration,  the 


188  MEDICAL    DIAGNOSIS. 

dyspiicea  aggravated  in  paroxysms,  the  changed  voice,  the 
fever,  the  expectoration  ;  when  we  regard  the  comparatively 
short  duration  of  the  disease, — there  is  but  one  interpretation 
of  the  phenomena  possible,  and  that  is,  the  existence  of  true 
croup. 

It  is,  of  course,  of  the  utmost  consequence  to  distinguish 
between  false  croup  and  pseudomembranous  laryngitis.  The 
main  difference  consists  in  this :  in  the  former,  the  inva- 
sion is  usually  more  sudden  ;  we  do  not  find  the  pharyn- 
geal exudation  so  often  seen  in  true  croup ;  there  is  little 
fever,  or  this  disappears  with  the  paroxysm  ;  and  so  does  the 
croupal  breathing,  and,  to  a  great  extent,  the  hoarse  voice 
and  loud,  barking  cough.  The  disorder  lasts  rarely  more 
than  two  or  three  days,  the  attack  usually  occurring  at 
night;  whereas  in  true  croup  the  duration  is  seldom  less 
than  from  four  to  six  days,  and  the  disease  progresses 
steadily,  and  the  voice  and  respiration  show  at  all  times  the 
nature  of  the  affection.  Then  in  the  latter  we  find  expecto- 
ration of  false  membrane.  This  is,  indeed,  the  most  abso- 
lute proof;  yet  the  absence  of  membrane  in  what  is  coughed 
up  or  vomited  is  not  a  positive  sign  that  the  case  is  not  one 
of  membranous  croup.  The  membrane  may  be  retained  in 
the  larynx;  and  we  meet,  indeed,  with  instances  in  which  it 
is  impossible  to  say  whether  the  inflammation  has  or  has  not 
produced  a  plastic  exudation  ;  whether,  in  other  words,  the 
case  is  a  severe  one  of  false  croup,  or  one  of  pseudomem- 
branous laryngitis. 

The  disorders  which,  next  to  false  croup,  are  most  likely  to 
be  mistaken  for  the  formidable  malady  under  consideration, 
are :  acute  laryngitis,  oedema  of  the  glottis,  pseudomem- 
branous sore-throat,  and  retropharyngeal  abscesses. 

Acute  laryngitis  is,  like  croup,  a  disease  of  short  duration, 
and,  like  croup,  attended  with  a  changed  voice,  with  a  harsh 
cough,  and  with  dyspnoea.  But  it  attacks  adults,  not  chil- 
dren. It  presents  difficulty  in  swallowing,  for  which  the 
slight  marks  of  inflammation  in  the  fauces  are  insufficient 
to  account;  whereas,  in  croup,  in  spite  of  the  pharyngeal 
exudation,  there  is  little  or  no  difficulty  in  swallowing.  A 
form  of  laryngitis,  however,  happens  in  children,  wdiich  is 


DISEASES    OF    THE    UPPER    AIR-PASSAGES.  189 

very  liable  to  be  considered  as  croup ;  it  is  the  secondary 
laryngitis  of  the  exanthemata,  especially  of  variola.  Atten- 
tion to  the  history  of  the  case,  and  to  the  circumstance  of  the 
inflammation  having  spread  from  the  throat  downward,  will 
go  a  great  way  toward  forming  a  correct  opinion  of  the  dis- 
ease. Yet  the  diasrnosis  is  sometimes  one  of  extreme  diffi- 
culty,  and,  if  the  characteristic  expectoration  of  croup  be 
absent,  the  most  accomplished  physician  may  be  deceived. 

(Edema  of  the  glottis  resembles  croup  in  the  dyspnoea,  the 
tits  of  suflbcation  and  of  coughing,  the  altered  voice,  and  the 
noisy  inspiration.  It  resembles  it  further  in  the  fact  that 
most  of  the  symptoms  do  not  disappear  in  the  intervals 
between  the  paroxysms.  Here  is  certainly  a  strong  likeness. 
But  the  cough  has  not  the  croupal,  brazen  sound ;  there  is 
no  fever,  unless  the  oedema  occur  in  the  course  of  an  acute 
affection  ;  and,  above  all,  oedema  of  the  glottis  is  a  disease  of 
adults,  and  unattended  with  the  pharyngeal  exudation  and 
the  peculiar  expectoration.  Again,  the  history  of  the  case 
often  guards  against  error,  for  oedema  of  the  glottis  happens 
frequently,  perhaps  most  frequently,  in  those  who  have  been 
long  laboring  under  ulcerative  laryngitis. 

Pseudomembranous  angina^  or  diphtheria,  may  present  the 
same  expectoration  as  croup  ;  the  walls  of  the  pharynx,  and 
the  fauces,  too,  are  coated  with  false  membranes.  But  we 
know  that  the  windpipe  is  not  the  seat  of  the  comphiint 
by  the  absence  of  paroxysms  of  cough  and  of  difficulty  in 
breathing,  and  by  the  voice  being  unchanged  or  somewhat 
nasal,  but  not  husky  or  extinct.  And  there  are  some  other 
points  of  dilFerence  which  we  shall  further  on  inquire  into. 

Retropharyngeal  abscesses  share  with  croup  the  dyspnoea, 
the  stridulous  respiration,  and  the  altered  voice.  They  do 
not,  however,  share  with  it  the  expectoration  of  false  mem- 
brane or  the  peculiar  cough  ;  and  further,  in  croup  there  is 
not  that  trouble  in  swallowing,  nor  that  evident  tumefaction 
and  stiffness  of  the  neck,  nor  can  a  tumor  be  recognized  by 
the  touch,  as  it  can  when  an  abscess  is  seated  behind  the 
walls  of  the  pharynx.  Moreover,  the  dyspnoea  and  the  voice 
present  somewhat  different  characteristics.  In  the  case  of 
abscess,  the  former  is  greatly  augmented,  or  paroxysms  of  it 


190  MEDICAL   DIAGNOSIS. 

are  brought  on  by  attempts  at  deglutition,  and  it  is  frightfully- 
aggravated  by  the  horizontal  position;  whereas  in  croup  the 
patient  seeks  relief  by  throwing  back  his  head,  and  although 
he  loses  his  voice  and  speaks  in  a  hardly  audible  whisper, 
still  the  words  are  sufficiently  distinct ;  while  an  abscess 
gives  a  nasal  or  guttural  tone  to  the  voice,  which  makes  it 
impossible  to  understand  what  is  being  said. 

Croup  may  further  be  mistaken  for  tonsillitis,  for  capillary 
bronchitis,  for  hooping-cough,  and  for  the  presence  of  foreign 
bodies  in  the  larynx  or  trachea  ;  but  to  any  but  the  most 
careless  observer  the  points  of  distinction  are  evident.  In  ton- 
sillitis the  breathing  is  not  at  all  or  but  very  slightly  impaired  ; 
and  looking  into  the  mouth  is  sufficient  to  reveal  the  real 
nature  of  the  malady.  In  capillar}'  bronchitis  there  is  dys- 
pnoea, as  in  croup;  but  the  dyspnoea  is  unremitting  and  asso- 
ciated with  tine  rales  in  the  lungs,  and  not  with  a  ringing 
cough,  a  harsh  tracheal  breathing,  a  hoarse  voice.  In  hoop- 
ing-cough paroxysms  of  coughing  and  of  obstructed  respira- 
tion occur ;  but  then  follows  the  distinctive  hoop ;  and  there 
is  no  fever,  the  voice  is  not  husky,  the  child  does  not  suiter 
between  its  coughing  spells.  Foreign  bodies  in  the  windpipe 
give  rise  to  stridulous  breathing  and  to  cough,  but  they  do  not 
often  mimic  croup  closely  enough  to  deceive ;  and  the  absence 
of  the  peculiar  cough  and  of  fever,  and  the  history  of  the  case 
prevent  error  ;  so  also  does  attention  to  the  fact  that  the  signs 
vary  as  the  foreign  body  shifts  its  position. 

Chronic  Laryngeal  Affections. 

Of  the  chronic  diseases  of  the  larynx,  chronic  inflammation 
of  the  mucous  membrane  and  the  changes  produced  in  it  by 
inflammation,  viz.,  thickening  and  ulceration,  are  the  most 
common. 

Chronic  Laryngitis.  —  This  aflection  has  as  its  main 
symptom  an  alteration  of  the  voice ;  but  it  is  also  accom- 
panied by  cough  and  an  uneasy  feeling  in  the  larynx.  The 
cough  is  at  first  dry,  but  when  of  any  standing  is  followed 
by  a  yellowish  opaque  expectoration.  It  either  presents 
nothing  peculiar  in  its  tone,  or  else  it  is  harsh  and  barking. 


DISEASES    OF    THE    UPPER    AIR-PASSAGES.  191 

The  breathing  is  very  little,  if  at  all,  embarrassed,  excepting 
when  the  mucous  textures  are  greatly  thickened  or  ulcerated. 
In  that  case  there  is  dyspnoea,  the  respiration  is  apt  to  be 
noisy  and  the  voice  completely  lost,  because  the  vocal  cords 
have  also  suffered.  There  is,  moreover,  considerable  pain 
on  pressure;  the  sputum  is  muco-purulent,  or  else  purulent 
and  streaked  with  blood ;  and  sometimes,  if  the  cartilages 
also  be  involved,  fragments  of  them  are  expectorated,  and  by 
the  touch  we  recognize  the  changed  state  of  the  tube. 

The  symptoms  of  chronic  laryngitis  are  purely  local.  It  is 
only  when  there  is  considerable  ulceration  or  a  progressive 
alteration  of  structure  in  the  affected  part  that  the  general 
health  gives  way.  Yet  chronic  laryngitis  is  frequently  found 
to  be  connected  with  a  broken  constitution,  because  the  in- 
flammation of  the  larynx,  both  in  its  simple  and  ulcerated 
forms,  is  often  combined  with  the  tubercular  diathesis,  or 
with  syphilis.  In  every  patient,  therefore,  who  places  him- 
self under  our  care,  suffering  from  chronic  laryngitis,  we 
must  endeavor  to  ascertain,  by  careful  inquiry,  whether 
either  of  these  morbid  conditions  is  present.  Many  a  time 
what  has  been  considered  as  a  case  of  pure  chronic  laryn- 
gitis turns  out,  on  thorough  examination,  to  be  laryngitis 
linked  to  a  serious  pulmonary  trouble:  or  we  detect  ulcers 
in  the  pharynx  associated  with  those  in  the  larynx,  and  are 
enabled  to  trace  clearly  the  ravages  of  constitutional  syphilis. 

Chronic  laryngitis  is  liable  to  be  mistaken  for  an  aneurism 
of  the  aorta,  or,  more  strictly  speaking,  an  aneurism  of  the 
aorta  is  liable  to  be  regarded  and  treated  as  a  case  of  chronic 
laryngitis.  The  distinction,  as  will  hereafter  be  shown,  is 
mainly  made  by  attention  to  the  physical  signs. 

Cases  of  functional  or  nervous  aphonia,  too,  are  sometimes 
confounded  with  chronic  laryngitis,  and  it  is  by  no  means 
always  easy  to  avoid  this  error.  The  loss  of  voice  may  be 
either  partial  or  complete.  It  not  unfrequently  comes  on 
without  any  previous  warning,  and  this  fact  aids  us  greatly 
in  diagnosis.  So  does  the  absence  of  cough,  of  expectoration, 
of  local  pain,  and  of  all  trouble  in  breathing;  for  none  of 
these  symptoms  are  commonly  observed  in  aphonia  which  is 
solely  nervous.     One  of  the  causes  of  this  singular  disorder 


192  MEDICAL   DIAGNOSIS. 

is  overstimulation  of  the  vocal  nerves,  by  straining  the  voice 
in  singing  or  in  speaking.  We  also  meet  with  it  as  occa- 
sioned by  narcotics  or  by  lead  poisoning,  and  perhaps  most 
frequently  as  a  reflex  manifestation,  due  to  irritation  of  the 
intestines  by  worms,  or  to  a  disorder  of  the  uterine  system. 
In  these  instances  of  nervous  aphonia  the  voice  suddenly  dis- 
appears and  as  suddenly  reappears,  a  phenomenon  not  un- 
usual in  the  aphonia  of  hysteria.  It  is  evident  that  in  all 
cases  of  nervous  aphonia  the  laryngoscope  will  assist  us 
greatly  in  diagnosis,  as  it  will  show  us  the  true  condition  of 
the  parts,  both  as  regards  their  structure  and  their  mobility. 
It  also  aids  us  in  distinguishing  these  laryngeal  disorders 
from  cases  of  aphonia  due  to  want  of  strength  in  breathing, 
— to  want  of  power  in  expiration. 

Enlarged  bronchial  and  cervical  glands  and  an  aneurism 
which  paralyzes  the  vagus  and  the  recurrent  nerve,  also 
produce  hoarseness,  and  ultimately  complete  loss  of  voice. 
Under  such  circumstances,  the  trachea  is  insensible  to  press- 
ure; there  is  a  short  cough,  attended  often  with  loud  tracheal 
rales;  and  we  observe  attacks  of  dyspnoea,  with  a  noisy, 
hissing  respiration.  The  practical  lesson  which  all  such 
cases  teach,  is  to  remember  that  the  symptom  considered 
most  characteristic  of  chronic  laryngeal  inflammation — the 
altered  voice — may  occur  when  no  larj'ngitis  exists. 

Now,  with  reference  to  the  nervous  forms  of  aphonia  just 
alluded  to,  the  loss  of  voice,  with  the  exception  of  those 
caused  by  pressure,  is  due  to  deflcient  power,  and  the  cords 
move  sluggishly  or  not  at  all.  When  the  disorder  reaches  a 
high  degree  we  perceive,  on  looking  into  the  laryngeal  mirror, 
that  the  vocal  cords  do  not  approximate  as  the  patient  at- 
tempts to  say  a  or  o.  But,  besides  these  cases,  owing  to 
general  want  of  force,  we  find  cases  of  absolute  paralysis  of 
individual  muscles,  as  of  one  adductor  of  a  cord  ;  or  of  one  or 
both  posterior  crico-ary  tenoids,  or  abductors ;  or  of  the  crico- 
thyroids, or  tensors.  In  some  of  these  there  is  considerable 
dyspnoea,  with  noisy  breathing ;  in  all  the  laryngoscope 
affords  the  only  means  of  diagnosis.* 


*  See  Morell  Mackenzie,  London  Hospital  Keports,  vol.  iv.;  also  Oliver, 
Am.  Journ.  of  Med.  Sciences,  April,  1870. 


DISEASES    OF    THE    UPPER    AIR-PASSAGES.  193 

Chronic  laryngitis,  or  rather  its  ciiief  symptom,  loss  of 
voice,  is  at  times  feigned  ;  and  the  deception  may  be  kept  np 
for  an  indeiinite  period.  Yet  we  possess,  in  the  use  of  anaes- 
thetics, the  means  of  detecting  the  fraud  at  any  moment. 
Just  before  the  impostor  falls  into  the  deep  sleep  produced 
by  ether,  or  as  he  is  recovering  from  the  insensibility  it 
occasions,  his  will  no  longer  controls  his  voice,  and  he  speaks 
in  his  natural  tone,  or  even  screams  violently. 

Now,  under  the  term  chronic  larvno-itis,  which  formerlv 
for  want  of  more  precise  knowledge  was  made  to  embrace 
most  kinds  of  chronic  diseases  of  the  larynx,  many  different 
morbid  processes  are  embraced,  the  exact  nature  and  seat  of 
which  we  may  discriminate  by  the  laryngoscope.  Thus  the 
disorder  may  be  wholly,  or  nearly  wholly,  confined  to  the 
epiglottis.  We  may  find  this  structure  very  higljly  congested 
and  enlarged;  we  may  be  able  to  note  that  it  is  pendant, 
almost  completely  covering  the  glottis;  and  it  is  frequently 
the  seat  of  ulceration.  The  attending  symptoms  in  any  case 
are  those  regarded  as  characteristic  of  a  greater-  or  less  de- 
gree of  laryngeal  inflammation.  In  instances  of  ulceration, 
there  is  soreness  with  pain  in  swallowing,  hoarseness  and 
irritative  cough,  followed  at  times  by  blood- streaked  expec- 
toration. The  ulceration  may  terminate  in  total  destruction 
of  the  epiglottis. 

When  the  vocal  cords  are  affected,  we  recognize  in  the 
laryngeal  mirror  either  their  reddening  in  part  or  entirely, 
or  their  induration  and  thickening,  or  we  observe  edematous 
swelling  in  and  around  them,  or  their  ulceration  ;  and  we 
can  usually  detect  during  breathing  and  phonation  their 
impaired  action.  Now  all  these  conditions  are  generally 
combined  with  verj^  marked  aphonia;  the  voice  indeed  may 
be  reduced  to  the  merest  whisper.  And  in  making  our 
diagnosis  we  must  always  be  careful  to  find  out  if  the  laryn- 
geal phenomena  be  not  secondary,  forming  part  of  a  gen- 
eral morbid  state,  such  as  dropsy,  tuberculosis,  syphilis,  or 
changes  in  the  blood. 

Diseases  of  the  cartilages  and  of  the  perichondrium  are  still 
more  frequently  occasioned  by  the  conditions  alluded  to; 
tuberculosis,   syphilis,  and   low    forms    of  fever  are   at   all 

13 


194  MEDICAL    DIAGNOSIS. 

events  the  states  with  which  they  are  most  commonly  com- 
bined. The  affection  often  commences  in  the  submucous 
tissue,  and  the  ulceration  spreads  until  the  cartilaginous 
parts  of  the  larynx  are  involved.  The  arytenoid  cartilages 
are  generally  the  ones  iirst  attacked;  and  portions  of  these 
cartilages  may  be  thrown  oft*  and  expelled.  At  times  pus  is 
formed  which  gives  rise  to  swellings  which  can  be  recognized 
by  the  aid  of  the  laryngeal  mirror  ;  sometimes  a  displacement 
of  the  cartilages  takes  place,  before  any  portion  of  them  is 
completely  separated,  and  the  most  distressing  and  danger- 
ous attacks  of  suffocation  result ;  or  the  perichondritis  may 
lead  to  the  development  of  bone  substance  and  a  constric- 
tion of  the  tube.  In  some  instances,  the  purulent  collection 
presses  on  a  vocal  cord,  which,  when  the  laryngoscope  is 
used,  may,  as  Tuerck*  has  recorded,  be  seen  to  be  immov- 
able. This  instrument  reveals  very  often  the  ravages  the 
disease  has  committed;  and  w^e  are  thus  generally  enabled 
to  form  an  opinion  as  to  how  far  the  destruction  or  the 
"laryngeal  phthisis"  has  progressed,  and  which  of  the  soft 
parts  as  well  as  of  the  cartilages  are  involved.  The  symptoms 
attending  this  terrible  complaint  are  difBculty  in  breathing 
and  in  swallowing,  local  pain  and  soreness,  a  greatly  altered, 
or  a  lost  voice,  a  distressing,  harsh  cough,  which  is  followed 
at  times  by  a  purulent  expectoration. 

Respecting  tumors  of  the  larynx,  cancerous  or  otherwise, 
and  polypoid  growths  in  its  interior,  we  do  not  know  as  yet 
sufiicient  to  distinguish  them  with  any  certainty,  by  their 
symptoms  alone,  from  chronic  laryngitis.  Their  most  trust- 
worthy signs,  irrespective  of  the  cough,  altered  voice,  and 
the  other  manifestations  of  chronic  laryngeal  inflammation, 
are  a  steadily  increasing  difficulty  in  breathing  and  attacks 
of  suffocation,  for  which  nothing  in  the  lungs,  or  heart,  or 
great  vessels  accounts.  The  detection,  at  the  seat  of  the 
larynx,  of  a  growing  tumor,  accompanied  by  a  severe  cough, 
by  a  sanious  sputum,  and  by  emaciation,  would,  in  addition 
to  the  symptoms  just  enumerated,  warrant  the  diagnosis  of 
cancer,  whether  or  not  much  pain  were  present.  Polypi  in 
the  larynx  may  sometimes  be  seen  by  depressing  and  drag- 


*  Clinical  Researches.     Translated,  London,  1862. 


i 


DISEASES    OP    THE    UPPER    AIR-PASSAGES.  195 

ging  forward  the  tongue  until  the  epiglottis  is  brought  into 
view.  At  least  they  have  been  thus  discovered,  and  even 
successfully  operated  upon.*  But  as  regards  any  form  of 
morbid  growth,  and  particularly  as  regards  polypi,  we  pos- 
sess in  the  laryngoscope  the  most  certain,  usually  the  only 
certain,  means  of  detecting  them,  and  even  of  aiding  us  in 
removing  them,  as  is  now  being  constantly  done.  These 
laryngeal  growths  vary  much  in  size ;  they  are  often  seated 
at  the  anterior  free  edges  of  the  true  vocal  cords,  or  still 
more  generally  just  above  or  just  below  the  origin  of  the 
cords.  I  have  seen  numerous  instances  of  the  kind ;  and 
they  are,  as  a  rule,  very  readily  discerned.  Sometimes  they 
may  exist  for  years,  merely  producing  changes  in  the  voice 
and  some  cough,  but  no  very  great  distress  ;  or  they  may 
lead  to  fits  of  strangulation  and  to  sudden  death. 


t> 


Before  concluding  these  remarks  on  diseases  of  the  larynx, 
it  may  be  thought  necessary  to  point  out  the  differences  be- 
tween them  and  diseases  of  the  trachea.  But  affections  of  the 
trachea  need  not  be  separately  considered.  Lying  between 
the  larynx  and  the  bronchi,  the  trachea  commonly  shares  in 
their  disorders.  Thus  we  have  seen  croup  to  be  a  malady  in 
which  both  larynx  and  trachea  are  involved.  Slight  inflam- 
mation of  the  trachea  occurs  constantly  in  slight  attacks  of 
laryngitis  or  of  bronchitis.  Ulcers  in  the  trachea  may  exist 
without  ulceration  of  the  larynx ;  but  then  they  usually  es- 
cape detection.  Sometimes,  however,  they  reveal  themselves 
by  a  constant  pain  at  the  lower  portion  of  the  neck  and 
upper  part  of  the  sternum,  joined  to  all  the  symptoms  of  ulcer- 
ation of  the  larynx  excepting  the  impaired  voice.  Morbid 
growths,  too,  occur  in  the  trachea,  as  they  do  in  the  larynx, 
and  the  tube  may  be  altered  in  form  and  in  structure.  We 
can  make  use  of  the  laryngoscope  to  assist  us  in  the  diagnosis 
of  any  of  the  forms  of  tracheal  disease  referred  to.  Yet  the 
instrument  is  not  always  available;  for  it  is  only  under  very 
favorable  circumstances  that  the  entire  extent  of  the  trachea 
can  be  seen. 


*  Horace  Green,   Polypi  of  the   Larynx.     Also,  Ehrmann,   Histoire  des 
Polypes  du   Larynx:    Strasbourg,   1850.     Buck,  Transact,   of   Amer.    Med. 


Association,  vol.  vi. 


CHAPTER  IV. 

DISEA.SES    OF    THE    CHEST. 

An  examination  of  the  diseases  of  the  chest  must  be  pref- 
aced by  a  description  of  those  methods  of  investigation  which 
have  given  to  their  diagnosis  such  certainty.  The  same 
methods  may  be  applied  in  the  study  of  the  maladies  of  other 
parts  of  the  body,  but  they  are  of  special  service  in  the  recog- 
nition of  thoracic  disorders,  and  will  be  here,  therefore,  most 
appropriately  considered  in  detail. 

The  discrimination  of  disease  by  the  eye,  the  ear,  the 
touch,  in  fact  by  the  direct  aid  of  the  senses,  is  called  j)h}/sical 
diagnosis;  the  signs  thus  ascertained  are  connected  with  per- 
ceptible alterations  in  the  material  properties  or  physical 
nature  of  structures — such  as  alterations  in  their  form,  their 
density,  or  their  sounds — and  are  known  as  physical  signs. 

Physical  signs  are,  then,  the  exponents  of  physical  condi- 
tions, and  of  nothing  more.  But  as  the  same  physical  condi- 
tions may  occur  in  various  diseases,  so  may  the  same  physical 
signs  occur  in  various  diseases.  An  isolated  sign  is,  therefore, 
not  diagnostic  of  any  particular  malady.  It  reveals  usually 
an  anatomical  change;  but  it  does  not  determine  the  disorder 
occasioning  this  change.  The  tendency  to  ascribe  to  each 
thoracic  aifection,  and  even  to  each  stage  of  an  atfection,  a 
pathognomonic  sign,  has  greatly  retarded  the  usefulness  of 
physical  exploration.  By  presenting  a  never-ending  list  of 
specific  signs,  it  has  frightened  many  from  attempting  to  be- 
come acquainted  with  the  most  serviceable  of  all  the  means 
of  diagnosis,  and  many  more,  by  the  unnecessary  complica- 
tions introduced,  have  been  disheartened  at  the  very  threshold 
of  their  studies.  The  subject  may  be  much  simplified  by  lay- 
ing less  stress  on  individual  signs,  and  by  grouping  them  to- 
gether according  as  their  association  becomes  distinctive  of 
certain  well-marked  physical  states.  Morbid  anatomv  then 
(196) 


I 


DISEASES    OF    THE    CHEST.  197 

steps  in  with  its  teachings,  and  tells  ns  in  what  diseases  these 
states  are  comraonl}^  found.  It  is  in  conformity  with  these 
views  that  I  shall  attempt,  in  the  following  pages,  to  delin- 
eate the  signs  of  thoracic  affections. 

But  physical  signs  cannot  he  acquired  from  books ;  they 
must  be  learned  at  the  bedside.  Their  value  can  be  ascer- 
tained by  reading ;  yet  to  distinguish  them  with  readiness 
requires  constant  cultivation  of  the  eye,  the  ear,  and  the 
sense  of  touch.  And  it  is  of  great  importance  to  have  clear 
ideas  regarding  the  structure  of  the  parts  to  be  investigated, 
and  of  their  action  in  health.  It  must,  for  instance,  be  borne 
in  mind  that  the  lung  is  covered  by  a  serous  investment;  that 
it  consists  of  tubes  more  or  less  rigid,  the  bronchial  tubes, 
of  their  numerous  ramifications,  and  of  their  termination 
in  an  elastic  parenchyma,  the  air-vesicles,  or  the  pulmonary 
tissue  proper.  It  must  further  be  borne  in  mind  that  the 
organ  is  separated  into  lobes,  and  that  it  contains  air  which 
is  constantly  shifting,  and  that  locked  up  with  it  in  the  same 
cavity  is  the  main  organ  of  circulation. 

For  the  sake  of  convenience,  the  surface  of  the  chest  lias 
been  mapped  out  into  regions.  Various  arrangements  of 
these  have  been  made  by  different  authors.  The  simplest 
division  of  the  chest  is  into  ajiterior,  posterior,  and  lateral 
surfaces.  The  regions  into  which  the  anterior  surface  may, 
for  practical  uses,  be  subdivided,  are :  an  upper  region,  ex- 
tending from  just  above  the  clavicle  to  the  fourth  rib,  and  a 
lower  region  from  the  fourth  rib  downward.  Posteriorly, 
also,  there  are  an  upper  and  a  lower  part  of  the  chest  to  be 
specially  examined.  It  is  hardly  necessary  to  say  that  all  ' 
these  regions  are  double — the  same  on  each  side  of  the  chest. 
Many  more  divisions  are  usually  made;  but  they  are  perplex- 
ing to  the  student,  and  of  very  doubtful  value.  The  artificial 
boundaries  generally  laid  down  are,  indeed,  too  minute  and 
yet  not  minute  enough  ;  they  are  too  minute  for  ordinarj'  pur- 
poses, not  minute  enough  when  it  is  desirable  to  localize  a 
physical  sign.  Whenever  this  is  requisite,  instead  of  resort- 
ing to  the  names  of  the  regions  usually  employed,  I  think  it 
preferable  to  designate  the  seat  of  the  sign  with  reference  to 
some  fixed  anatomical  point.     This  may  be  done  for  the  an- 


198  MEDICAL    DIAGNOSIS. 

terior  part  of  the  chest  by  indicating  the  distance  above  or 
below  the  clavicle,  or  near  what  part  of  the  sternum,  or  at 
which  rib,  or  spreading  over  how  many  intercostal  spaces, 
the  sign  in  question  is  perceived.  At  the  posterior  part  of 
the  chest,  the  spinous  ridge  of  the  scapula,  its  lower  angle, 
and  the  spinal  column,  serve  as  landmarks.  For  most  clini- 
cal purposes,  it  is  only  needed  to  study  the  region  above  the 
spinous  process  of  the  scapula,  as  separate  from  the  space 
below.  But  in  some  instances  it  may  be  necessary  to  notice 
the  region  between  the  scapulse  (inter-scapular)  or  that  ex- 
tending from  the  lower  angle  of  the  bone  to  the  limits  of  the 
chest  (infra-scapular). 

Let  us  now  examine  the  different  methods  of  ph3'sical 
diagnosis,  and  particularly  in  their  relation  to  pulmonary 
diseases. 


SECTION   I. 

DISEASES    OF   THE   LUNGS. 

The  different  Methods  of  Physical  Diagnosis,  and  the 
Physical  Signs  of  Pulmonary  Diseases. 

INSPECTION. 

If  the  chest  be  examined  with  the  eye,  we  obtain  an  idea 
of  its  form,  size,  and  movements.  In  health  this  inspection 
shows  us  that  the  two  sides  of  the  chest  are,  to  a  great  ex- 
tent, symmetrical  in  form,  as  well  as  in  size  and  movement. 
Both  sides  rise  equally  during  inspiration  and  sink  equally 
during  expiration.  On  both  sides  the  motion  of  inspiration 
is  longer  than  that  of  expiration,  and  the  pause  between 
them  extremely  slight. 

This  respiratory  movement  is  visible  over  the  whole  thorax. 
In  males  it  is  most  distinct  at  the  lower  portions  of  the  chest; 
in  females  it  is  most  discernible  at  the  upper.  This  differ- 
ence in  the  breathing  of  the  two  sexes  becomes  the  more 
manifest,  the  more  hurried  the  respiration.  In  healthy  adults 
the  lungs  expand  with  regularity  from  sixteen  to  twenty  times 


DISEASES    OF    THE    CHEST.  199 

in  a  minute.  In  certain  pulmonary  affections,  especially  in 
pneumonia,  the  number  of  respirations  often  exceeds  fifty  in 
a  minute.  But  hurried  breathins;  and  chans^ed  movements 
of  the  thorax  occur  independently  of  diseases  of  the  lung. 
The  heaving  of  the  chest  in  a  hysterical  paroxysm  is  a  sight 
familiar  to  every  practitioner.  Where  the  diaphragm  does 
not  descend,  as  in  consequence  of  peritonitis,  or  of  abdominal 
dropsy  and  tumors,  the  breathing  is  much  more  rapid,  and  is 
perceptible  at  the  upper  parts  of  the  chest.  Again,  the  tho- 
racic movements  may  be  distinct  on  one  side  and  hardly  no- 
ticeable on  the  other,  as  in  pleurisy,  in  pneumothorax,  or  in 
hemiplegia.  Lastly,  as  happens  in  some  cerebral  lesions,  the 
motions  of  the  chest  may  be  very  slow  and  labored,  or  irregu- 
lar, or  they  may  have  apparently  ceased,  and  the  breathing 
be  altosrether  abdominal. 

The  form  of  the  chest  is  sometimes  strikingly  altered  by 
disease.  Congenital  malformations  and  curvatures  of  the 
spine  modify  it;  so  do  intra-thoracic  affections.  Frequently 
the  chest  presents  a  retracted,  or  an  expanded  look.  Retrac- 
tion denotes  diminished  size  of  the  lung,  and,  if  one-sided,  is 
usually  indicative  either  of  chronic  changes  in  the  lung  tissue, 
particularly  those  owing  to  tubercle,  or  of  false  membranes 
which  bind  down  the  lung.  Expansion  of  the  chest  is  met 
with  in  emphysema  and  in  pleuritic  effusion.  A  local  or  par- 
tial expansion,  or  bulging,  may  be  encountered  in  the  latter 
disease;  but  is  more  often  associated  with  the  former,  or  it 
may  depend  on  thoracic  tumors,  on  pericardial  effusions,  or 
on  hypertrophy  of  the  heart. 

The  size  of  the  chest  can  be  only  approximatively  judged 
of  by  the  eye.  Where  accuracy  is  required,  measurements 
must  be  resorted  to. 

MENSURATION. 

To  measure  the  circumference  of  the  chest  or  of  the  abdo- 
men, or  to  ascertain  the  distance  from  one  portion  of  the  sur- 
face to  the  other,  a  graduated  tape  is  all  that  is  required.  To 
attain  the  former  object,  the  spinous  process  of  a  vertebra  is 
chosen  as  a  fixed  point,  and  the  tape  is  thence  passed  round 
the  body  to  the  median  line,  first  on  one  side,  then  on  the 


200 


MEDICAL    DIAGNOSIS. 


Fig 


otlier,  taking  care  that  it  be  applied  evenly  to  the  skin,  and 
that  the  level  of  the  measurement  be  the  same  on  both  sides. 
This  level,  if  the  examination  be  recorded,  should  always  be 
noted,  that  we  may  have  a  uniform  standard  of  comparison. 
And  for  the  same  reason,  it  is  best  to  adopt  the  plan  of  always 
raakine:  our  measurements,  as  nearly  as  possible,  on  the  same 
line ;  for  example,  in  determining  the  circular  width  of  the 
thorax,  we  can,  as  a  rule,  select  a  line  immediately  above  the 
nipple,  or  draw  the  tape  around  the  chest  toward  the  sixth 
costo-sternal  joint,  and,  therefore,  on  the  level  of  the  sixth 
rib  near  its  attachment  to  the  cartilage. 

In  estimating  the  size  of  the  chest  in  disease,  it  must  be 

borne  in  mind  that  even  in 
health  its  two  sides  vary  wide- 
ly. The  half  circle  on  the 
right  side  is,  in  right-handed 
persons,  at  least  half  an  inch 
larger  than  the  half  circle  of 
the  left.  But  the  measure- 
ments, to  be  trusted,  must  be 
performed  while  the  patient  is 
holding  his  breath  in  expira- 
tion. If  it  be  desirable  to  as- 
certain in  how  far  the  respira- 
tory acts  modify  the  dimensions 
of  the  chest  or  of  the  abdomen, 
this  may  be  readily  etfected 
by  the  ingenious  "chest-measurer"  of  Dr.  Sibson,  or  by  the 
"  stethometer"  of  Dr.  Quain  or  of  Dr.  Carroll,*  all  of  which 
instruments  register  accurately  the  movements  of  breathing; 
or  the  respiratory  curves  can  be  traced  and  studied  by  the 
atmograph  of  Burdon  Sanderson,  or  by  the  anapnograph,  an 
instrument  made  use  of  by  Bergeon  and  Kastus,  and  similar 
to  the  sphygmograph.f 

The  transverse  diameter  of  the  chest  may  be  determined 
by  means  of  a  pair  of  callipers  ;  and  the  curves  or  flatness  of 
the  surface,  should  it  be  necessary,  by  Dr.  Alison's  stetho- 

*  New  York  Medical  J.niriial,  1868. 
t  Gazette  Hebdoni.,  scr.  2,  Y.  1808. 


The  stethometer  of  Quain.  The  box  is 
placed  on  the  sternum  ami  the  string  carried 
around  the  chest.  One  revolution  of  the  in- 
dex, which  is  moved  by  a  rack  attached  to 
the  string,  indicates  an  inch  of  motion  in  the 
chest. 


*■ 


DISEASES    OF    THE    CHEST. 


201 


goniometer  (Fig.  8) ;  but  it  is  rarely  necessary.  In  truth,  these 
minute  measurements,  however  interesting  to  the  physiolo- 
gist, have,  as  yet,  not  been  made  available  to  the  physician. 
Inspection  teaches  us  the  same  as  mensuration.      What  it 


Fig.  8. 


The  stetlio-souiometer  of  Scott  Alison. 


teaches  with  less  precision  can  be  learned  for  purposes  of 
diagnosis  with  a  graduated  tape. 

Mensuration  may  be  employed  not  only  to  judge  of  the 
size  of  the  chest  and  of  its  movements,  but  also  to  ascertain 
the  amount  of  air  which  is  received  into  the  lungs.  The  in- 
strument used  for  this  object  is  the  spirometer,  an  invention  of 
Dr.  Hutchinson  (Fig.  9);  and  since  his  time  numerous  modi- 
fications of  the  instrument  have  been  made  :  for  instance,  the 
ordinary  dry  and  the  wet  gas  meter  have  both  been  adapted 
to  the  purposes  of  spirometry,  and  an  instrument  small 
enough  to  be  carried  iti  the  pocket  has  been  suggested.  The 
results  the  spirometer  has  yielded  are  of  great  value  in  a 
physiological  point  of  view;  in  a  clinical,  there  are  too  many 
sources  of  fallacy  and  too  many  drawbacks  to  render  its  use 
of  much  importance;  and  not  the  least  of  these  drawbacks  is, 
that  it  takes  considerable  practice  to  learn  how  to  blow. 
The  spirometer  may  indicate  that  a  large  quantity  of  air 
enters  the  lungs,  and  thus  become  a  rough  test  of  tlieir  nor- 
mal condition.  But  when  less  air  passes  into  the  organ  than 
the  spirometric  standard  requires,  this  leads  in  itself  to  no 
conclusions;  certainly  not  to  any  concerning  the  disease 
which  occasions  the  diminished  vital  capacity.  In  esti- 
mating results  arrived  at  by  the  spirometer,  it  must  be  re- 
membered that  sex,  weight,  age,  and  height  have  to  be  taken 
into  account.   To  the  latter  Dr.  Hutchinson  assigns  much  im- 


0(V 


portuiu'O,  since 


MEDICAL    DIAGNOSIS. 

he  enunciates  the  hiw  that  for  every  inch  above 

five   feet,  eight  cubic 


Fid.  '^■ 


Dr.  Hutchinson's  spirometer. 


inches  are  to  be  added 
to  the  healthy  stand- 
ard.    For  the  height 
of  five  feet,  the  breath- 
ing volume  is  one  hun- 
dred and  seventy-four 
cubic   inches.        But 
these  calculations  are 
not  exact;    they  only 
approximate  the  truth. 
To  determine  both 
the  expiratory  and  in- 
spiratory   power,    the 
hsemadynamometer 
(Fig.  10)  may  be  em- 
ployed.       Dr.    Ham- 
mond* lays  great  stress 
on  the  indications  fur- 
nished by  testing  the 
inspiratory  power  as 
reo-ards  the  health  of 
the    individual,    and 
recommends   the    use 
of  the  instrument   in 
the  examination  of  re- 
cruits.    According  to 
his  observations,  men 
of  five  feet  eight  inches 
possess    the    greatest 
amount  of  inspiratory 
power.    They  raise  the 
column  of  mercury 
about   two  inches   by 
inspiration,  and  about 
three  inches  by  expira- 
tion. 


*  Treatise  on  Hygiene.     Philadelphia,  1863. 


DISEASES    OF   THE    LUNGS. 


203 


PALPATION. 


Palpation,  or  the  application  of  the  hand,  confirms  the  re- 
sults obtained  by  inspection  and  mensuration  as  to  size,  form, 


FiQ.  10. 


The  hseniadynamometer,  as  adopteil  l)y  Ilainiuoiiil  for  examinations  of  the  lungs.  Mercury  is 
poured  into  the  glass  tube  until  the  zero  on  botli  scales  is  reached.  Upon  expiring  into  the  appa- 
ratus, the  mercury  is  forced  to  rise  in  the  opposite  portion  of  the  tube,  and  is  correspondingly 
depressed  on  the  s'ide  to  which  the  elastic  tube  made  use  of  is  attached.  When  the  act  of  inspi- 
ration is  performed,  reverse  movements  of  the  mercury  occur.  Care  must  be  taken  to  exert  only 
the  muscles  of  the  chest,  and  not  those  of  the  mouth  and  cheeks. 


204 


MEDICAL   DIAGNOSIS. 


and  movonvents.  It  may,  in  addition,  be  employed  to  deter- 
mine' spots  of  soreness,  the  density  and  condition  of  tumors, 
the  slate  of  the  thoracic  walls,  the  frequency  of  the  breath- 
ing, and  the  action  of  the  heart.  The  hand  may  further  be 
of  service  as  a  means  of  distinguishing  vibrations  produced 
by  rhonohi  (rhonchal  fremitus),  or  by  the  voice  (vocal  fremi- 
tus); or  it  may  detect  fluid  by  the  sense  of  fluctuation  it 
imparts,  or  a  roughened  serous  membrane  by  the  friction 
fremitus.  When  both  fluid  and  air  are  present  in  a  large 
hollow  space,  by  shaking  the  patient  a  distinct  vibration  of 
the  parietes  is  felt,  accompanied  by  a  splashing  sound,  known 
as  the  Hippocratic  or  succussion  sound. 

Palpation  is  to  be  practised  by  applying  the  palmar  sur- 
face of  one  or  of  several  Angers  evenly,  and  without  too 
much  pressure,  on  the  part  to  be  examined. 


Fig.  11. 


PERCUSSION. 

By  percussing  or  striking  bodies  we  elicit  sounds  by  which 
we  judge  of  their  composition.     That  a  solid  body  sounds 

differently  from  a  hollow 
one,was  probably  familiar 
to  every  artisan  from  time 
immemorial;  but  the  ap- 
plication of  this  well- 
known  fact  to  the  study 
of  the  diseases  of  the  hu- 
man frame  is  a  discovery 
of  Avenbrugger,  a  Vien- 
nese physician  of  the  last 
century.  He  and  the 
brilliant  editor  of  his 
work,  Corvisart,  practised  percussion  by  striking  directly 
with  the  hand  over  the  organs  to  be  explored ;  a  method 
which,  although  serviceable  to  ascertain  marked  diflerences, 
or  to  obtain  an  idea  of  the  general  resonance  of  a  part,  is 
inferior  to  the  one  introduced  by  Piorry,  of  mediate  percus- 
sion. The  media  used  to  receive  the  blow  are  various:  a 
disk  or  plate  of  ivory,  of  wood,  or  leather;  a  piece  of  india- 


Tlie  pleximcter;  about  natural  size.     It  may  be 
conveniently  made  of  hard  rubber. 


DISEASES    OF   THE    LUNGS. 


205 


rubber;  or  the  middle  iinger  of  the 
left  hand.  The  linger  answers  best 
for  percussion  of  the  chest ;  for  ab- 
dominal percussion  a  pleximeter  is 
preferable. 

When  the  linger  is  employed,  it 
ought  to  be  applied  with  its  palmar 
surface  Urmly  pressed  against  the 
chest,  and  as  parallel  as  possible  to 
the  ribs.  One  or  two  lingers  of  the 
other  hand  may  then  be  used  to  tap 
with — for  the  linger  is,  for  ordinary 
purposes,  quite  as  good  as,  if  not  bet- 
ter than,  any  of  the  percussion  ham- 
mers invented — the  greatest  attention 
being  paid  to  the  circumstance  that 
the  percussing  linger  strikes  perpen- 
dicularly whatever  pleximeter  be 
used,  and  not  slantingly,  as  is  too 
generally  done.  The  w^iole  move- 
ment should  proceed  from  the  wrist, 
and  only  from  the  wrist,  and  ought 
not  to  be  too  rapid,  or  unequal,  or  of 
great  force.  If  all  of  these  apparently 
unimportant  points  are  attended  to, 
the  results  obtained  may  be  relied 
upon ;  if  not,  the  want  of  manual 
dexterity  invalidates  the  conclusions. 
No  fault  is  so  often  committed  by  the 
beo-inner  as  the  raisin o^  of  the  linsfer 
used  as  a  pleximeter  from  the  surface 
— thus  obtaining  the  sound  of  the 
finger,  and  not  that  of  the  organ  he 
wishes  to  percuss — unless  it  be  the 
fault  of  striking  with  great  force,  as  if 
the  object  were  to  break  into  the  cav- 


FiG.  12. 


Fig.  12. — A  servicealjle  model  of  a  pprcussion  hammer ;  not 
quite  natural  .size.  The  iuilia-niliber  is  screwed  to  the  ring, 
which  ha.s  a  diameter  of  five-eighths  to  three-quarters  of  an 
inch.  Tlie  metallic  ring  i.s  attached  to  a  steel  stem  with  a  very 
decided  spring.  The  pointed  portion  of  the  india-rubber  is 
used  to  strike  with  on  the  pleximeter. 


m 


20C)  MEDICAL    DIAGNOSIS. 

itv  of  tho  c'liost.   Forcible  percussion  is  only  of  use  when  the 
soiiiul  of  deop-seated  organs  is  to  be  brought  out. 

TIk'  main  sounds  elicited  by  percussion  maybe  designated 
as  dull,  clear,  and  tympanitic.  Of  course  these,  like  all  other 
sounds,  mav  ditfer  in  strength,  in  duration,  and  in  pitch. 

A  (iuU  sound  denotes  absence  of  air.  It  is  the  sound  both 
of  fluids  and  of  solids.  It  is,  thus,  the  sound  sent  forth  from 
the  airless  viscera:  from  the  liver,  spleen,  and  heart.  When 
it  takes  the  place  of  the  pulmonary  sound,  it  bespeaks  con- 
solidation, or  the  presence  of  something  which  checks  the 
normal  vibrations  of  the  lung  texture.  Dulness  is  always 
associated  with  an  increased  sense  of  resistance  to  the  per- 
cussing finger. 

A  cleai'  sound  is  produced  by  a  series  of  marked  and  un- 
hindered vibrations  which  are  emitted  from  a  substance  con- 
taining air.  As  thus  defined,  a  clear  sound  is  evidently 
yielded  by  percussing  any  air-containing  organ.  But  custom 
has  restricted  the  employment  of  the  term  clear  to  denote 
the  peculiar  resonance  obtained  by  striking  over  pulmonary 
tissue.  When,  therefore,  a  clear  sound  is  spoken  of,  it  means 
a  sound  having  the  nature  of  that  of  the  lungs,  or  of  normal 
vesicular,  or  pulmonary  resonance. 

A  tympanitic  sound,  on  the  other  hand,  is  a  non-vesicular 
sound,  having  the  character  of  that  of  the  intestine.  Where- 
ever  heard,  it  indicates  the  presence  of  quantities  of  air  in 
conditions  similar  to  that  contained  in  the  intestine,  namely, 
inclosed  in  walls  which  are  yielding,  but  neither  tense  nor 
very  thick.  When  elicited  over  the  chest,  it  may  be  only 
the  transmitted  sound  of  a  distended  stomach  or  colon.  But 
generally  a  tympanitic  sound  over  the  seat  of  the  lungs  is 
expressive  of  emphysema  or  of  pneumothorax,  or  sometimes 
of  a  cavity.  Many  find  ditficulty  in  distinguishing  between 
the  clear  sound  of  the  pulmonary  tissue  and  the  tympanitic 
sound.  The  more  ringing  character  of  the  latter,  and  its 
higher  pitch,  constitute  its  essential  properties. 

As  modifications  of  the  tympanitic  sound  may  be  viewed 
the  amphoric  or  metallic  sound,  and  the  cracked-pot  or  cracked- 
metal  sound.  The  first  of  these  is  a  concentrated  tympanitic 
sound  of  raised  pitch,  and  denotes  a  large  cavity  with  firm, 


DISEASES    OF    THE    LUNGS.  207 

elastic  walls.  The  second  is  not  unfrequently  found  asso- 
ciated with  it.  It  requires  for  its  development  a  strong,  ab- 
rupt blow  of  the  percussing  linger  while  the  patient  keeps 
his  mouth  open.  The  condition  usually  occasioning  the 
sound  is  a  cavity  communicating  with  a  bronchial  tube.  It 
is,  however,  also  met  with  uncombined  with  an  excavation, 
as  in  the  bronchitis  of  children,  in  pleurisy  above  the  seat  of 
effusion,  and  in  emphysema.  Indeed,  any  disorder  in  which 
the  chest  walls  remain  very  yielding,  and  in  which  a  certain 
amount  of  air  contained  in  the  lung  and  in  uninterrupted 
connection  with  the  external  air,  is,  by  sudden  percussion, 
forced  into  a  bronchial  tube,  will  occasion  this  cracked-metal 
sound. 

In  addition  to  the  character  of  all  these  sounds,  we  may 
advantageously  study  their  degree,  or  amount  of  fulness : 
such  changes  as  are  expressed  by  the  words  "more  or  less," 
"  diminished  or  increased."  Thus,  a  clear  sound  may  be  in- 
creased, owing  to  stronger  vibrations  and  a  larger  quantity 
of  air,  and  yet  not  lose  its  distinctive  pulmonary  character, 
as,  for  instance,  often  happens  when  the  air  cells  are  dilated; 
the  sound  of  the  large  intestine  is  fuller,  more  tympanitic 
than  that  of  the  small  intestine,  and  so  forth. 

With  changes  in  fulness  or  volume  of  sound  go  hand  in 
hand  changes  in  Ms, pitch.  Increased  volume  is  linked  to  low- 
ered pitch,  diminished  volume  to  higher  pitch. 

To  sum  up  the  chief  results  of  percussion,  as  above  de- 
scribed : 

Quality,  or  Character  of  Sound. 

Clear  : — Presence  of  air — as  in  the  lung  tissue. 
Dull  : — Solidification  or  compression. 

Tympanitic: — Certain  amount  of  air  inclosed  in  a  structure  or  cavity  the 
walls  of  which  are  not  too  tense. 
Metallic: — Lai'ge  hollow  space,  with  firm  hut  elastic  walls. 
Cracked-metal  sound : — Usually  a  cavity  communicating  with  a  bron- 
chus. 

Degree,  or  Intensity. 

Any  of  the  sounds  mentioned  may  be  diminished  or  increased  in  intensity  as 

the  conditions  which  produce  them  arc  modified. 

If  it  be  desirable  to  obtain  a  more  distinct  idea  of  the 
character  or  of  any  alteration  of  sound  than  can  be  done  by 


'208  MKDICAL    DIAGNOSIS. 

tho  ordinary  niotliod  of  practising  percussion,  it  may  be  ac- 
complisliiMl  hy  resorting  to  auscultatory  percussion — a  method 
iiitroducoil  by  Drs.  Cammann  and  Clark,  and  which  consists 
ill  listening,  witli  a  stethoscope  applied  to  the  parietes,  to 
the  sounds  elicited  by  percussion.  It  is  a  very  serviceable 
means  ol'  determining  with  accuracy  the  boundaries  of  va- 
rious organs,  as  of  those  of  the  lungs  and  heart,  or  of  the 
liver  or  spleen.  I  have  found  it  yield  particularly  exact  re- 
sults, when  carried  out  with  the  double  stethoscope  further 
on  described :  by  the  aid  of  which  differences  in  the  pitch 
and  intensity  of  sound  are  very  readily  detected. 

Percussion  of  the  HeaWiy  Chest. 

The  sound  elicited  by  striking  a  healthy  chest  differs  in 
accordance  with  the  part  percussed.  The  anterior  portion  of 
the  chest  renders  a  clearer  sound  than  the  posterior,  on  ac- 
count of  the  slighter  thickness  of  the  thoracic  walls.  But 
the  pulmonary  resonance  is  not,  even  anteriorly,  alike  at  all 
parts.  The  portion  of  lung  above  the  clavicle  yields  a  sound 
which  becomes  somewhat  tympanitic  as  the  trachea  is  ap- 
proached. Percussion  is  difhcult  in  this  region,  as  it  is 
almost  impossible  to  apply  the  finger  or  pleximeter  properly 
to  the  surface;  hence  arise  errors  in  diagnosis  if  too  much 
value  be  attached  to  trifling  differences  between  the  two 
sides.  Over  the  clavicle  the  sound  sent  forth  is  clear  and 
pulmonary  at  the  centre  of  the  bone;  at  its  scapular  ex- 
tremity it  is  duller;  toward  the  sternum  it  becomes  of 
higher  pitch,  and  mixed  with  the  sound  of  the  bone.  In 
the  region  bounded  above  by  the  clavicle,  and  below  by  the 
upper  margin  of  the  fourth  rib,  the  resonance  is  very 
marked.  In  fact  the  sound  of  this  region  may  be  taken  as 
a  type  of  the  pulmonary  sound:  it  is  very  clear  and  distinct, 
and  but  little  resistance  is  offered  to  the  percussing  finger. 
Yet  a  slight  disparity  generally  exists  between  the  two  sides. 
On  the  right  side  the  sound  is  somewhat  less  clear,  shorter, 
and  of  a  higher  pitch  than  on  the  left.  From  the  fourth  rib 
downward,  on  the  right  side,  the  resonance  of  the  lung,  on 
strong  percussion,  is  found  to  be  slightly  deadened ;    near 


DISEASES    OF    THE    LUNGS,  209 

the  sixtli  rib  the  perfectly  dull  sound  indicates  that  the  liver 
has  been  reached.  On  the  right  side,  during  full  inspiration, 
the  liver  is  pushed  downward  for  the  space  of  an  inch  or 
more;  and  the  dull  sound  on  percussion  begins,  therefore, 
lower  down,  and  on  a  line  corresponding  to  the  displacement 
of  the  organ. 

On  the  left  side  the  heart  deadens  the  sound  from  the  fourth 
tothesixth  rib, and, in  atransverse  direction, from  the  sternum 
to  the  nipple.  This  dull  sound  is  lessened  in  extent  during 
inspiration,  and  in  cases  of  emphysema;  indeed,  under  any 
circumstances  in  which  the  lung  more  completely  covers  the 
heart.  Lower  down,  owing  to  the  liver  reaching  over  to  the 
left  side,  and  to  the  presence  of  the  spleen  and  a  portion  of 
the  stomach,  the  sound  rendered  on  percussion  consists  of  a 
mixture  of  the  dull  sound  of  the  solid  viscera  and  of  the  clear 
sound  of  the  lung  with  the  tympanitic  sound  of  the  stomach. 
The  latter  character  of  sound  predominates  when  the  stomach 
is  empty.  Over  the  upper  part  of  the  sternum,  to  the  third 
rib,  the  percussion  sound  is  slightly  tympanitic;  at  the  lower 
part,  the  heart  and  liver  cause  this  tympanitic  or  tubular 
character  of  sound  to  give  way  to  a  dull  sound. 

At  the  posterior  portion  of  the  chest  die  sound  varies  ma- 
terially according  to  the  part  percussed.  Directly  on  the 
scapulae  the  sound  is  duller  than  between  the  bones,  or  than 
below  their  inferior  angles.  Beneath  the  scapulae  a  clear 
sound  is  emitted  as  far  as  the  lower  border  of  the  tenth  rib; 
here,  on  the  right  side,  the  dulness  of  the  liver  begins.  Strong 
percussion,  however,  causes  the  dulness  to  become  manifest 
higher  up.  On  the  left  side,  below  the  angle  of  the  scapula, 
the  percussion  sound  may  be  tympanitic  if  the  intestine  be 
distended;  or,  on  the  other  hand,  it  maybe  rendered  slightly 
dull  by  the  spleen.  In  and  under  the  axilla  the  sound  is  very 
clear.  But  on  the  right  side,  at  the  lower  border  of  the  sixth 
rib,  dulness  becomes  perceptible  ;  at  a  corresponding  situation 
on  the  left  side,  the  sound  is  clear  or  tympanitic  from  disten- 
tion of  the  stomach;  and  at  the  ninth  or  tenth  rib,  distinct 
dulness  and  a  sense  of  resistance  to  the  finger  disclose  the 
presence  of  the  spleen. 

14 


•JIO 


MEDICAL    DIAGNOSIS. 


AUSCULTATION. 


Ausc-ult:ifu>n,  or  listening  to  sounds,  informs  us  of  the  play 
ot'orsrans,  anil  furnishes  us  with  the  most  trustworthy  means  of 
8tuilying  their  action.  It  is  of  a  very  signal  service  in  diseases 
of  tlie  chest.  Indeed,  any  one  who  reflects  upon  the  cer- 
tainty with  which  cases  of  thoracic  disease,  which  would  have 
set  at  defiance  the  skill  of  a  Sydenham  or  a  Cullen,  are  now 
capahle  of  being  detected,  even  by  comparative  tyros,  will 
gladly  acknowledge  the  heavy  debt  of  gratitude  we  owe  to 
the  genius  of  Laennec. 

The  method  of  listening  he  practised  was  the  mediate,  or  by 
the  stethoscope.  Another  method  has  since  his  time  grown 
up — the  immediate,  or  the  direct  application  of  the  ear  to  the 
chest.  Much  controversy  has  arisen  as  to  which  is  to  be  pre- 
ferred ;  a  controversy  which  has  only  tended  more  and  more 
to  prove  that  both  are  good  and  that  both  are  to  be  learned, 
since  a  person  unaccustomed  to  the  use  of  a  stethoscope  hears 
hut  indifl'erently  with  it,  even  when  the  habit  of  immediate 
auscultation  has  made  him  familiar  with  the  sounds  in  the 
chest.  For  ordinary  purposes,  the  direct  application  of  the 
ear  is  best ;  but  where  it  is  desirable  to  analyze  circumscribed 
sounds,  as  in  diseases  of  the  heart,  the  stethoscope  is  prefer- 
able. 

Stethoscopes  are  made  of  various  materials  and  of  different 
shapes.  One  of  moderate  length,  with  an  ear- 
piece which  fits  the  pavilion  of  the  ear,  and  with 
the  extremity  not  too  much  expanded,  is  the 
best.  The  material  it  is  made  of  is  of  far  less 
importance.  Of  late  years  double  stethoscopes 
have  been  introduced.  The  ins^enious  instru- 
ment  invented  by  the.  late  Dr.  Cammann,  of 
New  York,  consists  of  two  tubes,  the  extremi- 

Aties  of  which  are  placed  into  the  ears.  It  pos- 
sesses the  advantage  of  rendering  sounds  louder : 
its  great  drawback  is,  that  it  indiscriminately 
intensifies  all  sounds,  whether  in  the  chest  or 
not,  and  its  use  is,  therefore,  at  first  very  con- 
tusing.    With  practice,  however,  this  objection 


Fig.  13. 


The  ordinary 
stethoscope. 


DISEASES    OF    THE    LUNGS, 


211 


lessens,  and  the  double  sj:ethoscope  is  in  many  cases  ex- 
tremely available.  A  similar,  but  not  identical  kind  of 
stethoscope  is  the  differential  stethoscope  of  Dr.  Alison,  by 
which  each  ear  receives  simultaneously  the  sound  from  a 


different  reo^ion 


Fig.  14. 


Fig.  Ij. 


The  double  stethoscope. 


Alji<<)n''s    differential    stetho- 
scope. 


In  auscultating,  the  following  rules  are  to  be  borne  in 
mind : 

Ist.  Place  yourself  and  your  patient  in  a  position  which  is 
the  least  constraining,  and  permits  of  the  most  accurate  ap- 
plication of  the  ear  or  stethoscope  to  the  surface.  Above  all, 
while  auscultating,  avoid  stooping,  or  having  the  head  too  low. 


2\'2  MKDIOAL    DIAGNOSIS. 

2(1.  Lot  the  chest  be  bare,  or,  what  ia  better,  covered  only 
with  II  towel  or  a  thin  shirt. 

3il.  Ifu  stethoscope  be  employed,  apply  it  evenly  and  closely 
to  the  surface,  but  abstain  from  pressing  with  it.  This  may 
be  obviated  by  steadying  the  instrument,  immediately  above 
ita  expanded  extremity,  between  the  thumb  and  the  index 
linsjer. 

4th.  Examine,  repeatedly  and  with  care,  the  different  por- 
tions of  the  chest,  and  compare  them  with  each  other  while 
the  patient  is  breathing  quietly.  Making  him  cough  or  draw 
a  full  breath  is  at  times  of  service ;  especially  the  former,  when 
lie  does  not  know  how  to  breathe. 

Sounds  of  Bespiration  in  Health  and  in  Disease. 

The  ear  applied  over  the  trachea  of  a  healthy  person,  and 
subsequently  over  the  lungs,  discriminates  two  dissimilar 
sounds,  which  may  be  severally  taken  as  starting-points. 

The  first  is  plainly  blowing,  both  in  inspiration  and  expira- 
tion. It  is  heard  over  the  larynx  and  trachea;  and  in  a 
slightly  modified  form,  as  a  less  intense  and  hollow  sound,  at 
the  upper  part  of  the  sternum;  and  sometimes,  owing  to  the 
closeness  of  large  bronchial  tubes  to  the  surface,  it  is  per- 
ceived between  the  scapulae,  on  a  level  with  their  ridges.  It 
ifl  occasioned  by  air  passing  through  the  tubes,  and  is  known 
as  the  tubular  or  the  bronchial  sound. 

The  sound  over  the  lung  tissue  is  very  different:  it  is  much 
softer,  more  gradually  formed,  of  lower  pitch,  mainly  inspira- 
tory, and  almost  immediately  followed  by  a  shorter  and  far 
less  distinct  expiration.  This  is  the  vesicular  murmur— pro- 
duced in  the  finest  bronchial  tubes  and  air-cells  by  their  ex- 
pansion and  contraction.  The  expansion  gives  rise  to  the 
distinct  breezy  inspiration ;  the  noiseless  contraction  of  the 
elastic  walls  of  the  vesicles  and  the  passage  of  air  back  into 
the  smaller  bronchial  tubes  cause  the  indistinct,  sometimes 
almost  inaudible  expiration.  But  the  vesicular  murmur  is 
not  exactly  alike  at  diflerent  parts  of  the  lungs.  It  is,  as  a 
rule,  better  marked  over  the  upper  lobes  than  over  the  lower, 
and  more  clearly  defined  anteriorly  than  posteriorly.     Nor  is 


DISEASES    OF    THE    LUNGS.  213 

the  sound  of  the  two  kings  precisely  the  same;  a  disparity 
may  generally  be  noticed  at  the  apices.  Most  authors  de- 
scribe the  vesicular  murmur  as  more  intense  on  the  richt 
side.  Investigations  instituted  to  determine  this  point  lead 
me  to  agree  with  Dr.  Flint,*  that  the  reverse  is  the  case. 
More  expiration,  a  higher  pitch,  therefore  more  of  the  bron- 
chial element,  is  presented  by  the  upper  portion  of  the  right 
lung.  But  a  stronger,  more  vesicular  inspiration  belongs  to 
the  left  lung. 

The  murmur  of  the  air-cells,  then,  is  the  sound  which  the 
ear  encounters  when  it  is  placed  over  the  greater  part  of  the 
chest.  Bronchial  respiration  is  constantly  engendered  in 
the  tubes  of  the  lung:  but  either  because  it  is  overpowered 
by  the  sounds  of  the  myriads  of  expanding  air-vesicles;  or 
because  the  pulmonary  tissue  is  a  bad  conductor  for  a  deep- 
seated  sound ;  or  perhaps  because  the  sound  requires  con- 
solidated tissue  for  its  perfect  production, — bronchial  breath- 
ing is  not  heard  over  the  chest  (excepting  at  the  very  limited 
space  indicated),  unless,  for  the  time  being,  the  action  of  the 
air-vesicles  has  been  suppressed. 

Disease,  however,  gives  rise  not  only  to  changes  as  abso- 
lute as  suppression  of  the  vesicular  murmur  and  its  substi- 
tution by  a  bronchial  respiration,  but  also  to  certain  modi- 
fications of  the  murmur,  which  serve  as  valuable  guides  in 
the  diagnosis  of  morbid  conditions  of  the  lung.  Thus  the 
vesicular  murmur  may  be  abnormal  in  its  intensity,  in  its 
rhythm,  or  it  may  have  lost  some  of  the  elements  of  its  dis- 
tinctive character,  such  as  its  softness. 

Changes  in  the  Vesicular  Murmur. — The  changes  of 
the  murmur  which  are  of  importance,  may  be  summed  up 

as  follows : 

{Increased,  or  puerile  breathing  ; 
Diminished,  or  feeble  respiration; 
Absent  respiration. 
{Divided  and  jerking  respiration  ; 
Alteration  of  length  of  expiration  relatively 
to  inspiration. 

Alteration  in  Character.  |  Harsh  respiration. 

*  Physical  Exploration  of  Diseases  affecting  the  Respiratory  Organs. 


214  MEDICAL    DIAGNOSIS. 

Iiifcnsifi/.— An  increase  of  the  vesicular  murmur  is  called 
wppltmcntnn/  respiration,  or,  from  its  resemblance  to  the 
hroiithing  of  c]iilclren,;>'^^cr/?e  respiration.  It  depends  upon 
jin  increased  action  of  the  air-vesicles;  more  air,  or  air  vfith 
greiitor  force,  entering  them.  The  sound  is  simply  a  loud, 
distinctly  vesicular  respiration;  both  inspiration  and  expira- 
tion being  augmented  in  duration  and  loudness,  but  retain- 
ing as  near  as  may  be  their  relative  length. 

ruorile  breathing  is  not  in  itself  a  sign  of  any  disease.  It 
indicates  rather  greater  activity  and  energy  of  the  part  over 
which  it  is  heard,  which  activity  makes  up  for  the  deficient 
action  of  other  parts.  In  this  manner  effusions  compressing 
one  lung,  one-sided  deposits,  or  obstruction  of  the  bronchial 
tubes  by  secretions,  necessitate  a  supplementary  respiration 
in  the  healthy  portion  of  the  same  lung,  or  in  the  other. 

A  diminution  of  the  vesicular  murmur,  or  feeble  respira- 
tion, consists  in  a  lessening  of  the  whole  sound  without 
change  in  its  character.  But  the  relation  of  inspiration  to 
expiration  does  not  remain  in  the  weakened  murmur  quite 
the  same  as  in  health.  In  the  large  majority  of  instances 
the  inspiration  suffers  most,  and  the  expiration  does  not 
diminish  in  proportion  :  a  circumstance  readily  explained 
by  reference  to  the  states  which  occasion  the  diminished 
vesicular  murmur.  These  are  varied;  but  their  causes  may 
be  reduced  to  four. 

1st.  Any  cause  which  obstructs  the  passage  of  air  and  pre- 
vents it  from  fully  reaching  the  pulmonary  tissue.  Foreign 
bodies  lodged  in  the  trachea  or  bronchi ;  affections  of  the 
larynx;  considerable  thickening  of  the  mucous  membrane  of 
a  bronchial  tube;  its  compression,  or  the  accumulation  in  it 
of  secretions,  or  its  contraction  by  a  spasm, — all  diminish 
the  quantity  and  force  of  the  air  which  reaches  the  vesicles, 
hence  reduce  the  strength  of  the  murmur. 

2d.  Deficient  respiratory  action.  This  may  arise  either 
from  general  debility ;  or  from  impairment  of  the  nervous 
force,  as  hi  paralysis ;  or  from  local  pain,  as  in  pleurisy  or 
pleurodynia. 

3d.  Causes  which  interfere  mechanically  with  the  free  ex- 
pansion of  the  air-cells.     Pleuritic  effusions,  by  compressing 


DISEASES    OF    THE    LUNGS. 


215 


tlie  lung  tissue,  will  of  course  diminish  the  vesicular  murmur; 
so,  too,  will  morbid  growths,  or  malformation  of  the  chest. 
Comparatively  slight  deposits  in  the  pulmonary  tissue  of 
tubercle  or  of  lymph  obliterate  some,  and  prevent  other  air- 
cells  from  unfolding,  and  by  having  impaired  their  elasticity, 
diminish  their  sound.  The  same  loss  of  elasticity  happens 
in  emphysema:  the  overdistended  cells  cannot  expand  much 
more,  they  are  rigid  and  more  or  less  fixed ;  the  vesicular 
murmur  is  therefore  feeble. 

4th.  The  respiratory  murmur  may  be  imperfectly  trans- 
mitted to  the  ear,  owing  to  intervening  fluids  or  solids.  To 
this  category  belongs  the  enfeebled  murmur  so  constantly 
met  with  in  fat  persons. 

As  so  many  conditions  may  occasion  a  feeble  respiratory 
murmur,  it  is  evident  that  it  is  only  b}^  association  with  other 
phenomena  that  it  acquires 
much  importance.  Taking  the 
diseases  in  which  the  sound 
is  most  frequently  found,  it 
may  be  stated  that  if  a  feeble 
respiratory  murmur  be  com- 
bined with  dulness  on  percus- 


FiG.  16. 


Diagram  illustrative  of  the  main  forms  of 
fooble  respiration,  ft,  from  distention  of  the 
cells  in  vesieiilar  emphysema;  b,  from  deposits 
in  the  pnlnionary  texture;  c,  from  a  sulid  liody 
((/)  lodged  in  a  bronchial  tube,  wiiich  has  led  to 
jiartial,  or,  in  some  spots,  to  comidete  collapse 
of  the  air-vesicles. 


sion,  it  signifies  a  tubercular 
deposit,  or  a  pleuritic  eftusion: 
the  former,  if  at  the  upper,  the 
latter,  if  at  the  lower  part  of 
the  lung.  If  it  be  connected 
with  increased  clearness  on 
percussion,  distention  of  the 
air-cells  is  its  cause.  A  vesic- 
ular murmur,  feeble  through- 
out both  lungs,  with  the  percussion  sound  unaltered,  arises 
from  general  debility,  or  from  obstruction  of  the  upper  air- 
passages.  Where  the  feebleness  of  the  murmur  is  found  to 
change  from  place  to  place,  it  is  dependent  upon  a  loose 
foreign  body  which  is  shifting  its  position  in  the  bronchial 
tubes.  Joined  to  unwillingness  to  expand  the  lung  (on 
account  of  the  pain  thereby  brought  on),  feeble  respiration 
denotes  pleurodynia  or  commencing  pleurisy. 


0]g  MEDICAL    DIAGNOSIS. 

All  ahse}}oe  of  (he  vesicular  murmur  is  produced  by  the  same 
causes,  carried  a  step  further,  which  occasiou  feeble  respira- 
tion. Complete  obstruction  of  the  tubes  by  foreign  bodies, 
extensive  deposits  in  the  pulmonary  tissue,  or  its  compres- 
sion by  large  pleuritic  effusions,  arrest  the  vesicular  murmur, 
lint,  i)ractically  speaking,  there  is  only  one  complaint  in 
wliich  wo  arc  apt  to  find  it  entirely  wanting,  and  that  is, 
wlu'u  associated  with  flatness  on  percussion  it  attests  the 
presence  of  a  large  collection  of  fluid  in  the  pleura.  Exten- 
sive deposits  in  the  lung  tissue,  tubercular  or  lymphous,  also 
suppress  the  sound  of  the  air-cells ;  but  they  do  not  suppress 
all  sound.  The  noise  of  the  tubes,  the  bronchial  respiration, 
then  takes  the  place  of  the  vesicular  murmur,  and  denotes 
the  perfect  consolidation  of  the  pulmonary  tissue. 

Khijthm. — The  inspiration  and  the  expiration  may  be  al- 
tered as  regards  their  rhythm.  The  inspiration  may  be 
broken  up  into  little  puffs — jerking  respiration  —  or  both 
inspiration  and  expiration  ma}'  be  lengthened  or  shortened. 
But  neither  lengthening  nor  shortening  of  the  inspiratory 
nmrmur  has  a  distinct  clinical  value  :  and  jerking  inspiration^ 
met  with  as  it  is  in  spasmodic  affections,  in  hysteria,  in  pleu- 
rodynia, and  in  tubercular  infiltrations,  is  present  under  too 
many  different  circumstances  to  have  by  itself  much  diag- 
nostic significance.  But  if  limited  to  the  apex,  it  may  serve 
to  excite,  or  aid  in  corroborating,  a  suspicion  of  tubercular 
deposit.  One  modification  of  the  rhythm  is,  however,  of 
decided  importance, — a  marked  increase  in  the  duration  of 
the  expiratory  murmur  while  the  patient  is  breathing  quietly. 

Prolonged  expiration  denotes  that  the  air  has  difficulty  in 
getting  out  of  the  lung.  It  is  detained  either  in  consequence 
of  loss  of  elasticity  of  the  cells,  or  of  an  obstruction  in  the 
bronchi.  The  former  state  may  be  occasioned  by  overdis- 
tention  of  the  air-vesicles,  as  in  emphysema,  or  by  deposits 
which  impair  their  contractile  power.  In  the  first  case,  the 
prolonged  expiration  is  associated  with  augmented  clearness 
on  percussion;  in  the  second,  with  impaired  clearness. 
A\  here  the  prolonged  expiration  is  met  with  at  the  apex  of 
the  lung,  in  connection  with  dulness,  it  is  for  the  most  part 
caused  by  a  tubercular  deposit. 


DISEASES    OF    THE    LUNGS.  217 

But  a  prolonged  expiration  from  tubercular  or  any  other 
kind  of  deposit,  is  not  simplj^  the  pure  prolonged  expiration 
of  deficient  elasticity  of  the  air-cells.  It  is  something  more. 
The  solid  material  conducts  a  portion  of  the  sound  of  the 
bronchial  tubes  to  the  ear;  and  bronchial  breathing  is  nearly 
always  best  and  earliest  perceived  in  expiration.  Thus  a  pro- 
longed expiration,  when  joined  to  dulness  on  percussion  and 
to  an  inspiration  still  vesicular,  is  a  sound  partly  vesicular, 
partly  bronchial,  and  may  be  interpreted  as  consolidation  of 
the  lung  tissue;  consolidation  not  sufficient  to  have  obliter- 
ated all  the  air-cells,  but  sufficient  to  have  obliterated  some, 
and  to  have  impaired  the  contractile  power  of  others. 

The  obstacle  to  the  exit  of  the  air  may  reside  wholly  in 
the  bronchial  tubes.  Such  is  the  source  of  the  prolonged 
expiration  when  the  mucous  membrane  of  the  bronchi  is 
swollen.  Kot  only  does  this  condition  cause  the  air  to  be 
retained  longer  in  the  air-cells,  but  the  resistance  to  the  exit 
of  the  columns  of  air  brings  out  more  of  the  bronchial 
sound.  On  the  whole,  then,  an  accurate  study  of  the  ex- 
piration is  of  decided  value;  and  it  is  of  great  importance  to 
impress  on  young  auscultators  the  advantage  of  becoming 
accustomed  to  inquire  into  the  expiration  separately  from 
the  inspiration. 

Character. — The  distinctive  character  of  the  vesicular  mur- 
mur is  its  softness.  From  the  moment  it  loses  this,  it  com- 
mences to  pass  into  the  bronchial  sound.  That  form  of  the 
respiration  which  is  wanting  in  softness  is  termed  harsh  or 
rude  respiration,  or,  very  slightly  to  modify  a  term  introduced 
by  Dr.  Flint,  vesiculo-bronchial.  Harsh  respiration  is,  in  truth, 
a  union  of  the  vesicular  and  the  bronchial  sounds:  it  is  a 
vesicular  sound  mixed  with  some  of  the  qualities  of  a  bron- 
chial sound — a  rough  inspiration  devoid  of  all  the  softness 
of  the  normal  respiratory  murmur,  with  a  prolonged,  some- 
what blowing  expiration.  Any  affection  which,  without 
destroying  the  murmur  of  the  vesicles,  causes  the  sound  in 
the  bronchial  tubes  to  be  produced  with  greater  intensity,  or 
to  be  better  transmitted,  will  occasion  harsh  breathing. 
Thus  it  exists  when  the  bronchial  membrane  is  swollen,  as 
in  bronchitis,  and  still  more  frequently  in  diseases  which  are 


218  MEDICAL    DIAGNOSIS. 

attoiKlod  with  conipreaaion  of  the  lung  tissue,  or  with  par- 
tial con.lonsation,  such  as  some  stages  of  phthisis  or  of 
pnounioiiia.  Being  a  transition  murmur  from  vesicular  to 
hi-oiK-liial,  harsh  respiration  shares  the  properties  of  the  latter 
in  having  its  expiration  more  developed  than  its  inspiration. 
It  is  true,  the  inspiration  alone  maybe  harsh,  and  the  expira- 
tion not  be  materially  changed ;  but  this  is  uncommon. 
Harsh  respiration  may  be  confounded  with  puerile  respira- 
tion, with  sonorous  rales,  and  with  bronchial  breathing. 
From  the  first  it  varies  by  its  higher  pitch,  its  roughness,  its 
more  distinct  and  blowing  expiration;  from  sonorous  rales, 
l)y  tlie  absence  of  all  vibrating  or  musical  character.  From 
bronchial  respiration  harsh  respiration  differs  merely  by  de- 
grees: it  is  mixed  with  more  of  the  vesicular  sound,  is  less 
blowing  in  inspiration,  and,  when  produced  by  condensation, 
is  not  associated,  owing  to  the  smaller  amount  of  deposit 
which  gives  rise  to  it,  with  so  much  dulness  on  percussion. 

Bronchial  Respiration. — A  purely  bronchial  respiration 
ma}'  exhibit  the  same  modifications  as  the  vesicular  murmur 
as  to  rhythm  and  intensity.  But  neither  its  rhythm  nor  its 
intensitv  is  of  much  sio-nificance  :  its  character  is.  To  hear 
a  well-detined  bronchial  respiration  is,  in  the  large  majority 
of  cases,  to  meet  with  complete  consolidation  of  the  pulmonary 
tissue.  It  is  thus  that  in  extensive  tubercular  infiltrations 
and  in  hepatization  of  the  lung  we  find  the  bronchial  or 
blowing  breathing  so  marked;  particularly  so  in  the  latter 
morbid  state,  for  the  most  distinct  blowing  or  tubular  res- 
piration is  heard  in  pneumonia. 

The  bronchial  breathing  encountered  in  disease  resembles 
more  that  heard  in  health  over  the  larynx  or  trachea,  than 
that  heard  over  the  larger  bronchial  tubes.  It  entirely  re- 
places the  vesicular  sound,  which  has  for  the  time  bein^ 
ceased  to  exist.  It  differs  from  the  normal  vesicular  murmur 
by  its  higher  pitch  ;  its  occurrence  equally  in  inspiration  and 
expiration;  its  blowing  character,  especially  in  expiration; 
and  by  the  pause  between  inspiration  and  expiration.  Harsh 
respiration  resembles  it  most;  but  this  or  vesiculo-bronchial 
respiration  is,  as  already  stated,  a  transition  from  vesicular 
to  bronchial  breathins 


'g- 


DISEASES    OF    THE    LUNGS.  219 

Whether  bronchial  respiration  be  owing,  as  Laennec 
taught,  to  a  better  transmission  of  the  sound  of  the  tubes 
through  the  solid  lung;  or  whether  w6  hold,  with  Skoda, 
that  it  is  produced  by  consonance, — is  not  of  much  conse- 
quence for  diagnosis.  The  important  practical  fact  con- 
nected with  this  form  of  respiration  is,  that  it  happens  when 
the  pulmojiary  tissue  is  condensed,  which,  in  the  large  ma- 
jority of  cases,  takes  place  from  deposits ;  in  a  small  propor- 
tion only,  from  compressions  by  growths  or  eflusions. 

As  a  variety  of  bronchial  respiration,  at  least  so  far  as  the 
quality  of  the  sound  determines  the  point,  is  to  be  regarded 
that  very  significant  sign,  cavernous  respiration.  This  is  es- 
sentially a  blowing  sound;  yet  it  is  not  always  distinct  during 
both  inspiration  and  expiration,  being  often  only  perceptible 
in  the  one,  and  mixed  in  tlie  other  with  a  gurgling  sound. 
The  question  whether  it  can  always  be  distinguished  from 
bronchial  breathing,  has  given  rise  to  much  dispute.  That 
cavities  may  exist  without  cavernous  respiration  being  per- 
ceived, and,  on  the  other  hand,  that,  owing  to  peculiar  phys- 
ical conditions,  cavernous  respiration  occasionally  may  have 
been  heard  where  no  cavities  were  present,  cannot  be  denied. 
But  that  a  sound  is  met  with  which  is  less  diffused,  much 
more  hollow,  and,  above  all,  of  a  much  lower  pitch  than  or- 
dinary bronchial  respiration  ;  that  connected  with  it  other 
signs  of  a  cavity  are  often  found ;  and  that,  under  such  cir- 
cumstances, a  post-mortem  examination  proves  an  excava- 
tion to  have  existed  at  the  spot  where  during  life  the  sound 
was  detected,  —  are  facts  which  equally  cannot  be  denied. 
The  peculiar  sound  occurs,  and  may  be  discerned  by  the 
ear.  And  no  theory,  however  cautious  it  may  make  us  in 
our  conclusions,  can  put  aside  the  evidence  of  the  senses. 

Cavernous  respiration  is,  then,  a  blovvijig  sound  of  a  low 
pitch,  circumscribed,  alternating  with  gurgling,  and  deriving 
its  chief  character  from  the  cavity  in  which  it  is  formed. 
Hollow  spaces  of  any  kind — from  abscesses,  from  gangrene, 
from  bronchial  dilatation,  or  from  softening  tubercle — give 
rise  to  it.  How  it  is  to  be  distinguished  from  bronchial  res- 
piration has  already  been  indicated.  A  student  learns  this 
sooner   than    he   does   to   discriminate    between    cavernous 


220  MEDICAL   DIAGNOSIS. 

l.ivatliini;  and  the  vesicular  murmur;  the  best  proof  that 
tlu'  oar  rocoi;ni7.es  a  difference  between  bronchial  and  cav- 
ernous respiration,  since  the  L^ter,  as  a  sound  of  lower  pitch, 
is  more  like  the  vesicular  murmur.  It  is  only  necessary  to 
recall,  with  reference  to  the  distinction  from  the  sound  of  the 
air-cells,  that  this  murmur  is  entirely  devoid  of  all  blowing 

quality. 

Amphoric  respiration  is  a  blowing  respiration  engendered 
in  a  large  cavity  with  iirm  walls.  Its  peculiar  character  is 
owing  to  an  echo  from  the  walls  of  the  cavity.  It  may  be 
hununing  and  of  low  pitch,  or  decidedly  ringing  and  metallic. 
An  imitation  of  the  sound,  but  only  an  imperfect  one,  is 
effected  by  blowing  into  an  empty  jar. 

Amphoric  or  metallic  respiration  is  always  indicative  of  a 
large  cavity.  The  sound  is  rarely  met  with  in  phthisis;  much 
oftener  is  it  heard  over  the  cavity  which  is  formed  between 
the  layers  of  the  pleura,  by  the  entrance  of  air,  and  in  which 
fluid  collects.  Yet  the  presence  of  liquid  is  not  necessary  for 
the  production  of  amphoric  breathing. 

New,  or  Adventitious  Sounds.— These  consist  of  sounds 
which  have  no  analogue  in  the  hedlthy  state,  and  which  can- 
not, therefore,  be  considered  as  modihcations  of  the  normal 
respiration.  Of  this  kind  are  the  rales;  the  sound  known  as 
crackling;  the  friction  sound. 

Nearly  all  rales,  or  rhonchi,  are  sounds  which  are  gener- 
ated in  the  air-tubes  by  the  passage  of  air  through  them 
when  contracted  or  when  containing  fluid.  In  the  first  case 
are  occasioned  dry,  in  the  second,  moist  rales.  Rales  may 
occur  in  inspiration  or  in  expiration,  or  during  both  acts. 
They  may  obscure  or  entirely  take  the  place  of  the  natural 
murmurs.  They  may  have  their  seat  in  the  upper  air-tubes, 
or  in  any  division  of  the  bronchi.  When  in  the  larynx  or 
trachea,  they  are  called  tracheal  rales ;  of  these  the  death- 
rattle  is  an  example.  When  in  the  bronchial  tubes,  they  are 
designated  bronchial  rales:  and  as  this  is  their  most  frequent 
situation,  the  term  rale  means  a  bronchial  rale,  unless  the 
location  be  specially  indicated. 

Dry  rales  are,  for  the  most  part,  produced  by  the  vibration 
of  thick  fluids  which  the  air  cannot  break  up,  and  wdiich  tern- 


DISEASES    OF   THE    LUNGS. 


221 


porarily  narrow  the  calibre  of  the  tube.  When  this  narrowing 
exists  in  the  smaller  bronchial  tube,  the  sound  which  results  is 
high  pitched — sibilant ;  when  in  the  larger,  unless  the  calibre 
be  very  much  altered,  it  is  low  pitched,  more  musical — sono- 
rous. A  similar  difference,  caused  by  the  varying  size  of  the 
tubes,  is  observed  with  reference  to  the  moist  or  bubbling 
sounds.  When  the  fluid  is  thin,  whether  it  be  mucus,  or 
blood,  or  serum,  and  breaks  up  into  large  bubbles,  large  bub- 
bling sounds  are  occasioned;  when  it  separates  into  small 
bubbles,  small  bubbling  sounds  are  the  consequence.  And 
the  latter,  for  obvious  reasons,  generally  take  place  in  the 
smaller  bronchial  tubes. 

Fig.  17. 


Large 
bubbling. 


Small 
bubbling. 


Crepitation. 


Sonorous. 


Sibilant. 


Diagram  illustratiye  of  rales.  The  narrowing  in  one  division  of  the  tube  gives  rise  to 
dry,  the  fluid  in  the  other  to  moist  rales.  The  rales  at  tho  termination  of  the  tube  and 
in  the  air-vesicles  are  the  crepitant  or  vesicular  rales. 


Neither  dry  nor  moist  rales  are  persistent,  but  vary  in 
intensity,  or  shift  their  position,  as  the  air  drives  the  liquid 
which  gives  rise  to  them  before  it.  Dry  rales  are  particularly 
prone  to  be  dislodged  by  coughing.     When  they  are  uuin- 


222  MEDICAL   DIAGNOSIS. 

thionced  by  the  act  of  breathing  or  of  coughing,  they  do  not 
dopond  upon  the  presence  of  secretions,  but  upon  a  narrowing 
of  the  air-tubos  from  the  pressure  of  surrounding  tumors  or 
from  u  foUl  of  thickened  mucous  membrane,  or  by  a  spasm. 

It  has  just  been  stated  that  rales  are,  for  the  most  part,  pro- 
duced in  the  bronchi  by  the  passage  of  air  through  fluids  there 
contained.  This  is  their  most  frequent  seat;  but  they  are 
not  limited  to  the  tubes.  Similar  conditions  may  give  rise  to 
rales  in  other  places.  We  find  liquids  in  cavities  breaking 
np  into  large,  sharply-defined,  bubbling  rales,  the  so-termed 
cavernous  rale — gurgling ;  and  again,  the  presence  of  fluid  in 
the  air-cells  occasions  a  minute  rale — the  crepitant. 

This  vesicular  rale,  or  crepitation,  is  a  very  fine  sound,  or 
rather  a  series  of  very  fine  sounds,  occurring  in  puffs  and 
liniited  to  inspiration.  It  resembles  the  noise  occasioned  by 
throwing  salt  on  the  fire.  Its  name  indicates  its  seat.  It  is 
caused  by  the  agitation  of  fluid  in  the  air-cells,  or  in  the 
finest  extremity  of  the  bronchial  tubes;  or,  to  adopt  a  view 
now  held  by  many,  by  the  forcing  open  during  inspiration  of 
the  air-cells  agglutinated  by  the  exuding  lymph.  The  first 
stage  of  acute  pneumonia  is  the  state  in  which  this  rale  is 
mostly  engendered. 

The  rales,  including  crackling,  may  be  thus  grouped : 


Bronchial  Kales.  \ 


I 


Dry  or   vibrating   r  Low  pitched  (sonorous). 

sounds.  \  High  pitched  (sibilant). 

Moist   or   bubbling  j  Large  bubbling  (mucous). 

sounds.  1  Small  bubbling  (subcrepitant). 


■tr.„^.,„ .  „  T>  /  Crepitation. 

V  EstcuLAR  Kales.  A         ^ 

^  Crackling? 
Kale  of  Cavities.  \  Hollow  bubbling,  or  gurs-line. 

Crackling  is  a  sign  closely  connected  with  rales,  and  although 
its  mechanism  is  undecided,  is  usually  regarded  as  a  rhon- 
chus.  It  consists  of  a  few  fine  and  readily-discerned  crack- 
hng  sounds  which  happen  generally  in  cases  of  tubercle  of 
the  lungs,  of  which,  therefore,  they  are  considered  a  diag- 
nostic sign. 

The  distinction  between  crackling  and  the  crepitant  rale  is 
one  most  puzzling  to  a  beginner.    Nor  is  there,  in  reality,  any 


DISEASES    OF    THE    LUNGS.  223 

difference,  excepting  in  the  number  of  the  sounds.  Crack- 
ling is  a  few  fine  sounds  limited  to  inspiration,  and  heard 
commonly  at  the  apex  of  the  lung.  Crepitation  is  a  number 
of  fine  sounds  limited  to  inspiration,  but  more  diffused,  and 
heard  generally  at  the  base  of  the  lung.  The  sound  is  simi- 
lar because  the  conditions  giving  rise  to  it  are  similar.  Both, 
so  far  as  we  know,  depend  upon  tenacious  fluid  in  the  ulti- 
mate structure  of  the  lung:  in  the  one  case  it  is  tubercle,  in 
the  other  usually  the  lymph  of  beginning  inflammation.  The 
crackling  which  indicates  softened  tubercle — called  by  some 
authors  moist  crackling,  by  others  clicking— is  a  succession 
of  sounds  like  small  moist  rales,  only  less  liquid  than  these, 
because  breaking  up  tubercle  is  not  very  fluid.  The  fine  or 
dry  crackling  of  the  earlier  stages  of  phthisis  correspoiids, 
then,  to  a  vesicular  rale;  the  coarser,  or  moist  crackling,  to 
the  small  bubbling  sound.  When  the  bubbles  become  larger 
and  larger,  and  cavities  form,  and  the  fluid  matter  in  them  is 
agitated  by  the  ingress  and  egress  of  air,  the  large  bubbling 
ringing  rale  of  cavities,  or  gurgling,  is  occasioned.  Dry 
crackling,  moist  crackling,  gurgling  accord  then  with  the 
crepitant  rale,  small  bubbling,  and  large  bubbling  sounds, 
and  happen  in  the  progressive  stages  of  infiltration  and  soften- 
ing of  deposits,  and  generally  in  those  of  a  tubercular  nature. 
Pleural  friction^  or  the  sound  due  to  the  rubbing  together  of 
roughened  pleural  surfaces,  consists  of  a  number  of  abrupt 
superficial  noises  heard  in  inspiration  and  expiration,  rarely 
in  expiration  alone.  Its  seat  is  not  usually  very  extended, 
for  it  is,  as  a  rule,  only  audible  over  portions  of  the  lower 
part  of  one  side  of  the  chest.  Sometimes  it  is  so  creaking 
and  intense  as  to  be  distinctly  perceptible  to  the  hand  as 
well  as  easily  recognizable  by  the  ear.  But  it  may  be  so 
much  like  crepitation  that  even  long  practice  in  auscultation 
does  not  enable  us  to  determine  at  once  whether  the  fine 
sounds  we  hear  are  the  friction  of  a  roughened  pleura,  or 
the  vesicular  rales  of  an  inflamed  lung.  It  is  easy  to  lay 
down  in  books  the  distinguishing  mark  of  greater  superfi- 
ciality ;  but  at  the  bedside  the  difliculty  remains  the  same, 
and  is  only  removed  by  attention  to  the  physical  signs  and 
symptoms  accompanying  the  doubtful  sounds. 


oo.j  MEDICAL    DIAGNOSIS. 

Nor  is  it,  in  some  cases,  less  perplexing  to  discriminate 
between  tine  friction  sounds  and  fine  moist  rales.  By  the 
sound  alone  it  is  often  impossible;  concomitant  phenomena 
must  be  taken  into  account.  A  friction  sound  is  mostly  con- 
lined  to  a  smaller  space,  and  is  uninfluenced  by  cough;  while 
couijli  changes  the  position  and  the  distinctness  of  rales.  Yet 
even  this  rule  is  not  absolute.  A  fine  friction  sound  may  be 
temporarily  increased  during  the  deep  breathing  which  fol- 
lows the  act  of  coughing;  and  on  the  other  hand,  the  influ- 
ence cough  exerts  on  the  small  moist  rale  is  not  so  great  as 
on  the  larger  bubbling  sound.  As  for  the  more  marked 
character  of  moisture  which  a  rale  is  said  to  possess,  that 
only  aids  us  in  some  cases.  Where  the  secretions  are  viscid, 
it  would  require  a  sense  of  hearing  more  delicate  than  be- 
longs to  the  majority  of  mankind  to  judge,  by  the  applica- 
tion of  this  test,  whether  the  sound  we  perceive  is  formed  in 
the  lunof  or  on  its  covering.  As  the  result  of  investigations 
undertaken  to  ascertain  whether  there  is  any  positive  difler- 
ence,  so  far  as  the  ear  can  detect,  between  some  of  the  finer 
kinds  of  friction  and  tine  moist  rales,  I  have  come  to  the 
conclusion  that  frequently  little  or  none  exists;  and  still  less 
is  there  between  crackling  and  the  crackling  variety  of  fric- 
tion sound,  or  between  this  and  the  vesicular  rale.  The 
features  most  at  variance  are:  that  the  friction  phenomena 
are  not  so  strictly  limited  to  inspiration  as  the  vesicular 
rales,  and  are  not  seldom  coarser  in  expiration  than  in  in- 
spiration ;  that  they  are  less  uniform ;  and  that  their  seat  is 
more  circumscribed.  Their  production  closer  to  the  ear  may 
assist  us  in  the  diagnosis,  but  does  not  always. 

The  reason  why  some  of  the  finer  friction  sounds  resemble 
so  closely  fine  moist  rales  or  crepitation,  is  apparent  when 
we  reflect  that  the  irregularities  in  the  pleura  may  be  very 
slight,  and  be  surrounded  by  fluid  which  keeps  them  moist- 
ened. 

The  creaking  or  grating  varieties  of  friction  are  much 
easier  of  recognition  than  the  finer  forms.  Their  discrimi- 
nation from  rales  is  readily  effected  by  noticing  the  distinctly 
rubbing  and  harsh  character  they  possess. 


DISEASES    OF    THE    LUN(4S.  225 


Auscultation  of  the  Voice. 


Attention  to  the  voice,  as  heard  over  the  chest,  is  bj  some 
auscnltators  regarded  as  very  important  in  examinations  of 
tlic  lungs.  The  one,  two,  three,  which  patients  are  made  to 
pronounce,  may  be  almost  daily  heard  resounding  in  clinical 
amphitlieatres.  Yet  the  information  derived  from  a  study  of 
the  thoracic  voice  is  very  small,  and  next  to  valueless,  unless 
confirmed  by  other  ph3'sical  signs. 

When  the  ear  is  applied  to  the  thorax  of  a  healthy  person 
who  is  speaking,  a  confused  hum  is  perceived,  most  distinct 
in  adults  who  are  possessors  of  a  deep  voice,  but  very  tremu- 
lous in  the  aged.  Now  the  normal  vocal  resonance,  for  by  that 
name  the  ill-deiined  vibrations  are  called,  is  more  marked  on 
the  right  than  on  the  left  side,  and  corresponds  to  the  vesicu- 
lar murmur.  Over  the  bronchial  tubes  a  more  concentrated 
sound  strikes  the  ear.  This,  termed  bronchojjhojii/,  accords 
with  bronchial  respiration,  and  when  detected  over  the  lung, 
denotes,  with  rare  exceptions  hereafter  to  be  referred  to,  the 
same  as  bronchial  respiration,  namely,  increased  density  of 
pulmonary  tissue  caused  by  pressure  or  by  deposit.  Any 
normal  vocal  resonance  which  is  augmented,  passes  by  de- 
grees into  bronchophony,  and  has  a  meaning  similar  to 
bronchophony. 

Of  the  sound  known  as  bronchophony  there  are  several 
varieties:  the  simple  broncho2)hony  ]\\Qi  explained  —  observed 
in  pneumonia,  or  in  tubercular  consolidation  ;  the  hollow, 
cavernous  voice,  or  pectoriloquy;  and  the  bleating  variety,  or 
egoi^hony.  The  latter,  indicative  of  a  thin  layer  of  fluid  be- 
tween compressed  lung  and  the  ear,  is  a  sign  generally  too 
transitory  to  be  of  much  diagnostic  value  ;  and  pectoriloquy, 
if  by  this  be  understood  what  Laennec  meant — complete 
transmission  of  articulated  words, — is  of  no  special  signifi- 
cance, as  it  may  be  met  with  where  no  cavity  exists.  But  if 
the  term  be  applied  to  a  well-detined  chest-voice,  of  hollow 
character,  and  heard  as  such  over  a  comparatively  limited 
space,  pectoriloquy  is  a  distinct  physical  sign,  and  really  de. 
serves  the  name  of  cavernous  voice.  This  is  particularly 
true  of  iddspering   pectoriloquy.       Over    large    cavities   the 

15 


2-2G  MEDICAL   DIAGNOSIS. 

voice  ii'  peculiarly  rinj^ing  and  metallic.  The  conditions 
w  liicli  produce  amphoric  or  metallic  voice  are  the  same  as 
those  which  occasion  any  of  the  amphoric  or  metallic  phe- 
nomena. Be  the  respiration  metallic,  be  the  voice  metallic, 
be  the  rales  metallic,  they  are  all  caused  by  a  cavity  large 
enough  and  with  walls  firm  enough  to  reflect,  to  echo  the 
sound. 

Bronchopliony  and  amphoric  voice  are  instances  of  in- 
crease and  chansre  of  character  of  the  normal  vocal  resonance. 
A  diminished  vocal  resonance  occurs  when  the  lung  is  com- 
pressed by  air  or  fluid,  as  in  pleuritic  effusions,  or  in  pneu- 
mothorax; or  when  it  is  greatly  distended  with  air,  as  in  ex- 
treme cases  of  emphysema.  Clinically  speaking,  the  sign  is 
most  frequently  encountered  in  pleuritic  effusions. 

The  vibrations  of  the  voice  may  be  felt  as  well  as  heard. 
The  vibration  detected  by  placing  the  hand  over  the  thorax 
when  the  patient  speaks,  or,  to  designate  it  by  the  name  it 
bears,  the  vocal  fremitus,  is,  like  the  voice,  increased  by  all 
consolidations  of  pulmonary  tissue,  and  diminished  by  fluid 
or  air  in  the  pleura.  Its  relations  to  the  voice  are,  however, 
not  uniform  ;  and  sometimes  with  increased  density  of  the 
lung  tissue  there  is  no  increased  fremitus,  although  increased 
voice.  In  women  the  sign  is  valueless;  and,  indeed,  its  main 
importance  is  derived  from  noting  its  absence  in  cases  of  pleu- 
ritic effusions.  Just  as  the  voice,  it  is  most  marked  on  the 
right  side. 

The  Combination  of  the  Physical  Signs,  and  the  Examination 
of  Patients  affected  with  Disease  of  the  Lungs. 

In  the  preceding  pages  isolated  physical  signs  have  been 
discussed.  But  if  in  the  investigation  of  disease  we  were  to 
trust  solely  to  isolated  signs,  incomplete  and  unsatisfactory 
indeed  would  be  our  conclusions.  All  the  methods  of  phys- 
ical exploration  must  be  employed;  the  results  obtained 
compared  with  each  other;  and  the  attending  symptoms 
carefully  inquired  into  and  brought  into  connection  with  the 
physical  signs,  before  a  diagnosis  is  made,  or  u  treatment  in- 
stituted. 


« 


DISEASES    OF   THE   LUNGS,  227 

A  patient  presents  himself  for  examination.  After  having 
obtained  the  history  of  the  case,  it  is  well  to  look  at  his  gen- 
eral appearance;  to  scan  the  expression  of  his  countenance; 
to  feel  the  skin  and  the  pulse ;  to  inquire  into  the  state  of 
his  digestion,  into  the  nature  of  the  cough  and  the  expecto- 
ration ;  to  determine  the  existence  or  non-existence  of  pain. 
The  character  and  frequency  of  the  breathing  are  then  noted. 
Next  we  proceed  to  a  physical  exploration.  The  chest  is 
narrowly  watched  ;  its  movements,  its  size  are  carefully  in- 
spected— if  necessary,  measured.  Percussion  is  employed, 
and  finally  auscultation. 

The  manner  of  investigating  by  these  different  methods 
has  been  already  detailed ;  it  need  not  here  be  repeated. 
But  what  may  be  repeated  is,  that  there  are  two  lungs,  and 
not  one ;  that  it  is  incumbent  always  to  examine  both,  and 
as  we  proceed,  to  compare  the  action  of  one  with  that  of  the 
other.  Nor,  even  when  the  pulmonary  affection  has  been 
made  out,  ought  the  examination  to  be  stopped.  The  state 
of  other  organs  and  of  the  system  must  be  inquired  into,  so 
as  not,  in  the  pursuit  of  a  few  physical  signs  in  the  lung,  to 
pass  by  accompanying  disorders  of  the  heart,  or  liver,  or 
stomach;  so  as  not  to  overlook  vital  conditions,  compared 
with  which,  as  respects  the  treatment,  the  physical  phe- 
nomena often  sink  into  insignificance.  There  are  acute  and 
chronic  diseases  of  the  lung.  The  physical  signs  of  both 
may  be  the  same ;  but  the  general  symptoms  and  the  consti- 
tutional state  attending  them  are  not  always  identical.  In 
truth,  these  are  at  times,  in  the  same  malady,  so  different, 
as  to  render  a  remedy  which  is  of  use  in  one  case,  useless  or 
worse  than  useless  in  another. 

As  many  of  the  signs  elicited  by  the  various  methods  of 
physical  diagnosis  depend  on  the  same  physical  conditions, 
they  may  be  studied  in  groups.  The  following  will  be 
usually  found  to  be  associated  : 


•J-28 


MEDICAL    DIAGNOSIS. 


Association  of  Physical  Signs. 


PrncissioN. 
Olcnr 

AlICCri-TATION 

OF  Ukspiua- 

TION. 

Vesicular 
murmur    or 
its  modifica- 

Arsci;i.T.4Ti0N 
OF  Voice. 

Normal    vocal 
resonance. 

Vocal  Fremi- 
tus. 

Unimpaired. 

tiiin. 

Bronchial, 
or  harsh 

Bronchophony 

Increased. 

Hull 

respiration. 
Absent    res- 
.    piration. 

Absent  voice. 

Diminished  or 
absent. 

T.vmpnnitic. 

Cavernous    or 
f  e  e  b  1  e,  ac- 
cording     to 
cause. 

Uncertain ; 
cavernou.sor 
diminished. 

Uncertain ; 
mostly  di- 
minished. 

Amphoric  or 
metallic.... 

Amplioric     or 
metallic. 

Aniphcric  or 
metallic. 

Mostly  dimin 
ished. 

Cracked  me- 

Cavernous 

Cavernous 

Uncertain. 

tal  SOUIlii.. 

respiration. 

voice. 

Physical  Condition. 

Lung  tissue  healthy  or  nearly 
so ;  at  any  rate  no  increased 
density  of  lung  tissue  from 
deposit  or  from  pressure. 

Solidification  of  pulmonary 
structure. 

Effusion  into  pleural  sac. 

Increased  quantity  of  air 
within  the  chest,  or  air  con- 
fined in  particular  points ; 
states  commonly  due  to  a 
cavity,  or  to  overdistention 
of  the  air-cells. 

Large  cavity  with  elastic 
Avails. 

Generally  a  cavity  communi- 
cating with  a  bronchial 
tube. 


In  adults  these  phenomena  are  commonly  combined.     In 
children,  however,  their  connection  is  not  so  constant  nor  so 
apparent.     Owing  to  the  extreme  elasticity  of  the  thoracic 
walls,  and  the  naturally  clearer  sound  of  the  lungs,  the  rela- 
tions of  percussion  to  auscultation  are  in  them  not  the  same 
as  in  the  adult.     Dulness,  even  where  the  condition  exists 
for  its  production,  is  rarely  as  marked;  nor  is  comparison 
between  the  two  sides  of  the  chest  as  valuable,  since  most  of 
the  acute  pulmonary  affections  of  childhood  are  more  often 
double  than  those  of  grown  persons.     Again,  the  diagnosis 
of  the  diseases  of  the  lung  in  children  requires  some  knowl- 
edge of  the  disorders  to  which  they  are  peculiarly  liable,  and, 
above  all,  great  care  and  patience.     Yet,  no   matter  what 
trouble  be  taken,  the  information  gained  will  amply  repay 
tor  it.     When  we  consider  the  very  great  frequency  of  affec- 
tions of  the  respiratory  organs  in  youth ;   when  we  reflect 
upon  their  danger,  upon  the  tendency  of  the  main  fevers  of 
childhood,  such  as  scarlatina  and  measles,  to  involve  the 
bronchial  mucous  membrane  or  the  lung  structure  proper ; 
when  we  take  into  account  tlie  valuable  information  gained 


DISEASES    OF    THE    LUNGS.  229 

in  the  diagnosis  of  the  disorders  of  other  organs,  as  of  the 
brain,  b}'  watching  the  movements  of  the  thorax, — no  care 
appears  too  much,  and  the  advice  to  examine  the  chest  and 
the  manner  of  the  respiration  in  every  sick  child,  as  we  would 
feel  the  pulse,  or  inquire  into  the  state  of  the  skin,  or  into 
the  discharges,  Avill  not  seem  far  fetched  or  ill  judged. 

Among  some  of  the  peculiarities  of  the  respiratory  function, 
before  the  age  of  puberty,  maybe  mentioned  the  greater  fre- 
quency in  breathing.  Infants  between  two  months  and  two 
years  breathe  irregularly^,  and  about  thirty-live  times  in  a 
minute.  Between  the  age  of  two  and  six  years  the  average 
number  of  respirations  in  the  same  space  of  time  is  twenty- 
three.  The  breathing  is  also  of  a  different  type  from  that  of 
the  adult:  it  is  abdominal,  and  can  be  more  readily  counted 
by  noting  tiie  rising  and  sinking  of  the  abdomen  than  by 
watching  the  slight  movements  of  the  chest. 

Of  the  methods  of  physical  exploration,  auscultation  is  in 
children  the  most  applicable.  It  is  fjir  more  so  than  percus- 
sion, and  is  to  be  practised  first,  since  percussion  causes  the 
child  to  cry.  The  voice  as  well  as  the  breathing  may  be  ad- 
vantageously listened  to ;  and  although  the  fretful  patient 
will  not  or  cannot  speak,  it  can  and  does  cry.  From  the 
cry,  when  studied  with  the  ear  applied  to  the  thoracic  walls, 
we  may  obtain  the  same  indications  as  from  the  vocal  reso- 
nance. 

The  back  of  the  lungs  should  be  invariably  examined.  It 
is  there  where  the  mischief  is  mostly  seated.  Fortunately, 
also,  this  investigation  does  not  occasion  the  same  fear  or 
struggling  on  the  part  of  the  little  sufferer;  hence  it  is  better 
not  to  place  the  ear  to  the  anterior  portion  of  the  chest  until 
the  posterior  has  been  listened  to.  The  position,  too,  in  which 
the  child  is  auscultated  should  vary  with  its  age.  Very  young 
children  may  be  examined  either  in  a  lying  or  sitting  posture 
on  the  lap  of  their  nurses,  or  may  be  held  in  the  arms  of  an 
attendant,  who  is  directed  to  present  the  different  parts  of 
the  thorax  successively  to  the  ear  of  the  physician. 

Before  proceeding  to  the  discussion  of  the  symptoms  of 
pulmonary  diseases  and  of  the  diseases  themselves,  let  us 
group  the  latter  according  to  their  anatomical  seat. 


230 


MEDICAL    DIAGNOSIS. 


DibKASES   OF   THE    LUNGS   AND   THEIR   COVERINGS. 

^.jji^jg  .  i  -^^"^^  I  Of  capillary  tabes. 

" '  (  Chronic 

Bronchial  Tvhes.  .    Dilatation  ; 

Narrt)wing ; 

Diseases  of  bronchial  glands  ; 
Spasm  of  muscular  fibres,  or  asthma. 

Congestion ; 

Hemoptysis ; 

Apoplexy ; 

(Edema ; 

Collapse ; 

Inflammation,  or  pneumonia; 

Lung  Tissue -j   Induration; 

Cirrhosis  ; 

Gangrene ; 

Emphysema ; 

Tubercle,  or  phthisis ; 

Cancer ; 

Deposits,  such  as  syphilitic,  typhoid,  melanic,  etc. 

r  Inflammation,  or  pleurisy ; 

Pleura '   Empyema; 

I   Hydrothorax ; 

I  HiBmothorax. 
Pleura  and  Lung.  /  Pneumothorax; 


Walls  of  Chest... 


Perforations  and  fistulous  openings. 

Pleurodynia ; 
Intercostal  neuralgia ; 
Abscesses,  etc. 


The  Principal  Symptoms  of  Diseases  of  the  Lungs. 

After  having  in  general  terms  described  the  physical  signs; 
after  having  alluded  to  the  methods  pursued  to  ascertain  the 
existence  of  pulmonary  affections, — it  is  necessary  to  inquire 
into  the  more  prominent  symptoms  they  occasion.  At  the 
same  time,  several  of  the  disorders  which  are  mainly  recog- 
nized by  these  symptoms,  and  the  physical  signs  of  which 
are  comparatively  unimportant,  will  be  dwelt  upon. 

Yet  of  the  symptoms  about  to  be  mentioned,  not  one  be- 
longs exclusively  to  pulnionory  diseases.  We  have  met  with 
some  of  them  in  studying  laryngeal  complaints ;    we  shall 


DISEASES    OF    THE    LUNGS.  231 

meet  with  them  again  in  examining  the  affections  of  the 
heart.  And  in  investigating  tliem  here  we  shall  not  view 
them  simply  with  reference  to  morhid  states  of  the  lungs, 
but  shall  indicate  their  general  relations  to  diseased  condi- 
tions, even  at  the  risk  of  discussing  what  might  in  part  be 
more  appropriately  elsewhere  discussed. 

The  symptoms  which  it  is  proposed  more  specially  to  sift, 
are  dyspnoea,  cough,  and  hiemoptysis. 

Dyspnoea. — Dyspnoea  means  difficulty  of  breathing.  It  is 
mostly  accompanied  by  a  sense  of  uneasiness  and  suffocation, 
and  by  an  increased  frequency  of  the  respiratory  acts.  But, 
strictly  speaking,  it  is  not  correct  to  apply  the  term  dyspnoea 
to  mere  increased  frequency  of  breathing,  for  accelerated 
respiration  and  difficult  respiration  do  not  of  necessity  go 
hand  in  hand.  The  breathing  may  be  slower  than  natural, 
and  yet  very  laborious;  it  may  be  ver}'  quick,  and  not  im- 
peded. Pneumonia  furnishes  often  an  example  of  this  kind 
of  respiration. 

Dyspnoea  depends  upon  various  causes.  Feeble  persons 
are  sometimes  troubled  with  it  after  the  slightest  exertion. 
It  may  be  temporarily  produced  by  any  bodily  or  mental  ex- 
citement. It  is  observed  when  the  pla}'  of  the  diaphragm  is 
interfered  with,  and  the  lung  cramped  in  its  expansion.  This 
is  its  cause  in  ascites,  in  abdominal  tumors,  and  in  pregnancy. 
It  may  occur  in  perverted  innervation,  as  in  hysteria,  or  in 
connection  with  cerebral  affections,  from  a  want  of  power  in 
the  respiratory  muscles,  or  be  due  to  morbid  conditions  of  the 
blood,  as  in  anaemia,  scurvy,  and  pyaemia.  It  is,  however, 
most  frequently  met  with  as  a  prominent  symptom  of  the 
disorders  of  the  larynx  and  trachea,  or  of  the  heart,  and  in 
the  various  diseases  of  the  lung  and  pleura,  whether  idio- 
pathic or  secondary.  Being  common  to  so  many  morbid 
states,  it  is  not  diagnostic  of  any. 

Dyspnoea  is  usually  aggravated  by  position.  When  the 
patient  lies  on  his  back,  the  respiration  becomes  more  diffi- 
cult. The  form  of  dyspnoea  in  which  the  sufferer  is  obliged 
to  remain  in  the  erect  posture  in  order  to  breathe,  is  termed 
orthopnoea.  This  is  mostly  witnessed  in  hydrothorax,  in  oedema 
of  the  lung,  and  in  affections  of  the  mitral  or  tricuspid  valves. 


'2:V2  MEDICAL    DIAGNOSIS. 

In  i-hthisis  there  is  nuvly  marked  dyspnoea.  In  capillary 
bronehitis  the  trouble  in  respiring  is  very  great;  so,  too,  is  it 
in  pneumothorax,  in  emphysema,  and  in  pleurisy,  if  the  lung 
be  extensively  compressed. 

Dysitmi-a  nuiy  come  on  in  paroxysms,  and  constitute  the 
onlv,  or  certainly  the  main  symptom  of  disease.  This  is  the 
case  in  asthma. 

Asthma. — Asthma  consists  in  a  spasmodic  narrowing  of 
the  bronchial  tubes,  caused  by  a  contraction  of  their  circu- 
lar muscular  fibres.  Its  chief  symptom  is  great  distress  in 
breathing,  occurring  in  paroxysms,  and  attended  with  dis- 
tinct wheezing.  These  spasms  may  be  preceded  by  a  feeling 
of  suffocation,  or  they  may  come  on  suddenly.  The  patient 
wakes  up  out  of  his  sleep,  iinds  himself  wheezing  and  with  a 
fit  of  the  disease  fully  on  him.  He  continues  to  respire  with 
great  difficulty,  sits  upright  in  bed,  or  walks  about  the  room 
gasping  for  breath.  His  look  is  wild  and  anxious,  the  face 
pale,  the  skin  cold,  and  the  color  of  the  lips  shows  that  the 
blood  is  not  properly  aerated.  In  spite  of  the  struggle  to  get 
air  into  the  lungs,  the  chest  moves  but  little;  and  when  the 
ear  is  placed  on  it,  no  vesicular  murmur  is  heard — simpl}-  the 
same  loud  wheezing  which  is  perceptible  to  the  by-standers; 
or  sonorous  and  sibilant  rales  are  detected,  due  to  the  narrow- 
ing of  the  bronchial  tubes,  and  disappearing  with  the  spasm. 
At  the  end  commonly  of  several  hours  the  fit  passes  oft"  with 
a  copious  expectoration,  and  as  suddenly  as  it  came.  But  it 
may  last  for  days,  ameliorating  in  the  daytime,  exacerbating 
at  night,  and  only  ceasing  gradually. 

The  exciting  causes  of  these  bronchial  spasms  are  very 
various.  In  some  persons  there  is  no  apparent  reason  for 
the  attack;  in  others  it  is  brought  on  by  the  inhalation  of 
irritating  fumes  or  of  disagreeable  vapors.  In  some  it  is 
preceded  by  digestive  troubles,  or  by  inflammation  of  the 
bronchial  mucous  membrane ;  in  others,  again,  an  interrup- 
tion to  the  free  circulation  in  the  lung,  or  a  disturbance  in 
the  sexual  organs,  or  in  the  urinary  secretions,  seems  to  oc- 
casion it.  It  is  not  unusual  to  find,  on  closely  questioning 
patients,  that  for  some  time  prior  to  the  asthmatic  paroxysm 
they  have  passed  a  dark-colored,  heavy  urine. 


DISEASES    OF    THE    LUNGS.  233 

Now,  whatever  be  the  exciting  agent  tliat  calls  the  bron- 
chial spasm  into  existence,  the  symptoms  of  the  attack  of 
asthma  are  the  result  of  that  spasm.  And  yet  asthma  is  not 
often  a  purely  nervous  disease.  The  seizure  itself  is  the  ex- 
pression of  perverted  nervous  action;  but  there  are  generally 
permanent  conditions  present,  such  as  diseases  of  the  brain 
or  medulla  oblongata,  of  the  heart,  or  of  the  lungs,  which  act 
as  constantly  predisposing  causes  to  these  seizures,  and  lead 
to  attacks  either  by  direct  irritation  of  the  pneumogastric 
nerves  or  through  the  medium  of  the  reflex  system.  Em- 
physema especially  is  a  fruitful  source  of  spasmodic  asthma. 

The  detection  of  the  causes  inducing  an  asthmatic  lit  may 
be  at  times  very  difficult;  but  the  diagnosis  of  the  fit  itself 
is  not  so.  No  disease  of  the  lungs  or  bronchial  tubes  is  likely 
to  be  mistaken  for  it,  because  no  disease  of  either  sfives  rise 
to  the  same  symptoms.  The  dyspnoea  of  pleurisy  or  bron- 
chitis is  not  paroxysmal,  nor  is  it  attended  with  wheezing. 
Some  of  the  affections  of  the  larynx  and  trachea  bear  a 
nearer  resemblance;  yet  they,  too,  announce  themselves  by 
different  symptoms.  Asthma  may  be  distinguished  from 
croup  by  the  entire  absence  of  fever,  and  by  its  lacking  the 
peculiar  hoarse  voice  and  cough  which  appertain  to  both 
forms  of  this  malady.  The  age  of  the  patient  is  also  very 
different :  asthma  is  as  rare  in  a  child  as  croup  is  in  an  adult. 
CEdema  and  spasm  of  the  glottis  differ  from  asthma  by  the 
much  more  markedly  paroxysmal  nature  of  the  difficulty  of 
breathing,  by  the  shorter  duration  of  the  seizures,  and  the 
absence  of  the  loud  and  continued  wheezing.  The  sensa- 
tions of  the  sufferer,  further,  indicate  correctly  the  seat  of 
the  obstruction.  A  large  goitre  pressing  on  the  trachea  may 
give  rise  to  dyspncea  and  to  a  noisy  sound  in  breathing;  but 
the  cause  of  both  is  easily  traced  to  the  tumor  in  the  neck. 

The  most  deceptive  condition  is  when  the  glands  of  the 
neck  enlarge  suddenly  and  press  on  the  trachea.  I  had,  some 
time  since,  a* young  man  under  my  care  for  acute  bronchitis. 
He  was  progressing  favorably,  when  one  day  he  presented 
himself,  breathing  with  great  difficulty,  and  eacli  respiration 
attended  with  a  noise  like  the  wheeze  of  asthma.  It  is  very 
probable  that  I  should  have  been  deceived,  and  should  have 


234  MEDICAL    DIAGNOSIS. 

regarded  him  as  having  been  attacked  with  asthma,  had  I 
not,  in  looking  at  his  neck,  detected  the  group  of  enlarged 
glands.  Such  cases  are  extremely  rare,  and  belong  more  to 
the  curiosities  of  medical  practice. 

Verj  marked  dyspnoea  may  be  occasioned  by  the  pressure 
of  an  aneurismal  tumor,  or  by  an  organic  disease  of  the  heart. 
But  it  is  hardly  necessary  to  enter  here  into  a  detailed  de- 
scription of  the  distinctive  character  of  either  of  these  forms 
of  troubled  breathing.  The  stridor  and  the  persistent  diffi- 
culty of  respiration  in  the  first,  aggravated  though  it  may 
become  in  paroxysms,  and  the  constant  want  of  breath  in 
the  second,  are  not  likely  to  be  taken  for  the  wheezing  and 
the  paroxysmal  dyspnoea  of  asthma.  True  asthmatic  seiz- 
ures may  both  produce  and  be  produced  bj'  a  disease  of  the 
heart.  But  what  is  called  cardiac  asthma  is  not  always  a 
spasm  of  the  bronchial  tubes :  it  is  usually  only  a  temporary 
increase  of  the  dyspnoea,  dependent  upon  a  decided  obstruc- 
tion to  the  circulation  in  the  lungs,  and  not  accompanied 
by  wheezing. 

There  is  a  very  peculiar  form  of  difficulty  of  breathing 
connected  with  a  loss  of  power  in  the  diaphragm.  The  patient, 
when  the  disorder  is  full}^  developed,  cannot  make  even  the 
slightest  effort,  without  his  being  seized  with  a  feeling  of 
suftbcation  and  liis  respiration  being  very  greatly  accelerated. 
He  cannot  take  a  long  breath,  and  often  his  voice  is  very 
much  enfeebled.  But  the  most  significant  sign  of  paralysis 
of  the  chief  respiratory  muscle  is,  that  during  inspiration  the 
epigastrium  and  the  hypochondria  are  depressed,  while  the 
chest  dilates  ;  and  the  converse  takes  place  during  expiration. 
If  there  be  merely  a  lessened  power  of  the  diaphragm,  these 
phenomena  are  only  observed  during  forced  breathing;  a 
paralysis  of  one-half  of  the  muscle  occasions  them  on  one 
side  only.  Duchenne  adds  another  important  diagnostic 
test,  by  which  we  may  distinguish  a  paralyzed  state  of  the 
diaphragm,  namely,  that  if  the  phrenic  nerve  be  galvanized, 
the  diaphragm  acts  again  with  proper  strength,  and,  during 
inspiration,  the  abdomen  rises  simultaneously  with  the  tho- 
racic walls.  To  discriminate  the  cause  of  the  impaired  or 
lost  muscular  force, — whether  this  be  due  to  a  lesion  of  the 


DISEASES    OF   THE    LUNGS.  235 

nervous  system,  to  inflammation  of  the  muscle  or  of  the 
adjacent  textures,  whether  produced  by  rheumatism  or  by 
lead  poisoning,  or  having  its  origin  in  progressive  muscular 
atrophy, — we  have  to  rely  chiefly  upon  the  history  of  the 
case.  In  rheumatism  of  the  diaphragm,  an  absence  of  the 
vesicular  murmur  over  the  lower  portions  of  the  chest;  a 
respiration  effected  by  the  upper  ribs  exclusively;  tense,  hard 
abdominal  walls;  want  of  power  to  strain  so  as  to  aid  the 
bladder  or  intestines  in  expelling  their  contents,  with  darting, 
stabbing  pain  from  the  spine  to  the  margin  of  the  ribs  on 
each  effort  to  inspire, — have  been  particularly  noticed.*  In 
fatty  degeneration  of  the  diaphragm,  which  often  coexists 
with  a  fatty  heart,  we  find,  in  its  last  stage,  great  distress 
and  difficult}^  of  breathing,  and  death  may  rapidly  follow  the 
markedly  embarrassed  breathing.f 

From  the  foreo-oiusi:  remarks  it  will  have  become  obvious 
that  there  is  no  treatment  directly  applicable  to  dyspnoea. 
We  must  aim  at  removing  its  cause ;  and  if  this  be  possible, 
the  difficulty  of  breathing  ceases.  The  laborious  respiration 
of  a  fit  of  asthma  is  relieved  by  relaxing  the  spasm  Avhicli 
has  caused  it. 

Cough. — Cough  is  a  spasmodic  effort,  consisting  in  a 
sudden  and  violent  expiration,  and  having  usually  for  its  ob- 
ject the  expulsion  of  some  annoying  substance  from  the  air- 
passages.  But  it  may  be  purely  nervous,  and  unconnected 
with  the  presence  of  any  irritating  matter  in  the  respiratory 
organs.  There  are  several  kinds  of  cough :  according  to  the 
amount  of  expectoration  which  follows  the  act,  a  cough  is 
dry  or  moist ;  according  to  its  origin,  it  is  laryngeal,  tracheal, 
bronchial,  sympathetic,  etc. 

A  dry  cough  is  indicative  of  irritation.  This  is  often  seated 
in  the  larynx,  trachea,  or  in  their  vicinity,  or  in  the  bronchi, 
or  the  lung  itself.  An  elongated  uvula,  and  many  of  the 
diseases  of  the  larynx  or  pharynx,  give  rise  to  a  dry  cough  : 
it  happens,  too,  in  pleurisy  and  in  the  earlier  stages  of 
phthisis.    In  disorders  of  the  larynx  and  trachea  the  cough  is 


*  Chapman,  Boston  Med.  and  Surg.  Journal,  July,  1864. 
f  Callender,  London  Lancet,  Jan.  18G7. 


236  MEDICAL    DIAGNOSIS. 

attended  with  a  peculiar  shrill  noise,  or  a  hoarse  sound.  But 
the  irritation  may  not  be  situated  at  all  in  the  respirator}- 
S3'stem.  Affections  of  the  liver,  of  the  stomach,  the  intestine, 
the  uterus,  or  the  brain,  will  occasion  an  obstinate  dry  cough. 
It  is  also  produced  by  dentition,  by  the  presence  of  worms 
in  the  intestinal  canal,  and  by  diseases  of  the  organs  of  cir- 
culation. Again,  it  may  be  strictly  nervous.  The  brazen 
cough  of  hysteria  is  dvy  ;  indeed,  nearly  all  sympathetic 
coughs  possess  a  dry  character. 

A  moist  cough  may  succeed  to  a  dry  cough.  The  moist 
cough  is  rarely  associated  with  any  diseases  but  those  of  the 
respiratory  apparatus.  It  depends,  for  the  most  part,  on  the 
presence  of  fluid  in  the  bronchial  tubes  or  the  lung  structure. 
It  attends  bronchitis  with  free  secretion,  oedema  of  the  lung, 
the  more  advanced  stages  of  phthisis,  and  pneumonia  when 
the  exudation  is  breaking  up.  It  is  generally  accompanied 
by  a  free  expectoration,  which  varies  in  appearance  and 
amount  with  the  morbid  state  causino;  it. 

Cough  is  frequently  preceded  b}^  a  sensation  of  tickling  in 
the  larynx,  to  which  the  patient  is  apt  to  refer  his  whole 
trouble.  It  is  much  affected  by  position.  Lying  down  often 
increases  its  intensity.  Sometimes  a  cough  occurs  in  severe 
paroxysms.  In  various  laryngeal  affections,  in  abscess  of 
the  lung,  in  consumption,  and  in  bronchial  phthisis,  such  fits 
of  coughing  are  observed.  But  in  no  comphiint  are  they  so 
constant  as  in  hooping-cough. 

Hooping-cough. — This  is  essentially  a  disease  of  childhood, 
and  the  result  of  an  epidemic  influence,  or  of  contagion. 
The  peculiar  spasmodic  cough  succeeds  to  a  catarrh  of  more 
than  a  week's  duration.  During  the  paroxysms  the  eyes  fill 
with  tears,  the  child's  face  is  injected  and  anxious,  and  its 
whole  appearance  shows  how  it  is  suffering  for  want  of  breath. 
The  air  in  the  lungs  is  expelled  by  a  series  of  abrupt  spas- 
modic expirations,  when  a  long-drawn  inspiration,  attended 
with  a  hoop,  temporarily  puts  a  stop  to  what  appears  to  be 
threatening  suffocation.  The  rest  is,  however,  very  short. 
The  cough  recommences,  and  is  again  follow^ed  b}-  the  loud 
hooping  inspiration.  It  continues  in  this  manner  until  after 
a  copious  expectoration  of  stringy  mucus,  or  after  vomiting, 


DISEASES    OF   THE    LUNGS.  237 

tlie  paroxysm  ceases,  and  a  more  lengthened  calm  ensues. 
These  fits  of  coughing  repeat  themselves  at  varied  intervals, 
during  the  twenty- four  hours.  They  are  especially  frequent 
at  night.  Yet  the  cliild's  health  remains  good,  in  spite  of 
the  violence  of  the  attacks  and  the  length  of  time  they  are 
spread  over.  The  spasmodic  cough  lasts  for  weeks ;  the 
hoop  then  ceases,  the  cough  loses  its  ringing  sound,  and 
gradually  leaves  entirely.  It  is  onl}-  in  comparatively  rare 
instances  that  it  persists,  and  is  followed  by  the  development 
of  tubercles  in  the  lungs;  just  as  it  is  only  in  exceptional 
cases,  or  in  certain  epidemics,  that  bleeding  from  the  nose  or 
convulsions  happen  during  the  violent  coughing. 

An  affection  of  so  long  duration,  marked  by  such  a  pecu- 
liar sign  as  a  hoop,  is  etisy  of  diagnosis.  Yet  there  are  cer- 
tain conditions  with  which  occasionally  it  may  be  confounded. 
In  its  first  stage,  befoi-e  the  characteristic  cough  sets  in,  it 
may  be  mistaken  for  catarrhal  bronchitis.  There  is,  indeed, 
at  this  period,  no  means  of  distinguishing  between  the  two 
disorders,  except  by  taking  into  account  whether  or  not 
hooping-cough  be  prevalent  as  an  epidemic ;  for  it  is  only 
very  seldom  that  the  cough  possesses  from  the  onset  a  de- 
cided ring.  And  bronchitis  is  in  fact  the  most  frequent 
complication,  or,  to  state  it  more  accurately,  almost  an  es- 
sential element  of  the  malady.  It  is  usually  present  in  a 
mild  form  at  the  onset;  it  outlasts  the  paroxysmal  stage.  At 
the  height  of  this,  a  severe  attack  of  acute  bronchitis  or  of 
broncho-pneumonia  may  mask  the  special  traits  of  pertussis. 
Yet  whenever  these  are  detected,  we  know  that  the  com- 
plaint before  iis  is  not  pure  catarrhal  bronchitis.  It  is  true 
that  occasionally  acute  bronchitis  may  exhibit  paroxysms  of 
spasmodic  cough.  But  the  want  of  the  nervous  element  in 
the  disease,  the  absence  of  the  hoop  and  of  vomiting,  the 
dyspnoea  between  the  paroxysms,  the  decided  fever,  the  pres- 
ence of  manv  rales  indicatino;  abundant  secretions  in  the 
lung,  the  greater  violence,  and  the  shorter  duration  of  the 
disorder, — do  not  permit  us  to  be  long  in  doubt. 

A  disease  less  easy  to  discriminate  from  hooping-cough  is 
tuberculization  of  the  bronchial  glands,  or  bronchial  phthisis. 
It,  too,  produces  a  ringing  paroxysmal  cough.    It,  too,  occurs 


238  MEDICAL   DIAGNOSIS. 

in  children.  There  is,  however,  this  difference:  the  enlarged 
bronchial  glands  are  apt  to  press  on  the  surrounding  parts. 
This  becomes  manifest  by  the  engorgement  of  the  veins  of 
the  neck,  by  the  lividity  and  puffiness  of  the  skin,  by  the 
trouble  in  breathing  or  in  swallowing.  The  character  of  the 
voice,  also,  may  change  ;  and  yet,  as  at  times  happens  in  hoop- 
ing-cough, there  may  be  no  abnormal  physical  signs  in  the 
chest.  But  often  there  is  dulness  on  percussion  between  the 
scapul.'e,  where  the  swollen  bronchial  glands  lie,  and  impaired 
respiration  in  portions  of  the  lung.  The  symptoms  are  those 
of  pulmonary  phthisis,  with  which  the  disease,  indeed,  may 
be  associated :  there  are  emaciation  and  the  same  loss  of 
strength,  the  same  sweating  at  night,  the  same  hectic  fever, 
the  same  tendency  to  diarrhoja.  Now  when  we  compare 
these  phenomena  with  those  presented  by  hooping-cough, 
we  miss  the  hoop,  the  vomiting  accompanying  the  tits  of 
coughing,  the  epidemic  or  contagious  origin,  and  the  distinct 
periods,  first  of  catarrh,  then  of  spasmodic  cough,  then  of 
gradual  decline.  We  see,  on  the  contrary,  an  affection  of 
more  gradual  and  uniform  progress,  and  which  often  proves 
its  existence  by  special  signs.* 

When  emaciation,  hectic  fever,  and  marked  cough  are  met 
Avith  in  the  last  stage  of  hooping-cough,  it  is  always  highly 
probable  that  this  has  been  followed  by  a  tubercular  deposit. 
It  is  not  likely  that  such  cases  will  be  mistaken  for  those  in- 
stances of  pulmonary  consumption  in  which  violent  parox- 
ysms of  coughing  occur.  The  age,  the  origin,  the  history 
are  so  entirely  different.  Equally  dissimilar  are  the  history 
and  the  symptoms  in  other  spasmodic  coughs,  such  as  that 
of  hysteria,  or  of  some  laryngeal  affections. 

Haemoptysis. — Sputa  are  streaked  with  blood  in  bron- 
chitis, intimately  admixed  with  blood  in  pneumonia;  yet  we 
do  not  call  this  haemoptysis.  It  is  only  when  a  certain  quan- 
tity of  pure  blood  is  expectorated  that  the  complaint  is  re- 

*  Kefer,  for  cases  of  diseases  of  the  bronchial  glands,  to  J.  C.  T.  Tice. 
Medioo-Chirurg.  Transact.,  vol.  xxvi.;  P.  H.  Green,  Ibid  ,  vol.  xxvii.;  and 
Barthez  and  Rilliet,  Maladies  des  Enfants,  tome  iii.;  and  De  3Iussy,  Gaz. 
des  Hop.,  No.  67,  18G8,  where  also  instances  of  the  disease  in  adults  are 
analyzed. 


DISEASES    OF    TUE    LUNGS.  239 

garded  as  haemoptysis,  or  hemorrhage  from  the  lungs.  Now, 
a  puhiionary  hemorrhage  maybe  an  idiopathic  affection  ;  but 
it  is  not  often  so.  It  is  mostly  symptomatic  of  a  grave  disease 
of  the  lungs  or  heart,  and  usually  of  consumption.  It  is  at 
times,  although  rarel}',  a  discharge  which  takes  the  place  of 
a  suppressed  flow  of  blood  from  another  part  of  the  body. 
Some  females  have  these  vicarious  hemorrhages  from  the 
lungs  at  their  menstrual  periods. 

It  is  a  matter  of  dispute  among  pathologists  where  the 
blood  springs  from.  It  would  seem,  in  some  cases,  to  proceed 
from  the  capillaries  and  finer  arterial  branches  of  the  bron- 
chial mucous  membrane  and  lung  tissue ;  in  others,  from 
larger  vessels  that  have  been  laid  open.  But  what  interests 
us  rnainlv  as  diao-nosticians,  is  to  ascertain  whether  it  flows 
from  the  lung  at  all,  and  subsequently  why  this  organ  is  so 
disordered.  Now,  when  called  to  a  person  who  has  been 
spitting  blood,  we  have  first  to  solve  the  question.  Where 
does  the  blood  come  from?  It  may  issue  from  the  nose  or 
mouth;  from  the  trachea;  from  the  oesophagus  or  stomach  ; 
it  may  stream  from  an  aneurism  which  has  burst  into  the 
air-passages ;  or  it  may  be  that  the  lung  is  bleeding. 

When  in  epistaxis  the  blood,  instead  of  flowing  out  of  the 
nostrils,  flows  backward,  it  is  coughed  up.  But  on  the 
patient  inclining  forward,  it  will  issue  from  the  nose.  The 
color  of  the  blood  is  not  florid;  and  it  can  be  seen  trickling 
down  the  pharynx.  Inspection  is  of  equal  service  when  the 
blood  comes  from  any  part  of  the  oral  cavity;  especially  if  it 
proceed  from  the  gums.  Their  swollen  state,  their  spongy 
appearance,  and  the  readiness  with  which  they  bleed  when 
pressed,  point  out  at  once  the  source  of  the  hemorrhage. 

Loss  of  blood  from  the  larynx  and  the  trachea,  or  from  the 
msophagus,  is  exceedingly  rare :  and  when  it  does  occur,  it  is 
dependent  upon  some  local  lesion,  or  the  presence  of  some 
foreign  substance  which  has  been  swallowed.  By  attention 
to  the  history,  then,  we  can  recognize  the  cause  and  the  seat 
of  the  hemorrhage.  The  blood  itself  furnishes  no  certain 
mark  of  distinction. 

When  blood  is  vomited  from  the  stomach,  it  is  preceded  by 
a  feeling  of  weight  and  uneasiness  in  the  epigastric  region, 


240  MEDICAL    DIAGNOSIS. 

and  sometimes  by  decided  nausea.  The  ejected  matter  con- 
sists of  a  dark  grumous  blood,  thus  altered  by  the  gastric 
juice;  and  is  often  mixed  witli  broken-down  food.  Its  dark 
color  is  invariable,  excepting  where  an  artery  has  been  laid 
bare  by  an  ulcer,  in  which  case  a  sudden  discharge  of  florid 
blood  takes  place.  There  is  not  commonly  more  than  one 
act  of  vomitino-;  the  blood  which  remains  in  the  stomach 
passes  into  the  intestines,  and  goes  of  with  the  stools. 
Hsematemesis  is  attended  with  tenderness  at  the  epigas- 
trium. It  is  usually  symptomatic  of  an  organic  affection  of 
the  stomach,  of  the  liver,  intestine,  or  spleen  ;  it  may,  how- 
ever, depend  upon  the  swallowing  of  irritating  poisons;  or 
luippen  in  fevers  or  in  scurvy;  or  as  a  substitute  for  sup- 
pressed discharges. 

The  blood  which  gushes  out  of  the  mouth  when  an  aneurism 
opens  into  the  air-passages,  is  red  and  arterial.  It  spurts  out 
in  jets,  and  the  patient  rarely  long  survives  the  hemorrhage. 
Should  this  not  prove  quickly  fatal,  we  are  seldom  at  a  loss 
to  determine  the  cause  of  the  bleeding;  for  the  physical 
signs  of  the  aneurismal  tumor  in  the  chest  assist  us  in  arriv- 
ing at  a  correct  understanding  of  the  case. 

But  when  the  blood  comes  from  the  lungs,  it  presents  char- 
acters, and  is  connected  with  symptoms,  totally  different  from 
any  of  those  just  mentioned.  The  bleeding  is  preceded  by  a 
sense  of  weight  and  of  uneasiness  in  the  chest.  The  patient 
perceives  a  saltish  taste  in  the  mouth  and  a  tickling  sensa- 
tion in  the  larynx,  when  suddenly,  and  without  any  effort, 
the  mouth  fills  with  blood,  or  after  a  very  slight  cough  he 
expectorates  a  quantity  of  light-red  and  frothy  blood.  His 
anxiety  becomes  very  great;  the  skin  is  covered  with  a  cold 
sweat;  the  pulse  is  quick  and  full,  and  bounds  under  the 
finger.  He  spits  up  more  blood,  and  this  continues  to  come 
up  at  varying  intervals  and  in  changing  quantities  all  day,  or 
for  several  days,  or  even  for  a  very  much  longer  period.  It 
is  at  first  pure  blood,  or  mixed  with  the  sputum  ;  is  red  and 
not  coagulated,  and  frothy,  except  when  the  hemorrhage  is 
very  profuse.  But  after  one  or  two  bleedings,  the  matter 
which  is  coughed  up  contains  dark  clots,  being  the  blood 
which  has  been  retained  somewhere  in  the  air-passages  since 


DISEASES    OF    THE    LUNGS.  241 

the  previous  attack.  The  blood  is  never,  at  the  onset  of 
the  hemorrhage,  dark  and  grumons;  still,  in  rare  cases  it 
has  more  of  a  venous  than  of  an  arterial  hue. 

Tlie  amount  which  is  brought  up  at  one  bleeding  ranges 
from  one  to  two  drachms  to  as  many  pints;  but  the  quantity 
that  comes  out  of  the  mouth  is  by  no  means  an  index  of  the 
quantity  extravasated.  The  blood  may  be  effused  into  the 
pulmonary  structure,  and  but  little  be  expelled.  This  hap- 
pens in  j^idmonary  apoplexy. 

After  the  description  above  given,  it  is  not  necessary  to 
point  out  the  marks  of  discrimination  between  blood  ejected 
from  the  lungs  and  from  other  parts.  The  symptoms  are 
different;  the  blood  itself  is  different.  And  listening  to  the 
chest  detects  bubbling  sounds  in  the  air-tubes;  still,  to  find 
these  is  not  requisite  for  the  diagnosis  of  pulmonary  hem- 
orrhage, and  indeed,  while  the  bleeding  is  going  on,  the 
patient's  welfare  forbids  an  accurate  and  extended  thoracic 
examination.  But  as  soon  as  circumstances  permit,  that  ex- 
amination becomes  of  immense  value  by  teaching  us  with 
wdiat  morbid  state  the  hemorrhao-e  is  connected.  Ausculta- 
tion  alone  can  determine  w^hether  the  bleeding  is  sympto- 
matic of  a  disease  of  the  heart  or  lungs,  or  whether  it  depends 
upon  neither.  It  is,  however,  mostly  owing  to  an  affection  of 
the  heart  or  lungs;  and  is  exceedingly  prone  to  be  repeated. 

Yet  the  lungs  may  bleed  frequently  without  there  being  an 
organic  lesion  within  the  chest  to  account  for  the  hemorrhage. 
I  had,  some  years  ago,  a  patient  under  my  care,  who  had  been 
spitting  blood  daily  for  five  years.  Although  enfeebled  by  tiie 
loss  of  blood,  his  general  health  remained  good.  His  lungs 
and  heart  appeared  to  be  sound.  Another  patient  had  pulmo- 
nary hemorrhages  at  varying  intervals  for  eighteen  months. 
He  finally  died  of  exhaustion ;  but  he  never  presented  any 
physical  signs  of  thoracic  disease.  It  is,  however,  likely 
enough  that  latent  tubercle  existed  in  the  lungs.  An  exami- 
nation of  the  body  was,  unfortunately,  not  permitted. 

In  these  instances  the  hemorrhages  recurred  often.  But 
we  meet  with,  cases  in  robust  persons,  in  which  the  loss  of 
blood  follows  active  exercise  or  exertion,  and  is  not  apt  to 
be  protracted.    In  such  cases,  of  which  I  have  seen  a  number 

16 


242  MEDICAL    DIAGNOSIS. 

in  soldiers  sent  to  hospitals  after  the  fatigue  of  a  long  march 
or  the  excitement  of  a  battle,  simple  congestion  of  the  lungs 
is  probably  the  cause  of  the  disorder. 

Except  under  the  circumstances  mentioned,  haemoptysis 
may  be  looked  upon  as  a  grave  symptom.  It  is  not  dangerous 
as  regards  its  immediate  termination,  but  dangerous  because 
it  is,  for  the  most  part,  the  index  of  a  serious  malady.  Few 
die  as  the  direct  consequence  of  the  hemorrhage,  but  many 
die  of  the  disorder  of  which  the  hemorrhage  is  the  conse- 
quence. 

Diseases  in  which  Clearness  on  Percussion  is  met  with  and 
constitutes  a  Valuable  Sign. 

Some  of  these  ailments  are  acute,  others  chronic;  and 
nearly  all  have  as  their  prominent  .symptom  a  cough,  and  are 
affections,  or  follow  affections  of  the  bronchial  tubes. 

Acute  Bronchitis. — This  is  an  acute  inflammation  of  the 
bronchial  tubes,  which  occurs  idiopathically,  or  happens  as 
a  secondary  complaint  in  the  course  of  fevers,  of  rheumatism, 
and  of  cardiac  disorders.  Let  us  examine  the  manifestations 
of  the  idiopathic  malad3\ 

Bronchitis  varies  considerably  according  to  the  size  of  the 
tubes  involved.  When  the  smaller  tubes  are  affected,  a  dis- 
ease called  capillary  bronchitis,  or  suffocative  catarrh,  is  estab- 
lished, the  prognosis  of  which  is  very  grave,  and  the  diag- 
nosis of  which  presents  points  for  special  consideration. 

The  forms  of  bronchitis,  dissimilar  as  they  are  clinically, 
do  not  differ  much  in  their  anatomy.  Whatever  portion  of 
the  membrane  the  inflammation  attacks,  swells,  becomes 
injected  and  relaxed,  and  may  undergo  partial  softening.  Its 
surface  is  either  dry,  or  covered  with  cast-off  epithelium, 
muco-pus,  and  exudation  matter,  which,  if  it  collect  in  the 
smaller  tubes,  blocks  up  their  calibre.  In  ordinary  bronchitis, 
the  pulmonary  texture  is  undisturbed;  likewise  in  capillary 
bronchitis,  unless  the  inflammation  have  here  and  there  run 
into  the  lung  parenchyma  and  solidified  some  of  the  lobules. 

The  symptoms  of  acute  bronchitis  of  the  large  and  middle- 
sized  tubes  are,  a  sensation  of  tickling  in  the  throat,  soreness 


DISEASES    OF   THE    LUNGS.  243 

or  pain  behind  the  stern  am,  a  slight  oppression  in  breathing, 
rather  hurried  respiration,  and  a  paroxysmal  cough.  Let  us 
add  to  these  pain  in  the  limbs,  coryza,  and  a  fever  of  slight 
or  of  moderate  intensity,  and  we  have  the  main  phenomena 
met  with  during  the  onset  and  at  the  height  of  an  attack 
of  ordinary  acute  bronchitis.  The  fits  of  coughing  in  the 
earlier  stages  are  followed  by  a  clear,  frothy  expectoration, 
which,  as  the  cough  becomes  looser  and  less  fatiguing,  changes 
from  an  almost  transparent  fluid  to  a  yellowish  or  greenish 
sputum.  This  may  be  uniform,  or  streaked  with  blood ;  it 
may  be  small  in  amount,  or  in  large  quantities.  The  fever 
soon  leaves ,  but  long  after  it  has  ceased,  the  patient  still  has 
a  cough  and  expectoration,  both  of  which  only  gradually 
disappear. 

The  physical  signs  may  be  inferred  from  the  lesions.  As 
there  is  no  condensation  of  pulmonary  tissue,  there  is  no 
dulness  on  percussion,  the  thickening  of  the  bronchial 
mucous  membrane  and  the  injection  of  its  texture  not  being 
sufficient  to  modify  materially  the  normal  resonance.  But 
these  very  conditions  must  alter  the  .respiratory  murmur. 
They  bring  out  more  of  the  bronchial  element  of  sound, 
hence  more  expiration  with  the  coarser  inspiration — in  other 
words,  a  harsh  respiration ;  or  the  swelling  obstructs  the  en- 
trance of  air  into  the  air-vesicles,  and  enfeebles  the  vesicular 
murmur.  Again,  new  sounds,  the  rales,  are  produced:  first 
dry,  then,  as  the  disease  advances,  moist.  This  succession 
of  the  rales  is,  however,  not  absolute,  and  depends,  to  a 
great  degree,  on  the  density  of  the  fluid  in  the  bronchial 
tubes.  Dry  rales,  mixed  with  moist,  may  be  perceived  eveu 
in  the  latter  stages  of  acute  bronchitis,  and  long  after  the 
febrile  signs  have  ceased.  In  fact,  the  tenacity  alone  of  the 
exudation  determines  the  nature  of  the  rales,  and  even  some- 
what their  exact  character;  for  ever}'  dry  rale  is  not  pre- 
cisely like  every  other  dry  rale;  nor  every  moist  rale  equally 
moist.  With  reference  to  size,  the  sonorous  rales  and  the 
large  bubbling  sound  prevail  when  the  disorder  attacks  the 
larger  tubes.  Sometimes,  when  the  bronchial  inflammation 
is  severe  and  extensive,  we  find  a  sound  which  seems  to  be 
neither  a  dry  nor  a  bubbling  rale,  but  rather  a  compound  of 


244  MEDICAL    DIAGNOSIS. 

both — a  dry  sound,  yet  not  continuous,  giving  the  idea  of  its 
being  caused  by  the  breaking  up  of  fluid.  Or,  there  may  be 
a  mixture  of  the  sounds  of  respiration  with  the  rales,  occa- 
sioning a  very  peculiar  kind  of  breathing — one  in  which  the 
most  practised  ear  can  recognize  neither  a  distinctly  vesicular, 
nor  a  distinctly  bronchial  element,  nor  a  well-deiined  rale. 
All  these  states  are  dependent  upon  the  amount,  and,  above 
all,  upon  the  condition  of  the  exudation  in  the  bronchial 
tubes.  But  they  indicate  nothing  beyond  the  fact  that  there 
is  an  exudation  present  which  is  unusually  large  in  quantity 
and  tenacious  in  character.  When  the  sounds  are  of  the 
indeterminate  nature  just  alluded  to,  the  vibrations  produced 
in  the  tubes  are  apt  to  be  transmitted  to  the  parietes  of  the 
chest,  occasioning  with  each  respiration  a  marked  fremitus, 
the  so-termed  rhonchal  fremitus. 

The  diagnosis,  then,  of  acute  bronchitis  is  determined  by 
the  cough,  the  fever,  the  expectoration,  and  the  signs  of 
clearness  on  percussion,  diffused  rales,  or  harsh  respiration. 
From  all  those  diseases  of  the  lunar  which  result  in  the  con- 
solidation  of  the  pulmonary  tissue,  such  as  pneumonia  and 
tuberculosis,  we  distinguish  bronchitis  by  the  absence  of  dul- 
ness  on  percussion.  Some  cases  of  acute  consumption,  on 
account  of  the  sudden  invasion  of  the  malady  and  of  the 
general  dillusion  of  the  physical  signs,  are  liable  to  be  mis- 
taken for  acute  bronchitis;  but  the  different  progress  of  the 
disorder  usually  clears  up  all  doubt.  Error  in  diagnosis  is 
more  likely  to  arise  from  the  habit,  when  the  signs  of  bron- 
chitis have  been  made  out,  of  not  looking  further ;  forgetting, 
in  the  attention  to  the  disease  within  the  thorax,  the  various 
morbid  states  which  bronchitis  may  accompany,  and  particu- 
larly its  frequent  association  with  fevers. 

Ca'pillary  Bronchitis. — This  is  essentially  a  disease  of  the 
aged,  and  of  young  children.  It  begins  with  an  acute  in- 
flammation of  the  larger  bronchi ;  or  the  disorder  may  from 
the  onset  aifect  the  smaller  tubes.  In  either  case,  signs  of 
obstructed  circulation  soon  manifest  themselves:  there  is 
lividity  of  the  lips  and  cheeks,  with  hurried  breathing,  a 
rapid  pulse,  an  anxious  countenance,  great  restlessness,  a 
skin  the  temperature  of  whicii  is  either  natural  or  but  little 


I 


DISEASES    OF    THE    LUNGS.  245 

warmer  than  natural,  and  a  cough,  followed  b}^  viscid  expec- 
toration. As  the  raalad}^  advances,  the  color  of  the  skin  and 
the  mucous  membranes  shows  more  and  more  the  want  of 
properly  aerated  blood;  the  sputa  diminish  or  cease  with 
the  failing  strength;  and  in  old  persons  delirium  and  coma, 
in  young  children  convulsions,  mark  the  closing  struggle. 

The  physical  signs  are  those  of  ordinary  bronchitis,  but 
modified  by  the  seat  of  the  malady.  High-pitched  whistling 
sounds,  accompanied  or  superseded  by  very  fine  moist  rales, 
denote  the  smaller  size  of  the  tubes  involved.  The  resonance 
on  percussion  is  clear,  or  very  slightly  different  from  that  of 
health.  When  materially  duller,  it  indicates  that  the  pul- 
monary tissue  itself  shares  in  the  inflammation,  or  that  it  has 
been  exhausted  of  its  air  and  has  collapsed. 

The  parts  of  the  lung  which  the  physical  signs  prove  to 
bear  the  brunt  of  the  disease,  are  the  lower  lobes.  In  the 
upper  there  may  be  large  rales  and  some  fine  ones;  but  it  is 
low  down  and  at  the  posterior  portion  of  the  chest  that  the 
fine  sounds  are  always  most  abundant.  Yet  where  the  in- 
flammation is  extensive,  and  the  accumulation  of  secretions 
and  morbid  products  great,  quantities  of  small  rales  are  heard 
at  every  part  of  the  chest. 

From  this  description,  brief  though  it  be,  of  the  signs  and 
symptoms  of  capillary  bronchitis,  it  will  be  apparent  that  it 
difiPers  from  the  ordinary  acute  bronchitis  by  the  greater 
tendency  to  prostration  and  to  suffocation,  by  the  signs  of 
imperfect  aeration  of  the  blood,  and  by  the  fineness  of  the 
rales. 

Like  the  more  usual  kind  of  acute  bronchial  inflammation, 
capillary  bronchitis  is  liable  to  be  mistaken  for  acute  lobar 
pneumonia  and  for  phthisis.  And  in  the  majority  of  cases 
the  same  rules  serve  for  its  discrimination  :  the  absence  of 
percussion  duluess  and  the  diffusion  of  the  morbid  sounds 
are  here  again  of  the  utmost  value.  The  rapidity  of  the  at- 
tack and  the  signs  of  suffocation  might  mislead  into  the  sup- 
position of  oedema  of  the  glottis,  of  laryngitis,  or  of  croup; 
errors  in  diagnosis  which  the  detection  of  fine  rales,  by  the 
application  of  the  ear  to  the  chest,  will  prevent. 

Capillary  bronchitis  is  apt  to  be  confounded  with  lobular 


246  MEDICAL    DIAGNOSIS. 

pneumonia — a  form  of  inflammation  of  the  lung  occurring 
mainly  in  children,  and  which,  as  it  is  limited  to  the  lobules, 
yields  but  imperfect  signs  of  consolidation.  The  bronchial 
breathing  is  rarely  very  marked ;  the  minute  rale  indicative 
of  exudation  into  the  air-cells  is  not  usually  perceived,  or 
can  scarcely  be  distinguished  from  the  small  bubbling  sounds 
of  capillary  bronchitis  ;  and,  from  the  usual  association  of  the 
malady  in  question  with  inflammation  of  the  fine  bronchial 
tubes,  it  is  in  individual  cases  often  difficult,  nay,  it  is  impos- 
sible, to  say  whether  portions  of  the  lung  tissue  are  consoli- 
dated, or  whether  the  inflammation  is  limited  to  the  tubes. 
Theoretically  speaking,  broncho-pneumonia  may  be  distin- 
guished from  bronchitis  by  the  dulness  on  percussion ;  but 
practically,  this  aids  but  little.  Dulness  on  percussion  is  in 
children  difiicult  to  elicit;  and  again,  a  dulness  may  be  tem- 
porarily produced  in  capillary  bronchitis  by  collapse  of  the 
pulmonary  tissue.  There  are,  therefore,  no  trustworthy  signs 
of  difference.  Still,  we  may  suspect  that  the  inflammation 
has  consolidated  the  lobules  if  the  breathing  be  very  rapid, 
the  fever  severe,  and  if  in  addition  to  rales,  not  very  diffiised, 
spots  of  dulness,  which  do  not  change  their  seat,  be  discerned. 
On  the  other  hand,  when  there  are  signs  of  deficient  aera- 
tion of  blood ;  when  the  symptoms  point  more  to  prostration 
than  to  activit}'  of  febrile  action ;  when  the  child  seems  to 
suffocate  from  want  of  power  to  expectorate ;  when  multi- 
tudes of  fine  dry  and  moist  sounds  are  heard  at  every  part  of 
the  chest,  and  little  or  no  corresponding  impairment  of  the 
natural  resonance  on  percussion  is  detected, — we  know  that 
the  capillary  bronchi  are  extensivel}'  filled  with  pus  and 
morbid  secretions,  and  that  a  graver  disease  than  broncho- 
pneumonia usually  is,  that  true  suflbcative  catarrh  is  threat- 
ening life. 

The  two  forms- of  acute  bronchitis  considered,  furnish 
somewhat  different  indications  for  treatment.  There  is  too 
much  prostration  in  the  capillar}-  variety  of  the  disorder  to 
admit  of  any  depressing  agents,  and  carbonate  of  ammonia, 
beef  tea,  and  wine  are  more  often  called  for. 

Chronic  Bronchitis. — The  symptoms  and  signs  of  chronic 
bronchitis  are  not  very  different  from  those  of  the  ordinary 


DISEASES    OF    THE    LUNGS.  247 

form  of  acute  broncliitis.  The  duration  of  the  complaint 
and  the  absence  of  marked  fever  are  the  chief  distinfruishino- 
elements.  Yet  the  cough,  although  on  the  whole  chronic,  is 
far  from  being  constant.  It  may  disappear  almost  alto- 
gether, and  then  reappear  with  more  than  its  previous  se- 
verity; and  this  state  of  things  may  go  on  for  years  ;  undue 
exposure  and  change  of  season  aggravating  the  disorder. 

The  sputa  vary  even  more  than  in  acute  bronchitis  in 
tenacity  and  quantity.  There  may  be  merely  a  small  quan- 
tity of  yellowish  matter  expectorated  in  the  morning,  or  an 
almost  continued  flow  from  the  bronchial  tubes — bronchor- 
rhcea.  The  physical  signs  differ  accordingly.  A  harsh  or 
feeble  respiration,  and  few  or  many,  either  dry  or  moist, 
rales  are  present,  in  conformity  with  the  state  of  the  bron- 
chial mucous  membrane  and  of  its  secretions.  The  sound 
on  percussion  is  clear.  Excessive  secretions  somewhat  im- 
pair the  pulmonary  resonance ;  but  only  temporarily ;  for 
with  the  shifting  secretions  shifts  the  slight  dulness. 

One  of  the  most  important  points  in  the  diagnosis  of 
chronic  bronchitis  is  to  attend  to  the  manner  in  which  it 
prises.  It  may  follow  a  seizure  of  acute  bronchitis,  or  be 
the  result  of  recurring  attacks  of  subacute  character;  it  may 
appear  as  a  primary  affection ;  or  it  may  follow  the  exanthe- 
mata; or  again  it  may  complicate  some  previously  existing 
disorder,  as  Bright's  disease,  rheumatism,  gout,  psoriasis,  or 
eczema,  and  be  directly  traceable  to  the  constitutional  taints 
of  these  maladies ;  and  its  symptoms  will  vary  and  be  in- 
fluenced by  those  of  the  general  malady  to  which  it  is 
subordinate. 

In  the  ordinary  idiopathic  malady  the  general  health,  as  a 
rule,  suffers  but  little.  In  some  instances,  however,  emacia- 
tion takes  place,  and  the  disease  simulates  phthisis.*  The 
resemblance  becomes  still  greater,  when  superadded  bron- 
chial dilatation  produces  physical  signs  like  those  of  phthisis. 
Ordinarily,  the  chronicity  of  the  cough,  the  occasional  sub- 

*  This  is  particularly  the  case  in  the  bronchial  aftVctions  among  knife- 
grinders  and  coal-miners,  also  in  that  of  potters.  See  Parson  on  Potters' 
Bronchitis,  Edinb.,  18G4 ;  also  a  Lecture  on  Bronchitis  from  Mechanical  Irri- 
tation, in  Greenhow's  work  on  Chronic  Bronchitis,  London,  1809. 


248  MEDICAL    DIAGNOSIS. 

acute  exacerbations,  the  small  amount  of  constitutional  dis- 
turbance, the  post-sternal  pain,  the  diffusion  of  the  signs 
discerned  on  auscultation,  and  the  clearness  on  percussion, 
constitute  a  group  of  phenomena  which  do  not  permit  an 
error. 

A  chronic  catarrhal  inflammation  of  the  mucous  membrane  of 
the  nose  may  be  mistaken  for  chronic  bronchitis,  with  which, 
indeed,  it  may  coexist.  But  when  occurring  uncombined, 
tliere  are  no  rales  in  the  chest,  or  altered  breathing  sounds 
indicative  of  disorder  there,  though  there  ma}'  be  a  cough, 
from  the  throat  being  also  affected.  The  secretion,  too,  from 
the  nose  is  very  copious  and  of  muco-purulent  character,  the 
upper  part  of  the  nose  looks  somewhat  flattened,  and  the 
sense  of  smell  is  impaired, — not  one  of  which  signs  is  met 
with  in  chronic  bronchitis. 

The  treatment  of  chronic  bronchitis  is  not  always  the 
same.  Different  remedies  suit  different  cases.  In  selecting 
our  therapeutic  agents,  the  amount  and  condition  of  the  dis- 
charge from  the  membrane,  and  the  general  state  of  the 
patient  and  the  attending  complications  must  be  taken  into 
account.  The  acute  exacerbations  of  the  obstinate  disorder^ 
require  the  same  treatment  as  acute  bronchitis. 

We  meet  occasionally  with  a  form  of  bronchitis  in  which 
the  expectorated  matter  is  solid.  This  jjlastic  bronchitis  pre- 
sents all  the  usual  signs  and  symptoms  of  bronchial  inflam- 
mation. It  may  be  chronic,  or  it  may  be  acute.  It  is, 
perhaps,  most  frequently  chronic,  with  occasional  acute  or 
subacute  exacerbations.  The  disease  extends  in  this  way 
over  weeks,  months,  or  even  years,  and  is  apt  to  end  in  com- 
plete recovery.  But  in  its  acute  form  it  is  a  complaint  of 
great  danger,  and  accompanied  by  much  dyspnoea.  Males, 
as  we  find  by  looking  at  the  cases  which  Dr.  Peacock*  has 
collected,  are  more  often  attacked  than  females.  The  same 
carefully-collated  observations  show  that  the  disorder  affects 
more  commonly  the  upper  than  the  lower  part  of  the  lungs. 
As  regards  the  physical  signs.  Fuller,!  who  has  met  with  a 


*  Transactions  of  the  Pathological  Society,  vol.  v.;    Medical  Times  and 
Gazette,  vol.  ix. 

f  Diseases  of  the  Chest. 


DISEASES    OF    THE    LUNGS.  249 

number  of  well-marked  examples  of  the  complaint,  states 
that  there  is  weakness  or  entire  absence  of  breathins:  over 
the  affected  portions  of  the  lungs;  and  that,  from  attending 
collapse,  complete  and  rapidly  developed  dulness  on  per- 
cussion may  ensue.  But  the  only  absolutely  diagnostic 
phenomenon  is  the  peculiar  membranous  material  expecto- 
rated. In  form  this  may  either  be  in  thin  shreds,  or  it  maj'' 
be  moulded  into  an  accurate  cast  of  a  bronchial  tube  and  its 
ramifications.  The  expectoration  of  the  firm  bodies  is. some- 
times attended  with  copious  haemoptysis. 

The  little  round  solid  pellets  which  phthisical  patients  or 
even  some  persons  in  excellent  health  cough  up,  from  time 
to  time,  are  the  result  of  a  plastic  bronchitis  on  a  very  limited 
scale. 

Emphysema. — A  distention  of  the  air-cells  is  a  frequent 
sequel  of  chronic  bronchitis.  It  may  happen  in  onlj^  one 
lung;  but  the  air-vesicles  of  both  are  usually  distended. 
The  effect  of  this  is  to  obliterate  some  of  the  capillaries,  and 
to  interfere  with  a  flow  of  blood  through  the  lungs.  From 
this  proceed,  to  a  great  extent,  the  feeling  of  constriction  and 
the  dyspnoea;  from  this,  further,  result  the  anxious  look,  the 
bluish  lip  of  emphysematous  patients,  and  the  tendency  the 
disease  has  to  produce  dilatation,  or  dilated  hypertrophy  of 
the  right  side  of  the  heart. 

Emphysema  is  essentially  a  chronic  malady;  but  in  its 
course,  subacute  attacks  of  bronchitis  occur  which  much 
augment  the  difficulty  of  respiration.  The  trouble  in 
breathing  is,  indeed,  the  most  prominent  of  the  symptoms. 
It  is  not  so  much  the  difficulty  of  getting  air  into  the  lung,  as 
it  is  of  getting  it  out,  which  annoys  the  patient.  He  breathes 
as  if  he  had  no  object  in  life  but  that  of  forcing  the  air  out 
of  the  pulmonary  tissue.  And  this  task  is  often  aggravated 
by  spasmodic  narrowing  of  the  bronchial  tubes.  In  fact, 
nothing  is  more  common  than  to  meet  Avith  the  loud 
wheezing  of  asthma  in  those  whose  air-cells  are  permanentl}^ 
dilated. 

The  physical  signs  of  emphysema  are  easily  deducible 
from  the  pathological  conditions.  The  distention  of  the 
lung  tissue  explains  the  great  prominence  and  fulness  of  the 


250 


MEDICAL   DIAGNOSIS. 


chest,  and  the  displacement  of  the  liver  or  heart.  The  ring- 
ing clearness  on  percussion — at  times,  in  fact,  almost  tym- 
panitic in  its  character — and  the  increased  resistance  to  the 


Fig.  18. 


.^ 


<\y::-J '-.. 


Appearance  of  the  chest  in  a  patient  suffering  from  a  high  degree  of  emphysema. 
The  heart  is  displaced.  Tlie  otlier  phj'sical  signs  are  extreme  percussion  clearness  ; 
a  feeble,  hardly  audible  inspiration  ;  a  very  prolonged  expiration. 


finger  have  the  same  cause,  l^or  is  it  difficult  to  understand 
how  the  loss  of  elasticity  in  the  dilated  air-cells  will  give 
rise  to  a  prolonged  expiration,  and  to  a  feeble  inspiratory 
murmur.  If  bronchitis  coexist,  the  signs  on  auscultation  are 
necessarily  somewhat  altered.  The  respiration  is  harsh,  or 
intermixed  with  dry  and  moist  rales.  The  former  especially 
assume  great  prominence,  and  are  heard  as  sonorous,  or  still 
oftener  as  sibilant  rales,  during  the  prolonged  and  labored 
act  of  expiration.  When  the  emphysema  is  partial,  all  these 
signs  are  limited ;  when  more  general,  they  are  ditiused. 
If  the  upper  lobe  of  the  right  lung  or  the  lower  lobe  of  the 


DISEASES    OF    THE    LUNGS.  251 

left,  which,  as  Louis*  tells  us,  are  the  parts  most  frequently 
affected,  be  emphysematous,  the  visible  local  bulging  might 
mislead  into  the  idea  of  the  prominence  being  due  to  an 
aneurismal  tumor,  or  to  the  presence  of  fluid  in  the  pleural 
cavity.  Any  doubt  that  may  have  entered  the  mind  will, 
however,  be  dispelled  by  a  careful  examination  of  the  chest. 
The  dulness  over  an  aneurismal  tumor,  its  pulsation,  and  its 
sounds,  are  different  from  the  exaggerated  clearness  on  per- 
cussion, and  the  changed  respiratory  murmur  of  an  emphy- 
sematous lung.  Pleuritic  effusions  produce  a  bulging  at  the 
lower  part  of  the  thorax.  But,  although  there  may  be  a  very 
clear,  or  rather  a  tympanitic  sound  above  the  fluid,  the  abso- 
lute dulness  over  it  shows  that  the  prominence  of  the  chest  is 
not  caused  by  distended  air-vesicles.  Where  the  emphysema 
is  very  extended  and  general,  there  is  little  or  no  action  of  the 
diaphragm,  and  the  complaint  gives  rise  to  displacement  of 
the  liver  or  heart ;  and  this  circumstance,  taken  in  connec- 
tion with  the  dilatation  of  the  chest  and  the  dyspnoea,  brings 
the  malady  into  a  category  of  aftections  which  will  hereafter 
be  more  especially  examined  into.  When  considering  this 
group,  we  shall  return  to  emphysema,  and  point  out  its  dis- 
tinguishing marks  from  the  disease  for  which  it  is  most  likely 
to  be  mistaken,  namely,  pneumothorax.  Let  us  only  add 
here  that  in  its  general  forms  it  is  apt  to  be  associated  with 
marked  signs  of  impoverished  blood  and  of  cachexia. 

But  a  few  words  on  a  special  variety  of  the  complaint,  one 
more  closely  corresponding  to  what  surgeons  term  emphy- 
sema : 

An  eftusion  of  air  may  take  place  into  the  areolar  tissue 
uniting  the  lobules  of  the  lungs.  There  are  no  physical 
signs  peculiar  to  this  interlobular  emphysema;  they  are  exactly 
the  same  as  those  furnished  by  dilatation  of  the  air-cells,  ex- 
cept that  a  dry  friction  sound  and  a  large,  dry  crackling  (both 
of  which  occur  occasionally  in  vesicular  emphysema),  are  verj^ 
much  more  common.  Nor  are  there  any  general  circum- 
stances specially  indicative  of  the  disease,  save  its  sudden- 
ness, and  the  external  emphysema  which  follows.    The  latter 


Memoires  de  la  Soc.  Med.  d'Observat.,  tome  i. 


252  MEDICAL    DIAGNOSIS. 

is  detected  under  the  jaw,  or  at  the  base  of  the  neck,  and 
yields  a  peculiar  crepitation.  Yet  the  extravasation  of  air 
into  the  areolar  tissue  of  the  neck  is  not  a  constant  attendant 
on  the  extravasation  of  air  in  the  lung.  Besides,  the  possi- 
bility of  a  crepitating  swelling  in  the  neck  being  due  to  a 
rupture  of  "the  bronchial  tube  or  of  the  larynx,  must  be  borne 
in  mind. 

The  rupture  of  the  air-cells  which  gives  rise  to  interlobular 
emphysema  is  brought  about  by  any  severe  effort,  by  violent 
coughing,  by  laughing,  or  by  the  throes  of  parturition.  It 
has  also  been  known  to  have  happened  in  the  course  of  pneu- 
monia or  of  pulmonary  hemorrhage,  and  to  have  caused  sud- 
den death.  Its  most  frequent  association,  however,  is  with 
hooping-cough.  * 

In  all  of  the  disorders  which  have  just  been  treated  of,  the 
resonance  on  percussion  has  been  dwelt  upon  as  a  most  val- 
uable sign.  Before  proceeding  to  consider  the  diseases  in 
which  dulness  is  encountered,  a  few  words  may  here  find 
their  place  on  a  morbid  condition  in  ^Ahich  clearness  rapidly 
gives  way  to  dulness,  and  dulness  changes  quickly  back 
into  clearness.  As,  moreover,  the  complaint  to  which  I 
allude — collapse  of  the  lung — bears  a  close  connection  to  bron- 
chitis and  emphysema,  and  has  been  made  to  play  an  impor- 
tant part  in  the  explanation  of  some  of  their  symptoms  and 
complications,  its  consideration  is  at  this  time  most  fitting. 

In  noticing  that  dulness  on  percussion  sometimes  appears 
in  the  course  of  a  case  of  capillary  bronchitis,  it  was  remarked 
that  this  does  not  of  necessity  show  that  the  inflammation 
has  extended  to  the  lobules;  it  may  be  owing  to  the  air  in 
the  lung  being  exhausted,  and  the  pulmonary  tissue  col- 
lapsing. Collapse  of  the  lung  is  thus  a  return  of  the  organ 
to  a  condition  akin  to  its  foetal  state,  and  takes  place  through- 
out a  large  portion  of  the  lungs — diffused  collapse — or  it  is 
lobular.  Formerl}-  the  lobular  collapse  was  invariabl}'  mis- 
taken for  lobular  pneumonia;  and  indeed  it  is  still  often  so 
regarded  by  those  who  are  unwilling  to  admit  that  many,  it 

*  Roger,  Rev.  de  Therap.  Medic,  April,  1862. 


DISEASES    OF    THE    LUNGS.  253 

may  be  the  larger  number  of  cases  of  so-called  lobular  pneu- 
monia, are  really  cases  of  bronchitis  in  which  parts  of  the 
lung  have  been  deprived  of  their  supply  of  air  and  have 
closed. 

The  aspect  of  the  lung  in  lobular  pneumonia  had  attracted 
the  attention  of  pathologists  long  before  MM.  Legendre  and 
Baill}^  inflated  the  supposed  hepatized  lobules,  and  demon- 
strated their  essential  difference  from  the  recognized  features 
of  hepatization  by  restoring  them  absolutely  to  their  normal 
condition.  This  discovery  enhanced  the  importance  of  bron- 
chitis, and  lessened  that  of  lobular  pneumonia;  for  it  was 
soon  found  that  an  accumulation  in  the  bronchial  tubes  was 
the  most  frequent  exciting  cause  of  that  condensation  of  the 
pulmonary  tissue  which  had  previously  been  regarded  as  a 
sure  indication  of  an  inflammation. 

These  accumulations  occasion  collapse  by  shutting  up  the 
tube  through  which  the  air  reaches  the  air-vesicles.  No 
fresh  air  can  enter;  the  residual  air  is  gradually  exhausted, 
and  the  disordered  portion  of  lung  is  reduced  to  a  state  as  if 
it  had  never  breathed.  But  althougli  in  the  majority  of  in- 
stances this  coiidition  of  things  is  brought  about  by  catarrhal 
secretions  in  the  bronchial  tubes  which  cannot  be  expecto- 
rated, it  would  be  a  mistake  to  suppose  that  these  are  always 
present.  Any  want  of  power  to  fill  the  cells  of  the  lung  with 
air  may  lead  to  their  collapsing.  In  some  of  the  typhoid 
forms  of  acute  and  chronic  diseases,  in  the  pulmonary  con- 
gestions of  the  aged  and  enfeebled,  and  in  those  occurring 
just  prior  to  death,  large  portions  of  the  lung  tissue  may 
collapse  simply  from  inability  to  breathe  with  sufficient 
force. 

Such  is  a  sketch  of  collapse  of  the  lung  from  a  pathologi- 
cal point  of  view.  But  when  we  come  to  inquire  whether 
the  diagnostic  sio-ns  of  this  condition  are  so  clearly  defined 
that  we  can  always  make  out  a  collapsed  state  of  the  pul- 
monary tissue,  we  have  to  admit  that  our  knowledge  of  the 
pathological  phenomena  as  yet  exceeds  our  power  to  recog- 
nize them  in  the  living.  The  physical  signs  are  not  very 
satisfactory  ;  the  symptoms  vary  with  the  conditions  produc- 
inu-  the  disease.     There  is  dulness  as  in  the  other  forms  of 


254  MEDICAL    DIAGNOSIS. 

condensation,  as  in  pneumonia,  as  in  pleurisy.  Neither 
voice  nor  respiration  is  characteristic.  The  most  usual 
physical  sign  is  dulness  on  percussion,  with  an  ahsence  of 
all  respiration,  or  with  a  blowing  sound,  which  is  faint  and 
not  so  distinct  as  in  pneumonia.  The  dulness  is,  on  the  whole, 
not  very  great,  and  in  cases  dependent  upon  inspissated 
mucus  may  disappear  suddenly,  or  nearly  suddenly,  when 
the  obstructing  cause  is  removed.  Yet  it  must  not  be  for- 
gotten that  collapse  of  the  lung  is  at  times  a  state  of  long 
duration.  Great  stress  is  laid  by  some  on  the  signs  of 
emphysema  which  surround  the  dulness  of  the  condensed 
tissue. 

When  collapse  takes  place,  the  breathing  becomes  very 
difficult.  The  patient  makes  intense  efforts  at  inspiration. 
Dr.  George  A.  Rees  tells  us  that,  owing  to  the  non-expansion 
of  the  lung  during  this  inspiratory  effort,  the  ribs  move  in- 
ward and  recede,  instead  of  moving  outward,  as  in  ordinary 
respiration.  This  sign,  the  suddenly  increased  dyspnoea, 
and  the  appearance  of  dulness  unaccompanied  by  marked 
bronchial  breathing,  are,  in  a  case  of  bronchitis,  the  most 
trustworthy  indications  that  collapse  of  the  lung  tissue 
has  taken  place.  Yet  where  the  collapsed  lobules  are 
small  and  scattered  through  the  lung,  these  signs  are  not 
all  present,  and  the  diagnosis  is  very  uncertain.  The  dul- 
ness is  wanting;  and  the  peculiarity  in  inspiration  may  not 
be  observed. 

When  collapse  affects  a  large  portion  of  lung,  it  much  re- 
sembles lobar  pneumonia  and  pleurisy,  from  both  of  which, 
however,  it  may  often  be  distinguished  by  the  phenomena 
indicated,  and,  still  more  positively,  by  the  history  and  the 
absence  of  that  grouiJ  of  symptoms  and  physical  signs  which 
characterizes  inflammation  of  the  lung  or  pleura.* 

*Seo,  on  the  subject  of  collapse,  besides  the  writings  referred  to  of  Legen- 
dre  and  Baillj^,  Archives  Gener.  de  Medic,  184-1;  Fuchs,  Bronchitis  der 
Kinder,  Leipsic,  1849;  Gairdner,  Month.  Journal  of  Med.  Science,  Edinb., 
1850,  Brit,  and  For.  Med.-Chirg.  Keview,  April  and  July,  1853,  and  Jan. 
1854,  etc.;  Kees,  Essaj^  on  Collapse,  London,  1850;  Barthez  and  Billict, 
Maladies  des  Enfants;  and  AYest,  Diseases  of  Childhood. 


DISEASES    OF   THE    LUNGS.  255 


Diseases  in  which  Dulness  on  Percussion  occurs. 

The  diseases  of  the  lungs  in  which  dulness  on  percussion 
is  met  with,  are  all  those  in  which  compression  or  consoli- 
dation of  the  pulmonary  tissue  takes  place.  Especially, 
however,  do  we  find  dulness,  and  the  physical  signs  which 
accompany  it,  in  tubercular  infiltrations,  in  pneumonia,  and 
in  pleurisy. 

Phthisis. — Phthisis  presents  itself  in  a  chronic  and  in  an 
acute  form.  The  chronic  variety  is  by  far  the  most  frequent. 
It  is  essentially  "  the  consumption,"  which  is  such  a  scourge 
to  the  human  race.  Beginning  usually  with  a  short  and 
insidious  cough,  with  a  feeling  of  lassitude,  and  a  decline 
in  general  health ;  attended  at  times  from  its  onset  with  a 
pain  in  the  afi:ected  lung  and  a  somewhat  quickened  circula- 
tion ;  or  giving  the  first  indications  of  its  existence  by  the 
occurrence  of  a  hemorrhage  ;  or  developing  itself  after  severe 
bodily  or  mental  fatigue;  or  traceable  to  some  neglected 
cold, — the  disease  becomes  fully  established,  with  symptoms 
which  hardly  need  a  detailed  description.  The  harassing 
cough  by  day  and  by  night;  the  impaired  appetite  and  dis- 
turbed digestion ;  the  loss  of  blood  from  the  lungs ;  the 
steadily  augmenting  debility ;  the  short  breathing ;  the  ex- 
hausting night-sweats ;  the  hectic  fever ;  the  deceptive  blush 
which  this  imparts  to  the  cheek;  the  increased  lustre  of  the 
eye  ;  the  singular  hopefulness  ;  the  temporary  improvements; 
the  relapses;  and  the  greater  vividness  of  the  imagination, 
so  strongly  contrasting  with  the  waning  frame, — arc  phe- 
nomena with  which  sad  experience  has  made  not  only  every 
physician,  but  many  a  fireside  familiar. 

The  most  constant  of  all  these  symptoms  are  the  hemor- 
rhage, the  cough,  and  the  emaciation.  The  cough  of  phthisis 
is  at  first  dry,  and  followed  by  a  frothy  expectoration.  As 
the  disease  advances,  the  sputa  thicken.  They  become  green- 
ish in  color,  streaked  with  yellow,  and  "nummular,"  con- 
sisting of  large  greenish  masses  of  a  rounded  form,  or  some- 
times rounded  yet  with  jagged  edges,  which  masses  do  not 
sink  in  the  cup  containing  them,  but  float  imperfectly  in  a 


256  MEDICAL    DIAGNOSIS. 

thin  serum.  This  "money-like"  expectoration  is,  however, 
by  no  means  pathognomonic  of  tlie  mahidy.  Cases  of  phthisis 
occur  without  it;  and,  on  the  other  hand,  it  is  occasionally 
encountered  in  chronic  bronchitis.  In  the  last  stages  of  con- 
sumption, the  sputa  are  often  homogeneous,  and  have  a  dirty- 
grayish,  decidedly  purulent  aspect.  Examined  microscopic- 
ally, they  show  fragments  of  the  structure  of  the  lung,  many 
pus-cells,  exudation-globules,  and  those  peculiar  granular 
bodies  which  are  reo-arded  as  characteristic  of  tubercle.  Yet 
the  microscope  does  not  aid  us  very  much  in  the  diagnosis 
of  phthisis.  The  only  appearances  in  the  sputum  at  all  dis- 
tinctive, are  the  fragments  of  the  pulmonar}^  fibrous  tissue 
and  the  so-called  tubercle-corpuscles.  But,  though  from  the 
presence  of  the  former  we  are  sometimes  enabled  to  suspect 
the  existence  of  consumption  before  the  physical  signs  of  even 
its  early  stages  are  well  deliued,  we  can  never  be  quite  certain 
that  the  breakage  of  the  lung  texture  is  due  to  tubercular  dis- 
ease, And  as  regards  the  so-called  tubercle-corj)uscles,  they 
are  always  very  difficult  to  distinguish  from  shrivelled  pus- 
cells,  and  their  absence  in  the  expectoration  does  not  dis- 
prove the  possibility  of  the  lungs  being  filled  w^ith  tubercles. 
An  excellent  way  of  finding  the  lung  tissue  is  by  the  plan 
proposed  by  Dr.  Fenwick* — to  liquefy  the  sputum  by  means 
of  pure  caustic  soda,  when  any  particles  which  may  be  con- 
tained in  it  fall  to  the  bottom  of  the  vessel,  and  can  be  readily 
removed  and  placed  under  the  microscope. 

In  another  manner,  too,  has  it  been  proposed  to  make  use 
of  the  sputum  for  diagnostic  purposes.  Taking  as  a  starting- 
point  tlie  discovery  of  Villemain,  that  tubercular  matter  can 
be  inoculated  from  man  to  animals,  Dr.  William  Marcetf 
suggests  the  inoculation  of  the  expectoration  of  persons  con- 
sidered as  phthisical.  From  his  experiments  on  guinea-pigs, 
he  found  that  these  animals  die  of  tubercular  disease,  or  on 
being  killed  thirty  days  after  inoculation,  exhibit  tubercles 
in  their  organs,  when  inoculated  with  tubercular  sputum. 

In  rare  instances,  the  cough  remains  slight  throughout  the 
malady;  but  generally  it  is  a  very  distressing  feature  of  the 


*  Mcdico-Chirurg.  Transaclions,  vol.  xlix.  f  Ibid  ,  vol.  1. 


DISEASES    OF    THE    LUNGS.  257 

complaint,  and  is  particularly  worrying  at  night.    Sometimes 
its  violent  paroxysms  bring  on  vomiting. 

Among  the  less  constant  and  distinctive  symptoms  of  pul- 
monary consumption  are  a  troublesome  and  rebellious  diar- 
rhoea, chronic  laryngitis  and  pharyngitis,  and  the  red  line 
around  the  border  of  the  gum.  In  some  persons  this  gin- 
gival line  is  a  mere  streak;  in  others  it  is  more  than  a  line 
in  breadth;  in  none  is  it  a  certain  indication  of  phthisis.  A 
sign  which  has  a  much  more  detinite  connection  with  tuber- 
cular disease  of  the  lungs  is  the  strange  appearance  of  the 
nails.  The  end  of  the  linger  is  somewhat  clubbed;  the  nail 
is  curved,  prominent  in  the  centre,  depressed  at  tlie  sides,  its 
surface  slightly  cracked,  its  appearance  bluish.  This  peculiar 
condition  of  the  nails  is  not  always  present;  yet  it  is  tolerably 
constant,  and  is  sometimes  met  with  even  in  the  earlier  stasea 
of  the  disease.  A  similar  nail  is,  however,  seen  in  chronic 
pleurisy  and  in  diseases  of  the  heart. 

Another  symptom  of  phthisis  of  significance  is  the 
heightened  temperature  as  ascertained  by  the  thermome- 
ter. Ringer,*  who  in  an  able  essay  has  drawn  attention  to 
the  subject,  states,  indeed,  that  the  temperature  may  be 
greatly  elevated  for  several  weeks  before  we  find  physical 
signs  indicative  of  the  deposition  of  tubercle,  or  of  an  un- 
doubted increase  in  the  already  existing  deposition.  It  is 
furthermore  maintained,  that  the  rise  in  the  heat  of  the 
body  closely  corresponds  to  the  activity  of  the  deposition  of 
the  tubercle.  If  the  temperature  be  decidedly  and  perma- 
nently elevated  throughout  the  day,  there  is  active  deposi- 
tion; if  normal,  or  nearly  so  at  one  period,  though  at  another 
it  rises  to  considerable  height,  the  deposition  is  less  active; 
and  it  is  slow  if  the  rise  be  far  less  marked.  When  the 
animal  heat  is  normal,  the  deposition  in  the  lungs  has  ceased, 
and  the  tubercular  process  is  arrested  or  retrogressing. 

These  statements  are  clinically  of  importance;  but,  I  thiidc, 
from  repeatedly  examining  into  the  matter,  that  they  are  not 
to  be  trusted  absolutely.  They  only  represent  a  general 
truth,  and  do  not  aid  us  much,  for  instance,  in  lingering  lung 

*  On  the  Temperature  of  the  Body.     London,  1865. 

n 


258  MEDICAL    DIAGNOSIS. 

complications  iu  febrile  states,  nor  in  afiections  intercurrent 
in  plithisis,  nor  in  certain  forms  of  persistent  non-tubercular 
consolidations. 

The  symptoms  which  precede  a  fatal  termination  are  va- 
rious, and  depend  on  the  precise  manner  in  which  the  formi- 
dable malady  ends.  Patients  may  go  on  failing  for  years ; 
or  an  attack  of  acute  phthisis,  of  pneumonia,  or  of  inflamma- 
tion of  the  brain  or  of  tbe  intestinal  tract  may  at  any  time 
result  in  death. 

But  at  no  stage  of  the  disease  do  we  derive  as  exact 
knowledge  from  a  study  of  its  sj^mptoms  as  we  do  from  a 
study  of  its  physical  signs.  Before  explaining  these,  it  is 
necessary  to  recall  briefly  some  facts  connected  with  the 
general  laws  governing  tubercle. 

Tubercle  is  an  unorganized  substance,  the  deposits  of 
which  are  at  first  isolated,  then  accumulate,  and  lead  to  con- 
solidation of  the  part.  The  tendency  of  tubercular  matter 
is  to  soften  and  to  destroy  the  textures  among  which  it  is  in- 
filtrated. It  ma}-  undergo  at  any  period  in  its  course  a  retro- 
gressive development,  by  shrivelling  up,  or  by  passing  into 
a  calcareous  state.  AVhen  situated  in  the  luno;s,  it  seeks 
the  apices  by  preference;  it  is  rarely  limited  to  one  lung, 
although  one  lung  is  usually  tha  most  diseased,  and  often  at 
the  beginning  of  the  malady  alone  affected.  It  is  not 
merely  a  local  complaint,  but  it  stands  in  connection  with  a 
peculiar,  tainted  state  of  the  constitution ;  hence  the  symp- 
toms of  phthisis  are  not  solel}^  the  expressions  of  the  con- 
dition of  the  lungs. 

These  pathological  facts  are  all  of  the  greatest  importance. 
They  tell  us  where  to  seek  for  the  earliest  indications  of  a 
deposit.  They  explain  to  us  its  signs.  They  teach  us  to  look 
further  than  the  lungs,  and  prepare  us  for  finding  lesions  in 
other  organs.  They  point  out  the  path  which  alone  promises 
to  lead  to  any  result  in  treatment. 

In  accordance  with  the  laws  aifecting  tubercular  deposi- 
tions, we  have  three  stages  of  phthisis,  which  run,  however, 
by  almost  imperceptible  degrees  into  each  other.    They  are : 

1.  Incipient  stage,  or  commencing  deposition  ; 

2.  More  complete  deposition,  occasioning  consolidation  ; 


DISEASES    OF    THE    LUNGS. 


259 


3.  Stage  of  softening  and  formation  of  cavities. 

1.  A  few  scattered  tubercles  do  not  change  the  normal  per- 
cussion resonance;  nor  do  they  appreciably  alter  the  natural 
breathing  sounds  heard  on  auscultation.  But  as  soon  as  the 
deposit  is  at  all  sutiicient  to  impair  the  elasticity  of  the  lung 
tissue  or  increase  its  density,  a  relative  loss  of  clearness  on 
percussion  on  one  side,  and  modifications  of  the  vesicular 
murmur,  such  as  feeble  or  jerking  inspiration,  or  a  prolonged 
expiration,  may  be  ascertained.  The  dulness  is  most  readily 
detected  by  percussing  the  patient  with  his  mouth  open  and 
during  a  fixed  expiration.  To  find  it  at  the  upper  part  of  the 
chest  posteriorly,  the  position  recommended  by  Dr.  Corson,* 

Fig.  19. 


Slight  percussion  dulness. 


Feeble   or   harsh  respira- 
tion. 


Prolonged  E.xpiration. 


Exaggerated  respiration... 


Commencing  infiltration ;  masses  of  tubercle  have  accumulated, 
hut  the  intervening  lung  tissue  is  still  healthy. 


of  crossing  the  arms  and  clasping  the  shoulders,  is  very  advan- 
tageous. In  a  certain  number  of  cases,  with  the  slight  dulness 
on  percussion  and  changed  breathing  is  associated  a  blowing 
sound  in  the  subclavian  or  in  the  pulmonary  artery.    A  mur- 


*  New  York  Journal  of  Medicine,  March,  1859. 


260  MEDICAL    DIAGNOSIS. 

mur  is,  indeed,  at  times  present  in  the  pulmonary  artery  long 
before  any  other  physical  indication  of  tubercle  is  discernible. 
All  these  physical  signs  may  be  accompanied  by  rales  of  va- 
rious kinds.  What  makes  them  significant  is,  that  they  occur 
at  the  upper  portion  of  the  lung,  whether  anteriorly  or  pos- 
teriorly. If,  therefore,  any  moditication  of  the  vesicular  mur- 
mur, or  any  adventitious  sound  limited  to  the  apex,  exist;  if 
there  be  a  slight  dulness  on  percussion  above  or  under  the 
clavicle,  or  in  the  supra-spinous  fossa;  if  this  coincide  with 
flattening  of  the  anterior  surface  of  the  chest,  especially  on 
one  side,  with  defective  expansion  of  the  thorax  and  shortness 
of  breath,  with  a  cough  and  falling  off  in  general  health, — the 
diagnosis  of  commencing  tubercular  disease  is  almost  posi- 
tive. 

2.  As  the  infiltration  advances,  the  signs  become  more  de- 
cidedly those  of  consolidation.  Greater  dulness  on  percussion 
at  the  upper  portion  of  one  or  of  both  lungs;  more  resistance 
to  the  percussing  finger ;  stronger  vocal  resonance;  a  sinking 
in  of  the  side  most  affected,  and  often  soreness  to  the  touch 
over  the  diseased  part;  a  very  harsh  murmur;  or,  when  the 
infiltration  surrounds  the  bronchial  tubes,  a  distinct  blowing 
respiration, — are  all  present  in  varying  degree,  and  all  denote 
consolidation.  And  chronic  consolidation  at  the  apex  has, 
in  the  large  majority  of  instances,  but  one  interpretation  : 
phthisis.  In  the  second  stage,  as  well  as  in  the  first,  we 
often  meet  with  superadded  signs  of  bronchitis  which  occa- 
sionally mask  the  respiratory  sounds,  and  with  friction  sounds 
from  local  pleurisies,  or  with  fine  crackling. 

3.  The  diseased  organ  now  passes  into  a  state  of  softening, 
or  rather  some  portions  of  the  lung  begin  to  soften  while 
others  remain  indurated,  and  in  yet  others  fresh  infiltration 
takes  place.  Moist  crackling  or  persistent  moist  rales  indi- 
cate that  softening  has  begun.  Tlie  broken-down  material 
may  be  expectorated,  and  the  malady  for  a  time  be  stayed ; 
but  such  is  not  often  the  case.  The  area  of  the  softened  mass 
widens ;  cavities  form ;  and  in  addition  to  the  moist  rales,  to 
the  physical  phenomena  of  the  second  stage,  and  to  the  in- 
creasing debility,  night-sweats  and  hectic,  the  signs  indicative 
of  a  cavity  are  noticed.    What  these  are,  may  be  learned  from 


DISEASES    OF    THE    LUNGS. 


261 


the    eiii^raving   on  this  page.     But  the    hollow,   cavernous 
respiration  may  be  caught  only  in  expiration,  or  it  may  be 


Fig.  20. 


Cavernoiii' 
respiration. 


Amphoric 
percussion 

Amphoric 
respiration 

Amphoric 
voice. 


Cavities  of  various  sizes. 


temporarily  superseded  by  very  large  bubbling  sounds — gur- 
gling. Again,  over  small  or  over  very  deep-seated  cavities 
none  of  these  sounds  may  be  perceived ;  and,  in  truth,  even 
when  they  exist,  their  limitation  to  a  particular  locality  is  an 
element  in  the  diagnosis  of  a  cavity  almost  as  important  as 
their  presence. 

The  results  of  percussion  over  an  excavation  are  not  always 
the  same,  nor  can  they  be  relied  upon.  They  depend  too 
much  on  the  thickness  and  the  state  of  the  walls  of  the  cavity. 
If  dense,  percussion  yields  a  dull  sound  ;  if  thin,  a  tympanitic, 
or  its  varieties,  a  crucked-pot  or  metallic  sound.  If  only  a 
certain  amount  of  indurated  tissue  intervene  between  them 
and  the  surface  of  the  chest,  a  singular  sound,  a  mixture  of 
dull  and  tympanitic,  is  produced.  If  healthy  lung  tissue  form 
the  walls  of  the  excavation,  the  sound  is  clear,  or  nearly  so. 
Moreover,  in  all  cases  the  pitch,  and,  to  some  extent,  the 
character,  of  the  sound  are  changed  by  percussing  over  the 


262  MEDICAL    DIAGNOSIS. 

cavity  wliile  the  mouth  is  kept  open.  When  it  is  shut,  the 
sound  elicited  is  of  lower  pitch.  Another  sign  by  which  we 
may  judge  of  the  existence  of  a  cavity  at  the  upper  part  of 
the  lunsr,  is  the  extraordinary  clearness  with  which  the  heart 
sounds  are  heard  at  that  point,  and  the  perception  of  a  waving 
impulse  in  the  second  intercostal  space. 

Such,  then,  are  the  physical  signs  which  indicate  the 
varied  structural  conditions  of  the  lung  in  the  three  stages 
of  phthisis.  With  these  signs  are  associated,  as  sj'mptoms : 
cough,  increasing  quickness  of  breathing,  progressive  debil- 
ity, hectic  fever,  digestive  disorders,  and  emaciation — symp- 
toms the  occurrence  and  severity  of  which  mark  also,  though 
not  very  accurately,  the  periods  of  the  malady.  But  irre- 
spective of  these  three  stages,  some  have  admitted  a  stage 
preceding  the  deposition  of  the  tubercles.  That  such  a 
pretubercular  stage  exists,  is  not  improbable  ;  that  to  be  al)le 
to  recognize  it  would  be  one  of  the  most  important  and  valu- 
able gifts  to  practical  medicine,  is  undoubted;  but  whether  it 
be  recognizable,  is  another  matter.  It  does  not  seem  to  me 
that  the  advocates  of  the  possibility  of  detecting  phthisis  at 
this  stage  have  clearly  proved  their  point.  On  the  one  hand, 
they  lay  claim  to  signs,  such  as  diminished  expansion  of  the 
chest,  decreased  vital  capacity,  a  murmur,  feeble  and  remain- 
ing feeble  on  forced  breathing,  hosmoptysis,  even  slight  dul- 
ness  on  percussion — a  combination  which  we  are  accustomed 
to  i-egard  as  evidence  that  tubercle  already  exists ;  on  the 
other  hand,  they  assert  that  defects  of  temperature,  lessened 
muscular  power,  improper  assimilation,  emaciation,  sore- 
throat,  and  slight,  dry  cough,  are  prodromic  symptoms. 
Yet  all  of  these  may  be  associated  with  a  temporary  de- 
rangement of  health,  and  all  of  these  are  far  more  frequently 
so  associated  than  with  threatening  consumption.  And  to  sa}' 
that  they  become  of  value  only  when  coexisting  with  the 
physical  signs  alluded  to,  is  but  saying  that  they  are  the 
clinical  phenomena  which,  thus  grouped,  we  are  in  the  habit 
of  accepting  as  proof  of  the  first  stage  of  the  disease.  But 
without  entering  further  into  this  question,  it  may  be  stated 
that  the  deposition  can  generally  be  detected  at  a  very  early 
period  by  careful  explorations  of  the  chest,  and  by  connecting 


DISEASES    OF   THE    LUNGS.  263 

the  physical  signs  with  other  sources  of  information,  such  as 
the  symptoms  and  the  history  of  the  case. 

Let  us  now  examine  the  disorders  with  which  phthisis,  in 
its  various  stages,  is  likely  to  be  confounded.  They  are,  to 
speak  of  thoracic  affections  only : 

Chronic  Bronchitis; 

Chronic  Pneumonic  Consolidation  ; 

Chronic  Pleurisy; 

Pulmonary  Cancer; 

Syphilitic  Disease  of  the  Lungs; 

Bronchial  Dilatation; 

Pulmonary  Abscess; 

Pulmonary  Gangrene. 

Chronic  Bronchitis. — The  first  stage  of  consumption  is  par- 
ticularly prone  to  be  mistaken  for  chronic  bronchitis.  jSTor 
is  the  diagnosis  always  easy.  Distinct  dulness  on  percussion 
at  the  apex  is  of  much  aid  in  discrimination,  especially  if  it 
be  on  the  left  side.  On  the  right  side  it  is  of  far  less  value, 
unless  marked  alterations  of  the  vesicular  murmur  corre- 
spond to  it.  When  the  dulness  is  not  discernible,  we  have  to 
depend,  in  our  efforts  at  a  separation  of  the  two  diseases,  on 
the  history  of  the  case,  the  limitation  of  the  physical  signs 
to  the  apex,  and  the  proofs  of  increased  activity  of  the  sur- 
rounding lung.  Cough  and  expectoration  are  common  to 
both  affections.  But  thev  are  associated,  in  chronic  bron- 
chitis,  with  physical  signs  more  or  less  diffused  through  both 
lungs,  and  unaccompanied  by  much  constitutional  disturb- 
ance; while  from  the  onset  of  phthisis,  the  falling  off  in 
general  health  is  out  of  proportion  to  the  local  lesions.  Yet 
until  crackling  or  some  dulness  on  percussion  is  perceived, 
no  absolute  diagnosis  is  possible.  These  indications  of  be- 
ffinnine;  consolidation  settle  the  diao-nosis  a2:ainst  bronchitis. 
And  this  view  of  a  case  will  be  strengthened,  if  hemorrhage 
have  occurred  without  an}'-  other  more  certain  cause  to  ac- 
count for  it  than  the  tubercles  which  are  presumed  to  exist, 
and  if  the  phenomena  are  present  in  a  person  born  of  a  fam- 
ily in  which  consumption  is  hereditary. 

Where  the  deposition  is  at  all  extensive,  an  erroneous  diag- 
nosis of  bronchitis  is  with  ordinary  care  impossible,  unless,  as 


264  MEDICAL    DIAGNOSIS. 

is  always  highly  improbable,  phthisis  should  be  complicated 
with  emphysema,  or  the  tubercles  be  quiescent  and  so  dif- 
fused as  not  to  impair  the  resonance  on  percussion.  Under 
the  latter  circumstances  especially,  the  occasional  tympanitic 
character  of  the  sound  over  the  seat  of  the  tubercular  deposi- 
tion is  very  liable  to  be  misconstrued  into  increased  clearness 
on  percussion,  and  into  an  absolute  disproval  of  the  existence 
of  phthisis.  When  tubercle  and  emphysema  coexist,  the  per- 
cussion note  may  really  be  pulmonary  and  like  that  of  healthy 
lung.  We  would  then  have  to  judge  of  the  one  disease  follow- 
ing the  other  mainly  by  the  respiratory  sound,  which  becomes 
much  feebler;  generally,  too,  the  dyspnoea  is  increased.  Per- 
haps the  thermometer,  as  liinger  suggests,  by  showing  a 
higher  temperature  than  in  pure  emphysema,  may  assist  us 
in  the  diagnosis. 

In  the  staffe  in  which  the  siirns  of  consolidation  become 
well  defined,  phthisis  may  be  mistaken  for  any  of  those  con- 
ditions which  occasion  the  physical  signs  indicative  of  greater 
density  of  the  lung  tissue,  and  which  are  accompanied  by 
cough  and  by  loss  of  flesh.  Such  are  particularly  pneumonic 
consolidation,  pleuritic  eftusion,  and  cancerous  deposits. 

Chronic  Pneumonic  ConsoUdaiion. — Chronic  pneumonic  con- 
solidation, or,  as  the  affection  is  commonly  called,  chronic 
pneumonia,  gives  rise  to  man}^  manifestations  which  simu- 
late consumption.  These  are  cough,  emaciation,  and  the 
local  signs  of  chronic  pulmonary  condensation — increased 
voice  and  fremitus,  sinking  in  of  the  chest  M^all,  feeble  in- 
spiration and  prolonged  expiration,  or  a  fully-developed  bron- 
chial respiration.  But  in  pneumonic  consolidation  the  history 
usually  points  to  an  antecedent  acute  affection  ;  the  health  is 
not  so  mucli  impaired;  there  has  been  no  hemorrhage,  al- 
though, owing  to  an  intervening  acute  bronchitis,  the  sputa 
at  times  may  have  been  streaked  with  blood;  and  the  dul- 
ness  on  percussion  and  the  other  phj^sical  signs  of  consolida- 
tion are,  for  the  most  part,  perceived  over  the  lower  lobe  of 
one  lung. 

This  position  of  the  physical  signs  is  of  great  impor- 
tance. Yet  there  are  two  sources  of  fallacy  which  may  arise. 
On  the  one  hand,  tubercles  may,  by  way  of  exception,  be 


DISEASES    OF    THE    LUNGS.  265 

seated  in  tlie  lower  lobe;  on  the  other,  chronic  pneumonic 
induration  may  affect  the  apex.  When  an  infiltration  of 
tubercle  takes  place  in  the  lower  lobe,  its  distinction  from 
chronic  pneumonic  condensation  is  very  difficult.  Our  only 
guides  are  the  evidence  furnished  by  the  graver  constitu- 
tional symptoms  of  phthisis,  and  attention  to  that  patholog- 
ical law  which  teaches  that  consumption  is  not  met  with  in 
an  advanced  state  in  one  lung  alone;  hence  we  must  ex- 
amine accurately  and  watch  carefully  the  other  lung..  While 
it  is  not  involved,  there  is  certainly  reason  to  conclude  against 
the  tubercular  character  of  tlie  deposit.  In  like  manner, 
by  ascertaining  the  one-sidedness  of  the  disease,  and  by 
noting  the  want  of  those  serious  symptoms  which  go  hand  in 
hand  with  the  physical  signs  of  phthisis,  we  may  determine 
the  real  nature  of  the  case  when  an  inflan\mation  of  the 
upper  lobe  has  resulted  in  its  persistent  induration.  To  ad- 
duce a  few  instances,  by  way  of  illustration: 

A  gentleman  has  been  under  my  care  for  years,  in  whom, 
after  pulmonary  inflammation,  signs  of  condensation  re- 
mained in  the  upper  part  of  the  right  lung.  He  does  not 
suffer  at  all,  excepting  from  attacks  of  acute  bronchitis,  to 
which  he  is  very  liable.  During  these  he  loses  flesh;  but 
when  they  pass  off  he  rapidly  regains  it.  He  has  a  chronic 
cough,  but  it  is  slight. 

In  another  case,  with  a  similar  history,  I  found  dulness  on 
percussion,  prolonged  expiration,  and  a  friction  sound  limited 
to  the  apex  of  the  right  lung.  There  had  been  a  continuous 
cough,  but  very  little  constitutional  disturbance,  in  fact  next 
to  none,  and  no  hemorrhage.  The  abnormal  signs  lasted  for 
a  year,  and  then  almost  disappeared  under  a  succession  of 
blisters,  and  the  cough  ceased. 

In  both  cases  the  signs  were  entirely  confined  to  the  sum- 
mit of  one  luno;.  I  had  some  time  since  under  observation 
a  patient  affected  much  in  the  same  manner,  a  man  of 
seventy-five  years  of  age,  in  whom  the  dulness  at  the  right 
apex  had  for  years  remained  stationary.  I  might  cite  further 
examples;  but  these  are  sufficient  to  justify  the  conclusions 
that  can  be  drawn  from  the  facts  mentioned.  And  ought 
not  such  instances  to  make  us  careful  in  our  deductions? 


266  MEDICAL    DIAGNOSIS. 

Ought  they  not  to  have  their  full  weight  when  estimating 
the  cures  of  supposed  cases  of  consumption  by  cod-liver  oil, 
or  by  any  other  remedy? 

But  to  return  to  the  points  of  difference  between  chronic 
induration  of  the  lung  and  phthisis.  They  may  be  thus 
summed  up:  when  the  signs  of  consolidation,  whether  exist- 
ing at  the  upper  part  of  the  lung  or  not,  are  out  of  propor- 
tion to  the  general  symptoms,  there  is  reason  to  believe  that 
they  are  not  the  result  of  tubercular  infiltration.  The  non- 
occurrence of  hemorrhage  would  tend  to  strengthen  such  an 
inference.  But  the  most  important  information  is  drawn 
from  watching  whether  the  ph3'sical  signs  undergo  changes 
indicative  of  a  deposit  in  the  hitherto  healthy  portions  of  the 
pulmonary  texture.  And  it  must  be  confessed  that  minute 
and  accurate  examinations  having  reference  directly  to  this 
point  are  sometimes  the  only  means  through  which  anything 
like  a  positive  opinion  can  be  reached.  Hence  time  and  re- 
peated observations  are  important  elements  in  the  diagnosis. 

In  so  close  a  manner,  then,  may  phthisis  be  imitated  by 
chronic  pneumonic  induration.  It  is  true,  this  disease  is  a 
rare  one;  yet  we  meet  with  it  more  frequently  than  authors 
on  diseases  of  the  chest  imply,  who,  for  the  most  part,  ignore 
induration  of  the  pulmonary  tissue,  excepting  as  a  local  at- 
tendant on  cancerous  or  tubercular  depositions. 

But  a  great  and  complicating  difSculty  in  the  differential 
diao-nosis  remains  to  be  mentioned.  It  ffrows  out  of  the  cir- 
cumstance  that  tubercular  disease  may  be  devoloped  in  a  lung 
which  is  in  a  state  of  chronic  induration.  I  cannot  enter 
here  into  the  question  whether  latent  tubercle  maj-  not  have 
preceded  the  pneumonia  which  has  lapsed  into  the  chronic 
malady.  Be  that  as  it  may,  the  fact  cannot  be  disputed  that 
we  tind  persons  in  apparently  excellent  health,  and  without 
a  trace  of  any  pulmonary  disorder,  seized  with  an  inflamma- 
tion of  the  lung,  which  is  followed  by  persistent  consolidation, 
and  in  the  course  of  time  by  undoubted  phthisis.  I  have 
noted  a  number  of  such  instances,  and  I  cannot  but  believe 
that  many  of  the  reported  cases  of  tubercle  affecting  pri- 
marily the  lower  lobe  of  the  lung  are,  in  reality,  cases  of 
tubercle  following  chronic  pneumonic  consolidatioii. 


DISEASES    OF    THE    LUNGS.  267 

The  history  of  these  patients  is  usually  as  follows:  a  person 
previously  in  all  respects  healthy  is  attacked  with  an  acute 
pulmonary  affection.  He  recovers  from  it,  but  with  a  trifling 
cough,  with  a  persistent  dulness  on  percussion,  and  a  feeble 
respiration,  heard  over  one  of  his  lungs.  lie  continues  ailing, 
yet  is  not  positively  sick,  when,  without  any  apparent  cause, 
after  a  time  varying  from  a  few  months  to  years,  his  cough 
increases,  the  expectoration  augments  greatly  in  quantity  and 
becomes  decidedly  purulent,  and  he  commences  to  emaciate 
rapidly.  Profuse  night-sweats  occur;  and  the  physical  signs, 
which  have  been  stationary  for  a  long  time,  now  begin  to 
change.  The  dulness  extends;  and  instead  of  the  enfeebled 
respiration,  a  harsher,  blowing  respiration  is  perceived  over 
the  affected  part,  and  moist  crackling  and  the  signs  of  a 
cavity  follow.  Doubt  may  still  exist  as  to  the  nature  of  the 
malady,  but  the  advance  of  the  disease  clears  it  up.  True 
to  the  laws  of  tubercle,  a  deposit  takes  place  in  the  lung  pre- 
viously sound,  and  not  at  the  lower  portion,  but  at  its  apex. 

Hemorrhage  may  or  may  not  occur.  In  the  patient  from 
wdiose  case  the  above  description  is  di-awn,  it  did  not  happen; 
and  in  others,  too,  it  was  wanting.  Its  presence  is,  therefore, 
strongly  in  favor  of  the  fact  that  tubercles  have  been  devel- 
oped; its  absence  does  not  positively  prove  the  contrary. 

I  leave  these  remarks  as  they  were  originally  written.  Of 
late  years  a  school  of  pathologists,  with  Niemeyer  at  their 
head,  have  endeavored  to  re-establish  the  old  doctrine  that 
consumption  of  the  lung  and  the  formation  of  cavities  are 
most  frequently  the  result  of  chronic  inflammation.  Accord- 
ing to  this  view,  the  kind  of  cases  just  discussed  belong  to 
that  grand  group  of  phthisis  in  which  the  pneumonic  pro- 
cess terminates  in  caseous  degeneration  and  destruction  of 
tissue.  This  group,  the  most  common  form  of  consumption, 
presents  somewhat  different  traits  according  to  the  rapidity 
of  its  development.  It  differs  from  the  true  tuberculous 
consumption,  due  to  a  tubercular  deposit,  in  this:  the  latter 
has  no  precursory  catarrh,  the  fever  and  the  emaci^-tion  are 
not  deferred  until  the  expectoration  becomes  profuse  and 
purulent,  the  patient  first  wastes,  and  then  begins  to  cough 
and  expectorate.     At  first  the  physical  examination  of  the 


268  MEDICAL    DIAGNOSIS. 

chest  gives  negative  results,  and  even  at  a  later  period  the 
soliditication  is  not  so  extensive  as  in  the  first  form  of  con- 
sumption,— that  following  inflammation.  Of  this,  however, 
it  is  assumed  as  one  of  the  dangers,  that  it  may  become 
tuberculous,  though  even  then  the  morbid  process  appearing 
at  an  advanced  stage  of  the  phthisis  has  but  little  to  do  with 
disorganization  of  the  lungs.  How  the  tubercle  arises  is  not 
certain,  but  it  has  some  indirect  connection  with  the  cheesy 
changes  of  the  products  of  the  inflammation. 

Chronic  Pleurisy. — A  persistent  cough  attended  with  ema- 
ciation and  withdulness  on  percussion  is  common  to  chronic 
pleurisy  and  to  phthisis,  and  is  a  cause  of  many  errors  in 
diagnosis.  But  with  care  such  errors  may  be  avoided ;  cer- 
tainly by  those  who  pay  any  attention  to  physical  diagnosis. 
The  seat  of  the  dulness  at  the  lower  part  of  the  thorax;  its 
much  more  absolute  character;  the  almost  entire  cessation 
of  all  sound  of  respiration;  the  diminished  or  absent  vibra- 
tion of  the  chest  walls  when  the  patient  speaks  ;  the  dilatation 
of  the  afl'ected  side, — are  in  striking  contrast  with  signs  most 
manifest  at  the  apex,  with  the  distinctly-prolonged  expiration, 
with  the  rales  and  the  evidences  of  commencing  softening. 
Nor  are  the  symptoms  of  a  pleuritic  effusion  as  grave  as 
those  produced  by  phthisis.  Even  where  the  fluid  filling 
the  chest  is  pus,  we  do  not  find  hectic  fever  so  intense,  ema- 
ciation so  great,  or  night-sweats  so  constant  and  exhausting. 
And  the  patient  coughs  less,  and  never  spits  up  blood. 

In  those  cases  of  chronic  pleurisy  in  which  the  side,  instead 
of  being  dilated,  is  retracted,  the  diagnosis  is  more  difficult. 
Attention  to  the  seat  of  dulness  being  at  the  lower  part  of  the 
chest,  to  the  diminished  respiration,  voice  and  fremitus,  and 
to  the  shrinking  affecting  onl)'  one  side  of  the  thorax,  will, 
however,  serve  as  the  foundation  for  a  correct  conclusion. 

Tubercle  may  complicate  pleuritic  effusions.  We  suspect 
this  by  the  occurrence  of  hemorrhage,  and  b}^  the  marked 
emaciation  and  hectic.  We  can  only  be  sure  of  it  by  finding 
signs  of  deposit  on  the  non-affected  side,  which  deposit,  in  ac- 
cordance with  the  custom  of  tubercular  disease,  will  take 
place  first  at  the  apex.  Chronic  double  pleuris}^  is  very  apt 
to  be  associated  with  a  tubercular  affection  of  the  lungs. 


DISEASES    OF    THE    LUNGS.  269 

Pulmonary  Cancer. — Cancer  of  the  king  has  many  symp- 
toms which  it  shares  with  tubercle.  Emaciation,  couirh, 
night-sweats,  hemorrhage,  gradual  wasting  belong  to  both 
diseases,  as  do  also  the  signs  of  pulmonary  consolidation. 
But  cancerous  formations  are  usually  limited  to  one  lung. 
Only  one  side  of  the  chest  is,  therefore,  flattened;  the  other 
looks  distended.  Over  the  cancerous  lung  the  percussion 
dulness  is  very  great.  There  is  either  very  loud,  blowing 
respiration,  or,  if  the  mass  have  obliterated  a  bronchus,  en- 
feebled or  absent  breathing.  We  tind  no  rales;  but  all  the 
signs  of  consolidation  are  much  moi'e  perfect  than  in  tuber- 
cle. Owing  to  a  cancerous  deposit  in  the  mediastinum,  the 
dulness  at  times  extends  beyond  the  median  line.  Cancer 
in  the  lung  may  soften;  yet  the  signs  of  softening  are  wei-y 
rarely  as  manifest  as  they  are  in  tubercle.  The  sputa  are 
purulent,  or  like  currant-jelly.  Further,  a  cancerous  tint  of 
the  skin  may  be  present;  and  again,  cancerous  tumors  in 
other  parts  of  the  body  become  next  to  absolute  evidence  in 
favor  of  a  deposit  in  the  lung  being  cancerous,  since  with 
rare,  very  rare  exceptions,  cancer  and  tubercle  do  not  co- 
exist. The  different  character  of  the  pain  must  also  be 
taken  into  account.  In  tubercle,  it  is  transitory  and  shift- 
ing;  in  cancer,  it  is  much  more  constant,  and  usually  much 
more  severe.* 

Syphilitic  Disease  of  the  Lungs. — Syphilis  may  lead  to  tuber- 
cular disease  of  the  lungs.  But  it  will  also  occasion  a  specific 
form  of  bronchitis,  preceding  the  sy})hilitic  eruption;  or 
produce  gummata,  which  may  soften  and  be  eliminated,  and 
which,  according  to  Ricord,  form  in  the  lungs  toward  their 
periphery  and  base.  When  syphilis  manifests  itself  in  the 
pulmonary  structures,  it  gives  rise  to  most  of  the  phenomena 
of  phthisis.  The  chief  differences  are,  that  the  nodules 
affect  generally  only  one  lung,  and  principally  the  base  or 
the  lower  part  of  the  upper  lobe,  that  they  remain  circum- 
scribed, not  spreading  to  the  surrounding  textures,  and  oc- 
casion, as  a  rule,  neither  haemoptysis,  nor  fever,  nor  decided 

*  Compare,  on  this  subject,  the  cases  collected  by  Bennett  in  his  Clinical 
Lectures  ;  by  Hughes,  Guy's  Hospital  Reports,  1st  Series,  vol.  ii.;  by  Stokes, 
Dub.  Journ.  of  Med.,  vol.  xxi. 


270  MEDICAL    DIAGNOSIS. 

emaciation.  Still,  the  syphilitic  affection  can  only  be  distin- 
guished with  certainty  by  the  history  of  the  case,  and  by  the 
thickening  of  the  periosteum  of  the  head  of  one  or  both 
clavicles.  Milroy,*  in  his  investigations  on  soldiers,  also 
lays  stress  on  the  thickening  of  the  perichondrium  of  one 
or  more  of  the  upper  cartilages,  with  frequently  a  tumefac- 
tion of  the  soft  parts  between  them  and  the  skin.  To  these 
tests  may  be  added  that  recognized  by  Broderickf — sub- 
sternal tenderness  as  a  means  of  diagnosis  of  acquired  syph- 
ilitic taint.  In  all  cases,  we  must  be  careful  that  the  thick- 
ening at  the  upper  part  of  the  chest  walls  and  the  altered 
resonance  thus  occasioned  be  not  looked  upon  as  a  sign  of  a 
tubercular  consolidation. 

The  preceding  diseases  are  most  likely  to  be  confounded 
with  the  stages  of  consumption  prior  to  softening  and  the 
formation  of  cavities.  Next,  to  review  those  affections 
which,  like  phthisis,  occasion  the  signs  of  excavation,  and 
which,  therefore,  may  be  mistaken  for  its  third  stage :  they 
are,  chiefl}^,  bronchial  dilatation,  abscess,  and  gangrene  of 
the  lung. 

Bronchial  Dilatation. — A  dilatation  of  the  bronchial  tubes 
takes  place  in  two  forms :  either  the  tubes  are  uniformly 
dilated  and  like  the  fingers  of  a  glove,  or  else  they  form 
cavities  by  undergoing  a  saccular  enlargement.  The  former 
variety  furnishes  the  symptoms  and  physical  signs  of  a  case 
of  chronic  bronchitis,  attended  with  copious  expectoration. 
The  percussion  clearness  may  be  slightly  lessened,  owing  to 
the  condensation  of  the  surrounding  pulmonary  tissue;  the 
respiration  be  more  strictly  bronchial ;  but  otherwise,  both 
symptoms  and  signs  are  those  of  chronic  bronchial  inflam- 
mation. 

In  the  globular  form  of  dilatation,  however,  we  meet  with 
all  the  sounds  of  tubercular  excavations:  the  hollow,  blow- 
ing respiration;  the  hollow,  well-transmitted  voice;  gurgling; 
even  metallic  tinkling.  Yet  all  these  phenomena  are  in 
strange  contrast  to  the  almost  unimpaired  health,  and  to  the 


*  British  Army  Medical  Report,  quoted  in  Annals  of  Milit.  and  Naval 
Surg.,  vol.  i.,  1863. 

f  Madras  Medical  Journal,  July,  1865. 


DISEASES    OF    THE    LUNGS.  271 

non-occurrence  of  hemorrhage,  of  night-sweats,  and  of  ema- 
ciation.   Hence  when  we  find  the  signs  of  a  cavit}-,  and  when 
the  general  symptoms  do  not  indicate  that  profound  constitu- 
tional disturbance  with  w^iich  consumption  is  always  asso- 
ciated, we  may  suspect  a  bronchial  dilatation.     This  suspicion 
becomes  a  certainty,  if  the  cavity  be  at  the  middle  or  lower 
portion  of  the  lung,  and  if  the  resonance  on  percussion  be 
but  little  impaired.     For  it  is  settled  beyond  doubt  that,  in 
bronchial  dilatation,  the  dulness  over  the  seat  of  the  disease 
is  very  slight;  certainly  not  nearly  so  great  as  that  yielded 
by  the  dense  walls  of  a  tubercular  excavation.     It  is  also  true 
that  the  dulness  on  percussion,  for  the  most  part,  follows, 
and  does  not  precede  the  auscultatory  phenomena  of  a  cavity. 
And  we  tiud  further  evidence  of  the  affection  not  beinff  tuber- 
cular,  in  the  stationary  character  of  the  physical  signs :  for 
months  they  do  not  change  ;  whereas  in  phthisis  they  con- 
tinually alter  with  the  advancing  malady.     The  expectora- 
tion of  bronchial  dilatation,  too,  is  generally  more  abundant 
than  that  of  consumption,  and  in  very  chronic  cases  fetid, 
suggesting,  indeed,  at  times,  the  probability  of  the  existence 
of  gangrene.     Nor  does  it  look  like  the  sputum  of  phthisis, 
for  it  is  much  more  fluid,  and  in  the  watery  secretion  small 
masses  of  pus  float,  far  less  coherent  and  compact  than  the 
nunmiular  sputum   of  phthisis.     As  regards   the  cough  of 
dilated  bronchi,  it  is  much  more  persistent,  being  constant 
by  day  and  night,  and  only  at  times  relieved  by  expectora- 
tion, which  then  varies  in  copiousness  according  to  the  size 
of  the  sac* 

Skodaf  describes,  as  a  peculiar  physical  sign  present  in 
sacculated  bronchial  dilatation,  a  large  and  coarse  crackling, 
called  by  him  the  large  bubbling,  dry  crepitant  rale.  In  a 
case  which  came  under  my  observation,  the  diagnosis  was 
made  by  this  auscultatory  sign.  The  patient,  a  boy  aged 
twelve  years,  had  swallowed  a  bone,  which  lodged  in  a  bron- 
chial tube,  and  gave  rise  to  bronchitis  and  bronchial  widen- 
ing.    He  died  subsequently  of  acute   meningitis,  and   the 


*  Skoda,  Allgem.  Wien.  Mediz.  Zeitung,  1864,  No.  26. 
f  Perkussion  und  Auskultation. 


272  MEDICAL    DIAGNOSIS. 

boae  was  found  firmly  imbedded  on  one  side  of  the  globu- 
larly-dilated  bronchial  tube. 

Pulmonary  Abscesses. — The  circumstance  that  cavities  or  ab- 
scesses in  the  lung  tissue  are  so  generally  caused  by  softening 
tubercles,  makes  physicians  overlook  the  fact  that  abscesses 
of  the  lung  occur  unconnected  with  tubercular  disease.  Such 
abscesses  may  form  in  the  course  of  acute  pneumonia,  but 
are  not  then  likely  to  be  mistaken  for  chronic  phthisis.  Dif- 
ferent is  it  with  abscesses  which  are  developed  three  or  four 
months  after  an  attack  of  pneumonia,  and  where  the  lung 
texture  has  remained  partially  consolidated.  I  have  seen  not 
a  few  examples  of  chronic  induration  of  the  lung  terminating 
in  this  way.  A  man  who  was  shot  through  the  lung  was 
seized,  soon  after  the  injury,  with  inflammation  of  that  organ. 
Percussion  dulness  and  blowing  respiration  continued  at  the 
lower  part  of  the  left  lung,  notwithstanding  all  efforts  to  re- 
move the  lymph  which  caused  them.  One  day,  after  exertion, 
he  suddenly  expectorated  a  considerable  amount  of  pus.  The 
signs  of  a  cavity  were  detected  at  once ;  but  they  have  since 
disappeared,  and  perfect  recovery  has  taken  place.  In  an- 
other case  of  pneumonia,  the  disease  in  like  manner  lapsed 
into  a  chronic  state.  Five  months  after  the  acute  attack,  the 
evidences  of  an  excavation  became  manifest  at  the  edi^e  of 
the  right  scapula,  and  existed  there  for  two  months;  then,  so 
far  as  phj'sical  signs  could  prove,  the  cavity  closed.  Instead 
of  the  hollow,  blowing  respiration  and  gurgling,  only  a  some- 
what roughened  vesicular  murmur  was  perceived. 

Such  is,  however,  not  always  the  termination.  The  ab- 
scess may  grow  larger  and  larger,  until  the  entire  lung,  as 
proved  by  post-mortem  examination,  is  destroyed. 

These  abscesses  differ  from  bronchial  dilatation  in  not 
being  permanent  and  fixed.  They  have  this  in  common 
with  tubercular  excavations — they  change.  They  increase 
like  these;  but  further,  they  do,  what  tubercular  cavities  do 
not,  they  decrease.  Their  physical  signs  are  in  every  re- 
spect like  those  of  all  cavities,  and  vary  with  the  size  of  the 
excavation.  Sometimes  metallic  respiration  and  voice  may 
be  heard  over  it;  or  perforation  of  the  pleura  produces  the 
signs  of  pneumothorax  with  eti'usion.     In  fortunate  instances 


DISEASES    OF    THE    LUNGS.  278 

the  pus  is  expectorated,  or  the  abscess  opens  externally,  and 
a  cure  is  thus  established.  But  very  large  abscesses  are  apt 
to  wear  out  the  patient.  Hectic  fever,  and  occasional  hemor- 
rhage, attend  them ;  yet  neither  is  so  constant  a  symptom  as 
it  is  in  consumption.  The  sputa  are  usually  copious,  puru- 
lent, and  very  fetid,  differing  in  this  respect  from  the  expec- 
toration of  phthisis.  Again,  abscess  of  the  lung  may  be 
distinguished  from  tubercular  disease  by  being  ordinarily 
situated  at  the  base  of  the  organ  ;  by  its  following — although 
there  are  exceptions  to  this  rule — pneumonic  consolidation; 
by  the  occurrence  of  copious  expectoration  being  often, 
not  constantly,  sudden  ;  but,  especially,  by  its  limitation  to 
one  lung.  The  other  lung  remains  perfectly  healthy.  It 
may  enlarge,  and  its  murmur  be  more  distinct;  but  all  its 
movements  and  sounds  denote  its  texture  to  be  in  a  normal 
condition. 

The  small  amount  of  constitutional  disturbance  which  pul- 
monary abscesses  sometimes  entail  is  very  remarkable.  In 
several  patients,  in  whom  I  have  noticed  abscess  of  the  lung 
consequent  upon  chronic  pulmonary  consolidation,  the  phys- 
ical signs  of  a  large  cavity  were  in  strange  contrast  to  the 
regular  pulse,  the  easy  breathing,  the  slight  cough,  and  the 
healthy  complexion. 

To  tabulate  the  differences  between  a  tubercular  excava- 
tion and  a  pulmonary  abscess  : 

Pulmonary  Abscess.  Cavity  from  Phthisis. 

Signs  of  cavity  usually  at  the  lower  Signs  in  the  upper  lobe. 

lobe. 

Copius  and  purulent  sputa.  Sputa  less  copious;  and  at  first  num- 
mular. 

Comparatively  small  amount  of  con-  Graver   symptoms,   and   a   ditierent 

stitutional  disturbance.  history. 

One  lung  aftected.  IJsually  both  lungs  affected. 

Pulmonary  Gangrene. — Another  disease  whi^;h  yields  the 
signs  of  an  excavation,  and  which,  like  phthisis,  is  attended 
with  wasting  of  the  body,  here  claims  attention.  Gangrene 
of  the  lung  occurs  either  as  diffused  or  as  circumscribed 
gangrene,  after  pneumonia,  from  blows  on  the  chest,  or  from 

18 


274  MEDICAL    DIAGNOSIS. 

poisoned  blood.  The  physical  signs  are  those  of  a  cavitj', 
seated  usually  in  the  lower  portion  of  the  lung.  The  symp- 
toms are:  great  and  increasing  prostration,  dyspnoea,  a  very 
pale  face,  a  quick  pulse,  hemorrhage,  emaciation,  and  a 
cough,  followed  by  profuse  purulent  sputum  of  a  greenish 
or  brown  color.  But  nearly  all  these  symptoms  happen  also 
in  phthisis.  What  is  characteristic  of  gangrene,  is  the  ex- 
treme fetor  of  the  expectoration  and  of  the  breath.  The 
sickening  odor  is  not  perceived  during  each  act  of  breathing, 
but  mainly  after  coughing,  and,  as  it  were,  in  jets.  It  is  the 
symptom  by  which,  especially  if  taken  in  connection  with 
the  signs  of  breaking  up  of  the  pulmonar}-  tissue,  gangrene 
is  with  certainty  recognized ;  and  without  it,  a  diagnosis  is 
impossible.  Some  authors  lay  stress  on  the  fact  that  a  cavity 
is  found  in  only  one  lung,  and  at  its  lower  part.  This  is  un- 
questionably of  aid  in  discriminating  between  phthisis  and 
o:ano^rene;  but  it  does  not  distino-uish  between  a  2:''vnsj:renous 
excavation  and  a  simple  abscess  of  the  lung.  The  only  posi- 
tive proof  of  gangrene  of  the  lung  is,  as  just  stated,  that  the 
signs  of  breaking  down  of  the  pulmonary  tissue  are  accom- 
panied by  a  most  disgusting  and  more  or  less  persistent  fetor 
of  the  expectoration  and  of  the  breath.  I  say  persistent,  be- 
cause local  gangrene,  on  a  small  scale,  occurring  around 
tubercular  cavities  or  in  bronchitis,  may  give  rise  to  tempo- 
rary extreme  fetor  of  the  breath.  But  it  is  only  temporary, 
and  therefore  not  liable  to  lead  to  fallacious  inferences.  The 
expectoration  may  be  fetid  in  cases  of  bronchial  dilatation 
or  of  abscess  of  the  lung,  but  is  never  brownish,  as  in  gan- 
grene ;  and  neither  it  nor  the  breath  has  that  peculiar  gan- 
grenous odor  which  makes  the  patient  as  unbearable  to 
himself  as  to  his  attendants.* 

*  But  what  that  odor  is,  is  very  difficult  to  define.  Dr.  Laycock  (Edinb. 
Med.  Journ.,  May,  1865)  states  that  there  are  three  distinct  Ivinds  of  pul- 
monary fetor — that  of  ozaena,  that  of  feces,  that  of  gangrene.  The  latter, 
due  to  putrescent  decomposition  of  pulmonary  tissue,  is  characteristic  of 
tru<^  gangrene.  The  oziena  odor  is  connected  with  chronic  tissue  changes 
of  rheumatic  origin,  as  with  fibrinous  exudation  and  degeneration.  It  is 
found  chiefly  in  fetid  bronchitis  and  bronchorrhoea,  and  in  fetid  fibroid 
vomicii?.  Tlie  fecal  odor  may  also  be  observed  under  these  circumstances, 
and  has,  too,  probably  a  rheumatic  origin.     In  rare  instances  pleurisy  with 


DISEASES    OF    THE    LUNGS.  275 

The  complaints  just  considered  exhibit  thus,  all  of  them, 
points  in  which  they  are  similar,  and  all  of  them  points 
in  which  they  are  dissimilar,  to  pulmonary  consumption. 
Others  might  be  added  which  are  sometimes  mistaken  for 
this  malady,  such  as  dyspepsia,  chronic  diarrhoea,  chronic 
laryngitis,  chronic  pharyngitis,  and  thoracic  pains.  But  each 
of  these,  although  it  may  accompany  tubercular  consump- 
tion, and  even  mask  some  of  its  symptoms,  lacks,  when  it 
is  present  as  an  idiopathic  aftection,  those  local  evidences  of 
deposition  and  softening,  lacks  that  profound  constitutional 
disturbance  which  forms  as  much  a  part  of  phthisis  as  the 
disease  in  the  lungs.  Throughout,  then,  the  wide  range  of 
affections  with  which  this  fatal  malady  may  be  confounded, 
we  find  invariably  appearing  as  landmarks  those  pathological 
laws  which  impart  to  the  complaint  a  distinctive  character, 
and  which  teach  us : 

That  pulmonary  tubercle  is  not  merely  a  disorder  of  the 
lungs,  but  is  accompanied  by  a  special  train  of  vital  symp- 
toms, in  their  gravity  often  out  of  proportion  to  the  local 
lesions. 

That  tubercular  matter  is  usually  deposited  at  the  apex  of 
the  lung. 

That  it  invades  in  its  progress  both  organs. 

And  clinically  speaking,  we  find  that  while  not  a  symp- 
tom, hardly  a  physical  sign,  is  strictly  peculiar  to  the  disease, 
yet  that  in  no  other  malady  do  they  appear  in  exactly  the 
same  combinations. 

In  the  above  remarks  on  the  diagnosis  of  pulmonary  con- 
sumption, the  complaint  has  been  assumed  to  be  progressive; 
but  in  rare  instances  it  retrogresses.  JSTow  before  dismissing 
the  subject  of  phthisis,  the  signs  by  which  such  retrogression 
can  be  discovered  may  be  alluded  to.  They  are  not  very 
fixed.  In  those  cases  in  which  many  tubercles  undergo  a 
cretaceous  transformation,  calcareous  particles  are  coughed 
up;  the  signs  of  softening  cease;  the  apex  flattens;  and  a 


fetid  effusion  may  occasion  a  fecal  smell  of  the  expectoration  and  breath, 
which  is  gradually  lost,  as  happened  in  the  case  reported  by  Dr.  William 
Moore  (Dub.  Quart.  Journ.,  May,  1865). 


276  MEDICAL    DIAGNOSIS. 

feeble  murmur,  with  prolonged  expiration,  or  a  harsh  res- 
piration, -with  slight  dulness  on  percussion,  is  all  that  re- 
mains to  indicate  that  tubercular  disease  has  existed.  It  is 
hardly  necessary  to  say  that  the  cough  stops,  and  that  flesh 
and  strength  return.  These  phenomena  may  be  noted  even 
when  large  cavities  have  existed.  But,  unfortunately,  it  is 
not  often  that  we  have  opportunities  to  make  such  obser- 
vations,* 

We  meet  occasionally  with  instances  in  which  the  physical 
signs  of  an  infiltration  into  the  lung  tissue  depart  with  toler- 
able rapidity.  They  occur  in  those  who  have  a  decidedly 
scrofulous  aspect,  enlargement  of  the  glands  of  the  neck,  or 
a  scrofulous  inflammation  of  the  eyes.  In  accordance  with 
the  generally  acknowledged  identity  of  scrofula  and  tubercle, 
we  should  be  forced  to  admit  that  the  disease  in  the  luno-s 
is  tubercular.  Yet  the  connection  with  the  enlarged  lym- 
phatics;  the  circumstance  that  the  diminution  in  size  of  the 
glands  is  often  followed  by  distinct  evidence  of  increased 
pulmonary  deposits;  that  these  depositions  are  very  bene- 
ficially influenced  by  treatment;  that  they  disappear  some- 
times altogether,  or  only  reappear  months  afterward, —  all 
make  it  a  question  whether  there  be  not  a  scrofulous  disease 
of  the  lung  independent  of  a  tubercular,  and  one,  moreover, 
which  presents  a  much  more  favorable  prognosis.  Among 
the  scrofulous  children  who  throng  our  public  institutions, 
cases  like  those  alluded  to  are  not  uncommon.  The  dis- 
order certainly  differs  from  the  ordinary  forms  of  pulmo- 
nary tuberculosis,  and  it  is  not  bronchial  phthisis.  It  does 
not  present  the  paroxysmal  cough,  the  signs  of  pressure 
on  the  trachea  or  large  bronchi,  and  the  dull  sound  on 
percussion  between  the  scapulae,  which  are  the  common 
accompaniments  of  enlarged  and  tubercularized  bronchial 
glands. 

Some  years  since  I  had  an  opportunity  of  inspecting  the 


*  Observations  illustrative  of  this  subject  are  furnished  by  Walshe,  in  his 
Treatise  on  Diseases  of  the  Lungs  ;  by  Bennett,  in  his  work  on  Pulmonary 
Tuberculosis  ;  by  Flint,  in  the  American  Journal  of  Medical  Sciences,  Jan- 
uary, 185H;  and  by  Lawson,  in  his  work  on  riithisis. 


DISEASES   OF   THE    LUNGS.  277 

lungs  in  one  of  these  instances  of  supposed  pulmonary 
scrofula.  I  was  treating  a  little  girl  for  this  affection,  when 
she  received  a  severe  injury  which  resulted  in  her  death.  She 
had,  when  first  seen,  an  eruption  on  the  scalp,  sore  eyes,  and 
enlarged  cervical  glands.  She  was  also  very  much  troubled 
by  a  cough ;  and  marked  dulness  on  percussion  was  dis- 
cerned at  the  upper  portion  of  the  left  lung.  Here,  as  in 
fact  throughout  the  whole  of  the  left  lung  and  the  upper  part 
of  the  right,  the  respiration  was  harsh.  But  for  two  weeks 
before  her  death  the  symptoms  and  signs  had  strikingly  im- 
proved under  cod-liver  oil  and  iodide  of  iron.  She  was 
rapidly  losing  her  cough  and  gaining  strength.  The  dulness 
on  percussion  was  diminishing,  the  respiration  becoming 
less  and  less  rough.  At  the  autopsy  the  greater  part  of  the 
left  lung  and  a  portion  of  the  right  were  found  to  contain 
yellowish,  chees}'  deposits,  which  exhibited  under  the  micro- 
scope a  large  quantity  of  granules  and  some  shrivelled  cells, 
without  distinct  nuclei. 

It  would  be  out  of  place  to  pursue  here  this  intricate  sub- 
ject any  further.  I  will  only  add  that  there  are  no  phenom- 
ena which  will  serve  as  a  foundation  for  an  absolute  diagno- 
sis of  a  scrofulous  in  distinction  to  a  tuberculous  infiltration. 
But  the  rapid  fluctuation  in  the  physical  signs,  their  occur- 
rence in  those  who  present  a  strongly  scrofulous  aspect,  and 
the  course  of  the  disease,  may  furnish  a  clue  by  which  to 
separate,  so  far  as  thej'-  can  be  separated,  cases  of  these  kin- 
dred disorders.  Perhaps  the  absence  of  haemoptysis  from 
among  the  symptoms  may  turji  out  to  be  a  matter  of  much 
importance  in  a  diagnostic  point  of  view.  Certainly  hemor- 
rhage did  not  happen  in  any  of  the  cases  of  pulmonary 
scrofula  which  have  come  under  my  observation. 


The  Acute  Affections  of  the  Lungs  accompanied  by  Dulness  on 

■     Percussion. 

In  continuing  the  consideration  of  the  diseases  in  which 
dulness  on  percussion  is  a  marked  sign,  let  us  glance  at  a 
group  of  acute  affections,  in  the  distinction  of  which  dulness 


278"  xMEDICAL    DIAGNOSIS. 

and  the  physical  sounds  which  correspond  to  it  hold  an  im- 
portant part. 

The  acute  diseases  aftecting  that  portion  of  the  respiratory 
apparatus  which  lies  within  the  chest  are  bronchitis,  pneu- 
monia, pleurisy,  and  acute  phthisis.  They  have  some  signs 
and  many  symptoms  in  common.  They  all  present  fever; 
they  are  all  associated  with  more  or  less  dyspnoea  and  thora- 
cic pain ;  they  all  occasion  a  cough.  If,  therefore,  a  practi- 
tioner meets  with  an  acute  disease  of  the  chest,  and  finds  the 
heart  healthy,  his  mind  is  forcibly  directed  to  the  disorders 
mentioned,  and  he  asks  himself,  Is  the  malady  acute  bron- 
chitis ?  is  it  acute  phthisis  ?  is  it  acute  pneumonia?  is  it  acute 
pleurisy? 

jSTow,  the  symptoms  and  signs  of  acute  bronchitis  have 
already  been  discussed.  It  has  been  pointed  out  that  the 
want  of  intensity  of  the  fever,  and  particularly  the  unim- 
paired resonance  on  percussion,  separate  bronchial  inflam- 
mation from  all  affections  which  occasion  consolidation  or 
compression  of  the  lung  tissue.  Its  farther  consideration 
among  diseases  accompanied  by  dulness  on  percussion  would 
be,  therefore,  evidently  out  of  place;  and  we  may  proceed  to 
examine  the  other  acute  pulmonary  affections. 

Acute  Phthisis. — When  phthisis  runs  its  course  rapidl}', 
it  constitutes  the  malady  known  as  acute  phthisis,  or  gallop- 
ing consumption.  This  formidable  complaint  is  met  with  at 
the  close  of  other  diseases,  especially  of  fevers  ;  but  exposure, 
never-ending  toil,  and  anxiety  are  also  among  the  exciting 
causes  of  acute  tubercular  formations. 

Acute  phthisis  shows,  more  even  than  chronic  pulmonary 
consumption,  that  the  disease  is  not  simply  one  of  the  lungs. 
The  lesions  found  by  the  knife  of  the  pathological  anatomist 
are  for  the  most  part  insufficient  to  account  for  the  early  ex- 
haustion and  the  emaciation,  and  indicate  a  constitutional 
aflfection,  of  which  the  tubercles  in  the  lungs  are  but  the 
local  expression. 

The  disorder  often  begins  with  a  chill  :  fever  follows ;  at 
first  like  any  inflammatory  fever  with  thirst,  anorexia,  quick- 
ened pulse,  parched  lips,  and  hot  skin,  but  soon  accompanied 
by  exhausting  night-sweats  and  rapid  emaciation,  which,  in 


DISEASES    OF    THE    LUNGS.  279 

connection  with  the  intense  restlessness  and  prostration,  and 
the  frequent  supervention  of  delirium,  may  cause  the  febrile 
disturbance  closely  to  resemble  typhoid  fever.  The  symp- 
toms which  point  to  the  thoracic  malady  are  the  accelerated 
breathing,  the  cough,  the  copious  expectoration,  the  pain  in 
the  chest,  and  the  spitting  up  of  florid  blood. 

The  physical  signs  are  not  always  the  same.  If  the  tuber- 
cles be  scattered  through  the  lungs,  no  signs  are  perceived 
but  those  of  diffused  acute  bronchitis.  More  commonly  the 
signs  are  like  those  of  chronic  phthisis,  and  associated  with 
the  fever  and  prostration  we  find  the  percussion  dulness  of  a 
deposit  or  the  evidences  of  the  breaking  up  and  destruction 
of  the  pulmonary  tissue,  furnished  by  coarse,  moist  rales, 
and  cavernous  breathino;. 

When  the  malady  assumes  the  form  resembling  chronic 
pulmonary  consumption,  the  diagnosis  from  bronchitis  is  not 
perplexing;  but  when  its  phenomena  are  similar  to  those  of 
acute  bronchitis,  the  recognition  of  the  tubercular  affection  is 
often  impossible.  This  remark  applies  particularly  to  the  dis- 
tinction of  the  miliary  form  of  acute  phthisis  from  capillary 
bronchitis ;  since  the  slight  constitutional  symptoms  and  the 
coarseness  of  the  rales  of  ordinary  bronchial  inflammation 
are  too  unlike  the  phenomena  of  acute  consumption  to  occa- 
sion commonly  much  difficulty  in  their  discrimination.  But 
from  bronchitis  of  the  finer  tubes  the  diagnosis  can  only  be 
efl'ected  b}^  taking  into  account  that  emaciation  and  profuse 
sweats  are  wanting  in  the  bronchial  aftection ;  that  the  skin 
is  not  hot  but  more  livid  ;  that  the  rales  are  more  abundant, 
and  more  perceptible  at  the  lower  part  of  the  chest;  and  that, 
perhaps,  the  breathing  is  usually  not  so  hurried.  Yet  none 
of  these  are  convincing  proofs.  The  presence  of  dulness  on 
percussion,  or  the  sinking  in  at  the  upper  part  of  the  chest, 
the  occurrence  of  hemorrhao^e,  and  the  lons^er  duration  of  the 
case  are  alone  conclusive  evidence  in  favor  of  the  existence 
of  acute  phthisis.  Hemorrhage  is,  however,  by  no  means  so 
constant  in  the  acute  as  in  the  chronic  form  of  the  malady. 

When  the  dulness  on  percussion  is  well  defined,  acute 
phthisis  might  be  mistaken  for  acute  inflammation  of  the 
lung.     But  the  signs  of  deposit  and  of  softening  in  both  lungs. 


280  MEDICAL    DIAGNOSIS. 

and  the  seat  of  the  lesions  at  the  apices,  show  differences  from 
a  disease  which,  in  the  large  majority  of  instances,  is  one-sided 
and  at  the  lower  part  of  the  lung,  which  exhibits  a  charac- 
teristic sputum,  and  in  which  breaking  up  of  the  pulmonary 
tissue  is  so  rare. 

Yet  there  are  cases  of  acute  phthisis  that  display  symptoms 
and  signs  very  puzzling,  and  strongly  simulating  those  of 
pneumonia. 

A  person  in  perfectly  good  health  is  seized,  after  exposure, 
with  cough  and  fever.  It  is  accompanied  by  dyspnoea,  and 
soon  we  find  signs  of  consolidation  of  the  lower  lobe,  or  of 
the  entire  lung.  The  dulness  on  percussion  does  not  disap- 
pear under  treatment;  and  a  hollow,  blowing  respiration  and 
gurgling,  usually  first  perceptible  at  the  angle  of  the  scapula, 
gradually  appear,  and  indicate  the  formation  of  a  cavity. 
Emaciation,  which  commenced  from  the  onset,  progresses 
more  rapidly,  and  goes  hand  in  hand  with  extreme  prostra- 
tion and  profuse  perspirations.  'I'he  sputa  are  copious  and 
purulent,  but  at  no  time  mixed  with  blood.  The  other  lung 
is  carefully  examined ;  all  its  sounds  are  normal.  The  case 
remains  in  this  condition  for  several  weeks,  the  patient 
temporarily  improving  under  stimulants,  yet,  on  the  whole, 
growing  weaker  and  weaker.  A  slight  roughening  of  the 
inspiratory  murmur,  or  dry  rales  at  the  apex  of  the  unaffected 
lung,  attract  attention,  and  dulness  on  percussion  and  the 
signs  of  deposition  become  there  more  and  more  manifest. 
A  post-mortem  examination  exhibits  nearly  the  whole  of  one 
lung  converted  into  a  uniform  yellowish  or  grayish  mass  of 
tubercle,  and  containing  one  or  several  large  excavations; 
not  a  vestige  of  healthy  lung  structure  is  to  be  seen.  Scat- 
tered tubercles  are  found  in  the  other  lung,  and  mainly  at  its 
apex. 

The  case  just  described  is  one  of  a  group  which  every 
practitioner  must  have  met  with.  Whether  the  disease 
commences  as  tubercle,  or  as  pneumonia,  is  next  to  im- 
possible to  say.  Perhaps  the  tubercle  has  lain  dormant  in 
the  lung,  and  has  been  roused  into  action  by  the  inflamma- 
tion. Perhaps  the  inflammation  was  of  a  kind  to  predispose 
to  the  formation  of  tubercle.     These  questions,  however  in- 


DISEASES    OF    THE    LUNGS.  281 

teresting,  need  not  be  here  mooted,  since  the}'  do  not  mate- 
rially concern  us.  What,  however,  does  concern  us,  is  to 
know  that  the  occurrence  of  rales  and  of  subsequent  dulness 
on  percussion  at  the  upper  part  of  the  previously  unaffected 
side,  the  persistence  of  the  disease  and  the  prostration  and 
sweats  which  accompany  it,  permit  us  to  foretell  the  tuber- 
cular nature  and  the  fatal  termination  of  the  disorder. 

I  may,  in  this  connection,  again  revert  to  the  views  of 
those  who,  like  Niemeyer,  accord  to  inflammation  and  the 
degeneration  of  its  products  the  chief  place  in  the  produc- 
tion of  consumption.  Such  cases  as  just  described  would 
be  classed  as  acute  galloping  consumption,  the  result  of 
caseous  infiltration  of  the  pulmonarv  tissues  and  the  disinte- 
gration  of  the  cheesy  infiltration.  On  the  other  hand,  in 
true  acute  tuberculosis  an  eruption  of  miliary  tubercles  in 
the  lungs  and  in  most  other  organs  takes  place,  and  there 
are  repeated  chills,  the  febrile  symptoms  run  very  high,  the 
dyspnoea  is  intense,  but  the  physical  signs  are  usual!}'  more 
those  of  an  extensive  bronchitis. 

Acute  phthisis  may  simulate  other  affections  besides  those 
of  the  chest.  It  has  at  times  the  delirium  and  prostration, 
the  dry  tongue,  and  the  bronchial  rales  of  typhoid  fever. 
The  diarrhoea  and  the  abdominal  symptoms  are,  however, 
wanting.  Yet  simultaneous  deposition  of  tubercles  in  the 
intestine  may  cause  these;  and  in  this  case  the  only  mark  of 
dift'erence,  from  typhoid  fever,  is  the  absence  of  an  eruption  ; 
unless,  even  under  these  circumstances,  we  are  aided  by  the 
fact  pointed  out  by  Dr.  Fox,*  namely,  that  unlike  the  per- 
sistent high  temperature  of  typhoid  fever  with  its  regular 
diminution  when  the  disease  declines,  the  thermometric 
record  in  acute  phthisis  shows  great  and  sudden  variations 
of  animal  heat,  bearing  no  regular  relation  to  the  number 
of  respirations  or  to  the  beats  of  the  pulse.  The  tempera- 
ture may  vary  many  times  in  the  course  of  the  disease  to  the 
extent  of  six  or  seven  degrees.  Acute  phthisis  lacks  the  wild 
eye,  the  gastric  disturbance,  the  convulsions  of  meningitis; 

*  St.  G-eorge's  Hospital  Keports,  1869. 


282  MEDICAL   DIAGNOSIS. 

or   the  active   delirium   it  occasionully  produces  might  be 
attributed  to  inflammation  of  the  membranes  of  the  brain. 

Acute  phthisis  sometimes  progresses  with  extreme  rapidity. 
I  have  seen  a  case  terminate  in  thirteen  days.  It  is  almost 
invariably  fatal.  Yet  it  has  its  periods  of  deceptive  improve- 
ment :  the  tubercular  disease  may  proceed  speedily  toward 
softening,  and  then  remain  for  a  time  stationary. 

Acute  Pneumonia. — Inflammation  of  the  lung  is  the  type 
of  the  acute  pulmonary  affections.  The  hot,  dry  skin,  the 
flushed  face,  the  quickened  pulse,  the  extremely  rapid  breath- 
ing, the  thoracic  pain,  the  cough,  and  the  peculiar  expecto- 
ration point  out  at  once  the  acute  nature  of  the  attack  and 
the  organ  which  is  disturbed.  Beginning  commonly  with  a 
chill,  or  with  flushes  of  heat,  the  disease  progresses  with  the 
symptoms  indicated.  A  few  of  these  require  a  more  detailed 
description. 

The  expectoration  is  very  characteristic.  It  consists  at 
first  of  a  dry,  glairy  mucus  ;  soon  it  becomes  more  viscid,  and 
acquires  that  significant  appearance  dependent  upon  the  ad- 
mixture of  blood  Avith  the  mucus  and  exudation  matter,  to 
which  the  term  rusty-colored  has  been  given.  This  rusty 
sputum  is  pathognomonic  of  the  disorder;  yet  it  is  well  to 
be  aware  that  cases  of  pneumonia  run  their  course  without 
it.  The  expectoration  is  sometimes  like  prune-juice,  or  it 
is  purulent.  Both  augur  badly;  both  indicate  that  destruc- 
tion of  the  lung  tissue  has  commenced. 

The  shortness  or  increased  frequency  of  breathing  is 
another  vevy  marked  symptom.  The  patient  draws  from  forty 
to  eighty  breaths  a  minute ;  but  the  pulse,  although  rapid, 
does  not  quicken  in  proportion.  Pneumonia,  therefore, 
forms  an  exception  to  the  rule,  that  with  greater  frequency  of 
breathing  the  pulse  rises.  This  perverted  pulse  respiraiion- 
raiio,  on  which  Dr.  "Walshe  dwells,  may  be  made  an  important 
element  in  the  diagnosis  of  the  disorder.  The  febrile  symp- 
toms are  ordinarily  very  severe  ;  still  they  are  not  associated 
with  decided  cerebral  disturbance.  Headache  is  common, 
but  delirium  rare,  and  when  it  occurs,  is  indicative  of  great 
danger.  The  heat  of  the  skin  is  burning;  and  the  flush  on 
the  cheek  so  decided,  that  by  this  and  the  hurried  breathing 


DISEASES    OF    THE    LUNGS.  283 

alone  the  disease  may  often  be  recognized.  The  flush  on  the 
cheek  is  not  accidental.  It  is  sometimes  very  dark,  and,  ac- 
cording to  Bouillard,  it  is  most  obvious  when  the  inflamma- 
tion aflects  the  apex  of  the  lung. 

The  urine  is  high  colored,  and  that  of  fever.  A  notable 
circumstance  about  it  is,  that  nitrate  of  silver  does  not  pre- 
cipitate its  chlorides.  They  commonly  disappear  during  con- 
solidation of  the  lung,  and  their  reappearance  shadows  forth 
returning  health.  The  vanishing  of  the  chlorides  from  the 
urine  happens  also  in  other  acute  affections;  but  in  pneumo- 
nia it  is,  perhaps,  most^constant,  and  most  absolute. 

The  j^hysical  signs  which  denote  that  the  lung  tissue  has 
become  the  seat  of  an  acute  inflammation  may  be  deduced 
from  a  knowledge  of  the  effects  which  the  inflammation  oc- 
casions. In  the  first  stage,  or  that  of  engorgement,  occur 
increased  vascularity  and  commencing  exudation  in  the  air- 
cells,  into  which,  however,  the  air  is  still  capable  of  entering. 
There  is,  therefore,  only  a  very  slight  impairment  of  the  nor- 
mal resonance  on  percussion.  The  vesicular  murmur  is  at 
first  somewhat  altered;  it  maybe  feebler  or  harsher.  But 
soon  are  heard  with  each  act  of  inspiration,  and  limted  to  the 
mspiration,  numerous  equally  and  rapidly-evolved,  very  fine, 
crackling  sounds,  the  "crepitant"  or  vesicular  rales. 

As  the  exudation  becomes  firmer,  and  the  tissue  of  the  lung 
solidifies  by  occlusion  of  the  air-cells,  the  stage  of  red  hepa- 
tization is  before  us.  Now  all  the  signs  of  complete  consoli- 
dation are  discerned.  We  find  decided  dulness  on  percus- 
sion; blowing  respiration  in  all  its  purity,  high  pitched  and 
tubular  sounding;  bronchophony;  and  increased  vocal  fre- 
mitus. Rales  from  the  accompanying  bronchitis  are  heard 
with  extreme  distinctness  throu2:h  the  solidified  tissue 
(Skoda's  consonating  rales);  and  so  are  the  sounds  of  the 
heart.  A  crepitant  rale  is  still  here  and  there  perceptible, 
or  the  ear  catches  a  friction  sound — a  sure  sia^n  that  inflam- 
mation  has  involved  the  pleura.  "When  the  exudation  is  re- 
absorbed or  expectorated,  the  signs  of  consolidation  become 
less  and  less  perfect.  A  vesiculo-bronchial  respiration  suc- 
ceeds to  the  bronchial  breathing.  The  dulness  on  percus- 
sion lessens ;  crepitant  rales — not,  however,  so  fine  as  at  the 


284 


MEDICAL    DIA«NOSIS. 


onset  of  the  aftectioii,  and  mixed  with  larger  moist  rales — 
return ;    the  cough    increases ;    the    expectoration   becomes 


Fig.  21. 


Percussion  dulness.  . 
Bronchial  breathing. 
Bronchial  voice.  .  .  . 
Increased  fremitus. 


Diagram  illustrative  of  perfect  pulmonary  consolidation,  sucli  as  happens  in  the 
second  stage  of  jineumonia. 

more  copious,  loses  its  tenacity  and  rusty  color,  and  con- 
tains, when  microscopically  examined,  broken-down  exuda- 
tion corpuscles  and  a  large  quantity  of  fat ;  the  dyspncea 
diminishes, — all  phenomena  indicative  of  the  breaking  up  of 
the  exudation,  and  of  the  return  of  air  into  the  vesicles.  If, 
instead,  the  exudation  be  converted  extensively  into  pus, 
and  the  lungs  soften,  the  physical  signs  are  the  same  as  in 
the  second  stage.  The  rarity  of  excavations  of  sufficient 
size  explains  why  gurgling  and  the  signs  of  a  cavity  are  not 
perceived.  We  suspect  the  mischief  that  is  going  on  within 
the  chest  from  the  protracted  dyspnoea,  the  increasing  ra- 
pidity of  pulse,  the  purulent  or  brownish  sputa,  the  pinched 
features,  the  drj'  tongue,  and  the  mental  wandering.  Re- 
covery may  take  place  even  then.  This  third  stage  is  in- 
deed not  so  much  an  abrupt,  suddenly  established  process, 
as  it  is  the  extension  and  greater  diffusion  of  a  state  that 
may  be  found  in  portions  of  the  lung  which  to  the  eye  have 
all  the  appearance  of  red  hepatization.     In  every  instance  of 


DISEASES    OF    THE    LUNGS. 


285 


red  hepatization  the  microscope  shows  that  in  parts  the  hmg 
tissue  is  infiltrated  witli  s^ranules  and  is  undero-oino-  soften- 
ing,  and  it  is  probable  that  this  breaking  down  occurs,  even 
though  on  a  small  scale,  in  all  cases  of  pneumonia  which 
recover.  And  these  minute  appearances  explain  why  com- 
plete gray  hepatization  is  so  rare;  why,  further,  it  is  often 
so  difficult  or  impossible  to  fix  the  limits  of  the  second  stage, 
and  determine  that  the  third  stage  has  arrived;  and  why 
death  may  take  place  long  before  the  lung  presents  the  con- 
dition which  pathologists  term  gray  hepatization.  It  is  in- 
deed a  great  mistake  to  suppose  that  a  case  does  not  end 
fatally  until  gray  hepatization  has  become  established,  for 
long  before  it  is  fairly  developed  death  may  ensue.  And  with 
reference  to  the  diagnosis  of  this  third  stage,  it  can  safely  be 
affirmed  that  we  may  suspect,  in  fact  we  may  feel  sure,  from 
the  symptoms,  that  the  pulmonary  tissue  is  seriously  dam- 
aged. But  we  can  never  know  it,  unless  we  find  the  physical 
signs  of  extensive  softening;  and  in  the  large  majority  of 
cases  this  cannot  be  done. 

To  recapitulate.  The  morbid  phenomena,  physical  signs 
and  symptoms  of  the  malady  correspond  usually  in  this 
manner: 

Pneumonia. 

I.  Stage  of  engorgement       Crepitant   rale;    slight       Cough;       beginning 
and      commencing  percussion  dulness.  dyspnoea  and  fever, 

exudation. 


II  Stage  of  solidifica- 
tion of  lung  tissue 
(red  hepatization). 

III.  Stage  of  soften- 
ing (gray  hepati- 
zation). 


Percussion  dulness; 
bronchial  respiration; 
bronchophony. 

The  same  physical  signs 
as  in  the  second  stage ; 
unless  large  abscesses 
have  formed. 


Kusty-colored  sputum  ; 
dyspnoea  ;  c  o  a  g  li ; 
high  fever. 

Chills;  prostration,  etc.; 
purulent  or  brownish 
sputum. 


Here,  then,  is  a  disease  which  presents  such  striking  symp- 
toms and  signs  in  nearly  all  its  phases,  in  which  the  sputa 
are  so  peculiar,  the  liurried  breathing  so  evident,  the  physi- 
cal signs  so  distinct,  that  error  is,  with  ordinary  care,  difficult. 
It  becomes  still  more  so,  if  a  few  of  the  pathological  peculi- 


286  MEDICAL    DIAGNOSIS. 

arities  of  pneumonia  be  borne  in  mind :  the  fact  that  it  is 
rarel}-  double ;  that  it  comparatively  seldom  afiects  the  upper 
lobe  of  the  lung,  and  that  it  is  often  accompanied  by  the 
signs  of  slight  pleurisy  or  bronchitis. 

But  to  contrast  pneumonia  with  the  various  diseases  with 
which  it  may  be  confounded.  In  its  first  stage,  on  account 
of  similar  signs,  the  acute  inflammatory  disorder  is  some- 
times mistaken  for  osdema  of  the  lung,  or  for  the  pul- 
monary engorgement  which  takes  place  in  some  fevers; 
and  still  more  frequently,  these  morbid  states  are  mistaken 
for  it. 

Pulmonary  CEdema. — (Edema  of  the  lung  consists  in  the 
transudation  of  serum  into  the  air-vesicles.  It  may  be  acute, 
the  result  of  sudden  consrestion,  such  as  that  following  in- 
juries  of  the  brain,  or  irritation  of  the  par  vagum;  or  arise 
at  the  termination  of  acute  affections  of  the  lungs.  It  is 
more  usually,  however,  chronic,  and  is  seen  as  a  dropsy  of 
the  air-cells,  associated  with  dropsies  elsewhere,  and  in  con- 
nection with  organic  disease  of  the  liver,  heart,  or  kidneys. 
The  characteristic  manifestations  of  oedema — be  it  acute  or 
chronic — are  embarrassed  breathing,  expectoration  of  frothy 
serum,  and  crepitating  and  very  fine  bubbling  sounds  dif- 
fused over  both  lungs,  and  dependent  upon  the  fluid  in  the 
air-cells  and  small  bronchial  tubes.  It  presents,  thus,  many 
points  of  similarity  to  the  first  stage  of  acute  pneumonia. 
The  dyspnoea,  the  crepitation  in  the  lung,  maj-  well  mislead ; 
but  we  cannot  err,  if  the  frothy  sputum,  the  general  distri- 
bution of  the  rales,  their  somewhat  coarser  character,  the 
bluish  lip,  the  noisy  breathing,  and  the  absence  of  fever  be 
taken  into  account.  In  acute  oedema  these  phenomena  are 
but  the  precursors  of  death.  In  chronic  oedema  the  rales 
are  persistent,  and  so  is  the  difliculty  of  respiration.  The 
patient  has  usually  to  be  propped  up  with  pillows,  or  he  can- 
not breathe  at  all. 

Pulmonary  Engorgement  in  Fevers. — In  fevers  of  a  low  type 
a  crepitant  rale,  which  might  be  supposed  to  be  a  proof  of 
commencing  inflammation  of  the  lung,  is  often  heard  at  the 
back  part  of  the  chest.  The  sound  is  probably  the  result  of 
pulmonary  congestion.     It  is  ordinarily  perceived  over  both 


DISEASES    OF    THE    LUNGS.  287 

lungs;  and  this  fact,  taken  in  connection  with  the  history  of 
the  case,  and  with  the  circumstance  that  the  rale  is  not  fol- 
lowed by  decided  shortness  of  breath,  by  dulness  on  percus- 
sion, and  blowing  respiration,  shows  that  it  is  not  dependent 
on  inflammation  of  the  pulmonary  tissue.  It  is  very  neces- 
sary to  be  aware  that  these  fine  rales  may  occur  in  fevers 
without  being  due  to  a  true  pneumonia;  as  otherwise  the 
patient  is  apt  to  be  treated  for  a  disease  of  the  lung  which 
has  really  no  existence. 

In  its  second  stage,  owing  to  the  cough  and  dyspnoea,  and 
in  part,  also,  to  some  similarity  in  the  physical  signs,  acute 
pneumonia  may  be  confounded  with  pulmonary  apoplexy, 
acute  pleurisy,  acute  phthisis,  and  acute  bronchitis. 

Pulmonary  Ayoplexy. — An  eiiusion  of  blood  into  the  text- 
ure of  the  lung  is  a  rare  aftection.  "When  met  with,  it  is 
generally,  although  by  no  means  invariably,  accompanied  by 
external  hemorrhage  and  by  difficulty  of  breathing.  Over 
the  effused  blood  there  is  dulness  on  percussion,  and  the  ear 
hears  an  enfeebled  or  bronchial  respiration.  Around  the  seat 
of  the  mishap  it  encounters  moist  rales.  Now  here  are  signs 
bearing  some  resemblance  to  those  of  pneumonia.  But  we 
miss  from  among  them  the  fever.  We  find,  on  the  other 
hand,  not  blood  intimately  mixed  with  the  expectoration,  but 
pure  blood,  florid  or  sooty  looking  ;*  and  on  close  scrutiny  a 
grave  disease  of  the  heart  is  generally  detected  to  explain 
why  an  extravasation  of  blood  into  the  pulmonary  structure 
has  taken  place.  Again,  the  dyspnoea  is  diflerent.  In  pneu- 
monia it  augments  from  the  beg-inninij  to  the  heis-ht  of  the 
malady.  In  pulmonary  apoplexy  it  is  greatest  when  the 
blood  is  extravasated,  and  after  that  it  declines.  Yet  we 
must  bear  in  mind  that  the  two  aftections  sometimes  coexist. 
The  blood  acts  as  a  foreign  body,  and  around  it  is  lighted  up 
an  inflammation  of  the  luno-  structure. 

Of  the  other  diseases  mentioned  which  resemble  pneu- 
monia, the  distinguishing  points  need  not  be  here  fully 
described.  Acute  2:)leurisy  will  be  further  on  more  particu- 
lai-ly  studied.     With  regard  to  acute  phthisis,  it  is  only  neces- 

^Walshe,  Treatise  on  Diseases  of  tlic  Lungs. 


288  MEDICAL    DIAGNOSIS. 

sary  to  repeat  that  cases  are  encountered,  apparently  of 
pneumonia,  in  which,  after  the  symptoms  of  acute  inflam- 
mation of  the  lung  pass  ofl^",  those  of  phthisis  come  into 
the  foreo^round.  "With  reference  to  acute  bronchitis,  I  will 
merely  recall  that  the  dyspnoea  is  not  so  great,  and  that  no 
percussion  dulness  is  yielded  by  an  inflamed  bronchial  mem- 
brane. 

Percussion  is  thus  of  signal  value  in  the  diagnosis  of  pneu- 
monia. In  fact,  when  bronchitis  complicates  pneumonia,  and 
loud,  dry  rales  take  the  place  of  the  blowing  respiration,  it  is 
our  only  trustworthy  guide.  A  single  tap  on  the  chest  which 
elicits  an  absolutelj^  dull  sound,  tells  the  dift'erence  between 
pure  bronchitis  and  the  inflammation  of  the  bronchial  mucous 
membrane  which  accompanies  inflammation  of  the  parenchy- 
matous structure  of  the  lung. 

The  form  of  pneumonia  most  liable  to  be  mistaken  for 
bronchitis  is  undoubtedly  the  pneumonia  of  childhood,  the 
lobular  -pneuiaoum.  It  would  be  obligatory  here  to  dwell  on 
its  special  characters,  its  diflusion,  its  relations  to  capillary 
bronchitis  and  to  collapse  of  the  lung,  were  it  not  that,  in 
treating  of  these  disorders,  it  has  been  described  with  them. 
To  enter  into  particulars  at  this  place  would,  therefore,  be  a 
tiresome  repetition.  But  there  are  two  other  forms  of  in- 
flammation of  the  lung  which  have  not  been  elsewhere  con- 
sidered, and  which,  as  they  present  somewhat  peculiar  symp- 
toms, require  to  be  explained.  They  are  typhoid  pneuihonia 
and  bilious  pneumonia. 

Typhoid  Pneumonia. — Inflammation  of  the  lung  may  be 
from  its  onset  attended  with  extreme  prostration.  This  form 
of  the  disease  has  been  made  a  matter  of  very  warm  contro- 
versy, both  as  to  the  symptoms  which  characterize  it  and  as 
to  the  relation  it  bears  to  other  varieties  of  the  malady, 
l^ow,  any  one  who  reads  the  dissimilar  descriptions  given  of 
it  by  difterent  authors  will  become  convinced  that,  under  the 
term  typhoid  pneumonia,  the  most  various  disorders  have 
been  ranged  together.  On  the  one  hand,  it  has  been  applied 
exclusively  to  the  inflammation  of  the  lung  which  may  com- 
plicate typhus  or  typhoid  fever;  on  the  other  hand,  it  has 
been  made  to  include  an  idiopathic  fever  in  which  the  aflec- 


I 


DISEASES    OF    THE    LUNGS.  289 

tion  of  the  respiratory  organs  is  occasionally  wanting.  It  is 
evident  that  to  neither  of  these  diseases  ous-ht  to  belong  the 
name  of  typlioid  pneumonia,  since  in  both  the  inflammation 
of  the  king  is  but  an  incidental,  although  a  grave,  accom- 
paniment. 

Typhoid  pneumonia  is  pneumonia  wnth  symptoms  of  a  ty- 
phoid type,  and  marked  by  rapid  failing  of  the  vital  powers. 
The  inflammation  of  the  lung  arising  in  the  course  of  typhus 
or  typhoid  fever  will  of  course  be  apt  to  present  this  charac- 
ter: but  the  malady  is  also  noticed  as  a  consequence  of 
phlebitis;  as  supervening  in  cases  of  erysipelas,  of  Bright's 
disease,  and  of  delirium  tremens  ;  or  as  the  sole  apparent 
affection.  It  happens  not  unfrequently  in  epidemics,  and  is 
very  often  observed  among  negroes.  Its  ravages  on  the 
plantations  of  South  Carolina  and  Georgia  are  sometimes 
frightful.  Often,  too,  it  is  very  fatal  among  troops  in  the 
field,  serving  in  unhealthy  localities  and  placed  under  unfa- 
vorable hygienic  conditions. 

The  physical  signs  are  those  of  the  sthenic  form  of  the  dis- 
ease, except,  perhaps,  that  the  crepitant  rale  is  less  frequent. 
Most  of  the  same  symptoms,  too,  show  themselves :  cough, 
short  breathing,  and  pain  in  the  chest.  All  of  these  may  be 
very  marked,  or  so  trifling  as  hardly  to  direct  attention  to 
the  lungs.  There  is,  however,  one  symptom  characteristic 
and  constant,  and  but  one,  and  that  is  the  great  tendency 
toward  sinking.  As  regards  the  expectoration,  it  may  be 
rusty  colored  ;  yet  occasionally,  even  in  the  early  stages  of 
the  complaint,  it  consists  of  pure  blood.  The  pulse  is  always 
quick,  but  weak.  Dark  sordes  often  collect  on  the  teeth 
and  gums,  as  they  do  in  typhoid  fever.  Pain  is  absent  in 
some  cases,  and  extremely  acute  and  of  a  radiating  character 
in  others.  Concerning  delirium,  we  know  that  it  is  much 
more  common  in  this  asthenic  form  than  it  is  in  the  sthenic 

I'  variety  of  pulmonary  inflammation.  Some  authors  mention 
the  occurrence  of  an  eruption.  It  is,  however,  questionable 
whether  the  cases  which  came  under  their  notice  were  not 
rather  instances  of  typhus  or  typhoid  fever,  in  the  course  of 
which  pneumonia  appeared.  The  flush  on  the  face  in  the 
low  type  of  the  malady  under  consideration  is  usually  of  a 

19 


290  MEDICAL    DIAGNOSIS. 

dusky  hue,  but  not  invariably:  a  pink-colored  blush,  extend- 
ing sometimes  all  over  the  body,  seems  to  have  specially 
attracted  the  attention  of  several  observers.  The  disease  is 
always  dangerous,  and  often  lingering.  Dr.  Stokes*  writes 
of  the  typhoid  pneumonia  he  met  with  in  Dublin,  that 
although  it  is  generally  developed  with  rapidity,  its  resolu- 
tion is  extremely  slow.  Chronic  hepatization,  with  or  with- 
out a  low  hectic  fever,  or  a  lurking  congestion,  may  continue 
for  man}^  weeks. 

The  symptoms  of  typhoid  pneumonia  are  at  times  strangely 
mixed  up  with  those  produced  by  other  conditions.  In  many 
districts,  in  which  the  complaint  is  very  prevalent,  it  bears 
the  distinct  impress  of  malaria.  Again,  articular  symptoms 
seem  to  predominate  in  some  regions  of  country,  and  in  some 
epidemics.  Dr.  Gibbesf  speaks  of  an  acute  pain  in  the  back 
part  of  the  eye,  in  the  ears,  or  side  of  the  neck,  attended 
with  stiffness  of  the  muscles;  and  of  a  swelling  of  the  tonsils, 
the  submaxillary  and  sublingual  glands,  which  he  states  to 
be  of  evil  augury.  And  Dr.  Dickson, |  drawing  his  descrip- 
tion of  the  disease  from  a  larsje  number  of  cases  observed  in 
and  around  Charleston,  portrays  several  forms,  the  most 
common  of  which  exhibits  a  respiration  hurried,  uneasy,  and 
irregular;  deep  and  heavy  sighing;  a  feeling  of  weight  at 
the  precordial  region,  with  nausea,  gastric  distress,  and  vom- 
iting; and  a  tongue  clean,  but  red.  Delirium  is  present  from 
the  beginning,  and  does  not  subside  nntil  recovery  takes 
place.  The  duration  of  such  attacks  averages  from  six  to 
ten  days.  In  another  form,  there  are  at  the  onset  great  gas- 
tric oppression  and  vomiting,  and  signs  of  vascular  excite- 
ment. But  muscular  prostration  and  debility  soon  happen ; 
and  lividity  of  the  countenance,  petechial  spots,  and  coma 
are  symptoms  which  usher  in  dissolution. 

Bilious  Pneumonia. — Jaundice  and  other  indications  of  he- 
patic and  gastric  derangement  are  not  usual  in  ordinary 
sthenic  pneumonia.  They  may  be  occasionally  caused  by 
the  inflammation  spreading  to  the  liver,  or  be  noticed  where 

*  Diseases  of  the  Chest. 

f  Amer.  Journ.  of  Med.  Sciences,  18-12. 

X  Elements  uf  Medicine. 


DISEASES    OF   THE    LUNGS.  291 

no  evidence  of  such  an  occurrence  exists.  But  in  the  pneu- 
monia so  general  in  spring  and  autumn  in  the  miasmatic 
regions  of  some  of  the  Southern  and  Western  States,  these 
symptoms  are  very  common,  and  mark  a  special  type  of  the 
disease,  known  as  malarial  pneumonia,  bilious  pneumonia,  or 
by  the  more  familiar  name  of  "bilious  pleurisy." 

This  form  of  inflammation  of  the  lung  is  simply  pneumonia, 
sthenic  or  asthenic,  on  whose  features  the  stamp  of  malaria 
is  imprinted.  The  chill  with  which  it  begins  is  usuallv  very 
protracted,  and  is  followed  by  pain  in  the  side,  by  fever,  by 
hurried  breathing,  by  cough,  and  by  tenacious,  rusty-colored 
expectoration.  The  pain  in  the  side,  which  depends  upon 
accompanying  pleurisy,  is  sharp  and  severe,  and  renders  the 
respiration  irregular.  The  sputum  is  at  times  rusty  colored, 
while  at  others  a  frothy  and  bloody  serum  or  pure  blood  is 
expectorated.  The  fever  shows  the  type  of  the  disease.  It 
is  much  more  paroxysmal  than  in  the  other  varieties  of  the 
malady.  This  peculiarity,  and  the  obvious  symptoms  of  he- 
patic and  gastric  disorder,  are  indeed  the  only  absolutely  dis- 
tinguishing traits  of  bilious  pneumonia.  The  febrile  exa- 
cerbations are  stated  by  Dr.  Manson,  a  physician  of  North 
Carolina,  to  be  preceded,  during  the  morning  hours,  by  an 
insensible  chill — a  coolness  of  the  ends  of  the  nose,  fingers, 
and  toes,  which,  in  grave  cases,  .extends  over  the  entire  ex- 
tremities.* The  same  writer  dwells  on  the  irritability  of  the 
intestinal  canal,  and  the  occurrence  of  greenish-black,  viscid 
and  inodorous  stools.  This,  and  the  diminution  of  the  dysp- 
noea, diaphoresis,  and  a  copious  secretion  of  urine,  point  to  a 
favorable  issue  of  the  disease.  On  the  other  hand,  it  may 
terminate  fatally  with  symptoms  indicative  of  great  pros- 
tration. 

The  physical  signs  are  those  of  ordinary  acute  pneumonia. 
Bronchial  breathing  and  bronchophony  are  said  to  be  more 
often  absent,  or  to  appear  and  disappear  rapidly.     It  is  cer- 

*  Virgin.  Med.  Journ.,  Sept.  and  Oct.  1857;  see  also  an  excellent  essay 
on  the  subject  by  W.  F.  Howard,  ]S^orth  Carol.  Journ.,  Feb.  1859;  Eamsay, 
Chariest.  Med.  Journ.,  vol.  vi.;  Merrill,  New  Orleans  Med.  and  Surg.  Journ., 
July,  1851 ;  and  Drake  on  the  Diseases  of  the  Interior  Valley  of  North 
America. 


292  MEDICAL    DIAGNOSIS. 

tain,  if  this  be  true,  that  in  these  instances  the  malady  could 
not  have  been  inflammation,  but  was  more  probably  a  col- 
lapse of  the  pulmonary  tissue.  Any  one,  indeed,  who  com- 
pares the  various  statements  made  with  reference  to  the 
disease,  must  have  been  struck  with  the  fact  that  cases  of 
congestive  fever  in  which  the  lungs  have  become  simply  en- 
gorged, or  perhaps  collapsed,  and  cases  of  inflammation  of 
the  lung  arising  in  the  course  of  remittent  fevers,  are  in- 
cluded in  the  same  description  with  true  cases  of  idiopathic 
bilious  pneumonia. 

The  nature  of  an  inflammation  of  the  lung  bearing  so  de- 
cidedly the  livery  of  malaria  has  given  rise  to  warm  contro- 
versies. Regarded  by  some  as  nothing  more  than  a  special 
form  of  remittent  or  intermittent  fever,  in  which  the  lungs 
are  made  to  bear  the  burden  of  the  disease,  it  is  by  others 
held  to  be  simply  a  variety  of  pneumonia,  occasioned  by  the 
ordinary  causes  of  this  aftection,  but  owing  its  peculiar  symp- 
toms to  its  happening  in  those  in  whose  systems  the  poison  of 
malaria  has  been  slumbering. 

Acute  Pleurisy. — Acute  pleurisy  has  been  so  often  inci- 
dentally mentioned,  that  a  description  of  its  main  points  will 
here  silffice.  The  first  efleet  of  the  inflammation  is  to  redden 
the  pleural  membrane ;  an  exudation  of  a  soft,  grayish,  and 
easily-detached  lymph  then  takes  place.  This  constitutes 
the  first  or  dry  stage  of  the  disease  ;  and  if  the  two  inflamed 
surfaces  unite,  the  disorder  does  not  pass  beyond  this  stage. 
Often,  however,  along  with  the  exudation  of  lymph  occurs 
an  efl'usion  of  serum,  which  produces  a  special  train  of  phe- 
nomena, and  gives  rise  to  the  second  stage,  or  that  of  liquid 
efl'usion. 

The  physical  signs  of  the  dry  stage  are  impaired  movement 
of  the  chest,  a  feebler  respiration,  and  a  friction  sound  of 
varying  extent  and  intensity.  The  first  two  signs  are  caused 
by  the  patient  instinctively  recoiling  from  expanding  the 
lung,  because  of  the  pain  it  occasions.  The  mechanism  of 
the  friction  sound,  its  nature,  its  superficial  character  and 
want  of  uniformity  have  been  pointed  out  in  a  previous  part 
of  this  chapter.  In  the  stage  of  effusion  the  physical  signs 
difiTer  somewhat,  according  to  the  amount  of  fluid  the  pleural 


DISEASES    OF    THE    LUNGS. 


293 


cavity  contains.     A  moderate  quantity  of  liquid  only  con- 
stricts the  lung  texture,  and  leaves  the  bronchial  tubes  intact: 


Fig.  22. 


Friction  sound. 


Roughening  of  the  pleura  from  inflammation  ;  a  small  amount 
of  fluid  has  begun  to  collect. 

a  large  accumulation  compresses  everything;  it  drives  all  air 
out  of  the  lung,  pushes  it  into  a  small  space  against  the  ver- 
tebral column,  and  displaces  the  liver  or  heart.  Wherever 
the  fluid  accumulates  there  is  dulness  on  percussion.  "When 
the  patient  is  in  the  erect  posture,  the  flat  sound  on  striking 
the  chest  and  the  sense  of  resistance  to  the  finger  are  marked 
at  the  lower  part  of  the  thorax,  since  the  fluid  naturally  set- 
tles there.  The  line  of  dulness  is,  however,  not  the  same  in 
front  as  it  is  behind.  It  is  mostly  much  higher  behind,  and 
alters,  of  course,  with  the  changing  quantity  of  effusion,  and 
somewhat  with  the  position  of  the  patient.  When  he  lies 
upon  his  face  the  fluid  gravitates,  if  not  circumscribed  by  ad- 
hesions, toward  the  anterior  chest  walls,  and  the  percussion 
dulness  becomes  posteriorly  far  less  perceptible. 

Where   the   effusion   is  at  all   extensive,  the   intercostal 


294 


MEDICAL    DIAGNOSIS. 


spaces  are  widened  and  their  depressions  eft'aced.     The  side 
appears  to  the  eye  distended,  and,  owing  to  the  absolute 


Fig.  23. 


Great  dulness.  .  . 

Absent  voice 
Absent   respiration 
Absent   fremitus.  . 


Examination  of  tlie  posterior  portion  of  the  ohest  while  a  large  effusion  is 

occupying  the  left  pleural  cavity. 

compression  of  the  lung,  no  sound  is  heard  over  the  chest 
when  the  patient  breathes,  or  speaks,  or  coughs.  In  more 
moderate  collections  of  fluid,  the  cessation  of  sound  is  not 
so  absolute.  There  is  an  ill-defined,  deep-seated  respiration, 
and  the  voice  reaches  the  ear  -with  tolerable  distinctness, 
and  occasionally  with  a  peculiar  bleating  resonance  attend- 
ing it.  But  as  large  collections  of  fluid  are  more  common 
than  small  ones,  the  former  set  of  phenomena  are,  at  the 
height  of  the  disease,  more  frequent  than  the  latter. 

Above  the  liquid  there  is  mostl}^  increased  resonance  on 
percussion,  or  a  tympanitic  sound.  Various  explanations 
have  been  given  of  this  phenomenon.  It  has  been  attrib- 
uted to  the  complete  compression  of  the  lung :  it  has  been 


DISEASES    OF   THE    LUNGS.  295 

thought  to  be  clue  to  its  slight  condensation.  "Whatever  be 
the  true  explanation,  the  ftict  of  its  occurrence  is  undeniable. 
This  tympanitic  sound  is  more  manifest  at  the  upper  part  of 
the  chest  in  front  than  behind;  it  may,  indeed,  sometimes  be 
found  in  front  when  it  does  not  exist  at  all  behind.  In  many 
cases  the  sound  has  a  decidedly  amphoric,  in  others  a  cracked- 
metal  character.  When  the  ear  is  applied  above  the  line 
of  percussion  dulness,  it  recognizes  occasionally  a  friction 
sound;  and  near  the  spinal  column  posteriori}',  where  the 
compressed  lung  lies,  it  perceives  often — were  I  only  to  take 
m}'  own  notes  as  a  basis,  I  should  say  almost  invariably — a 
distinct  bronchial  respiration. 

When  the  fluid  begins  to  be  absorbed,  the  voice  becomes 
more  audible  over  the  seat  of  the  eifusion,  the  vocal  vibra- 
tions may  be  felt  by  the  fingers,  and  the  respiration  too  is 
again  heard.  But  for  a  long  time  it  continues  enfeebled, 
and  its  character  is  indeterminate  ;  it  is  neither  vesicular,  nor 
purely  bronchial.  As  more  and  more  of  the  fluid  disappears, 
the  voice  becomes  more  and  more  distinct ;  a  friction  sound 
finally  shows  that  the  roughened  surfaces  come  in  contact; 
and  the  dulness  on  percussion  is  replaced  by  a  far  clearer 
sound.  False  membranes  now  unite  the  two  pleurae ;  the 
intercostal  spaces  resume  their  normal  shape;  and  the  chest 
is  either  restored  to  its  natural  size,  or  is  left  permanently 
somewhat  contracted.  The  bronchial  breathing  near  the 
vertebral  column  persists  for  a  long  time,  since  a  lung  that 
has  been  compressed  unfolds  but  very  slowly. 

Such  are  the  different  physical  signs  which  inflammation 
of  the  pleura  exhibits.  They  have  been  discussed  first,  and 
at  some  length,  because  I  wished  to  make  it  apparent  that 
these  signs  are  the  most  important  elements  in  the  diagnosis 
of  the  disease.  The  symptoms,  indeed,  often  hardly  attract 
attention  ;  and  if  we  trusted  to  them,  we  should  be  constantly 
groping  in  the  dark.  Pleurisy  mostly  begins  with  a  chill, 
followed  by  fever  and  by  a  dry,  irritating  cough.  The  most 
distinctive,  though  not  a  constant  symptom  of  the  first  stage, 
is  the  sharp,  acute  pain,  the  "stitch  in  the  side."  It  is  com- 
monly felt  under  the  nipple  or  in  the  axilla,  and  is  somewhat 
increased  on  pressure.     Its  seat  by  no  means  always  corre- 


296  MEDICAL    DIAGNOSIS, 

spends  to  the  seat  of  the  friction  sound.  As  the  effusion 
takes  place  the  pain  disappears,  dyspnoea  becomes  evident, 
and  the  patient  ordinarily  lies  on  the  affected  side.  The 
febrile  symptoms  and  dry  cough  continue;  yet  neither  is 
very  marked,  and  both  disappear  long  before  the  fluid  is  en- 
tirely absorbed. 

Pleurisy  may  be  "idiopathic,  or  occur  as  an  attendant  upon 
other  diseases,  such  as  affections  of  the  lungs,  measles,  scar- 
latina, typhoid  and  typhus  fevers.  It  may  be  caused  by 
wounds  of  the  thoracic  walls,  or  by  Bright's  disease,  by 
rheumatism,  gout,  pyaemia,  and  by  many  other  morbid 
states. 

The  malady  with  which  acute  idiopathic  pleurisy  is  most 
likely  to  be  confounded,  is  acute  pneumonia.  Both  are  af- 
fections occasioning  dyspnoea ;  both  are,  in  the  majority  of 
cases,  one-sided  ;  both  present,  in  their  most  advanced  stages, 
dulness  on  percussion.  But  the  dulness  in  the  latter  disease 
is  far  less  absolute  than  in  the  former;  nor  do  we,  save  in 
very  rare  instances,  meet  with  a  tympanitic  or  amphoric  per- 
cussion sound  in  pneumonia,  while  in  pleurisy,  as  we  have 
just  seen,  it  is  far  from  unusual  above  the  level  of  the  fluid. 
In  those  few  cases  in  which  an  amphoric  or  a  tympanitic 
sound  is  perceived  in  pneulnonia, — a  condition  of  things,  it 
may  be  mentioned  in  passing,  which  has  not  as  yet  received 
a  satisfactory  explanation, — the  peculiar  tone  is  most  ob- 
vious over  the  consolidated  tissue.* 

The  other  physical  signs  of  the  two  diseases  show  still  less 
similitude.  The  absence  of  respiration,  of  vocal  resonance 
and  of  thrill,  are  in  striking  contrast  with  the  loud  blowing 
respiration,  the  strong  chest-voice  and  increased  vocal  thrill 
of  pneumonia.  There  are,  however,  exceptional  cases  of 
pleuritic  eflusion,  in  which  bronchial  breathing  is  heard  all 
over  one  side  of  the  chest.  Especially  does  this  happen  if 
pneumonic  consolidation  accompany  the  effusion ;  but  even 


*  Dr.  Flint  suggests  that  the  line  of  flatness  may  serve  as  a  dintinguishing 
mark.  In  pneumonia,  if  the  disease  be  limited  to  the  lower  lobe,  the  line 
follows  the  situation  of  the  inter-lobar  fissure,  crossing  the  chest  obliquely 
from  the  fourth  or  fifth  cartilages  to  the  spinal  extremity  of  the  spinous  ridge 
of  the  scapula. 


DISEASES    OF   THE   LUNGS.  297 

ill  simple  compression  of  the  lung,  and  where  the  collection 
of  liquid  is  not  extensive,  bronchial  respiration  may  be  per- 
ceived. The  difHculty  of  distinguishing  such  cases  of  pleurisv 
(in  which  probably  the  lung  tissue  is  compressed  around 
the  bronchial  tubes,  but  these  are  not  encroached  upon) 
from  pneumonia  is  great.  As  aids  in  diagnosis,  we  seek  for 
the  dilatation  of  the  chest;  we  note  the  peculiarities  of  the 
breathing,  which,  although  blowing,  is  mostly  fainter  than, 
and  unlike  the  high-pitched,  brazen  respiration  of  pneumo- 
nia; we  observe  that  the  voice  is  less  strong  and  ringing,  and 
has,  perhaps,  a  bleating  tone;  and  we  take  into  account  the 
appearance  of  the  sputum  and  the  character  of  the  fever.  But 
leaving  these  cases  out  of  consideration — and  they  do  not 
often  occur — the  diagnosis  between  the  two  afiections  is  easy. 
It  may  be  thus  summed  up  : 

Pleurisy.  Pneumonia. 

Sharp    pain;    friction    sound;    dry  Dull  pain  ;  crepitant  rale;  cough,  fol- 

cough  ;  impaired  chest  motion.  lowed  by  expectoration. 

In  stage  of  effusion,  obliteration  of  In    stage   of    hepatization,    none    of 

the    intercostal    spaces  ;    enlarge-  these  signs  are  manifest. 

ment  of  the  side;  displacement  of 

several  viscera. 

In  the  large  majority  of  ca.ses,  dul-  Dulness,  with  marked  bronchial  res- 

ness,  with  enfeebled  or  absent  res-  piration  ;    distinct  thoracic  voice; 

piration,  voice,  and  fremitus.  increased  vocal  fremitus. 

Decubitus   is   often   on   the   affected  Decubitus   not   peculiar  ;   sometimes 

side.  on  the  sound  side. 

Sputa  frothy  ;  rarely  any  rales  in  the  Sputa  rusty  colored  ;  rales  from  ac- 

chest.  companying   bronchial    inflamma- 
tion common. 

Febrile  symptoms  usually  .slight.  Febrile  symptoms  severe. 

In  the  first  stage  of  pleurisy  the  pain  might  cause  the  dis- 
ease to  be  confounded  with  pleurodynia  or  intercostal  neural- 
gia. In  all  three  pain  is  the  prominent  symptom.  Let  us 
see  how  it  differs. 

Pleurodynia. — Pleurodynia  is  generally  described  as  a  form 
of  muscular  rheumatism.  But  frequently  it  is  pleurisy,  which 
does  not  pass  beyond  the  dry  stage.  Of  this  nature  are  most 
of  the  fugitive  chest-pains  from  which  phthisical  patients 
suffer.     Yet  there  are  cases  in  which  no  signs  whatever  of 


298  MEDICAL    DIAGNOSIS. 

pleurisy  exist,  which  are  attended  with  the  same  or  with  more 
pain  than  pleurisy,  but  which  have  little  or  no  fever,  and  are 
devoid  of  the  rubbing  indicative  of  the  motion  of  roughened 
pleurae.  The  pain  of  pleurodynia  is  often  excessively  severe ; 
the  patient  refrains  from  breathing  with  the  affected  side, 
since  every  motion  of  his  chest,  voluntary  or  involuntary,  in- 
creases his  suffering.  The  pain  is  augmented  by  movements 
of  the  arm  and  by  pressure,  and  is  very  generally  associated 
with  tenderness.  Pleurodynia  shares  with  pleurisy  the  feeble 
respiration  and  the  want  of  action  of  the  affected  side.  It 
differs  from  it  by  the  absence  of  friction  sound  and  of  fever; 
by  the  shifting  tendency  of  the  pain  ;  by  its  attacking  often 
both  sides;  and  by  the  greater  tenderness  of  the  walls  of  the 
chest. 

Intercostal  Neuralgia. — In  anemic  women  and  in  consump- 
tives acute  thoracic  pain  is  not  uncommonly  the  result  of  an 
intercostal  neuralgia.  The  same  want  of  expansion  of  the 
chest  and  enfeebled  breathing,  as  in  pleurodj-nia,  are  here 
noted,  also  the  same  absence  of  fever  and  of  pleural  friction. 
The  distinguishing  marks  of  intercostal  neuralgia  are :  its 
intermittent  character;  its  frequent  association  with  uterine 
disturbance,  especially  with  leucorrhoea;  and  the  limitation 
of  the  tenderness  to  special  p'oints  in  the  course  of  the  affected 
nerve.  Valleix  has  drawn  attention  to  three  painful  spots 
which  are  tender  to  the  touch:  one  at  the  exit  of  the  nerve 
from  the  spinal  column,  the  second  in  the  axillary  region,  and 
the  third  near  the  sternum  or  in  the  epigastric  region.  It  is 
on  the  left  side  that  we  are  most  apt  to  find  intercostal  neu- 
ralgia, and  between  the  sixth  and  ninth  ribs  that  the  painful 
places  are  usually  detected. 

Pain  occurs  also  in  diseases  affecting  the  lung  texture. 
There  is  pain  of  a  dull  nature  in  pneumonia,  of  a  more  severe 
character  in  cancer.  But  the  pain  is  so  dissimilar,  and  the 
coexisting  symptoms  so  unlike,  that  the  error  of  confounding 
these  maladies  with  pleurisy,  on  account  of  the  pain,  is  not 
likely  to  be  committed. 


DISEASES    OF    THE    LUNGS.  299 

Diseases  presenting  Dilatation  of  the  Chest,  Displacement  of 
the  Liver  or  Heart,  and  Dyspnoea. 

A  group  of  diseases  may  here  be  studied,  all  of  which  oc- 
casion more  or  less  dilatation  and  prominence  of  the  chest, 
and  all  of  which  are  attended  with  decided  shortness  of  breath. 
In  bronchitis  and  pneumonia  a  slight  increase  in  the  diam- 
eters of  the  chest  may  take  place ;  but  it  is  not  a  sign  of  any 
diagnostic  importance.  In  the  recognition  of  emphysema, 
pneumothorax,  and  ptleuritic  effusions,  the  dilatation  of  the 
thorax  forms  one  of  the  main  elements  ;  moreover,  it  is  often 
combined  with  marked  dyspnoea  and  with  displacement  of 
the  liver  or  heart.  These  afiections,  then,  may  be  examined 
in  the  same  connection,  and  compared  with  each  other,  and 
incidentally  with  several  less  common  diseases  which  present 
similar  manifestations. 

The  history  and  signs  of  emphysema  were  given  when 
treating  of  the  diseases  accompanied  by  clearness  on  percus- 
sion. It  was  there  mentioned  that  in  many  instances  the 
prominence  of  the  chest  was  circumscribed.  Such  cases  can- 
not be  mistaken  :  the  bulging  is  too  limited.  But  when  the 
emphysema  is  more  general,  and  an  entire  side  of  the  chest 
or  the  whole  chest  becomes  dilated,  or  when  the  inflated  lung 
displaces  the  liver  or  heart,  the  affection  comes  into  the  group 
under  consideration.  A  patient  seeks  advice  for  shortness 
of  breath.  His  chest  is  inspected,  and  looks  enlarged.  Tlie 
physical  signs  prove  that  the  disease  is  not  one  of  the  heart. 
"What,  then,  is  it  ?  Is  it  an  effusion  into  the  pleura?  is  it  pneu- 
mothorax? is  it  emphysema?  A  tap  on  the  chest  goes  far 
toward  showing  whether  it  be  the  former.  If  the  sound 
rendered  be  resonant,  it  is  not  liquid  in  the  chest  that  is 
producing  the  disturbance:  the  disorder  is  either  pneumo- 
thorax or  emphysema. 

Pneumothorax. — Of  all  thoracic  maladies,  pneumothorax 
is  the  one  the  similarity  of  which  to  extensive  dilatation  of 
the  air-cells  is  the  greatest.  In  both,  the  large  quantity  of  air 
occasions  increased  clearness  on  percussion;  in  both,  there  is 
considerable  and  persistent  difficulty  of  breathing;  in  both, 
the  distention  of  the  chest  and  displacement  of  organs  may 


300  MEDICAL    DIAGNOSIS. 

be  very  obvious.  The  symptoms  and  signs  are,  however,  in 
pneumothorax,  associated  with  different  conditions,  which 
reveal  themselves  on  close  inquiry.  Pneumothorax  is  an  ac- 
cumulation of  air  in  the  pleural  cavity;  but  it  is  something 
more :  the  entrance  of  air  is  soon  followed  by  the  effusion  of 
liquid. 

Air  is  let  into  the  cavity  of  the  chest  by  the  pleura  being 
perforated  by  wounds,  or,  as  is  more  common,  by  its  partial 
destruction  consequent  upon  disease  of  the  lung.  It  is  in 
this  way  that  pneumothorax  originates  in  the  course  of  tuber- 
cular softening,  of  gangrene,  pneumonia,  or  from  the  burst- 
ing of  a  distended  air-vesicle,  or  of  a  dilated  bronchial  tube.* 
In  the  large  majority  of  instances  it  occurs  in  tubercular 
patients. 

When  air  passes  from  the  lung  into  the  pleura,  it  usually 
happens  during  a  paroxysm  of  coughing.  The  pain  which 
ensues  is  mostly  intense;  and  the  frightful,  though  suddenly 
developed  dyspnoea,  and  the  anxious  expression  of  face,  soon 
show  how  seriously  the  respiration  is  interfered  with.  If 
death  does  not  take  place,  symptoms  of  pleurisy  with  effusion 
begin  to  manifest  themselves;  and,  as  in  pleurisy,  the  patient 
lies  ordinarily,  but  not  invariably,  on  the  affected  side.  Saus- 
sier,f  in  analyzing  the  position  of  fifty-six  patients,  notes  that 
twentj^-eight  lay  on  the  affected  side,  nine  on  the  opposite, 
and  nineteen  in  various  postures. 

The  absolute  and  distinctive  marks  of  pneumothorax  are 
furnished  by  its  phj-sical  signs.  The  ingress  of  air  into  the 
pleural  cavity  widens  the  chest,  effaces  the  depression  of  the 
intercostal  spaces,  and  occasions  an  extremely  clear,  or,  more 
correctly  speaking,  a  tympanitic  sound  on  percussion.  The 
air  prevents  the  lung  from  expanding;  hence  there  is  an  en- 
feebled or  absent  respiration,  excepting  near  the  spinal  col- 
umn where  the  compressed  organ  lies,  and  where  the  breath- 
ing is  bronchial.  The  hand,  if  laid  on  any  other  portion  of 
the  chest,  feels,  when  the  patient  speaks,  no  thrill,  and  no 
vocal  vibration  is  detected  by  the  ear.    When  the  perforation 

*  Case  recorded  by  Taylor,  Prov.  Med.  Journal,  vol.  i.,  1842. 
f  Kecherches  sur  le  Pneumothorax.     Paris,  1841. 


DISEASES    OF   THE    LUNGS.  301 

has  not  closed,  and  the  air  rushes  into  the  artificial  cavity 
produced  by  the  separation  of  the  two  surfaces  of  the  pleura, 
the  respiration  is  amphoric,  or  it,  the  voice,  and  the  rales  are 
all  accompanied  by  a  distinct  metallic  ring.  Drops  of  fluid 
falling  into  the  cavity,  or  the  bursting  of  bubbles  on  the  sur- 
face of  the  liquid  in  the  pleura,  are  also  echoed  to  the  ear 
vpith  a  metallic  sound,  and  are  often  heard  as  a  clear,  silvery 
tinkle. 

The  presence  of  the  fluid  in  the  pleural  cavity  gives  rise  to 
a  dull  sound  on  percussion  at  the  lower  part  of  the  chest,  and 
to  a  splash,  perceptible  to  the  ear  and  to  the  finger  when  the 
thorax  is  suddenly  shaken.  This  continues  until  the  eflusion 
increases,  and  until  the  opening  in  the  membrane  closes,  the 
air  disappears,  and  the  case  resolves  itself  into  one  of  chronic 
pleurisy — the  most  favorable  termination  of  pneumothorax. 

Now  let  us  compare  these  physical  signs  with  those  pro- 
duced by  emphysema.  The  sound  on  percussion  in  both  is 
very  clear,  or  is  tympanitic :  more  so,  however,  in  pneumo- 
thorax, which,  in  addition,  exhibits  dulness  at  the  lower  part 
of  the  chest.  The  respiration  in  both  is  feeble.  But  it  is 
feebler  in  pneumothorax,  and  not  accompanied  by  a  long, 
laborious  expiration;  besides,  it  is  often  amphoric,  and  at- 
tended with  metallic  voice  and  tinkling — phenomena  which 
dilated  air-cells  cannot  occasion.  Moreover,  there  can  be  no 
splashing  sound  in  emphysema;  and,  on  the  other  hand,  the 
displacement  of  the  heart  is  generally  much  greater  in  pneu- 
mothorax, and  the  dilatation  of  the  chest  is  more  apt  to  be 
one-sided.  Yet  too  much  stress  has  been  laid  on  the  latter 
point  as  a  means  of  differential  diagnosis,  for  emphysema 
may  be  one-sided ;  and,  on  the  other  hand,  pneumothorax, 
as  the  cases  of  Stokes  and  of  Reynaud*  prove,  may  occur  on 
both  sides.  In  some  cases  we  are  aided  in  the  discrimination 
by  noticing  that  distinct  bulging  is  perceptible  over  the  dis- 
placed heart,  and  that  a  metallic  echo  follows  the  cardiac 
sounds. 

The  physical  signs  of  the  two  diseases  are  thus  very  difier- 

*  Journ.  Hebdomad.,  tome  vii.,  1830.     I  saw  last  winter  a  case  of  double- 
sided  pneumothorax. 


302 


MEDICAL    DIAGNOSIS. 


ent ;  so,  too,  are  many  of  the  symptoms.    Difficulty  of  breath- 
ing exists  ill  both.    But  in  emphysema  it  takes  more  the  form 


Fig.  24. 


Physical  signs  in  pneumotliorax  on  the  right  side.  The  heart  is  observed  to  be  dis- 
jdaced  toward  the  left,  as  actually  happened  in  the  case  from  wliich  the  outline  was 
taken.  The  percussion  resonance  on  the  right  side  was  tympanitic,  extending  some- 
what over  the  left  margin  of  the  sternum;  the  fremitus  was  annulled;  the  voice 
metallic. 


of  attacks  of  asthma;  besides,  whether  spasmodic  or  not,  it 
does  not  set  iu  suddenly  and  with  great  intensity,  and  remain 
intense.  In  pneumothorax  the  patient  remembers  to  have 
been  seized  with  a  pain  in  his  chest,  since  which  period  he 
has  been  continuously  very  short  of  breath. 

Yet  there  are  exceptions  to  this :  there  are  cases  in  which 
the  symptoms  occasioned  by  perforation  of  the  pleura  are 
from  the  onset  so  slight  as  not  to  attract  the  least  attention. 
Such  cases  cannot  be  recognized,  save  by  their  physical  signs. 
Among  these,  dilatation  of  the  chest,  with  the  widened  inter- 
costal spaces,  the  displacement  of  the  liver  or  heart,  and  the 


DISEASES    OF   THE    LUNGS.  303 

exaggerated  and  altered  resonance  on  percussion  are  most 
valuable  in  preventing  the  disease  from  being  confounded 
with  some  affections  which  otherwise  give  rise  to  many  of 
the  same  phenomena.  In  large  cavities,  for  instance,  the 
respiration  and  voice  may  be  metallic ;  metallic  tinkling,  nay, 
even  a  succussion  sound  may  occur.*  But  the  prominent 
chest,  the  extremel}^  clear,  tympanitic,  or  metallic  sound  on 
percussion,  bordered  by  the  line  of  absolute  dulness  due  to 
the  effusion,  are  not  met  with.  The  history  also  is  different, 
and  the  dyspnoea  is  not  so  great.  The  same  dissimilarities 
will  prevent  us  from  mistaking  for  pneumothorax  a  pneumo- 
nia in  which,  byway  of  exception,  the  percussion  sound  over 
the  consolidated  lung  is  tympanitic  or  amphorio.  And  a 
study  of  the  physical  signs,  too,  will  at  once  enable  us  to 
discern  whether  the  difficulty  in  breathing,  though  it  be  sud- 
denly developed,  and  apparently  under  circumstances  which 
make  the  swallowing  of  a  foreign  body  seem  likely,  be  due 
to  this  cause,  or  to  perforation  of  the  pleura  and  pneumo- 
thorax, f 

There  is,  however,  a  morbid  condition  which  exhibits 
nearly  all  the  signs  and  many  of  the  symptoms  of  pneumo- 
thorax, and  which,  were  it  more  frequent,  would  be  the 
source  of  constant  errors  of  diagnosis — diaphragynatic  hernia. 

Of  this  rare  affection  we  know  but  little.  Yet,  thanks  to 
Dr.  Bowditch,!  what  we  do  know  of  it  teaches  us  that  a  pro- 
trusion of  the  abdominal  organs  through  the  diaphragm  will 
generally  dilate  one  side  of  the  chest,  compress  the  lung,  and 
displace  the  heart.  It  will  do  more  :  it  results  in  dyspnoea ; 
and  as  the  stomach  or  intestines  are,  for  the  most  j)art,  the 
viscera  which  find  their  way  into  the  chest,  metallic  tinkling 
and  a  tympanitic  sound  on  percussion  are  detected.  These 
are  all  also  signs  of  pneumothorax.  And  there  is  no  mode 
of  separating  the  two  diseases,  excepting  by  attention  to  the 
history  of  the  case,  by  noting  that  the  dyspnoea  of  the  former 
suddenly  appears  and  as   suddenly  disappears  ;  that  it  has 

*  Cases  cited  by  Gendrin,  Gaz.  des  Hopit.,  No.  113,  1847;  and  Wintrich, 
Krankheiten  der  Kespiralions  Organe,  page  3G7. 

f  As  in  a  case  of  the  disease  communicated  to  me  by  Dr.  Walter  F.  Atlee. 
X  Buffalo  Med.  Journ.,  June  and  July,  18.53. 


304  MEDICAL    DIAGNOSIS. 

often  existed  from  birth ;  and  that  the  metallic  phenomena 
happen  when  the  patient  is  not  breathing,  and  are  mixed  up 
with  the  rumbling  sound  arising  in  the  stomach  or  intestine. 

It  has  been  made  a  question  whether  we  can  distinguish 
ordinary  cases  of  pneumothorax  from  these  very  rare  ones, 
which  are  supposed  to  occur  without  perforation.  Now,  even 
admitting  that  such  cases  really  happen,  for  instance,  as  a 
sequence  of  decomposition  in  pleuritic  eft'usions,  there  are  no 
diagnostic  signs  by  w^iich  we  can  recognize  them  with  any 
certainty.  It  has  been  claimed  for  them  that  there  is  no  an- 
tecedent history  of  a  chronic  pulmonary  trouble,  particularly 
of  phthisis,  that  there  is  not  that  suddenly  occurring  severe 
pain  and  extreme  dyspnoea,  tiiat  the  sputum  and  breath  are 
not  offensive,  that  metallic  tinkling  is  absent,  or  very  rare 
and  inconstant,  and  that  the  amphoric  breathing  is  not  so 
well  developed  or  so  clearly  defined.  If  in  a  case  of  perfora- 
tion, however,  the  opening  has  closed,  the  physical  signs,  it  is 
granted,  are  the  same.* 

Chronic  Pleurisy. — Chronic  pleurisy  is  the  third  of  the 
group  of  more  usual  affections  which  is  characterized  by 
dilatation  of  the  chest,  by  displacement  of  the  intra-thoracic 
viscera,  and  by  shortness  of  breath.  It  is  true  that  acute 
pleurisy  in  the  stage  of  effusion  would,  strictly  speaking,  find 
here  a  place  ;  but  the  acute  symptoms  bring  it  into  another 
class  with  which  it  has  been  more  conveniently  described. 

Chronic  pleurisy  is  established  if  the  fiuid,  after  an  acute 
attack,  be  not  absorbed,  or  if  an  accumulation  of  liquid  take 
place  gradually,  in  consequence  of  subacute  inflammation 
of  the  pleura.  The  disease  has  no  constant  symptoms,  and 
is  often  remarkably  latent :  the  patient  frequently  does  not 
remember  to  have  had  acute  pleurisy.  He  is  not  commonly 
troubled  with  much  cough,  nor  is  the  want  of  breath  so  great 
as  might  be  expected  :  he  is  not  capable  of  talking  for  any 
length  of  time,  or  in  a  loud  voice,  but  does  not  really  suffer 
from  dyspnoea.  His  general  health  may  remain  good,  and  no 
emaciation  occur.  In  some  persons,  on  the  other  hand,  the 
loss  of  flesh,  the  quickened  pulse,  the  sweats,  the  paroxysms 

*  Boisseau,  Archiv.  G^ner.  de  Med.,  vol.  ii.,  1867. 


DISEASES    OF    THE    LUNGS,  S05 

of  hectic  fever  are  so  marked  as  to  produce  a  close  resem- 
blance to  the  last  stages  of  tubercular  consumption. 

While  the  differing  symptoms  rather  hide  the  pleurisy 
from  detection,  the  physical  signs  render  it  easy  of  recoo-ni- 
tion.  What  these  signs  are,  need  not  be  repeated.  They 
haye  been  fully  studied  in  describing  the  effusion  in  acute 
pleurisy.  It  is  only  necessary  to  recall  that  the  most  signifi- 
cant are  absent  respiration  and  yoice,  a  flat  sound  on  per- 
cussion, with  a  vesiculo-bronchial  or  a  bronchial  respiration 
above  the  seat  of  the  liquid.  The  intercostal  spaces  are  ob- 
viously widened ;  their  depressions  are  eftaced.  They  are, 
indeed,  sometimes  convex,  and  the  finger  pressed  on  them 
detects  a  distinct  fluctuation.  During  the  act  of  breathing, 
the  diseased  side  is  almost  motionless,  presenting  a  strong 
contrast  to  the  obvious  plav  of  the  healthy  side.  The  luns: 
which  is  not  disturbed  increases  in  size.  Its  murmur  is  more 
intense,  sometimes  harsher;  and  the  percussion  sound  over 
it  is  exceedingly  clear.  In  some  cases  it  becomes  emphyse- 
matous. The  heart  or  liver  is  displaced.  A  lateral  curvature 
of  the  spinal  column  is  apt  to  take  place,  and  the  shoulder, 
as  Dr.  Corson  points  out,  remains  fixed  and  stiff  during  the 
respirator}'  acts. 

Effusions  into  the  pleural  sac  may  last  for  a  long  time,  and 
lead  to  death  by  progressive  exhaustion  :  or  the  patient  may 
recover  by  the  fluid  being  absorbed,  or  by  its  finding  a  vent 
through  the  bronchial  tubes  or  thoracic  walls.  But  the  chest 
is  rarely  restored  to  its  former  state.  The  lung  \vas  too 
much  compressed,  or  is  still  bound  down  by  too  firm  ad- 
hesions, to  resume  its  full  share  in  the  function  of  respira- 
tion. The  walls  of  the  chest  sink  in  around  it,  and  the  side 
is  flattened,  sounds  duller  on  percussion,  and  presents  a 
feebler  breathing  than  the  other  lung,  which  remains  some- 
what enlarged.  The  heart  generally  returns  to  its  normal 
position,  but  the  shoulder  on  the  aftected  side  is  apt  to  show 
a  permanent  depression. 

ISTotwithstanding  the  decided  character  of  the  physical  signs 
in  all  its  stages,  it  is  astonishing  how  frequently  chronic 
pleurisy   is   overlooked.     The    only  explanation   of  this  is, 

20 


306  MEDICAL    DIAGNOSIS. 

that  SO  little  attention  is  paid  to  the  signs.  Were  the  chest 
more  often  carefully  explored,  we  should  cease  to  hear  of 
patients  whose  pleural  cavit}'  is  filled  with  pus  being  pro- 
nounced incurable  consumptives,  because  they  are  emacia- 
ting and  have  hectic  fever  and  clubbed  nails;  or  being  treated 
for  disease  of  the  Jieart,  on  account  of  the  displacement  of 
that  organ,  and  of  dyspnoea  and  oedema;  or  being  dosed  with 
mercur}',  for  an  imaginary  disorder  of  the  liver;  or  subjected 
to  long  courses  of  quinia  and  arsenic,  to  check  a  rebellious 
ague  which  the  chilly  sensations  and  paroxysms  of  fever  at 
times  simulate. 

These  physical  signs  are  the  same,  whether  the  fluid  be 
serum  or  pus.  The  character  of  the  fluid  produces,  indeed, 
no  distinctive  changes,  either  in  the  signs  or  in  the  symp- 
toms. We  suspect  empyema  if  the  emaciation  be  great  and 
accompanied  by  a  quick  pulse  and  hectic  fever;  but  we  can- 
not be  sure  of  it. 

When  we  come  to  inquire  into  the  thoracic  diseases  with 
which  chronic  pleurisy  is  likely  to  be  confused,  we  shall  find 
that,  although  many  have  some  signs  in  common,  few,  if 
any,  present  the  same  association  of  signs.  Leaving  out  the 
malady  which  is  most  commonly  mistaken  for  it  —  pul- 
monary^ consumption — since  the  points  of  difference  have 
already  been  fully  discussed,  the  affections  with  which 
chronic  pleurisy,  while  the  pleura  is  full  of  liquid,  and  the 
chest  consequently'  enlarged,  is  liable  to  be  confounded,  are: 

Emphysema  and  Pneumothorax; 

Intra-thoracic  Tumor  ; 

Enlargement  of  the  Liver; 

Enlargement  of  the  Spleen  ; 

Abscess  in  the  Thoracic  Walls  ; 

Pericardial  Effusion  ; 

Hydrothorax. 

Emphysema  and  Pneumothorax. — These,  although  distinct 
diseases,  are  grouped  together  because  they  agree  in  possess- 
ing physical  signs  indicative  of  an  increased  quantity  of  air 
within  the  chest;  and  they  give  rise,  like  chronic  pleurisy, 
to  a  dilated  chest,  and  to  displacement  of  the  liver  or  heart. 
Jjut  the  other  signs  above  pointed  out,  which  are  due  to  the 


DISEASES    OF    THE    LUNGS.  307 

presence  of  air,  arc  so  striking,  that  an  error  in  diagnosis 
can  only  be  the  result  of  carelessness. 

Intra-thoracic  Tumor.— A  tumor  within  the  chest  may  occa- 
sion the  same  distention  of  its  walls,  the  same  displacement 
of  organs,  the  same  dulness  on  percussion,  and  absent  respi- 
ration as  an  effusion  of  liquid  into  the  pleura;  yet  the  signs 
are  not  exactly  alike.  There  is  no  fluctuation  in  the  bulging 
intercostal  spaces;  the  vocal  fremitus  is  not  so  constantly 
abolished;  and  the  level  of  the  dulness  is  not  changed  by 
altering  the  patient's  position.  Nor  is  the  flat  sound  so  uni- 
form nor  so  strictly  limited  as  that  produced  by  fluid.  Amid 
the  dulness  may  be  detected  here  and  there  a  spot  yielding 
a  clear  sound  on  percussion.  A  tnmor  in  the  chest,  more- 
over, presses  on  the  nerves,  or  bronchial  tubes,  or  great 
vessels,  and  thus  gives  rise  to  severe  pain,  and  to  dyspnoea 
and  signs  of  interrupted  circulation  for  more  evident  than 
are  caused  by  a  pleuritic  effusion.  It  frequently  grows  into 
the  mediastinum,  and  then  leads  to  prominence  of  the  ster- 
num, and  to  dilatation  of  both  sides  of  the  chest.  These 
phenomena  are  found,  whatever  be  the  nature  of  the  morbid 
growth.  As  most  of  the  thoracic  tumors  are  cancerous,  we 
are  often  much  assisted  in  our  diagnosis  by  discovering  a 
cancer  in  other  parts  of  the  body,  and  by  noting  the  severe 
pain  in  the  chest,  the  harassing  cough,  and  the  expectora- 
tion of  blood,  or  of  a  peculiar  jelly-like  substance.  Yet 
these  evidences,  while  they  aid  us  in  establishing  the  fact 
of  a  morbid  growth  in  the  thoracic  cavity,  do  not  by  any 
means  determine  its  situation.  We  cannot  go  a  step  further 
and  say,  with  certainty,  whether  the  abnormal  formation  be 
situated  exclusively  in  the  lung,  or  in  the  pleura,  or  aflect 
both. 

In  those  cases  in  which  an  effusion  into  the  pleura  com- 
plicates an  intra-thoracic  tumor,  attention  to  the  history  and 
to  the  signs  of  pressure  alone  apprises  us  of  its  presence. 
Yet  both  signs  and  symptoms  may  be  so  closely  like  those 
of  chronic  pleurisy  as  to  render  a  diflerential  diagnosis  im- 
possible. Nay,  friction  sounds,  a  stitcli  in  the  side,  and  fever 
may  be  produced  by  a  cancer  of  the  pleura,  and  be  appa-' 
rently  so  rapidly  developed  as  to  cause  the  disease  to  be  re- 


308  MEDICAL    DIAGNOSIS. 

gurded  as  an  acute  or  subacute  intiaramation  of  that  mem- 
brane. Cancer  of  tlie  pleura,  like  tubercle  of  this  structure, 
has,  therefore,  no  pathognomonic  signs.  The  most  certain 
sign  of  cancer  of  the  pleura  is  probably-  the  one  mentioned 
by  Trousseau,  namely,  that  the  liuid  which  is  evacuated  by 
paracentesis  consi^sts  of  a  bloody  serum. 

It  is  at  times  equally  impossible  to  distinguish  a  circum- 
scribed pleurisy  from  a  tumor  in  the  chest.  In  those  rare 
cases  in  which  adhesions  bound  the  liquid  eit'usion  and  encyst 
it,  we  observe  all  the  marks  of  a  tumor — a  restricted  bulging 
and  percussion  dulness,  and  an  absent  respiration.  Several 
cysts  may  form  as  the  result  of  successive  attacks  of  pleurisy, 
and  may  exist  at  any  portion  of  the  chest.  The  fluid  may 
be  collected  in  the  mediastinum,  or  between  the  lobes  of  the 
lung,  or  anywhere  between  the  surfaces  of  the  pleural  mem- 
brane. The  purulent  contents  of  the  sac  sometimes  find 
their  waj^  into  the  bronchial  tubes,  and  are  expectorated,  or 
give  rise  to  a  distinct  fluctuation  in  the  intercostal  spaces, 
and  then  discharge  through  the  thoracic  parietes.  In  such 
cases  the  diagnosis  is  not  difficult.  But  where  these  phe- 
nomena are  not  present,  the  dissimilar  history  of  the  case 
and  the  absence  of  symptoms  of  pressure  are  the  only  means 
of  distinction  from  a  tumor  in  the  chest.  Fortunatel}'  for 
the  diagnostician,  encysted  pleurisy  is  a  rare  disease  ;  were 
it  frequent,  it  would  be  a  fruitful  source  of  error.  Tlie  same 
remark  applies  to  those  cysts  known  as  hydatids,  and  which 
may  occasion  all  the  signs  of  a  circumscribed  pleurisy.* 

Enlargement  of  the  Liver. — An  enlarged  liver  usually  de- 
scends into  the  abdominal  cavity;  yet  it  may  be  forced  up- 
ward as  ifiir  as  the  fourth  rib,  and,  by  encroaching  upon  the 
lung,  may  give  rise  to  many  of  the  physical  signs  of  apleuritic 
efli'iision.  The  surest  diagnostic  test  is,  that  during  full  in- 
spiration and  expiration  the  line  of  dulness  descends  and 
ascends;  while  the  flat  sound  of  a  pleuritic  eftusion  is  not 

*.See  the  observations  of  Vigla,  Archiv.  Generale  de  Medic,  Sept.  and 
Nov.  1855,  and  of  Koger,  ibid.,  Nov.  1861;  also  cases  quoted  in  Schmidt's 
Jalub.,  No.  10,  1869;  and  compare  the  cases  of  circumscribed  pleurisy  in 
IJlakiston's  Practical  Observations  on  Diseases  of  tlie  Chest,  and  in  Durrani's 
paper,  Prov.  Med.  and  Surg.  Journ.,  1849. 


DISEASES    OF    THE    LUNGS.  309 

afFected  b}'  the  play  of  the  kings.  This  test  will  always  he 
applicable,  excepting  where  the  liver  is  firmly  adherent  to 
the  walls  of  the  abdomen.  As  circumstances  to  assist  in 
discriminating  between  the  enlargement  of  the  abdominal 
organ  and  the  presence  of  liquid  in  the  chest,  may  be  men- 
tioned that  the  heart,  if  at  all  displaced,  is  pushed  upward, 
and  not  toward  the  side;  that  the  dulness  of  an  enlarged 
liver  extends  higher  up  anteriorly  than  posteriorly,  which 
is  the  reverse  of  what  takes  place  in  a  pleuritic  etiusion. 
Moreover,  the  respiration  at  the  lower  portion  of  the  lung 
posteriorly,  although  enfeebled,  is  still  audible. 

Enlargement  of  the  Spleen. — An  enlarged  spleen  is  attended 
with  prominence  and  with  dulness  on  percussion  at  the 
lower  part  of  the  chest  on  the  left  side,  and  might,  there- 
fore, mislead  into  the  idea  of  a  pleuritic  eflusion.  Error  in 
diagnosis  is  prevented  by  attention  to  the  fact  that  the  dul- 
ness extends  also  dovvnward  and  toward  the  median  line. 
Again,  the  heart  is  not  laterally  displaced,  but  tilted  upward ; 
the  respiration  is  feeble,  but  not  absent ;  and  the  vocal 
vibrations  are  mostly  unimpaired. 

Abscess  in  the  Thoracic  Walls. — This,  too,  leads  to  local 
tumefiiction  and  fluctuation  ;  but  we  can  always  ascertain 
whether  a  fluctuating  tumor  in  the  intercostal  spaces  com- 
municates with  the  pleural  cavity  or  not — whether,  in  other 
words,  it  is  or  is  not  the  result  of  an  effusion  which  is  point- 
ing externally — by  watching  how  pressure  and  the  acts  of 
respiration  affect  it.  For,  unless  the  diaphragm  has  become 
immovable  from  the  extent  of  the  effusion,  a  bulging  which 
is  in  connection  with  the  pleura  is  diminished  during  a 
full  inspiration,  and  becomes  more  prominent  when  the  dia- 
phragm ascends  in  expiration.  The  swelling,  moreover,  can 
be  made  to  disappear  to  some  extent  by  pressure.  It  is  not 
so  with  an  abscess  seated  in  the  walls  of  the  chest.  It  is 
not  reducible,  and  does  not  recede  during  inspiration. 

Pericardial  Effusion. — An  effusion  into  the  pericardium 
cannot  be,  certainly  ought  not  to  be,  mistaken  for  an  effu- 
sion into  the  pleura.  The  first  induces  prominence  and  in- 
creased dulness  on  percussion  over  the  region  of  the  heart; 
the  second,  dulness  and  prominence  over  the  back  part  as. 
well  as  over  the  front  of  the  lung.     A  few  cases  are,  how- 


310  MEDICAL    DIAGNOSIS. 

ever,  recorded  in  which  an  enormously  distended  pericardial 
sac  produced  a  Hat  sound  posteriorly,  and  gave  rise  to  signs 
of  compression  of  the  lung.  But  in  these  attention  to  the 
feeble  impulse  of  the  heart  and  its  muffled  sounds  permitted 
it  to  be  foretold  that  fluid  had  accumulated  in  the  pericar- 
dium, and  not  in  the  pleura. 

Hydrothorax.  —  A  dropsy  having  its  seat  in  the  pleural 
cavity  is  called  hydrothorax,  or  water  on  the  chest.  The 
term  is,  in  truth,  sufficiently  significant,  the  fluid  which  is 
poured  out  being  mostly  very  thin  and  watery.  The  physical 
signs  of  hydrothorax  are  the  same  as  those  of  an  efiasion  due 
to  inflammation ;  but  as  the  dropsy  results  from  an  organic 
disease  of  the  liver,  heart,  or  kidneys,  the  serum  collects  in 
both  pleural  sacs.  ISTow,  an  eftusion  caused  by  an  inflamma- 
tion of  the  pleura  is  nearly  always  one-sided.  Even  where 
both  pleurae  are  filled  with  fluid — a  rare  condition,  excepting 
in  tubercular  pleurisy — one  is  aflected  before  the  other.  This 
does  not  happen  in  hydrothorax.  Thus  the  double-sided  eff'u- 
sion,  and  its  usual  association  with  dropsies  in  other  parts  of 
the  body,  are  matters  of  much  significance.  Besides,  in 
forming  a  diagnosis  of  hydrothorax,  we  may  lay  some  stress 
on  the  absence  of  friction  sounds;  on  the  smaller  quantity  of 
fluid ;  on  the  history  of  the  malady ;  and  on  the  presence  of 
a  structural  lesion  of  the  liver,  kidneys,  or  heart. 

These,  then,  are  the  diseases  with  which  chronic  pleurisy, 
when  it  produces  dilatation  of  the  chest,  maybe  confounded. 
I  have  entered  into  the  subject  somewhat  at  length,  because, 
in  view  of  the  frequency  of  the  operation  of  paracentesis,  it 
is  important  to  know  what  affections  besides  chronic  pleurisy 
ma}'  lead  to  prominence  of  the  chest  and  to  compression  of 
the  lung.  It  is  well  to  be  able  to  prove  that  none  of  them 
are  present  before  a  trocar  is  plunged  through  the  intercostal 
spaces. 

Diseases  in  which  Ketraction  of  the  Chest  occurs. 

Chronic  Pleurisy. — We  may  here  continue  the  descrip- 
tion of  chronic  pleurisy  in  the  stage  of  absorption,  since  it  is 
under  these  circumstances  that  the  most  marked  retraction 
of  the  walls  of  the  chest  takes  place.     This  shrinking  of  the 


DISEASES    OF    THE    LUNGS.  311 

thoracic  parietes  is  not  a  sudden,  but  a  very  gradual  act,  and 
instances  are  therefore  constantly  met  with  in  which  the 
upper  part  of  the  chest  is  flattened  and  the  lower,  owinir  to 
its  still  containing  fluid,  bulges.  The  contraction  of  one  side 
of  the  thorax  attains  its  highest  degree  when  the  eft'usion  in 
the  pleura  is  discharged  through  the  chest  walls  and  external 
fistulous  openings  are  established. 

The  symptoms  in  the  stage  of  retraction  are  those  of 
chronic  pleurisy  with  dilatation  of  the  chest,  and  present, 
therefore,  the  same  variability.  But  oedema  of  the  aftected 
side,  which  is  sometimes  so  striking  a  symptom  of  chronic 
pleurisy  where  the  effusion  is  considerable,  is  here  not  no- 
ticed. The  physical  signs  alter  somewhat,  according  to  the 
presence  or  absence  of  fluid  in  the  pleural  sac.  When  none 
exists,  respiration  is  heard  all  over  the  lung  as  a  feeble  in- 
spiration with  prolonged  expiration,  or  as  an  indistinct  blow- 
ing. ISTow  and  then  a  friction  sound  may  be  caught  by  the 
ear.  Where  the  pleura  still  contains  liquid,  these  signs  occur 
at  the  upper  portion  of  the  chest,  and  a  much  more  absolute 
dulness  on  percussio)i,  an  absent  voice  and  vocal  fremitus  at 
the  lower  part  denote  that  fluid  has  there  accumulated.  The 
heart  is  found  either  in  its  normal  position  or  still  displaced. 
The  force  wdth  which  contraction  takes  place  may  pull  it  over 
to  the  side  on  which  the  shrinking  is  going  on. 

Now,  it  is  evident  that  chronic  pleurisy,  when  leading  to 
retraction  of  one  side  of  the  chest,  cannot  be  mistaken  for 
diseases  attended  with  thoracic  distention;  but  it  may  be 
mistaken  for  affections  like  pulmonary  cancer,  tubercle,  and 
chronic  consolidation,  which  also  occasion  a  flattening  of  the 
chest  walls. 

From  cancer  vfe.  distinguish  it  by  the  absence  of  the  peculiar 
expectoration,  and  of  hemorrhage ;  by  the  want  of  signs  of 
perfect  consolidation  ;  by  the  dissimilar  history.  From  tuber- 
cle, by  the  diminution  of  the  chest  in  the  latter  not  being 
confined  to  one  side ;  by  the  physical  signs  indicative  of  de- 
posit and  softening  at  the  upper  portions  of  the  lungs  ;  by  the 
presence  of  rales;  by  the  occurrence  of  hemorrhage  ;  and  b}'' 
tlie  greater  emaciation. 

Chronic  pneumonic  consolidation  presents,  on  the  whole,  most 


■M'2  MEDICAL    DIAGNOSIS. 

points  of  resemblance.  But  there  is  this  difference:  the 
shrinking  of  the  side  in  chronic  pneumonia  is  less  marked, 
and  is  confined  to  the  part  involved — usually  the  lower  lobe 
of  the  luno;.  The  retraction  is  much  more  o^eneral  in  chronic 
pleurisy;  or  whek*e  it  is  partial,  it  is  the  upper  segment  of  one 
side  of  the  chest  which  is  flattened,  and  the  lower  is  promi- 
nent, sounds  very  dull  on  percussion,  and  yields  the  ordinary 
physical  evidences  of  fluid.  In  the  former  malady  the  blow- 
ing respiration,  or  the  enfeebled  inspiration  and  prolonged 
expiration,  and  the  distinct  voice  are  heard  only  over  the 
consolidated  lobe  ;  in  the  other  lobes  the  breathing  is  dis- 
tinctly vesicular.  In  chronic  pleurisy  the  same  abnormal 
signs  are  either  manifest  over  an  entire  side,  or  they  are 
perceived  over  the  narrowed  portion  of  the  chest,  and  below, 
the  respiration,  voice,  and  fremitus  are  abolished. 

In  that  form  of  chronic  pulmonary  induration  attended 
with  dilatation  of  the  bronchial  tubes,  to  which  the  name  of 
cirrhosis  of  the  lung  has  been  given,*  the  flattening  of  the 
affected  part  is  as  obvious  as  it  is  in  pleurisy ;  and,  as  in  this 
complaint,  the  heart  may  be  drawn  to  the  diseased  side. 
The  only  traits  of  dift'erence  consist  i\i  the  signs  indicative 
of  bronchial  dilatation  and  of  copious  bronchial  secretion;  in 
the  sound  afforded  by  percussion  being  less  dull,  or  at  times 
tympanitic  ;  and  in  the  well-defined  and  harsher  bronchial 
respiration,  mixed  often  with  coarse  rales. 

A  collapsed  state  of  the  lung,  resulting  from  a  plug  of 
mucus  in  the  bronchial  tubes,  may,  in  rare  instances,  yield 
the  manifestations  of  chronic  pleurisy  with  partial  retrac- 
tion. No  signs  distinguish  such  cases,  except  the  more  lim- 
ited depression;  the  absence  of  any  disease  above  the  flat- 
tened spot;  the  want  of  friction  sound,  and  of  tenderness 
on  pressure;  and  the  rapid  disappearance  of  the  physical 
phenomena  after  an  effort  of  coughing  has  removed  the 
obstruction. t 

Where  external  fishdous  openings  exist,  tlie  shrinking  of 
the  side,  as  already  stated,  is  carried  to  the  highest  degree. 


*  Corrigan,  Dublin  Quart.  Jcnirn.,  vol.  xiii. 

f  An  interesting  instance  of  this  kind  is  related  by  the  late  Prof.  Pepper  in 
the  American  Journal  of  the  Medical  Sciences  for  April,  1852. 


DISEASES    OF    THE    LUNGS.  313 

Those  fistula},  wlicther  produced  artificially  or  by  luitnre, 
may  close  after  they  have  served  the  purpose  of  evacuatiu<^ 
the  liuid  in  the  pleural  cavity.  But  they  ofteu  persist  for 
months  or  years,  and  keep  on  discharging  oflensive,  puru- 
lent matter.  The  patient  emaciates  under  this  continued 
drain,  yet  not  so  quickly  as  might  be  imagined.  More  or 
less  troublesome  cougli  annoys  him,  but  it  is  not  ordinarily 
accompanied  by  much  expectoration.  Every  now  and  then, 
however,  he  discharges  for  days  a  quantity  of  fetid,  puru- 
lent sputum.  It  is  difficult  to  understand  why  this  happens.  ' 
It  seems  certainly,  so  far  as  physical  signs  can  prove,  not  the 
liquid  in  the  pleura  which  is  being  voided  through  a  perfora- 
tion of  the  pulmonary  tissue,  for  the  physical  signs  of  pneu- 
mothorax are  absent. 

The  clubbing  of  the  nails  is  often  extremely  marked,  and 
may  exist  to  an  extent  far  greater  than  in  phthisis.  The  nail 
is  rounded  and  bluish,  and  the  whole  end  of  the  finger  looks 
enlarged.  This  appearance  is  even  more  striking  than  the 
curve  of  the  nail.  Tiie  nails  and  last  joints  of  the  toes  show 
the  same  alteration. 

The  fistulous  opening  is  situated  ordinarily  in  the  inter- 
costal space  below  the  nipple.  It  may,  however,  be  seated 
at  the  back  of  the  chest,  and  communicate  by  a  tortuous 
sinus  with  the  intestine  and  other  abdominal  viscera.  If  it 
pass  into  the  lung,  the  physical  evidences  of  pneumothorax 
are  present;  but  the  side  is  still  retracted,  and  striking  the 
chest  elicits  a  mixture  of  a  dull  and  a  tympanitic  sound. 
Where  merely  an  external  opening  exists,  no  signs  of  pneu- 
mothorax occur,  because  no  air  finds  its  way  into  the  pleural 
cavitv. 

A  fistulous  opening  into  the  pleura  is  not  difficult  of  diag- 
nosis. It  is  easy  to  establish  the  fact  tliat  the  fistula  is  not 
simply  produced  by  caries  of  the  rib,  for  a  probe  may  be  run 
into  the  chest  for  two,  three,  or  four  inches. 

I  base  these  statements  on  several  instances  of  chronic 
pleurisy  attended  with  external  fistula  which  have  come 
under  my  notice.  The  seat  of  the  opening  near  the  nipple; 
the  peculiar  nail ;  the  occasional  flow  for  days  of  a  most 
offensive    sputum    from    the    bronchial    tubes,   without   any 


314  MEDICAL    DIAGNOSIS. 

traces  of  pneumothorax;  the  ease  with  which  the  fistula 
could  be  probed,  and  its  depth ;  the  gradual  emaciation  ; 
and,  I  may  add,  the  decided  improvement  under  the  per- 
sistent use  of  tonics, — belonged  to  them  all  and  justify  the 
description  given. 


SECTION  II. 


DISEASES    OF    THE    HEART. 


The  diagnosis  of  affections  of  the  heart  turns  so  completely 
upon  a  knowledge  of  its  anatomy  and  physiology,  that  it  will 
be  necessary,  before  we  study  its  diseases,  to  recall  some  of 
the  more  important  anatomical  and  physiological  facts  con- 
nected with  the  organ. 

The  heart  is  a  hollow  muscle  employed  in  forcing  blood 
into  all  parts  of  the  body.  It  is  kept  from  rolling  about  in 
the  chest  by  the  great  vessels  which  spring  from  its  base,  and 
by  the  attachment  to  the  diaphragm  of  its  membranous  cover- 
ing— the  pericardium.  It  lies  obliquely  in  this  membrane, 
with  its  long  axis  directed  downward  and  toward  the  left. 
Its  broad  end,  or  base,  points  backward  and  upward  toward 
the  right  shoulder;  its  under  side  rests  upon  the  central 
tendon  of  the  diaphragm.  The  interior  of  the  heart  is  lined 
by  a  serous  membrane — the  endocardium — which  is  reiiected 
over  the  valves  ojuardins;  the  inlets  and  outlets  for  the  blood. 
These  valves  all  lie  in  close  proximity  to  each  other,  and 
within  a  space  of  less  than  an  inch  square. 

The  relations  the  diftei-ent  parts  of  the  organ  bear  to  the 
chest  walls  are  as  follows:  the  auricles  are  on  a  line  with 
the  third  costal  cartilages;  the  right  auricle  extends  across 
the  sternum  to  the  right  side  of  the  chest.  The  right  ven- 
tricle is  phiced  partly  under  the  sternum,  and  partly  to  the 
left  of  it  Its  inferior  border  is  on  a  level  with  the  sixth  car- 
tilage. The  left  ventricle  lies  within  the  nipple,  between  the 
third  and  fifth  intercostal  spaces.    The  apex  is  seated  between 


DISEASES    OF    THE    HEART. 


315 


the  cartilages  of  the  fifth  and  sixth  ribs,  to  the  inner  side  of, 
and  from  an  inch  and  a  half  to  two  inches  below  the  left  nip- 
ple. The  base  of  the  heart  corresponds  posteriorly  to  the 
sixth  and  seventh  dorsal  vertebrae,  from  which  it  is  separated 
by  the  aorta  and  oesophagus.  The  greater  portion  of  tlie  an- 
terior surface  of  the  heart  is  removed  from  the  thoracic  walls 
by  the  lungs.  The  right  lung  extends  to  the  middle  of  the 
sternum.  The  left  lung  spreads  out  as  far  as  the  fourth  car- 
tilage, and  covers  the  whole  of  the  left  ventricle,  excepting 
the  apex.  The  part  of  the  heart  which  remains  exposed  con- 
sists thus  mainly  of  the  lower  portion  of  the  right  ventricle; 
it  presents  the  shape  of  a  rude  triangle. 

Fig.  25. 


Topography  of  the  heart.  Tlie  relations  of  eacli  jiortion  of  the  lieart  to  the 
walls  of  the  chest  are  shown.  The  dotted  lines  mark  tlu'  lungs.  Tlie  figure 
may,  I  think,  be  relied  upon  :  it  is  based  upon  several  careful  dis.sections. 


The  position  of  the  valves  can  be  learned  by  running 
needles  into  the  chest  before  the  viscus  is  taken  out.  In  this 
manner  it  is  ascertained  that  at  the  left  border  of  the  sternum, 


316  MEDICAL    DIAGNOSIS. 

Oil  a  level  with  the  third  intercostal  space,  lies  the  mitral,  and 
in  front  of  this,  more  directly  under  the  sternum,  and  but  a 
few  lines  lower  down,  the  tricuspid  valve.  The  pulmonary 
oritice  is  seated  opposite  the  junction  of  the  cartilage  of  the 
third  rib  with  the  left  edo-e  of  the  sternum.  Near  it,  verv 
slightly  lower,  but  placed  more  obliquely,  are  the  aortic 
valves.  The  aorta  then  proceeds  from  left  to  right,  and  as- 
cends to  the  upper  border  of  the  second  costal  cartilage  on 
the  right  side  ;  thence  it  crosses,  under  the  sternum  and  in 
front  of  the  trachea,  to  the  left  side.  The  pulmonary  artery 
is  found  in  the  second  intercostal  space  on  the  left  side,  in- 
closed in  the  pericardium,  and  passes  to  the  cartilage  of  the 
second  rib,  where  it  bifurcates. 

The  size  of  the  heart  is  about  that  of  the  closed  fist. 
Bouillaud  estimates  its  mean  weight  in  adults  as  between 
eight  and  nine  ounces.  Only  in  very  large  persons  does  it 
exceed  this. 

This  organ,  so  essential  to  life,  exhibits,  when  in  action, 
a  wonderfully  perfect  mechanism  and  regularity  of  move- 
ment. Its  cavities  contract  on  both  sides  at  the  same  time, 
and  distend  on  both  sides  at  the  same  time.  It  then  rests 
for  a  short  period.  This  process  is  repeated  about  seventy 
times  in  the  course  of  a  minute.  The  contraction  of  the 
ventricles  occasions  the  impulse  which  is  seen  and  felt  in  the 
fifth  intercostal  space.  While  the  blood  is  flowing  in  and  out 
of  the  heart,  the  valves  are  kept  in  constant  motion.  Their 
play  makes  itself  known  by  two  distinct  sounds  of  unequal 
length,  which  are  produced  mainly  by  their  opening  and 
closing.  The  first  long  and  dull  sound  is  caused  by  the 
forcible  closure  of  the  valves  at  the  auriculo-ventricular  open- 
ings. Yet  it  is  not  a  purely  valvular  sound.  The  stroke  of 
the  heart  against  the  walls  of  the  chest,  and  the  muscular 
contraction  itself,  aid  in  its  formation.  The  first  sound  cor- 
responds, therefore,  to  the  impulse  of  the  heart,  to  the  open- 
ing of  the  valves  at  the  orifice  of  the  aorta  and  of  the 
pulmonary  artery,  and  to  the  passage  of  blood  along  the 
arteries. 

The  second  sound  is  short,  abrupt,  and  ringing.  It  results 
from  the  sudden  closure  of  the  semilunar  valves.     During  its 


DISEASES    OF    THE    HEART.  317 

occurrence  the  blood  rushes  in  through  the  opened  mitral 
and  tricuspid  valves,  and  dilates  the  ventricles. 

This  seems  to  be  the  simplest  explanation  of  the  sounds 
of  the  heart.  At  all  events,  it  is  the  one  best  supported  by 
physiological  proofs,  and  most  in  harmony  with  those  mani- 
festations of  disease  by  which  nature  teaches  us,  more  cer- 
tainly than  vivisections  do,  her  great  truths.  Yet  I  cannot 
dismiss  the  subject  without  adverting  to  the  probability  of 
the  view  of  Skoda,  that  other  causes  may  concur  in  producing 
the  sounds  of  the  heart ;  that,  in  other  words,  the  aorta  and 
pulmonary  artery  at  their  origin,  and  even  the  ventricles  at 
times,  may  severally  assist  in  occasioning  both  sounds. 
There  are  certainly  phenomena  which  are  met  with  in  some 
instances  of  disorders  of  the  valves  that  do  not  seem  capable 
of  being  explained  in  any  other  way. 

Examination  of  the  Heart  by  the  Different  Methods  of 

Physical  Diagnosis, 

Before  proceeding  to  examine  the  heart,  it  is  best  to  in- 
quire into  the  history  of  the  case,  and  into  such  symptoms  as 
the  expression  of  the  face;  the  appearance  of  the  eye;  the 
condition  of  the  capillary  circulation  ;  the  presence  or  absence 
of  dropsical  swellings  and  of  cough  ;  the  state  of  the  breath- 
ing; the  character  of  the  pulse  ;  and  the  frequency  and  vio- 
lence of  the  palpitations.  By  the  time  these  points  have 
been  ascertained,  the  agitation  arising  from  the  proposed  ex- 
ploration is  somewhat  calmed  down,  and  the  heart  itself  may 
be  more  advantageously  interrogated.  First,  the  cardiac  re- 
gion is  scrutinized  by  the  eye  and  by  the  hand  ;  then  the  size 
of  the  organ  is  estimated  by  percussion  ;  and  lastly,  its  sounds 
are  studied  by  the  stethoscope.  These  different  methods  are 
most  conveniently  practised  when  the  patient  is  in  an  easy 
position,  leaning  back  in  a  chair  or  propped  up  with  pillows 
in  bed.     To  examine  them  more  in  detail : 


318  MEDICAL    DIAGNOSIS. 


INSPECTION. 

Inspection  detects  on  the  chest  of  some  healthy  persons  a 
slight  protrusion  over  the  seat  of  the  heart ;  yet  this  is  far 
from  being  constant  or  even  the  general  rule.  When  the 
heart  is  hypertrophied,  or  when  fluid  has  accumulated  in  the 
pericardium,  we  perceive  a  marked  prominence  in  the  pre- 
cordial region.  A  depression  at  the  lower  part  of  this  region 
may  he  natural ;  a  very  evident  depression  is  almost  always 
the  result  of  an  attack  of  pericardial  inflammation. 

Yet  neither  prominence  nor  depression  is  a  very  important 
sign.  One  much  more  so,  which  inspection  shows,  is  the  im- 
pulse of  the  heart.  This  is  seen  where  the  apex  beats  against 
the  walls  of  the  chest :  between  the  fifth  and  sixth  ribs,  about 
an  inch  inward  from  the  nipple  and  two  inches  downward. 
It  is  for  the  most  part  confined  to  this  point,  and  appears 
as  a  brief  raising  of  the  integument,  occurring  with  great 
regularity  of  succession.  In  lean  persons  it  is  very  distinct; 
in  fat  persons  it  is  generally  not  at  all  perceptible.  Its  seat, 
even  in  those  who  are  in  perfect  health,  is  not  always  ex- 
actly the  same.  It  is  changed  by  different  positions,  and  by 
the  distention  of  the  stomach  after  a  full  meal  or  by  flatu- 
lence. It  is,  however,  most  modified  by  the  acts  of  respira- 
tion. During  a  long-drawn  inspiration  the  expanded  lung 
sweeps  the  heart  inward,  and  the  impulse  becomes  discern- 
ible in  the  epigastrium.  During  a  fixed  expiration  the  beat 
moves  upward,  and  appears  more  extended  and  weightier. 
The  changes  produced  in  its  situation  by  disease,  both 
thoracic  and  abdominal,  are  many.  It  is  tilted  upw^ard  and 
outward  by  the  left  lobe  of  an  enlarged  liver.  It  is  displaced 
by  diverse  affections  of  the  lungs  and  pleura.  It  is  forced 
up,  as  Walshe  so  accurately  notices,  by  a  pericardial  effusion. 
It  is  visible  lower  down  and  over  a  larger  surface  in  enlarge- 
ments of  the  heart;  but  even  then  it  is  most  distinct  at  the 
apex. 

The  alterations  in  the  character  and  force  of  the  impulse 
are  as  diversified  as  those  of  its  seat.  But  they  are  more 
readily  appreciated  by  the  hand  than  b}-  the  eye. 


DISEASES    OF    THE    HEART.  319 

PALPATION. 

Palpation  is,  as  far  as  the  exploration  of  the  heart  is  con- 
cerned, mucli  preferable  to  inspection.  Manj  an  impulse  can 
be  felt  which  cannot  be  seen.  The  rhythm  of  the  motion  is 
changed  by  a  large  number  of  cardiac  affections,  both  func- 
tional and  organic.  So  are  the  extent  and  force  of  the  beat. 
Both  are  temporarily  increased  by  any  powerful  excitement; 
both  are  permanently  augmented  by  hypertrophy.  In  dila- 
tation and  pericardial  eftusion,  the  extent  over  which  the 
stroke  is  felt  is  greater  than  in  health;  but  the  impulse  is 
feeble,  and  in  the  latter  disease  irregnlar  and  wavy.  Soften- 
ing of  the  texture  of  the  lieart,  diseases  of  the  brain,  some 
morbid  states  of  the  blood,  and  a  low  condition  of  the  sys- 
tem will  also  enfeeble  the  beat. 

The  hand,  when  laid  on  the  precordial  region,  perceives 
at  times  two  impulses.  This  double  impulse  is  often  recog- 
nizable in  health,  especially  in  thin  persons.  It  becomes  still 
more  evident  in  hypertrophy  with  dilatation  of  the  ventri- 
cles. One  of  the  beats  is  systolic  ;  the  other  corresponds  to 
the  diastole.  Bouillaud  cites  examples  in  which  the  diastolic 
stroke  was  double.  Such  cases  must  be  uncommonly  rare. 
The  systolic  beat  is  occasionally  split  into  several  parts  when 
the  pericardium  adheres  to  the  heart. 

All  these  modifications  of  the  impulse  stand  in  direct  con- 
nection with  the  action  of  the  ventricles.  The  auricles,  save 
in  some  rare  instances  in  which  they  are  dilated  and  their 
walls  thickened,  give  rise  to  no  perceptible  movement. 

Besides  the  impulse  of  the  heart,  other  phenomena  may 
be  studied  by  placing  the  hand  over  the  cardiac  region.  The 
sounds  of  the  heart  can  be  analyzed  by  means  of  the  touch. 
They  will  be  felt:  the  one  as  a  long  and  dull,  the  other  as  a 
short  and  distinct  vibration.  The  motion  is  due  to  the  pla^' 
of  the  valves,  and  disappears  with  their  destruction. 

The  fingers  applied  over  the  heart  perceive  at  times  a  pe- 
culiar thrill,  or  a  rubbing  movement.  The  first — called  by 
Laennec,  from  its  resemblance  to  the  pur  of  a  cat,  the  pur- 
ring tremor — is  nearly  always  indicative  of  a  valvular  lesion. 
The  second  is  caused  by  the  to  and-fro  motion  of  a  rough- 
ened pericardium. 


320  MEDICAL    DIAGNOSIS. 

A  more  accurate  means  of  studying  the  varying  impulse 
than  is  afibrded  by  the  fingers,  has  been  sought  to  be  at- 
tained by  instruments  to  record  the  beat  of  the  heart.  The 
cardioscope  of  Alison  was  invented  for  this  purpose,  and  the 
sphygmograph  oY  Marey  has  been  used  for  the  cardiac  im- 
pulse as  well  as  for  the  pulse.  How  this  ingenious  instru- 
ment is  made  applicable  to  the  study  of  diseases  of  the  heart 
has  been  mentioned  in  another  part  of  this  volume,  and  its 
tracings,  so  far  as  they  have  been  proved  to  be  of  real  diag- 
nostic value,  will  be  examined  in  connection  with  individual 
maladies. 

PERCUSSION. 

Percussion  afibrds  the  readiest  means  of  judging  of  the 
size  of  the  heart.  But  to  percuss  a  heart  is  not  easy;  it 
requires  care  and  some  skill.  The  patient  is  placed  in  a  re- 
cumbent position ;  then,  by  a  series  of  moderately  strong 
taps,  we  proceed  downward  from  near  the  middle  of  the 
clavicle,  until  a  dull  sound,  accompanied  by  decided  resist- 
ance, tells  that  we  are  striking  over  a  solid  organ.  The 
point  at  which  this  dull  sound  begins  is  over,  or  immedi- 
ately at,  the  lower  border  of  the  fourth  cartilage.  It  corre- 
sponds to  the  upper  limit  of  the  portion  of  the  heart  which 
is  left  uncovered  by  the  lung. 

The  superior  border  of  the  dulness  having  been  thus  as- 
certained, we  next  percuss  on  the  right  side  of  the  sternum, 
on  about  a  level  with  the  fifth  rib,  and  progress  across  the 
bone.  At,  or  very  near  to,  its  left  edge  we  find  marked  re- 
sistance and  a  duller  sound.  Here  we  draw  our  second  line, 
and  continue  to  strike  straight  across  the  cardiac  region  up 
to  the  point  at  which  a  clear,  full  note  demonstrates  that  the 
pulmonary  tissue  is  resounding.  This  determines  the  ti-ans- 
verse  diameter  of  the  heart;  at  least  so  far  as  it  can  be 
mapped  out  on  the  chest.  The  apex  of  the  organ  and  its 
inferior  surface  remain  yet  to  be  fixed.  The  first  is  readily 
done  by  advancing  in  an  oblique  direction  from  the  already 
ascertained  rio-ht  border.  But  we  can  save  ourselves  this 
trouble  by  feeling  for  the  impulse  or  listening  for  it  with  a 
stethoscope. 


DISEASES    OF   THE    HEART.  321 

The  inferior  surface  is  exceedingly  perplexing  to  circnm- 
scribe.  It  can  only  be  accomplished  by  prolonging  the  line 
of  the  dulness  on  percussion  of  the  upper  border  of  the  liver, 
and  then  judging  by  tlie  greater  amount  of  resistance  and 
the  fall  in  pitch  that  the  heart  has  been  reached.  These  are 
not  easy  to  appreciate;  nor  is  it  indeed  often  necessary  to 
define  the  contiguous  edges  of  the  left  lobe  of  the  liver  and 
of  the  heart.  If  the  other  boundaries  have  been  correctly 
drawn,  the  size  of  the  heart  can  be  accurately  estimated, — 
accurately  enough,  at  least,  for  any  practical  purpose.  But 
the  dulness  elicited  by  percussing  the  cardiac  region  is  not 
so  absolute  as  that  of  the  liver  or  of  some  other  solids.  It 
is  mixed  up  with  the  sound  of  the  lung  tissue,  or  with  the 
resonance  of  the  sternum.  Nor  is  it  a  representation  of  the 
size  of  the  entire  organ.  It  simply  portrays  the  more  super- 
ficial portion,  which  is  uncovered  by  the  lungs. 

In  women  it  is  particularly  difficult  to  define  these  limits. 
It  can  only  be  done  by  having  the  mammary  gland  drawn  to 
one  side  while  percussing.  It  is  equally  difficult  in  children, 
as  the  space  over  which  the  dulness  is  perceived  is  very  small. 
Indeed,  so  unsatisfactory  are  in  them  the  results  of  percus- 
sion, that,  were  we  to  trust  only  to  this  method  of  investiga- 
tion, we  should  often  have  to  conclude  that  the  heart  was 
wanting.  In  adults  the  dulness  ordinarily  spreads  over  two, 
or  nearly  two,  intercostal  spaces.  Its  transverse  diameter  in 
a  grown  person  of  medium  size  is  about  two  inches  and  a 
half.  In  tall,  broad-chested  men  it  is  upwards  of  three 
inches.  Such  at  all  events  is  the  result  of  measurements  I 
have  made.  It  does  not  ascree  with  the  statement  of  a  dis- 
tinguished  clinical  teacher.  Dr.  Bennett:  that  if,  as  a  general 
rule,  the  transverse  diameter  of  the  dulness  measure  more 
than  two  inches,  the  heart  is  abnormally  elilarged. 

The  range  of  the  dulness  is  changed  by  a  number  of 
causes,  physiological  as  well  as  pathological.  A  full  inspira- 
tion alters  it  materially,  by  bringing  the  lung  down  over  the 
heart,  and  by  displacing  the  organ  itself.  The  upper  border 
of  the  percussion  dulness  shifts  to  the  extent  of  an  inter- 
costal space.  Below^  the  nipple,  between  the  fifth  and  sixth 
ribs,  the  sound  becomes  clear;  but  over  the  dislodged  lower 

21 


322  MEDICAL    DIAGNOSIS. 

part  of  the  heart,  the  beat  of  which  is  distinctly  seen  under 
the  cartilages  of  the  ribs,  at  a  point  varying  from  three- 
fourths  to  one  and  a  fourth  inch  from  the  median  line,  there 
is  dulness  with  resistance  to  the  finger.  A  full  expiration 
produces,  for  the  most  part,  converse  phenomena.  It  en- 
larges the  boundaries,  especially  in  an  upward  and  trans- 
verse direction.  The  dulness  reaches  nearly,  or  even 
entirely,  across  the  sternum. 

The  area  of  dulness  is  diminished  in  emphysema.  It  is 
increased  by  a  shrinking  of  the  left  lung,  and  by  diseases  of 
the  heart  and  of  its  membranes.  Prominent  among  these 
stand  hypertrophy,  dilatation,  and  an  eftusion  into  the  peri- 
cardial sac. 

AUSCULTATION. 

When  the  ear  or  a  stethoscope  is  applied  over  a  healthy 
heart,  it  detects  two  sounds  of  very  dissimilar  character:  the 
first  is  long,  dull,  heavy,  and  corresponds  to  the  impulse 
against  the  walls  of  the  chest;  the  second  is  short  and  flap- 
ping, and  occurs  after  the  impulse.  These  sounds  are  audible 
at  all  parts  of  the  precordial  region,  but  not  everywhere  with 
equal  distinctness.  The  first  being  more  ventricular  in  origin, 
is  best  heard  over  the  lower  part  of  the  heart ;  the  second,  a 
more  strictly  valvular  sound,  is  more  defined  at  the  base. 

The  causes  of  these  sounds  have  been  already  explained. 
It  has  been  stated  that  they  are,  to  a  great  extent,  produced 
by  the  play  of  the  valves.  Each  of  these  forms  a  separate 
sound,  or  at  least  a  portion  of  one.  Now,  experience  teaches 
that  there  are  points  at  which  the  sounds  of  the  several  parts 
of  the  heart  may  be  isolated.  Some  of  these  accord  with 
the  anatomical  seat  of  the  valves;  others  do  not.  None  do 
80  very  closely;  and  the  proximity  of  the  valves  to  each  other 
is  such  as  to  make  it  desirable  that  the  localities  selected  for 
listening  to  them  should  be  some  distance  apart. 

Clinical  observation  sanctions  the  following :  the  sounds 
of  the  aorta  are  to  be  studied  at  the  right  edge  of  the  ster- 
num, in  the  second  intercostal  space.  From  there  the  stetho- 
scope may  be  carried  to  the  second  costal  cartilage  of  the 
right  side,  tlie  "aortic  cartilage,"  and  down  to  the  left  edge 


DISEASES    OF    THE    HEART. 


323 


of  the  sternum  opposite  the  third  intercostal  space ;  that  is, 
not  far  from  the  seat  of  the  aortic  valves.  The  pulmonary 
orifice  lies  very  close  to  them ;  but  the  artery  itself  ascends  to 
the  second  costal  cartilage  on  the  left  side.  Its  sound  may, 
therefore,  be  isolated  in  the  second  intercostal  space,  near  to 
the  left  edge  of  the  sternum.  The  mitral  is  listened  to  im- 
mediately fibove  the  beat  of  the  apex.  The  sounds  of  the 
tricuspid  and  of  the  right  ventricle  may  be  sought  for  in  the 
vicinity  of  and  somewhat  above  the  ensiform  cartilage. 


Fig.  26. 


.Aorli 


aru  r/rterj^  valves 


Diagram  showing  the  points  at  which  the  separate  valves  may  be  listened  to. 


Both  sounds  are  discerned  at  each  of  these  points.     But 
the    same    sound    varies   in   difierent   situations.     The  first 


324  MEDICAL    DIAGNOSIS. 

sound  over  the  left  ventricle  near  the  apex  of  the  heart  is 
dull,  heavy,  and  prolonged  ;  that  over  the  right  ventricle  is 
clearer,  shorter^  and  of  higher  pitch.  The  second  sound 
heard  there  presents  no  constant  and  appreciable  variance 
from  that  of  the  left  ventricle  ;  yet  it  is  less  ringing  and  dis- 
tinct than  the  second  sound  of  the  pulmonary  artery  and 
aorta.  Even  these  two  are  not  precisely  alike.  The  second 
sound  of  the  latter,  when  compared  with  that  of  the  former, 
is  found  to  be  sharper  and  more  accentuated.  The  first 
sound,  however,  does  not  differ  materially  from  that  of  the 
pulmonary  artery.  But  the  first  sound  of  both  does  difiier 
most  materially  from  that  over  the  ventricles.  Compared 
w^ith  the  first  sound  over  the  right  ventricle,  the  first  sound 
of  the  pulmonary  artery  is  much  duller,  more  indistinct  and 
like  a  vibration,  and  not  of  so  high  a  pitch.  Compared  with 
the  first  sound  at  the  apex,  the  first  sound  of  the  aorta  lacks 
the  weighty,  prolonged  character  which  belongs  to  the  ven- 
tricular sound. 

These  statements  are  based  on  a  series  of  observations 
made,  some  with  an  ordinary  stethoscope,  some  with  a  double 
stethoscope.  They  certainly  would  seem  to  favor  the  view 
of  Skoda,  that  the  first  sound,  as  heard  over  the  great  vessels, 
is  not  merely  a  transmitted  sound,  but  is  one  which  is  partly, 
if  not  entirely,  generated  by  the  arteries  themselves  when 
the  blood  rushes  into  them. 

The  sounds  just  considered  undergo  various  modifications, 
both  when  the  heart  is  aftected  and  when  it  is  free  from  dis- 
ease. They  may  be  audible  over  a  larger  space  of  the  chest 
than  usually;  they  may  be  changed  in  character  and  rhythm. 
Their  transmission  over  a  larger  space  is  an  unimportant 
sign.  1'hey  are  undoubtedly  perceived  over  a  more  ex- 
tended surface  when  the  heart  is  enlarged ;  but  they  are 
equally  or  more  diffused  when  the  surrounding  tissues  are 
condensed.  And  even  in  the  most  perfect  health  their  range 
is  very  diversified. 

During  a  full  inspiration,  the  sounds  at  the  interspace  be- 
tween the  second  and  third  costal  cartilages  on  the  left  side 
disappear  almost  entirely,  and  become  faint  at  the  aortic  car- 
tilage.    The  first  sound  at  the  apex  lessens  also  very  much 


DISEASES    OF    THE    HEART.  325 

in  distinctness,  but  it  is  better  heard  at  a  new  point  of  impulse, 
visible  toward  the  median  line  and  iust  below  the  cartilasces 
of  the  ribs.  During  a  full  expiration,  the  extent  over  which 
the  heart  sounds  are  perceived  is  increased. 

The  sounds  grow  in  loudness  in  any  functional  disturbance 
of  the  heart.  When  the  organ  is  palpitating  violently  under 
strong  nervous  excitement,  they  may  become  short  and  sharp, 
and  sometimes  so  loud  and  rino^ino-  as  to  be  audible  to  the 
by-standers.  They  are  often  permanentl}^  louder  than  in 
health,  and  shorter  and  more  clearly  defined  when  the  walls 
of  the  heart  are  thinned.  This  is  particularly  the  case  with 
the  Jirsi  sound.  When  the  walls  of  the  heart  are  thick,  the 
first  sound  over  the  hypertrophied  portion  is  apt  to  be  ex- 
ceedingly dull  and  prolonged.  The  first  sound  is  weakened 
if  the  structure  of  the  heart  be  softened;  hence  it  is  feeble  in 
some  low  fevers,  and  in  fatty  degeneration  of  the  organ.  It 
is  also  less  distinct  when  there  is  a  want  of  tone  in  the  mus- 
cle, or  when  the  mitral  and  tricuspid  valves  are  thickened.* 

The  second  sound  is  not  so  liable  to  be  changed  as  the  first. 
It  is  rendered  somewhat  duller  by  a  thickening  of  the  serai- 
lunar  valves,  and,  on  the  other  hand,  more  ringing  when  they 
are  thin,  and  in  some  cases  of  great  functional  excitement  of 
the  heart.  The  sound  becomes  more  distinctly  accentuated 
if  the  column  of  blood  return  on  the  valves  and  close  them 
forcibly.  This  occurs  in  some  cases  of  hypertrophy  of  the 
ventricles.  It  also  takes  place  where  a  decided  obstruction 
exists  to  the  passage  of  blood  through  the  lungs.  It  is  then 
over  the  pulmonary  artery  alone  that  this  accentuated  second 
sound  is  audible. 

Both  the   sounds  are  occasionally  obscure,  and   seem   to 

*  To  determine  whether  a  dull  first  sound  heard  at  the  apex  be  due  to  an 
injured  mitral  valve,  or  to  an  alteration  of  the  muscular  power  of  the  heart, 
Dr.  Flint,  in  his  Essay  on  the  Heart  Sounds  in  Health  and  Disease,  advises 
to  place  the  stethoscope  over  the  apex  of  the  heart,  and  then  on  the  outside 
of  the  left  nipple.  The  element  of  im])ulsion  and  the  valvular  element  which 
unite  to  form  the  complex  first  sound  may  thus  be  isolated  and  turned  to 
practical  account.  If  there  be  a  marked  imjjulsion  over  the  apex,  but  if  by 
means  of  the  stethoscope  placed  to  the  left  we  perceive  no  sound  at  all  which 
possesses  a  valvular  character,  or  but  a  faintly  valvular  sound,  the  inference 

•  that  the  mitral  valves  are  more  or  less  damaged. 


326  MEDICAL    DIAGNOSIS. 

arrive  at  the  ear  from  a  distance.  This  happens  when  fluid 
has  aecuraulated  in  the  pericardium.  The  sounds  may  be 
changed  in  their  relative  proportion  to  each  other,  and  the 
pauses  between  them  be  lengthened  or  shortened,  or  else  the 
sounds  may  intermit  from  time  to  time.  From  this  perverted 
rhythm  we  do  not  derive  any  definite  instruction  as  to  the 
condition  causing  it.  It  serves  only  to  show  that  the  heart 
is  acting  irregularly,  and  thus  directs  our  attention  to  the 
state  of  the  organ.  It  is  apt  to  be  associated  with  organic 
disease  ;  but  it  can  exist  without  it.  The  same  may  be  said 
of  that  curious  phenomenon,  the  reduplication  of  the  sounds 
of  the  heart.  The  second  sound  is  the  one  which  is  more 
generally  split.  Yet  both  of  them  may  be  doubled,  or  one 
may  be  doubled  over  one  part  of  the  heart  and  not  over 
another;  so  that  four  or  three  sounds  are  counted  to  each 
beat  of  the  pulse.  The  cause  of  the  reduplication  is,  so  far 
as  we  know,  the  want  of  svnchronous  action  of  the  two  sides 
of  the  heart.  The  direct  value  for  diagnosis  of  the  altered 
movement  is  not  great;  but  indirectly  it  teaches  a  most  im- 
portant lesson :  it  tells  us  that  each  side  of  the  heart  forms 
its  own  sounds,  and  that,  to  arrive  at  accurate  conclusions, 
each  side  has  to  be  separately  examined. 

Such,  then,  are  the  modifications  which  the  healthy  sounds 
present.  At  times  we  meet  with  sounds  which  do  not  in  the 
least  resemble  those  naturall}-  heard,  and  which  overshadow 
them  or  take  their  place.  They  are  called  murmurs,  and  are 
mainly  produced  either  within  the  heart  or  on  its  surface. 

Those  that  are  endocardial  have  all  a  common  quality: 
they  are  all  more  or  less  blowing.  Yet  the  sound  is  not 
always  of  the  same  character  or  pitch.  It  may  be  low  toned, 
it  may  be  high  pitched ;  it  may  be  soft,  it  may  be  harsh  ; 
it  may  resemble  the  blowing  of  a  bellows,  it  may  be  mu- 
sical; or  it  may  be  filing,  or  rasping,  or  sawing.  The  inge- 
nuity of  every  listener  exerts  itself  in  tracing  a  similarity  to 
some  familiar  noise ;  biit  all  to  no  practical  purpose.  These 
diflferent  sounds  have  not  been  proved  to  have  a  significance 
beyond  that  of  a  blowing  sound.  They  teach  us  nothing  cer- 
tain as  to  its  source.  They  are,  moreover,  not  at  all  times 
the  same  in  the  same  case,  since  the  heart,  when  excited, 


DISEASES    OF    THE    HEART.  327 

may  emit  a  sound  different  from  that  which  it  does  when  it 
is  beating  quietly. 

A  blowing  sound  originates  in  the  altered  relation  of  the 
blood  to  the  part  over  which  it  moves.  This  general  state- 
ment opens  the  way  to  the  consideration  of  the  specially 
acting  elements,  both  in  the  blood  and  the  heart  itself 

Most  usually  a  cardiac  murmur  springs  from  a  change  at 
one  of  tlie  orifices.  This  mav  be  either  a  narrowing  or 
roughening,  which  interposes  a  local  obstruction  to  the  flow 
of  the  blood,  or  it  may  be  an  insufficiency  to  close  the  open- 
ing. In  the  latter  case  the  blood  regurgitates,  and  a  mur- 
mur is  occasioned  by  the  deviation  of  the  direction  of  the 
current  and  the  establishment  of  another.  This  subversion 
of  the  course  of  the  circulating  fluid,  added  to  its  increased 
velocity  and  force,  is  one  of  the  sources  of  those  temporary 
blowing  sounds  not  unfrequently  perceived  when  a  heart  is 
violently  excited,  while  both  its  valvular  apparatus  and  mus- 
cular texture  are  perfectly  healthy.  But  we  meet  every  now 
and  then  with  instances  where  none  of  these  causes  are 
present,  and  where  altered  blood  is  the  foundation  of  the 
murmur. 

Thus,  to  sum  up  the  subject,  we  find  murmurs  which  de- 
pend upon  organic  change,  and  murmurs  which  are  uncon- 
nected with  any  structural  alteration ;  and  these  inorganic 
murmurs  are  either  due  to  an  unnatural  condition  of  the 
blood,  or  to  temporarily  perverted  action  of  the  heart — in 
other  words,  they  are  either  hsemic  or  dj'namic. 

The  murmurs,  however  caused,  have  different  effects  on 
the  sounds  of  the  heart.  They  either  accompany  the  sound 
throughout  its  whole  or  part  of  its  duration,  and  thus  ob- 
scure it,  or  else  they  take  its  place,  and  hinder  it  from  being 
generated.  In  time  of  their  occurrence  they  correspond  to 
the  contraction  or  to  the  dilatation  of  the  heart,  and  there- 
fore to  the  first  or  second  sound.  At  any  rate,  they  do  so 
as  far  as  we  can  ascertain  practically.  It  is  true,  they  may 
immediately  precede  or  succeed  either,  and  fill  mainly  the 
intervals  of  silence  between  the  sounds;  but  attention  to 
such  minute  divisions  is,  for  ordinary  purposes,  unnecessary, 
and  indeed  they  cannot  be  often  readily  recognized  at  the 


328  MEDICAL    DIAGNOSIS. 

bedside.  In  point  of  fact,  it  is  often  difficult  enough,  and 
sometimes  even  impossible,  to  say  wbetlier  the  murmur  we 
hear  is  systolic  or  diastolic. 

The  readiest'  method  of  judging  of  tlie  time  of  the  pro- 
duction of  a  murmur  is  to  feel  for  the  impulse  with  the 
linger  while  listening  with  the  stethoscope.  The  blowing 
sound  which  agrees  with  the  beat  of  the  heart  is  systolic; 
the  one  which  takes  place  between  the  beats  is  diastolic. 

When  a  murmur  is  once  established,  it  attends  each  motion 
of  the  heart  that  can  give  rise  to  it ;  but  it  is  not  always 
equally  perceptible.  It  may  become  very  faint,  or  disappear 
entirely  by  the  patient  changing  his  position.  It  is  sometimes 
only  manifest  when  the  heart  is  acting  strongly.  Indeed,  it 
always  requires  a  certain  force  and  velocity  in  the  passage  of 
the  blood,  to  generate  a  murmur.  Yet  overaction  of  the 
heart  may  be  as  destructive  of  its  distinctness  as  diminished 
action.  This  is,  however,  a  matter  that,  should  it  be  de- 
sirable for  diagnosis,  we  can  control  by  the  administration 
of  medicines  like  digitalis,  aconite,  or  veratrum  viride,  pro- 
vided their  use  be  not  contraindicated  by  other  considera- 
tions. 

A  murmur  is  sometimes  heard  by  the  patient  himself,  or  is 
audible  before  the  ear  is  placed  over  the  heart.  It  may  be 
perceived  as  an  abrupt  blowing  sound,  apparently  coming  out 
of  the  mouth.  A  gentleman,  whose  mitral  valves  permitted 
of  regurgitation,  was  under  my  charge.  When  he  held  his 
breath  and  kept  his  mouth  open,  he,  as  well  as  I,  could  detect 
an  abrupt  blowing  sound  issuing  from  the  oral  cavity.  This 
sound,  when  the  heart's  action  was  at  all  excited,  accom- 
panied regularly  each  impulse. 

Posture  exerts  a  very  decided  effect  upou  murmurs.  A 
blowing  sound  distinct  in  the  recumbent  position  may  become 
very  faint  or  disappear  when  the  patient  stands  erect ;  and 
the  reverse  equally  holds  good.  Its  nature — whether  organic 
or  inor2:anic — does  not  seem  to  influence  the  readiness  with 
which  it  is  aflected  by  change  of  posture.  Pressure,  too, 
has  an  influence  upon  the  abnormal  cardiac  sound;  it  nota- 
bly augments  it,  and  often  raises  its  pitch.  Yet,  pressing 
the  stethoscope  firmly  against  the  chest  does  not  occasion 


DISEASES    OF    THE    HEART.  329 

as  much  cliaiige  in  endocardial  as  it  docs  in  pericardial 
sounds. 

A  murmur  may  be  obscured  by  the  respiratory  sound  ;  but 
this  is  not  apt  to  be  a  cause  of  error  in  diagnosis.  It  is  not 
nearly  so  fruitful  a  source  of  mistake  as  considering  the 
natural  sounds  of  the  lungs  to  be  blowing  sounds  in  the 
heart.  Certainly  the  resemblance  is  often  very  great,  and 
we  must  be  aware  of  it  to  avoid  blunders,  which  may  be 
readily  done  by  listening  to  the  heart  while  the  patient  sus- 
pends his  breathing. 

Having  ascertained  positively  the  existence  and  the  time 
of  occurrence  of  an  endocardial  murmur,  the  next  thing  is 
to  determine  its  exact  seat,  and,  if  possible,  its  immediate 
cause.  The  seat  of  the  murmur  is  judged  of  by  the  place  of 
its  greatest  intensity,  and  the  relation  this  bears  to  one  of 
the  four  points  for  the  clinical  examination  of  the  heart  above 
described.  If  it  be  most  distinct  at  or  near  the  apex  of  the 
heart,  it  is  produced  at  the  mitral  orifice ;  if  immediately 
above  or  at  the  ensiform  cartilage,  it  is  generated  in  the 
right  ventricle  and  at  the  tricuspid  opening.  If  we  hear  it 
most  plainly  at  the  sternum,  somewhat  toward  its  left  border 
on  a  level  with  the  third  intercostal  space  or  even  the  fourth 
rib,  and  with  equal  or  nearly  equal  distinctness  at  the  second 
costal  cartilage  on  the  right  side,  we  are  enabled  to  decide 
that  it  is  developed  at  the  origin  of  the  aorta.  The  pul- 
monary artery  is  not  often  the  seat  of  a  murmur.  When  it 
is,  this  is  clearly  perceptible  in  the  second  intercostal  space 
on  the  left  side,  and  extends,  if  the  valves  be  diseased,  to  the 
junction  of  the  third  left  cartilage  with  the  sternum. 

Each  of  these  situations  may  be  the  site  of  a  distinct  mur- 
mur occupying  only  one  sound  of  the  heart,  or  produced  in 
both, — one  murmur  taking  place  Avith,  the  other  against  the 
current  of  blood.  Yet  it  rarely  happens  that  the  niurnmr  is 
strictly  limited  to  one  of  these  positions;  it  will  mostly  ex- 
tend from  its  point  of  intensity  in  various  directions,  growing 
fainter  and  fainter  as  this  is  left.  A  blowing  murmur  thus 
transmitted  may  drown  the  natural  sounds  of  the  heart  at 
the  parts  not  diseased.  But  when  one  orifice  only  is  aft'ected, 
we  can  usually  find  the  sounds  at  the  other  valves.     They 


830  MEDICAL    DIAGNOSIS. 

may  be  obscured,  but  still  they  exist;  and  it  is  a  vast  aid 
when  they  are  heard,  since  they  set  the  limits  to  the  disease. 
How  important  is  it,  then,  to  examine  each  portion  of  the 
heart  separately,  as  much  for  the  purpose  of  saying  what  is 
not  as  what  is  deranged  ! 

If  satisfied  as  to  the  seat  of  the  murmur,  we  naturally  turn 
to  inquire  into  its  origin.  Is  it  caused  by  an  alteration  of  the 
valves?  Is  it  unconnected  with  any  appreciable  change  of 
structure  in  the  heart?  There  is  nothino;  in  the  murmur 
itself  which  will  tell  us  positively.  As  a  rule,  it  is  true  that 
a  harsh  murmur  results  from  organic  disease,  and  a  soft  mur- 
mur is  inorganic  ;  but  there  are  a  fair  number  of  exceptions. 
We  judge  with  much  more  certainty  by  the  time  of  the  occur- 
rence of  the  blowing  sound  and  by  the  accompanying  phe- 
nomena. A  murmur  attending  the  distention  of  the  heart 
shows  that  the  orifices  are  injured.  A  systolic  murmur  may 
be  either  organic,  or  it  may  indicate  simply  a  change  in  the 
state  of  the  blood,  or  of  the  force  and  velocity  with  which  it 
is  circulating.  In  the  latter  case,  however,  the  abnormal 
sound  is  temporary,  and  disappears  with  the  excitement.  If 
arising  from  an  impoverished  state  of  the  blood,  it  is  gen- 
erally soft,  of  low^  pitch,  is  perceived  over  the  base  of  the 
heart,  and  is  accompanied  by  a  humming  sound  in  the  veins 
of  the  neck.  But  we  shall  further  on  examine  this  question 
more  in  detail. 

Throughout  the  consideration  of  the  endocardial  murmurs, 
they  have  been  treated  as  originating  at  the  seat  of  the 
valves.  In  truth,  it  is  there  where  they  are  formed.  Still 
they  are  occasionally  due  to  morbid  states  in  the  body  of 
the  ventricle,  or  in  the  auricle.  But  in  either  case  they 
are  clinical  curiosities.  As  regards  the  auricles,  they  yield 
no  appreciable  sound  in  health,  nor  are  they  in  disease  but 
very  rarely  the  source  of  either  sound  or  murmur. 

A  blowing  sound  is  not  of  necessity  limited  to  the  heart; 
it  may  be  transmitted  all  over  the  arterial  system.  Yet  it 
would  be  a  great  mistake  to  suppose  that  every  murmur 
heard  over  the  arteries  is  connected  with  a  disease  of  the 
heart.     It  is  often  but  the  sign  of  impoverished  blood,  or  a 


DISEASES    OF    THE    HEART.  331 

sound  dependent  upon  local  roughening  or  narrowing  of  the 
tube.  The  latter  may  be  temporarily  produced  by  the  press- 
ure of  a  stethoscope;  a  fact  of  which  it  is  well  to  be  aware. 
It  is  even  stated  that  pressure  over  a  healthy  heart  may  gen- 
erate a  murmur;  but  I  confess  that  I  have  never  been  able 
to  satisfy  myself  of  the  truth  of  this  statement.  It  is  cer- 
tainly incorrect  as  a  general  rule,  and  depends,  when  it  hap- 
pens, much  more  likely  upon  the  condition  of  the  blood  and 
the  force  with  which  it  circulates. 

Let  us  now  examine  the  sounds  which  originate  on  the 
outside  of  the  heart.  These  pericardial  murmurs  have  all  a 
common  source :  they  all  result  from  irregularities  on  the 
membrane.  Like  the  pleura,  the  smooth  serous  covering  of 
the  heart  moves  noiselessly  in  health;  but  when  it  is  rough- 
ened by  a  deposit  of  any  kind,  the  friction  of  its  surfaces 
gives  rise  to  a  sound  which  may  be  single,  but  which  is  more 
usually  double.  The  character  of  this  sound  is  very  variable. 
It  may  be  a  distinct  to-and-fro  rubbing  murmur,  or  it  may  be 
grazing,  or  scratching,  or  creaking,  or  whistling,  or  clicking 
and  resembling  the  valvular  sounds.  It  has  but  one  quality 
which  is  constant,  and  that  is,  its  superficiality,  liy  this  super- 
ficiality ;  by  the  strict  limitation  of  the  sound  to  the  region  of 
the  heart;  by  its  altering  from  time  to  time  its  precise  seat; 
by  its  greater  extent  and  intensity  when  the  patient  bends 
forward ;  by  its  occasional  increase,  and  even  change  of 
character  on  external  pressure;  by  its  following,  rather  than 
occurring  with,  the  movements  of  the  heart;  and  by  the 
sensation  of  friction  which  it  communicates  to  the  finger, — 
we  know  that  the  sound  heard  is  produced  on  the  surface, 
and  not  in  the  inside  of  the  heart.  Yet  in  spite  of  this  array 
of  points  of  diflerence,  it  is  often  diflicult  enough  to  distin- 
guish an  endocardial  from  a  pericardial  murmur. 

A  friction  sound  is  prone  to  mask  the  natural  sounds  of 
the  heart.  At  times,  although  heard  over  the  cardiac  region, 
it  is  not  due  to  inflammation  of  the  pericardium.  The  exuda- 
tion may  be  on  the  surface  of  the  pleura  adjacent  to  the  peri- 
cardium, and  the  murmur  be  caused  solely  by  the  movements 
of  the  heart.  Sometimes,  again,  the  sound  heard  in  the 
cardiac  region  is  in  reality  the  rubbing  of  an  inflamed  pleura. 


332  MEDICAL    DIAGNOSIS. 

If  any  doubt  exist,  let  the  patient  be  told  to  suspend  bis 
breathing.     As  this  is  stopped,  the  pleural  sound  ceases. 

Such  is  a  brief  description  of  the  difi'erent  physical  signs 
met  with  in  examining  the  heart,  both  in  health  and  disease. 
Their  importance  for  diagnosis  it  is  difficult  to  overestimate. 
A  knowledge  of  the  physical  signs  is  the  solid  foundation, 
without  which  any  structure  that  may  be  raised  will  soon 
tumble  to  pieces. 

The  General  and  Local  Symptoms  of  Diseases  of  the  Heart. 

It  is  not  easy  to  say  what  are  and  what  are  not  the  symp- 
toms that  belong  to  diseases  of  the  heart.  There  are  vital 
manifestations  directing  attention  to  the  heart  which  are  not 
associated  with  any  change  in  its  structure;  and  most  serious 
changes  in  its  structure  may  occur  without  any  of  these  vital 
manifestations.  Yet  we  often  find  a  significant  group  of 
symptoms  which  accompany  an  afiection  of  the  heart.  Some 
of  these  attest  directly  to  the  organ  disturbed,  such  as  pain 
in  the  cardiac  region,  and  palpitation.  Others  are  the  indi- 
rect and  more  remote  expressions  of  its  derangement,  such 
as  cough,  dyspnoea,  hemorrhages,  dropsy,  disorders  of  the 
brain  and  nervous  system,  engorgement  of  the  abdominal 
viscera,  a  peculiar  state  of  the  arteries  and  veins,  and  the 
aspect  of  the  face.  It  is  unnecessary  to  do  more  than  men- 
tion some  of  these,  since  several  have  been  already  described 
in  connection  with  pulmonary  complaints,  and  there  is 
nothing  in  the  cough  or  in  the  shortness  of  breath  by  which 
we  can  absolutely  determine  it  to  be  caused  by  a  disease  of 
the  heart.  The  same  with  respect  to  the  hemorrhage;  there 
is  nothing  characteristic  about  it.  It  simply  proves  the 
efforts  of  the  blood-vessels  to  relieve  themselves  of  the  strain 
which  the  disturbance  in  the  flow  of  the  blood  has  put  on 
them.  The  capillaries  and  the  smaller  blood-vessels  give 
way  first;  partly  from  the  reason  just  assigned,  and  partly 
from  the  altered  state  of  their  nutrition,  which  a  disordered 
circulation  brings  in  its  train.  These  hemorrhao:es  are 
prone  to  happen  from  the  bronchial  tubes  and  the  lung,  ajid 
the  blood   is   expectorated;    but  they  may  also  take  place 


DISEASES    OF    THE    HEART.  333 

directly  into  the  pulmonary  tissue,  or  into  or  from  any  part 
of  the  body.  Their  danger  is  in  proportion  to  the  amount, 
to  the  importance  of  the  function  of  the  structures  into 
which  the  blood  is  effused,  and  to  the  possibility  of  its  find- 
ing an  outlet.  It  is  hardly  requisite  to  state  that  the  peril  is 
greatest  when  the  circulating  fluid  has  been  poured  out  into 
the  brain  or  into  other  parts  of  the  nervous  system. 

Cardiac  Dropsy. — The  dropsy  caused  by  a  disease  of  the 
heart  is  met  with  in  different  situations :  in  the  cellular  tis- 
sues, in  the  peritoneal  and  pleural  cavities,  in  the  pericar- 
dium, in  the  ventricles  of  the  brain,  and  under  the  arach- 
noid, in  the  air-cells  of  the  lungs — in  fact,  in  any  part  where 
fluid  can  exude,  and  where  there  is  a  space  which  can  receive. 

In  anasarca  dependent  upon  a  cardiac  lesion,  the  dropsical 
swelling  commences  about  the  ankles  and  feet;  hence  oedema 
beginning  in  this  situation  is  regarded  as  among  the  surest 
of  the  symptoms  of  a  disease  of  the  heart.  The  accumula- 
tion is  much  influenced  by  position  :  the  feet  are  more  puffy 
toward  evening,  when  the  patient  has  been  all  day  in  the 
erect  posture,  and  least  so  when  he  gets  up  in  the  morning. 

What  the  condition  of  the  heart  is  that  o-ives  rise  to 
dropsy,  has  been  made  a  matter  of  much  dispute.  It  has 
been  held  to  be  uniformly  connected  with  dilatation  of  the 
right  side  of  the  heart.  It  has  been  thought  not  to  happen, 
unless  a  tricuspid  regurgitation  was  also  present.  It  has 
been  taught  to  be  invariably  linked  to  a  valvular  affection. 
Clinical  experience  shows  us  that  it  may  or  may  not  exist 
where  these  states  are  present.  The  dropsy  is  most  con- 
stantly found  to  be  associated  with  an  impediment  to,  or 
disturbance  in  the  flow  of  the  venous  blood,  and,  therefore, 
with  disorder  of  the  right  side  of  the  heart,  particularly  with 
a  dilatation  of  the  cavities.  It  may  be  permanent  or  not. 
Its  extent  certainly  does  not  bear  a  constant  relation  to  the 
extent  of  the  cardiac  disease.  It  bears  a  more  constant 
relation  to  the  amount  of  venous  congestion,  and  to  the  im- 
poverishment of  the  blood. 

Derangement  of  the  Circulation.— Unmistakable  evi- 
dence of  the  obstruction  to  the  flow  of  the  blood  through 
the  veins  is  afforded  by  their  prominence  in  different  por- 


334  MEDICAL    DIAGNOSIS. 

tions  of  the  body.  This  is  specially  manifest  in  the  super- 
ficial veins  of  the  neck,  which,  moreover,  when  the  tricuspid 
orifice  is  pe-rmanently  open,  exhibit  a  distinct  pulsation  with 
each  beat  of  the  heart.  The  turgid  condition  of  the  venous 
system  is  rendered  equally  obvious  by  the  livid  tinge  of  the 
skin  and  the  bluish  color  of  the  lip,  and  by  those  ramifica- 
tions of  fine  bluish  vessels  which  strike  the  eye  at  once.  But 
the  arterial  system  may  also  be  gorged,  and  we  may  find  the 
capillaries  and  the  smaller  arteries  seemingly  read}''  to  burst. 
The  conjunctiva  is  then  highly  injected,  and  the  cheek  has  a 
coarse,  red  look.  This  change  in  the  color  and  appearance 
of  the  face,  tlie  thickening  of  the  eyelids,  and  the  prominent 
eye,  make  up  the  peculiar  physiognomy  of  a  chronic  cardiac 
malady.  The  state  of  the  larger  arteries  is  very  variable,  and 
mainly  according  to  the  nature  of  the  disorder.  The  pulse 
may  be  small  and  tense ;  it  may  be  full ;  it  may  be  rebound- 
ing ;  it  may  be  very  irregular ;  and  it  is  often  out  of  all  pro- 
portion to  the  forcible  action  of  the  heart.  But  these  are 
matters  to  whicb  we  shall  return. 

The  derangement  of  the  circulation  of  individual  parts  mani- 
fests itself  by  special  S3'mptoms.  It  shows  itself  in  the  brain 
by  violent  headaches,  by  vertigo,  by  apoplectic  seizures.  We 
see  evidences  of  the  congestion  of  the  nervous  system  in  the 
disturbed  dreams;  in  the  sudden  starting  up  from  sleep;  in 
the  irregular  action  of  certain  muscles ;  in  the  spots  which 
float  before  the  eye.  It  is  possible  that  the  strange  sense  of 
insecurity,  and  the  irritability  of  which  patients  afflicted  with 
a  cardiac  malady  complain,  are  produced  by  the  same  cause. 
At  any  rate,  whether  produced  thus  or  not,  they  are  remark- 
able symptoms.  There  is  no  disease  which  unnerves  more 
than  a  disease  of  the  heart.  Indeed,  mere  fear  of  its  pres- 
ence gives  rise  to  restlessness  and  gloom,  and  breeds  timidity 
in  those  who  would  look  any  danger  boldly  in  the  face. 

The  disordered  flow  of  blood  through  the  abdominal  vis- 
cera occasions  organic  changes  and  a  disturbance  of  the  func- 
tions of  the  several  organs.  Thus  the  liver  increases  in  size, 
or  undergoes  other  alterations  which  interfere  more  or  less 
seriously  with  the  elimination  of  the  bile;  or  the  kidneys  no 
longer  secrete  as  in  health,  but  drain  oft'  the  albumen  of  the 


DISEASES    OF    THE    HEART.  335 

blood,  and  finally  pass  into  a  state  of  disorganization ;  or  the 
spleen  sustains  textural  transformations.  These  states  all 
tend  to  give  rise  to  more  and  more  dropsy,  and  hence  to 
more  and  more  sufferins:. 

The  symptoms  which  point  most  directly  to  the  heart  itself 
are  palpitation  and  irregularity  of  action,  and  pain.  These 
symptoms  always,  or  nearly  always,  imply  that  the  function 
of  the  organ  is  disturbed,  or  that  its  innervation  is  in  some 
manner  deranged;  but  they  imply  nothing  more.  They  are, 
therefore,  common  to  functional  derangement  which  occurs 
associated  with  structural  changes  in  the  heart,  and  to  purely 
functional  derangement  which  occurs  dissociated  with  such 
changes. 

Cardiac  Pain. — Pain  in  or  over  the  heart  is  met  with  both 
in  acute  and  chronic  diseases ;  yet  it  is  not  a  regular  or  well- 
defined  symptom  of  either.  When  we  reflect  that  the  heart 
may  be  pinched,  maybe  torn,  without  exciting  any  suffering, 
it  will  be  readily  understood  why  its  disorders  do  not  occasion 
much  pain.  Indeed,  many  a  case  of  enormous  enlargement 
of  the  heart,  or  of  profound  textural  alteration  of  its  walls  or 
valvular  apparatus,  is  unaccompanied  by  pain.  This  is,  per- 
haps, the  general  rule;  but,  like  every  general  rule,  it  has  its 
exceptions.  We  sometimes  meet  with  instances  in  which  a 
distress  at  the  heart  and  uneasy  sensations  of  various  kinds 
are  among  the  more  marked  symptoms  of  a  chronic  cardiac 
lesion  ;  and  we  even  find  persons  complaining  of  a  persistent 
pain  in  the  heart,  which  extends  to  the  left  side  of  the  neck 
and  arm,  in  whom  this  symptom  has  preceded  the  signs  of  a 
disease  of  the  heart,  or  of  its  great  vessels. 

In  the  acute  cardiac  afifections  pain  is  a  not  inconstant 
symptom.  Uneasy  sensations,  not  amounting  perhaps  to  ab- 
solute pain,  are  complained  of  in  endocarditis.  Actual  pain 
is  among  the  vital  manifestations  of  inflammation  of  the  sub- 
stance of  the  heart,  and  of  the  pericardium.  In  the  latter 
disorder  it  is  usually  increased  by  pressure,  and  is  frequently 
very  severe.  But  no  suffering  in  the  cardiac  region  is  as  har- 
rowing as  that  which  happens  in  the  obscure  malady  termed 
angina  pectoris. 

Angina  Pectoris. — Although  the  nature  of  the   complaint 


336  MEDICAL    DIAGNOSIS. 

may  be  hidden,  the  symptoms  are  obvious  enough.  We  do 
not  know  what  the  precise  causes  of  this  angina  are ;  but  we 
do  know  that  the  disease  occasions  paroxj'sms  of  the  most  in- 
tolerable anguish.  These  paroxysms  come  on  suddenly,  and 
pass  off  as  suddenly.  Their  main  feature  is  an  agonizing  pain 
in  the  prsecordia,  as  if  the  heart  were  being  firmly  grasped  by 
an  invisible  hand,  or  as  if  it  were  being  torn  to  pieces.  The 
pain  is,  however,  not  limited  to  the  cardiac  region  ;  it  radiates 
in  various  directions,  shooting  to  the  back,  to  the  neck,  and 
especially  down  the  left  arm.  But  this  is  not  all :  worse  than 
the  pain  are  the  intense  anxiety  and  the  feeling  of  impending 
death.  The  heart  palpitates  during  the  fit ;  and  yet,  if  we  judge 
by  the  character  of  the  pulse,  its  movements  are  not  always 
materially  disturbed.  The  beat  of  the  artery  at  the  wrist 
maybe  small,  maybe  weak,  may  be  irregular,  may  be  accel- 
erated; but  it  may  also  be  full,  be  strong,  be  regular,  and  not 
increased  in  frequency.  The  face  is  generally  pale.  Diffi- 
culty in  breathing,  contrary  to  what  might  be  expected,  is  not 
a  prominent  symptom,  and  is,  in  fact,  often  wanting. 

The  duration  of  the  fits  is  as  uncertain  as  the  causes  Avhich 
excite  them.  They  may  cease  in  a  few  minutes;  they  may 
last  upwards  of  an  hour.  They  come  on  rapidly,  without  any 
assignable  reason;  they  are  reproduced  by  bodily  ailment,  or 
by  exertion,  or  mental  irritation.  However  provoked,  they 
are  always  dangerous.  The  heart  may  stop  beating  during 
the  paroxysm.  "  My  life  is  in  the  hands  of  any  rascal  who 
chooses  to  annoy  and  tease  me,"  was  a  saying  of  John  Hun- 
ter's. And  in  truth,  after  he  had  suffered  for  years  from 
these  seizures,  his  ungovernable  temper  brought  on  one  in 
which  he  expired.  It  happens  sometimes  that  the  second 
attack  follows  the  one  by  which  the  disease  first  declares 
itself  at  a  short  interval,  and  proves  fatal.  Dr.  Latham*  nar- 
rates the  history  of  two  cases  of  this  kind.  In  the  one,  life 
ceased  in  a  fortnight  after  the  first' seizure  ;  in  the  second,  in 
ten  days.  Nay,  it  may  be  cut  short  even  in  the  midst  of  the 
first  manifestation  of  this  strange  malady.  Such  was  the 
death  of  the  esteemed  Arnold,  of  Rugby. f 

*  Lectures  on  Diseases  of  the  Heart,  vol.  ii. 

f  Stanley,  Life  iind  Correspondence  of  Thomas  Arnold. 


DISEASES    OF    THE    HEART.  337 

The  immediate  coriditions  on  which  the  symptoms  of  the 
attack  depend  are  veiled  in  obscurity.  Whether  they  be  or 
be  not  produced  by  a  temporary  increase  of  weakness  in  an 
ah-eady  enfeebled  organ  ;  whether  a  cardiac  spasm  occur  or 
do  not  occur;  whether  the  sensation  of  approaching  death  be 
or  be  not  caused  bj^  a  distention  of  the  heart  with  blood, — 
we  do  not  know.  All  we  do  know  positively  is,  that  the  ex- 
cessive pain  abruptly  appearing  and  disappearing  points  to 
what  we  are  content  to  call  deranged  innervation.  Yet  we 
can  go  a  step  further:  we  can  say  with  certainty,  what 
our  forefathers  were  not  aware  of,  that  angina  pectoris  i« 
very  rarely  a  purely  nervous  disease.  Modern  research, 
which  has  taught  us  what  dilatation  of  the  heart  is,  and 
what  softening,  and  what  fatty  degeneration ;  which  ex- 
plains to  us  that  the  heart  may  be  in  a  state  of  profound 
alteration  when  it  looks  healthy, — has  also  taught  us,  or,  to 
speak  more  guardedly,  has  rendered  it  more  than  highly 
probable,  that  these  so-called  spasms  of  the  heart  are  always, 
or  nearl}^  always,  linked  to  some  structural  change.  This 
structural  change,  so  far  as  we  can  now  see,  is,  however,  not 
at  all  times  the  same.  The  list  of  disorders  of  the  heart  and 
arteries  which  angina  pectoris  may  accompany,  is  indeed 
very  long.  There  is  hardly  an  affection  of  the  walls  or  cavi- 
ties of  the  heart,  scarceh'  a  morbid  condition  of  the  arteries 
that  nourish  it  or  spring  from  it,  with  which  the  distressing 
malady  has  not  been  observed  to  have  been  associated.  It 
has  been  found  as  an  attendant  on  ossification  of  the  coronary 
artery;  on  every  form  of  valvular  disease;  on  thinning  of  the 
parietes  of  the  heart;  on  their  fatty  softening;  on  fungoid 
growths  springing  from  the  apex  of  the  organ.*  It  is  possible 
that,  combined  with  all  of  these  states,  is  fatty  degeneration, 
which  thus  would  be  at  the  root  of  the  angina.  Such  is  the 
opinion  of  Dr.  Watson,  and  such  would  also  seem  to  be  the 
result  of  the  observations  of  Dr.  Quain.f  And  whether  this 
view  be  correct  or  not,  it  is  undoubted  that  fatty  degenera- 
tion is  more  frequently  conjoined  with  angina  than  is  any 


*  B.  Travers,  Med.-Chirg.  Transact.,  vol.  xvii. 
f  Med.-Chirg.  Transact.,  vol.  xxxiii. 

22 


338  MEDICAL    DIAGNOSIS. 

Other  organic  disease.  Yet  fatty  degelieration  occurs  often 
without  angina,  and  we  are  thus  forced  to  admit  that,  how- 
ever frequent  the  association,  some  unknown  element  is  still 
here,  as  in  all  cases,  the  determining  cause. 
•  '  Angina  pectoris  is  easy  of  recognition.  It  may  be  a  question 
whether  those  severe  pains  in  the  region  of  the  heart,  which 
are  apt  to  occur  in  feeble  persons  after  unaccustomed  exer- 
tion, or  which  are  brought  on  by  the  excessive  use  of  tobacco,* 
or  which  happen  in  rheumatic  or  gouty  subjects,  especially 
while  suffering  from  indigestion,  are  real  angina,  or  may  be 
separated  from  this  aifection.  They  dift'er  from  it,  irre- 
spective of  being  far  less  violent  and  less  radiating,  by  the 
:circumstances  leading  to  an  attack,  and  by  their  constant  as- 
sociation with  palpitation.  Intercostal  neuralgia  with  palpi- 
tation might  be  mistaken  for  angina;  but  the  painful  spots 
in  the  course  of  the  affected  nerve,  and  the  comparatively 
slight  sufiering,  distinguish  it.  In  truth,  it  is  a  complaint 
seated  only  in  the  thoracic  walls,  and  referred  by  the  patient 
to  the  heart.  Great  irritability  of  the  heart,  attended  with 
pain,  due  perhaps  to  neuralgia  of  the  cardiac  plexus,  is  dis- 
criminated from  angina  by  the  palpitations,  and  by  their  con- 
nection with  pain  which  never  rises  to  the  anguish  of  angina 
pectoris.  Often,  too,  this  apparent  angina  is  found  in  per- 
sons who  are  subject  to  neuralgia,  or  who  are  laboring  under 
a  disorder  of  one  of  the  abdominal  viscera.  And  again  it 
must  be  admitted  that  the  distinction  may  be  rather  one  of 
degree  than  of  kind ;  for  the  cardiac  plexus  is  precisely  the 
point  particularly  involved  in  angina,  and  it  is  thought  by 
several  recent  observers,  that  the  disturbance  of  the  heart  in 
this  painful  malady  occurs  through  the  influence  of  the  sym- 
pathetic fibres  which  meet  in  the  plexus. f 

Palpitation. — This  arises  in  various  diseases  of  the  heart. 
It  happens  at  the  commencement  of  acute  affections;  it  is  an 
unfailing  accompaniment  of  some  chronic  lesions.  It  is  es- 
pecially distressing  when  the  cavities  are  dilated  and  the  walls 
of  tlie  organ  thinned.     But  it  bears  no  positive  relation  to 


*  Beau,  .Journ.  de  Med.  et  Chirurg.,  Jul}',  1862. 

I  EuU'uberir  and  Guttmauu,  Pathologic  des  Synipatliicus.     1868. 


I 


DISEASES    OF   THE    HEART.  339 

any  special  cardiac  malady ;  and  is  therefore  not  diagnostic 
of  any.  So  too  witli  irregular  rhythm  of  the  heart's  action, 
with  which  palpitation  is  in  truth  often  combined.  It  tells 
us  nothing  more  than  that  the  regular  movements  of  the 
heart  are  disarranged.  Frequently,  however,  this  disarrange- 
ment is  due  to  a  serious  change  of  the  valves  or  of  the  mus- 
cular structure.  But  palpitation,  with  or  without  irregular 
rliythm,  may  take  place  in  a  perfectly  sound  heart — sound, 
at  least,  so  far  as  our  means  of  investigation  enable. us  to 
determine. 

Often  the  pulsations  of  the  heart  become  stronger,  more 
extensive,  and  more  perceptible  from  mere  nervous  excite- 
ment. But  it  is  not  necessary  to  detail  the  symptoms  of  a 
purely  nervous  palpitation.  Every  one  has  experienced  them. 
Every  one  knows  that  there  is  a  feeling  of  slight  constriction 
about  the  chest,  with  a  hurried  breathing,  and  a  strange  sen- 
sation as  if  the  heart  were  leaping  from  its  place.  Every  one 
is  also  aware  that  the  organ  is  felt  thumping  against  the  w'alls 
of  the  chest,  and  that  with  a  force  which  shakes  them.  The 
popular  notion,  that  the  heart  is  the  seat  of  the  emotions,  is 
based  on  these  strildng  evidences  of  its  disturbed  action,  and 
poets  have  seized  upon  and  delineated  with  accuracy  some  of 
even  the  more  purely  physical  phenomena  of  the  extended 
impulse  under  strong  nervous  excitement.  Thus  the  great 
dramatist,  in  the  Rape  of  Lucrece : 

"  His  hand,  that  yet  remains  upon  her  breast 
(Kude  ram  to  batter  such  an  ivory  wall !), 
May  feel  her  heart,  poor  citizen,  distressed,  . 
Wounding  itself  to  death,  rise  up  and  fall, 
Beating  her  bulk,  that  his  hand  shakes  withal." 

But  apart  from  the  increase  of  the  beat  by  mere  temporary 
agitation,  a  heart  may  act  overfrequently  and  overstrongly 
and  its  action  become  sensible  to  the  person  ;  in  other  words, 
it  may  palpitate,  from  some  more  unremitting  excitement 
dependent  upon  perverted  innervation.  This  is  the  main 
cause,  as  we  shall  presently  see,  of  the  altered  impulse  of  the 
heart  in  the  so-called  functional  disorders. 


340  MEDICAL    DIAGNOSIS. 


FUNCTONAL  DISORDERS  OF  THE  HEART. 

It  has  just  been  stated  that  the  direct  symptoms  of  a  car- 
diac disorder — pain,  palpitations,  irreguUir  action — are  met 
with  when  no  recognizable  structural  changes  have  taken 
place.  Under  such  circumstances  the  ntfection  of  the  heart 
is  termed  functional,  and  its  symptoms  are  those  already  men- 
tioned, variously  combined,  sometimes  the  one,  sometimes 
the  other  predominating.  These  functional  disorders  are  very 
much  more  frequent  than  the  organic.  They  are,  for  the 
most  part,  produced  by  direct  excitement  of  the  heart,  or  b}" 
its  being  sympathetically  disturbed  by  some  source  of  irri- 
tation existing  remote  from  it,  or  in  the  system  at  large.  The 
symptoms  may  be  said  to  constitute  the  disease.  As  they 
have  been  above  examined  separately  in  connection  chiefly 
with  organic  aiFections,  they  may  be  here  examined  sepa- 
rately in  connection  ehiefl}^  with  functional  derangements. 
And  as  in  the  former,  so  in  the  latter,  one  symptom  is  apt  to 
attend  the  other. 

Disorders  characterized  by  Palpitation,  associated  or  not  with 

change  of  Rhythm. 

We  have  already  briefly  alluded  to  the  causes  of  augmented 
action  which  are  associated  wuth  organic  changes,  and  to 
those  occasioning  temporary  disturbance  of  the  heart.  A 
more  permanent  form  of  palpitation  is  engendered  when  the 
organ  is  kept  more  constantly  excited  by  a  deranged  condition 
of  some  viscus  remote  from  it;  by  the  use  of  stimulating  sub- 
stances; or  by  some  general  morbid  states.  Thus  a  dis- 
ordered stomach  or  liver  leads  to  a  reflex  disturbance  of  the 
heart,  which  ceases  if  the  disorder  of  the  stomach  or  liver 
be  remedied.  In  gouty  and  rheumatic  persons  the  heart  fre- 
quently pulsates  with  increased  quickness  and  violence,  and 
sometimes  Avith  marked  irregularity.  Special  articles  of 
diet,  especially  tea  or  coftee,  produce  palpitation  ;  so  does 
the  inordinate  use  of  tobacco  in  an}-  form.  Masturbation 
and  excessive  sensual  indulgence,  but  particularly  the  for- 
mer, are  prolific  sources  of  continued  palpitation.     We  also 


J 


DISEASES    OF    THE    HEART.  341 

see  those  affected  with  it  who,  addicted  to  laborious  studies, 
give  their  minds  no  rest,  and  grudge  themselves  the  neces- 
sary time  for  food,  sleep,  and  exercise.  Women  who  are 
hysterical,  or  whose  uterine  functions  are  disordered,  suffer 
continually,  or  fancy  that  they  suffer  continually,  from  palpi- 
tation, -So  do  so-called  nervous  people  invariably  complain 
of  the  beating  at  the  heart. 

In  those  whose  blood  is  much  impoverished,  the  palpita- 
tions are  often  very  severe  and  very  constant,  and  theii^  sen- 
sitive state  of  system  is  apt  to  be  increased  by  the  fear  of 
laboring  under  an  incurable  disease  of  the  heart.  There  is, 
indeed,  from  the  strong  resemblance  to  an  organic  affection, 
apparent  cause  for  alarm.  The  heart  strikes  sharply  and 
abruptly  against  the  walls  of  the  chest;  its  action  is  very 
frequent;  the  breathing  becomes  hurried  on  the  slightest 
exertion.  Nay,  even  the  physical  signs  may  be  those  of  a 
structural  lesion.  The  altered  blood  gives  rise  to  a  blowing- 
sound  in  the  heart,  which  is  transmitted  into  the  carotid  and 
subclavian  arteries.  The  difficulty  of  diagnosis  is  at  times 
great.  The  age;  the  sex;  the  anemic  look;  the  presence 
of  a  continuous  humming  sound  in  the  veins  of  the  neck; 
the  strict  synchronism  of  the  murmur  with  the  impulse ;  its 
seat  at  the  base  of  the  heart, — furnish  a  clue  to  the  nature 
of  the  ease.  Still  wo  have  often  to  judge  as  much  or  more 
by  the  ajbsence  of  the  signs  of  cardiac  enlargement,  and  of 
impediment  to  the  flow  of  the  blood,  Avhether  the  heart  be 
affected  in  its  valvular  apparatus,  or  whether  it  be  simply 
functionally  disturbed  and  circulating  watery  blood.  And 
even  with  all  the  assistance  which  the  closest  investigation 
can  furnish,  the  distinction  may  remain  doubtful. 

A  troublesome  kind  of  palpitation  is  that  attende<l  with 
marked  irregularity  of  the  action  of  the  heart,  displaying  it- 
self by  the  beat  being  now  slow,  now  fast,  or  occasionally 
intermitting.  Sufferers  from  gout,  or  old  persons  whose 
stomachs  are  unable  to  digest  food  properly,  are  particularly 
liable  to  it.  This  form  of  palpitation  is  not  without  its 
danger.  It  is  very  prone  to  be  associated  with  an  alteration 
in  the  structure  of  the  heart,  such  as  flabbiness  of  the  walls, 
which  may  not  be  sufficient  to  yield  any  distinctive  physical 


342  MEDICAL    DIAGNOSIS. 

signs,  but  which  is  nevertheless  sufficient  to  be  a  source  of 
apprehension. 

Some  who  experience  these  fits  of  palpitation  faint  away 
during  them.  But  the  complete,  or  almost  complete  suspen- 
sion of  the  movements  of  the  heart  which  characterizes  an 
attack  of  syncope,  has  no  definite  connection  with  any  form 
of  palpitation,  nor,  indeed,  with  any  form  of  cardiac  disorder, 
either  oro;anic  or  functional. 

It  has  been  made  a  question  whether,  in  those  who  are 
subject  to  attacks  of  palpitation  or  to  irregular  action  of  the 
heart,  the  organ  may  not  finally  become  enlarged.  There 
seems  to  be  no  reason  why  this  should  not  take  place,  and 
there  is  a  very  decided  reason  why  it  should.  If  the  muscles 
of  the  arm  be  placed  in  constant  and  very  active  motion, 
they  increase  in  size.  Wli}',  then,  may  not  the  heart,  which 
is  composed  of  the  same  kind  of  muscular  fibre,  also  grow, 
if  it  be  often  called  upon  to  act  more  frequently,  and  in  a 
difl:erent  manner  from  that  to  which  it  is  accustomed  ? 
Hence  we  ought  to  be  very  careful  not  to  negleci;  any  func- 
tional disturba!ice  of  the  heart,  but  aim  at  removing  the 
condition  which  keeps  the  organ  in  a  state  of  irritation,  lest 
it  should  suffer  a  mishap  that  no  exercise  of  skill  can  wholly 
repair. 

We  sometimes  meet  with  a  singular  form  of  functional  dis- 
turbance of  the  heart  which  leads  to  textural  changes,  and 
to  which  Graves  called  particular  attention.  It  consists  in 
a  long-continued  excitement  of  the  organ,  as  evinced  by  its 
increased  force  and  rapid  and  irregular  action,  and  is  fol- 
lowed by  a  swelling  of  the  thyroid  gland,  pulsation  of  the 
arteries  of  the  neck,  and  enlargement  of  the  eyeballs.  This 
strange  disease  is  most  commonly  observed  in  females,  and 
connected  with  hysteria,  neuralgia,  or  uterine  disturbance; 
but  is  now  considered  by  many  as  being  due  to  an  affection 
of  the  cervical  sympathetic  nerve.  All  the  signs  may  remit 
or  become  aggravated  from  time  to  time,  and  especially 
during  a  severe  attack  of  palpitation.  The  turgescence  of 
the  thyroid  gland  arises  quite  independently  of  the  usually 
exciting  causes  of  bronchocele.  It  is  accompanied  by  a  pul- 
sating thrill  similar  to  that  of  an  aneurismal  varix,  and  by  a 


DISEASES    OF    THE    HEART.  343 

distinct  throb.  At  an  advanced  period  of  the  complaint,  these 
signs  subside,  and  the  gland  becomes  more  solid.  Indeed, 
the  whole  atiection  may  disappear,  and  the  gland,  the  eyes, 
the  beat  of  the  carotids,  the  action  of  the  heart,  may  all  be 
brought  back  to  a  normal  condition.  On  the  other  hand, 
hypertrophy  and  dilatation  may  result  from  the  cardiac  pal- 
pitations. 

There  is  another  form  of  functional  disorder  of  the  heart, 
so  peculiar  as  to  demand  a  special  notice.  It  is  the  curious 
cardiac  malady  of  which  we  lately  saw  so  many  examples  in 
soldiers.  Its  main  symptoms  are  habitual  frequency  of  the 
action  of  the  heart,  constantly  recurring  attacks  of  palpita- 
tions, and  pain  referred  to  the  lower  portion  of  the  precordial 
region.  The  palpitations  occur  chiefly  during  exercise,  but 
may  also  take  place  when  the  patient  is  quiet,  and  in  many 
cases  happen  most  often,  or  indeed  entirely,  at  night,  thus 
interfering  with  sleep.  It  is  not  unusual  to  hear  soldiers  who 
are  subject  to  the  disorder  complain  much  of  headache  and 
of  dizziness,  and  especially  of  being  thus  affected  when  suf- 
fering from  palpitation.  The  pain  is  generally  dull  and  con- 
stant, but  is  often  also  described  as  shooting,  and  as  taking 
place  only  in  paroxysms.  Its  chief  seat  is  near  the  apex,  and 
it  is  combined  very  commonly  with  excessive  cutaneous  sen- 
sibility. Often  there  is  pain  nowhere  else  in  the  body ;  but 
in  some  instances  the  cardiac  distress  is  associated  with  pain 
in  the  back,  which  itself  is  not  unusually  connected  with  the 
excretion  of  oxalate  of  lime  by  the  kidneys. 

The  action  of  the  heart  is  very  rapid,  and  in  many  in- 
stances its  rhythm  is  irregular.  The  impulse  is  slightly  ex- 
tended, but  not  forcible,  like  that  of  hypertrophy:  it  is  rather 
abrupt  and  jerky.  As  a  rule,  to  which  thus  far  I  have  met 
Avith  but  few  exceptions,  the  sounds  of  the  heart  are  moditied 
as  follows  :  the  ffrst  sound  is  short,  sometimes  sharp  like  that 
of  the  second  ;  at  other  times  extremely  deficient  and  hardly 
recognizable;  the  distinctness  of  the  second  sound  is  very 
much  heightened.  We  hear  no  murmurs  either  in  the  heart 
or  in  the  neck,  or  they  are  inconstant.  The  area  of  percus- 
sion dulness  does  not  appear  to  be  augmented.  The  pulse  is 
almost  always  easily  compressible  ;   it  may  or  may  not  share 


344  MEDICAL    DIAGNOSIS. 

the  character  of  the  impulse.  It  is  usually  very  much  infiu- 
ejiced  by  position,  falling  rapidly  twenty  beats  or  more,  when 
the  erect  is  exchanged  for  the  recumbent  posture.  The  in- 
creased frequency  of  beat  is  not  connected  with  increased 
frequency  of  respiration,  for  often  wnth  a  pulse  of  one  liun- 
di-ed,  the  respirations  scarcely  exceed  twenty  in  the  minute. 
The  disorder  is  a  very  obstinate  one  to  manage,  and  improve- 
ment comes  but  slowly.  Keeping  the  heart  quiet  by  occa- 
sional doses  of  digitaline,  or  of  veratrum  viride,  or  by  atropia, 
and  improving  its  tone  as  much  as  possible  by  tonics,  has 
been  the  treatment  which  I  found  to  be  the  most  successful. 

What  the  cause  of  the  morbid  cardiac  impressibility,  is 
verj'  difficult  to  ascertain.  It  seems,  in  many  instances,  to 
have  followed  fatiguing  marches  ;  in  some  it  occurred  after 
fevers  or  diarrhoea.  As  far  as  I  have  been  able  to  observe,  it 
was  not  connected  with  scurvy,  or  with  the  abuse  of  tobacco. 
That  it  was  not  due  to  anaemia,  was  at  once  proved  by  the 
general  aspect  of  the  men,  which  was  often  that  of  ruddy 
health.* 

These,  then,  are  the  principal  varieties  of  functional  dis- 
orders of  the  heart.  It  is  hardly  necessary  again  to  state 
that  the  physical  signs  present  the  most  certain,  if  not  the 
only  means  of  distinguishing  the  functional  from  the  struct- 
ural affection.  They  show  us  that  neither  the  size  of  the 
organ,  nor  its  sounds,  with  the  exceptions  above  mentioned, 
are  materially  difterent  from  what  they  are  in  health.  They 
enable  us,  therefore,  to  decide  whether  the  symptoms  whicli 
are  common  to  functional  or  organic  diseases  are  removable, 
or  are  associated  with  conditions  which  no  therapeutic  means 
that  have  been  yet  devised  can  fully  remedy. 


*  These  statements  are  not  intended  to  be  final.  They  are  but  a  very  short 
summary  of  the  results  of  a  large  number  of  observations  which  I  had  an 
opportunity  of  making  on  these  cases  of  "  irritable  heart,'"  and  which  else- 
where, and  in  a  more  complete  form,  will  be  laid  before  the  profession.  Some 
pf>ints  bearing  on  the  inquiry  have  been  published  in  the  Medical  Memoirs 
of  the  U.  S.  Sanitary  Commission. 


DISEASES    OF    THE    HEART. 


345 


ORGANIC  DISEASES  OF  THE  HEART. 

Organic  diseases  of  the  heart  may  be  cLassified  as  follows; 

Organic  Diseases  of  the  Heart. 

Diseases  affecting  the  walls  of  the  heart,  but   r  Hypertrophy, 
mostly  also  changing  the  size  of  the  cav-  j    Dilatation, 
ities. 


Diseases  affecting  chiefly  the  walls  alone. 


Inflammations. 


r 


of  membrane.^ 


Atrophy. 

Patty  degeneration. 
Malformations. 
Rupture  of  the  heart. 
Injuries  and  wounds. 
Aneurism  of  heart. 
Endocarditis, 
icarditis. 


f  Enc 
I  Per 


I  of  muscular 
L      structure. 


Myocarditis  (Carditis). 


Diseases  of  the  valvular  apparatus |  y.ivular  diseases. 


Diseases  affecting  the  pericardium. 


/-  Chronic  pericarditis. 

^   Hydi'opercardiura. 

(•  Pneumo-hydropericardium. 

These  are  not  all  the  organic  diseases  of  the  heart;  vet 
they  are  all  save  the  rarest.  But  let  us  study  the  cardiac 
maladies  rather  according  to  their  symptoms  and  signs  than 
according  to  their  anatomical  classitication.  And  first,  of  a 
group  of  acute  affections. 

Acute  Diseases  presenting  Pain  in  the  Cardiac  Eegion;  the 
Symptoms  of  a  Disturbed  Circulation ;  and  a  Change  in  the 
Sounds  of  the  Heart,  or  their  EepLacement  by  Murmurs, 

All  the  acute  affections  of  the  heart  come  under  this  head. 
In  all  the  sounds  are  either  chancred  in  tlieir  character  or  re- 
placed  by  murmurs.  This  is  certainlv  true  of  the  only  acute 
diseases  of  which  we  have  anything  like  an  accurate  knowl- 
edge— of  endocarditis  and  pericarditis.  All  the  acute  dis- 
orders give  rise  further  to  more  or  less  pain,  and  to  anxiety 
of  expression  ;  in  all  there  is  fever;  all  are  prone  to  occur  in 
connection  with  other  morbid  conditions,  and  especially  with 
a  contaminated   state  of  the  blood.     In   all,  moreover,  tlie 


346  MEDICAL   DIAGNOSIS. 

symptoms  of  a  disturbed  circulation  are  met  with :  palpita- 
tion, irre^^ular"  action  of  the  heart,  deranged  flow  of  blood 
through  the  capillaries  of  different  organs,  and  a  tendency 
to  dropsical  accumulations.  That  these  symptoms  are  not  so 
clearly  defined  as  in  some  of  the  chronic  cardiac  maladies, 
is  owimr  to  the  shorter  time  the  complaint  lasts. 

Acute  Endocarditis. — Acute  endocarditis  is  acute  inflam- 
mation of  the  lining  membrane  of  the  heart.  It  arises,  as  most 
otlier  internal  inflammations  arise,  from  exposure  to  cold,  or 
without  any  cause  being  discoverable.  It  sometimes  results 
from  violent  efforts,  or  from  blows  and  other  injuries  to  the 
chest.  It  is  often  connected  with  a  vitiated  condition  of  the 
blood,  as  in  pyaemia  or  Bright's  disease.  But  more  fre- 
quently still  does  it  form  part  of  an  attack  of  acute  articular 
rheumatism. 

As  the  anatomical  characters  illustrate  the  physical  signs 
and  many  of  the  symptoms  of  the  disease,  they  may  be  here 
briefly  described.  The  membrane  itself  loses  its  transpar- 
ency and  smoothness,  and  is  injected.  On  its  free  surface 
lymph  exudes,  and  is  moulded  into  patches  of  various  size, 
which  may  be  torn  off"  by  the  blood  and  washed  into  the  cir- 
culation :  and  so  may  the  coagula  which  form,  in  severe  cases, 
in  the  chambers  of  the  heart.  The  inflammation  stops  short 
at  the  muscular  structure.  Yet  it  may  implicate  this,  and 
result  in  softening  the  walls  of  the  heart,  or  in  developing 
purulent  cysts  in  them.  It  is  not  uncommo!i  to  find  the  peri- 
cardium involved,  and  then  the  serous  lining  of  the  heart 
and  its  serous  covering  are  both  the  seat  of  exudation.  But 
the  inflammation  inside  is  not  usuall}^  so  extensive  as  the  in- 
flammation without.  Indeed,  one  of  the  peculiarities  and 
chief  sources  of  danger  in  endocarditis  is  this  very  tendency 
it  has  to  limit  itself.  It  coniines  itself,  or  is  most  strikingly 
developed,  at  apart  which  bears  least  of  all  any  impairment 
— at  the  valves — and  often  leaves  behind  it  some  permanent 
disorganization  of  their  delicate  structure.  But  it  does  not 
generally  affect  the  entire  valvular  apparatus ;  that  of  the  left 
side  is  usually  alone  the  seat  of  the  disease. 

What  morbid  anatomy  thus  teaches,  explains  the  occur- 
rence and  situation  of  the  principal  sign  by  which  endocar- 


DISEASES    OF    THE    HEART,  347 

ditis  is  recognized.  The  roughness  of  the  surface  over  which 
the  blood  tlows,  or  the  lymph  deposited  on  or  in  the  neigh- 
borhood of  the  valves,  interfering  with  their  function,  occa- 
sions a  distinct  murmur,  which,  it  is  scarcely  necessary  to 
say,  is  mostly  confined  to  the  mitral  and  aortic  openings. 

Independently  of  the  development  of  this  blowing  sound, 
there  are  other  signs  worthy  of  note.  It  is  true,  they  do  not 
form  so  leading  a  feature  of  the  disease;  still  they  aid  in 
its  correct  appreciation.  The  excited  heart  beats  with  aug- 
mented force,  and  sometimes  with  great  irregularity,  as  the 
not  unusual  doubling  of  the  second  sound  at  the  base  proves. 
The  size  of  the  organ  is  not  notably  increased,  excepting  in 
those  cases  in  which  its  cavities  are  choked  witli  blood  or  clots 
of  fibrin.  The  pulse  corresponds  to  the  action  of  the  heart; 
yet  not  so  closely  as  might  be  expected.  It  is,  for  the  most 
part,  frequent  and  strong,  and  rather  forcible  at  first;  or 
sometimes  small  and  frequent.  It  becomes  irregular,  one 
beat  being  strong,  the  next  weak,  if  the  circulation  through 
the  heart  be  seriously  obstructed.  But  it  may  be  feeble 
while  the  heart  is  thumping  with  violence  against  the  walls 
of  the  chest.  Occasionally  at  the  onset  of  the  attack  it  has 
been  observed  to  be  slower  than  natural. 

The  general  symptoms  are  not  always  uniform.  There  is 
usually  a  sense  of  uneasiness  around  the  heart,  with  decided 
fever,  a  short  cough,  difficulty  of  breathing,  and  an  extreme 
anxiety  depicted  in  the  countenance.  To  these  are  not  un- 
commonly added  a  turgescenee  of  the  face,  headache,  some 
wandering  of  the  mind,  a  yellowish  hue  of  the  skin,  gastric 
irritabilit}',  diarrhoea,  and  rigors,  followed  by  sensations  of 
heat.  Excessive  pain  in  the  heart  is  rare,  and  is  not  likely 
to  happen,  unless  the  pericardium  or  the  muscular  walls  be 
implicated. 

Now,  where  these  symptoms  arc  present ;  where  they 
manifest  themselves  in  a  patient  whose  system  is  in  a  state 
in  which  endocarditis  is  apt  to  take  place  ;  and  where,  above 
all,  they  are  accompanied  by  signs  of  irritation  of  the  heart, 
and  by  a  blowing  sound  recently  and  rather  suddenly  devel- 
oped,— we  are  certain  that  inflammation  is  working  its 
chano-es  in  the  linina^  membrane  of  the  heart.     Yet  some 


348  MEDICAL    DIAGNOSIS. 

ciivumspection  is  requisite  before  arriving  at  this  conclusion, 
an.l  before  the  patient  is  subjected  to  bleeding,  to  mercurials, 
or  some  such  similar  energetic  treatment,  with  the  view  of 
saving  him  from  the  supposed  damage  which  his  heart  is 
about  to  undergo.  A  murmur  may  be  attended  with  febrile 
signs,  and  still  not  be  dependent  upon  acute  endocarditis. 
The  s(Min(l  may  be  of  organic  origin  ;  or  it  may  be  engen- 
dered in  the  course  of  an  idiopathic  fever,  and  the  lining 
membrane  of  the  heart  be  unaltered. 

In  the  first  instance,  the  murmur  is  old,  and  results  from 
some  chronic  injury  to  the  valve,  the  attending  fever  being 
an  accidental  complication.  Here  is  undoubtedl}^  a  difficult 
case  for  diagnosis.  We  see  the  patient  for  the  iirst  time  :  he 
has  fever;  his  heart  is  acting  strongly;  a  distinct,  blowing 
sound  is  perceived  over  it.  How  are  we  to  te)l  that  his  com- 
plaint is  not  acute  endocarditis  ?  We  have  no  absolute  means 
of  deciding  that  it  is  not.  Yet  by  careful  inquiry  we  can  usu- 
ally come  to  a  knowledge  of  the  truth.  If  the  patient  do  not 
recollect  to  have  suffered  previously  from  dyspnoea,  palpita- 
tion, or  other  signs  of  an  affection  of  the  heart;  if  the  cardiac 
excitement  and  irritation  be  well  defined;  if  the  face  denote 
distress;  if  the  accompanying  symptoms  indicate  a  state 
which  is  prone  to  be  complicated  with  endocardial  inflam- 
mation,— it  is  this  disease  under  which  he  is  laboring.  I 
may  add  another  and  very  important  element  of  distinction 
deduced  from  the  study  of  the  blowing  sound,  to  wit,  that  the 
murmur  of  endocarditis  is  not  so  rough,  is  not  often  heard 
during  the  distention  of  the  heart,  and  may  be  changeable  in 
its  seat,  which  an  old-standing  murmur  never  is.  Besides,  it 
is  not  associated  with  those  sio-ns  of  enlarsrement  which  are 
so  invariably  found  when  the  valves  have  been  for  any  length 
of  time  affected,  unless  the  acute  inflammation  occur  in  a 
heart  the  valves  of  which  have  been  previously  spoiled. 
Under  such  circumstances,  we  can  only  conjecture  what  is 
going  on  within  the  organ  by  its  increased  excitement;  and, 
if  I  may  take  my  own  experience  as  the  general  rule,  by  the 
character  of  the  blowing  sound  beins:  altered.  It  is  rendered 
often  less  distinct,  nay,  it  is  even  entirely  muffled,  by  the  pro- 
ducts of  the  recent  inflammation. 


DISEASES    OF    THE    HEART.  349 

But  how  are  we  to  disting-uish  between  the  soft  murmur 
arising  in  the  course  of  fevers,  and  that  resulting  from 
effused  lymph  ?  It,  too,  is  not  rough.  It,  too,  happens  with 
the  impulse.  It,  too,  is  preceded,  as  some  cases  of  endocar- 
ditis are,  by  a  lengthening  of  the  lirst  sound.  Here  is  assur- 
edly a  very  strong  resemblance,  yet  by  no  means  an  identity. 
The  blowing  sound  in  fevers  does  not  exist  until  the  blood  is 
profoundly  altered.  In  endocarditis  it  takes  place  almost  as 
soon  as  the  disease  begins, — certainlj-  as  soon  as  we  are  able 
to  recognize  positively  its  commencement.  The  heart  in 
fevers  may  be  softened,  but  it  is  not  so  directly  disturbed  in 
its  action.  We  do  not  find  those  symptoms,  local  as  well  as 
general,  which  show  that  the  circulation  is  obstructed.  The 
blowing  sound  is  rarely  found  at  the  apex.  To  the  last  par- 
ticular some  weight  may  be  attached,  since  the  murmur  of 
endocarditis  is  very  apt  to  be  heard  at  the  apex.  But  to  no 
fact  ought  as  much  weight  to  be  attached  as  to  the  one  first 
mentioned,  that  the  murmur  takes  place  early,  and  not  late 
in  the  disease. 

Throughout  this  description  of  inflammation  of  the  inte- 
rior of  the  heart,  only  simple,  uncomplicated  cases  have  been 
kept  in  view;  yet  it  is  not  often  that  the  malady  is  seen  in  so 
pure  a  type.  It  is  more  generally  accompanied  by  the  fric- 
tion sounds  and  other  signs  of  acute  pericarditis,  and  by  the 
swollen  joints,  the  painful  movements,  the  acid  perspirations 
of  acute  rheumatism. 

Nor  is  what  has  been  said  of  its  manifesting  itself  by  a 
murmur  the  invariable  rule.  If  the  question  be  asked,  "Can 
endocarditis  occur  without  a  blowing  sound?"  it  must  be 
answered  in  the  afifirmative.  AVhen  the  seat  of  the  inflamma- 
tion is  not  near  the  valves,  no  murmur  is  generated.  There 
may  be  also  none  if  no  vegetations  exist  on  the  valves,  and 
perhaps  in  states  of  the  exudation  with  which  we  are  at  pres- 
ent unacquainted.  We  cannot,  under  sucii  circumstances, 
detect  an  attack  of  endocarditis.  Yet  it  may  be  even  then 
strongly  suspected  to  be  present  if  great  excitement  and 
irritation  of  the  heart  manifest  themselves  in  a  person  wlio 
is  laboring  under  a  disease  which  predisposes  to  endocardial 
inflammation,  such  as  rheumatism.     Cases  of  this  nature  are, 


350  MEDICAL    DIAGNOSIS. 

liowever,  exceptional.  They  do  not  happen  sufficiently  often 
to  invalidate  the  value  of  the  statement  that  the  development 
of  a  murmur  is  the  sign  indicative  of  inflammation  of  the 
inner  surface  of  the  heart.  Yet  they  happen  sufficiently 
often  to  impress  upon  us  that  our  knowledge  of  endocarditis 
is  not  complete. 

The  clinical  study  of  endocarditis  is,  in  truth,  a  recent 
study.  There  are  some  points  about  it  which  are  as  yet  next 
to  unknown,  and  others  which  are  now  being  cleared  up, 
and  in  a  mnnner  that  must  let  in  light  on  man}'  obscure  sub- 
jects of  pathology.  To  this  class  belong  those  interesting 
researches  on  the  formation  of  clots  in  the  heart,  and  the 
effects  produced  when  they  or  the  vegetations  which  stud  the 
valves  are  washed  into  the  circulation.  The  formation  of 
clots  of  fibrin  in  the  cardiac  cavities,  if  at  all  extensive,  an- 
nounces itself  bv  a  sudden  appearance  or  a  sudden  augment- 
ation of  the  symptoms  of  obstructed  circulation  :  the  skin  is 
cold  and  the  surface  maybe  bluish;  tliere  is  dyspnoea,  the 
heart's  action  becomes  exceedinolv  irregular,  its  sounds  indis- 
tinct,  and  the  extent  of  the  precordial  percussion  dulness  is 
somewhat  increased.  Great  anxiety  of  countenance,  nausea, 
vomiting,  excitement  of  the  nervous  system  and  delirium, 
and  fits  of  fainting  are  also  among  the  manifestations  of  the 
clogged  flow  of  blood  through  the  heart.  ISTow,  portions  of 
the  clots,  or  of  the  vegetations  on  the  valves,  are  sometimes 
washed  into  the  current,  and  occasion  symptoms  which,  be- 
fore we  were  aware  of  the  damages  to  Avhich  these  detached 
masses  may  give  rise,  appeared  inexplicable.  At  present — 
thanks  to  Yirchow,  Kirkes,  and  Paget — when  we  see  the  cir- 
culation speedily  diminished  or  arrested  in  a  limb,  and  the 
limb  swelling  or  beginning  to  mortify;  when  we  find  that 
the  flow  of  the  blood  through  the  brain  has  become  suddenly 
disturbed,  and  the  muscles  of  one  side  drop  paralyzed;  when 
the  difficult  breathing  becomes  rapidly  still  more  difficult, 
while  there  are  no  signs  of  a  superadded  affection  of  the  lung, 
nay,  while  the  power  fully  to  fill  the  lungs  remains  unimpaired, 
or  while  an  effusion  of  fluid  into  the  air-vesicles  follows  the 
dyspnoea, — we  know  what  has  happened  :  we  know  that  a 
broken  off"  piece  of  fibrin  has  been  driven  into  the  artery  of 


DISEASES    OF    THE    HEART.  351 

the  limb,  or  into  the  brain,  or  into  the  branches  of  the  pul- 
monary artery,  and,  being  too  large  to  go  any  farther,  has 
stuck  fast,  and  has  given  rise  to  all  of  these  sudden  and  sad 
consequences.  Sad,  indeed,  they  are;  for,  even  if  the  plugs 
do  not  lead  to  an  immediately  fatal  result,  they  are  apt  to 
lay  the  groundwork  for  structural  alterations  in  any  organ 
or  tissue  in  which  they  become  impacted. 

With  respect  to  the  frequency  with  wliich  changes  remote 
from  the  heart  are  produced  by  the  disintegration  of  masses 
of  fibrin  formed  in  it,  we  are  not  yet  in  a  condition  to  speak 
positively.  Nor  are  the  signs  of  either  the  formation  of  these 
clots,  or  of  their  dispersion,  as  well  understood  as  is  desirable. 
We  are,  indeed,  better  acquainted  with  those  of  the  latter 
than  with  those  of  the  former;  for  as  great  an  observer  as 
Dr.  Walshe  records  that  the  eftects  of  a  rupture  of  a  sigmoid 
valve  or  of  a  tendinous  cord,  during  the  acute  endocardial 
disease,  will  give  rise  to  symptoms  exactly  similar  to  the  ob- 
struction of  the  circulation  resulting  from  polypoid  concre- 
tions in  the  heart.  Our  knowledge  of  the  whole  subject  is, 
in  truth,  still  at  its  commencement. 

But  let  it  not  be  understood  that  the  detachment  of  vege- 
tations from  the  valves,  or  of  fragments  of  clot  formed  in  the 
cavities  of  the  heart,  happens  only  in  endocarditis.  Pieces 
have  been  found  which  were  separated  from  valves  that  were 
in  a  state  of  chronic  induration,  or  so-called  ossification.  And 
the  blood  in  the  heart  may  clot  from  any  interference  with 
the  current,  or  from  changes  in  the  vital  fluid  wholly  uncon- 
nected with  inflammation.  But  when  it  coagulates,  from 
whatever  cause,  the  symptoms  are  the  same  as  those  just 
described.  A  murmur,  too,  is  not  uncommonly  produced, 
which  is  not  distinguishable  from  that  due  to  endocardial 
inflammation,  but  which  is  not  of  long  duration,  since  death 
follows  the  impediment  in  the  heart  in  a  few  days  at  furthest. 

Iiiflammatioji  of  the  aorta  may  occasion  many  of  the  symp- 
toms of  acute  endocarditis ;  at  all  events  it  may  do  so  when 
the  upper  part  of  the  aorta  is  implicated.  Nor  can  it  be  said 
that  it  is  a  condition  which  with  certainty  may  be  discrim- 
inated. The  most  signiflcant  signs,  though  they  are  by  no 
means  constantly  present,  are  a  hurried  respiration,  a  sharp, 


352  MEDICAL   DIAGNOSIS. 

rapid  pulse,  tuninltuous  action  of  the  heart,  pain  in  the  pre- 
cordial region^  often  severely  increased  by  movements,  and 
also  felt  along  the  course  of  the  spine,  and  a  loud  systolic 
blowing  sound.  AVhen  the  abdominal  aorta  is  affected,  there 
is  a  strong  local  pulsation  and  a  very  marked  murmur  will 
be  beard  with  greatest  distinctness  at  or  near  the  seat  of  the 
inflammation.  In  some  cases  of  aortitis,  Bright*  noticed  an 
extremely  high  degree  of  morbid  sensibility  over  all  parts  of 
the  body,  which  caused  the  patient  to  scream  with  pain  when 
his  wrists  were  merely  touched.  The  disorder  is  most  apt 
to  happen  in  cachectic  persons;  and  it  has  been  repeatedly 
observed  in  those  attacked  with  erysipelas,  or  after  operations 
and  injuries.f 

Acute  Pericarditis. — Acute  inflammation  of  the  serous 
membrane  of  the  exterior  of  the  heart  is  very  similar  to  that 
of  its  interior.  It  is  developed  under  the  same  circumstances. 
It  exhibits  the  same  frequent  association  with  rheumatism. 
It  presents  the  same  symptoms.  Nature  has  not,  indeed, 
drawn  a  very  strict  line  of  demarcation  between  the  two  dis- 
eases. When  one  exists,  the  other  is  very  apt  to  attend  it. 
Yet  we  do  m-eet  with  endocarditis  without  pericarditis,  and 
more  often  still,  with  pericarditis  without  endocarditis. 

The  anatomical  effects  of  inflammation  of  the  pericardium 
are  like  those  of  acute  endocarditis,  and  resemble  yet  more 
closely  those  which  inflammation  of  the  adjoining  serous 
membrane — the  pleura — occasions.  The  pericardium  becomes 
injected  and  dry;  plastic  lymph  accumulates  on  its  surfaces, 
and  especially  on  the  surface  which  tits  tightly  around  the 
heart.  The  extent  and  appearance  of  the  deposited  lymph 
are  very  various.  It  may  be  limited  to  part  of  the  covering 
of  one  ventricle,  or  be  distributed  in  layers  all  over  the  inner 
face  of  the  membrane.  It  may  give  to  this  the  look  of  having 
been  besmeared  with  a  sticky  substance,  or  of  having  been 
enveloped  with  a  delicate  network  resembling  lace.  More 
often  it  is  rough  and  shaggy,  and  presents  a  strong  likeness 
to  the  villi  of  the  intestine,  to  the  dorsal  surface  of  a  bul- 


*  Guy's  Hospital  Keports,  vol.  i. 
fChevers;  ib.  vol.  vi.,  iuid  2d  Series,  vol.  i. 


DISEASES    OF    THE    HEART.  353 

lock's  tongue,  to  the  mucous  membrane  of  the  gall-bladder, 
and  to  other  objects  of  uneven  outline  with  which  the  fancy 
of  different  observ^ers  has  compared  it.  This  stasre  of  the 
disease  corresponds  to  the  dry  stage  of  acute  pleurisy.  It 
may  have  the  same  termination  by  the  two  roughened  sur- 
faces adhering.  But  it  is  often  followed  by  a  stage  similar 
to  that  of  pleural  etfusion.  The  bag  in  which  the  heart  lies 
is  filled  with  fluid;  sometimes  with  serum  in  which  flocculi 
of  lymph  float ;  at  times  with  a  thicker,  more  highly  albu- 
minous liquid;  less  frequently  with  a  watery  blood,  or  with 
pus.  The  effusion  may  remain  stationary  or  be  absorbed, 
and  the  rugged  portions  of  the  membrane  be  placed  again  in 
apposition. 

Kow  from  a  knowledge  of  these  anatomical  changes,  the 
physical  signs  may   be  foretold.     It  is  obvious  that  there 
must  be  at  first  a  friction  sound,  just  as  there  is  a  friction 
sound  at  first  in  pleurisy ;  that  then  the  fluid  which  distends 
the  pericardium  will  increase  the  area  of  percussion  dulness 
over  the  heart,  and  prevent  the  sounds  and  the  impulse  from 
being  distinctly  perceived.     But  the  friction  sound  is  not 
always  the  same  in  extent  and  character,  because  the  de- 
posited lymph  is  not  always  the  same  either  in  extent  or 
character.     The  sound  is  like  the  crumpling  of  parchment, 
or  the  creaking  of  new  leather,  or  it  is  grazing,  or  a  series  of 
irregular  clicks.    It  is  a  single  or  it  is  a  double  sound,  and  is 
prone  to  mask  the  natural  sounds  of  the  heart.     But  these 
are  all  points  which  have  been  already  described ;  we  shall 
merely  add,  that  when  the  friction  develops  itself  under  our 
observation,  and  with  signs  of  excitement  of  the  heart,  it  is 
as  distinctive  of  inflammation  of  the  pericardium  as  a  recent 
blowing  sound  is,  under  the  same  circumstances,  distinctive 
of  inflammation  of  the  endocardium.     AVhen   the  efi'usion 
takes  place,  it  ceases;  but  only  gradually,  and  not  always 
completely;  and  in  any  case  it  is  not  uncommon  for  the  ear 
still  to  recognize  the  murmur  at  the  base  of  the  heart,  and 
around  the  origin  of  the  great  vessels. 

The  percussion  dulness  of  the  effusion  is  generally  con- 
siderable. Its  contour  is  peculiar  and  characteristic.  As  the 
fluid  gravitates  to  the  lower  portion  of  the  sac,  this  distends, 

23 


354 


MEDICAL    DIAGNOSIS. 


of  necessity,  more  than  the  part  where  the  pericardium  ad- 
heres to  the  vessels.  The  consequence  is,  that  the  dnhiess, 
when  the  patient  is  in  the  erect  posture,  is  pyramidal;  when 


Fig.  27. 


Illustration  of  the  position  of  the  heart  in  pericarditis,  antl  of  the 
distention  of  the  pericardium  with  fluid.  The  heart  sounds  are  in- 
distinct, excepting  above  tlie  efl'usion  ;  the  impulse  is  feeble.  The 
extent  and  i^hape  of  the  percussion  dulness  may  be  judged  of  by  the 
appearance  of  the  distended  sac. 

he  lies  on  his  back,  or  changes  from  side  to  side,  the  outline 
of  the  flat  sound  is  somewhat  altered.  In  cases  of  consider- 
able efl:'usion,  the  intercostal  spaces  of  the  cardiac  region 
widen,  the  eye  recognizes  a  distinct  bulging,  and  the  dul- 
ness on  percussion  reaches  to  the  second,  or  even  to  the  first 
rib.  Within  the  space  of  dulness  is  sometimes  seen  an  irreg- 
ular, wavy  motion;  and  what  the  eye  detects,  the  hand  feels. 
Yet  no  movements,  or  only  ver}'  slight  movements,  may  be 
perceptible  in  the  praicordia.  The  heart,  with  its  point 
pushed  upward  by  the  accumulating  liquid,  has  to  struggle 
to  reach  the  walls  of  the  chest.  Its  contractions  are  irregu- 
lar ;  its  impulse  is  very  feeble,  or  all  appreciable  impulse  has 
ceased.     The  sounds  are  not  clearly  heard  through  the  mass 


DISEASES    OF    THE    HEART.  355 

of  fluid,  but  seem  distant  and  muffled.  Yet  the  second  sound 
over  the  upper  part  of  the  sternum  and  at  the  base  of  the 
heart  retains  its  sharpness. 

During  the  stage  of  absorption  the  apex  returns  to  its 
normal  position  ;  the  dulness  gradually  disappears;  the  sounds 
and  the  impulse  regain  more  of  their  normal  character;  the 
friction  murmur  reappears,  and  then  ceases,  leaving  fre- 
quently the  two  surfaces  of  the  pericardium  glued  together 
— a  condition  which  is  not  so  harmless  as  the  adhesions  which 
terminate  an  attack  of  acute  pleurisy,  since  it  not  unusually 
leads  to  dilated  hypertrophy,  or  to  dilatation. 

There  is  no  saying  how  long  it  will  take  for  tlie  disease  to 
run  througli  its  different  stages.  Death  may  occur  in  less 
tlian  thirty  hours,  the  heart  being  paralyzed  by  an  enormous 
effusion  :  on  the  other  hand,  the  acute  attack  maj'  last  for  as 
many  days,  and  tlien  leave  serious  traces.  But  whatever 
stage  the  malady  be  in,  it  can  only  be  recognized  by  the 
physical  signs  just  detailed;  by  the  friction,  by  the  peculiar 
percussion  dulness,  by  the  enfeebled  impulse  and  heart 
sounds. 

There  are  no  general  symptoms  that  prove  a  pericarditis 
to  exist.  There  are  symptoms  by  which  we  may  infer  that 
pericarditis  is  present;  but  there  are  none  which  absolutely 
belong  to  it,  and  would  prevent  it  from  being  overlooked. 
The  symptoms  usually  met  with  are  those  of  inflammation 
of  the  endocardium,  but  with  more  decided  evidence  of  a 
local  trouble  in  the  chest.  We  find  the  same  anxious  ex- 
pression ;  the  same  fever;  the  same  oedema;  the  same  un- 
certain or  irregular  pulse.  But  there  is  more  pain  over  the 
heart — acute,  severe  pain,  shooting  to  the  left  shoulder,  aug- 
mented by  movement,  increased  by  pressure  ;  there  is  more 
dyspnoea,  because  the  distended  sac  presses  on  the  lung;  and 
there  is  sometimes  difficulty  in  swallowing.  Yet  every  one 
of  these  symptoms  may  be  absent.  The  pulse  may  be  regu- 
lar; the  breathing  not  perceptibly  accelerated,  nor  laborious; 
and  even  the  symptom  regarded  as  the  most  important  of 
all— the  pain— may  be  wanting  from  the  beginning  to  the 
end  of  the  disease. 

When  the  action  of  the  heart  grows  weaker  and  weaker, 


356  MEDICAL    DIAGNOSIS. 

the  circulation  becomes  more  irregular.  The  beat  of  the 
artery  at  the  wrist  is  feeble,  and  intermits ;  the  veins  of  the 
neck  are  prominent ;  the  skin  is  cold  and  pale  ;  the  extrem- 
ities are  edematous.  Tliese  are  always  symptoms  of  grave 
import:  they  tell  of  the  failing  power  of  the  heart,  and  call 
for  agents  which  will  sustain  it. 

If  next  we  come  to  inquire  with  what  complaints  acute 
pericarditis  is  likely  to  be  confounded,  inflammation  of  the 
endocardium  and  of  the  pleura  occur  at  once  to  the  mind. 
To  contrast  the  signs  of  the  first  two  maladies,  for  the  slight 
diflerence  in  their  symptoms  has  already  been  alluded  to: 

Endocarditis.  Pericarditis. 

Blowing   sound ;    excited   action   of  Friction    sound  ;    excited   action   of 

the  heart.  the  heart. 

Slight,  if  any  increase  of  percussion  In  stage  of  effusion,  marked  and  ex- 

dulness.  tended  percussion  dulness. 

Impulse  strong.  Impulse  wavy  and  feeble. 

Sounds  normal  or  more  distinct,  ex-  Sounds  feeble  and  muffled  ;  no  blow- 

cept    at    site    where    murmur     is  ing  sounds. 

beard. 

Such  is  the  distinction  of  pure  cases  of  each  disease.  But, 
a's  already  stated,  the  aftectious  are  often  combined.  It  is 
not  very  uncommon  to  hear  with  the  friction  sound  a  dis- 
tinct endocardial  murmur.  But  there  is  sometimes  a  diffi- 
culty of  another  kind  in  the  way  of  a  precise  diagnosis.  The 
murmur  produced  on  the  outside  of  the  heart  may  simulate 
so  closely  the  murmur  produced  in  its  interior  that  it  is  next 
to  impossible  to  discriminate  between  them.  The  former 
may  completely  possess  the  blowing  characters  of  the  latter. 
Mostly,  however,  it  is  rougher;  more  prone  to  be  double; 
and  each  division  is  like  the  other,  equally  rough,  equally 
superficial  sounding,  equally  lacking  in  strict  correspondence 
to  the  systole  or  to  the  diastole.  And,  above  all,  the  sound 
alters  at  times  both  situation  and  character  with  amazing 
rapidity.  Perceived  now  as  an  ordinary  bellows  murmur  on 
the  left  side,  it  is  after  the  lapse  of  some  hours  heard  as  a 
rough  rasping  sound  on  the  right.  These  changes  have  a 
high  degree  of  value.     But  they  are  not  of  constant  occur- 


DISEASES    OF    THE    HEART.  357 

reiiee ;  and  to  say  that  it  is  sometimes  impossible  to  tell  a 
pericardial  from  an  endocardial  sound,  is  to  say  no  more 
than  is  borne  out  by  every-day  experience.  Fortunately,  in 
point  of  treatment,  an  error,  should  it  be  committed,  is  not 
fatal  to  the  patient's  safety ;  for,  at  all  events  before  the  stage 
of  effusion  in  pericarditis,  the  two  diseases  require  much  the 
same  means  for  their  relief;  and  endocarditis  is  not  likely  to 
be  mistaken  for  pericarditis  in  its  stage  of  effusion. 

Inflammation  of  the  adjoining  serous  membrane,  the  jJleura, 
gives  rise  to  some  of  the  same  symptoms  and  signs  as  peri- 
carditis. It  develops  a  friction  sound :  it  occasions  dulness 
on  percussion,  dyspnoea  and  cough.  But  the  physical  signs 
are  in  different  situations.  In  one  disorder  they  are  noted 
in  the  region  of  the  heart,  and  are  confined  there;  in  the 
other  they  are  spread  over  the  whole  side  of  the  chest,  and 
are  most  perceptible  at  the  back.  This  is  true  of  the  dulness, 
and  also,  for  the  most  part,  of  the  friction  sound,  which,  when 
of  pericardial  origin,  is  very  rarely  heard  posteriorly. 

At  times,  however,  we  meet  with  very  puzzling  cases.  A 
friction  sound  discerned  over  the  heart  may  be  in  reality 
produced  in  the  adjoining  pleura.  The  patient  is  directed 
to  suspend  his  breathing.  The  friction  sound  does  not  stop. 
Now  the  inference  from  this  would  be  that  the  sound  origi- 
nates in  the  pericardium ;  and  in  the  large  majority  of  in- 
stances this  is  a  correct  inference.  But  it  is  not  always  so. 
The  friction  may  be  engendered  in  the  pleura  and  be  caused 
by  the  movements  of  the  heart.  To  mention  an  example  : 
a  laboring  man  was  attacked  with  acute  articular  rheuma- 
tism, in  the  course  of  which  a  friction  sound  was  heard  over 
the  outer  limit  of  the  left  ventricle,  and  also  posteriorly  over 
the  lower  portion  of  the  left  lung.  Occasionally  it  ceased 
entirely  when  the  patient  stopped  breathing,  and  during  a 
few  beats  of  the  heart.  Then  it  recommenced  with  unequal 
intensity  while  the  respiration  was  still  arrested.  It  is  evi- 
dent that  this  sound  could  not  have  been  that  of  an  inflamed 
pericardium;  certainly  the  one  perceived  anteriorly  was  not. 
I  know  of  no  absolute  means,  besides  the  intermission  of  the 
sound  during  some  of  the  beats  of  the  heart,  of  detecting  in 
these  rare  cases  the  true  seat  of  the  disease. 


358  MEDICAL    DIAGNOSIS. 

To  confound  the  dulness  on  percussion  caused  by  liquid  in 
the  pericardium  with  that  due  to  liquid  in  the  pleura,  is  a 
mistake  the  more  likely  to  happen,  because  the  two  serous 
membranes,  and  indeed  the  lung,  are  often  implicated  in  the 
same  inflammation.  But  a  pericarditis  uncomplicated  with 
pleurisy  or  with  pleuropneumonia,  does  not  change  the  clear 
sound  at  the  back  of  the  chest  save  in  rare,  very  rare  cases 
of  enormous  accumulation  of  fluid  within  the  sac.  Effusion 
into  the  pleura  gives  rise  to  a  flat  sound  anteriorly;  yet  to  a 
still  more  perceptible  dulness  at  the  inferior  portion  of  the 
chest  posteriorly;  and  the  sounds  of  the  heart  remain  un- 
altered, unless  its  investing  membrane  contain  fluid  also. 

These,  then,  are  the  diseases  with  which  acute  pericarditis 
is  liable  to  be  confounded.  There  are  several  chronic  car- 
diac maladies  which  will  occasion  some  of  the  same  signs 
and  symptoms:  such  are  thinning  of  the  ventricles  with  dis- 
tention of  the  cavities,  and  a  dropsy  of  the  pericardium.  But 
the  history  of  these  atfections  is  diiferent,  and  their  signs, 
although  similar,  are  not  precisely  the  same.  The  dropsy 
of  the  pericardium  is  associated  with  dropsies  elsewhere,  and 
with  some  obvious  cause  accounting  for  the  watery  exuda- 
tion, and  at  no  stage  of  its  existence  does  it  exhibit  a  friction 
sound. 

But  there  is  another  acute  complaint  of  which  pericarditis 
sometimes  borrows  the  garb.  The  thoracic  symptoms  maj- 
be  latent,  but  the  disease  may  produce  the  symptoms  of  ex- 
treme gastric  irritation  or  inflammation.  There  are  nausea 
and  vomiting,  and  tenderness  on  pressure  in  the  epigastric 
regiou.  All  the  remedies  are  directed  to  the  stomach;  and 
at  the  post-mortem  examination,  the  physician  stands  amazed 
at  finding  this  viscus  healthy  and  the  pericardium  full  of 
serum  or  pus.  An  inquiry  into  the  state  of  the  heart  might 
have  saved  him  from  a  serious  blunder,  which  could  have 
been  avoided  and  the  patient's  life  been  probably  preserved. 

Another  grave  error  which  may  be  thus  obviated  is  the 
mistaking  of  some  cases  of  acute  pericarditis,  on  account  of 
the  wild  delirium  they  present,  for  acute  inflammation  of  the 
brain.  Now,  both  in  endocarditis  and  in  pericarditis  this 
active  delirium  may  throw  all  the  other  symptoms  into  the 


DISEASES    OF    THE    HEART.  359 

background.  How  it  is  produced  is  not  easy  to  understand. 
It  is  difHcult  to  see  why  a  pericardial  inflammation  should 
give  rise  to  such  violent  disturbance  of  the  brain.  It  is  not 
at  all  unlikely  that  it  has  its  origin  in  the  contaminated  state 
of  the  blood  which  occurs  in  the  affections,  such  as  rheu- 
matism or  Bright's  disease,  with  which  pericarditis  is  often 
associated.  At  all  events,  however  occasioned,  it  is  necessary 
to  be  aware  that  the  cerebral  symptoms  arising  in  inflam- 
mation of  the  membranes  of  the  heart  may  entirely  draw  of!' 
attention  from  the  serious  lesions  within  the  chest. 

Before  dismissing  the  subject  of  pericarditis,  let  us  inquire 
in  how  far  one  of  its  terminations — by  adhesion  or  aggluti- 
nation of  the  surfaces — can  be  recognized.  In  many  of  such 
cases,  whether  or  not  there  be  coexisting  dilatation,  or  hyper- 
trophy, or  that  rare  condition,  cardiac  atrophy,  or  even  prob- 
ably when  the  heart  is  of  normal  size,  we  find  changed 
rhythm  and  dyspnoea.  Yet  surely  these  cannot  be  considered 
as  special  signs  of  pericardial  adhesions.  ISTor  is  the  "  abrupt, 
jogging,  or  trembling  motion"  of  the  heart,  described  by 
Hope,  pathognomonic;  nor  the  extinction  of  the  second 
sound,  on  which  Aran  dwells.  For  the  pericardial  surfaces 
may  be  found  most  thorouglily  glued  to  each  other  where 
neither  of  these  signs  was  present.  But  it  must  be  admitted 
that  the  double  jog  is  often  seen,  especially  if  the  enlarge- 
ment of  the  heart  be  at  all  extensive.  The  most  trustworthy 
signs  of  pericardial  adhesion  are  those  given  by  Skoda:*  a 
drawing  up  of  the  heart's  apex  during  the  contraction  of  the 
ventricles,  with  a  depression  in  the  intercostal  spaces  becom- 
ing visible  at  the  same  time,  and  sometimes  Avith  a  simulta- 
neous siidving  in  at  the  lower  half  of  the  sternum  ;  the  limits 
of  the  dull  percussion  sound  remaining  unaffected  during 
inspiration  and  expiration;  and  a  confused  instead  of  a  dis- 
tinct and  punctuate  beat  of  the  impulse  against  the  finger. 
Gairdner,f  too,  lays  stress  upon  the  marked  movement  of 
the  intercostal  spaces  over  the  heart;  while  \V"alshe|  thinks 
that  the  systolic  dimpling  and  the  undulatory  movements  in 

*  Zeitsch    der  K.  K.  Gesellsch.  der  Acrzte  zii  "Wion.     April,  1852. 

t  Edinburgh  Med.  Journ.,  1851,  1859,  etc. 

X  On  Diseases  of  the  Heart.     Third  edition,  p.  194,  Am.  ed. 


360  MEDICAL    DIAGNOSIS. 

tbe  pi'jieeordia  only  happen  if  there  be,  in  addition  to  the  peri- 
cardial adhesions,  pleuritic  adhesions  in  front  of  the  organ, 
or  if  the  agglutination  of  the  pericardium  be  combined  with 
cardiac  hypertrophy.  When  the  pericardial  surfaces  are  very 
extensively  and  firmly  united,  the  eye  is  struck  by  the  evi- 
dent depression  of  the  precordial  region. 

Carditis. — The  substance  of  the  heart  itself  undergoes  at 
times  intlaramation.  We  can  recognize  such  a  condition 
after  death,  by  the  changed  color,  the  flabbiness,  and  the 
presence  of  granules  of  exudation  and  of  pus  corpuscles 
among  the  fibres  of  the  heart.  It  is  known  that  the  inflam- 
mation may  also  occasion  local  softening  and  circumscribed 
abscesses,  and  even  gangrene  and  perforation  of  the  ven- 
tricle. But  though  familiar  with  the  post-mortem  appear- 
ances, we  are  not  enabled  to  foretell  the  state  of  the  heart 
during  life,  mainly  because  the  muscular  structure  is  rarely 
affected  without  the  endocardium,  or  still  more  frequently 
the  pericardium,  being  implicated,  and  thus  the  manifesta- 
tions of  these  disorders  occur  mixed  up  with  those  of  true 
carditis.  On  anal3'zing  the  cases  on  record,  I  cannot  indeed 
find  either  a  symptom  or  sign  which  can  be  considered  as  in 
the  least  pathognomonic.  Extreme  pain  in  the  cardiac  region 
is  the  most  usual  and  the  most  prominent  of  the  symptoms. 
It  is  sometimes  very  excruciating  and  sharp,  at  other  times 
dull,  but  most  distressing  and  constant.  The  breathing  is 
generally  much  oppressed;  delirium  is  often  present;  the 
skin  becomes  cold;  and  the  patient  dies  in  a  state  of  utter 
prostration  or  of  apparent  suffocation.  The  pulse  is  much 
like  that  of  endocarditis  or  pericarditis — that  is,  it  exhibits 
no  uniform  character.  The  statement  that  it  is  invariably 
intermittent,  feeble,  and  quick,  is  not  correct.  It  is  so  as 
the  disease  advances,  but  it  has  been  reported  to  be  full,  and 
not  above  eighty,  long  after  the  distress  in  the  chest  was  un- 
bearable.* 


*  Salter,  Medico-Chirurg.  Transactions,  vol.  xxii.  In  several  of  the  cases 
on  record,  for  instance  in  the  one  mentioned  hy  Graves,  in  his  Clinical  Lec- 
tures, there  was  coexisting  valvular  disease,  which,  of  course,  invalidates  the 
statements  as  regards  the  character  of  the  pulse,  and  indeed  as  regards  many 
of  the  other  symptoms. 


I 


DISEASES    OF    THE    HEART.  361 

Chronic  Diseases  attended  with  Increased  Extent  of  Percus- 
sion Dulness,  but  with  Normal  or  almost  Normal  Heart 
Sounds. 

We  often  meet  with  a  group  of  affections  whicli  present 
the  phenomena  of  extended  dulness  on  percussion  in  the 
cardiac  region,  associated  with  sounds  like  those  heard  in 
health  :  they  may  be  louder  or  less  loud,  better  defined  or 
less  well  defined,  still  they  are  the  natural  sounds  of  the 
heart,  and  no  cardiac  murmur  is  detected,  unless  the  dis- 
order be  no  longer  uncomplicated. 

To  this  group  belong  those  diseases  which  affect  the  walls 
of  the  heart  or  its  cavities,  without  having  involved  the  val- 
vular apparatus,  such  as  hypertrophy  and  dilatation— types 
of  the  two  different  states  of  force  and  of  weakness ;  but 
both  exhibiting  an  extent  of  percussion  duhiess  greater  than 
in  health,  and  heart  sounds  not  very  materially  changed. 

Hypertrophy. — Hypertrophy  of  the  heart  is  an  over- 
growth of  its  walls,  and  most  usually  also  of  its  cavities; 
for,  although  w^e  may  have  the  muscle  thickening  without 
the  cavity  enlarging,  nay,  even  with  its  diminishing  in  size, 
neither  this  simple,  nor  the  concentric  hypertrophy  occurs, 
save  in  rare  instances.  It  is  evident  that  any  one  of  the 
chambers  of  the  heart  may  alone  become  liypertrophied. 
But  practically,  the  state  we  mean,  when  speaking  of  hyper- 
trophy of  the  heart,  is  an  increase  of  the  ventricles,  and 
especially  an  increase  of  the  left  ventricle,  in  its  wall  and 
cavity,  with  a  similar,  althougli  much  slighter  expansion  of 
the  right  side.  Whether  tlje  auricles  be  enlarged  or  not,  is 
a  matter  always  more  of  conjecture  than  susceptible  of  abso- 
lute proof. 

The  physical  and  vital  manifestations  of  the  heart  having 
outgrown  its  natural  dimensions  are  these:  the  pulse  is  full 
and  strong,  and  somewhat  tense.  The  face  is  florid,  or  else 
it  is  pale ;  but  the  mucous  membranes  of  the  lips  and  eyelids 
are  injected.  The  eyes  are  bright,  and  apt  to  be  prominent. 
The  carotids  pulsate  forcibly  under  the  least  excitement. 
Some  persons  suffer  from  headache  and  giddiness ;  in  fact, 


3(32  MEDICAL    DIAGNOSIS. 

iill  tlic  symptonis  denote  a  circulation  activelj-,  too  actively 
carried  on.  Yet  the  symptons  directly  referable  to  the  heart 
are  not  marked.  There  is,  as  a  rule,  no  pain,  nor  irregular 
action  of  the  heart,  nor  do  violent  fits  of  palpitation  occur. 
What  the  patient  comes  to  consult  his  physician  about,  are 
rushes  of  blood  to  the  head ;  or  a  ringing  in  the  ears;  or  a 
feeling  of  weight  in  the  epigastrium  which  troubles  him  after 
a  full  meal;  or  on  account  of  shortness  of  breath  ;  or  because 
the  powerful  action  of  the  heart,  when  lying  in  bed,  attracts 
his  attention  ;  or  sometimes  he  is  alarmed  about  a  dr}^  cough, 
and  believes  himself  the  victim  of  pulmonary  consumption. 

The  physical  signs  are  more  uniform  than  the  symptoms. 
We  observe  a  fulness  or  arching  of  the  precordial  region, 
and  an  impulse  strong,  heaving,  and  extended  over  several 
intercostal  spaces.  The  apex  does  not  strike  the  chest  walls 
between  the  fifth  and  sixth  ribs,  but  its  beat  is  perceived 
lower  down,  and  more  inward,  toward  the  median  line,  in 
consequence  of  the  enlarged  and  weighty  heart  not  retaining 
its  normal  position.  The  extent  of  percussion  dulness  in- 
creases, both  longitudinally  and  transversely ;  and  particu- 
larly in  the  latter  direction,  if  the  right  ventricle  be  much 
enlarged.  This  peculiarity  in  the  expansion  of  the  dulness 
on  percussion  forms,  in  truth,  with  the  greater  dyspnoea,  and 
with  an  impulse  more  directly  perceived  over  the  right  side 
of  the  heart,  near  the  pit  of  the  stomach,  the  sign  that  hyper- 
trophy with  dilatation  has  principally  afi:ected  the  right  side 
of  the  heart. 

The  first  sound  of  a  hypertrophied  heart  is  duller  than  in 
health,  but  prolonged  and  weighty.  The  second  sound  is  not 
particularly  changed.  There  are  no  murmurs,  excepting 
under  rare  circumstances,  which  will  be  alluded  to  in  dis- 
cussing valvular  diseases.  Thus  the  greatest  value  of  auscul- 
tation is,  that,  by  showing  us  that  the  sounds  are  but  little 
altered,  it  enables  us  positively  to  exclude  a  lesion  of  the 
valves;  just  as  the  chief  service  of  percussion,  with  reference 
to  an  enlarged  heart,  consists  in  permitting  us  to  distinguish 
the  excited  motions  of  the  simply  disturbed  organ  from  the 
action  of  a  heart  the  walls  of  which  are  thickened ;  and  as 
the  main  use  in  noting  the  impulse  is,  that  it  serves  as  a 


DISEASES    OF    THE    HEART. 


363 


means  of  discrimination  between  hypertrophy  and  those  af- 
fections in  which  the  beat  is  weakened,  such  as  dilatation,  or 
a  pericardial  effusion,  or  between  the  dulness  in  the  precor- 
dial region  due  to  hypertrophy  and  that  caused  by  deposits 
in  the  pleura  or  lung. 

Fig.  28. 


^>S\v.M^>N^ 


A  hypeitropliicrl  hfart  lying  in  its  position  in  the  chest.  The  cau.se  of  the 
lowered  apex  bent,  and  of  tlie  extension  of  tlie  impulse,  as  well  as  of  the 
somewliat  squarer  outline  of  the  increased  dulness  over  the  enlarged  organ, 
is  obvious  Ironi  the  shape  an<l  jiosition  of  the  heart. 

Hypertrophy  of  the  heart  affects  males  much  more  fre- 
quently than  females.  Its  causes  are  various.  Continued 
functional  excitement  produces  it;  so  does  perhaps  excessive 
nourishment.  But  the  main  cause  is  an  obstruction  to  the 
circulation,  either  in  the  heart  or  in  other  organs.  It  is  for 
this  reason  that  the  complaint  is  so  often  seen  in  connection 
with  diseases  of  the  valves  or  of  the  large  arteries,  and  that 
the  right  side  of  the  heart  enlarges  when  the  pulmonary  air- 
vesicles  are  overdistended.  We  also  meet  with  hypertrophy 
of  the  heart  as  a  consequence  of  the  obliteration  of  the  peri- 
cardial sac  by  its  two  surfaces  adhering.     Of  this  form  of 


;3(U  MEDICAL    DIAGNOSIS. 

liypertrophy  there  are,  as  we  have  above  seen,  no  positive 
and  distinctive  "signs. 

Dilatation. — Dilatation  of  the  heart  is  the  reverse  of  hj- 
pcrtroi)hv.  By  this  it  is  not  meant  that,  because  the  cavities 
are  dihited,  the  walls  may  not  be  increased;  for  we  constantly 
meet  with  this  form  of  dilated  hypertrophy.  But  it  is  meant 
that  the  morbid  condition  in  which  the  cavities  have  been 
stretched  out  of  all  proportion  to  the  thickness  of  the  mus- 
cular walls  is  the  reverse  of  the  condition  in  which  the  walls 
are  stronger,  firmer,  and  more  powerful  than  in  health;  in 
other  words,  the  latter  state  is  very  different  from  the  former, 
and  when  it  predominates  we  call  the  aflfection  hypertrophy; 
when  the  former  is  in  excess,  we  speak  of  the  disease  as  dila- 
tation, no  matter  whether  the  walls  be  slightly  thicker  than 
normal,  or  of  natural  thickness,  or,  as  they  often  are,  thinner, 
and  apparently  hardly  capable  of  supporting  the  weight  of 
the  blood. 

From  these  almost  opposite  pathological  states,  almost 
opposite  physical  signs  or  symptoms  might  be  expected. 
And  so  we  find  it.  We  look  in  dilatation  in  vain  for  the 
activity  and  power  with  which  the  blood  is  forced  out  of  a 
hypertrophied  heart.  Everything  indicates  debility,  inaction, 
and  stagnation  of  the  vital  current.  There  is  a  strong  tend- 
ency to  venous  congestions  and  to  dropsies.  The  portal  sys- 
tem is  gorged.  The  liver  increases  in  size.  The  bowels  are 
constipated.  The  urinary  secretion  is  interfered  with,  and 
sometimes  albumen  is  passed  from  the  kidneys.  The  hearing 
may  become  dull.  The  patient  is  languid  and  feeble,  and 
his  intellect  obtuse.  He  sufters  from  chilly  sensations,  and 
from  distressing  palpitations  and  uneasiness  in  the  cardiac 
region.  The  pulse  is  small  and  irregular,  and  the  veins  of 
the  surface  swollen.  The  skin  around  the  ankles,  and  often 
at  other  parts  of  the  body,  pits  on  pressure.  But  since  it  is 
the  right  side  of  the  heart  which  is  usually  the  most  affected, 
the  lungs  show  most  plainly  the  eft'ects  of  the  venous  stagna- 
tion. Difficulty  in  breathing,  making  itself  at  times  mani- 
fest in  paroxysms  attended  with  wheezing  respiration ;  a 
chronic  cough;  a  collection  of  serum  in  the  pulmonary 
structure,— all  add  to  the  misery  which  this  perilous  malady 


DISEASES    OF    THE    HEART. 


365 


entails.  And  as  it  is  commonly  some  obstructive  disease  in 
the  kings,  such  as  emphysema,  which  has  given  rise  to  the 
dlLatation  of  the  right  side  of  the  heart,  so  this  again  aug- 
ments the  morbid  state  of  the  lungs,  and  aggravates  the 
symptoms. 

Fig.  29. 


A  dilated  heart,  the  riglit  ventriclu  opened.  In  this  case  there  was 
no  valvular  disease.  Ilenee  the  characteristic  jihysical  signs;  the  in- 
creased dulness  on  percussion,  the  extended  but  weak  impulse.  The  first 
sound  was  feeble,  for  the  organ  was  soft  as  well  as  diluted. 

The  physical  signs  are  very  unlike  those  of  hypertrophy. 
The  same  extended  dulness  on  percussion  exists;  but  it  is 
associated  with  a  feeble,  fluttering,  and  irregular  impulse, 
which  is  in  strong  contrast  with  the  heaving,  powerful 
blow  of  a  hypertrophied  left  ventricle.  The  sounds  are  not 
always  the  same.  When  the  walls  are  thin,  they  are  clearer, 
sharper,  and  more  ringing  than  in  health;  if,  however,  the 
muscular  structure  be  at  all  disorganized,  the  first  sound  is 
faint  and  very  ill  defined.  But  no  murmurs  are  perceived, 
unless  a  watery  state  of  the  blood  produces  them,  or  unless  it 
happens,  and  it  does  not  unfrequently  happen,  that  the  dilata- 
tion of  the  heart  is  conjoined  to  valves  incompetent,  either 
temporarily  or  permanently,  to  prevent  regurgitation. 


366  MEDICAL    DIAGNOSIS. 

Such  is  the  description  of  cases  of  very  marked  dilatation. 
All  cases  are  not,  however,  so  distinct,  nor  are  they  uncom- 
plicated. Organic  aftections  of  the  heart  are,  indeed,  indef- 
initely blended,  and  dilatation  is  met  with  in  different  com- 
binations and  in  every  possible  degree.  Accordingly,  its 
svmptoms  and  signs  are  somewhat  dissimilar.  But  one  con- 
stant feature  it  certainly  preserves :  it  always  holds  up  to 
view  both  the  vital  and  physical  manifestations  of  a  weak- 
ened heart.  It  is  thus  that  it  is  likely  to  be  confounded  with 
the  diseases  in  which  an  enfeebled  action  of  the  heart  is  en- 
countered, and  these  are  fatty  degeneration  and  a  pericardial 
effusion. 

Fatty  Degeneration. — This  is  one  of  those  disorders  with  the 
anatomical  characters  of  Avhich  we  are  far  better  acquainted 
than  with  their  clinical  history.  The  microscope  has  revealed 
to  us  that  the  soft,  flabby  heart,  which  appears  to  the  eye  but 
little  changed  from  health,  has  had  its  muscular  fibres  atro- 
phied and  transformed  into  fat  granules  and  oil.  It  has  thus 
explained  to  us,  what  w^as  previously  incomprehensible,  why  a 
heart  seemingly  so  little  altered  should  rupture,  or  why  death 
should  set  in  with  all  the  evidences  of  failing  circulation, 
wdien  nothing  in  the  whole  body  can  be  found  sufficiently  dis- 
eased to  account  for  the  termination  of  the  vital  action.  But 
our  power  to  recognize  the  fatty  change  during  life  has  not  kept 
pace  with  our  power  to  recognize  it  after  death.  There  is  as 
yet  no  sign  discovered,  by  which  we  can  say  that  the  danger- 
ous disorganization  of  the  muscular  fibres  of  the  heart  is  in 
progress.  We  may,  however,  suspect  it,  if  the  signs  of  weak 
action  of  the  heart — feeble  impulse  and  ill-defined  sounds — 
coexist  with  a  pulse  permanently  slow  or  permanently  fre- 
quent and  irregular,  and  be  met  with  in  a  person  who  is  the 
subject  of  a  wasting  disease,  or  who  has  arrived  at  a  time  of 
life  at  which  all  the  organs  are  prone  to  undergo  decay. 
Something  more  than  a  suspicion  is  warranted,  if,  in  addi- 
tion, there  be  proof  of  fatty  degeneration  elsewhere,  such  as 
an  arcus  senilis ;  or  if  it  be  ascertained  that  the  patient  suffers 
from  paroxysms  of  severe  pain  in  the  heart;  that  he  sighs 
frequently;  that  he  is  subject  to  seizures,  during  which  his 
respiration  seems  to  have  come  to  a  stand-still,  and  that  he 


DISEASES    OF    THE    HEART.  367 

is  liable  to  be  stricken  down  with  repeated  attacks  having 
the  character  of  apoplexy,  save  that  they  are  not  followed  by 
paralysis.* 

Now,  here  are  certainly  a  group  of  phenomena  dissimilar 
to  those  of  a  dilated  heart.  Let  us  add  to  them,  that  the 
extent  of  the  cardiac  percussion  dulness  remains  unaltered, 
that  dropsies  and  local  congestions  are  not  prominent  symp- 
toms, or  indeed  do  not  happen  at  all,  and  the  dissimilarity 
becomes  still  greater.  A  ditferential  diagnosis  would,  under 
such  circumstances,  be  anything  but  difficult.  Bat  in  point 
of  fact,  the  matter  is  generally  not  so  easily  decided,  and 
there  are  several  reasons  why  it  is  not.  One  is,  that  all  the 
features  described  are  but  rarely  combined  in  ihe  same  case; 
indeed,  some  of  the  more  marked,  such  as  the  peculiar  res- 
piration, the  seizures  like  apoplexy,  are  uncommon  rather 
than  common,  and  the  altered  breathinsj  occasional! v  occurs 
in  other  cardiac  maladies.  The  second  is,  because  non-fatty 
softening  may,  it  is  believed,  present  the  same  vital  and 
physical  manifestations.  The  third,  because  a  fatty  heart 
has  a  tendency  to  become  dilated,  and  the  symptoms  and 
signs  of  the  former  disease  are  then  merged  into  the  symp- 
toms and  signs  of  the  latter,  throwing  us  back  into  the  prov- 
ince of  conjecture  and  probability  for  a  diagnosis.  "With  the 
organ  in  such  a  condition,  the  practical  value  of  a  ditferential 
diagnosis  is,  however,  not  very  great;  for  both  affections  are 
benefited  by  the  same  treatment :  both  require  that  the  power 
of  the  heart  should  not  be  lowered.  In  both,  therefore,  the 
treatment  applicable  to  hypertrophy  is  to  be  avoided;  instead 
of  weakening  the  action  of  the  heart,  it  must  be  sustained, 
and  the  blood  enriched.  It  is  hardly  necessary  to  add,  that 
all  causes  of  serious  excitement  are  to  be  strenuously  guarded 
against. 

Persons  who  have  fatty  hearts  are  subject  to  attacks  of  faint- 
ness,  preceded  or  attended  with  sensations  of  great  coldness  or  a 
chill.     And  sometimes  these  attacks  happen  daily,  or  every 


*  But  the  exact  ruhition  the  arcus  senilis  bears  to  a  fatty  heart  is  not 
ascertained.  See,  on  its  diagnostic  value,  a  paper  by  Lee.  Araer.  Medical 
Monthly,  September,  1856. 


368  MEDICAL    DIAGNOSIS. 

few  days,  and  in  a  manner  to  give  rise  to  the  impression  tliat 
they  are  due  to  malaria.  A  number  of  instances  of  the  kind 
liave  come  under  my  observation,  and  I  have  met  with  them 
more  particularly  at  the  end  of  fevers  or  other  debilitatino^ 
diseases  happening  in  those  affected  with  feeble  hearts.  The 
seizures,  though  bearing  a  certain  resemblance  to  intermit- 
tent fever,  are  unlike  it  in  being  associated  with  signs  of 
great  weakness  of  the  circulation,  sometimes  almost  a 
vanishing  pulse  and  a  sense  of  impending  dissolution;  in 
their  irregular  accession  ;  and  in  their  not  being  followed 
by  febrile  phenomena.  In  doubtful  cases  the  thermometer, 
by  showing  the  absence  of  the  great  rise  of  temperature  of 
the  malarial  disorder,  will  materially  assist  us  in  the  diag- 
nosis. 

A  fatty  heart  sometimes  nq)hires.  Now,  in  spite  of  the 
care  with  which  some  authors  have  detailed  the  physical 
signs  of  this  mishap,  we  know  nothing  positively  about 
them  ;  for  death  usually  takes  place  far  too  rapidlj^  to  have 
permitted  of  any  such  observations.  The  symptoms  that  are 
mostly  noticed  are  these :  the  patient  is  suddenly  attacked 
with  intolerable  anguish  in  the  heart ;  he  presses  his  hand 
to  it ;  then  faints  and  soon  expires.  Or  else  he  lives  for  a 
short  time,  suffering  from  faintness,  cramps,  and  difficulty  of 
breathing,  and  with  death  plainly  written  in  his  face. 

Pericardial  Effusion. — Pericardial  effusion  also  presents  the 
signs  of  a  weakened  heart  with  increased  dulness  on  per- 
cussion in  the  cardiac  region,  and  is  thus  very  liable  to  be 
mistaken  for  a  dilatation  of  the  organ.  Where  the  effusion 
forms  part  of  a  general  dropsy,  the  detection  of  the  cause  of 
the  latter,  in  connection  with  the  different  signs  which  fluid 
in  the  pericardium  occasions,  will  prevent  error.  AVherethe 
liquid  has  remained  after  an  inflammation  of  the  membrane, 
both  signs  and  symptoms  are  like  those  of  the  stage  of  effu- 
sion in  acute  pericarditis,  and  although  there  are  points  of 
resemblance  to  a  dilated  heart,  there  are  also  points  of  con- 
trast, as  the  subjoined  table  shows  : 


DISEASES    OF    THE    HEAllT. 


360 


Dilatation  of  the  Heart. 

Percussion  dulness  increased  in  ex- 
tent, but  square  in  outline. 

Heart  sounds  clear  and  sharp  ;  some- 
times, however,  feeble. 

No  friction  sound. 

Dropsy  ;  signs  of  venous  stagnation  ; 
severe  cough,  and  dyspnoea. 


History  of    disease    shows    it  to    be 
gradually  developed. 


Chronic  Pericarditis  with 
Effusion. 

Percussion  dulness  increased,  but  of 
pyramidal  shape. 

Heart  sounds  feeble  and  distant 
sounding  at  the  apex,  but  distinct 
near  the  upper  part  of  the  sternum. 

Often  friction  sound  still  heard  at 
the  base  of  the  heart. 

Neither  dropsy  nor  venous  stagna- 
tion is  observed;  or,  if  at  all,  only 
in  a  very  limited  degree.  Cough 
and  dyspncea  are  not  so  promi- 
nent .symptoms. 

The  historj'  frequently  points  to  the 
acute  attack. 


These,  then,  are  the  marks  of  similitude  and  of  distinction 
presented  by  a  chronic  pericardial  effusion,  a  fatty  heart,  and 
cardiac  dilatation  ;  in  other  words,  between  the  morbid  states 
which  occasion  the  signs  and  symptoms  of  a  feebly  acting 
heart.  Before  proceeding  to  another  subject,  let  us  glance 
at  one  more  condition,  fortunately  infrequent,  which  may 
give  rise  to  some  of  the  same  phenomena  as  those  described 
— an  accumulation  of  blood  in  the  cavities  of  the  heart.  Like  dila- 
tation, this  increases  the  area  of  percussion  dulness;  like  it, 
too,  it  is  often  associated  with  perverted  rhythm.  The  chief 
differences,  so  far  as  our  very  limited  clinical  knowledge  of 
the  subject  permits  us  to  say,  are  these:  the  impulse  is  gen- 
erally much  more  labored,  is  more  irregular,  is  sometimes 
strong,  sometimes  weak,  not  so  almost  uniformly  indistinct 
or  tremulous.  There  is  much  more  venous  congestion  of  the 
face  with  greater  dyspnoea,  and  we  often  find  some  acute 
malady,  such  as  endocarditis  or  pneumonia,  giving  rise  to  the 
cardiac  engorgement.  But  the  matter  is  often  a  very  diffi- 
cult one  to  determine;  for  many  of  the  same  states  which  lead 
to  dilatation  may  produce  an  accumulation  of  blood  in  the 
heart;  nay,  dilatation  itself  predisposes  to  it. 


24 


;370  MEDICAL    DIAGNOSIS. 


Diseases  of  the  Heart,  exhibiticg  more  or  less  of  the  Signs 
and  Symptoms  of  Enlargement  of  the  Organ,  and  accom- 
panied by  Endocardial  Murmurs. 

Valvular  Affections. — To  find  the  sounds  of  the  heart 
clearly  and  well  defined,  is  to  know  that  no  disease  of  the 
valves  exists.  No  matter  whether  there  be  reason  to  believe 
that  the  walls  of  the  lieart  are  hypertrophied  to  twice  their 
thickness,  or  the  cavities  stretched  to  twice  their  capacity,  if 
the  ear  recognize  the  natural  sounds,  it  is  evidence  that  the 
valvular  apparatus  is  not  atiected.  When  it  is  disordered, 
the  mischief  betrays  itself,  for  the  most  part,  by  a  blowing 
sound.  If,  therefore,  a  murmur  of  any  permanence  be  met 
with  in  the  heart,  if  especially  it  be  associated  with  the  signs 
of  either  hypertrophy  or  dilatation,  the  inference  that  valvu- 
lar disease  exists  will  in  the  vast  majority  of  cases  be  a  cor- 
rect inference. 

Yet  it  will  not  be  always  so;  for  there  are  other  morbid 
states  besides  valvular  aft'ections  which  engender  a  murmur, 
that  may  be  even  accompanied  by  all  the  manifestations  of 
enlargement  of  the  heart.  Malformations,  such  as  commu- 
nications between  the  auricles  or  between  the  ventricles,  or 
between  the  great  vessels  near  their  origin,  or  impoverished 
blood,  or  a  misdirected  blood  current,  may  occasion  a  mur- 
mur. 

Now,  with  reference  to  malformations,  their  presence  in 
adults,  or  in  children  that  have  passed  the  days  of  infanc}',  is 
exceedingly  rare.  The  most  trustworthy  symptom  they  pre- 
sent is  that  which  indicates  the  admixture  of  arterial  and 
venous  blood ;  in  other  words,  the  symptom  of  cj'anosis,  the 
bluish  discoloration  of  the  skin.  In  addition,  we  may  per- 
ceive the  signs  of  disturbed  circulation  in  the  lungs,  such  as 
dyspnoea  and  cough;  and  of  irregular  action  of  the  heart;  and 
a  blowing  sound  in  the  cardiac  region.  Still,  the  recognition 
of  these  malformations  is  always  more  or  less  a  matter  of 
conjecture,  and  to  mistake  them  for  other  organic  changes  in 
the  heart,  particularly  those  of  the  valves,  is  a  mistake  which 
in  tlie  actual   state  of  our  knowledsre  cannot  be  avoided. 


DISEASES    OF    THE    HEART.  371 

With  the  aid  of  more  such  researches  as  those  of  Dr.  More- 
ton  Stille*  or  of  Dr.  Peacock,t  we  shall  become  accurately 
acquainted  with  the  pathology  of  the  different  lesions,  and 
perhaps  ultimately  be  able  to  discern  them  with  certainty 
during  life.  At  present  it  is  in  their  rarity  alone  that  the 
safety  against  errors  of  diagnosis  lies. 

As  a  few  points  of  assistance  may  be  mentioned  that  com- 
munication of  the  ventricles  through  the  septum  gives  rise 
to  a  systolic  murmur  at  or  near  the  base  of  the  heart  not 
propagated  into  the  arteries ;  that  the  passage  of  blood 
through  an  open  foramen  ovale  very  rarely  engenders  any 
sound;  and  that,  whether  coexisting  with  these  lesions  or  not, 
the  majority  of  instances  of  cardiac  malformation,  after  the 
age  of  twelve,  present  signs  of  obstruction  at  the  orifice  of 
the  pulmonary  artery.  In  this  instance  either  a  systolic  or 
diastolic  murmur  maybe  there  perceived;  in  the  first  case 
the  second  sound  of  the  heart  is  weak  or  wanting  in  the 
second  interspace  on  the  left  side. 

The  resemblance  borne  by  cases  oi  functional  disturbance  of 
the  heart,  associated  with  impoverished  blood,  to  valvular 
affections,  has  already  engaged  our  attention.  The  age;  the 
appearance  of  the  patient;  the  seat  of  the  blowing  sound  at 
the  base  of  the  heart;  the  venous  hum ;  the  fact  that  the  car- 
diac murmur  is  followed  by  a  sharp  second  sound, — all  are 
points  upon  which  some  stress  may  be  laid  ;  yet  not  so  much 
as  upon  the  absence  of  the  phenomena  of  an  enlarged  heart. 
But,  if  the  question  be  asked,  are  the  latter  absolute  demon- 
strations of  the  existence  of  an  affection  of  the  valves,  cannot 
a  hypertrophied  or  dilated  heart,  with  sound  valves,  be  com- 
l»ined  with  a  condition  of  blood  capable  of  producing  a  mur- 
mur?— we  are  forced  to  answer  that  such  is  possible.  Under 
these  circumstances,  the  tact  of  the  physician  may  help  him 
to  a  well-judged  decision  ;  but  the  only  proof  of  a  well-judged 
decision  is  aftbrded  by  time  or  the  result  of  tlie  treatment 
which  restores  the  blood  to  its  normal  state. 

A  murmur  caused  in  violent  excitement  of  the  heart  by 
misdirection  of  the  current,  due  chiefly  to  temporary  interference 


*  American  Journal  of  the  Medical  Sciences,  July,  1844. 
f  Treatise  on  Malformations  of  the  Heart. 


372  MEDICAL    DIAGNOSIS. 

with  the  closure  of  the  valves,  or,  perhaps,  by  altered  tension 
of  the  valves-^^causes  the  exact  working  of  which  I  have 
elsewhere  fully  inquired  into* — may  become  a  troublesome 
source  of  error  in  diagnosis,  especially  when  heard  over  a 
heart  in  a  state  of  dilated  hypertrophy  or  of  dilatation.  For- 
tunately, a  blowing  sound  of  this  origin  is  comparatively  rare, 
and  we  are  generally  enabled  to  discriminate  it  from  an  or- 
ganic valvular  murmur  by  its  not  being  persistent.  It  is  much 
more  likely  to  be  heard  at  the  apex,  or  rather,  according  to 
my  own  observations,  somewhat  above  the  apex,  than  is  a 
murmur  owing  to  changes  in  the  blood;  and  it  differs  from 
the  systolic  bloAving  sound  of  mitral  disease  partly  by  the 
peculiarity  of  seat  just  mentioned,  partly  by  its  non-dift'usion, 
its  usual  absence  at  the  back  of  the  chest,  the  want  of  harsh- 
ness in  the  inconstant  murmur,  and  the  low  pitch.  Murmurs 
of  this  kind  are  also  caused  by  obstructive  diseases  of  the 
lungs,  without  a  disease  of  the  heart  being  present. 

These,  then,  are  the  causes  which  impair  the  value  of  the 
cardiac  blowing  sound  as  a  sign  of  a  valvular  lesion.  Yet 
they  do  not  happen  often  enough  to  prevent  us  from  regarding 
a  murmur  as  eminently  indicative  of  an  organic  afiectiou  of 
the  valves. 

Let  us  suppose  that  we  are  convinced  that  the  murmur  is 
due  to  a  structural  lesion.  Can  we  say  what  its  precise  nature 
is  ?  Can  we  accurately  foretell  that  the  valve  is  merely  rough- 
ened; or  that  it  has  undergone  calcareous  transformation;  or 
that  it  has  been  bound  down  ;  or  that  it  is  lacerated  ;  or  that 
vegetations  spring  from  it ;  or  that  its  muscular  attachments 
are  sound  or  unsound?  No,  assuredly  not.  Tlie  most  we 
can  do  is  to  judge  whether  the  orifices  through  which  the 
current  flows  be  narrowed,  or  whether,  by  the  valves  not 
closing,  the}'  permit  of  regurgitation  ;  and  to  distinguish  even 
this  we  have  to  take  into  account  more  the  time  of  the  oc- 
currence of  the  sound  than  its  particular  character  or  pitch. 
Indeed,  all  distinctions  based  entirely  on  either  of  these  are 
not  borne  out  by  clinical  experience.  Valves  incompetent 
to  close  the  openings  at  which  they  are  seated  may  permit  a 

*  On  Functional  Valvular  Disorders.   An\.  Journ.  Med.  Sciences,  July,  1869. 


DISEASES    OF    THE    HEART. 


373 


murmur  to  be  generated  of  any  character  and  of  any  pitch. 
It  is  true  that  a  harsh  murmur,  like  that  of  a  saw  or  of  a  rasp, 
is  for  the  most  part  occasioned  by  a  contracted  orifice  with 
rigid  valves;  but  many  contracted  orifices  with  rigid  valves 
exist,  without  producing  such  a  rough  noise. 


Fig.  30. 


Niinowiiio:  of  tliP  acirtio  orifico  by  vcRetations  spriiiRinK  from  the 
valves,  the  structure  of  wiiicli  was  iuileed,  to  a  great  extent,  de- 
stroyed. The  engraving  illustrates  at  the  same  time  the  physical 
signs  of  aortic  constriction. 

A  cardiac  sound  which  is  rare,  but  which,  when  present, 
is  most  uniformly  associated  with  a  narrowed  orifice,  is  a  dis- 
tinct musical  tone  heard  at  the  mitral  or  aortic  valves.  It 
resembles  the  cooing  of  a  pigeon  ;  or  the  auscultator  listens 
and  listens  again,  and  directs  the  patient  again  and  again  to 


374  MEDICAL    DIAGNOSIS, 

suspend  the  respiration  before  he  becomes  convinced  that  the 
sound  is  not  a  sibilant  rale  in  the  lung.  It  is  sometimes  per- 
ceived merely  at  the  end  of  an  ordinary  bellows  murmur,  and 
disappears  and  reappears  from  time  to  time.  Where  this 
rare  sound  is  met  with,  the  valves  after  death  are  commonly 
found  to  be  rigid  and  unyielding.  Yet  this  is  not  always 
the  case.  Sometimes  the  musical  note  is  produced  by  the 
vibrations  of  clots  which  impede  the  rush  of  blood  through 
the  apertures  of  the  heart,  perhaps  even  by  the  loose  edge  of 
a  valve  flapping  to  and  fro  in  the  current.  Occasionally,  too, 
we  hit  upon  it  in  chlorosis;  but,  in  truth,  onl}- very  occasion- 
all}',  and  never  unless  it  be  then  equally  or  more  marked  in 
the  arterial  system.  We  have  the  authority  of  Dr.  Stokes  for 
the  observation,  that  it  may  be  suddenly  developed  and  pre- 
cede the  signs  of  structural  alteration  of  the  heart. 

It  has  been  already  stated  that,  on  the  whole,  we  judge 
best  of  the  state  of  the  orifices  and  of  the  valves,  by  ascer- 
taining the  time  at  which  the  bellows  sound  occurs.  To  do 
this  it  is,  however,  necessary  to  know  in  what  condition  the 
orifices  are  during  the  movements  of  the  healthy  heart. 
Briefly  to  recapitulate  what  we  have  previously  discussed : 
during  the  contraction  of  the  ventricles,  the  valves  at  the 
auriculo-ventricular  openings  are  closed,  since  if  they  were 
not  closed,  the  blood  Avould  regurgitate  into  the  auricles;  and 
the  valves  of  the  aorta  and  pulmonary  artery  are  open,  so  as 
to  permit  the  blood  to  pass  along  the  arterial  trunks.  During 
the  dilatation  of  the  heart  the  reverse  takes  place;  the  valves 
at  the  origin  of  the  great  arteries  are  shut,  to  prevent  the 
blood  which  has  just  been  sent  forth  from  regurgitating,  and 
those  valves  the  function  of  which  is  to  act  as  o-ates  to  the 
auriculo-ventricular  apertures  are  swung  back  to  allow  the 
stream  to  flow  into  the  ventricles. 

If  thus  a  murmur  occur  with  the  contraction  of  the  heart 
and  the  flrst  sound,  it  is  either  the  blood  regurgitating  from 
the  ventricles  into  the  auricles,  or  meeting  with  difJiculty  in 
passing  into  the  aorta  or  pulmonary  artery  ;  if,  after  the  con- 
traction of  the  heart,  and  corresponding  to  the  second  sound, 
it  is  the  blood  passing  thi'ough  a  narrowed  mitral  or  tricuspid 
orifice,  or  streaming  back  into  the  ventricles  through  incom- 


DISEASES    OF    THE    HEART. 


Ui) 


petent  aortic  or  pulmonary  valves.  But  can  we  distiiitruish 
at  which  valve  the  mischief  lies?  Generally  we  can."  By 
attending  to  the  site  of  greatest  intensity  of  the  niurmur,  we 
become  aware  of  the  seat  of  its  production,  provided  it  be 


Fig.  31. 


Insufficient  mitral  valves  peiniittiiig  regurgitation  i)f  tlic  hlnoil.  The  position  and 
time  of  occurrence  of  tlie  most  significant  sign  of  the  affection  is  indicated  in  the 
engraving. 

borne  in  mind  what  are  the  points  for  listening  to  the  differ- 
ent valves.  It  is,  however,  also  necessary  to  recollect  that, 
as  the  whole  heart  is  somewhat  lowered,  tliese  points  arc 
rather  below  what  they  are  in  a  natural  state  of  things. 

]!^ow,  we  cannot  always  say  whether  more  than  one  valve 
is  affected.  A  blowing  sound  in  the  heart,  no  matter  where 
generated,  is  usually  transmitted  all  over  the  organ.  If  it 
mask  the  natural  sounds  at  other  valves,  it  is  very  difficult, 
nay,  it  is  often  impossible,  to  tell  positively  how  many  of  the 
valves  are  injured,  unless  several  spots  are  detected  at  which 
the  niurmur  is  intense,  and  yet  not  alike  in  character. 

Thus  the  blowing  sound  is  the  most  conspicuous  and  most 
constant  sis^n   of  a  valvular  lesion.     The  other  signs  and 


376  MEDICAL    DIAGNOSIS. 

symptoms  vary  in  individual  cases.  Where  the  valves  are 
but  slightly  affected,  let  us  say  slightly  roughened,  as  they 
sometimes  are  after  an  attack  of  rheumatic  endocarditis,  the 
heart  does  not  undergo  any  decided  change  in  size ;  the  cir- 
culation is  carried  on  regularly;  and,  in  spite  of  the  abnormal 
.sound  in  the  heart,  the  patient's  health  remains  unimpaired, 
or  it  is  only  occasionally  that  he  suffers  from  slight  palpita- 
tions. An  alteration  of  the  valves  of  the  heart  of  any  extent 
produces,  however,  an  alteration  either  in  the  capacity  of  its 
cavities  or  in  the  thickness  of  its  walls,  and  the  symptoms  of 
dilatation  or  hypertrophy  make  their  appearance  along  with 
the  physical  signs  of  extended  percussion  dulness  and  feeble 
or  heaving  impulse.  Ordinarily  it  is  the  latter  we  meet  with, 
because  the  valves  of  the  left  side  are  so  very  much  more 
frequently  diseased  than  those  of  the  right,  and  their  derange- 
ments lead  to  hypertrophy  rather  than  to  dilatation.*  Affec- 
tions of  the  tricuspid  valves  are  very  usually  connected  with 
dilatation  of  the  organ  ;  hence  dropsy,  venous  turgescence, 
and  albuminous  urine  are  in  them  more  specially  observed. 
We  also  find  in  them,  or  rather  in  tricuspid  insufficiency, 
what  Mahot  has  recently  more  particularly  called  attention 
to, — a  pulsation  of  the  liver  corresponding  to  each  systole  of 
the  heart,  which  can  be  perceived  by  gently  depressing  the 
abdominal  parietes  with  the  hand  on  the  epigastrium. 

All  valvular  lesions  may  be  combined  with  pain  in  the 
preecordia,  with  palpitations,  with  restlessness  and  disturbed 
dreams.  And  according  as  the  deranged  circulation  through 
the  heart  interferes  with  the  circulation  in  other  parts,  special 
symptoms  show  themselves  prominently.  Thus  we  find  those 
laboring  under  a  mitral  disease  suffering  most  from  cough, 
from  dyspnoea,  and  from  attacks  of  cardiac  asthma,  since  it 
is  the  lung  which  has  to  bear  the  brunt  of  the  embarrassed 
flow  of  the  blood. 

*  But  if  we  may  accept  Dr.  Blakiston's  resenrches  as  final,  aflTections  of  the 
tricuspid  valves  are  both  much  more  common  and  much  more  important  thnn 
is  usually  supposed.  Tricuspid  regurgitation,  he  states,  is  tlie  most  direct 
and  almost  constant  cause  of  that  engorgement  of  the  vessels  of  the  brain  and 
of  the  general  circulation,  with  their  consequences,  which  originates  within 
the  heart.  It  is,  therefore,  the  predisposing  cause  of  cerebral  apoplexy  when 
in  connection  with  cardiac  disease. 


DISEASES    OF    THE    HEART.  377 

If  we  examine  this  organ  closely,  the  physical  signs  afford 
direct  proof  of  its  disordered  condition.  Here  and  there  are 
heard  plentiful  moist  sounds  from  fluid  which  has  leaked 
into  the  air-tubes;  here  and  there  the  respiratory  murmur  is 
roughened;  here  and  there  percussion  elicits  impaired  clear- 
ness. This  loss  of  the  natural  resonance  is  at  times  verv 
manifest  at  the  upper  part  of  the  lung,  and  I  have  known  it 
to  lead  to  the  suspicion  of  tubercular  deposit  in  cases  in 
which  the  autopsy  showed  the  pulmonary  tissue  to  be  sound, 
though  in  a  state  of  extreme  congestion. 

When  the  aortic  valves  permit  of  regurgitation,  this  gives 
rise  to  effects  which  are  perceptible  along  the  track  of  the 
arteries.  These  all  look  superficial,  and  beat  with  iipparent 
violence,  from  the  force  with  which  the  thickened  left  ven- 
tricle is  driving  the  blood  through  the  tubes.  Yet  when  the 
finger  is  applied  to  the  artery  at  the  wrist,  the  strength  of 
the  beat  is  not  so  great  as  is  expected.  A  short,  abrupt, 
jerking  impulse  is  indeed  communicated  to  the  finger;  but 
then  the  artery  immediately  recedes,  proving  that  it  was 
only  imperfectly  filled.  This  pulse  is  the  only  one  which 
ffives  us  anv  real  information  as  to  the  state  of  the  orifices 
of  the  heart;  otherwise  the  pulse  does  not  afford  any  very 
trustworthy  indications.  In  general  terms,  it  may  be  stated 
to  be  small  and  rather  tense  wdien  the  openings  are  nar- 
rowed. Still,  no  stress  caii  be  laid  on  this  in  a  diagnostic 
point  of  view.  The  want  of  correspondence  between  its 
strength  and  the  force  with  which  the  heart  is  acting  is  often 
amazing. 

Much  more  information  than  by  merely  feeling  the  pulse 
can  be  obtained  by  studying  it  with  the  sphygmograph. 
But  even  with  this,  as  thus  far  developed,  we  gather  in 
valvular  diseases  rather  corroborative  evidence  than  knowl- 
edge which  is  not  attainable  by  other  means  of  diagnosis. 
Very  probably,  with  further  research,  the  instrument  may 
be  made  available  to  inform  us  with  certainty  of  the  degree 
of  the  valvular  imperfection,  and  this  would  be  a  great  step 
in  advance.  As  regards  the  most  distinctive  graphical  signs, 
we  obtain  them  in  aortic  regurgitation,— a  vertical  line  of 
ascent  of  great  amplitude,  a  sharp  and  pointed  summit,  and 


378 


MEDICAL    DIAGNOSIS. 


a  sudden  descent,  with  comparatively  very  little  dicrotism. 
If  there  be  also  marked  aortic  obstruction,  the  line  of  ascent 
is  oblique,  or  oftener  rather  the  first  part  is  vertical,  and  fol- 
lowing the  sharp  point  is  a  gradual  curvelike  rise;  if  senile 
changes  in  the  artery  complicate  the  aortic  insufficiency,  the 
sharp-pointed  process  terminating  the  line  of  ascent  passes 
usualh'  into  a  more  or  less  horizontal  plateau.  In  mitral 
regurgitation  the  pulse  tracing  is  usually  very  irregular;  the 
line  of  ascent  is  short,  but  apt  to  be  very  unequal,  and  the 
line  of  descent  disposed  to  be  oblique  and  to  present  very 
marked  dicrotism. 

Fig.  32. 


Sphyfjinogram  taken  from  a  pntieiit  witli  aortic  insufficiency.  The  line  of 
ascent  does  not  terminate  in  as  sharp  a  point,  nor  is  the. descent  as  sudden 
as  we  sometimes  find  it. 


Tig.  33. 


Sphygmogram  taken  from  a  patient  presenting  tlie  signs  of  mitral  regurgitation. 


But,  instead  of  entering  into  a  detailed  description  of  the 
pulse,  however  studied,  or  of  any  separate  symptoms  of 
valvular  disease,  let  us  group  them  together  with  the  physical 
signs,  according  to  the  combination  in  which  we  are  wont  to 
meet  with  them : 


DISEASES    OF    THE    HEART. 


379 


Table  of  Valvular  Diseases. 


Seat  OF  Murmur. 

Murmur  most  in- 
tense at  or  near 
apex  of  heart. 


Murmur  most  in- 
tense at  or  near 
the  middle  of 
the  sternum, 
or  heard  with 
equal  distinct- 
ness close  to 
the  sternum  in 
the  second  in- 
terspace on  the 
right  side,  and 
thence  propa- 
gated into  the 
arterial  sys- 
tem. 


Murmur  most  in- 
tense at  or  very 
near  to  the 
ensiform  carti- 
lage, and  over 
the  lower  part 
of  riglit  ven- 
tricle. 


Seat  of  Dis- 
ease. 

Mitral  ori- 
fice. 


Aortic     ori- 
fice. 


Tricuspid 
orifice. 


Character  of 
Disease. 
With  impulse, 
me  a  a  s  i  u- 
sufficiency  of 
valves,  permit- 
ting of  regur- 
gitation ;  after 
impulse,  a  n  d 
running  into 
or  correspond- 
ing to  second 
sound,  or  prc- 
c  e  d  ing  first, 
m  cans  n  a  r- 
rowing  of  the 
orifice. 

W  i  t  li  impulse, 
means  7iarrow- 
i?i/7,or  obstruc- 
tion ;  with  di- 
astole,and  tak- 
ingtheplaceof 
second  sound. 
means  regur- 
gitation. 


W  i  t  h  impulse, 
regurgitation  ; 
with  diastole, 
and  taking 
therefore  the 
l)Iace  of  second 
sound,  or  pre- 
cedin  g  first, 
narrowing  ? 


Correlative  I'iiyhicai,  Signs  and  Srnp- 
toms. 

In  mitral  disease  the  heart  very  com- 
monly undergoes  dilated  hypertrophy, 
especially  the  riglit  ventricle.  The  sec- 
ond sound  of  till'  pulmonary  artery, 
heard  in  tlic  second  left  interspace,  is 
sharii,accciituated.  Tlie  cardiac  murmur 
is  most  often  distinctly  perceived  pos- 
teriorly on  tlie  left  side,  near  the;  angh; 
of  the  scapula.  Dyspiia-a  and  drcpjisy 
are  prominent  symptoms,  especially 
dysiinwa.  Cough  is  not  unusual,  and 
the  pulse  is  not  unfrequently  found  to 
be  feeble  and  irregular.  In  some  forms 
of  mitral  obstruction,  where  the  cur- 
tains are  not  too  rigid,  the  murmur  is 
always  rough. 

llyjiertrophy  of  left  ventricle.  The  cardiac 
sounds  may  all  be  normal,  excepting  at 
the  affected  valve,  although  they  are 
often  somewhat  obscured  by  the  mur- 
mur. This  is  distinct  in  the  carotids, 
and  is  sometimes  as  well  lieard  at  the 
ensilbrm  cartilage  as  over  the  sternum, 
and  on  a  line  with  the  third  intercostal 
space — a  fact  necessary  to  be  aware  of,  so 
as  to  avoid  confounding  the  aortic  lesion 
with  one  of  the  tricuspid  valve.  ■When 
the  orifice  is  constricted,  a  purring  thrill 
isfrequently  observed  to  attendeacli  beat 
of  the  heart.  The  symptoms  are  often 
remarkably  latent.  There  is  very  com- 
monly neither  dropsy  nor  dyspnoea.  The 
pulse  is,  in  constriction,  not  materially 
affected  ;  in  regurgitation  it  is  abnijit  and 
jeiking.  and  all  the  superficial  arteries 
pulsate  distinctly.  It  is  not  unusual  to 
find  a  double  blowing  sound  attending 
aortic regurgi  tation,probablyfrom3liglit 
coexisting  obstruction  of  the  orifice. 

Tricuspid  regurgitation  (for  of  tricuspid 
narrowing  our  knowledge  is  little  else 
than  theoretical)  exists  very  usually  in 
combination  with  dilatation  of  the  right 
ventricle,  and  tberelbre  with  the  syiiip- 
tonis  of  this  condition  :  with  venous  con- 
gestions, with  dropsies,  with  difliculty  in 
breathing.  On  account  of  the  open  state 
of  the  orifice,  the  cervical  veins  may  pnl- 
.sate  during  the  movements  of  the  heart ; 
and  in  all  cases  they  are  distended.  The 
pulsatile  motion  in  the  neck  become.') 
especially  visible  when  the  breath  is  held 
in  expiration.  The  cardiac  murmur  is 
ordinarily  soft,  of  low  pitch,  is  not  trans- 
mitted into  the  arteries,  and  not  heard 
above  the  level  of  the  third  rib.  In  some 
cases  it  issofeebleas  tobe  with  difficulty 
discernible. 


380 


MEDICAL   DIAGNOSIS. 


Table  of  Valvular  Diseases 


Seat  OF  Murmur. 

Seat  op  Dis- 
ease. 

Character  of 
Disease. 

Murmur  most  in- 

Pulmonary 

With    impulse, 

tense  at   third 

orifice. 

is  narrmving ; 

left  costal  car- 

taking  place  of 

tilage   near 

second  sound. 

the     sternum, 

rtgurgilation. 

0  r     somewhat 

lower,  or  in  se- 

cond   intercos- 

tal space  of  left 

side. 

[Continued). 

Correlative  Physical  Signs  and  Symp- 
toms. 

We  have  very  little  actual  knowledge,  de- 
rived from  clinical  observation,  of  dis- 
eases of  the  pulmonary  valves;  of  all  the 
valves  the  ones  most  rarely  affected. 
Nor  does  a  murmur  in  the  situation  in- 
dicated, and  hardly  audible  over  the  left 
apex  or  along  the  sternum,  or  in  the 
course  of  the  great  vessels,  having  there- 
fore the  characteristics  of  a  pulmonic 
murmur,  warrant  a  diagnosis  of  disease 
of  the  valves :  for  it  may  be  due  to  anae- 
mia; be  caused  by  deposits  at  the  upper 
part  of  the  left  lung;  or  be  observed 
immediately  after  or  during  the  contin- 
uance of  hemorrhage  from  the  lungs. 
But  these  remarks  scarcely  hold  good 
with  reference  to  a  diastolic  murmur, 
and  not  at  all  as  regards  a  doulile  mur- 
mur. If  this  be  present,  and  signs  of 
dilated  hypertrophy  exist,  we  are  justi- 
fied in  concluding  the  disease  to  be  a 
lesion  of  the  pulmonary  valves,  or  at  the 
origin  of  the  artery. 


In  this  manner  are  the  symptoms  and  signs  of  valvular 
affections  associated.  But  I  do  not  pretend  to  say  that  this 
is  exactly  the  combination,  and  precisely  the  way  in  which 
they  happen  in  every  instance.  There  are  too  many  circum- 
stances which  modity  them;  disorders  of  several  valves  are 
too  constantly  conjoined;  at  the  same  orifice  both  narrowing 
and  a  state  permitting  of  regurgitation  are  too  often  found 
to  coexist, — to  permit  any  tabular  representation  to  express 
either  all  the  symptoms  or  signs  which  may  occur  in  indi- 
vidual cases.  Apart  from  this  ditiiculty  there  is  another: 
even  where  the  affection  of  a  second  valve  has  been  correctly 
fixed  upon,  the  irregularity  of  the  heart's  action  may  be 
such  that  it  is  impossible  to  say  whether  the  blowing  sound 
wdiich  is  heard  be  systolic  or  diastolic;  whether,  therefore, 
the  orifice  be  narrowed  or  the  valves  insufficient.  Fortu- 
nately, this  is  not  a  matter  of  so  much  consequence;  the 
matter  of  consequence  is,  to  determine  that  a  disease  of  the 
valves  of  the  heart  is  present. 

Presuming  that  we  have  been  enabled  to  fix,  and  to  fix  ac- 
curately, the  state  of  each  aperture,  there  is  a  point  where 
all  our  skill  invariably  comes  to  a  stand-still.     We  cannot 


DISEASES    OF    THE    HEART.  381 

tell  how  long  it  is  possible  for  life  to  continue,  or  under  what 
circumstances  death  will  happen.  It  may  take  place  sud- 
denly and  most  unexpectedly  in  cases  in  which  the  amount 
of  disease  in  the  heart  is  not  found  to  be  verv  irreat:  and,  on 
the  other  hand,  life,  and  even  a  tolerable  degree  of  health, 
may  be  maintained  with  valves  so  rigid  and  unyielding  that 
the  point  of  the  knife  can,  at  the  autopsy,  hardly  be  forced 
through  them.  In  mitral  disease,  the  patient  is  liable  to  be 
worn  out  by  the  dropsy  and  by  the  steadily  increasing  diffi- 
culty of  breathing ;  and  so,  too,  in  that  still  more  serious 
lesion — tricuspid  regurgitation.  In  affections  of  the  aortic 
valves  the  patient  suffers  less,  but  he  is  more  liable  to  sudden 
death. 

From  these  remarks,  it  is  apparent  that  the  treatment  of 
valvular  disease  is  very  unsatisfactory.  In  truth,  no  remedy 
has  any  direct  action  on  the  valves,  and  we  have  to  content 
ourselves  with  palliating  what  we  cannot  cure.  The  dropsy 
and  the  dyspnoea  generally  demand  special  attention,  and 
tax  the  practitioner's  efforts  to  the  utmost;  for,  although 
they  can  be  greatly  benefited  by  treatment,  they  cannot  be 
cured  so  long  as  their  irremediable  cause  persists. 

Before  dismissing  these  valvular  affections,  there  are  a  few 
other  matters  which  claim  consideration,  though  the  limits 
set  to  this  work  will  prevent  their  full  discussion.  The  blow- 
ing sound  has  been  insisted  upon  as  the  diagnostic  sign  of  a 
valvular  lesion,  and  to  insist  upon  this  is  to  do  no  more  than 
universal  experience  warrants.  But  we  can  rarely  thus  ab- 
solutely connect  a  disease  with  a  special  sign.  Undoubtedly 
there  are  instances  in  which  no  murmur  readies  the  ear  to 
show  that  the  valves  are  damaged. 

I  shall  cite,  as  concisely  as  possible,  two  examples.  A 
man,  thirty-five  years  of  age,  came  under  my  care,  complain- 
ing of  palpitation  of  the  heart,  of  occasional  attacks  of  bron- 
chitis, and  of  shortness  of  breath.  His  health  was  otherwise 
good.  A  physical  examination  of  the  chest  showed  the 
action  of  the  heart  to  be  extremely  disturbed :  the  impulse 
was  strong,  and  the  extent  of  dulness  in  the  precordial  re- 
gion increased.  A  blowing  sound  v.-as  heard  near  the  apex, 
but,  owing  to  the  great  irregularity  of  the  movements  of  the 


382  MEDICAL    DIAGNOSIS. 

heart,  it  was  impossible  to  say  whether  it  corresponded 
in  time  to  the  contraction  or  relaxation  of  the  orofan.  The 
pulse  was  small,  frequent  and  intermittent.  The  patient 
continued  in  this  state  for  seven  months,  the  beat  of  the 
heart  becoming  more  and  more  tumultuous;  but  the  murmur 
gradually  disappeared.  A  peculiar  clacking  sound  took  its 
place,  which  was  most  distinct  near  the  apex,  and  was  faintly 
transmitted  to  other  portions  of  the  heart.  It  O'^curred  with 
but  one  sound  of  the  heart, — with  which  could  not  be  deter- 
mined. For  some  time  before  his  death  he  had  considerable 
cough,  with  a  frothy  expectoration  and  great  difficulty  in 
breathing.  lEis  face  and  hands  had  begun  to  swell.  The 
immediate  cause  of  death  seemed  to  have  been  pulmonary 
apoplexy.  The  heart  was  found  in  a  state  of  dilated  hyper- 
trophy, and  the  mitral  valves  had  been  converted  into  a  cal- 
careous mass,  which  had  left  but  an  extremelv  narrow  chink 
for  the  blood  to  pass  through. 

The  next  case  presents,  in  several  respects,  a  striking  sim- 
ilarity. A  gentleman,  about  fifty  years  of  age,  who  had  led 
a  gay  and  somewhat  dissipated  life,  noticed  that  he  experi- 
enced difficult}'  in  breathing  on  the  slightest  exertion.  He 
complained  also  much  of  loss  of  appetite  and  of  distention 
of  the  stomach.  I  could  not  find  any  cause  bej^ond  flatu- 
lency to  account  for  this;  the  abdomen  yielded  all  over  an 
extremely  tympanitic  sound.  But  to  the  dyspticea,  an  in- 
quiry into  the  state  of  the  heart  furnished  a  clue.  The  size 
of  the  organ  was  evidently  augmented,  and  its  rhythm  very 
irregular.  The  impulse  was  strong;  but  the  sounds  were 
normal,  excepting  near  the  apex,  where,  taking  the  place  of 
one,  was  heard  a  dull  but  verv  marked  clack.  When  the 
hand  was  applied  over  this  point,  it  felt  a  vibration  of  very 
much  the  same  character  as  that  which  the  ear  could  hear, 
and,  like  this,  it  was  limited,  or  certainly  only  distinctly  per- 
ceptible, at  or  near  the  apex  of  the  organ.  The  diagnosis  of 
disease  of  the  mitral  valves  was  made,  and  it  proved  to  be 
correct.  The  dyspnoea  became  greater  and  greater;  the  feet, 
and  subsequently  the  abdomen,  were  distended  with  fluid; 
and  the  patient  died  with  all  the  sj^mptoras  of  an  unmistak- 
able valvular  lesion. 

My   note-book  would   furnish   me  with  innnv   more  such 


DISEASES    OF    THE    HEART,  383 

cases;  but  these  two  present  the  main  features  of  all.  All 
the  instances  I  have  met  with  of  valvular  disease,  unaccom- 
panied by  blowing  sounds,  have  been  instances  of  disease  at 
the  mitral  orifice,  and  of  extreme  narrowing  of  that  orifice. 
They  were  all  attended  with  excessive  irregularity  of  the 
action  of  the  heart,  and  with  hypertrophy.  They  all  pro- 
duced difficulty  of  breathing.  They  all  presented  this  pecu- 
liar clacking  sound  most  marked  near  the  apex.  In  some, 
another  sound,  more  like  that  heard  in  health,  followed  it; 
in  others,  not.  In  some,  the  blowing  sound  gradually  dis- 
appeared;  in  others,  none  w^as  perceived  when  first  exam- 
ined; and  in  others,  again,  it  could  be  caught  occasionally, 
as  a  very  short  whifi",  along  with  the  clacking  sound.  Tlie 
impulse  was  in  all  strong  and  very  variable  in  its  rhythm, 
and  a  peculiar  movement  was  felt  near  the  seat  of  the  apex — 
not  the  purring  tremor  which  so  coinmonly  accompanies  the 
movements  of  a  heart  the  valves  of  which  are  damai^red,  but 
a  more  localized  vibration,  similar,  as  far  as  such  simihirity 
can  exist,  to  the  sound  the  ear  hears. 

These  cases  are  probably  of  the  same  nature  as  those  that 
are  every  now  and  then  reported  as  valvular  lesions,  in  which 
the  sounds  of  the  heart  were  normal.  I  cannot  think  that 
with  a  disease  of  the  valves  they  ever  are  so.  There  may 
be  no  blowing  sounds  present,  but  the  sounds  of  the  valve 
affected  must  be  difierent  from  what  they  are  in  health;  and 
it  may  again,  in  all  truth,  be  said,  that  to  hear  the  natural 
sounds  of  the  heart  well  defined,  is  to  be  able  to  exclude  a 
valvular  disease. 

The  other  subject  to  which  wc  may,  in  conclusion,  advert, 
is  the  possibility  of  valves  having  been  insufficient  to  perform 
their  functions  during  life,  and  yet  no  signs  of  their  incom- 
petence be  detected  after  death,  at  least  none  indicated  by 
any  structural  change  in  the  valves.  That  such  cases  occur, 
is  attested  by  more  than  one  observer.  They  have  generally 
been  found  to  be  connected  with  dilatation  of  the  ventricles 
of  the  heart,  and  are  perhaps  due,  as  suggested  by  Dr.  Bris- 
towe,*  to  a  ventricle  becoming  dilated  without  a  correspond- 


*  Brit,  and  Foreign  Med.-Chirg.  Review,  July,  1861  ;  see  also  cases  by- 
Hare,  Transact,  of  London  Patli.  Society,  vol.  ii.,  and  by  Cuming,  Dublin 
Quarterly  Journal,  Myy,  18G8. 


384  MEDICAL    DIAGNOSIS. 

ing  elongation  of  the  muscnli  papillares  and  chordse  tendinese. 
Of  course  this  explanation  only  holds  good  with  reference  to 
regurgitation  through  the  auriculo-ventricular  apertures ;  but 
it  is  to  this  condition  that  the  instances  recorded  refer.  Yet 
in  explaining  them  we  must  not  overlook  those  blowing 
sounds  produced  by  mere  abnormal  action  of  the  textures 
of  the  heart,  to  which  we  have  elsewhere  alluded,  and  the 
existence  of  which  no  one  can  call  in  question. 

Displacements  of  the  Heart. 

The  heart  is  a  very  movable  organ.  This  is  proved  by  the 
ease  with  which  it  is  displaced,  and  with  which  it  returns  to 
its  normal  position.  Its  apex  is  tilted  upward  by  an  enlarged 
liver,  by  an  abdominal  tumor,  or  by  a  pericardial  effusion. 
It  gravitates  toward  the  median  line  when  the  walls  of  the 
heart  have  increased  in  weight  and  firmness.  But  these 
changes  are  hardly  of  a  nature  to  attract  as  much  attention 
as  finding  a  heart  beating  on  the  right  side  of  the  sternum. 

Now,  it  is  nothing  very  uncommon  to  meet  with  it  there, 
and  the  question  immediately  arises,  what  does  this  strange 
alteration  in  its  situation  signify,  and  how  is  it  brought 
about?  It  is  usually  produced  by  pressure  exercised  on  the 
heart  by  accumulations  of  fluid  or  of  air  in  the  left  plenral 
cavity,  and  therefore  denotes,  as  a  rule,  a  pleuritic  effusion  or 
pneumothorax  of  the  left  side,  and  is  accompanied  by  dis- 
tention of  that  side.  In  rarer  instances,  the  heart  is  pushed 
across  by  a  highly  distended  emphysematous  lung;  in  still 
rarer  instances,  it  is  drawn  over  to  the  right  side  by  a  shrink- 
ing of  the  right  lung,  attended  with  dilatation  of  the  bron- 
chial tubes,  the  so-called  pulmonary  cirrhosis.  It  is  some- 
times found  on  the  right  side,  because  it  had  been  forced 
there  by  a  pleuritic  eft'usion,  and  has  formed  adhesions,  so 
that  when  the  fluid  was  absorbed  it  was  unable  to  return  to 
its  natural  place.  In  this  case  the  left  side  will  be  markedly 
retracted,  and  not  the  right,  as  it  is  if  cirrhosis  be  the  cause 
of  the  abnormal  position  of  the  heart. 

The  displacement  may  further  have  been  brought  about 
by  a  cancerous  or  an  aneurismal  tumor,  or  by  any  of  the  ab- 


THORACIC    ANEURISM.  385 

(lominal  viscera  having  slipped  into  the  chest  through  a  her- 
nial opening  in  the  diaphragm  ;  or  it  may  he  congenital.  But 
these  are  all  causes  which  seldom  exist.  Practically  speakino-, 
transpositions  of  the  heart  are  met  with  in  connection  with 
diseases  of  the  lungs,  as  has  been  explained  in  a  previous 
chapter.  Here  we  shall  merely  add,  that  a  congenital  dis- 
placement cannot  be  diagnosticated,  unless  all  other  causes 
capable  of  producing  a  displacement  have  been  proved  to  be 
absent ;  and  that  a  dislocated  heart  is  able  to  perform  all  its 
functions.  It  may  even  be  attacked  by  acute  diseases ;  the 
recognition  of  which,  under  such  circumstances, — and  they 
have  been  recognized,*  —  belongs  most  assuredly  to  the 
triumphs  of  physical  diagnosis. 


SECTION  III. 


THORACIC   ANEURISM. 


The  heart  is  not  the  only  part  of  the  circulatory  system 
within  the  chest  which  is  liable  to  become  diseased.  The 
great  vessels  which  spring  from  it  are  subject  to  the  same  mor- 
bid conditions  as  the  vessels  of  any  other  portion  of  the  body. 
Especially  do  we  find  this  to  be  the  case  with  the  aorta,  the 
coats  of  which  are  frequently  roughened  by  calcareous  or 
atheromatous  deposits.  These  alterations  are,  however,  be- 
yond the  discernment  of  the  physician.  He  may  infer  that 
they  exist,  if  a  distinct  systolic  blowing  sound  be  heard  in 
the  track  of  the  aorta  or  its  branches,  in  a  person  who  is  not 
anemic,  who  is  past  middle  life — and  therefore  at  an  age  at 
which  these  kinds  of  alterations  of  tissues  happen — and  in 
whom  no  cardiac  murmurs,  or  only  very  faint  cardiac  mur- 
murs, are  perceived.  But  it  is  not  until  after  death  that  the 
practitioner  learns  the  precise  nature  or  extent  of  the  struct- 
ural  lesions.     They  are  thus   only  interesting  to  him  as  a 

*  By  Stokes.     See  Diseases  of  the  Heart,  page  463. 

25 


386  MEDICAL    DIAGNOSIS. 

pathologist,  apd  important,  because  he  knows  that  tliese 
changes  in  the  coats  of  the  arteries  are  often  but  the  first 
step  toward  their  laceration  or  a  dilatation  of  the  vessels; 
in  other  words,  toward  the  establishment  of  an  aneurism. 

Now,  an  aneurism  of  the  aorta,  whether  caused  by  a  dis- 
ease of  the  coats  of  the  artery  or  not,  whether  true  or  false, 
may  affect  any  part  of  the  vessel.  But  it  is  chiefly  at  the 
ascending  portion  and  at  the  arch  that  it  is  met  with.  Where 
it  occurs  just  after  the  artery  has  left  the  heart,  it  is  prone  to 
elude  discover3\  Higher  up,  nearer  to,  or  at  the  arch,  it 
more  rarely  escapes  detection.  The  tumor  manifests  itself 
by  a  local  bulging,  varying  in  extent  and  situation  according 
to  the  extent  and  situation  of  the  aneurism.  A  single  rib 
alone  mav  be  raised,  or  nothins^  but  a  fulness  be  observed. 
But  some  prominent  spot  is  generally  detected,  and  when 
this  is  percussed,  it  is  more  resistant,  and  returns  a  duller 
sound  than  when  there  is  nothing  wrong  underneath.  Yet 
neither  the  bulging  nor  the  dulness  on  percussion  is  of  as 
much  significance  as  finding  a  distinct  pulsation  remote  from 
the  beat  of  the  heart.  Every  time  the  latter  is  perceived,  an 
impulse  is  communicated  to  the  finger  at  the  point  in  the 
chest  walls  which  appears  to  project;  that  is,  usually  on  the 
right  side  of  the  sternum  in  the  second  intercostal  space,  or 
in  the  same  interspace  on  the  left  side,  or  immediately  under 
the  top  of  the  bone.  Occasionally  the  beat  is  double,  and  at 
times  so  violent  as  to  shake  the  head  of  the  listener. 

The  impulse  may  be  accompanied  by  a  distinct  thrill.  Yet 
this  is  not  always  present,  and,  when  present,  not  always  con- 
stant;  since  it  may  disappear  and  reappear.  It  is  thus  a 
serious  mistake  to  regard  the  thrill  as  the  requisite  sign  of 
an  aneurismal  enlargement,  and  j^et  there  is  no  mistake  more 
common,  excepting,  perhaps,  one  :  to  consider  that  the  motion 
of  the  blood  in  the  sac  must  necessarily  engender  a  murmur. 
The  ear,  applied  over  the  prominence,  hears  often  nothing 
that  in  the  least  resembles  a  murmur,  but  sounds  like  those 
of  the  heart,  sometimes  two — the  first  weighty  and  prolonged : 
sometimes  but  one,  and  that  one  longer  and  more  intense 
than  the  corresponding  first  sound  over  the  ventricles. 

Thus,  then,  neither  thrill  nor  murmur  is  essential  to  the 


THORACIC    ANEURISM.  387 

diagnosis  of  an  aneurism.  What  is  much  more  so,  is  to  find 
two  points  of  pulsation  in  the  chest— two  hearts,  each  with 
its  own  distinct  beat,  its  own  distinct  sounds. 

The  aneurismal  tumor  in  the  chest  gives  rise  to  symptoms 
which  vary  somewhat  according  to  its  seat  and  extent.  Prom- 
inent among  them  stand  those  occasioned  by  pressure.  The 
sac  presses  on  the  adjacent  air-tubes,  and  shortness  of  breath- 
ing, or  peculiar  cough  and  signs  counterfeiting  those  of  a 
chronic  laryngeal  disease,  are  the  result;  or  it  presses  on  the 
oesophagus,  and  the  patient  suffers  from  difficulty  in  swallow- 
ing; or  it  presses  on  the  subclavian  artery,  and  the  pulses  at 
the  two  wrists  are  noticed  to  be  strikingly  different;  or  on 
the  carotid,  and  pain  in  the  head,  dulness  of  mind,  occasional 
giddiness,  and  flashes  of  light  before  the  eyes,  are  complained 
of;  or  on  the  venous  trunks,  and  the  superficial  veins  of  the 
neck  and  thorax  are  seen  to  be  engorged,  and  the  skin  be- 
comes very  puffy  and  swollen  ;  or  on  the  trunk  of  the  sympa- 
thetic nerve  or  on  its  ganglia  and  their  communications,  and 
marked  contraction,  or,  in  rare  instances,  dilatation  of  the 
pupil  of  the  eye  on  the  side  of  the  aneurismal  swelling,  is 
perceived,  or  profuse  sweating  becomes  a  very  annoying 
complication.  All  these  signs,  then,  denote  pressure,  and 
pressure  connected  with  a  pulsating  tumor  in  the  chest 
means  an  aneurism. 

I  say  with  a  pulsating  tumor,  because  a  cancerous  or  any 
other  morbid  growth  may  produce  exactly  the  same  signs  of 
compression  as  an  aneurismal  tumor, — the  same  stridor,  the 
same  cough,  the  same  feebleness  of  respiration  in  one  lung 
from  partial  obliteration  of  its  bronchial  tube.  But  the  solid 
tumor,  large  though  it  be,  does  not  pulsate,  or  if  it  does,  pul- 
sates but  very  feebly,  and  not  with  the  heaving  motion  of  a 
distending  aneurismal  sac*  The  tumor  renders  a  large  sur- 
face dull  on  percussion,  and  communicates  a  much  greater 


*  This  same  absence  of  distinct  pulsation  was  the  main  point  of  dissimi- 
larity between  an  aneurism  and  an  abscess  of  the  mediastinum  some  time 
since  under  my  care,  and  w^hich,  after  lasting  a  year,  and  simulating  aneurism 
most  closely  in  the  pain,  the  dulness  on  percussion,  the  ditficulty  of  breathing 
and  of  swallowing,  and  the  altered  voice,  got  well  by  breaking  internally  and 
by  the  discharge,  as  expectoration,  of  large  amounts  of  purulent  matter. 


388  MEDICAL    DIAGNOSIS. 

feeling  of  resistance  to  the  percussing  finger.  Yet  the  ear 
listens  in  vain  over  the  prominence  for  the  weighty  sound 
with  each  beat  of  the  heart,  or  for  the  hoarse  murmur  of  the 
blood  streaming  through  the  sac.  It  is  only  where  a  solid 
growth  weighs  on  the  artery  that  an}^  murmur  is  perceived, 
and  this  is  diflerent  from  the  superficial,  loud  sounds  or  mur- 
murs of  an  aneurism.  Further,  a  tumor  is  not  confined  to 
the  course  of  the  aorta;  it  is  more  commonly  connected  with 
a  distended  state  of  the  veins  of  the  neck  and  thorax,  and 
with  oedema  of  the  arm  and  chest;  the  pain  it  occasions  is 
often  more  continued,  and  less  neuralgic  in  its  nature.  More- 
over, as  most  thoracic  tumors  are  cancerous,  the  violent  con- 
stitutional disturbance,  the  formation  of  external  swellings, 
and  the  peculiar  currant-jelly  expectoration,  aid  us  in  arriving 
at  a  correct  conclusion.  The  obvious  inequality  of  the  pupils, 
which  is  found  in  a  certain  number  of  cases  among  the  signs 
of  an  aneurism,  is  of  little  aid  in  a  differential  diagnosis,  for 
a  thoracic  cancer  has  been  noted  to  occasion  the  same.*  The 
rarity  of  a  non-aneurismal  tumor  in  the  chest  is,  however, 
very  great;  and,  practically  speaking,  when  the  signs  of  an 
intra-thoracic  tumor  are  met  with,  we  are  generally  correct 
in  thinking  that  it  is  an  aneurism  we  have  to  treat,  even 
should  the  pulsations  not  be  very  obvious. 

Let  us  suppose  that  we  are  perfectly  satisfied,  owing  to  a 
marked  impulse,  that  we  have  not  a  solid  growth  to  deal 
with — does  a  pulsation  uniformly  denote  an  aneurism?  Can 
we  absolutely  say,  on  account  of  the  impulse,  that  it  is  an 
aneurismal  enlargement  ?  If  there  be  also  a  swelling  and 
signs  of  pressure,  we  can ;  should  these  not  exist,  we  cannot 
be  quite  so  sure.  For  a  pulsation  in  the  chest  not  immedi- 
ately over  the  region  of  the  heart,  although  it  is  nearly 
always  indicative  of  an  aneurism,  may  be  owing  to  other 
causes: 

Where  the  aortic  valves  are  insufficient,  and  permit  of  re- 
gurgitation, there  may  be  a  pulsation  in  the  aorta;  an  empy- 
ema may  pulsate;  a  dilated  auricle  may  occasion  an  impulse 

*  MacDonnell,  Montreal  Medical  Chronicle,  June,  1858;  see,  also,  the  Re- 
searches of  Gairdner,  Clinical  Medicine,  and  of  Ogle,  31edico-Chirurgical 
Transactions,  vol.  xli. 


THORACIC    ANEURISM.  389 

separate  from  that  of  the  ventricles  ;  a  pulmonary  artery  sur- 
rounded by  consolidated  lung  may  distinctly  exhibit  its  beat. 
In  all  of  these  the  siarns  of  pressure  on  the  surroundino- 
parts  are  wanting;  and,  on  the  other  hand,  they  show  phe- 
nomena which  an  aneurism  lacks. 

Insifffident  aortic  valves  are  accompanied  by  hypertroph}-  of 
the  left  ventricle.  So  is  very  constantly  a  thoracic  aneurism; 
but  instead  of  the  throbbing  at  the  upper  anterior  part  of 
the  chest  beins;  attended,  as  it  is  in  aneurismal  swcllimr, 
with  a  natural,  or  an  unequal  and  diminished  beat  at  the 
wrist,  there,  as  well  as  in  the  larger  trunks  in  the  neck  and 
arms,  is  perceived  that  strong  and  peculiar  pulsation  which 
is  so  characteristic  a  sign  of  inadequate  aortic  valves.  Then, 
again,  a  murmur  is  much  more  common  in  this  organic 
affection  of  the  valves  than  it  is  when  an  aneurism  has 
formed  above  the  origin  of  the  vessel.  And  even  where  a 
murmur  is  heard  over  the  seat  of  an  aneurismal  pulsation, 
it  is  better  marked  there  than  over  the  heart,  and  not  unfre- 
quently  short,  hoarse,  and  of  low  pitch  ;  in  truth,  it  differs  in 
distinctness  as  well  as  in  quality  from  the  murmur  discerned 
at  the  base  of  the  heart,  which  may  be  transmitted  from  the 
aneurism,  or  depend  upon  coexisting  cardiac  disease. 

A  pulsating  empyema  is  very  seldom  met  with;  yet  it  is  well 
to  have  a  knowledge  of  the  fact  that  a  collection  of  fluid  in 
the  cavity  of  the  chest  may  vibrate  witli  the  motion  of  the 
heart,  and  throb  with  such  violence  as  closely  to  simulate  an 
aneurism.  To  determine  the  real  nature  of  the  pulsation  in 
these  cases,  we  must  attach  importance  to  the  situation  of 
the  expanding  mass,  which  is  not  often  that  of  an  aneurism, 
and  to  the  signs  which  point  out  that  liquid  has  accumulated 
within  the  pleural  sac.  "We  also  note  the  circunistajice  that 
over  the  seat  of  impulse  there  are  no  peculiarly  marked 
sounds,  no  murmurs,  no  thrill. 

A  dilated  auricle,  the  walls  of  which  are  at  the  same  time 
hypertrophied,  may  give  rise  to  a  movement  separate  from 
that  of  the  beat  of  the  ventricle.  Bouillaud  cites  an  example 
of  this  nature,  in  which  a  double  motion  was  perceptible  in 
the  second  intercostal  space  of  the  left  side,  in  a  person 
whose  heart  was  extensively  hypertrophied,  and  whose  mitral 


390  MEDICAL    DIAGNOSIS. 

valves  were  indurated.  Such  cases  are  extremely  rare.  The 
signs  of  an  accompanying  valvular  affection  and  of  enlarge- 
ment of  the  ventricles,  and  the  probable  presence  of  dropsy 
would  serve  to  distinguish  a  dilated  auricle  from  aneurism 
of  the  arch.  And  this  is  the  only  form  of  enlargement  of 
the  heart  which  is  at  all  likely  to  be  mistaken  for  an  aneu- 
rism. In  cases  of  hypertrophy  or  dilatation  as  we  ordinarily 
meet  with  them,  there  is  but  one  motion  discernible — that 
over  the  ventricles — ajid  not  two  beats  at  some  distance  from 
each  other;  the  signs  of  pressure,  too,  are  absent. 

A  pulmonary  artery  surrounded  by  consolidated  lung  tissue 
may  cause — especially  if,  in  addition,  the  vessel  be  somewhat 
widened — a  very  distinct  pulsation.  But  the  seat  of  the 
dulness  at  or  near  the  apex  of  the  left  lung;  its  non-exten- 
sion over  the  median  line  ;  the  limitation  of  the  murmur  to 
the  site  of  the  pulmonary  artery,  or,  in  some  instances,  to 
this  vessel  and  the  subclavian ;  the  sharply-detined  second 
sound  of  the  pulmonary  artery  in  the  second  interspace  on 
the  left  side;  the  symptoms  and  physical  signs  of  phthisis, 
the  most  common  cause  of  the  consolidation  and  a  morbid 
condition  which  of  itself  would  appear  to  exclude  an  aneu- 
rism; the  absence  of  the  phenomena  caused  by  pressure, — 
all  these  prove  the  murmur  and  the  pulsation  not  to  be  due 
to  an  aortic  aneurism. 

Another  abnormal  condition,  which  may  be  mistaken  for 
an  aneurism,  is  a  7nalformaiion  of  the  chest,  particularly  when 
produced  by  great  prominence  of  the  upper  part  of  the 
sternum.  This  error  is  more  specially  apt  to  occur  if  there 
be  coexisting  disturbance  of  the  heart,  whether  of  functional 
or  organic  origin.  I  saw  some  time  since  a  case  where  the 
beating  of  the  arteries  of  the  neck,  accompanied  by  an  en- 
largement of  the  thyroid  gland  and  by  cardiac  palpitation, 
was  believed  to  be  an  aneurism,  mainly  because  it  was  com- 
bined with  very  decided  prominence  of  the  upper  portion 
of  the  sternum.  But  there  were  neither  distinctlv  localized 
tumefaction  and  pulsation,  nor  altered  sounds,  nor  any  signs 
of  pressure. 

The  signs  of  pressure  play,  then,  a  very  important  part  in 
the  diagnosis  of  an  aneurism.     To  those  morbid  states  already 


THORACIC    ANEURISM.  391 

rnentioued,  between  which  they  enable  us  to  discriminate, 
another  may  be  added.  Instances  have  been  recorded  of 
constriction  of  the  aorta  giving  rise  to  a  marked  thrill  at  the 
npper  part  of  the  chest  in  front,  near  the  sternum,  and  a 
murmur  much  louder  there  than  over  the  heart.  The  ab- 
sence of  the  signs  of  pressure,  and  the  throbbing  and  dis- 
tention of  the  vessels  of  the  neck,  head,  and  chest,  of  the 
carotid,  the  subclavian,  the  temporal,  and  the  mammary 
arteries  may  lead  to  the  correct  appreciation  of  such  cases. 

It  is  rarely  that  these  signs  of  pressure  are  absent,  although 
they  do  not  always  manifest  themselves  in  the  same  manner; 
sometimes  it  is  bone,  sometimes  lung,  sometimes  oesophagus, 
sometimes  nervous  fibre  which  bears  the  brunt  of  the  dis- 
tending swelling.  They  are  wanting  if  the  sac  be  very  small, 
and  absent,  or  not  prominent,  if  the  artery  be  simply  dilated, 
in  which  case  nothing  but  a  constantly  pulsating  tumor  can 
be  detected.  Sometimes  evidences  of  compression  may  be 
recognized  by  the  attentive  physician  when  no  throbbing 
swelling  can  be  discerned ;  and  from  them  he  mfers  the  true 
nature  of  the  case,  although  utterly  unable  to  discover  any 
of  the  ordinary  physical  signs  of  an  aneurism.  Whenever, 
indeed,  obstinate  and  anomalous  thoracic  symptoms,  which 
might  be  explained  by  the  presence  of  an  aneurismal  sac, 
occur  in  a  person  whose  lungs  and  heart  appear  to  be  in 
every  respect  sound,  and  whose  general  health  is  not  very 
materially  affected,  we  may  suspect  an  aneurism  to  be  the 
source  of  the  trouble. 

So,  too,  if  any  laryngeal  aftection,  or  if  a  difficulty  in  swal- 
lowing exhibit  rather  peculiar  symptoms.  It  is,  in  'truth, 
proper  in  all  cases  of  chronic  disease  of  the  larynx,  or  where 
there  are  indications  of  a  stricture  of  the  oesophagus,  to  ex- 
amine the  chest  carefully,  so  as  to  avoid  the  grave 'error  of 
overlooking  what  may  be  the  real  and  only  cause  of  the 
whole  disturbance. 

The  symptoms  of  chronic  laryngitis  especially  are  at  tmics 
most  astonishingly  simulated,  and  it  may  happen  that  the 
patient,  trusting  to  his  feelings,  refers  obstinately  to  the 
chest  as  the  seat  of  the  disorder,  while  the  physician  as 
obstinately  sees  nothing  and  treats  nothing  but  the  presumed 


392  MEDICAL    DIAGNOSIS. 

affection  of  the  larynx.  Even  if  we  cannot  discern  any  pul- 
sation, the  following  signs  may  furnish  a  key  to  the  case. 
There  is,  as  in  chronic  laryngeal  disease,  alteration  of  the 
voice,  with  stridor,  and  peculiar  cough  ;  but  the  voice  is  not  so 
uniforral}'  changed.  Often  it  retains  much  of  its  natural  char- 
acter; and  the  loss  is  not  so  progressive,  and  the  aphonia  not 
80  permanent.  Hoarse  the  voice  may  be,  but,  as  the  direc- 
tion of  the  pressure  varies,  it  alters  rapidly  both  in  pitch  and 
power.  The  cough  is  most  commonly  loud  and  paroxysmal,  and 
has  a  ringing  sound.  Dyspnoea  is  a  very  constant  symptom, 
and  is  often  attended  with  wheezing  or  stridulous  breathing, 
which  is  not  persistent,  and  is  sometimes  only  produced  after 
a  deep  inspiration.  The  stridor,  however,  as  Dr.  Stokes 
points  out,  differs  from  that  of  an  obstructive  disease  of  the 
larynx  by  its  seeming  to  issue  from  the  notch  at  the  sternum, 
and  not  from  above,  from  the  larynx  itself.  If,  in  addition, 
the  respiration  be  found  to  be  markedly  unequal  in  the  two 
lungs,  the  diagnosis  of  aneurism  may  be  ventured  upon;  and 
it  will  be  condrmed  by  finding  no  change  in  the  larynx,  when 
examined  with  the  laryngoscope,  sufficient  to  account  for 
the  laryngeal  symptom,  or  a  change,  such  as  one-sided  par- 
alysis of  a  cord,  as  can  be  readily  explained  by  pressure  on 
one  recurrent  nerve.*  Of  course,  the  detection  of  dulness 
on  percussion,  of  sounds  stronger  than  or  otherwise  different 
from  those  in  the  cardiac  region,  or  the  occurrence  of  a  hem- 
orrhage, would  place  the  diagnosis  beyond  doubt. 

In  some  cases  of  aneurism,  pain  is  among  the  earliest 
S}' mptoms,  and  the  patient  complains  much  of  it  before  there 
is  a  single  physical  sign  indicative  of  the  presence  of  a  tumor. 
I  had,  several  years  ago,  a  case  of  this  kind  under  my  care. 
The  patient  suffered  much  from  fugitive  chest  pains,  very 

^ 

*  The  aphonia  iu  aneurism  is  indeed  attributable  to  pressure  on  the  recurrent 
laryngeal  nerve;  and,  as  mentioned  by  Tufnell,  a  stridulous  voice,  unaccom- 
panied by  aphonia  and  dysphagia,  tends  to  show  that  the  tumor  is  on  the 
right  side  of  the  trachea,  and  does  not  affect  the  oesophagus  or  the  recurrent 
laryngeal  nerve.  When  the  aneurism  presses  on  the  trachea  at  its  bifur- 
cation, the  voice  will  be  raucous.  In  a  case  of  aortic  aneurism  recorded  by 
Habershon  (Medico-Chirurg.  Trans.,  1865),  the  aneurism  implicated  the  left 
recurrent  laryngeal  nerve,  and  there  was  atrophy  of  the  muscles  of  the  larynx 
as  well  as  left-sided  pneumonia. 


THORACIC    ANEURISM.  393 

acute  and  violent.  He  bad  at  the  same  time  a  couErh,  but  no 
stridor.  The  respiration  in  both  lungs  was  natural,  and  so 
likewise  was,  as  far  as  could  be  ascertained,  every  part  of  the 
chest.  Dyspnoea  gradually  developed  itself,  and  a  cough  with 
a  metallic  clang  and  stridulous  breathing  appeared,  while  a 
pulsation  became  more  and  more  manifest  immediately  below 
the  notch  of  the  sternum. 

The  pain  is  dependent  upon  pressure  on  the  nervous  fila- 
ments:  it  may  shoot  toward  the  shoulder  or  the  neck,  along 
the  arm,  or  deep  into  the  centre  of  the  chest.  Dull,  deep 
pain,  boring  and  constant,  is  prone  to  occur  when  the  press- 
ure of  the  sac  is  leading  to  absorption  of  the  vertebrae.  Over 
the  seat  of  the  swelling  there  is  often  pain,  associated  with 
great  tenderness. 

The  severity  of  the  pain  may  give  rise  to  emaciation  and 
exhaustion,  and  become  a  cause  of  death ;  hut  death  does  not 
often  take  place  from  exhaustion.  More  usually  the  patient's 
life  is  cut  short  b}'^  the  aneurism  bursting,  either  exter- 
nally or  into  internal  parts — into  the  trachea,  bronchial  tubes, 
oesophagus,  pericardium,  pleura,  pulmonary  artery,  or  spinal 
canal.  Yet  it  is  not  always  the  first  rent  which  leads  to  the 
fatal  issue. 

Now,  can  we  foretell  the  course  of  an  aneurism,  and  the 
probable  mode  of  death  it  is  likely  to  occasion  ?  We  cannot ; 
for  in  order  to  do  so,  it  would  be  requisite  to  determine  ac- 
curately its  seat,  so  as  to  know  what  tissues  are  likely  to  be 
encroached  upon.  And  this  is  very  difiScult,  nay,  often  im- 
possible. It  is  true  that,  when  the  swelling  gives  rise  to  phe- 
nomena like  those  of  angina  pectoris,  we  may  surmise  it  to 
be  in  the  ascending  portion  of  the  aorta  and  near  the  cardiac 
plexus  of  nerves,  and  look  for  its  breaking  into  the  pericar- 
dium or  pulmonary  artery;  when  it  is  accompanied  by  laryn- 
geal stridor  or  other  laryngeal  symptoms,  it  very  probably 
involves  the  posterior  and  lower  portions  of  the  arch,  and 
will  cause  death  by  strangulation  or  exhaustion  ;  when  it  pro- 
duces much  dyspnoea,  it  is  apt  to  be  seated  in  the  descending 
part  of  the  arch,  and  death  may  take  place,  by  the  aneurism 
bursting  into  a  bronchial  tube,  or  by  pneumonia.  But  in 
regard  to  all  these  matters,  we  can  usually  do  little  else  than 


394  MEDICAL    DIAGNOSIS. 

conjecture,  because  a  tumor  within  the  chest  leads  to  such 
displacements  that  its  relations  to  the  surrounding  structures 
cannot  be  clearly  ascertained  during  life.  The  most  valuable 
information  we  obtain  is  from  a  study  of  the  physiological 
changes,  from  the  symptoms,  therefore,  of  disturbed  function  ; 
indeed,  the  correctness  of  our  conclusions  will  depend  almost 
entirely  on  that  of  our  interpretation  of  these  symptoms. 

An  aneurism  of  the  descending  aorta,  between  the  arch  and 
the  diaphragm,  produces,  if  extensive,  dulness  on  percussion 
and  bulging  posteriorly,  and  may  exhibit  the  same  physical 
signs  and  sj^mptoms  as  an  aneurism  in  the  neighborhood  of 
the  arch.  A  gnawing  sensation  in  the  vertebras  has  been 
especially  noticed.  Yet,  in  spite  of  the  most  careful  scrutiny, 
an  aneurism  of  the  descending  aorta  often  escapes  detection, 
or  its  physical  signs,  as  a  case  recorded  by  Walshe*  proves, 
may  exist  to  the  right,  instead  of  to  the  left  of  the  spinal 
column,  because  the  vessel  has  been  dragged  across  the  me- 
dian line  by  its  enlargement,  and  thus  very  considerable 
doubt  may  be  thrown  upon  the  diagnosis. 

Let  us,  in  conclusion,  glance  at  the  other  kinds  of  aneurism 
within  the  thorax — that  of  the  innominate  and  of  the  pul- 
monary artery. 

An  aneurism  of  the  innominate  artery  is  strictly  limited  to 
the  right  side  of  the  body.  It  ditfers  from  that  of  the  arch 
by  the  higher  situation  of  the  pulsating  swelling;  by  the  dis- 
placement of  the  clavicle;  the  comparative  absence  of  signs 
of  pressure  on  the  larynx  and  oesophagus ;  and  by  the  fact 
that  compression  of  the  right  subclavian  and  carotid  dimin- 
ishes the  beat  of  the  tumor,  while  it  exerts  no  effect  on  an 
aortic  aneurism.  Such  are,  at  all  events,  the  marks  of  dis- 
tinction which  are  indicated  by  the  observations  in  Dr.  IIol- 
laud'sf  excellent  memoir. 

An  aneurism  of  the  'pulmonary  artery  is  a  very  rare  disease. 
Its  main  phenomena,  so  far  as  the  few  cases  which  have  been 
placed  on  record  enable  us  to  judge,  are:  a  strongly  pulsating 
swelling,  perceptible  to  the  left  of  the  sternum,  and  limited 
to  the  second  intercostal  space  near  the  costal  cartilages ;  a 

*  Diseases  of  the  Heart. 

I  Dublin  Quarterly  Journal,  vol.  xii. 


THORACIC   ANEURISM.  395 

very  marked  thrill  occurring  with  each  expansion  of  the 
aneurism  ;  and  in  some  instances  a  rougli  muimur,  which  is 
not  discovered  at  the  notch  of  the  sternum  or  above  the  clav- 
icles ;  lividity  of  face ;  dropsy  ;  and  very  great  difficulty  of 
breathing.*  The  most  significant  points  of  difference  be- 
tween an  aneurism  of  the  pulmonary  artery  and  of  the  aorta 
consist  in  the  symptoms  just  alluded  to,  and  in  the  absence 
of  obvious  evidences  of  pressure.  The  situation,  too,  of  the 
physical  phenomena  is  important ;  but  we  must  bear  in  mind 
tliat  an  aneurism  of  the  arch  may  occasion  a  pulsating  tumor, 
mainly  to  the  left  of  the  sternum.  A  mere  distinct  beating 
of  the  pulmonary  artery  is  discriminated  from  an  aneurism 
by  the  non-existence  of  a  palpable  swelling,  of  dropsy,  or  of 
lividity  of  the  face,  and  by  the  usually  coexisting  signs  of 
consolidation  of  the  lung  texture. 


*  In  the  case  detailed  by  Skoda  (Auscultation  and  Percussion),  the  dropsy- 
was  very  great,  and  the  face  cyanotic;  there  was  a  faint  murmur  over  the 
base  of  the  heart,  but  none  over  the  pulmonary  artery. 


CHAPTER  V. 

DISEASES    OF    THE    MOUTH,    PHARYNX,    AND   (ESOPHAGUS. 

The  diseases  of  this  part  of  the  digestive  system  need  not 
here  be  described  at  any  length,  because  many  of  them  have 
ah-eady  been  considered  in  treating  of  the  aftections  of  the 
larynx,  and  of  the  heart  and  great  vessels. 

MOUTH. 

Soreness  of  the  month,  pain  in  masticating,  and  a  fetid 
breath  are  usually  complained  of  in  diseases  of  the  oral 
cavity.  Let  us  suppose  a  patient  to  present  himself  with 
such  symptoms ;  the  interior  of  the  mouth  is  exposed  to  a 
strong  light,  and  its  diflerent  parts  inspected. 

The  gums  are  noticed  to  he  swollen  and  injected^  and  the  mucous 
membrane  lining  the  cheeks  reddened. — This  is  a  state  of  things 
observed  in  the  different  forms  of  stomatitis.  In  the  common 
diffused  inflammation,  be  it  the  result  of  direct  irritation, 
such  as  the  swallowing  of  hot  liquids  or  of  corrosive  sub- 
stances, or  an  accompaniment  and  consequence,  as  it  so  often 
is,  of  gastric  disorder,  the  redness  is  very  marked ;  any 
attempt  at  chewing  is  painful ;  the  taste  is  impaired  ;  and  not 
unfrequently  a  flow  of  saliva  takes  place  from  the  mouth, 
and  superficial  ulcerations  occur  at  its  various  parts.  In 
mercurial  stomatitis  there  are  much  the  same  sjmiptoms  ;  but 
the  more  copious  discharge  of  saliva  ;  the  pain  in  the  jaws ; 
the  loosening  of  the  teeth ;  the  enlarged  tongue,  exhibiting 
their  impress;  the  painful  and  swollen  state  of  the  salivary- 
glands;  and,  above  all,  the  peculiar  nauseous  breath,  testif}' 
to  the  specific  character  of  the  inflammation.  The  sore 
mouth  of  scurvy  may  be  distinguished  from  either  of  the 
preceding  forms  by  the  spongy,  purplish,  or  livid  gums, 
which  bleed  on  the  slightest  touch ;  by  the  eruption  on  the 
(396) 


DISEASES    OF    THE    MOUTH.  397 

skin,  and  the  other  signs  which  attend  a  scorhutic  state  of 
system. 

The  gums  and  the  inside  of  the  cheeks  and  lips  are  covered  with 
a  whitish  curd-like  exudation. — This  is  especially  noticed  in 
children.  It  constitutes  the  form  of  stomatitis  known  as 
"  thrush,"  so  frequent  in  infants  at  the  breast,  and  so  con- 
stantly associated  with  intestinal  disorder,  with  diarrhoea, 
with  colicky  pains,  and  not  unusually  with  a  feverish  heat  of 
skin  and  a  hot,  dry  mouth.  Very  similar  to  it,  regarded 
indeed  by  some  as  identical,  is  the  aphthous  ulceration,  to 
which  adults  as  well  as  children  are  liable.  Here,  too,  a 
whitish  deposit  is  perceived  in  various  parts  of  the  mouth ; 
it  is  apt  also  to  be  combined  with  gastric  or  intestinal  dis- 
turbance. The  recognized  difference  consists  in  the  presence 
of  the  small  ulcers  which  may  be  detected  when  the  white 
crusts  that  cover  them  are  removed,  and  in  the  vesicular 
nature  of  the  disease  during  its  formative  stage.  Then  the 
grayish  covering  of  the  ulcers  in  aphtha3  is  found  to  be  sol- 
uble in  ether,  and  to  present  many  oil  globules  under  the 
microscope.  On  the  other  hand,  this  instrument  shows  us  in 
thrush  a  special  parasitic  formation,  the  oidium  albicans. 

Ulcerations  are  perceived  on  the  gums,  tongue,  and  various  jmrts 
of  the  mouth. — We  meet  with  ulcers  in  the  ordinary,  in  the 
mercurial,  in  the  scorbutic,  and  in  the  aphthous  inflammation 
of  the  mouth.  But  ulceration  is  apt  to  show  its  most  hor- 
rible features  in  the  sore  mouth  which  follows  in  the  train 
of  syphilis,  and  in  that  essentially  ulcerative  disease  called 
canker,  cancrum  oris,  or  ulcerative  stomatitis.  In  the  for- 
mer, the  fauces  as  well  as  the  mouth  are,  as  a  general  rule, 
chiefly  involved,  and  the  ulcers  exhibit  peculiarities  which 
we  shall  presently  study.  The  latter  is  an  affection  which 
prevails  especially  among  the  poor,  and  in  enfeebled  consti- 
tutions. It  is  seen  chiefly  in  hospitals,  and  not  uncommonly 
in  epidemics.  It  begins  with  pain  in  the  gums,  and  these 
soon  swell,  redden,  and  bleed  most  readily.  They  are  cov- 
ered with  a  soft,  grayish  exudation,  which  is,  however,  not 
limited  to  them,  but  often  extends  to  the  soft  palate.  If  the 
layer  of  exudation  be  scraped  away,  a  bleeding,  ulcerated 
mucous  membrane  comes  into  view,  provided  the  swelling 


398  MEDICAL    DIAUNOSIS. 

be  not  so  ofreat  as  to  render  a  careful  examination  of  the 
mouth  impossible.  The  breath  is  most  offensive ;  there  is 
usually  fever;  yet  the  disease  does  not  progress  uniformly 
with  activity.  It  may  last  for  weeks,  or  even  for  months. 
Owino-  to  the  ulceration  and  to  the  extreme  fetor  of  the 
breath,  it  is  often  mistaken  for  gangrene  of  the  mouth.  But 
although  it  may  terminate  in  gangrene,  it  does  not  do  so  of 
necessity.  It  is  a  far  less  serious  complaint,  runs  a  less  speedy 
course,  presents  a  breath  fetid  it  is  true,  but  not  of  the  pecu- 
liar gangrenous  odor,  and  lacks  the  very  symptoms  which 
gangrene  within  the  mouth  gives  rise  to — the  rapid  extension 
of  the  ulceration;  the  dark-gray  tint  around  it ;  the  extensive 
swelling  of  the  cheek;  its  altered  color  and  partial  destruc- 
tion; the  constant  and  profuse  flow  from  the  mouth  of  blood 
or  pus  mixed  with  saliva;  and  the  laying  bare  of  the  bones 
and  loosening  of  the  teeth. 

The  tongue  is  red  and  swollen.  —  Changes  in  color  and  in 
appearance  of  the  tongue  are  very  common,  not  because  the 
tongue  is  often  diseased,  but  because  it  acts  as  an  index  to 
the  condition  of  the  system,  and  especially  to  the  alimentary 
canal.  It  is  also  more  or  less  involved,  or  at  all  events  its 
mucous  membrane  is,  in  the  diiierent  forms  of  stomatitis. 
An  abnormal  state  of  the  covering  of  the  tongue  is,  there- 
fore, far  from  being  a  sign  that  the  organ  itself  is  primarily 
affected. 

Occasionally,  however,  we  do  meet  with  diseases  of  its 
deeper  structures.  Its  nerves  may  be  the  seat  of  violent  neu- 
ralgia; its  muscles  may  be  paralyzed;  it  may  have  become 
hypertrophied  or  cancerous ;  it  may  undergo  progressive 
muscular  atrophy  ;  or  it  may  be  in  a  state  of  acute  inflamma- 
tion. The  latter  is,  perhaps,  the  most  frequent  of  its  mala- 
dies, and  is  readily  recognized  by  the  red,  swollen  look  of 
the  organ,  joined  to  a  burning  pain  in  it,  and  either  to  great 
dryness  of  the  mouth  or  to  a  constant  dribbling  of  saliva. 
The  swelling  usually  commences  at  the  anterior  portion,  and 
may  become  so  considerable  as  to  threaten  suflbcation ;  the 
inflamed  tongue  Alls  up  the  fauces  and  protrudes  out  of  the 
mouth,  and  the  unhappy  patient  can  neither  swallow  nor 
utter  a  word.     He  has  active  fever,  headache,  great  restless- 


DISEASES    OF    THE    MOUTH.  399 

ness,  and  intense  thirst,  which  symptoms  last  for  several 
days,  and  until  the  inflammation  subsides.  But  unless  prop- 
erly treated,  and  sometimes  in  spite  of  proper  treatment,  the 
inflammation  is  very  likely  not  to  end  in  resolution,  but  runs 
on  to  suppuration  or  gangrene.  In  some  instances,  it  leaves 
a  permanent  induration,  which  may  be  mistaken  for  a  can- 
cerous nodule.  Acute  glossitis  is  alwaj^s  a  dangerous  com- 
plaint;  fortunately,  it  is  not  a  common  one.  Its  most  fre- 
quent cause,  as  now  seen,  is  direct  injury,  either  from  wounds 
or  the  stings  of  venomous  insects,  or  from  the  introduction 
of  corrosive  substances  into  the  mouth.  Its  most  frequent 
cause  formerly  was  the  abuse  of  mercury  pushed  to  saliva- 
tion. It  is  at  times  observed  as  a  complication  of  scarlatina 
or  of  erysipelas. 

FAUCES. 

The  fauces — that  is,  the  different  parts  at  the  back  of  the 
mouth  which  are  brought  into  view  when  the  lips  are  widely 
opened,  such  as  the  half  arches,  the  uvula,  the  tonsils,  the 
posterior  wall  of  the  pharynx — may  be  involved  in  the  same 
diseases  as  the  parts  situated  in  front.  The  contiguity  of 
these  structures  is  in  tact  such  that  any  morbid  action  is 
very  apt  to  spread  to  them,  or,  on  the  other  hand,  to  extend 
from  them  either  forward  or  downward  into  the  pharynx, 
and  even  into  the  larynx.  Moreover,  on  this  very  account  a 
disorder  is  rarely  found  limited  to  any  one  portion  of  the 
fauces,  but  transfers  itself  generally  from  one  to  the  other, 
from  the  tonsils  to  the  soft  palate,  from  the  soft  palate  to  the 
tonsils.  The  most  common  affections  of  the  fauces  are  in- 
flammation and  ulceration,  both  of  which  occasion  a  feeling 
of  uneasiness  in  the  throat,  and  also  difliculty  or  pain  in  de- 
glutition, and  both  of  which  are  readily  enough  detected  by 
looking  into  the  mouth  Avhen  the  jaws  are  widely  separated 
and  the  tongue  depressed. 

In  the  ordinary  inflammation  of  the  fauces,  the  simjile 
angina,  or  sore  throat,  the  parts  are  of  a  bright-red  color,  the 
uvula  is  long  and  swollen,  and  by  dropping  on  the  tongue 
gives  rise  to  a  constant  disposition  to  swallow,  although  the 
act  of  swallowing  is  attended  with  pain.     Associated  with 


400  MEDICAL    DIAGNOSIS. 

the  angina  are  ^coryza  and  febrile  disturbance;  and,  owing 
to  the  inflammation  travelling  up  the  Eustachian  tube,  the 
sense  of  hearing  is  impaired. 

The  same  symptoms  are  observed  in  the  'pseudomembranous 
inflammation  of  the  fauces ;  but  in  this  dangerous  complaint, 
instead  of  the  viscid  mucus  which  lines  the  membrane  in 
the  simple  form  of  sore  throat,  we  find  patches  of  fibrinous 
exudation-matter;  the  discharges  from  the  mouth  and  nos- 
trils are  fetid;  there  is,  as  when  describing  diphtheria  we 
shall  make  apparent,  a  tendency  to  great  prostration,  and 
not  unfrequently  to  an  extension  of  the  affection  toward 
the  windpipe. 

Tonsillitis. — When  the  inflammation  penetrates  into  the 
substance  of  the  tonsils,  occasioning  the  disease  popularly 
known  as  quinsy,  much  the  same  general  symptoms  occur  as 
in  ordinary  angina.  But  the  sense  of  constriction  in  the 
throat  is  greater,  so  is  the  difiiculty  in  swallowing ;  and 
liquids  are  apt  to  return  through  the  nose.  The  voice  is 
thick,  and  has  often  a  peculiar  sound;  it  is  painful  to  the 
patient  to  talk,  and  on  looking  into  the  throat,  the  tonsils 
may  be  seen  red  and  prominent  and  covered  with  mucus, 
which  is  not  easily  detached.  Sometimes  the  swelling  is  so 
considerable  that  the  tumid  glands  fill  up  the  space  between 
the  half  arches,  and  leave  but  a  small  interval  for  the  pas- 
sage of  food  or  drink.  In  some  instances,  w^e  cannot  sepa- 
rate the  jaws  sufliciently  to  get  a  view  of  the  throat,  and 
have  to  trust  to  the  introduction  of  the  finger  to  tell  us 
what  is  the  condition  of  the  aflected  parts.  Occasionally  the 
inflammation  extends  from  the  tonsils  to  the  salivary  glands; 
the  submaxillary  and  parotid  glands  swell,  and  ptyalism  takes 
place.  It  is  necessary  to  be  aware  of  this  fact,  for  if  a  mer- 
curial cathartic  has  been  administered,  the  profuse  flow^  of 
saliva  might  be  incorrectly  attributed  to  it.  ^ 

There  is  not  much  likelihood  of  confounding  this  secondary 
parotitis  with  mumps,  in  which  an  outward  swelling,  visible 
beneath  the  ear,  is  found,  but  not  a  swelling  within  the 
throat,  and  in  Avhich  no  real  difiiculty  in  swallowing  occurs, 
except,  perhaps,  when  the  tumefaction  is  at  its  height.  This 
comparative  absence  of  difficulty  in  deglutition,  added  to  the 


DISEASES    OF    THE    iMOUTH.  401 

tension,  fulness,  and  soreness  at  the  angles  of  the  jaw,  the 
pain  felt  there,  the  almost  impossible  mastication,  tlio  ]iurelv 
external  character  of  the  tumefaction,  and  the  febrile  excite- 
ment and  disfigured  face,  are  indeed  the  signs  by  which  paro- 
titis is  generally  at  once  distinguished  from  any  of  the  morbid 
states  which  resemble  it. 

Tonsillitis  terminates  by  resolution  or  by  the  formation  of 
pus.  There  are  no  positive  means  of  ascertaining  that  the 
inflammation  is  going  to  end  in  suppuration,  although  we 
may  suspect  that  this  will  be  the  case  when  much  pain  is 
felt  at  the  angles  of  the  jaws  and  shooting  to  tlie  ear;  and 
when  the  symptoms  have  been  severe  and  persistent  for  more 
than  four  or  five  days.  Sometimes  the  pus  may  be  seen 
through  the  covering  of  the  tonsils ;  but  often  tlie  vast  sense 
of  relief  experienced  by  the  patient,  and  the  sudden  improve- 
ment in  deglutition,  attended,  perhaps,  with  an  unpleasant 
taste,  are  the  only  signs  that  the  collection  of  pus  has  been 
discharged.  Attacks  of  tonsillitis  are  very  prone  to  be  re- 
peated, and  may  lead  to  permanent  enlargement  and  indura- 
tion of  the  tonsils. 

Diphtheria. — There  is  another  kind  of  inflammation  of 
tlie  iauces  whicli,  in  obedience  to  the  clinical  classiflcation  of 
disease  followed  in  this  work,  may  be  fittingly  here  considered 
— membranous  angina  or  diphtheria.  Not  that  it  is  really  a 
purely  local  malady.  Ofi  the  contrary,  it  is  a  general  disease, 
of  which  the  exudative  inflammation  of  the  throat  is  merel}' 
the  most  usual  characteristic.  Yet  the  local  lesion  is  so 
marked,  and  the  symptoms  are  so  nearl}-  related  to  those 
of  the  common  forms  of  acute  sore  throat,  that  practically  the 
diphtheritic  disorder  is  best  regarded  in  connection  with  them. 

Diphtheria  is  an  affection  of  remote  antiquity,  which  had 
to  a  great  extent  disappeared  from  view,  but  which  in  our 
generation  is  again  extending  over  all  portions  of  the  globe. 
Let  us  in  a  cursory  manner  view  its  symptoms. 

It  begins  usually  as  an  ordinary  sore  throat,  with  redness 
and  swelling  of  the  arches  of  the  [)alate,  and  of  the  tonsils. 
There  is  a  slight  stiffness  of  the  neck,  and  the  glands  at  the 
angles  of  the  jaw  are  enlarged  and  tender.  AVitliin  a  period 
varying  from  a  few  hours  to  a  few  day.-^,  an   exudation   takes 

26 


402  MEDICAL    DIAGNOSIS. 

place  on  tlie  tonsils,  uvula,  and  the  soft  palate.  This  exuda- 
tion is  more  or  less  extensive,  generally  tough,  and  of  a  white 
or  grayish  hue.  It  may  show  but  little  tendency  to  spread; 
or  it  may  extend  to  the  gums  and  along  the  walls  of  the 
pharynx,  and  into  the  windpipe.  In  some  cases  it  passes  up- 
ward into  the  nares;  yet  it  may  commence  there  simultane- 
ously with  its  appearance  in  the  throat.  The  false  membrane 
once  formed,  darkens,  wastes  from  the  circumference  toward 
the  centre,  and  gradually  disappears.  But  sometimes  the 
coat  becomes  for  a  time  thicker  and  thicker  by  the  constant 
addition  of  fresh  laj'ers.  When  artificially  removed,  it  is 
soon  redeveloped.  After  the  first  week  from  its  beginning, 
however,  no  further  exudation  is  apt  to  occur,  and  the  danger 
arising  from  the  membrane  may  be  looked  upon  as  over. 

The  constitutional  symptoms  vary  greatly  in  different  cases. 
The  pulse  may  be  frequent,  the  skin  hot,  there  may  be  much 
pain  in  the  head;  in  fact,  the  symptoms  are  those  of  asthenic 
fever.  But  generally  there  is  little  febrile  excitement,  a  sense 
of  weakness  and  prostration  being  prominent  from  the  onset. 
In  some  instances,  real  typhoid  phenomena  show  themselves; 
and  the  more  asthenic  the  disorder,  the  more  apt  is  the 
exudation  to  be  pulpy  and  granular. 

In  diphtheria  the  danger  is  twofold :  it  arises  partly  from 
the  depressing  effect  of  the  poison,  increased  as  this  effect 
may  be  by  the  absorption  of  putrid  matter  from  the  throat; 
partly  from  the  extension  of  the  disease  to  the  larynx  and 
lunffs.*  I^or  is  the  termination  of  the  acute  disorder  alwavs 
the  termination  of  the  complaint.  A  chronic  irritation  of 
the  throat,  lasting  weeks  or  months,  and  possibly  relapsing, 
under  exposure,  into  a  diphtheritic  sore  throat,  remains  ;  or 
albuminuria,  which,  indeed,  shows  itself  during  the  height 
of  the  malady,  but  which  also  outlasts  its  acute  manifesta- 
tions; or  bronchitis  and  pneumonia — both  of  which  may  be 
delayed  until  after  the  exudation  has  disappeared  from  the 
throat — increase  the  list  of  the  complications  of  the  affection, 
and  protract  or  imperil  the  convalescence.     And  there  are 

*  In  some  cases  death  seems  to  be  due  to  the  formatidii   of  heart-clots. 
John  F.  Meigs,  Am.  Journ.  of  Med.  Sci.,  April,  18G4. 


DISEASES    OF    THE    MOUTH.  403 

morbid  conditions  which  may  be  whoUj'  looked  upon  as 
after-symptoms.  A  paralysis  of  the  velum,  palate,  and 
pharyngeal  arches,  making-  itself  apparent  by  a  peculiar 
nasal  intonation  of  the  voice,  and  by  a  proneness  to  regurgi- 
tation of  fluids  through  the  nostrils,  is  among  the  earliest 
of  them.  Later  appear  impairment  of  vision,  gastrodynia, 
ulcers  in  various  parts  of  the  body,  profound  anfemia,  and 
that  gradual  failing  of  muscular  power,  with  numbness  and 
increasing  weakness,  which  ordinarily  does  not  take  place 
until  after  complete  convalescence,  and  which  winds  up  in 
almost  total,  although  not  irremediable  loss  of  muscular  force, 
— in  fact,  in  diphtheritic  paralysis. 

ITow,  all  these  facts  go  to  indicate  the  malignant  character 
of  the  disease,  and  how  essential  it  is,  even  while  the  malady 
is  in  its  acute  stage,  to  counteract,  by  nourishment  and  stim- 
ulants, the  depressing  effect  of  the  poison;  how  essential  to 
continue  the  treatment  long  after  the  throat  affection  has 
been  removed. 

But  to  look  at  the  differential  diagnosis  of  the  disorder. 
It  varies  widely  from  stomatitis,  from  tonsillitis,  from  phar- 
yngitis— in  truth,  from  all  the  ordinary  local  inflammations 
of  these  structures — by  the  presence  of  a  membrane,  by  the 
striking  constitutional  symptoms,  and  by  the  scquelfe. 

Yet  there  are  certain  sources  of  error  which  it  is  necessary 
to  be  on  our  guard  against.  In  simple  pharyngitis  a  mass  of 
mucus,  in  part  derived  from  the  nares,  is  apt  to  collect  on 
the  inflamed  membrane,  and  looks  at  first  sight  like  the 
coating  from  an  exudation  ;  but  it  may  be  very  easily  re- 
moved, and  a  closer  inspection  proves  its  true  nature.  In 
tonsillitis,  little  yellowish  or  whitish  points  form  at  the  open- 
ing of  the  follicles  on  the  surface  of  the  swollen  tonsils.  But 
they  are  very  limited,  are  strictly  contined  to  the  gland,  ex- 
hibit no  tendency  to  spread  or  to  coalesce,  are  generally 
small  white  specks  of  roundish  or  oval  shape,  and  when 
cast  off,  a  superficial  ulceration  is  seen  on  the  gland.  I  de- 
sire particularly  to  call  attention  to  the  possibility  of  con- 
founding these  appearances,  which  are  by  no  means  uncom- 
mon in  tonsillitis,  with  diphtheria,  for  I  have  known  them 
to  have  occasioned  more  than  one  mistake.     Should,  in  an 


404  MEDICAL   DIAGNOSIS. 

individual  cam,  tlie  facts  mentioned  be  insufficient  to  solve 
the  doubt,  the  microscope  can  do  so  readily,  for  it  shows  the 
Avhite  masses  to  be  largely  composed  of  epithelium,  and  not, 
like  the  diphtheritic  membrane,  mainly  of  iibrillated  iibrin, 
of  granular  corpuscles,  and  of  pus. 

Ulcerative  stomatitis,  the  form  of  stomatitis  most  likely  to 
be  confounded  with  diphtheria,  and  especially  with  this  mal- 
ady when  the  exudation  lines  the  gums,  is  discriminated  by 
the  ulceration  or  sloughing;  whereas  the  mucous  membrane 
in  the  pseudomembranous  disease  remains  intact,  save  in 
the  rarest  instances.  The  same  feature  distinguishes  diph- 
theria from  gangrene  of  the  mouth,  for  which,  on  account 
of  the  extreme  fetor  of  the  breath,  it  is  sometimes  mis- 
taken, and  aids  in  distino-uishino-  also  from  other  kinds  of 
stoniatitis,  as  from  thrush.  Then  here,  too,  the  buccal  mucous 
membrane,  and  not  the  throat,  is  chielly  atfected,  and  the 
abdominal  symptoms,  and  the  other  constitutional  phenom- 
ena, are  so  different.  So  are  they  in  aphthae,  in  which,  more- 
over, the  superficial  ulcerations,  the  pustules,  and  the  seat  of 
the  disorder — usuallv  on  the  edsj-e  of  the  tono-ue,  on  the  in- 
ternal  surface  of  the  lips,  and  on  the  gums  and  inside  of  the 
cheek — are  points  to  be  taken  into  account. 

Besides  these  atiections,  there  are  others  which  must  be 
distinguished  from  diphtheria.  We  occasionally  find  cases 
occurring  in  epidemics,  and  where  the  membrane  is  limited 
nearly  altogether  to  the  follicles,  and  chiefly  to  the  tonsils. 
As  the  membrane  passes  away,  ulcerations  are  obvious. 
Swelling  of  the  glands  of  the  neck,  and  fever,  but  not  of  acute 
type,  attend  this  ulcero-membrai'ioiis  angina,  which,  moreover, 
shows  a  strong  disposition  to  relapses.  But  though  kindred  to 
diphtheria,  and  in  isolated  instances  perhaps  difficult  to  dis- 
criminate, it  clifi'ers  from  it  in  its  seat  and  want  of  tendency 
to  spread,  in  the  formation  of  superficial  ulcers,  its  less  marked 
constitutional  depression,  and  its  invariably  favorable  termi- 
nation.* Whether  there  are  not  also  other  kinds  of  nieni- 
branous  sore  throat  to  be  separated  from  true  diphtheria,  is 
a  matter  requiring  further  investigation. 


*  See  a  pa|ior,  in  wliitli  I  luive  described  an  epideiiiio  of  the  Iciiul,  in  the 
Am.  Jtnirn.  of  Mod.  Sciences,  July,  1870. 


DISEASES    OF    THE    MOUTH.  405 

There  is  an  acute  disease  of  the  throat  to  which  Dr.  Todd, 
among  others,  has  called  attention,*  and  which  presents  also 
some  strong  points  of  similitude  to  diphtheria — erysipelas  of 
the  fauces.  Like  diphtheria,  it  is  a  most  dangerous  ailment; 
as  in  diphtheria,  the  morbid  process  may  extend  to  the 
larj'nx;  as  happens  often  in  diphtheria,  the  mucous  mem- 
brane may  exhibit  a  peculiar  dusky-red  color;  as  in  diph- 
theria, the  poison  paralyzes  the  muscles  of  the  palate  and 
pharynx,  and  liquids  are  apt  to  be  rejected  through  the 
nostrils  and  mouth.  But  the  difficulty  in  deglutition  differs 
from  that  of  diphtheria  in  being  present  from  the  onset;  and 
is  not  attended  with  enlargement  of  the  glands  of  the  neck, 
nor  with  the  formation  of  a  false  membrane.  In  some  in- 
stances, too,  we  find  vivid  redness  of  the  throat,  which  may 
be  associated  with  much  swelling.  If  the  erysipelatous  in- 
flammation extend  to  the  larynx,  there  is  local  pain,  with 
urgent  dyspnoea  and  hoarseness ;  and  usually  rapid  exhaus- 
tion supervenes.  In  cases  of  this  kind,  the  submucous  tissues 
of  the  larynx  are  found  extensivelj'  infiltrated  with  pus.  They 
may  happen  without  erysipelas  showing  itself  on  any  external 
part  of  the  body ;  on  the  other  hand,  erysipelas  beginning 
in  the  fauces  ma}'  spread  to  the  face.f 

This  erysipelas  of  the  fauces  is  nota  very  frequent  disease; 
and  it  must  be  stated  that  there  are  cases  of  diphtheria  which 
simulate  it  very  closely.  I  have  seen  a  number  of  instances 
of  the  malady  in  which  the  whole  mucous  membrane  was  of  a 
vivid  or  dusky  hue ;  in  which  there  was  much  swelling  with 
an  effusion  of  serum,  especially  in  the  submucous  tissue  of 
tlie  uvula,  causing  it  to  look  like  a  small  transparent  bag;  in 
which  immense  difficulty  or  even  impossibility  in  degluti- 
tion existed, — yet  in  which  no  membrane  appeared  for  days 
after  the  violent  inflammation  of  the  throat,  and  was,  when 
it  showed  itself,  very  slight  in  extent,  and  out  of  all  i)ropor- 
tion  to  the  inflammation.  But  the  constitutional  symptoms 
and  the  sequelae  were  the  same  as  those  of  ordinary  diph- 
theria.    In  one  of  the  cases  of  the  kind  referred  to,  suppura- 


*  Clinical  Lectures  on  Acute  Diseases. 

f  Cases  quoted  in  Schmidt's  Jahrl).,  1869,  No.  1. 


406  MEDICAL    DIAGNOSIS. 

tion  of  one  of  .the  tonsils  took  place  in  consequence  of  the 
inflammation  ;  a  layer  of  deposit  had  coated  parts  of  the 
tonsils  and  of  the  half  arches  and  uvula. 

How  shall  we  separate  diphtheria  from  me-nbraiious  croup, 
a  disease  with  which,  indeed,  it  is  by  some  regarded  as  iden- 
tical ?  Yet  this  is  taking  a  narrow  view  of  the  facts.  In  the 
first  place,  croup  is  a  purel}^  local  complaint,  and  lacks  the 
peculiar  constitutional  symptoms  and  sequelse  of  diphtheria. 
Secondly,  an  affection  of  the  windpipe  is  not  by  any  means 
an  essential  element  of  diphtheria,  for  in  the  majority  of 
cases  the  disease  does  not  spread  to  the  larynx.  Thirdly, 
when,  by  the  paroxysms  of  irritative  cough,  the  disturbed 
breathing,  the  huskiness  or  extinction  of  voice,  we  may  infer 
that  the  exudative  inflammation  has  reached  the  larynx; 
wlien,  in  other  words,  the  symptoms  of  croup  arise,  the  first 
manifestations  of  the  membranous  affection  are  perceived 
in  the  throat,  and  not  in  the  larynx.  To  sum  up:  pseudo- 
membranous angina  aflects  primarily  the  throat,  and  may 
extend  to  the  Avindpipe;  pseudomembranous  croup  affects 
primarily  the  windpipe,  and  may  extend  to  the  throat. 

Lastly,  diphtheria  may  be  confounded  with  scarlatina. 
When,  indeed,  we  reflect  on  the  similar  appearance  of  the 
throat,  on  the  occurrence  of  albuminuria  in  both  maladies, 
and  on  the  frequency  with  which  both  are  found  at  the  same 
time  to  prevail  as  epidemics  in  a  community,  it  is  not  aston- 
ishing that  one  should  be  looked  upon  as  but  a  modified 
form  of  the  other.  Allied  they  certainly  are,  but  not  iden- 
tical ;  for  the  poison  of  one  leads  to  a  thoroughly  defined 
rash,  and  leaves  a  protective  influence  against  a  second  at- 
tack, but  often  also  deafness,  suppuration  of  the  glands  of  the 
neck,  and  dropsy — phenomena  which  are  not  encountered  in 
the  other.  Moreover,  the  exudation  in  the  throat  is  not  ex- 
actly similar  in  the  two  diseases.  In  scarlatina  it  is  pulta- 
ceous,  and  not  coherent,  and  has  no  tendency  to  spread  to 
the  respiratory  passages.  Then  the  albuminuria  happens  at 
a  difterent  period.  In  scarlatina  it  is  a  sequel  rather  than  a 
concomitant;  in  diphtheria  it  is  a  concomitant  rather  than 
a  sequel.     Further,  the  gravity  of  the  symptom  is  not  the 


DISEASES    OF    THE    MOUTH.  407 

same.  In  the  Latter  malady,  it  is  an  indication  of  danger ;  it 
has  not  so  serious  a  meaning  in  the  former. 

Diphtheria  may  be  intercurrent  in  various  mahidies:  in 
typhoid  fever,  in  the  exanthemata,  in  pneumonia.  Nor  is 
the  exudation  always  restricted  to  the  throat.  It  may  show 
itself  in  a  wound  or  on  excoriated  skin,  on  the  nasal  mu- 
cous membrane,  the  conjunctiva,  the  nipple,  the  uvula,  or 
around  the  anus;  it  may  be  found  coating  the  stomach,  the 
intestines,  and  the  ramifications  of  the  bronchial  tubes.* 

Nasal  diphtheria  is  a  serious  form  of  the  malady;  it  may 
either  be  present  alone,  or  coexist  with  a  deposit  in  the  fauces 
and  pharynx.  In  the  latter  case,  particularly,  must  it  be 
looked  upon  as  verj^  grave.  It  generally  occuis  with  symp- 
toms of  a  low  type,  and  we  recognize  it  by  carefully  inspecting 
the  posterior  pharynx,  and  seeing  the  membi-ane  extend  up- 
ward;  by  noting  the  irritated,  reddened  look  of  the  nostril, 
even  where  no  membrane  can  be  discerned  in  it,  though  the 
membrane  may  at  times  be  easih'  seen  ;  and  by  the  coryza,  the 
sense  of  obstruction  in  the  nose,  and  the  sanious  discharge 
which  comes  from  it.  In  cases  in  which  the  nasal  duct  and 
laryngeal  canal  are  stopped  up  by  the  false  membranes,  tears 
are  constantly  rolling  down  the  cheeks. 

Chronic  Sore  Throat. — Attacks  of  angina  are  prone  to 
recur,  and  to  lead  to  chronic  inflammation  of  the  structures. 
ISTow,  an  affection  of  this  kind  is  liable,  on  any  exposure,  to 
be  kindled  into  the  acute  complaint;  and  besides,  it  yields  at 
all  times  some  manifestations  of  a  disorder  of  the  throat.  A 
thickening  of  the  folds  of  membrane  forming  the  half  arches, 
a  tumefaction  of  the  follicles  at  the  upper  part  of  the  pharynx, 
a  lengthening  of  the  uvula,  are  the  visible  signs  of  the  chronic 
malady;  a  constant  disposition  to  clear  the  throat,  and  a  dry 
cough  are  often  the  attending  general  symptoms.     Owing  to 

*  Sec  on  this  subject,  as  "well  as  concerning  some  points  which  in  the 
above  sketch  have  been  but  alluded  to,  Bretonneau's  Memoirs  ;  the  writings 
of  Trousseau,  Bouchut,  and  Daviot,  which,  with  those  of  Brctonneau,  were 
republished  by  the  New  Sydenham  Society,  1859 ;  Trousseau's  Clinique 
Medicale ;  W.  F.  Wade,  Observations  on  Diphtheritis,  London,  1858,  de- 
scribing clearly  the  association  of  diphtheria  with  albuminuria  ;  Greenhow 
on  Diphtheria;  Maingault,  Memoire  sur  la  Paralysie  Diphtherique,  Paris, 
1860;  Jenner  on  Diphtheria,  London,  1861 ;  and  Slade  on  Diphtheria. 


408  MEDICAL    DIAGNOSIS. 

the  habitual  coughing,  the  patient  may  be  suspected  to  be 
laboring  under  phthisis,  and  treated  accordingly,  when  the 
whole  trouble  lies  not  in  the  lungs,  but  in  the  throat.  Yet 
an  error  in  the  opposite  direction  is  quite  as  easily,  and  per- 
haps more  frequently,  committed.  It  is,  indeed,  the  fashion 
with  many  to  snip  oft"  tonsils  and  uvulas,  with  the  view  of 
curing  a  cough  which  really  is  kept  up  by  a  source  of  irrita- 
tion in  the  lungs,  forgetting  that  in  scrofula  and  tuberculosis 
chronic  enlargement  of  the  tonsils  and  follicular  pharyngitis 
are  by  no  means  unusual.  A  careful  examination  of  the  chest 
ought  always  to  be  made,  even  when  inspection  of  the  throat 
shows  disease  to  be  there  present. 

The  follicular  disease  of  the  throat,  or  "  clergyman's  sore 
throat,"  is  the  most  frequent  of  all  the  morbid  conditions 
which  produce  a  chronic  sore  throat.  As  Dr.  Green,  who 
so  well  described  the  disease,  pointed  out,  the  abnormal 
condition  of  the  follicles  of  the  mucous  membrane  of  the 
pharynx  and  fauces  often  extends  to  the  larynx.  There  are 
constant  hawking  and  attempts  at  clearing  the  throat,  and 
not  unfrequently  roughness  of  voice  or  decided  hoarseness. 
On  inspecting  the  throat,  the  enlarged  mucous  follicles  can 
be  readily  discerned;  those  on  the  pharynx  are  very  promi- 
nent. In  cases  of  long  standing,  the  follicles  may  ulcerate, 
and  very  commonly  they  pour  out  an  acrid  secretion.  But 
unless  from  coexisting  enlargement  of  the  uvula  or  an  altered 
position  of  the  epiglottis,  or  marked  laryngeal  disease,  or 
a  bronchial  complication,  there  is  no  decided  cough.  The 
follicular  disease  may  occur  in  consequence  of  repeated  at- 
tacks of  sore  throat,  or  be  an  attendant  upon  gastric  disorder, 
or  follow  constant  exercise  and  straining  of  the  voice. 

Ulcers  are  not  often  developed  in  the  fauces  during  an 
attack  of  acute  inflammation,  except  in  the  specilic  sore 
throat  of  scarlatina ;  in  chronic  inflammation,  especially  if 
occurring  in  scrofulous  persons,  they  are  more  common. 
The  most  profound  ulcerations  are  those  of  constitutional 
syphilis,  implicating,  as  they  do,  not  onl}-  the  tissues  of  the 
fauces,  but  the  parts  in  front,  and  destroj'ing  both  the  fleshy 
covering  of  the  bones  and  the  bones  themselves.  With 
regard  to  treatment  and  to  prognosis,  it  is  of  the  utmost  im- 


DISEASES    OF    THE    MOUTH.  409 

portance  to  distinguish  these  syphilitic  ulcers  from  those  pro- 
duced by  other  causes.  A  cutaneous  eruption  of  a  syphilitic 
character,  and  enlarged  lymphatic  glands,  or  the  history  of 
antecedent  syphilis,  would  lead  us  to  a  correct  conclusion  ; 
but  an  accurate  history  of  a  syphilitic  infection  cannot  always 
be  obtained.  The  ulcers  themselves  furnish  some  informa- 
tion by  which  we  may  suspect  their  origin.  They  are  not 
superficial  and  stationary,  like  those  resulting  from  ordinary 
inflammation ;  on  the  contrary,  they  are  deep,  and  have  a 
strong  tendency  to  spread.  They  are  rounded,  or  of  a  ser- 
piginous form,  with  borders  well  defined  and  elevated,  and 
surrounded  by  a  distinct  zone  of  redness;  and  the  inflamma- 
tion which  precedes  them  is  limited  to  spots,  and  is  not  so 
diflfused,  nor  attended  with  so  much  swelling,  as  the  inflam- 
mation which  exists  prior  to  simple  ulceration. 

PHARYNX  AND  CESOPHAGUS. 

In  describing  the  aflt'ections  of  tlie  fauces,  the  affections  of 
that  portion  of  the  pharynx  which  is  most  usually  the  seat 
of  disease  have  been  at  the  same  time  described.  Intleed, 
when  we  speak  of  acute  or  chronic  pharyngitis,  we  generally 
mean  acute  or  chronic  inflammation  of  the  fauces,  to  which 
the  upper  part  of  the  pharynx  belongs.  Inflammation  of 
the  portion  of  the  pharynx  which  is  out  of  sight  when  the 
tongue  is  depressed,  is  rare.  It  may  be  presumed  to  exist,  if 
there  be  pain  and  an  impediment  in  the  act  of  swallowing 
when  the  food  arrives  opposite  the  top  of  the  larynx,  while 
the  respiration  remains  free,  and  the  voice  unaft'ected.  Ab- 
scesses sojiietimes  form  between  the  textures  composing  the 
pharynx,  and  between  its  posterior  wall  and  the  cervical 
vertebrae.  These  reirojjharyngeal  abscesses  mostly  result  from 
disease  of  the  vertebrte.  They  occasion  very  great  difficulty 
in  deglutition  and  in  breathing;  an  altered  voice;  dull  pain 
and  stiflness  in  the  neck;  external  swelling,  whicli  may  or 
may  not  be  edematous;  and  commonly  a  tumefaction  at  the 
back  of  the  throat,  which  can  be  seen,  or  which  at  least  can 
be  felt  with  the  finger  pressed  against  the  posterior  wall  of 
the  pharynx.     On  account  of  the  obstructed  respiration  and 


410  MEDICAL    DIAGNOSIS. 

the  changed  voice,  the  disease  is  very  liable  to  be  mistaken 
for  laryngeal  complaints,  especially  for  croup.  Its  differ- 
ences have  been  enumerated  above.  I  will  only  add  that  a 
safeguard  against  error  is,  to  bear  in  mind  the  possibility  of 
these  abscesses  simulating-  affections  of  the  larynx.* 

The  oesophagus  is  not  ver}^  often  the  seat  of  disease.  We 
sometimes  meet  with  acute  inflammation  of  this  division  of 
the  alimentary  canal  produced  by  swallowing  boiling  water 
or  corrosive  poisons,  especially  nitric  or  sulphuric  acid,  or 
ammonia.  The  symptoms  of  acute  cesophagitis  are  usually 
mixed  up  with,  or  masked  by  those  of  inflammation  of  the 
pharynx,  or  of  the  stomach.  We  may,  however,  infer  its 
presence,  if  difficulty  and  pain  in  deglutition  exist,  for  which 
nothing  in  the  throat  can  be  found  to  account,  and  if  these 
phenomena  be  associated  with  iiiccough  and  with  a  burning 
sensation  between  the  shoulders,  in  the  course  of  the  tube. 

Of  the  chronic  diseases  of  the  oesophagus,  stricture  is  beyond 
doubt  the  most  common.  The  narrowing  may  take  place  at 
any  part  of  the  passage,  and  a  large  pouch  sometimes  forms 
in  front  of,  or  behind  it.  The  constriction  results  from  pre- 
ceding inflammation  or  ulceration,  from  cancerous  degenera- 
tion of  the  walls  of  the  tube,  or  from  the  pressure  of  a  tumor 
or  an  aneurism.  The  formidable  malady  manifests  itself  by 
an  impediment  in  swallowing — even  liquid  food  cannot  pass 
without  great  ditficulty;  and  if  the  stricture  goes  on  increas- 
ing, the  patient  perishes  miserably  by  starvation.  In  addi- 
tion to  the  obstruction  to  the  passage  of  food,  we  maj-  find  a 
peculiar  pain  occurring  at  a  particular  part  of  the  tube,  and 
the  raising,  without  cough  or  vomiting,  of  clots  of  blood 
presenting  nearly  always  the  same  shape. 

The  matter  ejected  in  the  attempts  at  deglutition  consists 
simply  of  masticated  food  together  with  more  or  less  mucus. 
Should  there  be  any  doubt  as  to  the  seat  of  the  obstruction, 
a  bougie  will  clear  up  the  doubt,  and  thus  we  possess  in 
this  instrument  the  most  valuable  diaa-nostic  as  well  as 
therapeutic  agent.     But  we  must  not  immediately  conclude, 

*  Seo  an  elaborate  paper  on  the  subject  of  these  abscesses  by  AUin,  New 
York  Joiirn.  of  Med.,  Nov.  1851. 


DISEASES    OF    THE    MOUTH.  411 

because  the  bouo'ie  when  introduced  meets  with  resistance, 
that  an  organic  stricture  is  present.  The  narrowing  may 
be  simply  spasmodic,  yet  give  rise  to  all  the  symptoms  of  an 
organic  constriction.  But  they  are  not  permanent:  at  times 
nourishment  is  readily  enouo;h  swallowed,  and  a  full-sized 
bougie  passes  with  the  greatest  ease.  This  singular  disorder 
occasionally  accompanies  ulceration  of  the  larynx;,  but  it  is 
chiefly  met  with  in  hypochondriacs  and  in  hj'sterical  women. 
The  latter,  indeed,  sometimes  fancy  that  they  are  incapable 
of  swallowing,  and  reject  the  food  they  take  without  there 
being  the  least  impediment,  or  even  a  temporary  spasm,  to 
prevent  its  passage,  just  as  sometimes  they  lie  in  bed  and 
imagine  themselves  paralyzed  and  unable  to  walk,  until  they 
are  compelled  to  do  so. 

The  disorders  of  the  pharynx  and  oesophagus  which  we  have 
just  been  considering  have  as  a  common  symptom  difficulty 
in  swallowing.  In  truth,  they  are  the  most  usual  cause  of 
dysphagia.  But  we  must  not  forget  that  other  causes  may 
produce  it,  such  as  paralysis  of  the  muscles  of  the  throat, 
diseases  of  the  larynx  or  trachea,  particularly  ulcerative 
diseases,  and  aneurismal  tumors  within  the  chest. 


CHAPTER  VI. 

DISEASES    OF    THE    ABDOMEN. 

The  abdominal  cavity  contains  viscera  of  very  varied  func- 
tions ;  some  form,  others  break  down  organic  constituents; 
while  others  again  excrete  the  broken-down  material.  They 
all,  however,  labor  in  one  cause ;  they  all  work  together 
toward  preserving  a  normal  state  of  the  blood,  either  by 
preparing  tit  matter  for  it,  and  consequently  for  the  healthy 
nutrition  of  the  frame,  or  by  removing  such  substances  as 
would  be  hurtful  if  they  were  retained.  Any  serious  de- 
rangement of  any  of  these  viscera,  especially  any  serious 
chronic  derangement  of  those  which  are  not  simply  reservoirs, 
must  therefore  inevitably  lead  to  a  deterioration  of  the  blood 
and  to  a  defective  nourishment  of  the  bodj-.  But,  inde- 
pendently of  the  change  of  the  blood  and  the  tailing  off  in 
the  general  nutrition,  there  are  no  vital  symptoms  which  char- 
acterize abdominal  diseases  as  a  group  ;  and  as  many  other 
causes  may  give  rise  to  the  same  symptoms,  they  furnish  on 
the  whole  but  little  information  of  real  value  in  diagnosis, 
and  none  at  all  as  to  the  particular  organ  at  fault.  This  we 
learn  to  some  extent  by  examining,  where  it  can  be  done,  the 
secretions  or  excretions  ;  to  some  extent  by  noticing  the  pecu- 
liar appearances  of  the  skin  wliich  are  produced  by  deteriora- 
tion of  the  blood,  or  by  substances,  such  as  bile,  circulating 
in  it;  and,  perhaps,  to  a  still  greater  extent  by  the  explora- 
tion of  the  organs  through  the  flexible  parietes  of  the  abdo- 
men. It  is,  in  truth,  by  means  of  the  physical  method  of 
investigation  that  we  often  obtain  the  most  valuable  informa- 
tion, not  only  as  to  the  seat,  but  even  as  to  the  nature  of  the 
morbid  action ;  and  although  physical  exploration  of  the 
abdomen  does  not  yield  as  perfect  results  as  when  this  form 
(412) 


DISEASES    OF    THE    ABDOMEN.  413 

of  diagnosis  is  applied  to  the  afiectious  of  the  thorax,  the 
senses  of  sight  and  touch  still  supply  us  with  an  amount 
of  knowledge  most  valuable,  and  with  whicli  it  would  be 
difficult  to  dispense.  I  speak  only  of  the  senses  of  sight  and 
touch,  because  the  sense  of  hearing,  save  in  so  far  as  it  en- 
ables us  to  judge  of  the  sounds  elicited  b}'  percussion,  is  not 
very  applicable  to  the  study  of  diseases  below  the  diaphragm. 
But  let  us  pass  in  review  the  different  methods  of  physical 
diagnosis  with  reference  to  abdominal  disorders. 


Methods  and  General  Eesults  of  Physical  Tlxamination 

of  the  Abdomen. 

INSPECTION, 

B}'  inspection,  we  learn  the  size,  shape,  form,  and  move- 
ments of  the  abdomen.  To  inspect  the  abdomen  satisfac- 
torily, the  patient  should  be  placed  in  an  easy  attitude,  either 
standing  or  sitting.  The  recumbent  position  is  less  eligible, 
yet  we  are  often  obliged  to  examine  sick  persons  in  this 
posture.  Whenever  practicable,  ocular  inspection  must  not 
only  be  made  from  the  front,  but  also  from  the  sides,  and, 
under  some  circumstances,  the  back  ought  to  be  inspected. 
In  appreciating  the  results  thus  obtained,  it  is  very  necessary 
to  bear  in  mind,  that  even  in  health  the  appearance  of  the 
abdominal  walls  is  raoditied  by  certain  physiological  condi- 
tions. The  abdomen  is  much  larger,  in  comparison  to  the 
size  of  the  chest,  in  childhood  than  in  adult  age.  It  is  more 
voluminous  in  females,  especially  in  such  as  have  given  birth 
to  several  children.  It  increases  in  size  with  advancing 
years,  particularly  when  a  tendency  to  obesity  exists.  Its 
shape  is  somewhat  altered  by  the  pernicious  habit  of  wear- 
ing tight  stays.  Its  upper  portion  is  more  distended  after  a 
copious  meal  than  when  the  stomach  is  in  an  empty  state. 

In  disease  we  may  observe  either  a  partial  or  a  general 
abdominal  enlargement.  Tlie  latter  is  caused  by  accumula- 
tions of  air  in  the  intestinal  canal;  by  liquids  in  the  perito- 
neum; by  an  edematous  condition  of  the  abdominal  walls; 
or  by  large  tumors  which  till  up  the  whole  cavity.     A  partial 


414  MEDICAL    DIAGNOSIS. 

enlargement  is  mainlj-  produced  b}'  the  increase  in  size  of 
particular  organs,  such  as  of  the  liver,  or  spleen,  or  ovaries. 
It  may  also  be  brought  about  by  induration  and  swelling  of 
the  mesenteric  glands,  or  by  tumors  of  various  kinds — solid 
or  hernial ;  and  it  is  sometimes  due  to  diseases  above  the  dia- 
phragm. A  pleuritic  or  a  pericardial  etfusion,  or  emphysema 
of  the  lungs,  may  give  rise  to  a  marked  fulness  below  the 
margin  of  the  ribs. 

A  retraction  of  the  abdominal  parietes  is  perceived  in 
general  emaciation,  and  very  obviously  in  that  dependent 
upon  a  narrowing  of  the  cardiac  or  pyloric  orifice  of  the 
stomach,  or  upon  chronic  diarrhoea  and  dysentery.  It  is 
also  noticed  in  lead  colic  and  in  cephalic  diseases,  especially 
in  tubercular  meningitis. 

There  are  some  further  changes  in  the  appearance  of  cer- 
tain external  parts  which  may  tend  to  elucidate  the  state  of 
the  parts  within.  Thus  we  learn  from  the  distention  of  the 
superficial  veins,  that  an  obstruction  exists  to  the  flow  of 
blood  in  the  large  veins  of  the  abdomen,  either  in  the  portal 
system  or  in  the  vena  cava.  The  lessening  of  the  depression 
at  the  umbilicus  is,  unless  it  be  produced  b}'  pressure  limited 
to  the  particular  spot  where  the  umbilicus  lies,  a  sign  indica- 
tive of  a  general  abdominal  enlargement. 

While  inspecting  the  abdomen,  we  sometimes  see  distinct 
movements  of  very  ditlerent  kinds.  The  act  of  breathing 
gives  rise  to  a  motion  which  is  very  slight  when  a  tumor  or 
any  other  impediment  interferes  with  the  free  action  of  the 
diaphragm,  and  which  is  much  exaggerated  by  diseases  within 
the  thoracic  cavity.  The  rolling  of  the  intestines  is  sometimes 
visible  on  the  exterior;  so  are  at  times  those  shiftings  of  ac- 
cumulations of  gas  which  give  rise  to  a  series  of  jerking  ele- 
vations; so,  too,  are  occasionally  the  spasmodic  contractions 
and  relaxations  of  the  abdominal  muscles.  But  none  of  these 
is  as  often  encountered,  and  none  occasions  as  much  alarm 
as  a  pulsation,  the  chief  seat  of  which  is  the  epigastric  region, 
and  which,  as  we  shall  presently  see,  is  not  unfrcquently  mis- 
taken for  an  aneurism. 


DISEASES    OF    THE    ABDOMEN.  415 


PALPATION. 


Palpation  teaches  us  some  very  important  lessons.  We 
learn  by  the  application  of  the  hand  to  the  abdomen  many 
things  of  which  the  eye  cannot  inform  us.  We  can  judge  of 
the  size,  position,  and  consistence  of  the  viscera  which  are 
felt  through  the  abdominal  walls.  We  can  determine  whether 
the  parts  are  firmly  attached  or  movable;  whether  they  are 
smooth  or  nodulated;  and  whether  or  not  they  possess  amo- 
tion of  their  own.  We  can  ascertain  whether  they  are  tender 
or  not;  and  by  tapping  with  the  lingers  of  one  hand,  while 
those  of  the  other  are  applied  to  another  portion  of  the  sur- 
face, we  can,  by  the  peculiar  feeling  of  fluctuation,  detect  the 
presence  of  fluid  in  the  abdominal  cavity.  We  can  satisfy 
ourselves  further,  by  the  sense  of  touch,  of  the  state  of  the 
parietes:  whether  hot  or  cold,  resistant  or  elastic,  edematous 
or  not. 

In  order  to  use  palpation  with  most  eftect,  the  abdominal 
muscles  must  be  relaxed,  and  to  do  this  the  patient  should 
be  placed  on  his  back,  and  his  thighs  be  flexed  on  the  body. 
Occasionally  it  is  essential  to  vary  this  position  ;  to  turn  him 
from  side  to  side,  or  to  examine  him  when  erect.  The  amount 
of  pressure  too  should  not  always  be  the  same.  When  we  wish 
to  examine  deep  parts,  the  pressure  is  increased;  when  it 
causes  pain,  the  exploration  must  not  be  uimecessarily  re- 
peated. The  character  and  the  intensity  of  pain  which 
pressure  calls  forth,  often  throw  considerable  light  on  the 
disease  we  are  investigating.  Thus,  if  it  take  deep  pressure 
to  produce  pain,  we  are  usually  right  in  concluding  that  the 
mischief  is  not  superficially  seated.  The  pain  of  inflamina- 
tion  of  the  serous  membrane  is  commonly  much  augmented 
by  pressure,  and  is  of  a  very  severe,  cutting  character.  Pain 
due  to  inflammation  of  any  part  of  the  mucous  membrane  of 
the  intestinal  tract  is  duller.  All  neuralgic  or  nervous  pain, 
such  as  that  of  colic,  is  relieved  rather  than  augmented  b}' 
pressure,  and  may  thus  be  distinguished  from  the  tenderness 
caused  by  inflammation.  Yet  this  is  not  always  the  case;  it 
is  to  be  regarded  as  a  rule  which  has  manj'  exceptions. 


416  MEDICAL    DIAGNOSIS. 

But  we  cannot  enter  into  an}^  fuller  particulars  as  to  what 
palpation  teaches  us  in  individual  diseases  of  the  abdomen ; 
because,  as  there  is  hardly  one  of  any  importance  in  which 
it  is  not  of  some  service,  we  should  say  here  what  it  would 
be  necessary  to  dwell  upon  repeatedly  further  on. 

PERCUSSION. 

Percussion  is,  in  the  study  of  abdominal  affections,  as  val- 
uable as,  perhaps  even  more  valuable  than,  palpation.  By  it 
we  can  circumscribe  the  different  organs  with  great  accuracy; 
we  can  judge  of  the  position  of  the  stomach  and  intestines; 
Me  can  limit  the  distended  bladder;  and  fix  the  borders  of  the 
liver  and  spleen.  By  its  aid,  further,  we  tell  whether  a  dis- 
tention of  the  abdomen  is  produced  by  air,  or  by  a  solid  tumor, 
or  by  liquid.  But  without  entering,  for  the  present,  into  any 
particulars  as  to  its  use  in  the  recognition  of  individual  ab- 
dominal disorders,  we  may  here  examine,  in  a  cursory  man- 
ner, the  results  it  yields  when  applied  to  the  healthy  abdomen. 

To  render  percussion  a  trustworthy  interpreter  of  the  state 
of  the  abdominal  viscera,  the  patient  should  be  placed  in  the 
same  position  as  for  palpation.  The  sounds  are  best  elicited 
by  mediate  percussion,  and  especially  by  mediate  percussion 
performed  by  means  of  a  pleximeter.  But  to  appreciate  them 
full}-,  something  more  is  requisite  than  to  produce  a  distinct 
sound,  and  be  able  to  tell  whether  it  is  dull  or  tympanitic. 
We  must  be  acquainted  with  the  relations  of  the  parts  con- 
cealed from  view  by  the  abdominal  walls  ;  and  more,  we  must 
understand  the  physiology  of  the  organs  they  cover,  and  take 
into  account  that  during  the  digestive  process  their  contents 
and  position  may  vary  sufficiently  to  modify'  the  sound. 

To  commence  with  the  airless  viscera.  The  liver  is  one  of 
the  easiest  organs  to  limit.  We  determine  its  upper  bound- 
ar}'  by  striking  with  moderate  force  in  a  line  from  somewhat 
above  the  right  nipple  toward  the  lower  part  of  the  thorax, 
until  marked  resistance  and  dulness  tell  us  that  a  solid  organ 
has  been  reached.  At  this  point  we  draw  a  line  ;  then  we  re- 
commence percussing  downward  from  near  the  median  line, 
and  above  the  dulness  just  obtained;  then  we  percuss  from 


DISEASES    OF    THE    ABDOMEN.  417 

the  axilla  downward ;  then  posteriorly  from  beneath  the  lower 
angle  of  the  scapula,  and  so  on,  until  the  line  traced  out 
reaches  the  vertebral  column. 

The  dulness  thus  elicited  marks  the  upper  boundary  of  the 
liver;  at  least  of  the  portion  which  comes  more  directly  in 
contact  with  the  abdominal  walls.  Anteriorly  it  extends  from 
the  lower  extremity  of  the  sternum  to  between  the  fifth  and 
sixth  ribs ;  at  the  side,  the  dulness  is  generally  in  the  seventh 
intercostal  space;  near  the  vertebral  column,  it  is  on  a  level 
with  the  tenth  or  the  eleventh,  more  rarely  with  the  ninth 
interspace.  The  dulness  of  the  left  lobe  reaches  nearly  two 
inches  across  the  median  line ;  but  the  heart  lies  here  so  near 
to  the  liver,  that  we  cannot,  with  any  accuracy,  distinguish 
the  flat  sound  of  the  one  from  the  flat  sound  of  the  other; 
nor  indeed  is  this,  for  practical  purposes,  of  any  very  great 
consequence. 

.  After  the  upper  border  has  been  fairly  traced  out  anteriorly, 
laterally,  and,  should  it  be  thought  necessary,  posteriorly,  we 
next  determine  the  inferior  margin  of  the  organ.  This  is 
readily  effected  by  percussing  downward  from  the  already  as- 
certained line  of  dulness,  and  noting  where  the  large  intestine 
sends  forth  its  distinct  tympanitic  sound.  To  determine  the 
lower  border  correctly,  the  pleximeter  must  be  pressed  firmly 
on  the  integuments,  and  the  stroke  of  the  finger  be  slight; 
for  if  it  be  strong,  we  obtain  the  sound  of  the  surrounding 
hollow  viscera  through  the  thin  layer  of  liver  which  covers 
them,  and  before  we  have  arrived  at  its  margin.  This  mode 
of  procedure  is  different  from  the  one  pursued  to  determine 
the  height  to  which  the  liver  rises,  because  the  position  of  the 
parts  is  diff'erent.  Superiorly,  the  lung  descends  between  the 
surface  and  that  portion  of  the  convex  surface  of  the  liver 
which  fits  into  the  diaphragm,  and  it  requires  very  strong 
percussion  to  bring  out  the  dulness  of  the  deep-seated  solid 
organ.  By  forcible  percussion,  however,  we  detect  a  decided 
loss  of  the  pulmonary  resonance  at  about  the  fourth  intercostal 
space. 

The  inferior  border  of  the  liver  will,  anteriorly,  be  gener- 
ally found  to  lie  immediately  at,  or  to  project  below,  the  last 
rib;  posteriorly,  we  cannot  determine  this  border  positively, 

27 


418  <*  MEDICAL    DIAGNOSIfS. 

for  it  becomes  continuous  with  the  dulness  occasioned  by  the 
presence  of  the  right  kidnej.  Tlie  lower  margin  of  the  left 
lobe  is  commonly  met  Avitli  at  the  upper  third  of  a  line  drawn 
from  the  ensiform  cartilage  to  the  umbilicus.  A  much  dis- 
tended gall-bladder  may  cause  a  strictly  defined  dulness  lower 
than  the  dulness  of  the  surrounding  liver. 

The  spleen  is  a  solid  organ  which  is  not  so  easily  circum- 
scribed as  the  liver.  Indeed,  if  the  stomach  contain  much 
food,  or  if  it  or  the  intestines  be  distended  with  gas,  it  is  very 
difficult  to  discriminate  the  dull  sound  of  the  spleen.  To  find 
its  limits,  we  must  place  the  patient  on  his  right  side,  with 
his  legs  flexed;  or  let  him  stand  erect,  and  then  begin  to 
strike  with  some  force  in  a  line  from  the  axilla  to  the  crest 
of  the  ilium.  At  the  ninth,  or  sometimes  at  the  tenth  rib, 
the  sound  becomes  dull,  and  there  is  much  greater  resist- 
ance to  the  finger.  Here  is  the  upper  boundary  of  the  spleen. 
We  mark  the  spot,  and  continue  to  percuss  in  the  same  line 
until,  at  about  the  twelfth  rib,  we  arrive  at  the  lower  boundary 
of  the  organ,  as  indicated  by  the  distinct  tympanitic  sound  of 
the  intestines. 

After  the  vertical  diameter  has  been  thus  ascertained,  the 
horizontal  is  readily  determined  by  percussing  from  the  me- 
dian line  to  a  point  between  the  lines  which  trace  the  superior 
and  inferior  margins,  and  by  noticing  where  the  sound  of  the 
stomach  gives  way  to  the  dull  sound  of  the  solid  viscus.  When 
these  three  points  have  been  decided  upon,  we  have  learned 
enough  for  practical  purposes.  We  may  then,  if  we  choose, 
percuss  posteriorly;  but  we  cannot  circumscribe  the  spleen 
with  any  accuraej'  behind,  because  its  dulness  becomes  con- 
tinuous with  that  of  the  left  kidney. 

The  average  size  of  the  spleen  is  four  inches  in  length  and 
three  in  width;  but  it  may,  if  in  a  diseased  state,  increase  to 
twice  or  three  times  that  size.  Mailliot  tells  us  that  when,  as 
occasionally  happens,  the  viscus  eludes  detection  by  percus- 
sion, we  may  infer  that  its  dimensions  are  small.  This  re- 
mark only  holds  good  provided  the  stomach  and  intestines  be 
not  very  much  distended  with  gas. 

The  information  obtained  from  percussing  the  kidneys  \s,oi' 
so  little  value,  that  I  shall  not  enter  into  a  description  of  hew 


DISEASES    OF    THE    ABDOMEN.  41'.» 

these  organs  are  to  be  percussed ;  nor,  indeed,  can  they  he 
limited  with  anything  like  accurac}',  except  at  their  inferior 
and  outer  borders,  where  the  dull  sound  they  occasion  is  sur- 
rounded by  the  intestinal  resonance.  This  dulness  extends 
somewhat  lower  during  a  full  inspiration. 

To  set  limits  to  the  stomach  and  intestines,  by  means  of  per- 
cussion, requires  an  ear  accustomed  to  discriminate  between 
shades  of  sound,  since  we  have  to  judge  more  between  sounds 
of  different  degree,  but  similar  to  each  other,  than  between 
sounds  of  different  character.  Nor  are  the  tones  elicited 
always  the  same  over  the  same  spot;  on  the  contrary,  they 
vary  according  as  the  contents  of  the  hollow  viscera  vary. 
And  we  can  make  use  of  this  circumstance  for  purposes  of 
diagnosis. 

The  stomach,  when  not  unusually  distended  with  gas  or 
with  food,  renders  a  sound  which  is  hollow,  ringing,  and 
tympanitic  to  a  certain  degree,  yet  which  is  not  tympanitic 
as  that  of  the  intestine  is.  It  is  in  fact  a  sound  unlike  any 
other,  and  experience  soon  enables  us  to  distinguish  it  from 
that  of  the  surroundinsr  viscera.  Sometimes  the  sound  is  dis- 
tinctly  amphoric. 

Now,  to  determine  the  boundaries  of  the  stomach,  it  is  ne- 
cessary to  mark  out  first  the  lower  margin  of  the  liver,  for  it 
covers  a  portion  of  the  stomach;  then  the  heart  and  the  inner 
border  of  the  spleen.  The  part  which  lies  between  these  solid 
viscera  yields  the  sound  of  the  stomach,  mixed  at  one  point, 
namely,  to  the  left  of  the  apex  of  the  heart,  with  the  reso- 
nance of  the  lung.  iN'ear  this  spot,  about  opposite  to  the 
seventh  rib,  the  cardiac  extremity  of  the  stomach  is  situated; 
below  it  is  the  body  of  the  organ.  To  ascertain  its  lower 
border,  we  percuss  gently  in  a  downward  direction,  until  the 
alteration  in  sound  shows  that  we  are  striking  over  the  colon. 
The  difference  is  at  times  very  obvious,  at  times  very  slight. 
It  is  most  readily  detected  if  the  stomach  contain  either  solid 
or  liquid  ingesta.  And  availing  ourselves  of  this  fact,  we  may 
sometimes  follow,  with  advantage,  Mailliot's  advice,  and,  un- 
less the  circumstances  of  the  case  forbid  it,  let  the  patient 
swallow  a  glass  of  water.  By  placing  him  in  the  erect  posi- 
tion, the  fluid  will  gravitate  to  the  greater  curvature;  and  the 


420 


MEDICAL    DIAGNOSIS. 


line  of  comparative  dulness  indicates  the  lower  margin  of  the 
stomach,  which  is  generally  found  near  the  umbilicus. 

The  colon  j'ields,  in  its  ascending  and  transverse  as  well  as 
in  its  descending  portion,  a  sound  of  a  far  purer  tympanitic 
character  than  the  stomach,  the  note  of  which  is,  indeed,  in 
many  respects,  more  amphoric  than  tympanitic.  When,  how- 
ever, the  tube  contains  feces,  the  sound  is  modified ;  and  as 
these  are  prone  to  accumulate  on  the  left  side  in  the  descend- 
ing colon,  and  especiallj'  where  it  passes  into  the  iliac  fossa, 

Fig.  34. 


Results  of  abdoniiiiiil  porcnssion,  as  set  forth  in  [\w  toxt  Tlio  diiik  sliades  indi- 
cate marked  dulness  ;  the  light  shading  exhibits  a  lessening  of  the  clear,  or  of  tho 
tympanitic  character  of  the  sound — an  approach  to  duluess. 

it  is  usually  not  so  resonant  as  the  ascending  colon.  The 
mnall  intestines,  unless  they  are  filled  with  fluid  or  solids,  or 
distended  with  gas,  render  a  sound  of  higher  pitch  and  of 
smaller  volume   than   the  surrounding  large  intestine,  and 


DISEASES    OF    THE    STOMACH.  421 

by  this  less  deep-toned  sound  their  position  may  be  accu- 
rately determined. 

The  position  of  the  viscera  in  the  pelvis  cannot  be  ascer- 
tained by  means  of  percussion.  It  is  only  when  the  bladder 
is  much  distended,  or  the  uterus  augmented  in  size,  that  the 
outline  of  either  can  be  traced  on  the  walls  of  the  abdomen. 

AUSCULTATION. 

Auscultation  does  not  stand  us  in  much  stead  in  abdom- 
inal diseases.  It  is  serviceable  in  aiding  in  the  detection  of 
an  abdominal  aneurism;  and  sometimes  an  enlarged  spleen 
gives  rise  to  a  distinct  blowing  murmur;  or  the  rubbing  of  a 
roughened  peritoneum  may  occasion  a  friction  sound;  but, 
on  the  whole,  the  application  of  the  stethoscope  to  the  ab- 
dominal walls  is  rarely  called  for.  In  health,  no  constant 
sound  is  heard  save  that  of  the  aorta;  for  the  rush  of  blood 
through  the  other  arteries,  or  through  the  veins,  produces 
no  appreciable  murmur.  "When  the  stomach  is  distended 
with  air  and  contains  liquid,  sounds  possessing  a  metallic 
character  are  perceived,  which  an  inexperienced  observer  is 
very  apt  to  consider  as  originating  in  the  lungs;  over  which, 
in  truth,  they  are  often  audible.  The  passage  of  gas  through 
the  intestines  gives  rise  to  those  peculiar  noises  termed  "bor- 
borygmi."  In  the  pregnant  state,  auscultation  is  of  value 
in  detecting  the  pulsations  of  the  foetal  heart  and  the  utero- 
placental murmur. 


SECTION  I. 


DISEASES    OF    THE   STOMACH. 


As  the  disorders  of  the  stomach  are  so  common ;  as  we  are 
so  constantly  called  upon  to  remedy  them;  as  a  patient  hardly 
ever  gives  a  history  of  his  ailment  without  thinking  it  obli- 
gatory to  enter  into  a  minute  account  of  the  state  of  his  diges- 
tion, it  would  be  reasonable  to  suppose  that  as  a  class  no 


422  MEDICAL    DIAGNOSIS. 

affections  are  so  well  understood  and  so  susceptible  of  clear 
description  as  those  of  this  viscus.  But  in  point  of  fact  there 
are  none  so  little  understood ;  and  indeed  it  is  only  within 
the  last  few  years  that  any  attempts  have  been  made  to  pene- 
trate, with  the  light  thrown  by  modern  means  of  research,  the 
darkness  which  surrounds  the  pathology  of  one  of  the  most 
important  organs  in  the  body.  All  these  attempts  have 
had  as  their  o;'oal  to  ascertain  the  exact  anatomical  chano;es 
and  modifications  in  the  secretions  which  give  rise  to  the 
symptoms  commonly  referred  to  perverted  function  ;  and  to 
a  certain  degree  they  have  been  successful ;  but  not  to  that 
degree  which  enables  us  to  associate  each  symptom  with  some 
definite  alteration  in  the  healthy  structure  or  the  normal 
action  of  the  part. 

The  symptoms  which  are  very  constantly  met  with  in  de- 
rangements of  the  stomach,  whether  organic  or  functional,  are 
loss  of  appetite,  nausea  and  vomiting,  acidity,  flatulency,  and 
pain.  Before  inquiring  into  the  individual  diseases  of  the 
viscus,  we  shall  briefly  pass  these  symptoms  in  review. 

Loss  of  Appetite. — This  is  one  of  the  most  common  signs 
of  a  disordered  stomach.  It  manifests  itself  in  various  ways. 
It  may  amount  to  absolute  repugnance  to  taking  any  kind  of 
food,  or  be  merely  an  inability  to  partake  of  certain  articles. 
Again,  little  by  little  the  process  of  digestion  may.  become 
more  and  more  diflicult  and  annoying,  and  the  patient  in 
consequence  instinctively  abstains  from  eating,  excepting  in 
quantities  barely  sufiicient  to  keep  up  life.  What  the  loss  of 
appetite  depends  on,  we  do  not  know;  nor  shall  we  until  the 
causes  of  appetite  and  hunger  are  definitely  settled.  That 
nervous  influence  has  something  to  do  with  the  anorexia,  is 
seen  by  the  sudden  deprivation  of  all  desire  to  eat  when  any 
strong  impression  is  made  on  the  nervous  system — such  as 
that  caused  by  the  unexpected  receipt  of  unwelcome  news. 
The  amount  of  epithelium  on  the  mucous  membrane  is  also 
connected  with  a  marked  diminution  of  the  appetite  ;  for  with 
a  tongue  much  coated,  absolute  disgust  at  the  mere  thought 
of  taking  food  often  exists,  which  juelds  to  relish  for  food  as 
soon  as  the  tonffue  beo:ins  to  clean. 

Attending  the  diminished  or  lost  appetite,  we  meet  some- 


DISEASES    OF    THE    STOMACH.  423 

times  with  great  emaciation  and  with  signs  as  if  even  the  small 
quantity  of  food  taken  were  not  absorbed  into,  or  utterly 
failed  to  nourish,  the  system.  Moreover,  there  is  apt  to  be 
sensitiveness  over  the  abdomen,  and  spots  of  particular  sen- 
sitiveness exist  which  correspond  to  the  situation  of  the  mesen- 
teric glands.  We  find,  however,  no  evidence  of  actual  organic 
disease,  either  in  the  abdomen  or  in  the  lungs;  nor  does  this 
pseudo-tabes  mesenterica,  if  I  may  so  call  it,  occur,  like  the  dis- 
ease it  simulates,  in  scrofulous  or  tubercular  patients.  I  have 
met  with  a  number  of  cases,  chiefly  in  young  women  with 
lowered  vital  force,  fond  of  excitement,  and  living  indoleiit 
lives.  Some  were  hysterical,  others  not.  But  in  all  the  dis- 
order seemed  to  be  due  to  deficient  nervous  power,  with  im- 
paired function  of  the  stomach,  and  very  possibly  of  the  ab- 
dominal glands. 

Instead  of  the  appetite  being  lost,  it  is  at  times  capricious, 
or  even  ravenous.  A  craving  after  food  is  not  often  combined 
with  a  structural  lesion.  Yet  we  occasionally  meet  with  it  in 
persons  affected  with  gastric  ulcers.  It  is  common  to  find 
it  in  those  who  suffer  from  neuralgia  of  the  stomach.  And 
sometimes  in  cases  of  mere  nervous  gastric  disturbance, 
with  or  without  pain,  there  is  an  extraordinary  exaggeration 
of  the  appetite.  The  patient  eats  eight  or  even  fifteen  times 
a  day  largely,  digests  his  food  properly,  yet  is  constantly 
hungry.* 

The  feelino;  of  thirst  does  not  lessen  when  the  desire  for 
food  does.  On  the  contrary,  it  usually  increases  when  the 
latter  diminishes. 

Excessive  Acidity  of  the  Stomach.— Excessive  acidity 
occurs  from  various  causes.  The  gastric  juice  may  be  secreted 
in  very  great  quantities,  or  it  may  contain  an  abnormal 
amount  of  acid.  But  excessive  acidity  is  most  frequently  due 
to  the  decomposition  of  food  and  to  a  process  of  fermentation, 
dependent  rather  upon  an  insufficient  amount  of  the  gastric 
solvent  than  upon  its  superfluity.  It  then  manifests  itself 
only  after  meals.  When  the  mucous  membrane  is  covered 
with  a  tenacious  mucus  or  with  thick  layers  of  epithelium, 


*  Cases  recorded  by  Guipon,  Bulimic  and  Syncopal  Dyspepsia. 


424  MEDICAL    DIAGNOSIS. 

slow  digestion  and  acidity  from  fermentation  result;  because, 
although  the  gastric  juice  is  sufficient,  it  cannot  mix  as  readily 
with  the  aliment. 

The  acids  formed  in  the  stomach  are,  besides  the  muriatic 
acid  of  the  gastric  juice,  lactic  acid,  acetic  acid,  carbonic  acid, 
butyric  acid,  and  oxalic  acid.  Some  articles  of  food  produce 
these  difl'erent  acids  in  considerable  quantities.  Thus  sugar 
generates  lars^e  amounts  of  lactic  acid.  The  acids  which  are 
created  in  the  stomach  may  get  into  the  blood,  and  by  vitia- 
tino;  this  fluid  s^ive  rise  to  various  disorders. 

When  much  acid  is  present  in  the  viscus,  it  occasions  a 
sensation  of  heat  which  extends  along  the  oesophagus.  This 
"heart-burn"  is  apt  to  happen  in  paroxysms,  and  is  attended 
with  a  feeling  of  constriction  or  with  actual  pain  at  the  epi- 
gastrium. As  a  symptom  it  has  no  special  diagnostic  value, 
for  it  is  met  with  both  in  functional  and  organic  diseases  of 
the  stomach.  It  simply  denotes  extreme  acidity  ;  and  is  very 
common  in  gouty  persons.  It  probably  arises,  as  Dr.  Cham- 
bers surmises,  from  the  action  of  the  acid  contents  of  the 
organ  on  the  oversensitive  cardiac  and  cesophageal  nerves. 

Flatulency. — The  gas  in  the  intestinal  canal  may  be 
merely  air  which  is  swallowed;  or  may  be  generated  from 
imperfectly  digested  food ;  or  it  may  be  a  secretion  from  the 
blood-vessels  of  the  part.  In  those  who  sutler  from  indiges- 
tion, it  is  produced  in  the  last  two  ways,  and  the  patient 
complains  greatly  of  the  annoyance  it  occasions.  It  causes 
a  diso;nst  for  eatins:,  a  feelino;  of  distention,  and  sometimes 
actual  pain.  By  interfering  with  the  downward  movements 
of  the  diaphragm,  it  induces  a  sensation  of  constriction  in 
the  chest,  shortened  breathing,  and  palpitation  of  the  heart; 
and  the  sleep  is  broken  by  uneasy  dreams. 

An  expulsion  of  the  gaseous  contents  of  the  stomach  by 
the  mouth  gives  rise  to  eructation,  or  belching.  The  belching 
which  follows  the  decomposition  of  food  has  sometimes  the 
taste  and  the  odor  of  rotten  ee:gs,  owins^  to  the  ffas  evolved 
consisting  of  sulphuretted  hydrogen.  At  other  times,  the 
eructation  is  odorless,  because  the  gases  formed  are  carbonic 
acid,  or  hydrogen  or  nitrogen,  or  some  of  their  compounds. 
When  the  gas  results  from  fornientation  or  decomposition  of" 


DISEASES    OF    THE    STOMACH.  425 

food,  it  frequently  coexists  with  acidity  occurring  only  after 
meals,  and  we  remedy  it  by  administering  the  mineral  acids 
or  agents  which  promote  digestion.  When  it  is  a  secretion 
from  the  blood-vessels,  it  happens  in  an  empty  state  of  the 
stomach,  and  is  often  relieved  by  simply  regulating  the  time 
of  taking  food,  so  as  to  avoid  too  long  intervals  between 
the  meals.  As  a  cause  of  flatulence  and  eructation  which  it 
is  important  not  to  overlook  may  be  mentioned  thoracic 
aneurism.* 

Nausea  and  Vomiting. — Tliese  are  frequently  combined. 
But  sometimes  there  is  persistent  nausea  without  vomiting; 
sometimes  vomiting  occurs  without  any  or  with  but  slight 
preceding  nausea.  Yet  they  are  both  occasioned  in  much 
the  same  way :  what  gives  rise  to  one  will  give  rise  to  the 
other. 

Vomiting  is  a  very  complex  act.  But  its  causes,  although 
various,  may  all  be  ranged  under  four  heads.  It  arises  either 
from  an  irritation  of  the  peripheral  extremities  of  the  nerves 
which  supply  the  parts  more  directly  concerned  in  the  act 
itself,  such  as  the  stomach,  the  diaphragm,  and  the  oesopha- 
gus; or  the  irritation  originates  in  the  centres  from  which 
these  nerves  spring,  and  is  referred  to  their  peripheries;  or 
there  is  a  mechanical  obstruction  in  the  stomach  or  intes- 
tines;  or  the  vomiting  is  purely  sympathetic.  To  illustrate 
these  dift'erent  forms  in  full  is  not  necessary.  I  will  merely 
mention  a  few  examples  of  each.  Under  the  first  head  be- 
longs the  vomiting  observed  in  acute  or  chronic  inflamma- 
tion of  the  stomach,  in  ulcer,  or  in  cancer;  also  that  follow- 
ing a  debauch,  or  the  introduction  of  irritating  substances 
into  the  viscus.  Under  the  second  head  may  be  ranged  the 
vomiting  which  occurs  in  diseases  of  the  brain  ;  perhaps,  also, 
that  which  arises  in  morbid  states  of  the  blood.  Under  the 
third  head  we  may  class  the  vomiting  in  narrowing  of  the 
oesophagus,  and  of  the  pyloric  or  cardiac  extremity  of  the 
stomach,  and  in  obstructions  of  the  intestine.  It  ma}',  how- 
ever, be  made  a  question  whether  the  vomiting  in  all  these 
cases  is  not  owing  to  the  same  ultimate  cause  as  that  of  the 

*  Walter  F.  Atlee,  Amer.  Jouni.  of  Med.  Sciences,  July,  1869. 


426  MEDICAL    DIAGNOSIS. 

first  group ;  whether,  hi  other  words,  it  is  not  a  reflex  phe- 
nomenon called  forth  hy  the  irritation  at  the  seat  of  the 
impediment. 

The  fourth  group  is  exemplified  by  the  vomiting  in  preg- 
nancy, in  wounds  of  the  extremities,  by  that  occurring  in 
peritonitis,  in  inflammation  of  the  intestines  and  of  the  liver, 
and  in  irritation  of  the  fauces.  In  the  four  last  instances  the 
vomiting  is  due  to  direct  transmission  of  the  irritation,  and 
must  be  looked  upon  as  originating  through  means  of  that 
sympathy  called  by  physiologists  continuous.  The  first  two 
illustrate  the  remote  sympathy  between  different  parts  of  the 
body,  of  which  disease  often  furnishes  such  striking  proofs. 

Connected  thus  with  so  many  various  conditions,  the  act 
of  vomiting,  taken  by  itself,  is  of  very  little  diagnostic  value. 
It  presupposes  a  certain  amount  of  irritation  existing  in  the 
stomach,  or  reflected  to  it;  but  nothing  more.  It  is  of  course 
a  frequent  symptom  in  disorders  of  the  stomach,  especially 
in  those  which  are  organic ;  3^et  the  error  ought  to  be  stren- 
uously guarded  against  of  considering  it  as  having  reference 
only  to  derangements  of  that  viscus.  As  it  is  allied  to  mor- 
bid states  too  numerous  to  be  here  examined  into  in  detail, 
I  shall  content  mvself  with  makins;  a  few  o-eneral  statements 
reo;ardino^  the  indications  to  be  drawn  from  it. 

When  vomiting  is  observed  in  a  person  previously  in  good 
health,  we  may  suspect  either  the  invasion  of  some  acute 
malady,  or  that  some  poisonous  substance  has  been  wilfully 
or  accidentally  taken.  Again,  it  may  come  on  suddenly 
from  violent  mental  emotion.  When  everything  that  is 
swallowed  is  immediately  expelled,  the  difldculty  lies  in  tlie 
oesophagus,  or  at  the  cardiac  orifice  of  the  stomach,  or  in 
an  extreme  irritability  of  the  viscus ;  and  this  irritability, 
attended  as  it  often  is  with  unceasing  nausea,  experience 
teaches  to  be  far  more  frequently  due  to  a  sympathetic  ex- 
citement of  the  organ  than  to  any  derangement  of  its  owu. 

As  regards  the  vomiting  wdiich  is  brought  about  by  gas- 
tric disorders,  it  is  of  much  consequence  to  note  the  period 
at  which  it  happens,  whether  before  meals  or  after  meals, 
and  how  long  afterward.  In  some  diseases,  such  as  ulcer 
and  cancer,  it  rarely  occurs  excepting  when  food  has  been 


DISEASES    OF    THE    STOMACH.  427 

taken.  The  act  of  vomiting  then  afibrds  relief  from  the 
pain,  and  is,  as  it  were,  rather  ph^-siological  than  patho- 
logical. In  narrowing  of  the  pylorus,  it  takes  place  some 
hours  after  digestion  has  commenced.  But,  as  vomiting  will 
be  described  hereafter  in  its  relations  to  the  individual  dis- 
eases of  the  stomach,  Ave  shall  not  anticipate  what  will  be 
more  fitly  discussed  elsewhere.  For  the  same  reason  we 
need  not  dwell  on  the  characteristics  of  the  ejected  matter. 
Yet  a  few  words  on  the  subject  can  hardly  be  omitted. 

The  nature  and  the  quantity  of  the  vomit  are  of  course 
most  various.     The  following  are  its  most  common  kinds  : 

Food  or  liquid,  mixed  with  saliva  and  some  mucus,  is  ex- 
pelled when  the  stomach  is  very  irritable,  or  if  an  obstruction 
exist  which  renders  the  entrance  into  the  ors-an  difficult  or 
impossible.  Half-digested  food,  in  a  state  of  acetous  ferment- 
ation and  with  a  strongly  acid  reaction,  is  cast  out  when  the 
proper  secretion  of  the  gastric  juice  or  its  intimate  admixture 
with  the  aliment  has  been  interfered  with,  or  when  this  has 
been  detained  for  a  long  time  in  the  stomach.  This  kind  of 
vomit  is  usual  in  chronic  inflammation  and  in  cancer  of  the 
stomach,  especially  in  the  latter.  In  the  ejected  matter  the 
particles  of  food  may  still  be  recognized  with  the  unassisted 
eye  ;  but  when  the  food  has  been  kept  for  a  prolonged  period 
in  the  stomach,  or  when  it  has  passed  on  into  the  duodenum 
and  is  returned,  it  is  changed  into  an  apparently  homogeneous 
mass.  Examined,  however,  under  the  microscope,  the  differ- 
ent elementary  structures  of  the  animal  or  vegetable  sub- 
stances partaken  of  can  even  then  be  detected.  Mixed  with 
muscular  fibre,  fibrous  tissue,  starch 
corpuscles,  and  vegetable  cells,  is  usu- 
ally found  a  considerable  quantity  of 
oil. 

Sarc'mse  and  veast  fung-i  are  some- 
times  discovered,  by  means  of  the 
microscope,  in  the  vomit.     These  or- 

Sarciiiif  vcntriouli. 

ganisms  are  the  result  of  a  process  of 

fermentation,  and  are  generally  associated  with  most  copious 
vomiting.  Of  sarcinae  we  knew  nothing  previous  to  their 
description  by  John  Goodsir,  in  1842.    They  are  small  square 


428  MEDICAL    DIAGNOSIS. 

or  slightly  oblong  bodies,  divided  into  similar  smaller  por- 
tions b}"  cross  lines,  and  each  portion  thus  formed  is  again 
subdivided;  but  the  markings  of  the  smaller  squares  are 
not  so  distinct  as  those  of  the  larger.  The  accompanying 
illustration  shows  a  mass  of  sarcinse  found  in  the  vomit  of  a 
patient  who  suft'ered  from  gastric  ulcer. 

Vomit  containing  sarcinse  is  always  indicative  of  some 
structural  change  in  the  stomach.  It  is  sometimes  found 
in  chronic  gastritis  of  long  standing;  or  in  connection  with 
ulcer,  and  yet  oftener  with  cancer,  and  especially  in  those 
cases  in  which  the  narrowing  at  the  pyloric  extremity  has 
led  to  distention  of  the  organ.  In  truth,  it  is  the  opinion 
of  several  eminent  pathologists,  and  among  them  Dr.  Budd, 
that  the  disorder  requires  that  there  should  be  some  condition 
which  prevents  the  stomach  from  completely  or  readily  emp- 
tying itself. 

Sarcina  vomit  has  an  acid  smell  and  an  acid  reaction,  and 
often  a  peculiar  brownish  appearance.  After  standing,  it 
becomes  covered  with  a  dirty,  frothy  matter,  like  yeast;  but 
owino;  to  the  amount  of  half-dio;ested  food  at  times  mixed 
with  it,  its  aspect  is  not  uniform,  and  it  is  only  by  the  micro- 
scope that  the  presence  of  the  strange  bodies  can  be  recog- 
nized with  certaintv. 

The  process  of  fermentation  which  attends  the  development 
of  tlie  sarcinfie  occasions  heart-burn  and  extreme  flatulency, 
both  of  which  add  greatly  to  the  distress  of  the  patient;  and 
the  copious  vomiting  is  a  source  of  relief  rather  than  of  ag- 
gravation of  his  sutferino^,  since  the  formation  of  acid  and  of 
wind  is,  for  the  time  being,  almost  entirely  or  wholly  arrested. 
Our  aim,  in  treating  cases  of  this  disorder,  is  of  course  to  re- 
move the  cause  which  incites  to  the  development  of  sarcinse ; 
but  as  this  object  is  not  often  attainable,  we  have  to  rest  con- 
tent in  checking  the  activity  of  the  process  of  fermentation 
by  the  administration  of  alkalies,  and  in  preventing  it  as  far 
as  possible,  by  such  medicines  as  creasote,  or,  better  still,  by 
the  remedy  proposed  by  Dr.  Williams,  the  sulphite  of  soda, 
in  doses  of  from  half  a  drachm  to  a  drachm. 

3Iucus  is  occasionally  ejected  in  large  quantities,  both  mixed 
with  food  and  pure.     In  chronic  gastritis,  and  in  the  milder 


DISEASES    OF    THE    STOMACH.  429 

forms  of  acute  gastritis,  the  mucous  membrane  is  covered 
with  a  tenacious  secretion,  and  a  considerable  amount  of  a 
glairy  or  stringy  matter  is  expelled  by  the  act  of  vomiting. 
As  a  general  rule,  indeed,  it  may  be  stated  that,  when  much 
mucus  is  evacuated,  an  inflammatory  state  of  the  mucous 
membrane,  or  what  is  termed  a  catarrhal  state  of  the  stomach, 
is  present. 

A  thin,  watery  fluid,  looking  much  like  saliva,  is  discharged 
in  some  cases  of  organic  disease  of  the  stomach,  and  more 
frequently  still  in  functional  derangementof  the  organ  brought 
on  by  eating  coarse  food.  Now  and  then  it  is  met  with  iji 
pregnancy.  This  variety  of  vomiting  is  popularly  known  as 
"water- brash  ;"  technically,  as  pyrosis.  It  is  not  seldom  at- 
tended with  a  burning  sensation  extending  to  the  fauces, 
and  with  pain  running  back  to  the  spine.  Generally  it  is  a 
tractable  disorder  if  proper  food  be  taken.  The  fluid  is  com- 
monly alkaline  ;  sometimes,  owing  to  its  intimate  admixture 
with  the  gastric  contents,  it  is  acid. 

The  source  whence  the  fluid  is  derived  is  not  settled.  Fre- 
riehs  found  that  it  possessed  the  power  of  converting  starch 
into  sugar.  On  this  account,  it  has  been  presumed  to  be 
saliva,  which,  after  having  accumulated  in  the  stomach,  in- 
duces vomiting;  or  saliva  which  by  a  spasm  at  the  entrance 
of  the  stomach  is  prevented  from  entering  that  organ,  and  is 
ejected  after  collecting  in  considerable  quantities.  By  others 
it  is  regarded  as  being  formed  by  the  glands  at  the  lower  part 
of  the  oesophagus.  It  was  for  a  long  time  looked  upon  as  a 
secretion  from  the  pancreas;  and  was  considered  a  sign  that 
the  pancreas  was  diseased,  and  not  performing  its  function. 
But  these  views  may  be  easily  proved  to  be  untenable. 

Bile  may  find  its  way  into  the  stomach,  and  be  expelled  by 
the  mouth,  imparting  to  the  vomit  a  greenish  or  yellowish 
color,  and  a  very  bitter  taste.  The  occurrence  of  bilious 
vomiting  is  commonly  held  to  indicate  a  disease  of  the  liver, 
or  that  the  patient  is  extremely  "bilious."  It  is  a  proof  of 
neither.  It  is  observed  when  there  is  much  retching,  and 
when  the  act  of  vomiting  is  protracted  and  frequently  repeated, 
and  is  chiefly  met  with  in  the  various  forms  of  acute  gastritis, 
and  at  tlie  invasion  of  some  acute  malady  which  gives  rise  to 
sympathetic  disturbance  of  the  stomach. 


430  MEDICAL    DIAGNOSIS. 

Fecal  vomiting  never  depends  upon  a  disease  of  the  stom- 
ach. It  may  possibly  be  owing  to  a  fistulous  opening  between 
the  colon  and  the  stomach ;  but  such  cases  are  extremel}-  rare. 
Generally  it  is  due  to  a  mechanical  obstruction  to  the  pas- 
sage of  feces.  Occasionally  it  happens  in  fevers  of  a  low  type, 
or  in  peritonitis,  and  is  then,  perhaps,  the  result  of  paralysis 
of  a  portion  of  the  intestinal  tube,  which  acts,  to  some  extent, 
as  a  mechanical  obstruction.  The  matter  that  is  ejected  has 
the  odor  of  feces  ;  but  it  is  commonly  of  less  firm  consistence, 
and  of  lighter  color.  And  this  because  it  is  often  the  contents 
rather  of  the  small  than  of  the  large  intestine.  Sometimes  it 
is  perfectly  fluid  and  quite  thin. 

It  is  commonly  supposed  that  fecal  vomiting  is  caused  by 
an  inversion  of  the  natural  peristaltic  action  of  the  bowel. 
This  doctrine  has  been  called  in  question  by  Dr.  William 
Brinton.  He  attributes  the  reflux  of  fecal  matter  to  the 
peristalsis  itself,  which,  acting  on  an  obstructed  and  distended 
bowel,  occasions,  as  far  as  possible,  the  forward  propulsion  of 
the  contents  of  the  intestinal  tube,  but  which  also  gives  rise 
to  a  current  in  the  opposite  direction  in  the  fluid  substances 
occupying  the  centre  of  the  tube.  For  the  ingenious  argu- 
ments by  which  this  position  is  maintained,  I  must  refer  to 
his  Gulstonian  Lectures.* 

Pus  in  small  amount  is  sometimes  found  mixed  with  the 
vomit  in  cases  of  large  ulcers  in  the  stomach,  simple  or  can- 
cerous. When  in  quantities,  it  is  owing  to  an  abscess  in  the 
neighborhood  of  the  viscus  having  poured  its  contents  into  it. 
On  the  whole,  pus  is  rarely  met  with  in  the  matters  expelled. 
And  the  same  can  be  said  of  other  substances  which  may  find 
their  way  into  the  stomach,  like  echinococcus  sacs  and  worms, 
and  also  of  masses  of  false  membrane. 

Blood,  on  the  other  hand,  is  not  infrequentlj'  vomited.  It 
is  unnecessary  that  I  should  describe  the  appearance  of  the 
blood  when  it  comes  from  the  stomach,  nor  the  symptoms 
which  accompany  its  discharge ;  this  has  been  done  already 
in  treating  of  the  diagnosis  of  hemorrhage  from  the  lungs. 
I  will  merely  here,  before  examining  into  the  circumstances 


*  Lancet  for  July,  August,  and  Septcaibur,  ISoO. 


DISEASES    OF    THE    STOMACH.  431 

which  cause  a  hemorrhage  from  the  stomach,  recall  the  fact 
that  it  is  preceded  bj  nausea  and  followed  by  black  stools, 
and  that  the  fluid  ejected  is  generally  black,  and  presents  an 
acid  reaction. 

The  quantity  of  blood  lost  varies,  of  course,  very  greatly; 
but  the  amount  vomited  is  by  no  means  a  proof  of  the  amount 
efl'used.  The  larger  portion  may  pass  off  by  the  bowels, 
giving  rise  to  peculiar  tarry  stools.  N'ay,  the  whole  may  be 
voided  with  the  stools;  so  that  vomiting  of  blood  and  hem- 
orrhage from  the  stomach  are  not  always  synonymous. 

Hemorrhage  occurring  from  the  stomach  is  difierently 
caused.  It  may  spring  from  an  injury  to  the  organ,  or  from 
a  disease  of  its  coat ;  it  may  be  vicarious ;  it  may  be  the 
consequence  of  disorder  elsewhere  than  in  the  stomach,  as 
of  a  mechanical  obstruction  in  the  portal  system;  it  may 
depend  upon  an  altered  state  of  the  blood.  But  in  all  cases, 
however  caused,  with  the  exception  of  those  which  arise 
from  a  large  vessel  being  eaten  into  by  the  process  of  ulcer- 
ation, a  hemorrhage  from  the  stomach  is  an  illustration  of 
that  kind  of  capillary  hemorrhage  which  modern  research 
has  proved  to  lie  at  the  root  of  the  so-called  hemorrhages 
"by  exhalation."  The  overdistended  capillaries  burst;  yet 
no  traces  of  their  rupture  can  be  discovered  with  the  unas- 
sisted eye  after  death.  Nor  is  this  difficult  to  account  for, 
when  the  number  and  the  extreme  minuteness  of  the  vessels 
implicated  are  considered. 

In  the  hemorrhage  that  follows  blows  or  kicks  on  the 
stomach,  an  active  hypersemia  of  the  mucous  surface  is  occa- 
sioned, which  leads  to  the  extravasation  of  blood.  An  active 
arterial  hypersemia  also  precedes  the  hemorrhage  that  some- 
times follows  the  swallowing  of  irritant  poisons;  and  it  is 
probably  the  cause  of  the  hsematemesis  in  several  of  the 
organic  atiections  of  the  stomach,  -Of  these,  only  cancer 
and  ulcer  are  apt  to  present  hemorrhage  as  a  prominent 
symptom;  and  of  these  two,  again,  it  is  much  more  frequent 
in  the  latter  than  in  the  former.  The  blood  cfllised  may  be 
so  slight  in  amount  as  to  escape  detection  ;  and  this  is  es- 
pecially likely  to  happen  when  it  is  intimately  admixed  with 
food  or  with  bile.     Yet,  by  means  of  the  microscope,  the 


432  MEDICAL    DIAGNOSIS. 

existence  of  blood  corpuscles  in  the  ejected  matter  can  be 
alwaj's  demonstrated. 

When  blood  has  been  detained  for  some  time  in  the 
stomach,  and  has  become  intimately  mingled  with  the  acid 
contents  of  the  organ,  it  loses  entirely  its  natural  appear- 
ance. "What  is  termed  "  coffee-ground  vomit"  is  blood 
which  has  been  thorous-hlv  intermixed  with  other  substances. 
It  is  the  result  of  a  comparatively  small  or  gradual  hemor- 
rhage ;  and  as  this  is  the  kind  which  is  apt  to  happen  in 
gastric  cancer,  it  is  common  in  this  affection.  It  has  been 
held  to  be  pathognomonic  of  it;  but  it  is  not.  It  occurs  in 
other  morbid  states  of  the  organ.  It  is  also  met  with  in 
3'ellow  fever,  because  in  this  dreadful  malady  the  blood  often 
accumulates  little  by  little  in  the  stomach  before  it  is  expelled. 

Vicarious  hemorrhage  from  the  stomach  is  not  at  all  un- 
frequent,  and  especially  frequent  is  that  which  takes  the 
place  of  the  natural  flow  of  the  menses.  It  is  never  danger- 
ous. The  blood  escapes  more  or  less  exactly  at  the  time  of 
the  normal  discharge,  and  while  the  bleeding  lasts  the 
stomach  is  slightly  tender,  and  the  digestion  impaired.  But 
during  the  intervals  there  are  no  signs  of  a  disturbance  of 
the  functions  of  the  organ,  and  no  pain;  both  of  which  are 
points  of  importance  in  distinguishing  between  loss  of  blood 
caused  by  suppressed  menstruation  and  by  disease  of  the 
stomach. 

Gastric  hemorrhage,  dependent  upon  a  state  oi  imssim  con- 
gestion brought  on  by  an  obstruction  to  the  flow  of  venous 
blood,  is  occasionally  seen  in  organic  affections  of  the  heart. 
But  it  is  much  more  common  as  the  result  of  embarrassment 
of  the  portal  circulation,  from  tumors,  or  from  affections  of 
the  liver  and  spleen.  It  frequently  attends,  therefore,  cir- 
rhosis and  enlargement  of  the  spleen,  and  for  obvious  reasons 
it  is  often  joined  to  intestinal  hemorrhage. 

The  last  cause  of  gastric  hemorrhage  I  have  mentioned  is 
that  resulting  from  changes  in  the  blood.  The  vessels  them- 
selves also  are  toneless,  and  rupture  easily  or  offer  no  resist- 
ance to  their  altered  contents  escaping.  This  kind  of  hem- 
orrhage is  met  with  in  scurvy,  in  typhus  fever,  and  in  j'cllow 
fever. 


DISEASES    OF    THE    STOMACH.  433 

We  see  thus  that  blood  is  vomited  from  various  causes, 
and  that  merely  from  the  occurrence  of  hsematemesis,  we 
can  determine  nothino;  definite  as  to  its  oris-in.  Yet  the 
symptom,  for  a  symptom  it  always  is,  is  one  of  serious 
import,  and  when  taken  in  connection  with  other  signs 
is  of  verv  2:reat  service  in  dias-nosis.  We  ouffht,  in  chronic 
cases,  first  to  suspect  the  hemorrhage  to  be  due  to  some  or- 
ganic disease  of  the  stomach  ;  when  there  is  no  other  proof 
of  a  structural  affection  of  this  organ,  we  turn  to  the  liver, 
spleen,  or  heart  for  its  explanation,  or  examine  carefully 
every  part  of  the  abdominal  cavity,  to  see  whether  or  not  a 
tumor  is  the  source  of  the  trouble.  If  occasioned  by  none 
of  these  conditions,  its  cause  lies  probably  in  altered  blood, 
or  in  suppressed  discharges;  of  course,  the  history  of  the 
case  is  indispensable  to  any  induction.  Thus,  in  low  fevers 
there  is  not  often  much  difficulty  in  determining  what  has 
brought  about  the  hemorrhage.  The  facts  speak  for  them- 
selves. 

There  is,  however,  one  difficulty  present  in  all  instances; 
and  that  is,  to  tell  whether  the  ejected  blood  has  found  its 
way  into  the  stomach,  and  has  been  subsequentl}-  expelled, 
or  whether  the  hemorrhage  is  really  gastric.  The  only 
method  to  avoid  being  deceived,  is  to  scrutinize  closely 
the  history  and  attending  phenomena.  Blood  may  be  in- 
troduced into  the  stomach  by  the  bursting  of  an  aneurism, 
or  from  an  ulcerating  pancreas;  or  it  may  have  been  swal- 
lowed during  an  attack  of  epistaxis  or  of  haemoptysis,  or 
wilfully,  to  excite  sympathy,  or  to  escape  punishment  for 
crime.  The  records  of  medicine  teem  with  such  instances 
of  deception. 

So  much  for  vomiting  of  blood,  and  for  the  different  char- 
acters presented  by  the  vomit.  In  describing  them  we  have 
been  led  away  from  the  indications  they  furnish  in  diseases 
of  the  stomach.  But  it  was  more  convenient  here  to  con- 
sider vomiting  somewhat  connectedly  and  in  detail,  than  to 
be  obliged  to  treat  of  it  in  various  chapters.  To  return  now 
to  the  more  special  symptoms  of  a  deranged  stomach. 

Pain. — Pain  occurs  in  many  of  the  gastric  disorders,  and 

28 


434  MEDICAL    DIAGNOSIS. 

is  met  with  in  every  conceivable  form.  It  is  sometimes  very 
slight ;  at  others,  very  violent.  It  is  often  more  a  feeling  of 
soreness  than  actual  pain.  It  may  or  may  not  be  increased 
by  pressure ;  and  may  either  be  augmented  or  relieved  by 
the  taking  of  food.  If  persistent  or  severe,  and  accompanied 
by  tenderness  at  the  epigastrium,  it  is  almost  always  linked 
to  a  morbid  state  of  tbe  tissues  of  the  viscus.  Mere  uneasy 
sensations,  on  the  other  hand,  also  happen  in  functional  de- 
rangement of  the  organ  while  the  food  is  being  digested; 
and  may  even  be  attended  with  slight  tenderness  at  the 
epigastrium. 

^ow,  as  both  pain  and  soreness  to  the  touch  may  be  pres- 
ent, as  well  in  functional  disturbance  as  in  organic  change, 
bow  can  we  tell  with  which  they  are  associated?  Dr.  Budd* 
lays  down  a  law  on  this  point  which,  on  the  whole,  is  borne 
out  by  the  experience  of  the  profession.  The  pain  and  sore- 
ness, he  affirms,  dependent  on  organic  disease  may  be  distin- 
guished from  the  pain  and  soreness  which  result  from  func- 
tional disorder  by  noticing  the  time  at  which  they  take 
place.  If  they  are  more  severe  soon  after  meals,  or  when 
the  stomach  is  full,  and  more  severe  after  a  heavy  meal  of 
animal  food  than  after  a  light  one  of  farinaceous  substances 
and  milk,  they  point  to  a  structural  afiection.  If  they  occur 
only  when  the  stomach  is  empty  and  are  relieved  by  food, 
they  are  indicative  of  a  functional  derangement.  This  gen- 
eral rule  is  as  true  as  most  general  rules ;  but  no  truer.  The 
confidence  to  be  placed  in  it  depends  to  some  extent  on  the 
meaning  attached  to  the  word  pain ;  for  the  rule  would 
prove  a  very  fallacious  guide,  were  the  uneasiness  and  sense 
of  weight  attendant  on  the  act  of  digestion,  in  those  whose 
gastric  juice  is  deficient  in  quantity  or  in  an  unhealthy  con- 
dition, to  be  regarded  in  the  same  light  as  pain,  and  as  unde- 
niable evidence  of  organic  disease. 

Occasionally  the  stomach  is  the  seat  of  violent  paroxj'sms 
of  pain.  These  are  at  times  linked  to  a  chronic  organic 
affection;  at  others,  they  are  apparently  connected  with  a 
perfectly  sound  state  of  the  viscus,  and  coexist  with  a  tend- 


*  Diseases  of  the  Stomach. 


DISEASES    OF    THE    STOMACH.  435 

ency  to  neuralgic  pains  all  over  the  body;  at  others,  again, 
they  are  brought  about  by  some  article  of  food  which  the 
stomach  does  not  tolerate  or  is  unable  to  digest.  This  sin- 
gular disorder  is  variously  described  under  the  name  of  gas- 
trodynia  or  gastmlgia,  or,  by  some  authors,  as  a  form  of  cardial- 
gia.  The  pain  is  supposed  to  be  associated  with  or  be  due 
to  a  cramp  of  the  stomach ;  but  whether  it  is  so  or  not,  is  far 
from  being  certain.  When  the  predisposition  to  it  exists, 
exposure  to  cold  and  damp,  a  draught  of  cold  water  drunk 
when  heated,  sudden  and  violent  emotions,  or  a  collection  of 
wind  in  the  alimentary  canal,  will  bring  it  on.  And  this 
predisposition  is  met  with  in  gouty  and  rheumatic  per- 
sons, and  in  those  who  are  debilitated, — in  women  who  are 
anemic,  and  in  men  who  have  been  exposed  to  exhausting 
influences. 

The  pain  varies  very  much  in  intensity;  it  is  usually  severe 
and  agonizing;  but  it  is  not  permanent:  intervals  of  rest 
and  comfort  succeed  to  the  paroxysms  of  harrowing  distress. 
During  a  violent  attack,  the  skin  is  cold,  the  pulse  slow, 
there  are  frequently  nausea,  vomiting,  sometimes  fainting, 
and  often  a  feeling  of  utter  prostration  and  impending  dis- 
solution. The  seat  of  the  pain  is  in  the  epigastrium,  im- 
mediately beneath  the  ensiform  cartilage.  The  patient  feels 
as  if  the  coats  of  the  stomach  were  being  violently  drawn 
together,  or  rent  asunder,  or  rapidly  pierced  by  a  sharp  in- 
strument. Thence  the  pain  extends  toward  the  umbilicus 
and  the  hypochondria.  It  is  sometimes  relieved  by  the 
recumbent  position  and  by  external  pressure. 

But  relief,  under  these  circumstances,  depends  much  on 
the  condition  with  which  the  Dain  is  associated.  If  it  be 
connected  with  a  chronic  gastritis  or  an  ulceration,  external 
pressure  aggravates  rather  than  alleviates  it.  This  is  cer- 
tainlj-  true  as  a  general  rule,  yet  we  cannot  always  positivel}- 
announce  that  the  pain  which  is  conjoined  with  tenderness 
at  the  epigastrium  is  a  proof  of  an  organic  lesion.  There  is 
sometimes  sensitiveness  to  the  touch  in  purely  nervous  gas- 
tralgia;  or  slight  pressure  may  augment  the  pain,  but  iirmly 
compressing  the  pit  of  the  stomach  diminish  it. 

In  a  practical  point  of  view,  it  is  very  important  to  dis- 


436  MEDICAL   DIAGNOSIS. 

criminate  between  the  cases  of  gastralgia  which  may  be 
viewed  as  pure  neuralgia  of  the  stomach  and  those  in  which 
the  paroxysms  of  pain  are  combined  with  a  chronic  lesion. 
We  infer  that  we  have  to  deal  with  instances  of  the  former, 
when  the  attacks  occur  in  those  whose  impoverished  blood 
or  enfeebled  health  predisposes  to  neuralgia,  and  especially 
if  they  happen  in  women  laboring  under  disorders  of  the 
uterus  or  ovaries,  or  in  persons  who  suffer  from  neuralgic 
pains  in  other  parts  of  the  body.  But  the  broadest  line  of 
distinction  is  drawn  from  the  state  of  the  digestive  apparatus 
during  the  intervals.  The  disordered  digestion;  the  pain 
after  eating;  the  tenderness  at  the  epigastrium  ;  the  nausea 
and  vomiting ;  and  the  other  symptoms  common  in  morbid 
alterations  of  the  coats  of  the  stomach,  are  not  seen  in  pure 
neuralgic  gastrodynia.  I  have  already  stated  that  too  much 
stress  ought  not  to  be  laid  on  the  influence  of  pressure  on 
the  paroxysmal  pain  during  the  paroxysm.  A  sign  more 
trustworthy  is  the  alleviation  following  the  taking  of  food, 
for  which,  in  truth,  there  may  be  a  craving;  and  occasion- 
ally cases  of  gastralgia  are  met  with,  in  which  the  pain 
occurs  only  early  in  the  mornings,  and  is  very  distressing, 
but  is  almost  immediately  eased  by  a  hearty  breakfast. 

The  form  of  gastrodynia  which  is  produced  by  some  article 
of  food  that  disagrees  with  the  individual  is  readilv  distin- 
guished  from  the  other  varieties,  by  observing  that  it  is  tran- 
sient and  by  noting  its  cause.  The  indigestible  substance 
undergoes  fermentation  in  the  stomach,  and  acidity,  flatulent 
distention,  and  nausea  attend  the  pain,  which  ceases  when 
the  offending  matter  is  ejected  and  the  gas  expelled. 

The  remarks  just  made  apply  also,  in  the  main,  to  other 
manifestations  of  perverted  innervation  of  the  stomach,  such 
as  to  hyperiesthesia,  erethism,  with  or  without  persistent 
vomitings, — forms  happening  usually  in  weak  or  hysterical 
persons,  but  which  in  the  present  state  of  our  knowledge 
are  still  conveniently  classed  with  gastralgia. 

The  nervous  fllaments,  the  irritation  of  which  occasions 
pain  in  the  stomach  whether  paroxysmal  or  not,  belong  to 
the  vagus;  sometimes,  perhaps,  the  distress  originates  in  the 
branches  of  the  sympathetic  that  supply  the  organ.     But  we 


DISEASES    OF    THE    STOMACH.  437 

must  be  careful  not  to  ascribe  tbe  seat  of  every  pain  which  is 
felt  between  the  umbilicus  and  sternum,  or  referred  there,  to 
the  stomach.  Diseases  of  the  pleura,  of  the  heart  and  its 
covering,  aft'ections  of  the  intercostal  nerves,  abscess  of  the 
liver,  intestinal  disorders,  rheumatism  of  the  abdominal 
muscles,  may  give  rise  to  a  pain  in  the  epigastric  region. 
And  again,  spasmodic  pain,  like  that  of  gastralgia,  may  be 
caused  by  colic,  by  disorganization  of  the  tissue  of  the  kid- 
ney and  of  the  pancreas,  and  by  the  passage  of  gall-stones 
or  of  renal  calculi.  The  great  safeguard  against  error  is  to 
bear  in  mind  that  painful  complaints  of  the  stomach  may  be 
mistaken  for  those  enumerated,  and  to  ascertain  carefully, 
in  cases  of  epigastric  distress,  that  there  is  no  cause  beyond 
the  stomach  to  account  for  it.  The  nearer,  in  many  in- 
stances, the  pain  is  to  the  median  line,  or  should  it  occupy 
this,  and  be  very  iixed  and  confined  to  a  small  spot,  the 
greater  is  the  probability  of  its  being  dependent  upon  gastric 
disease ;  and  pain  of  the  character  alluded  to  is  generally 
indicative  of  a  serious  malady. 

Pain  is  the  last  of  the  symptoms  directly  referable  to  the 
derangement  of  the  viscus  itself  to  which  we  shall  allude. 
But  when  the  great  organ  of  assimilation  is  disordered,  other 
organs  suffer,  either  through  sympathy  or  because  the  irrita- 
tion is  transmitted  to  them,  or  because  a  similar  state  of  their 
mucous  surface  is  induced.  The  bowels  are  usually  in  a  very 
sluggish  condition.  It  is  commonly  only  when  the  gastric 
acidity  is  extreme  that  they  are  relaxed.  The  viscera  within 
the  chest  are  frequently  disturbed.  The  patient  is  annoyed 
by  palpitation  and  shortness  of  breathing  after  meals;  and  as 
he  feels  the  agitation  of  his  heart,  and  finds  that  always,  after 
he  has  eaten,  his  face  is  flushed,  the  palms  of  his  hands  hot, 
and  his  temporal  arteries  throbbing,  he  is  apt  to  overlook  the 
derangement  of  his  stomach,  and  to  fancy  himself  laboring 
under  an  incurable  cardiac  affection.  A  dry  cough,  also,  is 
a  not  unusual  concomitant;  but  a  cough  is  sometimes  the 
result  of  coexisting  catarrh  of  the  bronchial  mucous  mem- 
brane,  or  disease  of  the  lung  structure;  and  sometimes  the 
affection  of  the  lungs  precedes  that  of  the  stomach. 

So,  too,  with  the  kidneys.     They  may  be  irritated  by  the 


438  MEDICAL    DIAGNOSIS. 

crude  material  which  has  made  its  way  into  the  blood,  and 
which  they  are  called  upon  to  excrete.  The  urine  often  con- 
tains various  abnormal  constituents  ;  yet  not  seldom  a  morbid 
state  of  the  urine  is  found  previous  to  the  derangement  of 
the  stomach,  and  the  indigestion  is  the  secondary,  rather 
than  the  primary  ailment. 

Indeed,  we  must  never  be  too  hasty  in  concluding,  when  a 
disordered  stomach  is  associated  with  diseases  of  other  vis- 
cera, that  it  is  their  cause ;  it  may  exist  as  their  consequence. 
Diseases  of  the  liver  and  intestines  are  especially  prone  to 
induce  a  gastric  affection. 

One  of  the  worst  results  of  a  disordered  digestion  is  the 
state  of  mind  it  produces.  It  occasions  listlessness  and  sad- 
ness, and  a  disposition  to  look  at  all  events  in  a  gloomy 
light,  and  sometimes  brings  on  the  most  inveterate  hypo- 
chondriasis. Aretseus  ascribed  to  the  stomach  as  its  primary 
power,  that  it  acted  as  the  president  of  pleasure  and  disgust, 
"being,  from  tlie  sympathy  of  the  soul,  an  important  neigh- 
bor to  the  heart  for  imparting  good  or  bad  spirits."  Now, 
although  no  one  at  present  would  agree  with  the  physiology 
of  the  learned  Cappadocian,  who  will  deny  that,  mixed  up 
with  strange  error,  there  is  in  the  remark  a  germ  of  truth  ? 
How  few  men  have  not,  at  one  time  or  another,  experienced 
the  depression,  the  lack  of  energy  which  a  disturbance  in  the 
main  organ  of  digestion  brings  with  it!  But  here,  again, 
we  must  be  careful  not  to  confound  cause  with  effect;  for 
want  of  activity  or  a  distressed  state  of  mind  may  seriously 
impair  the  appetite  and  subvert  the  normal  action  of  the 
viscus.  The  exquisite  description  of  Juvenal,  in  his  Thir- 
teenth satire,  of  the  conscience-stricken  perjurer,  is  hardly 
drawn  with  too  much  poetic  license : 

Perpetua  anxietas,  nee  inonsa3  tempore  cessat, 
Faucibus  ut  niorbo  siccis,  interque  molares 
Difficili  crescenle  cibo  :  sed  vina  misellus 
Exspuit ;  Albani  vcteris  pretiosa  sencctus 
Displicet :  ostendas  melius  dcnsissima  ruga 
Cocritur  in  frontem,  velut  acri  dueta  Falerno. 


^a' 


In  the  rough  sketch  just  finished  of  the  symptoms  encoun- 


DISEASES    OF    THE    STOMACH.  439 

tered  in  gastric  disorders,  no  attempt  has  been  made  to  sep- 
arate the  signs  which  belong  more  particularly  to  alteration 
of  its  coats  from  those  which  occur  in  derano-ement  of  its 
functions  ;  in  other  words,  I  have  not  tried  to  dissociate  the 
symptoms  of  "  dyspepsia"  from  those  of  actual  lesions. 

And  this  for  two  reasons :  in  the  first  place,  the  most  pal- 
pable indications  of  organic  disease  of  the  stomach  are  those 
of  disordered  function  ;  and  secondly,  there  are  no  symptoms 
which  belong  exclusively  to  d^-spepsia.  This  complaint  con- 
sists simply  of  the  phenomena  of  indigestion,  but  in  such 
infinitely  varied  combination  as  to  baffle  the  pen  of  any  one 
who  attempts  to  delineate  it  completely :  in  some  cases  we 
find  pain;  in  others,  nausea  and  disgust  for  food;  in  others, 
again,  uneasiness  after  meals  and  acid  eructations,  or  flatu- 
lency; in  some  the  gastric  symptoms  are  connected  with  de- 
bility, great  depression  of  spirits,  and  with  wasting ;  in  others 
a  fair  amount  of  health  is  preserved,  the  appetite  is  uncertain 
or  perverted,  and  the  signs  of  indigestion  are  onh^  manifest 
after  certain  articles  of  food  have  been  partaken  of  Thus  it 
is  impossible  to  present  anything  like  a  complete  picture  of 
merely  functional  dyspepsia.  ISTor  is  this  necessary;  for  its 
main  features  are  easily  enough  recognized.  In  truth,  the 
liability  to  error  lies  in  an  opposite  direction.  The  faulty 
performance  of  the  act  of  digestion  is  too  often  regarded  as 
the  whole  ailment.  Too  often,  if  the  practitioner  has  made 
out  the  diagnosis  of  "  dyspepsia,"  he  seeks  no  further,  and 
treats  the  patient  for  this,  and  this  alone,  by  means  of  some 
of  the  innumerable  mixtures  which  enjoy  the  reputation  "  of 
being  good  for  dyspepsia."  He  does  not  remember,  or  choose 
to  remember,  that  dyspepsia  ma}'  be  bound  as  a  symptom  to 
structural  alteration  of  the  stomach,  just  as  palpitation  and 
irregular  action  of  the  heart  may  constitute  the  whole  com- 
plaint, but  may  also  be  joined  to  a  serious  valvular  lesion. 
It  is  true  that,  in  an  organ  like  the  stomach,  it  is  particularly 
difficult  to  tell  where  disturbed  function  ceases  and  anatomical 
change  begins.  Still,  that  this  can  be  done  to  a  greater  ex- 
tent than  it  is  usually  done,  caunot  be  gainsaid.  Moreover, 
there  are  a  great  many  affections  which  probably  have  con- 
nected with  them  definite  anatomical  lesions  and  constant 


440  MEDICAL    DIAGNOSIS. 

modifications  of  the  gastric  juice  and  of  the  secretions  of  the 
mucous  follicles  of  the  stomach,  which  we  are  as  yet  obliged 
to  embrace  under  the  name  of  dyspepsia;  and  this  because 
we  are  unacquainted  with  their  clinical  expression.  But  we 
may  fairly  hope  that,  through  those  admirable  physiological 
and  pathological  researches  which  have  of  late  commenced 
to  illuminate  the  subject,  our  ignorance  will  be  dispelled, 
and  b}^  their  aid  we  may  expect  the  limits  of  purely  func- 
tional dyspepsia  to  be  much  reduced ;  so  that  what  the  phy- 
sician of  the  present  day  is  compelled  to  class  under  the  gen- 
eral term  dyspepsia  will  be  recognized  by  the  physician  of 
the  twentieth  century  as  several  distinct  aft'ections,  each  with 
its  characteristic  structural  change, — much  in  the  same  way 
that  the  physician  of  the  eighteenth  century  was  obliged  to 
regard  and  to  Ireat  dyspnoea  as  an  individual  disease,  while 
now  we  have  learned  to  separate  it  into  different  varieties,  in 
conformity  with  its  prominent  anatomical  causes,  and  to  treat 
it  in  accordance  with  its  source. 

Diseases  of  the  Stomach  in  which  Pain  and  Soreness  at  the 
Epigastrium,  and  Vomiting  occur. 

After  what  has  been  premised,  it  is  obvious  that  the  struc- 
tural diseases  of  the  stomach,  so  far  as  they  are  known  up  to 
this  time,  present  but  very  few  symptoms  which  can  be  re- 
garded as  at  all  characteristic.  Indeed,  the  only  ones  which 
can  lay  any  claim  to  be  so  considered — and  we  have  already 
seen  that  this  claim  is  not  always  valid — are  pain  and  sore- 
ness at  the  epigastrium,  and  vomiting.  We  may,  then,  take 
these  symptoms  as  a  starting-point  in  diagnosis,  and  describe 
the  individual  organic  afiections  in  which  they  chiefly  occur, 
speaking  first  of  those  that  are  acute. 

Acute  Gastritis. — This  malady  is  now  pronounced  by  all 
authors  to  be  exceedingly  rare,  save  as  the  result  of  irritant 
poisons.  Yet  there  was  a  time,  and  that  not  fifty  years  ago, 
when  acute  inflammation  of  the  stomach  was  held  to  be  very 
frequent,  and  when  this  idea  was  made  the  keystone  of  a 
wondrous  edifice  of  pathological  and  therapeutic  theory,  which 
counted  its  admirers  by  hundreds  in  every  part  of  the  civilized 


DISEASES    OF    THE    STOMACH.  441 

world.  The  discrepancy  of  opinion,  as  regards  the  frequency 
of  the  disease,  may,  to  some  extent,  be  explained  by  the  var}'- 
inff  latitude  ficiven  to  the  term  inflammation.  Undoubtedly, 
inflammation  of  an  intense  kind,  involving  more  than  the 
mucous  membrane,  originating  spontaneously,  and  not  from 
the  introduction  of  any  highly  acrid  or  corrosive  substance 
into  the  stomach,  is  very  seldom  met  with.  But  it  is  no  less 
certain  that  inflammation  of  a  less  active  character,  limited 
to  the  most  important  part  of  the  stomach,  to  the  mucous 
membrane,  and  especially  to  its  surface,  is  far  from  being  a 
rare  disease;  and  whether  as  a  concomitant  of  fevers,  or  as 
an  idiopathic  malady,  is  a  disorder  to  which  the  practitioner's 
attention  is  constantly  drawn. 

Thus,  then,  acute  inflammation  of  all  the  coats  of  the 
stomach,  or  even  of  the  entire  mucous  membrane,  is  uncom- 
mon ;  acute  inflammation  of  its  surface  is  common.  Yet  it 
is  the  doctrine  of  the  day,  not  to  regard  any  case  as  acute 
gastritis,  unless  serious  changes  have  been  wrought  by  the 
inflammation  in  the  tissues  of  the  organ,  so  serious  as  almost 
to  preclude  recovery.  To  discuss,  in  a  work  of  this  kind,  the 
correctness  or  incorrectness  of  this  view,  would  hardly  be 
justifiable.  But,  before  proceeding,  I  would  venture  to  sub- 
mit, whether  the  limits  within  which  acute  inflammation  is 
supposed  to  be  confined  are  not  more  rigidly  marked  out  for 
the  stomach  than  for  any  other  viscus  ;  whether  it  is  not  very 
arbitrary  and  artificial  to  make  severity  and  consequence  the 
test  of  acute  inflammation;  and  whether  a  state  of  things 
fully  entitled  to  be  called  acute  idiopathic  gastritis  is  not  more 
frequent  than  is  generally  admitted  ?  I  am  sure  that  I  have 
seen  cases  which  diflfered  in  nothing  from  the  typical  and 
graphically  described  cases  of  Andral,*  save  in  the  fatal  ter- 
mination and  in  lacking  the  symptoms  which  immediately 
precede  that  termination. 

To  detail  one  which  was  very  striking:  a  robust  woman, 
the  mother  of  several  children,  whom  she  was  obliged  to 
support  by  hard  labor,  was  suddenly  seized  with  a  pain  in 
the  epigastric  region,  and  vomiting.    There  was  no  apparent 


*  Clinique  Medicalc,  tome  ii. 


442  MEDICAL   DIAGNOSIS. 

cause  for  the  attack:  she  had  certainly  not  swallowed  any 
irritating  substance.  Although  at  one  time  a  sufierer  from 
indigestion,  her  digestive  organs  had  not  been  markedly  dis- 
ordered for  weeks  prior  to  the  appearance  of  the  pain  and 
irritability  of  the  stomach.  The  former  seemed  to  come  on 
before  the  latter.  It  was  of  a  dull  character,  increased  by 
swallowing  either  solids  or  liquids,  and  associated  with  the 
greatest  tenderness.  Nausea  was  constant,  and  vomiting  very 
frequent.  Large  quantities  of  a  greenish  fluid  were  ejected, 
as  well  as  nearly  everything  she  swallowed.  The  tongue  was 
deeply  coated;  its  edges  and  tip  were  red.  The  bowels  were 
constipated,  but  not  painful  on  pressure.  There  was  fever, 
not,  however,  of  an  active  type;  the  skin  was  hot  toward 
evening;  the  pulse  quick  and  small ;  the  breathing  was  hur- 
ried, and  the  patient  exceedingly  restless  and  prostrated. 
She  complained  most  of  the  distress  in  her  head,  and  of  vio- 
lent thirst.  The  treatment  pursued  consisted  mainly  in  open- 
ing the  bowels  b}^  enemata,  and  in  administering  ice  and  re- 
peated doses  of  calomel,  some  of  which  she  retained.  After 
the  symptoms  had  lasted  for  about  ten  days,  they  graduall}' 
disappeared,  and  she  slowly  recovered.  The  pain  on  swal- 
lowing and  the  soreness  at  the  epigastrium  were  the  last  to 
leave.  Indeed,  when  she  passed  from  under  my  care,  they 
had  not  ceased  entirely.  I  cannot  say  whether  the}'  ever  did, 
for  I  lost  sight  of  the  patient. 

Now,  here  is  a  case  which  presented  all  the  symptoms  of  a 
severe  inflammation  of  the  stomach,  similar  to  that  produced 
when  an  irritant  poison  has  been  received  into  the  organ. 
In  all  such  instances  there  are  the  same  nausea  and  vomit- 
ing, and  pain;  the  same  restlessness  and  headache;  the  same 
form  of  fever  and  small  or  feeble  pulse;  the  same  unquench- 
able thirst.  Sometimes  the  pain  is  of  a  burning  kind;  and  in 
those  cases  which  prove  fatal, — and  many  do  prove  fatal,  as 
much  perhaps  from  the  destructive  effect  of  the  irritant  on 
the  tissues  as  in  consequence  of  the  inflammation, — there  is 
hiccough,  the  skin  becomes  cold,  the  features  collapse,  and 
the  sufferer  dies  prostrated,  yet  frequently  preserving  his 
mental  faculties  to  the  last. 

From  these  severe  cases  of  acute  gastritis,  however  caused, 


DISEASES    OF    THE    STOMACH.  443 

there  exists  every  grade  of  inflammation  down  to  an  active 
congestion  of  the  mucous  membrane,  and  to  a  mere  redden- 
ing of  its  surface.  Of  course,  there  will  not  be  in  the  milder 
forms  the  same  intensity  in  the  symptoms.  But  the  outline 
is  the  same,  although  the  filling  in  be  in  far  less  vivid  hues. 
There  is  in  all  the  same  tendency  to  nausea  and  to  vomit- 
ing, with  more  or  less  epigastric  pain  and  uneasy  sensations, 
and  more  or  less  tenderness  at  the  pit  of  the  stomach,  and 
headache. 

A  mild  gastritis  is  very  commonly  brought  on  by  a  de- 
bauch or  by  the  introduction  of  irritating  articles  of  diet 
into  the  stomach.  These  cases  are  popularly  known  as 
severe  attacks  of  indigestion ;  that  they  are  owing  to  an  in- 
flammatory state  of  the  mucous  membrane,  was  proved  by 
the  ocular  demonstration  Dr.  Beaumont  had  of  the  process 
in  the  person  of  Alexis  St.  Martin.  Dr.  Beaumont  found 
that  whenever  Alexis  had  been  eating  plentifully  of  sub- 
stances hard  of  digestion,  or  drinking  freely  of  ardent 
spirits,  the  mucous  surface  of  the  stomach  exhibited  patches 
of  redness  of  various  size,  from  which  now  and  then  small 
drops  of  blood  exuded.  Aphthous  spots  were  also  detected, 
and  the  secretions  were  evidently  arrested,  although  occa- 
sionally a  considerable  quantity  of  ropy  mucus  collected  on 
the  surface  of  the  membrane.  The  symptoms  these  changes, 
when  they  were  marked,  produced,  were  some  tenderness  at 
the  epigastrium;  nausea;  vomiting;  constipation,  or  some- 
times diarrhoBa ;  a  coated  tongue,  and  headache, — in  fact, 
just  the  symptoms  of  which  patients  complain  when  thej  are 
suffering  from  an  acute  attack  of  indigestion. 

Another  common  and  kindred  kind  of  mild  inflammation 
of  the  stomach  is  that  usually  called  a  "  bilious  attack."  The 
French  designate  it  expressively  as  emharras  gasirique.  English 
writers,  borrowing  a  term  from  the  Germans,  describe  it  as 
a  variety  of  gastric  catarrh.  In  truth,  it  is  like  a  catarrhal 
affection,  and  is  often  associated  with  catarrh  of  other  mu- 
cous membranes.  It  sometimes  occurs  in  epidemics.  The 
symptoms  are  those  already  detailed.  There  is  nausea, 
and  frequently  bile  is  vomited.  We  do  not  usually  observe 
much  pain  in  the  epigastrium;  but  rather  a  feeling  of  uneasi- 


444  MEDICAL    DIAGNOSIS. 

uess,  and  a  slight  soreness  to  the  touch.  The  urine  is  com- 
monly dark,  and  deposits  urate  of  ammonia ;  the  tongue  is 
much  coated ;  there  is  thirst,  with  generally  a  slight  fever, 
which  exacerbates  at  night.  From  the  latter  circumstance, 
remittent  fever  is  treated  of  by  some  authors  as  an  acute 
gastric  catarrh  ;  but  this  is  giving  to  one  of  the  j)henomena 
in  this  disease  a  prominence  to  which  it  is  not  entitled. 

Secondary  acute  inflammation  of  the  mucous  membrane  of 
the  stomach  is  found  in  association  with  various  disorders. 
It  is  met  with  in  remittent  fever,  in  typhus,  in  the  exanthe- 
mata, in  rheumatism,  and  oftener  in  gout,  and  partakes 
somewhat  of  the  specific  character  of  the  malady  with  which 
it  happens  to  be  combined.  Indeed,  instead  of  being  a  sec- 
ondary inflammation,  it  is  oftener,  to  speak  correctly,  a  local 
expression  of  a  constitutional  state. 

Several  writers  describe  a  form  of  gastritis  which  occurs 
in  very  young  children,  and  leads  to  softening  of  the  mucous 
lining  of  the  stomach.  Jseger,  Cruveilhier,  and  Billard  in 
particular  have  made  this  acide  gastric  softening  the  subject  of 
special  study.  Yet  its  nature  is  not  fully  understood.  There 
are  some  who  believe  the  gelatinous  softening  to  be  the  con- 
sequence of  inflammation ;  others  who  regard  it  as  nothing 
but  the  post-mortem  result  of  the  solvent  powers  of  the 
gastric  juice ;  while  others  again  maintain  it  to  be  due  to  a 
pathological  process  that  is  not  inflammatory,  but  which  has 
disorganized  the  tissues  during  life.  The  symptoms  which 
are  ascribed  to  the  malady  are  certainly  exactly  like  those  of 
acute  inflammation  of  the  stomach.  As  I  have  no  experience 
in  this  strange  disorder,  I  shall  follow  closely  the  delineation 
given  of  it  by  Billard.* 

The  disease  usually  commences  with  the  signs  of  a  violent 
gastritis,  with  tension  of  the  epigastric  region,  which  is  pain- 
ful to  the  touch ;  with  vomiting,  not  only  of  the  milk  and  the 
other  liquids  swallowed,  but  also  of  a  green  or  yellow  fluid. 
This  vomiting  happens  either  immediately  or  some  time  after 
the  child  has  taken  food  or  drink.  There  is  occasionally 
diarrhoea ;  and  the  discharges  from  the  bowels  are  frequently 

*  Maladies  des  Enfants  nouveau-nes. 


DISEASES    OF    THE    STOMACH.  445 

greenish,  resembling  those  from  the  stomach.  The  respira- 
tion is  hurried  and  jerking;  the  extremities  are  cold;  the 
face  and  cry  expressive  of  suftering ;  the  agitation  is  great. 
To  this  state  succeeds  one  of  general  prostration  and  insen- 
sibility, and  at  the  end  of  six,  eight,  or  fifteen  days,  the 
patient  dies  exhausted,  from  want  of  sleep  and  from  the  con- 
stant vomiting  and  pain.  In  very  young  children,  there  is 
hardly  any  fever.  The  disease  sometimes  runs  a  more  chronic 
course.  It  may  be  combined  with  a  similar  softening  of  the 
intestines.  Cruveilhier  has  seen  it  occur  in  epidemics.  He 
describes  a  prodromic  period,  marked  by  a  rapid  loss  of 
strength,  and  by  intense  thirst. 


Chronic  Diseases  attended  with  Pain,  Epigastric  Tenderness, 

and  Vomiting. 

The  chronic  diseases  of  the  stomach  may,  like  the  acute, 
be  considered  in  accordance  with  the  pain,  the  soreness  at 
the  epigastrium,  and  the  vomiting  that  attend  them.  At  all 
events,  these  are  the  symptoms  common  to  the  chronic  dis- 
eases which  are  susceptible  of  diagnosis.  Besides  these,  there 
are  some  chronic  disorders  with  the  morbid  anatomy  of  which 
recent  careful  researches  have  made  us  familiar, — such  as 
destruction  of  the  tubular  structures ;  hypertrophy  of  the 
solitary  glands  ;  interstitial  growths  leading  to  their  wasting, 
and  to  a  o-radual  fibroid  thickening  of  the  entire  mucous  or 
submucous  coat;  fatty  degeneration  of  the  atrophied  masses,* 
— but  which  we  are  as  yet  utterly  unable  to  distinguish  at 
the  bedside,  and  which,  so  far  as  has  been  ascertained,  may 
even  be  entirely  latent. 

Contrasting  the  chronic  diseases  with  which  we  are  clin- 
ically acquainted  with  the  acute,  vomiting  is  found  to  be  a 
symptom  of  greater  diagnostic  value — not  the  act  itself,  but 
the  appearances  of  the  ejected  matter.  And  further,  the  phe- 
nomena of  dyspepsia  stand  forth  much  more  conspicuously. 

Chronic  Gastritis.— In  chronic  inflammation  of  the  mu- 


*  See  Hfindfield  Jones,  Pathological  and  Clinical  Observations  respecting 
Morbid  Conditions  of  the  Stomach. 


446  MEDICAL   DIAGNOSIS. 

cous  membrane,  or  clironic  catarrh  of  the  stomach,  as  it  is 
called  by  some,  the  symptoms  of  indigestion  are  very  per- 
sistent and  very  manifold.  They  vary  somewhat  according 
to  the  extent  of  the  mucous  surface  involved  and  the  amount 
of  mucus  and  epithelium  which  accumulates  on  it,  and  prob- 
ably also  according  to  the  healthy  or  wasted  state  of  the  gas- 
tric glands.  Generally  there  is  a  sensation  of  discomfort,  of 
weight,  and  of  soreness  at  the  pit  of  the  stomach,  which  is 
aggravated  by  food ;  the  part  is  also  tender  to  the  touch. 
Sometimes,  even  when  the  stomach  is  empty,  a  burning  at 
the  epigastrium  and  an  inward  fever  are  complained  of.  The 
appetite  is  impaired  or  capricious.  Fermentation,  heart-burn, 
and  flatulency  frequently  attend  the  slow  digestion  of  the 
food ;  the  tongue  is  usually  heavily  coated ;  it  may,  how- 
ever, be  clean.  The  bowels  are  almost  always  constipated. 
The  urine  contains  an  excess  of  phosphates  or  urates,  or  ex- 
hibits crystals  of  oxalate  of  lime.  The  patient's  circulation 
is  languid.  He  sutlers  from  chilliness.  His  spirits  are  de- 
pressed. Not  unfrequently,  when  the  case  has  been  of  long 
duration,  he  is  annoyed  by  vomiting,  after  meals,  the  half- 
digested  food  mixed  with  strings  of  mucus.  But  the  vomit- 
ing may  also  take  place  when  the  stomach  is  empty,  and  the 
ejected  matter  be  fluid  and  colorless.  Drunkards  who  sufier 
from  chronic  gastritis  often  throw  up  a  quantity  of  glairy 
fluid  on  rising  in  the  morning.  A  colorless  vomit,  joined  to 
symptoms  of  long-continued  indigestion,  is  always  very  char- 
acteristic of  chronic  gastritis. 

Thus,  then,  occasionally  the  character  of  the  vomit,  more 
frequently  the  coated  tongue,  the  distress  after  eating,  the 
soreness  at  the  epigastrium,  and,  especially,  the  permanence 
of  the  symptoms,  distinguish  the  dyspepsia  of  chronic  in- 
flammation of  the  stomach  from  that  which  is  purely  func- 
tional ;  for,  although  cases  of  chronic  gastritis  may  recover, 
and  often  do  recover,  yet  the  amelioration  is  very  gradual, 
and  months  or  years  elapse  before  restoration  to  health  takes 
place. 

The  causes  of  the  malady  are  often  obscure.  It  certainly 
cannot  always,  nor  in  truth  frequently,  be  traced  to  an  ante- 
cedent acute  attack,  although  those  who  sufler  from  the 


DISEASES    OF    THE    STOMACH.  447 

chronic  disorder  are  particularly  prone  to  acute  exacerba- 
tions. It  is  more  common  in  persons  over  than  under  forty 
years  of  age.  It  is  especially  common  in  gourmands  and 
drunkards,  and  in  those  who  live  on  coarse  food.  It  is  often 
found  conjoined  with  chronic  bronchitis,  and  sometimes 
with  tubercular  disease  of  the  lungs.  Passive  congestion 
undoubtedly  acts  as  a  predisposing  element.  The  inflam- 
mation is  seen  to  arise  from  this  cause  in  the  course  of 
chronic  affections  of  the  heart,  of  the  liver,  and  of  obstruc- 
tions to  the  portal  circulation,  whether  complicated  with  a 
lesion  of  the  liver  or  not. 

Chronic  gastritis  is  frequently  associated  with  ulcers  in  the 
organ  or  with  cancer,  and  many  of  the  symptoms  of  these 
disorders  are  clearly  attributable  to  it.  Let  us  inquire 
whether  there  are  any  special  symptoms  to  inform  us  that 
something  more  dangerous  than  chronic  inflammation  of  the 
mucous  membrane  of  the  stomach  exists. 

Gastric  Ulcer. — Ulcer  of  the  stomach  is  a  disease  com- 
paratively rare  in  this  country  ;  but  it  is  not  so  in  some  parts 
of  the  Continent  of  Euroj)e  and  in  England.  It  has,  es- 
pecially of  late  years,  been  made  the  subject  of  careful 
study  by  several  eminent  pathologists  and  physicians.  The 
remarks  about  to  be  made  are  based  partly  on  a  perusal  of 
the  valuable  material  that  has  been  collected;  partly  on  a 
number  of  undoubted  cases  of  the  aflection  which  have 
come  under  mv  notice. 

The  ulcer  or  ulcers,  for  there  are  sometimes  several  pres- 
ent, are  seated  most  usually  in  the  posterior  wall  of  the 
stomach,  in  or  near  the  lesser  curvature  and  toward  the  py- 
loric extremity.  The  great  danger  arises  from  perforation 
of  the  coats  and  subsequent  peritonitis.  But  the  ulceration 
may  prove  fatal  by  opening  a  large  blood-vessel.  Again, 
the  protracted  suffering  and  excessive  vomiting  may  grad- 
ually exhaust  the  vital  energies.  On  the  other  hand,  the 
ulcers  may  heal  by  cicatrization;  and  this,  according  to  Dr. 
Brinton,  who  has  written  a  very  able  monograph  on  Gastric 
Ulcer,  takes  place  in  about  half  the  instances.  In  cases 
which  may  be  regarded  as  typical,  the  malady  is  announced 
by  symptoms  exactly  like  those  witnessed  in  chronic  gas- 


448  MEDICAL    DIAGNOSIS. 

tritis — the  same  uneasiness  and  pain  at  the  epigastrium,  and 
occasional  nausea  and  vomiting  of  food,  or  of  a  watery  fluid. 
Perforation  may  at  this  early  stage  of  the  disease  most 
unexpectedly  cut  short  the  patient's  life.  Should  perfora- 
tion not  take  place,  hemorrhage  from  the  stomach,  with 
emaciation  and  anaemia,  next  appears.  In  this  way  the 
disease  usually  continues  for  several  months,  or  sometimes 
for  a  much  longer  period,  the  symptoms  remitting  from 
time  to  time,  and  showing  sino-ular  variations  in  their 
severity. 

Of  these  symptoms,  the  pain  and  the  vomiting  are  the 
most  characteristic.  Pain  is  rarely  absent;  never,  perhaps, 
except  in  cases  which  run  a  rapid  course.  It  is  generally  a 
continuous  dull  feeling;  sometimes  a  burning,  at  others  a 
gnawing  sensation.  As  a  rule,  it  is  rendered  more  acute 
within  a  quarter  of  an  hour  after  eating,  and  remains  so  as 
long  as  food  occupies  the  stomach.  Its  situation  is  commonly 
in  the  middle  of  the  epigastric  region,  and  there  it  continues 
strictly  limited.  At  that  point,  too,  there  is  localized  sore- 
ness, or  even  great  tenderness  to  the  touch.  Sometimes  the 
pain  is  seated  behind  the  ensiform  cartilage,  or  is  referred  to 
the  right  or  to  the  left  hypochondrium.  It  is  often  asso- 
ciated with  a  gnawing  pain  in  the  lower  dorsal  vertebrae, 
which  may  shoot  between  the  scapulfe  or  down  the  spine ; 
but  the  dorsal  pain,  like  the  epigastric,  is,  on  the  whole,  very 
fixed,  and  radiates  but  little.  Besides  this  continued  feeling 
of  distress  occur  violent  paroxysms  of  pain,  which  may  last 
for  several  hours ;  nay,  with  trifling  intermissions,  even  for 
days.  They  are  aggravated  by  pressure  or  by  food  ;  and,  in 
fact,  they  are  often  thus  induced,  but  not  always,  for  they 
sometimes  come  on  suddenly  when  the  viscus  is  empty.  The 
patient  refers  the  suffering  chiefly  to  the  pit  of  the  stomach, 
or  to  the  dorsal  vertebrae.  He  is  apt  to  seek  the  recumbent 
posture  for  its  relief.  Yet  it  is  a  circumstance  not  a  little  re- 
markable in  the  history  of  gastric  ulcer,  that  there  are  some- 
times long  intervals  during  which  all  pain,  whether  par- 
oxysmal or  not,  ceases,  and  during  which  food  can  be  taken 
without  inconvenience. 

The  peculiarities  the  pain  exhibits  form,  on  the  whole,  the 


DISEASES    OF    THE    STOMACH.  449 

most  distinctive  symptom  of  gastric  ulceration.  Tlie  parox- 
ysms just  spoken  of  might  be  mistaken  for  a  purely  nervous 
gastralgia.  And,  indeed,  when  it  is  considered  that  both 
disorders  are  specially  apt  to  occur  in  anemic  women,  and  in 
those  whose  menstrual  functions  are  deranged,  it  becomes 
apparent  how  easily  this  mistake  may  be  committed.  The 
soreness  at  the  epigastrium;  the  persistent  symptoms  of  in- 
digestion ;  the  increase  of  pain  after  meals, — constitute,  in  a 
diagnostic  point  of  view,  the  great  safeguard  against  error. 
To  these  might  be  added  the  vomiting  of  blood,  were  it  not 
that  vicarious  hemorrhages  are  not  at  all  unlikely  to  take 
place  in  young  women  who  are  troubled  with  amenorrhcea. 

This  is,  in  truth,  a  matter  having  a  very  close  connection 
with  the  diao;nosis  of  gastric  ulceration.    Persons  who  suffer 
from  a  disturbance  of  the  menstrual  function  are  prone  to  be 
hysterical ;  and  it  may  happen  that  one  of  the  most  marked 
traits  of   the  hysterical  disorder  is,  that  it   manifests  itself 
by  tenderness  in  the  epigastric  region,  and  by  pain  in  the 
stomach.     We  may  thus  have  the  most  significant  signs  of 
gastric  ulcer,  occurring,  as  so  very  many  cases  of  amenorrhcea 
do,  in  chlorotic  young  women;  therefore  in  the  very  class 
among  whom  ulceration  of  the  stomach  is  most  frequently 
found.     Nay,  as  I  had  occasion  to  note  in  a  patient  who  was 
under  my  care,  the  very  history  may  point  to  the  probability 
of  a  gastric   ulcer.*     Yet   generally,  by  close   attention  to 
all  of  the  phenomena  of  the  case,  we  can  arrive  at  a  correct 
conclusion.     The  tenderness  of  the  simulated  malady,  as  in 
all  local  hysterical  affections,  is  very  great  on  the  slightest 
touch;  and  there  is  no  severe  pain  posteriorly  corresponding 
to  the  spot  of  soreness  in  the  epigastric  region.     Pressure 
upon  a  spinous  process  may  cause  pain ;  but  it  is  not  the  pe- 
culiar dorsal  pain  of  gastric  ulceration.    Then,  in  the  hyster- 
ical complaint  there  is  often  hyperpesthesia  of  the  skin  in 
various  portions  of  the  body,  and  the  apparent  gastric  distress 
bears  no  relation  to  the  takins:  of  food  or  to  the  circumstance 
of  its  being  of  an  irritating  character  or  otherwise.     Lastly, 

*  Philadelphia  Hospital,  Jan.  21st,  1863 ;  reported  by  Dr.  H.  C.  Wood, 
in  Med.  and  Surg.  Keporter,  Feb.  1863. 

29 


450  MEDICAL    DIAGNOSIS. 

the  cast  of  the  features  and  other  evidences  of  a  hysterical 
constitution  will  assist  us  in  the  diagnosis. 

But  to  return  to  the  vomiting  of  blood.  "When  this  is  not 
traceable  to  a  suppression  of  a  natural  discharge,  and  when 
it  does  not  befall  a  person  who  suffers  from  a  disease  of  the 
heart,  or  liver,  or  spleen,  or  oesophagus,  it  acquires  great  sig- 
nificance. It  is  the  only  kind  of  vomit  at  all  distinctive  of  a 
gastric  ulcer;  for  the  substances  ejected  present  otherwise 
appearances  not  different  from  what  they  do  in  chronic  gas- 
tritis. The  blood  may  be  pure  and  red,  but  it  is  more  fre- 
quently blackened  by  the  gastric  juice;  and  large  quantities 
are  sometimes  passed  by  stool.  Now,  hemorrhage  does  not 
take  place  in  chronic  inflammation  of  the  mucous  membrane 
of  the  stomach.  In  those  instances  in  which  erosions  exist 
on  the  surface,  the  vomited  mucus  may  be  a  little  streaked 
with  blood ;  yet  anything  like  a  profuse  hemorrhage  never 
happens.  Hence  its  occurrence  in  a  case  with  the  symptoms 
of  chronic  gastritis  renders  the  presence  of  an  ulcer  very 
probable. 

But  in  concluding  this  sketch  of  gastric  ulceration,  two 
questions  arise  which  require  solution  :  Does  an  ulcer  always 
produce  the  peculiar  train  of  symptoms  mentioned?  May  not 
the  same  phenomena  be  met  with  in  other  disorders?  The 
first  question  must  be  answered  in  the  negative.  Many  a  case 
of  ulceration  of  the  stomach  occasions  nothing  but  the  symp- 
toms of  chronic  gastritis  ;  and  even  these  may  not  be  marked. 
The  second  question  is  to  be  answered  in  the  affirmative. 
There  is  a  disorder  with  symptoms  almost  identical  with 
gastric  ulceration,  namely,  the  corrosive  ulcer  of  the  duodenum. 
Now  this  affection,  were  it  more  frequent,  would  be  a  con- 
stant source  of  error  in  diagnosis.  It  may  run  an  acute,  or  at 
least  an  apparently  acute,  or  a  chronic  course.  In  either  case, 
it  is  scarcely  distinguishable  from  gastric  ulceration.  Trier,* 
from  an  analysis  of  twenty-six  cases,  mentions  as  the  most 
important  ground  for  a  difierential  diagnosis,  signs  of  dila- 
tation of  the  stomach ;  a  sensitive  tumor  in  the  epigastrium, 


*  Quoted  in  Brit,  and  Foreign  Medico-Chirurg.  Eeview,  Fob.  1864 ;  see, 
also,  monograiih  by  Krauss,  and  remarks  on  it  in  Nicmcyer's  work  on  Prac- 
tical Medicine. 


I 


DISEASES    OP    THE    STOMACH.  451 

proceeding  from  adhesion  with  the  pancreas;  and  jaundice 
or  other  hepatic  phenomena.  But  these  symptoms  are  far 
from  constant,  and  in  accordance  with  his  own  showing,  in 
the  acute  cases,  and  in  those  chronic  cases  which  run  a  latent 
course,  the  diagnosis  is,  with  our  present  means  of  research, 
impossible.  It  may  be  added  that  the  perforating  ulcer  of 
the  duodenum  is  much  more  apt  than  ulcer  of  the  stomach 
to  remain  latent,  and  to  lead  suddenly  to  a  fatal  termination. 

There  is  yet  another  disorder  with  symptoms  like  those  of 
ulcer,  a  disorder  still  more  serious  and  destructive — namely, 
cancer. 

Gastric  Cancer. — Cancer  is  found  more  frequently  in  the 
stomach  than  in  any  other  organ  excepting  the  uterus.  Of 
nine  thousand  one  hundred  and  eighteen  cases  of  cancer 
which  occurred  in  Paris  from  1837  to  1840,  two  thousand 
three  hundred  and  three  were  in  the  stomach.*  The  disease 
is  generally  primary.  It  is  most  often  seated  at  the  pylorus; 
next  in  frequency  stands  the  cardiac  orifice;  most  rarely  does 
it  involve  the  whole  viscus.  We  find  all  the  varieties  of 
cancer  affecting  the  stomach ;  but  none  is  so  common  as 
scirrhus.  Indeed,  what  is  called  cancer  of  the  stomach 
means,  in  the  large  majorit}'  of  cases,  scirrhus;  and,  more- 
over, scirrhus  at  the  pyloric  extremity,  deposited  primarily 
in  the  textures  which  intervene  between  the  mucous  and  the 
serous  coat.  It  would  be  out  of  place  to  enter  here  into  a 
minute  description  of  the  appearances  of  a  gastric  scirrhus. 
I  will  only  state  that  I  have  usually  found  it  to  present  cell- 
growths  less  marked  than  those  of  scirrhus  of  any  other  part 
of  the  body. 

The  symptoms  of  cancer  of  the  stomach  are  the  same  as  of 
chronic  gastritis — pain,  tenderness  in  the  epigastrium,  dis- 
ordered digestion,  vomiting.  In  a  more  advanced  state  of  the 
cancerous  malady  they  may  be  those  of  gastric  ulcer,  hemor- 
rhage being  added  to  the  list  above  given.  There  is  only 
one  symptom  at  all  distinctive  of  cancer — namely,  the  exist- 
ence of  a  tumor,  and  this  is  so  only  when  it  is  joined  to 
digestive  troubles  and  to  increasing  debility  and  emaciation. 

But  let  us  see  if  there  is  nothing  in  the  pain  and  vomiting, 


*  "Walshe  on  Cancer. 


452  MEDICAL    DIAGNOSIS. 

or  ill  the  accompanying  circumstances  of  the  case,  by  wliich, 
even  when  a  tumor  cannot  be  discovered,  the  presence  of  a 
cancer  may  be  suspected.  Pain  is  a  very  constant  symptom; 
quite  as  constant  as  it  is  in  gastric  ulcer.  But  the  pain  is,  as 
a  rule,  more  continued,  much  less  influenced  by  the  taking 
of  food,  and  more  radiating,  being  often  referred  to  the  right 
or  left  hypochondrium.  Its  character  is  very  varying.  It 
may  be  dull,  gnawing,  or  it  may  be  lancinating.  It  may  be 
slight,  or  it  nuiy  amount  to  excruciating  agony.  It  is  often 
of  the  latter  kind.  But  it  is  a  mistake  to  suppose  that  a 
cancer  of  the  stomach  necessarily  causes  severe  or  lancinating 
pain.  Again,  it  should  be  borne  in  mind  that  the  part  dis- 
eased may  ulcerate,  and  then  the  pain  is  exactly  like  that  of 
an  ordinary  gastric  ulcer,  and  is  affected  in  the  same  way  by 
food. 

Vomiting  is  not  an  invariable  result  of  a  cancer;  yet  it  is 
a  very  frequent  one.  The  seat  of  the  morbid  growth  deter- 
mines, to  a  great  extent,  the  occurrence  of  vomiting  and  the 
period  at  which  it  will  happen.  When  the  body  of  the  stom- 
ach is  attacked,  but  the  oriiices  are  not  obstructed,  it  may 
not  take  place  at  all ;  or  if  it  take  place,  it  is  within  a  brief 
time  after  meals.  When  the  disease  has  narrowed  the 
cardiac  extremity,  vomiting  supervenes  almost  immediately; 
the  food  has  hardly  been  swallowed  before  it  is  brought  up 
again.  But  when,  as  is  so  much  more  common,  the  pylorus 
is  constricted,  the  food  is  not  thrown  ofi'  until  it  attempts  to 
pass  through  into  the  intestine;  therefore  not  until  a  con- 
siderable time  after  meals. 

With  respect  to  the  character  of  the  substances  ejected,  this 
too  depends  on  the  seat  of  the  cancer,  and  the  time  at  which 
the  vomiting  arises.  If  it  ensue  several  hours  after  meals, 
the  cast-otf  matter  consists  of  food  partly  digested,  partly  in 
a  state  of  highly  acetous  fermentation.  An  enormous  quan- 
tity of  acid  material,  the  accumulation  of  several  meals,  is 
sometimes  brought  up  during  one  act  of  emesis.  The  ejected 
matter  may  be  intermingled  with  blood,  and  have  a  blackish 
or  reddish-brown,  "coffee-ground"  appearance;  or  the  mucus 
which  is  thrown  up  is  tinged  with  black  iiakes.  But  it  is  rare 
that  any  considerable  amount  of  unmixed  blood  is  vomited. 


I 


DISEASES    OF    THE    STOMACH.  •  453 

Thus  a  close  study  of  the  pain  and  vomiting  may  furnish 
evidence  by  which  the  existence  of  a  gastric  cancer  might  be 
suspected.  There  are  a  few  other  circumstances  which  would 
strengthen  this  suspicion:  one  of  these  is  the  intense  acidity 
of  the  stomach  with  the  sour  eructations;  another,  the  ex- 
treme flatulency;  another,  the  fetid  breath,  for  although  fetor 
of  tlie  breath  may  result  from  putrefactive  changes  in  the  food 
in  almost  any  form  of  gastric  disorder,  it  is  perhaps  never  so 
permanent  or  so  much  complained  of  as  in  cancer.  A  fourth 
is  the  obstinate  constipation.  A  tifth,  the  progressive  loss  of 
flesh  and  the  cachectic  appearance  of  the  patient,  who  is  pale 
and  tired  looking,  or  has  a  complexion  slightly  jaundiced,  or 
whose  face  is  of  a  color  which  seems  to  have  arisen  from  a 
combination  of  the  hue  of  chlorosis  and  of  jaundice.  The 
supposed  characteristic  straw  color  of  cancer  is  not  often 
met  with  ;  sometimes  we  observe  red  spots  on  the  cheek  in 
the  afternoon.  And  there  are  cases  in  which  irritative  fever 
accompanies  the  gradual  wasting  —  gradual,  because  the 
duration  of  the  malady  averages  fully  a  year. 

Now,  should  all  these  symptoms  be  met  with  in  a  person 
who  is  steadily  becoming  feebler,  whose  age  is  above  forty, 
in  whose  family  cancer  is  hereditary ;  should  cancerous  tu- 
mors develop  themselves  in  any  other  part  of  the  body,  the 
suspicion  entertained  would  be  converted  into  almost  a  cer- 
tainty. But  it  is  not  often  that  a  perfectly  typical  case,  pre- 
senting a  combination  of  all  the  symptoms  enumerated,  is 
met  with.  And  I  repeat,  that,  the  most  distinctive  sign  is  a 
tumor;  when  this  is  not  detected,  considerable  uncertainty 
hangs  over  any  diagnosis  of  gastric  cancer. 

To  contrast,  then,  cancer  of  the  stomach,  with  chronic  gas- 
tritis and  gastric  ulcer: 

Chronic  Gastritis.                          Gastric  Ulcer.  Gastric  Cancer. 

Pain  at  the  epigastrium  some-      Pain  at  the  epigastrium  much  Pain  frequently  of  a  radiating 

what  augmented  by  food;          augmented  by  food;  subsides  kind,  often  paroxysmal,  not 

also    soreness.      Both    con-          when  this  is  digested  ;parox-  unusually    severe    and    lan- 

stant,    although     compara-          ysms  of  pain,  but  not  lau-  cinating,   but   not  of  neces- 

tively  slight.                                      cinating;  astrictly  localized  sity  associated  with  soreness. 

soreness  to  the  touch  in  the  Little  or  not   at  all  affected 
epigastric  region,  sometimes  by  food.    Pain  rarely  remits  ; 
a  painful  spot  over  the  lower  never  intermits  for  any  con- 
dorsal  vertebra;.     Intennis-  siderable  time. 
sions  in  the  pain  of  consider- 
able length  are  frequent. 


454 


MEDICAL   DIAGNOSIS. 


Chronic  Gastritis. 
Symptoms  of  indigestion. 

Sometimes  vomiting. 

No  hemorrhage,  or  but  trifling 
hemorrhage ;  and  even  a  tri- 
fling hemorrhage  is  rare. 

Bowels  constipated. 

No  fever. 

Not  much  emaciation  ;  no  ca- 
chectic appearance. 

Not  conSned  to  any  age.  More 
common  in  middle-aged  or 
elderly  people. 

Disease  may  he  relieved  or 
cured,  or  is  of  very  long  du- 
ration. 

No  tumor. 


G.A.STRIC  Ulcer. 

Symptoms  of  indigestion  some- 
times very  slight. 

Vomiting  may  be  present  or 
alisent. 

Abundant  hemorrhage  from 
the  stomach  common. 


Bowels  may  or  may  not  be 
constipated ;  usually  are. 

No  fever. 

Frequently  extreme  pallor  and 
debility. 

May  occur  in  middle-aged  per- 
sons; but  is  also  frequently 
seen  in  young  adults,  espe- 
cially in  young  women. 

Duration  uncertain  ;  may  get 
well,  may  run  on  rapidly  to 
perforation  ;  on  the  other 
hand,  may  last  for  years. 

No  tumor. 


Gastric  Cancer. 

Symptoms  of  indigestion.  Ex- 
treme acidity  of  stomach. 

Vomiting  a  very  frequent  symp- 
tom. 

Hemorrhage  not  very  abund- 
ant ;  but  occasioning  fre- 
quently coffee-ground  look- 
ing vomit. 

Bowels  obstinately  constipated. 

Fever  not  uncommon. 

Gradual  and  progressive  loss 
of  flesh,  and  debility. 

Most  common  in  elderly  peo- 
ple ;  rarely  occurs  in  persons 
under  forty  years  of  age. 

Average  duration  one  year; 
may  be  shorter,  but  seldom 
longer ;  very  rarely  reaches 
two. 

Generall3'  a  tumor. 


The  clifFerences  laid  down  in  the  table  are  derived  from  an 
analysis  of  well-marked  cases.  In  the  early  stages  of  the 
cancerous  malady,  a  differential  diagnosis  is  impossible. 
Subsequently,  as  already  stated,  the  detection  of  a  tumor 
plays  an  important  part  in  any  induction.  But  this  remark 
does  not  apply  to  cases  of  cancer  of  the  cardiac  orifice,  which 
are  rare,  and  in  which  a  tumor,  from  its  deep  situation, 
almost  always  eludes  discovery.  Such  cases  are,  however,  dis- 
criminated by  their  presenting  the  same  signs  as  a  stricture 
of  the  oesophagus  low  down;  indeed  they  are  very  constantly 
combined  with  a  narrowing  of  the  tube,  produced  by  the 
cancer  spreading  to  it.  Cancer,  at  other  parts  of  the  organ, 
occasions  a  perceptible  tumor  in  about  three-fourths  of  all 
the  instances;  its  situation  is  of  course  not  always  the  same. 
Where  no  tumor  can  be  discerned,  and  particularly  if,  as 
may  happen,  portions  of  the  stomach  remain  healthy  and 
the  digestive  disturbances  are  slight,  the  existence  of  cancer 
ma}^  not  reveal  itself  by  any  symptoms,  and  the  case  run  a 
latent  course.* 

A  cancer  of  the  anterior  wall  produces,  as  a  rule,  fulness, 
resistance,  and  percussion  dulncss  in  the  epigastric  region. 

*See  report  of  case  under  mv  care  at  the  Penna.  Hospital,  published  in 
Amer.  Journ.  of  Med.  Sci.,  vol.  lii.  1806. 


DISEASES    OF    THE    STOMACH.  455 

A  cancer  involving  the  greater  curvature  gives  rise  to  a  swell- 
ing near  the  umbilicus,  or  to  one  extending  toward  either 
hypochondrium.  The  tumor  formed  by  cancer  of  the  pylorus 
is  commonly  felt  plainly  a  little  to  the  right  of  the  median 
line,  and  one  to  two  inches  below  the  cartilages  of  the  ribs. 
In  women  its  position  is  apt  to  be  even  lower  than  this;  and, 
indeed,  in  both  sexes  the  situation  of  the  indurated  pylorus 
is  very  variable.  It  may  be  pushed  down  to  near  the  um- 
bilicus, nay,  it  has  been  discerned  near  the  anterior  superior 
spinous  process  of  the  ilium.*  It  is  very  rarely  found  in 
the  left  hypochondrium,  but  not  unfrequently  in  the  right. 
Then  it  may  form  adhesions  to  the  liver,  which  viscus  at 
times  so  completely  covers  the  tumor  as  to  render  it  impos- 
sible of  detection. 

The  reason  w^hy  the  swelling,  in  not  a  few  instances,  shows 
itself  much  lower  than  the  normal  seat  of  the  pylorus,  is 
obvious.  Meal  after  meal  the  organ  seeks  to  overcome  the 
resistance  offered  by  the  narrowed  pyloric  orifice,  and  does 
so  witli  great  and  increasing  difficulty.  The  constantly- 
repeated  and  long-continued  struggle  leads  to  hypertrophy 
of  the  muscular  coat  and  to  distention  of  the  hollow  viscus. 

The  tumor  may  or  may  not  be  movable;  its  surface  may 
be  either  smooth  or  nodulated.  It  may  be  large  and  dis- 
tinct, or  small  and  requiring  a  careful  examination  to  distin- 
guish it  from  the  surrounding  and  more  yielding  textures. 
It  is  much  more  perceptible  on  some  days  than  it  is  on  others. 
Its  existence,  as  has  been  already  insisted  on,  furnishes  the 
most  conclusive  evidence  in  favor  of  a  cancer. 

But  is  a  swelling  in  the  region  of  the  stomach  strictly 
pathognomonic  of  gastric  cancer?  Unfortunately  for  diag- 
nostic purposes,  it  is  not,  even  when  the  swelling  has  been 
ascertained  to  belong  to  that  viscus.  A  mere  fibroid  thick- 
ening of  the  pylorus  will  occasion  a  tumor,  and,  more- 
over, produces  symptoms  which  resemble  so  closely  those  of 
malignant  disease  at  the  orifice,  that  I  much  doubt  the  possi- 
bility of  distinguishing  during  life,  with  any  certainty,  be- 


*  See  Lebert's  cases  in  Traito  Pratique  des  Maladies  Cancereuses. 


456  MEDICAL   DIAGNOSIS. 

tweeu  the  two  afieetions.     Let  ns  take  this  case,  which  I  saw 
with  Dr.  Moss,*  of  this  city,  as  an  example. 

A  woman,  aged  forty,  complained  much  of  pain  at  the  pit 
of  the  stomach,  and  of  a  heavy  sensation  throughout  the 
abdomen.  For  some  months  she  had  been  sufi'ering  from 
indigestion,  and  had  been  steadily  losing  flesh  and  strength. 
Her  countenance  had  a  tired  look,  and  she  was  verj' despond- 
ent. She  had  a  slight  cough;  and  on  percussing  the  lungs, 
impaired  resonance  was  detected  at  the  apices.  The  bowels 
were  obstinately  constipated,  the  tongue  was  smooth  and  red, 
the  pulse  feeble.  She  vomited  shortly  after  meals,  j-et  never 
anything  but  the  ingesta.  There  was  no  pain  on  pressure 
over  the  pylorus ;  but  a  greater  resistance  to  the  finger  than 
usual  was  detected.  The  further  progress  of  the  complaint 
was  marked  by  the  most  incessant  vomiting,  only,  however, 
after  meals.  Hydrocyanic  acid,  creasote,  opiates  were  given 
in  vain  to  arrest  it.  Once,  and  once  only,  did  it  cease  for 
several  days  ;  and  then  without  apparent  cause.  As  the 
case  drew  toward  its  fatal  termination,  the  patient  was  much 
troubled  with  acid  eructations,  and  had  occasionally  slight 
febrile  attacks.  The  distress  in  the  epigastrium  increased  in 
severity.  About  tliree  weeks  before  her  death  she  was  seized 
with  lancinating  pains  under  both  patellfe,  which  were  neither 
relieved  nor  aggravated  by  pressure  or  motion.  They  were 
accompanied  by  pricking  sensations  and  numbness  in  the 
legs,  and  an  inability  to  walk.  The  pains  gradually  ceased, 
but  the  loss  of  motion  and  numbness  increased  from  day  to 
day.  She  died,  utterly  exhausted  by  the  abdominal  pains 
and  the  incessant  vomiting,  about  three  months  after  she  be- 
gan to  reject  her  food.  On  post-mortem  examination,  tuber- 
cular deposits  were  found  at  the  apices  of  the  lungs.  The 
abdominal  viscera  were  healthy,  excepting  the  stomach;  and 
this,  too,  was  healthy,  save  at  its  pyloric  orifice,  which  was  so 
narrowed  that  the  tip  of  the  little  finger  could  liardly  be 
forced  into  it.  The  mucous  lining  lay  in  folds,  but  on  dis- 
section was  found  to  be  perfectly  normal.  At  the  pylorus, 
but   only   there,   the    submucous   and   muscular   coat   were 

*  Published  in  full  in  Proceedings  of  Path.  Society  of  Phihi.,  vol.  i. 


I 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  457 

uniformly  thickened.  Examined  microscopically,  they  con- 
tained nothing  but  fibro-areolar  tissue,  spindle-shaped  tibre- 
cells,  and  very  distinct  organic  muscular  fibres. 

Now,  here  is  a  case  which  evidently  was  not  cancer;  and 
yet  it  had  the  symptoms  of  cancer.  It  is  true  that  the  ab- 
sence of  blood  and  of  glairy  mucus  in  the  matter  vomited, 
and  the  indistinctness  of  the  swelling,  in  spite  of  the  great 
emaciation,  were  against  the  supposition  of  cancer  of  the 
pylorus.  Still  no  inference  based  on  these  data  alone  could 
be  strictly  trusted,  since  every  cancer  is  not  associated  with 
the  vomit  of  cofi'ee-ground  material,  or  of  glairy  mucus,  or 
with  a  palpable  tumor.  The  disease  was  combined  with 
tubercular  deposits  in  the  lung.  Nor  is  this  the  only  ex- 
ample of  the  combination  wliich  has  come  under  my  notice. 
And  when  a  tubercular  state  of  the  lung  has  been  fairly 
made  out,  and  there  exist  at  the  same  time  signs  of  pyloric 
obstruction,  I  should  be  much  inclined  to  hazard  a  diagnosis 
that  this  is  not  of  a  cancerous  nature,  but  consists  simply  of 
an  increased  abnormal  development  of  the  submucous  coat, 
with  probable  subsequent  hypertrophy  of  the  muscular  tunic. 

The  fibroid  thickeniy^g  may  extend  throughout  the  whole 
stomach.  Such  cases  differ  from  cancer  by  their  long  dura- 
tion ;  the  absence  of  hemorrhage,  of  vomiting  and  severe 
pain;  and  the  more  uniform  gastric  swelling.  They  are 
sometimes  observed  in  spirit  drinkers.  Yet  their  discrim- 
ination from  cancer  is  never  a  certainty,  but  merely  a  matter 
of  conjecture. 


SECTION  11. 

DISEASES   OF    THE    INTESTINES   AND    PERITONEUM. 

In  considering  the  diseases  of  the  intestines,  we  meet  again 
with  symptoms  into  the  import  of  which  we  have  examined 
in  connection  with  affections  of  the  stomach.  We  encounter 
nausea,  vomiting,  and  derangement  of  the  powers  of  digestion. 
These  disturbances  are  to  a  great  extent  sympathetic  or  de- 


458  MEDICAL    DIAGNOSIS. 

pendent  upon  coexisting  gastric  disorder;  they  do  not  serve, 
therefore,  as  guides  in  the  detection  of  intestinal  maladies. 
The  signs  upon  which  we  rely  much  more  implicitly  are  pain 
and  the  fecal  discharges.  Now,  as  regards  the  former,  we 
draw  the  most  trustworthy  inferences,  as  we  shall  presently 
see,  from  its  kind  rather  than  from  its  mere  occurrence.  The 
study  of  the  fecal  discharges  tells  us  often  in  a  more  direct 
manner  what  is  going  on  in  the  long  tract  of  intestinal  mem- 
hrane. 

Alvine  Discharges. — To  examine  briefly  into  the  diversi- 
fled  appearances  of  the  stools  : 

Watery  stools  are  observed  whenever  a  large  quantity  of 
the  sernm  of  the  blood  finds  its  way  through  the  intestinal 
coats.  They  are  met  with  after  the  administration  of  saline 
purgatives,  in  serous  diarrhoea,  and  in  cholera.  Their  hue 
varies :  they  may  be  almost  colorless,  or  tinged  with  yel- 
low. Sometimes,  although  very  thin  and  watery,  they  are 
decidedly  yellow;  again  they  are  rendered  turbid  by  the 
dissemination  of  whitish  flocculi  of  cast-off  epithelium,  or  by 
mucus.  Whether  they  be  yellow  or  colorless  depends  on  the 
existence  or  non-existence  in  them  of  fecal  matter  and  of 
bile.  In  a  prognostic  point  of  view,  the  most  colorless 
evacuations  are  the  most  dangerous.  Their  persistence  be- 
speaks a  continued  absence  of  healthy  fecal  matter  and  of 
the  proper  secretion  of  bile. 

The  presence  of  an  excessive  quantity  oi  nmcus  renders  the 
discharges  less  consistent  than  natural;  yet,  unless  they  eon- 
tain  more  or  less  serum,  they  are  not  of  necessity  very  liquid. 
Stools  wnth  much  mucus  are  met  with  in  some  cases  of  diar- 
rhoea and  in  dysentery.  The  appearance  they  present  is  often 
similar  to  the  white  of  an  e^g ;  or  the  whitish  masses  of 
mucus  surround  the  lumps  of  feces,  or  are  intermingled  with 
the  fluid  alvine  dischars^es. 

Pas  in  laro-e  amount  and  unmixed  with  feces  is  onlv  dis- 
charged  when  an  abscess  has  ruptured  into  some  part  of  the 
intestine.  Stools  composed  of  feces  and  pus  are  encountered 
in  chronic  inflammation  and  in  ulceration  of  the  bowels;  and 
whitish,  creamy  streaks  indicate  the  presence  of  the  foreign 
substance.     Yet  the  pus  may  be  so  intimately  blended  with 


I 


DISEASES    OF   THE    INTESTINES   AND    PERITONEUM.  459 

the  feces,  or  with  masses  of  mucus,  as  to  require  the  micro- 
scope for  its  detection. 

Stools  consisting  entirely  of  bile  are  very  rarely  met  with. 
More  generally  there  are  other  elements  joined  to  the  voided 
secretion  of  the  liver.  An  excess  of  bile  in  the  alvine  dis- 
charges gives  rise  to  evacuations  of  a  yellowish-brown  or  yel- 
low hue,  which  darkens  on  exposure  to  the  air.  When  the 
alimentary  tube  is  highly  acid,  the  resulting  color  is  green. 
Both  these  kinds  of  stools  are  commonly  called  "bilious;" 
but  the  latter  is,  perhaps,  less  absolutely  so  than  the  former. 
A  deficiency  of  bile  manifests  itself  by  clayey,  sometimes 
even  by  almost  white  stools. 

Black  stools  result  from  the  action  of  certain  medicines,  as 
of  iron  ;  from  a  vitiated  condition  of  the  bile  and  intestinal 
secretions,  such  as  occurs  in  bilious  fever;  or  from  the  effu- 
sion of  blood  into  the  alimentary  canal.  At  all  events,  when 
the  hemorrhage  proceeds  from  the  stomach  or  upper  part  of 
the  canal,  the  stools  have  a  black,  tarry  appearance;  when 
from  the  lower  section  of  the  tube,  pure  blood  is  passed,  or, 
if  it  be  small  in  quantity,  a  blood-streaked  mucus.  Should 
any  doubt  exist  as  to  whether  the  dark  discharges  be  depend- 
ent or  not  upon  the  presence  of  blood,  let  them  be  dilated 
with  water;  they  will  assume  a  reddish  tinge  if  this  be  the 
cause  of  the  abnormal  color. 

The  odor  of  the  evacuations  is  extremely  offensive  in  fevers 
of  a  low  type,  and  when  the  intestinal  secretions  are  vitiated. 
So,  too,  at  times  in  small-pox  and  in  cholera.  Acidity  of  the 
intestinal  canal,  as  in  the  diarrhoea  of  children,  or  iu  rheuma- 
tism or  gout,  imparts  to  the  stools  a  sour  smell. 

In  cases  of  constipation  it  may  be  important  to  notice  the 
sha-pe  of  the  passages,  because  this  may  show  whether  an  im- 
pediment in  the  gut  has  flattened,  or  otherwise  altered  them. 
In  fevers,  as  well  as  in  affections  of  the  intestinal  mucous 
membrane,  whether  inflammatory  or  not,  we  often  derive 
much  information  from  studying  the  form  of  the  voided  mat- 
ter. Figured  stools,  succeeding  to  fluid  passages,  are  always 
of  favorable  omen. 

Chemical  and  microscopiccd  examinations  of  the  feces  are  not 
often  made ;  yet  chemistry  and  the  microscope  may  be  fre- 


460  MEDICAL   DIAGNOSIS. 

qiiently  of  very  great  service.  They  enable  us,  for  instance, 
to  recognize  with  certainty  that  the  yellowish  lumps  con- 
tained in,  or  the  greasy  film  which  collects  upon  the  surface 
of  the  evacuation,  consist  of  fat.  The  microscope,  too,  de- 
tects pus  and  blood ;  and  it  exhibits,  in  the  fecal  discharges 
of  putrid  fevers,  masses  of  crystals  of  the  ammonio-phos- 
phates.  One  drawback  to  the  use  of  chemical  research  for 
clinical  purposes,  is  the  uncertain  composition  of  the  feces, 
owing  to  the  number  of  elements  derived  from  the  food.  A 
further  objection,  both  to  it  and  to  microscopical  investiga- 
tion, is  the  repugnance  every  one  feels  to  the  close  examina- 
tion of  human  excrement.* 

So  much  for  the  alvine  discharges.  Their  study,  it  is  evi- 
dent, is  of  service  not  merely  in  intestinal  complaints,  but 
equally  in  the  many  maladies  in  which  the  alimentary  tube 
sympathizes  or  becomes  involved.  But  to  return  to  the 
uncomplicated  intestinal  diseases,  grouping  them  as  they  may 
be  recognized  by  pain  and  peculiarity  in  the  fecal  discharges, 
and  describing  with  them,  for  convenience  sake,  the  affections 
of  the  peritoneum. 

Diseases  attended  with  Paroxysms  of  Pain  referred  chiefly  to 
the  Middle  or  Lower  Part  of  the  Abdomen,  and  not  asso- 
ciated with  marked  Tenderness  or  with  Fever. 

The  type  of  these  is  colic. 

Colic. — This  is  an  intestinal  pain,  paroxysmal  in  its  char- 
acter, and  usuall}^  combined  with  constipation,  but  unattended 
with  febrile  symptoms.  The  pain  is  of  a  severe  griping,  or 
pinching,  or  twisting  kind,  and  is  commonly  referred  to  the 
neighborhood  of  the  umbilicus.  It  is  generally  relieved,  or 
at  any  rate  not  aggravated,  by  pressure.  Yet  this  is  not  so 
invariable  as  it  is  ordinarily  held  to  be ;  for  sometimes  there 
is  some  soreness  with  the  pain,  and,  indeed,  a  slight  soreness 
not  unfrequently  remains  after  the  paroxysm  has  passed  off. 


*  See,  on  the  minute  examination  of  the  feces,  Lehmann's  Physiological 
Chemistry ;  a  paper  by  Marcet,  Proceedings  of  Koyal  Society,  1854 ;  and 
the  Inaugural  Dissertations  of  Wehsarg  and  Ihring,  quoted  in  Brit,  and  For. 
Med.-Chirg.  Kev.,  Oct.  1854. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  4G1 

While  the  pain  lasts,  the  countenance  wears  an  anxious, 
frightened  expression  ;  the  skin  is  cold,  or  covered  with  clam- 
my perspiration  ;  the  pulse  is  depressed.  Occasionally  there 
is  vomiting,  and  in  severe  cases  the  abdominal  walls  are  tense 
or  raised  in  hard  knots  by  the  spasmodic  contraction  of  the 
muscles.  A  lit  may  last  only  a  few  minutes,  or,  with  trifling 
remissions,  for  several  hours. 

Some  persons  are  very  liable  to  attacks  of  colic.  Those 
who  suffer  from  indigestion,  or  are  enfeebled  by  exhausting 
maladies,  are  predisposed  to  them;  so  also  are  hysterical, 
gouty,  and  rheumatic  individuals.  As  to  the  exciting  causes, 
they  are  vei'y  various ;  and  somewhat  according  to  its  difterent 
causes,  colic  presents  difl'erent  forms.  Let  us  indicate  the 
more  prominent. 

Colic,  simple  and  unconnected  with  a  disease  of  the  howel. — Now, 
in  these  cases,  which  are  generally  called,  from  the  supposed 
pathological  condition,  spasmodic  colic,  the  paroxysmal  pain 
may  have  a  threefold  origin.  It  may  be  the  result  of  direct 
excitation  of  the  peripheral  intestinal  nerves  by  the  presence 
of  irritating  substances  in  the  intestinal  canal,  such  as  indi- 
gestible food,  acid  drinks,  hardened  feces,  gases,  morbid  se- 
cretions, worms,  medicines,  or  poisons.  It  may  proceed  from 
an  irritation  of  the  central  nervous  system  reflected  to,  and 
manifesting  itself  in  the  intestinal  nerves.  It  may  be  sympa- 
thetic, and  produced  by  a  morbid  state  of  the  adjacent  abdom- 
inal viscera,  at  times,  perhaps,  through  the  intervention  of 
the  central  nervous  system. 

1.  Colic,  owing  to  food  difiicult  of  digestion,  is  very  com- 
mon, especially  at  the  time  of  year  when  fruit  is  beginning 
to  ripen.  Sometimes  it  is  caused  by  food  which  is  not  in 
itself  injurious,  but  which  is  taken  in  quantities  greater  than 
the  digestive  organs  can  manage.  Hence  it  is  frequent  in 
children  at  the  breast  who  are  overnourished;  and  in  per- 
sons in  delicate  health  with  enfeebled  digestive  powers. 

The  form  of  colic  under  discussion  is  often  attended  with 
vomiting  and  diarrhoea;  it  may  be  of  only  a  few  hours'  dura- 
tion, or  it  may  last  for  several  days.  It  is  for  the  most  part 
readily  relieved  by  the  administration  of  a  mild  cathartic, 
joined  to  a  small  quantity,  or,  if  the  pain  be  very  severe,  to 


462  MEDICAL   DIAGNOSIS. 

a  full  dose,  of  opium.  An  emetic  is  at  times  of  signal 
service,  and  so  are,  as  in  all  forms  of  colic,  warm  anodyne 
fomentations. 

Colic  arising  from  distention  of  the  intestines  with  flatus, 
or  "  flatulent  colic,"  is  the  result  of  the  decomposition  of  food 
in  the  alimentary  canal ;  sometimes,  however,  the  gases  are 
extricated  from  morbid  secretions,  or  are  exhaled  directly 
from  the  blood-vessels.  The  abdomen  is  very  t3'mpanitic 
and  greatly  distended,  and  the  flatus  is  from  time  to  time 
discharged  by  the  mouth  or  by  the  anus,  with  great  relief  to 
the  patient.  Hysterical  persons  are  very  subject  to  this  form 
of  colic,  which  yields,  like  the  preceding  variety,  to  opiates, 
purgatives,  and  warm  fomentations,  and  to  the  administration 
of  carminatives,  or  of  stimulating  injections. 

Colic  from  accumulation  of  hardened  feces  is  preceded  by 
obstinate  constipation,  and  is  usually  a  tedious  disorder.  The 
accessions  of  pain  are  easily  enough  remedied  by  emptying 
the  bowels,  but  they  are  constantly  recurring. 

Colic  from  the  presence  of  morbid  secretions  in  the  intes- 
tinal canal  is  not  so  often  encountered  as  that  from  indigest- 
ible food  or  retained  fecal  masses.  Yet  it  is  occasionally  met 
with  in  cases  of  diarrhoea  attended  with  a  disordered  state  of 
the  intestinal  functions.  And  it  is  very  probable  that  even  in 
the  so-termed  bilious  colic,  the  intestinal  pain  is  not  purely 
sympathetic,  but  is  owing  to  the  irritating  character  of  the 
bile  discharged  into  the  intestine. 

This  "bilious  colic"  is  often  preceded  by  nausea,  loss  of 
appetite,  and  a  coated  tongue.  The  paroxysms  of  pain  fre- 
quently go  hand  in  hand  with  vomiting — first  of  the  contents 
of  the  stomach,  then  of  bile.  They  are  in  general  accom- 
panied or  soon  followed  by  a  yellowish  tinge  of  the  conjunc- 
tiva, by  tenderness  in  the  region  of  the  liver,  and  by  a  desire 
to  go  to  stool.  The  bowels  are,  however,  apt  to  be  obsti- 
nately constipated.  Bilious  colic  is  common  in  malarious 
districts  ;  it  occurs  especially  during  the  summer  and  autum- 
nal months,  and  frequently  follows  exposure.  It  sometimes 
begins  with  a  chill,  and,  unlike  the  other  forms  of  colic,  it 
has  as  a  companion  febrile  excitement,  and  a  full,  frequent 
pulse. 


i 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  463 

2.  In  the  second  class  of  cases  to  which  alUision  lias  been 
made,  colic  is  dependent  upon  some  abnormal  condition 
affecting  primarily  the  great  centres  of  innervation.  The 
colic  arising  from  fright,  from  anger;  that  happening  in 
nervous  females  and  hypochondriac  males  ;  perhaps  that  pro- 
ceeding from  sudden  exposure  to  cold;  the  form  which  is 
sometimes  seen  coexisting  v/ith  neuralgic  pains  in  other  parts 
of  the  body, — in  short,  all  those  cases  which  are  spoken  of  as 
nervous  colic,  might  here  be  mentioned. 

The  attack  is  sudden,  and  not  commonly  of  long  duration ; 
but  it  is  very  apt  to  be  repeated,  and  requires  strict  attention 
to  diet,  proper  exercise,  and  frequently  iron,  quinia,  wine,  or 
the  vegetable  tonics  for  its  prevention. 

The  so-termed  "metallic  colics"  are  further  instances  of 
colic  produced  through  agents  which  act  primarily  on  the 
general  nervous  system.  This  is  at  any  rate  true  of  lead 
colic.  Copper  colic  is  not  a  purely  neuralgic  colic.  It  ex- 
hibits paroxysms  of  severe  pain  like  those  caused  by  the 
poisonous  influence  of  lead ;  but  it  is  attended  with  nausea, 
vomiting,  diarrhoea,  tenesmus,  an  abdomen  distended  and 
tender  to  the  touch, — in  other  words,  it  is  rather  an  inflam- 
mation of  the  intestine  with  colicky  pain,  than  uncomplicated 
colic.  Lead  colic,  on  the  other  hand,  is,  so  far  as  is  known, 
a  pure  colic;  for  in  the  recorded  examinations  of  those  who 
have  died  of  the  disorder,  no  abnormal  appearances  were 
found  in  the  intestines.  The  distinguishing  marks  of  lead 
colic  are  the  bluish-gray  line  along  the  gums;  the  contracted 
abdomen ;  the  obstinate  constipation  ;  the  great  relief  usually 
afibrded  to  the  pain  by  pressure  ;  the  duration  of  the  pain  ; 
its  marked  and  agonizing  exacerbations ;  and  the  history  of 
the  case.  The  signs  of  the  lead  poisoning  also  manifest  them- 
selves in  other  parts  of  the  body,  but  I  shall  not  particularize 
them  here,  as  the  poisonous  eflects  of  lead  will  be  elsewhere 
more  specially  considered. 

3.  Aftections  of  various  organs  may  give  rise  to  colic,  by 
sympathy,  and  generally  through  the  intervention  of  the 
nervous  system  to  which  the  irritation  is  first  transferred, 
and  from  which  it  is  then  reflected.  Thus  colic  is  a  not  un- 
common attendant  on  morbid  states  of  the  kidneys,  of  the 


464  MEDICAL    DIAGNOSIS. 

liver,  of  the  bladder,  the  testicles,  the  ovaries,  and  on  dis- 
ordered menstruation.  Yet  we  must  not  forget  that  the 
pain,  although  spoken  of  as  colic,  is  often  not  strictly  intes- 
tinal, but  is  merely  a  pain  radiating  from  the  aifected  organs 
themselves. 

Colic  arising  in  consequence  of  some  abnormal  state  of  the  bowel. 
— In  the  preceding  illustrations  of  colic,  the  disorder  was 
viewed  as  occurring  in  a  healthy  bowel.     But  colic  may  have 
only  the  significance  of  a  symptom,  and  be  combined  with 
an  altered  structure  or  a  changed  position  of  the  intestine. 
This  is  a  point  to  which  sufficient  attention  is  not  generally 
paid  in  practice.     The  word  colic  suggests,  to  the  minds  of 
most,  a  paroxysmal  pain,  constipation,  and  a  spasm  of  the 
bowel.     Now,  without  discussing  whether  a  true  spasm  be 
a  necessary  attendant   on    the   paroxysmal  pain,  it  would 
appear  to  be  certain  that  there   is   nothing  so  absolutely 
peculiar  about  the  pain  that  its  association  with  an  involun- 
tary muscular  contraction  of  the  intestine  can  be  regarded  as 
invariable.     We  meet,  indeed,  with  colicky  pains,  undistin- 
guishable  from  those  of  pure  colic,  linked  to  an  organic  dis- 
ease of  the  bowel,  and  under  circumstances  some  of  which 
forbid  the  idea  of  a  spasm.     They  are  encountered  in  dysen- 
tery; enteritis;  hernia;  ulceration;  intussusception;  strangu- 
lation; twisting;  strictures;  distention, — in  fact,  in  the  most 
various  morbid  states  of  the  intestine.     And  colic  as  a  symp- 
tom can  be  discriminated,  so  far  as  the  pain  is  concerned, 
from  colic  as  an  idiopathic  disorder,  only  by  a  careful  study 
of  the  history  and  the  concomitant  phenomena  of  the  case. 
In  several  of  the  maladies  cited,  however,  the  more  transitory 
nature  of  the  pain, — or  gripings,  as  they  are  termed, — in 
others,  the   presence   of  fever  and  of  tenderness,  serve  as 
guides  in  diagnosis.     Fever  and  soreness  to  the  touch  are 
also  met  with  in  that  form  of  inflammation  of  one  or  several 
coats  of  the  bowel  which  happens  after  exposure  or  after  the 
retrocession  of  rheumatism  from  some  external  part,  and 
which  is  commonly  known  as  rheumatic  or  inflammatory 
colic. 

Having  thus  indicated  the  various  forms  of  colic ;  having 
alluded  to  the  relation  they  bear  to  structural  diseases  of  the 


I 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  465 

intestines,  and  to  affections  of  adjacent  viscera ;  it  is  unneces- 
sary to  re-examine  the  field  and  point  out  how  wide  its  ex- 
tent is  from  a  diagnostic  point  of  view.  I  shall  only  here 
again  insist  on  the  necessity  of  tracing  out  in  every  case,  as 
far  as  possible,  the  cause  of  the  painful  malady,  so  as  to  know 
if  any  serious  mischief  lie  at  the  bottom  of  it;  and  Avill  but 
add  a  few  words  with  reference  to  the  disorders  with  which 
uncomplicated  colic,  or  that  v/hich  is  held  to  be  purely  spas- 
modic, may  be  confounded.     They  are  : 

Gastralgia; 

Perforation  of  the  Intestine  ; 

Strangulated  Hernia  ; 

Passage  of  Gall-stones  ; 

Nephralgia  ; 

Spasm  of  the  Bladder  ; 

Uterine  Colic  ; 

[N'euralgia  of  the  Dorsal  and  Lumbar  Nerves; 

Abdominal   Aneurism   and   Tumors  ;    Diseases   of   the 
Spine  ; 

Enteritis  and  Peritonitis. 

Gastralgia. — In  gastralgia  or  gastrodynia  the  pain  is  seated 
in  the  epigastric  region;  whereas  in  colic  it  is  either  in  the 
neigliborhood  of  the  umbilicus,  or  rapidly  shifts  its  position 
from  that  point  to  different  parts  of  the  abdomen,  and  is 
often  connected  with  a  spasmodic  contraction  of  the  abdom- 
inal muscles.  Again,  the  history  in  cases  of  gastralgia;  the 
fact  that  the  attacks  happen  most  frequently  after  meals ; 
their  association  with  signs  of  a  diseased  stomach, — indicate 
the  organ  in  which  the  paroxysms  of  pain  arise. 

Perforation  of  the  Intestine. — When  paroxysms  of  pain  have 
their  origin  in  perforation  of  the  intestine,  the  extreme  pros- 
tration and  collapse  show  that  they  are  not  produced  by  a 
harmless  disorder  like  colic.  Further,  the  abdominal  dis- 
tress is  in  such  cases  preceded  by  symptoms  of  a  diseased 
state  of  the  stomach  or  intestines ;  and  if  the  patient  live 
sufficiently  long  after  the  accident,  the  pain  is  followed  by 
great  distention  of  the  abdomen  and  extreme  tenderness, — 
in  fact,  by  the  signs  of  peritonitis.  However,  the  differen- 
tial diagnosis  is  occasionally  very  difficult.     Especially  is  it 

30 


4<)6  MEDICAL    DIAGNOSIS. 

SO  in  typhoid  fever ;  for  in  this  aft'ection  colic  is  readily  in- 
duced, or  perforation  of  the  intestine  may  be  brought  on  by 
very  slight  exciting  causes,  and,  moreover,  peritonitis,  so 
several  excellent  observers  think,  may  occur  without  per- 
foration. 

Sfrangulaicd  Hernia. — All  mechanical  obstructions  of  the 
intestine  will  lead  to  paroxysms  of  intestinal  pain.  They 
are  met  with  in  cases  of  intussusception  and  ileus;  they  are 
equally  frequent  in  cases  of  strangulated  hernia.  In  all,  the 
obstinate  constipation  must  arouse  suspicion  regarding  the 
true  nature  of  the  complaint.  But  to  detect  a  hernia,  a 
local  examination  is  required ;  and  a  careful  search  at  the 
usual  seats  of  this  atfection  ought,  therefore,  to  be  made  in 
every  instance  of  severe  or  protracted  colic.  Persons  have 
lost  their  lives  in  consequence  of  the  practitioner  neglect- 
ing, until  too  late,  this  simple  precaution  against  disastrous 
error. 

Passage  of  Gall-stones. — The  passage  of  a  gall-stone  is  gen- 
erally attended  with  paroxysms  of  intense  pain  which  might 
be  readily  mistaken  for  colic.  There  is,  as  a  rule,  the  same 
absence  of  fever  and  of  tenderness.  Indeed,  pressure  is  often 
resorted  to  in  order  to  mitigate  the  suffering,  and  thus  the 
resemblance  to  colic  is  heightened.  The  points  of  distinction 
from  colic  are,  the  position  of  the  pain  in  the  epigastric 
region ;  its  sudden  commencement  and  sudden  termination ; 
the  severe  nausea  and  vomiting  attending  the  attack;  the 
jaundice  ;  and  the  voiding  of  gall-stones  with  the  stools.  The 
latter  sign,  however,  though  a  positive  one,  assists  less  in  the 
discrimination  of  the  disorder  than  would  appear  at  first  sight; 
partly  because  it  does  not  serve  as  a  means  of  indicating  the 
nature  of  the  affection  until  its  close,  partly  because  the  stone 
often  escapes  detection  in  the  feces.  The  other  circumstances 
have,  therefore,  a  more  available  diagnostic  value.  Yet  even 
they  do  not  enable  us  to  distinguish  positively  between  the 
transit  of  a  biliary  concretion  from  the  gall-bladder  to  the 
intestine,  and  the  bilious  colic  which  is  joined  to  derange- 
ment of  the  function  of  the  liver.  The  repetition  of  the  attack 
is  always  a  strong  reason  for  suspecting  it  to  be  owing  to  a 
discharge  of  calculi  IVom  the  gall-bladder;  and  so  are  severe 


I 


DISEASES    or    THE   INTESTINES   AND    PERITONEUM.  467 

retching  and  vomiting,  the  sudden  supervention  of  jaundice, 
and  the  localized  epigastric  pain.  But  these  phenomena,  too, 
it  may  here  be  mentioned,  are  produced  by  hepatic  neuralgia, 
which  in  very  rare  cases  is  believed  to  happen  independently 
of  gall-stones.  And  there  is  nothing  by  which  we  can  dis- 
criminate this  malady— the  very  existence  of  which  is  indeed 
denied — except  by  its  recurrence  after  certain  intervals,  the 
alternations  with  other  affections  of  the  nervous  system,  and 
by  the  slightest  touching  of  the  part  inducing  at  times  the 
acute  pains.* 

Where  the  gall-stones  are  large  and  have  become  impacted 
in  their  course  toward  the  intestine,  they  give  rise  to  inflam- 
mation which  may  lead  to  ulceration  and  to  the  discharge  of 
the  concretion — generally  then  very  large — into  the  intestine 
or  stomach.  Subsequently  an  obliteration  of  the  duct  may 
happen  ;  or  the  inflammation  and  ulceration  of  the  duct  may 
result  in  perforation  into  the  peritoneum.  In  some  cases 
the  gall-stones  are  voided  through  the  abdominal  walls,  in 
consequence  of  their  having  caused  inflammation  of  the  gall- 
bladder and  subsequent  adhesions  to  the  abdominal  parietes. 
The  fistulous  passages  discharge  pus  and  bile,  and  occasion- 
ally fresh  concretions  :  they  may  last  for  years  ;  but  in  time 
they  generally  heal.  As  regards  the  other  forms  of  fistu- 
lous communications  alluded  to,  they  very  rarely  present 
symptoms  so  peculiar  as  to  warrant  anything  like  a  certain 
diagnosis.f 

Nephralgia. — Paroxysms  of  pain  with  intervals  of  compara- 
tive ease  and  unassociated  with  fever  occur  in  nephralgia,  or 
pain  of  the  kidney,  and  are,  therefore,  often  mistaken  for 
colic.  IsTow,  nephralgia  is  generally,  although  not  invariably, 
caused  by  the  passage  of  a  calculus  through  the  ureter.  Its 
symptoms,  besides  the  pain,  are  numbness  of  the  thigh,  nausea 
and  vomiting,  a  constant  desire  to  make  water,  and  aching 
and  drawing  up  of  the  testicle.  The  patient,  as  in  colic,  is 
restless,  and  seeks  relief  by  frequently  changing  his  position. 
The  pain  comes  on  suddenly,  and  is  excruciating.     It  is  felt 

*  See  the  cases  of  Budd,  on  Diseases  of  the  Liver;  of  Andral,  Clinique 
Medicale,  tome  ii.;  and  of  Frerichs,  Diseases  of  the  Liver. 

f  See  a  collection  of  cases  by  Murchison,  Edinb.  Med.  Journ.,  July,  1857. 


468  MEDICAL    DIAGNOSIS. 

in  the  loins,  usually  on  one  side,  and  shoots  along  the  track 
of  the  ureter  to  the  corresponding  hip  and  thigh.  It  some- 
times extends  to  the  pelvis  or  toward  the  umbilicus,  and  is 
often  attended  with  tenderness  in  the  course  of  the  ureter. 
Occasionally  it  is  almost  exclusively  felt  at  the  hip.  When 
the  stone  reaches  the  bladder,  the  pain  ceases  as  abruptly  as 
it  began  ;  though  sometimes  there  is  still  discomfort  produced 
b}^  the  stone  interfering  with  the  act  of  micturition.  During 
the  attack  the  urine  is  passed  in  small  quantities  at  a  time. 
It  is  high  colored;  sometimes  it  contains  a  little  blood.  If  it 
be  collected,  and  after  all  pain  has  disappeared  be  carefully 
examined,  a  small,  hard  body  or  a  sandy  deposit  is  generally 
detected,  and  reveals  the  cause  of  the  past  anguish.  It  is  from 
the  presence  of  the  sandy  deposit  that  the  complaint  has  re- 
ceived popularly  the  name  of  a  tit  of  "  the  gravel." 

From  the  description  given  it  will  be  seen  that,  in  several 
respects,  the  disorder  is  exactly  like  intestinal  colic.  The 
seat  of  the  pain  is  a  point  of  distinction  ;  yet  in  neither  com- 
plaint is  the  seat  entirely  characteristic.  It  is  not  always 
strictly  umbilical  in  colic ;  it  is  not  always  exactly  in  the 
region  of  the  ureter  or  kidney  in  nephralgia.  Of  more  im- 
portance is  the  state  of  the  urinary  functions,  whicli  are  com- 
paratively undisturbed  in  colic.  Again,  the  numbness  of  the 
thio;handthe  retraction  of  the  testicle  are  valuable  dia2:nostic 
marks ;  they  would  be  absolutely  decisive,  were  they  con- 
stantly present  in  nephralgia. 

Spasm  of  the  Bladder. — The  bladder  is  sometimes  the  site  of 
paroxysms  of  violent  pain,  supposed  always  to  attend  upon  a 
spasm  of  the  viscus.  There  is  an  intense  desire  to  urinate, 
which  the  passing  of  water  does  not  allay.  The  pain  is  not 
steady;  it  has  its  intervals  of  cessation.  It  is  accompanied 
by  a  sense  of  constriction  at  or  near  the  pelvis,  and  sometimes 
by  tenesmus,  and  may  extend  to  the  kidneys,  to  the  thighs, 
and  to  the  sacrum:  or  the  irritation  may  be  communicated 
to  the  penis,  and  cause  erections.  If  the  sphincters  be  in- 
volved, the  urine  cannot  be  voided.  The  bladder  distends ; 
there  is  most  intense  anxiety  with  restlessness;  the  pulse  is 
feeble;  the  skin  cold,  and  covered  with  clammy  perspiration. 

A  spasm  of  the  bladder  may  be  caused  by  the  presence  of 


DISEASES    or    THE    INTESTINES    AND    PERITONEUM.  469 

a  stone  in  it,  or  of  irritating  urine.  It  is  also  encountered  in 
gout  and  hysteria,  and  as  the  result  of  stimulating  diuretics. 
Violent  fright,  too,  may  occasion  it.  It  sometimes  proceeds 
from  a  disorder  of  adjacent  structures,  such  as  of  the  rectum, 
or  of  the  uterus.  Now  and  then,  as  Sir  Benjamin  Brodic 
pointed  out,  it  is  associated  with  inflammation  or  suppuration 
of  the  kidney,  and  the  vesical  pain  is  so  intense  that  it  draws 
oflT  attention  from  the  organ  most  affected.  To  distinguish  it 
from  colic  is  not  difficult;  the  position  of  the  pain  and  the  dis- 
turbed condition  of  the  urinary  functions  serve  as  guides.  It 
resembles  more  closely  nephralgia,  and  its  treatment  is  much 
the  same  as  that  of  this  distressing  complaint.  It  is  palliated 
by  hip-baths ;  by  hot  fomentations  and  mustard  plasters  ap- 
plied over  the  seat  of  pain  ;  by  warm  water  enemata;  by  the 
internal  administration  of  ether  and  opium,  or  of  Indian  hemp; 
and,  if  need  be,  bv  the  inlialation  of  ether  or  chloroform. 
Should  symptoms  of  inflammation  supervene,  cupping  or 
leeching  the  parts  is,  as  in  nephralgia,  proper;  and,  indeed, 
if  the  case  be  of  any  duration,  this  is  always,  as  a  matter  of 
precaution,  advisable.  As  in  nephralgia,  too,  after  the  tit  is 
relieved,  the  important  indication  is  to  prevent  its  repetition 
by  endeavoring  to  remove  its  source. 

Uterine  Colic. — The  painful  sensations  experienced  by  some 
women  at  their  menstrual  periods  may  come  on  in  paroxysms 
similar  to  those  of  colic.  In  truth,  the  pain  is  often  spoken 
of  as  uterine  colic,  and  at  times  continues  for  many  days,  per- 
sisting during  the  whole  menstrual  period,  or  even  longer. 
In  some  of  these  cases  the  trouble  is  localized  in  the  uterus  ; 
in  others  more  especially  in  the  ovaries,  which  are  then  ten- 
der to  the  touch.  Similar  attacks  of  pain,  also  accompanied 
by  congestion,  or  even  by  inflammation  of  the  ovaries,  are 
occasionally  met  with  as  the  result  of  falls  or  of  blows  on 
the  hypogastric  region. 

Now,  with  reference  to  the  disorder  first  alluded  to,  or 
ordinary  dysmenorrhosa,  it  may  be  generally  easily  discrim- 
inated from  colic  by  its  concurrence  with  tlie  setting  in  of  the 
menstrual  flow;  by  the  pain  remitting  rather  than  intermit- 
ting ;  by  the  seat  of  the  pain  in  the  pelvis,  or  the  lower  part 
of  the  abdomen;  by  its  not  uncommon  association  with  sick- 


470  MEDICAL    DIAGNOSIS. 

ness,  nausea,  and  vomiting  ;  and  by  the  fact  that  all  the  signs 
of  disordered  menstruation  have  happened  over  and  over 
again  at  the  menstrual  periods. 

Where  the  ovaries  are  very  much  congested  or  inflamed, 
whether  or  not  the  affection  exist  in  connection  with  dysmen- 
orrhcea,  or  occur  in  consequence  of  other  causes,  among  which 
gonorrhoea  may  be  one,  the  pain,  tenderness,  and  swelling  in 
the  hypogastric  region  ;  the  not  unusual  numbness  and  flexed 
position  of  one  or  both  thighs;  the  febrile  irritation,  and 
the  hysterical  sjmiptoms;  the  retention  of  the  urine;  the  vio- 
lence of  the  paroxysms  of  pain,  and  the  duration  of  the  malady 
form  a  group  of  phenomena  very  dissimilar  to  those  of  ordi- 
nary cases  of  colic. 

Neuralgia  of  the  Dorsal  and  Lumbar  Nerves  ;  Abdominal  Neu- 
ralgia.— The  dorsal  and  lumbar  nerves  are  subject  to  neural- 
gic affections,  wliich  exhibit,  like  colic,  paroxysms  of  pain 
unaccompanied  by  fever.  In  truth,  the  resemblance  to  colic 
is  so  great  that,  until  Valleix  made  abdominal  neuralgias  a 
subject  of  special  study,  their  discrimination  from  colic  was 
unsatisfactory,  perhaps  impossible.  This  distinguished  ob- 
server has  taught  us  to  look  for  spots  painful  to  the  touch  in 
the  course  of  the  aching  nerves,  and  has  shown  that  the  dis- 
turbance of  tbe  nerves  supplying  the  abdominal  parietes 
manifests  itself  onl}-  on  one  side  of  the  body,  whereas,  as  is 
well  known,  an  irritation  of  the  intestinal  nerves  obeys  no 
such  law. 

In  neuralgia  of  the  lumbar  nerves,  or  lumbo-abdominal 
neuralgia,  to  employ  the  term  sanctioned  by  Valleix,  the 
pain  is  commonly  felt  in  the  hypogastric  region,  a  little  to 
one  side  of  the  median  line.  In  this  situation,  too,  there  is 
localized  soreness  on  pressure  ;  the  other  tender  spots  are, 
generally,  one  a  little  to  the  outside  of  the  first  or  second 
lumbar  vertebra,  and  one  immediately  above  the  middle  of 
the  crest  of  the  ilium.  In  women,  who  are  by  far  the  great- 
est sufierers  from  the  disease,  there  is  sometimes  also  a  pain- 
ful place  about  the  middle  of  the  Fallopian  tube,  or  on  the 
neck  of  the  uterus;  in  men,  a  point  on  the  scrotum  is  here 
and  there  found  sore  to  the  touch.  These  spots  of  tenderness 
serve  as  characteristic  signs ;  and  the}'  enable  us  to  separate 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  471 

neuralgia  not  oiilv  from  colic,  but  also  from  lumbago,  and 
from  rheumatism  of  the  abdominal]  walls. 

Besides  these  forms  of  neuralgia,  we  find  other  kinds  of 
abdominal  neuralgia,  which  may  be  mistaken  for  colic.  They 
are  attacks  of  pain  afi'ecting  especially  the  mesenteric  plexus 
or  the  solar  plexus,  happening  in  paroxysms  of  great  severity, 
and  attended  with  a  sense  of  faintness  and  annihilation.  The 
disorder  is  unconnected  with  lead  poisoning  or  any  of  the 
causes  which  produce  colic,  is  often  excited  by  exertion,  and 
is  associated  with  debility  and  relieved  by  an  antineuralgic 
treatment.  In  some  cases  the  painful  disorder  is  clearly  of 
malarial  origin;  and  in  every  case  we  must  lay  great  stress 
on  the  frequent  recurrence  of  the  pain  and  on  the  history  to 
enable  us  to  discriminate  between  the  neuralgic  complaint  and 
colic.  The  distinction  from  gastralgia  can  only  be  made  by 
the  more  marked  gastric  symptoms,  and  the  absence  of  or  the 
less  decided  prostration  and  sense  of  fainting  in  this  malady.* 

Abdominal  Aneurism  cmd  Tumors  ;  Diseases  of  the  Spine. — In 
all  of  these  we  may  find  violent  pain  of  a  paroxysmal  kind 
referred  to  various  portions  of  the  abdomen,  and  unaccom- 
panied by  fever.  We  judge  that  the  pain  is  not  colic,  by  its 
frequent  repetition  ;  by  its  want  of  association  with  intestinal 
or  gastric  disturbance;  by  its  being,  although  liable  to  ex- 
acerbations, so  steadily  present  at  some  part  either  of  the 
spine  or  abdomen  ;  and  by  the  attending  symptoms  and  signs 
occasioned  by  an  abdominal  tumor,  or  by  a  disease  of  the 
lower  dorsal  or  of  the  lumbar  vertebrae. 

Enteritis  and  Peritonitis. — Inflammations  of  the  intestines 
and  peritoneum  also  give  rise  to  severe  abdominal  pain. 
But  it  is  more  constant,  linked  to  great  tenderness,  and,  in 
acute  cases,  to  symptoms  of  high  febrile  excitement.  Thus 
enteritis  and  peritonitis  belong  to  a  different  group  of 
diseases — a  group  of  inflammatory  affections,  which  I  shall 
describe  somewhat  at  length,  before  contrasting  the  symp- 
toms of  inflammation  of  the  intestines  or  of  the  peritoneum 
with  those  of  colic. 

*  A  number  of  cases  of  abdominal  neuralgia  are  reported  by  Handficld 
Jones,  in  his  Treatise  on  Functional  Nervous  Disorders ;  see,  also,  Porcher's 
cases  in  Am.  Journ.  of  Med.  Sciences,  Jul}',  1869. 


472  MEDICAL    DIAGNOSIS. 

Diseases  attended  with  Pain  and  marked  Tenderness  in  the 
Umbilical  Region  or  diffused  over  the  Abdomen. 

Acute  Enteritis. — Enteritis  means  now,  by  common  con- 
sent, inflammation  of  the  small  intestine,  and  especially  of 
the  portion  that  lies  between  the  duodenum  and  the  colon. 
The  morbid  process  may  extend  to  the  colon ;  if,  however,  it 
involve  a  large  portion  of  the  latter,  it  is  colitis  or  dysentery, 
and  not  enteritis,  with  which  we  have  to  deal.  There  are  two 
forms  of  enteritis :  one  in  which  the  mucous  membrane  of 
the  bowel  is  alone  affected;  the  muco-enteritis,  or  the  catar- 
rhal inflammation  of  recent  authors,  the  erythematous  ente- 
ritis of  Cullen.  In  the  second,  more  than  the  mucous  tunic 
is  implicated ;  there  is  also  inflammation  of  the  submucous 
and  muscular  coats,  or  even  of  the  serous  investment  of  the 
bowel.  To  this  variety  of  the  complaint  the  term  enteritis 
is  by  several  writers  restricted;  and  it  is  to  this  form  of  the 
malady,  occurring  acutely,  that  the  description  about  to  be 
given  more  particularly  applies. 

The  symptoms  of  an  acute  attack  of  enteritis  are  those  of 
colic,  attended  with  fever  and  tenderness.  The  disorder 
may  begin  with  the  symptoms  of  colic,  and  in  such  cases  the 
inflammation  of  the  bowel  is  said  to  have  supervened  on 
colic ;  or  it  may  set  in  with  a  chill  and  fever,  and  extreme 
thirst. 

AVlienthe  disease  is  fully  established,  the  fever  runs  high; 
the  pulse,  tense  and  full  at  the  onset,  becomes  small  and 
wiry,  although  it  remains  frequent.  There  are  nausea  and 
vomiting,  and  sometimes  most  distressing  fits  of  retching, 
produced  either  by  sympathy,  or  because  the  stomach  shares 
in  the  inflammation.  The  tongue  is  clean  and  of  natural  ap- 
pearance, or  it  is  covered  with  a  white  coat,  or  again  it  may 
be  red  and  dry.  The  bowels  are  constipated;  sometimes, 
however,  there  is  diarrhoea,  or  constipation  alternating  with 
diarrhoea.  The  stools  are,  in  consequence,  of  varying  con- 
sistency and  color;  they  may  contain  a  small  quantity  of 
blood,  but  they  very  rarely  contain  pus.  The  appetite  is 
completely  lost;  the  thirst  is  unceasing;  the  pain,  as  in  colic. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  473 

is  paroxysmal.  It  commences  near  the  umbilicus,  and  thence 
may  shift  to  various  parts  of  the  abdomen,  but  not  to  the 
epigastrium  ;  yet  it  is  not  so  violent,  nor  does  it  cease  so  en- 
tirely as  in  colic,  but  rather  exacerbates,  and  then  changes  to 
a  dull  feeling  of  distress.  It  is  greatly  increased  by  pressure, 
and  the  patient  seeks  relief,  as  in  peritonitis,  by  lying  on  his 
back  with  his  thighs  flexed,  so  as  to  relax  the  abdominal  mus- 
cles. Toward  the  right  of  the  umbilicus,  it  is  not  uncommon 
to  find  a  marked  pulsation,  as  if  from  throbbing  of  the  ab- 
dominal aorta  or  of  its  large  branches, — a  sign  to  which,  if  I 
mistake  not,  Dr.  Stokes*  first  directed  attention.  This  pulsa- 
tion may  be  very  annoying.  In  looking  over  the  notes  of 
cases  on  which  the  description  of  the  symptoms  of  enteritis 
just  given  is  based,  I  find  one  in  which  neither  the  thirst,  nor 
the  pain,  nor  the  nausea  and  vomiting  occasioned  as  much 
distress  as  the  violent  throbbing  in  the  abdomen. 

In  those  instances  of  the  malady  which  advance  to  a  fatal 
termination,  the  pulse  becomes  quick  and  irregular,  and  loses 
its  tenseness;  hiccough  appears;  the  abdomen  swells;  the 
features  are  haggard,  and  expressive  of  great  suffering;  and 
the  patient's  strength  becomes  gradually  exhausted.  The 
worst  and  most  hopeless  cases  of  the  disease  are  those  de- 
pendent on  mechanical  obstruction  of  the  bowel,  whether  it 
proceed  from  organized  bands  in  which  a  loop  of  intestine  is 
caught,  or  from  invagination,  or  from  accumulation  of  hard- 
ened feces,  or  from  a  hernial  strangulation. 

Among  the  symptoms  and  signs  of  enteritis  mentioned,  the 
pain  is  one  of  the  most  important  for  diagnosis.  It  is  never 
absent,  save  in  some  rare  instances  in  which  the  inflamma- 
tion is  very  intense  at  the  onset.f  Still  more  important  is 
the  great  tenderness.  This  enables  us  to  say  that  the  case, 
in  spite  of  the  colicky  pains,  is  not  colic.  It  warns  us  not 
to  resort  to  stimulants,  and  remedies  merely  to  relieve  the 
seemingly  spasmodic  pain.  It  tells  us,  when  it  succeeds  to 
what  began  as  ordinary  colic,  that  inflammation  of  the  bowel 
has  supervened  and  requires   immediate  attention.     It  ad- 


*  Article  "  Enteritis,"  in  Cyclop,  of  Pract.  Med. 
f  Andral,  Pathologie  Interne,  tome  i   page  47. 


474  MEDICAL   DIAGNOSIS. 

monishes  us  not  to  administer  strong  cathartics  to  overcome 
the  constipation  which  appears  in  consequence  of  the  severe 
inflammation. 

The  disease  in  its  violent  form  just  described  bears  a  close 
resemblance  to  peritonitis.  We  shall  presently  see  what  are 
its  distinguishing  marks.  But  there  is,  as  above  stated,  an- 
other variety  of  the  disease,  a  mild  varietj',  or  muco- enteritis, 
in  which  the  disturbance  is  limited  to  the  mucous  membrane. 
The  main  features  of  this  disorder  are  the  same,  but  they 
stand  out  in  less  bold  relief.  There  are  griping  pains,  a  slight 
soreness  to  the  touch,  general  uneasiness,  loss  of  appetite, 
thirst,  nausea,  and  sometimes  vomiting.  But  we  find  only 
slight  fever;  or  rather,  the  skin  is  dry  and  becomes  hot 
toward  night,  and  the  febrile  excitement  remits  in  the  morn- 
ing. Diarrhcea  is  always  present,  and  the  stools  are  some- 
times very  offensive.  This  form  of  the  disease  may  termi- 
nate, as  the  severer  inflammation  generally  does,  in  less  than 
a  week;  yet  it  may  persist  for  several  weeks,  and  thus  grad- 
ually lapse  into  a  chronic  complaint.  It  is  common  in  chil- 
dren, especialW  during  dentition.  It  is  also  observed  when 
irritating  food  or  secretions  occupy  the  alimentary  canal  for 
any  length  of  time,  or  after  exposure,  and  as  an  attendant 
upon  the  exanthemata  and  typhoid  fever.  Indeed,  it  is  some- 
times difiicult,  particularly  in  children,  to  know  whether  we 
have  to  deal  with  a  case  of  muco-enteritis,  or  with  the  intes- 
tinal complication  of  enteric  fever.  The  state  of  the  cere- 
bral functions,  and  the  pain  and  gurgling  in  the  iliac  fossae 
may  clear  up  the  doubt;  yet  in  some  cases  nothing  but  the 
eruption  and  the  course  of  the  symptoms  Avill  do  so. 

Acute  Peritonitis. — As  in  acute  enteritis,  so  in  acute 
peritonitis,  pain  and  tenderness  are  the  most  signiflcant 
symptoms.  To  these  are  joined  fever,  distention  of  the  ab- 
domen, and  frequently  cold  sweats,  nausea,  vomiting,  and 
obstinate  constipation. 

To  understand  these  symptoms,  it  is  necessary  to  be  ac- 
quainted with  the  morbid  anatomy  of  the  disease.  I  shall 
endeavor  to  sketch  it  in  a  few  words.  Acute  inflammation 
attacking  the  peritoneum  may  be  confined  to  one  spot;  but 
it  is  very  apt,  even  if  limited  at  its  onset,  to  spread  over  the 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  475 

entire  membrane.  It  commences  with  injection  of  the  ves- 
sels. This  is  soon  followed  by  an  exudation  of  lymph,  or  of 
lymph  and  serum  ;  or  the  effused  fluid  may  be  hemorrhagic, 
or  purulent,  or  ichorous.  The  last-mentioned  varieties  occur 
in  depraved  states  of  the  blood,  or  in  asthenic  conditions  of 
the  system.  The  inflammation,  even  when  general,  is  usually 
most  marked  at  one  or  several  portions  of  the  membrane. 
It  leads  to  paralysis  of  the  intestine,  and  to  its  distention 
by  gas. 

The  effects  of  the  exudation  are  somewhat  different  ac- 
cording to  its  kind  and  amount.  If  much  liquid  be  effused, 
the  abdomen  is  swollen  ;  but  the  fluid,  as  a  rule,  is  readily 
taken  up  again.  When  the  inflammation  is  followed  by  the 
pouring  out  of  coagulable  lymph,  the  two  surfaces  of  the 
peritoneum  are  very  prone  to  become  either  partially  or 
generally  agglutinated,  and  strings  of  flbrin  stretch  between 
the  intestinal  coils.  Nor  is  the  lymph  very  likely  to  be  re- 
absorbed. On  the  contrary,  it  is  often  transformed  into 
tissue,  and  gives  rise  to  induration  and  roughening  of  the 
membrane,  or  to  a  permanent  attachment  of  its  two  layers, 
or  to  fibrous  bands  fastening  one  portion  of  intestine  to  the 
other.  When  the  serous  membrane  adheres  in  spots,  it  some- 
times incloses  pus  in  the  sacs  thus  formed.  These  abscesses 
may  discharge  into  the  bowel,  or,  as  Rokitansky  tells  us, 
they  may  evacuate  their  contents  through  the  abdominal 
parietes.  Hence  the  results  of  acute  peritonitis  do  not  pass 
off  with  the  attack  itself.  Indeed,  these  sequelae  may  be  as 
grave  as  the  original  malady. 

But  to  return  to  the  symptoms  of  acute  peritonitis,  and 
especially  to  those  characterizing  the  form  in  which  the  in- 
flammation has  involved  the  whole  membrane  or  a  very  large 
part  of  it.  The  disease  begins  with  chilly  sensations  or  a 
protracted  rigor.  To  these  succeed  fever,  and  abdominal 
pain  and  distention.  The  fever  runs  high  at  the  onset;  it 
exhibits  a  dry,  burning  skin,  a  pulse  frequent,  but,  as  in  most 
of  the  acute  inflammations  of  the  mucous  and  serous  mem- 
branes below  the  diaphragm,  small  and  wiry.  However, 
both  the  character  of  the  pulse  and  the  temperature  of  the 
skin  change  as  the  dangerous  malady  progresses.     The  pulse 


476  MEDICAL    DIAGNOSIS. 

will  be  less  tense  and  more  developed  as  the  inflammation 
subsides,  or  exceedingly  feeble  and  flickering  if  the  disorder 
proceed  toward  a  fatal  termination.  The  skin  of  the  ex- 
tremities becomes  cool,  and  is  frequently  covered  with  cold 
sweats.  The  features  are  sharpened  and  wear  the  look  of 
death,  even  in  cases  which  ultimately  recover. 

The  pain  is  constant  and  very  severe.  It  may  exacerbate, 
but  it  never  intermits.  At  flrst  the  pain  is  confined  to  a  par- 
ticular point;  but  as  the  inflammation  extends,  so  it  extends 
over  the  whole  abdomen.  It  is  increased  by  the  slightest 
pressure,  be  that  pressure  exerted  by  the  hand  or  by  move- 
ments of  any  kind.  To  obviate  the  pressure,  the  patient  lies 
on  his  back  with  his  thighs  flexed,  and,  however  tired  of  re- 
taining the  same  position,  he  does  not  change  it.  The  de- 
scent of  the  diaphragm  augments  the  pain  ;  instinctively, 
therefore,  he  refrains  from  drawing  long  breaths,  and  his 
respiration  is  short  and  frequent.  If  closely  watched,  it  is 
found  to  be  purely  thoracic,  the  abdominal  walls  neither 
rising  nor  falling  during  the  respiratory  acts. 

The  abdominal  distention  is  in  part  owing  to  meteorism, 
in  part  to  the  liquid  etfused  into  the  peritoneum.  Percussion 
tells  us  in  individual  cases  how  fiir  each  acts  as  a  cause  of 
the  enlargement,  by  the  tympanitic  or  the  dull  sound  elicited. 
Palpation,  too,  reveals  the  presence  of  liquid.  Yet  neither 
percussion  nor  palpation  ought  to  be  employed,  save  when 
really  necessary  for  diagnosis,  and  then  only  with  the  greatest 
care,  on  account  of  the  pain  they  occasion.  The  fluid  does 
not  gravitate  as  invariably  as  in  ascites  to  the  lower  portion 
of  the  belly.  It  is  often  caught  in  sacs  formed  by  the  mem- 
brane adhering  in  spots;  and  thus  circumscribed  dulness 
may  be  found  at  one  or  several  parts  of  the  abdomen. 
Sometimes  the  roughening  of  the  membrane  gives  rise  to  a 
distinct  friction  sound. 

Independently  of  the  abdominal  pain  and  swelling,  we 
meet,  in  acute  peritonitis,  with  constipation,  nausea  and  vom- 
iting, headache,  a  suppression  of  the  urinary  discharge,  and 
in  rare  instances  with  priapism  ;  of  these  symptoms,  constipa- 
tion is  the  most  constant.  The  bowels  are  never  relaxed, 
except  in  the  puerperal  form  of  the  malady.     The  constipa- 


DISEASES    OF   THE    INTESTINES    AND    PERITONEUM.         477 

tion  is  caused  by  the  paralyzed  state  of  the  intestine,  to 
portions  of  which  the  inflammation  may  spread;  or  by  the 
lymph  gluing  together  the  coils  of  the  bowels,  and  thus 
interfering  with  their  peristaltic  action. 

Death  in  acute  peritonitis  is  commonly  preceded  by  enor- 
mous tumefaction  of  the  belly,  by  cold  sweats,  a  pinched 
countenance,  a  rapid,  flickering  pulse.  When  recovery  takes 
place — unfortunately  a  rarer  issue  of  the  malady  than  its  fatal 
termination — it  is  commonly  very  slow  and  gradual.  The 
symptoms  diminish  one  by  one;  the^-  do  not  cease  suddenly; 
and  often  morbid  conditions  remain  which  prolong  greatly  the 
patient's  illness,  and  may  lead  in  themselves  to  a  disastrous 
result.  It  is,  therefore,  impossible  to  foretell  the  duration 
either  of  the  acute  disease  or  of  its  consequences.  Andral 
fixes  the  average  length  of  an  acute  attack  at  between  six 
and  nine  days,  and  of  a  subacute  attack  at  from  twenty  to 
thirty  days.  But  the  nature  of  the  malady  is  such,  that 
many  cases  last  a  longer,  many  a  much  shorter  period. 

Acute  peritonitis  arises  occasionally  from  exposure  to  cold 
and  wet;  much  oftener  in  consequence  of  injuries  to  the 
abdomen,  such  as  blows,  stabs,  or  kicks;  or  from  perforation 
or  laceration  of  some  of  the  abdominal  organs,  and  discharge 
of  their  contents  into  the  peritoneal  cavity.  It  also  results 
from  some  peculiar  and  poisoned  state  of  the  blood,  as,  for 
example,  that  frightful  form  of  peritonitis  occurring  in  child- 
bed fever.  It  sometimes  originates  from  an  inflammation  of 
the  abdominal  viscera,  especially  of  the  spleen,  intestines,  or 
uterus  and  its  appendages,  spreading  to  their  serous  cover- 
ing, and  thence  extending  more  or  less  rapidly.  Again,  other 
morbid  states  of  the  abdominal  organs,  such  as  cysts  of  the 
ovaries,  intestinal  intussusception,  or  strangulated  hernia, 
may  compress  or  irritate  the  membrane,  and  lead  to  inflam- 
matory action.  Owing  to  these  diverse  sources,  peritonitis 
presents  varieties  which  exhibit  points  of  difl:erence  suflicient 
to  require  special  notice. 

The  inflammation  produced  by  extravasation  into  the  peri- 
toneal sac  is  characterized  by  its  sudden  development.  The 
matters  extravasated  may  be  blood,  or  bile,  or  urine,  or  the 
contents  of  the  stomach.     Most  frequently  perforation  of  the 


478  MEDICAL   DIAGNOSIS. 

stomacli  or  intestine  lies  at  the  bottom  of  the  mischief. 
Whatever  its  cause,  the  perforation  is  immediately  followed 
by  collapse;  and  tenderness  and  distention  of  the  abdomen 
soon  make  their  appearance.  Yet  peritonitis  may  set  in 
rapidly  in  cases  in  which  there  has  been  no  rupture;  and,  on 
the  other  hand,  in  rare,  very  rare  instances,  the  contents  of 
the  alimentary  canal  may  be  discharged  into  the  sac  without 
giving  rise  to  inflammation.* 

The  peritonitis  of  childbed  fever,  or  puerperal  peritonitis,  is 
principally  distinguished  by  its  occurring  during  the  puer- 
peral state.  Its  symptoms  are,  so  far  as  the  peritoneal  in- 
flammation is  concerned,  exactl}^  those  of  any  other  kind  of 
peritonitis,  excepting  that  diarrhoea,  instead  of  constipation, 
is  commonly  present.  The  uterus  or  the  uterine  append- 
ages are  generally,  but  not  invariably,  first  attacked ;  and  it 
is  in  tliese  regions  that  pain  and  tenderness  are  first  felt. 
The  inflammation  begins  in  those  structures  and  spreads  to 
their  serous  investment,  or  it  may  be  primarily  seated  in  that 
investment ;  in  either  case  it  soon  involves  the  entire  mem- 
brane. 

But,  independently  of  the  symptoms  of  the  local  disorder, 
there  are  phenomena  which  clearly  belong  to  the  general 
puerperal  disease,  of  wliich  the  inflammation  of  the  perito- 
neum is  but  a  local  expression  ;  there  are  evidences  of  a 
poisoned  state  of  the  blood  and  a  general  disturbance  of  the 
system.  How  else  account  for  the  exudations  into  the  peri- 
cardium and  pleura  being  like  those  on  the  peritoneum  ? 
How  else  account  for  the  black  vomit,  and  for  the  delirium, — 
symptoms  far  from  seldom  met  with  in  puerperal  peritonitis, 
but  not  in  the  purely  local  disease  ?  How  else  account  for 
the  uniform  type  exhibited  by  the  malady  in  some  epidemics, 
and  its  varied  form  in  others  ? 

What  the  poison  is  which  determines  the  terrible  disease, 
we  cannot  here  inquire.  It  may  be,  as  some  think,  atmos- 
pheric ;  it  may  be,  as  others  hold,  the  absorption  of  putrid 
matter  from   the  uterus;  it  may  be  an  animal  virus  trans- 


*  Ciisos  reported  by  BurdeleLcn  and  Siebert,  quoted  in  Henoch's  Clinic  of 
Abdominal  Diseases.  Instances  of  rapid  peritonitis  without  })erforation  are 
given  by  Thirial,  TUnion  M^dicale,  1853. 


DISEASES    OF   THE    INTESTINES   AND    PERITONEUM.  479 

mitted  by  the  hand  of  the  attendant;  the  complaint  may  he, 
as  is  now  so  generally  believed,  closely  analogous  to  erysipe- 
latous inflammation  ;  it  may  be  eminently  contagious;  it  may 
not  be  so  at  all.  These  are  not  points,  however  important 
their  solution  to  the  well-being  of  thousands  of  lying-in 
women,  which  concern  us  here.  For  diagnostic  purposes,  it 
is  of  more  consequence  to  know  that  the  distemper  prevails 
epidemically  and  endemically,  that  its  features  change,  and 
that  the  puerperal  peritonitis  of  one  year  is  not  the  puerperal 
peritonitis  of  another;  in  short,  that  w^hile  childbed  fever, 
whatever  its  cause,  occasions  peritonitis,  peritonitis  does  not 
constitute  childbed  fever. 

Taking  this  view  of  the  disease,  it  is  obvious  that  those 
sporadic  cases  of  peritonitis  occasionally  encountered  after 
delivery,  in  which  the  inflammation  has  either  become  gen- 
eral or  remains  limited  to  the  womb  and  its  surroundino:s, 
are  very  different  from  the  pestilential  disorder  which  attacks 
numbers  of  parturient  females  simultaneously,  or  in  rapid 
succession.  And  the  inference  from  these  statements  is,  that 
under  the  general  name  of  puerperal  peritonitis  are  grouped 
together  several  forms  of  peritoneal  inflammation,  having 
not  one,  but  several  causes,  accompanying  not  the  same,  but 
diverse  constitutional  states,  and  presenting  not  always  iden- 
tical, but  at  times  most  opposite  indications  for  treatment. 

Partial  or  local jjeritojiitis  is  almost  invariably  owing  to  a  pre- 
existing morbid  condition  of  some  abdominal  viscus.  Some- 
times the  circumscribed  inflammation  is  protective  rather  than 
calculated  to  work  mischief.  It  arrests  a  destructive  perfora- 
tion of  the  membrane,  or  it  limits  the  matter  discharged  to  a 
certain  spot;  it  may  at  least  do  so  for  a  time,  for  general 
peritonitis  is  very  apt  ultimately  to  follow. 

Partial  peritonitis  often  pursues  a  subacute  rather  than  an 
acute  course.  It  may  end  in  adhesions  or  lapse  into  a  chronic 
state.  Its  symptoms  are  much  the  same  as  those  of  a  more 
general  inflammation:  the  sariie  fever  and  constipation,  the 
same  pain  and  tenderness.  The  fever  docs  not,  however,  run 
so  high,  and  the  pain  and  the  great  tenderness  are  much  more 
localized.  The  abdomen,  also,  is  not  so  swollen  nor  so  tym- 
panitic.    But  perhaps  even  more  frequently  than  in  general 


480  MEDICAL    DIAGNOSIS. 

peritonitis  are  found  accurately  limited  spots  of  duluess  on 
percussion  corresponding  to  circumscribed  collections  of  pus 
in  the  peritoneal  cavity. 

Partial  peritonitis  is  more  liable  than  the  general  disease  to 
be  confounded  with  other  disorders.  Yet  error  can  hardly 
arise,  or,  should  it  arise,  it  is  not  of  much  consequence,  pro- 
vided we  bear  in  mind  that  it  is  precisely  with  the  morbid 
states  of  the  viscera  which  lie  below  the  peritoneum  that  the 
circumscribed  inflammation  of  the  serous  membrane  is 
usually  connected,  and  that  local  peritonitis,  therefore,  fre- 
quently attends  the  very  disorders  from  which  it  is  sought  to 
be  distinguished.  Let  us,  however,  examine  into  some  of  the 
complaints  with  which  peritonitis,  whether  local  or  general, 
may  be  confounded.     They  are  : 

Gastritis  ; 

Enteritis  ; 

Metritis  ; 

Cystitis  and  Distention  of  the  Bladder; 

Rheumatism  of  the  Abdominal  "Walls; 

Abdominal  Hysteria; 

Colic. 

Gastritis. — Acute  inflammation  of  the  stomach  can  scarcely 
be  mistaken  for  inflammation  of  the  peritoneum,  provided 
attention  be  paid  to  the  history  of  the  case  and  the  seat  of  the 
pain.  The  former  disorder  commences  with  vomiting,  and 
this  continues  a  prominent  symptom  throughout ;  whereas 
vomiting  is  neither  so  constant,  nor  does  it  occur  so  early,  in 
peritonitis.  The  pain  and  tenderness  are  limited  to  the  re- 
gion of  the  stomach  in  gastritis;  they  are  diffused  and  ac- 
companied by  general  abdominal  enlargement  in  peritonitis. 
They  may,  it  is  true,  be  localized  when  the  peritonitis  is 
partial.  But  acute  inflammation  of  the  gastric  peritoneum 
is  hardly  encountered,  save  as  an  attendant  on  severe  in- 
flammation of  the  stomach,  or  on  a  destruction  of  its  coats. 
And  in  the  first  instance  it  is  practically  gastritis  we  are 
dealing  with ;  in  the  second,  the  history  of  the  case,  the 
sudden  increase  of  the  pain  and  tenderness,  and  the  develop- 
ment of  fever  will  go  far  toAvard  evincing  the  nature  of  the 
disorder.     However,  if  a  partial  i)eritonitis  occurring  in  con- 


DISEASES    OF   THE    INTESTINES    AND    PERITONEUM.  481 

sequence  of  serious  gastric  disease  be  subacute  or  chronic,  it 
eludes  discovery. 

Enteritis. — Enteritis  differs  from  general  peritonitis  by  the 
less  extended  tenderness ;  by  the  seat  of  the  pain  near  the 
umbilicus,  and  its  more  paroxysmal  character;  by  the  com- 
parative absence  of  tympanites  and  abdominal  tumefaction  ; 
and  by  the  greater  prominence  of  nausea  and  vomiting.  It 
is,  moreover,  a  disease  far  less  violent  and  dangerous  than 
acute  peritonitis  ;  yet  it  cannot  be  distinguished  with  cer- 
tainty from  the  partial  form  of  this  disorder.  In  truth,  so 
far  as  the  diagnosis  of  enteritis  is  concerned,  it  is  not  of 
much  importance  that  it  should  be;  for  inflammation  of  the 
intestine  is  generally  associated  with  a  local  peritonitis,  to 
which  some  of  its  symptoms  are  clearly  owing. 

Metritis. — Inflammation  of  the  womb  is  not  likely  to  be 
mistaken  for  general  peritonitis  ;  tlie  pain  on  pressure,  which 
they  have  in  common,  is  confined  in  the  former  disease  to 
the  uterus  and  its  annexes,  and  there  is  little  or  no  tympa- 
nites. It  is  thus,  and  thus  only,  that  the  acute  metritis  of 
childbed  fever  may  be  distinguished  from  the  acute  general 
peritonitis  of  the  same  malady.  For  otherwise  the  resem- 
blance is  strong;  in  both,  the  disease  is  ushered  in  by  chills, 
and  the  lochial  discharge  soon  diminishes  or  ceases.  When 
the  puerperal  malady  attacks,  as  it  often  does,  the  uterus  as 
well  as  the  whole  peritoneal  surface,  the  signs  of  inflamma- 
tion of  the  serous  membrane  mask  those  of  inflammation  of 
the  womb. 

Now,  a  local  inflammation  of  the  peritoneum  occurs  still 
more  constantly  as  an  attendant  on  inflammation  of  the 
womb  and  its  appendages,  whether  the  disorder  of  the  sex- 
ual organs  be  or  be  not  puerperal.  It  frequently  leads  to 
collections  of  pus,  which  can  be  readily  felt  through  the 
parietes  of  the  abdomen,  or  through  the  rectum  and  the 
vagina,  and  which  sometimes  discharge  into  the  bowel  or 
vagina  after  a  lingering  sickness.  The  proofs  that  the 
uterus  is  involved  in  these  cases  of  partial  peritonitis,  are 

the  sio-ns  of  its  disordered  functions  and  the  excessive  pain 

~  ... 

occasioned  by  pressing  on  the  cervix  during  an  examination 

per  vaginam. 

31 


482  MEDICAL    DIAGNOSIS. 

Cystitis  and  Distention  of  the  Bladder. — Both  inflammation 
and  distention  of  the  bladder  are  occasionally  mistaken  for 
general  acute  peritonitis.  An  acute  inflammation  of  the 
bladder  gives  rise  to  frequent  calls  to  pass  urine :  yet  the  act 
is  performed  with  great  difficult}',  and  in  severe  cases  may 
become  impossible;  the  bladder  distends;  a  sense  of  un- 
easiness is  felt  in  the  perineum ;  the  region  above  the  pubis 
becomes  tender  to  the  touch,  and  sounds  dull  on  percussion; 
the  unhappy  sufferer  is  very  restless  and  distressed ;  he  has 
the  excited  pulse  and  the  hot  skin  of  an  inffammatory  fever; 
at  times  vomiting  and  hiccough  supervene;  and  death  is 
preceded  by  gradually  deepening  coma.  Such  cases  re- 
semble in  some  respects  those  of  peritonitis  with  suppression 
of  the  urinar}'  discharge  and  with  strangury.  But  the  urine 
which  is  voided  in  peritonitis  is  simply  high  colored,  like 
that  of  any  febrile  state.  In  cystitis  it  contains  large  quan- 
tities of  mucus  and  pus,  and  often  blood  and  crj'stals  of 
phosphates.  Again,  the  abdominal  tenderness  is  localized, 
and  is  frequently  accompanied  by  a  smarting  in  the  course 
of  the  urethra.  JSTeither  of  these  signs  is  encountered  in 
peritoneal  inflammation.  The  disturbance  of  the  urinary 
organs  which  not  unfrequently  takes  place  in  the  latter  dis- 
order has  been  variously  explained ;  it  has  been  attributed 
to  inflammation  of  the  part  of  the  peritoneum  covering  the 
bladder,  or  its  immediate  neighborhood.  But  whether  it  be 
so  or  not,  is  as  uncertain  as  whether  it  be  an  inflammation  of 
the  serous  investment  of  the  stomach  which  occasions  the 
nausea  and  vomiting  of  the  same  disease. 

An  overdistention  of  the  bladder,  not  the  result  of  inflam- 
mation of  its  coats,  may  produce  a  local,  tenderness  spread 
over  a  considerable  portion  of  the  lower  part  of  the  abdomen. 
But  the  outline  of  the  dulness  coextensive  Avith  that  of  the 
tenderness  ;  the  fact  that  the  patient  has  generally  not  passed 
urine  for  a  considerable  time  and  the  sudden  cessation  of  the 
supposed  peritonitis  on  passing  a  catheter,  show  the  true 
nature  of  the  malady.* 

*A  case  of  this  kind,  occiin-iiig  aftor  deliver}-,  is  given  by  Lever,  Guy's 
Hospital  Reports,  2d  Series,  vol.  viii.  pa;;!'  41. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  483 

hvflammation  and  Abscess  in  the  Ahdoyninal  Muscles. — Wlien 
the  abdominal  walls  become  inflamed,  symptoms  are  occa- 
sioned which  are  not  always  easily  distinguished  from  those 
of  acute  peritonitis.  Tlie  disease  is  attended  with  some  fever, 
with  pain  increased  by  movement,  by  the  act  of  coughing,  and 
by  pressure,  and  sometimes  with  excessive  tenderness.  The 
seat  of  the  inflammation  is  generall}^  the  rectus  muscle  and 
the  surrounding  cellular  tissue.  The  parts  on  one  side  of  the 
umbilicus  are  most  commonly  attacked,  and  it  is  there  that  a 
hard  swelling  is  perceived,  over  which  the  skin  is  rather  hot 
and  sometimes  red.  The  tumefaction  gradually  disappears 
by  resolution,  or  else  fluctuation  becomes,  from  day  to  day, 
more  distinct,  showing  that  suppuration  is  taking  place;  and 
the  pus  being  discharged,  immediate  relief  follows,  and  the 
pain  and  febrile  symptoms  instanth'  cease. 

Now,  the  disorder  rarely  runs  a  very  acute  course ;  it  lasts 
at  least  a  week  or  two  ;  and  often  much  longer.  Where  much 
of  the  muscle  is  involved,  the  complaint  closely  simulates 
peritonitis  ;  more,  however,  the  partial  than  the  general  kind. 
Where  the  inflammation  of  the  muscle  is  not  extended,  the 
resemblance  to  inflammatory  aftections  of  the  organs  lying 
underneath  the  point  of  tenderness  is  even  greater  than  to 
inflammation  of  the  peritoneum.  Hepatitis,  splenitis,  and 
gastritis  have  been  mistaken  for  the  aflection  of  the  abdom- 
inal parietes.  These  errors  can  only  be  avoided  by  taking 
into  account  the  absence  of  disttirbed  function  of  the  sus- 
pected viscus;  often,  too,  the  peculiar  swelling  furnishes  a 
clue  to  the  real  nature  of  the  case. 

But  can  we  distinguish,  with  anything  like  certainty,  be- 
tween these  abscesses  in  the  abdominal  Avails  and  instances 
of  partial  peritonitis  leading  to  collections  of  pus  in  the  peri- 
toneal cavity?  I  believe  not:  for  in  both  there  is  a  tume- 
faction;  in  both  the  general  symptoms  are  much  the  same; 
and,  as  happens  sometimes  in  peritoneal  abscesses,  the  pus 
presses  its  way  through  the  parietes  of  the  abdomen.  How, 
then,  are  we  to  know  where  was  the  seat  of  its  fornnition  ? 
Whenever  we  find  a  sweUing  which  has  come  on  gradually, 
or  has  followed  a  blow  or  kick  on  the  abdomen,  or  a  swelling 
which  is  very  hard  before  fluctuation  appears ;  whenever  the 


484  MEDICAL    DIAGNOSIS. 

softening  of  the  tumor  is  immediately  preceded  by  distinct 
chills,  and  the  skin  covering  it  is  tense,  and  heated,  or  red- 
dish; whenever  there  is  nothing  pointing  to  the  occurrence 
of  partial  peritonitis,  as  an  attendant  on  visceral  disease,  or  as 
a  consequence  of  an  attack  of  general  peritonitis, — we  may 
infer,  from  the  history  and  the  signs,  that  the  aflection  lies  in 
the  abdominal  walls.  But  the  skin  is  not  always  discolored 
nor  hot;  the  commencement  of  the  swelling  is  sometimes 
veiled  in  obscurity,  and  an  error  in  diagnosis  is  not  discredit- 
able, because  it  is  unavoidable. 

But  it  is  not  every  case  of  abscess  in  the  walls  which  is 
attended  with  symptoms  that  render  it  likely  to  be  mistaken 
for  inflammation,  or  the  results  of  inflammation.  Sometimes 
the  preceding  tumefaction  is  so  hard,  or  it  is  so  long  before 
the  process  of  suppuration  sets  in,  that  the  aflection  is  much 
more  liable  to  be  confounded  with  abdominal  tumors.  The 
most  trustworthy  points  of  difierence  are  furnished  by  a  study 
of  the  history  of  the  case,  and  of  the  mode  of  invasion;  by 
the  slow  growth  of  the  tumor  on  the  one  hand,  its  far  more 
rapid  growth  on  the  other ;  and  by  the  absence,  or  at  all 
events  the  comparative  absence,  of  signs  denoting  serious  dis- 
turbance in  one  or  several  of  the  abdominal  viscera.  Then, 
in  doubtful  cases,  the  exploring  needle  may  be  of  use.  The 
fluid  thus  obtained  shows,  under  the  microscope,  shreds  of 
broken-down  muscle  and  of  areolar  tissue,  mixed,  if  suppura- 
tion have  commenced,  with  pus.  Again,  stress  may  be  laid 
on  the  occurrence  of  chills  preceding  the  softening  of  the 
mass.  In  some  patients  the  inflammation  is  unaccompanied 
by  any  appreciable  signs :  it  leads  to  gradual  changes  in  the 
muscular  fibres,  which  do  not  reveal  themselves  until  the  dis- 
organized muscle  gives  way.  The  fibres  undergo  softening 
or  a  true  fatty  metamorphosis,  and  the  slightest  force  suflices 
to  produce  a  rupture.  Kot  a  few  cases  have  been  reported  in 
which  one  of  the  recti  muscles  has  been  torn  asunder  during 
a  fit  of  coughing.  The  seat  of  laceration  is  generally  about 
midway  between  the  umbilicus  and  the  pubis,  a  little  to  one 
side  of  the  median  line;  the  rent  fills  with  blood,  occasioning 
a  circumscribed  swelling  and  rigidity  of  the  abdomen.  There 
is  sometimes  pain,  with  nausea,  vomiting,  and  obstinate  con- 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  485 

stipation.  N'ay,  the  symptoms  have  mimicked  so  closely  a 
strangulated  ventral  hernia  as  to  have  led  to  the  performance 
of  an  operation.* 

Rheumaiism  of  the  Abdominal  Walls. — Occasionally  rheuma- 
tism attacks  the  abdominal  muscles,  and  gives  rise  to  local 
symptoms  similar  to  those  of  peritonitis.  But  the  pain  is  not 
so  constant,  nor  is  it  spontaneous,  as  in  this  disorder.  It  is 
also  less  affected  by  movements  or  by  pressure.  I^ot  that 
these  diminish  it;  on  the  contrary,  they  aggravate  it.  But 
deep  pressure  causes  little  or  no  more  pain  than  sliglit  press- 
ure; and  it  is  only  during  certain  motions — when  the  mus- 
cles are  placed  on  the  stretch — that  the  pain  is  severe,  or 
sometimes,  indeed,  at  all  produced. 

The  pain  is  often  one-sided,  or,  at  any  rate,  much  more 
marked  on  one  side,  and  we  find  no  meteorism  and  but  slight 
fever,  and  not  the  anxious  expression  of  countenance  of  peri- 
tonitis. So  strong  a  degree  of  similarity  may,  however,  exist 
between  the  two  diseases,  as  to  keep  judgment  in  suspense. 
In  such  cases  it  is  better  to  treat  the  disorder  as  if  it  were 
inflammation  of  the  peritoneum.  In  point  of  fact,  it  may 
hiippen  that  such  inflammation  does  succeed  to  the  rheumatic 
affection  of  the  abdominal  muscles,  and  this  occurs  chiefly 
when  the  disturbance  in  the  muscles  forms  part  of  an  attack 
of  acute  rheumatism  having  a  decided  tendency  to  shift  its 
seat. 

Abdominal  Hysteria. — ^o  disease  simulates  peritonitis  so 
closely  as  hysteria.  The  abdomen  may  l)e  extremely  painful 
to  the  touch,  swollen  and  distended  with  gas,  fever  may  set 
in,  and  yet  the  whole  disorder  be  purely  hysterical.  To  illus- 
trate which  I  quote  the  following  instance  of  this  remarkable 
afltection  : 

An  unmarried  woman,  twenty  years  of  age,  placed  herself 
under  my  care,  on  account  of  extreme  tenderness  of  the  abdo- 

*  Kichardson's  case,  Amer.  Journ.  of  the  Med.  Sciences,  January,  1857. 
Further  instances  of  this  accident  are  given  by  Vircbow,  in  the  ''Wiirzburg. 
Verhandl.,"  Band  vii.  The  description  of  abscesses  in  the  abdominal  parietes 
I  have  drawn  from  cases  coming  under  my  own  notice,  from  manuscript  notes 
taken  by  Dr.  .J.  K.  Kane,  at  the  Philadelphia  Hospital,  and  from  the  cases 
collected  in  the  DictionnairedesDictionnaires  de  Medecine,  art.  ''Abdomen." 


486  MEDICAL    DIAGNOSIS. 

men  and  febrile  irritation,  both  of  which  had  become  devel- 
oped in  a  few  days.  The  abdomen  was  swollen  and  tympa- 
nitic, and  so  sensitive  that  it  would  not  bear  the  pressure  of 
her  clothes;  the  pulse  was  frequent;  the  skin  dry  and  hot; 
the  tongue  was  slightly  coated ;  the  bowels  constipated ;  the 
countenance  expressive  of  distress.  Here  was  certainly  a 
group  of  symptoms  like  those  of  acute  peritonitis.  But  the 
absence  of  the  wiry  pulse,  the  comparatively  slight  fever, — 
slighter,  at  any  rate,  than  was  to  be  expected  from  such  gen- 
eral andgreat  tenderness, — and  the  expression  of  countenance, 
which  was  not  that  of  acute  inflammation  of  the  peritoneum, 
arrested  my  attention.  I  inquired  more  closely  into  the  case, 
and  found  that  the  patient  had  had  similar  attacks  previously ; 
that  they  had  come  on  sometimes  shortly  before,  sometimes 
shortly  after,  her  menstrual  period ;  but  that  for  several  months 
her  menses  had  ceased  to  flow.  The  abdominal  tenderness 
was  in  reality,  as  she  represented  it  to  be,  very  great;  yet 
strong  pressure  produced  no  more  pain  than  the  lightest 
touch.  Nor  was  the  pain  increased  by  deep  inspiration,  or 
by  coughing,  or  by  extending  the  thighs.  Taking  all  these 
circumstances  into  account,  as  well  as  her  age  and  sex,  in- 
stead of  treating  her  for  acute  peritonitis,  cold  water  injec- 
tions, mild  purgatives,  and  a  mixture  of  assafetida  and  vale- 
rian were  employed.  Under  these  remedies,  all  the  symptoms 
of  the  apparent  peritonitis  speedily  vanished. 

Yet  all  cases  of  abdominal  hysteria  do  not  pass  off  so 
quickly;  sometimes  they  are  much  more  persistent.  Then, 
however,  they  are  from  the  onset  unattended  with  fever,  or 
the  fever  soon  ceases,  which  fact  would  in  itself  clear  up  any 
doubt  as  to  the  non-inflammatory  nature  of  the  complaint. 
The  absence  of  febrile  excitement,  too,  especially  if  taken  in 
connection  with  the  several  localized  and  more  or  less  dis- 
tinctly circumscribed  spots  of  tenderness,  enables  us  to 
distinguish  between  peritonitis  and  those  instances  of  neu- 
ralgia of  nerves  supplying  the  abdominal  parietes,  to  which 
women  who  are  laboring  under  disorders  of  the  uterus  are  so 
liable. 

Colic. — As  already  stated,  the  pain  of  colic  is  paroxj^smal, 
and  not  attended  with  fever,  or  with  much,  if  any,  tender- 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  487 

ness;  while  it  is  hardly  necessary  to  repeat  that  the  pain  of 
an  inflamed  peritoneum  is  constant,  and  associated  with  the 
greatest  tenderness  and  with  fever.  Cases  of  colic  do  indeed 
occur  in  which  we  find  fever  and  some  tenderness;  but  these 
signs  then  are  out  of  proportion  to  the  amount  of  pain.  The 
pulse  is  not  wiry,  nor  the  tenderness  so  exquisite  or  so  dif- 
fused. Further,  it  is  not  at  all  unlikely  that  in  such  cases 
the  peritoneum  is  reall}^  in  parts  injected  and  slightly  in- 
flamed. We  know  that  even  a  more  severe  form  of  perito- 
nitis ma}"  follow  colic ;  why  should  not  an  injection  of  the 
membrane  frequently  coexist  ? 

The  same  remarks  are  applicable  to  those  severe  parox- 
ysmal pains  which  accompany  the  passage  of  gall-stones  or 
of  urinary  concretions,  or  which  occur  at  the  menstrual 
periods.  They  are  frequentl}-  spoken  of  as  varieties  of  colic, 
and,  so  far  as  their  discrimination  from  peritonitis  goes,  there 
is  no  difference — it  rests  on  the  same  grounds  precisely;  for 
when  there  is  fever  or  tenderness  on  pressure,  it  is  likely  that 
inflammation  has  been  set  up  in  those  parts  in  which,  or  in 
the  neighborhood  of  which,  the  pain  is  felt.  In  the  so-called 
uterine  colic,  an  injection  of  the  peritoneum  has  positively 
been  demonstrated. 

Chronic  Peritonitis. — An  acute  attack  of  peritonitis  may 
imperceptibly  assume  a  chronic  form.  The  fever  gradually 
disappears,  or  at  all  events  lessens  ;  but  the  exudations  into 
the  peritoneal  cavity,  whether  organized  or  not,  remain,  and 
80  do  some  abdominal  pain  and  tenderness.  In  this  con- 
dition the  patient  may  continue  for  many  months ;  now  and 
then  a  fresh  inflammation  starting  up  in  tlie  peritoneum  and 
giving  rise  to  acute  symptoms,  or  an  intercurrent  severe 
diarrhoea  leading  to  rapid  loss  of  strength.  In  all  such 
cases,  indeed,  if  they  last  for  any  length  of  time,  debility 
and  emaciation  become  marked  symptoms;  then  hectic  fever 
is  observed;  the  legs  become  edematous;  and  the  patient 
may  die,  worn  out  and  presenting  the  symptoms  of  pyemic 
poisoning.  When  recovery  takes  place,  the  exudation  into 
the  peritoneal  cavit}^  is  either  discharged  through  adjacent 
viscera;  or  it  may  be  gradually  reabsorbed;  or  it  may  be 
transformed,  more  or  less  quickly,  into  tissue.     When  the 


488  MEDICAL    DIAGNOSIS. 

disease  terminates  in  this  way,  it  is  apt  to  leave  traces  of  its 
action  in  a  chronic  thickening  and  roughening  of  the  peri- 
toneum. 

But  chronic  peritonitis  now  and  then  comes  on,  and  ends 
in  a  different  fashion.  It  is  insidious  in  its  approach,  and  its 
fatal  termination  is  preceded  by  evident  signs  of  tubercular 
or  cancerous  deposits  in  the  abdominal  cavity  or  in  the 
lungs.  The  disease  is  not  then  simply  chronic  peritonitis, 
but  chronic  peritonitis  in  connection  with  a  cachexia.  Cases 
of  the  kind  are  commonly  of  long  duration.  They  are  at- 
tended with  ascites,  and  often  with  very  considerable  abdom- 
inal distention.  I  shall,  therefore,  postpone  most  of  what  I 
have  to  say  about  their  diagnosis  until  I  come  to  abdominal 
enlargements,  and  shall  then  consider  what  differences  there 
are  between  these  various  forms  of  chronic  peritoneal  affec- 
tions and  other  disorders  leading  to  ascites,  and  to  consequent 
abdominal  distention. 

Diseases  attended  with  Pain  and  Tenderness  in  the 
Right  Iliac  Fossa. 

Affections  of  the  Caecum  and  its  Appendix.— Standing 

clinically  in  close  connection  with  inflammatory  affections 
of  the  peritoneum,  are  the  disorders  of  the  cfecum  and  its 
appendix.  They  frequently  give  rise  to  a  partial  peritoneal 
inflammation ;  they  sometimes  lead  to  fatal  general  peri- 
tonitis. Their  chief  manifestations  are  localized  pain  and 
tenderness,  and  a  tumefaction  in  the  right  iliac  fossa.  In 
truth,  they  are  the  disorders  which  pre-eminently  occasion 
signs  of  disturbance  in  this  region. 

Ivfiamniation  is  the  most  common  of  the  morbid  processes 
aft'ecting  the  caecum  and  its  appendix.  This  inflammation 
may  be  limited  to  the  csecum ;  it  may  have  its  seat  entirely 
in  the  appendix.  It  may  be  equally  violent  in  both ;  it  may 
cause  ulceration  in  one  and  not  in  the  other.  It  may  origi- 
nate in  the  loose  areolar  tissue  around  the  csecum ;  it  may 
begin  in  the  cfecum,  and  spread  from  its  peritoneal  covering 
to  the  areolar  tissue  of  the  iliac  fossa.  Here  are  certainl}' 
conditions  which  are  different,  and  between  which  it  would 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  489 

be  very  desirable,  in  a  prognostic  point  of  view,  to  be  able  to 
discriminate.  But  such  discrimination  is  clinically,  for  the 
most  part,  impossible.  If  an  inflammatory  affection  of  this 
out-of-the-way  corner  of  the  alimentary  tube  has  been  de- 
tected, we  cannot,  with  any  certainty,  go  further.  The  his- 
tory and  progress  of  the  disease  may  determine  the  exact 
diagnosis;  but  we  cannot  always  rely  upon  their  aid. 

Inflammation  of  the  caecum  or  of  its  appendix  is,  in  the 
majority  of  instances,  caused  by  accumulation  of  hardened 
feces,  or  by  hardened  bodi  es  which  have  there  become  im- 
pacted. Both  structures  are  also  at  times  found  highly  in- 
flamed in  cases  of  dysentery.  But  here  the  inflammation 
forms  part  of  a  more  general  inflammation  of  the  bowel; 
and  as  it  is  not  my  present  object  to  consider  the  disorders  in 
which  the  caecum  may  participate,  but  rather  those  in  which 
it  is  chiefly  concerned,  and  without  any  other  part  of  the  tube 
being  implicated,  such  accidental  inflammation  need  not  be 
further  alluded  to. 

Now,  the  morbid  phenomena  which  attend  inflammation 
of  the  csecum  or  its  appendix  will  vary  materially  according 
to  the  acuteness  of  the  disorder,  its  course,  its  termination 
in  ulceration,  the  presence  or  absence  of  peritonitis,  and  the 
extent  and  rapidity  of  appearance  of  this  dangerous  complica- 
tion. Sometimes  the  csecal  disease  sets  in  suddenly  with  all 
the  symptoms  and  signs  of  a  severe  local  peritonitis  in  the 
right  iliac  fossa.  There  is  pain,  with  tenderness,  a  chill,  and 
fever;  and  the  pain  and  tenderness  soon  spread,  as  the  peri- 
toneal inflammation  becomes  more  general.  But  usually  the 
complaint  is  of  more  gradual  formation,  and  presents  the 
following  history  and  symptoms :  the  patient  has  been  suf- 
fering for  some  time  from  constipation,  or  alternately  from 
diarrhoea  and  constipation.  He  has  a  dull  pain  referred 
principally  to  the  iliac  fossa,  and  sometimes  radiating  to  the 
hips.  When  this  region  is  examined,  it  is  tender  to  the 
touch,  full  and  hard,  and  sounds  dull  on  percussion,  while 
around  the  dulness  there  is  a  very  tympanitic  sound,  if  the 
gut,  as  it  often  is,  be  much  distended  with  gas.  Colicky 
pains  occur  from  time  to  time,  but  are  mainly  confined  to 
the  lower  portion  of  the  abdomen.     In  such  cases  there  has 


490  MEDICAL   DIAGNOSIS. 

been,  in  all  likelihood,  a  distention  of  the  caecum,  which 
favors  an  accumulation  of  feces,  and  these  again  have  acted 
as  exciting  causes  to  an  inflammation ;  or  foreign  bodies, 
such  as  cheny-stones  or  concretions  of  various  kinds,  have 
become  impacted  in  the  c?ecum  or  the  vermiform  appendix, 
and  have  gradually  provoked  the  morbid  action. 

In  its  further  progress  the  case  exhibits  varied  features:  it 
may  end  in  resolution;  or  the  tenderness  in  the  iliac  fossa 
may  become  greater,  and  vomiting,  fever,  and  the  marked 
signs  of  a  local  peritonitis  appear ;  or  ulceration  of  the 
bowel,  and  more  frequently  still  of  the  appendix,  may  allow 
a  discharge  of  extraneous  matter  into  the  peritoneal  cavity, 
which  produces  violent  general  peritonitis ;  or,  again,  the 
bowel  may  become  so  paralyzed  that  it  can  no  longer  con- 
tract to  propel  its  contents,  and  the  patient  dies  with  all  the 
distressing  signs  of  intestinal  obstruction.  In  more  fortu- 
nate instances  the  constipation  at  length  yields  to  remedies; 
large  quantities  of  hardened  fecal  matter  are  passed  ;  and  the 
distended  and  irritated  intestine  gradually  regains  its  tone. 

Inflammation  of  the  loose  areolar  tissue  around  the  cfecum 
presents  much  the  same  symptoms  and  signs.  This  peri- 
typhlitis is,  in  truth,  frequently  combined  with  inflammation 
of  the  caecum  or  its  appendix.  Even  where  perforation  has 
taken  place,  the  matters  may  be  detained  in  the  neighbor- 
hood of  the  lesion,  giving  rise  to  circumscribed  inflammation 
around  the  csecum,  and  to  an  abscess.  Subsequently,  the 
collection  of  pus  may  find  its  way  into  neighboring  viscera, 
or  be  discharged  externally,  when  the  ruptured  intestine 
may  heal ;  although  sometimes  the  perforation  remains  open, 
and  fecal  matter  is  found  oozing  through  the  abdominal 
parietes.  The  tumefaction  which  the  abscess  occasions, 
whether  it  be  or  be  not  connected  with  disease  of  the  intes- 
tine, is  generally  very  evident.  When,  however,  the  pus 
burrows  under  the  iliac  fascia,  the  swelling  may  be  slight. 
But  under  such  circumstances  there  appears  a  characteristic 
sign :  the  pain,  on  moving  the  right  foot,  is  intense,  because 
the  iliac  muscles  become  involved  in  the  disorder.  If  the 
swelling  be  great,  there  may  be  oedema  of  the  foot  and 
numbness  of  the  thigh,  from  pressure  on  the  vein  and  nerves. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  491 

When  these  abscesses  in  the  right  iliac  fossa  are  not  com- 
bined with  disease  of  the  adjoining  bowel,  they  give  rise  to 
but  slight  fever  and  pain  ;  the  action  of  the  intestine  is  not 
very  materially  interfered  with  ;  there  is  no  nausea ;  and,  as 
the  abscesses  frequently  have  a  favorable  termination  by  dis- 
charging into  the  intestine,  or  through  the  abdominal  parietes, 
we  do  not  observe  acute  peritonitis  supervening  on  them,  as 
it  does  so  often  on  ulcerative  disease  of  the  intestine  or  its 
appendix.  Yet  there  are  cases  in  which  judgment  is  held  in 
suspense;  in  which  it  cannot  be  said  whether  the  swelling 
does  or  does  not  communicate  with  the  gut.  Fortunately, 
this  makes  little  difl'erence  in  respect  to  treatment.  Inflam- 
mation of  the  tissue  around  the  crecum  requires  chiefly  leech- 
ing, warm  fomentations,  and  opiates;  and,  in  case  of  sup- 
puration, surgical  aid  to  produce  an  early  exit  for  the  pus. 
Inflammation  of  the  csecum  or  its  appendix  is  remedied,  when 
it  can  be  remedied,  by  the  same  agents. 

Independently  of  the  difiiculty  of  distinguishing  between 
the  inflammatory  disorders  of  this  portion  of  the  alimentary 
tube  and  its  surroundings,  there  are  sources  of  perplexity 
introduced  by  the  circumstance  that  other  diseases  of  the 
csecum  and  affections  of  adjacent  structures  may  simulate 
typhlitis  and  perityphlitis.  Thus  distention  and  cancer  of 
the  caecum ;  inflammation  and  ulceration  of  the  ilium ;  sup- 
puration of  the  kidney  or  its  envelopes ;  psoas  abscess ;  ab- 
scesses of  the  abdominal  walls;  intussusce{)tion  of  the  intes- 
tine; and  inflammation  of  the  ovary, — occasion  some  of  them 
pain  and  tenderness  in  the  right  iliac  fossa,  some  of  them  a 
fulness  in  this  region:  therefore  all  of  them  have  signs  which 
they  share  with  an  inflammation  of  the  caecum.  But  although 
they  all  offer  points  of  similitude,  they  also  offer  points  of 
contrast. 

A  distention  of  the  csecum  gives  rise  to  fulness  in  the  right 
iliac  fossa,  and  to  pain  ;  but,  unless  associated  with  inflam- 
mation, not  to  tenderness  or  to  fever;  copious  enemata  too, 
or  purgatives,  clear  out  the  feces  which  accumulate  from 
want  of  power  of  the  bowel  to  propel  them,  and  the  dulness 
on  percussion  vanishes  after  the  free  evacuations.  Another 
element  of  distinction  is  furnished  by  the  circumstance  that 


492  MEDICAL   DIAGNOSIS. 

those  who  suffer  from  atony  of  this  portion  of  the  alimentary 
tube  Labor  under  it  for  a  long  time ;  they  are  generally  highly 
nervous  persons,  of  sallow  complexion  and  with  impaired 
digestion,  whose  bowels  are  habitually  constipated,  and  who 
complain  of  attacks  of  spasmodic  pain  and  fulness  in  the  iliac 
region.  Yet,  although  there  is  fulness,  there  is  no  dulness 
on  percussion,  and  no  hard  swelling  is  detected,  unless  the 
caecum  be  loaded  with  feces.  On  the  contrary,  the  cpecuni 
and  ascending  colon  generally  show,  by  the  excessive  tym- 
panitic resonance  when  they  are  percussed,  that  they  are 
distended  with  flatus. 

In  that  rare  disease — cancer  of  the  caecum — there  is  a  fixed, 
firm  swelling;  but  it  is  of  very  gradual  growth,  and  the  dis- 
order generall}'  produces  a  stricture  of  the  gut,  and  is  asso- 
ciated with  malignant  disease  in  other  parts  of  the  body. 
Ulceration  of  the  ilium  produces  pain  and  tenderness  in  the 
iliac  fossa.  But  combined  as  it  generally  is  with  phthisis  or 
with  typhoid  fever,  the  history  of  the  case  gives  a  clue  to  the 
probable  nature  of  the  disorder.  Moreover,  there  is  not  pres- 
ent a  tumefaction  which  sounds  dull  on  percussion.  Should, 
however,  perforation  of  the  bowel  take  place  before  the 
patient  is  seen,  and  general  peritonitis  come  on,  the  diag- 
nosis is  not  so  readily  made,  because  we  are  deprived  of  the 
decisive  proof  furnished  by  the  hard  swelling. 

As  regards  timiors  of  the  kidney  and  abscesses  in  it,  or  con- 
nected with  its  envelopes,  the  situation  of  the  swelling  is  not 
exactly  in  the  ilio-cfecal  region,  or  at  all  events  it  is  not 
confined  to  this  spot.  The  mass  of  the  tumor  lies  in  the  loin, 
or  above  the  anterior  termination  of  the  crest  of  the  ilium; 
and  the  urine  contains  ingredients,  such  as  pus,  or  blood,  or 
heavy  deposits  of  urates  or  phosphates,  which  show  that  the 
secretion  of  the  kidney  is  abnormal. 

An  inflammation  in  or  about  the  right  ovary  gives  rise  to  pain 
and  tenderness  in  the  right  iliac  region,  and  to  fever.  But 
it  is  attended  with  disturbance  of  the  uterine  functions,  and 
occasions  no  very  perceptible  swelling.  A  tumor  of  the 
ovar}'  or  of  the  uterus  may  produce  a  visible  tumefiiction  ; 
but  springing  as  it  does  out  of  the  pelvis,  its  exact  scat,  its 
bulk,  its  shape,  the  absence  of  marked  intestinal  symptoms, 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  493 

and  a  per  vaginam  examination  will,  nnder  ordinary  circum- 
stances, permit  its  cause  to  be  discovered. 

An  inmginaiion  of  the  intestine  has  a  diflerent  history,  and 
makes  its  appearance  suddenly  with  such  peculiar  signs  that, 
although  it  may  be  likewise  the  occasion  of  a  tumor  in  the 
right  iliac  region,  it  can  generally  be  distinguished  from 
caacal  disease.  Yet,  where  the  latter  leads  to  intestinal  ob- 
struction, the  diagnosis  is  not  always  obvious.  In  truth,  as 
I  shall  further  on  attempt  to  enforce,  to  determine  the  pre- 
cise character  of  an  intestinal  impediment  may  bafHe  the 
skill  of  the  most  experienced  diagnostician. 

So,  too,  it  is  with  abscesses  in  or  near  the  region  in  which 
those  connected  with  the  csecnm  occur.  Their  discrimina- 
tion is  far  from  being  invariably  an  easy  matter.  An  abscess 
in  the  abdominal  walls  furnishes  very  many  of  the  signs  of  ab- 
scess around  the  c£ecum.  The  most  trustworthy  source  of 
distinction  is,  that  the  former  is  unassociated  with  intestinal 
irritation,  while  the  latter,  from  its  being  often  connected 
with  a  disorder  of  the  caecum,  is  not  uncommonly  so  com- 
bined. Then  the  pus  discharged  is,  for  the  same  reason,  in 
some  cases  very  offensive,  and  of  fecal  odor. 

Now,  this  character  of  the  pus,  were  it  more  generally  ob- 
served, would  serve  equally  as  a  most  valuable  diflerential 
mark  between  the  matter  which  finds  its  way  to  the  surface 
from  a  csecal  and  from  a  jjsoas  abscess.  But  as  it  is  not  con- 
stant, we  have  to  apply  other  tests  to  the  recognition  of  a 
psoas  abscess.  A  psoas  abscess  is  associated  with  caries  of 
the  vertebrae;  an  excurvation  of  the  spine,  dorsal  pain  and 
tenderness  testify  to  this  connection.  It  occurs  in  scrofulous 
j)ersons,  and,  although  gradual  in  its  formation,  is  often  sud- 
den in  its  manifestation ;  for  not  unusually  a  fluctuating, 
painless  tumor  appears  below  Poupart's  ligament  as  the  first 
positive  sign  of  this  formidable  disorder.  Yet,  preceding 
the  pointing  of  the  abscess  at  this  spot,  there  are  often  indi- 
cations of  irritation  in  those  muscles  in  the  sheath  of  which 
the  pus  travels ;  there  is  difficulty  in  extending  the  leg ;  an 
inability  to  stand  upright;  and  a  dull,  uneasy  sensation  in 
the  loins,  which  the  patient  persists  in  regarding  as  rheu- 
matic.    Of  all  these  signs,  there  are  none  more  important. 


494  MEDICAL    DIAGNOSIS. 

as  sources  of  distinction,  tlian  the  seat  of  the  visible  abscess 
and  its  painless  nature.  The  interference  with  the  move- 
ments of  the  right  leg  is  not  so  valuable  as  it  appears  at  first 
sight;  since  when  the  iliac  muscle  is  involved,  the  same  diffi- 
culty in  moving  the  limb  may  exist;  and  the  iliac  muscle 
may  be  implicated  in  an  infiaramation  of  the  loose  areolar 
tissue  around  the  caecum  by  the  inflammation  extending  to 
the  iliac  fascia  and  causing  pus  to  collect  under  it;  what  sur- 
geons term  iliac  abscesses  are,  indeed,  collections  of  pus 
under  this  fascia.  And,  in  point  of  fact,  the}"  not  unfre- 
quently  originate  near  the  caecum,  or  spread  to  the  tissues 
surrounding  this  portion  of  the  gut,  break  into  the  cavity 
of  the  peritoneum,  and  therefore  practically  constitute  peri- 
typhlitic  abscesses.* 

Disorders  attended  with  Constipation,  and  of  which  it  is  a 

Prominent  Symptom. 

To  enumerate  all  the  complaints  in  which  constipation  ma}" 
occur,  would  require  me  to  pass  in  review^  the  majority  of  all 
the  affections  of  the  body.  J^or  would  this  serve  any  useful 
purpose ;  for  the  inactive  state  of  the  bowels  is  often  but  a 
concomitant  of  some  disorder  which  presents  phenomena 
much  more  striking  than  the  imperfect  voidance  or  the  pro- 
longed retention  of  the  feces.  But  there  are  cases  in  which 
the  constipation  is  a  very  prominent  symptom,  in  which  it 
constitutes  the  aihuent  for  which  we  are  consulted,  and  in 
which  it  furnishes  the  most  decisive  proof  of  a  serious  morbid 
condition  of  the  intestine.  Now,  these  cases  are  either  those 
in  which  the  constipation  arises,  as  it  were,  suddenly,  or  at 
any  rate  becomes  suddenly  aggravated,  is  attended  with  severe 
symptoms,  and  is  often  insuperable  ;  or  cases  in  which  it  is  a 
habitual  state,  and  not  associated  with  any  signs  of  urgent 
distress. 


*  See,  for  collection  of  cases,  and  for  observations  on  these  abscesses  and 
on  diseases  of  the  cascum,  J.  Burne,  Mccl.-Chirurg.  Transact.,  vol.  xx.;  Cop- 
land, Dictionary  of  Practical  Medicine,  article  "  Ca3cum  ;'"  Duiiglison,  Prac- 
tice of  Medicine;  Jackson,  Letters  to  a  Young  Physician;  Oppulzer  on 
"  Perityphlitis,"  Alig.  Wien.  Med.  Zeit.,  Nos.  20  and  21,  1858;  and  Eartho- 
low,  Araer.  Journ.  of  Med.  Sciences,  Oct.  18GG. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  495 

I  shall  describe  the  former  set  of  cases  first,  because  thej* 
bear  a  close  relation  to  aftections  we  have  just  been  consid- 
ering— to  acute  enteritis  and  peritonitis.  Not  that  I  mean 
here  to  dwell  upon  the  constipation  which  occurs  in  these 
maladies, — it  forms  only  one  of  the  symptoms,  and  that  not 
the  most  distinctive, — but  I  wish  to  discuss  at  some  length 
the  constipation,  frequently  insurmountable,  produced  by  an 
obstruction  to  the  passage  of  the  intestinal  contents,  and 
which  often  brings  with  it  acute  inflammation  of  the  bowel 
and  of  its  serous  investment. 

Intestinal  Obstruction.  —  Intestinal  obstruction,  when 
coming  on  suddenly,  manifests  itself  generally  in  the  follow- 
ing manner:  a  person,  previously  in  good  health,  or  perhaps 
of  costive  habit,  notices  that  his  bowels  have  not  been  moved 
for  several  days,  and  that  he  has  an  uneasy  feeling  in  the  ab- 
domen in  consequence.  He  takes  the  purgative  he  is  wont 
to  employ,  but  without  the  usual  effect.  Something  more 
active  is  tried,  and  still  the  bowels  remain  obstinately  bound. 
Colicky  pains  have  in  the  mean  time  made  their  appearance, 
or,  if  present  from  the  onset  of  the  disorder,  have  become 
aggravated.  He  becomes  alarmed,  and  sends  for  his  physician. 
On  his  arrival,  the  medical  attendant  sees  that  there  is  indeed 
cause  for  alarm.  He  finds  the  abdomen  somewhat  distended, 
but  not  painful,  or  perhaps  only  slightly  painful  on  pressure. 
But  through  its  parietes  may  be  noticed  the  violent,  rolling- 
motion  of  the  excited  intesthie.  Vomiting  sets  in — first,  of 
the  substances  contained  in  the  stomach  or  of  a  bilious  fluid, 
and,  as  the  case  progresses,  of  stercoraceous  matter.  In  this 
way,  unless  nature  or  art  comes  to  the  rescue,  the  disease 
continues  ;  and  signs  of  inflammation  of  the  bowels,  and  with 
them  fever,  appear  as  preludes  to  the  fatal  termination. 
Sometimes,  however,  the  patient  becomes  gradually  ex- 
husted;  there  are  no  tenderness  and  fever,  but  a  cool  skin,  a 
quick,  small  pulse,  a  countenance  ghastly  and  panic-stricken. 
Severe  paroxysms  of  pain,  alternating  with  intervals  of  ease, 
may  occur  to  the  last  moment.  But  in  spite  of  the  utter 
prostration,  the  mind  generally  retains  its  clearness  until 
death  comes  to  put  a  merciful  end  to  the  prolonged  and  irre- 
mediable suflering.     Should  recovery  take  place,  large  quan- 


496  MEDICAL    DIAGNOSIS. 

titles  of  fecal  matter  are  discharged,  and  all  the  symptoms  of 
the  impediment  speedily  disappear. 

Such  are  the  phenomena  presented  by  an  intestinal  ob- 
struction. They  are  too  striking  to  permit  of  errors  in  diag- 
nosis. And  yet  errors  have  been  committed,  and  are  still  of 
frequent  occurrence,  because  the  history  of  the  attack  and 
the  sequence  of  the  symptoms  are  not  taken  into  account. 
Many  a  person  laboring  under  enteritis  or  peritonitis  has 
been  violently  purged  to  remove  the  stubborn  constipation, 
believed  to  be  due  to  a  mechanical  hinderance  in  the  bowels; 
and,  on  the  other  hand,  many  a  case  of  intestinal  obstruction 
has  been  treated  solely  with  reference  to  the  inflammation 
which  may  attend  it,  and  without  regard  to  the  source  of  this 
inflammation.  Yet  it  is  not  ordinarily  difficult  to  distinguish 
which  is  cause  and  which  effect.  A  case  that  commences 
with  colicky  pains  and  obstinate  constipation,  in  which,  at 
first,  in  spite  of  the  pain,  there  is  little  or  no  tenderness  or 
fever;  in  which  vomiting  soon  occurs;  in  which  fecal  matter 
is  ejected  by  the  mouth  after  a  stoppage  of  the  bowels  of  a 
few  days'  duration, — is  not  primarily,  Avhatever  may  be  the 
ultimate  complications,  enteritis  or  peritonitis.  A  case  pre- 
senting almost  from  the  onset  fever  and  great  tenderness,  in 
which  vomiting  of  fecal  matter,  if  it  happen  at  all,  does  not 
happen  until  late;  in  which  diarrhoea  is  sometimes  found  to 
supersede  the  enduring  constipation, — is  inflammation  of 
the  intestine  or  of  the  peritoneum,  but  not  a  mechanical 
obstruction. 

Only  in  rare,  very  rare  instances,  and  especially  when  the 
bowel  is  invaginated,  is  this  formidable  malady  so  quickly 
succeeded  by  inflammation  as  seemingly  to  make  its  appear- 
ance with  the  signs  of  peritonitis.  Should  the  disease  then 
run  a  rapid  course,  and  stercoraceous  vomiting  not  occur,  an 
error  in  diagnosis  is  unavoidable.  Should  it  be,  however,  of 
some  duration,  the  unyielding  constipation  and  the  character 
of  the  vomit  come  to  our  aid ;  and  casting,  as  they  do,  the 
signs  of  inflammation  more  and  more  into  the  background, 
force  the  conviction  on  the  mind  that  they  are  not  simply 
the  result  of  a  paralysis  of  the  tube,  the  consequence  of  the 
inflammation,  but  are  dependent  on  an  impassable  barrier 
to  the  passage  of  the  intestinal  contents. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  497 

The  symptoms  upon  which  I  have  been  dwelHng  as  point- 
ing toward  an  intestinal  obstruction  bear  a  close  resemblance 
to  those  of  external  strangulated  hernia.  In  truth,  they  not 
only  resemble,  but  are  identical  with  those  of  this  affection. 
Hence,  in  every  case  of  obstinate  constipation,  each  point 
which  may  be  the  seat  of  a  hernia  must  be  explored  by  the 
eye  and  the  hand.  'No  motives  of  false  delicacy,  no  re- 
luctance on  the  part  of  the  patient,  should  prevent  the  practi- 
tioner from  insisting  on  a  search,  the  neglect  of  which  will 
cost  a  life  entrusted  to  his  care,  should  he  fail  to  discover, 
until  too  late,  the  real  cause  of  the  alarmJng  symptoms  he 
has  been  endeavoring  to  alleviate. 

It  would  be  foreign  to  the  object  of  this  w^ork  were  I  to 
attempt  to  discuss  the  external  signs  by  which  a  strangulation 
of  the  intestine  at  a  hernial  opening  manifests  itself  This 
belongs  to  surgical,  and  not  to  medical  diagnosis.  JSTor  shall 
I,  for  the  same  reasons,  do  more  than  indicate  that  it  is  at  the 
groin,  at  the  umbilicus,  at  the  side  of  the  anus,  or  through 
the  ischiatic  notch  that  the  gut  descends  and  forms  a  tumor, 
and  that  these  are,  therefore,  the  regions  to  be  scrutinized. 

But  there  is  one  part  of  the  subject,  alike  of  importance  to 
the  physician  and  to  the  surgeon,  which  I  cannot  pass  by 
without  a  few  words,  since  it  may  be  a  cause  of  much  per- 
plexity, namely,  the  possibility  of  intestinal  obstruction 
taking  place  in  a  person  laboring  under  an  irreducible 
hernia  and  simulating  strangulation  without  any  strangula- 
tion having  occurred.  Of  this  the  following  case  furnishes 
an  example  : 

In  October,  1857,  I  was  requested  by  a  pliysiciaii  in  this 
city  to  see  with  him  a  person,  the  mother  of  thirteen  children, 
who  had  been  for  several  days  laboring  under  obstinate  con- 
stipation. Large  doses  of  mercurials,  croton  oil,  and  turpen- 
tine euemata  had  failed  to  procure  a  passage,  and  the  patient 
was  becoming  very  much  frightened  about  herself.  Nor  was 
her  situation  one  free  from  danger.  She  had  considerable 
pain  in  the  abdomen ;  she  had  been  vomiting  stercoraceous 
matter  profusely ;  the  rolling  of  the  intestines  could  be  plainly 
perceived.     On  her  right  side  was  a  small  irreducible  femoral 

32 


498  MEDICAL    DIAGNOSIS. 

hernia,  which,  on  inquiry,  was  found  to  have  existed  for  many 
years.  It  was  not  painful  on  pressure,  nor  was  the  skin  cov- 
ering it  discolored  ;  neither  did  the  mass  itself  communicate 
an  impulse  during  the  act  of  coughing.  Now,  here  were 
signs  of  a  serious  impediment  to  the  onward  passage  of  the 
intestinal  contents,  as  the  fecal  vomiting  and  the  rolling  of 
the  intestines  showed  plainly.  But  what  was  its  nature? 
Was  it  due  to  strangulation  at  the  hernial  opening?  Was 
it  an  internal  intestinal  obstruction  ? 

An  accurate  examination  of  the  abdomen  did  not  throw 
much  light  on  these  all-important  questions.  The  belly  was 
moderately  tympanitic,  and  not  painful  to  the  touch,  except- 
ing when  the  pressure  was  considerable.  The  rolling  of  the 
intestines  was  perhaps  more  obvious  on  the  left  side;  but 
nowhere  could  a  tumor  be  felt.  Taking  all  the  circumstances 
of  the  case  into  account :  the  fact  that  the  patient  was  of  very 
costive  habit;  that  she  was  subject  to  attacks  of  colic  and  of 
obstinate  constipation  ;  that  there  was  nothing  to  prove  that 
the  hernia  had  recently  increased,  or  was  in  any  way  in- 
flamed,— I  was  led  to  the  conclusion  that  the  case  was  not 
one  of  hernial  strangulation,  but  of  internal  intestinal  obstruc- 
tion ;  and  she  was  treated  for  this.  Copious  warm  water 
injections  were  thrown  into  the  colon  through  a  flexible  tube ; 
her  abdomen  was  rubbed  with  mercurial  ointment.  But  all 
in  vain  :  she  continued  vomiting  fecal  matter. 

Her  situation  now  appeared  desperate.  She  had  not  had  a 
passage  for  six  days — remedies  had  failed  to  procure  her  one; 
she  was  steadily  sinking.  Knowing  that  sometimes  the  gut 
may  be  strangulated  at  a  hernial  opening  without  much  pain 
or  tenderness,  the  counsel  of  an  eminent  surgeon  was  sought, 
to  aid  in  determining  whether  this  was  not  the  cause  of  the 
impediment.  He  thought  it  probable  that  it  was,  and  pro- 
posed an  operation,  to  which  consent  was  reluctantly  ob- 
tained. The  patient  was  etherized,  and  the  hernial  section 
rapidly  and  skilfully  performed ;  but  no  constriction  was 
found.  The  wound  was  closed,  and  large  doses  of  opium 
administered  to  the  unhappy  suftbrer,  so  as  to  mitigate,  as 
far  as  practicable,  the  torturing  distress  of  the  only  termina- 
tion to  the  case  which  seemed  possible.     On  the  day  after 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  499 

the  operation,  the  intestines  had  ceased  to  roll;  there  was  no 
vomitino;.  But  stercoraceous  vomiting  reappeared  two  days 
afterward,  and  the  rolling  of  the  intestines  was  occasionally, 
although  faintly,  perceptible. 

The  patient's  exhaustion  was  now  extreme  ;  her  pulse  was 
very  quick  and  small;  her  skin  cold,  of  a  dirty  look;  the  odor 
of  the  breath  and  of  the  whole  body  offensive ;  and  the  eyes 
sunken  and  surrounded  by  a  broad  leaden  ring.  There  was 
slight  pain  on  pressure  between  the  umbilicus  and  the  sig- 
moid flexure.  The  vomiting  had  ceased,  or  occurred  only 
very  occasionally.  Although  there  was  little  hope,  we  had, 
as  soon  as  admissible  after  the  operation,  recommenced  rub- 
bing mercurial  ointment  over  the  abdomen,  and  giving  in- 
jections in  the  manner  before  described.  This  was  continued 
until,  to  our  great  gratification,  one  morning,  after  a  tube  had 
been  passed  a  distance  of  several  feet  into  the  colon,  the  pa- 
tient had  a  copious  discharge  of  tarry  fecal  matter  from  her 
bowels, — seventeen  days  after  the  symptoms  of  complete 
intestinal  obstruction  had  declared  themselves  by  the  occur- 
rence of  stercoraceous  vomiting. 

This  case  is  instructive  in  several  respects.  It  teaches  that 
recovery  may  take  place  most  unexpectedly  after  the  patient 
has  been  kept  at  death's  door  for  many  days.  It  shows  the 
beneficial  results  of  filling  the  colon  with  fluid  in  instances 
of  intestinal  obstruction  ;  and,  in  a  diagnostic  point  of  view, 
it  illustrates  a  difficulty  which  any  practitioner  may  have  to 
encounter  in  attending  a  patient  who  is  the  subject  of  a  long- 
standing hernia. 

Supposing,  however,  that  we  have  sufficient  grounds  for 
the  opinion  that  no  hernia  exists,  and  that  the  symptoms  are 
altogether  owing  to  an  obstacle  seated  at  some  portion  of  the 
intestine  within  the  abdomen, — can  we  go  any  further,  can 
we  determine  the  exact  position  of  the  impediment,  and  what 
its  nature  is?  We  know,  from  dissection,  how  varied  are  the 
conditions  which  lead  to  sudden  and  invincible  constipation. 
We  know  that  intussusceptions,  twists,  displacements,  strict- 
ures of  the  gut,  bands  and  adhesions,  or  gaps  in  the  omentum, 
foreign  bodies,  impacted  feces,  gall-stones,  and  spasmodic 


500  MEDICAL    DIAGNOSIS. 

contraction  of  the  intestine,*  —  may  all  occasion  intestinal 
obstruction,  and  some  of  these  states  even  an  internal  stran- 
gulation. Can  we  distinguish  these  dift'erent  lesions  from 
each  other  at  the  bedside?  In  certain  cases  we  can, — we  can 
determine  exactly  both  the  position  and  character  of  the 
lesion ;  in  others  there  is  no  clue  to  an  accurate  discernment 
of  either. 

Of  the  causes  of  intestinal  obstruction,  inhissusception  or  in- 
vagination is  the  most  frequent  and  at  the  same  time  the  most 
susceptible  of  being  recognized  during  life.  Part  of  the  gut 
becomes  inverted,  slipping  for  a  variable  distance  into  the 
cavity  of  the  adjoining  upper  or  lower  portion.  Inflamma- 
tion is  generally  soon  set  up,  and  produces  infiltration  of  the 
tissues  and  their  tumefaction,  and  often  leads  to  adhesions 
between  the  opposed  serous  surfaces,  and  to  efi"nsions  of 
blood  and  mucus  into  the  canal.  The  swelling  entirel}- 
blocks  up  the  tube;  yet  it  does  not  of  necessity  do  so.  The 
congestion  and  inflammation  which  have  caused  the  tumefac- 
tion may  spread  rapidly  over  the  serous  membrane,  and  the 
patient  may  die  from  general  peritonitis.  But  sometimes  in 
this  inflammation  that  is  lighted  up  at  the  seat  of  the  ileus 
lies  the  safety  of  the  patient.  It  may  give  rise  to  a  sloughing 
ofi"  of  the  invaginated  part  and  its  discharge  into  the  bowel, 
and  thus  pave  the  way  to  a  favorable  issue  by  restoring  the 
calibre  of  the  tube — sufiiciently  at  any  rate  to  permit  of  the 
transit  of  its  contents. 

Now,  these  pathological  peculiarities  develop  special  symp- 
toms which  not  unfrequently  enable  us  to  determine  the 
nature  of  the  obstruction.  When  the  intussusception  takes 
place  rapidly,  a  sudden  local  pain  is  produced,  recurring  in 
paroxysms,  and  likely  to  be  referred  to  the  seat  of  the  dis- 
turbance. The  pain  is  quickly  followed  by  vomiting,  by 
constipation,  and  by  peritonitis.  But  the  constipation  is  not 
so  absolute  as  in  other  cases  of  intestinal  impediment.  Some- 
times, in  fact,  owing  to  the  invaginated  bowel  remaining 
open,  the  liquid  contents  of  the  intestine  may  pass  through 
the  intussuscepted  part  and  produce  a  deceptive  diarrha?a ; 

*  Archives  Gener.,  Aug.  1868. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  501 

yet  ottener  will  occur  tenesmus,  and  discharges  of  the  hloody 
serum  which  has  accumulated  iu  the  intestine.  Both  of  the 
latter  signs  are  eminently  diagnostic  of  the  lesion.  Still 
more  so  would  be  feeling  the  end  of  the  invaginated  gut  by 
an  exploration  of  the  rectum,  or  finding  the  loosened  seg- 
ment of  the  bowel  in  the  stools.  But  of  course  it  is  only  in 
a  certain  class  of  cases,  those  in  which  the  lower  portion  of 
the  canal  is  affected,  or  which  have  been  sufficiently  pro- 
tracted to  allow  of  the  curative  efforts  of  nature  being  accom- 
plished, that  signs  so  strictly  pathognomonic  are  met  with. 

The  casting  off  of  the  sloughed  portion  of  the  intestine  is, 
we  are  informed  by  several  observers,  always  attended  with 
hemorrhage.  Whether  this  be  the  cause  of  the  hemorrhage 
or  not,  it  is  undoubted  that  purging,  nay,  sometimes  vomit- 
ing of  blood,  are  among  the  most  important  differential  signs 
of  intussusception.  But  a  sign  yet  more  valuable,  because 
so  much  more  common,  is  the  presence  of  a  tumor.  Its  seat 
varies,  of  course,  with  the  seat  of  the  lesion.  And  as  the 
most  frequent  of  all  invaginations  are  those  of  the  ilium  and 
caecum  into  the  colon,  or  those  at  the  inferior  portion  of  the 
ilium,  it  is  at  the  lower  part  of  the  belly,  and  generally  pass- 
ing in  direction  from  left  to  right,  and  in  the  right  iliac  fossa, 
that  the  swelling  is  detected.  The  malady  occurs  at  all  ages. 
It  is  often  preceded  by  diarrhoea. 

The  course  invagination  pursues  is  very  rapid.  The  acute 
inflammation  it  occasions  soon  leads  to  a  fatal  termination, 
or  the  patient  dies  generally  in  less  than  a  week  after  the 
occurrence  of  the  accident,  utterly  prostrated.  Yet  the 
records  of  medicine  furnish  us  with  instances  in  which  life 
has  been  prolonged  far  several  months.  The  cases  which  get 
well,  recover  either  gradually  after  the  invaginated  bowel 
has  been  discharged,  or,  in  very  rare  instances,  more  quickly 
by  the  inverted  bowel  righting  itself. 

As  regards  other  forms  of  intestinal  obstruction,  they  are, 
with  our  present  knowledge,  undistinguishable  from  each 
other.  However  desirable  it  might  be  on  therapeutic  grounds 
to  be  able  to  diagnosticate  a  twist  of  the  intestine,  or  its  block- 
ing up  by  hardened  feces  or  gall-stones,  or  its  strangulation 
by  bands  ;  however  desirable  to  know  whether,  if  medical 


502  MEDICAL    DIAGNOSIS. 

means  do  not  bring  relief,  the  liazarclous  operation  of  lay- 
ing open  the  belly  may  be  attempted  with  some  hope  of 
success,  or  whether  the  impediment  is  not  even  to  be  re- 
moved by  such  a  mode  of  succor, — it  must  be  confessed  that 
there  are  no  positive  signs  which  enable  us  to  decide  on  the 
nature  of  the  obstacle. 

Yet  there  are  sometimes  circumstances  in  the  case  which 
may  help  us  to  a  correct  decision.  For  example,  if  the 
complaint  occur  in  one  who  has  previously  suffered  from  the 
passage  of  gallstones,  it  is  likely  that  a  large  concretion 
of  this  kind  has  been  arrested  in  its  passage  through  the 
intestine,  and  is  the  cause  of  the  mischief.  Should  the  dis- 
order be  encountered  in  a  person  who  has  before  had  attacks 
of  constipation  almost  invincible ;  who  at  all  times  has  diffi- 
culty in  voiding  the  contents  of  the  tube  ;  whose  feces  present 
peculiarities  in  shape  and  size,  and  are  sometimes  mixed  with 
blood;  whose  health  has  been  gradually  breaking  down; 
whose  abdomen  is  much  distended  and  yields  a  ringing  tym- 
panitic resonance  on  percussion;  in  whom  a  bougie  passed 
into  the  rectum  has  detected  a  marked  resistance, — should 
such  a  person  have  an  attack  of  constipation  more  than 
usually  protracted,  attended  with  enormous  distention  of  the 
bowel,  and  in  wl  ich  the  remedies,  whether  mechanical  or 
medicinal,  that  hitherto  barely  procured  a  passage,  now  fail 
utterly,  it  would  not  require  much  sagacity  to  discern  that 
a  stricture  of  the  intestine,  and  probably  of  a  cancerous 
kind,  is  the  source  of  the  cruel  and  irremediable  sufiering. 
If,  in  addition  to  the  symptoms  enumerated,  a  bougie  passed 
into  the  rectum  meet  in  its  course  with  a  decided  obstacle, 
an  error  in  diagnosis  is  hardl}^  possible.  When,  however, 
the  stricture  is  not  accessible  to  instrumental  examination, 
although  we  can  commonly  recognize  its  presence,  we  cannot 
fix  its  site.  The  distention  above  the  narrowed  part  is  often 
so  extreme  as  to  lead  to  displacement  of  the  colon  and  to  an 
almost  uniform  swelling  of  the  whole  abdomen,  thus  baffling 
all  attempts  at  determining  the  point  of  constriction.  For 
instance,  in  a  case  reported  by  Dr.  Albert  11.  Smith,  the 
enormously  dilated  colon  had  broken  loose  from  its  attach- 
ments and  concealed  the  rest  of  the  viscera.     It  was  in  sev- 


DISEASES    OP    THE    INTESTINES    AND    PERITONEUM.  503 

eral  plr^ces  eighteen,  iu  none  less  than  fifteen  inches  in  cir- 
cumference; and  fnlly  two  gallons  of  liquid  feces  were  found 
in  the  bowels.* 

In  the  other  kinds  of  obstruction  the  same  difficulty — al- 
though  not  of  necessity  arising  from  the  same  cause — may 
exist  in  determining  with  certainty  the  location  of  the  lesion. 
There  are,  however,  a  few  circumstances  which  may  aid  us 
in  arriving  at  such  a  determination  :  one  is  the  interestine: 
fact  pointed  out  by  Dr.  BarIovv,t  that  the  higher  up  the  ob- 
struction is  in  the  canal,  the  nearer  therefore  to  the  stomach, 
the  smaller  is  the  quantity  of  urine  passed;  another  is  the 
early  occurrence  of  the  vomiting  and  the  want  of  stercoraceous 
character  of  the  matters  ejected — both  of  which  render  it 
likely  that  the  impediment  is  in  the  small  intestine  and  re- 
mote from  the  csecum.  Yet  another  is  the  speedy  presence 
and  the  greater  severity  of  hiccough  when  the  mischief  is  in 
the  small  intestine.  Sometimes  the  patient  is  himself  aware 
of  the  exact  seat  of  the  cause  of  his  suiFering ;  he  notices  that 
the  injecting  tube  or  the  enemata  seem  to  reach  a  certain 
point  and  go  no  farther;  so,  also,  with  the  rumbling  of  the 
wind.  Again,  these  borborygmi  are  especially  apt  to  occur  in 
obstructions  of  the  large  intestine,  and,  if  joined  to  tenesmus, 
are  signs  of  some  importance. 

The  position  of  the  pain,  too,  may  furnish  a  clue  to  the 
position  of  the  impediment.  If  this  be  in  the  small  intestine, 
the  pain  is  apt  to  be  chiefly,  if  not  entirely,  in  the  neighbor- 
hood of  the  umbilicus.  Another  circumstance  on  which  some 
stress  maybe  laid,  is  the  distention  of  the  intestine  above  the 
point  of  interception.  Indeed,  this  distention  may  occasion 
a  visible  fulness,  sounding  extremely  tj^mpanitic  on  percus- 
sion ;  at  times,  too,  a  slight  dulness  is  found,  attended  with 
some  resistance  at  or  immediately  above  the  seat  of  the  ob- 
struction. But  with  reference  to  the  swelling  and  the  tym- 
panitic dilatation  of  the  bowel,  there  are — as  Dr.  Brinton| 
sets  forth  in  his  extended  researches  on  the  subject — several 
reasons  which  render  these  signs  uncertain  guides  in  a  diag- 

*  Proceed,  of  Path.  Society  of  Philadelphia.  Deo.  1858,  vol.  i. 

f  Guy's  Hospital  Reports,  2d  Series,  vol.  ii. 

J  Cronian  Lectures;  see  London  Lancet,  vol.  i.  1859. 


504  MEDICAL    DIAGNOSIS. 

nosis  of  the  situation  of  the  aftection.  The  distended  intes- 
tine may  not  be  capable  of  being  traced  by  the  eye  or  by 
percussion,  owing  to  its  occupying  a  large  portion  of  the 
abdominal  cavity.  Moreover,  a  stoppage  at  the  descending 
part  of  the  large  intestine,  for  instance  at  the  sigmoid  flexure, 
may  lead  to  most  j)alpable  distention  of  the  caecum,  and  to 
pain  in  that  region;  while  pain  and  swelling  are  also  observed 
in  the  same  locality  in  obstructions  which  affect  the  small 
intestine.  Thus,  then,  there  are  several  modifying  circum- 
stances which  prevent  too  much  importance  being  attached 
to  any  of  the  signs  mentioned  as  proofs  of  the  seat  of  the 
obstacle;  for,  with  the  exception  of  a  tumor  dull  on  percus- 
sion and  resistant  to  the  touch,  there  is  nothing  absolutely 
indicative  of  the  lesion  being  at  a  particular  spot.  And  it 
is  hardly  necessary  to  say  that  a  swelling  of  this  kind  cannot 
always  be  found. 

Internal  strangulation — as  by  a  band  acting  as  the  con- 
stricting agent,  or  a  diverticulum,  or  the  pedicle  of  an 
ovarian  tumor — has  it  seat  almost  constantly  in  the  small 
intestine.  Dr.  Hilton  Fagge,*  who  has  recently  very  ably 
investigated  the  subject,  considers  these  symptoms  as  sig- 
nificant, and  warranting  a  diagnosis  of  internal  constriction  : 
the  sudden  and  definite  onset  of  the  illness ;  the  occurrence 
of  collapse  at  its  commencement;  the  comparatively  early 
age ;  the  severity  of  the  pain,  which  is  generally  referred  to 
the  umbilicus;  the  absence  of  external  or  of  discoverable 
obturator  hernia ;  the  absence  of  precursory  symptoms  and 
of  visible  peristole  —  such  as  happen  in  stricture  and  con- 
tractions— of  tumor,  hemorrhage,  and  dysenteric  symptoms 
— as  seen  in  intussusception — and  of  that  extreme  intensity 
and  rapidity  of  the  disorder  which  characterize  the  more 
acute  forms  of  volvulus. 

In  referring  to  the  usual  seat  of  pain  and  swelling  in  the 
right  iliac  fossa,  and  to  the  difliculties  which  on  this  account 
beset  the  recognition  of  the  precise  site  of  the  hinderance,  one 
source  of  error  deserving  of  special  notice  was  not  mentioned. 
The  pain  and  the  fulness  in  this  region  may  be  caused  b}'  a 

*  Gay's  Hospital  Reports,  3d  Series,  vol.  xiv. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  505 

disease  of  the  csecum  or  of  its  appendix.  Moreover,  affections 
of  this  part  of  the  alimentary  tract,  like  intestinal  occlusion, 
give  rise  to  constipation  which  is  most  obstinate  and  in 
some  instances  incurable.  Therefore  they  in  reality  enter  at 
times  into  the  category  of  intestinal  obstructions,  from  the 
other  varieties  of  which  they  are,  under  such  circumstances, 
undistinguishable  save  by  the  history  of  the  case  and  the  dif- 
ferent sequence  of  the  phenomena.  The  tumor  and  the  other 
local  signs  do  not  follow  the  insuperable  constipation,  but 
they  precede  it.  Yet  if  the  patient  be  seen  for  the  iirst  time 
when  he  is  laboring  under  an  irremovable  intestinal  im- 
pediment, it  may  be  impossible  rightly  to  determine  its 
character. 

Habitual  Constipation. — We  are  often  called  upon  to 
remedy  a  sort  of  constipation  which  is  very  difterent  from 
that  of  an  intestinal  obstruction.  It  is  a  chronic  state  unat- 
tended with  fever,  or,  under  ordinary  circumstances,  with 
urgent  symptoms  of  any  kind.  Still  it  is  a  very  annoying 
disorder,  and  so  prevalent  that  there  is  hardly  a  person,  among 
the  thousands  who  lead  sedentary  lives,  who  does  not  or  has 
not  suflered  from  it.  The  symptoms  encountered,  independ- 
ently of  the  rare  and  difficult  fecal  evacuations,  are  headache, 
giddiness,  sluggishness  of  the  mind,  a  want  of  the  natural 
appetite,  and,  joined  as  the  complaint  not  unfrequently  is  to 
derangement  of  the  stomach  and  of  the  biliary  secretion, 
digestive  disturbances  and  a  sallow  complexion.  In  women 
there  are  also  often  added  to  the  list  of  evils  to  which  costive- 
ness  gives  rise,  neuralgic  pains,  palpitation  of  the  heart,  cold 
feet  and  hands.  Not  that  infrequent  evacuation  of  the  bowels 
always  produces  such  unpleasant  consequences.  It  may  in- 
deed in  individual  cases  be  compatible  with  perfect  health ; 
for  what  is  costiveness  in  one  person  may  be  a  natural  state 
in  another.  But  when  the  bowels  are  acting  less  frequently 
than  is  their  wont,  the  disagreeable  symptoms  mentioned  are 
apt  to  arise. 

Habitual  constipation  is  produced  by  various  causes.  It 
may  be  brought  about  by  the  peculiar  nature  of  the  diet.  It 
may  depend  upon  a  deficiency  or  a  faulty  composition  of  the 
intestinal  secretions,  or  upon  disorders  of  those  neighboring 


506  MEDICAL    DIAGNOSIS. 

glands  which  pour  their  secretions  into  the  intestines.  It  may 
result  from  impaired  power  of  the  bowel  to  propel  its  contents, 
the  consequence  either  of  some  mechanical  interference  with 
its  action,  or  of  nervous  influences,  or  of  exposure  to  the 
poisonous  eiFects  of  certain  substances,  as  of  lead.  To  par- 
ticularize the  numerous  conditions  which  furnish  illustrations 
of  each  of  these  different  causes  would  be  tedious,  and  serve 
no  useful  purpose.     I  shall  select  only  a  few  for  special  notice. 

We  have  often  to  treat  constipation  in  those  who  are  dys- 
peptic and  suffer  from  piles.  In  them  there  is,  in  all  proba- 
bility, some  congestion  of  the  portal  system,  and  not  unfre- 
quently  a  constant  derangement  of  the  flow  of  blood  through 
the  liver.  The  normal  secretion  of  intestinal  juices  is  inter- 
fered with,  healthy  bile  is  not  supplied,  and  thus  eostiveness 
results.  A  similar  cons^estion  of  the  intestinal  mucous  mem- 
brane  has  its  share  in  producing  the  constipation  which  is 
encountered  in  diseases  of  the  heart.  Sometimes,  however, 
enough  healthy  fluid  is  poured  out  within  the  intestine ;  yet 
there  is  practically  a  deficiency,  because  the  inclination  to  go 
to  stool  is  resisted,  and  the  liquid  that  has  been  mixed  with 
the  matter  to  be  voided  is  reabsorbed.  In  women  who  neglect 
the  calls  of  nature  from  carelessness,  or  because  circumstances 
prevent  their  being  obeyed  at  the  proper  time,  this  is  a  very 
common  cause  of  constipation. 

The  influence  of  the  nervous  system  on  the  alimentary  tube 
is  shown  by  the  confined  state  of  the  bowels  which  attends 
excessive  intellectual  exertion  and  violent  emotions.  And 
when  these  states  are  protracted,  they  lead  to  a  permanent 
and  annoying  debility  of  the  intestine.  The  colon  especially 
becomes  torpid  in  its  action,  and  all  the  evil  results  of  consti- 
pation show  themselves  in  their  most  marked  degree.  ISTot 
that  an  atony  of  the  bowel  is  always  due  to  psychical  agencies. 
Any  disorder  which  induces  loss  of  power  in  the  muscular 
fibres  may  give  rise  to  it.  We  find  it  where  the  blood  is 
watery  and  deficient  in  red  corpuscles,  and  in  those  who  lead, 
so  far  as  bodily  exertion  is  concerned,  a  sluggish  life.  In 
some  cases — fortunately  rare — the  weak  intestine  distends 
greatly,  and  becoming,  as  above  explained,  unable  to  propel 
the  accumulated  feces,  insuperable  constipation  occurs. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  507 

The  same  complete  paralysis  of  the  tube,  attended  with 
the  same  unfortunate  consequences,  may  be  brought  about 
by  chronic  lesions  of  the  brain  or  spinal  cord.  Perhaps, 
however,  the  inveterate  constipation  which  is  so  constant  an 
accompaniment  of  these  states  is  partly  owing  to  the  power- 
less condition  of  the  abdominal  muscles. 

Among  the  different  organic  changes  in  the  intestine 
which,  by  interfering  mechanically  with  the  peristaltic  wave 
and  the  onward  transmission  of  the  feces,  set  up  constipation, 
w^e  find  distention  of  the  tube,  with  atrophy  of  the  muscular 
fibres;  various  infiltrations  into  the  walls,  producing  a  nar- 
rowing of  the  calibre ;  and  adhesions  between  the  serous  coats 
of  the  intestines,  or  between  these  viscera  and  the  parietes. 
Of  the  iirst,  it  need  only  be  said  that  the  symptoms  are  due 
to  the  same  paralyzed  condition  of  the  intestine,  whether 
complete  or  incomplete,  which  has  been  just  considered,  and 
which  has  been  dwelt  upon  more  at  length  when  discussing 
diseases  of  the  ctecum,  and  intestinal  obstruction.  The 
second  group  embraces  those  infiltrations  which  result  from 
inflammations,  and  new  growths  of  different  kinds  which 
lead  to  strictures. 

The  former  of  these  are  recognized,  as  far  as  the}'  can  be 
with  certainty,  by  the  history  of  the  case.  The  latter  pre- 
sent peculiarities  in  the  form  and  size  of  the  feces,  disten- 
tion of  the  bowels  above  the  seat  of  the  narrowing,  vomiting, 
attacks  of  colic,  gradual  wasting  and  exhaustion  ;  besides 
which,  extreme  costiveness,  deepening  gradually  into  invin- 
cible constipation,  furnishes  a  key  to  the  grievous  nature  of 
the  disorder. 

When  the  constipation  arises  as  the  result  of  peritoneal 
adhesions,  there  are  sometimes  signs  in  the  case — such  as 
tenderness  at  a  particular  spot  from  still  existing  inflamma- 
tion, or  partial  distention  or  retraction  of  the  abdomen — 
which  point  out  its  nature.  In  the  absence  of  these,  the  his- 
tory is  our  only  guide,  excepting  in  those  instances  in  which, 
as  Dr.  Bright*  first  informed  us,  a  peculiar  sensation  is  com- 

*  Cases  illustrative  of  the  diagnosis  of  adhesions  and  other  morbid  changes 
of  the  peritoneum,  Med.-Chirg.  Trans.,  vol.  xix. 


508  MEDICAL    DIAGNOSIS. 

municated  to  the  touch,  varying  between  the  crepitation  pro- 
duced by  emphysema  and  the  feel  derived  from  bending  new 
leather  in  the  hand. 

Thus  a  protracted  state  of  constipation  may  be  due  to 
several  causes,  some  of  which  are  of  very  serious  character. 
And  this  only  proves  how  important  it  is  to  look  further 
than  the  mere  constipation ;  how  necessary  in  every  case  to 
endeavor,  as  nearly  as  possible,  to  arrive  at  the  determining 
cause  of  the  imperfect  or  difficult  alvine  evacuations.  Still  it 
is  often  impossible  to  assign  any  one  cause,  because  the  com- 
plaint is,  in  fact,  dependent  upon  the  union  of  several  of 
those  which  have  been  mentioned.  Moreover,  we  must  not 
forget  that  a  constipated  state  is  often  joined  to  affections  of 
the  stomach  or  liver,  and  our  treatment  for  the  habitual  con- 
stipation should  merge  into  that  of  the  disorder  of  which  the 
constipation  is  a  symptom. 

Disorders  in  which  Morbid  Discharges  from  the  Bowels  occur. 

Matters,  very  unlike  the  healthy  alvine  evacuations,  are 
often  voided  from  the  intestinal  canal ;  loose  watery  stools, 
large  quantities  of  mucus,  pus,  or  blood  may  be  discharged. 
I  shall  here  describe  the  disorders  which  occasion  these  dis- 
charges. 

Diarrhoea. — The  remark  made  of  constipation  is  equally 
applicable  to  diarrhoea.  Both  occur  as  an  accompaniment 
in  a  vast  number  of  diseases  which  present  symptoms  more 
characteristic  than  the  confined  or  loose  state  of  the  bowels. 
At  this  place,  therefore,  diarrhoea  will  be  merely  treated  of 
as  we  meet  with  it  constituting,  so  far  as  can  be  ascertained, 
the  entire  ailment,  or  at  all  events  by  far  its  most  prominent 
symptom.  There  are  several  varieties  of  diarrhoea.  Differ- 
ence in  time  gives  rise  to  marked  varieties — to  an  acute  and 
a  chronic  form. 

Acute  Diarrhoea, — Now,  acute  diarrhoea  proceeds  from  more 
than  one  cause  :  it  may  be  excited  by  the  irritating  character 
of  the  food  taken ;  it  may  be  brought  about  by  the  morbid 
nature  of  the  secretions  poured  into  the  intestines  ;  it  may 
be  owing  to  atmospheric  influences — to  heat,  to  moisture,  to 


DISEASES    OF    THE    INTESTINES    AND    PEIlITONEUxM.  509 

contaminated  air  ;  it  may  be  due  to  mental  emotions,  and 
especially  to  fear.  Its  symptoms  are  thirst;  a  griping  pain 
in  the  bowel,  of  all  grades  of  severity;  pallor;  a  slight  de- 
bility, and  frequent  fluid  alvine  evacuations. 

In  the  diarrhoea  caused  b}^  a  debauch  or  by  indigestible 
food,  nausea  and  a  furred  tongue  are  added  to  the  list  of 
symptoms  mentioned.  This  kind  of  diarrhoea  is  generally 
of  very  short  duration.  It  is  an  effort  of  nature  to  get  rid  of 
obnoxious  matter ;  and  when  this  is  effected,  the  looseness 
of  the  bowels  ceases  of  itself.  The  discharc-es  from  the  in- 
testines  are  therefore  rather  to  be  favored  than  suppressed. 
And  we  can  greatly  aid  the  recovery  by  enjoining  absti- 
nence from  food,  and  by  administering  diluent  drinks  and  a 
purgative,  to  which  a  small  quantity  of  some  opiate  is  added, 
sufficient  to  soothe,  but  not  sufficiently  to  interfere  with  the 
aperient  action. 

The  variety  of  diarrhoea  under  consideration  sometimes 
goes  hand  in  hand  with  a  disturbance  of  the  biliary  func- 
tions, and  the  stools  discharged  are  fetid,  and  present  the 
appearance  generally  described  as  bilious.  This  "  bilious 
diarrhoea,"  too,  is  not  uncommon  in  persons  whose  livers  are 
habitually  sluggish.  It  is  also  frequently  encountered  during 
the  hot  months  of  summer  and  early  in  the  autumn,  and 
has  a  tendency  to  run  on. 

Owing  to  the  extreme  rarity  with  which  an  opportunity 
offers  to  examine  it,  the  state  of  the  mucous  membrane  dur- 
ing an  attack  of  acute  diarrhoea  is  not  accurately  determined. 
In  some  instances  redness,  swelling,  and  other  evidences  of 
acute  inflammation  have  been  found.  But  these  were  cases 
in  which  during  life  the  symptoms  had  been  severe  ;  in  fact, 
more  or  less  those  of  an  inflammation — pain,  some  soreness 
to  the  touch,  and,  what  is  not  ordinarilv  met  with  in  diar- 

7  7  f 

rboea,  heat  of  skin  and  excited  pulse.  These  graver  kinds  of 
acute  diarrhoea,  or  rather  of  muco-enteritis  with  diarrhoea  as 
a  symptom,  are  often  the  result  of  irritant  poisoning.  They 
are  still  more  usually  observed  as  secondary  disorders  in 
typhoid  fever  and  in  the  exanthemata. 

Chronic  Diarrhoea. — In  chronic  diarrhoea  the  lesions  encoun- 
tered are  much  more  marked  than  they  ever  are  in  the  acute 


510  MEDICAL    DIAGNOSIS. 

form.  The  mucous  membrane  is  tumid  and  discolored;  its 
follicles  are  not  unfrequently  ulcerated.  Chronic  looseness 
of  the  bowels  originates  in  a  diarrhoea  which  is  permitted  to 
continue,  either  from  neglect  or  because  the  patient  remains 
for  a  long  time  exposed  to  the  original  cause.  But  the  dis- 
order, no  matter  under  what  circumstances  it  originated,  is 
apt  to  prove  rebellious,  and  to  end  by  breaking  down  the 
constitution.  Wlien  of  long  standing,  the  patient  becomes 
gradually  weaker  and  weaker,  and  more  and  more  emaciated. 
The  abdomen  is  sunken;  the  expression  of  the  face  despond- 
ent; the  complexion  pale;  the  eyes  are  surrounded  by  a 
dark  ring.  The  character  of  the  discharge  is  very  various. 
The}^  are  often  dark  colored  and  very  offensive.  Sometimes 
the  looseness  of  the  bowels  alternates  with  an  opposite  con- 
dition, but  the  irritability  of  the  intestines  never  intermits. 

This  morbid  excitability  of  the  intestinal  tube  is  more  es- 
pecially brought  about  in  persons  of  nervous  temperament 
and  of  dissipated  habits.  The  abuse  of  purgatives,  too,  in- 
duces it,  and  in  consequence  chronic  diarrhoea  is  not  an  un- 
common result  of  the  cathartic  pills  which  many  of  the 
patrons  of  quack  medicines  so  habitually  swallow. 

But  perhaps  the  most  persistent  irritability  of  the  intestines 
is  found  in  the  diarrhoea  to  which  soldiers  are  so  liable,  and 
which,  as  the  result  of  hardships,  exposure,  and  defective 
diet,  is  so  apt  to  pass,  no  matter  what  its  beginning,  into  the 
chronic  form  of  the  disease.  And  this  complaint,  which  is 
generally  associated  with  a  morbid  state  of  the  large  intes- 
tine as  well  as  of  the  small,  which  combines  therefore  some 
of  the  features  of  chronic  dysentery  with  those  of  chronic 
diarrhoea,  is  one  that  often  clings  to  its  victim  through  life ; 
many  a  soldier,  in  truth,  escapes  the  bullet  and  the  sword, 
only  to  die  of  the  intestinal  affection  long  after  his  return  to 
his  home. 

The  causes  of  the  diarrhoea  of  soldiers  are  the  ordinary 
causes  of  chronic  diarrhoea  already  mentioned,  favored  in 
their  development  by  fatiguing  marches,  by  want  of  personal 
cleanliness,  by  the  exposure  and  drawbacks  of  life  in  camp 
or  in  the  field,  by  hot  weather,  by  malaria,  and  in  many  in- 
stances by  a  specific  epidemic  poison  in  the  atmosphere.     To 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  511 

this  origin  are  chiefly  referred  the  numerous  instances  of 
atonic  diarrhoea  which  happened  among  the  British  troops 
in  the  Crimea.*  During  the  late  war  on  this  continent,  we 
did  not  escape  the  scourge  of  all  armies.  Irrespective  of  the 
causes  always  acting  whenever  large  numbers  of  men  are 
collected  together  for  warlike  operations,  scurvy  is  stated  to 
have  been  a  prolific  source  of  the  thousands  of  cases  of  diar- 
rhoea which  occurred  in  the  army  during  the  past  conflict.f 

The  chronic  diarrhoea  among  soldiers  is  not  materially 
different  in  its  symptoms  from  chronic  diarrhoea  of  civil  life, 
excepting  that  perhaps  we  find  more  frequently  thickening 
and  ulceration  of  the  colon ;  more  frec|uently,  therefore, 
stools  containing  pus  and  more  of  the  evidences  of  chronic 
dvsenterv  than  usuallv  coexist  with  what  is  known  as  chronic 
diarrhoea.  Then,  the  affection  is  very  often  witnessed  as  a 
complication  of  other  disorders.  Two-thirds  of  the  fever 
patients  received  in  the  hospitals  at  Constantinople  during  a 
long  period  of  the  Crimean  war  were  aftected  with  diarrhoea 
or  with  dysentery.  Diarrhoea  was  so  very  general  that  nearly 
all  disorders  were  preceded  by  acute  diarrhoea,  and  termi- 
nated in  chronic  diarrhoea.^  To  any  one  who  had  opportuni- 
ties of  observing  cases  of  the  Chickahominy  fever  and  diar- 
rhoea so  prevalent  during  General  McClellan's  peninsular 
campaign,  a  parallel  will  at  once  occur. 

But  chronic  diarrhoea,  as  the  practitioner  of  medicine  com- 
monly sees  it,  is  not  always  so  strictly  an  idiopathic  ailment 
as  are  for  the  most  part  the  forms  of  the  malady  just  dis- 
cussed. It  is  often  attendant  on  general  constitutional  afi'ec- 
tions,  or  on  abdominal  diseases  which  have  led  to  a  secondary 
disorder  of  the  secretions,  or  even  of  the  coats  of  the  intes- 
tine. Thus  we  find  chronic  looseness  of  the  bowels  in  scurvy, 
in  pyasmia,  in  Bright's  disease,  in  scrofula  of  the  mesenteric 
glands,  and  in  tuberculosis.  In  the  last  of  these  complaints, 
the  diarrhoea  may  be  occasioned  by  changes  in  the  secretions 
of  the  intestinal    glands.     But  it  is  not  seldom  dependent 


*Blue   Book,  Medical  and  Surgical  History  of  the  War  against  Kussia, 
vol.  ii.  page  101. 

J  Woodward,  Outlines  of  the  Chief  Camp  Diseases,  page  253. 
^  Baudens,  La  Guerre  de  Cfimee. 


512  MEDICAL   DIAGNOSIS. 

upon  a  true  tubercular  disease  of  the  intestines,  which  leads, 
like  phthisis,  to  softening  and  ulceration.  The  discharges 
are  generally  copious  and  verj-  offensive.  They  contain  fre- 
quently undigested  food.  The  abdomen  is  retracted,  and 
presents  spots  very  tender  to  the  touch.  Yet,  after  all,  the 
signs  of  tubercle,  or  scrofula  elsewhere,  furnish  alone  any 
positive  indications  by  which  the  true  nature  of  the  wasting 
malady  may  be  discerned. 

In  the  chronic  diarrhoBa  of  strumous  children  there  is 
sometimes  a  scrofulous  iniiltration  into  the  intestinal  walls, 
sometimes  scrofula  of  the  mesenteric  glands,  sometimes  both, 
but  in  some  cases  neither.  Improper  nourishment  may  be 
the  exciting  cause  of  the  continued  purging;  for  do  we  not 
see  even  healthy  infants,  surrounded  by  everj"  comfort  and 
every  care  that  wealth  can  procure,  when  unsuitably  fed,  or 
weaned  too  soon,  suft'er  from  continued  irritation  of  the  ali- 
mentary tube  ? 

These  facts  teach  us  that,  in  the  treatment  of  the  chronic 
diarrhoea  of  children,  the  regulation  of  the  diet  is  of  the 
utmost  importance ;  and  the  same  is  true  of  the  chronic 
diarrhoea  of  adults. 

Sometimes  chronic  diarrhoea  assumes  an  interynitient  type, 
and  its  malarial  nature  is  clearlj"  proved  by  the  readiness 
with  which  the  disorder  yields  to  quinine.*  In  this  respect 
this  malarial  diarrhoea  difters  from  cases  of  diarrhoea  we 
sometimes  encounter,  in  which  the  pain  and  discharges  come 
on  at  an  early  hour  of  the  day,  and  cease  toward  evening 
and  during  the  night. 

Another  form  of  looseness  of  the  bowels  is  the  membranous. 
Here  the  discharges  show  shreds  of  membrane,  either  in 
connection  with  the  loose  stools,  or  sometimes  in  such  quan- 
tities that  the  whole  mass  voided  seems  to  consist  of  them. 
Griping  pains  and  tenderness  usually  precede  this  form  of 
diarrhoea,  which  may  happen  in  attacks  of  a  subacute  form, 
or  as  a  persistent  and  very  obstinate  disorder.  The  fecal 
discharges  are  usually  loose,  but  occasionally  for  a  time  there 
is  constipation. 

*  See  contribution  by  Dr.  Sanford  B.  Hunt  on  Diarrhoea,  in  Medical 
Memoirs  of  U.  S.  Sanitarj'  Commission,  p.  30G. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  513 

Dysentery. — Frequent  and  painful  passages  of  mucus 
mixed  with  blood,  accompanied  with  straining  and  bearing- 
down,  are  the  characteristic  symptoms  of  dysentery.  In  its 
acute  form  we  find  thirst,  restlessness,  and  heat  of  skin  super- 
added;  and  sometimes,  in  severe  cases,  especially  when  the 
disease  prevails  epidemically,  those  symptoms  of  prostra- 
tion which,  grouped  together,  are  commonly  designated  as 
typhoid. 

Acute  Dysentery. — The  acute  disorder  is  at  times  ushered  in 
by  a  chill;  at  times  it  is  preceded  by  diarrhoea.  The  fever 
which  attends  it  is  not  generally  intense.  It  is  the  exception 
to  find  a  hard,  rapid  pulse,  and  a  very  hot,  dry  skin ;  and  in 
slight  cases  the  pulse  is  but  little  excited,  and  the  skin  re- 
mains cool.  More  or  less  pain  is  always  present.  It  has  its 
seat  mostly,  but  not  invariably,  at  some  part  of  the  colon, 
and  this  is  tender  on  pressure.  It  is  not  constant,  but  inter- 
mitting and  shifting,  and  is  often  accompanied  by  a  disagree- 
able, weighty  feeling  near  the  anus,  which  causes  a  continual 
desire  to  go  to  stool.  Yet  no  relief  follows  the  frequent 
attempts  at  defecation  ;  the  violent  straining  only  adds  to  the 
discomfort  of  the  patient. 

The  matters  voided  are  small  in  quantity.  They  consist  of 
blood  mixed  with  mucus;  but,  like  nearly  all  of  the  so-termed 
mucous  discharges,  they  are  composed  not  simply  of  mucus, 
but  also  of  pus  corpuscles,  exudation  globules,  granules,  and 
large  quantities  of  cast-off  epithelium.  They  are  in  some 
cases  highly  offensive,  and  resemble  the  washings  of  meat; 
in  others,  they  are  like  jelly,  or  greenish  in  color.  They  do 
not  contain  feces,  or  only  here  and  there  small,  firm  lumps 
of  fecal  matter;  hence  we  may  justly  say  that,  for  the  most 
part,  dysentery  is  in  reality  attended  with  constipation. 
When  the  dysenteric  inflammation  subsides,  the  bowels  are 
unloaded  of  their  contents  ;  in  consequence,  the  passage  of 
quantities  of  small,  hard  masses  of  feces  is  generally  a  sign 
that  the  acute  malady  is  inclining  to  a  favorable  termination. 

But  how  long  it  will  take  for  the  disorder  to  run  its  course, 
or  whether  the  acute  disease  will  pass  into  chronic  dysentery, 
cannot  be  foretold.  Generally  this  is  not  its  termination  ;  it 
very  often  ends,  within  a  week  from  its  commencement,  in 

33 


514  MEBICAL    DIAGNOSIS. 

recovery.  But  severe  cases  occur  which  are  of  much  shorter 
duration,  and  in  which  the  symptoms  hasten  on  to  complete 
prostration,  and  death  takes  place  early  in  the  malady.  In 
these  frightful  cases — most  frequently  encountered  in  epidem- 
ics and  where  the  distemper  prevails  among  large  bodies  of 
men — collapse  may  happen  with  almost  the  same  rapidity  as 
it  does  in  malignant  cholera. 

Dysentery  is  essentially  a  disease  of  hot  climates.  It  is 
very  common  in  this  country  in  summer  and  in  autumn, 
Eating  green  fruits,  exposure  to  a  chilly  night  after  a  hot 
day,  or  sleeping  on  damp  ground,  are  prolific  exciting  causes. 
It  is  occasionally  found  in  combination  with  malarial  fevers, 
adding  greatly  to  their  danger.  The  immediate  cause  of 
most  of  the  symptoms  is  the  inflammation  of  the  large  in- 
testine, and  especiall}^  of  the  portion  which  commonly  bears 
the  brunt  of  the  disorder — the  descending  colon.  Yet  in 
many  cases  of  dysentery  we  see  phenomena  manifested  which 
are  clearly  not  to  be  accounted  for  solelj-  by  the  local  morbid 
appearances  detected  after  death,  and  which  show  that  dys- 
entery is  often  something  more  than  mere  inflammation  of 
the  colon.  In  truth,  inflammation  of  the  colon  may  give  rise 
to  the  symptoms  of  acute  diarrhoea;  for  it  is  a  great  mistake 
to  suppose  that  the  cause  of  diarrhoea  is  only  to  be  sought  in 
some  abnormal  change  in  the  small  intestines.  Thus  colitis 
is  not  always  dysentery ;  and  dysenter}',  to  repeat,  is  often 
something  more  than  mere  colitis. 

But  whether  we  believe  dysentery  to  be  simply  inflamma- 
tion of  the  colon ;  or  an  inflammation  of  the  colon  arising 
from  a  diseased  state  of  the  blood,  and  forming,  therefore, 
only  part  of  a  general  malady ;  or  believe  it  to  be  sometimes 
one,  sometimes  the  other, — we  have  to  admit  that  it  presents 
peculiarities  which  render  it  easy  of  recognition  at  the  bed- 
side. 

Yet  we  should  take  good  care  to  ascertain  that  the  supposed 
characteristic  tenesmus  and  bloodj-  discharges  are  not  really 
owing  to  piles  or  to  morbid  growths  in  the  rectum.  There  is 
less  danger  of  confounding  enteritis  or  diarrhoea  with  dysen- 
tery, for  symptoms  exist  in  the  latter  which  do  not  belong  to 
either  of  the  former.     Enteritis  has  fever;  so  has  dj'sentery, 


DISEASES    OP    THE    INTESTINES    AND    PEllITONEUM.  515 

though,  as  already  stated,  the  febrile  disturbance  is  not  often 
of  a  very  high  grade.  And,  independently  of  the  differences 
arising  from  the  absence  of  the  peculiar  discharges  of  dysen- 
tery, the  pulse  of  enteritis  is  small,  tense,  and  quick;  that  of 
dysentery,  if  the  febrile  action  be  marked,  full  and  rapid. 
Diarrhoea  differs  from  dysentery  by  the  liquid  fecal  evacua- 
tions, and  by  the  fact  that  neither  tenesmus,  nor  bloody  stools, 
nor  discharges  of  mucus  occur.  Yet  in  practice  we  meet 
with  cases  which  commence  with  diarrhoea  and  end  with 
dysentery,  or  begin  with  dysenteric  symptoms  and  terminate 
in  diarrhoea,  and  in  which  it  becomes,  therefore,  puzzling  to 
say  whether  we  are  dealing  with  the  former  or  with  the  latter 
disorder. 

Chronic  Dysentery. — In  chronic  dysentery  this  mingling  of 
the  two  complaints  is  especially  apt  to  happen.  We  rarely  see 
chronic  dysentery  without  chronic  diarrhoea.  At  all  events, 
we  seldom  find  instances  of  the  former,  in  which  the  tenesmus 
and  the  discharge  of  blood  and  mucus  mixed  with  pus  are  not 
accompanied  by  frequent  loose  alvine  evacuations,  by  griping, 
by  the  same  gradual  wasting  and  the  same  irritability  of  the 
bowels  as  are  encountered  in  chronic  diarrhoea;  nay,  the 
symptoms  of  the  latter,  and  the  difficulty  of  determining  the 
presence  of  pus  when  mixed  with  fluid  feces,  may  so  obscure 
the  true  nature  of  the  malady,  that  what  has  been  regarded 
as  chronic  diarrhoea  turns  out,  at  the  autopsy,  to  be  chronic 
dysentery.  The  mucous  membrane  of  the  colon  is  found  to 
be  extensively  inflamed;  its  texture  altered  and  irregularly 
thickened  ;  its  surface  riddled  with  ulcers.  In  such  cases  the 
patient  goes  on  steadily  losing  flesh;  but  no  pain  on  pressure 
or  localized  distress  exists  to  denote  the  ravages  the  disease 
is  making  in  the  alimentary  tube. 

The  prognosis  is  never  very  favorable.  To  say,  indeed, 
that  it  is  wholly  unfavorable,  would  hardly  be  to  overrate 
the  serious  character  of  the  disease.  Many  die  exhausted  ; 
others,  in  consequence  of  abscess  of  the  liver,  which  chronic 
as  well  as  acute  dysentery  may  induce. 

Intestinal  Hemorrhage  or  Melaena. — The  discharge  of 
blood  in  large  quantities  from  the  bowels  is  not  apt  to  occur 
in  dysentery.     It  is  much  more  common  as  the  result  of  a 


516  MEDICAL    DIAGNOSIS. 

mechanical  hinderance  to  its  flow  through  the  liver,  or  of  a 
depraved  state  of  the  circulating  fluid — such  as  exists  in 
typhus  fever,  in  yellow  fever,  and  in  scurvy.  Occasionally 
the  hleeding  proceeds  from  a  fungoid  growth  in  the  intes- 
tine, or  an  ulcer  in  the  duodenum,  or  from  the  bursting  of 
an  aneurism.  Rokitansky  informs  us  that  intestinal  liemor- 
rhaffes  sometimes  follow  extensive  burns  of  the  abdominal 
parietes.  And  in  very  young  infants,  a  discharge  of  blood, 
both  by  the  mouth  and  rectum,  is  not  of  unusual  occur- 
rence. 

The  blood  passed  by  stool  is  generally  of  dark  color,  like 
tar.  When  it  is  not,  we  may  fairly  infer  that  it  flows  from 
the  lower  part  of  the  intestine  and  has  not  had  much  chance 
to  become  admixed  with  other  matters.  In  all  such  cases, 
however,  we  must  make  sure,  before  arriving  at  any  conclu- 
sion as  to  the  source  of  the  bleeding,  that  it  does  not  proceed 
from  hemorrhoids.  The  exact  seat  of  the  hemorrhage  can- 
not be  determined;  nay,  blood  may  be  evacuated  by  the 
bowel,  and  not  be  poured  out  at  all  from  the  intestine,  but 
from  the  stomach.  In  some  instances  the  blood  accumulates 
in  the  bowel,  and  before  the  clots  moulded  to  its  shape  are 
discharged,  death  results.* 

Fatty  Diarrhoea. — The  occurrence  of  cases  in  which  large 
quantities  of  fat,  mixed  or  pure,  are  voided  by  the  rectum,  is 
attested  by  many  observers.  In  some  of  these  cases  oil  was 
at  the  same  time  passed  with  the  urine;  in  others  the  urinary 
secretion  was  healthy;  some  cases  ended  fatally,  others  in 
recovery;  some  were  found  to  be  connected  with  a  disease 
of  the  pancreas,  others  were  not ;  in  some  the  disorder  was 
not  of  long  continuance,  while  in  others  it  lasted,  with  occa- 
sional intervals,  for  years.  Thus  the  morbid  state  with 
which  fatty  diarrhoea  is  associated  is  far  from  being  always 
the  same. 

As  a  rule,  the  occurrence  of  fatty  stools  is  a  matter  of  seri- 
ous concern.  The  recognition  of  the  malady  is  easy.  The 
white,  fatty  masses,  or  the  oily  matter  which  collects  on  the 


*  See  observations  of  Cheyne,  Dublin   Hospital    Reports,  vol.  i.;    iind    of 
Belcombe,  Medical  Gazette,  vol.  iv. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  517 

discharges,  are  soluble  in  ether,  and  are  readily  proved  to  be 
fat  by  the  microscope  ;  they  burn,  too,  like  fat,  with  a  flame. 
In  some  instances  the  bowels  are  very  constipated,  and  lumps 
of  hard  feces  are  discharged  along  with  the  fatty  substance. 
This  happened  in  a  marked  example  of  the  disorder  that 
came  under  my  observation.  The  patient,  a  man  twenty-six 
years  of  age,  passed  a  considerable  amount  of  fat  both  by 
the  rectum  and  with  the  urine.  He  suftered  much  from 
digestive  disturbance,  from  constipation,  and  from  weakness. 
He  had  a  good  appetite,  but  a  dislike  to  fats  of  any  kind. 
In  his  case  there  was,  so  far  as  the  physical  signs  indicated, 
no  tumor  in  the  region  of  the  pancreas.  The  man's  condi- 
tion was  much  improved  by  the  administration  of  cinchona 
and  rhubarb ;  but  whether  permanentl}'  or  not  I  cannot  say, 
as  I  lost  sight  of  him. 

Diseases  attended  with  Vomiting  and  Purging. 

There  is  a  group  of  diseases  in  which  vomiting  and  purg- 
ing are  very  prominent  symptoms.  It  embraces  those  dis- 
orders in  which  the  intestine  and  stomach  are  equally  in- 
volved. To  this  group  belong  some  affections  which  have 
already  been  considered,  which  begin  in  one  viscus  and  then 
spread  to  the  other.  But  those  in  which  both  are  primarily 
affected,  still  remain  to  be  described.  The  most  important 
of  them  are  the  various  forms  of  cholera.  Now,  there  are 
several  very  different  complaints  classed  together  under  the 
head  of  cholera.  Let  us  proceed  to  consider  them  one  by 
one. 

Cholera  Infantum.— And  first,  of  the  so-called  cholera  of 
infants.  It  is  an  endemic  in  the  larger  cities  of  the  United 
States  during  the  hot  months,  and  one  fraught  with  danger 
to  all  young  children.  Hundreds  die  of  this  summer  com- 
plaint every  year  in  our  densely  populated  towns. 

It  commences  generally  with  diarrhoea.  Vomiting  soon 
follows;  and  for  a  time  the  two  go  hand  in  hand  ;  but  unless 
the  case  be  of  very  short  duration,  the  spontaneous  vomiting 
ceases,  or  at  all  events  gives  way  to  occasional  exacerbations 
of  irritability  of  the  stomach,  wdiile  the  looseness   of  the 


518  MEDICAL    DIAGNOSIS. 

bowels  remains,  or  even  augments.  The  discharges  are 
colorless,  or  yellowish,  or  greenish.  There  is  thirst ;  some- 
times fever.  The  abdomen  may  be  sunken  or  swollen  ;  and 
it  may  be  tender.  Sometimes  the  disease  runs  its  course 
within  three  or  four  days ;  at  the  end  of  which  time  the  child 
dies,  worn  out  by  the  constant  vomiting  and  purging.  More 
generally  the  disorder  is  of  longer  duration  ;  for  weeks  or  for 
months  it  continues;  the  diarrhoea  improving  and  then  re- 
turning with  redoubled  severity.  The  irritability  of  the  in- 
testinal canal,  and  the  utter  impossibility  of  retaining  enough 
food  to  nourish  the  wasting  body,  gradually  wear  out  the 
system.  The  child  before  death  is  wan  and  distressingly 
emaciated ;  sometimes  restlessness,  plaintive  cries,  rolling  of 
the  head,  strabismus,  coma, — the  symptoms  of  hydrocephalus, 
— precede  the  fatal  termination. 

Such  is  a  sketch  of  grave  and  intractable  cases.  Yet  many 
cases  are  far  from  being  so  desperate.  Under  judicious  treat- 
ment a  large  number  are  annually  saved.  Recoveries  would 
bear  a  still  higher  proportion  to  the  deaths,  were  it  not  that 
the  greatest  suft'erers  from  the  disease  (the  children  of  the 
poor)  are  unable  to  obtain  the  means  most  certain  to  restore 
them  to  health — change  of  air.  Cooped  up  in  crowded 
neighborhoods,  surrounded  on  all  sides  by  filth  rapidl}-  de- 
composing under  the  burning  rays  of  the  sun,  they  are  com- 
pelled to  breathe  the  hot,  noxious  atmosphere  which  has 
been  the  chief  agent  in  generating  the  complaint.  And  by 
bearing  this  fact  in  mind  we  may  do  much  to  alleviate  the 
disorder.  Even  when  circumstances  render  exchanging  the 
city  for  the  country  impossible,  much  good  may  be  efl'ected 
by  directing  the  child  to  be  carried  daily  into  situations 
where  the  air  is  pure.  In  all  cases,  irrespective  of  the  medi- 
cinal means  employed,  the  diet  must  be  regulated,  and  the 
gums  carefully  examined  to  see  that  the  irritation  of  teeth- 
ing does  not  keep  up  or  increase  the  gastro-intestinal  excita- 
bility. 

Cholera  Morbus. — Like  the  cholera  of  intants,  cholera 
morbus  is  a  disease  of  the  hot  season  ;  yet  it  is  also  observed 
at  other  times  of  the  year.  But,  although  the  chief  predis- 
posing cause  is  undoubtedly  heat,  there  is  generally  an  excit- 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  519 

ing-  cause  which  develops  the  disorder  :  such  as  exposure, 
checked  perspiration,  drinking  large  quantities  of  ice-water, 
or  imprudence  in  eating.  The  attack  is  characterized  by 
spasmodic  pains  in  the  abdomen,  by  cramps  in  the  legs,  by 
rapid  loss  of  strength,  and  by  repeated  vomiting  and  purg- 
ing. The  matter  ejected  both  from  the  stomach  and  intes- 
tines is  liquid,  and  contains  a  large  quantity  of  bile.  In  truth, 
the  affection  is  in  reality  a  cholera,  a  flow  of  bile,  which  its 
more  formidable  namesake,  Asiatic  cholera,  is  not. 

The  disease  is  sometimes  preceded  bj-  colicky  pains, 
nausea,  and  rumbling  in  the  intestines.  More  generally  it 
comes  on  suddenly.  When  at  its  height,  the  cramps  in  the 
calves  of  the  legs  cause  the  muscles  to  rise  up  in  hard, 
knotty  masses;  the  stools  are  fetid;  the  vomiting  is  con- 
stant; the  thirst  is  very  great,  and  the  skin  is  cool  or  cold. 
But  the  patient  does  not  long  remain  in  this  condition.  In 
the  course  generally  of  a  few  hours,  or  at  the  utmost  of  a 
day,  the  symptoms  mitigate,  or  yield  entirely  to  treatment; 
and  pale  and  visibly  emaciated  though  he  be,  he  speedily 
regains  his  previous  health.  Onl}'  in  some  cases  the  disease 
proves  intractable,  and,  after  running  on  for  several  days, 
passes  into  a  state  of  hopeless  collapse. 

There  are  not  many  morbid  states  with  which  cholera 
morbus  is  likely  to  be  confounded.  It  may  be  mistaken,  as 
we  shall  presently  see,  for  epidemic  cholera.  We  And  many 
points  of  similarity  between  it  and  irritant  poisoning,  and 
some  between  it  and  acute  gastritis.  But  there  are  also 
strong  points  of  difference  :  the  vomiting  and  purging  pro- 
duced by  an  irritant  poison  do  not  come  on  at  the  same  time  ; 
the  vomiting  precedes  the  purging.  The  pain  is  first  in  the 
epigastrium,  thence  it  may  spread.  Moreover,  we  detect 
often  signs  in  the  mouth  or  fauces  which  prove  the  irritating 
character  of  the  substance  swallowed.  The  vomiting  of  acute 
gastritis  is  accompanied  by  a  hot  skin,  a  small,  tense  pulse  ; 
whereas  the  skin  of  cholera  morbus  patients  is  commonly 
cool,  and  the  pulse  very  compressible  and  feeble. 

Cholera. — The  formidable  complaint  known  as  epidemic 
cholera,  Asiatic  cholera,  malignant  cholera,  or  by  the  simple 
name  of  cholera,  has  some  striking  features  of  resemblance 


520  MEDICAL    DIAGNOSIS. 

to  the  disorder  just  considered.  It  shares  with  cholera 
morbus  the  vomiting  and  purging,  the  cramps,  the  sudden 
depression;  but  it  is  an  affection  of  different  origin,  and  of 
much  more  serious  import,  and  presents  symptoms  not  en- 
countered in  the  cholera  that  occurs  yearly  during  the  hot 
weather.  And,  although  I  am  describing  it,  on  account  of 
the  gastric  and  intestinal  disturbances  which  form  so  promi- 
nent a  part  of  its  manifestations,  in  the  same  group  with 
cholera  morbus  and  among  the  disorders  of  the  alimentary 
tube,  I  am  doing  so  for  the  sake  of  clinical  convenience,  and 
contrary  to  sound  pathology ;  for  cholera  is  not  an  affection 
either  of  the  stomach  or  intestines ;  it  is  an  epidemic  consti- 
tutional disorder  of  the  most  formidable  character,  generated 
by  a  poison  transmitted  to  us  from  the  East.  The  poison 
leads  to  a  casting  off  of  the  epithelium  of  the  mucous  mem- 
brane of  the  alimentarj'  tube;  perhaps  to  changes  in  the 
membrane.  But  the  engorged  veins  all  over  the  body ;  the 
ready  exosmose  of  the  watery  parts  of  the  blood ;  the  fright- 
fully rapid  prostration  ;  the  sudden  blight  which  befalls  the 
nervous  powers, — are  elements  even  more  characteristic,  and 
which  throw  more  light  on  the  nature  of  the  fearful  malady, 
than  the  comparatively  uncertain  and  far  from  uniform  ap- 
pearances of  irritation  in  the  intestinal  canal. 

The  access  of  cholera  is  at  times  sudden  and  most  unex- 
pected ;  the  patient,  previously  in  good  health,  is  stricken 
down  without  warning  by  the  force  of  the  poison.  More 
generally  there  is  a  premonitory  stage :  a  stage  of  languor, 
low  spirits,  uneasiness,  headache,  and  diarrhoea.  The  effects 
of  the  tainting  of  the  atmosphere  with  the  morbific  matter 
are  indeed  visible  in  hundreds  of  individuals  who,  during 
the  prevalence  of  cholera,  suffer  from  these  premonitory 
symptoms  without  any  of  greater  danger  arising,  iSTaj', 
the  same  influences  which  give  rise  to  a  choleraic  diarrhoea  in 
healthy  persons  have  the  effect  of  rendering  the  bowels  of 
those  habituall}'  constipated  regular,  and  sometimes  even 
loose. 

When  the  malignant  disease  is  fairly  developed,  there  is 
vomiting  as  well  as  purging.  The  contents  of  the  stomach 
and  intestines  are  first  voided,  and  then  large  quantities  of  a 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  521 

rather  turbid  fluid  resembling-  rice-water,  and  with  whitish 
particles  like  rice  floating  in  it.  They  are  the  epithelial  cells 
of  the  alimentary  tube,  which  have  been  thrown  ofl^"from  tlie 
mucous  membrane.  Simultaneously  with  the  vomiting  and 
purging,  or  very  shortly  after,  come  on  severe  spasmodic 
pains  in  the  abdomen  and  cramps  of  the  muscles  of  the  belly 
and  extremities.  "With  all  this  there  are  a  burning  sensation 
in  the  epigastric  region;  an  unquenchable  desire  for  cold 
drinks ;  a  cool  skin ;  a  pulse  slightly  more  frequent  than 
normal;  a  hurried  and  oppressed  breathing;  and  a  rapidly 
progressing  exhaustion.  The  case  now  stands  on  the  very 
verge  of  collapse.  Should  this  succeed, — and  unfortunately 
it  does  succeed  in  a  fearfully  large  number  of  instances, — a 
state  of  things  is  witnessed  which,  once  seen,  remains  in- 
delibly engraved  on  the  memory.  The  pulse  is  quick,  but 
hardly  perceptible.  The  discharges  cease,  and  so  do  often 
the  cramps.  The  skin  is  cold,  covered  with  a  clammy  sweat, 
and  has  a  bluish  look.  The  nails  and  the  lips  have  the  same 
unnatural  appearance.  The  whole  body  shrinks,  and  seems 
at  times  almost  to  wither  visibly  even  while  under  inspec- 
tion. The  countenance  assumes  the  aspect  of  death ;  the 
eyes  are  sunken  and  have  a  glassy  look.  The  intellect  is 
commonly  clear;  but  when  the  patient  talks,  the  words  tall 
strangely  on  the  ear.  It  seems  as  if  a  corpse  had  spoken, 
and  the  voice  is  husky  and  faint.  The  tongue  and  the  ex- 
pired air  are  cold.  No  symptom,  indeed,  has  struck  me 
more  forcibly  than  the  icy  breath. 

But  the  symptoms  do  not  always  take  place  in  the  order 
described,  nor  are  all  uniformly  present.  The  vomiting  and 
purging  may  be  wanting  from  the  onset,  and  so  too  may  the 
cramps.  Only  one  symptom  is  never  absent — the  tendency 
to  early  sinking.  And  sometimes  a  stage  of  perfect  collapse 
is  reached  with  frightful  rapidity.  Instead,  as  is  commonly 
the  case,  of  several  hours  elapsing  before  complete  prostra- 
tion comes  on,  the  vital  powers  are  at  once  laid  low  by  the 
assault  of  the  dreadful  malady.  When  cholera  prevailed  in 
Philadelphia  some  years  since,  I  attended  a  woman  who  at 
six  o'clock  in  the  morning  was  in  perfect  health,  and  in  a 
little  more  than  half  an  hour  afterward  was  a  lifeless  body. 


522  MEDICAL    DIAGNOSIS. 

There  was  neither  vomiting  nor  purging;  nothing  but 
cramps,  stupor,  and  speedy  collapse.  Such  cases  are  not 
uncommon  in  the  home  of  cholera — ^India.  Post-mortem 
inspection  shows  the  thin  rice-water  fluid  locked  up  in  the 
alimentary  canal.  Nature  may  have  made  an  eft'ort  to  elimi- 
nate the  poison ;  but  before  she  completes  her  task,  life  is 
palsied. 

In  those  cases  that  recover,  the  vomiting  and  purging  grad- 
ually subside,  the  skin  becomes  warm,  the  pulse  fuller,  the 
urine — which,  while  the  disease  was  at  its  height,  was  not 
passed,  perhaps  not  secreted — is  again  voided,  the  patient 
falls  into  a  refreshing  sleep,  and,  the  symptom  most  favor- 
able of  all,  bile  reappears  in  the  stools.  Even  in  apparently 
hopeless  cases  of  collapse  may  we  be  fortunate  enough  to 
witness  these  favorable  changes.  But  where  the  prostration 
has  been  great,  the  reaction  is  apt  to  be  violent.  A  decided 
fever  of  low  type,  with  rapid  pulse  and  heat  of  skin,  and  at- 
tended very  often  by  alarming  cerebral  symptoms,  succeeds; 
and  the  urinary  secretion,  even  if  it  have  been  restored,  be- 
comes again  very  scanty.  Thus  the  period  of  reaction  brings 
with  it  new  dangers,  and  of  a  kind  which  are  sometimes  in- 
surmountable. And  this  low  form  of  fever,  very  similar  to 
typhoid,  though  readily  enough  distinguished  by  the  pre- 
ceding symptoms,  may  last  for  upwards  of  a  week  before 
death  takes  place  or  the  signs  of  danger  gradually  yield. 
Now  this  cholera  typhoid  may  be  preceded  by  scanty  urine 
and  marked  urremia,  but  it  may  also  exist  independently  of 
this  morbid  state,  though  probably  due  equally  to  the  blood 
beino;  loaded  with  brokeu-down  material.  In  cases  in  which 
ursemia  sets  in,  whether  it  be  followed  or  not  by  a  fever  of 
low  type,  there  is  at  first  but  little,  if  any,  heat  of  skin  and 
a  slow  pulse;  the  patient  is  wild,  restless  or  drowsy,  the  kid- 
neys act  very  imperfectly,  the  urine  is  greatly  deficient  in 
urea,  and  usually  contains  albumen.  These  are  very  dan- 
gerous cases,  and  if  the  secretion  is  seriously  retarded  for 
more  than  twenty-four  hours  they  are  likely  to  perish. 

In  any  case  of  cholera  convalescence  is  apt  to  be  slow.  For 
weeks  or  months  irritability  of  the  intestinal  canal  remains; 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.  523 

and  I  have  met  with  instances  in  which  it  has  never  disap- 
peared. 

It  would  be  needless  to  go  into  any  minute  description  of 
the  differences  between  cholera  and  other  affections;  its 
features  are  not  to  be  mistaken.  Cholera  morbus  is  the  only 
disorder  which  really  resembles  it.  The  dividing  line  is 
drawn  by  the  absence  of  bile  in  the  discharges,  the  rice-water 
evacuations,  the  greater  severity  and  more  rapid  progress  of 
the  symptoms,  the  bluish  color  of  the  surface  in  the  stage  of 
collapse,  and  the  epidemic  character  of  the  more  fatal  dis- 
ease. In  the  truly  epidemic  nature  of  the  distemper,  and  in 
the  speedy  collapse,  which  shows  but  too  plainly  that  some 
highly  deleterious  matter  has  poisoned  the  system,  lie  even 
in  doubtful  cases  the  proofs  that  we  are  dealing  with  malig- 
nant cholera ;  for  sometimes  rice-water  discharges  occur  in 
bad  cases  of  cholera  morbus ;  occasionally,  too,  this  disorder 
appears  to  be  epidemic;  but  it  is  only  so  on  a  very  small 
scale.  To  speak  more  accurately,  it  is  an  endemic  on  a  Uirge 
scale.  We  find  no  proofs  of  a  virulent  poison  wafted  about 
in  the  atmosjohere,  or  directly  conveyed  by  human  inter- 
course and  traffic,  and  so  noxious  as  to  smite  animals  as  well 
as  man. 

The  mortality  of  cholera  is  very  various.  In  many  epi- 
demics one-half,  or  more  than  one-half,  die.  In  some  the 
havoc  is  far  less.  The  first  cases  that  occur  almost  invariably 
perish;  and,  taken  altogether,  the  disorder  ranks  among  the 
most  destructive  to  life.  Its  epidemic  visitations  are  what 
the  plague  was  to  the  Europeans  of  the  seventeenth  century, 
and  what  yellow  fever  still  is  to  the  inhabitants  of  this  con- 
tinent. It  is  at  least  as  dangerous  ;  its  nature  is  as  hidden ; 
its  management  quite  as  unsatisfactory. 

But  although  science  has  not  as  yet  taught  us  how,  with 
any  certainty,  to  cure  the  pestilent  disorder,  she  has  taught 
us  how  we  may  do  much  toward  averting  it.  Cleanliness ; 
free  ventilation  ;  avoiding  indigestible  food  ;  separating  the 
sick  from  the  well  ;  and  immediately  checking  the  copious 
watery  diarrhoea, — will  reduce  greatly  the  number  of  cases 
in  every  epidemic. 


524  MEDICAL    DIAGNOSIS. 


SECTION  III. 


DISEASES    OF    THE    LIVER. 


We  have  already  iuqiiired  into  the  clinical  methods  of 
examining  the  liver,  so  as  to  form  a  judgment  of  its  position, 
size,  and  other  physical  characteristics.  Let  us  now  look  at 
some  of  the  symptoms  which  a  disease  of  the  viscus  generally 
manifests. 

Pain  is  one  of  these.  It  is  generally  dull,  and  radiates 
from  the  seat  of  the  liver  to  the  upper  portion  of  the  thorax, 
to  the  scapula,  to  the  shoulder,  to  the  umbilicus.  Commonly 
it  is  persistent  and  increased  by  strong  pressure,  but  the  ex- 
ceptional cases  are  numerous. 

Digestive  troubles  are  very  usual  accompaniments  of  hepatic 
affections.  They  are  of  all  grades:  from  mere  indigestion 
to  the  sio;ns  announcino^  chronic  tjastritis. 

Disturbance  of  the  -portal  circulation  is  another  very  frequent 
consequence  of  disease  of  the  liver.  The  flow  of  blood  is 
interfered  with,  and  the  result  is  seen  in  the  occurrence  of 
dropsy,  of  piles,  of  partial  peritoneal  inflammation,  of  hemor- 
rhages from  the  engorged  stomach  and  intestines,  or  of  en- 
largement of  the  spleen  and  of  the  veins  on  the  surface  of 
the  abdomen. 

Jaundice. — But  tbe  most  frequent,  and  certainly  the  most 
significant  manifestation  of  hepatic  disorder,  is  jaundice. 
This  marked  sign  shows  itself  by  the  yellow  tinge  imparted 
to  the  skin  and  to  the  conjunctiva ;  yet  the  yellowness  is  not 
confined  to  these  structures.  It  may  often  be  found  in  in- 
ternal organs.  Besides  the  peculiar  aspect  of  the  surface, 
icterus  is  usually  attended  with  depression  of  the  circulation; 
with  pruritus;  with  high-colored  urine,  in  which  the  main 
ingredients  of  bile  can  be  detected ;  with  constipation,  the 
feces  passed  being  hard  and  knott}',  and  often  of  bad  odor, 
and  almost  devoid  of  color,  or  sometimes  of  a  leaden  hue. 

Jaundice,  there  can  be  no  doubt,  is  due  to  the  presence  of 
biliary  constituents  in  the  blood ;  but  it  is  as  yet  not  satis- 


I 


DISEASES    OF    THE    LIVER.  525 

factorily  solved  how  they  get  there.  It  was  the  opinion  of 
Haller  and  of  Boerhaave,  and  it  is  still  the  opinion  of  many, 
that  the  hile,  in  consequence  of  some  impediment  to  its  out- 
ward passage  after  it  is  formed  in  the  liver,  is  reabsorbed 
and  conveyed  into  the  circulation.  Others  hold  that  the 
liver  is  at  fault  by  not  performing  its  function  and  clearing 
the  blood  of  the  ingredients  which  form  the  bile  ;.  these, 
whether  they  be  bile  pigment,  or  the  biliary  acids,  or  choles- 
terin,*  accumulate  in  the  blood,  and  give  rise  to  the  char- 
acteristic discoloration  of  jaundice.  Kow,  neither  of  these 
theories  will  explain  all  cases :  many  instances  of  jaundice 
are  at  once  interpreted  by  the  former  supposition;  but  in 
others  it  does  not  suffice,  and  the  view  of  jaundice  from  sup- 
pression appears  more  probable.  Yet  other  theories  have 
been  advanced  to  account  for  some  obscure  forms  of  jaun- 
dice ;  such  as  the  view  of  Frerichs,  that  the  metamorphosis 
of  the  colorless  bile  acids  which  enter  the  blood  and  are 
there  changed  into  urinary  pigment,  is  arrested  b}' the  action 
of  some  poison,  and  that  the  acids  are  converted  into  bile 
pigment,  which,  circulating  with  the  blood,  changes  the  hue 
of  the  surface  and  of  the  secretions. 

The  diagnosis  of  jaundice  is  easy.  The  only  two  morbid 
states  with  which  it  is  liable  to  be  confounded  are  the 
slightly  yellowish  hue  of  chlorosis,  and  the  yellow  appear- 
ance of  the  conjunctiva  which  is  natural  to  some  persons. 
The  changed  color  of  the  countenance  due  to  alteration  of 
the  blood  is  discriminated  by  its  association  with  a  bluish- 
white  or  pearly-tinted  eye.  The  yellow  look  of  the  eye  some- 
times found  in  health  is  known  by  the  unequal  distribution  of 
the  color  and  the  absence  of  a  yellow  hue  of  the  complexion. 
But  in  negroes,  and  it  is  in  them  especially  that  we  meet  with 
the  discolored  conjunctiva,  we  have  to  judge  by  the  character 
of  the  coloration  alone.  In  doubtful  cases,  the  chemical  tests 
bv  which  we  recoo-nize  bile  in  the  urine  would  solve  the 
doubt. 

When  once  jaundice  has  been  recognized,  the  difficulty  in 
diagnosis  may  be  said  to  begin.     Of  the  very  many  distinct 


•"■  Austin  Flint,  Jr.,  Amer.  Journ.  of  the  Med.  Sciences,  Oct.  1802. 


526  MEDICAL    DIAGNOSIS. 

sources  of  icterus,  which  one  is  before  us  ?  Now,  clinically 
speaking,  the  causes  may  be  thus  grouped :  1.  Diseases  of 
the  liver.  2.  Diseases  of  the  bile  ducts.  3.  Diseases  of  parts 
remote  from  the  liver,  or  general  diseases  leading  to  a  disorder 
of  the  viscus.  4.  Certain  poisons  acting  upon  the  blood.  In 
the  first  two  of  these  causes  there  is,  as  it  were,  a  mechanical 
difficulty  impeding  or  arresting  the  excretion  of  bile ;  in  the 
third  and  fourth,  no  obvious  impediment  exists,  and  the 
origin  of  the  jaundice  is  usually  very  obscure.  Cases  belong- 
ing to  the  third  group,  however,  may  be  at  times  explained 
on  the  supposition  of  a  derangement  of  the  hepatic  circula- 
tion. Let  us  now  look  at  some  of  the  peculiarities  of  these 
groups. 

1.  The  jaundice  connected  with  diseases  of  the  liver  is,  as 
a  rule,  recognized  by  its  association  with  changed  dimensions 
of  the  organ,  and  with  pain  or  other  palpable  signs  referred 
to  the  hepatic  region.  It  is  met  with  in  all  disorders  of  the 
liver;  but  does  not  exist  in  all  in  the  same  degree  of  intensity. 
It  reaches  a  high  development  and  is  combined  with  cephalic 
symptoms  in  acute  yellow  atrophy.  In  fatty  liver,  in  waxy 
liver,  in  cancer,  in  cirrhosis,  and  in  acute  hepatitis  it  is  not 
very  marked,  and  may  be,  indeed,  absent;  in  truth,  it  can 
hardly  be  looked  upon  as  belonging  to  the  first-mentioned 
morbid  states. 

2.  Jaundice  arising  from  disease  of  the  larger  biliary  ducts, 
or,  what  is  more  common,  in  consequence  of  their  obstruction 
by  pressure  exercised  by  a  morbid  enlargement  of  adjacent 
parts,  such  as  of  the  pyloric  extremity'  of  the  stomach  or  the 
pancreas;  or  by  their  stoppage  by  inspissated  bile  or  a  biliary 
calculus, — is  a  form  of  the  raaladv  in  which  the  icterus  is 
commonly  very  intense.  It  occasions  no  head  symptoms:  and 
when  these  are  absent  in  a  case  of  very  deep  jaundice;  when, 
further,  the  stools  are  completely  discolored, — we  arc  gen- 
erally correct  in  attributing  the  morbid  phenomena  to  an  im- 
pediment to  the  flow  of  bile  through  the  common  bile  duct 
or  the  hepatic  duct.  If  this  impediment  be  due  to  the  im- 
paction of  a  gall-stone,  severe  colicky  pains  are  encountered 
in  addition  to  the  signs  iust  mentioned. 

As  a  further  means  of  discriminating  the  jaundice  due  to 


DISEASES    OF    THE    LIVER.  527 

obstruction,  no  matter  what  the  immediate  cause,  we  may 
avail  ourselves  of  the  researches  of  Dr.  Ilarley.*  This  physi- 
cian found  that  in  the  jaundice  due  to  reabsorption  of  the  bile 
into  the  blood, — precisely  the  form  of  jaundice,  therefore, 
that  happens  if  an}'  serious  obstacle  in  the  biliary  passages 
exists, — the  biliary  acids  which  have  been  formed  in  the  liver 
pass  into  the  blood,  and  thence  into  the  urine.  This  does 
not  occur  if  the  jaundice  be  due  to  suppression.  Hence,  if 
we  may  accept  these  researches  as  conclusive,  an  examination 
of  the  urine  will  throw  much  light  on  the  cause  of  jaundice, 
and  especially  on  the  circumstance  whether  or  not  it  be  due 
to  obstruction  of  the  bile  ducts.f 

3.  Illustrations  of  jauiidice  following  some  local  lesion  of 
other  parts  of  the  body,  or  appearing  in  the  course  of  a  gen- 
eral constitutional  afi'ection,  are  furnished  by  the  jaundice 
which  happens  in  some  cases  of  pneumonia,  or  which  is  en- 
countered in  remittent,  in  typhus,  or  in  yellow  fever.  In 
these  fevers,  the  jaundice  is  generally  found  to  be  connected 
with  an  acute  enlargement  and  with  structural  changes  in  the 
organ;  and  in  the  latter  malady,  with  disordered  hepatic  cir- 
culation and  a  fatty  degeneration  of  the  secreting  cells. 

To  recognize  the  form  of  jaundice  under  discussion,  we 
must  examine  all  the  viscera  of  the  body  with  care,  laying  at 
the  same  time  stress  upon  the  history  of  the  case  and  the  phe- 
nomena attending  the  jaundice.  Otherwise,  too  much  im- 
portance will  be  attached  to  this  symptom,  and  the  disturb- 
ance of  the  liver  be  regarded  as  forming  the  whole  com- 
plaint, when  in  realitj^  it  is  but  a  very  small  part  of  it. 

4.  Poisons  acting  upon  the  blood  sometimes  give  rise  to 
jaundice  very  rapidly;  for  instance,  the  jaundice  from  snake- 
bites or  from  pyemic  infection  is  very  apt  to  be  suddenly 
developed  and  to  become  quickly  intense.  In  the  history 
of  the  accident  and  the  signs  of  alteration  of  the  blood,  we 
possess  the  means  of  distinguishing  this  form  of  jaundice  at 
the  bedside. 

*  Jaundice,  its  Pathology  and  Treatment.     London,  1863. 

f  The  accuracy  of  the  conchisions  as  well  as  the  availahility  of  the  modi- 
fication of  Pettenkofer's  test,  by  which  the  biliary  acids  are  tested  for,  is 
denied  by  Murchison  in  his  recent  work  on  Diseases  of  the  Liver. 


528  MEDICAL    DIAGNOSIS. 

Thus,  then,  we  can  bring,  clinically  speaking,  most  of  the 
varieties  of  jaundice  under  one  or  the  other  of  the  four  heads 
mentioned.  But  there  are  a  few  kinds  of  jaundice  which  it 
is  far  from  easy  to  classify  ;  one  of  these  is  the  jaundice 
from  mental  emotion;  the  other,  the  jaundice  of  newly-born 
children. 

As  regards  the  former,  it  is  very  difficult  to  explain  its 
cause  ;  nor,  indeed,  has  any  satisfactory  explanation  been 
given.  All  we  know  is,  that  violent  anger  or  fright  may  lead, 
within  a  very  brief  space  of  time,  to  the  development  of 
jaundice,  and  that  the  quickly-occurring  discoloration  of  the 
skin  is  n'ot  generally  dangerous,  nor,  in  fact,  of  long  duration. 

The  jaundice  of  newly-born  children — icterus  neonatorum — 
is  ordinarily  a  very  mild  complaint  which  appears  soon  after 
birth,  and  which  rarely  lasts  over  two  wrecks.  The  yellow 
hue  of  the  skin  is  often  very  deep;  yet  the  child  does  not 
suffer,  and  has  no  febrile  excitement.  The  bowels  are  consti- 
pated, but  the  stools  are  not  necessarily  altered  in  their  color, 
nor  do  they  usually  present  the  clayey  look  which  might  be 
expected  from  the  aspect  of  the  skin  and  conjunctiva.  The 
origin  of  the  jaundice  is  very  obscure.  It  was  attributed  by 
Frank  to  a  stoppage  of  the  choledoch  duct  by  meconium. 
Dr.  West  states  that  it  is  most  frequently  observed  in  children 
prematurely  born. 

The  prognosis  of  jaundice  depends  upon  its  cause.  In  gen- 
eral terms,  we  may  say  that,  if  the  icterus  last  upwards  of  two 
months,  it  is  always  a  matter  of  some  danger,  as  showing,  in 
all  likelihood,  an  organic  lesion  of  the  liver  or  biliary  passages. 
If  the  discoloration  of  the  skin  be  attended  with  cerebral 
symptoms,  the  patient's  state  is  precarious.  Icterus  accom- 
panying affections  of  the  blood,  peritonitis,  or  pneumonia  is 
an  unfavorable  sign  ;  so  is  a  very  dark  color  of  the  skin.  In- 
deed, cases  of  "green"  or  "black"  jaundice  generally  prove 
fatal. 

The  treatment  of  jaundice  turns  upon  the  condition  of  the 
liver  to  which  it  may  be  owing.  Still,  although  in  accord- 
ance with  this  view  the  indications  for  treatment  are  drawn 
rather  from  our  recognition  of  the  source  of  the  icterus,  and 
although   we  ought  to  be  on  our  guard  against  treating  a 


DISEASES    OF    THE    LIVER. 


529 


83'mptom  instead  of  the  primary  cause  of  that  symptom, 
yet  tliere  are  certain  general  indications  whicli  are  con- 
stantly recurring:,  and  of  which  we  must  not  in  any  case  lose 
sight. 

One  of  these  is  to  increase  the  action  of  the  skin ;  another 
to  keep  up  the  action  of  the  kidneys ;  a  third  indication  is 
to  stimulate  the  bowels  to  free  action. 

Before  examining  the  hepatic  maladies  according  to  their 
clinical  features,  let  us  look  at  their  pathological  classifi- 
cation : 


Diseases  of 
hepatic- 
parenchy- 
ma. 


Diseases   of 
biliary  1 
passages. 


Diseases  of 
blood-ves- 
sels. 


Diseases  of  the 
Hypersemia 


Inflammation  and  its  conse- 
quences   


Atrophy 

Hypertrophy 


Degeneration  and  new  for- 


mations . 


Inflammation  of  gall-bladder 
and  gall-ducts 

Occlusion  of  biliary  pas- 
sages. 

Dilatation  of  gall-bladder. 

Morbid  growths. 

Foreign  bodies ;  concretions, 
such  as  gall-stones. 

Of  hepatic  artery. 

Of  hepatic  vein. 


Liver. 

/  Acute  congestion. 
I  Chronic  congestion. 
'  Acute  hepatitis. 

Chronic  hepatitis. 

Interstitial     inflammation,    or 
cirrhosis. 

Abscess. 

Softening. 
-  Syphilitic  hepatitis. 
r  Acute  or  yellow,  with  suppres- 
sion of  function  of  liver. 
L  Simple  chronic  atrophy. 
f  Partial. 
L  General. 

Fatty  liver. 

AVaxy  liver. 

Pigment  liver. 

Cancer. 

Hydatids. 
,  Tubercle,  etc. 

Catarrhal. 

E.xudative. 

Suj)purutive. 


Of  portal  vein., 


Suppurative  inflammation. 
Coagulation  of  blood. 


34 


530  MEDICAL    DIAGNOSIS. 


Acute  Diseases  of  the  Liver  attended  generally  with  slight 
Enlargement  of  the  Organ,  and  with  more  or  less,  though 
rarely  very  much,  Jaundice. 

Acute  Congestion. — This  arises,  like  chronic  hyper?emia, 
from  organic  disease  of  the  heart,  from  obstructed  portal  cir- 
culation, from  disturbed  digestion,  or  from  malarial  poison  ; 
sometimes  it  is  caused  by  a  high  temperature,  bj^  a  blow  on 
the  hepatic  region,  or  by  arrest  of  the  menstrual  flow.  The 
acute  congestion  is  characterized  by  pain  in  the  right  shoulder 
and  loin,  by  an  unpleasant  sensation  of  weight  and  of  tension 
in  the  right  hypochondrium,  and  by  nausea  and  vomiting. 
At  the  same  time  the  action  of  the  bowels  is  deranged,  being 
generally  too  frequent ;  the  tongue  is  coated;  there  is  depres- 
sion of  spirits,  with  loss  of  appetite  and  of  strength;  and  the 
liver  is  enlarged.  But  we  lind  ordinarily  only  slight  jaundice, 
and  there  is  no  fever.  Gradually  these  signs  disappear;  the 
increased  hepatic  dulness,  however,  remaining  for  some  time 
after  the  gastric  and  intestinal  disturbances  have  abated. 
ISTot  unfrequently  the  acute  disorder  passes  by  imperceptible 
degrees  into  a  chronic  state. 

Acute  Hepatitis. — The  symptoms  of  this  afi:ection  are 
much  the  same  as  those  of  acute  congestion,  excepting  that 
we  observe  more  thirst,  greater  gastric  irritabilit}',  a  more 
embarrassed  respiration,  heat  of  surface,  dry  cough,  and  in 
some  cases  an  accelerated  pulse,  enlargement  of  the  spleen, 
and  albumen  in  the  urine.  The  pain  is  dull,  and  associated 
with  a  feeling  of  tension  in  the  hypochondrium.  It  is  some- 
what increased  on  pressure,  but  not  much  so,  unless  the  peri- 
toneal covering  of  the  liver  be  involved.  Jaundice  is  not 
generally  very  marked  ;  indeed,  at  the  commencement  of 
the  disease  it  is  often  absent. 

Acute  hepatitis  is  very  common  in  liot  countries,  and 
many  of  the  cases  are  found  to  be  connected  with  dysentery. 
It  may  end  in  resolution  ;  but  the  inflammation  often  termi- 
nates in  suppuration,  and  pus  collects  in  the  substance  of 
the  liver.  The  occurrence  of  this  untoward  event  is  indi- 
cated by  recurring  rigors,  by  cold  and  clammy  perspirations, 


DISEASES    OF    THE    LIVER.  531 

by  prostration,  and  loss  of  flesh.  Not  unfrequently,  too,  a 
decided  fulness  of  the  side  may  be  noticed,  and  occasionally 
careful  palpation  detects  deep-seated  fluctuation.  After  an 
abscess  has  formed,  the  danger  is  very  great.  The  patient 
is  apt  to  perish  from  peritonitis  or  from  blood-poisoning; 
delirium,  singultus,  and  meteorism  preceding  the  fatal  issue. 
Yet  recovery  may  take  place.  The  matter  may  be  discharged 
through  the  abdominal  walls,  or  burst  into  the  intestine,  or 
find  its  way  through  the  diaphragm  into  the  pleural  cavity, 
to  be  discharged  through  the  lung.  But  as  the  phenomena 
of  abscess  of  the  liver  following  acute  inflammation  are  the 
same  as  when  the  collection  of  pus  is  consequent  upon  other 
morbid  states,  we  shall  not  here  indicate  what  we  shall  have 
presently  more  fully  to  consider. 

Let  us  now  examine  the  maladies  with  which  acute  inflam- 
mation of  the  liver  may  be  confounded,  premising  the  state- 
ment that,  making  allowance  for  the  febrile  phenomena  and 
the  other  slight  signs  of  difl'erence  just  indicated  between 
hepatic  inflammation  and  hepatic  congestion,  the  same  re- 
marks will  apply  to  the  distinction  between  this  morbid  con- 
dition and  the  afiections  about  to  be  mentioned.  The  com- 
plaints resembling  acute  hepatitis  are  : 

Perihepatitis  ; 

Inflammation  of  the  Portal  Veins; 

Pigment  Liver  ; 

Chronic  Hepatic  Diseases  with  Acute  Symptoms  ; 

Acute  Non-hepatic  Diseases  with  Jaundice; 

Diaphragmatic  Pleurisy; 

Inflammation  of  the  Biliary  Passages; 

Acute  Yellow  Atrophy. 

Perihepatitis. — Inflammation  of  the  serous  covering  of  the 
liver,  limited  to  this  covering,  or  spreading  perhaps  here 
and  there  to  the  most  superficial  portions  of  the  structure  of 
the  gland,  is  not  a  very  frequent  disease.  It  is  generally 
caused  by  the  extension  of  inflammation  from  organs  ad- 
jacent to  the  liver, — as  for  instance  from  the  stomach,  intes- 
tines, diaphragm,  or  pleura, — and  may  therefore  be  looked 
upon  as  a  local  peritonitis  ;  or  it  is  an  attendant  upon  disease 
of  the  liver  itself.     In  the  latter  case,  it  presents  no  peculiar 


532  MEDICAL    DIAGNOSIS. 

symptoms,  excepting,  perhaps,  tliat  it  adds  tenderness  to  tlie 
signs  of  the  hepatic  nuihidy  it  complicates.  In  the  former 
case  it  is  more  likely  to  be  confounded  with  acute  inflamma- 
tion of  the  liver  texture,  yet  the  far  greater  tenderness,  the 
pain  upon  motion  or  deep  inspiration,  the  perfectly  normal 
size  of  the  gland,  the  evidences  of  a  disease  in  the  neighbor- 
hood of  the  liver  which  is  likely  to  have  caused  the  malady, 
the  absence  of  jaundice  and  of  splenic  enlargement,  and  the 
sliglit  fever,  distinguish  the  perihepatic  inflammation  from 
true  liepatitis. 

Inflammation  of  the  Portal  Veins. — An  inflammation  of  the 
portal  veins,  terminating  in  suppuration,  is  very  liable  to  be 
mistaken  for  acute  inflammation  of  the  liver.  Nor  are  there 
in  truth  any  positive  symptoms  by  which  we  can  discriminate 
between  the  two  maladies.  Still,  we  may  sometimes  suspect 
that  the  veins  are  the  seat  of  inflammation,  rather  than  the 
structure  of  the  liver,  if,  with  the  signs  of  acute  and  painful 
enlargement  of  the  organ,  we  find  jaundice,  thin  and  copious 
stools,  recurring  chills  and  profuse  sweats,  emaciation,  in- 
crease in  size  of  the  spleen,  without  any  apparent  fluctuation 
or  other  signs  of  a  hepatic  abscess;  if  there  exist  pains  between 
the  ensiform  cartilage  and  umbilicus,  or  in  the  epigastrium 
or  right  hypochondrium,  or  shooting  to  the  lumbar  and  sacral 
regions ;  if  following  these  symptoms  appear  striking  evi- 
dences of  hectic  fever,  or  peritonitis;  and  if  these  phenomena 
are  encountered  in  a  person  who,  on  account  of  a  previous 
aflection  of  the  intestines  or  spleen,  or  any  other  organ 
having  a  direct  venous  connection  with  the  portal  circulation, 
is  liable  to  disease  of  the  portal  system.  Enlargement  of  the 
spleen  is  a  very  constant  feature  of  impediment  in  the  portal 
vein,  whether  from  inflammation  or  thrombosis. 

Pigment  Liver. — "  In  individuals  who  die  from  the  effects 
of  marsh  poison,  under  symptoms  of  severe  intermittent, 
remittent,  or  continued  fevers,  we  frequently  find  peculiar 
changes  of  the  liver  associated  with  functional  derangements 
of  the  organ,  and  of  the  parts  pertaining  to  the  portal  system. 
The  liver  presents  a  steel-gra^-,  or  blackish,  or  not  un fre- 
quently a  chocolate  color  ;  brown  insulated  figures  are  ob- 
served upon  a  dark  ground.     This  change  of  color  is  pro- 


DISEASES  OF  THE  LIVER.  533 

duced  by  pigment  matter  which  is  acenmulated  in  the 
vascular  apparatus  of  the  ghind."  So  says  Frerichs,  the 
observer  who  has  most  carefully  described  the  pigment 
liver.* 

But  the  liver  is  not  the  only  organ  implicated  in  the  mor- 
bid process:  the  spleen  is  commonly  affected;  the  blood 
becomes  watery,  its  corpu^^cles  are  broken  down,  and  it  con- 
tains large  quantities  of  pigment;  and  pigment  accumulates 
in  the  kidneys  or  brain.  ISTow,  the  effect  of  all  this  is  to 
occasion  marked  symptoms,  besides  those  referable  to  the 
derangement  of  the  liver;  for  it  is  not  unusual  to  find  grave 
cerebral  disturbance,  albuminuria,  hemorrhage  from  the  in- 
testines, profuse  diarrhoea,  and  enlargement  of  the  spleen. 
Irrespective  of  these  manifestations,  we  must  note  the  sin- 
gular ash,  or  grayish-yellow  color  of  the  skin,  the  evident 
hydri^emia,  and  the  very  great  amount  of  pigment  which  is 
readily  detected  in  even  a  few  drops  of  the  blood.  The 
fever  that  accompanies  the  morbid  condition  is  of  an  inter- 
mittent type;  the  pulse  is  not,  as  a  rule,  much  accelerated, 
and  the  jaundice  is  generally  slight.  In  India  pigmentary 
degeneration  of  the  liver  tends  to  suppurative  hepatitis.f 

When  we  contrast  the  phenomena  described  with  those  of 
acute  hepatitis,  we  see  at  once  the  difference.  The  fever,  the 
aspect  of  the  patient,  the  blood  full  of  dark  pigment,  and  the 
frequency  of  cerebral  symptoms  are  entirely  unlike  the  indi- 
cations of  acute  hepatic  inflammation. 

Chronic  Hepatic  Diseases  y-ifh  Acute  Symptoms. — We  occa- 
sionally meet  patients  who,  when  they  first  present  themselves 
to  us,  seem  to  be  laboring  under  an  acute  affection  of  the 
liver,  either  some  form  of  acute  inflammation  of  the  liver 
structure  or  the  biliary  passages,  or  acute  congestion  of  the 
liver;  but  in  whom  the  acute  symptoms  have  merely  super- 
vened upon  a  chronic  complaint.  Such  cases  are  very  puz- 
zling; it  may  be  indeed  impossible  to  arrive  immediately  at 
their  solution,  and  we  have  to  wait  until  the  acute  symptoms 
subside,   before    the    diagnosis  is  determined.     Sometimes, 


*  Treatise  on  Diseases  of  the  Liver,  vol.  i. 
f  Aitken's  Pract.  of  Medicine,  vol.  ii. 


534  MEDICAL   DIAGNOSIS. 

however,  an  accurate  inquiry  into  the  history  of  the  affection 
will  lead  to  a  knowledge  of  the  real  condition — still,  far  from 
always ;  for  the  malady  may  have  been  latent  and  scarcely 
attracted  the  patient's  attention.  In  hepatic  cancer,  as  an 
example  presently  to  be  mentioned  will  show,  the  sudden 
and  rapid  development  of  the  malady  amid  the  signs  of  acute 
congestion  is  not  very  uncommon.  Occasionally  the  peculiar 
physical  phenomena  of  individual  hepatic  diseases,  such  as 
the  nodular  tumors  of  a  malignant  growth,  or  the  fluctuation 
of  a  hydatid  cyst,  will  assist  materially  in  the  diagnosis. 

Acute  Non-hepatic  Diseases  with  Jaundice. — As  we  have  al- 
ready observed,  while  treating  of  jaundice,  there  are  many 
acute  affections,  such  as  pneumonia,  pyaemia,  puerperal  fever, 
and  some  forms  of  poisoning,  in  which  jaundice  may  coincide 
with  febrile  sj^mptoms,  and  excite  suspicions  of  acute  hepa- 
titis, or,  at  all  events,  of  an  extreme  degree  of  acute  hepatic 
congestion.  But  the  yellowness  of  the  skin  which  may  at- 
tend the  non-hepatic  disorders  mentioned  is  accompanied  by 
symptoms  so  different  from  those  connected  with  the  jaundice 
of  acute  inflammation  of  the  liver,  that  a  mistake  is  not  likely 
to  arise  if  the  history  of  the  case  be  taken  into  account,  and 
other  viscera  besides  the  liver  be  explored,  A  careful  exam- 
ination will  therefore  prevent  a  serious  error. 

Diaphragmatic  Pleurisy. — The  manifestations  of  inflamma- 
tion of  the  pleural  covering  of  the  diaphragm  are  in  several 
respects  similar  to  those  of  inflammation  of  the  liver.  We 
find,  for  instance,  pain  in  the  right  hypochondrium,  nausea 
and  vomiting,  cough  and  embarrassed  respiration,  occasion- 
ally jaundice — much  the  same  symptoms  which  we  observe 
in  hepatitis,  especially  if  the  serous  envelope  of  the  liver  be 
at  the  same  time  implicated.  But  the  pain  in  diapbragmatie 
pleurisy  is  greater,  more  suddenly  developed,  and  is  much 
more  aggravated  by  movements  and  by  full  inspiration  ;  the 
difliculty  in  breathing  amounts  to  orthopnoea;  we  frequently 
encounter  hiccough  and  great  anxiety,  sometimes  a  sardonic 
grin  on  the  features,  and  the  cough  comes  on  in  paroxysms. 
And  although,  as  a  case  recorded  by  Andral*  proves,  there 

*  Clinique  Modioale,  tome  ii. 


I 


DISEASES    OF    THE    LIVER.  535 

may  be  jaundice ;  yet  this  is  in  reality  so  very  generally  want- 
ing, as  scarcely  to  belong  to  the  symptoms  of  diaphragmatic 
pleurisy.  Then  in  this  complaint  we  may  find  friction  sounds, 
— though  the  physical  signs  will  not  always  aid  us,  being,  as 
the  febrile  excitement  is,  often  but  slight  and  uncertain.* 

Inflammation  of  the  Biliary  Passages;  Acute  Yellow  Atrophy. — 
Both  of  these  maladies  may  be  readily  confounded  with  he- 
patitis. But  the  former,  although  presenting  more  jaundice 
than  the  other  maladies  of  the  group  now  under  discussion, 
is  otherwise  so  similar  that  it  mny  be  classed  with  tliem,  and 
will  be  described  as  one  of  the  main  affections  of  this  group; 
the  other  belongs  clinically  to  a  different  section — namely, 
among  diseases  characterized  by  decrease  in  size  of  the  liver, 
and  it  is  there  that  we  shall  point  out  its  differences  from 
acute  hepatitis. 

Inflammation  of  the  Gall-bladder  and  Gall  Ducts. — 

Intianimation,  when  it  attacks  the  biliary  passages,  is  most 
apt  to  affect  the  gall-bladder  and  the  ductus  choledochus. 
Yery  frequently  the  morbid  process  is  propagated  from  the 
stomach  or  intestines  to  the  common  duct,  and  nausea,  furred 
tongue,  a  feeling  of  weight  in  the  epigastrium,  and  diarrhoea 
occur  previously  to  the  discoloration  of  the  feces,  the  jaun- 
dice, the  increased  hepatic  dulness,  and  the  very  slight  ten- 
derness on  pressure  in  the  right  hypochondrinm  ;  in  other 
words,  the  symptoms  of  gastric  or  gastro-intestinal  catarrh 
precede  those  of  "icterus  catarrhalis," — by  far  the  most 
common  form  of  inflammation  of  the  gall-bUidder ;  for  sup- 
purative inflammation  is  very  rare. 

]S"ow,  this  icterus  catarrhalis  is  generally  a  very  tractal^le 
disorder;  and  after  continuing  for  two  or  three  weeks,  it 
usually  subsides.  But  it  may  last  for  as  many  months  ;  and 
in  rare  insfances  the  inflammation  leads  to  an  occlusion  of 
the  bile  ducts,  and  to  a  fatal  issue.  I  had  such  a  case  in  1863 
under  my  charge  at  the  Philadelphia  Hospital.  The  patient, 
a  man  upwards  of  sixty  years  of  age,  died  deeply  jaundiced 
and  comatose.  He  had  presented,  during  life,  the  signs  of 
enlargement  of  the  liver;    little  or    no   tenderness    in    the 


*  Cases  by  Habershon,  Guy's  Hospital  Reports,  1869. 


536  MEDICAL    DIAGNOSIS. 

hepatic  region;  no  fever;  but  raucli  gastric  irritability  and 
obstinate  constipation,  both  of  which  had  existed  for  three 
weeks  prior  to  a  noticeable  discoloration  of  the  skin.  The 
whole  disease  was,  so  far  as  could  be  ascertained,  of  only  two 
months'  duration  ;  and  the  jaundice  steadily  deepened  from 
the  time  of  its  first  appearance.  At  the  autopsy,  the  gall- 
bladder was  found  enormously  distended,  its  coats  thin,  yet 
otherwise  scarcely  abnormal ;  but  the  common  duct  was  ob- 
literated by  inflammation.  The  stomach  and  upper  bowel 
were  congested,  while  the  coats  of  the  stomach  toward  the 
pylorus  were  thickened. 

Now,  in  point  of  diagnosis,  it  is  not  generally  difficult  to 
distins^uish  the  catarrhal  inflammation  of  the  o-all-bladder, 
excepting  in  those  rare  instances  in  which  the  common  duct 
or  the  hepatic  duct  is  obliterated.  It  difters  from  hepatic 
inflammation  chiefly  by  the  absence  of  fever  and  of  grave 
constitutional  disturbance ;  from  the  ordinary  congestion  of 
the  liver,  by  the  diff'erent  etiological  elements  in  the  history 
of  the  case, — the  one  disorder  occurring  most  commonly  in 
connection  with  disease  of  the  heart  or  an  obstruction  of 
the  portal  circulation,  or  a  miasmatic  poison  ;  the  other  fol- 
lowing most  usually  exposure  to  cold  and  damp.  Then,  in- 
flammation of  the  gall  ducts  gives  rise  to  very  much  more 
jaundice.  Further,  we  must  not  forget  that  what  is  called 
congestion  is  often  really  the  disease  we  are  discussing. 

From  the  jaundice  of  chronic  hepatic  maladies — such  as 
cancer  or  cirrhosis — we  separate  catarrhal  icterus  by  the  non- 
existence of  the  significant  physical  signs  of  these  maladies, 
by  its  acute  course,  and  by  the  dissimilar  progress  of  the 
symptoms.  Inflammation  of  the  biliary  passages,  and  the 
jaundice  arising  in  consequence  of  biliary  calculi,  are  dis- 
tinguished by  the  severe  pain,  the  sudden  appearance  of  the 
icterus  subsequent  to  the  paroxysms  of  pain,  its  increase 
after  such  paroxysms,  and  its  often  rapid  fading  after  the 
gall-stone  is  voided.  The  symptoms  of  the  early  stages  of 
acute  atrophy  of  the  liver,  as  well  as  those  of  some  cases  of 
acute  inflammation,  may  be  so  like  the  phenomena  of  in- 
flammation of  the  o^all-bladder  and  s^all  ducts,  that  their  dis- 
crimination  is  for  a  time  impossible. 


DISEASES    OF    THE    LIVER.  537 

Acute  Diseases  characterized  by  a  Decrease  in  the  Size  of 
the  Liver  and  by  Deep  Jaundice. 

Acute  Yellow  Atrophy. — This  dangerous  affection  con- 
sists in  a  rapid  diminution  in  size  of  the  liver,  with  changes 
in  its  secreting  cells,  amounting  often  to  their  complete  dis- 
integration. The  functions  of  the  liver  are,  in  consequence, 
almost  wholly  suspended,  and  the  evil  effects  of  the  accumu- 
lation of  the  elements  of  the  bile  in  the  blood  show  them- 
selves plainly  in  the  deep  jaundice,  and  the  profound  disturb- 
ance of  the  nervous  system.  To  this  disease  belong  most  of 
those  cases  of  malignant  jaundice  which  terminate  rapidly  in 
death  after  violent  cerebral  symptoms.  The  malady  scarcely 
ever  lasts  a  week ;  generally  a  few  days  only  elapse  before 
the  patient  becomes  comatose  and  dies. 

The  complaint  is  sometimes  ushered  in  by  nausea,  a 
coated  tongue,  irregular  action  of  the  bowels,  a  frequent 
pulse;  at  other  times  it  begins  abruptly  with  pain  in  the 
head,  and  vomiting,  at  first  of  the  contents  of  the  stomach, 
but  soon  of  coffee-ground  material,  which  is  evidently  altered 
blood.  The  skin  is  of  a  deep  yellow,  and  becomes  from  hour 
to  hour  more  intensely  discolored.  Jaundice  is,  indeed, 
never  absent:  it  may  not  make  its  appearance  before  the 
other  urgent  symptoms;  but  sometimes  it  precedes  the 
sign-s  of  serious  trouble  for  several  days,  or  even  for  longer — 
perhaps  for  upwards  of  two  weeks.*  There  are  not  uncom- 
monly pain  in  the  hepatic  region,  raeteorism,  enlargement  of 
the  spleen,  and  hemorrhage  from  the  bowels.  The  pulse 
exhihits  extraordinary  changes:  it  is  generally  very  rapid, 
but  sinks  at  times,  without  anv  assiornable  reason,  to  a  nor- 
mal  frequency;  during  the  deep  coma  of  the  last  stages  of 
the  malady,  the  beat  of  the  artery  is  apt  to  become  slow  and 
full,  but  it  may  be  very  quick  and  very  small.  There  is 
fever,  generally,  however,  not  very  active  or  presenting  a 
marked  rise  in  the  temperature ;  and  the  surface  may  be 
covered  with  petechiis,  on  account  of  the  progressing  dis- 


*  As  in  Observation  ISTo.  XVII.  of  Frerichs'  Treatise  on  Diseases  of  the 
Liver,  vol.  i.  p.  214,  Sydenham  Society's  Transl. 


538  MEDICAL    DIAGNOSIS. 

solution  of  the  blood.  But  if  we  except  perhaps  the  deep 
jaundice,  the  most  significant  symptoms  are  those  referable 
to  the  nervous  sj'stem.  Severe  headache,  delirium,  tremors, 
spasms,  or  a  constantly-increasing  stupor  and  sluggish  pujjils 
are  the  phenomena  which  show  clearly  what  disturbance  the 
poisoned  blood  is  creating  in  the  nervous  centres. 

Now,  how  does  this  fatal  malady  differ  from  acute  inflam- 
mation of  the  liver?  By  the  marked  jaundice,  the  cerebral 
symptoms,  the  rapid  diminution  in  the  volume  of  the  liver, 
the  frequent  pulse,  and  the  occurrence  of  hemorrhages. 
Then,  the  circumstances  under  which  acute  atrophy  makes 
its  appearance  are  very  dissimilar :  we  And  it  not  unusually 
following  violent  mental  emotions  or  excesses;  or  it  occurs 
during  pregnancy,  and  is  then  accompanied  by  renal  dis- 
order. 

Indeed,  the  diagnosis  is  not  generally  a  difficult  one  ;  not 
nearly  so  difficult  as  between  acute  atrophy  and  typhoid 
fever,  or  between  the  former  affection  and  yellow  fever  or 
certain  local  diseases,  such  as  peritonitis,  pneumonia,  and 
meningitis,  when  accompanied  by  jaundice  and  delirium. 
The  character  of  the  eruption,  the  presence  of  diarrhoea 
instead  of  constipation,  the  milder  nature  of  the  mental  wan- 
dering, and  the  slower  progress  of  the  disease  are  of  much 
value  in  enablino;ns  to  distino^uish  between  enteric  fever  and 
acute  yellow  atrophy  of  the  liver.  From  yellow  fever,  acute 
atrophy  differs  by  the  epidemic  character  of  the  former  and 
the  difi'erent  circumstances  under  which  it  arises,  by  the  in- 
tense pain  in  the  back,  limbs,  and  forehead,  the  stages  the 
febrile  malady  presents,  the  high  fever  temperature,  tiie  com- 
parative absence  of  cerebral  symptoms,  and  the  enlargement 
rather  than  the  atrophy  of  the  liver. 

From  the  other  affections  named,  the  hepatic  disorder 
may  be  discriminated  by  a  thorough  examination  of  the 
various  organs  of  the  body,  and  by  a  careful  weighing  of  all 
the  symptoms.  In  truth,  it  is  thus  only  that  we  can  avoid 
error  in  diagnosis,  since,  unless  we  can  establish  satisfac- 
torily the  most  positive  sign  of  acute  atrophy — the  diminu- 
tion of  the  percussion  dulncss  corresponding  to  the  wasting 
of  the  liver — there  is  hardly  a  manifestation  of  the  hepatic 


DISEASES    OF    THE    LIVER.  539 

malady  so  exclusive  that  it  may  not  occur  in  the  diseases 
mentioned,  when  these  are  complicated  by  jaundice.  It  is 
true  that  vomiting  of  blood  is  scarcely  among  their  symp- 
toms; but  this  does  not  invariably  happen  in  acute  atrophy. 
In  many  cases  of  doubt  we  may  turn  to  account  the  re- 
searches of  Frerichs  on  the  character  of  tlie  urine  in  this 
complaint,  and  seek  in  the  urinary  secretion  for  the  deposi- 
tion of  sediments  of  tyrosine  or  for  leucin ;  and  test  for  the 
urea,  which  is  greatly  deficient  or  absent.  We  may  in  this 
connection  remark  that  leucin  and  tyrosine  have  also  been 
found  in  the  blood  and  in  many  tissues  of  the  bod3\  This 
happened  in  a  case  which  I  saw  with  Dr.  II.  C.  Wood,  and 
which  he  has  fully  and  carefully  reported.* 

The  occurrence  of  the  fatal  malady  in  pregnant  women  has 
already  been  alluded  to.  jS"ow,  jaundice  from  mental  emo- 
tion, or  produced  by  the  pressure  of  the  gravid  womb,  is  in 
them  not  unusual ;  and  we  may  be  called  upon  to  distinguish 
this  simple  and  harmless  form  of  icterus  from  that  of  yellow 
atrophy.  In  the  serious  derangement  of  the  nervous  system, 
and  the  graver  character  of  all  the  symptoms,  lie  the  marks 
of  separation. 

Chronic  Diseases  attended  with  Enlargement  of  the  Liver, 
and  with  slight  or  no  Jaundice. 

Chronic  Congestion. — This  morbid  condition  is  observed 
chietly  in  persons  of  sedentary  habits,  who  indulge  too  freely 
in  the  pleasures  of  the  table,  in  those  who  use  large  quan- 
tities of  alcoholic  drinks  or  fermented  liquors,  and  is  very 
frequently  met  with  in  hot  climates  and  in  malarial  districts. 
It  may  also  occur  in  scurvy,  and  in  connection  with  abdomi- 
nal affections  which  interfere  with  the  portal  circulation,  and 
thus  produce  a  fulness  of  the  blood-vessels  of  the  liver  ;  or  it 
may  happen  in  consequence  of  a  disturbance  of  the  flow  of 
blood  through  the  liver,  dependent  upon  disease  of  the  heart. 

Whatever  the  source  of  the  hypenemia,  the  symptoms  are 
very  similar.  They  are  usually  an  impaired  appetite,  a  coated 
tongue,  a  feeling  of  tension  and  weight  in  the  right  hypo- 

*  Amer.  Journ.  of  Med.  Sciences,  April,  1867. 


540  MEDICAL    DIAGNOSIS. 

chondrinm,  depression  of  spirits,  loss  of  strength,  and  occa- 
sional nausea  and  diarrhoea,  or  looseness  of  the  bowels  alter- 
nating with  constipation.  The  conjunctiva  has  constantly  a 
more  or  less  jaundiced  tinge ;  the  dulness  on  percussion  in 
the  hepatic  region  is  increased  in  extent.  In  some  cases,  the 
habitual  congestion  leads  to  an  altered  condition  of  the  hile 
ducts  and  of  the  secretins:  cells  of  the  liver;  hut  ordinarilv, 
unless  the  hypergemia  he  kept  up  by  some  exciting  cause 
which  it  is  impossible  to  remedy — such  as  an  abdominal  tu- 
mor, or  an  organic  affection  of  the  heart — w^e  can,  by  a  care- 
fully regulated  diet  and  by  active  exercise  in  the  open  air, 
together  with  the  use  of  laxatives,  restrain  the  congestion, 
and,  indeed,  in  time  remove  it.  A  very  troublesome  feature, 
however,  of  the  malady  is  its  disposition  to  return. 

By  attention  to  the  signs  mentioned,  there  is  usuall}-  little 
difficulty  in  recognizing  chronic  hepatic  congestion.  How  it 
may  be  discriminated  from  other  forms  of  enlargement  of  the 
liver,  we  shall  presently  inquire.  It  is  sometimes  confounded 
with,  or  rather  there  is  sometimes  mistaken  for  it,  a  liver 
which  has  been  pushed  downward  by  the  habit  of  tight  lacing. 
But  the  absence  of  any  signs  of  hepatic  derangement,  and  the 
lowered  outline  of  the  upper  border  of  the  displaced  right 
lobe,  will  generally  enable  us  to  distinguish  this  state  from 
chronic  congestion  of  the  liver. 

Chronic  hepatic  congestion,  as  indeed  any  disease  of  the 
liver  which  leads  to  its  enlargement,  may  be  confounded 
with  chronic  gastritis;  and  on  account  mainly  of  the  fulness 
in  the  epigastric  region  which  may  happen  in  the  hepatic 
malady,  and  which  is  so  constant  in  the  gastric  affection.  The 
error  is  particularly  likely  to  occur  in  those  cases  of  enlarged 
liver  in  which  there  is  pain  on  pressure.  But  the  outline  of 
the  dulness  when  the  liver  is  increased  in  size,  the  jaundiced 
hue  of  the  conjunctiva,  the  altered  character  of  the  stools,  and, 
on  the  other  hand,  the  more  marked  indigestion  and  the  ful- 
ness and  tenderness  being  equally  perceived  in  positions  to 
which  the  liver,  unless  very  greatly  augmented,  does  not  ex- 
tend, will  ordinarily  enable  us  to  arrive  at  a  correct  diag- 
nosis. Yet  in  attempting  to  do  so  we  must  not  forget  that 
the  two  morbid  states  may  be  conjoined. 


DISEASES    OP    THE    LIVER.  541 

Hypertrophy  of  the  liver,  it  is  believed,  may  present  at 
times  the  manifestations  of  congestion.  The  little  we  know 
of  an  increased  formation  of  the  liver-cells,  teaches  us  that 
this  may  happen  as  a  partial  hypertrophy^  to  compensate  for 
loss  of  substance,  in  instances  in  which  a  portion  of  the  gland 
has  been  destroyed  ;  or  as  a  more  general  increased  growth 
in  diabetes,  in  leucocythsemia,  and  as  a  consequence  of  ma- 
laria. Perhaps  the  history  of  the  case  may  enable  us  to  arrive 
at  the  discrimination  of  the  rare  disease.  Yet  there  is  never 
any  certainty  in  the  diagnosis :  in  truth,  we  cannot  be  said  to 
possess  the  means  which  would  enable  us  at  the  bedside  to 
distinguish  hypertrophy  of  the  liver  from  other  forms  of 
hepatic  enlargement. 

Chronic  Hepatitis. — The  symptoms  of  this  malady  are 
very  obscure  ;  indeed,  it  is  difficult  to  say  Avhat  are  its  symp- 
toms, because  of  the  extreme  latitude  which  has  been  given 
to  the  term  chronic  hepatitis,  under  which  have  been  ranged 
most  of  the  chronic  aftections  of  the  organ — especially,  how- 
ever, the  waxy,  the  fatty,  the  congested,  and  the  cirrhotic 
liver.  If,  following  Andral,  we  call  only  that  state  chronic 
inflammation  in  which  the  liver  is  augmented  in  size,  harder 
than  natural,  yet  easily  torn,  of  deep-red  color,  and  in  which 
the  exudation  is  very  apt  to  become  purulent,  we  iind  these 
manifestations  :  dull,  heavy  pain  in  the  hepatic  region,  some- 
what augmented  by  pressure;  dry,  heated  skin,  of  sallow  hue, 
and  often  the  seat  of  distressing  itching;  a  yellowish  conjunc- 
tiva ;  indigestion;  whitish  stools,  generally  hard;  a  short 
cough ;  and  the  physical  signs  on  palpation  and  percussion  of 
an  enlarged  liver,  the  border  of  which  is  uniformly  thickened 
and  hardened. 

The  inflammation  may  be  chronic  in  its  course  almost  from 
its  onset,  and  be  developed  under  much  the  same  circum- 
stances as  chronic  congestion ;  or  it  may  succeed  to  an  attack 
of  acute  hepatitis.  But  chronic  hepatitis  is  not  a  commou 
disease,  excepting  in  hot  climates,  and  is  scarcely  to  be  dis- 
tinguished, with  any  certainty,  from  persistent  hypenemia  of 
the  organ,  unless  when  the  inflammation  leads  to  the  forma- 
tion of  abscesses. 

Abscess  of  the  Liver. — Hepatic    abscesses,  as  we  have 


542  MEDICAL    DIAGNOSIS. 

already  seen,  may  form  as  the  result  of  either  acute  or 
chronic  inflammation  of  the  liver.  In  the  tropics  this  is  not 
at  all  an  unusual  termination  of  the  inflammation;  in  tem- 
perate climates  we  seldom  encounter  the  atiection,  save  as 
the  consequence  of  metastatic  or  pyemic  inflammation  of  the 
liver,  or  in  connection  with  some  disease  of  the  intestines. 

The  symptoms  of  hepatic  abscess  are  very  obscure.  In 
pyaemia  the  collection  of  pus  may  take  place  in  the  liver 
without  causing  scarcely  any  phenomena  which  direct  atten- 
tion to  the  viscus.  In  the  other  forms  of  inflammation  of 
the  liver  which  produce  abscesses,  w^e  are  likely  to  have  the 
same  symptoms  as  in  acute  hepatitis,  excepting  that  the  for- 
mation of  pus  is  apt  to  give  rise  to  rigors,  to  quicken  the 
pulse  very  much,  to  lead  to  night-sweats,  and  not  unfre- 
quently  to  the  development  of  a  fever  simulating  that  of  a 
quotidian  or  tertian  intermittent. 

The  local  signs,  too,  are  far  from  being  always  very  ob- 
vious, or  indeed  uniform.  In  some  instances  the  hepatic 
region  is  more  prominent  than  natural,  and  we  can  detect 
fluctuations  over  portions  of  the  enlarged  gland;  but  neither 
sign  is  constant,  and  the  latter  depends  greatly  upon  whether 
or  not  the  abscess  be  deeply  seated  in  the  hepatic  paren- 
chyma. Tenderness,  either  general  or  limited  to  a  particular 
spot,  is  found  only  in  a  certain  proportion  of  cases.  It  is 
frequently  associated  with  a  throbbing  or  a  dull  pain,  which 
may  be  transmitted  to  the  right  shoulder.  According  to 
Annesle}^,*  this  sympathetic  pain  in  the  right  shoulder  in- 
dicates that  the  convex  part  of  the  right  lobe  of  the  viscus 
is  affected.  Conjoined  to  the  feeling  of  weight,  and  to  the 
throbbing  in  the  hepatic  region,  is  at  times  a  tension  occa- 
sioned by  palpation  of  the  abdominal  muscles,  especially  of 
the  rectus.  Twiningf  regards  this  circumstance  as  a  very 
significant  manifestation  of  deep-seated  abscess. 

But  a  positive  diagnosis  of  abscess  of  the  liver  is  often 
a  very  difficult  matter;  for  there  are  a  number  of  other 
affections  with  which  it  may  be  readily  confounded.     I'roin- 

*  Researches  into  the  Diseases  of  India, 
f  Dijcasos  of  Bengal. 


DISEASES    OF    THE    LIVER.  543 

inent  among  these  are  hydatids,  cancer  of  the  liver,  diseases 
of  the  gall-bhxdder,  and  a  pleuritic  etfasion  on  the  right  side. 

From  hydatids  of  the  liver,  the  febrile  symptoms,  the  dis- 
turbed nutrition,  and  the  pain  distinguish  a  hepatic  abscess, 
excepting  in  those  cases  in  which  the  cyst  becomes  the  seat 
of  suppuration.  Under  these  circumstances  error  can  scarcely 
be  avoided,  unless  we  are  fully  cognizant  of  the  history  of 
the  patient,  and  are  in  possession  of  facts  furnishing  clear 
evidence  as  to  the  state  of  the  liver  prior  to  the  formation 
of  pus. 

Cancer  of  the  liver  differs  from  an  abscess  by  its  dissimilar 
history,  by  the  hard  nodular  masses,  and  by  the  absence  of 
fluctuation.  It  is  only  in  rapidly  growing  medullary  cancer 
that  we  can  discern  a  sense  of  fluctuation  ;  but  even  here  Ave 
can  eenerallv  distino-uish  some  nodules  which  do  not  flue- 
tuate;  and  should  the  soft  cancerous  matter  impart  to  the 
finger  a  feeling  of  fluctuation,  it  is  very  rarely  as  distinct  as 
that  of  an  abscess.  Further,  the  marked  febrile  phenomena 
and  the  other  constitutional  symptoms  are  not  like  wdiat 
occur  in  hepatic  cancer. 

Of  the  diseases  of  the  gall-bladder,  the  one  which  is  most 
liable  to  be  confounded  with  hepatic  abscess  is  distention  of 
the  bladder.  This  occurs  either  from  a  closure  of  the  cystic 
or  common  duct,  especially  from  the  former,  or  from  an  in- 
flammation of  the  gall-bladder  itself,  and  perhaps  a  subse- 
quent closure  of  the  ducts.  In  such  a  case  the  gall-bladder 
may  become  enormously  distended  with  irritating  and  de- 
composing bile  and  puriform  matter,  and  thus  may  be  occa- 
sioned a  fluctuating  tumor,  tender  on  pressure,  and  readily 
mistaken  for  an  abscess. 

]!*[ow,  we  are  sometimes  able  to  distinguish  the  soft  swell- 
ing caused  by  a  diseased  gall-bladder  by  its  situation,  its 
pear-shaped  form,  its  mobility  and  absence  of  adhesions  to 
the  abdominal  walls,  its  distinct  and  persistent  fluctuations; 
by  its  never  having  been  hard;  by  the  normal  appearance  of 
tlie  parietes  of  the  abdomen  ;  by  the  non-existence  of  local 
oedema  and  redness;  and  by  the  fact  that  afl'ections  of  the 
gall-bladder  are  frequently  preceded  by  repeated  attacks  of 
violent  pain  due  to  the  passage  of  biliary  calculi,  or  by  bilious 


544  MEDICAL    DIAGNOSIS. 

fever.  Then  we  find  very  little  jaundice,  or  none  at  all ;  and 
no  hectic  fever.  But  to  neither  of  these  circumstances  can 
we  trust  implicitly.  For  there  is  apt  to  be  very  intense  jaun- 
dice in  an  affection  of  the  gall-bladder,  if  the  common  duct 
also  be  implicated;  and  jaundice  is,  in  abscess  of  the  liver, 
a  symptom  much  more  frequently  absent  than  present.  And 
with  reference  to  hectic  fever,  the  continued  suppuration  in 
the  distending  sac  may  produce  it,  and  lead,  indeed,  as  in  a 
case  reported  by  the  late  Dr.  Pepper,*  to  very  great  constitu- 
tional disturbance.  As  regards  the  shape  of  the  swelling, 
due  to  an  enlarged  gall-bladder  being  diagnostic,  we  must 
bear  in  mind  that  it  may  be  changed  by  contraction  of  the 
muscular  coat. 

A  plewitic  effusion  on  the  right  side  of  the  chest  is  distin- 
guished from  a  hepatic  abscess  by  the  same  phenomena  which 
we  found,  in  discussing  pleurisy,  to  separate  this  affection 
from  all  forms  of  enlargement  of  the  liver.  But  abscesses 
may  open  into  the  right  pleural  cavity.  Then  we  observe 
the  physical  signS'  of  a  pleuritic  effusion  subsequent  to 
those  of  hepatic  abscess.  Generall}',  too,  the  pus  which  has 
made  its  way  through  the  diaphragm  destroys  the  lung 
texture,  until  it  reaches  the  bronchial  tubes,  when  large 
quantities  of  purulent  sputa  are  expectorated ;  or,  in  rarer 
instances,  it  is  discharged  through  the  walls  of  the  chest.  In 
the  former  case,  the  disturbance  in  the  pleura,  and  the  accu- 
mulation of  pus  there,  may  be  very  limited :  the  inflamma- 
tion of  the  pleural  membrane  may  be  circumscribed,  while 
the  signs  of  an  inflammation  at  the  lower  portion  of  the  right 
lung,  dulness  on  percussion,  tubular  breathing,  rusty-colored 
sputa  are  very  evident.  These  j)henomena  may  subside,  and 
the  respiration  in  parts  become  inaudible,  when  a  discharge 
of  a  large  quantity  of  a  reddish  or  whitish  pus  takes  place, 
in  which  the  elements  of  bile,  and  the  microscopical  appear- 
ances of  the  hepatic  tissue  may  be  detected.  Gradually  this 
expectoration  ceases,  and  the  affected  textures  heal.  But  in 
some  instances  the  discharge  never  stops,  and  the  patient 
dies  worn  out  by  the  constant  drain  upon  his  strength. 


*  Ainericau  Journal  of  the  Medical  Sciences,  Jan.  1857. 


DISEASES    OF    THE    LIVER.  545 

When  the  abscess  forces  its  way  externaUy,  it  may,  prior  to 
its  discharge  through  the  thoracic  or  abdominal  walls,  occa- 
sion difficulty  in  diagnosis  as  regards  abscesses  originating 
in  these  walls.  Nothing  but  a  careful  consideration  of  the 
attending  symptoms  and  of  the  history  of  the  case  will  lead 
to  a  differential  distinction.  N"or  does  the  difficulty  wholly 
cease  when  the  slowly  developed  tumor,  which  a  hepatic  ab- 
scess forms,  has  opened,  since  it  is  far  from  always  that  we 
find  in  the  pus  the  evidences  of  the  broken-down  liver  tissue; 
and  it  is  only  occasionally  that  the  fluid  is  of  yellow  or  green- 
ish color  and  yields  the  reactions  of  bile.  The  means  of  dis- 
crimination most  to  be  relied  upon  is  a  probe,  for  by  the 
depth  to  which  it  can  be  passed,  the  direction  it  takes,  and 
the  feel  of  the  structures  it  encounters,  Ave  are  placed  in 
possession  of  many  important  facts  bearing  on  the  diagnosis. 
It  was  only  thus  that  in  a  case  under  my  charge  at  the  Penn- 
sylvania Hospital,  and  in  -which  the  symptoms  were  very  con- 
flicting, a  positive  diagnosis  could  be  reached. 

Fatty  Liver. — A  fatty  liver  occurs  in  drunkards  :  in  per- 
sons who  lead  indolent  lives  and  are  large  eaters;  in  wasting 
diseases,  especially  in  phthisis;  in  the  course  of  a  protracted 
diarrhoea;  and  sometimes  in  children  after  exanthematous 
fevers.  But  of  all  these  causes,  pulmonary  consumption  is 
the  most  common. 

I^Tow,  a  knowledge  of  the  sources  of  fatty  liver  is  the  most 
important  element  in  the  diagnosis ;  for  neither  the  physical 
signs  nor  the  symptoms  present  anything  which  is  really 
characteristic.  The  physical  signs  are  simply  those  of  an 
enlarged  liver.  The  symptoms  are  mnch  the  same  as  of 
hepatic  congestion,  excepting  that  there  is  perhaps  greater 
tendency  to  diarrhoea,  and  that  we  find,  in  some  instances,  a 
pale,  smooth,  greasy-feeling  skin.  The  amount  of  jaundice 
is  always  very  slight;  in  truth,  this  symptom  is  frequently 
w^inting.  And  partly  in  consequence  of  the  absence  of  this 
important  symptom  of  hepatic  affections,  and  partly  because 
of  the  little  appreciable  disturbance  a  fatty  liver  may  occa- 
sion, this  morbid  state,  especially  if  it  be  slight,  at  times 
escapes  our  observation  entirely. 

Waxy  Liver.— A  peculiar  infiltration  into  the  structure 

35 


54G  MEDICAL    DIAGNOSIS. 

of  the  liver,  or  its  degeneration  into  a  substance  rendering  it 
firmer  and  more  glistening,  gives  rise  to  tliat  appearance  of 
the  liver  which  is  variously  designated  as  waxy,  lardaceous, 
amyloid,  albuminous,  or  scrofulous  liver. 

The  symptoms  of  a  waxy  liver  are  those  of  a  hepatic  de- 
rangement which  manifests  itself  rather  by  the  signs  of  dis- 
turbances of  other  organs  than  by  the  direct  proof  of  altered 
function  of  the  viscus  really  affected.  Thus  disordered  diges- 
tion, nausea,  vomiting,  tympanites,  discolored  stools,  and 
diarrhoea  are  very  much  more  frequent  than  jaundice,  which, 
indeed,  is  infinitely  oftener  absent  than  present.  There  is  a 
feeling  of  fulness  in  the  hepatic  region,  but  little  or  no  pain; 
while  physical  exploration  exhibits  an  increased  percussion 
dulness,  and  shows  the  organ  to  have  a  well-defined  though 
somewhat  rounded  margin. 

Enlargement  of  the  spleen  very  commonly  coexists  with 
the  enlargement  of  the  liver,  and  in  many  cases  the  urine  is 
albuminous  from  waxy  disease  of  the  kidneys.  Dropsy,  as 
a  rule,  is  not  encountered ;  but  in  this  respect  much  depends 
upon  the  state  of  the  kidneys  and  of  the  blood. 

The  etiology  of  a  waxy  liver  teaches  us  that  it  is  more 
common  in  males  than  in  females;  that  the  malady  is  most 
usually  caused  by  constitutional  syphilis;  that  in  rarer  in- 
stances it  is  produced  by  the  tubercular  diathesis ;  also  that 
it  coexists  with  scrofulous  diseases  of  the  bones,  with  collec- 
tions of  pus  in  various  parts  of  the  body,  with  repeated  at- 
tacks of  intermittent  fever,  or  results,  perhaps,  from  the  abuse 
of  mercury.  In  some  cases  we  cannot  trace  the  pathological 
process  to  any  known  cause ;  yet  even  in  these  cases  we  find 
it  attended  with  signs  of  impaired  nutrition,  and  occurring 
in  persons  evidently  cachectic. 

N'ow,  when  we  contrast  a  waxy  liver  with  other  hepatic 
complaints  in  which  the  liver  is  enlarged,  we  find  it  resembling 
most  closely  the  fatty  and  the  syphilitic  affections.  But  in 
the  former  although  there  is  enlargement,  there  is  not  often 
so  much  increase  in  volume  as  in  the  waxy  liver.  Besides, 
the  organ  has  a  softer  feel  on  palpation,  and  the  disorder  is 
not  associated  with  a  diseased  spleen  or  kidney,  and  is  far  less 
likely  than  a  waxy  liver  to  give  rise  to  dropsy.     A  sypliilitic 


DISEASES    OF    THE    LIVER.  547 

hepatitis,  with  which  indeed  the  vinxy  liver  is  at  times  com- 
bined, is  raaiidy  distinguished  by  the  prominent  nodules  felt 
on  the  surface  of  the  liver,  and  which  result  from  syphilitic 
inflammation  of  the  organ. 

From  congestion  of  the  liver,  waxy  liver  is  readily  discrimi- 
nated. A  comparatively  slight  affection  in  which  jaundice 
is  frequent  is  very  different  from  a  grave  malady  in  which  the 
hepatic  disease  forms  but  part  of  a  general  cachexia,  and  in 
which  jaundice  is  very  infrequent. 

Cancer  of  the  Liver. — In  cancer  of  the  liver  the  size  of 
the  organ  is  almost  invariably  increased,  and  sometimes  it 
reaches  an  enormous  volume.  The  form  of  the  gland,  too, 
is  generally  altered.  It  is  irregular  and  uneven,  nodules  of 
various  size  being  developed  in  its  substance  and  projecting 
from  its  border  and  surfaces.  These  prominences  are  usually 
harder  than  the  surrounding  hepatic  tissue:  but  there  are 
exceptions  to  this  rule,  for  sometimes,  especially  in  the  en- 
cephaloid  variety  of  the  malady,  the  elastic  tumors  impart, 
when  pressed,  a  very  deceptive  sense  of  fluctuation.  The 
cancerous  masses  generally  increase,  and  in  some  cases  with 
great  rapidity. 

The  malignant  disease  is  rarely  confined  to  the  liver;  it 
frequently  supervenes  upon  cancer  of  the  mammary  gland  or 
of  the  uterus.  It  is  an  affection  pre-eminently  of  middle  life 
or  of  old  age;  yet  it  occasionally  occurs  in  young  persons.  I 
have  seen  two  cases  of  primary  cancer  of  the  liver  in  women 
not  twenty-five  years  of  age. 

Now,  many  of  the  pathological  facts  just  mentioned  have 
a  strong  bearing  on  the  diagnosis  of  hepatic  cancer.  They 
especially  throw  light  on  the  most  important  signs  of  the 
malady — to  wit,  the  increased  percussion  dulness  in  the  he- 
patic region,  and  the  uneven  surface  detected  on  palpation. 
The  enlarged  liver  is  found  extending  across  the  epigastrium 
far  into  the  left  hypochondrium ;  it  reaches  at  times  lower 
than  the  umbilicus,  and  presses  the  diaphragm  upward.  The 
nodules  can  often  be  felt  distinctly  through  the  abdominal 
walls.  The  diseased  organ  is  painful,  and  usually  tender  to 
the  touch.  In  cases  in  which  the  peritoneal  covering  is 
afiected,  the  tenderness  is  greatest.     And,  although  any  of 


548  MEDICAL   DIAGNOSIS. 

these  three  phenomena — the  enlargement,  the  uneven  surface, 
and  the  tenderness — may  be  absent,  they  are  tolerably  con- 
stant attendants  on  cancer  of  the  liver.  The  tenderness  is, 
I  think,  the  sign  least  frequently  wanting. 

Among  the  symptoms  of  hepatic  cancer,  we  find  gastric  and 
intestinal  disturbances,  pain  in  the  right  shoulder,  rigidity  of 
the  abdominal  muscles,  a  disordered  nutrition  of  the  whole 
body,  a  cachectic  look,  occasional  febrile  attacks,  and,  in  the 
latter  stages  of  the  disease,  sometimes  hemorrhages  from  the 
stomach  or  bowels,  and  diarrhoea.  Ascites,  too,  is  observed 
among  the  symptoms  of  the  malignant  malady,  and  is  gener- 
ally dependent  either  upon  chronic  peritonitis  attending  the 
development  of  the  cancer,  or  upon  the  pressure  this  exerts 
upon  the  larger  branches  of  the  portal  vein.  Jaundice  may 
or  may  not  be  present ;  it  is,  on  the  whole,  most  frequently 
wanting.  There  are  cases  in  which  all  these  symptoms  are 
perceived;  while  in  others  only  some,  in  others,  again,  even 
these  few  may  not  be  well  defined.  Indeed,  when  we  consider 
the  amount  of  deposit  which  is  generally  present;  when  we 
regard  its  character ;  when  we  take  into  account  the  neces- 
sarily impaired  function  of  one  of  the  most  important  glands 
in  the  body  ;  when  we  reflect  upon  the  pressure  which  the 
enlarged  organ  must  occasion, — it  is  truly  astonishing  that 
often  so  little  dropsy,  so  little  jaundice,  so  little  pain,  so  little 
constitutional  disturbance  should  be  produced  by  the  disease. 

Yet,  in  point  of  diagnosis  we  can  generally  discern  the 
malady  by  the  combination  of  the  symptoms  and  signs  indi- 
cated. It  is  only  at  an  early  stage  of  the  disease,  or  when  the 
liver  is  not  enlarged,  that  we  are  apt  to  be  in  doubt.  Under 
the  former  circumstance,  a  swelling  in  the  hepatic  region, 
pain  upon  pressure  associated  with  nausea  and  vomiting  and 
with  failing  health,  occurring  in  a  person  above  thirty-five 
years  of  age,  may  well  excite  our  suspicion.  But  unless  there 
be  a  cancer  in  some  other  part  of  the  body,  we  cannot  be  cer- 
tain that  the  commencing  swelling  in  the  right  hypochon- 
drium  is  malignant  When  the  liver  is  the  seat  of  cancer, 
but  is  not  increased  in  size,  the  recognition  of  the  malady  is 
next  to  impossible.  In  these  obscure  cases,  the  persistent 
tenderness  in  the  hepatic  region,  accompanying  the  evidences 


i 


DISEASES    OP    THE    LIVER.  549 

of  disturbed  function  of  the  liver,  ascites,  and  a  cachectic 
appearance,  are  the  signs  most  trustworthy  and  most  likely 
to  lead  to  a  correct  conclusion. 

But  let  us  pass  in  review  the  affections  with  which  well- 
marked  cancer  of  the  liver  is  likely  to  be  confounded. 
Omitting  here  hydatids,  abscess  of  the  liver  and  cirrhosis, 
they  are: 

Waxy  Liver;  Fatty  Liver;  Chronic  Congestion; 

Acute  Congestion  and  Acute  Hepatitis  ; 

Syphilitic  Liver; 

Diseases  of  the  Gall-bladder; 

Cancer  of  the  Stomach  ; 

Cancer  of  the  Omentum  ; 

Enlargement  of  the  Right  Kidney. 

Waxy  Liver;  Fatty  Liver ;  Chronic  Congestion. — A  waxy  liver 
presents  often  as  much  increase  in  size  as  cancer;  moreover, 
like  cancer,  it  is  associated  with  evident  signs  of  cachexia. 
The  main  points  of  distinction  are  the  combination  of  the 
former  morbid  condition  with  enlargement  of  the  spleen  and 
albuminous  urine,  and  the  history  of  the  case  pointing  to  con- 
stitutional syphilis  or  to  diseases  of  the  bones,  or  long-con- 
tinued suppuration, — in  fact,  to  the  causes  which  generally 
lie  at  the  root  of  the  development  of  a  waxy  or  lardaceous 
state  of  organs.  When  distinct  nodules  are  perceived  in 
examining  the  liver,  of  course  the  difficulty  in  diagnosis 
ceases. 

A  fatty  liver  is  much  easier  to  discriminate  from  hepatic 
cancer.  The  occurrence  of  the  non-malignant  malady  in 
consumptives  or  in  drunkards,  the  absence  of  pain, — in 
truth,  of  any  decided  indications  of  hepatic  disease,  except- 
ing increased  size  of  the  organ, — enable  us  to  distinguish 
between  the  two  affections  with  certainty.  The  slighter 
signs  of  disturbance,  both  constitutional  and  local,  the  dis- 
similar history,  and  the  uniform  enlargement  of  the  liver 
separate  chronic  congestion  from  cancer.  As  a  mark  of  dis- 
tinction, too,  of  the  cancerous  from  all  of  these  non-malignant 
disorders,  Virchow  lays  stress  on  the  existence  of  swollen 
jugular  glands. 

Acute  Congestion  and  Acute  Hejmtitis. — It  is  very  rarely,  in- 


550  MEDICAL    DIAGNOSIS. 

i 

deed,  that  either  of  these  ailments  is  confounded  with  cancer 
of  the  liver,  because  the  history  in  this  malady  and  the  course 
it  takes  are  so  dissimilar  to  an  acute  hepatic  disorder.  Yet 
there  are  cases  in  which  the  malignant  disease  is  either  de- 
veloped with  great  rapidity,  thus  simulating  acute  congestion 
or  acute  inflammation,  or  in  which  it  has  lain  dormant  and 
passed  unnoticed  until  it  begins  suddenly  to  increase.  Under 
such  circumstances  even,  we  may  be  able  to  recognize  the 
malignant  complaint,  if  its  physical  phenomena  be  well  de- 
fined; but  if  these  be  not  clearly  marked,  the  diagnosis 
becomes  one  of  very  great  difiiculty. 

To  cite  a  case  in  illustration : 

A  married  woman,  twenty-five  years  of  age,  was  admitted 
into  the  Philadelphia  Hospital  on  January  14th,  1862,  with 
jaundice  and  slight  fever.  She  stated  that  she  had  been  in 
excellent  health  until  about  two  weeks  before,  when  she 
caught  cold  by  sleeping  in  a  damp  apartment.  Her  appe- 
tite and  digestion  had  been  good  previous  to  her  present  ill- 
ness, and  she  had  been  fully  able  to  perform  her  household 
work.  Since  she  was  taken  sick  she  had  noticed  a  feeling  of 
weight  in  the  region  of  the  stomach  and  liver.  "When  exam- 
ined, rales  indicative  of  bronchitis  were  found  in  the  chest, 
and  the  impulse  of  the  heart  was  feeble.  The  hepatic  per- 
cussion duluess  was  observed  to  be  increased  in  extent, 
especially  that  of  the  left  lobe ;  but  the  outline  of  the  organ 
appeared  regular  and  even.  Tenderness  at  the  lower  portion 
of  the  abdomen,  but  more  particularly  in  the  epigastrium  and 
right  hypochondrium,  was  also  noted.  There  was  nausea, 
but  no  vomiting;  the  tongue  was  clean;  the  evacuations 
were  discolored. 

Now,  here  was  certainly  a  ])atient  presenting  none  of  the 
signs  of  hepatic  cancer,  excepting,  perhaps,  the  tenderness 
over  the  enlarged  gland.  Yet  at  the  autopsy,  which  was 
made  within  a  week  after  her  reception  into  the  hospital, 
and  therefore  not  three  weeks  from  the  apparent  beginning 
of  the  complaint,  whitish  nodular  spots,  evidently  cancerous, 
and  many  of  them  soft,  were  found  in  the  substance  of  the 
liver,  but  not  at  its  edges,  nor  forming  anywhere  distinct 
protuberances  which  could  have  been  detected  during  life. 


DISEASES    OF    THE    LIVER.  551 

and  which,  harl  they  existed  and  been  discerned,  might,  not- 
withstanding the  history  of  the  case,  have  furnished  a  chie 
to  the  cause  of  the  tenderness  and  of  the  hepatic  enlarge- 
ment. 

Syphilitic  Liver. — Asa  consequence  of  constitutional  syphi- 
lis, the  liver  may  at  times  exhibit  cicatrices  on  its  surface, 
and  scattered  nodules,  consisting  of  connective  tissue,  and 
extending  into  the  parenchyma.  This  condition  is  styled 
syphilitic  inflammation  of  the  liver,  or  the  syphilitic  liver. 
The  orsan  becomes  uneven  from  the  contraction  of  the  cica- 
trized  parts,  and  is  very  apt  to  be  somewhat  increased  in  size, 
from  coexisting  waxy  degeneration.  The  patient  has  a  pale, 
cachectic  look,  but  is  not  jaundiced;*  nor  is  dropsy  present, 
unless  there  be  at  the  same  time  an  aifectiou  of  the  kidneys 
or  enlargement  of  the  spleen.  But  the  most  important  ele- 
ments in  the  diagnosis  are  the  history  of  the  case  and  the 
detection  of  syphilitic  cicatrices  in  the  throat.  When  con- 
trasted with  cancer,  we  find,  besides  these  points,  the  chief 
distinctive  marks  to  be :  the  much  more  usual  absence  of 
jaundice  and  of  dropsy,  the  not  uncommon  increase  of  the 
spleen,  the  want  of  local  hepatic  tenderness,  and  the  smaller 
size  and  softer  feel  of  the  nodules. 

Diseases  of  the  Gall-bladder.— DWatation  and  cancer  of  the 
gall-bladder  are  both  very  liable  to  be  mistaken  for  cancer 
of  the  liver.  The  former  affection  may  result  from  occlusion 
of  the  hepatic  and  common  bile  ducts,  produced  by  pressure 
of  surrounding  tumors  or  by  an  impaction  of  gall-stones;  or 
it  may  be  owing  to  the  distention  of  the  bladder  with  an 
albuminous  fluid— the  so-called  dropsy  of  the  gall-bladder. 
Now,  in  either  instance  the  bladder  may  attain  an  enormous 
volume,  and  give  rise  to  a  marked  tumor  at  the  lower  margin 
of  the  liver.  The  prominence  is  very  apt  to  be  rounded  or 
pear-shaped,  and,  excepting  in  those  cases  in  which  the  oc- 
clusion is  in  the  cystic  duct  or  at  the  neck  of  the  gall-bladder, 
the  impediment  to  the  flow  of  bile  is  accompanied  by  intense 


*  No  jaundice  is  mentioned  in  the  cases  of  Dittrich,  Prag.  Vierteljahrschr.. 
Bd.  vi.  and  vii.;  of  Gubler,  Mem.  do  la  Societe  de  Biologie,  tome  iv.;  or  of 
Bamberger,  Krankheiten  der  Leber,  in  Virchovv,  Pathologic,  etc.;  of  Moxon, 
in  Guy's  Hospital  Reports,  1867. 


552  MEDICAL    DIAGNOSIS. 

jaundice  and  by  decided  hepatic  swelling.  Hence,  in  the 
deep  hue  of  the  skin,  the  uniform  enlargement  of  the  liver, 
the  peculiar  contour  of  the  prominence,  and  the  history  of 
the  case,  which  not  unfrequently  points  to  repeated  attacks 
of  colic  from  the  passage  of  gall-stones, — we  find  the  clue 
which  permits  us  to  determine  that  we  have  not  to  deal  with 
hepatic  cancer.  , 

Cancer  of  the  gall-bladder  is  scarcely  ever  met  with  in 
3'oung  persons,  and  is,  as  a  rule,  associated  with  cancerous 
formations  in  the  liver  or  in  other  organs.  It  is  very  diffi- 
cult to  make  out  a  certain  diagnosis  of  the  affection,  for  it 
presents  a  strong  likeness  both  to  cancer  of  the  pyloric 
extremity  of  the  stomach  and  to  cancer  of  the  liver.  From 
the  latter  it  is  undistiuguishable,  unless  the  situation  and 
form  of  the  tumor  be  such  that  we  can  clearly  recognize  it 
as  belonging  to  the  gall-bladder.  Jaundice,  as  in  cancer  of 
the  liver,  may  be  absent  or  present :  in  five  cases  reported  by 
Bamberger*  it  was  found  in  all,  and  was  even  very  intense. 
Frerichs,  on  the  other  hand,  states  that  in  most  instances  it 
is  wanting.  The  signs  of  the  cancerous  cachexia  are  always 
very  strongly  marked;  perhaps,  as  a  rule,  more  strongly  than 
in  hepatic  cancer. 

Cancer  of  the  Stomach. — This  is  discriminated  from  cancer 
of  the  liver  by  the  far  more  constant  vomiting,  by  the  dark 
appearance  of  the  ejected  matter,  by  the  more  obvious  symp- 
toms of  indigestion,  the  persistent  pain  in  the  stomach,  or 
the  pain  radiating  from  there  to  either  hypochondrium. 
Moreover,  the  seat  of  the  tumor  is  different ;  it  is  epigastric, 
or  extending  downward,  but  not  often  passing  into  the  right 
hypochondrium,  and  it  shows  on  percussion  a  very  different 
contour  from  an  enlarged  liver.  Yet  there  are  cases  in  which 
w^e  are  kept  in  doubt;  especially  those  in  which  the  left  lobe 
of  the  liver  is  chiefly  affected  with  the  cancerous  malady 
and  presses  upon  the  stomach,  inducing  perhaps — and  thus 
making  the  likeness  still  closer — obstinate  vomiting.  The 
only  traits  of  distinction  are  then  found  in  the  presence  or 
absence  of  the  signs  of  marked  derangement  of  the  functions 
of  the  liver. 


*  Krankheiten  des  Digestions-Apparates. 


DISEASES    OP   THE    LIVER.  558 

Cancer  of  the  Omentum. — The  absence  of  jaundice,  and  tlie 
unaltered  appearance  of  the  stools  are  here,  too,  of  great 
value  in  indicating  that  a  tumor  near,  or  joining  the  left 
lobe  of  the  liver,  is  not  due  to  cancer  of  that  viscus.  More- 
over, the  boundaries  of  the  morbid  mass  are  very  different 
from  those  of  a  diseased  liver.  But  we  cannot  alwa^-s  trust 
to  this.  Cancerous  tumors  of  the  lesser  omentum  may  so 
surround  the  liver,  and  correspond  so  closely  to  the  irregular 
form  produced  by  hepatic  cancer,  that  the  two  maladies  can- 
not be  distinguished  ;  at  least  not  by  the  local  signs.  Again, 
a  loop  of  intestine  may  be  thrust  across  the  enlarged  liver 
at  a  point  corresponding  to  the  usual  limit  of  the  percussion 
dulness  of  its  left  lobe,  thus  dividing  the  most  prominent 
nodules  from  the  greater  portion  of  the  viscus,  and  making 
it  appear  as  if  the  tumor  were  to  the  left  of,  and  below  the 
stomach,  and  belonged,  therefore,  probably  to  the  omentum.* 
Such  cases,  unless  the  history  and  the  attending  symptoms 
throw  light  upon  them,  are  beyond  the  reach  of  diagnosis. 

Enlargement  of  the  Right  Kidney. — A  tumor  formed  by  an 
enlargement  of  the  kidney  does  not  present  the  same  outline 
of  percussion  dulness  as  a  cancerous  liver.  The  dulness  is, 
moreover,  bounded  by  the  tympanitic  sound  of  the  intestine, 
and  is  not  lowered  by  a  deep  inspiration  ;  and  the  signs  of 
disturbed  function  of  the  kidney,  and  an  examination  of  the 
urine,  will  generally  materially  assist  the  diagnosis.  Still, 
cases  may  occasionally  happen  in  which,  owing  to  a  peculiar 
shape  of  the  diseased  kidney  and  to  the  obscurity  of  the  symp- 
toms, an  error  in  diagnosis  can  scarcely  be  avoided.  The  dif- 
ficulty in  discrimination  is  heightened  by  the  circumstance 
that  most  cases  of  morbid  growth  of  the  kidney,  at  least  of 
one-sided  growth  sufficient  to  give  rise  to  a  palpable  tumor, 
are  cancerous ;  and  are  therefore,  so  far  as  the  manifestations 
of  a  cachexia  go,  similar  to  cancer  of  the  liver. 

Hydatids  of  the  Liver. — The  development  of  one  or  of 
several  cysts  in  the  liver,  containing  within  them  echinococci, 
is  not  as  a  rule  a  disorder  which  occasions  anv  serious  dis- 


*  This  happened  in  a  case  seen  with  Dr.  S.  "Weir  Mitchell,  and  published 
bj'  him,  Proceedings  of  Path.  Society  of  Philadelphia,  vol.  i.  p.  275. 


554  MEDICAL    DIAGNOSIS. 

turbance  of  the  general  health.  Nor  do  the  hydatids  usually 
give  rise  to  either  jaundice,  dropsy,  or  any  marked  signs  of 
gastric  or  intestinal  irritation,  or  to  fever,  or  local  pain. 
Their  most  constant  manifestations  are  a  decided  increase 
of  the  size  of  the  liver,  and  the  presence  of  elastic  tumors 
discernible  in  the  hepatic  region. 

The  growth  of  the  hydatid  is  generally  very  slow,  but 
in  most  cases  it  attains  considerable  dimensions,  and  the 
liver  may  be  found  to  encroach  upon  the  lung  as  far  as  the 
second  intercostal  space,  or  to  extend  far  down  into  the  ab- 
dominal cavity.  On  percussion,  the  line  of  dulness  either  of 
the  upper  or  the  lower  boundary  of  the  viscus,  or  of  both,  is 
perceived  to  be  very  irregular,  and  occasionally  on  striking 
a  series  of  abrupt  blows  on  the  pleximeter,  or  the  lingers  of 
the  left  hand  used  as  such,  we  discern  a  peculiar  vibration 
(similar  to  the  sensation  perceived  on  striking  a  mass  of  jelly), 
to  which  Piorry  was  the  first  to  call  attention,  and  which  is 
very  significant  of  the  existence  of  the  cyst.  Owing  to  the 
pressure  the  increasing  tumor  may  exert  on  adjacent  struc- 
tures, we  observe  in  some  cases  dry  cough ;  palpitation  and 
displacement  of  the  heart;  vomiting, — possibly  jaundice  and 
ascites. 

Hydatids  ordinarily  last  for  years.  The  echinococci  may 
die,  the  sac  become  much  reduced  in  size,  or  obliterated, 
and  recover}-  take  place  ;  or  the  cyst  may  discharge  its  con- 
tents through  the  stomach  and  intestines,  through  the  bron- 
chial tubes,  or  through  the  walls  of  the  abdomen,  and  the 
patient  then  gets  well.  But  so  favorable  a  termination  can- 
not be  counted  upon.  A  fatal  issue  may  at  any  time  ensue 
by  the  hydatid  tumor  bursting  into  the  pleura  or  peritoneum, 
and  leading  to  violent  inflammation,  or  by  inflammation  and 
suppuration  occurring  in  the  sac,  or  in  the  tissues  immediately 
surrounding  it.  Even  when  the  hydatids  are  discharged 
through  the  stomach,  intestines,  or  bronchial  tubes,  recovery 
is  apt  to  be  very  slow;  nor  is  it,  indeed,  very  uncommon  to 
find  the  patient's  strength  giving  wa}-  before  the  contents  of 
the  sac  have  been  entirely  voided  and  it  has  closed. 

In  some  countries  hydatids  are  much  more  frequent  than 
in  others.  In  Iceland  these  growths  developed  from  the  eggs 


DISEASES    OF    THE    LIVER.  555 

of  a  tapeworm  are  so  common    that  they  cause  one-seventh 
of  the  human  mortality. 

Now,  in  point  of  diagnosis,  it  is  not  generally  very  diffi- 
cult to  detect  the  presence  of  hydatids.  It  is  true  that  when 
these  are  small  or  deep  seated,  it  may  be  impossible  to  dis- 
cern them.  But  a  large  and  superficially  seated  hydatid 
tumor  can  usually  be  distinguished,  and  can  be  separated  in 
most  cases  from  the  maladies  to  which  it  bears  a  resem- 
blance. 

It  diflers  from  an  abscess  of  the  liver  by  the  want  of  that 
febrile  action,  pain,  and  great  constitutional  disturbance  to 
which  the  formation  of  an  abscess  is  so  prone  to  give  rise ; 
from  cancer  of  the  liver,  by  the  absence  of  evident  cachexia; 
of  local  tenderness  and  of  the  unevenness  of  the  surface 
which  the  small,  hard  tumors  projecting  from  it  occasion. 
A  distended  gall-bladder  may,  like  a  hydatid  tumor,  be  free 
from  pain  on  pressure,  but  unlike  this,  it  is  preceded  by 
attacks  of  colic,  is  generally  accompanied  by  deep  jaundice, 
and  its  situation  corresponds  to  the  normal  seat  of  the  gall- 
bladder. 

An  aneurism  of  the  aorta  dift'ers  from  hydatids  in  the  pul- 
sation and  the  severe  pain  the  patient  suffers,  so  utterly  dis- 
similar to  the  absence  of  pain  or  to  the  mere  feeling  of  tension 
and  weight  of  a  hydatid  swelling. 

Pleuritic  effusions  have  man}'  features  in  common  with 
those  cases  of  hydatids  of  the  liver  in  which  the  growing- 
tumor  extends  upward  into  the  chest.  All  the  physical  signs 
of  a  large  effusion  may  be  present,  even  the.  dilatation  of  the 
thorax  and  a  sense  of  fluctuation  in  the  intercostal  spaces. 
But  the  irregular  outline  of  the  dulness  on  percussion  of  the 
hydatid  cyst,  the  great  displacement  of  the  heart,  and  the 
lowering  of  the  upper  margin  of  dulness  upon  deep  inspira- 
tion enable  us  commonly  to  detect  the  real  nature  of  the 
disease.  When  the  cyst  has  opened  into  the  lung  and  the 
hydatids  are  being  expectorated  through  the  air-passages, 
the  harassing  cough,  the  copious  sputum,  and  the  inflamma- 
tion of  the  pulmonary  tissue  which  is  apt  to  be  occasioned, 
may  cause  the  affection  to  be  mistaken  for  pulmonary  abscess 
or  phthisis.     The  surest  marks  of  distinction  are  furnished 


556  MEDICAL   DIAGNOSIS. 

by  the  changed  form  of  the  lower  part  of  the  thorax,  and  by 
finding  bile  and  the  hooks  of  the  echinococci  in  the  sputum. 

But  though  we  may  thus  generally  distinguish  hydatids  of 
the  liver  from  the  maladies  which  have  similar  symptoms, 
there  are  unquestionably  cases  in  which  it  is  extremely  dif- 
ficult to  arrive  at  a  satisfactory  conclusion.  Under  these 
circumstances,  an  exploratory  examination  with  a  grooved 
needle  or  a  very  fine  trocar  has  been  recommended;  but  this 
proceeding  is  not  wholly  free  from  danger  unless  the  swelling 
be  prominent  and  superficial.  The  character  of  the  fluid 
drawn  off  will  assist  us  materially  in  diagnosis.  It  is  as  clear 
and  colorless  as  water,  has  a  specific  gravity  of  1007  or  1009, 
and  contains  not  a  trace  of  albumen,  but  large  quantities  of 
chloride  of  sodium.  No  other  fluid  in  the  human  body, 
whether  in  health  or  in  disease,  presents  these  peculiarities.* 

Occasionally  portions  of  the  liver  are  transformed  into  a 
mass,  consisting  of  connective  tissue  stroma,  and  numerous 
large  and  small  cells  filled  with  a  gelatinous  substance.  The 
disorder  looks  like  alveolar  carcinoma,  but  it  is  really  multi- 
locular  hydatids  or  echinococcous  tumors.  The  centre  of  the 
mass  suppurates,  but  even  this  does  not  diminish  the  great 
resistance  of  the  hepatic  tumor,  nor  is  fluctuation,  save  in  the 
rarest  instances,  perceptible.  The  liver  may  retain  its  normal 
shape,  or  elevations  may  be  perceptible,  such  as  we  observe 
in  carcinoma  and  syphiloma  of  the  organ.  No  jaundice 
usually  attends  the  hard  hepatic  swelling;  but  in  cases  in 
which  the  bile  ducts  are  obstructed  we  meet  with  jaundice 
without  dyspeptic  symptoms  or  previous  paroxysms  of  pain, 
and  usually  without  enlargement  of  the  gall-bladder.  In 
cases  with  icterus,  unlike  what  we  find  in  syphilis  or  in 
cancer,  there  is  complete  discoloration  of  the  feces.f 

Let  us  now,  in  concluding  the  review  of  the  hepatic  mala- 
dies which  are  attended  with  decided  increase  of  the  size  of 
the  organ,  briefly  contrast  their  most  important  manifesta- 
tions.   "We  have  found  that,  as  regards  the  enlargement,  they 


*  Murchison,  Lancet,  Nov.  1865;  also  Lectures  on  Diseases  of  the  Liver, 
1868. 

f  See  the  cases  of  Friedrich  and  of  Nieineyer,  referred  to  in  his  Practice 
of  Medicine. 


DISEASES    OF   THE    LIVER.  557 

differ  materiall3\  Simple  congestion,  chronic  inflammation, 
a  fatty  liver,  do  not  attain  nearly  the  volume  of  cancer,  of 
hydatids,  of  abscess,  nor  even  of  waxy  disease  of  the  liver. 
The  three  affections  first  mentioned  differ,  moreover,  from 
all  of  the  others,  excepting  the  waxy  liver,  by  presenting  a 
uniform,  and  not  an  irregularly-shaped  swelling  nor  uneven 
outline  of  the  percussion  dulness. 

Concerning  the  symptoms,  we  observe  that,  although  these 
hepatic  disorders  all  agree  in  not  being  in  any  way  charac- 
terized by  jaundice,  yet  that  this  sign  is  more  commonly 
present  and  more  distinct  in  some  than  in  others.  In  hvda- 
tids,  and  in  the  syphilitic  liver,  there  is  no  yellow  hue  of  the 
skin  or  conjunctiva;  so,  too,  as  a  rule,  in  waxy  liver.  In 
fatty  liver  and  in  abscess  it  is,  on  the  whole,  most  frequently 
wanting.  The  same  may,  perhaps,  be  said  of  cancer,  though 
sometimes  there  is  decided  icterus  in  this  malady.  In 
chronic  congestion  and  in  chronic  inflammation  we  ordi- 
narily find  jaundice,  though  it  may  be  but  a  slight  yellow 
tinge  of  the  skin  and  eye.  With  reference  to  dropsy,  we 
are  not  apt  to  encounter  it  in  any  of  the  hepatic  affections 
under  consideration,  excepting  in  cancer  and  in  waxy  disease. 
It  is  in  these  two,  also,  that  the  most  obvious  signs  of  a  ca- 
chexia are  met  with;  while  in  abscess  we  find  fever,  and  per- 
haps the  greatest  and  most  evident  constitutional  disturbance. 

Viewed  with  regard  to  their  iJrognosiSj  none  of  these  dis- 
eases, unless  it  be  congestion  and  fatty  liver,  can  be  stated  to 
be  devoid  of  danger.  Abscess,  waxy  infiltration,  and  cancer 
have  the  most  unfavorable  prognosis. 

In  point  of  treatment,  the  different  maladies  present  very 
dissimilar  indications;  indeed,  the  treatment  must  be  guided 
chiefly  by  our  knowledge  of  the  particular  condition  of  the 
liver,  and  by  the  constitutional  state  of  the  patient. 

Chronic  Diseases  attended  with  Decreased  Size  of  the  Liver, 
and  with  Abdominal  Dropsy. 

Cirrhosis. — A  liver  reduced  in  bulk,  very  dense  and  hard, 
exhibiting  granulations  of  various  size  separated  by  bands 
of  fibrous  tissue,  and  surrounded  by  a  thickened  serous  en- 


558  MEDICAL    DIAGNOSIS. 

velope,  presents  the  morbid  state  known  as  cirrhosis,  or  by 
the  familiar  name  of  hob-nail  liver.  The  change  in  the  organ 
is  produced  by  a  new  formation  of  areolar  tissue,  due  to  in- 
flammation of  the  fibrous  texture,  called  Glisson's  capsule, 
which  accompanies  the  vessels  and  biliary  ducts  in  their  rami- 
fications through  the  hepatic  parenchyma.  The  bands  that 
result  from  the  thickening  of  the  areolar  structure  compress 
the  parenchyma  and  destroy  some  of  its  secreting  cells.  The 
inflammation  which  leads  to  these  alterations  in  the  tissue  of 
the  liver  is  generally  developed  from  a  chronic  congestion 
consequent  upon  the  abuse  of  spirituous  liquors.  But  this 
cause  does  not  explain  all  cases :  in  some,  the  malady  is  con- 
nected with  disease  of  the  heart;  in  others,  with  constitu- 
tional syphilis;  in  others,  again,  it  cannot  be  attributed  to 
any  known  agency.  Sometimes  it  is  combined  with  fatty  or 
waxy  degeneration. 

In  the  first  stage  of  cirrhosis,  the  organ  is  somewhat  in- 
creased in  size;  then,  as  Glisson's  capsule  thickens  more 
and  more,  the  bulk  becomes  lessened.  It  is,  however,  very 
doubtful  whether  the  stage  of  enlargement  invariably  pre- 
cedes that  of  shrinking;  probably  the  process  of  reduction 
constitutes  at  times  the  first  morbid  chansre. 

But  without  entering  into  this  question,  we  may  state  that 
there  are  no  symptoms  by  which  we  can  recognize  the  dis- 
ease at  an  early  period,  whether  or  not  the  liver  be  aug- 
mented in  volume;  for  the  symptoms  at  first  are  the  same 
as  those  of  chronic  congestion  or  chronic  inflammation  of 
the  organ  —  namel}^  dull  pain,  perhaps  tenderness  at  the 
hypochondrium,  disordered  digestion,  and  a  sallow  or  a 
jaundiced  hue  of  the  skin.  Nor  can  we  say,  even  after  the 
stage  of  contraction  is  fairh'  developed,  that  the  diagnosis 
of  the  affection  is  easy,  or  indeed  always  possible.  It  may 
rest  on  no  stronger  grounds  than  finding  in  a  person  who  is 
known  to  be  a  spirit  drinker  an  intractable  ascites,  without 
any  obvious  cause  to  account  for  the  dropsy. 

Besides  the  dropsy,  the  other  clinical  features  of  the  mal- 
ady are  not  very  marked.  The  most  significant  signs  consist 
in  the  diminution  of  the  percussion  duluess  in  the  hepatic 
region,  and  the  detection,  by  the  touch,  of  firm,  irregular 


DISEASES    OF    THE    LIVER.  559 

granulations  on  the  margin  and  under  surface  of  the  liver. 
But  both  these  signs  are  very  difficult  to  discern,  on  account 
of  the  distention  of  the  abdomen  by  the  fluid  eftused  within 
it,  and  the  displacement  of  the  liver  this  may  occasion.  In 
fact,  it  is  often  only  after  the  performance  of  paracentesis  that 
the  abdominal  walls,  then  no  longer  tense,  will  permit  us  to 
judge  of  the  altered  state  and  volume  of  the  organ.  This  is 
more  especially  true  with  reference  to  palpation  ;  as  regards 
percussion,  it  is  sometimes  possible,  even  when  the  abdo- 
men is  still  full  of  dropsical  effusion,  to  detect,  by  repeated 
and  careful  examination,  the  lessened  extent  of  the  hepatic 
dulness. 

Irrespective  of  these  phenomena,  we  find  at  times  other 
manifestations  which  will  assist  us  in  the  diagnosis  of  cirrho- 
sis. They  are  enlargement  of  the  spleen ;  dilatation  of  the 
veins  of  the  abdomen;  gastric  and  intestinal  derangements; 
loss  of  flesh  and  strength ;  jaundice ;  a  decidedly  cachectic 
appearance ;  and  hemorrhages  from  the  nose  and  mouth,  or 
stomach,  or  into  internal  cavities.  The  increase  in  size  of  the 
spleen  is,  however,  far  from  constant,  and  rarely  reaches  a 
very  considerable  extent.  The  dilatation  of  the  abdominal 
veins  is  not  perceived  until  an  advanced  stage  of  the  disease, 
and  is  sometimes  connected  wdth  a  peculiar  vascular  network, 
stretching  from  the  umbilicus  upward  and  downward,  and, 
as  Sappey*  was  the  first  to  describe,  with  a  decided  enlarge- 
ment of  the  epigastric  and  mammary  veins,  the  blood  flowing 
through  the  former  in  a  reversed  direction  from  what  it  does 
in  health — namely,  not  toward  the  liver,  but  from  it  to  the 
veins  of  the  abdominal  wall,  and  thence  to  the  vena  cava. 

The  gastric  and  intestinal  derangements  are  rarely  wanting; 
they  manifest  themselves  by  failing  appetite,  impaired  diges- 
tion, both  gastric  and  intestinal,  flatulency  and  constipation, 
or  the  frequent  voiding  of  pale-colored  stools.  The  jaundice 
does  not  often  attain  a  very  high  degree.  It  shows  itself 
usually  in  a  yellowish  tinge  of  the  skin  and  conjunctiva;  but 
in  some  cases  even  this  hue  is  absent,  and  we  find  the  pale 
skin  and  pearly  eye  of  anaemia. 


*  Bulletin  de  I'Academie  de  M^decine,  tome  xxiv. 


560  MEDICAL    DIAGNOSIS. 

Yet  not  one  of  these  symptoms  is  really  characteristic  ;  they 
only  become  so  when  viewed  in  connection  with  the  dropsy, 
with  the  local  signs  in  the  hepatic  region,  with  the  history  of 
the  case,  and  with  the  absence  of  any  organic  disease  of  the 
stomach  or  intestine,  which  might  account  for  them. 

Let  US  now  look  at  the  marks  of  distinction  between  cir- 
rhosis and  some  of  the  maladies  which  resemble  it;  and  first 
let  us  compare  its  traits  with  those  of  other  hepatic  affections. 
From  diseases  of  the  liver  attended  with  enlargement,  such 
as  waxy  liver,  fatty  liver,  chronic  congestion,  fully  developed 
cirrhosis  is  discriminated  by  the  presence  of  ascites  and  the 
other  signs  of  seriously  obstructed  portal  circulation,  by  the 
diminished,  certainly  not  augmented,  size  of  the  organ,  and 
the  different  history  of  the  disorder.  From  hydatids  of  the 
liver,  we  diagnosticate  cirrhosis  by  the  irregularity  of  outline 
of  the  enlarged  liver  in  the  former  complaint,  by  the  sense  of 
fluctuation  and  the  comparatively  unimpaired  general  nutri- 
tion of  the  body.  Cancer  of  the  liver  is  unlike  cirrhosis  in 
the  distinctness  and  size  of  the  protuberances,  in  the  obvious 
hepatic  enlargement,  in  the  less  marked  or  entirely  absent 
dropsy,  and  in  the  normal  size  of  the  spleen.  But  Avhen  a 
cirrhosed  liver  is  associated  with  syphilitic  nodules,  or  when 
its  volume  is  augmented  by  waxy  infiltration,  the  discrim- 
ination from  cancer  becomes  a  matter  of  extreme  difficulty ; 
indeed,  it  may  be  impossible  to  avoid  erroneous  conclusions. 

An  inflammation  of  the  portal  vein,  with  coagula  forming 
in  it,  may  occasion  the  same  manifestations  of  deranged  ab- 
dominal circulation,  the  same  tumefaction  of  the  spleen,  and 
decrease  of  the  liver  as  cirrhosis.  And  what  complicates  the 
diagnosis  very  much  is,  that  cirrhosis  is  one  of  the  chief  dis- 
eases which  lead  to  obstruction  of  the  portal  vein.  Indeed 
we  cannot,  under  any  circumstances,  positively  discriminate 
this  affection  from  cirrhosis.  Still,  we  are  sometimes  enabled 
to  distinguish  the  former  disorder  by  laying  stress  on  the 
much  quicker  development  of  the  symptoms,  and  by  noting 
the  rapidity  with  which  the  dropsy  returns  after  the  perform- 
ance of  the  operation  of  paracentesis.  Compressioti  of  the 
portal  vein  and  of  the  biliary  ducts  in  the  fissure  of  the  liver, 
in  consequence  of  the  inflammation  of  the  areolar  tissues 


DISEASES    OF    THE    LIVER,  561 

surrounding  them,  may  be  separated  from  cirrhosis  chiefly 
by  the  intense  icterus  and  the  complete  discoloration  of  the 
stools. 

Of  non-hepatic  affections,  cirrhosis  is  most  liable  to  be  con- 
founded with  chronic  peritonitis ;  a  mistake  rendered  the  more 
likely,  because  chronic  congestion,  or  even  chronic  inflam- 
mation of  the  peritoneum,  may  exist  as  a  complication  of 
cirrhosis.  But  even  when  no  such  complication  is  present, 
the  diagnosis  may  be  diflicult.  It  rests  chiefly  upon  the 
greater  tenderness  of  the  abdomen  in  peritonitis,  the  absence 
of  splenic  enlargement,  the  usually  unchanged,  or  certainly 
not  jaundiced,  hue  of  the  skin,  the  association  with  signs  of 
disease  in  other  viscera,  especially  of  the  lungs,  and  the 
dissimilar  history  of  the  case. 

Under  rare  circumstances,  cancer  of  the  stomach  may  simu- 
late cirrhosis.  I  had  some  j-ears  since  a  case  under  my  charge 
at  the  Pennsylvania  Hospital,  in  which,  with  very  slight 
digestive  symptoms,  and  without  discernible  epigastric  tumor, 
considerable  ascites  and  effusion  into  the  left  pleural  cavity 
existed.  Owing  to  this  eflrusion,  the  state  of  the  spleen  could 
not  be  very  accurately  ascertained.  There  was  some  fulness 
of  the  abdominal  veins,  and  the  hepatic  percussion  dulness  did 
not  extend  entirely  to  the  margin  of  the  ribs.  Bile  pigment 
was  present  in  the  urine,  and  the  bowels  were  loose,  and 
progressive  emaciation  ensued.  The  man  had  been  very  in- 
temperate, and  his  case  might  certainly  have  been  selected  as 
an  illustration  of  cirrhosis;  yet  at  the  autopsy,  the  liver, 
though  small,  rather  hard,  and  deeply  congested,  was  not 
cirrhotic,  and  a  cancer,  involving  nearly  the  whole  stomach, 
excepting  the  pylorus,  was  found.* 

Chronic  Atrophy  of  the  Liver.— Although  cirrhosis  is 
the  most  frequent,  it  is  not  the  sole  cause  of  dwindling  of  the 
liver.  AVe  have  just  alluded  to  its  diminution  in  consequence 
of  obstruction  of  the  trunk  of  the  portal  vein  ;  but,  be- 
sides this  cause,  we  iind  others,  such  as  a  decrease  of  the 
orijan  from  lone^-continued  closure  of  the  common  duct,  or 


*  See,  for  a  fuller  report  of  the  phenomena  in  this  singular  case,  Proceed- 
ings of  Pathol.  Society,  Amer.  Journ.  of  Med.  Sciences,  vol.  Hi.,  1866. 

36 


562  MEDICAL    DIAGNOSIS. 

its  atrophy  in  old  age,  or  as  an  accompaniment  of  chronic 
disease  of  the  intestine.  The  first  of  these  morbid  states  is 
mainly  discriminated  by  the  deep  jaundice;  the  second  by 
the  absence  of  any  important  symptoms  referable  to  the  liver 
and  associated  with  the  diminished  hepatic  dulness;  the  other 
form  presents  the  phenomena  of  cirrhosis,  and  cannot  be  dis- 
tinguished from  this  unless  the  surface  of  the  liver  can  be  dis- 
tinctly  felt  through  the  abdominal  walls,  and  be  ascertained 
not  to  be  irregular.  We  may  sometimes  suspect  the  cause  of 
the  shrinking  of  the  organ  from  the  persistent  and  intract- 
able diarrhoea  and  disturbance  of  the  stomach.  But,  on  the 
whole,  this  decrease  in  size  of  the  liver  following  gastro- 
enteric inflammation  is  not  frequent ;  in  truth,  there  is  no 
cause  of  simple  atrophy  of  the  liver  so  common  as  coagula- 
tion of  blood  in  the  portal  vein. 


SECTION  lY. 


ABDOMINAL   ENLARGEMENT. 


In  describing  the  causes  of  abdominal  enlargement,  I  shall 
view  them  as  they  occasion  a  general  and  uniform,  or  a  more 
circumscribed  and  partial  swelling. 

General  Abdominal  Enlargement, 

Ascites. — The  collection  of  serous  fluid  in  the  peritoneal 
sac  gives  rise  to  dropsy  of  the  belly,  or  ascites.  This  may 
form  part  of  a  general  dropsy,  and  be  dependent  upon  an 
organic  disease  of  the  kidneys  or  the  thoracic  viscera,  or  the 
accumulation  of  liquid  may  be  confined  to,  or  at  all  events 
occupy  principally  the  abdomen.  In  either  case  the  local 
signs  are  much  the  same.  They  are:  enlargement  of  the 
belly;  a  dull  sound  on  percussion,  due  to  the  presence  of 
liquid;  and  the  sense  of  fluctuation  imparted  to  the  hand  on 


ABDOMINAL  ENLARGEMENT.  563 

one  side  of  the  abdomen  by  a  wave  of  fluid  put  into  motion 
by  a  tap  on  the  other  side. 

As  regards  the  former  of  these  signs,  it  is  uniform  and 
progressive,  and  is  usually  very  evident — so  evident  as  fre- 
quently to  attract  the  patient's  attention  ;  although,  of  course, 
when  the  quantity  of  liquid  is  small,  enlargement  of  the 
abdomen  may  escape  detection.  The  percussion  dulness  is 
most  readily  perceived  at  the  lower  portion  of  the  abdomen, 
where  the  fluid  gravitates,  unless  when  prevented  from  so 
doing  by  being  circumscribed  by  peritoneal  adhesions.  The 
bowels  float  usually  to  the  upper  part  of  the  liquid,  and  at 
that  spot  their  tympanitic  resonance  may  be  distinctly  dis- 
cerned. When  the  patient  is  in  the  erect  position,  the  in- 
testinal percussion  note  is  commonly  discoverable  in  the  epi- 
gastric and  umbilical  regions.  If  he  be  placed  upon  his 
back,  the  tympanitic  sound  is,  for  the  most  part,  found  to 
extend  lower  than  the  umbilical  region,  while  duhiess  will 
be  elicited  in  the  hypogastric  region  and  the  flanks.  If  the 
person  affected  with  ascites  be  placed  upon  his  side,  the  flank 
which  is  uppermost  becomes  resonant.  This  alteration  of 
the  level  of  the  fluid  with  the  change  of  position  is  thus  a 
very  significant  sign,  and  always  happens  except  when  the 
effusion  is  encysted;  it  is  also,  as  a  rule,  detected  without 
difficulty,  save  where  very  great  flatulent  distention  of  the 
bowels  accompanies  the  accumulation  of  liquid. 

Ordinarily  the  fluctuation  wave  felt  by  the  hand  is  easily 
discerned.  It  is,  however,  obscured  by  thickening  of  the 
abdominal  walls  from  oedema,  or  from  the  accumulation  of 
fat  in  the  subcutaneous  tissues  ;  it  is,  moreover,  indistinct  if 
adhesions  circumscribe  the  fluid  in  the  peritoneum. 

The  other  symptoms  often  found  in  ascites,  such  as  a  push- 
ing upward  of  the  liver,  spleen,  and  stomach,  embarrassed 
breathing,  perhaps  compression  of  the  lungs,  and  digestive 
disturbances,  need  not  be  specially  described,  as  they  present 
nothing  characteristic.  Nor  is  it  necessary  to  insist  upon  the 
self-evident  fact  that  a  diagnosis  of  ascites  is  only  half  the 
diagnosis  of  a  case,  and  that  we  should  in  every  instance 
endeavor  to  ascertain  the  cause  of  the  collection  of  fluid  in 
the  peritoneal  sac.    And  we  may  at  once  proceed  to  consider 


564  MEDICAL    DIAGNOSIS. 

the  morbid  states  with  which  dropsy  in  the  peritoneum  is 
liable  to  be  confounded.     They  are  chiefly : 

Ovarian  Dropsy; 

Chronic  Peritonitis  ; 

Distention  of  the  Bladder  ; 

Gravid  Uterus  ; 

Chronic  Tympanites. 

Ovarian  Dropsy. — It  is  not  until  an  ovarian  cyst  rises  above 
the  brim  of  the  pelvis  that  it  occasions  a  swelling  marked 
enough  to  be  mistaken  for  abdominal  dropsy.  Supposing 
that  it  has  led  to  considerable  enlargement  of  the  belly,  Ave 
are  vet  able  to  discriminate  between  the  two  disorders  bv 
attention  to  the  physical  signs  and  the  history  of  the  case. 

As  regards  the  former,  we  perceive  these  differences:  the 
sound  on  percussion  over  an  ovarian  cyst  is  dull  in  the  um- 
bilical and  hypogastric  regions,  while  at  the  sides  the  tympan- 
itic resonance  of  the  intestines  may  be  obtained.  Moreover, 
when  the  patient  assumes  different  postures  the  dulness  in 
ovarian  dropsy  does  not  change  its  position;  and,  like  all 
ovarian  tumors,  it  causes  a  projection  in  the  centre  of  the 
abdomen,  not  a  flattening  there  and  a  bulging  of  the  flanks, 
as  is  not  uncommon  in  ascites.  Lastly,  the  fluctuation  from 
an  ovarian  cyst  is  rarely  as  perfect  as  from  a  collection  of 
fluid  in  the  peritoneum,  and  is  apt  to  be  very  unequal  at  dif- 
ferent parts  of  the  distended  abdomen.  Thus  the  physical 
phenomena  of  the  two  maladies  are  very  dissimilar. 

When,  however,  there  is  ascites  complicating  an  ovarian 
tumor,  the  diagnosis  is  very  difficult.  Finding  the  fluctuation 
unequal,  and  an  irregular  outline  of  the  ovarian  growth,  may 
aid  us ;  but  a  preliminary  tapping  may  be  necessary  to  settle 
the  diagnosis.  The  microscope  often  shows  lymph  and  pus 
in  the  fluid  from  an  ovarian  disease ;  yet  we  cannot  trust 
exclusively  to  the  character  of  the  fluid  voided. 

In  uncomplicated  cases,  the  history  assists  us  greatly  in 
arriving  at  a  correct  diagnosis.  In  ovarian  dropsy,  we  can, 
as  a  rule,  make  out  that  the  distention  of  the  abdomen  has 
commenced  at  its  lower  portion,  and  has  gradually  spread 
upward,  one  side  being  very  much  more  prominent  than 
the  other,  until  the  abdominal  enlargement  has  become  cou- 


ABDOMINAL  ENLARGEMENT.  565 

siderable.  Again,  the  constitutional  disturbance  is  less, — 
often,  indeed,  the  general  health  is  scarcely  disturbed ;  and 
we  do  not  find  those  signs  of  disease  of  the  liver,  heart,  or 
kidneys  which  are  so  apt  to  coexist  with  ascites. 

Attention  to  the  history  and  progress  of  the  complaint  is 
especially  valuable  in  the  class  of  cases  in  which  the  physical 
signs  are  modified  by  the  intestines  not  being  able  to  float 
to  the  surface  of  the  fluid  in  the  peritoneal  cavity,  in  conse- 
quence of  adhesions  to  each  other,  or  of  a  diseased  omentum, 
or  in  which  the  fluid  has  been  limited  in  sacs  by  inflamma- 
tory adhesions.  These  cases  are  those  in  which  a  peritoneal 
inflammation  has  led  to  the  effusion  of  liquid;  and  the  his- 
tory of  antecedent  peritonitis,  or  of  peritonitis  in  connection 
with  tubercular  disease,  the  pain  and  tenderness,  the  signs 
sometimes  of  a  tubercular  aflection  of  the  peritoneum  and 
mesenteric  glands,  and  the  evidences  of  serious  impairment 
of  the  whole  system,  will  go  far  toward  elucidating  the 
diagnosis. 

Chronic  Peritonitis, — The  eff'usion  which  forms  in  conse- 
quence of  inflammation  of  the  peritoneum  is  very  commonly 
spoken  of  as  one  of  the  forms  of  ascites.  Excluding  the  kind 
of  chronic  inflammation  which  is  due  to  an  attack  of  acute 
peritonitis  passing  into  a  chronic  state,  let  us  inquire  how 
cases  of  chronic  peritonitis,  in  which  the  disease  was  gradual 
in  its  development,  can  be  distinguished  from  pure  dropsical 
eftusion. 

Now,  these  cases  of  chronic  peritonitis  are  almost  invari- 
ably associated  with  tubercle  or  with  cancer.  In  the  former 
instance,  by  far  the  most  common,  the  malady  generally 
occurs  in  those  who  have  at  the  same  time  tubercles  in  the 
lungs;  and  when  we  find  such  a  patient  complaining  of  ab- 
dominal pain  and  uneasiness,  of  soreness  to  the  touch,  of 
nausea,  of  an  irregular  state  of  the  bowels,  of  having  more 
or  less  fever,  and  of  losing  flesh  and  strength ;  when  we  dis- 
cover the  abdomen  to  be  very  tense  and  much  distended,  in 
part  with  liquid,  but  especially  with  wind,  and  sometimes 
very  resistant  to  the  touch,  and  exhibiting  clearly  on  its  ex- 
terior the  tracings  of  the  convolutions  of  the  intestines, — we 
can  hardly  be  wrong  in  presuming  the  signs  of  chronic  peri- 


566  MEDICAL    DIAGNOSIS. 

toneal  inflammation  to  be  owing  to  the  presence  of  tuber- 
cular granulations  or  of  tuberculous  disease  of  the  mesenteric 
glands.  Even  when  the  sig-ns  of  disease  of  the  lung's  are  want- 
ing,  or  are  not  well  defined,  we  shall  generally  be  correct,  if 
the  abdominal  symptoms  mentioned  exist,  in  determining 
the  peritoneal  affection  to  be  tubercular. 

In  some  instances  the  tubercular  abdominal  disorder  de- 
velops with  rapidity,  and  the  disease  has  not  so  much  the 
aspect  of  a  chronic  as  of  an  acute  complaint.  The  tumefac- 
tion and  tension  of  the  belly  produced  may  be  so  great  as  to 
simulate  an  abdominal  tumor.* 

A  cancer  of  the  peritoneum  gives  rise  to  many  of  the  same 
phenomena  as  tuberculous  disease.  But  there  is  this  difter- 
ence :  the  malady  usually  happens  consecutively  to  an  ex- 
ternal or  an  internal  cancer,  and  scarcely  ever,  save  in  persons 
advanced  in  years;  there  is  less  fever;  no  diarrhoea,  or  but 
little  diarrhoea,  and  no  profuse  sweats  occur;  and  as  the 
omentum  is  the  most  common  seat  of  the  cancerous  growth, 
we  can  generally  detect  a  tumor  stretching  across  the  upper 
portion  of  the  abdomen,  and  extending  perhaps  from  the 
epigastrium  nearly  to  the  pelvis.  The  morbid  mass  is  une- 
qual and  usually  detected  readily,  excepting  where  separated 
by  fluid  from  the  abdominal  parietes. 

!Now,  it  is  not  necessary  to  point  out  at  any  length  the 
dift'erences  between  these  forms  of  chronic  peritonitis  and 
the  ordinary  kind  of  dropsy  of  the  peritoneum.  Both  the 
local  and  general  symptoms  are  very  dissimilar,  as  will  be 
seen  at  once  by  contrasting  the  description  just  given  with 
that  of  ascites. 

Distention  of  the  Bladder. — This  may  give  rise  to  a  sense  of 
fluctuation  and  to  very  marked  abdominal  enlargement ;  so 
marked,  indeed,  that  patients  have  been  tapped,  under  the 
supposition  that  they  were  laboring  under  dropsy  of  the 
abdomen.  But  when  the  bladder  is  so  much  distended  as  to 
simulate  ascites,  there  is  usually  more  or  less  tenderness  on 
pressure  over  the  seat  of  the  obvious  swelling:  which,  more- 
over, presents  a  rounded  outline  of  dulness  on  percussion. 


*  Seo  case  in  Liverpool  Hospital  Keports,  1868. 


ABDOMINAL  ENLARGEMENT.  567 

Again,  we  either  have  the  history  of  retention  or  of  apparent 
incontinence  of  urine.*  But,  so  as  to  avoid  all  possible 
chance  of  error,  in  any  case  of  doubt  a  catheter  should  be 
introduced  into  the  bladder.  This  mode  of  procedure,  it 
may  here  be  mentioned,  is  the  one  which  leads  most  speedily 
and  decisively  to  a  true  appreciation  of  the  abnormal  phe- 
nomena ill  those  rare  cases  of  anasarca  which  are  produced 
by  distention  of  the  bladder,  and  of  which  Trousseau  lias 
recorded  several. 

The  Gravid  Uterus. — A  gravid  womb  is  readily  distinguished 
from  abdominal  dropsy  by  the  peculiar  form  of  the  dulness 
on  percussion,  its  steady  and  uniform  increase  corresponding 
to  the  enlargement  of  the  womb,  the  absence  of  fluctuation, 
the  detection  of  the  sounds  of  the  fcetal  heart,  and  the  pro- 
duction of  movements  in  the  womb  on  making  an  examina- 
tion per  vaginam.  Very  much  the  same  signs,  too,  enable  us 
to  discriminate  between  pregnancy  and  ovarian  dropsy. 

Chronic  Tympanites. — A  great  prominence  of  the  abdomen, 
due  to  flatulent  distention  of  the  bowels,  is,  if  at  all  a  per- 
sistent state,  very  apt  to  be  mistaken  for  drops}'  of  the  belly. 
But  the  large  abdomen  yields  not  a  dull,  but  everywhere  a 
tympanitic  sound,  and  there  is  no  fluctuation.  Then,  as  we 
shall  presently  discuss,  the  history  of  the  case  and  the  at- 
tending symptoms  throw  light  upon  the  nature  of  the 
ailment. 

Besides  the  complaints  just  reviewed,  which  are  those 
most  commonly  confounded  with  ascites,  there  are  a  few 
very  rare  disorders  which  might  be  mistaken  for  collections 
of  fluid  in  the  peritoneal  sac.  They  are :  dropsy  of  the 
womb;  dropsy  of  the  Fallopian  tubes;  dropsy  of  the  omen- 
tum; very  large  serous  cysts  in  the  kidney;  hydatids  of  the 
liver,  of  size  so  great  as  to  lead  to  general  abdominal  disten- 
tion ;  and  a  dilatation  of  the  stomach  so  extensive  that  the 
viscus  occupies  almost  the  whole  abdomen.  With  reference 
to  the  latter  affection,  which  has  been  encountered  in  cases 


*  In  a  case  recorded  by  Dr.  Watson,  in  his  Lectures  on  the  Practice  of 
Physic,  although  the  bladder  was  enormously  distended,  large  quantities  of 
urine  were  constantly  passing  from  the  patient. 


5G8  MEDICAL    DIAGNOSIS. 

of  boLilimia,  and  in  cancer  of  the  pylorus,  or  stricture  of  the 
duodenum,  we  may  distinguish  it  from  ascites  by  the  history 
of  the  case,  by  the  gurgling  discerned  on  sudden  pressure, 
by  the  indistinct  fluctuation,  which  is  not  noticed  except 
over  the  most  dependent  part  of  the  organ,  and  the  metallic 
or  amphoric  sounds  which  are  perceived  when  its  contents 
are  agitated.*  The  other  maladies  mentioned  can  only  be 
separated  by  taking  into  account  their  history  and  progress, 
by  laying  stress  upon  the  absence  of  those  morbid  states 
which  generally  cause  ascites,  and  upon  the  occurrence  of 
special  phenomena  which  point  to  the  structures  implicated. 
Yet  it  may  not  always,  even  with  the  utmost  care,  be  possible 
to  form  a  correct  diagnosis. 

Chronic  Tympanites. — A  collection  of  gas  in  the  cavity 
of  the  peritoneum  is  of  rare  occurrence;  but  is  frequent  in 
the  intestinal  tube,  and  the  accumulation  become  sometimes 
a  chronic  condition,  and  leads  to  very  great  and  uniform 
enlargement  of  the  abdomen.  We  find  this  form  of  tympan- 
ites in  some  cases  of  hysteria;  in  instances  of  constriction  of 
portions  of  the  intestinal  canal,  either  in  consequence  of  cica- 
trization, or  of  cancer  of  the  bowels,  or  of  their  compression 
by  a  morbid  growth;  as  a  sequel  of  enteritis  or  peritonitis,  or 
of  a  spinal  lesion,  under  which  circumstances  it  is  evidently 
due  to  atony  of  the  muscular  fibres;  we  also  observe  it  in 
persons  whose  digestive  powers  are  not  strong,  and  who  par- 
take much  of  food — such  as  cabbages,  beans,  and  peas — 
whicli  is  apt  to  occasion  flatulency. 

Among  soldiers  this  chronic  tj'mpanites — owing,  perhaps, 
in  many  cases  to  the  character  of  their  diet  and  consequent 
digestive  disturbances — is  far  from  being  an  uncommon  dis- 
order, and  may  be  a  very  obstinate  one.  It  gives  rise  to 
abdominal  enlargement,  which  is  constantly  mistaken  for 
dropsy,  but  which  does  not  yield  a  sense  of  fluctuation,  nor 
return,  on  percussion,  any  other  than  a  well-marked  tj'm- 
panitic  sound.  The  distention  produces,  moreover,  an  ina- 
bility to  take  active  exercise,  sensations  of  cutting  pain  under 


*  See  cases  of  enlargement  of  stomach,  by  Oppolzer,  quoted  in  Ranking's 
Abstract,  July,  1868,  p.  65;  also  Am.  Journ.  of  Med.  Sciences,  Jan.  1869. 


ABDOMINAL  ENLAKGEMENT.  569 

the  ribs,  and  palpitation  of  the  heart;  pressure  on  the  abdo- 
men occasions  much  discomfort;  the  soldiers,  therefore, 
walk  with  their  clothes  unbuttoned,  and  find  it  very  irksome 
to  wear  their  belts.  They  are  sometimes  troubled  by  indi- 
gestion, and  feel  particularly  uncomfortable  after  meals;  or 
the  symptoms  of  indigestion,  although  they  may  have  been 
present  at  the  beginning  of  the  complaint,  disappear,  but 
the  swelling  of  the  abdomen  persists  for  many  months. 
According  to  my  experience,  the  ailment  is  always  gradual 
in  its  development. 

Partial  Abdominal  Enlargement. 

Abdominal  Tumors. — I  propose  here  to  offer  a  few  obser- 
vations on  abdominal  tumors,  even  at  the  risk  of  repeating 
much  that  has  been  already  said  while  discussing  affections 
of  individual  abdominal  viscera.  But  for  clinical  purposes, 
it  is  a  matter  not  only  of  convenience,  but  of  importance,  to 
point  out  connectedly  the  relations  an  abdominal  swelling 
is  likely  to  bear  to  the  normal  structures  of  the  abdominal 
cavity,  and  to  consider,  moreover,  the  fact  of  the  swelling  as 
constituting,  what  in  truth  at  the  bedside  it  so  constantly 
becomes,  the  starting-point  of  our  diagnosis. 

Let  us  first  examine  the  meaning  of  an  abdominal  tume- 
faction occupying  solely  or  principally  one  region  of  the 
abdomen. 

Bigld  Hypochondrium. — The  most  usual  cause  of  a  tumor 
in  this  region  is  an  enlargement  of  the  liver,  whether  that 
enlargement  be  due  to  congestion,  to  fatty  or  waxy  degenera- 
tion, to  chronic  hepatitis,  to  cancer,  or  to  an  abscess.  The 
mere  fact  of  the  swelling  teaches  us  nothing  as  to  its  cause ; 
to  discern  this,  we  have  to  trace  the  outline  of  the  morbid 
increase,  to  ascertain  its  feel,  and  to  inquire  into  similar 
points  that  we  have  already  discussed  when  reviewing  the 
hepatic  diseases  attended  with  enlargement  of  the  organ. 

Sometimes  a  tumor  which  seems  to  be  principally  in  the 
right  hj'pochondrium,  or  to  proceed  from  the  termination  of 
this  region,  is  simply  a  displaced  liver,  or  an  affection  of  the 
gall-bladder.     In  the  first  instance,  the  recognition  of  the 


570  MEDICAL    DIAGNOSIS. 

disorder — such  as  a  pleuritic  effusion — which  has  given  rise 
to  the  displacement ;  in  the  second,  the  history  of  the  case, 
the  shape  of  the  swelling,  and  the  symptoms  attending  it, — 
will  give  us,  as  has  been  elsewhere  indicated,  an  insight  into 
its  cause.  Again,  a  tumor  in  the  parts  mentioned  may  he  due 
to  an  enlarged  kidney, — enlarged  either  by  cancerous  trans- 
formation or  cystic  degeneration.  Careful  examinations  of 
the  urine  and  the  history  of  the  case  furnish  the  most  certain 
means  of  discrimination.  Then  we  must  also  bear  in  mind 
that  all  enlarged  kidneys  displace  the  bowel  in  a  particular 
manner;  they  press  it  forward,  and  the  dulness  over  the 
tumor  is  largely  mixed  with  a  tympanitic  sound,  or  the  dul- 
ness is,  indeed,  not  very  appreciable. 

Left II)/pocho7uhium. — The  most  usual  tumors  in  this  region 
are  those  produced  by  enlargement  of  the  spleen,  l^ow,  an 
increase  in  size  of  this  viscus,  if  acute,  is  either  owing  to  in- 
flammation or  to  those  alterations  in  its  structure  which  take 
place  during  typhoid  or  the  malarial  fevers.  Under  the  latter 
circumstances,  the  cause  of  the  swelling  is  disclosed  b}^  the 
history  of  the  case  and  the  symptoms  accompanying  the 
fever. 

Inflammation  of  the  spleen  is  an  affection  very  difficult  to 
recognize.  The  most  trustworthy  symptoms  are:  pain  in  the 
left  hypochondrium,  radiating  thence  in  various  directions, 
as  far  as  the  left  shoulder,  and  augmented  by  pressure,  by 
coughing,  and  by  a  deep  inspiration ;  nausea ;  vomiting ; 
fever  having  irregular  fits  of  exacerbation;  sometimes  de- 
lirium, dry  cough,  and  a  sense  of  suffocation.  The  extent  of 
the  splenic  percussion  dulness  is  decidedly  increased,  and 
when  we  are  sure  that  the  spleen  is  not  displaced,  the 
widened  area  of  dulness  always  forms  a  most  important 
element  in  the  diagnosis. 

Chronic  enlargement  of  the  spleen  ma}''  be  caused  by  hyper- 
trophy, by  waxy  disease,  by  fibrinous  infiltration,  by  malig- 
nant growth,  and  by  congestion  with  subsequent  structural 
changes,  such  as  occur,  for  instance,  in  miasmatic  affections. 
There  are  scarcely  any  symptoms  which  are  characteristic  of 
these  states,  excepting  it  be  the  alteration  the  blood  under- 
goes, as  evinced  by  a  diminution  of  the  red  globules  and  an 


ABDOMINAL  ENLARGEMENT.  571 

increase  of  the  white,  and  the  waxy  hue  of  the  face.  Dropsy, 
bleeding  from  the  nose,  stomach,  or  intestinal  canal,  and 
digestive  disturbances,  though  far  from  infrequent,  are  less 
constant,  and  have  thus  a  less  available  diagnostic  value. 
And  in  truth,  all  of  the  phenomena  mentioned,  unless,  per- 
haps, the  microscopical  evidences  of  deteriorated  blood,  are, 
in  the  recognition  of  a  splenic  tumor,  of  secondary  impor- 
tance as  compared  with  the  extended  percussion  dulness  in 
the  splenic  region.  There  is  said  to  be  a  constant  relation 
between  the  variations  of  the  volume  of  the  spleen  and  of 
the  temperature.*  In  some  cases  the  symptoms  are  very 
ill  defined,  and  death  may  result  from  rupture  of  varices  of 
the  enlarged  viscus,  without  any  signs  of  a  lesion  than  those 
of  increased  size  of  the  organ. f  When  enlargement  of  the 
spleen  has  reached  a  certain  point,  the  organ  curves  into  the 
hypogastric  and  right  iliac  regions,  and  a  notch  or  notches 
may  be  felt  on  its  anterior  and  inner  surfaces. J 

Having  determined  the  persistent  swelling  to  be  due  to 
the  abnormal  size  of  the  spleen,  we  must  next  endeavor  to 
ascertain  the  cause  of  it.  The  history  of  the  case  forms,  in 
this  inquiry,  the  main  element  in  diagnosis. 

A  fulness  projecting  from  the  left  hypochondrium  toward 
the  umbilical  or  lumbar  region  may  be  owing  to  fecal  accu- 
mulations in  the  colon,  as  well  as  to  an  enlarged  spleen.  Now, 
althou2:h  these  fecal  accumulations  do  not  occur  so  often  in, 
or  near  either  hypochondrium  as  they  do  in  the  iliac  regions, 
yet  they  are  not  very  uncommon,  and  we  should  be  on  our 
guard  against  confounding  them  with  organic  disease.  Their 
irregular  outline,  and  close  attention  to  the  history  of  the  case 
and  to  the  accompanying  disorder  of  the  digestive  functions, 
will  generally  enable  us  to  detect  the  true  nature  of  the  swell- 
ing. But  we  must  not  lay  stress  on  the  non-existence  of 
constipation,  for  sometimes  great  irritability  of  the  bowels 
or  persistent  diarrhoea  is  kept  up  by  a  large  collection  of  fecal 
matter  in  the  colon.     Repeated  attacks  of  colicky  pains  and 


*  Am.  Journ.  of  >Ied.  Sciences,  Jvily,  1867. 

t  Traube,  Virchow's  Arcliiv,  and  Brit,  and  For.  Medico-Chirurg.  Kev., 
October,  1809. 

%  Fagge,  Guy's  Hospital  Keports,  1868. 


572  MEDICAL    DIAGNOSIS. 

some  soreness  to  the  touch  are  not  unusual  in  cases  of  exten- 
sive fecal  accumulation. 

As  regards  swellings  of  any  kind  situated  in  either  hypo- 
chondrium,  or  in  fact  at  any  portion  of  the  upper  third  of  the 
abdomen,  it  is  always  to  be  inquired  into  whether  they  are 
affected  by  the  act  of  respiration.  This,  as  Dr.  Kennedy*  has 
pointed  out,  is  a  very  valuable  sign,  for  if  the  morbid  mass 
move  in  consequence  of  the  depression  of  the  diaphragm,  it 
is  because  structures  are  involved,  such  as  the  stomach  and 
transverse  colon,  the  liver  or  spleen,  which  admit  of  some 
mobility;  whereas  a  tumor  that  is  uninfluenced  must  apper- 
tain to  a  fixed  part, — for  instance,  to  the  aorta. 

Epigastrium. — The  most  common  cause  of  an  epigastric 
tumor  is  cancer  of  the  stomach.  The  swellino;  is  then  asso- 
ciated  with  extreme  gastric  acidity,  with  frequent  vomiting, 
with  pain,  and  with  gradual  and  progressive  loss  of  flesh,  and 
debility. 

But  a  tumor  in  this  region  may  be  also  produced  b}''  a  dis- 
ease of  the  pancreas.  ITow,  practically  speaking,  there  is  but 
one  affection  of  the  pancreas  which  we  can  recognize  with 
anything  like  certainty — cancer;  for  neither  acute  nor  chronic 
pancreatitis,  nor  fatty  degeneration,  nor  uniform  simple  hard- 
ening of  the  gland,  can,  as  a  rule,  be  discerned  at  the  bed- 
side. With  reference  to  the  two  forms  of  inflammation,  we 
suspect  their  presence  if  a  large  quantity  of  matter  like 
saliva  be  passed  by  stool,  or  if  profuse  salivation  happen  ; 
but  though  these  symptoms  have  been  observed  in  individual 
eases,  they  are  far  from  being  constant.  As  regards  cancer, 
the  most  trustworthy  sj^mptoms  are  :  a  tumor  in  the  epigas- 
tric region ;  pain  there  or  in  the  back,  not  increased  by  the 
taking  of  food,  but  usually  augmented  by  the  erect  posture ; 
progressive  emaciation  and  debility ;  an  appetite  capricious 
rather  than  diminished,  and  in  some  instances,  indeed,  a  rav- 
enous desire  for  food ;  constipation,  and,  at  times,  but  far 
from  invariably,  fatty  stools. f     Besides  these  indications,  we 

*  Dublin  Quarterly  Journ.,  Aug.  1864. 

f  In  analyzing  forty  cases  that  have  been  placed  on  record  by  difteront 
authors,  and  some  that  have  come  under  my  own  notice,  I  do  not  find  this 
symptom  mentioned  in  one-third. 


ABDOMINAL  ENLARGEMENT.  573 

not  uncommonly  find,  as  the  disease  advances,  obstinate 
jaundice  and  occasional  vomiting.  Very  many  of  these 
phenomena  belong  also  to  cancer  of  the  stomach  ;  in  truth, 
we  never  can  be  certain  of  the  existence  of  the  pancreatic 
malady  until  we  have  excluded  the  gastric  affection.  In  a 
differential  diagnosis  of  this  kind,  the  early  presence  and 
habitual  occurrence  of  vomiting  after  meals,  the  sour  eructa- 
tions, the  hsematemesis,  the  absence  of  jaundice,  assist  us 
very  materially  in  locating  the  seat  of  the  disease  in  the 
stomach. 

An  epigastric  tumor  is  sometimes  simulated  by  a  contrac- 
tion of  the  upper  portion  of  the  rectus  muscle  on  palpation; 
but  the  swelling  in  the  latter  case  generally  soon  subsides, 
especially  if  rubbed.  Occasionally,  however,  a  tumefaction 
due  to  contraction  of  an  abdominal  muscle  may  be  of  some 
duration.*  And  I  have  known  a  contraction  of  the  rectus 
muscle  in  a  case  of  gastric  cancer  occasion  so  obvious  a  re- 
sistance and  swelling,  that  it  was  looked  upon  as  due  to  ma- 
lignant disease  of  the  intestine,  or  peritoneum-.  Moreover, 
the  rigid  muscle  gave  rise  to  duluess  on  percussion.  But 
though  the  phenomena  lasted  for  some  time,  and  were  indeed 
for  a  lengthened  period  a  marked  feature  of  the  case,  it  was 
observable  that  the  muscle  was  raised  and  rigid  to  a  decided 
degree  only  in  certain  positions ;  at  all  events,  that  certain 
positions  gave  a  distinct  outline  to  the  swelling,  and  that  this 
then,  like  the  line  of  dulness,  was  regular  and  straight,  evi- 
dently corresponding  to  the  contour  of  the  muscle. 

The  muscular  contractions  are  not  always  confined  to  one 
muscle,  or  to  the  whole  of  one  muscle,  and  when  irregular, 
and  particularly  when  associated  with  tympanitic  distention 
of  the  intestine,  give  rise  to  most  of  the  so-called  "phantom" 
tumors  of  the  abdomen.  These  swellings  are  often  very  per- 
plexing, and  are  constantly  mistaken  for  serious  abdominal 
tumors.  The  history  of  the  case,  the  absence  generally  of 
grave  constitutional  symptoms,  the  most  frequent  occurrence 
of  the  tumefaction  in  females,  especially  in  hysterical  females, 
and  the  usually  existing  constipation  furnish  us  with  valuable 


*  Greenhow's  cases,  London  Lancet,  1857. 


574  MEDICAL    DIAGNOSIS. 

signs  of  distinction.  But  I  believe  the  use  of  anaesthetics  to 
be  the  most  important  means  of  diagnosis.  I  was  first  led  to 
employ  them,  a  number  of  years  ago,  in  a  case  which  had 
baffled  the  skill  of  several  eminent  surgeons,  one  of  whom 
had  proposed  to  the  patient  an  operation  as  the  only  means 
of  relief  from  what  was  considered  an  ovarian  disease.  The 
patient  was  thirty-one  years  of  age,  a  widow,  and  evidently 
of  highly  hysterical  temperament.  She  was  very  subject  to 
constipation  ;  and  the  swelling  of  which  she  complained  was 
of  irregular  outline  and  occupied  the  centre  of  the  abdomen, 
extending  some  distance  on  each  side  of  the  median  line.  It 
was  hard  and  resisting  to  the  touch,  but,  on  strong  percussion, 
yielded  a  tympanitic  sound.  Whenever  it  was  touched  she 
shrank.  Thorough  relaxation  was  produced  by  the  adminis- 
tration of  ether ;  the  hand  could  be  pressed  almost  against 
the  vertebral  column,  and  all  signs  of  the  tumor  had  disap- 
peared. A  complete  recovery  took  place;  and  thus  termi- 
nated a  case  which  had  lasted  for  fully  one  year,  and  in  which, 
it  is  highly  probable,  from  the  fact  that  the  patient  was  fond 
of  having  her  urine  drawn  off  by  the  catheter,  and  had  shown 
other  manifestations  of  a  similar  type  of  hysteria,  that 
the  swelling  was  in  part  at  least  artificially  produced.  But 
in  any  of  the  phantom  tumors  I  would  recommend  the  use 
of  anaesthetics  for  purposes  of  diagnosis;  nay,  they  may  be 
most  advantageousl}'  employed  for  similar  reasons  in  all  cases 
of  abdominal  swelling  in  which  the  rigid  state  of  the  abdomi- 
nal walls  interferes  with  accuracy  of  investigation. 

In  soldiers  we  at  times  observe  one  or  several  small  mova- 
ble tumors,  yielding  a  tympanitic  sound  on  percussion  in  the 
epigastric  or  at  the  upper  part  of  the  umbilical  region.  Their 
nature  is  very  obscure  :  they  are,  probably,  small  portions  of 
intestine  which  have  been  pushed  between  the  fasciculi  of  a 
ruptured  rectus  muscle. 

Umbilical  Region. — Tumors  which  are  found  in  this  region 
form,  as  a  rule,  merely  portions  of  a  swelling  that  is  princi- 
pally seated  in  the  epigastrium  or  the  hypochondria,  such  as 
cancer  of  the  stomach,  of  the  liver,  of  the  pancreas,  or  of  the 
omentum,  and  dilatation  of  the  gall-bladder.  The  only  two 
affections  which  are  apt  to  occasion  a  swelling  solely,  or  at 


ABDOMINAL  ENLARGEMENT.  575 

least  principally,  limited  to  and  perceptible  in  the  umbilical 
region,  are  tuberculous  disease  of  the  mesenteric  glands  and 
a  movable  kidney. 

The  symptoms  of  the  former  malady,  or  tabes  meserilerica, 
are  much  the  same  as  those  which  we  have  already  described 
as  characterizing  tubercular  peritonitis.  Indeed,  unless  the 
enlarged  mesenteric  glands  can  be  felt  through  the  abdominal 
parietes,  the  discrimination  is  very  uncertain.  The  abdomen 
is  prematurely  large,  is  slightly  tender  on  pressure,  and  has 
often  a  doughy  feel;  the  child — for  it  is  almost  e::clusively  in 
children  that  the  disease  is  seen — loses  flesh,  its  digestion  is 
impaired,  its  evacuations  frequent  and  unhealthy.  It  often 
presents  signs  of  scrofulous  disease  elsewhere ;  and  under 
such  circumstances,  we  cannot  be  at  a  loss  in  determining  the 
nature  of  the  tumefaction  in  the  umbilical  region.  The  sim- 
ulation of  the  disease  in  adults,  especially  in  young  women, 
from  mere  ataxia  and  probable  functional  disorder  of  the 
glands,  has  been  described  in  reviewing  the  aifections  of  the 
stomach. 

When  the  kidneys  are  not  firmly  held  by  their  attachments, 
they  become  displaced,  and  are  then  apt  to  give  rise  to  serious 
errors  in  diagnosis.  The  dislocated  organ  is  generally  per- 
ceived under  the  margin  of  the  ribs  on  the  right  flank,  or  in 
the  umbilical  region,  and  sometimes  extends  across  the  me- 
dian line.  The  apparently  morbid  mass  is  very  easily  moved, 
may  be,  by  careful  and  methodical  pressure,  returned  to  the 
renal  region,  and  presents,  on  percussion,  the  outline  of  the 
kidney.  The  lumbar  region  yields  a  tympanitic  sound  on 
percussion,  and  we  find  less  resistance  and  a  slight  depres- 
sion over  the  usual  seat  of  the  organ,  which  depression  is 
efiaced  by  pressing  the  tumor  into  the  lumbar  region.  There 
is  in  some  instances  sensitiveness  over  the  displaced  organ, 
especially  after  fatigue,  or  a  blow,  or  strong  pressure ;  and 
pressure  in  examining  the  part  is  very  apt  to  give  rise  to  the 
same  sensation  as  when  the  renal  region  of  the  non-aftected 
side  is  pressed;  but  we  never  find  any  disturbance  of  the 
urinary  functions,  nor,  in  fact,  excepting  a  disagreeable  feel- 
ing in  walking,  does  any  real  inconvenience  result  from  the 
accident,  save  in  those  cases  in  which  the  movable  kidney 


576  MEDICAL    DIAGNOSIS. 

has  become  painful,  or,  by  compressing  the  vena  cava  or  portal 
veins,  occasions  dropsy.  The  disorder  is  most  apt  to  occur 
after  violent  exertion,  or  after  many  pregnancies,  or  may  be 
due  to  attacks  of  congestion  of  the  organ.  The  right  kidney 
is  more  frequently  movable  than  the  left;  and  women  are 
more  liable  to  displacements  of  the  organ  than  men.* 

The  affection  may  of  course  be  mistaken  for  any  form  of 
abdominal  tumor;  but  can  be  distinguished  b}^  the  absence 
of  signs  of  constitutional  disturbance ;  by  the  history  of  the 
case ;  and  by  the  physical  phenomena  already  alluded  to.  To 
these  may  be  added  the  comparatively  slight  dulness,  or  the 
rather  tympanitic  character  of  sound  elicited,  excepting  on 
very  strong  percussion,  over  the  seat  of  the  tumor.  This  is 
an  important  fact  as  regards  the  discrimination  of  a  movable 
and  displaced  spleen,  in  which,  as  the  organ  is  generally  en- 
larged, there  is  considerable  and  extended  dulness  on  percus- 
sion. Moreover,  the  history  of  the  splenic  disorder,  which 
not  uncommonly  can  be  traced  to  a  malarial  aftection,  the 
usually  great  tenderness,  and  the  nausea  and  dyspeptic 
symptoms  and  hemorrhagic  tendencies  which  attend  the 
displacement  of  the  spleen,  will  assist  us  in  our  diagnosis. f 

Yet  another  of  the  abdominal  organs  is  occasionally  dis- 
placed and  movable — the  liver.  !N^ow,  a  movable  liver  would 
be  often  mistaken  for  a  movable  spleen,  were  it  a  more 
common  afl'ection.  But  only  very  few  well-authenticated 
cases  are  on  record. J  In  these  the  peritoneal  attachment  of 
the  organ  had  become  lax,  usually  in  consequence  of  preg- 
nancy; in  the  hepatic  region  there  was  a  tympanitic  sound 
on  percussion ;  and  in  the  umbilical  region  and  toward  the 
right  flank  a  solid  body  was  discerned,  the  upper  border  of 
which  presented  a  convex  outline,  the  lower  border  was  in 


*  See  the  cases  of  Henoch,  Klinik  der  Unterleihs-Krankheiten  ;  and  of 
Fritz,  Arch.  Gen.  de  Medecine,  1859;  Becquet,  ib.,  Jan.  1865;  Hare,  Med. 
Times  and  Gazette,  1860;  Oppolzer,  quoted  in  Canst.  Jahrb.,  vol.  iii.  p.  212; 
Durham,  Guy'.s  Hosp.  Reports,  vol.  ix.,  3d  Series;  Trousseau,  Cliniquo 
Medicale. 

f  Cases  of  displaced  spleen  are  quoted  in  Archives  Generales,  1858,  tome 
ii.;  Brit,  and  For.  Mcd.-Chir.  Eev.,  Oct.  1860;  sec  also  Clarke,  Dubl.  Hosp. 
Gazette,  Aug.  1860;  and  Med.  Times  and  Gazette,  Nov.  1869. 

%  See  Cantani,  Ann.  univers.  di  Medicina,  1866  ;  and  Meissner's  article  in 
Schmidt's  Jahrb.,  1869,  No.  1. 


1 


ABDOMINAL    ENLARGEMENT,  577 

the  inguinal  region.  The  dispLaced  organ  was  very  easily 
pushed  about,  and  could  be  replaced  in  its  proper  situation. 
The  spleen  was  found  in  its  usual  seat;  the  symptoms  were 
merely  those  of  weight  and  uneasiness  in  the  abdomen. 

Lumbar  Begion. — Tumors  in  this  region,  or  on  either  flank, 
are  apt  to  be  occasioned  by  some  morbid  growth  of  the  kid- 
ney, or  by  an  abscess  in  it  or  its  surroundings,  or  in  the  psoas 
muscles.  Again,  they  may  be  due  to  fecal  accumulations; 
or,  if  on  the  right  side,  to  very  considerable  increase  of  the 
liver;  if  on  the  left,  to  a  greatly  enlarged  spleen.  To  dis- 
criminate between  these  ditfere*nt  conditions,  we  have  to  de- 
termine whether  the  swelling  fluctuates  or  not;  we  must 
also  analyze  the  urine,  and  inquire  minutely  into  the  cir- 
cumstances preceding  and  attending  the  tumefaction.  It  is 
thus  only  that  we  can  hope  to  attain  the  necessary  data  for  a 
diagnosis,  which  has,  indeed,  often  to  be  reached  by  the  pro- 
cess of  exclusion. 

Tumors  behind  the  peritoneum  may  give  rise  to  a  visible 
prominence  in  either  lumbar  region,  extending  to  the  upper 
part  of  the  iliac  region.  The  most  common  cause  of  these 
tumors  is  cancer  of  the  lymphatic  glands  lying  by  the  sides 
or  in  front  of  the  verbebral  column.  The  disease  is  very  dif- 
ficult of  detection.  Still,  we  may  suspect  its  existence  if,  in 
a  patient  who  is  evidently  cachectic,  and  who  is  steadily  losing 
flesh  and  strength,  we  discover,  on  deep  palpation  on  one 
side  of  the  linea  alba  or  in  the  flank,  a  tumor  which,  owing 
to  its  being  surrounded  by  intestine,  returns  a  tympanitic 
percussion  sound.  In  some  cases  the  swelling  communicates 
the  beat  of  the  aorta  and  simulates  an  aneurism,  or  it  presses 
on  the  vena  cava  and  gives  rise  to  enlargement  of  the  abdom- 
inal veins  and  of  those  of  the  lower  extremities,  and  to  oedema 
of  the  legs.  The  disease  may  involve  the  iliac  glands  and  the 
tumor  extend  into  the  pelvis,  or  it  may  reach  upward  to  the 
diaphragm;  and  by  the  cancer  spreading  to  the  posterior 
mediastinum  and  softening,  it  may  finally  open  into  the  aorta, 
producing  hemorrhages  precisely  like  those  coming  from  an 
aneurismal  sac* 


*  Case  reported  hy  Haldaiie,  Edinb.  31ed.  Journal,  Aug.  1868. 

37 


578  MEDICAL   DIAGNOSIS. 

Iliac  Regions. — Tumors  in  either  of  these  regions  may  be 
due  to  many  cliflerent  causes.  They  are,  as  we  have  else- 
where discussed,  principall}^  owing  to  ovarian  aifections ;  to 
fecal  accumulations ;  to  diseases  of  the  large  intestine,  such 
as  intussusception  or  cancer ;  and  to  pelvic  abscess.  Some- 
times they  are  caused  by  displacement  of  the  kidney,  by  en- 
largement of  the  spleen,  and  in  women  by  periuterine  htema- 
tocele,  or  by  extra-uterine  pregnancy. 

The  ovarian  tumors  are,  as  a  rule,  distinguished  from  the 
other  disorders  mentioned  by  their  more  or  less  globular 
form,  by  their  movability  from  side  to  side  or  in  an  upward 
direction,  by  their  seeming  to  spring  out  of  the  pelvis,  and 
their  evident  attachment  below,  by  the  displacement  of  the 
womb,  by  the  comparatively  unimpaired  general  health,  and 
by  their  indolent  and  generally  painless  nature.  These  re- 
marks do  not  apply  to  the  very  slight  swelling  occasioned  by 
ovarian  inflammation,  for  here  the  tumid  spot  is  often  the 
seat  of  severe  pain.  The  healthy  ovary  is  not  sensitive  to 
the  touch.  To  examine  the  ovar}^  with  exactness,  the  abdom- 
inal muscles  must  be  as  completely  as  possible  relaxed;  the 
patient  is  best  placed  in  the  attitude  recommended  by  Dr. 
Marion  Sims  :  on  her  back,  with  the  shoulders  supported, 
the  legs  drawn  up  so  that  the  heels  are  a  few  inches  asunder, 
and  that  the  thighs  fall  easily  apart. 

But  to  return  to  ovarian  tumors.  As  these  ffrow  and 
spread  upward  they  give  rise  to  difliculties  in  diagnosis, 
which  we  have  already  examined  into,  so  far  at  least  as  is 
possible  in  a  work  of  this  kind.  We  may  here  again  allude  to 
the  manner  in  which  ovarian  may  simulate  renal  growths, — a 
similarity  so  close  that  even  as  accomplished  an  expert  as 
Mr.  Spencer  Wells  has  been  deceived.  This  distinguished 
authority  dwells  particularly*  on  the  absence  of  fluctuation  in 
the  vast  majority  of  instances  of  enlarged  kidney;  on  the 
renal  tumor  being  first  detected  between  the  false  ribs  and 
the  ilium ;  on  the  signs  in  the  urine,  and  on  the  absence  of 
those  changes  in  the  quantity  and  regularity  of  the  menstrual 
discharo^es  which  are  common  in  ovarian  disorders.     More- 


*  Dublin  Quarterly  Journal,  Feb.  18G7. 


ABDOMINAL  EXLARGEMENT.  579 

over,  the  ovarian  growth  usually  displaces  the  intestine  back- 
ward ;  in  the  renal  growth  it  is  pressed  forward ;  and  large 
tumors  of  the  right  kidnev  ordinarily  have  the  ascendinff 
colon  on  their  inner  border,  while  tumors  of  the  left  kidney 
are  generally  crossed  from  above  downward  by  the  descend- 
ing colon. 

Among  the  causes  of  a  tumor  in  either  iliac  fossa  periuterine 
hasmatocele  has  been  mentioned.  The  tumor  rising  above 
the  brim  of  the  pelvis  is  traceable  into  it,  and  the  quick 
manner  in  which  the  swelling  has  formed,  the  faintness  and 
prostration  which  the  effusion  of  blood  occasioned,  and  the 
swelling,  commonly  of  rounded  shape,  either  hard  or  soft, 
discernible  by  an  examination  through  the  vagina,  render 
the  meaning  of  the  tumor  generally  a  clear  one.  Much  the 
same  physical  phenomena  are  presented  by  the  swelling  due 
to  pelvic  cellulitis.  But  the  slow  way  in  which  the  tumor 
forms,  the  presence  of  that  hot,  putfy,  thickened,  brawnlike 
condition  of  the  vaginal  wall,  so  especially  dwelt  upon  by 
Simpson,  the  usually  greater  tenderness  of  the  swelling  felt 
through  the  walls  of  the  vagina,  and  the  feverishness  and 
constitutional  symptoms  attending  the  gradual  formation  of 
the  abscess,  are  distinguishing  marks,  excepting  where  the 
contents  of  the  hfematocele  suppurate ;  when  for  a  differential 
diagnosis  we  may  have  to  rely  on  the  history  of  the  case. 

Hypogastric  Region.. — Distention  of  the  bladder  and  enlarge- 
ment of  the  uterus,  whether  produced  by  air,  by  liquid,  by  a 
morbid  growth,  or  by  pregnancy,  are  the  most  usual  sources 
of  a  swelling  in  this  region.  If  due  to  either  of  these  causes, 
the  outline  of  the  tumor  is  regular  and  rounded ;  and  by  the 
aid  of  the  catheter,  of  explorations  through  the  vagina  and 
the  rectum,  and  of  the  history  of  the  case  and  the  attending 
symptoms,  we  are  generally  enabled  to  arrive  at  a  correct 
diagnosis. 

A  tumor  in  the  hypogastrium  may  also  have  its  origin  in 
splenic  enlargement,  in  disease  of  the  peritoneum,  or  in 
hfematocele.  In  the  latter  case,  it  is  apt  to  be  uniform,  and 
to  extend  to  the  iliac  fossse. 

In  concluding  this  sketch  of  abdominal  tumors,  we  shall 
briefly  glance  at  those  which  are  likely  to  occupy  more  than 


580  MEDICAL    DIAGNOSIS. 

one  region,  and  sometimes  even  the  whole  or  the  greater  part 
of  the  abdomen.  In  rare  instances,  a  cancer  of  the  liver,  or 
hydatids  of  that  organ,  or  a  fibrous  tumor  of  the  uterus,  or  a 
solid  ovarian  growth,  or  an  enlarged  spleen,  or  a  kidney  the 
pelvis  of  which  has  become  enormously  distended  in  conse- 
quence of  obstruction  of  the  ureter,  may  lead  to  the  forma- 
tion of  a  swelling  which  occupies  nearly  the  entire  abdomen. 
But  the  most  usual  cause  of  so  extensive  a  tumor  is  malig- 
nant disease  of  the  peritoneum. 

This  affection  may  give  rise  to  a  uniform  swelling  stretch- 
ing across  the  abdomen,  and  equally  extensive  on  both  sides  of 
the  median  line,  or,  as  is  not  at  all  unusual,  to  several  small 
tumors,  which  are  evidently  unconnected  with  any  organ  be- 
neath. It  is,  moreover,  apt  to  occasion  a  peritoneal  friction 
sound,  to  exhibit  a  varying  resistance  to  pressure  at  different 
points,  to  lead  to  ascites,  to  loss  of  flesh  and  appetite,  and  to  the 
occurrence  of  irritative  fever.  Much  the  same  sj^mptoms  may 
be  produced  by  hydatid  disease  of  the  peritoneum,  though 
here  there  is  usually  less  fever,  the  swelling  is  even  more 
irregular,  the  abdominal  enlargement  greater,  and — the  test 
which  alone  is  certain — we  may  be  able  to  detect  the  hydatid 
fremitus.*  Peritoneal  abscesses  inclosed  by  adhesions  will 
also,  if  large,  give  rise  to  several  of  the  signs  of  a  cancer;  but 
the  history  of  an  antecedent  local  or  general  peritonitis,  the 
swelling  not  being  influenced  by  changes  in  the  posture  of 
the  patient  or  by  the  acts  of  respiration,  the  indistinct  fluctu- 
ation of  the  tumefaction,  and  its  acute  course,  will  ordinarily 
enable  us  to  distinguish  the  non-malignant  from  the  malig- 
nant affection. 

In  some  cases,  too,  the  malignant  disease  is  closely  simu- 
lated by  dilatation  of  the  colon.  This,  though  it  may  present 
but  a  single  swelling,  generally  occasions  several,  which  are 
commonly  seated  at  the  middle  third  of  the  abdomen,  are  apt 
to  appear  on  both  sides,  be  movable,  change  their  position 
slightly  at  intervals,  and  become  occasionally  less  in  size. 
Then,  after  the  case  has  been  for  some  time  under  observa- 

*  See  the  cases  of  Bright,  in  Clinical  Memoirs  on  Abdominal  Tumors,  re- 
published from  Guy's  Hospital  Reports  hj  the  New  Sydenham  Society. 


ABDOMINAL    PULSATION.  581 

tion,  we  may  be  able  to  notice  large  and  characteristic  dis- 
charges; though  we  must  not  forget  that  a  mere  sluggish  state 
of  the  bowels,  or  even  diarrhoea,  may  exist  while  the  colon  is 
dilated  and  perhaps  filled  with  fecal  accumulations.* 


SECTION  Y. 

ABDOMINAL   PULSATION. 

Aortic  Pulsation. — By  far  the  most  frequent  cause  of  a 
pulsation  visible  in  the  abdomen,  and  especially  at  the  epi- 
gastric region,  is  a  throbbing  of  the  abdominal  aorta.  It  is 
not  at  all  uncommon  in  hysterical  persons.  Some  women 
are  liable  to  it  immediately  before  their  menstrual  periods  or 
during  the  earlier  months  of  pregnancy.  In  men  it  is  most 
often  seen  in  those  who  suffer  from  inveterate  dyspepsia ;  and 
is  apt  to  come  on  in  severe  paroxysms,  which  are  ver}-  alarm- 
ing to  the  patient,  but  which  generally  disa[)pear  under  brisk 
purging.  In  hypochondriacs  whose  abdominal  walls  are  thin, 
the  beating  at  the  epigastrium,  from  which  they  may  sutier, 
becomes  a  source  of  continued  study  and  distress. 

The  increased  action  of  the  aorta,  or,  as  happens  in  ema- 
ciated persons,  the  greater  distinctness  with  which  the  beat 
of  the  artery  is  perceived,  without  there  being  really  much, 
if  any,  abnormal  throbbing,  may  be  distinguished  from  an 
enlarged  and  somewhat  displaced  heart  by  the  circumstances 
of  the  case  and  the  absence  of  any  physical  signs  of  cardiac 
disease  ;  and  from  an  aneurism,  by  the  mode  of  invasion,  and 
by  the  want  of  those  signs  which,  as  will  be  presently  de- 
scribed, characterize  an  aneurism. 

Abdominal  Aneurism.  —  Aneurism  of  the  abdominal 
aorta  is  a  disease  of  middle  life,  and  of  males.  Its  most  fre- 
quent cause  is  excessive  muscular  exercise;  sometimes  it  is 
produced  by  a  blow  on  the  abdomen.     Its  duration  is  very 


*  For  several  interesting  cases  of  the  disorder,  see  Kennedy,  loc.  cit. 


582  •  MEDICAL   DIAGNOSIS. 

uncertain :  occasionally  six  or  seven  years  elapse  from  its 
earliest  indications  until  the  fatal  termination  ;  and  not  un- 
usually the  patient  lives  twenty  to  thirty  months  after  the 
outbreak  of  the  manifestations  of  the  complaint. 

The  chief  symptoms  of  the  aneurismal  disorder  are  pain, 
and  an  absence  of  dropsy,  of  fever,  or  of  any  considerable 
constitutional  disturbance.  The  pain  is  generally  felt  in  the 
back,  or  in  the  right  hypochondrium,  or  shooting  down  the 
sciatic  nerves  to  the  lower  limbs.  It  may  be  constant  and 
dull,  or  occur  in  protracted  and  violent  paroxysms  ;  ordinarily 
there  is  a  persistent  pain  which  has  periods  of  fierce  exacer- 
bation. The  disproportion  between  its  violence  and  the 
otherwise  almost  unimpaired  health  is  a  striking  and  com- 
mon feature  of  the  disease,  and  is  apt  to  continue  until  the 
aneurism  becomes  very  large  and  occasions  displacement  of 
important  organs. 

The  2)hysical  signs  of  an  abdominal  aneurism  are:  an  im- 
pulse communicated  to  the  hand  when  placed  over  the 
swelling;  a  systolic  blowing  sound;  a  thrill;  and  in  some 
instances  a  distinct  prominence  and  alteration  in  the  form  of 
the  abdomen.  The  impulse  corresponds,  with  very  rare  ex- 
ceptions, to  the  beat  of  the  heart,  is  single,  and  ordinarily 
very  forcible.  Generally  it  cannot  be  felt  from  behind ;  it  is 
a  beat  discerned  o\\\j  anteriorly  and  on  either  side  of  the 
pulsating  sac.  Corresponding  to  the  throbbing  of  the  tumor, 
we  often  hear  a  short  blowing  sound,  sometimes  perceived 
in  the  recumbent  posture  only,  or  a  dull,  muffled  sound; 
but  rarely  are  there  two  sounds,  A  thrill  felt  at  the  same 
time  as  the  pulsation  is  not  unfrequently  noticed;  still,  it 
may  be  absent,  even  in  large-sized  aneurisms. 

Aneurism   of  the   abdominal   aorta  may  be   confounded 
with — 

Rheumatism  ;  Neuralgia  ;  Colic  ; 

Disease  of  the  Spine  ; 

Aortic  Pulsation  ; 

Lumbar  and  Psoas  Abscess  ; 

Non-aneurismal  Pulsating  Tumor. 

The  first  four  of  these  aftections  are  likely  to  be  mistaken 
for  an  abdominal  aneurism,  on  account  merely  of  the  pain  ; 


ABDOMINAL    PULSATION.  583 

the  others,  because  of  the   presence  of  pulsation,  or  of  a 
swelling,  or  of  both  pulsation  and  swelling. 

Bheumatism;  Neuralgia;  Colic. — The  pain  caused  by  an 
aneurism  may  closely  simulate  rheumatism  of  the  lumbar 
muscles,  or  sciatica,  or  abdominal  neuralgia,  or  colic.  There 
is  nothing  in  the  pain  itself  which  would  lead  to  the  detec- 
tion of  its  origin  ;  this  can  only  be  etfected  by  a  recogni- 
tion of  the  physical  signs  of  the  aneurism.  When  these 
are  not  well  defined,  the  diagnosis  is  doubtful.  Yet,  even 
when  they  are  slightly  marked  or  absent,  if  the  pain  be  very 
obstinate,  and  we  have  excluded  the  affections  named  or 
cannot  trace  them  to  their  usual  causes,  we  shall  often  be 
right  in  attributing  the  pain  to  an  aneurism.  This  is  espe- 
cially true  as  regards  abdominal  neuralgia  occurring  in 
males, — a  disorder  which  ought  always  to  make  us  examine 
for  an  aneurism,  and  which  is  not  unfrequently  found  to  be 
due  to  it. 

Disease  of  the  Spine.  —  Patients  who  are  suffering  from 
aneurism  often  complain  of  pain  in  the  spine,  and  present 
sometimes  an  obvious  spinal  curvature.  But  a  careful  exam- 
ination, by  detecting  the  physical  signs  of  an  aneurism,  v.-ill 
generally  enable  us  to  distinguish  the  source  of  the  trouble. 
The  constant  boring  pain  so  much  complained  of  in  cases 
of  aneurism,  is  usually  thought  to  be  due  to  absorption  of  the 
vertebrae ;  but,  as  the  observations  of  Stokes  have  proved,  it 
has  no  necessary  connection  with  this  lesion. 

Aortic  Pulsation. — Simple  abdominal  pulsation,  such  as  we 
observe  in  hysteria,  in  dyspepsia,  and  in  pregnancy;  or  ex- 
cessive pulsation  in  the  abdomen  due  to  an  enlarged  right 
ventricle,  or  to  insufficient  aortic  valves, — may  be  readily 
mistaken  for  an  aneurism.  But  in  the  former  case  the  his- 
tory will  generally  lead  us  to  a  correct  conclusion,  especially 
if  taken  in  connection  with  the  facts,  that  the  pulsation  is 
not  heavy  and  slow,  as  in  an  aiieurism,  but  jerking  and  sud- 
den;  that  there  is  no  thrill;  no  tumor  with  corresponding 
dulness  on  percussion,  if  we  except  pregnancy;  no  systolic 
murmur  audible  in  front  of  the  abdomen  or  along  the  spine; 
and  no  pain. 

The  pulsation  due  to  disease  of  the  heart  is  discriminated 


584  MEDICAL   DIAGNOSIS. 

by  the  physical  signs  iu  the  thorax.  Regurgitation  at  the 
aortic  orifice,  which  is  the  cardiac  affection  most  liable  to  be 
confounded  with  an  aneurism,  on  account  of  the  marked  pul- 
sation it  may  occasion  in  the  left  hypochondrium  or  at  the 
serobiculus  cordis,  is  distinguished  by  the  single  or  double 
blowing  sounds,  which  are  heard  not  only  over  the  thorax, 
but  over  so  many  arteries  of  the  body. 

Lumbar  and  Psoas  Abscess. — In  some  cases,  soft,  fluctuating, 
deep-seated  tumors,  which  are  really  produced  by  an  aneu- 
rism, may  arise  in  the  lumbar  region  ;  nay,  they  may  seem 
to  point,  as  happens  in  psoas  abscess,  at  Poupart's  ligament. 
But,  unlike  an  abscess,  the  effusions  of  blood  give  rise,  with 
rare  exceptions,  to  impulse  and  to  murmur. 

Non-aneurismal  Pulsating  Tumors. — When  a  tumor  of  any 
kind  presses  upon  the  aorta,  a  distinct  pulsation  is  communi- 
cated, which  is  very  apt  to  be  mistaken  for  an  aneurism  ;  and 
the  similarity  to  this  is  heightened  by  the  circumstance  that 
the  morbid  growth  may  produce  a  murmur.  The  tumors 
which  most  usually  occasion  the  phenomena  mentioned,  are 
enlargement  of  the  left  lobe  of  the  liver,  cancer  of  the  py- 
lorus, disease  of  the  pancreas,  or  in  the  omentum  or  mesen- 
tery; and,  in  rarer  instances,  enlargement  and  distention  of 
the  kidney,  fecal  accumulation,  and  cancer  of  the  lumbar 
inlands. 

Now,  to  avoid  error,  we  must  pay  close  attention  to  the 
history  of  the  disorder;  we  must  trace,  by  percussion,  the 
outline  of  the  solid  mass,  and  see  if  it  correspond  with  any 
viscus;  we  must  lay  stress  on  the  presence  of  digestive  disor- 
ders, and  on  the  amount  of  constitutional  disturbance — both 
of  which  are  so  slight  in  abdominal  aneurism ;  we  must  ex- 
amine the  urine  carefully,  and  find  out  whether  there  are 
renal  symptoms  in  the  case.  Then,  in  non-aneurismal  tumor 
the  patient  has  almost  always  been  in  bad  health  before  the 
tumor  is  detected,  and  the  swelling  rarely  causes  pain  of  such 
severity  as  is  observed  in  an  aneurism:  moreover,  the  trans- 
mitted aortic  impulse  is,  as  a  rule,  lessened  by  placing  the 
patient  on  his  hands  and  knees,  thus  taking  away  the  press- 
ure from  the  artery.  A  varicose  state  of  the  epigastric  veins 
and  tlic  existence  of  ascites  will  also  decide  against  the  diag- 


ABDOMINAL    PULSATION.  585 

nosis  of  an  aneurism;  while,  on  the  other  hand,  the  lateral 
as  well  as  the  forward  direction  of  the  impulse,  violent  neu- 
ralgic pains  in  the  loins  or  shooting  down  the  back,  and  an 
immovable  tumor  are  in  its  favor.  Still,  there  are  cases  in 
which  a  morbid  growth  lying  across  the  aorta  may  occasion 
symptoms  so  nearly  like  those  of  an  aneurism,  that  the  most 
skilful  diagnostician  linds  himself  at  a  loss  to  determine  their 
real  meaning. 

In  these  remarks  on  abdominal  aneurism,  it  has  been 
assumed  that  certain  well-defined  physical  signs  are  always 
present.  But  it  is  very  necessary  to  be  aware  that  there  are 
cases  in  which  the  physical  signs  are  obscure  or  absent,  and 
in  which  an  aneurism  affords  no  indication  of  its  existence, 
beyond,  perhaps,  pain.  Under  these  circumstances  we  may 
suspect  the  occurrence  of  the  affection,  but  we  cannot  be 
certain  of  it. 

But  supposing  that,  from  the  combination  of  the  physical 
signs  and  s^-mptoms,  we  are  certain  that  we  are  dealing  with 
an  abdominal  aneurism,  can  we  be  sure  that  it  is  aortic  ?  We 
cannot;  for,  although  this  is  generally  its  seat,  an  aneurism 
of  the  splenic  or  the  cjeliac  artery,  of  the  superior  mesenteric 
artery,  or  of  the  renal  artery,  may,  so  far  as  the  collected 
cases  enable  us  to  judge,  produce  the  same  phenomena.* 

When  an  aneurism  bursts,  it  gives  rise  to  symptoms  which 
vary  much  with  the  seat  of  the  rent.  The  blood  is  often 
effused  behind  the  peritoneum  or  into  it.  Death  may  not 
follow  for  several  days;  but  usually  very  great  tenderness  of 
the  abdomen,  not  due  to  inflammation,  and  changes  in  the 
physical  signs  are  at  once  produced  by  the  accident. 

*  See  Ballard,  Physical  Diagnosis  of  Diseases  of  the  Abdomen,  page  217. 


CHAPTER  VII. 

ON  THE  URINE,  AND  ON  DISEASES  OF  THE  URINARY  ORGANS. 

The  diseases  of  the  urinary  organs  with  which  the  prac- 
titioner of  medicine  has  to  deal  are  mainly  those  of  the  kid- 
ney. In  the  delineation  about  to  be  attempted,  they  chiefly 
will  be  discussed;  and  along  with,  or  rather  for  the  most 
part  preceding  their  consideration,  I  shall  brieflj'  notice  the 
urine  in  its  pathological  and  clinical  aspects. 

URINE. 

Physiology  teaches  us  that  the  main  function  of  the  kid- 
neys is  to  remove  water  and  nitrogen  from  tlie  system,  at  the 
same  time  that  it  takes  from  the  blood  many  of  its  salts.  The 
excreted  liquid  contains,  therefore,  a  variety  of  elements,  and 
by  its  study  we  are  fortunately  enabled  to  arrive  not  only  at 
the  condition  of  the  organ  which  prepares  it,  but  also  at  the 
state  of  the  circulating  fluid,  and  often  indirectly  at  that  of 
several  viscera,  the  disorders  of  which  give  rise  to  impuri- 
ties in  the  blood,  which  the  kidneys  endeavor  to  eliminate. 
Hence  the  urine,  besides  being  the  most  accurate  index  of 
the  condition  of  the  urinary  organs,  also  becomes  a  fair  in- 
dication of  that  of  many  of  the  more  important  secreting 
glands  in  the  body;  and  furthermore,  though  to  a  less  ex- 
tent, throws  some  light  on  the  workings  of  the  nervous 
system. 

But  to  glean  the  full  benefit  from  an  analysis  of  the  urine, 
we  must  be  acquainted  with  its  complex  composition  ;  be  able 
to  explore  it  not  merely  qualitatively,  but  quantitatively,  and 
be  accustomed  to  examine  its  deposits  with  the  microscope. 
An  immense  field  of  useful  research  is  thus  thrown  open,  tho 
(586) 


THE    URINE,  AND    DISEASES    OF   THE    URINARY   ORGANS.      587 

limits  of  which  are  indeed,  in  our  time,  almost  daily  widen- 
ing by  the  active  exertions  of  many  devoted  laborers.  Modern 
chemistry  especially  is  endeavoring  to  tind  means  which  will 
bring  it  within  the  power  of  the  busy  practitioner  to  deter- 
mine, by  apt  volumetric  processes,  the  exact  proportion  of  the 
ingredients  as  accurately  and  as  easily  as  hitherto  we  have 
detected  their  presence.  But  this  is  a  subject  which  cannot 
be  .more  than  indicated  in  these  pages;  in  this  brief  inquiiy, 
only  such  of  these  ingenious  investigations  will  be  noticed  as 
have  furnished  results  that  may  be  made  readily  available 
for  the  exigencies  of  professional  life.  A  few  remarks,  how- 
ever, as  to  the  mode  of  procedure :  we  must  have  at  hand 
accurate  test  solutions,  the  strene-th  of  which  is  exactly 
known;  be  provided  with  graduated  pipettes,  for  sucking 
up  and  measuring  the  fluid  to  be  examined  prior  to  its  trans- 
fer to  a  convenient  vessel  ;  and  with  graduated  glass  instru- 
ments, or  burettes,  from  which  exact  quantities  of  the  test 
solutions  may  be  dropped.  Graduated  flasks,  also,  for  the 
preparation  of  the  solutions  of  the  reagents  are  very  useful, 
and  beaker  glasses  to  hold  the  urine.  It  is  further  customary, 
in  the  quantitative  analyses,  to  use  the  French  system  of 
measures,  and  to  employ  instruments  on  which  cubic  centi- 
metres are  marked.  One  thousand  cubic  centimetres  are 
equal  to  one  litre,  or  61-028  English  cubic  inches,  or  to  a 
thousand  grammes  of  water;  and  one  gramme  is  equal  to 
15-434  troy  grains. 

The  urine,  in  its  healthy  state,  is  a  fluid  of  acid  reaction, 
of  an  amber-yellow  color,  and  of  a  speciflc  gravity  of  about 
1018  to  1020  as  compared  with  distilled  water  at  1000.  On 
standing  from  eight  to  twelve  hours,  a  slight  cloudy  deposit 
takes  place,  consisting  mainly  of  epithelial  cells  from  the 
urinary  passages,  and  of  a  few  crystals. 

The  manner  of  obtaining  a  specimen  of  urine  is  not  unim- 
portant. We  should  always  instruct  our  patient,  as  is  so 
strongly  recommended  by  Sir  Henry  Thompson,*  to  pass  the 
first  two  ounces  into  one  vessel,  and  the  remainder  into  an- 
other.    We  thus  procure  a  specimen  of  the  renal  secretion, 


*  Clinical  Lectures  on  Diseases  of  the  Urinary  Organs. 


588  MEDICAL   DIAGNOSIS. 

in  addition  to  anything  in  the  bladder,  separate  from  any 
urethral  products,  and  avoid  the  error  of  confounding  pros- 
tatic or  urethral  with  vesical  or  renal  disease.  When  it  is 
essential,  for  a  positive  diagnosis,  to  obtain  a  specimen  of 
urine  absolutely  pure,  and  unmixed  with  products  of  the 
bladder,  the  same  authority  recommends  the  drawing  off  of 
the  urine  by  means  of  a  soft  gum  catheter,  of  medium  size, 
w^hile  the  patient  is  standing.  The  bladder  should  then  be 
carefully  washed  out  by  repeated  small  (one  ounce)  injec- 
tions of  warm  water.  The  urine  is  now  to  be  permitted  to 
pass,  as  it  will  do,  drop  by  drop,  into  a  small  glass  vessel.  The 
bladder  contracts  around  the  catheter,  and  the  urine  perco- 
lates direct  from  the  ureters,  through  their  virtual  prolonga- 
tion,— the  catheter, — into  the  receptacle.  The  urine  passed 
in  the  morning,  immediately  after  rising,  will  be  found  to 
represent  with  sufficient  accuracy  the  general  process  of  dis- 
assimilation;  but  if  greater  accuracy  be  desirable,  a  specimen 
of  the  mixed  urine  of  the  twenty -four  hours  sbould  be  used. 

The  quaniiii/  of  urine  daily  voided  is,  at  a  low  estimate, 
from  thirty-five  to  forty  ounces  ;  Vogel  places  it  at  fifty-seven 
ounces,  and  some  observers  even  higher.  Becquerel  states 
tbe  diurnal  average  to  be  in  men  forty-four,  and  in  women 
forty-seven  ounces.  In  summer,  when  the  skin  is  acting 
freely,  less  fluid  passes  off  by  the  kidneys  than  in  winter. 
The  more  liquid  that  is  taken  into  the  system,  the  greater  is 
the  secretion  of  urine,  unless  the  other  organs  which  elim- 
inate water,  as  the  skin,  lungs,  and  intestines,  are  excreting 
with  unwonted  activity. 

The  quantity  is  diminished  in  all  cases  of  increased  specific 
gravity,  with  the  exception  of  diabetes,  in  which  it  is  largely 
increased;  it  is  diminished  in  acute  diseases,  in  fevers,  and 
in  the  early  stage  of  dropsies ;  in  some  forms  of  Bright's  dis- 
ease through  their  entire  course ;  and  in  the  last  stage  of  all 
forms.  It  is,  on  the  other  hand,  augmented  in  all  cases  of 
diminished  specific  gravity;  in  hysteria;  in  the  atrophic, 
nodular  kidney,  in  the  contracted  kidney,  and  in  waxy  dis- 
ease. In  almost  all  vesical  and  kidney  aft'ections  frequent 
micturition  is  a  marked  symptom;  not  alwaj^s,  however, 
associated  with  increased  quantity  of  urine. 


THE    URINE,   AND   DISEASES    OF    THE    URINARY    ORGANS.       589 

The  ivgredienis  of  urine  are  very  various.  The  principal 
are:  urea,  the  alkaline  sulphates,  phosphates,  uric  acid  and 
urates,  chloride  of  sodium,  mucus,  coloring  matter,  and  a 
large  proportion  of  water.  Small  quantities  of  lime,  silica, 
alumina;  of  iron,  hippuric  acid,  and  carbonic  acid  have  also 
been  detected  by  careful  analysis. 

Yet  it  is  not  only  requisite  to  be  aware  of  the  ingredients, 
but,  so  as  to  have  a  basis  for  comparison,  it  is  necessary  to 
know  the  quantity  of  each  ingredient  commonly  present  in 
healthy  urine.  Here  is  Lehmann's  analysis  of  1000  parts, 
and  side  by  side  with  it  Thudichum's  estimate  of  the  average 
composition  of  the  urine  passed  within  twenty-four  hours; 


, Lehmaxn 

Water 

932-019 

Solid  matter 

G7-981 

Urea 

32-909 

Uric  acid 

1-098 

Lactic  acid 

1  513 

Lactates 

1-732 

Water  extract      .... 

■632 

Spirit  and  alcohol  extract 

10-872 

Chloride  of  sodium,            ") 
Chloride  of  ammonium,  / 

3-712 

Alkaline  sulphates    .     .     . 

7-321 

Phosphate  of  soda     .     .     . 

3  989 

Phosphates  of  lime  ") 
and  magnesia,         J 

1-108 

Mucus 

-110 

-Thxjdichum- 


1345  to  1534  grammes. 
850  to 
4G3  to 


850  to  1020  grains. 


617 
7-5 
4-5 
70 


(1 


1 


Undetermined. 


i  -0  irrains. 


92  to  123      " 


Water     . 
Solids      . 

Urea    . 

Uric  acid 

Creatine  .     . 

Creatinine    . 

Sarkine    .     . 

Ur£ematine  . 

Uroxanthine 

Hippuric  acid 

Chlorine  .     . 

(or  chloride  of 
sodium)     .     154  to  200 

Sulphuric  acid     23  to    38 

Phosphoric  acid  .     .     56 

Potassa  and  soda,        "I    Undcter- 

Lime  and  magnesia,   J         mined. 

Earthy  phosphates   .    19  grains. 

Iron Undetermined 

Ammonia   ....    10  grains. 

Trimcthylamine,  ] 

Carbonic  acid, 

Phenj-lic  acid, 

Damaluric  acid, 


u 
(I 
l( 


|-  Undetermined. 


Some  of  these  constituents  are  derived  entirely  from  the 
food  ;  others  from  the  metamorphosis  of  tlie  tissues.  Hence 
we  find  them  in  increased  or  diminished  quantities  in  the 
urine,  as  a  greater  or  smaller  supply  enters  the  body,  or 
according  to  the  activity  of  the  process  of  nutrition.     Their 


590  MEDICAL    DIAGNOSIS. 

amount  is  furthermore  influenced  bj'  the  power  of  elimina- 
tion of  the  kidneys  and  the  proportion  excreted,  and  some- 
times vicariously  excreted,  by  the  skin,  lungs,  and  intestines. 

Besides  the  elements  mentioned,  the  quantities  of  which 
it  is  evident  must  fluctuate  much  when  the  system  is  de- 
ranged, we  meet,  in  morbid  states,  with  substances  that  do 
not  exist  at  all  in  healthy  urine,  or  the  presence  of  which  is, 
to  say  the  least,  doubtful,  such  as  albumen,  sugar,  blood,  bile, 
fats,  oxalate  of  lime,  and  certain  pigments.  Some  of  these 
are  dissolved  in  the  urine,  and  are  not  detected,  except  by 
chemical  tests;  others  soon  form  in  sediments  after  the  urine 
has  been  discharged,  and  may  be  at  once  recognized  by  the 
microscope. 

Having  thus,  in  a  general  manner,  mentioned  the  constit- 
uents of  the  urine,  habitual  and  accidental,  let  us,  in  the 
same  general  manner,  look  at  the  points  of  clinical  interest 
to  be  decided  by  an  analysis  of  the  urine  ;  in  other  words, 
let  us  endeavor  to  ascertain  what  the  physician,  not  the  pro- 
fessed chemist,  is  commonly'  in  quest  of  in  his  explorations. 
And  here  it  may  be  stated  that,  in  a  search  of  the  kind,  we 
are  always  somewhat  guided  by  our  knowledge,  of  the  nature 
of  the  case.  We  would,  for  instance,  be  most  likely  to  look 
for  albumen  in  dropsical  affections ;  or  for  sugar  where  a 
large  quantity  of  urine  was  habitually  passed. 

Usually,  we  endeavor  to  fix  all,  or  very  nearly  all,  of  these 
waymarks :  the  specific  gravity,  the  color,  the  quantity,  the 
reaction,  the  presence  or  absence  of  such  important  abnor- 
mal ingredients  as  albumen  and  sugar,  and  the  character  of 
the  deposits.  Frequently,  too,  we  extend  our  examination 
until  we  have  determined  approximately,  if  not  accurately, 
the  increase  or  diminution  of  the  main  constituents  of  the 
urine,  especially  of  the  urea,  uric  acid,  chlorides,  phosphates 
and  sulphates,  and  the  distribution  or  non-distribution  of  bile 
and  other  unusual  constituents  through  the  fluid.  To  ex- 
amine these  points  more  in  detail : 

Color. — As  is  well  known,  the  color  of  the  urine  varies 
considerably.  Its  hue  is  very  much  att'ectcd  by  food  and 
medicine,  as  w^ell  as  by  various  morbid  processes ;  so  readily, 
indeed,  aftected,  that  we  must  be  very  chary  of  drawing  con- 


THE    URINE,    AND    DISEASES    OF    THE    URINARY   ORGANS.      591 

elusions  from  the  appearance  of  the  secretion  alone.  Yet  we 
may  sometimes  suspect  the  presence  of  certain  substances,  or 
be  nearly  positive  of  their  absence,  by  the  look  of  the  fluid. 
Thus  a  smoky  or  a  red  aspect  is  apt  to  be  owing  to  the 
admixture  of  blood  ;  a  very  light  color  denotes  generally  an 
increase  of  water,  and  is  commonly  found  in  diabetes,  in 
hysteria,  and  in  nervous  affections  of  a  similar  character.  It 
is  never  met  with  in  diseases  attended  with  fever,  for  the 
urine  of  persons  suiiering  from  fever  is  always  of  a  dark 
hue.  A  greenish-yellow  or  brownish  tint  of  the  discharge 
is  indicative  of  bile ;  but  a  similar  tinge  may  be  present 
when  rhubarb  has  been  taken.  Strong  coffee  darkens  the 
urine;  turpentine  darkens  and  imparts  a  violet  odor  to  it; 
senna  gives  it  a  yellowish  color  ;  tar  and  creasote  render  it 
black;  so  does  disintegrated  blood. 

In  most  of  these  instances  the  altered  appearance  is  due  to 
the  respective  coloring  matter  of  these  articles  being  excreted 
with  the  urine.  But  sometimes  the  unnatural  hue  cannot  be 
thus  accounted  for,  and  is  rather  owing  to  a  change  in  the 
normal  coloring  matter.  Now,  this  pigment,  on  which  the 
complexion  of  the  urine  depends,  has  been  subjected  by 
several  chemists  to  careful  examination,  and  consists,  accord- 
ing to  some,  of  a  substance  called  uropheein,  or  urolucmatin, 
bearing  a  close  relation  to  the  pigment  of  the  blood,  and, 
like  it,  containing  iron.  Its  presence  may  be  demonstrated 
by  adding  about  double  the  quantity  of  strong  sulphuric  acid 
to  urine,  which  then  assumes  a  decidedly  brown  tint.  If  it 
become  very  dark,  we  may  infer  that  the  quantity  of  the  uro- 
hi^matin  is  increased,  which  is  the  case  in  pyrexias  and  in 
affections  of  the  liver.  But  according  to  Schunck,*  the  color 
of  normal  urine  is  not  doe  to  one  substance,  but  to  two  dis- 
tinct and  peculiar  pigments;  one  urian,  soluble  in  alcohol  and 
ether,  the  other,  urianine,  soluble  in  alcohol,  but  insoluble  in 
ether. 

A  method  for  estimating  the  quantity  of  the  pigment  with 
accuracy  has  been  proposed  by  Vogel.t     It  consists  in  com- 

*  Proceedings  of  the  Royul  Society,  vol.  xvi.  p.  73  et  seq. 
t  Yogel  and  Neubauer,  "  Anleitung,"  etc.,  Guide  to  the  Analysis  of  Urine. 
Translated  for  the  New  Sydenham  Society  by  Dr.  Markham. 


592  MEDICAL   DIAGNOSIS. 

paring  the  hue  of  the  urine  with  a  table  of  fixed  colors  which 
serve  as  starting-points,  and  each  shade  of  which  represents 
a  definite  proportion  of  pigment. 

There  are  besides  pigments  developed  in  the  urine,  owing 
to  the  decomposition  of  substances  pre-existing  in  that  fluid. 
Thus,  for  instance,  indican  does  not  itself  impart  any  color  to 
the  urine,  but'by  its  decomposition,  to  which  it  is  very  prone, 
it  yields  indigo-blue,  indigo-red,  and  glucose.  8chunck* 
finds  it  as  a  normal  constituent  of  the  urine,  and  Carterf 
gives  the  following  test  for  its  detection:  into  a  test-tube 
pour  urine  to  the  depth  of  half  an  inch ;  to  this  add  one- 
third  of  its  volume  of  commercial  sulphuric  acid  of  the  sp. 
gr.  1830,  by  allowing  it  to  trickle  down  the  side  of  the  tube 
so  as  to  form  the  lower  stratum.  The  fluids  should  then 
be  intimately  mixed  by  agitating  them  together.  There  is 
produced,  according  to  the  amount  of  indican  present,  a 
color  varying  from  the  faintest  tinge  of  pink  or  lilac,  to  the 
deepest  indigo-blue.  Unless  due  regard  be  paid  to  these 
minutiae,  the  reactions  mentioned  will  not  be  observed.  A 
tolerably  correct  estimate  of  the  share  taken  by  the  difi:erent 
coloring  matters  in  the  production  of  a  given  ti-nt  may  be 
made  by  neutralizing  the  sulphuric  acid,  added  as  above, 
with  caustic  ammonia,  then  agitating  the  mixture  with  one- 
third  of  its  volume  of  ether,  and  allowing  it  to  remain  at 
rest  for  a  few  minutes.  The  ether  rises  to  the  surface,  hold- 
ing the  indigo-red  in  solution,  and  the  blue  in  suspension — 
if  any  have  been  generated — leaving  the  ordinary  urine  pig- 
ment dissolved  in  the  aqueous  fluid  below.  . 

There  can  be  little  doubt  that  a  considerable  number  of  the 
coloring  matters  mentioned  as  present  in  the  urine  are  pro- 
duced by  spontaneous  decomposition,  or  b}'^  the  action  of 
agents  on  substances,  either  colored  or  colorless,  existing 
in  the  urine.  Schunck  has  already  proved  the  identity  of 
indican  and  the  products  of  its  oxidation,  indigo-blue  and 
indigo-red,  with  the  uroxanthine  of  Heller,  and  the  products 
of  its  decomposition,  uroglaucine  and  urorliodinc. 


*  Philoso])hieal  Magazine,  Aug.  1857. 
f  Edinburgh  Med.  Journ.,  Aug.  1859. 


THE    URINE,   AND    DISEASES    OF    THE    URINARY    ORGANS.       593 

Uroxantliine,  or  iiidican,  as  Heller  describes  it,  is  detected 
by  dropping  twenty  to  thirty  drops  of  urine  on  at  least  five  or 
six  times  as  much  strong  hydrochloric  or  nitric  acid.  After 
the  fluid  has  been  agitated  for  some  time,  it  becomes  red  or 
faintly  violet ;  and  if  it  contain  more  than  a  very  small  quan- 
tity of  the  uroxanthine,  it  assumes  a  very  decidedly  violet  or 
blue  color.  Exposure  to  air,  too,  evolves  this  pigment,  which 
in  composition  is  closely  allied  to  hsematin  and  to  the  color- 
ing matter  of  the  bile.  It  is  noticed  in  considerable  excess 
in  very  concentrated  urine,  and  in  afltections  of  the  nervous 
system,  of  the  serous  membranes,  and  of  the  kidneys. 

Of  the  pathological  coloring  matters  peculiar  to  the  urine, 
the  purple  or  pinkish,  the  uroerythrine  of  Heller,  the  pur- 
purine  of  Bird,  is  the  most  common.  It  has  a  strong  affinity 
for  uric  acid  and  the  urates,  and  stains  their  deposit  deep- 
red  or  pink.  It  abounds  in  the  urine  of  febrile  or  inflam- 
matory diseases,  and  is  common  in  acute  rheumatism,  in 
gout,  and  in  diseases  of  the  liver.  Its  test  is  a  solution  of 
acetate  of  lead,  which  produces  a  pinkish  precipitate. 

Specific  Gravity. — We  take  the  specific  gravity  of  urine 
to  judge  of  the  solid  matter  it  contains.  The  readiest, 
although  not  the  most  exact,  means  of  proceeding,  is  by  the 
use  of  an  instrument — the  "urinometer" — now  in  the  hands 
of  nearly  every  physician.  But  for  the  implement  to  yield 
trustworthy  results,  the  fluid  should  be  brought  to  the  tem- 
perature at  which  the  urinometer  has  been  graduated — gen- 
erally 60°  F.  A  difterence  of  temperature  of  7°  F.  corresponds 
with  about  1  degree  of  the  urinometer,* 

From  the  specific  gravity  we  may  calculate  the  quantity  of 
solid  matter  passed  by  multiplying  the  number  above  1000 
by  2  for  the  specific  gravities  below^  1018,  and  by  2-33  for 
those  above.  For  instance :  in  urine  of  specific  gravity  of  1010 
there  would,  according  to  this  formula,  be  20  grains  of  solid 
matter  in  each  1000  grains  of  urine;  in  urine  of  1030,  69*90 
grains.  This  information  obtained,  it  is  easy  to  find  the 
whole  amount  of  solids  contained  in  the  urine  of  twenty-four 
hours,  by  ascertaining  first  the  quantity  passed  in  that  time, 

*  Simon,  quoted  by  Neubauer,  op.  cit. 
38 


594  MEDICAL    DIAGNOSIS. 

and  then  working  the  problem  out  by  a  very  simple  calcula- 
tion. To  take  the  first  illustration:  if  1000  gr.  yield  20  of 
solid  matter,  how  much  would  20,000  yield  ?  (the  quantity 
passed,  we  will  say,  in  twenty-four  hours). 

1000  :  20  :  :  20,000  :  x.     x  =  400  grains. 

This  method  is  not,  however,  very  precise;  indeed,  wiiere 
exactness  is  required,  the  urine  must  be  evaporated  until 
nothing  but  a  dry  residue  is  left,  which  should  then  be  care- 
fully weighed. 

The  amount  of  solids  in  healthy  urine  is  variously  estimated. 
Golding  Bird  rates  it  at  about  650  grains  in  the  twenty-four 
hours ;  Beale  and  other  recent  observers  place  it  approxima- 
tively  at  from  800  to  1000.  As  a  general  rule,  the  proportion 
is  greatest  in  persons  of  heavy  weight;  if,  therefore,  we  wish 
to  make  nice  comparisons,  the  weight  of  the  body  must 
always  be  stated.  To  ascertain  how  much  of  the  solid  matter 
consists  of  the  salts,  the  organic  substances  must  be  driven 
ofi'  at  a  red  heat.  The  following  process,  recommended  by 
i^eubauer,  insures  accuracy :  a  measured  quantity  of  urine, 
20  to  30  c.  c,  is  evaporated  in  a  porcelain  crucible  of  ascer- 
tained weight  by  means  of  the  water-bath.  When  the  residue 
has  become  nearly  dry,  from  one  to  two  grammes  of  finely 
powdered  and  carefully  weighed  spongy  platinum  are  mixed 
with  it  by  the  aid  of  a  small  platinum  wire,  and  the  whole  is 
then  evaporated  to  dryness.  The  residue,  with  the  platina,  is 
then  heated  over  a  spirit-lamp,  at  first  very  gently,  and  then 
more  strongly,  until  the  whole  of  the  carbon  in  it  is  con- 
sumed, and  the  residue  has  assumed  a  light-gray  color.  By 
subtracting  the  Aveight  of  the  crucible  and  of  the  spongy 
platinum,  we  obtain  the  amount  of  the  incombustible  salts 
in  the  urine. 

In  disease,  the  solids,  and  with  them  of  course  the  specific 
gravity,  fluctuate  very  much.  We  find  the  specific  gravity 
decidedly  increased,  rising  to  1030  or  higher,  when  sugar  or 
an  excess  of  urea  is  present,  and  when  the  urine  is  concen- 
trated and  of  deep  color.  A  low  specific  gravity  is  met  with 
in  certain  forms  of  Bright's  disease,  in  many  cases  of  hysteria, 
and  in  all  pale  urines  excepting  that  of  diabetes.  But  to  be 
accurate, — and  indeed  accuracy  in  regard  to  the  other  physi- 


THE    URINE,  AND    DISEASES    OF   THE    URINARY   ORGANS.       595 

cal  aud  chemical  properties  is  unattainable  without  attending 
to  the  same  rule, — we  must  not  lay  stress  on  the  specific 
gravity  without  taking  into  account  the  measure  of  urine 
passed  in  the  twenty-four  hours,  as  well  as  the  quantity  of 
drink  and  of  food  swallowed;  all  of  which  of  necessity  influ- 
ences the  specific  gravity.  So,  too,  does  the  activity  of  the 
tissue  metamorphosis. 

Reaction. — Healthy  urine  reddens  blue  litmus-paper — a 
proof  of  its  acid  reaction.  The  acidity  depends,  in  all  proba- 
bility, upon  acid  salts,  especially  upon  the  acid  phosphate  of 
soda.*  The  degree  of  acidity  is,  even  in  health,  not  always 
equal,  and  is  much  influenced  by  digestion,  as  Bence  Jones 
has  pointed  out.  If  no  food  have  been  taken  for  hours,  the 
discharge  is  highly  acid ;  that  passed  after  a  meal,  and  while 
the  process  of  digestion  is  going  on,  is  but  faintl}'  so,  or 
neutral,  or  even  alkaline.  In  about  three  or  four  hours  after 
meals  the  alkaline  tide  turns,  and  the  acidity  of  the  urine 
slowly  increases  until  food  is  again  taken.  There  seems, 
however,  to  be  a  limit  to  the  increase  of  acidity,  for  Bence 
Jones  found  that  continuing  to  fast  for  twelve  hours  beyond 
the  usual  meal  time  did  not  intensity  the  acidity  of  the  urine. 
The  alkalinity  of  the  urine  after  meals  is  rarely  detected  at 
the  bedside.  For,  although  it  may  be  alkaline  when  secreted 
by  the  kidneys,  it  is  generally  mixed  in  the  bladder  with 
urine  which  collected  before  or  after  the  alkaline  tide,  and 
the  mixed  urine  when  passed  may  have  an  acid  reaction. f 

The  acidity  of  the  urine  is  augmented  by  the  administra- 
tion of  the  vegetable  or  mineral  acids ;  yet  they  do  not  cause, 
even  in  large  doses,  as  great  variations  as  does  digestion. 

*  Dr.  Thudichum  announces  that  he  has  just  discovered  a  normal  free  acid 
in  the  health}'  urine,  which  he  designates  as  krj-ptophanic  acid.— (Med. 
Times  and  Gazette,  June,  1870.) 

t  Dr.  Eoberts  (Urinary  and  Eenal  Diseases)  attributes  the  occurrence  of 
the  alkaline  tide  after  meals  to  the  entrance  of  the  newly-digested  food  into 
the  blood.  "If,  as  is  believed,  the  normal  alkalescence  of  the  blood  is  due  to 
the  preponderance  of  alkaline  bases  in  all  our  ordinary  articles  of  food,  a 
meal  is,  pro  tanto,  a  dose  of  alkali,  and  must  necessarily,  for  a  time,  add  to  the 
alkalescence  of  the  blood  ;  and  as  the  kidneys  have  delegated  to  them  the 
function  of  regulating  the  reaction  of  the  blood,  the  urine  immediately  re- 
flects any  undue  addition  to,  or  subtraction  from,  the  blood's  proper  alkales- 
cence." 


596  MEDICAL   DIAGNOSIS. 

We  find,  too,  this  condition  of  the  urine  strongly  marked  if 
any  acid  be  present  in  it  which  sets  the  uric  acid  free  from 
the  ammonia  with  which  it  is  combined,  or  if  the  former  be 
in  decided  excess. 

"We  estimate  the  amount  of  free  acid  in  the  urine  by  a 
sokition  of  caustic  soda,  or  by  a  solution  of  carbonate  of  soda, 
containing  53  grammes  to  the  litre  or  530  grains  to  10,000 
grains.  Some  of  this  solution  is  added  drop  by  drop  to  100 
c.  c.  of  urine,  which  has  been  measured  oft"  in  a  beaker  glass. 
After  the  addition  of  each  half  cubic  centimetre,  a  drop  of 
the  mixture  is  placed,  by  means  of  a  glass  rod,  on  well-pre- 
pared litmus-paper.  When  the  paper  is  no  longer  reddened, 
the  analysis  is  finished;  and  by  noting  how  much  of  the 
standard  solution  has  been  used,  we  can  determine  the 
acidity  of  the  urine,  which  it  is  customary  to  express  as 
equal  to  so  many  grains  of  oxalic  acid,  that  being  the  sub- 
stance used  to  determine  the  activity  of  the  soda  solution. 

Urine,  when  voided,  remains  ordinarily  acid  for  at  least  a 
day ;  but  it  may  lose  its  acidity  much  sooner.  This  is  always 
a  significant  fact,  having  much  the  same  meaning  as  if  the 
fluid  had  been  discharged  in  a  neutral  or  alkaline  state. 

Now,  an  alkaline  reaction  may  result  from  several  causes : 
from  the  eftect  of  digestion,  as  already  mentioned;  from 
the  presence  of  a  fixed  alkali,  as  the  carbonate  of  soda  or 
potassa;  or  from  a  volatile  alkali,  due  to  the  decomposition 
of  the  urea  into  carbonate  of  ammonia.  In  the  former  case, 
heat  does  not  restore  the  color  of  the  red  litmus-paper — it  re- 
mains blue ;  in  the  latter,  a  gentle  heat  soon  brings  back  the 
original  red  tint.  Moreover,  in  alkalescence  from  either 
cause,  the  earthy  phosphates  are  precipitated,  the  fixed  alkali 
causing  the  precipitation  of  the  amorphous  phosphate  of 
lime;  while  by  the  volatile  alkali,  the  phosphates  of  ammo- 
nia and  magnesia,  in  conj unction  with  the  phosphate  of  lime, 
are  thrown  down  and  the  triple  phosphate  is  abundantly 
formed,  and  can  be  easily  recognized  under  the  microscope 
by  its  beautiful  prismatic  crystals. 

Alkalinity  of  tlie  urine  from  a  fixed  alkali  is  not  incon- 
sistent with  health.  We  have  already  alluded  to  the  effects 
of  digestion  ;   and  alkaline  urine  also  results  from  the  use 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.      597 

of  certain  articles  of  vegetable  food,  or  of  the  salts  of  soda 
and  potassa  administered  as  medicine.  Urine  owing  its 
alkalinity  to  a  volatile  alkali,  like  carbonate  of  ammonia,  is 
always  to  be  viewed  as  pathological.  The  disturbance  is 
generally  long  continued,  and  the  urine  loses  its  acidity  in 
the  bladder,  in  consequence  of  a  disease  of  the  mucous  coat 
of  the  viscus ;  or  from  being  very  long  retained  there,  as  in 
cases  of  paraplegia ;  or  from  admixture  with  pus,  which  acts 
as  a  kind  of  ferment,  and  leads  to  decomposition  of  the  urea. 

Changes  in  the  Quantity  of  the  more  Important  Con- 
stituents of  Urine. — Here  we  shall  have  mainly  to  investi- 
gate the  excess  or  deficiency  of  urea,  of  uric  acid,  the  urates, 
phosphates,  sulphates,  and  chlorides. 

Urea. — The  amount  of  urea  excreted  by  adult  males  in  the 
twenty-four  hours  is  diflferently  estimated.  Becquerel  places 
it,  in  round  numbers,  at  286;*  Bischofi',  at  542  grains;  and 
Roberts  estimates  it  in  a  healthy  adult  man  at  ?>h  grains  per 
pound  weight  of  the  body.  Thus  the  amount  is  very  vari- 
able ;  yet  it  is  not  so  variable  that  a  study  of  the  quantity 
may  not  answer  useful  practical  purposes.  Urea  is  the  prin- 
cipal product  of  the  change  of  nitrogenized  substances.  Its 
proportion  fluctuates,  therefore,  with  the  food  partaken  of,  as 
well  as  with  the  activity  of  the  transformation  of  the  struct- 
ures of  the  system  ;  and  hence  it  becomes  the  most  important 
index  of  the  waste  and  repair  of  tissues.  Exertion  of  body 
and  of  mind  leads  to  the  discharge  of  a  larger  quantity  of 
urea.  If  this  be  replaced  by  a  nourishing  diet,  nothing  is 
lost;  the  body  retains  its  health.  But  when  the  requisite 
amount  of  nitrogenized  aliment  is  not  taken,  or,  if  taken, 
cannot  be  assimilated,  owing  to  a  disturbance  in  digestion, 
the  person  wastes.  We  notice,  too,  in  acute  febrile  states, 
hand  in  hand  with  the  emaciation,  an  increase  of  this  sig- 
nificant urinary  constituentf  —  a  proof,  then,   of  the  rapid 


*  Traite  de  Chemio  Pathol.     Paris,  1854. 

t  Eosenstein,  in  his  researches  on  the  excretion  of  urea  in  exanthematous 
ty]>hus,  found  that,  in  the  commencement,  the  quantity  eliminated  with  the 
urine  is  remarkably  increased,  and  then,  according  to  the  previous  mode  of 
living  of  the  individual,  sooner  or  later  sinks,  Avith  simultaneous  increase  of 
the  fever,  to  far  beneath  the  normal  standard,  to  rise  again  with  the  aug- 
mented ingestion  of  food.— (Med.  Times  and  Gaz.,  1869,  vol.  i.  p.  90.) 


598  MEDICAL    DIAGNOSIS. 

and  unsupplied  disintegration  of  the  tissues.  "We  see  the 
same  in  inflammations,  and  in  some  cases  of  nervousness; 
also  in  certain  forms  of  indigestion,  in  which  the  food  is 
speedily  passed  off  in  the  shape  of  urea  instead  of  acting  its 
part  in  the  nutrition  of  the  economy. 

A  lessened  quantity  of  urea  is  excreted  in  many  long-con- 
tinued organic  diseases  which  slowly  and  gradually  under- 
mine the  general  health ;  but  the  diminished  amount  in  the 
urine  may  also  be  due  to  a  want  of  secreting  power  of  the 
kidneys.  The  urea  then  acts  as  a  poison  in  the  blood ;  and 
headache,  nausea,  convulsions, — in  fact,  the  train  of  symp- 
toms classed  as  urpemic  poisoning  is  encountered.  Many 
affirm  that  the  morbid  phenomena  are  not  so  much  owing 
to  the  retention  of  the  ingredient  as  to  its  decomposition  into 
carbonate  of  ammonia;  but  this  view  of  the  subject  is  contro- 
verted by  the  experiments  of  Bernard  and  of  Hammond. 

Urea  is  sometimes  not  found  in  the  urine  at  all,  or  only  in 
traces,  having  been  replaced,  as  Frerichs  tells  us,  by  leucine 
and  tyrosine. 

There  are  several  tests  for  urea ;  for  Liebig,  Bunsen,  and 
other  distinguished  chemists  have  proposed  ingenious  methods 
of  determining  both  its  presence  and  its  quantity.  Liebig's 
process  is  based  on  the  fact  that  if  bichloride  of  mercury  in 
solution,  and  bicarbonate  of  potassa  in  excess,  be  added  to  a 
solution  of  urea,  we  obtain  a  compound  of  urea  and  mercury 
which  is  perfectly  insoluble  in  water.  The  method  of  pro- 
cedure is  thus  given  :  lirst  separate  the  phosphoric  acid. 
This  is  accomplished  by  measuring  off  with  a  pipette  40  c.  c. 
of  urine,  and  adding  20  c.  c.  of  a  baryta  solution,  obtained 
by  mixing  one  volume  of  a  solution  of  nitrate  of  baryta  with 
two  volumes  of  a  caustic  baryta  solution,  both  prepared  by 
cold  saturation.  The  precipitate  is  separated  by  filtration ; 
and  15  c.  c.  (corresponding  with  10  c.  c.  of  the  urine)  of  the 
filtered  fluid  are  placed  in  small  beakers  for  each  analysis. 
To  this  quantity  of  urine  a  solution  of  nitrate  of  mercury  of 
known  strength  (and  the  strength  recommended  is  that  20  c.  c. 
of  the  solution  exactly  suffice  for  tlie  precipitation  of  the  urea 
in  10  c.  c.  of  a  standard  solution  of  urea,  in  which  this  quan- 
tity contains  precisely  200  milligrammes  of  urea)  is  added  bj' 


THE    URINE,  AND    DISEASES    OF   THE    URINARY   ORGANS.       599 

a  pipette  or  from  the  burette  in  very  small  quantities,  the  mix- 
ture being  constantly  stirred.  When  no  further  precipitation 
or  turbidity  is  observed,  a  few  drops  of  the  mixture  are  placed 
by  means  of  a  glass  rod  on  a  watch-glass,  and  some  drops  of 
a  solution  of  carbonate  of  soda  are  brought  in  contact  with 
them.  So  long  as  the  fluid  in  the  watch-glass  retains,  even 
for  some  seconds,  its  white  color,  it  still  contains  free  urea; 
and  more  of  the  test  solution  of  the  mercury  must  be  dropped 
into  the  beaker,  until,  on  a  renewal  of  test  in  the  watch-glass, 
a  distinct  yellow  color  becomes  instantly  apparent.  The 
amount  of  urea  is  now  calculated  from  the  quantity  of  the 
mercurial  solution  employed ;  flrst  we  find  how  much  the  10 
c.  c.  of  urine  contained,  and  then  the  total  discharge  in  the 
urine  passed  in  twenty-four  hours  is  readily  determined. 
When  albumen  is  present,  it  has  flrst  to  be  coagulated  by 
exposure  to  heat,  and  the  fluid  carefully  filtered  before  the 
amount  of  the  urea  can  be  ascertained. 

An  easier  method,  and  one  which  gives  results  correspond- 
ing closely  with  Liebig's,  is  Davy's,  with  the  hypochlorite  of 
soda  or  Labarraque's  solution.  With  the  imported  French 
solution  this  method,  Dr.  Austin  Flint,  Jr.,  states,*  is  all  that 
can  be  desired,  but  with  the  American  article  it  is  verv  un- 

7  »> 

certain.  The  process  is  as  follows :  a  strong  glass  tube, 
with  a  bore  not  larger  than  the  thumb  can  conveniently  cover, 
twelve  or  fourteen  inches  in  lenacth,  closed  at  one  end  and 
ground  smooth  at  the  other  extremity,  capable  of  holding 
from  two  to  three  cubic  inches,  and  graduated  into  tenths  and 
hundredths  of  a  cubic  inch,  is  filled  more  than  a  third  full 
of  mercury,  to  which  afterward  a  measured  quantity  (from  a 
quarter  of  a  drachm  to  a  drachm)  of  the  urine  to  be  examined 
is  added.  The  tube  is  then  to  be  exactly  filled  with  a  solu- 
tion of  hypochlorite  of  soda  (Labarraque's  solution).  The 
mouth  of  the  tube  is  then  instantly  tightly  covered  with  the 
thumb,  inverted  once  or  twice  to  mix  the  urine  with  the 
hypochlorite,  and  finally  placed  beneath  a  saturated  solution 
of  salt  in  water  contained  in  a  cup.  Tiie  mercury  then  flows 
out,  and  the  solution  of  common  salt  takes  its  place ;  the  mix- 


Chemical  Examination  of  the  Urine,  p.  46. 


(300  MEDICAL    DIAGNOSIS. 

tnre  of  urine  and  hypochlorite,  being  lighter  than  the  solu- 
tion of  salt,  remains  in  the  upper  part  of  the  tube.  Decom- 
position of  the  urine  soon  takes  place,  bubbles  of  nitrogen 
escape  and  collect  in  the  upper  part  of  the  tube.  When  de- 
composition is  complete,  which  is  known  by  the  cessation  of 
the  evolution  of  bubbles  of  gas,  the  quantity  collected  is  read 
oft' the  scale  on  the  tube.  When  great  accuracy  is  required, 
corrections  must  be  made  for  temperature  and  atmospheric 
pressure,  if  these  vary  from  the  standard  of  comparison. 
Each  cubic  inch  of  gas  represents  0-645  of  a  grain  of  urea. 
Several  of  the  substances  found  in  urine  during  disease,  as, 
for  example,  sugar,  albumen,  biliary  and  excess  of  urinary 
coloring  matter,  produce  scarcely  any  eftect  on  the  results 
obtained  by  this  method.*  Another  method  for  fixing  the 
quantity  of  urea  approximately  is  proposed  by  Prof.  Samuel 
Haughton.f  It  consists  in  the  use  of  tables  showing  how 
many  grains  of  urea  are  excreted  in  the  urine,  of  which  the 
amount  daily  passed  and  the  specific  gravity  are  predeter- 
mined. On  the  opposite  page  is  the  table,  as  abridged 
by  Roberts.  It  explains  itself,  and  can,  for  practical  pur- 
poses, be  depended  on,  excepting  when  sugar  or  albumen 
is  present. 

A  rough  way  of  estimating  the  urea  is  to  drop  nitric  acid 
into  a  porcelain  capsule  holding  urine  which  has  been  evap- 
orated to  a  mucilaginous  consistence.  Crystals  of  a  pearly 
lustre,  which  the  microscope  at  once  shows  to  be  nitrate  of 
urea,  are  developed ;  and  by  always  evaporating  the  same 
quantity  and  using  a  capsule  of  equal  size,  we  may  judge  of 
the  amount  of  the  important  ingredient  as  compared  with 
that  contained  in  other  specimens  of  both  normal  and  abnor- 
mal urine.  If  crystals  form  without  the  urine  being  concen- 
trated by  evaporation,  simply  on  the  addition  of  about  an 
equal  bulk  of  nitric  acid,  urea  is  always  in  considerable  ex- 
cess. But  we  may  often,  even  without  subjecting  the  fluid 
to  this  test,  guess  that  the  urea  is  increased  by  observing  the 

*  Vide  Thudichum  on  the  Pathology  of  the  Urine,  p.  68,  or  Dublin  Hosp. 
Gaz.,  June,  1854,  p.  134,  quoted  in  Braithwaite's  Ketrospect,  1854,  vol.  xxx. 
p.  109. 

+  Medical  Times,  Oct.  1864. 


THE    URINE,  AND   DISEASES    OF   THE    URINARY   ORGANS.      601 


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602  MEDICAL    DIAGNOSIS. 

deep-yellow  color,  the  strong  urinous  smell,  and  high  specific 
gravity  of  the  discharge. 

Uric  Acid. — Uric  acid,  like  urea,  is  a  product  of  the  meta- 
morphosis of  tissue.  It  is,  indeed,  supposed  by  Liebig  that 
the  acid  is  an  early  stage  of  the  transformation  of  urea ;  but 
this  view  has  not  been  generally  adopted.  Hoffman*  teaches 
that  uric  acid  is  deposited  owing  to  the  decomposition  of  the 
urates  by  the  acid  phosphate  of  soda.  Under  ordinary  cir- 
cumstances the  deposition  of  uric  acid  occurs  subsequent  to 
the  expulsion  of  the  urine;  but  should  the  acid  phosphate  of 
soda  be  in  excess,  the  uric  acid  may  then  be  precipitated  be- 
fore the  secretion  is  voided,  and  may  thus  give  rise  to  gravel 
and  calculi.  This  may  also  occur  through  too  great  concen- 
tration of  the  urine. 

In  healthy  urine  the  presence  of  uric  acid  cannot  be  de- 
tected without  the  addition  of  a  strong  acid,  since  it  exists  in 
the  form  of  soluble  urates,  which  must  be  decomposed  before 
the  uric  acid  separates.  It  is  gradually  thrown  down  in  small 
red  grains,  which,  should  it  be  desirable  to  determine  the 
quantity  of  the  acid,  are  washed,  dried,  and  then  carefully 
weighed.  And  where  accuracy  is  called  for,  it  is  best  to  allow 
the  acid  to  separate  at  a  low  temperature,  by  keeping  the 
fluid  in  a  cool  place  for  about  four  days,  after  acidulating 
it  with  nitric  acid  about  one  ounce  to  fifty.f  It  is  also  ad- 
visable to  use  always  the  same  quantity  of  urine.  Neubauer 
recommends  200  c.  c.  of  urine  and  5  c.  c.  of  hydrochloric  acid. 

The  characteristic  reaction  of  uric  acid  is  furnished  by  the 
murexide  test.  A  few  drops  of  nitric  acid  are  mingled  with 
the  suspected  deposit  in  a  capsule,  and  the  mixture  is  slowly 
evaporated  nearly  to  dryness  over  a  lamp  ;  a  drop  of  ammo- 
nia is  then  added,  which  produces  instantly  a  rich  purple — 
Dr.  Prout's  purpurate  of  ammonia. 

But  both  uric  acid  and  the  urates  can  be  much  more  easily 
and  quickly  discriminated  by  the  microscope.  The  crystals 
of  uric  acid  are  very  readily  discerned,  notwithstanding  that 


*  Med.  Times  and  Gaz.,  1868,  vol.  i.  p.  340,  or  Medical  News,  vol.  xxvi. 
p.  77. 

f  Lee  and  Atlee  on  Under-estimation  of  Uric  Acid,  Amer.  Journ.  of  Med. 
Sciences,  April,  1869,  p.  355. 


THE    URINE,  AND    DISEASES    OF   THE    URINARY    ORGANS.      603 

they  vary  both  in  size  and  form.  Rhombic  plates  with  rounded 
angles  are  very  frequent.  To  obtain  the  crystals  rapidly, 
where  they  are  not  passed  as  uric  acid,  a  portion  of  the  sus- 
pected deposit  is  dissolved  in  a  drop  of  potassa,  and  the  alka- 
line solution  then  treated  with  an  excess  of  acetic  acid;  after 
the  lapse  of  a  few  hours  crystals  of  uric  acid  will  be  formed. 

Fig.  3G. 


Crystals  of  uric  acid,  maguified  al^out  200  diameters  ;  most  of 
these  forms  are  seen  in  the  urine  of  acute  rheumatism. 

In  disease,  the  fluctuations  in  the  quantity  of  uric  acid  are 
very  great;  as  a  general  rule,  they  correspond  to  the  rise  and 
fall  of  urea.  We  find  the  acid  diminished  in  affections  in 
which  the  eliminating  power  of  the  kidneys  is  interfered  with, 
as  in  the  more  advanced  stages  of  Bright's  disease;  an  increase 
is  encountered  in  acute  inflammations,  in  fevers,  and  in  acute 
rheumatism.  In  the  latter  malady  this  increase  is  very  de- 
cided, and  little  red  granules,  visible  to  the  naked  eye,  form 
a  deposit  in  the  urine  soon  after  it  is  voided. 

We  must,  however,  be  very  careful  not  to  suppose  the  uric 
acid  to  be  in  excess  because  it  is  readily  precipitated.  It  may 
or  may  not  be  in  larger  amount ;  the  sediment  merely  proves 
an  augmentation  of  acidity  in  the  urine  sufficient  to  take 
away  the  base  from  the  uric  acid.  Very  frequently  urates  are 
separated  along  with  the  uric  acid  ;  we  find  then  generally  a 
dark  urine  of  high  specific  gravity  and  very  acid  reaction. 

Persons  who  habitually  pass  urine  of  the  character  de- 


604  MEDICAL    DIAGNOSIS. 

scribed  are  subject  to  gastric  disorders  or  are  afl'ected  with  a 
chronic  hepatic  malady.  They  are  also,  for  the  most  part, 
intemperate  or  indolent  in  their  habits.  Hence  it  is  not  un- 
commonly perceived  that  exercise  in  the  open  air,  attention 
to  the  action  of  the  skin,,  and  mild  aperients,  by  tending  to 
eliminate  the  acid  and  by  keeping  the  blood  from  becoming 
vitiated,  afford  more  real  and  permanent  benefit  than  the 
exhibition  of  alkalies  to  neutralize  the  acidity  of  the  urine. 

Occasionally  precipitates  of  uric  acid  or  urates  occur  in 
the  urinary  passages.  Now,  these  sediments  may  concrete 
and  form  the  nuclei  of  calculi ;  or  they  may  be  passed  in 
small  particles,  commonly  spoken  of  as  "gravel."  If  they 
are  formed  in  the  kidney  or  ureter,  their  onward  passage, 
presuming  the  concretions  to  be  of  sufficient  size,  is  attended 
with  severe  pain,  with  nausea,  and  retraction  of  the  tes- 
ticle,— with  the  symptoms,  indeed,  attributed  to  an  attack 
of  nephralgia. 

Urates. — The  pathological  conditions  in  which  the  urates 
are  found  to  be  changed  are  much  the  same  as  those  in 
which  alterations  in  uric  acid  occur.  It  only  remains,  there- 
fore, to  indicate  how  the  salts  may  be  chemically  and  micro- 
scopically distinguished.  The  urates  consist  principally  of 
urate  of  soda  and  of  ammonia,  and  of  small  quantities  of 
urate  of  lime  and  magnesia.  The  deposits  formed  by  their 
precipitation  are  of  a  pink  color,  yet  sometimes  brown,  or 
even  white.  They  are  dissolved  with  great  readiness  by 
heating  the  urine.  Acids  decompose  them  and  separate  uric 
acid. 

Under  the  microscope,  the  urates  are  seen  to  be  either 
irregular  amorphous  particles,  needle-like  crystals,  or  round 
globules  of  varying  size,  from  some  of  which  fine  needles 
project.  The  latter  are  commonly  supposed  to  be  urate  of 
soda;  the  globules  and  crystals,  urate  of  soda  and  of  ammo- 
nia ;  the  fine  powder,  urate  of  lime  and  soda. 

But  these  are  not  facts  which  are  established  beyond  doubt ; 
it  is  only  certain  that  the  granular  amorphous  deposit,  until 
lately  called  urate  of  ammonia,  really  consists  of  the  mixed 
urates,  more  especially  of  the  urate  of  soda  and  ammonia. 
These  amorphous  urates  may,  under  the  microscope,  be  mis- 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.      605 

taken  for  phosphate  of  lime.  The  differential  test  consists 
in  their  behavior  with  acids ;  the  phosphate  is  dissolved  by 
acetic  or  hydrochloric  acids ;  the  urates  are  gradually  trans- 
formed into  crystals  of  uric  acid.  Then,  a  deposit  of  phos- 
phate of  lime  is  often  more  cloudy  and  less  defined  than  the 

Fig.  37. 


Mixed  urates. 


urates,  and,  unlike  them,  not  soluble  in  liquor  potassae.  From 
carbonate  of  lime,  which  also  occurs  in  a  granular  form, 
both  urates  and  phosphate  of  lime  are  distinguished  by  the 
effervescence  of  the  carbonic  acid  which  happens  on  the 
addition  of  a  strong  acid. 

Urine  containing  a  sediment  of  urates  is  generally  very 
acid,  or  soon  becomes  so,  either  from  an  absolute  increase 
of  the  uric  acid,  or  in  consequence  of  changes  in  some  of  the 
constituents  of  the  fluid — as  of  the  pigment — which  take 
place  either  before  or  shortly  after  emission.  Not  unfre- 
quently,  too,  it  is  scanty,  and  the  urates  are  deposited  as 
soon  as  the  urine  cools  to  the  temperature  of  the  atmosphere. 
Their  precipitation  may  be,  and  indeed  often  is,  owing  to 
there  not  being  water  enough  to  hold  them  in  solution.  We 
may  judge  of  this  being  the  case,  by  ascertaining  the  amount 
of  urine  passed  in  twenty-four  hours.  If  the  quantity  be 
about  normal,  the  deposit  is  in  all  likelihood  due  to  an  excess 
of  urates.  In  cold  weather  these  deposits  occur  more  quickly 
and  more  extensively  than  in  warm. 


606 


MEDICAL    DIAGNOSIS. 


But  sediments  of  urates  are  encountered  irrespective  of 
these  conditions.  Thej  are  met  with  in  pale  urine,  and 
without  either  diminution  of  water  or  excess  of  acidity  to 
account  for  their  presence.  The  urine  yields  but  a  faintly 
acid  or  a  neutral  reaction,  and  under  these  circumstances 
phosphate  of  lime,  or  even  triple  phosphates,  may  be  ob- 
served to  accompany  the  urates. 

Phosphates. — The  phosphates  are  derived  in  part  from  the 
food,  in  part  from  the  disintegration  of,  or  rather  the  oxidation 
of  the  disintegrated,  albuminous  substances,  and  especially 
of  the  nerve  structures.  They  occur  as  the  combination  of 
phosphoric  acid  with  soda,  lime,  and  magnesia.  In  health 
they  are  kept  in  solution  by  the  acidity  of  the  urine;  but  as 
soon  as  the  secretion  ceases  to  be  acid,  they  come  into  view, 

Fig.  38. 


Earthy  phosphates;  the  granules  are  phosphate  of  lime,  the  rest 
triple  phosphates. 


and  are  very  quickly  deposited.  We  may  hence  lay  down 
the  general  law,  that  the  appearance  of  phosphates  goes  hand 
in  hand  with  a  neutral  or  alkaline  condition  of  the  urine. 
Very  often  the  fluid,  as  we  have  already  seen,  becomes  alka- 
line from  the  decomposition  of  the  urea  into  carbonate  of 
ammonia.  The  ammonia  unites  with  the  phosphate,  forming 
triple  salts,  ammonio-magnesian  phosphates,  which  crystal- 
lize commonly  in  transparent  prisms  or  in  feathery-looking 
bodies,  easily  distinguished  from  the  amorphous  powder,  or 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.      607 

roimd,  small  globules  of  phosphate  of  lime.  Yet  we  must 
remember  that  there  is,  as  Dr.  Roberts  has  pointed  out,  a 
crystalline  form  of  phosphate  of  lime,  which  may  be  mis- 
taken for  one  of  the  stellar  forms  of  crystallization  of  uric 
acid,  from  which  it  may  be  distinguished  by  being  inva- 
riably colorless.  These  earthy  phosphates  are  all  readily 
soluble  in  acids,  even  in  weak  acids  like  acetic  acid.  In 
many  specimens  of  urine  they  are  precipitated  by  heat;  but 
the  addition  of  an  acid  soon  dissolves  them,  and  thus  prevents 
the  turbidity  from  being  mistaken  for  that  due  to  albumen. 

The  triple  phosphates  are  often  met  with  in  heavy  deposits 
mixed  with  pus;  in  the  alkaline  purulent  urine  resulting 
from  chronic  vesical  catarrh  they  are  very  common.  They 
are  also  seen  in  cases  of  retention  of  urine  in  the  bladder  due 
to  its  temporary  or  permanent  paralysis,  as  in  low  fevers,  in 
hemiplegia,  or  in  paraplegia.  They  are  found,  too,  in  many 
affections  in  which  the  vital  powers  have  been  seriously  low- 
ered and  the  acidity  of  the  urine  diminished,  as  during  con- 
valescence from  acute  disease.  Under  the  latter  circum- 
stances, and  in  fact  whenever  the  urine  has  become  alkaline 
from  the  presence  of  a  fixed  alkali,  the  phosphatic  deposit  is 
apt  to  show  a  large  excess  of  the  amorphous  phosphates,  if, 
indeed,  it  does  not  altogether  consist  of  them. 

Urine  alkaline  from  fixed  alkali,  and  depositing  phosphates, 
is,  unless  this  condition  have  been  brought  about  temporarily 
by  fruit  or  other  food,  a  matter  of  serious  import.  We  en- 
counter it  in  persons  laboring  under  great  general  debility 
and  indigestion  associated  with  an  impaired  tone  of  the 
nervous  system, — in  fact,  in  those  of  Avhom  it  is  the  fashion, 
or  has  been  the  fashion,  to  speak  as  exhibiting  the  "phos- 
phatic diathesis."  Such  a  morbid  state  is  not  at  all  uncom- 
mon in  men  depressed  by  mental  toil  or  intense  anxiety,  and 
is  mostly  benefited  by  rest,  change  of  scene,  tonic  medicines, 
and  generous  diet.  Opiates,  too,  have  an  excellent  effect  in 
restoring  the  acid  character  of  the  urine,  by  their  quieting 
influence  on  the  nervous  system. 

In  these  cases,  in  spite  of  the  distinct  sediment  of  the 
phosphates,  it  is  very  doubtful  if  they  are  really  increased  in 
quantity.    The  want  of  the  acidity  of  the  urine  permits  their 


608  MEDICAL   DIAGNOSIS. 

precipitation,  and  causes  them  to  become  readily  apparent. 
On  the  other  hand,  they  may  be  actually  in  excess,  and  yet 
this  excess  be  concealed  from  view  until  a  careful  analysis 
has  been  performed.  This  happens  especially  with  the  alka- 
line phosphates,  the  phosphate  of  soda  and  the  ammonio- 
phosphate  of  soda,  the  proportions  of  which  change  in  dis- 
ease much  more  than  do  the  earthy  phosphates,  and  indicate 
much  more  clearly  the  variations  of  the  phosphoric  acid. 
And,  paradoxical  as  it  may  appear,  the  acidity  of  the  urine 
may  be  so  much  augmented  by  the  increase  of  the  phosphoric 
acid,  that  a  very  large  excess  of  alkaline  phosphates  may  be 
present  in  solution  in  a  highly  acid  urine. 

Now,  a  real,  not  merely  an  apparent  increase  of  the  phos- 
phates, occurs,  according  to  Dr.  Bence  Jones,  in  acute  inflam- 
matory diseases  of  the  nervous  structure  during  the  existence 
of  the  most  marked  febrile  symptoms,  and  in  fractures  of  the 
skull  when  an  inflammatory  action  takes  place  in  the  brain. 
We  find  the  phosphates  also  augmented  by  the  abundant  use 
of  animal  food,  by  very  active  exercise,  and  in  acute  rheu- 
matism ;  while  the  phosphoric  acid,  as  well  as  the  sulphuric 
acid,  the  urea,  and  the  chloride  of  sodium,  is  excreted  during 
the  course  of  a  maniacal  paroxysm,  in  epilepsy  and  in  melan- 
cholia in  less  amount  than  in  health.* 

To  determine  the  proportion  of  the  earthy  phosphates,  a 
few  drops  of  ammonia  are  added  to  the  urine;  soon  a  whitish 
precipitate  is  produced,  which  is  not  dispersed  b}'^  heat.  From 
the  quantity  of  the  deposit  we  may  form  a  rough  estimate  of 
that  of  the  earthy  phosphates.  But  if  the  amount  is  to  be 
accurately  ascertained,  we  must  employ  a  graduated  glass, 
separate  the  precipitated  phosphates  by  filtration,  ignite  them 
in  a  platinum  capsule,  and  weigh  the  ashes.  The  alkaline 
phosphates  are  not  thrown  down  by  alkalies,  and,  unlike  the 
earthy  phosphates,  are  very  soluble  in  water.  They  are  pro- 
cured by  taking  the  fluid  from  which  the  earthy  phosphates 
have  been  carefully  removed  by  filtration,  and  adding  to  it  a 
saturated  solution  of  sulphate  of  magnesia. 

*  Adam  Addison,  Brit,  and  Foreign  Med.-Chirg.  Kcv.,  April,  1865.  As  re- 
gards the  excess  of  ]iliosjihatcs  being  a  sign  of  wear  and  tear  of  nervous  tissue, 
til  is  is  not  universally  admitted.     Beale,  for  instance,  does  not  so  regard  it. 


I 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       609 

From  the  deposit  obtained  iu  testing  for  the  phosphates, 
some  idea  may  also  be  formed  of  the  quantity  of  'phosphoric 
acid  in  the  urine.  The  average  quantity  passed  by  an  adult 
male  in  twenty-four  hours  is,  according  to  Vogel,  about  3-5 
grammes,  or  nearly  53  grains.  But  for  more  minute  informa- 
tion respecting  this  point,  as  well  as  for  the  several  admirable 
volumetric  processes  by  which  the  amount  of  the  acid  may 
be  not  only  approximately,  but  precisely  determined,  I  must 
refer  to  special  treatises  on  the  chemistry  of  the  urine,  espe- 
cially to  such  works  as  those  of  Neubauer,*  of  Beale,t  and  of 
Thudichum.| 

Chlorides. — Unlike  the  phosphates,  the  chlorides  in  the 
urine  are  exclusively  derived  from  the  food ;  they  correspond 
closely  with  the  amount  of  salt  ingested.  In  consequence, 
the  chloride  of  sodium — the  main  chloride  in  the  urine,  for 
it  does  not  contain  much  more  than  a  trace  of  chloride  of  po- 
tassium— is,  even  in  health,  liable  to  great  fluctuations ;  in 
twenty-four  hours  the  mean  is  estimated  by  Vogel  and  Parkes 
at  11-5  grammes,  or  about  177  grains.  Bischoff  states  the 
average  at  14-73  grammes.  In  disease,  very  various  amounts 
are  eliminated  with  the  urine.  In  typhus  fever  and  in  acute 
inflammatory  aftections,  the  chlorides  sink  to  a  very  low 
level,  and  rise  again  in  convalescence;  an  increase  after  a 
diminution  is  thus  always  a  very  fVivorable  sign.  We  may 
study  these  changes  to  advantage  in  pleurisy  and  pericarditis, 
but  especially  iu  pneumonia.  At  the  period  of  hepatization, 
the  chlorides  are  absent  from  the  urine,  and  appear  in  in- 
creased quantity  in  the  sputum;  during  resolution  they  reap- 
pear in  the  urine;  between  these  stages  there  is,  probably,  a 
determination  of  the  salt  to  the  inflamed  organ. 

Chloride  of  sodium  is  detected  with  great  ease.  The  urine 
is  strongly  acidulated  with  nitric  acid,  and  a  solution  of  nitrate 
of  silver  is  added ;  a  dense  white  precipitate  of  chloride  of 
silver  quickly  takes  place,  insoluble  in  nitric  acid,  but  soluble 
in  ammonia.  The  amount  of  the  chloride  is  estimated  by 
comparison  with  healthy  urine ;  but  to  determine  its  quantity. 


*  Op.  cit.  J  On  Urine,  Urinary  Deposits,  and  Calculi. 

X  Treatise  on  the  Pathology  of  the  Urine. 

39 


610  MEDICAL    DIAGNOSIS. 

or  that  of  the  chlorine,  with  accuracy,  Liebig's  volumetric 
process,  by  means  of  the  nitrate  of  protoxide  of  mercury, 
should  be  employed.  It  consists  in  first  removing  the  phos- 
phates by  the  standard  baryta  solution,  of  which  20  c.  c.  are 
mixed  with  40  c.  c.  of  urine.  The  mixture  is  poured  upon  a 
dry  filter,  and  the  filtered  liquid  is  rendered  very  slightly 
acid  by  the  addition  of  a  few  drops  of  nitric  acid;  15  c.  c.  of 
the  fluid  thus  prepared,  and  which  correspond  to  10  c.  c. 
of  urine,  are  measured  ofl:"  into  a  beaker  glass,  and  the  test 
solution  of  mercury  is  then  dropped  from  a  burette  into  it 
until  a  distinct  cloudiness,  or  a  precipitate  which  does  not 
disappear  by  stirring,  is  produced.  The  amount  of  the  mer- 
curial test  solution  used  is  now  read  ofl'  from  the  burette, 
and  we  calculate  the  amount  of  chloride  of  sodium  or  of 
chlorine,  by  estimating  that  each  cubic  centimetre  corre- 
sponds with  10  milligrammes  of  chloride  of  sodium,  or  6"065 
milligrammes  of  chlorine. 

Sulphates. — The  sulphates  are  found  in  the  urine  in  large 
quantities.  They  consist  of  sulphate  of  potassa  and  sulphate 
of  soda;  the  former  in  excess.  Like  the  alkaline  phosphates, 
they  are  dissolved  in  the  urine,  and  must  be  precipitated  by 
chemical  reagents.  To  eft'ect  this,  a  few  drops  of  nitric  acid 
are  added  to  urine,  and  subsequently  from  fifteen  to  twenty 
drops  of  a  saturated  solution  of  chloride  of  barium,  when  a 
white  precipitate  insoluble  in  acids  is  thrown  down. 

The  sulphates  are  obtained  in  part  from  the  food,  in  part 
from  the  oxidation  of  the  sulphur  entering  into  the  constitu- 
tion of  the  albuminous  substances  of  the  body  and  the  sub- 
sequent union  with  a  base  of  the  sulphuric  acid  which  is 
formed.  They  are  enhanced  by  an  exclusively  animal  diet, 
and  after  violent  exercise ;  in  truth,  their  increase  is  apt  to 
go  hand  in  hand  with  that  of  urea.  An  exception  to  this  is 
noticed  by  Dr.  Parkes*  to  occur  in  rheumatic  fever.  Here 
the  sulphuric  acid  in  the  urine  is  greatly  augmented,  but  the 
urea  not  correspondingly  so.  The  administration  of  potassa 
raises,  in  a  very  striking  degree,  the  proportion  of  the  sul- 
phates. 


*  Brit,  and  For.  Med.-Cliir.  Eev.,  vol.  xiii. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       611 

The  average  daily  quantity  of  sulphuric  acid  passed  in  the 
urine  is  about  2  grammes.  A'^ogel  gives  an  easy  method  of 
determining  approximately  whether  it  is  increased  or  dimin- 
ished. After  ascertaining  the  whole  amount  of  urine  in 
twenty-four  hours — say  it  is  2000  c,  and  then  each  100  c.  c. 
would  contain  0-10  gramme  of  sulphuric  acid — 100  c.  c.  are 
rendered  acid,  and  as  much  of  a  test  solution  of  chloride  of 
barium*  is  added  as  corresponds  with  0-05  gramme  of  the 
acid.  The  mixture  is  now  filtered,  and  if  the  filtered  liquid 
is  not  made  turbid  by  the  chloride  of  barium,  we  may  infer 
that  the  patient  has  secreted  less  than  1  gramme  of  sul- 
phuric acid  in  the  twenty-four  hours.  If  the  liquid,  how- 
ever, is  rendered  turbid  by  chloride  of  barium,  then  a  fur- 
ther quantity  of  this  agent  corresponding  with  0-5  gramme 
of  sulphuric  acid  is  added;  and  if  the  filtrate  is  still  ren- 
dered turbid,  it  is  evident  that  the  quantity  of  sulphuric  acid 
is  greater  than  normal. 

Oreatineand  Creatinine. — These  substances  found  in  the  urine 
are  purely  excrementitious,  and  are  derived  from  a  disin- 
tegration of  the  muscular  tissue.  Creatinine  exists  in  larger 
quantities  than  creatine,  and  is  the  product  of  its  decompo- 
sition. 

But  few  observations  have  as  yet  been  made  on  their  in- 
crease, or  on  their  significance  in  showing  the  activity  of 
nutrition  in  tht.  muscles  in  health  or  in  disease.  Active  mus- 
cular exercise  augments  their  quantity;  and  the  same  efiect 
is  probably  produced  by  all  spasmodic  affections. 

Both  are  generally  included,  in  analyses,  under  the  head 
of  extractives.  Their  separation  is  effected  by  a  process 
proposed  by  Liebig,  consisting  of  the  addition  to  the  urine 
of  lime-water  and  chloride  of  calcium,  and  subsequently  of 
chloride  of  zinc.  But  for  the  chemical  particulars  I  must 
refer  to  special  works  on  the  chemistry  of  the  urine.  Under 
the  microscope,  the  crystals  of  creatine  are  colorless  and 
beautifully  transparent.     Their  appearance,  as  well  as  that 

*  Made  generally  by  dissolving  30-5  grammes  of  crystallized  chloride  of  ba- 
rium, powdered  and  air  dried,  and  diluting  the  solution  up  to  1  litre  ;  1  c.  c. 
of  it  then  equals  10  milligrammes  of  anhydrous  sulphuric  acid. 


612  MEDICAL    DIAGNOSIS. 

of  creatinine,  is  faithfully  represented  in  Robin  and  Verdeil's 
plates.* 

Presence  of  Abnormal  Substances  in  the  Urine. — Here 

may  be  mentioned  the  ingredients  which  are  observed  in 
the  urine  in  disease  only,  as  bile  and  blood;  and  along  with 
them,  I  shall  notice  those  constituents  the  occurrence  of  which 
in  healthy  urine  is  so  occasional  that  it  is  still  undetermined 
whether  they  belong  to  health  or  disease,  but  of  which  it  is 
certain  that  their  presence  in  any  marked  degree  is  abnormal. 

Oxalate  of  Lime. — This  appertains  to  the  class  just  alluded 
to.  There  can  be  no  doubt  that  the  salt  may  be  detected  in 
the  urine  of  persons  who  enjoy  good  health  ;  but  there  can  be 
equally  no  doubt  that  the  crystals  are  not  found  in  large  num- 
bers, excepting  in  a  morbid  condition.  Some  pass  habitually 
a  considerable  quantity  of  oxalic,  acid  in  the  form  of  oxalate 
of  lime.  They  are  generally  persons  weighed  down  by  care 
and  anxiety,  or  who  overtask  their  brains  by  incessant  appli- 
cation to  stud}',  or  weaken  their  nervous  power  by  excessive 
sexual  indulgence  or  by  masturbation.  Sometimes  they  are 
troubled  with  frequent  seminal  emissions  and  irritation  of  the 
bladder,  or  they  are  dyspeptic,  and  sutler  from  uneasiness 
after  meals;  but  not  uncommonly  the  appetite  is  good,  and 
the  digestion  unimpaired.  They  are  alwaj^s  languid,  and 
either  very  irritable  or  very  dejected.  Frequently  they  com- 
plain of  loss  of  memory,  and  of  a  sensation  of  weight,  or  a 
dull  pain  across  the  loins.  They  are  very  liable  to  boils  and 
carbuncles,  grow  thin,  and  evidently  are  generally  out  of 
health.  Tlie  urine  voided  is  of  high  specific  gravity,  shows 
an  increase  of  urea,  and  ordinarily  a  cloudy  deposit  consist- 
ing of  mucus  and  the  crystallized  oxalates. 

This  is  the  disorder  called  by  Dr.  Golding  Bird  "  oxaluria," 
and  which  is  very  generally  combined  with  tissue  changes 
and  increased  excretion  of  urea.  Its  existence  as  a  separate 
affection  has  been  denied;  but  that  the  formation  of  oxalate 
of  lime  in  any  considerable  quantity  is  associated  with  the 
symptoms  described,  can  be  satisfactorily  ascertained  by  any 
one  who  will  take  the  trouble  to  examine  the  urine  with  care, 

*  Truite  dc  Chemie  Anatomique.     Paris,  1853. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY   ORGANS.      613 

ill  cases  like  those  referred  to.  The  origin  of  the  oxalic  acid, 
however,  is  not  certain  ;  Gohling  Bird  attributed  it  to  a  sec- 
ondary or  destructive  assimilation  of  tissue.  The  evidence 
is  certainly  in  favor  of  its  being  formed  in  the  sj-stem,  for  it 
has  been  found  in  the  blood.  Still  it  is  not  improbable  that 
it  may  at  times  be  the  product  of  a  species  of  fermentation 
occurring  in  the  urinary  passages,  and  therefore  after  the 

Fig.  39. 


Crystals  of  oxalate  of  lime. 


urine  is  secreted.  Probably  in  the  former  class  of  cases  alone 
are  the  constitutional  symptoms  described  present.  In  the 
latter  we  may  at  times  detect  evidence  of  the  irritation  of  a 
calculus,  or  of  disease  of  the  bladder  or  kidneys.* 


*  As  regards  the  origin  of  oxalic  acid,  Dr.  Owen  Kees,  in  his  Croonian 
Lectures  in  1856,  stated  that  it  was  formed  after  the  urine  had  been  secreted 
by  the  kidneys,  and  was  derived  directly  from  the  decomposition  of  uric  acid 
and  the  urates.  In  a  recent  valuable  contribution  to  the  chemistry  of  the 
subject,  Schunck*  establishes  the  presence  in  the  urine  of  oxaluric  acid,  which 
he  thinks  presents  an  easy  and  satisfactory  solution  of  the  formation  of 
oxalate  of  lime.  The  conversion  of  oxaluric  acid  into  oxalic  acid  may 
take  place  after  the  urine  is  voided,  or  commence  in  the  bladder,  or  even  in 
more  remote  parts  of  the  urinary  apparatus,  and  thus  lead  to  the  formation 
of  calculi  of  oxalate  of  lime.  The  oxaluric  acid  is  derived  from  the  oxidation 
of  uric  acid. 


*  Proceedings  of  the  Royal  Society,  vol.  xvi.  p.  140,  On  Oxalurate  of  Ammonia  as  a  Constit- 
uent of  the  Human  Urine. 


614  MEDICAL    DIAGNOSIS. 

Oxalate  of  lime  may  be  detected  in  the  urine  when  articles 
which  contain  it,  such  as  the  rhubarb  plant,  have  been  eaten. 
It  may  be  also  found  in  the  urine  of  patients  recovering 
from  severe  acute  maladies  ;  and  is  encountered,  but  only 
in  very  small  quantities,  in  the  urine  of  healthy  persons. 
But  in  neither  instance  is  it  at  all  permanent,  nor  can  the 
presence  of  a  few  crystals  be  looked  upon  as  of  the  least 
practical  importance. 

The  microscope  is  incomparably  the  readiest  means  of  de- 
tecting the  salt.  This  appears  in  the  urine  in  well-defined 
octahedra  of  most  varying  size,  and  in  dumb-bell  bodies. 
The  former  are  much  the  more  common  and  characteristic, 
for  the  dumb-bells  are  not  frequent,  nor  is  this  formation 
peculiar  to  oxalate  of  lime ;  occasionally,  long  or  pointed 
octahedra  or  prismatic  crystals  are  observed. 

The  oxalates  are  often  mixed  with  deposits  of  urates  or 
uric  acid.  Sometimes — Beneke  says  constantly — the  earthy 
phosphates  coexist  in  large  amount  with  the  oxalates.  Occa- 
sionally the  irritation  the  passage  of  the  crystals  produces 
gives  rise  to  tube-casts.  A  case  came  under  my  observation, 
iu  which  a  patient  suffering  from  a  protracted  and  severe 
attack  of  oxaluria  voided  for  weeks,  along  with  the  oxalates, 
casts  of  the  character  known  as  hyaline,  exudative,  or  small 
waxy  casts.  Neitlier  heat  nor  nitric  acid  detected  albumen. 
Under  treatment,  the  crystals  disappeared  from  the  urine, 
and  with  them  the  casts.  The  gentleman  recovered  perfectly, 
and  is  now  in  excellent  health.  He  has  not  to  this  day  had 
the  slightest  signs  of  degeneration  of  the  kidneys. 

Leucine  and  Tyrosine. — Both  these  substances  are  the  result 
of  the  decomposition  of  highly  nitrogenous  anirnal  matter,  are 
very  similar,  and  usually  associated.  They  have  been  found 
in  the  urine  only  in  disease,  as  in  yellow  atrophy  of  the  liver, 
in  typhus  fever,  and  in  small-pox.  Tyrosine  is  most  readily 
detected  by  the  microscope.  It  crystallizes  in  long,  very 
fine,  shining  needles,  which  may  congregate  in  globular 
bodies. 

Hoffman  has  proposed  the  following  delicate  chemical  test 
for  tyrosine:  a  solution  of  mercnric  nitrate,  nearly  neutral, 
is  to  be  treated  with  the  solution  suspected  to  contain  tyro- 


THE    UKINE,  AND    DISEASES    OF   THE    URINAHY   ORGANS.      615 


sine;  if  it  is  present,  a  reddish  precipitate  is  produced, 
and  the  supernatant  fluid  is  of  a  very  dark  rose  color. 
Leucine  crystallizes  in  granular  masses,  consisting  of  round- 
ish globules,  sometimes  of  concentric  form,  and  for  the  most 
part  of  yellowish  color,  and  resembling  oil-drops.  The 
chemical  test  for  leucine  is  to  place  the  suspected  deposit  on 
platina  foil,  and  then  to  evaporate  it  with  nitric  acid.  The 
residue  that  is  left  is  moistened  with  caustic  soda,  and  this 
mixture  carefully  heated  over  a  spirit-lamp.  It  is  gradually 
condensed  into  oily-looking  drops;  a  property  which  Scherer 
has  pointed  out  as  characteristic  of  leucine. 

Bile. — The  occurrence  of  bile  in  the  urine  imparts  to  it  a 
ver}'  dark  color.  Its  presence  is  a  proof  that  the  bile  passes 
into  the  blood,  and  that  the  kidneys  are  performing  a  func- 
tion forced  on  them  by  the  deranged  action  of  the  liver,  or  by 
an  impediment  in  the  biliary  passages.  All  the  constituents 
of  the  bile  may  appear  in  the  urine,  or  only  the  pigment, 
without  the  acids  or  their  salts.  The  pigment  is  sometimes 
found  transiently,  and  in  small  quantities,  without  yellowness 
of  the  skin  ;  its  more  permanent  and  marked  occurrence  is, 
however,  always  attended  with  jaundice.  It  may  be  discerned 
both  before  the  discoloration  of  the  skin  is  noticeable,  and 
after  it  has  lost  its  yellow  hue.  The  biliary  acids  are  not  of 
necessity  present  in  the  urine  of  icterus. 

The  detection  of  the  coloring  matter  of  bile  is  eifected  by 
pouring  a  small  quantity  of  urine  on  a  white  plate;  a  drop 
of  nitric  acid  is  then  permitted  to  fall  on  the  thin  layer  of 
fluid.  Soon  a  play  of  color  takes  place,  commencing  with 
green  and  blue,  passing  to  violet  and  red,  and  often  finally 
to  yellow  or  brown.  According  to  Frerichs,*  this  reaction 
may  fail  in  cases  where  the  other  symptoms  of  jaundice  are 
undoubted,  owing  to  the  bile-pigment  having  already  passed 
through  stages  of  transformation.  When  this  is  the  case, 
the  urine  is  at  one  time  of  a  brown  or  brownish-red  color, 
and  becomes  red  on  the  addition  of  nitric  acid  ;  at  another 
time  it  is  of  a  deep  red,  which  is  converted  by  nitric  acid 
into  a  dark  bluish-red.     Dr.  Murchison  has  made  a  similar 


*  Diseases  of  the  Liver.     Sydenham  Soc.  Trans.,  vol.  i.  p.  100. 


616  MEDICAL    DIAGNOSIS. 

observation*  in  rare  cases  where  jaundice  has  resulted  from 
a  blood  poison,  and  he  has  frequently  found  the  urine  to  pre- 
sent those  characters  where  there  has  been  no  jaundice,  but 
obvious  derangement  of  function,  or  alteration  of  structure  of 
the  liver. 

Dr.  Bashamf  speaks  highly  of  the  following  test  for  bile- 
pigment  as  being  very  delicate.  The  urine  is  shaken  up  with 
a  small  quantity  of  chloroform,  w^hich  dissolves  out  the  bile 
coloring  matter  and  retains  it  in  solution.  If  this  solution 
be  then  decanted  and  evaporated  carefully,  the  pigment 
which  is  left  gives,  on  the  addition  of  a  drop  of  nitric  acid, 
a  beautiful  ruby-red  color,  after  displaying  the  characteristic 
play  of  colors.  This  test  is  equally  available  for  detecting 
bile-pigment  in  other  fluids. 

Dr.  Carter  tells  us,|  that  urine  containing  an  excess  of 
indican,  presents  the  same  succession  of  colors,  when  treated 
with  nitric  acid,  as  urine  holding  bile-pigment  in  solution. 
To  avoid  this  fallacy  in  a  doubtful  case,  the  urine  should  be 
treated  with  sulphuric  acid,  as  described  while  discussing  in- 
dican. If  the  mixture  become  black  and  opaque,  depositing 
a  deep  blue  or  purple  precipitate  on  being  diluted  with 
water,  the  play  of  colors  may  be  attributed  to  the  excess  of 
indican. 

The  biliary  acids  are  sought  for  by  Pettenkofer's  test.  It 
consists  in  tincturing,  with  a  few  drops  of  a  solution  of  sugar, 
a  small  portion  of  urine  contained  in  a  test-tube  or  in  a  china 
dish,  placed  in  cold  water.  To  this  mixture  an  excess  of 
concentrated  sulphuric  acid  is  added,  drop  by  drop.  The 
fluid  assumes  a  yellowish-red  color,  which,  if  bile  be  present, 
passes  into  a  crimson  or  violet.  The  test  is  not  applicable  to 
albuminous  urine,  unless  the  albumen  be  flrst  coagulated  and 
separated.  And  it  is  inconclusive ;  for  urine  containing  an 
excess  of  indican  when  thus  treated,  may  display  a  reaction 
exactly  similar  to  that  caused  by  the  bile  acids.§     Moreover, 

*  Clinical  Lectures  on  Diseases  of  the  Liver,  p.  284. 
f  Renal  Diseases,  Am.  ed.,  p.  280. 
X  Edinburgh  Med.  Journ.,  Aug    1859,  p.  125. 

^  On  this  point  consult  Murchison  on  the  Liver,  p.  425,  and  Noubauer  and 
Vogel's  Analysis  of  the  Urine,  8yd.  Sue.  Trans.,  p.  47. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       617 

Nenbauer  and  Yogel  state*  that  oleic  acid  and  albumen  give 
analoo^ous  reactions. 

Sugar. — This  substance  is  not  a  normal  ingredient  of  urine, 
or  exists  only  in  traces  too  minute  to  be  detected  by  the  ordi- 
nary tests.  When  met  with  in  healthy  urine,  it  is  probably 
due  to  the  decomposition  of  the  indican.  Sugar  may  occa- 
sionally be  found  in  the  urine  of  those  who  live  exclusively 
on  a  starchy  diet,  or  who  take  large  quantities  of  sugar;  but 
the  proportion  even  then  is  very  small.  The  urine  secreted 
while  under  the  influence  of  ether,  chloroform,  or  chloral 
hydrate,  is  found  to  respond  to  the  copper  tests  for  sugar. 
And  Bordierf  has  grouped  together  many  observations,  which 
lead  him  to  conclude  that  diabetes  may  be  considered  as  an 
almost  normal  occurrence  in  the  stage  of  recovery  from  acute 
diseases.  Measles,  pneumonia,  erj-sipelas,  in  short,  all  in- 
flammatory fevers  are  liable  to  its  production  during  con- 
valescence. At  Guy's  Hospital  the  urine  of  a  large  number 
of  patients,  laboring  under  various  complaints,  was  found,  in 
several  instances,  particularly  in  cases  of  phthisis,  to  give  a 
more  or  less  maiked  reaction  of  sugar.|  But  a  large  and 
persistent  amount  occurs  onlv  in  diabetes. 

Urine  holding  sugar  in  solution  is  lisjht  colored,  of  his^h 
specific  gravity,  and  of  very  peculiar  smell.  It  rarely  deposits 
sediments,  and,  as  is  well  known,  the  excess  of  water  in  it  is 
enormous. 

To  detect  the  presence  of  sugar,  several  tests  have  been 
proposed,  nearly  all  of  which  are  easy  of  application. 

Moore's  test  is  the  simplest.  It  consists  in  boiling  the  sus- 
pected fluid  with  an  equal  quantity  of  liquor  potassge.  The 
mixture,  if  it  contain  sugar,  becomes  of  a  deep-brown  color, 
which  grows  deeper  the  longer  the  boiling  is  continued. 
This  method,  although  good,  is  not  to  be  depended  upon 
when  the  urine  contains  only  traces  of  sugar;  nor  ought  the 
change  of  hue,  when  slight,  to  be  accepted  as  conclusive,  for 
other  things  besides  sugar  alter  it.  Indeed,  it  is  always  better 
to  corroborate  the  evidence  thus  obtained  by  other  tests. 


*  Anleitung,  etc.,  p   76,  5th  ed.    Wiesbaden,  1867. 

f  Arcliiv    Gen.  de  Med.,  1868. 

X  Researches  on  Diabetes,  by  F.  W.  Pavy,  M.D.,  2d  ed.,  p.  126. 


618  MEDICAL    DIAGNOSIS. 

Trommer's  test  is  both  more  trustworthy  and  more  delicate. 
A  few  drops  of  a  solution  of  sulphate  of  copper  are  dropped 
into  the  test-tube  holding  the  urine.  Liquor  potassse  is  now 
added  in  excess.  If  the  fluid  be  saccharine,  the  faint  greenish 
tint  is  changed  to  a  deep  blue,  the  precipitate  which  is  formed 
when  the  alkali  is  first  added  being  soon  redissolved.  On 
heating  the  blue  mixture  it  becomes  brownish,  then  yellow, 
and  finally  a  reddish-brown  mass  of  suboxide  of  copper  is 
thrown  down,  very  different  from  the  flocculent  or  greenish 
sediment  noticed  when  no  sugar  exists.  A  very  small  quan- 
tity of  sugar  can  be  detected  by  this  process :  but,  good  as 
the  test  is,  it  has  its  drawbacks;  for  it  has  been  proved  that 
sugar  is  not  the  only  substance  which  possesses  the  power  of 
reducing  the  salts  of  copper.  Chloroform,  creatine,  and  to 
some  extent  uric  acid,  share  with  it  this  property.  Further- 
more, Beale  has  shown  that  the  presence  of  ammoniacal  salts 
will  prevent  the  precipitation  of  the  suboxide  in  urine  con- 
taining but  little  sugar. 

Fehlirufs  test  is  a  convenient  modification  test  of  the  copper 
for  ready  use,  and  may  be  also  employed  for  the  quanti- 
tative determination  of  sugar.  'J'his  is  the  direction  for  its 
preparation :  dissolve  69  grains  of  crystallized  sulphate  of 
copper  in  five  times  its  weight  of  distilled  water,  add  a  con- 
centrated solution  of  268  grains  of  tartrate  of  potassa^  and 
then  a  solution  of  80  grains  of  hydrate  of  soda  in  1  ounce  of 
distilled  water;  enough  water  is  now  poured  into  the  vessel 
to  make  1000  grains  of  the  mixture — each  100  grains  of  which 
will  be  equivalent  to  1  of  grape  sugar.*  Pavy,f  in  his  Re- 
searches on  Diabetes,  uses  a  liquid  containing  caustic  potassa; 
of  which  100  minims  reduce  exactly  half  a  grain  of  grape 
sugar.  It  consists  of  sulphate  of  copper,  320  grains;  tartrate 
of  potassa  (neutral),  640  grains ;  caustic  potassa  (fusa),  1280 
grains ;  distilled  water,  20  fiuid  ounces.  This  test  w'ill  be 
found  more  delicate,  as  well  as  more  striking,  by  boiling  the 
test-liquid  first,  and  then  adding  the  urine  drop  by  drop.  If 
sugar  be  present  it  will  produce  a  reddish  or  yellowish  opaque 


*  Lehmann's  Physiological  Chemistry,  vol.  i.  p.  256,  Am.  ed. 
f  Researches  on  Diabetes,  2d  ed. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       619 

precipitate,  the  difference  in  color  depending  merely  upon 
the  deficiency  or  excess  of  the  test-liquid.  If  no  such  reaction 
ensue,  urine  should  be  added  until  a  bulk  nearly  equal  to  the 
test-liquid  has  been  poured  in,  and  the  whole  then  boiled 
again;  the  characteristic  change  not  yet  occurring,  the  urine 
should  be  set  aside  to  cool.  If  it  contain  less  than  half  a  grain 
per  cent,  of  sugar,  the  precipitation  will  occur  as  the  liquid 
cools.  The  mixture  Urst  loses  its  transparency,  and  passes 
from  a  clear  olive-green  to  a  light-greenish  opacity,  looking, 
as  Roberts  describes  it,  as  if  some  drops  of  milk  had  fallen 
into  the  tube.  This  green,  milky  appearance  is  characteristic 
of  a  small  amount  of  sugar.  If  no  milkiness  is  produced,  the 
urine  can  be  confidently  pronounced  free  from  sugar. 

For  the  quantitative  analysis  of  sugar  contained  in  diabetic 
urine,  the  test-liquid  is  used  as  follows :  in  an  ordinary  case 
of  diabetes,  the  urine  is  diluted  with  four  times  its  bulk  of 
water,  mixed  in  a  narrow  graduated  glass  divided  into  100 
measures.  One  hundred  minims  of  the  blue  test-fluid  are 
now  placed  in  a  small  porcelain  capsule  with  a  fragment  of 
solid  caustic  potassa  about  double  the  size  of  a  pea,  if  Pavy's 
solution  be  employed.  The  contents  of  the  capsule  are  made 
to  boil  over  a  spirit-lamp,  and  the  diluted  urine  is  dropped 
into  it  slowly  from  a  graduated  glass,  until  the  blue  color  is 
entirely  removed.  The  amount  of  diluted  urine  employed 
is  read  off  from  the  graduated  scale  of  the  tube.  Let  us  say 
it  takes  30  minims  to  decolorize  the  100  minims  in  the  cap- 
sule, that  would  be  ^  gr.  of  sugar  in  each  30  minims,  or  8 
grains  to  the  ounce  of  diluted  urine,  which,  as  it  has  been 
diluted  to  the  extent  of  one-fifth,  the  8  grains  must  be  mul- 
tiplied by  5  to  get  the  amount  of  sugar  really  present  in  an 
ounce  of  the  urine. 

The  oxides  of  other  metals  besides  copper  are  reducible 
by  grape  sugar.  In  accordance  with  this  well-ascertained 
fact,  a  test  by  bismuth  has  been  proposed.  Subnitrate  of  bis- 
muth is  boiled  with  urine,  to  which  first  some  caustic  potassa 
has  been  added.  If  sugar  be  present,  a  gray  or  black  sedi- 
ment announces  the  reduction  of  the  oxide  to  metallic  bis- 
muth. I  have  used  this  test  of  late  frequently,  and  have 
found  it  very  satisfactory. 


620  MEDICAL    DIAGNOSIS. 

These  copper  solutions  are  liable,  after  having  been  kept 
for  some  time,  especially  if  exposed  to  the  light,  to  allow  a 
slight  reduction  to  occur  on  boiling  without  any  sugar  being 
present.  The  test-liquid  itself,  if  not  fresh,  should  be  tested 
by  boiling,  and  if  any  change  occur,  a  fragment  of  caustic 
soda  if  Fehling's,  or  caustic  potassa  if  Pavy's  solution  be 
used,  "will  render  it  as  iit  as  ever  for  use. 

The  fermentation  test  by  yeast  is  another  method  in  use  to 
determine  both  the  existence  and  the  quantity  of  sugar;  but 
for  qualitative  analysis  it  is  too  tedious.  As  a  quantitative 
test,  however,  it  is  easy  of  application  and  trustworthy.  It 
was  suggested  by  Dr.  Roberts,  and  its  accuracy  has  been 
recently  indorsed  by  Prof.  Doremus,  of  New  York.*  It  is 
known  as  the  differential  density  method,  and  depends  upon 
the  fact  that  by  fermentation  of  saccharine  urine  all  the 
sugar  is  converted  into  carbonic  acid,  water,  and  alcohol,  and 
consequently  the  urine  is  diminished  in  density,  and  each 
degree  of  density  lost  indicates  one  grain  of  sugar  to  the 
fluid  ounce  of  saccharine  urine.  The  method  of  procedure 
is  as  follows:  about  four  ounces  of  the  urine  are  put  into 
a  twelve-ounce  bottle,  and  a  lump  of  German  yeast  about 
the  size  of  a  small  walnut,  or  if  this  cannot  be  had,  ordi- 
nary brewer's  yeast,  is  added.  The  bottle  is  then  covered 
with  a  nicked  cork  (which  allows  the  escape  of  carbonic 
acid),  and  is  kept  in  a  warm  place  to  ferment.  Beside  it 
should  be  placed  a  closely-corked  four-ounce  vial  containing 
some  of  the  same  urine  Avithout  any  yeast.  The  object  of  this 
is  to  obviate  any  error  which  might  occur  were  the  specific 
gravity  of  the  urine,  before  and  after  fermentation,  taken  at 
diflferent  temperatures.  In  about  twentj'-two  hours  the 
fermentation  will  have  ceased.  The  two  vials  should  be 
removed  to  a  cool  place,  so  that  the  urine  may  acquire  the 
temperature  of  the  surrounding  air.  The  specific  gravity  of 
the  two  specimens  of  urine  should  then  be  taken,  and  their 
difference  of  density,  as  determined  by  the  urinometer,  in- 
dicates the  number  of  grains  of  sugar  contained  in  each 
fluid  ounce  of  the  saccharine  urine. 

*  Flint's  Manual  of  Urine,  p.  42. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       621 

The  peculiar  fungus  which  forms  in  saccharine  urine  has 
also  been  studied  to  confirm  the  diagnosis  of  the  unnatural 
ingredient. 

To  estimate  the  quantity  of  sugar,  various  ingenious  in- 
struments have  been  employed.  Of  these,  the  polarizing 
apparatus  proposed  by  Clerget  and  made  by  Soleil,  or  the 
color-tube  of  Garrod,  would  seem  to  be  the  best. 

Inosite. — This  is  a  substance  belonging  to  the  group  of 
sugars,  and  occasionally  found  in  the  urine.  It  is  not  de- 
tected in  health,  and  is,  according  to  Cloetta,  the  observer 
who  first  discovered  it  in  urine,  associated  either  with  glucose 
or  albumen.  It  does  not  appear  to  be  derived  from  the  food, 
nor  from  the  metamorphosis  of  glucose,  and  inosuria  is  a 
symptom  rather  than  a  disease.*  The  characteristic  reaction 
of  inosite  is  exhibited  when  a  solution  of  the  substance  is 
evaporated  with  nitric  acid  nearly  to  dryness  on  platina,  and 
the  residue,  moistened  with  a  little  ammonifi  and  a  solution 
of  chloride  of  calcium,  is  again  evaporated  to  dryness;  a 
marked  rose-color  appears,  which  does  not  happen  when 
true  sugars  are  treated  in  the  manner  described. 

Extractive  matters,  in  certain  diseased  conditions,  drain  off 
from  the  blood,  and,  sometimes,  in  large  quantity.  Dr. 
Owen  Rees,  some  years  since,  pointed  out  their  value  in 
diagnosis  and  suggested  the  tincture  of  galls  as  their  test.f 
Healthy  urine  is  scarcely  afi^'ected  by  tincture  of  galls ;  the 
blood  extractives  are  immediately  precipitated  by  it.  This 
precipitate  must  not  be  confounded  with  that  of  the  earthy 
and  potassa  salts  which  is  thrown  down  from  all  kinds  of 
urine  after  the  lapse  of  five  or  ten  minutes,  by  the  spirit  con- 
tained in  the  tincture.  Should  albumen  be  present  in  the 
urine,  it  must  be  separated  by  boiling  and  filtration  before 
applying  the  test. 

Tlie  presence  in  the  urine  of  the  blood  extractives  indi- 
cates merely  the  escape  of  blood  material,  and  proves  the 
existence  of  congestion  or  inflammation  of  some  part  of  the 
urinary  surfaces.     In  a  recent  contribution  to  medical  litera- 


*  Gallois,  I>e  I'lnosurie.     1864. 

t  See  London  Medical  Gazette,  1851,  N.  S.,  vol.  xiii.  p.  136. 


622  MEDICAL    DIAGNOSIS. 

ture  Dr.  Rees  has  pointed  out*  that  in  Bright's  disease  the  ex- 
tractives can  be  found  in  the  urine  before  albumen  is  met  with, 
and  also  that  they  exist  after  the  albumen  has  disappeared: 
thus,  on  the  one  hand,  warning  us  of  the  approach  of  albu- 
minuria, and,  on  the  other,  against  too  early  a  belief  in  con- 
valescence ;  for,  as  Dr.  Rees  justly  observes,  so  long  as  the 
blood  is  losing  its  extractives  so  long  is  our  patient  in  peril. 
The  presence  of  the  extractives  also  enables  us  to  diagnos- 
ticate nephritic  irritation  from  renal  calculus,  before  albu- 
men, blood,  or  pus  has  appeared.  It  is  highly  probable  that 
extractives  will  be  found  preceding  albumen  in  urine  in  most 
cases. 

Albumen. — Urine  may  be  albuminous  from  an  admixture 
with  blood  or  pus,  or  from  a  transudation  of  the  albumen  of 
the  serum  of  the  blood  through  the  walls  of  the  vessels  of 
the  kidneys.  Sometimes  the  albumen  appears  for  but  a 
short  time  in  thfe  urine  ;  at  other  times  it  is  permanent;  and 
in  accordance  with  the  length  of  its  stay  its  significance 
varies.  But  this  important  clinical  point  will  further  on  en- 
gage our  attention  more  fully.  Let  us  here  rather  examine 
the  tests  announcing  the  presence  of  the  foreign  substance. 

There  are  several  methods  enabling  us  to  ascertain  the 
occurrence  of  albumen.     Of  these,  the  chief  are  : 

Meat,  which  coagulates  the  albumen  ; 

Nitric  acid,  or  carbolic  acid,  which  causes  a  white  precipitate ; 

Corrosive  sublimate,  which  also  occasions  a  precipitate. 

The  first  and  second  of  these  tests  are  the  most  convenient 
and  the  most  in  use ;  but  they  must  be  employed  with  cer- 
tain precautions,  and  care  must  be  taken  not  to  rush  to  a 
conclusion  that  albumen  is  present  until  several  sources  of 
fallacy  have  been  guarded  against.  For  instance,  the  appli- 
cation of  heat  may  render  the  fluid  thick  by  throwing  down 
the  phosphates  instead  of  the  suspected  albumen.  We  can, 
however,  easily  avoid  being  led  into  error  by  adding  nitric 
acid,  wdiich  causes  the  turbidity  to  disappear,  it'  it  be  owing 
to  the  phosphates. 

Again,  if  the  urine  be  alkaline  and  the  quantity  of  albu- 


*  Guy's  Hosp.  Kep.,  3d  Series,  vol.  xiv.  p.  4:U. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       623 

men  small,  heat  will  not  produce  coagulation.  Hence  care 
must  be  taken  to  render  the  urine  slightly  acid  before  heat  is 
applied.  Acetic  acid,  which  does  not  precipitate  albumen, 
may  be  added  for  the  purpose  of  neutralizing  the  alkales- 
cence. A  highly  acid  urine  behaves  like  an  alkaline  urine; 
in  it,  too,  albumen  may  fail  to  be  exhibited  by  heat. 

The  addition  of  nitric  acid  may  give  rise  to  a  precipitate, 
which  is  not  albumen.  It  may  deposit  the  urates,  or  even 
uric  acid.  But  heat  here  supplies  the  touchstone.  The  boil- 
ing urine  clears  quickly,  if  the  opacity  be  not  caused  by  co- 
agulated albumen. 

Now,  as  both  the  heat  and  the  nitric  acid  test  may  lead  to 
wrong  conclusions,  if  trusted  to  exclusively,  but  as  they  are 
so  manifestly  complementary  to  each  other,  we  must,  to  ob- 
viate all  sources  of  error,  in  every  case  employ  both.  The 
best  method  of  proceeding  is  to  boil  the  urine,  after  having 
ascertained  it  to  be  of  acid  reaction,  in  a  test-tube,  by  the 
flame  of  a  spirit-lamp,  and  then  to  add  the  acid.  Or  a  second 
specimen  may  be  tested  according  to  a  plan  proposed  by 
Heller:  a  small,  conical  glass,  tilled  about  one-third  full,  is 
held  in  an  inclined  position  in  the  left  hand;  twenty  drops 
of  nitric  acid  are  then  allowed  to  flow  gradually  down  the 
side  of  the  vessel ;  the  acid  collects  at  the  bottom,  and  above 
it  may  be  seen  an  accurately-deflned  layer  of  coagulated 
albumen. 

The  quantity  of  nitric  acid  used  is  always  a  matter  of  im- 
portance; it  must  be  neither  too  much  nor  too  little.  A 
large  amount  redissolves  the  albumen  ;  merely  a  drop,  on 
the  other  hand,  may  retard  instead  of  favoring  coagulation, 
which  then  does  not  take  place  even  when  the  urine  is  boiled. 
In  testing  for  albumen  by  means  of  heat  and  nitric  acid, 
there  may  be  no  immediate  response;  yet  after  a  few  hours 
a  flocculent  precipitate  may  form  and  fall  to  the  bottom  of 
the  tube.* 

Sometimes  urine  is  encountered  on  which  neither  the  heat 
nor  the  acid  test  yields  the  customary  result.  This  is  owing 
to  its  containing  a  modified  form  of  albumen.     Such  a  case 


*  Andrew  Clark,  Lond.  Hosp.  Reports,  vol.  i.  p.  226. 


624  MEDICAL    DIAGNOSIS. 

was  published  by  Dr.  Beiiee  Jones.*  No  coagulation  was 
produced  by  heat,  and  none  by  nitric  acid,  unless  the  urine 
was  subsequently  heated  and  permitted  to  cool.  The  solid 
that  formed  on  cooling,  disappeared  on  heating.  The  sub- 
stance which  Avas  precipitated  by  alcohol  was  the  hydrated 
deutoxide  of  albumen.  The  patient  was  laboring  under  mol- 
lities  ossium.  Dr.  Basham  recommends  the  tincture  of  galls 
as  a  test  for  this  modified  form  of  albumen.  Scherer,  too,  has 
met  with  a  form  of  albumen  precipitable'from  the  solution 
containing  it  by  alcohol,  but  not  by  heat;  boiling  causing  a 
mere  turbidity. 

Recently  M^hu  has  recommendedf  the  following  carbolic 
acid  solution  as  a  test  for  albumen  : 

Of  crystallized  carbolic  acid,  1  part  by  weight ; 

Commercial  acetic  acid,  1  part ; 

Alcohol,  90  p.  c,  2  parts. 

This  solution  undergoes  no  change  by  keeping.  It  is  used 
as  follows:  to  100  grammes  of  urine  add  2  c.  c.  of  commer- 
cial nitric  acid,  and  thoroughly  mix.  Upon  the  addition  of 
10  c.  c.  of  the  carbolic  acid  solution  the  albumen  is  precipi- 
tated in  white  flakes.  In  testing  highly  albuminous  urine 
or  albuminous  solutions  charged  with  salts,  the  addition  of 
nitric  acid  is  scarcely  necessary.  This  method  I  have  fre- 
quently used  of  late,  and  have  found  it  a  very  delicate  and 
satisfactory  test. 

It  is  often  of  service  to  determine  the  exact  amount  of 
albumen  voided  with  the  urine.  This  may  be  accomplished 
by  adding  a  small  quantity  of  acetic  acid  to  a  weighed 
quantity  of  urine,  which  is  then  to  be  boiled.  The  precipi- 
tate is  collected  on  a  filter,  dried  and  weighed.  An  easier 
and  ordinarily  sufliciently  accurate  method  consists  in  add- 
ing a  small  quantity  of  acetic  acid  to  a  specimen  of  urine, 
boiling  and  allowing  the  flaky  precipitate  to  settle  in  the  test- 
tube  ;  the  proportion  of  precipitate  to  the  entire  bulk  is  then 
expressed  as  one-fifth,  one-eighth,  etc.,  as  the  case  ma}'  be. 

Blood. — The  passage  of  blood  with  the  urine  constitutes 

*  Philosophical  Transactions  for  1848. 

f  Archiv.  Gen.  de  Med.,  Mars,  18G9,  p.  268. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       625 

the  phenomenon  known  as  hsematuria.  The  urine  voided 
is  of  a  red  color,  or  of  a  more  or  less  dingy  or  smoky  hue, 
and  deposits,  on  standing,  a  reddish-brown  or  a  dark  coffee- 
ground  sediment.  If  much  blood  be  present,  small,  irregular 
masses  are  seen  at  the  bottom  of  the  vessel. 

The  appearance  of  urine  containing  blood  is  therefore  not 
uniform.  But,  whatever  the  look  to  the  naked  eye,  the  diag- 
nosis is  at  once  rendered  certain  b3'the  use  of  the  microscope. 
And  only  by  this  means  can  it  be  rendered  certain  ;  for  urine 
may  be  red  or  black,  from  the  admixture  of  various  pigments 
derived  from  substances  swallowed  as  food  or  medicine,  or 
belonging  to  the  economy.  Thus,  beet-root,  some  kinds  of 
strawberries,  logwood,  and  rhubarb  impart  a  deep-red  color, 
which  may  be  the  cause  of  groundless  alarms;  or  urine 
deeply  tinged  with  bile,  or  discolored  by  fever,  may  be 
thought  to  signify  the  occurrence  of  hemorrhage  from  the 
urinar}'^  passages. 

The  corpuscles  are  not  always  of  uniform  appearance,  yet 
they  are  never  seen  collected  in  rouleaux.  But,  after  having 
found  blood  corpuscles  to  indicate  the  true  nature  of  the 
changed  hue  of  the  excretion,  the  question  remains  to  be 
solved,  at  what  point  has  the  blood  been  poured  out?  Is  it 
really  from  the  urinary  organs?  and  if  it  be  from  them, 
whence? — from  the  kidneys,  from  the  bladder,  or  from  some 
other  portion  of  the  tract?  Again,  what  morbid  state  lies  at 
the  root  of  the  hemorrhage  ? 

Now,  the  iirst  of  these  questions  must  always  be  answered 
at  the  onset.  Blood  may  flow  from  the  vagina  or  uterus  and 
become  mixed  with  the  secretion  from  the  kidneys,  or  it  may 
have  been  added  for  purposes  of  deception.  In  the  former 
case,  a  careful  inquiry  into  the  state  of  these  organs,  or,  if 
necessary,  a  digital  examination,  will  eliminate  the  source  of 
error;  in  the  latter,  having  the  patient  watched,  and  drawing 
his  urine  off  by  the  catheter,  detects  the  imposture.  When 
we  have  fully  satisfied  ourselves  that  the  blood  is  derived 
from  the  urinary  organs,  the  next  point  to  be  ascertained — 
and  clinicall}^  its  importance  cannot  be  overrated — is,  whethei"' 
it  proceeds  from  the  kidney  or  the  bladder.  To  determine 
this,  we  have  not  only  to  study  the  character  of  the  fluid  ex- 

40 


626  MEDICAL    DIAGNOSIS. 

creted,  but  also  closely  to  investigate  all  the  conditions  of 
the  accident. 

If  the  blood  come  from  the  bladder,  it  is  not  equally  dif- 
fused through  the  urine ;  the  fluid  discharged  is  at  first  clear 
or  nearly  so,  but  at  the  end  of  the  act  of  micturition  is  much 
more  deeply  colored,  or  pure  blood,  in  a  liquid  form  or  in 
clots,  is  voided.  Then,  too,  there  is  usually  pain  over  the 
bladder,  with  a  frequent  desire  to  pass  water,  or  a  stoppage 
in  doing  so. 

When  the  blood  is  derived  from  the  kidney,  we  discover, 
on  the  other  hand,  pain  in  the  lumbar  region,  and  other 
symptoms  pointing  to  the  aflJected  organ,  such  as  dropsy, 
the  existence  of  albumen  in  considerable  quantities  in  the 
urine,  or  the  passage  of  gravel.  Clots  are  not  encountered 
in  renal  hemorrhage,  excepting  when  the  blood  coagulates  in 
the  infundibulum  or  the  ureter,  and  is  gradually  forced  down- 
ward. Such  clots  are  of  a  whitish  color,  and  generall}^  of 
cylindrical  shape.  In  their  transit  toward  the  bladder,  they 
become  often  the  source  of  distressing  pain.  They  are  very 
significant,  yet  they  are  not  absolutely  pathognomonic  of 
renal  hemorrhage ;  for  coagula  formed  in  the  bladder  may 
be  retained  there  for  some  time,  and  lose  their  color  before 
they  are  expelled. 

But  aid  in  diagnosis  may  be  derived  from  the  study  of  the 
shape  of  the  clots,  which  for  this  purpose  should  be  floated 
out  in  water.  According  to  Mr.  John  Hilton,*  they  will 
oftentimes  be  found  to  be  exact  moulds  or  casts  of  the  cavity 
in  which  the  blood  was  effused.  Thus,  for  instance,  coagula 
formed  within  the  bladder  are  found  to  have  a  somewhat  ir- 
regular, circular  outline,  and  to  be  flattened  in  shape,  with 
bevelled  and  serrated  edges.  In  their  passage  through  the 
ureters  and  urethra,  clots  are  often  the  source  of  distressing 
pain. 

The  use  of  the  microscope,  furthermore,  affords  most  val- 
uable aid  in  the  differential  diagnosis.  The  epithelium  which 
is  mixed  with  the  blood  is  not  flat  and  in  scales,  like  that 
from  the  bladder,  but  small  and  more  or  less  round.     Sonie- 


*  Guy's  Hosp.  Rep.,  3d  fcjerios,  vol.  xiii.  p.  19  et  seq. 


THE    URINE,  AND    DISEASES    OF   THE    URINARY    ORGANS.      627 

times  the  blood  globules  are  seen  to  be  collected  on  casts 
that  have  been  moulded  within  the  renal  tubes.  These 
blood-casts  warrant  an  absolute  conclusion  as  to  the  source 
of  the  hemorrhage.  But  they  do  not  always  occur  ;  and  their 
absence,  therefore,  is  not  so  complete  and  valuable  a  proof 
as  their  presence. 

On  the  whole,  then,  although  there  is  no  one  constant  and 
unequivocal  sign  of  either  renal  or  vesical  hemorrhage,  we 
may  generally  arrive,  by  care,  at  a  correct  knowledge  of  the 
source  whence  the  blood  proceeds.  In  perplexing  cases  we 
should  obtain  specimens  of  urine  for  examination  in  the 
manner  recommended  in  the  early  pages  of  this  chapter. 

But  let  us  suppose  that  the  origin  of  the  flow  has  been  sat- 
isfactorily settled ;  it  still  remains  to  determine  what  is  the 
probable  cause  of  the  bleeding.  Here,  too,  trustworthy 
knowledge  is  not  to  be  obtained,  save  by  careful  analj-sis  of 
the  group  of  symptoms  before  us.  Let  us  glance  at  some  of 
the  chief  causes  of  hsematuria. 

When  of  renal  origin,  it  is  often  due  to  an  irritation  or  in- 
flammation of  the  kidneys  produced  b}'  some  poison  escaping 
out  of  the  system  through  this  channel,  as  is  observed  in 
scarlatina  and  other  acute  idiopathic  diseases  in  which  the 
phenomena  of  acute  desquamative  nephritis  show  themselves. 
Here  we  have  the  history  of  the  malady,  and  the  presence  of 
tube-casts  and  of  a  considerable  amount  of  albumen  in  the 
urine,  to  explain  the  meaning  of  the  hemorrhage.  The  blood, 
it  has  been  demonstrated,  is  derived  from  the  engorged  and 
ruptured  Malpighian  corpuscles. 

A  congestion  of  the  kidneys  of  very  analogous  nature,  and 
leading  to  the  same  consequences,  is  occasionally  encountered 
in  typhus  fever,  in  small-pox,  in  malignant  measles,  and  in 
acute  rheumatism.  Irritant  medicines,  too,  such  as  turpentine 
and  cantharides,  cause  congestion  and  bloody  urine.  In  all 
these  varied  circumstances,  a  knowledge  of  the  history  of  the 
case  and  a  careful  survey  of  its  symptoms  render  the  diagnosis 
positive. 

Henal  hcematuria  of  a  more  chronic  character  is  generally 
due  to  cancer  of  the  kidney ;  to  ulceration  within  the  pelvis 
of  the  organ  ;  or  to  irritation,  with  or  without  ulceration,  set 


628  MEDICAL    DIAGNOSIS. 

up  by  a  calculus.  In  the  first  of  these  affections  there  is 
nothing  peculiar  in  the  sensible  qualities  of  the  urine  to  point 
out  the  source  of  the  hseraaturia  until  the  disease  is  far  ad- 
vanced, Avhen  pus,  and  sometimes  disorganized  cancerous 
tissue,  may  be  detected  in  the  sediment.  The  signs  of  a  non- 
calculous  pyelitis  are  not  sufficiently  definite  to  enable  us  to 
distinguish  this  rare  malady  with  anything  like  accuracy. 
The  existence  of  a  calculus — one  of  the  most  common,  if  not 
the  most  common  of  the  agents  producing  hematuria — is  in- 
dicated as  the  source  of  the  hemorrhage  by  the  bleeding  hav- 
ing followed  active  exertion,  or  ajar  of  the  body  from  a  fall, 
and  by  its  recurring  from  time  to  time  under  circumstances 
like  those  just  mentioned,  favorable  to  the  disturbance  of  a 
calculus  lodged  in  the  kidney.  The  presumption  of  this  being 
the  reason  of  the  repeated  bleeding  is  converted  almost  into 
certainty  if  there  be  localized  pain,  and  if  on  any  occasion 
one  of  the  stony  concretions  should  have  been  expelled. 

There  has  been  described,  under  the  name  of  paroxysmal 
or  intermittent  hcemaiuria,  a  disease  which  differs  from  ordinary 
renal  hemorrhage  in  that  in  the  latter  the  urine  is  not  only 
coagulable  by  heat  and  nitric  acid,  but  contains  blood  cor- 
puscles; while  in  the  former,  although  coagulable  by  heat 
and  nitric  acid,  it  exhibits  very  few  or  no  blood  corpuscles, 
and  the  coloring  matter  is  not  deposited  on  standing.  Besides, 
the  urine  shows  an  increased  proportion  of  urea.  According 
to  Greenhow,*  crystals  of  oxalate  of  lime  are  constantly 
passed  during  a  parox^'sm  and  are  absent  at  other  times. 
This  affection  is  unattended  by  any  permanent  lesion  of  the 
kidneys.  It  is  paroxysmal  in  form,  and  is  not  of  malarious 
origin. f  The  disease  is  ushered  in  by  rigor,  which  is  fol- 
lowed by  only  an  imperfect  hot  stage,  and  more  rarely  by 
sweating.  The  urine  voided  is  of  a  deep-blood  color,  and 
within  an  hour  or  two,  perhaps,  changes  suddenly  to  a  pale- 
straw  color.     The  etiology  of  the  disease  is  unknown. 

There  is  also  a  form  of  hasmaturia  which  is  endemic,  and 
depends  upon  the  presence  of  a  parasite  (Bilharzia  htemato- 

*  Trans,  of  Clinical  Society,  1868,  vol.  i, 

f  yide  Greenhow,  loc.  cit.;  also  Pavy,  Trans,  of  Path.  Soc.  of  Lond.,  xviii. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       629 

bia).  It  prevails  in  the  Mauritius,  certain  parts  of  the  Cape 
of  Good  Hope,  Natal,  Egypt,  and  Brazil.  The  parasite  in- 
habits chiefly  the  small  vessels  of  the  mucous  membrane  of 
the  urinary  passages  and  the  kidneys,  and  it  gains  access  to 
these  parts  chiefly  during  the  act  of  bathing  in  the  rivers. 
Persons  aflected  with  the  Bilharzia  haematobia  are  often  ob- 
served to  pass  small  renal  calculi  of  oxalate  of  lime,  which 
have  for  their  nuclei  the  ova  of  this  parasite.* 

Besides  these  causes,  renal  hemorrhage  may  result  from  an 
altered  state  of  the  blood.  Hematuria  of  this  kind  is  encoun- 
tered in  purpura  and  scurvy. 

To  consider  now  vesical  htematuria.  One  source  to  which 
it  may  be  owing  is  a  congestion  of  the  bladder,  as  witnessed 
in  fevers  of  a  low  type.  Another  is  inflammation,  whether 
acute  or  chronic,  and  whether  of  traumatic  origin  or  brought 
on  by  a  stone.  In  all  these  contingencies,  the  history  of  the 
case  and  the  local  symptoms  establish  the  diagnostic  distinc- 
tions; in  arriving  at  which  we  are  often  materially  aided  by 
the  introduction  of  a  sound  into  the  bladder.  It  has  been 
claimed  for  the  endosco'pe  that  it  also  assists  greatly  in  the 
diagnosis. f 

Another  form  of  hemorrhage  from  the  bladder  is  depend- 
ent upon  malignant  growths  on  its  mucous  coat.  Generally 
these  are  attended  with  pain,  with  a  constant  desire  to  empty 
the  viscus,  and  with  considerable  emaciation  and  a  general 
cachectic  condition.  The  fluid  which  is  passed  frequently 
contains  pus,  and,  as  the  malady  advances,  from  time  to  time 
large  quantities  of  blood.  Yet  it  is  not  a  little  singular  that 
the  appearance  of  the  blood  in  the  excretion  may  be  the  first 
sign  of  disturbance  of  the  urinary  apparatus.  J 

Vesical  hfematuria,  more  frequently  than  renal,  occurs  as  a 
vicarious  discharge.  Persons  who  are  subject  to  bleeding 
piles,  lose  blood  occasionally  from   the  bladder,  instead  of 


*  For  a  full  description  of  endemic  haematuria,  see  Dr.  Geo.  Harley,  in  the 
Medico-Chirurgical  Transactions,  vol.  xlvii.  p.  55,  and  vol.  lii.  p.  379. 

f  See  Desormeaux,  De  rEndoscope,  Paris,  1865  ;  and  Cruise,  Dublin  Quart. 
Journ.,  May,  1865. 

X  An  interesting  case  in  point  is  reported  by  Dr.  Tndd,  Case  XI.  Lectures 
on  TJrinarv  Diseases. 


630  MEDICAL    DIAGNOSIS. 

from  the  rectum.  But  in  obscure  cases  of  this  kind,  before 
arriving  at  a  definite  conclusion,  it  is  necessary  to  bear  in 
mind  that  some  writers,  Thudichum  prominently  among 
them,  believe  that  true  vesical  haemorrhoids  are  not  un- 
common. 

Blood  may  be  discharged  from  other  parts  of  the  urinary 
apparatus  as  well  as  from  the  bladder  or  the  kidneys.  It  may 
come  from  the  'prostate  gland  or  the  urethra.  Now,  in  either 
case  the  bleeding  is  usually  very  profuse,  and  large  quantities 
of  blood  are  passed  pure,  or  at  first  unmixed  with  urine. 
Besides,  there  are  local  signs  of  diseases  of  these  parts,  fur- 
nishing important  points  of  discrimination.  But  this  subject 
cannot  be  here  pursued ;  it  belongs  rather  to  the  domain  of 
surgery  than  to  that  of  medicine. 

Such,  then,  are  the  various  conditions  under  which  haema- 
turia  may  be  noticed.  As  regards  its  prognosis,  it  is  evident 
that  this  depends  less  upon  the  hemorrhage  itself  than  upon 
the  disorder  of  which  the  hemorrhage  is  a  symptom.  The 
flow  of  blood  in  itself  is  very  rarely  fatal.  One  of  the  worst 
consequences  it  may  entail  is  the  retention  of  a  clot  w^hich 
serves  as  a  nucleus  for  the  formation  of  a  calculus.  The  treat- 
ment, too,  varies  of  necessity  with  the  cause  of  the  affection. 
Without  entering  into  particulars,  I  will  merely  say,  that  for 
the  arrest  of  the  hemorrhage  rest  is  indispensable;  and  where 
we  desire  speedily  to  check  the  discharge,  gallic  acid  is  very 
valuable. 

Pus. — Urine  containing  pus,  deposits  an  opaque  creamy 
sediment,  or  a  glairj'  mass,  is  generally  alkaline,  and  always 
slightly  albuminous.  If  the  deposit  be  agitated  with  an  equal 
quantity  of  liquor  potassae,  a  dense  gelatinous  mass  results. 
This  is  the  chemical  test  for  pus  ;  but  it  is  a  clumsy  one,  com- 
pared with  the  rapid  and  absolute  diagnosis  of  the  pus  cor- 
puscles by  means  of  the  microscope. 

Sometimes  a  large  amount  of  mucus  is  mixed  with  the 
purulent  sediment,  or  a  deposit  due  wdiolly  to  the  former  in- 
gredient is  80  considerable  that  it  is  mistaken  for  pus.  Yet 
the  mucous  deposit  shows  distinct  points  of  difference :  it  is 
less  dense,  and  collects  more  in  clouds  at  the  bottom  of  the 
vessel.     And  here  again  there  is  no  means  of  discrimination 


THE    URINE,  AND    DISEASES    OF   THE    URINARY   ORGANS.       631 

as  certain  as  that  afforded  by  the  microscope.  Quantities  of 
epithelium  are  always  seen  to  be  entangled  in  the  transparent 
mucus,  and  the  action  of  acetic  acid  develops  the  filaments  of 
mucin.  Sometimes,  also,  there  are  thin  flakes  or  cylindrical 
bodies,  unlike  any  appearance  exhibited  by  pus. 

Fig.  40. 


'WB 


Pus  corpMscles;  those  at  the  lower  part  of  the  field  exhibit  the 
action  of  acetic  acid  on  the  corpuscles. 

Yet  when  the  urine  is  strongl}^  ammoniacal,  even  the  micro- 
scope does  not  furnish  a  certain  test ;  for  the  salts  of  ammo- 
nia obliterate  the  distinctive  pus  globules  and  convert  pus 
into  a  slimy  mass. 

The  occurrence  of  pus  in  the  urine  is  a  sign  of  suppuration 
somewhere  in  the  genito-urinary  system,  or  a  proof  that  an 
abscess  has  opened  into,  and  is  being  discharged  through  this 
channel.  But  as  to  the  exact  seat  of  the  formation  of  the  ab- 
normal product,  its  existence  in  the  urine  aftbrds  no  clue. 
To  some  extent,  however,  we  can  judge  of  this  by  the  micro- 
scopical appearance  of  the  corpuscles.  When  these  are  round 
and  well  developed,  with  their  characteristic  nuclei  readily 
brought  out  by  acetic  acid,  they  generally  have  their  origin  in 
a  catarrhal  inflammation  of  the  mucous  membrane,  especially 
of  the  bladder.  On  the  other  hand,  as  Yogel  points  out,  pus 
corpuscles  of  irregular  contour,  exhibiting  irregular  nuclei 
when  treated  with   acetic   acid,  or  an  ill-defi.ued   granular 


632  MEDICAL    DIAGNOSIS. 

mass,  consisting  of  irregularlj-sbaped  pus  corpuscles  and 
partial! j-destroyed  cells,  indicate  the  probable  existence  of 
deep-seated  suppuration,  ulceration,  or  tubercular  disease. 

Fat. — Fatt}^  matter  may  occur  in  the  urine  in  various  forms 
and  in  different  conditions.  It  may  be  found  in  the  shape  of 
globules,  when  oil  or  milk  has  been  added  to  the  urine  for 
purposes  of  deception,  or  when  the  former  article  has  been 
swallowed  for  some  time  in  considerable  quantities,  as  for 
instance  during  the  administration  of  cod-liver  oil.  It  is  also 
encountered  in  globules  of  varying  size,  either  free,  in  cells, 
or  in  tube-casts,  as  in  fatt}^  degeneration  of  the  kidneys. 

In  some  cases  it  is  met  with  in  a  molecular  state,  imparting 
to  the  urine  a  milky  appearance,  to  which  the  name  chylous 
urine  has  been  given.  The  cause  of  this  milky  urine  is  not 
positively  known.  Dr.  Beale  considers*  that  the  condition 
does  not  depend  upon  any  permanent  inorbid  change  in  the 
secreting  structure  of  the  kidney,  and  that  the  chylous  char- 
acter of  the  urine  is  intimately  connected  with  the  absorption 
of  chyle,  but  precisely  how  the  urine  acquires  that  character 
is  uncertain.  It  may  continue  for  years  without  impairment 
of  the  general  health,  being  always  perceptibly  increased  by 
exercise.  The  disorder  is  best  checked  by  the  use  of  astrin- 
gents, f 

The  tests  for  fat  are  its  solubility  in  ether,  and  its  micro- 
scopical characters.  Lea  and  Atlee  have  recently  pointed 
out|  an  error  which  is  apt  to  occur  in  analysis  of  urine,  viz., 
an  illusory  detection  of  fat.  They  found,  in  testing  a  speci- 
men of  urine,  that  the  ether  rose  to  the  top  so  charged  with 
matter  as  to  resemble  a  half-liquid  pomade.  Separated  by  a. 
pipette  and  spontaneously  evaporated,  it  left  a  dirty-whitish 
greasy  mass.  A  careful  examination  of  this  residue  showed 
that  instead  of  consisting  of  fatt}-  acids,  it  contained  nothing 
but  the  normal  constituents  of  the  urine,  for  it  was  soluble 

*  Kidney  Dis.  and  Urin.  Deposits,  3d  cd.,  p.  SOi). 

f  See  the  cases  of  the  disorder  in  the  papers  of  Bence  Jones,  Medico-Chi- 
rurg.  Transact.,  1850-53;  of  Gubler,  Gazette  M^dicale  de  Paris,  1858;  and 
of  Isaacs,  Transact,  of  New  York  Acad,  of  Medic,  vol.  ii.;  also  Bcalo,  Kidney 
Dis.  and  Urinary  Deposits,  3d  ed.,  p.  299. 

X  Am.  Journ.  Med.  Sciences,  April,  1869,  p.  S57. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.      633 

in  water,  reappearing  as  normal  urine.  It  was  then  ascer- 
tained that  almost  any  specimen  of  urine  will  form  an  emul- 
sion when  violently  agitated  with  ether,  especially  if  the  ether 
contain  a  small  amount  of  alcohol,  but  this  condition  is  not 
essential.  "When,  therefore,  ether  appears  to  dissolve  out 
fatty  matter  from  urine,  the  ethereal  solution  should  be  sepa- 
rated, allowed  to  evaporate  spontaneously,  and,  if  the  residue 
be  soluble  in  water,  it  cannot  be  held  to  contain  fat. 

When  passed  in  large  amounts,  fat  may  be  evident  to  the 
unassisted  eye.  But  there  is  no  certainty  of  its  presence 
unless  the  sediment  be  examined  chemically  and  microsco- 
pically. Much  error  has  indeed  been  occasioned  by  trusting 
solely  to  the  look  of  the  fluid.  Thus  the  opalescence  of  urine 
caused  by  a  sediment  of  urates  has  been  mistaken  for  that 
from  oily  matter,  and  so  also  has  been  the  pellicle  which 
often  forms  on  urine,  and  which  consists  not  of  fat,  but  of 
vibriones,  fungi,  and  cr^^stals  of  the  triple  phosphates.  The 
"kyestein"  pellicle  observed  in  the  pregnant  state  is  of 
similar  kind,  though  some  oily  matter  may  enter  into  its 
composition. 

Sediments. — In  connection  with  the  different  ingredients 
of  the  urine,  the  nature  of  the  various  urinary  sediments  has 
been  discussed,  and  it  has  been  insisted  upon  that  they  can- 
not be  accurately  determined,  save  by  a  careful  microscopical 
examination.  I  will  therefore  here  only  group  together  their 
general  characteristics : 

1.  A  light  and  flocculent  cloudy  deposit  is  commonly 
mucus,  entangling  epithelial  cells,  or  spermatozoids. 

2.  A  dense,  abundant,  white  deposit  is  generally  composed 
of  urates  or  phosphates;  but  it  may  be  pus  or  extraneous 
matter. 

3.  A  yellow  or  pink  deposit  is  almost  always  due  to  urates. 

4.  A  granular  or  crystalline  deposit,  of  reddish  color  and 
small  in  quantity,  is  uric  acid. 

5.  A  dark,  sooty  or  dingy-red  deposit,  is  blood. 

So  much  for  the  sediments.  The  following  table  may 
serve  a  useful  purpose,  in  showing  how  both  they  and  the 
soluble  urinary  ingredients  are  affected  by  the  reagents  com- 
monly employed : 


634 


MEDICAL    DIAGNOSIS. 


Table  exhibiting  the  Action  of  the  main  Keaqents  employed  in  the 

Examination  of  the  Urine. 


Specific  Gra- 
vity   


High. 


Low. 


{Urine   high    col-  r  Increase  of  urea, 
ored \      uric  acid,  etc. 
Urine  pale Diabetes. 

f  Urine   high    col-  r  Certain  forms   of 
ored  or  normal.  \    Briglit's  disease. 
Urine  pale Excess  of  water. 


Throws  down  de-  r  Soluble  in  acid..., 
posit \  Insoluble  in  acid. 

Heat -{   Dissolves  deposit.  •<  Urates. 

Does  not  dissolve  J  Uric  acid, 
deposit 1  Phosphates. 


Phosphates. 
Albumen. 


Nitric  Acid 


[Quickly JAlb 


umen. 


Precipitates . 


Uric  acid. 


More  gradually....!  Crystals  of  nitrate 
i      of  urea, 
f  Earthy  phos- 


I      phates. 
Dissolves -j  Alkaline  phos- 
phates. 


1   Causes    decompo- 
sition under  ef- 


Oxalates. 
With  heat. 


Urea  decomposed 
into  carbonate 
of  ammonia. 


Hydrochloric 
Acid 


fervescence Without  heat f  Carbonate  of  lime 

L  I-  Uric  acid. 

Precipitates i  Uric  Acid. 

Transforms f  Urates   into   uric 

I      acid. 
Detects,  by  violet  j  Uroxanthine  or 
chansreof  color.  \      Indican. 


Sulphuric 
Acid 


Changes  color  of 


urine. 


Brown s  Urohajmatin. 

Crimson  or  violet  r 
(if  sugar   have-|  ^'" 


iary  acids. 


been  added.) 
Violet  .  -!  Indican. 


f 


Acetic  Acid 


Precipitates  de- 
posit (not  solu- 

1 ,    .  e-l  Mucus, 

ble  in  excess  ol 

the  acid.) 


THE    URINE,  AND    DISEASES    OF    THE    URINAP.Y    ORGANS.       635 


Table  exhibiting  the  Action  of  the  main  Reagents  employed  in  the 
Examination  of  the  JJrine— {Continued). 

Precipitates f  Earthy  phos- 


\ 


phates. 


Liquor  Potass^.  . 


Liquor 


Ammo 


On  boiling,  turns  ^ 

urine  brown....  |  Sugar. 

Dissolves f  Uric  acid. 

t-  Deposits  of  urates. 
Forms  gelatinous  <- 

mass \  Fas. 

("precipitates /  Earthy  phos- 

C      phates. 


phfi 
Dissolves j  Cysti 


ne. 


Solut.ofChlor. 
OF  Barium 


Precipitates J 


f  Deposit  soluble  in  r  ,,,        ,    , 

/  .  -,  <  Phosphates. 

I       tree  acid.  I 

Deposit  insoluble  (  c,  ,  •,    . 
.        .  ^  {  sulphates, 

in  acids.  t. 


Nitrate  of 

Silver ^   Precipitates. 


Alcohol,  or 
Ether. 


Ether. 


I 

Yellow  deposit, 
soluble  in  nitric 
acid  and  ammo- 
nia. 
-{  White  deposit, 
insoluble  in  ni- 
tric acid,  but 
soluble  in  am- 
monia. 

Precipitates |  Albumen. 

Dissolves |  Hippuric  acid. 

Does  not  dissolve..  <  XJric  acid. 

j  Dissolves -|  Fat. 


Alkaline  phos- 
phates. 


I 


Chloride   of   so- 
dium. 


URINARY  ORGANS. 

Diseases  of  the  Kidney  of  whicli  Pain  is  a  Prominent  System. 

This  group  embraces  acute  inflammation  of  the  kidney,  and 
those  painful  aflfections  cLassed  under  the  term  nephralgia. 

Nephritis. — Acute  inflammation  of  the  kidney  is  chiefly 
observed  in  old  persons  and  in  damp  climates.     It  may  be 


636  MEDICAL    DIAGNOSIS. 

occasioned  by  an  attack  of  acute  rheumatism,  by  direct  vio- 
lence to  the  organ,  or  by  the  irritation  of  a  calcuhis;  but 
probably  its  most  frequent  cause  is  exposure. 

It  commences  with  a  chill,  soon  followed  by  fever.  The 
pulse  is  small  and  hard,  the  skin  is  frequently  dry.  There 
are  nausea  and  vomiting,  and  at  times  diarrhoea  with  tenes- 
mus. The  urine  is  voided  drop  by  drop ;  it  is  red,  and  may 
contain  blood.  The  patient  complains  of  a  pain  in  the  renal 
region,  sometimes  dull,  at  others  sharp  and  lancinating,  and 
augmented  by  pressure  and  by  moving.  The  pain  is  not 
limited  to  the  kidney,  but  radiates  to  the  diaphragm  and  to 
the  bladder.  With  it  are  often  associated  a  numbness  of  the 
thigh  on  the  afiected  side,  and  a  retraction  of  the  testicle. 

The  disease  may  occur  in  both  kidneys  ;  yet  it  rarely  affects 
more  than  one.  It  lasts  from  one  to  three  weeks,  and  gen- 
erally terminates  in  resolution.  But  it  may  lead  to  suppura- 
tion and  disorganization  of  the  organ. 

The  disorder  is  recognized  by  the  pain,  the  fever,  the  re- 
traction of  the  testicle,  and  the  appearance  of  the  urine.  It 
differs  from  an  attack  of  colic  by  the  signs  of  disturbance 
of  the  urinary  organs,  by  the  seat  of  the  pain  and  the  fever; 
from  rheumatic  pains  in  the  back,  by  the  former  of  these 
symptoms.  Then,  in  lumbago  we  rarely  find  much  febrile 
excitement,  nor  are  there  nausea  and  vomiting,  nor  numb- 
ness along  the  course  of  the  anterior  crural  nerve ;  but,  on 
the  other  hand,  the  pain  is  much  more  influenced  by  move- 
ments, especially  by  stooping  and  such  other  motions  as  call 
the  muscles  of  the  back  into  play.  Congestion  of  the  kid- 
neys is  distinguished  from  inflammation  by  its  affecting  both 
sides,  by  the  absence  of  protracted  or  severe  pain,  and.  the 
comparatively  slight  derangement  of  the  urinary  functions. 
Further,  the  congestion  is  not  idiopathic,  and  we  can  gener- 
ally trace  it  to  the  swalloAving  of  some  irritating  substance, 
or  to  the  poison  of  a  febrile  malady,  such  as  smallpox  or 
typhus. 

Chronic  nephritis,  if  such  a  disease  really  exists  irrespec- 
tive of  the  forms  of  it  associated  with  albuminous  urine,  and 
belonffino;  therefore  to  Brie-ht's  disease,  is  so  ill  defined  and 
uncertain  a  malady,  that  it  has  no  signs  which  positively  an- 
nounce its  presence. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       637 

Nephralgia.  —  Severe  pain  in  the  kidney,  unconnected 
Avitli  inflammation  of  the  organ,  is  ordinarily  caused  by  the 
passage  of  a  calculus.  In  such  cases  we  have  all  the  symp- 
toms of  acute  inflammation,  save  the  fever;  the  pain,  too, 
is  generally  much  more  violent,  and  ends  as  suddenly  as  it 
commenced.  With  reference  to  the  diagnosis,  the  complaint 
may  be  confounded  with  the  same  maladies  as  nephritis,  and 
the  diflferences  are  identical  as  between  nephritis  and  the 
ailments  resembling  it,  excepting,  of  course,  that  we  must 
leave  any  indications  afforded  by  febrile  signs  out  of  con- 
sideration. The  greatest  similarity  nephralgia  exhibits  is  to 
colic ;  but  elsewhere  this  has  already  been  discussed  at  some 
length ;  and  in  particular  cases  we  are  often  much  aided  by 
the  knowledge  that  our  patient  has  on  a  former  occasion 
passed  renal  concretions. 

The  amount  of  pain  varies  according  to  the  magnitude  of 
the  stone  and  its  character.  As  a  rule,  those  composed  of 
oxalate  of  lime  give  rise  to  most  pain.  "We  may  distinguish 
them  by  their  roughness  and  irregularity ;  those  of  urates 
and  uric  acid  are  much  softer  and  not  jagged,  and,  unlike 
calculi  consisting  of  the  salts  of  lime,  are  combustible  on 
platina  foil. 

As  already  stated,  we  have  in  the  severit}-  of  the  pain  a 
sign  indicative  of  the  probable  nature  of  the  case.  Still, 
there  are  states  in  which  paroxysms  of  pain  referred  to  the 
neighborhood  of  the  kidney  are  attributable  to  far  other 
causes  than  the  passage  of  a  calculus.  Leaving  that  obscure 
and  doubtful  disease,  a  pure  neuralgia  of  the  kidney,  out  of 
consideration,  we  find  a  few  affections,  very  rare,  it  is  true, 
which  closel}'  simulate  the  passage  of  a  renal  calculus. 

The  first  of  these  is  the  pain  occasioned  by  an  inflamed 
and  ulcerated  ureter.  Dr.  Todd  relates  a  case  of  the  kind.* 
The  patient  had  severe  attacks  of  lancinating  pain,  referred 
to  the  right  loin,  lasting  for  weeks,  and  accompanied  by  con- 
stant and  intractable  vomiting.  The  urine  contained  pus  in 
var3'ing  quantity,  but  neither  blood  nor  calculous  mattei* 
could  be  detected.     At  one  time  he  continued  free  from  any 

*  Lecture  Second,  on  Diseases  of  Urinary  Organs. 


638  MEDICAL    DIAGNOSIS. 

paroxysm  for  four  years.  After  death  the  most  careful  search 
was  made  for  a  calculus,  but  no  sign  of  one  could  be  discov- 
ered. The  ureter  of  the  right  side  was  thickened  through- 
out the  greater  part  of  its  course,  and  deposits  of  lymph 
adhered  to  its  mucous  membrane.  A  somewhat  similar  train 
of  phenomena  may  occur  from  an  irritation  or  inflammation 
of  the  ureter,  caused  by  the  poison  of  rheumatism  or  gout, 
although  the  paroxysms  of  pain  are  apt  to  be  neither  so 
severe  nor  of  so  long  duration. 

Another  morbid  condition  closely  resembling  the  passage 
of  a  renal  calculus  may  result  from  the  presence  of  the  mala- 
rial poison  in  the  system.  How  close  this  resemblance  may 
be,  the  following  case  will  show  : 

A  soldier,  twenty-four  years  of  age,  of  fair  complexion, 
and  evidently  of  strong  constitution,  was  seized  rather  sud- 
denly with  pain  over  the  left  kidney.  The  loin  was  sensitive 
to  the  touch,  and  appeared  somewhat  red  and  swollen.  The 
skin  was  hot;  the  pulse  100.  The  urine  was  not  found  to 
be  abnormal,  though  containing  a  reddish  coloring  matter. 
The  pain  continued  for  several  days,  becoming  more  severe, 
notwithstanding  that  by  Dr.  Hilborne  "West's  direction,  under 
whose  charge  the  man  was,  and  with  whom  I  saw  him,  six 
ounces  of  blood  were  drawn  from  near  the  affected  part.  On 
the  fourth  day  of  the  disorder  the  patient  was  assailed  with 
excruciating  pain  along  the  course  of  the  ureter,  attended 
with  the  voiding,  at  short  intervals,  of  a  high-colored  urine. 
The  attack  lasted  from  six  o'clock  in  the  evening  until  five 
o'clock  the  next  morning,  leaving  the  patient  much  ex- 
hausted ;  the  only  relief  throughout  its  duration  being  ob- 
tained from  the  inhalation  of  chloroform.  At  six  o'clock  in 
the  evening  another  seizure  of  equal  violence  set  in ;  and, 
after  the  lapse  of  twenty-four  hours,  again  another.  Seeing 
the  recurrence  of  the  paroxysms  at  about  the  same  time  of 
each  day,  and  learning  from  the  patient  that  a  few  months 
before  he  had  had  a  remittent  fever,  which  had  left  boliind 
an  irregular  intermittent,  we  resolved  upon  the  administra- 
tion of  large  doses  of  sulphate  of  quinia  in  the  interval 
between  the  paroxysms.  The  seizure  did  not  take  place 
that  night;  but  the  remedy  being  a  day  or  two  afterward 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       639 

suspended,  the  fourth  night  was  again  a  night  of  anguish. 
The  antiperiodic  was  resumed,  and  continued,  in  lessened 
doses,  for  three  weeks.  The  patient  remained,  for  about  six 
weeks  after  the  last  attack,  under  Dr.  West's  observation, 
gradually  recovering  his  health  and  spirits.  When  he  was 
lost  sight  of,  there  was  still  a  dull  pain  in  the  left  lumbar 
region,  with  inability  to  stand  erect ;  but  no  return  of  the 
excruciating  intermittent  neuralgic  pains. 

In  a  case  of  this  kind,  it  is  evident  that  nothing  but  a 
knowledge  of  the  history  of  the  patient,  and  noting  the  reg- 
ularly recurring  onsets  of  the  pain,  could  have  led  to  a  cor- 
rect appreciation  of  its  cause.  We  sometimes  meet  with  a 
so-called  neuralgia  of  the  bladder,  of  similar  origin,  and  hav- 
ing much  the  same  symptoms,  excepting  that  the  distressing 
pain  is  distinctly  referred  to  the  bladder.  As  in  the  case  just 
detailed,  the  attacks  occur  at  night. 

These  remarks  are  all  based  on  the  assumption  that  the 
renal  pain  is  very  severe  and  paroxysmal  in  its  character. 
Let  us  now  briefly  inquire  into  the  significance  of  a  steady 
and  less  acute  paijj,  premising  that  we  have  excluded  from 
consideration  abdominal  aneurism,  aifections  of  the  muscles 
of  the  back,  of  the  spine,  and  of  the  tissues  surrounding  the 
kidney,  in  which  diagnosis,  of  course,  we  are  materially  as- 
sisted by  an  examination  of  the  urine. 

We  meet  with  persistent  pain  referable  to  the  kidney  itself, 
in  inflammation  of  the  organ,  especially  in  that  variety  of 
inflammation  aflfecting  the  infundibula  and  pelvis,  termed 
pyelitis.  We  also  encounter  it  in  malignant  disease  of  the 
kidney  ;  sometimes,  although  it  is  not  then  of  long  duration, 
from  the  irritation  of  concentrated  and  highly  acid  urine; 
much  more  generally  from  the  presence  of  a  stone  lodged  in 
the  kidney.  The  pain  in  the  latter  complaint  often  extends 
along  the  course  of  the  ureter  to  the  testicle,  which  is  re- 
tracted and  swollen.  'Not  uufrequently  there  is  also  tender- 
ness on  pressure  over  the  aflected  kidney,  and  the  pain  is 
greatly  increased  b}'  active  exercise ;  and  it  is  not  uncommon 
to  find,  associated  with  these  exacerbations  of  pain,  nausea 
and  vomiting,  and  the  appearance  of  blood  in  the  urine. 

But  there  is  yet  another  point  in  the  diagnosis  of  the  pas- 


640  MEDICAL    DIAGNOSIS. 

sage  of  calculi  which  we  must  not  overlook,  namely,  that  the 
pain  may  be  referred  to  other  parts  than  to  the  region  of  the 
kidney.  It  may  be  felt  near  or  at  the  sacrum,  and  not  merely 
on  one  side;  or  it  may  be  referred  to  the  right  hypochondrium 
and  extend  downward,  but  not  be  perceived  in  the  loin. 
Under  the  latter  circumstances,  there  may  be,  with  pain  of 
great  intensity,  coexisting  distention  of  the  colon,  vomiting, 
and  constipated  bowels,  and  the  symptoms  so  closely  re- 
semble those  of  the  passage  of  a  biliary  calculus,  that,  as  we 
learn  from  a  case  recorded  by  Owen  Rees,*  nothing  but  the 
detection  of  blood  in  the  urine  prevents  error.  Again,  as 
happened  in  two  cases  which  came  under  my  notice,  the  pain 
may  be  referred  to  the  left  hypochondrium  or  along  the  course 
of  the  colon,  be  associated  with  soreness  to  the  touch  and 
digestive  disorders,  and  close!}-  simulate  an  organic  lesion 
of  these  structures.  Nothing  but  careful  and  repeated  ex- 
aminations of  the  urine,  and  observing  the  irregular  and 
whimsical  course  the  supposed  intestinal  malady  pursues, 
will  enable  us  to  arrive  at  a  knowledge  of  the  truth. 

Nor  must  we  be  unmindful  that  a  calculus  may  be  months 
in  passing,  and  that  as  it  changes  its  position  the  seat  of  the 
pain  changes.  I  had  a  case  of  the  kind  under  my  charge  in 
a  lady  of  about  fifty  years  of  age.  She  suffered  for  weeks  at 
a  time  from  excruciating  pains,  commencing  in  the  left 
kidney;  then  felt  somewhat  below  it;  and  finally  localized 
in  the  neighborhood  of  the  left  ovary.  She  was  occasionally 
free  from  pain  for  five  or  six  days.  But  it  was  only  after 
fully  nine  months  of  recurring  suffering  that  the  passage  of 
a  stone  the  size  of  a  plum-stone,  and  followed  by  a  discharge 
of  large  amounts  of  a  gritty  substance  and  a  soapy-looking 
urine,  removed  her  distress.     The  stone  consisted  of  urates. 

The  symptoms  of  renal  calculus  may,  after  having  existed 
for  a  longer  or  shorter  time,  entirely  cease,  owing  either  to 
the  calculus  becoming  encysted  and  thus  remaining  innocu- 
ous, or  to  its  obstructing  the  ureter,  causing  retention  of  the 
urine,  and,  by  pressure,  producing  gradual  atrophy  of  the 
cortical  and  tubular  structures,  the  kidney  being  finally  con- 
verted into  a  mere  bag. 

*  Guy's  Hospital  Reports,  3d  Series,  vol.  x. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.      641 

In  concluding  the  consideration  of  this  subject,  it  may  be 
useful  to  group  together  the  sjanptoras  by  which  we  may 
infer  the  existence  of  a  calculus  in  the  kidneij.  Tliey  are  :  fre- 
quent micturition,  often  attended  with  pain  at  the  end  of  the 
penis,  pain  in  the  loin,  with  or  without  accompanying  soreness, 
occasionally  passing  suddenly  into  a  violent  paroxysm,  with 
a  tendency  to  shoot  along  the  course  of  the  ureter  to  the 
testicle  and  hip  of  the  aching  side ;  and  in  some  cases  the 
discharge  of  pus  due  to  coincident  pyelitis.  These  symp- 
toms become  very  positive  evidence  if  the  blood  extractives 
are  present  in  the  patient's  urine,  or  if  this,  when  examined 
microscopically,  is  found  to  contain  blood  corpuscles;  or  if 
we  know  that  attacks  of  ha3maturia  have  previously  hap- 
pened, and  that  small  urinary  concretions  have  at  any  time 
been  discharged.  But  all  of  these  indications  are  far  from 
being  always  present.  Any  one  of  them,  or  several  of  them, 
may  be  absent. 

Diseases  marked  by  an  Albuminous  Condition  of  the  Urine, 
associated  with  more  or  less  Dropsy, 

Since  the  great  discovery  of  Bright,  that  dropsy  was  fre- 
quently dependent  on  a  disease  of  the  kidney,  revealing 
its  existence  by  the  occurrence  of  albumen  in  the  urine,  a 
host  of  laborers  have  endeavored  to  enlarge  the  edifice  he 
had  both  planned  and  erected;  but  thus  far  the  results  of 
their  work  are  not  so  extensive  as  to  have  materially 
changed  the  original  fabric.  Certain  it  is  that,  beyond  the 
researches  on  the  minute  character  of  the  urine, — researches 
which,  by  detecting  the  tube-casts,  have  added  to  our  knowl- 
edge in  a  way  not  to  be  overestimated, — little  has  been 
brought  forward  that,  in  a  clinical  point  of  view,  can  be 
said  to  have  altered  the  structure  reared  by  the  celebrated 
physician.  The  work  progressing  aims  mainly  at  denying 
the  unitv  of  the  affection  which  Brio-ht  described,  and  at 
proving  that  the  disease  which  bears  his  name  consists  of  a 
group  of  maladies  having  the  common  feature  of  a  more  or 
less  albuminous  state  of  the  urine.  Now,  it  is  not  at  all  im- 
probable that  this  view  will  ultimately  be  fully  accepted ; 

41 


64:2  MEDICAL    DIAGNOSIS. 

bat  as  yet  the  distinctions  proposed  are,  for  the  most  part, 
neither  very  definite  nor  so  constant  and  undoubted  as  to 
warrant  us  in  making  tliem  the  groundwork  of  a  practical 
separation.  I  shall,  tlierefore,  in  this  sketch,  prefer  to  con- 
sider the  disorder  as  it  is  seen  separated  by  broadly-drawn 
lines  into  an  acute  and  chronic  one,  merely  indicating  the 
disputed  points  of  pathology  as  I  proceed,  and  endeavoring  to 
incorporate  such  recently  acquired  facts  as  have  a  readily 
discerned  and  valuable  diagnostic  bearing. 

Acute  Bright's  Disease. — In  this  form  of  the  atfection 
the  symptoms  are  of  an  acute  character.  Especially  so  is 
the  dropsy,  which  is  quickly  developed,  and  soon  becomes 
the  most  marked  token  of  the  malady. 

The  history  of  a  large  number  of  cases  is  as  follows :  after 
exposure  to  wet  or  cold,  a  fever  sets  in,  accompanied  by 
nausea,  and  by  a  dull  pain  in  the  region  of  both  kidneys,  ex- 
tending along  the  course  of  the  ureters.  The  eyelids  and  face 
become  puffy  and  swollen,  and  soon  a  general  edematous 
condition  of  the  skin  is  observable,  showing  itself  very 
plainly  in  the  extremities,  scrotum,  and  abdominal  parietes. 
Subsequently  dropsical  effusions  frequently  take  place  into 
the  interior  cavities. 

A  similar  group  of  symptoms  is  apt  to  be  noticed  in  the 
acute  Bright's  disease  which  so  constantly  attends  scarlatina, 
excepting  that,  following  as  it  does  an  exhaustive  disease, 
there  are  from  the  onset  much  greater  pallor  and  general 
debility. 

The  urine  in  both  these  forms  of  the  acute  malady  is  of 
high  specific  gravity,  and  dingy  from  its  admixture  with 
blood.  It  contains  a  large  amount  of  alhuaien ;  a  minute 
examination  brings  to  light  casts,  lined  here  and  there  with 
blood  corpuscles.  As  the  malady  progresses,  these  "  blood- 
casts"  disappear,  and  we  find  the  coagulable  material  which 
has  been  effused  into  the  tubes  coated  with  epithelium,  which 
may  be  normal  or  slightly  fatty,  and  with  free  nuclei,  or 
slightly  granular,  or  quite  homogeneous;  or  we  may  discern 
pus  globules  taking  the  place  of  the  epithelial  cells.  Fur- 
thermore, crystals  of  uric  acid,  of  urates,  even  of  oxalates, 
and  a  considerable  amount  of  renal  epithelium  are  objects 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.      643 

often  seen  in  the  sediment.  The  normal  constituents  of  the 
urine  are  considerably  changed.  The  chlorine  may  have  dis- 
appeared altogether;  the  uric  acid  and  the  pigments  are  in- 
creased. The  amount  of  urea  fluctuates  much :  it  may  be 
either  augmented  or  diminished.  There  is  a  frequent  desire 
to  void  the  urine,  although  the  whole  quantity  passed  is 
rather  below  the  natural  average. 

Fig.  41. 


Epitlielial  casts  ami  epithelial  cells  IVoni  the  Uidnevs  tbund  in  a  case  of 
acute  Brighfs  disease  {acute  desquainalim  ne2}hritis);  magnified  al  out  460 
diameters 


The  constitutional  disturbance  is  not,  as  a  rule,  extreme  ; 
the  pulse,  however,  may  be  very  quick,  tense,  and  full.  The 
skin  is  generally  harsh  and  dry;  nausea  and  vomiting  are  of 
common  occurrence. 

The  urgent  symptoms  last  ordinarily  for  several  weeks. 
AVhen  recovery'  is  about  to  take  place,  they  abate  ;  the  skin 
becomes  moist,  the  pulse  is  no  longer  accelerated,  and  hand 
in  hand  with  a  diminution  of  the  dropsy,  the  quality  of  the 
urine  largely  increases.  But  this,  although  fortunately  the 
most  common,  is  not  the  invariable  issue.  The  disease  mav 
gradually  lapse  into  a  chronic  form,  or,  as  sometimes  hap- 
pens, the  patient's  condition  decidedly  ameliorates  :  he  leaves 
his  room,  as  he  thinks,  well,  yet  with  a  certain  amount  of 
albumen  in  his  urine ;  and  often  then  he  remains  to  all 
appearances  in  good  health,   until  after  a  fresh   exposure 


644  MEDICAL    DIAGNOSIS. 

the  albumen  increases  in  the  arine,  and  the  dropsy  and  most 
of  the  acute  symptoms  return. 

And  whatever  the  attending  circumstances  when  an  attack 
has  been  at  all  prolonged,  the  risk  to  life  is  greatly  increased 
by  the  supervention  of  local  inflammations — as  of  the  pleura, 
lungs,  peritoneum,  or  pericardium  ;  or  by  the  sudden  effusion 
of  fluid  into  the  pulmonary  structure ;  or  by  the  retention  of 
urea  in  the  blood  and  consequent  ursemic  intoxication.  If 
from  any  of  these  complications  death  take  place,  the  kid- 
neys are  found  to  be  enlarged  and  somewhat  irregularly  con- 
gested. The  medullary  cones  are  of  dark  color,  their  bodies 
are  compressed,  while  their  bases  expand  into  the  swollen 
cortical  substance.  The  surface  of  the  organ  is  smooth,  and 
the  investing  capsule  is  easily  detached. 

The  recognition  of  the  disease  is  readily  effected  The 
puffy,  pale  face ;  the  general  dropsy  ;  the  albumen  in  the 
urine,  associated  with  tube-casts,  form  a  combination  of  signs 
so  remarkable,  that  it  is  diflicult  to  mistake  their  meaning. 
The  same  phenomena  are  encountered,  although  not  always 
to  the  same  degree,  in  the  chronic  form  of  the  malady.  What 
is  therefore  about  to  be  said  of  the  differential  diagnosis  of 
the  acute  complaint,  applies  with  almost  equal  correctness  to 
both  varieties  of  the  ailment. 

The  main  disorders  with  which  acute  Bright's  disease  is 
apt  to  be  confounded  are : 

Acute  Nephritis  ; 

Suppurative  Nephritis  ; 

HEMATURIA    AND    PuRULENT    UrINE  ; 

Simple  Albuminuria  ; 

Pulmonary  G]dema  ; 

Pleurisy  and  Pericarditis  ; 

Dropsy  ; 

Coma;  Convulsions. 

Acute  Nephritis. — This  differs  from  acute  Bright's  disease, 
by  its  affecting  generally  only  one  kidney,  by  the  much 
greater  pain  and  tenderness  in  the  lumbar  region,  b}'  the 
retraction  of  the  testicle,  and  the  higher  degree  of  febrile 
excitement.  Then,  too,  the  deeply-colored  urine  which  is 
voided  contains  little  or  no  albumen. 


THE    URINE,  AND    DISEASES    OF   THE    URINARY   ORGANS.      645 

Suppurative  Nephritis. — There  is  testimony  proving  that  in 
rare  cases  the  suppurative  process  may  coexist  with  Bright's 
disease.  But,  on  the  whole,  the  two  disorders  are  totally  dis- 
tinct, and  may,  as  a  general  rule,  be  readily  discriminated. 
Suppurative  nephritis  occurs  from  external  violence,  from 
exposure  to  cold  and  wet,  from  a  morbid  condition  of  the 
blood,  or  the  impaction  of  a  renal  calculus,  and  may  lead, 
like  Bright's  disease,  to  ursemic  symptoms.  But  it  usually 
attacks  only  one  kidney,  occasions  much  local  pain,  is  fre- 
quently attended  with  a  fever  more  or  less  remittent  or  in- 
termittent in  its  character,  and  at  times  with  a  well-defined 
swelling,  which  may  be  felt  in  the  lumbar  region,  and  ex- 
tending far  downward.  l!^ow,  all  this  is  very  different  from 
Bright's  disease,  which  always  affects  both  kidneys,  and  in 
which  no  enlargement  of  the  organs  can  be  perceived  through 
the  abdominal  walls.  Then,  we  detect  blood  and  pus  in  the 
urine  of  cases  of  suppurative  nephritis,  and  any  casts  that 
are  found  are  seen  to  be  covered  with  pus  corpuscles. 

Hasmaturia  and  Purulevt  Urine. — In  both  these  complaints, 
if  we  can  speak  of  them  as  such,  and  otherwise  than  as 
symptoms,  there  is  albumen  in  the  urine;  and,  on  the  other 
hand,  traces  of  blood  and  pus  may  be  present  in  the  urine 
of  Bright's  disease.  But  the  quantity  of  albumen  met  with 
in  hsematuria  or  in  purulent  urine  is  small;  in  fact,  it  is  in 
exact  proportion  to  the  amount  of  pus  or  blood  the  excreted 
fluid  contains;  whereas,  on  the  contrary,  if  the  secretion 
from  a  Bright's  kidney  be  mixed  with  pus  or  blood,  the 
amount  of  albumen  is  very  large. 

Simple  Albuminuria. — By  this  is  meant  an  albuminous  urine 
unconnected  with  any  marked  structural  lesion,  such  an 
albuminuria  as  is  sometimes  observed  as  a  transient  phe- 
nomenon in  the  course  of  several  diseases ;  as,  for  instance, 
in  the  exanthemata,  in  typhus,  in  cholera,  in  hectic  fever,  or 
as  a  consequence  of  surgical  diseases  and  operations.*  An 
albuminuria  of  similar  kind  is  also  met  with  when  the  kid- 
neys become  congested  from  interference  with  the  circula- 


*  Henry  Lee,  Lectures  on  Practical  Path,  and  Surgery,  Sd  ed.,  Lond.,  1870, 
vol.  ii.  page  380. 


646  MEDICAL    DIAGNOSIS. 

tion,  as  in  disease  of  the  heart,  or  from  the  pressure  of  a 
gravid  womb.  Albumen  in  the  urine  may  also  be  encoun- 
tered in  diphtheria,  in  pneumonia,  in  acute  rheumatism  and 
gout,*  consecutively  to  a  blister,  or  after  partaking  plenti- 
fully and  exclusively  of  albuminous  food.f  But  in  all  these 
conditions  the  quantity  found  is  small  and  transitory,  very 
unlike  what  it  is  in  the  persistent  albuminuria  of  Bright's 
disease.  Then  the  constitutional  symptoms  in  the  morbid 
states  referred  to  are  so  dissimilar  to  those  of  Bright's  dis- 
ease, that  they  become  a  safeguard  against  error.  But  the 
most  valuable  aid.  in  forming  a  judgment  is  derived  from  a 
microscopical  investigation  of  the  urinary  sediment.  In 
simple  albuminuria  there  is  no  exudation;  hence  no  tube- 
casts  can  be  detected  in  the  urine.  This,  at  least,  represents 
the  general  truth.  But  we  must  admit  that  repeated  and 
searching  examinations  may  detect  occasionally  a  few.  Yet 
their  inconstancy,  their  character,  the  small  amount  of  albu- 
men they  are  commonly  associated  with,  are  of  significance; 
and  the  general  nature  of  the  symptoms  again  helps  to  ex- 
plain their  meaning.  Then,  too,  the  kidney  may  really  be, 
in  several  of  the  morbid  states  under  discussion,  in  the  same 
condition  as  in  the  earlier  stages  of  acute  Bright's  disease, 
but  it  is  unlike  the  fully  developed  malady  with  its  marked 
clinical  features  which  we  have  above  described. 

Pulmonary  (Edema. — Bright's  disease  is  one  of  the  most 
frequent  causes  of  pulmonary  congestion  and  dropsical  effu- 
sion into  the  air-cells;  oppression  in  breathing,  inability  to 
lie  in  the  recumbent  position,  cough,  frothy  expectoration, 
are  therefore  common  among  the  symptoms  attending  the 
renal  affection.  And,  to  distinguish  this  cedema  from  that 
produced  by  other  morbid  states,  we  have  only  to  examine 
the  urine  carefully, — a  matter,  indeed,  which  ought  not  to  be 
neglected  in  any  case  of  oedema  of  the  lungs. 

Pericarditis  and  Pleuriiis. — The  tendency  to  internal  inflam- 
mations, especially  to  those  of  the  serous  membranes,  is  a 
remarkable  peculiarity  of  Bright's  disease.     We  may  dis- 

*  Thudichum,  op.  cit. 

■)■  Hammond's  Physiological  Memoirs:  Simon's  Animal  Chemistry. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       647 

criminate  pericarditis,  or  plenritis  complicating  the  malady, 
from  either  of  these  affections  of  other  origin,  by  noting  the 
far  greater  amount  of  dropsy  than  is  ordinarily  found  in 
these  disorders,  and  by  detecting  albumen  and  tube-casts  in 
the  urine. 

Dropsy. — By  an  examination  of  the  urine,  too,  may  be 
distinguished  the  dropsy  of  the  complaint  under  consider- 
ation from  that  produced  by  other  causes.  And  independ- 
ently of  the  physical  properties  of  the  urine,  we  see  verj- 
often  the  evidences  of  the  true  nature  of  the  dropsy  in  its 
commencing  with  swelling  of  the  face,  and  then  becoming 
universal,  and  in  the  striking  and  characteristic  physiognomy 
which  it  has  a  share  in  developing.  But  more  will  be  said 
hereafter  on  these  points. 

Coma;  Convulsions. — A  common  and  very  dangerous  com- 
plication of  Bright's  disease  manifests  itself  by  signs  of  great 
derangement  of  the  nervous  system,  prominent  among  which 
are  drowsiness  and  convulsions.  Now,  it  is  evident  that  it  is 
very  important  to  distinguish  the  cases  produced  by  ursemic 
poisoning  from  epileptiform  convulsions  and  kindred  states 
in  which  there  is  no  appreciable  change  of  structure  in  the 
kidneys.     Let  us  see  how  they  differ. 

Uraemia,  or  ur?emic  intoxication,  is  most  commonly  pre- 
ceded by  a  diminution  in  the  urinary  secretion.  There  is 
headache,  with  indistinct  vision,  great  drowsiness,  and  ver- 
tiginous sensations;  the  pupils  are  sluggish  and  usually 
dilated;  the  hearing  is  impaired;  the  countenance  is  dusky; 
the  skin  cool,  with  short  exacerbations  of  heat,  and  the  pa- 
tient suffers  from  constipation  and  nausea  and  vomiting. 
Paralysis  of  sensation  may  be  observed  in  the  extremities. 
The  dulness  of  mind  is  apt  to  deepen  into  stupor  or  coma,  or 
convulsions  set  in  as  precursors  of  the  coma,  which  terminates 
in  death,  unless  the  urinary  secretion  be  freely  re-established. 
The  coma  may  at  one  time  be  so  profound  that  it  is  impos- 
sible to  arouse  the  patient,  whilst  at  another  time  he  rouses 
himself,  and  acts  with  considerable  intelligence. 

In  some  cases  the  marked  phenomena  set  in  with  a  chill, 
by  which  the  eliminating  function  of  the  skin  is  suppressed; 
in  other  cases,  however,  there  is  no  such  obvious  beginning. 


648  MEDICAL    DIAGNOSIS. 

And  as  regards  the  decided  lessening,  or  even  suppression  of 
the  urinary  secretion,  though  this  is  the  rule,  it  is  not  con- 
stant. I  wish  here  particularly  to  call  attention  to  this  point; 
for  I  have  known  many  an  error  in  diagnosis  committed,  and 
the  symptoms  of  uraemia  many  a  time  receive  an  erroneous 
interpretation,  by  supposing  that  this  state  could  not  exist, 
as  the  quantity  of  urine  passed  was  about  normal.  We  must 
test  for  urea  and  the  other  urinary  ingredients,  which  may 
be  profoundly  changed  in  amount,  notwithstanding  the  seem- 
ingly healthy  aspect  of  the  secretion,  and  notwithstanding, 
too,  that  it  may  be  found  free  from  albumen. 

Cases  of  ursemic  coma  differ  from  ordinary  comatose  con- 
ditions, as  witnessed  in  apoplexy,  in  fevers  of  a  low  type,  or 
following  narcotic  poisoning,  by  the  dissimilar  symptoms 
ushering  them  in.  The  coma  is  much  more  suddenly  developed 
than  that  in  fevers ;  far  less  suddenly  than  that  of  apoplexj' 
or  narcotic  poisoning.*  Then,  the  stertorous  respiration,  to 
adopt  the  observation  of  Addison, f  is  peculiar  —  the  loud 
sounds  of  the  expired  air  are  of  much  higher  key,  not  like 
the  low,  guttural  tones  of  apoplexy.  Furthermore,  we  have 
in  the  general  dropsy  a  clue  to  the  nature  of  the  case;  but 
of  course  the  most  certain  light  is  thrown  on  it  by  the  anal- 
ysis of  the  urine.  And  often,  indeed,  until  this  has  been 
effected,  no  positive  judgment  can  be  given  ;  for  the  dropsy 
may  be  so  very  slight  as  to  escape  observation,  and  tlie  other 
signs  be  ill  deiined. 

The  same  remarks  apply  to  the  delirium  or  to  the  epileptic 
convulsions  of  uremia.  And  here  the  difficulty  in  diagnosis 
is  increased  by  the  lirst  seizure  oftentimes  happening  unex- 
pectedly;  so  much,  in  truth,  increased',  that,  unless  we  are 
aware  of  the  history  of  our  patient  and  have  previously  ex- 
amined his  urine,  the  true  explanation  of  the  symptoms  is 
not  to  be  reached.  Cases  of  uremic  convulsions  may  occur 
in  pregnant  women;  in  them,  however,  the  tendency  to  dis- 


*  There  may,  however,  be  exceptions  to  this  rule,  as  in  a  curious  instance 
reported  by  Moore  in  the  London  Medical  Gazette,  1845,  in  which  a  person 
became  comatose  after  taking  hiudanum  ;  yet  his  death  was  found  to  have 
been  caused  by  contracted  kidneys. 

f  Guy's  Hosp.  Keports,  1859. 


THE    URINE,  AND    DISEASES    OF   THE    URINARY   ORGANS.      649 

order  of  the  kidney  is  so  great,  that  we  are  rarely  in  error  in 
concluding  the  convulsions  to  be  of  ursemic  origin.  Ilrfemic 
delirium  is  rare,  but  I  have  met  with  it  under  circumstances 
in  which  nothing  preceded  it  to  indicate  its  nature,  and  in 
which  it  was  very  marked.* 

The  fact  that  the  grave  phenomena  are  thought  by  some 
to  be  due  to  the  urea,  by  others,  to  its  decomposition  into 
carbonate  of  ammonia,  has  been  already  alluded  to.  A  dis- 
tinguished physician,  Prof.  See,  has  recently  suggested  that 
they  may,  in  different  cases,  be  owing  to  either,  and  has  in- 
dicated the  features  by  which  ursemia  may  be  distinguished 
from  amwoniosemia.  In  the  former  there  is  no  fever;  a  clean 
tongue;  a  smooth,  elastic  skin;  a  disordered  respiration,  but 
not  a  disordered  circulation  ;  convulsions  and  coma.  In  the 
latter,  we  always  find  mucus  or  pus  in  the  urine,  and  an  affec- 
tion in  consequence  of  which  the  urine  is  retained  some- 
where in  the  urinary  passages ;  there  are  chills,  followed  by 
burning  heat  of  surface;  a  dry,  grayish  skin,  exhaling,  like 
the  breath,  an  ammoniacal  odor;  a  dr}^  tongue;  emacia- 
tion ;  rarely  vomiting;  the  respiration  is  free,  the  circulation 
deranged;    headache  occurs,  but  the  intelligence  remains 


good. 


Chronic  Bright's  Disease. — An  acute  attack  of  Bright's 
disease  may  become  very  prolonged,  and  gradually  pass  into 
a  confirmed  malady,  or  the  complaint  may  come  on  insid- 
iously from  the  onset,  and  develop  itself  very  slowly.  In 
either  case  we  have  a  dangerous  chronic  affection  established. 

The  transition  from  the  acute  to  the  chronic  disease  is  in- 
dicated by  the  disappearance  of  blood  from  the  urine,  by  its 
lessened  specific  gravity,  and  the  smaller  amount  of  albumen 
it  contains ;  and  not  uncommonly  by  a  temporary  diminution 
of  the  anasarca  and  an  increase  in  the  quantity  of  urine 
voided. t  When  the  disease  runs  a  more  or  less  chronic 
course  from  the  commencement,  its  initiatory  steps  are  very 


*  Case  at  the  Penn.  Hosp. ,  April,  1865. 

t  Dr.  Ringer  (Lancet,  Nov.  1865)  states  that  a  sign  more  trustworth}-  than 
any  of  those  mentioned  is  afforded  by  the  temperature  of  the  body.  When 
the  acute  stage  ceases,  the  thermometer  Indicates  a  normal  temperature,  and 
not  a  temperature  ranging  from  100°  to  105°  Fahr. 


650  MEDICAL    DIAGNOSIS. 

obscure.  We  generally  find  such  cases  in  persons  who  are 
poorly  fed  and  half  clad,  who  live  in  damp,  ill-ventilated 
houses,  are  intemperate,  or  whose  constitutions  are  ruined 
by  syphilis  or  scrofula.  The  first  symptoms  they  notice  may 
be  a  frequent  desire  to  urinate;  a  swelling  of  the  extremities 
or  of  the  face ;  an  increasing  pallor  and  general  debility. 
They  seek  medical  advice,  and  an  examination  of  the  urine 
reveals  at  once  the  cause  of  their  protracted  indisposition. 
Yet  the  renal  disease  may  lead  suddenly  to  a  fiital  termina- 
tion without  the  patient  having  previously  experienced  any 
manifest  or  urgent  signs  of  ill  health.  And  even  after  the 
malady  has  been  fully  recognized,  it  is  very  difiicult  to  predict 
its  course.  In  truth,  difi'erent  cases  present  very  dift'erent 
symptoms.  We  meet  in  many  with  the  same  phenomena 
as  those  encountered  in  the  acute  variety,  and  life  is  threat- 
ened by  the  same  dangerous  complications  ;  but  in  others  the 
signs  are  dissimilar — the  dropsy,  for  instance,  is  very  slight 
or  wholly  wanting,  or  the  amount  of  albumen  is  small.  The 
only  constant  and  characteristic  manifestations  are  the  pro- 
found and  increasing  auEemia,  and  the  presence  of  albumen 
and  tube-casts  in  the  urine.  Generally,  too,  the  fluid  is  of 
low  specific  gravity. 

'Now,  the  altered  specific  gravity  can  only  be  dependent 
upon  a  diminution  of  the  urinary  solids.  The  urea  is  less- 
ened, and  so  are,  as  a  rule,  the  uric  acid,  the  pigment,  and 
the  salts.  Commonly,  also,  the  urine  is  not  so  abundant  as 
in  health,  and  its  reaction  is  less  acid. 

The  albumen  is  very  variable  in  amount;  its  quantity  may, 
indeed,  fluctuate  much  in  the  same  patient,  and  even  change 
from  day  to  day.  It  is  persistent;  3'et  the  observations  of 
Christison  and  Rayer  forbid  us  to  doubt  that  it  may,  in  some 
cases,  disappear  for  a  short  time. 

The  tube-casts,  too,  are  not  uniform — not  nearly  as  much 
80  as  in  the  acute  variety  of  the  afli"ection.  We  meet  with 
casts  almost  or  quite  homogeneous,  and  small  or  large;  with 
casts  besprinkled  with  shrivelled  degenerating  epithelium; 
with  casts  covered  with  granules  or  with  oil-drops.  In  the 
progress  of  a  particular  case,  nearly  all  of  these  forms  may 
be  encountered,  although,  as  we  shall  hereafter  see,  the  pre- 


THE    URINE,  AND    DISEASES    OF   THE    URINARY    ORGANS.      651 

ponderance  of  any  one  of  them  afibrds  au  indication  as  to  the 
exact  state  of  the  kidneys.  There  is  only  one  kind  we  do 
not  find  in  the  chronic  disorder:  the  one  covered  with  well- 
developed  epithelial  cells  or  blood  corpuscles.  The  apparent 
absence  of  casts  from  albuminous  urine  is  not  absolute  proof 
of  non-existence  of  renal  degeneration.  In  some  cases  their 
absence  is  only  temporary,  while  in  others,  they  are  small 
and  few  in  number  and  easily  escape  detection,  even  after 
most  careful  search. 

Other  minute  features,  too,  it  has  been  sought  to  turn  to 
advantage.  Thus  it  is  suggested  by  Dr.  J.  G.  Richardson* 
that  we  may  derive  additional  aid  in  diagnosticating  the  form 
and  stage  of  the  renal  affection  by  a  careful  study  of  the  white 
elements  of  the  blood,  found  in  varying  proportion  in  the 
urine. 

From  these  remarks,  it  is  obvious  that  a  great  diversity 
of  phenomena  is  witnessed  in  chronic  Bright's  disease;  so 
great,  in  truth,  is  this  diversity,  that  the  opinion  is  fast  gain- 
ing ground  that  there  are  several  distinct  pathological  affec- 
tions embraced  under  the  one  term,  and  attempts  have  of  late 
years  been  made  to  define  the  train  of  symptoms  significant 
of  each.  But,  notwithstanding  that  a  means  of  separation  is 
also  afforded  bj'  the  very  varied  aspect  of  the  organ, — enlarged 
or  fatty  in  some  instances,  diminished  or  waxy  in  others, — it 
is  not  clearly  enough  proved,  certainly  not  proved  as  regards 
all,  that  the  dissimilar  appearances  may  not  be  different 
stages  of  the  same  maladv  to  make  it  incumbent  to  arranije 
the  symptoms  with  reference  solely  to  the  morbid  anatomy 
of  the  kidney.  I  shall,  therefore,  consider  the  differential 
diagnosis  of  chronic  Bright's  disease  continuously,  and 
point  out,  after  having  done  so,  the  clinical  features  which 
are  supposed  to  be  indicative  of  the  various  forms  of  the 
maladv. 

Leaving  out  of  consideration  those  affections  for  which 
both  the  acute  and  the  chronic  disease  may  be  mistaken, 
and  which  have  been  already  discussed,  chronic  Bright's  dis- 
ease may  be  confounded  with — 


*  Am.  Jourii.  of  Med.  Sciences,  Jau.  1870. 


652  medical  diagnosis. 

Anaemia; 

Neuralgia; 

Chronic  Rheumatism; 

Chronic  Bronchitis  ; 

Cardiac  Dropsy; 

Gastro-intestinal  Disorders  ; 

Cancer;  Tuberculosis;  Cysts  of  Kidney. 

Anasmia. — There  are  few  diseases  which  alter  the  blood  so 
completely  as  does  chronic  Briglit's  disease.  The  blood  cor- 
puscles go  on  steadilj^  diminishing,  while  the  librin  holds  its 
own,  and  the  quantity  of  albumen  fluctuates  considerably, 
being  ordinarily  much  reduced.  Besides  these  changes,  the 
blood  often  retains  its  effete  ingredients,  since  the  kidneys 
are  incapable  of  performing  their  function.  The  alteration 
and  gradual  impoverishment  of  the  blood  make  themselves 
manifest  by  the  increasing  debility,  and  by  the  pallor  and 
waxy  look  of  the  countenance. 

We  may  discriminate  this  anemic  or  chlorotic  condition 
from  that  unconnected  with  renal  disease  by  the  existence 
of  albumen  and  tube-casts  in  the  urine,  and  often  also  by  the 
prominence  of  the  dropsical  symptoms.  But  it  is  essential 
to  know  that  some  of  the  phenomena — certainly  albumin- 
ous urine  and  dropsy — may  attend  the  anaemia  following  pro- 
fuse or  frequently-repeated  hemorrhages,  without  the  struc- 
ture of  the  kidneys  having  been  impaired.  It  is  difficult 
to  distinguish  these  cases  from  true  Bright's  disease,  except 
by  taking  into  account  the  diminution  of  the  albumen  as 
the  hemorrhagic  tendency  is  lost,  and  the  absence  of  the 
fibrinous  moulds  of  the  tubules.  The  dropsy,  unless  it  be 
considerable,  can  hardly  be  looked  upon  as  a  valuable  differ- 
ential index,  for  a  slight  or  moderate  amount  of  dropsy, 
or  even  none  at  all,  may  be  encountered  in  either  morbid 
state. 

The  ophthalmoscopic  appearances  presented  by  the  retina, 
and  described  in  a  previous  part  of  this  work,  aftbrd  help  in 
distinguishing  between  the  anaemia  of  Bright's  disease  and 
that  produced  by  any  other  cause.  The  white  patch  upon  the 
retina,  opposite  to  and  around  the  optic  entrance,  with  hem- 
orrhagic effusions,  is  quite  characteristic,  and,  according  to 


THE    URINE,  AN1>    DISEASES    OF    THE    URINARY   ORGANS.      653 

Dr.  Dickiuson,*  it  especially  belongs  to  that  state  of  the 
kidney  known  as  granular  degeneration. 

Neuralgia. — As  this  is  not  at  all  infrequent  in  the  chronic 
form  of  Bright's  disease,  we  must  always,  in  obstinate  cases, 
examine  the  urine,  so  as  to  see  whether  or  not  a  renal  affec- 
tion lie  at  the  root  of  the  painful  malady.  The  neuralgia 
may  aifect  the  fifth,  or  other  nerves;  sometimes  it  takes  more 
the  form  of  hemicrania,  and  it  is  often  associated  with  disor- 
dered vision,  or  impairment  of  other  special  senses;  or  it 
may  coexist  with  strange  and  anomalous  nervous  symptoms. 

Chronic  Rheumatism. — Very  frequently  patients  affected  with 
chronic  Bright's  disease  complain  of  muscular  pains.  The 
pain  is  dull,  not  increased  on  pressure  ;  sometimes  shooting, 
more  like  that  ordinarily  called  neuralgic,  and  to  which  we 
just  called  attention.  The  pain  is  oftenest  met  with  in  those 
instances  in  which  the  dropsy  is  slight  or  w^holly  wanting, 
and  an  examination  of  the  urine  is  then  the  only  means  of 
determining  its  real  significance. 

Chronic  Bronchiiis. — This  is  one  of  the  most  common  com- 
plications of  Bright's  disease  ;  so  common,  indeed,  that  Rayer 
observed  it  in  seven-eighths  of  his  patients,  and  Wilksf  states 
it,  from  an  extensive  analysis  of  cases,  to  have  been  more 
universal  than  any  other  single  symptom,  albuminous  urine 
alone  excepted.  It  is  hardly  necessary  to  add  that  the  last- 
mentioned  sign  is  the  one  that  distinguishes  this  secondary 
pulmonary  trouble  from  all  other  forms  of  bronchial  disease. 

Cardiac  Droj^sy. — A  chronic  disorder  of  the  kidney  is  often 
connected  with  disease  of  the  heart ;  and  knowing  the  fre- 
quent combination  of  an  organic  cardiac  malady  with  Bright's 
disease,  it  becomes  our  duty,  in  every  instance  of  dropsy 
associated  with  a  cardiac  affection,  to  examine  the  urinary 
secretion,  for  both  the  prognosis  and  treatment  are  influ- 
enced by  the  result  of  a  search  of  this  character. 

Let  us  suppose  that  in  cases  of  so-called  cardiac  dropsy 
we  find  albumen  in  the  urine ;  is  this  a  proof  of  coexisting 
Bright's  disease?  No;  not  unless  the  amount  of  the  abnor- 
mal ingredient  be  considerable,  or  tube-casts  accompany  the 


*  Pathology  and  Treatment  of  Albuminuria,  p.  134. 
f  Guy's  Hospital  Reports,  2(i  Series,  vol.  viii. 


654  MEDICAL    DIAGNOSIS. 

alburninuria.  Mere  congestion  of  the  kidneys,  resulting  as 
it  does  from  an  obstruction  to  the  flow  of  the  venous  blood 
along  the  vena  cava,  may  occasion  albuminuria  ;  but  the 
presence  of  albumen  is  temporary,  and  its  quantity  small.  A 
large  amount,  persistent  and  conjoined  with  tube-casts,  shows 
that  changes  have  begun  in  the  renal  textures. 

Gastro-intesiinal  Disorders. — These,  it  is  well  known,  are 
among  the  most  common  consequences  of  the  renal  malady. 
They  manifest  themselves  in  various  ways.  Some  patients 
suflfer  from  flatulenc}' and  indigestion  ;  others  from  diarrhcea; 
others,  again,  from  nausea  and  vomiting.  The  latter  symp- 
toms are  very  apt  to  occur  when  urea  accumulates  in  the 
blood,  and  the  phenomena  of  ursemic  intoxication  are  clearly 
developed.  They  may  be,  however,  also  met  with  at  any 
period  of  the  disease  without  the  concurrence  of  other  urgent 
symptoms;  and  become  so  prominent  as  to  throw  into  the 
background  most  of  the  other  signs  of  the  renal  aflPection. 

To  cite  a  case  in  point :  an  assistant  nurse  in  the  medical 
ward  of  the  Philadelphia  Hospital  was  attacked  suddenly 
Avith  nausea  and  vomiting,  which  persisted,  in  spite  of  the 
remedies  employed,  and  became  so  troublesome  that  the 
man  had  to  desist  from  his  occupation.  There  was  no  febrile 
disturbance  ;  the  tongue  was  clean  ;  the  epigastric  region  not 
tender  to  the  touch.  Excepting  a  slight  bronchitis,  there 
were  no  apparent  signs  of  disease  in  any  organ  in  the  body, 
and  nothing  to  account  for  the  gastric  irritability.  A  close 
inquiry  into  the  history  of  the  patient  revealed  that  he  had 
had  an  attack  of  dropsy  some  time  previousl}^  from  which 
he  had  recovered.  But  of  late  he  had  again  noticed  a  swell- 
ing of  the  feet;  and,  on  examination,  a  slight  edematous 
condition  was  indeed  found  to  exist.  From  the  combination 
ot  these  signs,  I  drew  the  conclusion  that  a  chronic  renal 
disease  lay  at  the  bottom  of  the  gastric  disturbance;  and  the 
detection  of  albumen  and  of  casts  in  the  urine  proved  the 
opinion  to  be  correct. 

Cancer;  Tubercle;  Cysts  of  Kiditey. — These  morbid  products 
aflect  the  kidneys  but  rarely — at  all  events  but  rarely  in  a 
form  so  marked  as  to  give  rise  to  conspicuous  clinical  phe- 
nomena. In  all  of  them  there  may  be  albumen  present  in 
the  urine,  but  it  is  generally  in  very  small  amount,  and 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       655 


mixed  with  some  ingredient  having  a  more  specific  meaning. 
Thus  in  cancer  of  the  kidney  we  may  find  blood  with  the 
albumen,  and  in  some  instances  cells  like  those  observed  in 
any  cancerous  growth  ;  sometimes  the  hemorrhages  are  pro- 
fuse and  frequentl}^  recurring,  and  we  may  detect  a  palpable 
tumor  in  the  flank.  In  cases  of  melanotic  cancer,  whether 
it  have  its  seat  in  the  urinary  apparatus  or  elsewhere,  Eiselt 
and  Bolze*  have  noticed  that  the  urine  on  standing  assumes 
the  color  of  porter,  and  that  on  the  addition  of  concentrated 
nitric  acid  it  instantly  presents  the  same  dark  color;  facts 
which  they  regard  as  highly  diagnostic. 

In  iuhcrclc,  little  yellow,  cheesy  masses  of  degenerated 
tubercular  matter  collect  as  a  sediment,  as  in  the  cases  re- 
ferred to  hy  Frerichs  in  his  work  on  Bright's  disease.  The 
constant  presence  of  this  sign  is,  however,  doubtful.  The 
tubercular  matter  is  derived  from  the  ureters  or  pelvis  of 
the  kidneys.  The  deposit  it  forms  in  the  urine  is  insoluble 
in  acetic  acid;  and  Vogel  describes  the  microscopical  char- 
acters of  the  deposit,  as  irregular  corpuscles  not  exhibiting, 
when  treated  with  acetic  acid,  normal  nuclei,  or  only  show- 
ing small,  irregular  nucleoli,  and  an  ill-defined  detritus,  with 
fragments  of  cells  and  an  indistinct  and  finely  granular  mass, 
with  which  crystals  of  cholesterine  are  sometimes  mingled. 
The  signs  of  chronic  pyelitis  are  also  present  and  there  is 
no  other  assio-nable  cause  for  its  existence  than  tubercle. 
We  may  be  assisted  in  the  diagnosis  by  finding  tubercles  in 
other  organs.  liayer  tells  us  that  scrofulous  disease  of  the 
vertebrae  has  repeatedly  been  observed  to  be  associated  with 
tubercular  kidneys. 

In  cysts  of  the  kidney — those  at  least  inclosing  echinococci 
— small  vesicles  containino-  the  characteristic  structures  of  the 
parasites  may  perhaps  be  detected.  Ordinary  cysts  are  not  to 
be  recognized  with  any  certainty  during  life;  nor  can  they  be 
distinguished  from  Bright's  disease,  since  they  are  very  fre- 
quently developed  in  the  chronic  varieties  of  this  disorder. 

Having  now  treated  of  chronic  Bright's  disease  as  one 
affection,  I  shall  here  briefly  refer  to  the  distinctions  that 
have  been  made  between   its  forms.     In  so  doing,  I  shall 


*  Prager  Yierteljahr.,  vols.  lix.  and  Ixvi. 


65Q 


MEDICAL    DIAGNOSIS. 


follow  the  classification  proposed  by  the  English  physicians, 
which  is  chiefly  based  on  the  diversified  anatomical  aspect 
of  the  kidneys. 

There  is  first  the  chronic  enlargement  of  the  organ,  of 
which  several  kinds  exist : 

1.  The  fatty  kidney,  pre-eminently  Bright's  disease.  The 
kidney  is  verj^  large  and  fatty.  The  deposit  may  occasion 
yellow  scattered  granulations,  or  the  enlarged  organ  is  pale, 

Fig.  42. 


Fatty  casts  and  epithelial  cells  filled  with  fat,  as  seen  in  the  discharge  coming 
from  a  highly  fatty  kidney. 

and  mottled  by  red  vascular  patches.  The  convoluted  tubes 
are  filled  with  oil,  accumulated  in  their  epithelial  cells.  The 
fatty  disease  is  recognized  by  the  numerous  oily  casts,  fatty 
cells  and  free  oil  cells  which  appear  in  the  highly  albuminous 
urine.  It  is  a  very  dangerous  complaint, — perhaps  the  most 
fatal  of  all  the  forms  of  the  malady, — is  general Ij^  very 
chronic  in  its  course,  and  attended  with  persistent  dropsy. 
This  morbid  condition  must  not  be  confounded  with  a 
simply  fatty  kidne}^  such  as  is  sometimes  found  in  phthisis, 
or  oftener  in  drunkards,  and  which  is  not  associated  with 
albuminous  urine. 

It  is  thought  by  several,  by  Dr.  Dickinson  especially,  that 
the  fatty  kidney  may  follow  a  high  degree  of  inflammation  in 
the  acute  form  of  Bright's  disease,  particularly  in  that  form 
brought  on  by  exposure  to  cold.  The  acute  form  attending 
scarlet  fever  is  more  apt  to  pass  into  the  large  white  kidney. 


THE    UKINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       fiST 

2.  The  enlarged,  chronically  inflamed  kidney.  I  allude  to 
the  chief  form  of  the  large  Avhite  kidney  so  frequently  men- 
tioned by  English  physicians.  This  is  probably  the  chronic 
non-desquaraative  nephritis  of  Johnson  ;*  it  is  the  kidney 
represented  by  the  third,  fourth,  and  fifth  form  of  Rayer's 
albuminous  nephritis  ;t  it  is  the  chronic  form  of  the  tubal 
nephritis  of  Dickinson.  The  organ  is  white,  enlarged,  dense ; 
its  tubes  are  filled  with  exudation  matter,  their  walls  thick- 
ened. The  cortical  portion  of  the  kidney  is  pale,  and  in- 
creased in  breadth,  evidently  full  of  an  inflammatory  de- 
posit; the  medullary  cones  retain  their  vascularity.  Tiiis 
variety  of  the  malady  often  follows  acute  Bright's  disease. 
It  may  last  for  a  few  years,  but  generally  terminates  before 
that  time  unfavorably.  The  dropsy  it  occasions  is  very  ex- 
tensive and  persistent,  and  there  is  usually  little  difiiculty  in 
tracing  it  to  an  acute  attack.  This  large  kidney  is  not  sup- 
posed ever  to  contract. 

3.  The  waxy  kidney,  an  afi:ection  in  which  the  enlarged 
organ  is  smooth,  of  firm  look,  and  of  pale-yellow  color,  and 
is  the  result  of  a  general  disease  involving  the  kidneys  in 
common  with  other  organs.  It  originates  in  the  exudation 
from  the  minute  arteries  of  a  waxy  material  which  infiltrates 
the  tissues.  This  disease,  as  Dickinson  ably  enforces,|  very 
generally  follows  upon  protracted  suppuration  from  what- 
ever cause,  either  wound  or  disease,  as  dysentery  or  phthisis. 
The  urine  is  increased  in  quantity  in  the  earlier  stages  and 
contains  much  albumen,  but  not  many  casts.  Those  which 
are  seen  are  pale,  and,  for  the  most  part,  transparent,  struc- 
tureless moulds  of  the  tubules,  generally  of  large  diameter. 
Blood  is  but  rarely  present  in  the  urine,  and  the  urea  is  but 
slightly  diminished  in  quantity.  Diarrhoea  frequently  coexists, 
and  the  liver  and  spleen  are  apt  to  be  enlarged,  Tlie  dropsy 
is  very  trifling  in  amount,  yet  its  persistence  while  the  urine 
is  increased  in  quantity  is  peculiar  to  this  form  of  renal  dis- 

*  Diseases  of  the  Kidney. 

f  Traite  des  Maladies  des  lieins,  tome  ii.  and  Atlas. 

X  Med.-Chir.  Trans.,  vol.  1.  j).  39;  also  Pathology  and  Treatment  of  Alhu- 
minuria. 

42 


658 


MEDICAL    DIAGNOSIS. 


ease;  the  patient  is  sallow  looking  and  emaciated;  his  dis- 
ease may  last  for  years. 

Fig.  43. 


Hyaline  or  waxy  casts,  magnilieil  about  40lJ  diametei-s.  taken  from  the  urine. 
On  some  of  them  are  scattered  a  few  shrivelled  epitlielial  cells  and  oil  drops;  the 
large  cells  to  the  left  are  epithelial  cells  from  the  Idadder. 

The  kind  of  casts  here  depicted  may  be  found  in  any  form  of  Bright's  disease, 
acute  as  well  as  chronic.  In  the  waxy  kidney,  however,  they  vastly  prepon- 
derate, and  are  of  large  size — many  much  larger  than  those  in  this  tigiire. 

Then  we  have  the  small  contracted  kidney,  which  is  viewed 
as  the  last  stage  of  Bright's  disease  by  those  who  believe  in 


Fig.  44. 


Granular  casts,  or  casts  covered  with  disintegrating  epithelium  and  granules. 
Casts  of  this  character  are  chiefly  found  in  tlie  dise;u<e  which  leads  to  the  con- 
tracted kidney.  They  are  never  seen  in  the  acute  complaint,  excepting  at  its 
close,  when  it  is  assuming  a  chronic  form. 

the  varying  appearance  being  only  successive  stages  of  the 
same  morbid  process.     This  form  of  disease  is  frequently 


I 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       659 

found  ill  gouty  persons.  The  urine  contains  but  an  incon- 
siderable amount  of  albumen  ;  the  tube-casts  are  granular, 
or  simple  fibrinous  moulds,  generally  small,  sometimes  large; 
here  and  there  a  little  oil  is  observed.  Dropsy  is  absent  in  a 
certain  proportion  of  cases,  and  when  present  is  generally 
slight.  It  often  disappears  for  awhile  and  returns.  The 
urine  is  increased  in  quantity,  although  toward  the  termina- 
tion it  becomes  scanty  or  even  suppressed.  The  disease  runs 
a  very  chronic  course.  It  is  chiefly  characterized  anatomi- 
cally by  an  affection  of  the  fibrous  tissue  lying  between  the 
tubes,  a  slow  increase,  followed  by  a  slow  contraction  of  the 
intertubular  fibrous  tissue.  The  disease  is  often  described  as 
the  granular  kidney,  or  as  granular  degeneration  of  the  organ. 
In  the  following  table,  part  of  the  framework  of  which  is 
taken  from  one  contained  in  Dr.  Todd's  Lectures  on  the 
Urinary  Organs,  the  clinical  differences  between  the  different 
forms  of  Brio-lit's  disease  are  set  forth : 

Table   exhibitiis'g  the    Clinical    Differences   between   the   Prin- 
cipal  Forms  of   Bright's   Disease. 


Cases  in  which  Dropsy  is  Urgent  and  Acute. 


Acute  desqua- 
mative, or  tu- 
bal nephritis ; 
or  acute  drop- 
sy from  expo- 
sure, or  after 
scarlet  fever.. 


Dropsy  extensive ; 
usually  febrile 
.symptoms. 

llecoveries     fre- 
quent ;  but  dis- 
ease may  termi- 
nate in  the  large 
white  kidnev. 


Urine  deeji  color- 
ed, of  higli  spec. 
grav.,  contain- 
ing much  albu- 
men, often 
blood;  also  casts 
covered  with 
epithelium. 


J 


Kidneys  enlarged 
and  vascular, 
shedding    their 
epithelium. 


Cases  in  which  Dropsy  is  very  Variable  in  Amount,  Chronic,  and 

may  he  Absent. 

( Urine    contains 
much  albumen, 


Fatty  kidney....  -| 


Persistent  and  ob- 
stinate dropsy, 
coming  on  grad- 
ually ;  face  pale 
and  puffed. 

Alwavs  fatal. 


fatty    casts,   fat 
cells,  free  oil. 

Spec.  grav. rather 
high,   usually 
from  1015   to 
1030 ;     rarely 
1010. 

Quantity  mode- 
rate or  dimin- 
ished. 


Kidneys  in  a  state 
of  enlargement, 
and  fatty;  some- 
times have  a 
mottled  appear- 
ance. 


660 


MEDICAL    DIAGNOSIS, 


Cases  in  lohich  Dj'opsy  is  very  Variable,  etc. — (Continued.) 


"Waxy  kidney... 


Chronic     c  o  n- 
traction  of  the  \ 
Kidney 


Dropsy  trifling,  or 
entirely  absent; 
great  emacia- 
tion ;  striking 
sallowness  o  f 
face ;  liver  and 
spleen  enlarged. 

Unfavorable 
prognosis. 


Dropsy  moderate, 
les.s  than  in  fat- 
ty kidney ;  face 
sallow,  yet  not 
so  much  so  as  in 
the  waxj"  dis- 
ease ;  often  re- 
tention of  urea, 
tendency  to  co- 
ma, and  to  con- 
vulsions ;  im- 
p  o  V  e  r  i  s  h  e  d 
blood  ;  epistax- 
is ;  liver  maybe 
cirrhosed. 

May  exist  for 
years  without 
being  suspect- 
ed ;  is  a  very 
chronic  disease. 


Urine  increased 
in  quantity, 
contains  much 
albumen,  but 
comparatively 
few  casts,  which 
are  pale  and 
transparent. 

Spec.  grav.  vary- 
ing, u  s  u  a  1 1  y 
above  1010. 


Urine  more  copi- 
ous than  in 
health,  yet  ex- 
tremely small 
amount  of  albu- 
men ;  hyaline 
and  large  gran- 
ular casts,  al- 
tered epi  th  e- 
lium,  a  little 
oil. 

Spec.  grav.  very 
low  :  rarely 
above  1010, 
m  u  c  h  often  er 
below. 


Kidneys  enlarged , 
smooth,  and 
waxy  looking. 


Kidneys  waste 
slowly,  are  full 
of  a  deposit, 
become  small, 
dense,  and  con- 
tracted ;  the 
capsule  very 
adherent ;  t  h  e 
thickness  of  the 
cortical  s  u  b- 
stance  dimin- 
ished. 


The  indications  for  treatment  are,  to  keep  up  the  action  of 
the  skin ;  not  to  allow  the  kidneys  to  become  clogged, — 
however  much  we  ought,  as  a  rule,  to  avoid  stimulating 
diuretics  ;  to  prevent  the  dropsy  from  gaining ;  and  to  check 
the  drain  of  albumen  from  the  system,  or  counteract  the 
bad  efiects  of  this  drain. 

The  food  taken  should  be  very  easy  of  digestion.  Exer- 
cise in  the  open  air  is  permissible,  if  the  dropsy  allow  of  it, 
excepting  in  the  acute  form  of  the  malady,  in  which  rest  in 
the  horizontal  position  should  be  rigidly  enforced. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       661 

Diseases  associated  with  Purulent  Urine, 

There  is  a  group  of  aftections  in  which  pus  is  found  in  the 
urine,  and  in  which  the  presence  of  this  abnormal  ingredient 
becomes  of  great  value  in  diagnosis;  yet  to  distinguish  the 
individual  members  of  the  group  from  each  other,  and  to 
ascertain  the  source  of  the  purulent  urine,  we  have  to  look, 
for  the  most  part,  to  the  other  symptoms.  In  every  case  in 
which  pus  in  any  quantity  is  detected  in  the  urine,  it  be- 
comes of  great  importance  to  ascertain  primarily  that  it  is 
not  derived  from  the  urethra,  from  the  vagina,  or  from  an 
abscess  that  has  opened  into  the  urinarj^  passages.  The  first 
point  we  may  decide  by  examining  into  the  history  of  the 
case,  and,  if  necessary,  by  an  exploration  of  the  parts,  as  well 
as  by  an  examination  of  the  urine  procured  in  the  manner 
recommended  in  the  first  part  of  this  chapter ;  the  second,  by 
the  same  means,  and  by  determining  that  a  discharge  takes 
place  equally  when  no  urine  is  voided;  the  third  is  more 
difiicult  to  make  out,  but  there  is  generally  something  in  the 
symptoms  and  in  the  history  of  the  case  furnishing  a  clue  to 
its  interpretation, — such,  for  instance,  as  the  sudden  appear- 
ance of  a  large  quantity  of  pus  in  the  urine.  Having  excluded 
each  of  these  morbid  states  as  the  source  of  the  purulent  urine, 
we  next  turn  to  see  which  of  the  maladies  that  are  its  most 
common  cause  is  before  us.     Thej'  are : 

Acute  Cystitis. — Acute  inflammation  most  frequently 
aft'ects  the  mucous  membrane  at  or  near  the  neck  of  the 
bladder.  The  inflammation  may  spread  from  the  mucous 
membrane  to  the  muscular  coat;  but  it  very  rarely  reaches 
the  peritoneal  covering.  In  some  cases  it  is  propagated 
along  the  ureters,  and  even  to  the  kidneys.  The  morbid  ac- 
tion is  not  often  of  idiopathic  origin — much  more  usually  is 
it  due  to  the  extension  of  an  attack  of  gonorrhcEa,  to  disease 
of  the  prostate,  to  traumatic  causes,  to  protracted  retention 
of  urine,  or  to  the  irritation  produced  by  medicines  or  stim- 
ulating drinks.  Sometimes  it  is  owing  to  the  poison  of 
rheumatism  or  gout. 

Acute  cystitis  is  much  more  frequently  encountered  in 
men  than  in  women,  and  in   adults  than  in  children.     Its 


662  MEDICAL    DIAGNOSIS. 

main  symptoms  are  a  feeling  of  weight  and  pain  in  tlie 
hypogastric  region,  augmented  by  movement  and  by  press- 
ure. The  pain  does  not,  however,  remain  confined  to  the 
region  about  the  bladder,  but  is  also  felt  in  the  iliac  and 
sacro-lumbar  regions.  It  is  attended  with  considerable  feb- 
rile disturbance  and  an  extreme  irritability  of  the  affected 
viscus.  The  urine  is  voided  drop  by  drop,  and  its  passage  is 
usually  accompanied  by  straining  and  a  scalding  sensation 
at  the  neck  of  the  bladder;  it  is  high  colored,  cloudy  from 
increased  vesical  mucus,  and  contains  blood  and  pus.  The 
acute  disease  generally  terminates  within  a  week,  leaving 
often  an  irritable  bladder  or  a  chronic  inflammation. 

The  symptoms  of  acute  cystitis  are  similar  to  those  of 
acute  nephritis,  and  the  exciting  causes  too  are  much  the 
same.  But  acute  inflammation  of  the  bladder  differs  from 
acute  inflammation  of  the  kidney  by  the  greater  severity  of 
the  pain,  its  much  lower  position,  and  the  distress  occasioned 
in  voiding  the  urine.  Neuralgia,  or  spasm,  of  the  bladder 
may  be  distinguished  from  acute  inflammation  by  the  ab- 
sence of  fever,  and  the  sharp,  lancinating,  but  paroxysmal 
pain  of  the  former  malady,  each  onset  of  which  lasts  hardly 
longer  than  from  two  to  six  hours,  and  is  attended  with 
difliculty  in  making  water,  which,  however,  disappears  as 
the  pain  subsides. 

Metritis  exhibits  several  of  the  traits  of  cystitis :  we  find 
the  same  hypogastric  pain  shooting  downward  to  the  thighs 
or  toward  the  anus  and  loins,  the  same  feeling  of  weight  in 
the  perineum,  and  the  same  signs  of  irritation  of  the  bladder 
and  of  fever.  As  it,  however,  generally  occurs  in  the  puer- 
peral state,  we  have  the  history,  and,  moreover,  the  character 
of  the  discharges  from  the  vagina,  to  guide  us ;  and  should 
doubt  still  exist,  the  knowledge  to  be  gained  by  a  digital  and 
a  specular  examination. 

Chronic  Cvstitis. — This  affection,  often  called  catarrh  of 
the  bladder,  is  very  common  in  advanced  age.  It  generally 
comes  on  in  an  insidious  manner,  and  is  excited  by  some  ob- 
stacle to  the  evacuation  of  urine,  such  as  a  stricture,  or  by 
the  presence  of  a  stone  in  the  bladder,  or  by  an  enlargement 
of  the  prostate  gland.     A  paralysis  of  the  viscus  leading  to 


THE    URINE,  AND    DISEASES    OF   THE    URINARY    ORGANS.       663 

retention  of  its  contents,  or  a  serious  structural  disease  of  its 
coats,  whether  malignant  or  non-malignant,  may,  however, 
also  establisli  tlie  morbid  process. 

The  symptoms  are  partly  those  of  constitutional  debility, 
partly  those  of  local  disease.  The  most  usual  of  the  latter, 
and  indeed  in  every  way  the  most  characteristic  of  the 
malady,  are  the  dull  pain,  a  frequent  desire  to  make  water, 
and  the  passage  of  a  large  quantity  of  pus  with  each  act  of 
micturition.  The  urine,  on  standing,  deposits  a  thick,  glniry, 
viscid  sediment,  in  which,  under  the  microscope,  triple  phos- 
phates and  large  pus  corpuscles,  extremely  regular  both  in 
contents  and  in  shape,  may  be  detected. 

The  diagnosis  of  the  disease  in  males  is  easy.  The  only 
affection  with  which  it  is  liable  to  be  confounded  is  abscess 
of  the  kidney.  In  females,  uterine  disorders  may  so  closely 
simulate  it  that  we  cannot  be  certain  of  the  existence  of  a 
disease  of  the  bladder  until,  b}'  careful  inquir}-  into  the  his- 
tory of  the  case,  and,  if  need  be,  by  aid  of  the  speculum,  we 
have  ascertained  with  accuracy  the  state  of  the  organs  of 
generation. 

But  having  decided  the  case  to  be  one  of  chronic  cystitis, 
it  is  always  more  difficult  to  discover  its  exciting  cause.  We 
have  to  depend,  to  a  great  extent,  upon  the  histoi-y  of  the 
malady;  its  association  with  a  stone  can  only  be  determined 
bv  the  use  of  the  sound. 

Abscess  of  the  Kidney. — This  dangerous  condition  is  the 
result  of  suppurative  inHammation  of  the  kidney,  or  of  ab- 
scesses forming  in  connection  with  a  poisoned  blood,  as  in 
pyaemia,  or  of  embolism.  The  suppurative  inflammation  is 
sometimes  traceable  to  an  acute  attack  of  nephritis  brought 
on  by  exposure  or  external  violence,  to  retention  of  urine,  or 
to  the  impaction  of  a  renal  calculus;  but  at  other  times  it 
originates  without  any  assignable  cause,  and  in  a  very  in- 
sidious w^ay. 

When  the  disorganizing  process  has  continued  for  some 
time,  and  the  abscesses  are  fairly  formed,  we  encounter  these 
signs:  a  fulness  on  one  side  of  the  spine  in  the  lumbar  re- 
gion, associated  with  some  tenderness  on  deep  pressure  and 
with  more  or  less  constant  pain  ;  occasional  rigors  and  fever- 


664  MEDICAL    DIAGNOSIS. 

ishness;  and  the  presence  of  blood  and  pus  in  tiie  urine.  In 
some  cases  a  marked  tumor  is  found  in  the  loin,  extending 
toward  the  iliac  fossa.  If  the  abscess  burst  into  the  calices 
there  occurs,  simultaneously  with  a  subsidence  of  the  tumor, 
a  sudden  and  copious  discharge  of  pus  with  the  urine,  or  if 
into  the  intestine,  with  the  fecal  evacuation. 

The  disease  almost  never  affects  more  than  one  kidney; 
hence  so-called  ursemic  symptoms  are  very  rarely  met  with, 
as  the  healthy  kidney  enlarges  and  becomes  capable  of  per- 
forming a  double  amount  of  work.  The  disorder  gradually 
leads  in  most  cases  to  a  fatal  issue,  from  the  irritation,  the 
wasting  discharge,  and  the  protracted  hectic.  There  is,  how- 
ever, a  possibility  of  recovery  if  the  patient  have  strength 
enough  to  withstand  the  purulent  drain  until  the  abscess 
empties  itself.  It  ma}^  do  this  through  the  urinary  passages, 
through  the  colon,  through  the  lumbar  muscles,  through  the 
diaphragm,  and  be  evacuated  by  coughing,  and  the  cavity 
of  the  abscess  then  cicatrizes ;  or  the  abscess  may  burst  into 
the  peritoneal  cavity  and  cause  rapid  death. 

The  diseases  for  which  the  malady  is  most  apt  to  be  mis- 
taken are  chronic  cystitis,  perinephritis,  and  pyelitis.  From 
cystitis  it  may  be  distinguished  by  the  dissimilar  local  signs 
and  the  different  appearances  of  the  urine.  Thus,  in  the 
affection  of  the  bladder  the  quantity  of  pus  constantly  dis- 
charged is  far  greater — for  in  abscess  of  the  kidney  there 
are  times  when  but  little  or  no  pus  is  voided ;  on  the  other 
hand,  the  urine  of  the  vesical  disorder  is  less  albuminous. 
Yet  this  is  not  a  certain  guide,  for  we  may  have  a  Bright's 
kidney  associated  with  a  catarrh  of  the  bladder,  and  thus 
both  a  highly  purulent  and  a  highly  albuminous  urine  be 
produced.  In  this  case,  however,  a  diligent  search  with  the 
microscope  will  detect  casts  and  other  renal  products  in  the 
sediment. 

Perinephritis  unconnected  with  inflammation  of  the  kid- 
ney is  a  very  rare  disease.  I  have  seen  but  one  instance  of  it, 
which  occurred  in  a  young  gentleman,  who,  returning  home 
from  a  long  walk,  strained  his  back  in  Jumping  a  fence.  An 
abscess  very  gradually  formed,  giving  rise  to  a  slight  fulness 
in  the  left  lumbar  region,  and  severe  pain,  which  disappeared 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       665 


as  matter  was  discharged  through  the  integuments.  The 
function  of  the  kidney  was  not  affected  :  proving  that  the 
disorder  was  in  the  neighborhood,  and  not  in  the  structure 
of  the  organ.* 

But  an  external  opening  may  be  established  when  the  pro- 
cess of  inflammation  and  suppuration  has  commenced  in 
the  kidney  and  thence  spread  to  the  loose  tissues  surround- 
ing it.  Under  these  circumstances,  the  appearance  in  the 
urine  of  pus  prior  to  its  discharge  through  the  muscles  of  the 
back,  would  be  the  only  certain  means  by  which  we  could 
judge  where  the  suppuration  had  primarily  taken  place. 

The  prominent  symptom  in  perinephritis  is  pain,  which 
at  times  is  so  severe  as  to  confine  the  patient  to  bed  with 
knees  flexed,  with  a  sense  of  fulness  and  dragging  weight 
in  the  region  of  the  kidney,  and  with  lameness  owing  to 
the  interference  with  the  play  of  the  psoas  muscles.  The 
urine  is  generally  unaltered;  the  bowels  may  be  constipated, 
owing  to  the  pressure  of  the  tumor  on  the  intestine.  A 
rounded,  doughy,  and  generally  indolent  tumor  is  usually 
found  in  the  renal  region.  In  Dr.  Bowditch's  three  cases 
the  abscess  extended  up  into  the  right  pleura,  without  appa- 
rently afl:ecting  the  liver,  after  having  probably  forced  its 
way  behind  that  organ  and  along  the  psoas  muscles  under 
the  right  crus  of  the  diaphragm,  and  caused  pulmonary  or 
pleuritic  complications,  but  not  jaundice.  As  the  disease 
advances,  severe  chills,  with  fever  and  copious  night-sweats, 
occur,  and  emaciation  and  marked  debility. 

As  regards  the  treatment  in  these  cases,  when  the  diag- 
nosis is  established,  an  external  incision,  permitting  the 
escape  of  pus,  is  demanded. 

Pyelitis. — This  is  the  name  given  by  Rayer  to  inflamma- 
tion of  the  mucous  membrane  of  the  pelvis  of  the  kidney 
— an  afl:ection  very  rarely,  in  fact  almost  never,  idiopathic, 
being  commonly  caused  by  a  calculus  that  has  been  arrested 
at  the  commencement  of  the  ureter,  or  by  a  retention  of 
urine  from  an  obstacle  in  the  ureter,  bladder,  or  urethra,  or 


*  Trousseau,  in  the  second  edition  of  his  Clinique  Medicalc,  Lect.  XCIV., 
cites  several  instances  of  perinephritic  abscesses,  and  Bowditch  narrates  three 
cases  in  the  Boston  Med.  and  Surg.  Journ.,  18G8,  N.  S.,  vol  i.  p.  357. 


G(J6  MEDICAL    DIAGNOSIS. 

by  an  extension  upward  from  the  bladder  of  an  inflammation. 
Bright's  disease  and  diabetes  are  usually,  and,  according  to 
Roberts,  tj^phus  and  the  eruptive  fevers,  pyfemia,  scurvy, 
diphtheria  and  carbuncle,  are  occasionally,  complicated 
with  some  degree  of  pyelitis.     The  urine  is  commonly  acid. 

'Vhe  symptoms  of  the  malady  are,  therefore,  in  part  those 
produced  by  the  morbid  states  exciting  it,  especially  those 
denoting  a  calculus  lodged  in  the  kidney  or  arrested  in  its 
transit  toward  the  bladder;  partly  those  directly  traceable  to 
the  inflammation  of  the  pelvis  and  infundibula.  The  mani- 
festations of  the  latter  disorder  are,  a  constant  pain  in  the 
loin,  felt  also  in  the  course  of  the  ureter,  and  the  passage  of 
pus  and  occasionally  of  blood  with  the  urine. 

The  most  difficult  point  connected  with  the  recognition  of 
pyelitis  is  to  be  certain  that  the  purulent  discharge  does  not 
proceed  from  the  bladder.  And  there  is  no  positive  sign  to 
guide  us  excepting  the  existence  in  the  urine  of  epithelium 
from  the  pelvis  of  the  kidney,  distinguishable  by  the  frequent 
occurrence,  in  a  cell,  of  clearly-defined,  dark-colored,  round 
granules,  and  of  two  nuclei.  But  this  epithelium  may  not 
always  be  found,  and  we  have  then  to  fall  back  upon  the 
history  of  the  case,  upon  the  attacks  of  renal  pain,  upon  the 
hematuria  caused  by  a  calculus,  and  the  combination  of 
signs  as  pointing  more  to  one  disease  than  the  other.  In 
some  cases  there  is  a  perceptible  swelling  in  the  loin,  which 
assists  us  materially  in  coming  to  a  conclusion  ;  at  times, 
too,  owing  to  coexisting  congestion  or  degeneration  of  the 
kidney,  the  amount  of  albumen  is  wholly  disproportionate 
to  that  contained  in  pus,  and  this  becomes  a  valuable  indica- 
tion of  the  affection  not  being  vesical.  But  if  there  be  a 
coincident  disease  of  the  bladder,  the  differential  distinction, 
on  Bayer's  own  showing,  becomes  impossible. 

Supposing,  however,  the  point  settled,  and  the  vesical 
origin  of  the  pus  disproved,  the  diagnosis  is  limited  to  an 
inflammation  of  the  ureter,  an  abscess  in  the  substance  of 
the  kidney,  and  to  pyelitis.  Here  again  the  history  of  the 
case  comes  into  play.  Furthermore,  in  the  former  of  these 
affections — a  very  rare  one,  unless  associated  with  pyelitis — 
the  amount  of  pus  in  the  urine  is  very  trifling;  in  the  second. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.       667 

too,  it  is  less  tlian  in  pyelitis,  excepting  wlien  the  abscess 
empties  itself.  The  pus  is  also,  as  already  indicated,  not 
constant,  alternately  appearing  in  and  disappearing  from  the 
urine,  and  the  disease  is  attended  with  much  greater  consti- 
tutional disturbance.  Yet  here  again  we  must  admit  that 
the  disorders  are  sometimes  very  obscure,  and  very  ditHcult 
to  distinguish,  and  it  may  be  impossible  to  discriminate  be- 
tween them  should  any  of  the  morbid  states  coexist. 

In  those  cases  of  pyelitis  in  which  there  is  a  decided  ob- 
struction to  the  flow  of  urine  through  the  ureter,  caused  by 
a  calculus,  clot  of  blood  or  viscid  pus,  or  other  debris,  the 
discharge  of  pus  is  suddenly  arrested  and  the  cavity  of  the 
pelvis  dilates  very  much;  gradually  the  gland  tissue  is  com- 
pressed, and  a  large  pus-containing  sac  is  formed,  giving  rise  to 
a  condition  known  as  j^yonejjJirosis,  and  to  a  distinctly  limited 
sw^elling  in  the  side.  These  kind  of  tumors  are  ordinarily 
not  painful  to  the  touch,  are  sometimes  very  indolent,  and, 
as  a  rule,  do  not  materially  atfect  the  general  health.  They 
not  unfrequently  subside  gradually  by  very  free  discharges 
of  pus,  and  the  patient  recovers.*  They  have  been  knowni 
to  occur  in  both  kidneys,  but  this  is  of  great  i-arity. 

When  the  changes  resulting  from  an  impediment  to  the 
flow  of  urine  are  unassociated  with  suppuration  of  the 
mucous  membrane  of  the  pelvis  of  the  kidney,  we  have  the 
condition  designated  by  Eayer  as  hydronephrosis.  It  is 
often  due  to  congenital  malformation  of  the  ureter,  and 
sometimes  is  double.  The  swelling  to  which  it  gives  rise 
may  subside  simultaneously  with  a  sudden  and  copious  dis- 
charge of  urine.  When  this  symptom  is  absent,  the  diag- 
nosis must  be  based  on  the  existence  of  a  fluctuating  renal 
tumor  and  the  absence  of  signs  of  suppuration. 

Hydatid  tumor  of  the  kidney  is  of  comparatively  rare  oc- 
currence and  is  very  apt  to  be  confounded  with  hydrone- 
phrosis. When  the  urine  contains  no  hydatid  vesicles  or 
their  ddbris  and  the  hydatid  fremitus  is  absent,  the  diagnosis 
is  extremel}-  difiicult  and  must  rest  chiefly  on  the  histor}- 
of  the  case. 


*  wSee,  for  instance.  Cases  XLVIII.  and  L.  in  Dr.  Todd's  Clinical  Lectures 


on  the  Urinary  Organs. 


668  MEDICAL    DIAGNOSIS. 

Disorders  in  which  a  very  large  Amount  of  Urine  is 

discharged. 

Diabetes. — An  excessive  flow  of  urine  was  formerly  called 
diabetes ;  it  is  now  customary  to  restrict  the  term  to  the  ex- 
cessive flow  accompanying  the  excretion  of  sugar,  the  dia- 
betes mellitus,  or  glucosuria,  of  many  authors. 

Diabetic  urine  is  of  pale  color  and  of  high  specific  gravity, 
ranging  generally  from  1030  to  1050.  The  quantity  passed 
is  enormous ;  seventy  pints  and  upwards  have  been  known 
to  be  discharged  daily. 

The  symptoms  attending  this  drain  of  fluid  from  the  sys- 
tem are,  as  may  be  supposed,  great  thirst,  constipation,  and 
generally  a  dry,  harsh  skin,  and  a  feeling  of  constant  empti- 
ness and  of  hunger.  To  these  are  added  a  steadily  progress- 
ing waste  of  the  body,  debility,  chills,  a  somewhat  hurried 
breathing,  peevishness  of  temper,  and  a  tendency  to  boils  and 
carbuncles.  Cataract  and  other  kinds  of  defective  vision  are 
not  infrequent ;  and  M.  Galezowski*  has  described  a  form  of 
retinitis  which  has  been  observed,  in  some  rare  cases,  to  ac- 
company diabetes. 

The  disease  is  a  very  fatal  one ;  yet  it  is  impossible  to  fore- 
tell its  exact  mode  of  termination.  Sorde  are  cut  off"  rather 
suddenly ;  others  drag  out  a  long  existence,  and  die  worn  out 
and  dropsical,  or  of  superadded  phthisis.  For  some  days,  or 
even  for  weeks  before  death,  the  sugar  may  disappear  from 

the  urine.t 

Whence  comes  the  sugar?  Is  it  from  the  food,  the  blood, 
the  kidneys,  the  stomach,  the  liver?  These  are  questions 
that  cannot  be  satisfactoril}'  answered.  Since  Bernard's  dis- 
covery of  the  sugar-forming  properties  of  the  liver,  saccha- 
rine urine  is  thought  to  proceed  from  an  inordinate  formation 
in  this  viscus  of  sugar,  which  is  not  fully  destroyed  in  the 
lungs,  and  is  excreted  by  the  kidneys.     But  the  experiments 

*  Compte  Kendu  du  Congres  Ophth.  de  Paris,  1862. 

I  In  a  case  for  a  long  time  under  my  charge,  in  which  the  diabetes  lasted 
for  several  years,  sugar  entirely  disappeared  from  the  urine  as  the  signs  of 
phthisis  became  fully  develo])ed,  and  for  several  months  before  death. 


THE    URINE,  AND   DISEASES    OF    THE    URINARY   ORGANS.      669 

of  Pavy  seem  to  throw  some  doubt  on  this  simple  and  inge- 
nious theory.  That  the  sugar  is  not  derived  from  the  food, 
is  very  certain  ;  for  patients  kept  even  on  the  most  rigorous 
meat  diet  still  pass  sugar.  In  some  cases  diabetes  has  been 
found  associated  with  paralysis  of  the  tongue,  palate,  and 
vocal  cord,  and  other  signs  of  disease  in  the  floor  of  the  fourth 
ventricle. 

Starchy  and  saccharine  substances  increase  the  quantit}'  of 
diabetic  sugar.  Nay,  they  may  be  the  cause  of  a  little  sugar 
appearing  in  the  urine  of  healthy  persons.  Yet  those  in 
whom  a  saccharine  state  of  the  urine  is  readil}'  induced  are 
in  great  danger  of  becoming  diabetic. 

In  the  aged,  sugar  may  be  present  in  the  urine  without 
being  attended  Avith  distressing  symptoms.  It  is  in  such 
cases  that  we  are  most  apt  to  meet  with  the  intermitting  dia- 
betes to  which  attention  has  been  called  by  Bence  Jones.* 
When  the  abnormal  ingredient  thus  disappears  from  the 
urine,  it  is  replaced  by  uric  acid  and  by  oxalates. 

There  is  still  another  form  of  intermitting  diabetes.  Sugar 
is  sometimes — Dr.  Burdelf  says  uniformly — found  in  the 
urine  during  the  paroxysms  of  intermittent  fever;  but  it 
vanishes  entirely  during  the  intervals. 

Chronic  Diuresis. — This  disease  is  otherwise  known  as 
hydruria,  or  diabetes  insipidus.  It  is  characterized  by  the 
habitual  discharge  of  a  very  large  quantity  of  urine  contain- 
ing an  excess  of  water,  but  no  sugar.  The  general  symp- 
toms are  much  the  same  as  those  of  diabetes ;  the  thirst  is 
generally  extreme,  and,  if  some  of  the  recorded  observations 
can  be  fully  relied  on,  more  water  is  passed  than  is  drunk. 

The  cause  of  this  singular  malady  is  obscure.  It  would 
seem  to  be  connected  with  some  abnormal  state  of  the  nerv- 
ous system.  It  certainly  was  in  the  following  marked  in- 
stance of  the  aflection : 

A  young  man,  twenty-four  3'ears  of  age,  was  admitted 
into  my  ward  at  the  Philadelphia  Hospital.  He  was  thin, 
greatly   troubled   with    thirst,   and   discharged   daily  from 

*  Med.-Chir.  Transact.,  vol.  xxxviii. 
t  L^Union  Medicale,  Is^o.  139,  1859. 


670  MEDICAL    DIAGNOSIS. 

thirty-six  to  forty  pints  of  limpid  urine  of  a  very  low  specific 
gravity,  in  which,  by  several  tests  repeatedly  employed,  not 
a  trace  of  sugar  could  be  detected.  He  stated  that  he  had 
been  in  good  health  until  about  five  months  previously, 
when  he  had  a  sunstroke  while  laboring  on  a  building.  He 
was  for  awhile  insensible,  and  from  that  time  had  had  con- 
stant pain  in  the  head,  and  had  been  unable  to  work.  He 
lost  flesh  rapidly,  and  was  much  annoyed  by  frequent  and 
excessive  emission  of  urine.  Be3'0nd  the  sj^mptoms  men- 
tioned, little  was  found  in  the  case.  All  the  internal  viscera 
appeared  to  be  healthy ;  the  bowels  were  constipated. 

The  patient  drank  an  enormous  amount  of  water,  though, 
unless  he  obtained  the  coveted  liquid  by  stealth,  not  so  much 
as  he  habitually  passed.  For  upwards  of  a  week  he  improved 
on  tonics,  especially  on  the  ignatia  amara,  voiding  once  only 
seventeen  pints  in  the  twenty-four  hours.  But  he  then  re- 
lapsed, discharging  as  much  water  as  before,  and  growing 
dail}^  weaker  and  weaker.  Suddenly  he  was  seized  with 
very  great  irritability  of  the  stomach  and  a  complete  suppres- 
sion of  urine,  repeated  catheterizations  proving  the  bladder 
to  be  empty.  He  was  cupped  over  the  kidneys,  placed  in  a 
warm  bath,  and  active  diuretics  were  administered,  with  the 
result  of  re-establishing  the  function  of  the  kidneys.  But 
the  diuresis  did  not  return;  the  man  passed  about  a  pint  of 
high-colored  fluid  daily  until  his  death,  which  took  place  on 
the  fifth  day  after  the  suppression  of  urine,  and  about  six 
months  after  the  sunstroke.  Toward  the  last,  he  was  much 
troubled  with  uncontrollable  vomiting  and  obstinate  consti- 
pation, became  very  dull  and  stupid,  and  his  features  and 
skin  assumed  the  appearance  of  the  stage  of  collapse  in 
cholera.  Unfortunately,  permission  to  examine  the  body 
could  not  be  obtained. 

We  meet  with  cases  of  polyuria  also  under  other  circum- 
stances. Lanceraux  tells  us  that  it  is  not  uncommon  in 
syphilitic  aflections  of  the  nervous  centres.* 

"We  must  take  care  not  to  confound  cases  of  chronic  hy- 
druria  with  true  diabetes.     They  difter  by  the  low  specific 


*  Sydenh.  Society's  Transl.,  p.  70. 


THE    URINE,  AND    DISEASES    OF    THE    URINARY    ORGANS.      671 

gravity  of  the  urine  and  the  utter  absence  of  a  saccharine 
ingredient.*  Sometimes  a  state, of  diuresis  is  found  to  exist 
temporarily  during  the  removal  of  dropsical  effusions,  or 
when  the  action  of  the  skin  is  insufficient.  We  also  meet 
with  apparent  eases  of  diuresis  in  hysterical  women  and  in 
persons  who  sufter  from  incontinence  of  urine,  whether  due 
to  an  external  injury,  or  dependent  upon  simple  irritability, 
or  upon  inflammation  or  paralysis  of  the  bladder.  In  all 
such,  however,  we  can  establish  the  diagnosis  by  laying 
stress  on  the  history  of  the  patient,  and  by  measuring,  as 
accurately  as  possible,  the  amount  of  urine  passed  in  the 
twenty-four  hours — which  amount  may  be  large,  but  is  not 
inordinate. 

Disorders  in  which  little  or  no  Urine  is  discharged. 

Suppression  of  Urine.  —  Suppression  of  urine,  uncon- 
nected with  already  existing  degeneration  of  the  kidney,  is 
a  rare  disorder.  Yet  it  may  occur  in  previously  healthy  per- 
sons, or  in  the  course  of  fevers  of  a  low  type,  and  probably 
associated  with  no  other  morbid  state  than  congestion  of  the 
kidneys.  It  is  occasionally  met  with  as  one  of  the  freaks  of 
hysteria,  or  is  caused  seemingly  by  the  irritation  reflected  to 
a  healthy  kidney  from  a  diseased  bladder. 

The  symptoms  it  occasions,  independently  of  the  absence 
of  the  discharge  of  urine,  are  drowsiness,  nausea,  vomiting, 
coma,  sometimes  convulsions;  in  one  word,  the  symptoms  of 
uraemic  poisoning.  Iri-espective  of  these,  the  formidable 
complaint  may  give  rise  to  marked  urinous  smell  of  the  per- 
spiration and  breath,  and  to  exceeding  and  very  general 
cutaneous  hypersesthesia.t 

Concerning  the  exact  cause  of  the  suf)pression,  we  are 
often  kept  in  the  dark  until  the  termination  of  the  malady; 

*  Sec,  on  the  examination  of  the  urine  in  instancesof  the  disorder,  the  eases 
collected  by  Parkes,  On  the  Composition  of  the  Urine.    London,  18G0. 

f  This  was,  next  to  the  suppression  of  the  discharge,  the  most  obvious 
symptom  in  a  case  under  my  care  in  18G4  at  the  Philadelphia  Hospital,  in 
which  no  urine  was  secreted  for  many  days,  the  catheter  being  repeatedly 
introduced  into  the  bladder.  The  patient  recovered.  She  had,  previous  to 
the  attack,  and  had  still,  when  last  seen,  vesical  catarrh. 


672  MEDICAL    DIAGNOSIS. 

for,  unless  we  are  familiar  with  the  patient's  antecedent 
symptoms,  we  are  unable  to  determine,  in  the  absence  of 
the  urinary  secretion,  whether  or  not  a  disease  of  the  kidney 
lies  at  the  origin  of  the  mischief  If  not  speedily  relieved, 
the  aftection  generally  ends  in  death. 

Retention  of  Urine. — Unlike  what  happens  in  suppres- 
sion of  urine,  the  kidneys,  when  the  urine  is  simply  retained, 
perform  their  secretory  function;  but  the  fluid  collects  in  the 
bladder  and  is  not  voided.  The  distended  viscus  forms  a 
swelling  in  the  hypogastrium,  discoverable  both  by  palpation 
and  by  percussion.  The  urine  is  generally  not  wholly  kept 
back,  for  a  slight  discharge  every  now  and  then  takes  place, 
or  there  is  a  constant  dribbling — a  matter  which  in  itself 
should  always  suggest  the  introduction  of  a  catheter. 

Retention  of  urine,  if  soon  recognized,  is  not  in  itself  a 
dangerous  complaint,  as  it  can  be  ordinarily  at  once  relieved 
by  the  passage  of  a  catheter;  but  if  the  ailment  escape  ob- 
servation, or  be  inefficiently  dealt  with,  the  bladder  is  very 
apt  to  burst,  or  the  patient  dies  from  the  absorption  of  the 
noxious  urinary  ingredients. 

The  causes  which  lead  to  retention  are  various ;  prominent 
among  them,  at  least  in  a  medical  point  of  view,  is  paralysis 
of  the  bladder,  especially  that  form  of  paralysis  which  occurs 
in  low  fevers ;  it  is  also  one  of  the  symptoms  of  paraplegia ; 
then  inflammatory  swelling  of  the  neck  of  the  bladder,  or- 
ganic stricture,  or  enlarged  prostate  may  give  rise  to  it ;  again 
retention  or  incontinence  may  be  due  to  hysteria. 

The  disorder  is  readily  detected.  It  may  be  discriminated 
from  suppression  of  urine  by  the  existence  of  the  hypogas- 
tric tumor,  and  by  the  introduction  of  a  catheter — a  means 
which,  in  cases  of  doubt,  ought  never  to  be  neglected.  Some- 
times the  abdominal  swelling  is  so  great  as  to  lead  to  the 
belief  of  the  existence  of  dropsy ;  and  the  error  is  fostered  b}" 
learning  that  the  patient  has  been  passing  his  water  and  has 
a  constant  desire  to  discharge  it,  or  by  seeing  that  it  dribbles 
from  him.*     But  I  have  already  discussed  these  points  in  con- 


*  In  a  case  reported  by  Schneider,  and  quoted  in  Br.  and  For.  Med.-Cliir. 
Kev.,  April,  1864,  urine  was  passed  :  yet  when  a  catheter  was  introduced, 


THE    URINE,  AND    DISEASES    OF    THE    URINARY   ORGANS.      673 


nection  witb  abdominal  swellings,  and  need  only  here  again 
draw  attention  to  the  errors  in  diagnosis  which  are  likely  to 
arise. 

The  retention  from  paralysis  is  distinguished  from  that  due 
to  other  causes,  as  to  obstruction,  by  observing  that  the  cathe- 
ter enters  readily,  and  that  the  urine  flows  out  in  a  continu- 
ous stream,  increasing  and  lessening  with  the  respiratory 
movements,  but  does  not  come  out  in  jets. 

because  the  peculiar  shape  of  the  tumefaction  seemed  to  indicate  that  the 
swelling  was  produced  by  a  distended  bladder,  14  pints  of  urine,  and  subse- 
quently 8  more,  were  removed. 


43 


CHAPTER  VIII. 

DROPSY. 

A^  abnormal  collection  of  wateiy  fluid  in  the  areolar  tis- 
sue or  in  the  serous  cavities  of  the  body,  constitutes  dropsy. 
Now,  dropsy  is  but  a  symptom,  and  as  such  we  have  already 
examined  into  it  as  associated  with  various  disorders  of 
M^hich  it  forms  a  striking  manifestation;  but,  though  only  a 
symptom,  it  is  one  so  obvious  and  prominent,  and  comprises 
so  often  apparently  the  whole  complaint,  that  it  will  serve  a 
useful  purpose  to  investigate  connectedly  the  clinical  mean- 
ing of  its  typical  forms. 

Dropsy,  according  to  its  Seat  and  Extent. 

Dropsies  may  be  external,  or  confined  to  internal  parts. 
To  the  latter  variety  belong  hydrothorax,  hydrocephalus, 
and  ascites — affections  elsewhere  described,  and  which  we 
shall  only  consider  here  so  far  as  they  may  form  part  of  a 
general  dropsy. 

External  dropsies  are  illustrated  by  anasarca  and  (Edema : 
the  first,  a  universal  accumulation  of  serous  fluid  in  the  are- 
olar textures ;  the  second,  a  more  localized  collection  in  the 
same  structures,  and  differing,  therefore,  in  nothing  but 
extent.  Both,  as  ordinarily  met  with,  exhibit  painless  swell- 
ing of  the  surface,  devoid  of  redness ;  a  skin  often  stretched 
and  shining,  pitting  upon  pressure,  and  retaining  for  some 
time  the  mark  of  the  finger;  and  in  both,  the  tumid  part,  if 
punctured,  allows  a  watery  fluid  to  run  out.  CEdema  is 
most  commonly  perceived  around  the  ankles ;  the  tumefac- 
tion of  anasarca  is  found  generally  not  only  in  the  lower 
extremities,  but  also  in  the  arms  and  in  the  face. 
(674) 


DROPSY.  675 

Anasarca  is  usually  dependent  upon  disease  of  the  kidneys, 
or  of  the  heart;  hence  an  extensive  infiltration  of  the  areolar 
tissues  must  always  lead  us  to  examine  these  viscera  with 
care.  The  swelling  rarely  shows  itself  at  all  parts  of  the 
body  at  once:  it  ordinarily  begins  at  the  feet  and  ankles, 
and  extends,  more  or  less  rapidly,  upward  ;  but  it  may  com- 
mence in  the  face.  It  becomes  greatest  where  the  areolar 
tissue  is  loosest. 

GEdema  may  be  due  to  the  same  causes.  Yet  a  limited 
collection  of  fluid  is  very  often  the  consequence  of  a  purely 
local  trouble  unconnected  with  a  visceral  disease,  but  of  a 
character  interfering  with  the  venous  circulation.  Thus,  the 
compression  or  obliteration  of  a  large  vein  occasions  oedema 
below  the  point  of  the  disorder.  We  see  oedema  happen- 
ing if  a  bandage  be  applied  too  tightly,  or  if  swollen  glands 
press  upon  the  main  vein  of  a  limb.  We  also  meet  with  it 
in  the  adhesive  form  of  venous  inflammation,  and  in  milk- 
leg,  or  2>/i^e^mas?«  dolens — a  condition  observed  in  puerperal 
women,  or  as  a  sequel  of  typhoid  fever,  in  which  the  whole 
of  one  lower  extremity  becomes  edematous,  in  consequence 
of  inflammation,  or,  to  adopt  the  view  which  is  much  more 
probably  the  correct  one,  of  blocking  up  of  the  femoral  vein 
by  a  coagulum.  In  all  of  these  forms  the  oedema  is  one-sided  ; 
and  the  cause  being  external  to  the  thoracic  or  abdominal 
cavities,  there  is  usually  little  difficulty  in  its  recognition. 
A  circumscribed  oedema  also  accompanies  erysipelatous  in- 
flammations of  the  skin  or  subjacent  tissues;  so,  too,  do  we 
And  oedema  confined  to  a  limb  the  general  nutrition  of  which 
has  been  lowered  by  the  occurrence  of  paralysis. 

When  the  dropsical  effusion  is  dependent  upon  some 
tumor  seated  in  an  internal  cavity  and  interfering  with  the 
passage  of  the  blood,  it  may  possibly  be  very  local  and  one- 
sided ;  but  it  is  most  apt  to  be  found  on  both  sides  of  a  por- 
tion of  the  body,  altliough  more  particularly  marked  on  one 
side.  The  extremities  which  are  edematous  or  anasarcous 
exhibit  usually  also  a  marked  enlargement  of  the  veins. 

Another  source  of  a  double-sided  oedema  is  a  watery  con- 
dition of  the  blood.  This  form  of  dropsy  is  often  seen  in 
chlorotic  girls  without  there  being  any  disease  of  an  internal 


676  MEDICAL    DIAGNOSIS. 

organ.  Tlie  state  of  tlieir  blood  is  liiglily  favorable  to  the 
transudation  of  the  serum,  and  this  collects,  first  about  the 
ankles,  and  subsequently,  perhaps,  in  other  parts  of  the 
body.  The  absence  of  any  discoverable  organic  aflfection, 
the  pallid  countenance,  and  the  venous  murmurs  in  the 
neck  furnish  the  key  to  the  recognition  of  the  origin  of  the 
dropsy. 

A  dropsical  efi^usion  in  part  of  similar  origin,  but  much 
more  often  connected  with  internal  dropsy,  especially  with 
ascites,  is  the  dropsy  we  observe  in  those  broken  down  by 
malarial  poisoning.  The  state  of  the  liver  and  spleen  added 
to  the  condition  of  the  blood  determines  the  greater  extent 
of  the  efii'usion.  One  of  the  most  extraordinary  forms  of 
dropsy  connected  with  debility  and  altered  blood  is  furnished 
by  the  disease  known  as  beriberi  to  the  physicians  in  India, 
and  in  which  the  ansemia  culminates  in  acute  oedema  asso- 
ciated with  stiffness  of  the  limbs,  numbness,  extreme  pros- 
tration, anxiety,  and  dyspnoea.  General  anasarca,  too,  and, 
in  some  instances,  paralysis  of  the  extremities,  happen.* 

Dropsy,  according  to  its  Causation. 

Having  viewed  anasarca  and  oedema  as  in  the  main  un- 
combined  with  internal  dropsies,  and  as  forming  the  sole 
signs  of  the  dropsical  complaint,  let  us  now  look  at  them 
when  associated  with  effusions  of  serum  elsewhere.  The 
same  remarks  will  also  apply  to  hydrothorax  and  ascites,  the 
meaning  of  which,  when  occurring  alone,  we  have  inquired 
into  already,  but  which  we  shall  here  consider  in  their  rela- 
tions to  general  dropsy,  or  that  form  of  the  disorder  in  which 
anasarca  or  oedema  coexists  with  dropsy  of  one  or  several  of 
the  large  serous  cavities. 

And  first,  let  us  examine  into  the  causes  of  general  dropsy. 
The  most  common  are  a  disease  of  the  heart,  of  the  kid- 
neys, of  the  liver;  so  common,  in  truth,  that  in  every  case 
of  dropsy  we  must  examine  these  organs  carefully.    Accord- 


*  For  a  full  iiccouiit  of  this  curious  malady,  see  Aitken's  Pract.  of  Medic, 
vol.  ii. 


DROPSY.  677 

ing  as  the  dropsical  accumulation  originates  in  a  morbid  state 
of  these  viscera,  it  is  called  cardiac,  or  renal,  or  hepatic. 

Cardiac  dropsy  arises  in  consequence  of  the  deranged  or 
enfeebled  circulation,  produced  by  a  disease  of  the  walls  and 
cavities  of  the  heart,  associated  or  not  with  a  valvular  lesion. 
The  dropsy  begins  in  the  feet  and  ankles,  being  very  much 
influenced  by  position,  and  gradually  extends  upward  ;  but  it 
is  rarely  very  obvious  in  the  face  or  upper  extremities.  The 
thighs  and  scrotum  are  sometimes  greatly  swollen,  and  there 
is  a  watery  effusion  into  the  pleural  cavities  or  into  the  pul- 
monary parenchyma. 

JRenal  dropsy  is  usually  much  more  general  than  cardiac 
dropsy.  It  does  not,  like  this,  begin  in  the  most  dependent 
parts,  but  is  often  first  noticed  in  the  face  and  eyelids. 
There  is  hardly  a  space  in  the  body  where,  as  the  complaint 
progresses,  fluid  may  not  accumulate.  The  proof  that  the 
dropsy  is  renal  is  furnished  by  the  presence  of  albumen  in 
the  urine,  and  by  the  other  signs  of  a  diseased  kidney. 

Occasionally  the  dropsy  is  owing  to  an  affection  of  both 
the  kidney  and  the  heart;  when  the  question  may  occur, 
which  of  the  organs  was  primarily  disturbed  and  gave  rise 
originally  to  the  dropsy?  But  this  is  a  matter  we  cannot 
more  than  indicate,  since  it  would  otherwise  involve  the 
discussion  of  a  much-vexed  question  in  pathology,  namely, 
whether,  when  Bright's  disease  coexists  with  a  disease  of  the 
heart,  the  renal  affection  has  produced  the  cardiac  malady, 
or  the  cardiac  malady  the  renal  affection.  And  should  it  be 
of  importance,  in  an  individual  case,  to  determine  the  point 
alluded  to,  we  may  be  enabled  to  arrive  at  a  conclusion  by  a 
close  examination  of  the  history  of  the  case  :  did  the  patient 
suffer  from  palpitation  and  shortness  of  breath  prior  to  or 
coincident  with  the  anasarcous  condition,  and  has  he  ever 
had  rheumatic  fever;  or  did  he  have  an  attack  of  acute 
dropsy  before  the  persistent  swelling  of  the  feet  or  of  the 
face  occurred?  It  is  scarcely  necessary  to  add,  that  if  this 
have  happened,  there  is  a  very  strong  probability  of  the  renal 
disease  having  been  antecedent  to  the  cardiac  disorder. 

Hepatic  dropsy  may,  like  the  preceding  forms,  be  more  or 
less  general ;  but  it  is,  on  the  w'hole,  very  rarely  so,  unless 


678  MEDICAL   DIAGNOSIS. 

of  long  standing,  or  unless  there  be  coexisting  disease  of  the 
heart  or  kidneys.  The  most  usual  kind  of  dropsy  depending 
upon  an  atieetion  of  the  liver  is  abdominal  dropsy,  and  this 
is  so  well  understood  that  ascites  is  very  frequently  looked 
upon  as  constituting  a  proof  of  hepatic  disorder.  But  it  is 
a  mistake  so  to  regard  it ;  for  ascites,  as  we  found,  when 
examining  into  the  causes  of  abdominal  swelling,  may  also 
be  produced  by  peritoneal  tumors  or  inflammation,  by  en- 
largement of  the  spleen  or  pancreas,  or  by  the  pressure  of 
diseased  glands, — in  fact,  by  any  lesion  which  occasions  a 
decided  impediment  to  the  portal  circulation. 

Besides  these  sources  of  general  dropsy,  we  may  find  dete- 
rioration of  the  blood,  with,  perhaps,  a  simply  enfeebled  con- 
dition of  the  heart,  giving  rise  to  it.  But  such  a  state  is 
much  more  likely  to  occasion  cedema,  or,  in  some  instances, 
anasarca,  than  general  dropsical  efibsions;  and  it  is  thus  that 
while  the  former  phenomena  are  not  uncommon  in  exhaust- 
ing diseases  or  in  marked  impoverishment  of  the  blood,  the 
latter  are  rarely  met  with  unless  there  be  at  the  same  time 
some  cardiac  or  renal  complaint. 

Dropsy,  according  to  the  Eapidity  of  its  Development. 

Dropsy  may  come  on  suddenly,  or  be  gradually  developed. 
The  first  is  called  acute  or  active  dropsy;  the  second,  chro7iic 
dropsy.  To  the  latter  class  belong  the  majority  of  instances 
of  the  forms  of  dropsy  we  have  just  been  discussing,  in  which 
the  watery  accumulation  is  thought  to  arise  from  defective 
action  of  the  absorbent  vessels,  or  in  which,  in  other  words, 
the  dropsy  is  passive.  Acute  dropsy  has  active  symptoms 
much  like  those  of  an  inflammatory  fever.  The  eliusion 
takes  place  suddenly,  and  in  consequence  of  exposure  to  cold 
and  wet,  or  of  a  checked  perspiration.  In  the  vast  majority 
of  examples  it  is  accompanied  by  albumen  in  the  urine,  and 
is,  in  truth,  due  to  a  disturbance  of  the  kidneys.  Yet  there 
are  cases  of  acute  dropsy  which  are  not  of  renal  origin,  and 
in  which  the  rapid  occurrence  of  universal  anasarca  is  not 
susceptible  of  being  traced  directly  to  a  definite  lesion. 

The  prognosis  of  dropsy  depends  upon  the  cause  of  the 


DROPSY.  679 

efl'nsion.  The  least  daiigerons  variety  of  the  complaint  is 
that  happening  in  connection  with  changes  in  the  blood. 
The  acute  dropsies  are,  as  a  rule,  much  more  curable  than 
the  chronic  or  passive  forms  of  the  disorder;  but  their  prog- 
nosis is  very  much  influenced  by  the  extent  of  the  effusion 
and  the  seat  it  may  occupy.  An  accumulation  of  liquid  in 
most  of  the  serous  cavities  of  the  body  is,  of  course,  vastly 
more  perilous  than  one  which  occupies  only  the  loose  sub- 
cutaneous tissues.  Local  dropsies  are  influenced  by  treat- 
ment in  proportion  to  the  readiness  with  which  the  obstruc- 
tion producing  them  is  susceptible  of  being  removed. 

In  the  treatment  of  dropsy,  we  find  constantly  two  indica- 
tions recurring:  the  first,  to  remedy  the  cause  of  the  accumu- 
lation ;  the  second,  to  remove  the  latter  from  the  system. 
The  former  of  the  indications  is  the  most  direct  way  of 
getting  rid  of  the  watery  collection,  and  of  preventing  its 
return ;  but  it  is  not  always  possible  to  accomplish  the  ob- 
ject. For  example,  we  cannot  do  so  if  the  dropsy  be  caused 
by  an  incurable  organic  disease  of  the  heart,  liver,  or  kid- 
neys. The  second  of  these  indications  is  fulfilled  by  attempt- 
ing to  carry  oflT  the  water  by  the  skin,  by  the  intestines,  or 
by  the  kidneys,  selecting,  in  individual  instances,  the  chan- 
nel which  the  circumstances  of  the  case  indicate  as  being 
the  best  suited,  or  making  use  of  all,  if  there  be  nothing 
which  forbids  us  from  so  doing.  When  we  cannot  get  rid 
of  the  fluid  in  this  way,  we  may  let  it  out  by  an  operation — 
by  tapping  the  internal  cavities,  or,  as  in  anasarca,  by  punc- 
turing the  skin. 


CHAPTER   IX. 

DISEASES   OF    THE    BLOOD. 

In  the  following  sketch  I  shall  attempt  to  describe  only 
those  disorders  of  the  blood  which  constitute  the  essential 
or  principal  forms  of  blood  disease,  which  are  seemingl}^, 
for  the  most  part,  idiopathic,  and  may  be  recognized  by 
well-marked  clinical  traits.  Prominent  among  these,  and  to 
a  certain  extent  characteristic  of  all  blood  disorders,  are 
general  debility,  a  changed  aspect  of  the  mucous  mem- 
branes and  of  the  skin,  especially  in  color,  and  alterations 
of  nutrition. 

Anaemia. — This  is  the  name  given  by  Andral  to  poverty 
of  blood.  The  morbid  state  is  met  with  as  a  consequence  of 
profuse  or  frequently  recurring  hemorrhages,  of  insufficient 
nourishment,  of  affections  which  prevent  the  nutriment 
taken  from  being  properly  absorbed  or  assimilated,  thus  im- 
poverishing the  blood  by  depriving  it  of  its  most  needed 
constituents,  and  of  profuse  chronic  discharges,  which  drain 
the  blood  of  many  of  its  important  elements,  and  especially 
of  its  albumen.  Besides  these  causes  of  anaemia,  we  find  it 
occasioned  by  particular  poisons,  as  by  malaria,  or  by  the 
retention  of  noxious  ingredients  in  the  blood,  or  by  diseases 
of  certain  glands.  Again,  it  is  sometimes  encountered  with- 
out our  being  able  to  trace  it  to  any  obvious  source.  But 
under  all  these  circumstances,  we  have  to  deal  with  a  watery 
blood  deficient  in  red  corpuscles ;  in  other  words,  with  an 
anemic  condition. 

Now,  whatever  may  have  given  rise  to  the  anaemia,  the 
manifestations  of  the  disorder  are  much  the  same.  The 
patient  is  weak  and  pale;  his  lips  and  tongue  have  lost  their 
red  color  ;  his  pulse  is  feeble,  but  generally  accelerated;  the 
appetite  is  deficient  or  depraved;  the  bowels  are  apt  to  be 
(C80) 


DISEASES    OF    THE    BLOOD.  681 

costive.  Exercise  induces  great  fatigue,  shortness  of  breath, 
and  palpitations ;  and  the  disturbance  of  the  heart  may  be 
associated  with  cardiac  murmurs  or  witli  blowing  sounds  in 
the  cervical  veins,  and  is  sometimes  so  persistent  as  to  lead, 
as  will  be  found  elsewhere  described,  to  structural  changes 
in  the  heart.  In  some  cases,  further,  we  meet,  among  the 
symptoms  of  the  affection,  with  obstinate  headache  and 
dropsy,  and  in  very  many  with  a  persistent  pain  in  the  left 
side  in  the  region  of  the  spleen. 

Chlorosis. — As  a  marked  form  of  ansemia,  we  may  consider 
chlorosis.  Here  the  pallid,  waxlike  countenance,  the  very 
pale  lips,  and  the  pearly  eye  aftbrd  unmistakable  evidence  of 
the  deterioration  of  the  blood.  The  complaint  is  especially 
encountered  in  young  females,  and  is,  as  a  rule,  associated 
with  amenorrhoea.  Indeed,  many  restrict  the  term  to  the 
obvious  ansemia  combined  with  suppression  of  the  menses, 
so  often  affecting  girls  about  the  age  of  puberty. 

Addison's  Disease. — There  is  another  form  of  ansemia  which 
requires  to  be  specially  mentioned,  namely,  that  connected 
with  disease  of  the  supra-renal  capsules.  Dr.  Addison,  whose 
name  the  complaint  now  bears,  met  with  a  form  of  general 
ansemia  which  had  no  perceptible  cause  whatever;  in  which 
there  had  been  neither  loss  of  blood,  nor  mental  shock  or 
anxiety,  nor  exhausting  diarrhoea;  which  was  concomitant 
with  neither  malignant  nor  scrofulous  disease,  nor  with  any 
affection  of  the  spleen,  kidneys,  or  lymphatic  glands,  nor,  in 
fact,  with  any  lesion  that  the  most  careful  examination  could 
detect. 

While  seeking  for  the  explanation  of  these  puzzling  cases, 
he  discovered  that  the  peculiar  ansemia  always  occurs  in  con- 
nection with  a  diseased  condition  of  the  supra-renal  capsules, 
and  is  characterized  by  distressing  languor  and  very  great 
general  prostration,  remarkable  feebleness  of  the  heart's 
action,  irritability  of  the  stomach,  and  a  singular  alteration 
in  the  hue  of  the  skin.  This  consists  in  a  dingy  or  smoky 
appearance  of  the  surface;  or  the  color  may  be  of  a  deep 
amber  or  chestnut  brown,  or  the  altered  skin  has  a  bronzed 
tinge.  The  discoloration  may  occur  in  patches,  which  are 
usually  most  obvious  on  the  face  or  superior  extremities,  or 


682  MEDICAL   DIAGNOSIS. 

it  may  extend  over  the  whole  hodj.  The  patient  ma3^seem, 
at  first  sight,  to  be  jaundiced;  but  the  pearly  whiteness  of 
the  conjunctiva  soon  dispels  such  an  idea.  The  nails  are 
pale  and  bluish ;  the  body  and  breath  of  the  sick  person  at 
times  exhale  an  offensive  odor ;  and  the  blood  has  been  found 
to  contain  an  excess  of  white  globules. 

The  disorder  is  a  chronic  one,  generally  lasting  for  years; 
but  it  almost  invariably  destroys  life.  Yet  cases  have  been 
recorded  in  which  most  of  the  symptoms  of  Addison's  dis- 
ease were  present  and  which  nevertheless  recovered.  In 
these  cases,  the  diagnosis  is  not,  however,  beyond  doubt,  for 
we  now  know  well  that  several  of  the  most  striking  features 
of  the  malady  may  occur  without  disease  of  the  supra-renal 
capsules.  Thus,  the  discoloration  of  the  skin  may  happen 
in  other  affections,  as  in  pregnancies  attended  with  much 
constitutional  disturbance — as  occurred  for  instance  in  a  case 
that  I  recently  had  under  my  observation  ;  or  during  ex- 
hausting lactation  ;  and  again,  particularly  in  those  examples 
of  the  disorder  which  progress  rapidly,  the  bronzing  may 
be  absent.  As  regards  the  character  of  the  altered  color  of 
the  skin  when  present,  by  far  the  most  significant  change  is 
a  gradual  and  uniform  discoloration  approaching  to  the  hue 
of  skin  of  a  mulatto,  and  dependent  upon  a  layer  of  pigment 
in  the  rete  mucosum.  The  discoloration  in  patches  is  both 
less  constant  and  less  significant.  And  under  any  circum- 
stances, before  we  attach  full  weight  to  the  bronzed  look  of 
the  skin,  we  must  be  very  certain  that  it  is  not  the  eff*ect  of 
the  sun.  In  Addison's  disease  the  discoloration  is  most 
evident  on  the  face,  neck,  superior  extremities,  penis  and 
scrotum,  and  in  the  flexures  of  the  axillse  and  around  the 
umbilicus. 

With  reference  to  the  other  symptoms,  the  most  conclusive 
of  them  are  remarkable  prostration,  generally  without  any 
marked  waste  of  the  body,  feebleness  of  pulse  and  obvious 
anffiraia.  These  symptoms  precede  in  most,  but  far  from  in 
all  cases,  the  discoloration  of  the  skin ;  and  they  are  not  un- 
frequently  associated  with  pain  in  the  back  and  gastro-intes- 
tinal  irritation,  with  breathlessness  upon  exertion,  and  dim- 
ness of  siglit.     A  peculiar  odor  of  the  body,  like  that  per- 


DISEASES    OF    THE    BLOOD.  683 

ceived  in  the  colored  race,  was  observed  in  two  cases  placed 
on  record  by  Mr.  Hutchinson. 

Death  may  take  place  gradually  from  the  constantly  grow- 
ing asthenia;  or  it  nmy  occur  suddenly,  and  where  the 
amount  of  prostration  does  not  appear  so  excessive  as  to 
foreshadow  it.  The  post-mortem  examination  shows  gen- 
erally the  organs  totally  destroyed,  and,  if  we  may  adopt  the 
researches  of  the  observer  who,  next  to  Addison,  has  done 
most  to  elucidate  the  subject — Dr.  Wilks,  that  destruction 
is  dependent  upon  a  peculiar  scrofulous  degeneration.  Should 
this  prove  to  be  the  correct  view  of  the  case;  should,  in 
other  words,  the  nature  of  the  disease  of  the  capsules  influ- 
ence its  symptoms  more  than  the  mere  fact  of  their  being 
diseased,  it  would  explain  why  in  some  cases  of  absence  of 
the  gland,  or  of  its  cancerous  degeneration  or  suppuration,  no 
signs  of  Addison's  disease  existed.  Many  of  the  symptoms 
of  the  fully  developed  malady  may  be  due  to  the  implica- 
tion of  the  nervous  branches,  derived  from  the  sympathetic 
and  pneumogastric,  which  go  to  the  gland.  And  as  regards 
all  the  symptoms,  it  must,  in  a  diagnostic  point  of  view,  be 
borne  in  mind  that  it  is  their  combination  rather  than  the 
presence  of  any  one  which  gives  them  their  value,  and  that 
this  combination  consists  chiefl^^  in  the  association  of  a  pecu- 
liar discoloration  of  the  skin  with  a  pearly  eye,  well-marked 
anemia,  and  prostration,  and  without  the  existence  of  any 
other  disease  than  of  the  supra-renal  capsules  to  account  for 
the  train  of  abnormal  phenomena.* 

Leucocythsemia  or  Leukaemia. — This  morbid  state  con- 
sists in  a  decided    increase  of  the  white   corpuscles  and  a 
decrease  of  the  red.     Under  the  microscope,  which  furnishes  » 
indeed  the  surest  means  of  recognizing  the  disease,  the  white 
globules  of  the  blood,  instead  of  bearing  the  normal  propor- 


*  See  the  cases  collected  by  Addison,  in  his  work  on  Diseases  of  the  Supra- 
renal Capsules;  by  Wilks,  Guy's  Hospital  lieports,  vol.  viii.  and  vol.  xi.,  3d 
Series ;  by  Harley,  Brit,  and  Foreign  Medico-Chirurg.  Keview,  1858 ;  hy 
Laycock,  ib.  Jan.  1861 ;  by  Habershon,  Guy's  Hosp.  Kep  ,  3d  Series,  vol.  x.; 
by  Copland,  in  Dictionary  of  Pract.  Medicine;  by  Greenhow,  quoted  in 
Anier.  Journal  of  Med.  Sciences,  Oct.  1866  ;  and  the  very  complete  report  in 
the  Transact,  of  Path.  Society  of  London,  1866. 


684  MEDICAL    DIAGNOSIS. 

tiou  of  about  1  to  50  of  the  red,  are  found  in  the  proportion 
of  1  to  6,  or  even  of  1  to  2;  and  after  death,  grayish  coagula, 
consisting  almost  entirely  of  colorless  blood-cells,  are  met 
with  in  the  heart  or  large  veins. 

The  abnormal  condition  exists  in  connection  with  hyper- 
trophy of  the  spleen  or  of  the  liver,  with  other  diseases  of 
these  viscera,  and  with  various  malignant  or  non-malignant 
affections  of  the  lymphatic  glands  or  of  the  thyroid  body. 
But  none  of  the  blood  glands  is  as  constantly  and  as  mark- 
edly aflected  as  the  spleen. 

The  disorder  may  occur  at  all  ages,  and  in  both  sexes;  but 
it  is  more  common  in  men  than  in  women.  Besides  the  ob- 
vious pallor  and  cachectic  appearance,  it  often  occasions  diar- 
rhoea, hurried  breathing,  hemorrhages  from  various  parts, 
especially  from  the  nose,  fleeting  abdominal  pains,  and  dropsy 
attendant  upon  the  enlargement  of  the  spleen  or  liver,  which 
is  so  usually  present.*  In  some  cases  a  swelling  of  the 
glands  on  both  sides  of  the  throat,  attended  with  inflam- 
mation of  the  mucous  membrane  of  the  mouth  and  pharnyx, 
and  followed  by  swelling  of  the  axillary  and  inguinal  glands, 
precedes  the  enlargement  of  the  liver  and  spleen. f 

As  regards  the  symptoms,  the  closest  similarity  to  leukaemia 
is  presented  by  the  afl'ection  described  as  pseudo-leuksemia, 
or,  more  frequently,  as  Hodgkin's  disease.  It  consists  in  an 
enlargement  of  the  lymphatic  glands  of  the  body,  which 
soon  becomes  complicated  with  extreme  anseniia  and  signs 
of  cachexia,  with  dropsy,  with  attacks  of  suflbcation,  and 
leads  usually,  in  the  course  of  not  many  months,  to  death. 
A  few  superficial  lymphatics  are  first  aflected,  others  fol- 
low ;  the  disorder  then  extends  more  decidedly,  the  spleen 
and  the  liver  increase  in  size,  other  organs,  too,  may  become 
involved ;  but  the  spleen  is  the  one  most  constantl}^  dis- 
turbed. The  chief  anatomical  lesion  is  found  to  be  an 
augmented  formation  of  the  structure  of  the  glands.     But 

*  Compare  the  cases  of  Bennett,  in  his  woi'k  on  Lcucocyth.'cmia,  1852,  and 
of  Virchow,  in  his  collected  Essays  (Gesammelte  Abhandlungen),  etc. 

I  Hosier,  in  Virchow's  Archiv,  xliii.,  quoted  in  Amer.  Journal  of  Med. 
Sciences,  July,  1868. 


DISEASES    OF    THE    BLOOD.  685 

although  we  might  expect  decided  alteration  in  the  blood, 
the  distinguishing  mark  from  leukseniia  is  that  there  is  not 
an  increase  of  the  white  corpuscles.* 

PyaBmia. — Purulent  contamination  of  the  blood  is  an 
affection  much  more  apt  to  be  met  with  by  the  surgeon  than 
by  the  practitioner  of  medicine;  yet  it  is  one  sufficiently 
often  encountered  by  him  to  require  that  he  should  be  famil- 
iar with  its  symptoms.  These  are,  great  depression  of  the 
vital  powers,  profuse  sweats,  rapid  pulse,  and  the  formation 
of  purulent  deposits  in  different  portions  of  the  body.  The 
symptoms  may  be  of  gradual  development;  but  often  they 
set  in  suddenly  with  a  chill,  to  which  a  fever  of  low  type 
soon  succeeds  ;  or  the  shivering  is  followed  even  from  the 
first  by  copious  sweating,  and  the  febrile  phenomena  sub- 
sequently appear. 

The  pysemic  fever  rarely  lasts  longer  than  a  week,  and 
during  its  continuance  it  usually  presents  the  most  marked 
variations  in  temperature.  Yet  the  disease  is  not  always 
alike  in  this  respect ;  for  we  find,  asHeubner  has  proved,  not 
only  cases  in  which  the  most  decided  increase  of  animal 
heat  is  constantly  followed  by  an  equally  decided  decrease, 
but  also  cases  in  which  there  are  febrile  attacks,  followed 
by  striking  intervals,  during  which  the  temperature  is  almost 
normal ;  and  cases  in  which  continuous  fever  exists  with 
intercurrent  decided  rises  in  temperature. f  Still,  in  all  the 
maximum  of  the  temperature  is  apt  to  be  very  high,  ranging 
from  106°  to  108°. 

The  disorder  may  arise  after  injuries  and  operations;  or 
where  sinuses  or  abscesses  exist  that  have  no  free  vent  for 
the  pus  ;  or  in  consequence  of  the  contamination  of  the  blood 
which  happens  in  phlebitis  or  arteritis;  or  results  from  the 
breaking  down  of  coagula  which  have  formed  in  the  blood- 
vessels; or  it  may  supervene  upon  diffuse  cellular  inflam- 
mations, or  upon  puerperal  fever, — in  fact,  it  will  be  found 

*  See  the  cases  of  Hodgkin,  Med.-Chirurg.  Transact.,  vol.  xviii.;  of  Wilks, 
Guy's  Hosp.  Reports,  vol.  xi.,  3d  Series;  of  Black,  Amer.  Journ.  of  Med. 
Sciences,  April,  1866;  of  Wunderlich,  Archiv  der  Heilkunde,  186G ;  and  a 
review  by  Spillman,  Archiv.  Gene.,  1867,  vol.  ii. 

t  Archiv  der  Heilk.,  ix.,  1868. 


686  MEDICAL    DIAGNOSIS. 

under  many  dissimilar  circumstances.  But  without  stopping 
to  explain  its  varying  sources  of  origin,  let  us  look  at  its 
diagnostic  traits. 

Now,  there  are  several  complaints  with  which  pyaemia  is 
likely  to  be  confounded,  the  chief  of  which  are  typhoid  fever, 
rheumatism,  acute  glanders  and  farcy,  and  acute  affections 
of  the  liver. 

It  is  liable  to  be  mistaken  for  typhoid  fever,  on  account  of 
the  adynamic  character  of  the  fever,  and,  it  may  be,  the  oc- 
currence of  diarrhoea  and  of  cerebral  symptoms.  But  the 
history  of  the  case  is  very  dissimilar;  there  is  no  eruption, 
or  if  there  be  an  eruption,  it  consists,  as  Bristowe  so  particu- 
larly points  out,  of  sudamina  surrounded  by  a  zone  of  con- 
gestion, and  is  therefore  not  the  eruption  of  the  typh- 
fevers;  and,  on  the  other  hand,  we  lind  in  typhoid  fever 
neither  the  profuse  sweating  nor  secondary  deposits  of  pus, 
and  the  thermometry  of  the  disease  is  very  different.  TVe 
must  not  forget,  however,  that  pyaemia  may  happen  as  a 
complication  of  the  febrile  malady. 

The  pain  in  the  joints  and  their  swelling  in  succession, 
the  fever,  the  perspirations  resemble  very  much  at  times  the 
symptoms  of  rheumatic  fever.  But  the  difference  consists  in 
the  greater  severity  of  the  constitutional  phenomena  caused 
by  the  poisoned  blood,  in  the  tnarked  exhaustion,  in  the 
rigors,  and  in  the  history  not  being  that  of  rheumatic  fever. 
Moreover,  the  frequent  signs  of  formation  of  abscesses  in 
internal  organs  or  around  the  joints,  the  development  of 
pustules  on  the  skin,  and  the  striking  redness  of  the  tumid 
joints  assist  materially  in  the  diagnosis. 

Acute  glanders  or  acute  farcy  is  a  disease  scarcelj^  distin- 
guishable from  pyaemia,  since  it  occasions,  for  the  most  part, 
the  same  manifestations.  The  knowledge  that  the  patient 
who  has  apparently  pyaeraic  symptoms  has  been  working 
among  horses,  the  ulceration  of  the  mucous  membrane  of 
the  nose,  and  the  fetid  discharge  proceeding  from  it,  which 
occurs  in  acute  glanders,  and  which  is  apt  to  be  associated 
with  nasal  hemorrhages,  with  an  offensive  breath,  with  en- 
largement of  the   lymphatic  glands  in  the  vicinity  of  the 


DISEASES    OF   THE    BLOOD.  687 

affected  mucous  membrane,  and  with  hurried  breathinGr,  or 
sometimes  with  gangrene  of  vartous  parts, — afford  us  the 
only  means  of  discrimination.  Then  we  find  a  peculiar 
tuberculated  or  pustular  eruption  which  appears  upon  the 
skin,  and  in  farcy  the  lymphatic  glands  and  vessels  specially 
suffer.  But  more  significant  than  all,  in  point  of  diagnosis, 
is  being  able  to  trace  the  distinct  history  of  the  contagion ; 
for  the  grave  coryza  and  some  of  the  other  prominent  symp- 
toms mentioned  do  not  happen  in  all  forms  of  equinia,^-cer- 
tainly  not,  at  least  it  is  generally  so  stated,  in  farcy. 

Acute  affections  of  the  liver  resemble  pyaemia  on  account  of 
the  jaundice  which  may  attend  the  latter  disorder;  but  the 
history  of  the  case,  the  rigors,  the  sweats,  and  the  purulent 
deposits  distinguish  it. 

In  conclusion,  let  us  inquire  where  and  how  these  second- 
ary deposits  are  formed.  They  may  take  place  in  the  paren- 
chymatous organs,  particularly  in  the  lungs  and  liver;  in  the 
synovial  sacs,  in  muscles,  or  in  areolar  tissue,  especially  in 
that  under  the  skin.  To  account  for  their  formation  is  not 
easy ;  and  there  is  very  great  difference  of  opinion  among 
pathologists  concerning  this  point.  The  views  now  most 
generally  received  are,  that  they  are  owing  to  a  suppurative 
form  of  capillary  phlebitis,  or — and  this  is  becoming  more 
and  more  the  accredited  opinion — that  the  vitiated  blood  co- 
agulates either  in  the  veins,  heart,  or  arteries,  usually  in  the 
former,  and  that  the  clots,  becoming  disintegrated,  are 
washed  into  the  smaller  vessels  or  capillaries  of  individual 
tissues,  and  there  give  rise  to  inflammation  and  the  develop- 
ment of  pus. 

It  has  just  been  indicated  that  the  altered  blood  may  co- 
agulate in  the  arteries.  Now  when,  from  this  cause,  or  from 
disintegration  of  fibrin  in  the  arterial  system,  the  fibrinous 
masses  occasion  deposits  in  solid  organs,  as  in  the  liver  or 
spleen,  we  may  have,  with  the  similar  pathological  states, 
similar  symptoms  arising  to  those  of  true  pyaemia.  Indeed,  in 
the  arterial  iDyaemia^  as  it  has  been  called,  rigors,  febrile  symp- 
toms and  sweating,  and  pains  in  the  joints  are  observable. 
In  connection  with  the  obscure  febrile  condition,  the  liver 


688  MEDICAL    DIAGNOSIS. 

and  spleen  are  often  observed  to  increase  in  size  slowly.* 
The  heart  ma}'  or  may  not  be  affected. 

The  description  of  pysemia  given  represents  it  as  an  acute 
affection,  and  so  it  almost  always  is.  Yet  there  are  cases 
much  slower  in  their  course,  and  extending  over  months. 
These  chronic  or  relajpsivg  instances  of  the  disease  have  been 
described  by  Mr.  Paget,t  in  his  usual  concise  and  happy 
manner.  The  symptoms  presented  are  the  same  as  in  the 
acute  malady ;  but  the  local  evidences  of  the  complaint  are 
more  often  seated  in  different  parts  of  the  same  tissues,  and 
less  frequently  in  internal  organs.  The  malady  is  not  nearly 
so  perilous  a  one. 

Septaemia. — This  is  a  poisoned  state  of  the  blood,  pro- 
duced by  mineral  and  vegetable,  but  especially  by  animal 
poisons,  such  as  the  bite  of  venomous  serpents  or  the  ab- 
sorption of  putrid  matters  which  have  been  generated  in  the 
economy,  or  by  their  inoculation.  The  continued  exposure 
to  the  breathing  of  foul  air  and  of  septic  gases  will  also  occa- 
sion septsemia.  The  symptoms  of  the  blood  poisoning  vary 
somewhat  with  the  individual  poison  that  has  occasioned  it. 
They  are,  in  the  main,  the  symptoms  of  pyaemia, — which 
indeed  may  be  viewed  as  a  form  of  septsemia, — excepting 
that  secondary  pus  formations  belong  to  the  former  rather 
than  to  the  latter,  and  the  same  of  course  may  be  said  of 
embolism  and  its  results.  In  many  instances  the  altered 
condition  of  the  blood  leads  to  hemorrhages  from  internal 
organs,  to  petechia,  to  delirium  and  coma,  to  extreme  ra- 
j)idity  of  pulse,  to  burning  heat  of  skin,  to  enlargement  of 
the  spleen,  to  cough  and  bronchial  catarrh,  and  to  gastric 
and  intestinal  disorders. 

Thrombosis  and  Embolism. — While  discussing  endocar- 
ditis, the  phenomena  of  embolism  have  already  been  alluded 
to,  and  they  have  also  been  mentioned  in  connection  with 
several  other  subjects,  as  of  obstruction  of  the  cerebral 
arteries,  and  of  some  diseases  of  the  kidney.  Yet  it  may 
serve  a   useful   purpose  to  view  here  connectedly,  though 


*  Samuel  Wilks,  Guy's  Hospital  Eeports,  vol.  xv.,  3d  Series, 
f  St.  Bartholomew's  Hospital  Reports,  vol.  i. 


DISEASES    OF    THE    BLOOD.  689 

chiefly  in  their  diagnostic  bearing,  some  of  the  results  of  the 
formation  of  the  clots  in  large  vessels  or  in  the  heart,  and  of 
their  being  carried  along  with  the  current  of  the  blood  and 
driven  into  remote  vessels.  The  whole  of  the  process  of  the 
formation  of  the  clots  is  included  under  the  term  "  thrombo- 
sis," while  the  projection  onward  of  a  thrombus,  or  of  the  frag- 
ments detached  from  it  and  the  phenomena  thus  occasioned, 
are  designated  by  the  great  pathologist  to  whom  our  knowl- 
edge of  the  subject  is  chiefly  due — Virchow,  as  "embolia." 

The  subject  of  embolia,  or  embolism,  is  that  which  more 
particularly  concerns  the  physician  in  its  immediate  practical 
bearing;  but  though  thrombi  do  not  as  often  produce  symp- 
toms which  the  medical  practitioner  is  called  upon  to  be 
acquainted  with  from  a  bedside  point  of  view,  he  must  have 
closely  studied  their  cause  and  meaning  to  appreciate  those 
of  embolia. 

The  embolus  may  produce  manifestations  in  the  venous  sys- 
tem, either  in  the  peripheral  veins;  or  in  the  venous  trunks 
of  the  great  internal  cavities  of  the  body  ;  or  portions  of  the 
thrombus  may  have  been  washed  into  the  pulmonary  artery 
from  the  right  side  of  the  heart;  or  it  may  have  become  im- 
pacted in  the  arteries  of  the  general  circulation,  in  the  larger 
arteries,  or  in  those  of  fine  calibre;  or  it  may  have  been 
washed  into  the  very  structure  of  oi-gans  through  these  arte- 
ries, as  into  the  liver  structure  through  the  hepatic  artery, 
into  the  splenic  parenchyma  through  the  splenic  artery.  Let 
us  examine  some  of  the  symptoms  thus  occasioned  a  little 
more  closely,  premising  that  arterial  embolism  is  of  much 
more  frequent  occurrence  than  the  other  forms. 

In  the  veins  thrombi  may  form,  which,  so  long  as  they  do 
not  produce  an  obstruction  of  the  canal,  give  rise  to  no 
marked  signs.  A  slight  hardening  and  pain  on  pressure  if 
the  coagulum  be  in  the  more  superficial  veins,  their  enlarge- 
ment if  the  clot  be  in  the  deeper  veins,  are  apt  to  be  the 
only  evidences  of  the  disordered  condition.  But  when  the 
occlusion  is  considerable,  and  especially  when  the  collateral 
circulation  is  insufficient,  oedema  is  developed,  which  may 
be  attended  with  very  great  tenderness  of  the  swollen  part, 
and,  if  the  impediment  be  of  long  duration,  witii  chaj'.ges 

44 


690  MEDICAL   DIAGNOSIS. 

in  the  nutrition  of  the  structures  sufficient  to  produce  phleg- 
monous inflammation.  These  phenomena  are  all  encountered 
to  a  greater  or  less  degree  in  milk-leg  or  phlegmasia  alha 
dolens,  which  in  all  likelihood  depends  upon  an  obstruction 
by  a  coagulum  of  the  venous  circulation  in  the  aftected  limb. 
In  some  cases  profuse  hemorrhages  occur  as  a  consequence 
of  the  stoppage  in  the  vein — as  cerebral  hemorrhages  pro- 
duced by  thrombosis  of  the  sinus,  or,  as  in  a  case  referred  to 
by  Virchow,*  enormous  hemorrhagic  infiltration  of  the  sub- 
peritoneal and  subcutaneous  tissues,  as  well  as  of  portions 
of  the  muscles  of  the  abdominal  walls,  as  the  result  of  a 
coagulum  in  the  external  iliac  vein,  the  epigastric,  and  the 
crural  vein. 

Xow,  portions  of  the  clot,  situated  in  any  part  of  the  venous 
system,  whether  peripheral  or  not,  and  however  remote  from 
the  heart,  may  become,  by  being  broken  ofl'  and  driven  on- 
ward with  the  circulation,  sources  of  great  danger.  Thus,  in 
cases  of  milk-leg  they  may  be  propelled  from  the  veins  of  the 
extremity  to  the  heart ;  or  the  same  may  happen  when  a  clot 
has  formed  in  the  pelvic  veins,  subsequent  to  the  ligation 
of  internal  piles.  Again,  when  the  blood  clogs  in  veins  con- 
nected with  the  portal  system,  the  detached  fragments  may  be 
washed  into  the  liver,  and  these  lead  to  secondary  abscesses. 
This,  for  instance,  is  the  most  likely  causation  of  the  so-called 
metastatic  abscesses  of  the  liver  in  dysentery.  But  when 
coagula  occur  in  the  venous  system  and  are  wholl}-  or  in  part 
carried  away  with  the  circulating  blood  (if  we  exclude  those 
which,  from  their  situation,  could  only  reach  the  liver),  we 
generally  find  the  manifestations  of  disturbance  arising  in 
the  heart  or  lungs.  Arriving  at  the  right  side  of  the  heart, 
the  concretion,  if  at  all  large,  or  if  it  become  so  by  serving 
as  a  nucleus  for  a  larger  clot,  occasions  symptoms  of  exhaus- 
tion and  collapse ;  an  intermitting,  feeble  pulse ;  irregular 
and  confused  beating  of  the  heart,  and  cardiac  sounds,  enfee- 
bled or  lost  over  the  right  side  of  the  organ  ;  rapidly  developed 
distress  in  breathing,  referred,  by  the  suft'erer,  to  the  heart,t 


*  Pathologie  und  Therapie,  p.  172. 

t  B.  W.  Richardson,  Medical  Times  and  Gazette,  Nov.  1868. 


DISEASES    OF    THE    BLOOD.  691 

and  signs  of  asphyxia,  thougli  all  the  time  the  patient  is  tak- 
ing deep  inspirations  ;  great  agitation  ;  and  a  swollen  state  of 
the  veins  of  the  body.  Death  may  then  take  place  suddenly 
if  a  portion  of  the  clot  separate  and  obstruct  the  pulmonary 
artery.* 

But  the  mode  of  death,  and  the  symptoms  preceding  it  in 
embolism  of  the  imlmonary  artery^  are  not  always  the  same, 
and  depend  very  much  upon  the  size  of  the  embolus  and 
where  it  is  arrested.  A  large-sized  clot,  whether  it  be  merely 
part  of  one  occupying  the  right  heart,  or  be  washed  at  once 
into  the  pulmonary  artery,  will  occasion  much  the  same 
signs  as  those  alluded  to  as  indicative  of  a  larsj-e  clot  in 
the  right  side  of  the  heart;  the  craving  for  air  is  particularly 
intense,  and  this  craving  is  increased  by  every  movement  of 
the  body  ;  the  muscular  debility,  the  lowered  temperature, 
the  cyanosed  look,  the  turgid  veins  of  the  neck  and  their 
undulations,  the  increased,  irregular  cardiac  impulse,  though 
the  heart's  action  is  not  sufficiently  disturbed  to  account  for 
the  disturbed  respiration  and  disordered  general  circulation, 
are  also  noticed:  and  in  some  cases  a  systolic  blowing  sound, 
and  where  the  case  is  at  all  protracted,  vertigo,  albuminuria, 
and  cedema  of  the  limbs  may  be  observable.  The  intellect  is 
always  apt  to  remain  clear.  As  regards  the  pulmonary  phe- 
nomena proper,  collapse  of  the  lung,  hemorrhagic  effusions, 
cedema,  or  capillary  bronchitis  are  likely  to  happen,  except- 
ing in  those  instances  in  which  the  principal  trunks  of  the 
pulmonary  artery  are  blocked  up,  and  almost  instantaneous 
asphyxia  ensues.  If  the  fragments  be  very  small,  the  amount 
of  dyspnoea  is  not  of  necessity  great,  nor  are  the  symptoms  of 
asphyxia  marked ;  and  inflammations  of  the  parenchyma  of 
the  lungs  may  take  place,  occasioning  often  secondary  ob- 
structions and  metastatic  abscesses  in  the  lungs,  from  which 
recovery  even  may  possibly  take  place.  These  kind  of  me- 
tastatic abscesses  are  observed  in  pytemia,  and  are  not  un- 
usual in  puerperal  fever. 

Blood  clots  in  the  arteries  as  a  consequence  chiefly  of  gan- 
grene and  of  ulceration.     The  vessels  for  instance  passing 


*  As  in  a  case  recorded  by  Druit,  Med.  Times  and  Gaz.,  July,  1862. 


692  MEDICAL    DIAGNOSIS. 

from  a  gangrenous  part  contain  coagula  forming  in  a  direc- 
tion from  the  periphery  to  the  centre.  We  may  find  the 
clots  in  gangrene  of  internal  organs,  as  of  the  pulmonary 
tissue.  Again,  atheromatous  disease  of  the  coats  of  the 
arteries  may  lead  to  the  development  of  thrombi.  But  the 
most  important  phenomena  connected  with  obstruction  of 
arteries  are  those  not  of  coagula  forming  in  them,  as  of  their 
being  washed  into  them  ;  the  phenamena  of  embolism  there- 
fore rather  than  those  of  thrombosis.  Now,  the  phenomena 
of  embolism  are  distinguished  from  those  of  the  mere  forma- 
tion of  clots  by  what  is  always  the  most  significant  sign  of 
either  arterial  or  venous  embolism — the  suddeimess  of  the 
manifestation  of  the  abnormal  state.  And  in  point  of  fact 
the  symptoms  arise  not  so  much  as  the  result  of  any  of  the 
conditions  alluded  to  that  occasion  coagulation,  but  very 
much  more  often  as  the  consequence  of  deposits,  fibrinous 
concretions,  and  excrescences  which  are  seated  on  the  valves 
on  the  left  side  of  the  heart,  and  portions  of  which  are  car- 
ried away  by  the  circulating  blood  into  remote  parts.  When 
these  bodies  become  impacted  in  a  vessel  the  calibre  of 
which  is  such  that  it  does  not  permit  them  to  pass  on,  we 
find  rapid  changes  taking  place  in  the  portions  of  the  body 
supplied  by  the  obstructed  artery;  coldness,  pallor  of  the 
parts,  a  diminished  functional  activity,  a  shrinking;  and  if, 
as  often  does  happen,  the  first  obstruction  is  followed  by 
others,  and  the  collateral  circulation  cannot  be  established, 
local  death  and  gangrene  ensue. 

All  these  changes  are  of  course  only  discernible  in  ex- 
ternal parts,  especially  in  the  extremities ;  the  disturbances 
of  function  are  the  most,  or  indeed  are  the  only,  obvious  signs 
where  the  internal  organs  are  the  sufi'erers.  If  the  emboli 
be  driven  to  the  brain,  we  have,  as  has  been  alreadv  else- 

7  7  V 

where  alluded  to,  softening  as  the  result,  and  this  may  be 
preceded  by  disorder  of  intellect,  without  motor  disturb- 
ances, and  by  severe  attacks  of  vertigo,  in  cases  in  which 
merely  the  smaller  arteries  supplying  the  surface  of  the  cere- 
bral hemispheres  are  obstructed.  liut  where,  as  is  indeed 
the  most  common  seat  of  emboli,  the  arteries  of  the  fissure 
of  Sylvius  are  clogged,  the  phenomena  are  those  of  apoplec- 


DISEASES    OF    THE    BLOOD.  693 

tic  hemiplegia;  and  the  palsy  affects  the  whole  of  one  side 
of  the  body,  even  the  face,  and,  though  u.shered  in  by  only 
very  passing  or  imperfect  unconsciousness,  is  apt  to  be  perma- 
nent. The  brain  may  also  suffer  from  the  seat  of  the  obstruc- 
tion being  in  the  carotids;  and  indeed  of  all  organs  the  effects 
of  embolism  are  most  plainly  perceptible  in  the  brain.  The 
presence  of  emboli  in  the  splenic,  renal,  and  mesenteric 
arteries  is  generally  rather  to  be  inferred  from  the  historj'-  of 
the  case,  and  does  not  occasion  any  obvious  discernible  s^gns. 
But  tenderness,  enlargement  of  the  spleen,  and  pain  in  the 
splenic  region  in  splenic  embolism,  or  disordered  secretion 
of  urine  and  pain  in  the  loins  in  embolism  of  the  renal 
artery,  may  be  very  marked. 

The  occurrence  of  pain  in  these  cases  of  internal  embolism 
must  not  be  overlooked;  and  in  embolism  of  the  arteries  of 
the  extremities  pain  is  a  sj-mptom  of  as  great  or  still  greater 
prominence.  It  may  be  like  a  violent  neuralgia,  or  so  con- 
stant that  it  is  mistaken  for  rheumatism  ;  and,  as  happened  in 
a  case  of  embolism  of  the  right  iliac  artery,  under  the  charge 
of  Dr.  Hutchinson,*  and  which  I  saw,  it  may  recur  in  par- 
oxysms of  intense  severity,  and  be  referred  to  the  foot,  though 
this  be  already  in  a  condition  of  sphacelus.  Besides  the 
pain,  we  are  apt  to  tind  extreme  hyperesthesia  in  some  parts 
of  the  affected  limb;  and  pricking  sensations,  formication, 
and  loss  of  tactile  sense,  followed  by  complete  anaesthesia  in 
others.  Then  painful  spasms  of  the  muscles,  and  a  more  or 
less  perfect  paralysis  of  motion  may  occur.  If  we  join  to 
these  symptoms  an  absence  of  pulsation  in  the  arteries  below 
the  seclusion  until  the  collateral  circulation  is  decidedly  es- 
tablished, a  strong  beat  of  the  vessel  on  the  cardiac  side  of 
the  obstruction,  the  coldness  of  the  limb  below  this  obstruc- 
tion, and  the  signs  of  defective  supply  of  blood,  we  have  a 
group  of  phenomena  which,  taken  in  connection  Avith  the 
history  of  the  case,  render  the  diagnosis  a  positive  one.  And 
in  reviewing  the  history  of  the  case,  the  state  of  the  heart  and 
the  cardiac  symptoms  must  be  always  carefully  examined 


*  Published  Proceed,  of  Path.  Society  of  Phila.,  Am.  Journ.  of  Med.  Sci- 
ences, Oct.  1863. 


694  MEDICAL    DIAGNOSIS. 

into.  It  is  there  in  truth  where  the  mischief  generally  be- 
gins; and  a  close  inquiry  may  show  that  the  sudden  mani- 
festations of  arterial  obstruction  were  preceded  by  an  attack 
of  palpitation  and  irregular  action.  A  change  in  the  physi- 
cal signs  of  the  diseased  organ,  as  of  its  murmurs,  may  not 
be  evident;  but  should  it  be  evident,  it  is  a  sign  of  the  utmost 
moment.  Indeed  any  change  in  what  may  be  viewed  as  the 
centre  from  which  the  embolus  may  be  detached,  is  of  great 
significance.  And  this  holds  good  quite  as  much  for  venous 
as  for  arterial  emboli.  Thus,  in  a  case  of  coagulum  in  a 
vein,  a  sudden  disappearing  of  swelling  and  oedema  of  the 
affected  limb,  with  the  supervention  of  signs  of  embarrassed 
circulation  and  respiration,  would  at  once  tell  what  had  taken 
place. 

In  regard  also  to  the  diagnosis  of  embolism  we  must  always 
bear  in  mind  the  causes  which  are  likely  to  give  rise  to  it. 
Several  of  the  causes  of  arterial  embolism  have  already  been 
mentioned;  those  of  venous  embolism  are  the  same  as  of 
venous  thrombosis,  or,  to  speak  more  explicitly,  the  break- 
ing up  of  the  clots  and  their  transportation  may  occur  in  any 
of  the  conditions  which  have  occasioned  them.  Now,  these 
conditions,  too,  will  produce  arterial  clots,  and  indeed  some 
are  more  apt  to  lead  to  coagulation  in  the  arteries  than  in 
the  veins.  Prominent  among  them  are  a  narrowing  of  the 
calibre  of  the  vessel,  as  by  pressure  ;  dilatation  of  the  vessels 
and  of  the  heart;  failure  or  great  diminution  of  cardiac 
power,  with  consequent  retardation  of  the  blood  stream — a 
state  which  is  more  likely  to  occasion  venous  than  arterial 
thrombosis;  a  breakage  in  the  continuity  of  the  vessel,  as 
when  it  is  torn  or  cut;  changes  which  take  place  in  the  coats 
of  the  vessels,  especially  inflammatory  changes ;  and  contact 
of  the  blood  within  the  vessels  with  foreign  bodies.  Then  it 
is  very  likely  that  special  states  of  the  blood,  by  altering  the 
cohesion  of  the  globules,  predispose  to,  if  they  do  not  abso- 
lutely cause,  the  clotting,  which,  if  one  of  the  other  elements 
alluded  to  then  favor,  is  readily  accomplished. 

Another  cause  of  embolism  is  that  due  to  accumulations  of 
pigment  in  the  blood,  the  result  of  malarial  fever.  The  pig- 
ment may  obstruct  the  capillaries  in  the  brain  and  thus  occa- 


DISEASES    OF    THE    BLOOP.  695 

sion  capillary  apoplexies;  or  be  driven  to  the  liver  and  there 
produce  signs  of  disturbance  of  its  circulation,  and  abscesses. 
As  in  all  forms  of  capillary  embolia,  the  symptoms  are  very 
obscure :  the  suddenness  of  their  development,  generally  so 
characteristic  of  the  other  forms  of  embolism,  is  wanting;  and 
the  diagnosis,  as  throughout  in  capillary  embolia,  is  always 
nothing  more  than  a  matter  of  conjecture,  based  on  a  close 
study  of  the  general  phenomena  and  history  of  the  case. 

In  conclusion,  the  subsequent  changes  of  the  thrombus 
must  be  alluded  to.  It  may  organize  and  be  converted  into 
connective  tissue  and  yield  an  impaired  passage  to  the 
blood;  and  perhaps  the  collateral  circulation  be  freely  estab- 
lished; or,  what  is  not  so  favorable  a  result,  it  may  soften 
and  undergo  fatty  metamorphosis.  But  even  when  large 
portions  are  not  detached  and  occasion  the  marked  symp- 
toms of  embolism,  small  ones  may  be  wafted  into  capillaries 
and  there  lay  the  foundation  of  abscesses.  It  is  thus  that  in 
a  case  of  thrombus  or  embolus  we  may  have  the  secondary 
results  of  pyaemia  to  deal  with — metastatic  abscesses  caused 
in  the  manner  described,  and  attended  with  a  blood  pro- 
foundly altered  and  vitiated  by  the  decomposing  products 
circulating  in  it.  It  is  almost  needless  to  add  that  under 
such  unfavorable  circumstances  the  therapeutic  means  at 
our  command  in  the  treatment  of  embolism  too  generally 
prove  wholly  nugatory. 

Scurvy. — This  disease  is  not  often  met  with  in  civil  prac- 
tice; but  it  is  one  very  familiar  to  the  military  and  naval 
surgeon.  It  consists  in  a  deterioration  of  the  blood,  produced 
by  living  for  a  long  period  upon  the  same  kind  of  food,  and 
especially  upon  salted  meats,  without  the  requisite  supply  of 
fresh  vegetables  being  taken.  Indeed,  the  privation  of  the 
latter  for  a  length  of  time  is  by  far  the  most  constant  and 
most  potent  cause  of  scurvy  ;  so  constant  and  potent,  in  fact, 
that  it  is  by  many  regarded  as  the  sole  determining  source  of 
the  disease.  JSTow,  this  influence  of  vegetables  is  attributed 
to  the  large  quantit}^  of  potassa  they  contain ;  and  as  it  has 
been  found  that  there  is  a  deficiency  of  the  salts  of  potassa 
in  scorbutic  blood,  it  was  concluded  that  this  deficiency  is 
the  cause  of  scurvy,  and  has  only  to  be  remedied  in  order  to 


696  MEDICAL    DIAGNOSIS. 

cure  the  scorbutic  taint.  But  this  theory  has  not  been  so 
positively  proved  that  it  may  be  definitely  adopted.  Another 
cause  of  scurvy  is  the  want  of  proper  assimilation  of  food, 
as  lias  been  noticed  in  prison  scurvy.* 

Scurvy  is  usually  slow  in  its  development.  The  patient 
becomes  low  spirited,  easily  fatigued,  is  loth  to  exert  him- 
self, and  complains  much  of  general  debility.  The  appetite 
is  impaired;  there  is  a  craving  for  acids  and  for  vegetable 
food;  the  tongue  is  large  and  flabby;  the  breath  fetid ;  the 
pulse  feeble;  the  skin  dry.  The  bowels  are  usually  consti- 
pated ;  but  a  tendency  to  diarrhoea  may  exist,  and  indeed  is 
apt  to  occur  as  the  disease  advances.  ISTeuralgic  pains,  re- 
ferred to  any  part  of  the  bod}^  but  chieflj^  to  the  lower  ex- 
tremities, to  the  bones,  and  to  the  back  or  thorax,  are  com- 
mon. The  face  is  pale,  or  has  a  yellowish  tinge;  the  eyes 
are  surrounded  by  a  dark  ring.  During  the  progress  of  the 
ailment,  or  in  severe  cases  almost  from  the  onset,  we  find 
swollen,  spongy  gums,  which  bleed  on  the  slightest  touch ; 
hurried  breathing;  a  rapid  pulse;  weakened  eyesight,  some- 
times night-blindness;  epistaxis;  painful  swelling  and  hard- 
ness about  the  joints  of  the  extremities  and  in  the  calves 
of  the  legs;  and  purple  spots  and  bruiselike  stains  on  the 
skin.  Should  the  malady  remain  unchecked,  the  symptoms 
described  heighten  in  severit}',  ulcers  form  which  have  a 
fungoid  look  and  a  great  tendenc}-  to  bleed,  hemorrhages  take 
place  from  internal  organs,  old  sores  and  wounds  reopen, 
well-knit  fractures  become  disunited,  there  is  a  constant 
tendency  to  swoon,  and  the  patient  perishes  miserably  ex- 
hausted, and  with  his  blood  in  a  complete  state  of  dissolution. 
In  some  cases  death  takes  place  from  diarrhcea  or  dropsy, 
which  may  be  suddenly  developed.  Even  under  the  most 
favorable  circumstances,  recovery  from  scurv}'  is  slow. 

Purpura. — Scurvy  is  not  a  disease  difficult  to  recognize  ; 
only  one  aiiection  resembles  it  at  all  closel}^,  and  that  is  jpur- 
pura.  In  this  disorder  also  red  or  purple  spots  or  livid 
blotches,  uninfluenced  by  pressure,  and  passive  hemorrhages 
from  the    mucous  membranes  happen.     But   there  is  this 

*  See  Med.  Memoirs  of  the  U.  S.  Sanitary  Commission,  p.  278. 


DISEASES    OF    THE    BLOOD.  697 

difi'erence  between  the  two  complaints :  purpura  is  common 
in  fruit  seasons,  and  often  attacks  persons  who  have  not  been 
in  any  way  deprived  of  vegetable  food.  The  gums  are  not 
soft  and  spongy,  as  in  scurvy,  nor  do  we  find  the  same  weak- 
ness of  mind  and  body.  Then,  the  stain  of  the  skin  in  pur- 
pura is  apt  to  be  more  generally  diffused,  and  the  purple 
blotches  are  smaller,  or,  at  all  events,  the  large  patches  of 
discoloration  consist  clearly  of  an  aggregation  of  very  many 
small  spots.  Moreover,  although,  like  scurvy,  the  disorder 
may  be  benefited  by  iron,  by  bark,  and  the  mineral  acids,  it 
is  not  controlled,  like  scurvy,  by  fresh  vegetables,  by  lemon- 
juice, — in  fact,  by  agents  which  are  most  decided  antiscor- 
butics. 

From  a  clinical  point  of  view  we  find  several  forms  of  pur- 
pura. In  the  mildest,  the  purpurous  spots  are  apt  only  to 
appear  on  the  legs.  They  come  in  crops,  which  fade,  and 
there  are  no  constitutional  symptoms  excepting  a  little  lassi- 
tude, and  perhaps  aching  of  the  limbs  and  pain  in  the  back.  In 
the  graver  cases,  "purpura  haemorrhagica,"  we  find,  in  addi- 
tion to  the  cutaneous  hemorrhage,  epistaxis,  hgematemcsis, 
hfematuria,  or  other  internal  hemorrhages,  and  extravasations 
of  blood  may  happen  into  the  substance  of  the  muscles.  The 
amount  of  pain  attending  the  malady  is  very  different.  There 
may  be  none,  or  it  may  be  trifling;  or  deep-seated  pains  in 
the  cavities  of  the  body,  or  extended  neuralgic  pains  may 
accompany  the  purpurous  complaint.  In  some  instances  the 
pains  are  chiefly  felt  in  and  around  the  joints,  and  the  appar- 
ently rheumatic  aches  subside  in  a  few  days,  and  spots  of  ex- 
travasated  blood  become  visible.  This  "  purpura  rheumatica," 
a  variety  particuarly  described  by  Schonlein,  is  usually  met 
with  in  the  strong  and  healthy.  It  is,  indeed,  one  of  the 
peculiarities  of  any  kind  of  purpura,  that  it  may  come  on  in 
the  midst  of  seemingly  excellent  health.  This  is  a  matter  to 
be  borne  in  mind;  for  while  it  is  true  that  the  disorder  may 
be  preceded  for  some  time  by  sigjis  of  general  debility,  or 
occur  in  the  course  of  disease  of  the  liver,  of  Bright's  disease? 
or  as  a  sequel  to  the  exanthemata  and  rheumatic  fever,  it  also 
happens  where,  from  previous  looks,  we  should  least  expect 
it.     Its  production,  as  the  result  of  a  sudden  shock  to  the 


698  MEDICAL    PIAGNOSIS. 

nervous  system,  such  as  fright,  and  its  occasional  intermittent 
character,  have  been  noticed  by  various  observers. 

The  duration  of  the  malady  is  very  variable, — only  a  week 
or  several  months  may  elapse  before  the  spots  disappear.  Its 
pathology  is  unknown.  It  is  clearly,  however,  not  merely  a 
disease  of  the  blood;  the  capillaries  lose  their  retentiveness, 
either,  as  has  been  actually  demonstrated,  in  consequence  of 
degenerative  change,  or  as  the  result  of  impaired  power,  from 
the  morbid  action  afiecting  directly  or  indirectly  the  part  of 
the  nervous  system  that  controls  them  —  the  vaso-motor 
system. 

In  some  cases  purpura  presents  an  acute  form.  It  is  ushered 
in  by  a  chill,  and  by  intense  pains  in  the  back  and  limbs,  but 
is  generally  unattended  with  fever  or  severe  constitutional 
disturbance.  The  purple  spots  usually  first  appear  on  the 
legs,  and  are  wholly  uninfluenced  by  pressure.  They  last 
five  or  six  daj-s,  or  somewhat  longer,  then  gradually  change 
their  color  and  fade.  The  patient  feels  languid,  but  unless 
from  loss  of  blood  his  strength  is  not  materially  impaired. 
The  effusion  of  blood  happens  in  some  cases  into  the  loose 
connective  tissues  of  the  body,  or  blood  is  lost  from  the 
lungs,  and  still  more  frequently  from  the  bowels  or  urinary 
organs.  Under  these  circumstances  the  pulse,  which  other- 
wise is  apt  to  preserve  its  normal  frequency,  becomes  very 
rapid;  but  until  exhaustion  begins  to  tell  on  the  nervous 
system  —  not  as  a  rule  long  before  dissolution — the  mind 
remains  clear,  and  cerebral  or  spinal  symptoms  are  absent. 
It  is  thus  that  we  are  able  to  distinguish  severe  cases  of  acute 
purpura,  which  may  indeed  prove  fatal  in  forty-eight  hours,* 
from  spotted  fever. 


*  As  in  a  remarkable  case  reported  hj  Dr.  Harrison  Allen,  Proc.  of  Path. 
Soc.  of  Phila.,  Am.  Journ.  Med.  Sci  ,  Jan.  1865. 


CHAPTER  X. 

RHEUMATISM    AND    GOUT. 

Rheumatism  and  Gout  are  afi'ections  having  a  strong  tend- 
ency to  change  their  seat,  and  are  dependent  upon  the  pres- 
ence in  the  blood  of  some  poisonous  material  which  probably 
accumulates  there  in  consequence  of  malassimilation.  The 
poison  which  is  supposed  to  occasion  the  most  frequent  of 
these  disorders — rheumatism — is  lactic  acid;  and  it  is  during 
an  effort  at  its  elimination  that  the  phenomena  of  rheumatism, 
or  at  least  the  phenomena  of  acute  rheumatism,  are  best 
studied. 

The  rheumatic  poison  has  a  singular  predilection  for  the 
fibrous,  serous,  and  muscular  textures.  Hence  we  find  it 
attacking  principally  such  structures  as  the  joints,  the  fasciae, 
the  endocardium  and  pericardium,  and  the  muscles  in  various 
parts  of  the  body.  According  to  its  main  forms,  it  is  some- 
times divided  into  articular  and  muscular;  but  the  more 
usual  division  into  acute  and  chronic  is  simpler,  and  will 
answer  our  purpose  best. 

Acute  Rheumatism. — Here  the  rheumatic  poison  gives 
rise  to  the  symptoms  of  an  acute,  active  disease,  and  attacks 
especially  the  larger  joints.  These  swell,  become  hot,  red, 
tense,  tender,  and  the  seat  of  pain  aggravated  by  the  slightest 
movement;  an  effusion  also  takes  place  into  the  surrounding 
structures,  or  into  them  and  the  synovial  membranes  of  the 
joint  itself.  The  rheumatic  inflammation  may  either  remain 
confined  to  the  joints  first  affected  until  the  disease  is  over, 
or,  what  is  more  common,  it  shifts  from  joint  to  joint,  impli- 
cating most  of  the  large  ones  in  succession,  yet  often  invading 
fresh  joints  before  the  swelling  has  subsided  in  the  parts  first 
attacked.     The  articular  disorder  is  ushered  in  and  accom- 

(699) 


700  MEDICAL    DIAGNOSIS. 

panied  bv  high  fever,  soon  attended  with  a  full,  boundins; 
pulse,  with  profuse,  sour  perspirations,  with  a  deeply-coated 
tongue,  a  scanty,  turbid,  highly  acid  urine,  and  a  counte- 
nance singularly  expressive  of  suffering. 

Now,  there  is  ordinarily  little  difficulty  in  recognizing  the 
complaint.  The  pains  in  the  joints,  their  tumefaction  and 
tenderness,  the  shifting  character  of  the  disorder,  and  tbe 
peculiar  constitutional  symptoms  form  a  group  of  phenomena 
eminently  characteristic.  Then  the  absence  of  the  s^'mp- 
toms  so  usualin  continued  fevers,  such  as  dulness  of  intel- 
lect or  delirium,  gastric  and  intestinal  disturbance,  and 
sordes  on  the  teeth  and  gums,  enables  us  at  once  to  separate 
the  rheumatic  disorder  from  these  febrile  states,  and  renders 
its  distinction  still  easier.  In  truth,  excluding  acute  gout, 
tbe  only  affections  at  all  likely  to  be  confounded  with  acute 
articular  rheumatism  are  pyaemia  and  glanders,  acute  sjmo- 
vitis,  and  milk-leg.  The  diagnosis  of  the  former  has  already 
been  discussed  in  connection  with  diseases  of  the  blood;  it 
only  remains,  therefore,  to  point  out  the  marks  of  similitude 
and  contrast  between  acute  articular  rheumatism  and  the 
other  maladies  just  mentioned. 

Acute  synovitis  resulting  from  an  injury,  or  from  cold,  occa- 
sions, like  articular  rheumatism,  pain  and  heat  in  the  joint, 
with  distention.  But  the  disorder,  excepting,  perhaps,  if  it 
happen  in  a  rheumatic  constitution,  does  not  affect  more  than 
one  joint;  and  as  there  is  scarcely  any  or  no  effusion  into  the 
surrounding  tissues,  the  outline  of  the  joint  can  be  distinctly 
discerned,  and  fluctuation  is  very  readily  detected.  Often, 
too,  the  accumulation  of  fluid  reaches  an  extent  f;ir  greater 
than  in  rbeumatic  inflammation ;  moreover,  the  febrile  and 
constitutional  derangement  is  not  so  severe  as  in  acute  rheu- 
matism, and  the  affection  has  no  tendency  to  change  its  seat. 
Still,  we  must  not  forget  tbat  acute  synovitis  maybe  rheu- 
matic* 

3Hlk-leg,  or  phlegmasia  dolens,  occurs  most  usually  in 
women  after  delivery,  or  as  a  sequel  of  continued  fevers. 
Generally  only  one  leg  swells,  and  this  becomes  throughout, 

*  See  Adams,  Med.  Times  and  Gazette,  Feb.  1869. 


RHEUMATISM    AND    GOUT.  701 

or  sometimes  only  around  the  calf,  preternaturally  white, 
firm,  hot,  and  shining.  The  tumefaction  is  uniform,  and 
very  painful,  especially  so  when  touched.  It  does  not  pit,  or 
pits  but  very  slightly,  upon  pressure,  unless  at  the  lower  part. 
There  is  in  some  cases  tenderness  with  a  sense  of  hardness  in 
the  course  of  the  femoral  vein,  though  this  is  by  no  means, 
constant;  and  we  are  apt  to  find  signs  of  much  debility  and 
of  altered  blood  and  febrile  symptoms.  But  these  are  uidike 
the  peculiar  constitutional  disturbance  of  rheumatism,  and 
equally  dissimilar  are  the  history  of  the  case  and  the  local 
signs.  Among  these,  two  giving  rise  to  striking  difl:erences 
may  be  mentioned:  the  almost  entire  loss  of  power  in  the 
affected  limb  in  phlegmasia  albadolens,  and  the  much  higher 
temperature  it  shows  by  the  thermometer  than  the  other 
members.  And  while  alluding  to  its  heat,  we  may  remark 
that  an  increase  of  general  temperature  corresponds  to  an 
increase  of  pain  and  swelling  in  the  limb,  and  of  constitu- 
tional distress.* 

Rheumatism  may  be  modified  in  its  manifestations  by  hap- 
pening in  connection  with,  or  consequent  upon  other  dis- 
orders. For  instance,  the  febrile  phenomena  may  be  of  an 
adynamic  type  when  the  disease  occurs  consecutively  to 
typhoid  or  typhus  fever;  or  we  may  find  the  local  signs  of 
acute  rheumatism  strangely  mixed  with  the  symptoms  of 
puerperal  fever,  and  in  some  of  these  cases  pus  may  fill  the 
tumid  joints ;  or  the  presence  of  the  syphilitic  poison  or  of 
gonorrhoea  may  imprint  peculiar  features  upon  the  rheumatic 
complaint.  Thus,  in  the  latter  instance  there  is  usually  less 
febrile  distress,  the  articular  pain  is  not  so  severe  nor  acute ; 
the  integument  covering  the  aftected  joint  is  apt  to  retain  its 
normal  color ;  there  may  be  but  one  joint — and  there  are  not 
generally  many — implicated;  the  intiammation  is  confined 
to  the  synovial  membrane;  the  joint  aftection  resembles 
rather  an  acute  or  subacute  rheumatoid  artln'itis  than  acute 
rheumatism;  and  the  eye,  too,  unlike  what  happens  in 
ordinary  acute  rheumatic  fever,  is  often  attacked.     But  the 


*  See  case  at  the  Pennsylvania  Hospital,  described  in  vol.  ii.  of  its  Reports, 
bv  Dr.  Elliott  Richardson. 


702  MEDICAL    DIAGNOSIS. 

most  significant  of  all  signs  is  finding  a  running  from  the 
urethra,  which  diminishes  when  the  gonorrhceal  rheumatism 
sets  in,  but  which  does  not  cease. 

The  traits  of  an  attack  of  acute  rheumatism  are,  however, 
still  more  frequently  altered  by  certain  complications  in  in- 
ternal organs  which  the  contaminated  blood  is  apt  to  occa- 
sion. Prominent  among  them  are  the  cardiac  troubles,  which 
are  in  tact  so  common  that  they  may  be  looked  upon  as  form- 
ing part  of  the  rheumatic  manifestation  rather  than  as  being 
one  of  its  complications.  The  affection  of  the  membranes  of 
the  heart  disturbs  the  pulse  and  renders  it  irregular,  hurries 
the  breathing,  and,  unless  carefully  managed,  is  very  prone 
to  leave  some  lasting  mischief.  It  is,  as  a  rule,  not  difficult  of 
diagnosis;  but  this  is  a  matter  we  have  investigated  already, 
while  examining  the  signs  of  endocarditis  and  pericarditis. 

Other  complications  are  inflammation  of  the  lung,  particu- 
larly of  the  bronchial  tubes  and  of  the  pleura,  or  cerebro- 
spinal disturbances,  exhibiting  themselves  by  headache,  vio- 
lent delirium,  convulsions,  and  coma,  and  occurring  either  in 
connection  with  a  thoracic  disorder,  or  solely  in  consequence 
of  the  action  of  the  vitiated  blood  on  the  nervous  centres, 
or  again,  as  has  been  recently  suggested,  in  consequence  of 
multiple  capillary  embolism,  or  the  sudden  exhaustion  of  the 
nervous  centres.*  This  explanation  has  been  more  particu- 
larly applied  to  the  cases  in  which  an  excessive  temperature 
attends  the  rapidly-developed  signs  of  cerebral  disturbance, 
a  temperature  of  107°  or  more.  But  speaking  from  a  bed- 
side point  of  view,  we  must  remember  that  such  cases  are 
comparatively  rare,  and  that  rheumatic  delirium  is  far  from 
always  of  the  same  nature.  It  may  be  of  the  kind  just 
mentioned.  It  may  develop  itself  with  or  without  the  signs 
of  cardiac  trouble.  It  may  come  on  early  in  the  disorder 
during  the  violence  of  the  fever;  or  late,  and  clearly  from 
debility  and  impoverished  blood,  yielding  to  nourishment 
and  stimulants.  It  is  very  rarely  the  result  of  meningitis. 
When  this  happens,  the  swelling  of  the  joints  usually  lessens  ; 
the  delirium  is  marked  by  great  talkativeness,  or,  on  the 


*  Weber,  Clinical  Society's  Transactions  of  London,  vol.  i. 


KHEUMATISM    AND    GOUT.  708 

other  hand,  the  patient  is  extremely  taciturn.     Headache  is 
rarely,  and  vomiting  is  not  at  all  among  the  symptoms. 

In  a  few  instances  of  rheumatism  we  find  arteritis  arisins'. 
and  especially  inflammation  of  the  fibrous  structures  of  the 
aorta.  This  condition  may  be  suspected  should  we  observe 
intense  general  uneasiness  and  distress,  with  pain,  increased 
pulsation,  a  distinct  murmur  in  the  course  of  the  vessel,  and 
tumultuous  action  of  the  heart  without  there  beina:  obvious 
signs  of  disease  of  that  organ  present.  Still,  the  diagnosis  is 
never  a  positive  one. 

Acute  rheumatism  is  not  a  disease  either  of  children  or  of 
persons  advanced  in  years.  Its  duration  is  very  variable.  By 
judicious  treatment  it  may  be  conquered  in  about  two  weeks ; 
but  often  convalescence  does  not  set  in  for  three,  four,  or  five 
weeks.  It  rarely  ends  fatally;  its  cardiac  consequences  are 
more  to  be  feared  than  the  acute  attack. 

Cases  occur  not  unfrequently  in  which  the  inflammation 
in  the  joints  is  somewhat  lingering,  and  in  which  the  febrile 
symptoms  are  not  intense.  These  cases  form  an  intermediate 
grade  between  acute  and  chronic  rheumatism,  and  are  gen- 
erally spoken  of  as  subacute.  The  disorder  is  more  apt  than 
the  acute  variety  to  afi:ect  the  muscles  as  well  as  the  joints ; 
nay,  the  former  may  be  alone  attacked.  It  may  be  witnessed 
in  the  joints  of  one  extremity,  or  in  one  joint,  and  might  then 
be  mistaken  for  synovitis.  But  the  dissimilar  history  of  the 
complaint  will  guard  against  error :  no  accident  has  happened 
to  account  for  the  swelling  of  the  joint,  and  often  the  patient 
will  tell  us  that  he  has  had  previously  an  attack  of  rheuma- 
tism. This  subacute  form  of  rheumatism  is  very  apt  to  be 
confounded  with  rheumatic  arthritis;  we  shall  presently  refer 
to  their  distinction. 

Chronic  Rheumatism. — This  may  be  either  a  sequel  of 
the  acute  disease,  or  the  disorder  from  the  onset  assumes  a 
lingering  form,  the  constitutional  symptoms  being  very 
slight.  The  affection  may  show  itself  in  the  joints,  giving 
rise  to  stiffness,  a  dull  aching,  and  pain  produced  by  motion, 
but  without  heat  or  very  obvious  swelling,  tenderness,  febrile 
excitement,  or  marked  sweating;  or  it  may  implicate  the 
muscles  in  various  parts  of  the  body,  occasioning  stiftiiess,  as 


704  MEDICAL    DIAGNOSIS. 

well  as  pain  when  tliej  are  moved;  or  it  attacks  both  joints 
and  muscles;  or  is  seated  chiefly  in  the  sheaths  of  nerves, 
leading  to  what  is  called  neuralgic  rheumatism,  of  which,  for 
instance,  sciatica  often  affords  a  striking  example.  In  any 
case,  the  occurrence  of  the  pain  furnishes  the  starting-point 
in  diagnosis,  and  we  must  ascertain,  by  careful  examination, 
whether  it  be  augmented  by  motion,  whether  it  be  more  or 
less  shifting,  whether  it  be  not  combined  with  stiffness  either 
of  the  muscles  or  joints,  whether  it  be  influenced  by  changes 
of  temperature,  whether  it  be  not  neuralgic,  or  associated 
with  a  disturbance  of  some  viscus,  such  as  of  the  liver  or 
kidneys, — before  we  conclude  that  the  complaint  is  really 
rheumatic. 

This  is  especially  necessary  in  the  most  common  form  of 
chronic  rheumatism — muscular  rheumatism.  All  kinds  of  pains 
in  the  muscles  or  their  surroundings,  the  cause  of  which  is 
not  at  once  apparent,  are  apt  to  be  pronounced  rheumatic. 
And  indeed  it  is  not  always  easy  to  say  whether  they  are  or 
are  not  of  that  character.  We  may  distinguish  them  from 
the  anguish  of  neuralgia  by  the  pain  in  the  latter  complaint 
being  ordinarily  confined  to  the  distribution  of  one  nerve, 
and  not  being  increased  by  movement  or  by  pressure  ;  nor  is 
it  so  stead}^,  or  attended  with  soreness,  excepting  over  a  few 
spots  at  some  distance  from  each  other  in  the  course  of  the 
aflected  nerve.  As  regards  the  pains  caused  by  organic 
structural  disease,  we  can  generally  discriminate  them  from 
those  of  rheumatism  by  close  attention  to  the  history  of  the 
case,  and  by  a  careful  exploration  of  the  internal  organs. 
Thus,  for  instance,  we  shall  find  pain  radiating  from  the 
right  hypochondrium  to  the  shoulder  to  be  dependent  upon 
hepatic  disease;  or  pain  shooting  down  to  the  groin,  thigh, 
and  testicle,  to  be  caused  by  a  disturbance  of  the  kidney ;  or 
a  bearing  down  and  an  aching  near  the  sacrum,  to  be  probably 
due  to  uterine  disorder. 

Muscular  rheumatism  may  affect  the  neck,  the  scalp,  the 
muscles  of  the  face,  and  the  parietes  of  the  chest  or  of  the 
abdomen.  It  may  be  not  only  chronic  in  any  of  these  situa- 
tions, but  also  acute;  or,  what  is  more  frequent,  when  it 
occurs  with  fever  and  is  transient,  it  is  a  sudden  acute  ex- 


RHEUMATISM    AND    GOUT.  705 

acerbatiou  in  persons  who  are  rheumatic  and  suffer  more 
or  less  persistently  from  rheumatism,  though  perhaps  in  a 
different  part  of  the  body,  from  the  one  in  which  the  acute 
affection  has  happened. 

One  of  the  most  common  seats  of  muscular  rheumatism 
is  in  the  loins.  It  then  constitutes  the  disease  known  as 
lumbago.  The  patient  is  unable  to  stand  erect,  and  finds  it 
nearly  impossible  to  stoop  forward,  on  account  of  the  severe 
pain  occasioned  when  the  muscles  of  the  back  are  called  into 
action.  Unless  the  attack  be  very  severe  or  acute,  there  is 
no  constitutional  disturbance ;  but  the  disorder  is  very  often 
obstinate.  It  is  easy  of  recognition.  We  distinguish  it  from 
pain  in  the  loins  due  to  disease  of  the  kidneys,  chiefly  hy  an 
examination  of  the  urine,  and  by  the  different  way  in  which 
movement  affects  the  rheumatic  pain ;  from  lumbo-abdom- 
inal  neuralgia,  by  the  two  or  three  sore  spots  in  the  course  of 
the  affected  nerve ;  from  rheumatism  of  the  vertebral  articu- 
lations, by  the  absence  of  tenderness  and  swelling  around 
the  spinous  processes;  from  lumbar  abscess,  by  the  want  of 
a  local  bulging  or  fulness,  of  fluctuation,  and  of  fever.  Then, 
we  must  be  careful  not  to  consider  as  lumbago  the  pain  in 
the  back  caused  by  disease  of  the  spine,  or  disorder  of  the 
uterus,  or  by  the  passage  of  abnormal  urinary  constituents, 
such  as  oxalate  of  lime,  or  consequent  upon  strains,  or  blows, 
or  scurvy,  or  malaria,  or  antemia,  or  a  general  or  local  mus- 
cular debility. 

Thus  there  are  many  causes  of  pain  in  the  loins,  and  where 
the  case  is  of  any  duration  or  of  any  doubt,  we  must  not 
rest  satisfied  until  we  have  excluded  these  causes  from  con- 
sideration before  we  assume  the  disease  to  be  really  rheuma- 
tism of  the  muscles  and  fascise  of  the  back.  This  caution  is 
very  necessary  in  investigating  the  cases  of  "weak  back,"  so 
prevalent  among  soldiers,  and  which,  though  commonly 
spoken  of  as  rheumatic,  are  really,  for  the  most  part,  due  to 
strains  or  injuries  which  have,  perhaps,  produced  a  weakness 
of  the  muscle  and  a  persistent  cutaneous  hypersesthesia;  or 
to  an  impoverished  blood,  to  neuralgia,  to  scurvy;  or  to 
digestive  disorders  attended  with  the  passage  from  the  kid- 
neys of  large  amounts  of  urates  or  oxalate  of  lime, 

45 


706  MEDICAL   DIAGNOSIS. 

The  remarks  made  with  reference  to  this  form  of  muscular 
rheumatism,  and  the  states  which  simulate  it,  are  also  appli- 
cable to  pains  apparently  muscular,  aftecting  other  portions 
of  the  body.  We  may  have  pain  and  soreness  of  the  muscles 
developed  by  overwork  and  attended  both  with  muscular  and 
cutaneous  hypersesthesia, — a  condition  very  different  from 
rheumatism,  and  designated  by  Dr.  Inman*  as  "  myalgia." 
This  soreness  of  the  muscles  is  thought  by  him  to  be  always 
in  direct  proportion  to  the  debility  of  the  muscular  system, 
and  is  chiefly  caused  by  long-continued  exertion  beyond  the 
power  of  the  muscle,  or  by  a  very  ordinary  amount  of  action 
when  the  muscle  itself  or  the  individual  is  extremel}^  debili- 
tated. The  morbid  state  is  most  marked  during  the  con- 
valescence from  scarlet  fever,  where  it  may  be  looked  upon 
as  due  to  overexertion  of  the  weakened  muscles.  The  sore- 
ness of  the  muscle  is  almost  constantly  accompanied  by 
heightened  sensibility  of  the  skin  over  it;  and  this  coexist- 
ing cutaneous  tenderness  may  be  in  any  case  regarded  as  a 
very  important  diagnostic  sign. 

Another  form  of  muscular  rheumatism  which  we  may  here 
allude  to  is  the  wry-neck,  or  torticollis.  This  depends  chiefly 
upon  contraction  of  the  steruo-cleido-mastoid  muscle  of  one 
side,  and  occasions  the  ungainly  appearance  with  which  most 
persons  are  familiar.  But  we  must  be  careful  not  to  consider 
every  case  as  of  rheumatic  origin.  The  disorder  may  be  spastic, 
or  depend  upon  nervous  injury,  and  when  chronic  may  lead 
to  alteration  in  the  muscular  structure.  Injections  of  atropia, 
hypodermically,  may  generally  be  used,  not  only  for  their 
good  therapeutic  eti'ect,  but  because,  in  chronic  cases  even, 
they  may  show  us,  by  the  difficulty  or  impossibility  of  relax- 
ing it,  how  much  of  the  muscle  is  really  changed. 

A  form  of  chronic  rheumatism  which  also  may  be  briefly 
mentioned  is  that  aftecting  chiefl}-  the  fibrous  membranes, 
such  as  the  periosteum.  This  becomes  thick,  and  tender  on 
pressure;  its  thickening  may  even  be  very  perceptible,  to  the 
touch  as  well  as  to  the  eye.  This  kind  of  rheumatism  hap- 
pens in  those  who  have  syphilis  ;  but  it  also  occurs  where  no 


*  Spinal  Irritation  explained,  or  a  treatise  on  Myalgia. 


RHEUMATISM    AND    GOUT.  707 

such  taint  exists.  The  pains  are  generally  much  more  severe 
at  night;  and  this  is  sometimes  assumed  to  be  a  proof  of 
the  syphilitic  character  of  the  disease.  But  incorrectly  so; 
for  many  varieties  of  chronic  rheumatism  are  aggravated 
by  the  warmth  of  the  bed.  Indeed,  the  only  really  diag- 
nostic signs  of  syphilitic  rheumatism  are  the  obvious  evi- 
dences of  constitutional  syphilis,  or  the  history  of  the  infec- 
tion. Still  to  cases  in  which  several  nodes  exist,  and  in 
which  the  pains  more  particularly  affect  the  long  and  flat 
bones,  and  in  which  iodide  of  potassium  speedily  modifies 
them,  we  shall  be  rarel}'  wrong  to  attribute  a  syphilitic 
origin. 

Chronic  rheumatism  is  often  feigned,  especially  by  malin- 
gerers in  the  army  and  navy,  and  the  deception  may  be  very 
difficult  of  detection.  They  pretend  to  be  scarcely  able  to 
walk,  or  hobble  around  with  a  cane,  and  complain  much  of 
the  pain  and  stiffness  in  their  joints.  Yet  there  is  not  the 
least  sign  of  deformity  or  real  stiffness;  the  pain  is  always 
stated  to  be  the  same;  and  their  general  health  is  excellent. 
Their  way  of  using  the  stick,  too,  is  characteristic :  they 
move  it  each  time  they  move  the  seemingly  crippled  leg, 
but,  as  a  rule,  not  immediately,  thus  not  employing  it  as  a 
support.  Anesthetics  are  of  great  value  in  enabling  us  to 
decide  as  to  the  real  amount  of  immovability  of  the  limb. 

Gout. — This  disease,  so  closely  allied  to  rheumatism,  may 
be,  like  the  latter,  either  acute  or  chronic.  Instead  of  de- 
scribing its  phenomena,  I  shall  at  once  point  out  the  marks 
of  difference  between  the  two  maladies.  In  gout,  the  small 
joints  are  chiefly  or  alone  affected;  in  rheumatism,  the  large. 
The  gouty  inflammation  is  accompanied  by  more  local  pain 
and  redness  than  the  rheumatic,  and  by  oedema,  by  enlarge- 
ment of  the  veins,  and  desquamation  of  the  cuticle,  and  im- 
plicates, at  least  at  first,  only  one  or  a  few  joints,  especially 
the  joint  of  the  great  toe;  while  rheumatism  attacks  the 
joints  of  the  upper  as  well  as  of  the  lower  extremities.  In 
gout  there  is  a  tendency  to  disease  of  the  kidneys,  but  we 
meet  with  no  cardiac  complication,  as  so  constantly  happens 
in  rheumatism,  with  a  moderate  febrile  disturbance,  and  no 
profuse  sweats.     Gout  is  much  more  decidedly  hereditary 


708  MEDICAL    DIAGNOSIS. 

than  rheumatism  ;  its  early  attacks  are  apt  to  recur  with  a 
certain  amount  of  periodicity,  and  last  about  a  week — there- 
fore a  much  shorter  time  than  those  of  rheumatic  fever. 

Gout  occurs  generally  in  those  who  live  high  or  drink 
large  quantities  of  malt  liquor,  and  especially  in  men  about 
middle  age;  while  rheumatism  is  usually  seen  in  the  weak, 
is  excited  by  cold  and  damp,  is  as  common  in  females  as  in 
males,  and  is  oftener  found  in  the  young  and  before  middle 
age.  Gout  is  frequently  combined  with  a  deposition  of 
chalk-stones  in  the  joints;  rheumatism  never.  Then,  if  we 
accept  the  observations  of  Dr.  Garrod*  as  conclusive,  we 
possess  an  absolute  means  of  diagnosis  in  the  examination 
of  the  blood.  Uric  acid  is  always  present  in  large  excess  in 
gout,  and  absent  in  rheumatism.  This,  should  further  re- 
searches prove  it  to  be  an  invariable  rule,  will  be  a  positive 
and  invaluable  diagnostic  test,  and  will  render  easy  of  dis- 
crimination even  those  cases  which,  with  the  usually  em- 
ployed means  now  at  our  command,  are  very  perplexing  to 
distinguish.  Nor  is  the  method  of  detecting  the  uric  acid 
difficult,  if  we  make  use  of  Dr.  Garrod's  ingenious  plan.  It 
consists  in  obtaining  the  crystals  of  uric  acid  on  a  thread 
placed  in  a  mixture  of  the  serum  of  the  blood  or  of  the 
fluid  from  a  blister,  with  acetic  acid,  in  the  proportion  of  six 
minims  of  the  acid  to  each  fluid  drachm  of  the  serum. 

Nearly  all  the  remarks  just  made  apply  more  especially  to 
the  distinction  between  acute  gout  and  acute  rheumatism. 
The  chronic  disorders  are  more  difficult  to  separate.  In- 
deed, unless  there  be  external  deposits  or  chalk-stones,  their 
discrimination  may  be  impossible.  In  these  obscure  cases, 
however,  the  history  and  an  examination  of  the  blood  may 
throw  considerable  light  on  the  diagnosis.  In  many  sub- 
jects, too,  Dr.  Garrod  informs  us,  the  exploration  of  the  ex- 
ternal ear  will  assist  us  in  arriving  at  a  correct  diagnosis:  we 
find  one  or  several  spots  of  deposit  of  urate  of  soda  on  the 
helix. 

Gouty  persons  are  subject  to  indigestion,  flatulency,  pains 
and  cramps,  or  palpitation  of  the  heart, — phenomena  which 


*  Gout  and  Ehcumatic  Gout,  2d  edit.     London,  1863. 


RHEUMATISM    AND    GOUT.  709 

are  due  to  the  gouty  poison,  and  which  are  general!}^  ameli- 
orated by  a  fit  of  gout.  Sometimes  the  gouty  inflammation 
of  the  joints  retrocedes  during  an  attack,  and  severe  epigas- 
tric pain,  nausea,  vomiting,  flatulence  and  acidity,  faintness 
and  a  feeling  of  sinking,  and  a  quick,  feeble  pulse,  show  that 
the  morbid  action  is  transferred  to  the  stomach ;  or  it  flies  to 
the  head,  and  apoplexy  or  maniacal  symptoms  occur ;  or  to 
the  heart,  and  there  is  violent  palpitation,  Avith  difllculty  of 
breathing,  and  intense  anxiety. 

Rheumatic  Arthritis  or  Rheumatic  Gout.— The  painful 
malady  last  discussed  is,  fortunately,  comparatively  rare  in 
this  country.  But  the  same  cannot  be  said  of  that  distress- 
ing disorder  known  as  rheumatic  gout,  and  which  is  generally 
viewed  as  a  blending  of  the  two  diseases,  though  there  are 
many  who  believe  that  it  is  neither  rheumatism  nor  gout, 
but  a  distinct  aftection.  The  disorder  may  be  acute  or 
chronic.  It  is  not  very  often  the  former;  many  of  the  acute 
cases  indeed  being  rather  subacute  than  acute.  Even  in 
those  belonging  to  the  amte  form  there  is  comparatively  little 
febrile  disturbance ;  and  though  we  observe  pain  and  aching 
iu  the  joints  and  some  discoloration,  we  find  less  redness  than 
in  acute  rheumatism,  and  certainly  the  tongue  less  furred, 
the  pulse  not  so  bounding,  much  less  profuse  perspiration,  no 
such  heavy  deposits  in  the  urine,  and  an  utter  freedom  from 
cardiac  complication.  The  acute  arthritic  disease  has  rather 
inflammation  of  the  pleura  and  of  the  eye  as  its  attendants,  and 
is  often  accompanied  by  a  sallow  skin,  yellowish  conjunctiva, 
and  discolored,  costive  stools.  It  implicates  the  large  and  small 
joints  equally,  thus  differing  from  gout,  and  causes  very  great 
swelling,  due  to  an  effusion,  not  around  the  joint,  but  into  its 
capsule.  It  fastens  upon  several  joints,  and  though  it  may 
pass  from  joint  to  joint,  it  shows  but  little  migratory  tend- 
ency; the  joints  first  attacked  remain  the  seat  of  disease. 
Unlike  gout,  it  is  apt  to  affect  the  smaller  joints  of  the  hands 
without  a  previous  affection  of  the  toes,  and  exhibits  no 
periodic  paroxysms  or  exacerbations.  Moreover,  an  acute 
attack  is  of  very  much  longer  duration.  Unlike  subacute 
rheumatism,  it  does  not  affect  the  muscles,  and  is,  both  in 


710  MEDICAL    DIAGNOSIS. 

the  suft'ering  at  the  time  and  in  its  ultimate  results,  a  very 
much  graver  malady. 

The  irrcat  danjrer  in  rheumatic  arthritis  is  from  the  effects  of 
the  inflammation  on  the  joints.  The  changes  there  produced 
are  very  ohvious  in  the  chronic  form,  for  each  joint  attacked 
is  apt  to  be  permanently  damaged.  The  chronic  complaint 
may  follow  the  acute,  or  it  may  commence,  without  any  feb- 
rile symptoms,  with  pain  and  stiffness  in  the  joints.  These 
soon  become  much  distended  with  fluid,  which  is  gradually 
absorbed,  and  the  structure  of  the  joint  alters,  the  cartilages 
become,  sooner  or  later,  implicated,  and  gradually  waste, 
and  there  are  often  chronic  changes  and  permanent  de- 
formity produced,  as  Dr.  Adams*  has  so  well  described. 
The  alterations  may  go  on  getting  worse  and  worse  in  con- 
sequence of  repeated  attacks,  until  complete  immobility 
ensues,  and  the  joints  becoming  permanently  affected,  the 
ends  of  the  bones  are  dislocated  and  enlarged.  But  although 
there  is  much  swelling  of  the  joints,  no  deposits  of  urate  of 
soda  are  found  in  them. 

Rheumatic  arthritis  is  more  common  in  females  than  in 
males  ;  may  be,  like  rheumatism,  excited  by  cold  and  damp, 
and  is  very  apt  to  occur  in  the  weak  and  unhealthy.  It 
often,  even  in  cases  that  recover,  persists  for  months.  Nor 
will  it  yield  to  the  remedies  usually  administered  in  acute 
rheumatism;  nor  to  colchicum  and  the  alkalies,  so  beneficial 
in  gout.  Guaiacum,  cod-liver  oil,  arsenic,  quinine,  and  other 
tonics  are  much  more  serviceable  agents ;  and  often,  too,  we 
may  use  in  addition,  with  advantage,  the  medicine  so  val- 
uable in  most  of  the  forms  of  chronic  rheumatism — the  iodide 
of  potassium. 


*  Treatise   on  Rheumatic   Gout,   or   Chronic    Kheumatic   Arthritis,  etc. 
London,  1857. 


CHAPTER  XI. 


FEVERS. 


The  lassitude,  the  heat  of  skin,  the  excited  cirenlation, 
and  the  altered  secretions — in  one  word,  the  group  of  morbid 
actions  recognized  as  fever,  is  often  consequent  upon  some 
strictly  local  malady.  But  here  the  fever  is  a  symptom,  and 
does  not  constitute  the  only  obvious  affection  present.  It  is 
onlv  in  the  latter  case  that  the  disorder  merits  the  name  of 
essential  fever.  The  first  step,  therefore,  Avhen  fever  has 
been  recognized,  is  to  determine  whether  it  is  symptomatic  or 
idiopathic;  whether,  in  other  words,  it  is  but  a  complement 
to  a  disease,  or,  so  far  as  can  be  ascertained,  the  disease  itself. 
This  is  not  generally  a  difficult  matter.  The  history  of  the 
case,  the  absence  or  presence  of  the  marked  peculiarities  of 
serious  local  disturbances  soon  determine  the  scale  of  evi- 
dence to  rise  on  the  one  side  or  sink  on  the  other.  And  it  is 
astonishing,  with  the  progress  of  medicine,  how  many  affec- 
tions have  been  passed  over  from  the  domain  of  fevers  to  the 
narrower  circle  of  inflammation  of  individual  organs;  how 
many  a  case  of  gastric  fever,  for  instance,  turns  out  to  be 
subacute  inflammation  of  the  stomach ;  and  with  what  a  dif- 
ferent eye  the  brain  and  lung  fevers  of  the  olden  times  are 
regarded.  While  thus  the  group  of  idiopathic  fevers  has 
been  considerably  winnowed,  some  of  their  broad  traits  have 
been  very  prominently  brought  forward.  It  is  now  well  un- 
derstood that,  with  few  exceptions,  they  are  characterized  by 
the  want  of  definite  and  invariable  anatomical  lesions.  That 
in  all  constant  changes  occur  in  parts  of  the  nervous  system, 
or  in  the  blood,  is  highly  probable;  but  these  changes  are 
not  of  a  nature  to  be  recognized  by  our  present  means  of 
research.  Certainly  there  is  no  invariable  injury  perceptible 
in  the  organs  of  the  body :  sometimes  one,  sometimes  an- 


712  MEDICAL    DIAGNOSIS. 

other  suffers;  sometimes  nearly  all;  at  times,  none.  When 
we  contrast  this  with  symptomatic  fever,  the  difference  is 
striking. 

The  visceral  lesions,  then,  of  an  idiopathic  fever  are  not 
the  starting-point  of  the  fever;  but  rather  secondary  and 
uncertain  complications  influenced  by  and  subordinate  to  the 
profound  disturbance  of  the  whole  system.  In  idiopathic 
fever,  the  fever  controls  the  lesions ;  in  symptomatic  fever, 
the  lesions  control  the  fever. 

Most  fevers  run  a  definite  course,  showing  a  strong  tend- 
ency to  a  spontaneous  termination  at  a  given  time.  At  their 
commencement,  too,  they  are  for  the  most  part  very  similar. 
There  is  a  prodromic  state,  marked  generally  by  unsound 
sleep,  pain  in  the  back,  and  lassitude.  This  is  followed  by 
chills,  which  are  succeeded  by  heat  of  skin,  arrested  secre- 
tions, quick  pulse,  and  evident  fatigue  upon  the  least  exer- 
tion. The  fever  has  now  reached  its  full  development.  Its 
precise  character  becomes  evident;  the  symptoms  caused  by 
disorders  of  individual  organs  stand  forth.  After  awhile  the 
disturbance  declines,  or  speedily  ceases  under  the  influence 
of  critical  discharges.  The  functions  are  re-established,  and 
a  convalescence,  more  or  less  rapid,  sets  in.  An  unfavorable 
termination,  on  the  other  hand,  may  take  place  at  any  period 
after  the  system  has  been  fairly  invaded. 

Such  is  a  brief  outline  of  the  general  phenomena  of  a 
fever.  But  varied  causes  and  secondary  changes  of  course 
modify  these  phenomena,  and  occasion  signs  serving  to  dis- 
tinguish one  febrile  disorder  from  the  other.  In  some,  the 
fever  is  continued;  in  others,  it  exhibits  a  distinct  periodi- 
city. Again,  some  fevers  are  attended  with  symptoms  of 
extremely  high  action ;  others  with  the  signs  of  most  pro- 
found prostration  and  blood-poisoning. 

The  marked  features  impressed  upon  the  fever,  either  by 
the  course  it  runs  or  by  the  speciflc  nature  of  the  symptoms, 
go  to  form  what  is  called  its  (ype,  and  may  be  made  the 
basis  of  the  classification  of  all  febrile  disorders.  But  as 
opinions  have  been  and  are  still  singularly  diversified  as  to 
what  really  constitute  the  most  palpable  characteristics,  so 
the  classification    of  fevers  is   as  yet,  to  a   great  extent,  a 


FEVERS.  713 

matter  of  speculation.  Nor  lias  the  difficulty  been  lessened 
by  the  disposition  to  assign  a  separate  place  to  each  fever 
presenting  any,  however  minute,  points  of  dissimilarity. 
Certain  it  is  that  very  many  divisions  are  uncalled  for;  for 
Nature  herself,  by  the  readiness  with  which  she  permits  even 
essential  traits  to  be  interchanged  or  to  become  blended  in 
the  same  attack,  proves  that  even  groups  are  not  widely  dis- 
tinct, and  that  minor  differences  are,  therefore,  wholly  un- 
worthy of  forming  the  touchstone  of  systematic  arrangement. 
In  the  following  table  no  attempt  is  made  at  an  exhaustive 
or  strictly  scientific  classification.  Some  disorders,  such  as 
cholera  and  puerperal  fever,  considered  by  many  eminent 
pathologists  to  belong  to  idiopathic  fevers,  have  no  place 
assigned  to  them  ;  while  others,  such  as  influenza  and  yellow 
fever,  the  claims  of  which  to  be  here  mentioned  are  un- 
doubted, might  have  their  positions  fairly  impugned.  But 
in  a  diagnostic  point  of  view,  the  arrangement  adopted  is 
convenient,  and  is  sufficiently  accurate  to  be  free  from  grave 
objections. 

Fevers. 

Simple  continued  fever. 
Catarrhal  fever  or  influenza. 
Typhoid  fever. 
Typhus  fever. 
Cerebro-spinal  fever. 
Relapsing  fever. 

Intermittent  fever. 


Continued  Fkvers. 


PEPaoDicAL  Fevers Remittent  fever. 

Congestive  fever. 


1 


'tj^- 


(^  Yellow  fever, 
f  Scarlet  fever. 
I  Measles. 

Eruptive  Fevers -{  Small-pox. 

I  Dengue. 
L  Erysipelas. 

Continued  Fevers. 

All  continued  fevers  are  characterized  by  a  steady  progress 
of  the  febrile  movement  without  either  decided  exacerbation 
or  relaxation,  the  rise  and  fall  observable  being  too  slight  to 
modify  the  impression  of  a  sustained  action. 


714  MEDICAL    DIAGNOSIS, 

Simple  Continued  Fever, — In  simple  fever  we  find  all 
the  pliononiena  which  constitute  a  fever.  It  sets  in  with 
feelings  of  lassitude  and  chilliness;  to  these  succeed  hot  skin, 
excited  pulse,  thirst,  headache,  pain  in  the  limbs.  The  bowels 
are  generallj'  confined,  the  urine  high  colored.  The  fever 
is  soon  at  its  height;  it  then  either  gradually  declines,  or  is 
more  suddenly  relieved  by  copious  perspiration  or  by  a  crit- 
ical discharge  from  the  bowels.  Generally  it  runs  through 
all  these  stages  in  a  few  days  ;  but  it  may  be  protracted  for 
several  weeks.  On  the  other  hand,  a  day  may  witness  both 
its  commencement  and  termination.  The  convalescence  is 
almost  always  rapid. 

The  exciting  causes  of  this  form  of  fever  are  fatigue,  errors 
in  diet,  change  in  mode  of  life,  exposure  to  cold  and  moist- 
ure, or  to  the  sun.  When  brought  on  by  mental  overwork 
or  by  grief,  it  is  not  uncommonly  attended  with  considerable 
prostration,  simulating  typhoid  fever,  but  differing  from  it 
by  the  absence  of  the  peculiar  abdominal  symptoms  and  of 
the  eruption.  More  frequently  the  fever  has  the  appearance 
of  one  of  high  action.  At  times,  indeed,  it  is  so  intense,  and 
the  vascular  system  so  wrought  up,  that  the  distemper  as- 
sumes what  is  called  an  inflammatory  type.  It  now  exhibits 
the  characteristics  of  the  fever  described  by  the  physicians 
of  the  last  century  as  synocha.  Burning  heat  of  the  surface, 
throbbing  of  the  temporal  arteries,  severe  headache  and  de- 
lirium are  among  its  symptoms.  This  variety  of  the  fever  is 
not,  however,  a  disease  at  present  encountered,  save  in  tropi- 
cal latitudes.  In  point  of  diagnosis,  it  is  most  apt  to  be  con- 
founded with  internal  inflammations,  especially  with  inflam- 
mation of  the  brain.  On  the  history  of  the  case,  and  on  the 
full  consideration  of  all  the  symptoms  before  us,  alone  can  a 
trustworthy  opinion  be  based.  In  truth,  in  all  the  grades  of 
what  appears  to  be  at  first  sight  simple  continued  fever,  we 
ought,  before  assuming  the  febrile  state  to  be  the  disease  and 
sufficient  to  explain  the  abnormal  phenomena,  to  examine 
carefully  all  the  organs,  and  see  whether  the  symptoms  may 
not  be  wholly  accounted  for  by  some  visceral  disturbance. 
And  often  then,  under  what  seems  to  be  a  very  active  or 
"ardent"  fever,  will,  on  closer  scrutiny,  be  found  lurking  the 
traits  of  an  inflammatory  lesion. 


FEVERS.  715 

Catarrhal  Fever. — It  is  not  common  to  class  this  epidemic 
malady  with  the  idiopathic  fevers;  it  is  oftener  described  as 
a  mere  variety  of  bronchitis,  because  inflammation  of  the 
bronchial  mucous  membrane  constitutes  one  of  its  most 
prominent  symptoms.  But  this  is  not  a  just  view.  With  as 
much  reason  might  typhoid  fever  be  omitted  from  the  list  of 
febrile  maladies,  and  described  as  a  variety  of  enteritis  or 
diarrhoea. 

Catarrhal  fever  is  essentially  an  epidemic  disease,  and  one 
which  has  visited  the  human  race  from  remote  antiquity. 
Its  history  is  thus  not  confined  to  any  particular  time,  nor  to 
any  particular  nation  ;  yet,  in  spite  of  its  frequency  and  wide 
prevalence,  its  cause  is  still  unascertained.  "VVe  know  nothing 
further  of  it  than  that  it  is  an  atmospheric  poison  traversing 
continents  with  extreme  rapidity,  just  as  cholera  does,  aft'ect- 
ing  animals  as  well  as  man,  and  leaving  behind  it  an  influ- 
ence which  shows  itself  long  after  the  epidemic  visitation. 
But  what  this  peculiar  state  of  the  atmosphere  is,  which  pro- 
duces such  potent  results,  is  not  understood.  It  is  certainly 
neither  heat,  nor  cold,  nor  damp,  nor  any  recognizable  phys- 
ical changes  in  the  surrounding  air ;  for  the  disease  has 
occurred  at  all  times  of  the  year,  and  with  every  kind  of 
weather. 

Each  epidemic  does  not  furnish  precisely  the  same  train  of 
symptoms ;  but  they  all  agree  in  this :  the  disorder  always 
sets  in  suddenly,  and  always  attacks  pre-eminently  the  mu- 
cous membranes.  Generally  it  is  the  mucous  membrane  of 
the  nose,  eyes,  and  bronchial  tubes  which  sufters  most,  and 
we  find  the  signs  of  coryza  and  bronchial  inflammation — 
a  watery  eye,  sneezing,  uneasiness  about  the  throat,  and 
cough.  But  associated  with  these  are  usually  an  extraordi- 
nary amount  of  lassitude  and  impairment  of  strength;  much 
more  than  the  cold  in  the  head  or  the  bronchitis  will  account 
for.  The  skin  is  hot,  the  pulse  only  of  moderate  volume,  or 
weak,  the  tongue  white  and  coated ;  the  patient  complains  of 
bis  debility,  and  of  the  aching  pains  in  his  back  and  limbs. 
Often  there  is  disturbance  of  the  alimentary  tract,  evinced 
by  loss  of  appetite,  nausea  and  vomiting,  or  by  diarrlicea. 
Commonly  after  three  or  four  days  these  symptoms  begin  to 


716  MEDICAL   DIAGNOSIS. 

subside,  the  cough  and  debility  outlasting  the  other  morbid 
signs. 

But  all  epidemics  do  not  run  precisely  this  course.  In 
some,  the  prostration  is  not  so  evident,  and  the  febrile  signs 
are  more  active  and  of  an  inflammatory  type;  in  others,  the 
pain  and  soreness  of  the  limbs  and  in  the  joints  constitute 
the  most  prominent  symptoms,  or  we  may  find  hemicrania, 
or  capillary  bronchitis,  or  pneumonia,  as  distressing  compli- 
cations. 

Influenza  is  not  ordinarily  in  itself  a  fatal  disease.  It  is 
only  so  in  the  very  young  or  the  very  old,  in  both  of  whom 
it  is  apt  to  become  combined  with  inflammation  of  the 
smaller  bronchial  tubes  or  of  the  lung. 

Catarrhal  fever  is  easily  discriminated  from  other  maladies. 
Its  peculiar  epidemic  character  prevents  us  from  mistaking 
an  ordinary  cold  or  bronchitis  for  it.  Occasionally  the  at- 
tending debility  makes  it  look  like  the  onset  of  a  low  con- 
tinued fever.  But  brain  symptoms  are  onl}'  present  in  rare 
instances  in  influenza ;  and,  on  the  other  hand,  decided 
catarrhal  symptoms  are  not  common  in  typhoid  or  typhus 
fever.  Before  long,  too,  the  occurrence  of  the  eruption  of 
these  diseases  clears  up  whatever  doubt  may  have  existed. 
The  all  but  constant  absence  of  an  eruption  in  influenza 
comes  also  elsewhere  into  play ;  it  serves  to  distinguish  this 
disorder  from  measles  or  small-pox. 

When  influenza  is  prevailing  on  a  large  scale,  it  is  often 
found  peering  out  from  under  the  garb  of  other  diseases,  and 
it  may  be  diiiicult  then  to  separate  its  manifestations  from 
those  of  the  malady  it  accompanies. 

Typhoid  Fever. — In  this  country  and  on  the  Continent 
of  Europe  a  form  of  continued  fever  largely  prevails,  marked 
by  great  prostration  and  disturbance  of  the  nervous  system, 
and,  unlike  most  essential  fevers,  by  constant  and  appreci- 
able anatomical  lesions.  To  this  disease  the  various  desig- 
nations of  typhoid  fever,  enteric  fever,  entero-mesenteric 
fever,  nervous  fever,  and  abdominal  typhus  have  been 
applied. 

The  disorder  either  attacks  single  individuals,  or  shows 
itself  as  an  epidemic.     It  occurs  at  all  seasons  of  the  year; 


FEVERS.  717 

but  ill  this  country,  at  least,  is  most  frequent  in  autumn.  In 
some  localities  it  is  thoroughly  at  home ;  in  others  it  is  only 
occasionally  seen.  It  avoids  both  extremes  of  age,  seizing 
mainly  on  young  adults  for  its  victims.  It  is  not  commonly 
regarded  as  contagious ;  yet  there  is  no  lack  of  trustworthy 
evidence  to  prove  that  it  has  been  communicated  by  contact. 

The  distemper  may  set  in  suddenly,  but  more  generally  it 
has  an  insidious  beginning.  For  some  days  preceding  the 
access  of  the  fever  the  patient  feels  weak  and  out  of  spirits. 
He  is  listless  and  without  animation,  and  his  countenance 
fully  expresses  his  languor.  He  complains  of  soreness  and 
fatigue,  of  dull  pain  in  the  head,  of  loss  of  appetite.  His 
sleep  is  unsound;  all  exertion  is  wearisome.  He  is  sick; 
something  is  evidently  weakening  his  nervous  energies.  A 
fever  now  appears,  preceded  mostly  by  a  chill,  or,  at  all 
events,  by  chilly  sensations,  which  alternate  with  flushes  of 
heat.  The  muscular  prostration  accompanying  the  febrile 
movement  is  so  great  that  the  patient  is  obliged  to  seek  his 
bed.  His  appetite  is  entirely  gone,  the  tongue  coated,  the 
bowels  loose,  the  abdomen  somewhat  swollen  and  tender  to 
the  touch.  On  close  inspection,  a  few  reddish  spots,  resem- 
bling flea-bites,  are  found  on  its  surface. 

The  malady  has  now  completed  its  first  week.  It  enters 
the  second  week  with  fever  unabated,  and  with  the  signs  of 
disturbance  of  the  alimentary  tract  and  of  the  nervous  sys- 
tem more  and  more  unmistakable.  There  is  sometimes 
nausea  or  epigastric  distress,  often  pain  in  the  right  iliac 
fossa,  increased  by  pressure,  and  tympanites.  The  tongue 
dries  and  becomes  reddish  or  brownish;  the  gums  and  teeth 
are  covered  with  dark  crusts.  The  mind  is  dull  and  wan- 
dering;  cough  and  great  restlessness  exist;  the  debility  is 
extreme. 

The  disease  now  begins  to  draw  to  its  close.  It  has  reached 
the  third  week,  and  a  change,  for  better  or  for  worse,  may 
be  looked  for.  Slowly  recovery  sets  in,  marked  by  a  bright- 
ening of  the  countenance  and  a  gradual  increase  in  con- 
sciousness and  strength;  or  deepening  insensibility,  jerking 
of  the  tendons,  feeble  pulse,  and  cold,  clammy  sweats  indi- 
cate that  dissolution  is  fast  approaching. 


718  MEDICAL   DIAGNOSIS. 

Thus,  in  one  way  or  the  other,  the  fever  itself  is  apt  to 
terniinate  by  the  twenty-first  day.  Yet  such  is  not  always 
the  case.  Death  may  take  place  at  an  earlier  period;  or,  on 
the  other  hand,  the  malady,  by  troublesome  complications, 
may  be  lengthened  beyond  the  second  month.  Under  any 
circumstances,  convalescence  is  protracted.  The  nervous 
system  rallies  but  gradually  from  the  shock  it  has  received. 

Among  the  symptoms  enumerated,  some  are  so  striking, 
and  tend  so  clearly  to  characterize  the  disease,  that,  in  ex- 
amining them  more  closely,  we  become  at  once  familiar  with 
the  features  distinguishing  typhoid  fever  from  a  host  of  other 
maladies.  And  first,  of  the  more  purely  febrile  symptoms. 
The  skin  is  hotter  than  natural;  this  is  especially  perceptible 
in  the  evening  exacerbations  of  the  fever.  Frequently  the 
surface  is  covered  with  an  acid  perspiration,  very  manifest 
during  the  whole  course  of  the  disorder,  and  also  encoun- 
tered long  after  convalescence  has  set  in.  The  pulse  is  ac- 
celerated, and  remains  so  after  the  heat  of  skin  has  left;  but 
it  is  rarely  tense,  and  even  in  intercurrent  acute  inflamma- 
tions it  seldom  loses  its  compressibility.  A  jerking,  irregu- 
lar beat,  or  ver}'  great  rapidity,  is  an  unfavorable  sign. 

When  we  investigate  the  febrile  symptoms  by  the  ther- 
mometer, we  find  them  striking,  and,  in  many  respects,  pe- 
culiar. Wunderlich's*  observations  on  very  many  cases  show 
that  the  temperature  on  the  first  day  of  the  fever,  in  the  morn- 
ing, may  be  stated  at  98-5°;  in  the  evening,  at  100-5°  Fahr. ; 
on  the  second  day,  in  the  morning,  it  is  apt  to  be  about  99*5°, 
in  the  evening  101*5°;  on  the  third  day,  in  the  morning, 
100-5°,  in  the  evening  102-5°;  on  the  fourth  day,  in  the  morn- 
ing, 101*5°,  in  the  evening  104°.  From  that  time  on  the  even- 
ing temperature  ranges  between  103°  to  104°,  the  morning 
temperature  being  about  1  degree  lower,  until  the  middle  of 
the  second  week,  when,  certainly  in  the  milder  cases,  although 
the  evening  temperature  may  remain  quite  or  nearly  so  high, 
there  is  an  abatement  of  heat  of  1°  to  2°  in  the  morning. 
These  changes  between  morning  and  evening  become  very 

*  Archiv  der  Heilkiinde,  vol.  ii.,  or  Edinb.  Med.  Journ.,  Nov.  1862;  also 
Die  Eigonwarme  in  der  Krankhoiten. 


FEVERS.  719 

evident  toward  the  end  of  the  week,  and  are  still  more  evident 
in  the  third  week,  when  the  morning  and  evening  tempera- 
tures may  vary  between  4°  to  6°.  During  this  week,  too,  the 
evening  temperature  gradually  decreases;  but  in  severe  cases 
it  remains  high,  and  there  are  no  decided  remissions,  either 
in  the  second  or  third  week.  The  morning  temperature  is 
high,  104°  or  more,  and  there  may  be  still  greater  heat  of 
skin  in  the  evening,  or  else  it  difl:ers  but  little  from  that  of 
the  morning. 

Among  the  abdominal  symptoms,  diarrhoxi  is  the  most 
prominent.  It  is  never  absent,  excepting  when  the  disease  is 
unusually  mild.  Generally,  and  especially  in  grave  cases,  it  is 
a  very  early  symptom.  The  clue  to  its  cause  is  found  in  the 
state  of  the  abdominal  glands;  in  the  enlargement  and  ulcer- 
ation of  the  glands  of  Peyer,  of  the  solitary  glands,  and  in  the 
tumefaction  of  the  mesenteric  glands.  And  in  these  morbid 
alterations,  which  are  so  constant  in  typhoid  fever  as  to  con- 
stitute its  anatomical  characteristics,  we  find  not  only  an 
explanation  of  the  occurrence  of  the  diarrhoea,  but  also  of 
its  frequency.  The  stools  are  thin,  of  a  yellow  or  dark- 
brown  color,  and  of  offensive  smell.  When  the  affection  is 
at  its  height,  from  three  to  four  evacuations  occur  during 
the  twenty-four  hours;  but  the  passages  may  become  much 
more  numerous,  and  with  their  number  the  danger  rises.  If 
they  take  place  without  the  knowledge  of  the  patient,  his 
situation  is  precarious.  Sometimes  the  stools  contain  blood. 
Should  this  be  present  in  considerable  quantity,  it  is  a  very 
unfavorable  circumstance.  Yet  intestinal  hemorrhage  is  by 
no  means  necessarily  fatal. 

Enlargement  of  the  spleen  is  a  very  constant  attendant  upon 
the  fever.  In  fact,  whenever  Ave  can  be  certain  that  the  evi- 
dent increase  in  size  is  not  due  to  some  previous  malady,  the 
extended  percussion  dulness  in  the  splenic  region  becomes 
an  element  of  importance  in  our  diagnosis. 

Another  abdominal  symptom  of  significance  is  jxdn.  It 
varies  much  in  its  severity  and  character;  and  is,  indeed,  not 
always  present.  It  is  rarely  acute ;  oftener  a  heavy,  aching 
feeling.  In  some  patients  it  is  of  a  griping  kind,  preceding 
the  loose  discharges ;  in  others,  it  only  seems  to  be  called 


720  MEDICAL    DIAGNOSIS. 

into  existence  by  pressure.  Its  most  common  seat  is  in  the 
iliac  fossfe;  yet  the  testimony  of  the  sick  man  himself  as  to 
its  exact  situation  must  he  received  very  cautiously.  He 
is  too  ill  to  answer  intelligently,  is  apt  to  reply  in  the 
afiirmative  to  any  leading  question,  and  thus  may  be  made 
to  say  that  almost  any  part  hurts  him  which  is  touched. 
Still  the  expression  of  suffering  on  his  face,  when  pressed  on 
either  side  at  the  lower  part  of  the  abdomen,  is  strongly  in- 
dicative of  the  pain  corresponding,  for  the  most  part,  to  the 
seat  of  the  irritation.  And  often  while  the  hand  is  exploring 
this  region,  a  movement  of  the  fluid  and  gas  in  the  distended 
bowel,  attended  with  a  gurgling  noise,  becomes  perfectly  ap- 
preciable. This  sign  is  best  elicited  near  the  ilio-csecal  valve, 
and  is  full  of  meaning. 

During  convalescence,  griping  pains  are  not  unfrequently 
complained  of.  They  are  colicky  pains,  produced  generally 
by  errors  in  diet,  and  may  be  followed  by  a  return  of  the 
diarrhoea  or  by  a  relapse  of  all  the  other  symptoms  of  the 
malady.  Occasioiuilly — fortunately  not  often — during  such 
a  relapse,  or  even  during  the  latter  period  of  the  fever,  a 
sudden  pain  sets  in,  of  great  intensity,  unremitting,  and  at- 
tended by  spreading  tenderness.  Such  a  pain  forebodes  evil. 
It  shows  that  peritoneal  inflammation  has  been  lighted  up  in 
consequence  of  the  intestine  having  been  perforated. 

Hardly  inferior  to  the  abdominal  symptoms  in  import — in 
many  respects  of  even  greater  significance — are  the  signs  of 
disturbance  of  the  nervous  system.  The  fever  is,  as  its  old 
name  implies,  pre-eminently  a  "  nervous"  fever:  the  nervous 
symptoms  are,  in  truth,  never  absent ;  but,  though  always 
present,  they  are  less  extensive  in  some  cases  than  in  others, 
and  not  the  same  throuo;hout  all  the  stao:es  of  the  disease. 
Thus,  early  in  the  disorder,  dull  headache,  mental  languor, 
and  a  perverted  state  of  the  senses,  such  as  ringing  in  the 
ears  and  dulness  of  hearing,  are  encountered ;  while  later, 
great  restlessness,  delirium  or  coma,  and  jerking  of  the 
tendons  are  phenomena  more  likely  to  be  met  with.  The 
delirium  especiallj'  requires  to  be  noted.  It  sets  in  generally 
during  the  second  week,  for  the  most  part  at  night,  and 
terminates  with  convalescence  or  else  ends  in  coma.     It  is 


FEVER?.  721 

not  a  wild  delirium,  but  a  confusion  of  mind  associated  with 
rambling  thoughts.  If  the  patient's  attention  be  strongly 
engaged,  he  may  almost  always  be  roused,  and  does  for  a 
time  as  he  is  told;  but,  after  a  short  interval,  his  muttering 
lips  indicate  that  some  curious  fancy  has  again  taken  pos- 
session of  him.  In  some  cases,  not  in  many,  the  delirium  is 
attended  with  great  restlessness  and  much  agitation,  and  the 
sick  man,  if  not  prevented,  attempts  to  walk  about  the  room. 
This  kind  of  frenzy  is  of  bad  augury,  and  often  ends  in 
fatal  coma.  Equally  unpromising  is  early  or  unremitting 
delirium. 

When  contrasted  with  the  mental  wanderins^  in  other  acute 
disorders,  the  delirium  of  typhoid  fever  exhibits  peculiar 
traits.  It  is  ordinarily  more  active  than  that  of  typhus;  far 
less  demonstrative  or  talkative  than  the  mania  of  drunkards ; 
as  aimless  as,  but  less  continued  than,  the  ravings  of  inflam- 
mation of  the  brain. 

In  some  cases  of  typhoid  fever  appear,  however,  symp- 
toms not  only  of  cerebralj  but  also  of  spinal  origin;  and  they 
may  indeed  assume  a  high  degree  of  intensity.  We  find 
cutaneous  hypersesthesia,  extending  over  a  large  portion  of 
the  body,  spinal  pain  and  tenderness,  with  a  sense  of  prick- 
ing along  the  vertebral  column,  and,  in  some  instances,  cuta- 
neous and  muscular  anaesthesia,  numbness  of  the  extremities, 
partial  paralysis  or  convulsive  contractions  of  the  respirator}^ 
muscles,  convulsive  cough,  paralysis  of  the  sphincters,  con- 
tractions of  the  extremities,  and  even  rigidity  of  the  muscles 
of  the  neck.*  These  spinal  symptoms  are  more  common 
when  the  disease  is  epidemic  than  when  sporadic,  and  are 
always  indicative  of  a  very  serious  form  of  the  disorder. 
They  sometimes  persist  after  the  fever  has  left,  or  indeed, 
and  this  is  especially  true  of  paralysis,  may  not  appear  until 
convalescence.  The  palsy  may  or  may  not  be  linked  to  an 
organic  lesion.  It  may  be  preceded  by  trembling  movements, 
suggesting  the  idea  of  sclerosis  of  the  cord  ;  hue  the  tremor  is 
rather  the  result  of  general  debility,  and,  unlike  sclerosis,  it 

*  Fritz,  Etude  clinique  sur  divers  Rymptomes  spinaux  observes  dans  la 
Fievre  typhoide,  referred  to  in  Arch.  Gener.  de  Med.,  June,  1864. 

46 


722  MEDICAL   DIAGNOSIS. 

occurs  before,  and  does  not  follow,  the  complete  loss  of  mus- 
cular power  in  the  limbs. 

Two  other  prominent  symptoms  of  the  malady  must  still 
be  inquired  into :  one  is  epistaxis ;  the  other,  the  cutaneous 
eruption.  Epistaxis  is  not  often  absent  in  grave  cases.  It  may 
happen  at  any  period  of  the  complaint;  but  it  is  most  apt  to 
take  place  before  the  disorder  is  far  advanced.  The  quantity 
of  blood  lost  is  rarely  considerable;  and  for  this  reason  the 
occurrence  of  the  hemorrhage  is  frequently  overlooked. 

The  eruption  which  is  peculiar  to  the  disease  is  commonly 
spoken  of  as  the  rose-colored  rash.  It  appears  about  or 
shortly  after  the  seventh  day;  but  occasionally  not  until  the 
end  of  the  second  week.  It  can  hardly  be  called  a  papular 
eruption,  as  it  consists  rather  of  small,  red  spots,  only  very 
slightly  elevated  above  the  skin,  somewhat  similar  to  flea- 
bites,  yet  differing  from  them  in  lacking  the  central  mark 
and  in  their  finer,  paler  color  and  less  obvious  outline.  The 
spots  are  seen  upon  the  abdomen  and  chest,  almost  never 
upon  the  extremities  or  upon  the  face.  They  disappear 
totally  on  strong  pressure,  yet  return  immediately  when  the 
pressure  ceases.  They  are  generally  few  in  number,  and  not 
persistent.  Each  spot  does  not  last  for  more  than  three  or 
four  days ;  then  it  fades,  and  a  fresh  one  near  by  replaces  it, 
and  runs  the  same  course.  Spots  thus  appear  and  pass  away 
for  more  than  a  week,  after  which,  in  most  cases,  they  entirely 
vanish.  During  convalescence  not  a  trace  of  them  can  be 
found;  but  should  the  patient  get  up  too  soon,  or  be  impru- 
dent in  his  diet,  and  a  relapse  take  place,  they  again  show 
themselves  with  the  other  symptoms  of  the  malady. 

This  eruption,  although  very  common,  is  not  invariably 
present;  at  all  events,  it  is  not  invariably  found.  Beyond 
doubt,  too,  it  is  in  some  epidemics  more  constant  and  marked 
than  in  others. 

Late  in  the  disease  another  eruption  appears,  consisting  of 
very  minute  transparent  vesicles,  scattered  plentifully  over 
the  body.  These  sudamina  are  not  so  frequently  encountered 
as  the  rose  rash,  and  are  certainly  not  so  characteristic ;  yet 
they  are  seen  often  enough  to  be  regarded  as  a  feature  of  the 
afl'ection. 


FEVERS.  723 

After  this  analysis  of  the  symptoms  of  typhoid  fever,  it 
would  be  useless  repetition  to  discuss  at  length  how  the  dis- 
ease difiers  from  all  other  idiopathic  fevers.  The  attempt 
will  rather  be  made  to  explain  its  diagnosis  from  those  mala- 
dies, whether  essentially  febrile  or  not,  to  which  it  bears  the 
closest  resemblance.  And  here  we  find  that  the  disorders 
with  which  typhoid  fever  may  be  confounded  are,  owing  to 
its  varying  aspect,  not  the  same  at  all  the  stages  of  the  com- 
plaint. Early  in  the  affection  it  is  most  likely  to  be  mistaken 
for  simple  continued  fever,  or  for  one  of  the  exanthem.ata. 
But  diarrhcea  is  not  present  in  these,  nor  are  there  marked 
prodromes;  and  whatever  doubt  may  exist  with  reference  to 
simple  continued  fever,  is  cleared  up  in  a  few  days,  as  the 
symptoms  come  to  an  end  at  a  time  at  which  in  typhoid 
fever  they  begin  to  be  more  and  more  developed.  Still  the 
exanthematous  fevers  cannot,  before  their  eruptions  appear, 
be  distinguished  with  absolute  certainty ;  though  we  may  sus- 
pect measles  by  the  attending  corj^za,  scarlatina  by  the  sore 
throat,  and  small-pox  by  the  lumbar  pains  and  high  fever. 

At  a  more  advanced  period,  typhoid  fever  may  be  con- 
founded with  typhus,  and  with  these  morbid  states : 

General  Debility; 

Typhoid  Conditions  ; 

Enteritis  ; 

Peritonitis  ; 

Meningitis  : 

Acute  Pulmonary  Affections. 

General  Debility. — It  does  not  at  first  sight  seem  very  likely 
that  so  acute  and  dangerous  a  disease  as  typhoid  fever  could 
he  mistaken  for  mere  debility  ;  yet  such  an  error  may  occur 
where  the  disease  is  latent,  or  so  very  light  as  hardly  to 
confine  the  patient  to  his  bed.  In  these  so-called  "  walking 
cases"  of  the  fever,  the  debility,  however,  sets  in  suddenly, 
and  not  graduallv,  asin  weakness  from  general  constitutional 
causes.  Moreover,  the  abdominal  symptoms  are  rarely  want- 
ing, and  there  is  always  more  or  less  confusion  of  mind. 
Due  attention  to  these  circumstances  will  prevent  mistake  ; 
but  the  sfreatest  safeo^uard  ayainst  error  is  to  be  aware  that 
the  disease  assumes  at  times  a  latent  form,  and  to  examine 


724  MEDICAL    DIAGNOSIS. 

every  case  of  great  and  sudden  debility,  to  see  if  under  its 
mask  are  hidden  the  features  of  typhoid  fever. 

Typhoid  Conditions. — No  blunder  is  more  common  than  to 
misconstrue  into  typhoid  fever  a  typhoid  condition  of  the 
e^-stcra.  We  may  find  this  condition  in  many  different  com- 
plaints, both  acute  and  chronic;  but  more  especially  are 
purulent  infection,  some  forms  of  pneumonia,  dysentery,  and 
erysipelas  attended  with  delirium,  drowsiness,  dry,  brown 
tongue,  and  extreme  prostration,  —  in  one  word,  with  a 
typhoid  state. 

Yet  a  typhoid  state  is  not  typhoid  fever;  it  is  simply  a 
low  condition  of  the  system  which  may  be  present  in  very 
many  dissimilar  maladies,  and  which  is  present  in  its  most 
perfect  form  in  typhoid  fever.  But  in  this  malign  complaint 
we  have  other  signs  than  those  of  vital  depression  :  we  find 
joined  to  it  diarrhoea,  tympanites,  epistaxis,  an  eruption,  and 
special  manifestations  of  disturbance  of  the  nervous  system, 
— all  symptoms  bearing  no  direct  relation  to  the  adynamia, 
and  thus  serving  as  valuable  distinctive  marks.  An  exami- 
nation, too,  of  the  urine  is  often  of  signal  service.  There  are, 
indeed,  cases  of  Bright's  disease  and  of  abscess  of  the  kid- 
ney, in  which  the  poisoning  of  the  blood  which  happens  occa- 
sions a  very  deceptive  likeness  to  typhoid  fever — so  deceptive 
that  only  a  minute  examination  of  the  urine  can  fully  explain 
the  true  meaning  of  the  symptoms.  The  following  case  well 
illustrates  this: 

A  man,  about  forty-five  years  of  age,  was  admitted  into 
the  Philadelphia  Hospital  in  January,  1863.  He  was  very 
prostrate,  and  hardly  able  to  give  an  account  of  himself. 
It  was,  however,  ascertained  that  he  was  not  a  person  of  in- 
temperate habits,  and  that  he  had  been  attending  to  his  work 
until  within  two  weeks.  He  was  evidently  stupid,  and,  when 
questioned  about  himself,  seemed  to  have  great  dilficulty  in 
remembering,  and  in  collecting  his  thoughts.  He  had  fever; 
a  pulse  above  100;  a  dry  brown  tongue.  The  heart  sounds 
were  feeble,  the  heart  increased  in  size.  The  urine  was  at 
times  turbid,  and  contained  a  slight  whitish  sediment,  which 
was  not,  however,  examined  with  tiie  microscope.  His  mind 
wandered  at  night ;  the  abdomen  was  distended  and  in  parts 


FEVERS.  725 

slight!}' tender;  several  doubtful  red  spots  were  detected  on 
its  surface.  In  fact,  he  appeared  to  have  almost  every  one 
of  the  more  constant  symptoms  of  typhoid  fever,  exceptinor 
the  diarrhoea.  A  few  days  after  his  admission  he  became 
comatose,  and  sank.  The  intestinal  glands  were  found  in  a 
healthy  condition  ;  but  both  kidneys  were  thoroughly  disor- 
ganized and  filled  with  pus. 

Enteritis. — The  great  difference  between  enteritis  and  ty- 
phoid fever  consists  in  this  :  in  enteritis  the  inflammation  of 
the  intestine  constitutes  the  disease;  in  typhoid  fever  the 
irritation  of  the  intestine  and  morbid  alteration  of  its  crlands 
are  merely  elements  of  the  disease.  In  enteritis,  therefore, 
there  are  no  further  symptoms  than  those  referable  to  the  in- 
flamed intestine.  We  tind  no  great  prostration;  no  mental 
wandering ;  no  enlargement  of  the  spleen  ;  no  rose  spots  and 
sudamina;  no  signs  of  abnormal  processes  due  to  a  typhoid 
dyscrasia.  The  disorder,  too,  gives  rise  to  much  more  ab- 
dominal pain,  and  is  of  shorter  duration. 

Peritonitis. — The  same  remarks  apply  to  peritoneal  inflam- 
mation. Here,  moreover,  the  expression  of  the  face,  the 
constipation  and  the  very  great  abdominal  tenderness  serve 
as  marks  of  discrimination.  But  we  must  not  forget  that 
acute  inflammation  of  the  peritoneum  may  appear  in  the 
course  of  typhoid  fever.  Generally  this  untoward  event 
happens  at  a  late  period  of  the  disease,  and  after  the  patient 
has  been  under  observation  for  some  time ;  we  are  then  at 
no  loss  to  understand  the  meaning  of  the  spreading  tender- 
ness, the  rapid,  small  pulse,  the  marked  tympanitic  distention, 
the  sweats,  the  nausea  and  vomiting,  the  collapse,  and  the 
pinched  features.  But  the  accident  may  occur  in  cases  which 
we  have  not  previously  seen,  or  in  which  the  affection  has 
run  so  latent  a  course  as  hardly  to  have  attracted  even  the 
patient's  attention.  The  cause  of  the  peritonitis  is  then  com- 
moidy  first  revealed  by  the  autopsy,  which  shows  actual  per- 
foration of  the  intestinal  walls,  in  consequence  of  ulceration 
of  a  solitary  or  aggregate  gland.  Whenever,  indeed,  in  ty- 
phoid fever  the  signs  of  peritonitis  can  be  clearly  traced,  the 
exciting  cause  of  the  inflammation  may  be  announced  to  be 
perforation ;  for  the  evidence  on  which  it  has  been  assumed 


726  MEDICAL   DIAGNOSIS. 

that  peritoneal  inflammation  may  take  place  without  the 
giving  way  of  the  intestine  is  not  so  positive  as  to  cause  us 
to  abandon  this  diagnof^tic  rale. 

Memrigiiis. — Typhoid  fever  has  some  symptoms  in  common 
with  inflammation  of  the  brain ;  but  the  signs  of  difierelice 
have  been  fully  discussed  in  connection  with  acute  and  with 
crebro-spinal  meningitis,  and  need  not  here  be  re-examined. 

Acute  Pulmonary  Affections. — In  a  large  number  of  cases 
of  typhoid  fever — in  fact  in  the  majority — we  find  cough,  de- 
pendent upon  an  affection  of  the  bronchial  tubes.  The  brou- 
chial  inflammation,  if  it  really  can  be  called  an  inflamma- 
tion, gives  rise  to  the  peculiar  signs  of  extreme  loudness  of 
the  rales,  with  a  cough  disproportionately  slight;  sometimes, 
too,  owing  to  the  blood  gravitating  to  the  most  dependent 
portions  of  the  lungs,  the  resonance  over  the  posterior  part 
of  the  chest  is  impaired.  From  these  phenomena,  added  to 
the  abdominal  and  cerebral  symptoms  of  the  fever,  there  is 
no  difiiculty  in  discriminating  between  idiopathic  bronchitis 
and  typhoid  fever.  J^ay,  even  before  the  symptoms  of  the 
febrile  malady  are  clearly  defined,  we  may  suspect  the  true 
explanation  of  the  rales  from  the  coexisting  extreme  vital 
depression. 

Not  uufrequently  we  find  pleurisy  combined  with  the 
bronchitis,  and  in  some  cases,  not  in  very  many,  the  cough 
is  associated  with  exudation  into  the  pulmonarj^  structure. 
Now,  it  may  be  extremely  diflicult  to  distinguish  a  pulmonic 
lesion  of  this  kind  from  inflammation  of  the  lung  setting  in 
amid  signs  of  prostration,  until  the  appearance  of  the  erup- 
tion and  of  the  marked  abdominal  symptoms  solves  the  diffi- 
culty. Generally,  however,  it  is  not  a  matter  of  much  doubt, 
as  the  condensation  of  the  lung  in  typhoid  fever  does  not 
occur  early  in  the  disease — not,  in  fact,  until  the  symptoms 
of  the  fever  are  clearly  developed.  Occasionally  a  cough 
remains  after  the  febrile  symptoms  have  begun  to  decline 
and  the  mind  is  reijainino^  its  clearness.  The  couoh  increases 
in  severity,  and  the  patient  soon  loses  the  strength  he  may 
have  acquired.  On  listening  to  the  chest,  we  find  scattered 
over  both  lungs  many  fine,  dry  and  moist  sounds.  The 
percussion  note  is  here  and  there  dull ;  the  expectoration  is 


I 


FEVERS.  727 

profuse;  there  are  dyspnoea  and  excessive  sweating.  Here 
is  a  group  of  signs  which,  if  not  absolutely,  are  at  least 
almost  invariably,  associated  with  the  occurrence  of  acute 
phthisis.  The  further  progress  of  the  disease  reveals  its 
nature  more  and  more  distinctly,  and  many  of  the  symptoms 
of  the  typhoid  state  reappear.  But  there  is  no  difficulty  in 
establishing  the  fact  that  the  formidable  complication  fol- 
lowed, or  was  at  least  fanned  into  life  by,  the  attack  of  fever. 
Sometimes,  however,  we  observe  acute  phthisis  with  most  of 
the  symptoms  of  typhoid  fever  without  that  affection  being 
really  before  us:  even  the  delirium,  the  stupor,  and  the  en- 
largement of  the  spleen  may  be  present ;  but  the  eruption 
never  is,  and  the  diarrhcea  very  rarely. 

Typhus  Fever. — The  term  typhus  is  not  very  definite  in 
its  signification.  The  German,  Swedish,  Irish,  and  most  of 
the  British  physicians  comprise  nnder  it  all  low  forms  of 
fever,  including  typhoid.  In  this  country  and  in  France  it  is 
applied  solely  to  that  low  continued  fever  prevailing  in  jails 
and  camps,  among  crowded  populations,  or  in  badly-ventilated 
localities,  and  which  is  not  characterized  by  any  constant 
structural  lesion.  Without  enterins;  into  the  discussion 
whether  or  not  it  ought  to  be  separated  from  typhoid  fever; 
whether  it  be,  as  so  many  still  affirm,  nothing  but  a  cerebral 
form  of  that  same  typhous  disorder  of  which  typhoid  is  re- 
garded as  the  abdominal  form,  having  the  same  cause,  obey- 
ing the  same  laws, — without  entering  into  this  vexed  question, 
we  cannot  but  recognize  in  it  many  phenomena  so  different 
from  those  of  typhoid  or  enteric  fever  that,  on  clinical  grounds 
alone,  if  on  no  others,  a  separate  recognition  is  called  for. 

Typhus  fever  very  rarely  occurs  sporadically.  It  is  a  highly 
contagious  malady,  almost  always  met  with  in  an  epidemic 
form,  and  generally  among  those  whose  systems  are  depressed 
or  blood  impoverished.  It  is  either  preceded  by  a  brief  stage 
of  lassitude  and  dejection,  or  is  ushered  in  with  a  chill  and 
pain  in  the  head  and  back.  The  skin  soon  becomes  dry  and 
of  pungent  heat;  the  pulse  rises  very  much  in  frequency,  and 
is  at  first  full,  sometimes  even  tense.  The  patient  lies  in  a 
state  of  half  consciousness;  very  dull,  very  drowsy,  very  weak, 
with  evident  signs  of  his  nervous  and  muscular  system  being 


728  MEDICAL    DIAGNOSIS. 

overwhelmed  by  the  influence  of  some  fearfully  depressing 
poison.  The  face  is  flushed  ;  the  eye  injected  ;  the  odor  from 
the  body  extremely  unpleasant. 

By  the  tifth  day  all  these  symptoms  are  plainly  marked, 
and  about  this  time  a  coarse,  red,  cutaneous  eruption  makes 
its  appearance.  But  it  occasions  no  change  in  the  gravity 
of  the  symptoms.  On  the  contrary,  the  confusion  of  mind 
and  stupor  increase,  the  patient  wanders,  picks  at  his  bed- 
clothes, and  ceases  to  complain  of  the  pain  in  the  head  or 
limbs.  The  pulse  is  frequent  and  feeble;  the  tongue  dry  and 
dark;  sordes  collect  on  the  gums  and  teeth.  The  bowels 
remain  as  they  were  at  the  onset — constipated.  The  urine 
often  comes  away  drop  by  drop  ;  or,  as  the  bladder  loses  the 
power  of  contracting,  is  retained.  The  case  has  now  reached 
its  height ;  the  signs  of  a  prostrated  nervous  system,  of  dete- 
riorated blood,  and  of  utter  loss  of  muscular  strength  either 
commence  to  pass  away  or  deepen  from  hour  to  hour,  and 
clearly  show  the  doom  that  awaits  the  fever-stricken  patient. 
From  the  beginning  of  the  distemper  until  the  unfortunate 
issue,  is  rarely  over  thirteen  daj-s.  If  the  sick  man  can  with- 
stand the  poison  until  the  third  week,  he  is  apt  to  throw  it  off 
and  recover;  but  it  may  be  so  virulent  as  to  overpower  him 
almost  at  the  onset. 

Let  us  examine  some  of  the  symptoms  of  this  pestilential 
disease  in  detail. 

The  jjlii/siognomy  of  typhus  is  very  peculiar.  The  expres- 
sion is  stupid,  and  coarser  than  in  health.  The  face  wears  a 
deep  flush,  of  a  dusky-red  hue.  The  eye  is  much  injected, 
the  pupil  often  contracted.  The  skin  is  verj'  hot  and  dry, 
and  covered  with  a  characteristic  eruption,  from  which  the 
disease  takes  its  name  of  "spotted"  or  "  maculated"  typhus. 
The  rash  is  well  defined,  at  first  slightly  elevated  and  usually 
much  like  that  of  measles.  It  is  of  a  dark  tint,  and  fades 
but  does  not  vanish  on  pressure.  It  makes  its  appearance 
from  the  fifth  to  the  seventh  day,  and  is  permanent ;  not 
consisting  of  successive  eruptions,  but  of  the  same  spots, 
which  deepen  or  lighten  with  the  changes  in  the  disease, 
and  do  not  pass  away  before  the  fourteenth  day.  Each  spot 
thus  lasts  until  recovery  or  until  death,  and  no  new  ones 


FEVERS.  729 

sliow  themselves  after  the  second  or  third  day  of  the  rash. 
Tliey  are  generally  very  numerous  on  the  trunk  and  ex- 
tremities, but  are  rarely  observed  upon  the  face.  Some  are 
much  lio-hter  than  others,  and  thus  a  mottled  aspect  of  the 
skin  is  produced,  on  which  Dr.  Jenner* — who  has  described 
the  typhus  fever  eruption,  or,  as  he  calls  it,  the  "  mulberry 
I'ash,"  with  much  fidelity — lays  great  stress.  Sometimes  the 
spots  are  of  purple  color  and  uninfluenced  by  pressure.  These 
petechias  are  the  attendants  of  the  worst  forms  of  the  malady. 

The  dift'erent  forms  of  eruption,  however,  are  different  in 
degree  rather  than  in  kind.  The  poison  leads  to  local  inter- 
ference in  the  capillary  circulation,  and  then  to  transudation 
from  and  rupture  of  the  distended  vessels ;  and  it  may  do  this 
partly  in  consequence  of  the  vitiation  of  the  blood,  partly  by 
its  action  on  the  sympathetic  nervous  system.  This  is  likely 
the  cause  of  the  eruption,  and  the  extent  and  consequences 
of  the  paralysis  of  the  capillaries  explain  the  more  or  less 
obvious  effect  of  pressure  on  the  rash  in  many  idiopathic 
fevers. 

The  skin  of  a  typhus  fever  patient  is  often  very  sensitive, 
and,  as  already  stated,  generally  very  hot.  In  some  cases 
the  thermometer  indicates  a  temjmrdure  of  107°,  or  more; 
and  most  commonly  it  ranges  above  104°.  The  heat  is  very 
sustained  :  it  does  not  show  the  marked  differences  between 
morning  and  evening  which  are  observed  in  tj^phoid  fever; 
the  daily  variations  to  the  middle  of  the  second  week  being 
rarely  1°  Fahr.;  and  from  that  time  onward  the  morning 
abatement  does  not  amount  to  more  than  about  1-5°,  until 
the  defervescence  is  reached.  The  passing  away  of  the  high 
temperature — "  the  defervescence" — occurs,  however,  not  as 
in  the  enteric  fever  by  gradual  though  more  and  more  evi- 
dent remissions,  but  suddenly.  Early  in,  or  toward'  the 
middle  of,  the  third  week,  the  temperature  falls  quickly,  and 
for  the  most  part  in  twenty-four  or  thirty-six  hours  a  normal 
standard  is  reached. 

The  cerebral  symptoms  of  typhus  fever  are  never  absent, 


*  Identity  or  Non-Identity  of  Typhoid  and  Typhus  Fevers,  London,  1850  ; 
and  Medico-Chirurg.  Transacts.,  vol.  xxxiii. 


730  MEDICAL    DIAGNOSIS. 

although  thej'  vary  much  both  in  intensity  and  character. 
In  some  epidemics  they  constitute  the  prominent  feature  of 
many  cases,  and  dangerous  and  fatal  these  cases  are  apt  to 
be.  One  of  the  most  striking  and  frequent  proofs  of  the 
disturbance  of  the  brain  is  seen  in  stupor.  The  patient's 
mind  seems  gone:  he  lies  in  a  heavy  slumber,  occasionally 
muttering  some  incoherent  words  ;  or  he  is  sleepless,  his 
eyes  remain  wide  open,  yet  he  cares  nothing  for,  and  takes 
no  notice  of,  anything  going  on  around  him.  Either  of  these 
states  may  deepen  into  coma. 

In  other  cases  delirium  is  the  most  conspicuous  sj-mptom. 
Now,  this  delirium  rarely  sets  in  before  the  end  of  the  first 
week,  though  it  may  precede  the  eruption.  In  type  it  is  low 
and  muttering,  and  unaccompanied  by  great  restlessness;  or 
it  may  be  associated  with  constant  movements  and  trembling 
of  the  limbs,  or  jerking  of  the  tendons, — in  fact,  with  symp- 
toms resemblins:  those  designated  as  hvsterical.  Sometimes 
the  mental  wandering  is  active  and  very  persistent.  The 
patient  tosses  about,  is  constantly  talking,  and  can  hardly  be 
restrained  from   o-ettino;  out  of   bed.      He  has  illusions  of 

~  CD 

hearing  and  of  sight;  his  eyes  are  injected,  the  pupils  often 
contracted;  there  is  great  headache  with  intolerance  of  light. 
Here  we  have  the  true  brain  typhus,  with  its  formidable 
cerebral  symptoms  simulating  closely  those  of  idiopathic 
inflammation  of  the  brain,  and  differing  from  them  onlj'  by 
their  union  with  a  cutaneous  eruption,  by  the  dissimilar 
aspect  of  the  tongue,  and  the  beat  of  the  pulse,  which  is 
rarelj'  verj'  full,  and  never  so  tense  as  that  of  meningitis. 
Then,  the  nervous  excitement  is  accompanied,  or,  at  all 
events,  soon  succeeded,  by  greater  and  more  rapid  prostra- 
tion of  strength,  and  is  often  exchanged  far  more  suddenly 
for  coma  than  is  observed  in  the  meningeal  disorder. 

The  cause  of  this  violent  disturbance  of  the  brain  is  either 
due  to  the  direct  effect  of  the  poison  on  the  nervous  centre, 
or  to  the  impure  blood  which  circulates  through  it;  and 
however  strange  it  may  seem  that  phenomena  so  vehement 
and  so  like  those  of  true  inflammation  should  not  be  really 
owing  to  this  morbid  process,  yet  it  is  beyond  doubt  that  the 
signs  of  the  severest  nervous  derangement  in  these  fevers 


FEVERS.  731 

may  coincide  with  a  mere  congestion — nay,  even  with  a 
brain  and  spinal  marrow  presenting,  to  all  appearances,  a 
perfectly  healthy  structure. 

These  head  symptoms  of  typhus  are,  as  those  of  enteric 
fever,  sometimes  connected  with  a  very  noisy,  shallow,  and 
irregular  respiration.  This  kind  of  breathing  can  be  clearly 
traced  to  the  abnormal  state  of  the  nervous  system,  as  no 
signs  of  alteration  in  the  lungs  coexist.  Often,  as  Dr.  Flint* 
has  lucidly  pointed  out,  it  is  a  forerunner  of  fatal  coma.  In 
one  case  I  found  the  strange  phenomenon  associated  with 
great  distention  of  the  bladder,  and  subsiding  very  materially 
after  the  introduction  of  a  catheter. 

The  remarks  made  with  reference  to  the  cerebral  phenom- 
ena of  typhus  apply  to  those  cases  in  which  there  is  no  in- 
flammatory disorder  Avithin  the  cranium.  But  we  must  not 
overlook  the  fact  that  this  may  ensue.  Such  cases  are  very 
difiicult  of  recognition.  The  pulse,  as  a  rule,  is  slow  and 
irregular,  the  pupils  contracted,  there  is  a  frown  on  the  fore- 
head and  intense  headache,  sometimes  screaming.  Vomiting 
is  not  always  encountered.  We  may  find  with  these  symp- 
toms acute  hydrocephalus,  and  the  morbid  appearances  may 
be  confined  chiefly  to  the  base  of  the  brain. f 

The  circulation  in  typhus  exhibits  some  peculiarities  worthy 
of  note.  The  pulse,  after  the  disease  is  fully  developed,  is 
generally  rapid,  and  either  of  moderate  volume  or  feeble. 
As  the  disorder  advances,  and  the  strength  becomes  more 
and  more  impaired,  it  rises  in  frequency,  while  it  diminishes 
in  force.  As  convalescence  is  established,  it  falls;  if  it  re- 
main frequent,  this  is  generally  indicative  of  some  concealed 
visceral  disorder,  often  of  a  disease  of  the  lungs.  It  does  not 
always  correspond  closely  with  the  condition  of  the  heart,  so 
far,  at  least,  as  this  is  revealed  by  the  impulse.  The  beat  may 
be  excited  and  violent,  while  the  pulse  is  very  weak.  At 
times  the  cardiac  impulse  undergoes  a  singular  diminution, 
and  with  its  change  the  first  sound  becomes  enfeebled;  in 
fact,  it  is  sometimes  almost  lost,  and  only  very  gradually  re- 

*  Clinical  Keports  on  Continued  Fover. 

f  Kennedy,  Dublin  Quarterly  Journal,  Feb.  18G7. 


732  MEDICAL    DIAGNOSIS. 

gains  its  natural  tone.  Occasionally,  at  the  height  of  the 
disease,  it  is  replaced  by  a  soft,  systolic  murmur;  not  here  a 
sign  of  inflammation,  but  dependent  upon  the  depraved  state 
of  the  blood.  The  sphygmograph  may  show  an  improvement 
in  the  pulse  by  demonstrating  a  slight  return  of  its  dicrotism 
before  any  improvement  can  be  ascertained  bj  the  finger.* 

The  urine  is  generally  high  colored  at  first,  but  may  become 
very  pale  as  convalescence  sets  in,  depositing  an  abundance 
of  urates  and  phosphates.  There  is  an  absence  of  the  chlo- 
rides, or  they  are  reduced  to  a  trace.  The  urea,  as  ascertained 
by  an  analysis  of  Dr.  Parkesf  in  a  case  in  which  no  medicine 
■was  given,  is  increased,  and  its  augmented  excretion  is  re- 
markably regular  during  the  height  of  the  malady.  Indeed, 
the  increased  amount  of  urea  is,  as  determined  by  repeated 
examinations  of  the  urine  of  t3'phus  fever,  very  constant,  and 
is  a  proof  of  the  more  active  metamorphosis  of  tissue. 
During  convalescence  the  urea  sinks  below  the  physiological 
standard,  and  then  graduallj^  rises  to  it.  These  observations, 
however,  must  be  compared  with  those  of  Roseustein,|  which 
we  have  referred  to  when  discussinor  the  chemistrv  of  urea, 

Notwithstanding  the  amount  of  water  drunk,  the  water 
passed  is  lessened,  and  it  would  appear  to  be  retained  in  the 
system.  The  urine  is  apt  to  contain  a  large  amount  of  uric 
acid,  and,  as  a  rule,  preserves  its  acidity.  In  8  out  of  21 
cases  that  I  examined  during  a  late  epidemic,§  it  contained 
albumen,  and  this  ingredient  was  only  present  in  the  severer 
cases.  In  some'instances  the  microscope  exhibits  in  the  de- 
posit, besides  the  salts  of  the  urine,  renal  as  well  as  vesical 
epithelium,  and  tube-casts,  either  finely  granular  or  hyaline, 
or  epithelial.  Very  much  the  same  condition  of  urine  as  re- 
gards most  of  the  constituents  is  also  found  in  typhoid  fever. 
But  the  pigment  which  in  typhus  fever  was  detected  by 
Parkes  throughout  only  in  small  amounts,  has  in  typhoid 
fever  been  found  to  be  immensely  increased. 

The  complications  encountered  during  the  course  of  the 


*  Dublin  Quarterly  Journal,  Feb.  1867. 

f  The  Urine  in  Disease,  p.  258 

X  Med.  Times  and  Gazette,  1869. 

§  See  Am.  Journ.  of  Med.  Sci.,  Jan.  1866. 


FEVERS.  733 

fever,  or  dnriiig  convalescence,  are  much  the  same  as  those 
of  typhoid  fever,  although  they  do  not  in  the  two  diseases 
occur  with  equal  frequency.  We  meet  with  abscesses,  with 
large  sloughs  on  the  trunk  and  extremities,  with  milk-leg, 
with  erysipelas,  with  inflammation  of  the  parotid  gland,  with 
oedema  of  the  glottis,  and  with  pulmonary  troubles.  The 
latter  are  very  common,  and  mostly  very  alarming.  Some- 
times they  consist  merely  in  afl^ections  of  the  larger  bronchial 
tubes;  hut  very  often  we  have  to  deal  with  a  dangerous 
capillary  form  of  bronchitis,  commencing  very  insidiously, 
not  attended  with  much  cough,  and  very  easily  overlooked. 
A  coarse  crepitation  or  tine  bubbling  sounds  are  heard  over 
the  whole  chest,  and  the  respiration  is  huri-ied.  At  times,  in- 
stead of  these  signs,  or  associated  with  them,  may  be  noticed 
dulness  on  percussion  and  bronchial  respiration  over  the 
low^er  lobes  of  the  lungs,  depending  upon  congestion,  with 
consolidation  more  or  less  perfect,  of  the  pulmonary  tissue. 
Here  is  one  of  the  worst  of  all  the  complications — a  low  form 
of  pneumonia.  During  the  last  stages  of  the  fever,  or  after 
convalescence  has  set  in,  acute  tubercular  deposits  occasion- 
ally develop  themselves  in  the  lungs  with  the  same  symp- 
toms as  during  or  subsequent  to  typhoid  fever.  One  of  the 
most  siofnificant  siojns  of  this  untoward  event  is  the  utter 
want  of  response  of  the  system  to  stimulants  and  tonics. 

To  discuss  now  the  differential  diagnosis  of  typhus  fever. 
We  find  various  maladies  resembling  it,  but  none  so  closely 
as  typhoid  fever.  The  subjoined  table  show-s  both  their 
similarities  and  their  dilierences: 

Typhoid.  Typhus. 

Age  generally  from  18  to  35.  At  all  ages ;  often  in  persons  beyond 

middle  life. 
Not    contagious,   or    but    feebly  so;    Highly    contagious;     generally    epi- 

often  sporadic.  demic. 

Attack  generally  insidious.  Attack  generally  sudden  ;  no  length- 

ened prodromes. 
Duration  fully  three  weeks  ;  very  fre-    Duration  somewhat  shorter;  often  not 

quently  much  longer.  .     prolonged  beyond  second  week. 

Death  hardly  ever  before  end  of  sec-    Death  not  unfrequently  at  end  of  first 

ond  week ;    more   generally  in,  or        week,  and  often  before  conclusion 

after  third  week.  of  second. 


734 


MEDICAL    DIAGNOSIS. 


TZPHOID. 

Cerebral  symptoms   come  on  gradu- 
ally ;  last  longer. 


Great  emaciation. 

Face  pale,  or  flush  confined  to  cheeks. 

Skin  hot,  sometimes  covered  with 
acid  perspiration. 

Abdominal  symptoms,  such  as  diar- 
rhoea, tympanites;  intestinal  hem- 
orrhage not  unusual. 


Epistaxis  common. 
Bronchitis  and  pleurisy. 


Eruption  light  red,  and  not  on  ex- 
tremities. 

Post-mortem  appearances  are :  mor- 
bid state  of  Peyer's  patches ;  en- 
largement of  mesenteric  glands ; 
ulceration  of  mucous  coat  of  intes- 
tine ;  enlargement  and  softening  of 
spleen  ;  ulceration  of  pharynx. 


Typhus. 

Delirium  or  decided  stupor  comes  on 
soon,  sometimes  almost  from  the 
onset;  headache  has  appeared  and 
disappeared  by  about  the  tenth  day. 

Less  emaciation  ;    greater  prostration. 

Face  deeply  flushed,  of  dusky  hue ; 
eye  dejected. 

Skin  of  pungent  heat ;  sometimes 
emitting  an  ammoniacal  odor. 

JNo  abdominal  sj-mptoms  ;  bowels  con- 
stipated ;  meteorism  rare;  intes- 
tinal hemorrhage  extremely  rare, 
if  it  ever  occurs  ;  sometimes  acute 
dysentery  during  convalescence,  or 
as  a  sequel. 

No  epistaxis. 

Pneumonia,  or,  at  .all  events,  more 
marked  intense  congestion  of  the 
lungs,  and  bronchitis  of  flner  tubes. 

Eruption  darlter  color,  and  all  over 
body. 

No  constant  post-mortem  appear- 
ances ;  the  most  frequent  are  the 
dark-colored,  liquid  state  ot  the 
blood,  and  enlargement  of  the 
spleen.  Softening  of  the  heart  is 
more  common  in  typhus  than  in 
typhoid.  There  are  no  intestinal 
lesions. 


The  points  of  contrast  between  the  two  aft'ections  are  here 
so  manifest  that  it  would  seem  impossible  ever  to  confound 
them.  Yet  it  must  be  remembered  that  all  the  signs  are  not 
present  in  every  case.  JSTor  does  this  table  go  to  prove  any- 
thing beyond  the  clinical  distinction  between  the  kindred 
maladies;  certainly  not  a  dilierent  cause  of  production,  nor  a 
dissimilar  nature.  Neither  can  it  be  denied  that  occasionally 
the  symptoms  of  the  two  diseases  are  strangely  blended  or 
interchanged.  Thus  we  may  have  constipation  in  typhoid, 
and  diarrhoea  in  typhus,  or  the  eruption  may  be  curiously 
mixed.     For  instance  : 

A  boy,  sixteen  years  of  age,  was  received  into  the  Phila- 
delphia Hospital,  with  evident  signs  of  a  commencing  fever 
of  a  low  type.     A  da}-  or  two  after  his  admission,  and  corre- 


FEVERS.  735 

spoiuling,  as  nearly  as  could  be  ascertained,  to  the  fifth  day 
of  the  disease,  an  eruption  showed  itself  all  over  the  body. 
It  was  dark  colored,  petechial  in  its  aspect,  and  did  not  dis- 
appear on  pressure.  Associated  with  it  were  drowsiness  and 
constipation.  In  a  few  days  more,  however,  the  symptoms 
changed.  The  dark  eruption  ftuled,  and  rose-colored  spots 
were  perceptible  on  the  chest  and  abdomen  ;  diarrhoea  set 
in,  and  the  fever  ran  its  course  to  a  favorable  termination 
wuth  the  character  of  typhoid,  just  as  at  the  onset  it  had 
assumed  the  character  of  typhus. 

Besides  typhoid  fever,  typhus  may  be  confounded  with 
meningitis,  with  inflammation  of  the  lungs,  with  measles, 
with  small-pox,  and  with  the  plague.  The  distinctive  marks 
between  the  first  two  and  typhus  fever  have  been  rendered 
apparent  while  discussing  the  cerebral  and  pulmonary  com- 
plications of  the  latter  malady.  I  shall  here  only  dwell  again 
upon  the  great  value  of  the  eruption  in  a  diagnostic  point  of 
\\e\v.  The  symptoms  which  approximate  measles,  small  pox, 
and  yellow  fever  to  typhus,  will  be  analyzed  in  connection 
with  these  affections.  One  word  here  as  to  its  difference 
from  the  plar/ue. 

This  pestilent  disease,  which  during  several  centuries  left 
almost  annually  its  deep  indent  upon  the  human  race,  is 
hardly  known  to  us  at  present,  save  by  description.  And 
the  descriptions  leave  on  the  mind  the  impression  of  an 
exposition  of  a  ftimiliar  malady;  for  the  authors  who  have 
most  carefully  delineated  its  traits  have  produced  a  picture 
which,  with  very  slight  changes,  may  be  suited  to  a  repre- 
sentation of  epidemics  of  typhus  fever.  Thus,  we  read  of 
a  highly  contagious  fever  setting  in  suddenly,  attended 
with  constipation,  with  a  rapid,  feeble  pulse,  with  delirium, 
with  a  dry  tongue,  with  noises  in  the  ears  and  deafness,  with 
starting  of  the  tendons,  with  w^atchfulness  or  stupor,  and  with 
red  patches  and  purple  spots  scattered  over  the  whole  surfiice 
of  the  body.  The  features  which  typhus  does  not  share  with 
the  plague  are  nausea  and  vomiting,  an  alarmed,  despairing 
look  of  the  countenance,  haemoptysis,  and,  above  all,  the 
buboes  and  carbuncles  in  different  parts  of  the  body. 

In  concluding  this  description  of  typhus  fever,  let  us  in- 


736  MEDICAL    DIAGNOSIvS. 

quire  what  are  its  relations  to  that  extraordinary  affection 
which  has  but  comparatively  lately  been  committing  such 
ravages  in  some  of  the  New  England  States,  in  parts  of  New 
York,  and  in  Pennsylvania,  and  with  which  we  have  had  to 
contend  in  this  city  and  its  environs — the  so-called  sjwUed fever. 

This  malignant  complaint  is  not  a  new  disease;  it  has  pre- 
vailed before  in  this  country,  and  has  been  sketched  by 
Miner,  Hale,  Gallup,  JSTorth,  and  others,  who  witnessed  it 
in  the  New  England  States,  and  by  Ames,  of  Montgomery, 
Alabama.  It  assumes  different  forms,  according  to  the 
origans  which  bear  the  brunt  of  the  disturbance.  The  form 
which  we  have  had  to  encounter  was  the  cerebro-spinal :  in 
truth,  the  phenomena  were  those  of  the  disease  usually  called 
cerebro-spinal  meningitis,  and  the  symptoms  of  which  have 
been  described  in  a  previous  chapter.  Prominent  among 
these  symptoms  were:  intense  headache;  pains  in  the  back 
and  extremities  ;  restlessness;  great  prostration  of  strength  ; 
increased  cutaneous  sensibility;  stupor,  delirium;  irregular 
pulse;  dilated  pupils;  dimness  of  sight;  nausea  and  vomit- 
ing; hurried,  shallow  breathing;  a  feeling  of  spasmodic  con- 
striction of  the  chest;  and  throwing  back  of  the  head.  The 
urine  was  high  colored,  containing  large  quantities  of  urates, 
and  often  a  small  amount  of  albumen  ;  the  skin  was  seldom 
more  than  slightly  heated,  sometimes  even  cold,  and  fre- 
quently but  not  invariably  the  seat  of  a  petechial  eruption, 
usually  of  purplish  color,  wholly  unchanged  by  pressure,  and 
appearing  ordinarily  on  the  first  day  of  the  disease.  The 
affection  ran  generallj'  a  very  rapid  course.  Many  died  on 
the  third  day;  some  perished  in  a  few  hours;  occasionally  it 
was  protracted  for  several  weeks.  Those  who  survived  the 
lifth  or  sixth  day  were  apt  to  recover,  and  entered  on  a 
tedious  convalescence. 

Now  this  strange  complaint,  which,  on  account  of  the  sore- 
ness of  the  throat  which  may  attend  it,  was  by  some  believed 
to  be  malignant  scai'let  fever,  was  by  others  regarded  as 
modified  typhus,  and  by  others  again  as  cerebro-spinal  in- 
flammation. That  it  is  the  disease  described  as  cerebro- 
spinal meningitis,  or  cerebro-spinal  typhus,  admits  now  of 
no  doubt.     But  whether  it  be  a  separate  disorder,  or  a  mere 


FEVERS.  737 

variety  of  typhus  fever,  is  a  question  still  at  issue.  Let  us 
contrast  its  phenomena  with  those  of  this  affection,  which  in 
many  respects  it  so  closely  resembles.  Both  diseases  are  apt 
to  prevail  at  the  same  time  ;  both  attack  all  classes  and  ages; 
both  are  evidently  attended  with  dissolution  of  the  blood, — 
but  this  alteration  in  the  blood  occurs  much  more  rapidly 
and  is  much  more  marked  in  spotted  fever  than  in  ordinary 
cases  of  typhus  ;*  the  eruption  is  different  from  that  of  the 
common  form  of  tj'phus;  there  is  less  delirium;  a  less  in- 
tense fever  ;  the  affection  is  of  much  shorter  duration,  and  not 
nearly  so  contagious,  if  in  truth  we  can  regard  as  proved  that 
it  is  contagious  at  all ;  the  countenance  is  not  of  a  dusky  hue 
and  stupid,  but  pale  or  of  a  sallow  color,  and  dull  or  expres- 
sive of  suffering.  And  certainly,  whether  or  not  spotted 
fever  be  a  peculiar  form  of  typhus,  clinically  its  manifesta- 
tions are  very  dissimilar  to  those  of  the  usual  varieties  of  this 
complaint.  But  they  are  not  so  dissimilar  to  those  occurring 
in  some  epidemics  of  malignant  cerebral  typhus  which  have 
been  described.  Indeed,  while  fully  admitting  that  we  can- 
not, from  the  evidence  in  our  possession,  as  yet  decide  with 
certainty  on  spotted  fever  being  merely  modified  typhus,  and 
developed  by  the  same  poison,  a  larger  experience  with  the 
disease  than  I  had  when  this  work  was  first  published,  makes 
me  adhere  still  more  decidedly  to  the  opinion  that  it  is  not 
an  inflammation,  but  a  fever  of  a  typhous  type,  a  cerebro- 
spinal fever,  kindred,  to  say  the  least,  to  typhus  fever.f 


*  The  deterioration  of  the  blood  occurs,  indeed,  very  soon  in  spotted  fever. 
In  an  autopsy  of  a  child  who  died  in  twenty-four  hours,  I  found  the  hlood 
diffluent  and  black  ;  in  an  adult  patient  who  had  been  sick  but  two  days,  I 
detected  blowing  sounds  in  the  heart,  evidently  of  blood  origin.  The  pois- 
oned blood  unquestionably  gives  rise  to  many  of  the  nervous  symptoms,  and 
it  is  on  the  blood  and  the  nervous  centres  that  the  poison  mainly  acts.  In 
this  respect  the  maladj'  is  very  like  typhus  fever.  In  fact,  I  think  it  may 
be  designated  as  a  fever  of  a  typhous  type,  varying  somewhat  in  its  mani- 
festations, according  as  the  nervous  centres,  the  intestinal  tract,  or  the  lungs 
arc  chiefly  attacked. — Note  to  first  edition. 

f  An  extraordinary  case,  bearing  on  the  relationship  of  the  complaints 
under  discussion,  was  under  my  charge  in  1865  at  the  Pennsylvania  Hospital : 
see  case  xii.  of  a  series  of  typhus  fever  cases,  published  in  Amer.  Journ.  of 
Med.  Sci.,  Jan.  1866.  For  accounts  of  the  late  epidemic,  consult  the  obser- 
vations of  Dr.  XJpham,  in  the  Boston  Med.  and  Surg.  Journ.,  vol.  Ixviii., 

47 


738  MEDICAL   DIAGNOSIS. 

Relapsing  Fever. — This  is  a  form  of  fever  characterized 
hy  its  rapid  course  and  its  proneness  to  relapse.  Epidemics 
of  this  disease — and  it  only  occurs  in  epidemics — are  fre- 
quently encountered  in  Ireland  and  in  Scotland.  In  this 
country  it  was,  until  hitely,  almost  unknown. 

The  disorder  is  decidedly  acute.  Its  invasion  is  sudden, 
and  marked  by  rigors,  pain  in  the  back  and  limbs,  vertigo, 
severe  headache,  and  nausea  and  vomiting.  Fever  is  soon 
developed,  and  rises  high  ;  there  are  severe  muscular  pains, 
particularly  in  tbe  muscles  of  the  extremities  ;  the  pulse  is 
very  rapid ;  the  temporal  arteries  throb;  the  tongue  is  covered 
with  a  thick,  white  fur.  The  bowels  are,  as  a  rule,  con- 
stipated. In  many  cases  there  is  engorgement  of  the  liver 
with  yellowness  of  skin;  in  nearly  all  epigastric  tenderness 
and  marked  enlargement  of  the  spleen.  The  matter  ejected 
from  the  stomach  is  greenish,  or  sometimes  black  and  like 
coffee-grounds.  Minute  points  of  extravasated  blood  are  not 
uncommonly  observable  upon  the  integument.  On  the  fifth 
or  seventh,  though  sometimes  not  until  the  tenth  day,  the 
symptoms  subside  as  speedily  as  they  have  set  in,  a  profuse 
perspiration  preceding  their  decided  abatement.  Convales- 
cence is  now  apt  to  be  rapid,  and  apparently  complete,  the 
patient  being  up  and  going  about ;  but  the  intermission  does 
not  last  long.  Ordinarily  after  a  week,  therefore  on  the 
twelfth  or  fourteenth  day  from  the  first  beginning,  sometimes 
sooner,  rarely  later,  the  attack  returns,  presenting  again  the 
same  signs,  and  again  terminating  by  a  critical  sweat  in  con- 
valescence. This  second  attack  may  be  short  and  mild;  but 
it  may  be  both  longer  and  of  graver  character  than  the  first. 
It  is,  at  times,  followed  by  another,  and  yet  another  relapse. 

1863  ;  the  communications  of  Drs.  Gerhard,  Jewell,  and  others,  in  the  Trans- 
actions of  the  Phila.  College  of  Physicians,  Am.  Journ.  of  Med.  Sci.,  1864 
and  18G5 ;  the  Publications  of  the  Massachusetts  Medical  Soc,  vol.  ii.; 
also  Dr.  Stille's  monograph  on  Epidemic  Meningitis  ;  Dr.  Githens,  Amer. 
Journ.  Med.  Sci.,  July,  1867,  and  various  jjapors,  by  Dr.  Liddell  and  others, 
published  in  the  same  journal.  To  contrast  our  epidemic  with  that  in  Great 
Britain  and  on  the  Continent,  see  discussions  and  papers  by  Murciiison,  San- 
derson and  others,  in  Med.  Times  and  Gazette,  London  Lancet,  and  Med. 
Press  and  Circular,  of  the  past  few  years  ;  and  Reports  in  Brit,  and  For.  Med.- 
Chirurg.  liov.,  Oct.  1868,  and  in  Dub.  Quart.  .Journ.,  Aug.  1868  ;  Ziemssen  and 
Heis,  in  Archiv  fiir  Klin.  Med.,  Bd.  i.,  and  Klebs,  Virchow's  Archiv,  1865. 


FEVERS.  739 

When  the  patient  finally  throws  off  the  disease,  he  is  very 
weak,  and  his  blood  is  much  impoverished.  He  shows  a 
tendency  to  dropsy  of  the  extremities;  and  blowing  mur- 
murs, evidently  not  organic,  are  perceptible  while  listening 
to  the  heart.  These  murmurs,  however,  may  also  be  heard 
during  the  paroxysms.  Is  the  patient  really  well  during  the 
intermission  ?  He  appears  so,  yet  his  spleen  remains  en- 
larged, the  pulse  is  apt  to  be  slow,  the  action  of  the  heart 
weak,  and  the  arthritic  pains  do  not  entirely  disappear. 

Relapsing  fever  has  an  intimate  connection  with  destitu- 
tion. It  is  contagious,  but  far  from  a  very  fatal  disorder. 
In  fatal  cases  death  sometimes  happens  during  the  first 
paroxysm  as  the  result  of  syncope,  of  hemorrhage  into  the 
brain,  or  from  the  lungs;  or  it  may  occur  suddenly  during 
the  intermission  from  paralysis  of  the  heart.  But  the  most 
common  termination  of  the  cases  having  an  unfavorable  issue 
is  in  consequence  of  states  which  have  been  induced  by  the 
malady,  such  as  lobular  inflammation  of  the  lung,  abscess  of 
the  spleen  or  kidney,  chronic  diarrhoea,  dropsy,  parotitis, 
palsies.  At  times  the  patient  perishes  in  a  condition  similar 
to  the  collapse  of  cholera,  though  the  collapse  is  more  pro- 
tracted and  the  pulse  can  be  felt,  and  discharges  from  the 
bowels  are  by  no  means  a  constant  accompaniment.  The  ex- 
treme prostration,  attended  with  great  coldness  of  the  skin, 
may  last  for  days.  It  is  more  particularly  met  with  in  the 
"bilious"  or  "bilious  typhoid"  form  of  the  malady — a  very 
dangerous  variety  in  which  severe  vomiting,  jaundice,  and 
delirium  are  encountered,  and  the  paroxysm  is  not  followed 
by  a  distinct  intermission  or  remission,  but  often  by  the  signs 
of  collapse  alluded  to,  and  in  which  nrremic  symptoms  have 
been  more  particularly  noticed.*  The  collapse,  however, 
may  happen  not  only  at  the  close  of  the  paroxysm,  but  in  the 
remission,  whether  this  be  distinct  or  not,  or  in  a  subsequent 
paroxysm ;  and  this  may  be  the  case  no  matter  what  variety 
of  the  disorder  we  have  to  deal  with,  and  whether  or  not  the 
grave  sj'mptoms  are  due  to  uroemia. 

Yet  it  will  be  probably  found  that  the  state  of  the  kidneys 


*  Hermann,  Account  of  St.  Petersburg  Epidemic;  Schmidt's  Jahrb.,  No.  6, 
I860;  see  also  further  observations  in  Meissner's  article,  ib.,  No.  2,  1870. 


740  MEDICAL   DIAGNOSIS. 

and  of  the  urinary  secretion  has  very  commonly  a  great  deal 
to  do  with  the  graver  phenomena  of  the  malady.  Acute 
renal  disease  with  albumen  and  tube-casts  in  the  urine  was 
discerned  by  Obermeier*  in  two-thirds  of  his  eases;  and  as 
regards  the  urine,  Riesenfeldf  found  that  the  urea  during  the 
first  paroxysm  was  always  increased,  and  that  this  increase 
continued  beyond  the  crisis.  The  products  of  the  heightened 
tissue  metamorphosis  may  be  retained,  and  thus  grave  symp- 
toms arise. 

There  is  no  constant  lesion  in  relapsing  fever,  unless  it  be 
the  lesion  in  the  spleen.  This  organ  is  enlarged,  and  pre- 
sents numerous  round  or  irregularly  shaped  bodies,  of  white 
or  yellowish-white  eolor.| 

The  description  of  the  malady  has  been  chiefly  taken  from 
the  epidemics  which  have  been  commented  on  by  Jenner, 
Lyons,  and  Murchison.  But  we  have  lately  had  relapsing 
fever  both  in  New  York  and  Philadelphia ;  and  I  have  en- 
countered the  disorder.  Its  features  have  appeared  to  me 
much  the  same  as  in  the  epidemics  already  described;  and 
this,  to  judge  from  the  interesting  lectures  of  Dr.  Alonzo 
Clark,§  is  also  the  case  with  the  fever  as  met  with  in  jN^ew 
York. 

The  diagnosis  of  the  malady  cannot  be  made  positively 
during  the  primary  seizure.  Yet  the  presence  of  the  fever, 
while  an  epidemic  prevails,  may  be  suspected  from  the  sud- 
den fierce  beginning  of  the  attack ;  and  the  fact  of  the  high 
fever  heat  of  104°  to  107°  C.  showing  itself  in  less  than 
twenty-four  hours,  and  exhibiting  but  little  difference  be- 
tween morning  and  evening,  until  the  rapid  and  great  fall 
which  takes  place  at  the  crisis;  and  the  character  of  the  gas- 
tric symptoms.  Relapsing  fever  resembles  yellow  fever  in 
its  short  duration  and  in  some  of  its  manifestations;  but 
there  is  this  evident  difference ;  in  yellow  fever  the  remis- 
sion constitutes  part  of  the  paroxysm,  the  symptoms  do  not 
subside  nearly  as  completely,  nor  does  the  black  vomit  come 
on  until  the  stage  of  collapse  is  reached. 

*  Virchow's  Archiv,  1869.,  Bd.  xlvii.,  quoted  in  Glasgow  Med.   Journal, 
Nov.  1869. 
t  lb.,  quoted  ib.  |  Pastau,  ib.,  quoted  ib. 

§  Medical  Kecord,  March,  1870. 


FEVERS.  741 

From  typhoid  and  typhus  fevers,  relapsing  fever  may  be 
distingnislied  by  the  shorter  prodromes,  the  presence  of  jaun- 
dice, which  hardly  ever  occurs  in  these  maladies,  and  b}^  the 
very  brief  period  during  which  the  symptoms  last  Again, 
critical  sweats  with  the  rapid  cessation  of  the  fever  are  not 
likely  to  be  seen  in  these  disorders,  certainly  not  in  typhoid 
fever;  and  the  intense  continuous  febrile  heat,  as  indicated 
by  the  thermometer,  the  severe  muscular  and  arthritic  pains, 
and  in  some  cases  the  early  collapse  without  apparent  cause 
are  characteristic;  and,  on  the  other  hand,  delirium  and 
stupor  are  very  rarely  encountered  in  relapsing  fever.  After 
the  relapse  has  taken  place,  the  diagnosis  is  easy,  if  the  case 
have  been  watched  during  the  first  attack.  But  should  it  not 
have  been  under  notice  before,  it  may  be  at  times  very  difli- 
cult,  if  not  wholly  impossible,  to  say  whether  we  are  dealing 
with  relapsing  fever  or  with  that  rare  condition,  a  relapse  of 
typhoid  or  typhus  fever.  And  this  difficulty  is  enhanced  by 
the  want  of  uniformity  of  the  symptoms  in  the  second  onset 
of  the  strangel}"  recurring  malady,  and  the  close  similarity 
they  occasionally  show  to  those  of  typhoid  or  of  typhus  fever. 
Another  difficulty,  too,  is  presented  by  the  fact  that  relapsing 
fever  may  exhaust  itself  in  the  first  paroxysm.  But  this  is 
a  very  unusual  occurrence. 

In  looking  at  the  dift'erent  forms  of  continued  fever  which 
have  just  been  passed  in  review,  we  cannot  help  being  struck 
witli  the  many  features  which  they  possess  in  common.  They 
are  nearly  all  apt  to  occur  as  epidemics  or  endcmically. 
They  are  nearly  all  more  prevalent  in  densely-populated 
parts  of  the  country,  or  among  masses  of  men,  than  in  local- 
ities where  the  population  is  scattered.  They  all  exhibit  a 
strong  disposition  to  run  a  certain  well-defined  course  before 
terminating.  In  truth,  it  is  very  doubtful  whether  any  med- 
ical means  can  cut  short  this  course ;  for  a  specific  treatment 
for  any  of  the  forms  of  continued  fever,  by  which  they  may 
be  controlled  with  the  same  readiness  as  the  malarial  fevers, 
has  not  yet  been  discovered.  But  we  can  accomplish  much 
by  seeking  to  remove  all  sources  of  irritation,  and  by  close 
attentipn  to  the  complications  which  arise.  In  simple  fever 
we  materially  aid  the  system  in  throwing  ofi"  the  morbid 


742  MEDICAL   DIAGNOSIS. 

matter  by  stimulating  the  secretions;  in  the  low  forms  of 
fever  we  interpose,  by  art,  to  prevent  the  disease  from  under- 
mining, step  by  step,  the  vital  powers.  The  greatest  peril 
in  these  fevers  is  generally  from  exhaustion.  Usually,  if 
that  can  be  guarded  against,  the  malady  is  nearly  conquered. 
To  use  the  forcible  words  of  Stokes:*  "In  a  disease  which 
is  under  the  control  of  the  mysterious  law  of  periodicity, 
every  hour  of  compelled  life  is  a  clear  gain." 

Periodical  Fevers. 

These  fevers  are  characterized  by  the  distinct  periodicity 
of  their  phenomena:  they  exhibit  intervals  during  which 
the  patient  is  wholly  or  nearly  free  from  febrile  disturbance. 
With  the  exception  of  one  (and  its  place  here  is,  indeed, 
doubtful),  they  are  all  owing  to  that  poison,  so  prolific  of 
disease,  termed  marsh  miasm  or  malaria,  of  the  intimate 
cause  of  which  as  yet  we  know,  unfortunately,  nothing  more 
definite  than  that  heat  and  moisture,  and  probably  vegetable 
decomposition,  are  essential  to  its  production.  This  noxious 
agent  gives  rise  to  a  group  of  fevers,  ever  betraying  their 
common  origin  by  their  strong  family  resemblance:  alike  in 
occurring  in  low,  swampy  localities;  alike  in  most  of  their 
symptoms,  and  in  the  difficulty  of  eradication  from  the  sys- 
tem ;  alike  in  the  secondary  lesions,  in  the  enlargement  of 
the  spleen  and  of  the  liver,  and  in  the  altered  condition  of 
the  blood,  which  thej'  leave  behind  them ;  and  also  alike 
in  being  under  the  control,  absolute  and  immediate,  of  cin- 
chona in  its  various  preparations. 

Along  with  the  forms  of  miasmatic  fever,  I  shall  describe 
yellow  fever ;  not  because  I  believe  it  to  be  of  identical  nature, 
but  on  account  of  the  similarity  of  the  prominent  symptoms. 

Intermittent  Fever. — The  phenomena  presented  by  an 
attack  of  intermittent  fever  are  so  well  understood,  that  a 
short  general  description  of  them  will  be  sufficient. 

The  paroxysm  comes  on  with  a  chill :  the  face  becomes 
pale,  the  lips  bluish;  the  teeth  chatter;  the  skin  is  cold  to 


*  Clinical  Lectures  on  Fevers,  London  Med.  Times  and  Gazette,  1854. 


FEVERS.  743 

the  touch;  there  is  generally  a  feeling  of  uneasiness  and 
fatigue.  After  a  period  varying  commonly  from  half  an 
hour  to  an  hour,  this  cold  stage  passes  off.  Now  we  iind 
decided  heat  of  the  surface,  with  restlessness,  thirst,  a  full, 
rapid  pulse,  muscular  pains,  a  scanty  secretion  of  urine ;  in 
other  words,  active  febrile  symptoms.  These  continue  for 
hours,  for  a  period  always  much  longer  than  the  tirst  stage: 
then  a  sweat  breaks  out  all  over  the  body;  the  pulse  be- 
comes softer  and  less  frequent;  the  secretions  are  fully  re- 
established; and  this  sweating  stage  terminates  the  paroxysm. 

The  patient  is  now  for  the  time  being  well ;  but  the  dis- 
ease soon  recurs :  in  from  twenty-four  to  seventy  hours  the 
paroxysm  repeats  itself.  In  the  former  case  we  call  the 
fever  a  quoiidkm;  in  the  latter,  a  quartan.  The  tertian  type  is 
before  us  when  the  paroxysm  sets  in  again  in  about  forty- 
eight  hours;  the  double  tertian,  when  we  find  a  daily  attack, 
but  those  of  alternate  days  alone  corresponding  in  time  and 
severity.  The  period  between  the  ending  of  one  attack  and 
the  beginning  of  another  is  spoken  of  as  the  intermission  or 
ajpyrexia ;  while  the  time  between  the  beginning  of  the  two 
paroxysms,  including  the  first  with  its  succeeding  intermis- 
sion, is  called  the  interval. 

The  varied  types  of  the  fever  present  marked  differences 
in  the  character  and  duration  of  the  several  stages.  The 
tertian  has  generally  the  longest  hot,  the  quartan  the  longest 
cold  stage.  In  the  quotidian  there  is  a  very  short  cold  stage, 
followed  by  a  hot  stage  which  may  last  for  upwards  of  fifteen 
hours.  Occasionally  the  stages  are  very  irregular  and  anom- 
alous. Thus,  the  sweating  stage  may  precede  the  cold  stage, 
or  it  may  be  the  only  one  which  shows  itself;  or,  again,  the 
rigor  may  be  altogether  wanting.  Sometimes  there  are  no 
distinct  stages ;  but  the  patient  has  a  "  dumb  ague,"  which 
manifests  itself  at  definite  periods  by  a  feeling  of  great  de- 
pression, or  a  severe  pain  at  some  portion  of  the  body,  or  by 
chilly  sensations,  or  headache,  or  by  nausea  and  vomiting, 
or,  as  I  have  seen  in  one  instance,  by  excruciating  pain  over 
the  kidneys,  and  almost  entire  suppression  of  urine. 

Now,  cases  of  this  kind  are  difiicult  to  distinguish  from 
organic  disease.     We  can  only  do  so  by  laying  stress  on 


744  MEDICAL    DIAGNOSIS. 

their  strictly  periodical  nature ;  by  noting  that  the  curious 
manifestations  cease  entirely  to  recur  with  intensity.  This 
does  not  happen  where  the  symptoms  are  not  caused  by  a 
lurking  malarial  poison  :  for  idiopathic  disorders  exhibit  the 
phenomena  of  structural  change  or  of  deranged  function  at 
all  times ;  not  merely  on  certain  days  or  at  certain  hours. 
It  is  true  that,  among  the  inhabitants  of  miasmatic  districts, 
some  complaints,  and  particularly  those  of  the  nervous  sys- 
tem, display  a  well-defined  periodicity;  but  here,  too,  are 
found  the  significant  traits  of  organic  or  functional  disturb- 
ance between  the  decided  exacerbations  of  the  symptoms. 

Then  again  we  must  remember  that  diseases  may  assume 
an  apparently  intermittent  character,  being  worse  every 
second  day,  and  yet  not  be  malarial  at  all.  Even  mania,  as 
Schroeder  van  der  Kolk  tells  us,  may  take  this  type.  The 
whole  aspect  of  the  symptoms  and  a  tentative  treatment  with 
quinine  will  help  to  inform  us  as  to  the  true  nature  of  the 
malady. 

The  temperature  in  intermittent  fever  shows  a  peculiar 
record,  and  one  which,  in  doubtful  cases,  may  be  turned  to 
great  advantage.  Notwithstanding  the  marked  sense  of 
chilliness,  the  thermometer  rises  suddenly  and  rapidly  to 
a  high  degree.  Even  during  the  decided  chill  of  the  be- 
ginning of  the  paroxysm,  it  indicates  105°  or  more.  But 
with  the  ending  of  the  paroxysm,  it  is  found  that  the  fall 
has  been  equally  rapid.  In  the  interval  it  marks  about  a 
normal  heat ;  rising  quickly  with  each  paroxysm.  No  other 
malady  presents  these  variations. 

The  diagnosis  of  an  ordinary  and  regular  intermittent  is 
easv.  Leavino-  the  other  malarial  fevers  out  of  consideration, 
only  two  morbid  states  present  recurring  rigors  and  febrile 
excitement,  and  are,  therefore,  apt  to  be  confounded  with  it: 
hectic  fever  and  chills  attending  upon  suppuration  in  deep- 
seated  parts.  Now,  hectic  fever  difters  in  this  from  an  inter- 
mittent :  it  is  simply  a  fever  of  irritation,  the  cause  of  which 
a  careful  scrutiny  will  generally  detect.  We  find  it  accom- 
panying many  chronic  diseases  in  which  destruction  of  tissue 
occurs,  especially  phthisis;  and  the  chronic  aftection  has  its 
own  signs,  which  exist  at  all  times,  whether  the  symptomatic 


FEVERS.  745 

fever  be  present  or  not.  Then  its  outbreaks  are  irregular. 
Several  often  take  place  within  the  twenty-four  hours ;  their 
intermissions  are  incomplete;  the  temperature  does  not  fall  as 
in  intermittent  fever,  for  there  is  not  complete  defervescence  ; 
and  although  the  paroxysms  may  commence  with  chilliness, 
they  are  not  ushered  in  b}"  a  well-defined  rigor.  Further, 
they  are  apt  to  be  morning  paroxysms,  and  are  not  modified 
by  antiperiodics.  Whenever,  indeed,  we  find  an  intermitting 
fever  not  influenced  by  these  agents,  it  ought  to  arouse  sus- 
picion, and  all  the  internal  organs,  particularly  the  lungs, 
should  be  carefully  explored.  Thus,  and  thus  only,  can 
serious  errors  in  diagnosis  be  positively  guarded  against. 

When  pus  forms,  and  especially  when  it  forms  in  internal 
cavities,  it  betrays  its  presence  by  rigors,  followed  by  more 
or  less  fever.  But  these,  unlike  the  chills  of  ague,  do  not 
repeat  themselves  at  definite  periods.  Moreover,  in  the 
midst  of  the  apparent  intermission,  febrile  signs  or  other 
manifestations  of  a  seriously  disordered  system  may  be  dis- 
covered. The  chills  of  ordinary  pyaemia  are  distinguished  by 
the  same  phenomena;  then  the  rigors,  unlike  the  malarial 
malady,  are  often  characterized  by  the  profuse  sweating 
which  immediately  follows  them  rather  than  by  an  active 
development  of  the  fever. 

An  affection  which  on  account  of  the  chill  succeeded  by 
fever  might  be  mistaken  for  the  malarial  disorder  is  the 
curious  so-called  urethral  fever  which  sometimes  arises  after 
the  passage  of  a  bougie,  and  which  may  even  terminate  in 
death.*  Our  knowledc-e  of  the  introduction  of  the  instru- 
ment  and  the  non-recurrence  at  a  fixed  time  of  the  rigor 
and  febrile  phenomena  furnish  the  points  of  distinction. 

Yet  another  affection  liable  to  be  mistaken  for  intermittent 
fever  is  syphilitic  fever.  The  fever  may  occur  in  attacks 
consisting  of  a  chill,  followed  by  a  hot  stage  and  sweating, 
and  be  so  similar  to  the  malarial  disorder  as  to  lead  to 
error.f      The  apparent  ague  tits  happen,  however,  toward 

*  Eoser,  quoted  in  Brit,  and  For.  Med.-Chirurg.  Review,  Oct.  1867. 
f  See  cases  of  Bassereau,  referred  to  bvBumstcad  in  his  Treatise  on  Vene- 
real Diseases. 


746  MEDICAL   DIAGNOSIS. 

evening,  and  are  succeeded  or  accompanied  by  severe  head- 
ache and  pains  in  the  bones, — in  fiict,  by  the  same  sjmiptoms 
as  the  more  ordinary  form  of  syphilitic  fever.  In  the  form  in 
which  the  febrile  symptoms  are  continuous,  these  generally 
precede  the  eruption  for  a  week  or  more,  and  may  continue 
after  this  appears. 

Remittent  Fever. — This  is  a  fever  pre-eminently  of  hot 
climates  and  malarial  districts.  It  is  the  fever  of  Hungary, 
of  the  Pontine  Marshes,  and  particularly  of  Africa  and  the 
southern  portion  of  the  l!Torth  American  Continent.  Occa- 
sionally, not  often,  we  meet  with  it  in  winter  and  in  early 
spring;  very  generally,  during  the  summer  and  autumn 
months. 

Remittent  fever  has  no  well-defined  and  constant  prodromic 
symptoms,  excepting,  perhaps,  a  singular  sense  of  gastric 
uneasiness.  It  is  ushered  in  by  a  marked  chill,  soon  suc- 
ceeded by  violent  fever,  which,  after  a  varying  period,  de- 
creases, and  then  breaks  out  again.  By  this  time  the  symp- 
toms of  the  disease  are  very  apparent.  The  patient  complains 
of  pain,  of  fulness  and  throbbing  in  his  head.  He  is  restless 
and  distressed ;  his  limbs  ache ;  his  tongue  has  become  coated ; 
he  suffers  from  thirst,  and  rejects  the  contents  of  the  stomach. 
After  continuing  at  their  height  from  six  to  eighteen  hours, 
these  symptoms  again  subside :  a  sweat  breaks  out  all  over 
the  body ;  the  irritability  of  the  stomach  lessens ;  the  patient 
is  composed,  even  cheerful;  his  headache  has  nearly  ceased; 
and  he  falls  into  a  quiet  slumber.  But  this  lull  is  not  of  long 
duration.  Soon  the  fever  is  rekindled :  the  skin  is  as  hot  and 
dry  as  before ;  the  pulse  as  full,  frequent,  and  hard;  and  the 
other  symptoms  return  with  increased  intensity,  again  to 
abate,  again  to  recur,  until  either  the  exacerbations  are 
effaced  and  the  fever  assumes  a  continued  type,  or  else  the 
remissions  become  better  and  better  defined, — more,  indeed, 
like  intermissions  than  remissions. 

The  average  duration  of  the  fever,  unless  protracted  by 
complications,  is  about  nine  days.  Its  most  common  type 
is  the  double  tertian ;  the  exacerbations  of  alternate  days 
corresponding  in  severity,  duration,  and  even  in  the  nature 
of  the  symptoms. 


FEVERS.  747 

The  urine  in  remittent  fever  presents  much  the  same 
changes,  though  in  a  different  degree,  as  those  occurring 
in  intermittent  fever.  Its  color  is  niucli  deeper  and  its 
acidity  greater,  but  during  convalescence  the  urine  passed 
rapidly  becomes  alkaline,  throwing  down  the  most  abundant 
deposit  of  phosphates.  During  the  active  stages  of  the  fever, 
there  is  an  increase  of  urea,  not  simply  above  the  standard  of 
health,  but  even  above  that  in  intermittent  fever ;  and  this 
increase  of  urea  during  the  fever  is  attended  with  a  diminu- 
tion of  uric  acid — unlike  what  happens  during  the  paroxysm 
.of  ague — and  of  the  coloring  and  extractive  matters;  while, 
as  convalescence  sets  in,  the  urea  decreases  in  amount,  and 
the  other  ingredients  mentioned  increase.*  A  copious  de- 
posit of  urates,  forming  with  the  phosphates  as  it  were  a 
critical  discharge,  is  noticed  as  the  fever  subsides,  and  is 
analogous  to  what  takes  place  after  the  paroxysm  in  inter- 
mittent fever.  At  no  stage  does  the  urine  contain  albumen,  as 
it  often  does  in  typhus,  and  so  very  generally  in  yellow  fever. 

Remittent  fever  is  readily  recognized :  the  rise  and  fall  of 
its  febrile  signs  are  too  striking  to  escape  observation.  Its 
characteristic  traits  are  more  closely  allied  to  those  of  inter- 
mittent fever  than  to  those  of  any  other  disorder.  But  there 
are  these  points  of  contrast :  in  intermittent  fever,  each  par- 
oxysm begins  with  a  chill,  which  is  not  the  case  in  re- 
mittent fever ;  for  after  the  first  paroxysm  there  is  rarely  a 
marked  chill,  and  even  tbe  chill  ushering  in  the  disease  is 
usually  not  violent.  After  each  febrile  exacerbation  comes 
an  abatement, — not  an  intermission,  for  the  fever  does  not 
wli^lly  leave;  the  tongue  remains  coated,  and  the  gastric 
derangement  does  not  entirely  cease ;  the  patient  is  not  well, 
as  after  a  fit  of  ague.  The  symptoms  grow  and  decline  ;  they 
do  not  appear  and  disappear. 

Owing  to  the  presence  of  jaundice  in  many  cases  of  bilious 
remittent  fever,  the  disease  is  often  mistaken  for  acute  con- 
gestion of  the  liver.  Here,  again,  the  exacerbations  and 
remissions  serve  as  distinguishing  marks ;   and  so,  too,  in 


*  Joseph  Jones,  Observations  on  Malarial  Fever.  Extr.  from  the  Transact, 
of  the  Am.  Med.  Association. 


748  MEDICAL   DIAGNOSIS. 

separating  the  gastric  complications  of  bilious  remitting  fever 
from  acute  gastric  inflammation.  The  severe  headache  is 
also  a  distinctive  feature  of  value. 

Under  ordinary  circumstances,  there  is  very  little  likeli- 
hood of  confounding  with  each  other  typhoid  and  remittent 
fevers.  The  lines  between  the  two  diseases  are  too  strongly 
drawn  :  no  marked  periodicity  exists  in  typhoid  fever,  and,  on 
the  other  hand,  we  find  no  diarrhoea,  no  eruption,  no  tho- 
racic symptoms,  no  deafness,  and  no  very  great  prostration 
in  remittent  fever.  But  instances  are  met  with  in  which  the 
diagnosis  is  not  easy,  because  the  symptoms  of  the  two  mala- 
dies are  blended.  Thus,  in  a  typhoid  fever  occurring  in  a 
malarious  region  there  are  often  distinct  exacerbations  and 
remissions  obscuring  the  real  ailment.  The  malarial  influ- 
ence has  set  its  stamp  on  the  disease,  and  may  for  several 
days  completely  veil  it ;  but  soon  its  real  nature  becomes 
manifest.  The  great  weakness ;  the  low  delirium  ;  the  tym- 
panitic abdomen  ;  the  thin  passages,  so  unlike  the  dark,  hard 
stools  of  remittent  fever, — all  unfold  to  the  careful  physician 
the  true  character  of  the  disease  before  him.  Sometimes  a 
certain  periodicity  is  witnessed  in  typhoid  fever  as  it  is  ap- 
proaching a  favorable  termination.  The  skin  becomes  hot 
every  afternoon  or  evening,  while  it  is  cool  during  the  night 
or  in  the  morning.  Here  a  knowledge  of  the  previous  his- 
tory of  the  case  guards  against  error. 

JSTot  unfrequeutly,  after  an  attack  of  remittent  fever  has 
lasted  for  ten  or  twelve  days,  these  symptoms  are  noticed : 
great  muscular  debilit}-,  jerking  of  the  tendons,  picking  at 
the  bedclothes,  dark,  dry  tongue,  and  weak  pulse.  The  fever 
becomes  of  a  continued  type,  and  the  whole  aspect  of  the 
malady  is  now  that  of  a  typhoid  disease.  It  is  these  cases 
w^hich  have  given  rise  to  the  opinion  that  bilious  fever  often 
changes  into  typhoid  fever.  But  in  reality  it  is  not  so  much 
the  peculiar  specific  typhoid  fever,  with  its  enteric  lesions, 
as  a  typhoid  condition,  that  is  ordinarily  developed.  The 
abdominal  signs  are  not  encountered,  nor  do  we  find  an 
eruption,  and  there  is  very  rarely  persistent  diarrhoea. 

During  the  exacerbations  of  remittent  fever,  the  cerebral 
symptoms  are  sometimes  almost  identical  with  those  of  idio- 


FEVERS.  749 

pathic  iuflamraation  of  tlic  brain.  Tliere  is  severe  head- 
ache, with  violent  beating  of  the  arteries  of  the  neck  and 
face,  a  wild  eye,  intolerance  of  light,  and  even  delirium. 
Were  the  patient  now  seen  for  the  first  time,  he  would  be  at 
once  pronounced  to  be  laboring  under  acute  meningitis,  and 
probably  be  bled  and  freely  purged, — a  treatment  which,  for- 
tunately, is  of  advantage  to  him.  Suddenly  the  pulse  loses 
its  throbbing  character,  a  perspiration  covers  the  surfece, 
and,  as  if  by  magic,  the  cerebral  disturbance  ceases  until  the 
next  paroxysm  redevelops  it. 

Cases  of  this  kind  are  readily  enough  recognized,  if  we 
know  something  of  their  history.  If  we  are  not  familiar 
with  it,  we  have  to  await  the  remission  for  their  explanation; 
and  after  the  sudden  withdrawal  of  the  signs  of  disorder  of 
the  brain,  it  is  hardly  possible  to  have  doubts  as  to  the  mean- 
ing of  the  acute  nervous  symptoms,  should  they  recur.  It 
cannot  be  a  meningitis  we  are  dealing  with, — a  steady,  pro- 
gressing disease,  and  one  never  exhibiting  such  strange 
freaks  of  intermission.  But  occasionally  the  symptoms  show 
themselves  under  circumstances  where  a  malarial  poison  is 
not  suspected  to  be  at  work. 

A  young  gentleman,  of  studious  habits,  while  diligently 
preparing  for  a  college  examination,  was  seized  with  violent 
headache  and  fever.  The  sense  of  fulness  in  the  head  was 
unbearable,  the  fever  was  high,  there  was  nausea  with  great 
gastric  irritability.  These  symptoms  lasted  for  nearly  twenty- 
four  hours,  and  then  subsided  in  the  forenoon,  to  become 
aggravated  in  the  evening.  Delirium  followed  by  great 
drowsiness  was  perceived  at  an  early  hour  of  the  third  day 
of  the  disease.  The  case  now  assumed  a  very  alarming 
aspect.  Local  blood-letting  was  resorted  to  with  some  relief, 
and  in  a  few  hours  the  symptoms  were,  fortunately,  favorably 
modified :  the  headache  was  much  less,  the  mind  was  again 
quite  clear.  Although  the  patient  had  never  sutiered  from  a 
malarial  fever,  he  had  spent  part  of  his  summer  vacation  in 
the  marshy  neighborhood  of  Washington;  but  several 
months  had  elapsed,  and  winter  was  setting  in.  The  time 
of  the  year,  therefore,  and  his  immediate  occupations  rather 
favored  the  view  of  an  inflammation  of  the  brain.     But  the 


750  MEDICAL   DIAGNOSIS. 

evident  remission  in  the  cerebral  symptoms,  the  coated  state 
of  the  tongue,  and  that  indescribable  malarial  look  of  the 
countenance,  which  became  daily  more  apparent,  decided  me 
upon  administering  quinine, — a  course  which,  under  other 
conditions,  would  have  been  very  injudicious.  The  evening 
exacerabation  came,  but  was  far  less  severe.  The  nature  of 
the  case  was  now  evident ;  the  quinine  treatment  was  vigor- 
ously pursued,  and  the  patient  soon  recovered. 

The  violent  headache  and  delirium  were  in  this  case  ob- 
served to  be  in  connection  with  well-defined  febrile  signs. 
Occasion  ally  one  or  both  of  the  symptoms  mentioned  last 
durins:  the  remission,  while  the  fever  abates.  I  have  even 
met  with  them  occurring  in  paroxysms  without  fever  being 
present,  as  in  the  following  case  : 

A  young  lady  of  delicate  constitution  was  attacked,  in 
September,  with  remittent  fever.  The  disease  ran  its  course 
without  any  unusual  symptoms;  a  violent  headache,  but 
little  if  any  wandering  of  the  mind,  being  observed  during 
the  daily  exacerbations.  After  the  tenth  day,  the  fever  less- 
ened, and  the  disease  assumed  a  continued  type;  but  very 
soon  afterward,  every  evening  for  three  days,  between  five 
and  six  o'clock,  a  boisterous  delirium  set  in,  lasting  for  three 
or  four  hours,  and  once  nearly  all  night.  It  was  followed  by 
a  profound  sleep,  from  which  she  woke  up  with  a  clear  mind. 
Strange  to  say,  during  these  fits  the  pulse  was  not  acceler- 
ated, and  there  was  no  heat  of  skin.  The  third  attack  was 
not  so  very  severe,  as  the  patient  was  already  in  part  under 
the  influence  of  decided  doses  of  quinine;  the  fourth  was,  I 
am  sure,  prevented  by  this  drug. 

In  both  these  cases  the  symptoms  approached  those  of  the 
congestive  tj^pe  of  the  disease,  and  the  issue  appeared  at  one 
time  doubtful.  Generally  speaking,  remittent  fever,  unless 
it  be  of  the  congestive  variety,  has  a  favorable  prognosis.  It 
is  difficult  for  us,  living  in  a  century  in  which  the  remarkable 
efi^ects  of  bark  are  so  well  understood,  to  believe  that  the 
complaint  was  once  so  fatal,  and  that  so  many  deaths  should 
have  taken  place  from  a  disorder  over  which  we  now  exercise 
so  undoubted  a  control.  But  the  long  list  of  distinguished 
names  that  have  fallen  victims  to  it,  and  among  them  we 


FEVERS.  751 

iiiicl  Cromwell,  James  L,  and  the  Emperor  Charles  V.,* 
proves  the  medical  skill  of  former  times  to  have  been  insuf- 
ticient  for  its  cure.  In  our  day,  the  consequences  of  remit- 
tent fever  are  more  to  be  dreaded  than  the  disease  itself 
We  often  find,  as  its  sequelse,  most  obstinate  intermittents, 
enlargement  of  the  liver  and  spleen,  dropsy,  protracted  anae- 
mia, headache,  and  impaired  activity  of  mind. 

And  it  is  in  this  malarial  cachexia  that,  on  pricking  the 
finger  and  examining  a  drop  of  the  blood  thus  obtained,  we 
are  apt  to  detect  a  large  number  of  those  particles  and  masses 
of  black  or  dark  color  and  irregular  shape  to  which  Frerichs 
has  so  particularly  called  attention.  Not  that  the  pigment 
matter  is  merely  found  in  the  cachexia  following  remittent 
fever.  We  observe  it  in  the  blood  in  the  severer  forms  of 
any  malarial  disease;  and  it  is  very  probable  that  the  spleen 
is  the  principal  seat  of  its  formation,  and  that  it  is  chiefly  de- 
rived from  a  destruction  of  the  red  globules.  The  pigment 
is  in  great  part  carried  from  the  spleen  to  the  liver,  where  it 
remains;  or  it  passes  through  this  viscus  to  the  lungs,  brain, 
and  kidneys.  The  clogging  of  the  coarser  fragments  in  the 
capillaries  of  the  liver  may,  as  Frerichs  suggests,  by  interfer- 
ence with  the  portal  circulation,  explain  the  intestinal  hem- 
orrhage and  diarrhoea  which  attend  some  severe  cases  of  re- 
mittent fever  ;  while  the  cerebral  phenomena  or  albuminuria, 
hematuria,  or  suppression  of  urine  may  also  be  caused  by 
retention  of  pigment,  in  the  one  case  in  the  capillaries  of  the 
brain,  in  the  other  of  the  Malpighian  bodies.  Thus,  then, 
would  be  solved  some  of  the  anomalous  symptoms  of  mala- 
rial fevers.  But  the  abundance  of  pigment  does  not  occur 
in  all ;  and  whether  a  peculiar  quality  or  an  unusual  intensity 
of  the  miasm  produces  it,  is  undetermined.  In  a  diagnostic 
point  of  view,  though  from  the  very  evident  grayish  or  ash- 
colored  hue  of  the  skin,  and  the  singular  character  of  the 
symptoms,  Ave  may  suspect  that  we  have  to  deal  with  the 


*  From  the  record  of  the  Emperor's  sickness,  as  given  by  the  historian 
Mignet  (Charles  V.  au  Monastcro  cle  Yuste),  we  may  learn,  what  fortunately 
now  we  hardly  have  an  opportunity  of  observing,  the  features  of  remittent 

fever  when  left  to  itself. 


752 


MEDICAL   DIAGNOSIS. 


pathological  state  under  discussion,  yet  we  cannot  be  sure  of 
it  until  we  have  examined  the  blood  microscopically.  And 
here,  too,  it  seems  to  me  that  the  question  of  the  amount  of 
pigmentary  matter  present  must  not  be  overlooked.  For 
pigment  may  be  found  in  the  blood  of  those  who  never,  to 
their  knowledcre,  have  had  intermittent  fever,  and  who  cer- 
tainly  present  no  signs  of  malarial  poisoning.* 

Fig.  45. 


A  drop  of  Ijlood  taken  from  the  finger  of  a  man  the  suliject  of  malarial 
cachexia.  The  granules  of  pigment,  as  well  as  the  larger  fragments  of 
irregular  form,  are  seen  among  the  blood  globules.  The  pigment  was 
for  the  most  part  black;  some  of  the  particles  were  reddish  brown. 


Another  test  of  malaria  has  been  recently  proposed.  Since 
the  discovery  of  Bence  Jones  of  the  existence  in  animal  text- 
ures of  a  substance  resembling  quinia,  the  diminution  of  this 
"animal  quinoidine"  has  been  thought  to  occur  in  malarial 
disease.  The  interesting  experiments  of  Rhoads  and  Pep- 
perf  strongly  favor,  indeed,  this  view;  though  we  cannot  as 
yet  regard  the  matter  as  settled,  since  it  has  been  stated|  that 
the  fluorescent  substance  is  introduced  in  the  food  taken,  and 
is  rapidly  excreted.     The  more  rigid  diet  of  fever  patients 


*  This  whole  subject  has  been  recently  most  thorough!}-  investigated  by  my 
colleague  Dr.  J.  F.  Meigs.     See  Pennsylvania  Hospital  ReportSj  vol.  i.,  1808. 
f  Pennsylvania  Hospital  Eeports,  1868. 
+  Chalvet,  Gaz.  Hebd.,  v.  1868. 


FEVERS.  753 

might  thus  exphiin  the  apparently  abnormal  decrease  of  the 
animal  qninoidine. 

In  chiklren,  a  fever  of  remittent  type  is  observed,  the  na- 
ture of  which  has  been  a  subject  of  the  gravest  controversy. 
By  some  it  is  ascribed  to  the  irritation  of  worms;  by  others 
it  is  regarded  as  only  a  variety  of  the  ordinary  malarial  fever. 
Now,  there  can  be  little  doubt  that  what  is  called  infantile 
remittent  is  rarely  a  miasmatic  disorder.  It  is  often  a  gastro- 
enteritis connected  with  verminous  irritation,  or  produced 
by  errors  in  diet ;  or  a  typhoid  fever, — an  affection  which  now 
and  then  occurs,  even  in  verj'  young  children.  What  has 
given  rise  to  this  confusion  is,  that  all  febrile  diseases  in 
children  exhibit  a  much  greater  periodicity  than  in  adults, 
and  in  all  cerebral  symptoms  are  apt  to  be  present.  To  dis- 
tinguish the  two  maladies  alluded  to  from  true  remittent 
fever,  we  must  study  particularly  their  manner  of  com- 
mencement and  probable  origin,  and  note  the  peculiarities 
of  the  abdominal  symptoms.  Then  we  may  lay  stress  on 
the  irregular  mode  and  unequal  duration  of  the  febrile  ex- 
acerbations. Sometimes,  also,  by  close  scrutiny,  the  charac- 
teristic eruption  of  a  low  continued  fever  may  be  found  in 
an  apparent  remittent. 

But  some  of  these  cases  of  remittent  fever  are  really  of 
malarial  origin  ;  even  in  very  young  children  this  may  be 
their  source.  I  saw,  for  instance,  some  years  ago,  a  little 
girl,  three  years  of  age,  who  had  a  distinctly  malarial  remit- 
tent fever,  which  was  checked  by  antiperiodics.  During  the 
violent  exacerbations  she  was  very  delirious;  her  face  had  a 
most  anxious,  frightened  look;  her  screams  could  be  heard 
all  over  the  house.  In  the  remissions  she  was  perfectly  sen- 
sible, but  there  was  gastric  irritability,  and  the  bowels  were 
very  constipated. 

Congestive  Fever.  — This  is  a  malignant,  destructive, 
malarial  fever,  which  may  be  either  of  the  intermittent  or 
remittent  form.  The  pernicious  attacks  are  of  the  tertian 
or  quotidian  type.  While  they  are  at  their  height,  there  is 
intense  congestion  of  one  or  several  internal  organs,  and 
with  the  abnormal  condition  of  the  circulation  a  dangerous 
perversion  of  the  function  of  iimervation  is  associated.    From 

48 


754  MEDICAL   DIAGNOSIS. 

this  state  the  |(atient  ma}'  I'^Hy?  ^"^  only  to  fall  a  victim  to 
another  paroxysm,  unless  art  intervenes  to  shield  him  from 
his  doom. 

The  symptoms  of  this  violent  malady  vary  according  to  the 
organ  more  specially  disturbed,  and  to  the  extent  of  the  de- 
rangement of  the  nervous  system.  We  have,  thus,  several 
distinct  varieties,  of  which  I  shall  describe  the  most  prom- 
inent. 

The  gastro-enteric  form  is  very  common  in  our  Southwestern 
States.  Its  distinctive  featui'es  are  nausea  and  vomiting, 
purging  of  thin  discharges  mixed  with  blood,  intense  thirst, 
and  an  equally  intense  desire  for  air.  There  is  little  abdom- 
inal pain  or  tenderness,  but  a  weak,  frequent  pulse  and  very 
great  restlessness.  The  patient  complains  of  a  sense  of  sink- 
ing and  of  weight,  and  of  burning  heat  in  the  stomach.  His 
breathing  is  deep  drawn;  to  each  expiration  succeed  two 
short  inspirations.  The  face,  hands,  and  feet  are  pale  and 
cold;  the  features  shrunken.  Sometimes  these  symptoms 
continue  for  several  days,  and  gradually  increase  in  intensity, 
in  spite  of  nature  making  several  efforts  at  reaction.  More 
frequently  reaction  does  take  place;  the  skin  becomes  hot, 
the  pulse  feeble,  and  the  stormy  symptoms  subside  or  wholly 
yield  until  another  outbreak,  which  is  very  apt  to  be  deadly, 
occurs.  The  usual  length  of  the  fatal  paroxysm  is  stated  by 
Dr.  Parr}',*  in  his  short  but  interesting  sketch  of  the  disease, 
to  be  from  three  to  six  hours. 

The  thoracic  variety  of  the  malady  is  often  combined  with 
the  one  just  described.  Its  most  characteristic  trait  is  violent 
dyspnoea,  caused  by  overwhelming  congestion  of  the  lungs. 
It  is,  perhaps,  the  most  rapidly  destructive  of  all  the  forms 
of  the  disastrous  affection. 

In  the  cerebral  variety  there  is  intense  congestion  of  the 
brain ;  and  sometimes  effusion  of  serum  into  the  ventricles 
takes  place,  or  even  rupture  of  the  blood-vessels.  The  ab- 
normal state  of  the  brain  manifests  itself  either  by  coma  or 
by  delirium.  In  the  former  case,  there  is  usually  preceding 
stupor  with  occasional  delirium;  the  pulse  is  slow  and  full; 

*  Amor.  Jouni.  uf  the  Med.  Sciences,  July,  1843. 


FEVER?.  7o5 

the  face  dull,  and  either  flushed  or  livid  ;  indeed,  some  of  the 
symptoms  which  are  observed  in  apoplexy  show  themselves. 
When,  on  the  other  hand,  delirium  is  marked,  we  have  much 
the  same  morbid  phenomena  as  in  acute  meningitis:  the 
patient  is  wild;  he  sings,  he  cries.  He  may  die  in  this  state 
without  coma  supervening;  but  a  comatose  condition  gener- 
ally succeeds  rapidly  to  tlie  fierce  excitement.  Should  re- 
covery take  place,  the  delirium  gradually  ceases. 

Another  variety  much  dwelt  upon  by  authors  is  the  so-called 
algid  form.  This  is  not  often  seen  in  this  country ;  I  abridge 
Maillot's*  description  of  it  as  he  noticed  it  in  Corsica  and 
Algeria.  The  disease  is  more  than  a  mere  continuation  of 
the  cold  stage  of  a  paroxysm  ;  most  commonly  the  character- 
istic symptoms  manifest  themselves  during  the  period  of  re- 
action. Tiie  pulse  slackens,  and  finally  ceases;  the  extrem- 
ities, face,  and  trunk  become  in  succession  rapidly  cold. 
There  is  no  thirst;  the  skin  feels  like  marble;  the  breath  is 
cold;  the  voice  broken.  The  mind  is  clear;  the  expression 
of  the  countenance  impassive,  and  like  that  of  a  dead  man. 
There  may  be  vomiting  and  choleraic  discharges.  These 
symptoms  go  on  steadily  toward  death,  unless  decided  re- 
action be  brought  about. 

Now,  in  none  of  these  forms  of  congestive  fever  is  the 
first  paroxysm  apt  to  be  of  a  pernicious  character.  In  the 
majority  of  instances  the  disease  begins  as  ordinary  periodic 
fever;  and  it  is  only  in  the  second  or  third  paroxysm 
that  the  alarming  symptoms  appear.  jSTor  is  the  first  con- 
gestive paroxysm  very  likely  to  prove  mortal ;  generally  it 
is  not  until  the  second  or  third  that  a  fatal  issue  is  to  be 
apprehended.  But  this  is  no  excuse  for  neglecting  to  pro- 
vide for  the  patient's  safety  by  the  promptest  treatment. 
Indeed,  whenever  we  are  dealing  with  a  periodical  fever  in 
districts  where  intermittents  or  remittents  are  known  to 
assume  a  malignant  form,  we  must  be  constantly  on  the 
lookout  for  the  possibility  of  their  becoming  of  the  perni- 
cious type.  Proper  w^atch fulness  will  sometimes  detect, 
even  at  the  onset  of  the  attack,  by  the  unusual  prolongation 


*  Traite  des  Fifevres  Intermittentes.     Paris,  1836. 


756  MEDICAL    DIAGNOSIS. 

of  the  cold  stage,  or  by  irregularity  of  the  pulse,  by  the 
great  sensitiveuess  in  the  splenic  region  and  by  the  pain 
pressure  there  may  occasion  all  over  the  body,  or  by  an  im- 
perfect hot  stage,  or  by  the  feeling  of  internal  heat  while 
the  surface  is  really  cold,  the  danger  that  is  approaching, 
and  arrest  its  further  steps  by  the  bold  use  of  antiperiodics.* 

The  cause  of  this  desperate  disease  is  evidently  a  highly 
active  malarial  poison;  and  once  in  the  system,  it  remains 
for  a  long  time.  Thus,  should  the  patient  even  weather  the 
first  attack  completely,  he  is  not  wholly  out  of  danger;  for 
he  has  not  entirely  gotten  rid  of  the  morbific  influence.  He 
may  have  a  second  seizure  quite  as  dangerous  within  the 
same  season. 

Before  proceeding  to  the  discussion  of  another  subject,  I 
shall  here  devote  a  few  pages  to  the  consideration  of  some 
of  the  irregular  forms  and  modifications  ot  malarial  poison- 
ing, and  to  its  share  in  producing  febrile  disorders  of  blurred 
and  uncertain  type.  Practically,  this  is  of  very  great  im- 
portance, and  specially  of  importance  to  American  phy- 
sicians. 

In  the  first  place,  I  shall  speak  of  the  chronic  malarial 
poisoning  so  often  seen  among  inhabitants  of  malarial  dis- 
tricts. It  manifests  itself  by  lassitude,  debility,  torpor  of 
the  liver,  and  enlargement  of  the  spleen.  The  stools  are 
often  black,  the  digestion  is  impaired,  the  complexion  sal- 
low. Occasionally  attacks  of  jaundice  occur,  which  rather 
relieve  than  aggravate  the  unhealthy  state  of  the  system. 
Sometimes  the  noxious  influence  shows  itself  in  another 
way  :  the  patient  is  seized  with  nausea,  and  gastric  irrita- 
bility so  great  that  almost  everjthing  he  takes  is  instantly 
rejected.  The  tongue  is  coated,  the  skin  dryish;  but  he  has 
little  if  any  fever.  The  bowels  are  confined,  the  urine  is 
turbid.  He  is  restless,  and  as  weak  as  if  he  had  typhoid 
fever;   but  he  has  neither  an  eruption  nor  diarrhoea.     His 


*  For  observations  illustrative  of  the  different  forms  of  the  disorder,  see 
Louis,  New  Orleans  Journal,  vol.  iv.;  A.mes,  ibid.;  Holmes,  American  Medi- 
cal Intelligencer,  vol.  xxxix.;  Ford,  South.  Medic.  Journ.,  vol.  iv.  Also 
iJurtlett  on  the  Fevers  of  the  United  States  ;  Dickson,  Elements  of  Medi- 
cine ;  Semenas,  De  la  Fi^vre  Pernicieuse  chez  les  Enfants,  Paris,  1848. 


FEVERS.  757 

sleep  is  disturbed,  and  he  often  suffers  with  hypcra?sthesia 
of  the  scalp,  and  neuralgic  pain  shooting  over  the  forehead 
and  causing  twitching  of  the  eyelids.  After  remaining  from 
six  to  seven  days  in  this  condition,  his  nails,  perhaps  at  a 
certain  hour  every  day,  are  noticed  to  become  bluish;  or  he 
feels  chilly,  and  a  slight  fever  immediately  afterward  sets  in. 
The  return  of  these  febrile  symptoms  is  checked  by  quinine, 
and  the  patient  enters  upon  a  slow  convalesence,  remaining 
for  a  long  time  enfeebled. 

Cases  of  this  stamp  were,  during  the  late  war,  frequently 
noticed  among  those  who  had  been  poisoned  by  malaria  in 
the  Southwestern  States  or  in  the  vicinity  of  Washington,  and 
who  had  returned  from  the  army  to  their  homes  in  the  condi- 
tion set  forth.  The  poison  was  often  very  obscure  in  its  mani- 
festations; at  times  it  became  the  occasion,  remote  if  not  im- 
mediate, of  a  state  resembling  typhoid  fever,  although  by  no 
means  identical  with  it.  Probably  for  the  most  part  of  simi- 
lar origin,  and  in  several  respects  of  kindred  nature,  was  that 
curious  fever  which  so  many  soldiers  brought  with  them  from 
the  swamps  of  the  Chickahominy.  Without  attempting  to 
describe  it  in  full,  I  shall  give  a  sketch  of  the  phenomena  I 
noticed  among  those  who  had  been  with  the  army  during 
the  Peninsular  campaign  and  were  sent  to  the  city  for  med- 
ical treatment. 

The  fever,  I  was  informed,  generally  commenced  with  a 
decided  chill,  to  which  febrile  excitement  soon  succeeded. 
This  chill  was  sometimes,  but  not  always,  repeated.  Many 
cases  of  the  disorder  showed  at  Urst  distinct  remissions  ;  but 
if  the  fever  lasted  for  more  than  a  week,  it  became  continued. 
Diarrhoea  was  a  prominent  symptom  from  the  iirst;  some- 
times it  preceded  the  disease  by  several  weeks.  In  the  cases 
that  I  saw  in  Philadelphia,  nausea,  and  vomiting  of  bile,  and 
great  thirst  were  often  present;  the  stools  were  very  frequent 
and  offensive;  the  eye  was  injected.  There  was  generally 
mental  confusion,  and  not  unusually  wild  delirium ;  but  no 
eruption — certainly  no  rose-colored  spots.  The  tongue  was 
sometimes  coated,  but  often  smooth,  clean,  and  moist.  The 
debility,  after  the  affection  had  reached  the  middle  or  the 
end  of  the  second  week,  was  extreme.     The  face  was  pale. 


758  MEDICAL    DIAGNOSIS. 

dull  in  its  expression,  and  became,  from  day  to  day,  like  the 
rest  of  the  body,  more  and  more  emaciated.  It  was  mostly 
of  a  very  sallow  hue,  seldom  really  jaundiced;  at  least  the 
conjunctivae,  although  injected,  were  not  discolored.  The 
skin  was  dry,  and  not  very  hot.  The  heart  sounds  were 
feeble,  as  was  also  the  pulse.  The  lungs  generally  remained 
healthy.  In  the  third  week  of  the  disease,  the  patient  was 
apt  to  enter  upon  convalescence,  or  he  died  utterly  exhausted, 
the  freest  stimulation  exerting  but  little  effect. 

The  post-mortem  examinations  were  only  to  a  certain  ex- 
tent satisfactory,  as  regards  the  light  they  threw  upon  the 
symptoms.  In  a  large  number  of  instances,  perhaps  the 
majority,  neither  the  solitary  nor  Peyer's  glands  were  ulcer- 
ated. They  were  frequently,  however,  found  to  be  swollen, 
and  sometimes  of  very  dark  color.  The  mucous  membrane 
of  the  lower  portion  of  the  ilium  and  of  the  colon  was  often 
seen  to  be  congested,  even  inflamed.  The  heart  was  several 
times  noted  as  flabby.  ISTone  of  the  other  organs  presented 
any  constant  lesions. 

The  convalescence  from  the  fever  was  very  slow;  and 
during  this  protracted  recovery  symptoms  occurred  quite  as 
striking  as  those  of  the  fever  proper.  Those  who  got  well 
did  so  with  a  broken  constitution,  and  showed  for  months, 
by  their  wan  face  and  their  great  debility,  the  hold  the  dis- 
ease had  had  upon  them.  Sometimes,  after  gaining  strength 
slowly  for  some  time,  they  lost  ground  again,  and  relapsed 
into  a  typhoid  condition  very  similar  to  that  of  the  first  at- 
tack, excepting  in  exhibiting  an  almost  undisturbed  state  of 
the  mind  and  a  more  continued  character  of  the  fever. 

The  blood  was  left  very  much  impoverished.  This  fact 
manifested  itself  b}'  the  pallid  face,  the  blood  murmurs  heard 
over  the  heart  or  the  irritability  of  that  organ,  and  the  dark- 
purple  spots,  unchanged  by  pressure,  which  showed  them- 
selves at  times  all  over  the  body,  and  often  did  not  appear 
until  Ions:  after  the  fever  had  left. 

As  other  sequelae  of  the  fever,  for  in  a  certain  sense  they 
were  sequelae,  I  noticed  milk-leg,  enlargement  of  the  liver, 
tympanites,  parotitis,  and  diarrhoea,  which  ceased  at  times, 
but  only  to  break  out  again.     The  looseness  of  the  bowels 


FEVERS.  750 

was  not  generally  associated  with  ulceration  or  thickening  of 
the  intestinal  mucous  membrane  ;  the  solitary  and  agminated 
glands  were  prominent,  and  contained  blackish  pigment. 
This  diarrhoea  was  very  obstinate,  is  still  met  with,  and  will 
probably  be  encountered  long  after  all  other  signs  of  the 
"Chickahomin}^  fever"  have  vanished  from  view.* 

Yellow  Fever. — This  formidable  malady  is  known  under 
more  than  one  name.  It  is  the  disease  of  Siam,  the  malig- 
nant pestilential  fever,  the  Mediterranean  fever,  the  malig- 
nant bilious  fever  of  America,  the  sailor's  fever,  typhus 
icterodes.  It  takes  its  familiar  appellation  of  yellow  fever 
from  the  yellow  tinge  assumed  during  its  course  by  the  skin. 

Yellow  fever  is  a  distemper  met  with  in  hot  climates  in  low 
and  level  localities  on  the  sea-coast.  It  is  a  virulent  disorder, 
presenting  many  valid  claims  to  be  recognized  as  a  separate 
member  of  the  family  of  fevers.  Its  source  is  unknown: 
and  though  in  many  respects  like  malaria,  it  is  so  unlike  it 
in  others  that  we  cannot  call  the  complaint  a  miasmatic  one. 
All  we  know  of  its  cause  is,  that  it  does  not  exist  without  a 
high  temperature,  and  that  frost  is  its  greatest  enemy. 

Yellow  fever  is  an  affection  of  very  short  duration  :  it 
rarely  lasts  a  week  ;  many  die  on  the  third  or  fifth  day  of  the 
disease.  It  has  but  one  paroxysm,  which  is  never  repeated. 
This  paroxA'sm  may  be  divided  into  three  stages,  which  are 
well  marked  in  some  epidemics,  far  less  so  in  others. 

The  first  stage,  called  that  of  reaction,  is  pre-eminently 

*  According  to  Dr.  Woodward  (Outlines  of  the  Chief  Carap  Diseases), 
this  fever  is  one  of  those  belonging  to  a  group  named  by  him  "  typho- 
malarial,"  which  was  the  most  frequent  form  of  camp  f(!ver  during  the  late 
war.  It  consists  of  mixed  cases,  in  which  the  malarial  and  typhoid  ele- 
ments are  variously  combined  with  each  other  and  with  the  scorbutic  taint, 
now  one,  now  the  other  of  these  elements  preponderating.  Prominent  among 
the  peculiarities  of  the  malady  are  stated  to  be  a  decided  tendency  to  perio- 
dicit}^  hepatic  tenderness,  with  an  icteroid  hue  of  the  countenance,  gastric 
disturbance,  excessive  enlargement  of  the  spleen,  a  very  protracted  convales- 
cence, and  the  appearance  throughout  of  the  signs  of  a  scorbutic  affection. 
The  rose-colored  rash  and  the  tympanites  of  typhoid  fever  are  generally 
absent.  Diarrhoea  is  ordinarily  very  marked,  and  is  apt  to  be  persistent.  A 
plate,  representing  very  artistically  the  intestine  in  the  so-called  typho- 
malarial  fever,  may  be  found  in  Circular  No.  6,  War  Department,  Surgeon- 
Greneral's  Office,  Washington,  1865. 


760  MEDICAL   DIAGNOSIS. 

the  febrile  stage.  Its  average  duration  is  from  thirty-six  to 
forty-eight  hours.  It  generally  commences  suddenly,  and  is 
very  frequently  ushered  in  by  a  chill.  Soon,  however,  the 
febrile  excitement  becomes  established.  The  skin  is  harsh 
and  hot ;  the  pulse  quick  and  tense,  although  sometimes  it 
is  both  easily  compressible  and  not  very  accelerated.  The 
face  is  flushed  ;  the  eye  brilliantly  injected,  yet  watery.  The 
patient  is  conscious,  restless,  anxious,  and  complains  much  of 
the  torturing  pains  in  liis  forehead,  loins,  and  legs.  The 
breathing  is  hurried;  the  stomach  irritable,  the  epigastrium 
painful  on  pressure  ;  there  is  great  thirst.  The  bowels  are 
constipated;  the  stools  very  dark  colored.  The  tongue  is 
more  or  less  coated  and  moist;  sometimes  it  is  red,  while 
at  others  it  remains  natural  throughout  the  disease.  The 
febrile  signs  increase  toward  evening,  and  lessen  toward 
morning;  but  do  not  distinctly  remit  until  after  from  thirty- 
six  to  forty-eight  hours,  when  a  remission  does  occur,  or 
when,  to  speak  more  correctly,  the  whole  aspect  of  the  ease 
chano;es. 

The  disorder  now  appears  in  its  second  stage :  the  fever 
subsides;  the  pulse  falls  and  becomes  easily  compressible ; 
the  headache  is  relieved  ;  the  breathing  is  no  longer  op- 
pressed. But  the  gastric  irritability  does  not  wholly  disap- 
pear, and  a  deep-yellow  or  orange  hue  gradually  tinges  the 
eye  and  the  whole  surface  of  the  body.  The  patient  is 
cheerful,  and  wishes  to  get  out  of  bed.  And  indeed  his  suf- 
ferings may  be  over,  his  convalescence  may  have  set  in : 
after  a  few  dark-colored,  biliarj-  stools,  the  yellowness  of  the 
skin  fades,  and  he  is  well. 

But  it  is  not  often  that  the  disease  relaxes  its  hold  so  easily; 
more  generally  the  deceptive  improvement  does  not  last  a 
(lay,  and  after  the  brief  lull  the  struggle  for  life  begins.  The 
patient  grows  again  very  uncomfortable  and  anxious.  In 
truth,  the  symptoms  of  the  first  stage  reappear  with  increased 
intensity.  In  addition,  new  signs  of  the  gravest  import  show 
themselves :  the  pulse  sinks,  and  becomes  slow  and  ex- 
tremely irregular;  the  skin  is  cool,  dry,  very  dark,  and  in 
some  cases  of  a  bronze  hue,  and  spots  may  occasionally  be 
seen  on  its  suiface.     The  stomach  is  as  irritable  as  before, 


FEVERS.  761 

but  the  act  of  vomiting  is  easier;  and,  without  nuu-h  retch- 
ing, large  quantities  of  altered  blood,  or  "black  vomit,"  are 
ejected.  Blood  oozes  from  the  mouth,  from  the  gums; 
sometimes  from  the  eyes  and  nostrils,  from  the  bowels,  and 
from  the  vagina  ;*  or  hemorrhage  takes  place  into  internal 
cavities,  and  the  blood  is  retained. f 

The  phenomena  of  collapse  become  now  more  and  more 
unmistakable :  the  black  vomit  often  ceases,  because  the 
contractile  power  of  the  stomach  has  ceased  ;  a  low,  mutter- 
ing delirium  sets  in,  and  the  patient  dies  prostrated.  Yet 
the  mind  may  remain  clear  almost  to  the  last,  and  the 
strength  be  but  little  impaired.  Should  reaction  take  place, 
recovery  is  only  very  gradual. 

But  yellow  fever  does  not  at  all  times  and  in  all  localities 
present  preciselj'  the  same  degree  of  intensity,  or  the  same 
group  of  symptoms.  Sometimes  it  exhibits  frank,  active 
febrile  phenomena;  at  other  times  there  is  little  febrile  ex- 
citement, but  a  disposition  to  internal  congestions  and  to 
earlv  prostration.  This  congestive  form  is  far  more  danorer- 
ous  than  the  infiammatory ;  yet  both  are  highly  destructive. 
From  10  up  to  75  per  cent,  are  the  figures  representing  the 
mortality  of  this  fearful  malady.  Omitting  the  instances  of 
an  exceptionably  mild  type,  the  average  is  calculated,  in  the 
elaborate  work  of  Dr.  La  Roche,|  to  be  1  in  2*32.  The  more 
rapidly  the  stages  succeed  each  other,  the  more  dangerous 
the  case.  The  occurrence  of  black  vomit,  of  very  great  epi- 
gastric tenderness,  of  hiccough,  of  suppression  of  urine,  of 
delirium,  of  early  jaundice,  of  oppression  in  breathing,  of 
convulsions,  of  a  fiery,  glistening  eye,  and  of  petechia, — 
warrant  an  unfavorable  prognosis.  "Walking  cases,"  or 
those  in  which  the  patients  walk  about  until  they  suddenly 
eject  black  vomit,  always  terminate  fatally. 

The  recognition  of  yellow  fever  is,  generally  speaking. 


*  Cases  in  the  epidemic  of  1850-57  at  Lisbon,  reported  upon  by  Lyons, 
London,  1858  ;  also  by  Da  Costa  Alvarengo,  Tiovre  jaune  a  Lisbonne,  Paris, 
1861. 

f  In  a  case  at  the  Pennsylvania  Hospital,  in  1853,  the  pericardium  was 
filled  with  blood  resembling  black  vojnit. 

X  Yellow  Fever.     Philadelphia,  1855. 


762  MEDICAL    DIAGNOSIS. 

easy.  The  intense  pain  in  the  hack,  limbs,  and  forehead  ; 
the  appearance  of  the  eye,  the  color  of  the  skin ;  the  short 
duration  of  the  febrile  symptoms;  the  nausea;  the  epigas- 
tric tenderness;  the  black  vomit, — constitute  a  group  of 
symptoms  which  unmistakably  mark  the  disease. 

But  let  us  look  at  the  points  of  contrast  which  yellow  fever 
presents  to  other  affections.  It  difiers  from  p?a^?/6  by  the 
absence  of  buboes  and  of  carbuncles,  and  the  much  more 
frequent  occurrence,  on  the  other  hand,  of  jaundice  and 
black  vomit.  Then,  too,  the  red,  suffused  eye  and  the  single 
paroxysm  are  not  witnessed  in  plague.  The  febrile  malady 
may  run  on  to  a  state  of  collapse  as  complete  as  in  Asiatic 
cholera;  but,  unlike  this  destructive  disease,  the  symptoms  of 
entire  prostration  are  preceded  by  fever,  and  not  by  vom- 
iting or  purging  of  rice-water. 

The  lines  of  demarcation  between  the  ordinary  forms  of 
continued  fever  and  yellow  fever  are  very  broadly  drawn. 
It  is  distinguished  from  relapsing  fever  by  the  different  coun- 
tenance, by  the  supra-orbital  pain,  and,  above  all,  by  the 
extreme  rarity  of  a  relapse  and  the  infinitely  greater  mortality. 
To  typhoid  fever  it  bears  so  slight  a  resemblance  that  it  is 
scarcely  possible  to  confound  the  two  affections:  one,  a  short, 
severe  disease,  with  its  peculiar  physiognomy  and  gastric 
symptoms;  the  other,  a  long-continued  malady,  of  low  type, 
with  its  characteristic  eruption  and  enteric  signs.  It  is  only 
when  yellow  fever  is  protracted  beyond  the  ninth  day  that 
the  diagnosis  is  rendered  doubtful;  and  then  we  have  gen- 
erally the  history  to  guide  to  a  correct  understanding  of  the 
case.  The  likeness  between  yellow  fever  and  typhus  is  much 
closer.  But  one  is  a  short  fever,  with  distinct  stages;  the 
other  is  a  longer,  much  more  continued  fever.  One  has  no 
marked  cerebral  symptoms;  in  the  other,  the  cerebral  symp- 
toms are  the  most  prominent  feature.  One  has  but  rarely  an 
eruption,  but  often  hemorrhages ;  the  other  has  always  an 
eruption,  and  hardly  ever  hemorrhages. 

The  disease  most  likely  to  be  confounded  with  yellow  fever 
is  bilious  remittent.  In  truth,  the  symptoms  are  very  similar, 
and  many  of  them  differ  only  in  intensity.  The  diagnosis 
of  the  milder  forms  of  yellow  fever  from  remittent  fever  is 


FEVERS. 


763 


indeed  extremely  difficult,  unless  the  epidemic  influences 
prevailing  be  taken  into  account.  Then,  as  is  well  known, 
the  affections  may  be  blended,  and  yellow  fever  become  obvi- 
ously periodical  in  its  febrile  phenomena.  The  occurrence  of 
black  vomit  is  not  in  itself  a  distinctive  sign  between  the 
two  diseases  ;  for  black  vomit  may  be  absent  in  yellow  fever, 
and,  on  the  other  hand,  it  may,  although  it  rarely  does,  occur 
in  remittent  fever,  just  as  it  has  been  known  to  occur  in 
child-bed  fever,  in  the  plague,  and  even  in  typhus  fever.* 

The  least  doubtful  sign,  a  recent  Avriter  tells  us,  is  derived 
from  an  examination  of  the  urine.  Unlike  what  happens  in 
bilious  fever,  albumen  appears  in  from  twelve  to  fourteen 
hours  after  the  fever  sets  in,  as  becomes  manifest  by  the 
cloud  which  nitric  acid  causes ;  then  the  albumen  increases, 
and  the  traces  of  urea  and  the  uric  acid  diminish  and  grad- 
ually disappear,  so  does  the  bile  pigment.f 

When  yellow  fever  is  well  marked,  it  differs  in  this  way 
from  remittent : 


Yellow  Fever. 

Of  short  duration,  ending  commonly 
in  from  three  to  seven  days. 

Period  of  incubation  from  five  to  nine 
days. 

A  disease  of  one  paroxysm,  termina- 
ting in  recovery  or  collapse. 

Verj'  severe  nausea  and  vomiting 
throughout ;  early  and  decided  epi- 
gastric tenderness ;  black  vomit. 


Hemorrhages  from  gums  and  various 
parts  of  the  body. 


BiLiOLrs  Kemittent. 
Lasts  nine  days  or  upwards. 

Period  of  incubation  very  variable  ; 
may  extend  to  months. 

A  disease  of  several  paroxysms,  with 
intervening  remissions. 

Nausea  and  vomiting  not  so  severe, 
and  rarely  as  marked  at  the  onset ; 
neither  as  early  nor  as  constant 
and  decided  epigastric  tenderness  ; 
vomiting  of  bile  and  of  the  con- 
tents of  the  stomach. 

No  hemorrhagic  tendency. 


*  This  statement  with  reference  to  typhus  fever  is  made  on  the  authority 
of  Dr.  Stokes.  The  occasional  occurrence  of  black  vomit  in  remittent  fever 
is  admitted  by  many  authors.  Several  winters  ago,  a  physician  of  this  city 
brought  to  me,  for  examination,  a  specimen  of  black  vomit  which  had  the 
same  microscopical  characters  that  I  have  been  in  the  habit  of  finding  in 
the  black  vomit  of  yellow  fever.  The  patient  undoubtedly  had  remittent 
fever,  from  which  he  recovered. 

t  Ballot,  Archiv.  Gener.,  Nov.  1869. 


764 


MEDICAL    DIAGNOSIS. 


Yellotv  Fever. 
Tongue  clean,  or  but  slightly  coated  ; 

pulse  very  variable,  becomes  slow 

in  last  stages. 
Highly  injected,    humid    eye;    often 

fierce,   or    anxious    expression    of 

face. 
Supra-orbital  pain,  and  pain  in  back 

and  in  calves  of  the  legs. 
Very  rarely  delirium  ;   mind  gener- 
ally clear. 
Urine   generally  contains  albumen  ; 

suppression  of  urine  common. 
Little    muscular    prostration ;    often 

rapid  convalescence  ;  no  sequelifi. 

Almost  certain  immunity  after  one 
attack. 

Very  high  mortality ;  disease  is  epi- 
demic. 

Treatment  unsatisfactory. 

Autopsy  shows  Inflammation,  or 
very  great  congestion  of  stomach, 
and  sometimes  ulceration  or  soft- 
ening. Liver  enlarged,  of  a  yel- 
lowish color;  its  secreting  cells 
filled  with  oil  globules.  Heart 
often  exhibits  disintegration  of 
muscular  fibres. 


Bilious  Eemittext. 

Tongue  heavily  coated  ;  pulse  varies 
less,  is  always  quick  until  conva- 
lescence sets  in. 

Eye  not  peculiar  ;  difi'erent  physiog- 
nomy. 

Headache  ;  sense  of  fulness  in  head  ; 

often  no  pain  in  loins  or  in  legs. 
Delirium  frequent;  mind  always  dull. 

No  albumen  in  urine  ;  suppression  of 
urine  rare. 

Much  greater  muscular  prostration  ; 
slow  convalescence  and  tedious  se- 
quelse. 

One  attack  seems  rather  to  predis- 
pose to  others. 

Slight  mortality ;  disease  more  en- 
demic in  its  nature.- 

Yery  amenable  to  treatment. 

Autopsy  shows  congestion  of  stom- 
ach ;  more  rarely  a  high  degree  of 
inflammation.  Liver  of  an  olive 
or  bronze  hue,  not  fatty. 


Eruptive  Fevers. 


The  eruptive  or  exanthematous  fevers  form  a  group  hav- 
ing numerous  features  in  common.  Thej  are  all  charac- 
terized by  a  period  of  incubation,  during  which  the  poison 
lies  dormant  in  the  sj'stem;  b}'  a  fever  of  more  or  less  inten- 
sity preceding  the  eruption;  by  an  eruption  which  presents  a 
distinct  aspect  in  each  disease,  and  which  pursues  a  definite, 
clearly-detined  course  until  it,  and  with  it  the  febrile  malady, 
disappears.  Moreover,  they  are  all  very  prone  to  occasion 
serious  sequelae;  are  all,  in  the  main,  disorders  of  childhood  ; 
rarely  attack  the  same  person  twice;  are  contagious;  and 
have  not  as  yet  been  brought  under  the  influence  of  specific 
treatment, — the  most  important  part  of  our  treatment  rela- 
ting to   remedying  the  complications  that  arise  while  the 


FEVERS.  765 

febrile  afFection  is  held  on  its  reo-iilar  course.  Their  ori<nn 
is  as  yet  unknown,  and  their  prevention,  as  a  groui),  uncer- 
tain. One  of  them,  however,  has  been  checked  in  its  ravasfes 
by  a  wonderful  discovery,  and  it  is  not  too  much  to  hope  that, 
one  of  these  days,  all  will  be  brought  similarly  under  the 
control  of  science. 

These  remarks  apply  particularly  to  the  three  chief  exan- 
thematous  fevers:  scarlet  fever,  measles,  and  small-pox.  In 
great  part,  too,  they  hold  good  in  regard  to  erysipelas,  de- 
scribed here  in  connection  with  the  eruptive  fevers. 

Scarlet  Fever. — This  disease,  known  also  as  scarlatina,  is 
one  of  the  gravest  of  the  exanthemata,  affecting  both  children 
and  adults,  and  marked  by  great  heat  of  skin,  frequent  pulse, 
sore  throat,  and  an  early  scarlet  eruption.  These  symptoms 
are  often  preceded  by  an  uncertain  period  of  incubation,  but 
soon  exhibit  their  striking  features.  The  febrile  excitement 
is  characteristic;  the  skin  very  hot  and  generally  dry,  and 
the  rapidity  of  the  pulse  so  great  that  often  by  this  sign  alone 
we  may,  especially  in  the  midst  of  an  epidemic,  predict  the 
coming  eruption.  Vomiting,  too,  is  a  frequent  symptom  at 
the  beginning  of  the  illness. 

The  rash  appears  on  the  second  day  of  the  disease.  It 
comes  out  almost  simultaneously  all  over  the  body,  although, 
on  close  scrutiny,  it  may  be  soonest  perceived  on  the  neck 
and  breast.  At  first  the  surface  exhibits  an  almost  uniform 
red  blush,  which  disappears  momentarily  on  pressure,  or 
rather  pressure  leaves  a  white  stain  on  the  skin,  which 
quickly  again  reddens  from  the  periphery  to  the  centre. 
Soon,  however,  the  eruption  presents  an  unequal  aspect:  it 
is  of  more  vivid  scarlet  hue  in  some  parts  of  the  body,  as  in 
and  around  the  flexures  of  the  joints,  and  is  not  everywhere 
smooth.  Here  and  there  are  seen  elevated  rough  points  of 
darker  tint  edged  by  the  red  integument,  and  not  unfre- 
quently  vesicles  containing  a  thin  fluid.  The  skin  is  very 
hot  and  itchy,  and,  especially  on  the  hands  and  feet,  tume- 
fied. On  the  fourth  or  fifth  day  of  the  eruption,  it  declines; 
by  the  seventh,  the  cuticle  begins  to  come  away  in  large 
flakes.  Sometimes  the  rash,  when  at  its  height,  recedes,  and 
then  appears  again.     In  malignant  cases  it  comes  out  late, 


766  MEDICAL    DIAGNOSIS. 

and  is  cither  pale  and  indistinct  or  dark  and  livid.  In  some 
instances  it  is  wholly  ^Yanting.  Some  years  ago,  I  saw  a  case 
of  this  "scarlatina  sine  exanthemate"  in  a  lady,  who,  watch- 
ing over  the  sick-bed  of  her  daughter,  contracted  the  disease 
and  went  regularly  through  it,  even  to  its  seqnelse  of  disorder 
of  the  kidneys  and  sw-elling  of  the  salivary  glands,  but  in 
whom  not  a  trace  of  an  eruption  could  be  detected. 

The  S07^e  throat  of  scarlatina  is  almost  as  constant  and  as 
characteristic  as  the  scarlet  rash.  It  shows  itself  very  early, 
sometimes  before  the  eruption,  and  rarely  waits  until  the 
third  da}'  of  the  coinplaint.  At  first  the  throat  trouble  con- 
sists in  a  diffused  redness  extending  over  the  tonsils,  j^alate, 
and  half-arches,  and  in  a  swelling  of  the  tonsils:  the  patient 
complains  of  pain  in  his  throat,  augmented  by  pressure  and 
by  swallowing,  and  of  stiflhess  of  the  muscles  of  the  neck. 
After  a  few  days,  if  the  disorder  be  severe,  irritating  dis- 
charges occur  from  the  inflamed  surfaces,  and  patches  of 
false  membrane  and  superficial  ulcerations  are  seen  in  the 
fauces.  The  glands  at  the  angle  of  the  jaw  become  much 
tumefied,  and,  by  pressing  on  the  cervical  vessels,  produce  a 
tendency  to  drowsiness  and  stupor.  These  are  grave  symp- 
toms ;  their  occurrence,  indeed,  is  indicative  of  one  of  the 
main  dangers  in  these  "anginose"  cases  of  the  disease. 

The  false  membranes  which  are  developed  last  about  five  or 
six  days;  they  form  as  well  as  re-form  in  patches,  and  are  very 
easily  removed.  Sometimes  they  extend  to  the  larynx;  but 
this  does  not  often  happen,  and  even  when  it  does,  the  symp- 
toms of  croup,  in  the  opinion  of  Barthez  and  Rilliet,*  do 
not  arise.  The  acrid  discharges  and  the  decomposing  mem- 
branes often  occasion  a  most  fetid  breath,  and,  by  being 
swallowed,  a  persistent  diarrhoea. 

The  tongue  has  a  peculiar  look.  At  first  it  is  thickly  coated, 
and  its  borders  only  are  red  ;  but  soon  the  fur  is  cast  off,  and 
the  whole  organ  becomes  very  red  and  its  papillae  prominent. 
After  it  has  presented  this  appearance  for  six  or  eight  daj's, 
it  returns  to  its  normal  condition.  In  bad  cases  it  is  ex- 
tremely dry  and  of  a  brownish  hue. 


*  Maladies  des  Enfants,  tomo  iii. 


FEVERS.  707 

In  children,  the  disease  frequently  sots  in,  as  the  eruptive 
fevers  are  apt  to  do,  with  convulsions.  In  truth,  cerebral 
symptoms  of  one  kind  or  another  are  not  uncommon  at  all 
stages  of  the  malady  ;  yet  very  great  differences  are  observed, 
in  this  respect,  in  different  epidemics.  In  some  cases  of  ma- 
lignant character,  the  vomiting,  the  screams,  the  grinding  of 
the  teeth,  the  occurrence  of  delirium  and  insomnia,  make 
the  attack  look,  at  the  onset,  like  one  of  acute  meningitis ; 
but  the  eruption  soon  sets  all  doubt  at  rest,  and  even  before 
it  is  noticed,  the  great  heat  of  the  skin  and  the  extreme  ra- 
pidity of  the  pulse  point  to  the  source  of  the  mischief.  The 
nervous  symptoms  in  these  dangerous  instances  of  the  affec- 
tion do  not,  however,  cease  with  the  eruption  ;  they  may  last 
to  the  end  of  the  malady.  Sometimes  they  are  not  noticed 
until  late  in  the  disorder,  and  after  the  period  of  desquama- 
tion has  fully  begun;  but  the  convulsions  and  stupor — for 
these  are  the  morbid  manifestations  then  more  specially  en- 
countered— are  owing  rather  to  a  diseased  state  of  the  kid- 
neys that  has  been  induced,  than  to  the  immediate  effect  of 
the  fever  poison. 

Occasionally  some  of  the  larger  joints  swell  up,  and  pre- 
sent the  appearance  of  subacute  rheumatism.  The  joints 
are  not,  however,  very  painful  on  pressure,  and  generally 
only  two  or  three  are  enlarged.  This  form  of  rheumatism  is 
evidently  owing  to  the  retention  in  the  blood  of  some  mor- 
bid material,  and  would  seem  to  simulate  ordinary  acute 
articular  rheumatism  in  presenting  endocarditis  and  pericar- 
ditis as  complications.* 

Further  complications  of  the  disease  are  dropsies,  passage 
of  blood  from  the  kidneys,  pleurisy,  tendency  to  gaiigrene, 
oedema  of  the  glottis,  diphtheria,!  and  a  very  low  state  of 
the  system.  These  complications  arc  not  apt  to  arise  until 
at  or  soon  after  the  period  of  desquamation;  sometimes  they 
lead  to  long-continued  trouble,  and  become  thus  the  most 
hazardous  of  the  sequelse  of  the  malady.  Other  conse- 
quences of  the  affection,  lasting,  it  may  be,  for  years  after 


*  Scott  Alison,  Medical  Gazette,  1845. 
f  Trousseau,  Clinique  Medicale,  tome  i. 


768  MEDICAL    DIAGNOSIS. 

the  febrile  attack,  are  a  tendency  to  boils,  swelling  of  the 
parotid  and  of  the  lymphatic  ghinds  of  the  neck,  diarrhoea, 
chronic  infianiniation  of  the  eyelids,  and  deafness  from  in- 
flammation extending  np  the  Eustachian  tube  to  the  mem- 
brane of  the  tympanum,  or  from  suppurative  destruction  of 
portions  of  the  ear. 

Of  all  these  morbid  states,  dropsy  is  the  most  common. 
The  effusion  of  fluid  may  be  caused  by  the  altered  state  of 
the  blood  ;  but  much  more  generally  it  is  owing  to  an  ab- 
normal condition  of  the  kidneys,  produced  by  their  efforts 
to  eliminate  the  poison  from  the  system.  The  organs  take 
on  the  disease  described  as  acute  desquamative  nephritis : 
their  secreting  function  is  impaired ;  albumen,  tube-casts, 
epithelial  cells,  and  sometimes  blood  are  found  in  the  urine; 
and  we  meet  with  severe  headache,  great  restlessness,  and 
cedema  of  the  face  and  extremities,  as  the  attending  vital 
sjmptoms.  Still,  notwithstanding  these  grave  phenomena, 
the  majority  of  the  cases  recover,  and  the  kidneys  are  rarely 
permanently  injured. 

The  dropsy  is  apt  to  show  itself  betw^een  the  tenth  and 
twentieth  day  of  the  malady.  The  albuminous  condition  of 
the  urine  may  precede  it  by  several  days;  yet  albumen  in  the 
urine  is  not  always  associated  with  dropsy.  In  most  cases 
of  scarlatina,  it  is  found  at  some  period  of  the  disease  for  a 
short  time  and  in  small  quantities;  but  this  transitory  albu- 
minuria is  hot,  like  the  albuminuria  coexisting  with  marked 
anasarca,  connected  with  many  tube-casts  in  the  urine  and 
numerous  epithelial  cells. 

The  state  of  exhaustion  noticeable  at  the  close  of  the  fever 
and  while  desquamation  is  still  going  on,  is  at  times  very 
great, — so  great  that,  in  young  persons  especially,  the  case 
wears  the  look  of  typhoid  fever.  And  the  resemblance  is 
heightened  by  the  occurrence  of  diarrhoea  associated  with 
and  perhaps  dependent  upon,  a  swelling  of  the  solitary  and 
agminated  glands.  But  the  signs  of  desquamation,  the  sore 
throat,  the  enlargement  of  the  cervical  glands,  and  the  his- 
tory of  the  affection  furnish  distinctive  marks  of  the  utmost 
value. 

The  allusions  that   have  just  been  made  to  the  diverse 


FEVERS.  769 

complications  of  the  malady  are  mainly  of  interest,  on  ac- 
count of  their  exhibiting  the  intricate  diagnostic  questions 
which  may  arise.  Of  the  recognition  of  the  disorder  during 
the  febrile  stage  it  is  not  necessary  to  say  much,  as  ordinarily 
it  is  not  difficult.  The  distinction  between  it  and  the  other 
exantheraatous  fevers  may  be  seen  by  glancing  at  the  table, 
to  which  a  place  is  elsewhere  assigned,  showing  their  simili- 
tudes and  their  diiierences.  I  will  only  here  mention,  as 
bearing  upon  the  distinction  between  scarlet  fever  and  mea- 
sles that  cases  are  occasionally  encountered  in  which  the 
eruption  alone  is  too  ill  defined  to  become  the  sole  basis  of 
an  opinion,  and  that  then  we  have  to  lay  the  greatest  stress 
on  the  presence  or  absence  of  catarrhal  symptoms  and  sore 
throat,  and  on  the  march  of  the  sj^mptoms.  So,  too,  with 
reference  to  small-pox.  The  rash  preceding  the  formation 
of  the  pustules  may  have  so  strong  a  resemblance  to  that  of 
scarlet  fever,  that  a  scrutiny  of  all  the  attending  circum- 
stances, and  a  careful  watching  of  the  eruption  for  at  least  a 
day,  are  requisite  to  the  detection  of  the  true  nature  of  the 
case.* 

An  erythematous  rash,  appearing  in  blotches  everywhere 
except  on  the  face,  has  been  noticed  in  membranous  croup 
and  laryngeal  diphtheria  after  the  operation  of  tracheotomy.f 
But  it  is  very  irregular,  runs  a  rapid  course,  and  is  not  fol- 
lowed by  desquamation  ;  a  point,  it  may  be  here  mentioned, 
distinguishing  all  the  forms  of  irregular  rashes,  happening 
at  times — though  very  rarely — in  diphtheria,  from  the  scarlet 
fever  eruption. 

Like  measles,  scarlatina  may  be  mistaken  for  that  curious 
form  of  eruptive  fever  called  by  the  Germans  rubeola,  or 
"fire  measles,"  and  which  is  regarded  by  some  as  roseola, 
but  is  more  generally  looked  upon  as  a  hybrid  of  measles 
and  scarlet  fever.  It  displays  a  red  eruption,  ushered  in  by 
a  chill,  followed  by  fever,  which  is  accompanied  by  coryza, 
cough,  and  sore  throat.  The  fever  prior  to  the  eruption 
lasts  for  three  or  four  days.     The  rash  then  comes  out  all 

*  The  disorders  may  also  be  combined.     See  the  cases  of  Marson,  Medico- 
Chirurg.  Trans.,  vol.  xxx. 

f  Bericht  des  K.  K.  Krankenhauses  Wieden,  1865. 

49 


770  MEDICAL    DIAGNOSIS. 

over  the  body  at  once.  It  is  most  distinct  on  the  trunk, 
neck,  and  face,  being  more  scattered  on  the  extremities.  It 
first  resembles  measles,  but  the  spots  soon  run  together  in 
irregular  patches,  unlike  the  well-defined  crescentic  eruption 
of  measles.  These  patches  are  of  variable  size  and  sur- 
rounded by  healthy  skin.  They  are  of  deepest  color  in  the 
centre,  distinctly  elevated,  and  very  much  infiuenced  by 
pressure.  The  eruption  lasts  ordinarily  four  or  five  days,  but 
in  severe  cases  eight  or  ten.  It  gradually  fades,  and  desqua- 
mation ensues,  though  the  scales  are  small,  and  never  in  size 
like  those  of  scarlet  fever.  During  the  continuance  of  the 
rash,  the  general  symptoms  are  much  aggravated;  the  sore 
throat  may  be  very  severe,  and  attended  with  inability  to 
swallow  and  hoarseness.  As  the  eruption  fades,  the  consti- 
tutional symptoms  subside.  Swelling,  and  even  suppuration 
of  the  cervical  glands,  are  not  uncommon  sequelse. 

Another  affection  with  several  features  corresponding  to 
scarlatina  is  the  breakbone  fever,  or  dengue.  The  points  of 
dissimilarity  may  be  learned  by  referring  to  the  description 
of  the  malady  further  on  given. 

Measles. — The  symptoms  precursory  to  the  specific  erup- 
tion of  this  affection  are  fever,  watery  eyes,  frequent  sneezing, 
flow  from  the  nose,  and  cough  ;  in  fact,  all  the  manifestations 
of  an  acute  coryza  or  catarrh.  To  these  diarrhoea  is  in  many 
instances  added,  indicating  a  simultaneous  irritation  of  the 
intestinal  mucous  membrane.  On  the  fourth  day  after  the 
commencement  of  the  morbid  signs,  a  rash  is  perceived  on 
the  face  and  neck;  thence  it  continues  to  extend  until,  in 
the  course  of  two  or  three  days,  the  whole  body  is  covered. 
The  eruption  does  not  alleviate  the  febrile  symptoms ;  on  the 
contrary,  while  it  is  spreading  to  the  trunk  and  lower  ex- 
tremities, the  constitutional  disturbance  increases.  But  as 
soon  as  it  begins  to  fade,  which  it  does  on  the  fourth  day  of 
its  appearance,  the  fever  lessens ;  and  by  the  ninth  day  of 
the  disease,  both  fever  and  rash  have  left.  Frequently  then 
the  cuticle  comes  away  in  fine  scales,  and  this  desquamation 
is  attended  with  very  annoying  itching.  The  patient,  now 
that  he  is  convalescent,  shows  his  sickness :  he  is  pale  and 
somewhat  emaciated.     Often  he  still  coughs,  and  his  eye  is 


FEVERS.  771 

slightly  inflamed.     These  signs  are  not  unusnally  the  last 
to  disappear. 

Of  all  the  symptoms  mentioned,  two  are,  in  a  diagnostic 
sense,  of  pre-eminent  importance:  the  catarrh  and  the  erup- 
tion. 

The  catarrh  is  nearly  constant.  It  is  true  that  a  variety  of 
measles  is  recognized — "rubeola  sine  catarrho ;"  but  this  is 
very  rare.  Generally  speaking,  the  coryza  and  catarrh  de- 
cline with  the  eruption;  occasionally,  however,  they  remain 
for  some  time  after  the  rash  has  left.  The  feature  which 
distinguishes  these  catarrhal  symptoms  from  those  of  influ- 
enza consists  in  the  eruption ;  before  this  happens,  the  diag- 
nosis is  uncertain,  though  we  ma}'  often  suspect  measles  by 
the  look  of  the  face,  the  greater  intensity  of  the  febrile  signs, 
and  a  knowledge  that  the  disease  is  prevailing  in  the  com- 
munity. 

The  eruption  is  very  peculiar:  it  consists  of  slightly  raised 
red  spots,  which  coalesce  and  form  blotches  of  an  irregular, 
crescentic  shape ;  between  these  blotches  the  skin  is  of 
natural  color.  The  eruption  disappears  first  from  the  face ; 
in  other  words,  it  disappears  in  the  same  order  in  which  it 
appeared.  As  it  fades,  it  becomes  brownish,  and  subse- 
quently of  a  yellowish  tint.  In  its  earliest  stages  it  is  similar 
to  the  papulae  of  small-pox ;  and  this  similarity  may  be 
heightened  by  its  being  mixed,  as  it  sometimes  is,  with  a 
few  miliary  vesicles.  But  after  the  first  day  of  the  rash  there 
is  little  room  for  doubt.  In  the  one  case  the  spots  remain  as 
they  were ;  in  the  other,  they  change  into  pustules. 

A  question  may  sometimes  arise  as  to  whether  the  eruption 
is  that  of  typhus  fever  or  of  measles.  Both  are  coarse,  both 
often  not  unlike  in  color,  and  both  may  be  developed  about 
the  same  time.  Generally  speaking,  however,  the  eruption 
of  typhus  fever  shows  itself  several  days  later  than  the  rash 
of  measles ;  and  although  coarse,  it  is  not  crescentic,  and  is 
found  on  the  trunk  and  extremities  rather  than  upon  the 
face.  Moreover,  the  physiognomy,  the  excessive  prostration 
of  strength,  and  the  marked  cerebral  symptoms  of  the  low 
fever  are  such  as  to  render  a  differential  diagnosis  seldom 
difiicult. 


772  MEDICAL    DIAGNOSIS. 

Measles  is  usually  met  with  in  children  ;  but  it  may  be 
encountered  in  adults,  especiallj'  among  soldiers,  and  is,  in 
adults,  a  much  more  severe  complaint  than  in  children.  In 
the  latter  it  is  not  an  alarming  disease.  Only  occasionally 
does  it  occur  in  epidemics  which  present  a  malignant  char- 
acter. Its  greatest  danger  commonly  consists  in  the  eruption 
disappearing  prematurely  or  appearing  but  partially,  and  in 
the  severity  of  the  thoracic  complications. 

These  are  either  acute  bronchitis  or  acute  pneumonia. 
The  former  may  occur  at  any  period  of  the  disorder,  and 
involve  the  liner  tubes.  But  it  does  not  generally  set  in  with 
severity  until  the  eruption  has  reached  its  height  or  is  begin- 
ning to  fade.  In  young  children,  symptoms  of  inflammation 
of  the  larynx,  or  of  croup,  are  at  the  same  period  apt  to 
manifest  themselves.  Acute  inflammation  of  the  lung,  too, 
is  met  with,  at  this  stage  of  the  malady,  or  sometimes  even 
after  convalescence  has  apparently  commenced.  We  may 
suspect  that  mischief  is  going  on  within  the  chest,  if  the 
breathing  be  very  oppressed  and  the  pulse  continue  to  be 
rapid;  but  so  as  to  detect  early  the  hazardous  and  insidious 
complication,  and  guard  against  it,  the  chest  should  be  ex- 
amined daily,  both  anteriorly  and  posteriorly.  Occasionally 
the  thoracic  afiection  leaves  a  chronic  bronchial  disease ;  or  a 
persistent  cough  and  night-sweats  make  us  fearful,  and  often 
but  too  justly,  that  tubercles  have  been  awakened  by  the  in- 
flammation ;  and  it  may,  in  individual  cases,  be  extremely 
difiicult  to  decide  with  which  of  tliese  morbid  states  we  have 
to  deal.  Emaciation  and  a  chronic  cough  are  found  in  both 
chronic  bronchitis  and  phthisis;  and  the  physical  signs  of 
tubercular  consumption  are,  in  children,  notoriously  ill  de- 
iined  and  untrustworthy.  Then,  the  nummular  sputum  may 
occur  in  the  bronchitis  of  measles.  We  may,  therefore,  be 
obliged  to  await  the  progress  of  the  abnormal  phenomena 
before  coming  to  a  definite  conclusion. 

At  times  we  meet  with  anomalous  forms  of  measles.  The 
peculiar  disease  called  "  rubeola,"  which  presents  in  its  symp- 
toms a  mixture  of  scarlet  fever  and  measles,  has  already  been 
alluded  to ;  irrespective  of  this,  there  is  a  kind  of  measles 
with  a  papular  eruption  like  ordinary  measles,  but  distin- 


FEVERS.  773 

gnished  from  it  by  the  papulge  not  being  arranged  in  cres- 
centic  clusters,  being  less  obvious  and  not  appearing  at  all, 
or  showing  themselves  but  imperfectly  on  the  limbs.  The 
patches  are  of  dusky  hue,  and  there  is  no  distinct  sore  throat, 
but  considerable  constitutional  disturbance.  This  "  rubeola 
notha"  prevailed  extensively  in  London  a  few  years  since.* 
A  somewhat  similar  anomalous  exanthem  was  common  in 
Philadelphia  during  the  winter  of  1865-1866,  occurring  at 
the  time  when  both  measles  and  scarlatina  were  frequent, 
and  particularly  the  former.  The  eruption,  more  partially 
papular  than,  but  of  dark  hue  like  measles,  was  principally 
conlined  to  the  face.  It  appeared  at  the  end  of  the  first  or  on 
the  second  day  of  a  slight  malaise;  though  in  some  instances 
I  saw  there  had  been  a  marked  chill  at  the  beginning  of  the 
complaint,  in  others,  the  rash  was  the  first  sign  of  disease  at- 
tracting attention.  There  was  very  little  constitutional  dis- 
turbance, a  slight  watery  appearance  of  the  eye,  no  sore  throat, 
or  a  mere  faucial  reddening,  and  cough  ;  yet  this  symptom 
was  not  constant.  The  eruption,  which  occurred  chiefly  in 
patches,  not,  however,  distinct  and  crescentic,  lasted  from 
five  to  seven  days,  gradually  fading  and  not  being  followed 
by  desquamation.  In  only  one  instance  did  I  observe  a'peel- 
ing  of  the  cuticle,  and  this  happened  on  the  hands  and  feet. 
An  almost  invariable  sequel  was  swelling  of  the  cervical 
glands.  The  urine  in  the  cases  I  examined  contained  no 
albumen,  and  convalescence  was  rapid.  In  one  family  I  at- 
tended, the  exanthem  attacked  three  out  of  four  children,  all 
of  whom  had  had  measles  two  years  previously. 

Small-pox. — This  fearful  disease,  which  formerly  ravaged 
all  parts  of  the  globe,  is  now,  fortunately,  much  less  seldom 
seen  in  civilized  countries ;  at  all  events,  we  do  not  now  en- 
counter those  frightful  epidemics  so  dreaded  and  so  disastrous 
to  the  human  race. 

Small-pox,  or  variola,  attacks  both  children  and  adults.  It 
is  a  highly  contagious  malady,  spreadiug  very  rapidly  among 
those  unprotected  by  vaccination,  and  among  masses  of  men  ; 
hence  its  presence  on  board  ship  or  in  camps  is  especially  to 
be  feared. 


*  Babington,  London  Lancet,  May  7th,  1864. 


774  MEDICAL    DIAGNOSIS. 

The  chief  symptoms  of  the  stage  of  invasion  are  chills, 
fever,  and  pain  in  the  back.  The  fever  runs  very  high,  and 
exacerbates  markedly  toward  evening.  The  pain  in  the  back 
is  very  severe,  and  particularly  severe  in  grave  cases ;  there 
are  also  nausea,  vomiting,  headache,  and  great  restlessness. 
All  these  symptoms  subside  at  the  end  of  the  third  or  on 
the  fourth  day,  when  an  eruption  shows  itself  on  the  lips 
and  forehead,  but  soon  extends  to  the  trunk,  and  from  the 
trunk  to  the  extremities. 

At  first  the  eruption  has  the  appearance  of  papulae ;  but  on 
the  second  and  third  day  the  coarse  spots  undergo  a  decided 
change.  At  the  top  of  each  papule  appears  a  vesicle,  which 
gradually  becomes  larger  and  larger,  and  fills  up  with  a 
milky,  thick  fluid  ;  in  short,  becomes  a  pustule.  By  the  fifth 
or  sixth  day  this  change  has  been  fully  accomplished,  and 
the  pustules  are  spheroidal  and  lose  the  umbilicated  look 
which  they  had  while  forming.  On  the  eighth  day  matter 
begins  to  ooze  from  their  edges,  and  a  secondary  fever  sets 
in,  lasting  for  three  or  four  da3\s,  until,  indeed,  all  the  pus- 
tules are  broken.  Now  crusts  form  where  previously  there 
had  been  pustules ;  and  as  these  crusts  dry  and  fall  ofl",  the 
skin  beneath  is  seen  to  be  of  a  red  color  which  only  very 
gradually  fades,  and  here  and  there  are  noticed  those  scars 
and  pits  which  the  patient  carries  daring  the  remainder  of 
his  life. 

When  the  pustules  are  in  great  abundance,  they  run  to- 
gether ;  such  cases  are  very  grave,  and  constitute  the  variety 
of  the  disease  known  as  confluent  small-pox.  The  eruption 
may  be  discovered  a  day  earlier  than  in  the  discrete  form, 
and  the  rough,  red  blotches  are  often  so  thickly  clustered 
as  to  give  a  uniformly  red  aspect  to  the  whole  surface.  When 
the  pustules  completely  till  up,  whole  portions  of  the  face  or 
of  the  trunk  seem  to  be  covered  by  one  extensive  pustule, 
which  gradually  dries  into  a  continuous  brownish  and  most 
disfiguring  crust.  While  the  process  of  maturation  is  going 
on,  the  features  are  observed  to  be  greatly  swollen;  the  eyes 
may  be  hidden  from  view ;  the  nose  and  lips  are  tumid.  The 
patient  complains  of  the  tension  of  the  skin,  and  not  unfre- 
qucntly  of  sore  throat  and  of  a  steady  flow  of  saliva  from  the 


FEVERS.  775 

mouth.  The  secondary  fever  is  very  violent,  far  more  so 
than  in  discrete  variola.  It  may  not  show  itself  until  a  day 
or  two  later,  lasts  longer,  and  is  the  period  of  danger,  since 
it  is  at  this  time  that  death  is  most  apt  to  happen. 

A  fatal  issue  is  often  preceded  by  dry  tongue,  by  delirium 
and  great  restlessness;  by  what,  in  fact,  are  called  typhoid 
symptoms.  Sometimes  it  is  brought  about  by  attacks  of 
dysentery  or  of  diarrhcBa,  by  passive  hemorrhages,  by  affec- 
tions of  the  larynx  or  trachea;  by  some  complications,  there- 
fore, which  the  worn  and  irritated  frame  is  unable  to  with- 
stand. Now  and  then  death  takes  place  from  supervening 
pneumonia  or  bronchitis;  but  an  unfortunate  termination 
from  maladies  of  the  respiratory  organs  does  not  occur 
only  in  the  secondary  fever,  as  these  affections  are,  perhaps, 
oftener  encountered  during  the  period  of  eruption.  Some- 
times the  patient  sinks  at  the  very  onset  of  the  disease.  In 
these  malignant  cases,  he  dies  from  the  virulence  of  the 
poison.  He  is  stupid,  delirious;  the  eruption  seems,  as  it 
were,  to  struggle  to  reach  the  surface,  is  of  a  livid  hue,  and 
may  fail  to  appear  until  after  death. 

Small-pox  is  occasionally  met  with,  during  the  progress  of 
other  disorders,  blending  its  symptoms  with  those  of  the  com- 
plaint to  which  it  becomes  superadded.  It  is  thus  found  as 
an  intercurrent  affection  in  typhoid  fever,  in  typhus,  in  scar- 
let fever,  and  in  measles  ;  yet  even  then  there  is  no  difficulty 
in  recognizing  its  peculiar  traits — its  lumbar  pain  and  char- 
acteristic eruption.  Ordinarily  the  detection  of  variola  is 
extremely  easy,  excepting  at  its  onset.  But  the  points  of 
similarity  it  may  present,  in  its  early  stages,  to  typhus  fever, 
to  erysipelas,  and  to  several  other  diseases,  have  been  already 
discussed,  and  need  not  be  repeated ;  elsewhere  it  has  been 
noticed  that  we  have  often  to  await  the  course  of  the  eruption 
before  framing  a  positive  diagnosis  from  the  symptoms  alone, 
and  without  taking  the  epidemic  influences  prevailing  into 
account.  When  the  disorder  is  fully  developed,  all  difficulty 
in  its  diagnosis  ceases.  Let  us  here  look  at  the  marks  of  dis- 
tinction between  it  and  the  other  principal  eruptive  fevers, 
premising  the  statement  that,  in  the  period  of  invasion,  the 
pain  in  the  loins  is  the  most  significant   differential  sign : 


776 


MEDICAL    DIAGNOSIS. 


Table  exhibiting  the  Differences  between  Scarlet  Fever, 

Measles,  and  Small-pox. 


Scarlet  Fever. 

Period  of  incubation 
very  uncertain  ;  may 
be  only  a  day,  or  may 
be  weeks. 

Fever,  with  very  great 
heat  of  skin  and  very 
frequent  pulse  ;  per- 
sists unabated  during 
eruption. 

Eruption  on  second  day, 
first  on  neck  and  chest; 
spreads  rapidly. 


Eruption  uniform  or  in 
very  large  patches  of 
scarlet  hue,  with  in- 
terspersed raised  spots 
and  some  vesicles  ; 
rash,  followed,  after 
the  seventh  day  from 
its  appearance,  b  j 
very  complete  desqua- 
mation. 

Sore  throat ;  rarely  co- 
ryza  or  bronchitis. 


Bed  "raspberry'- 
tongue. 

Cerebral  symptoms  fre- 
quent and  grave. 

Temperature  very  high ; 
may  range  from  105° 
to  112°;  no  rapid  fall 
soon  after  eruption, 
nor  decided  increase  of 
heat  preceding  it;  high 
temperature,  though 
not  so  high  as  at  first 


Measles. 

Period  of  incubation  va- 
riable ;  generally  seven 
to  fourteen  days. 

Fever,  with  heat  of  skin 
and  moderate  frequen- 
cy of  pulse ;  not  re- 
lieved, but  rather  in- 
creased by  eruption. 

Eruption  on  fourth  day, 
first  on  face ;  spreads 
gradually,  in  the 
course  of  about  forty- 
eight  hours,  to  rest  of 
body. 

Eruption  in  crescentic 
patcheSjWith  interven- 
ing portions  of  healthy 
skin ;  lasts  about  five 
days  ;  followed  by  par- 
tial and  very  incom- 
plete desquamation, 
and  scales  are,  as  a 
rule,  very  fine. 

Coryza    and    bronchitis 
very  constant ;    much 
more  rarely  sore 
throat. 

Tongue  coated  ;  may  be 
red  at  edges  ;  but  does 
not  lose  its  coat. 

Cerebral  symptoms 
neither   frequent   nor 
grave. 

Temperature  during 
fever  preceding  the 
eruption  high,  103° 
to  106°  ;  rises  rapidly 
toward  breaking  out 
of  eruption.  It  may 
remain  high  for  from 
twelve  to  twenty-four 


Small-pox. 

Period  of  incubation 
from  six  to  twenty 
days  ;  generally  about 
ten  days. 

Fever  often  very  violent, 
with  bounding  pulse 
and  pain  in  the  loins  ; 
great  relief  from  oc- 
currence of  eruption. 

Eruption  at  end  of  third, 
or  on  fourth  daj^ ;  first 
on  lips  and  forehead. 


Eruption  first  papular  ; 
remains  so  about  a 
day  ;  then  becomes 
vesicular,  then  pustu- 
lar; on  the  eighth  day 
of  eruption,  pustules 
maturate. 


Often  sore  throat  and 
dry  cough ;  bronchitis 
only  as  a  complica- 
tion. 

Tongue  coated  and  swol- 
len ;  may  become  red 
at  edges. 

Cerebral  symptoms,  es- 
pecially convulsions 
in  children,  frequent 

Temperature  during  fe- 
ver preceding  the 
eruption,  often  106°  ; 
then  speedy  deferves- 
cence taking  place 
within  thirty-six 
hours ;  subsequently 
thermometer     indica- 


FEVERS. 


777 


Scarlet  Fever. 

or  at  height  of  erup- 
tion, to  the  tenth  day, 
when  it  begins  to  sub- 
side gradually.  Ac- 
cording to  Einger,  a 
fall  of  temperature 
takes  place  on  the  5th, 
10th,  and  15th  day  of 
the  disease. 


No  secondary  fever. 


Pneumonia  rare ;    pleu- 
ris}^  more  frequent. 


Measles. 

hours  after  appearance 
of  rash ;  then  sinks 
very  speedily,  a  return 
to  almost  a  normal 
temperature  being  ar- 
rived at  on  the  second 
day  from  the  begin- 
ning of  its  fall.  Thus 
the  defervescence  is 
both  rapid  and  com- 
plete ;  a  protracted  de- 
fervescence, or  the 
maximum  of  tempera- 
ture lasting  for  a  con- 
siderable time  after 
the  coming  out  of  the 
eruption,  or  a  very 
high  degree  prior  to 
it,  indicates  a  severe 
case. 

No  secondary  fever ;  al- 
though sometimes  a 
slight  increase  of  fever 
just  before  eruption 
leaves. 

Pneumonia  a  very  fre- 
quent complication. 


Sequelae :    Bright's    dis-     Sequelns :   chronic  bron- 
ease  ;      dropsy ;     con-        chitis ;  phthisis  ;  con- 
junctivitis ;    deafness ;        junctivitis. 
phthisis  ;    chronic  di- 
arrhoea; glandular  en- 
largements. 


SMALL-rOX. 

ting  a  temperature  of 
about  100°,  notwith- 
standing the  progress- 
ing development  of 
the  pimples  into  pus- 
tules. Decided  rise 
of  temperature  during 
secondary  fever,  and 
then  gradual  and  pro- 
tracted defervescence; 
slight  rise  during  de- 
siccation. ( Wunder- 
lich. ) 


Always  secondary  fever. 


Pneumonia   not  a  very 
frequent  complica- 
tion. 

Sequelic :  chronic  diar- 
rhoea ;  glandular  en- 
largements ;  various 
diseases  of  the  eyeball 
and  eyelids. 


The  contagion  of  small-pox  does  not  always  manifest  itself 
by  an  attack  of  variola.  Sometimes  it  is  modified  by  hap- 
pening in  a  person  who  is  partially  protected  by  vaccination. 
This  varioloid  disease  is  mild.  It  is  distinguished  from  va- 
riola by  the  pustules  passing  more  quickly  through  all  their 
stages,  and,  above  all,  by  an  utter  absence  of  secondary  fever. 
Very  soon  after  the  eruption,  within  thirty-six  hours,  the 
thermometer  shows  entire  freedom  from  fever,  and  unless 
serious  complications  happen,  the  heat  of  the  body  remains 
at  very  nearly  the  normal  temperature. 


778  MEDICAL    DIAGNOSIS. 

Another  modification  of  the  affection,  to  express  the  cur- 
rent view,  or  a  specific  disorder  very  similar,  to  state  in  these 
words  an  opinion  which  has  been  the  subject  of  many  fierce 
disputes,  is  chicken-pox.  Without  entering  into  the  contro- 
versy, it  may  be  shown  to  differ,  as  regards  its  symptoms, 
from  small-pox  in  the  leniency  of  the  introductory  fever ;  in 
the  eruption  beginning  generally  first  on  the  trunk,  occur- 
ring often  on  the  second  day,  though  it  may  not  appear  until 
the  end  of  the  third,  and  continuing  to  appear  and  disappear 
in  crops,  the  mass  of  the  eruption,  however,  having  ap- 
peared within  twenty-four  hours ;  in  the  vesicles  being 
surrounded  by  little  or  no  inflammatory  redness ;  in  their 
remaining  vesicles,  and  not  becoming  pustules ;  in  their  at- 
taining their  height  on  the  third  or  fourth  day  of  the  eruption, 
and  then  bursting  and  shrivelling  without  presenting  depres- 
sions at  their  apices,  and  in  the  crust  which  falls  off  about 
five  days  subsequently  being  followed  by  a  smooth,  shining, 
round,  and  irregular  pit.  Then  the  eruption  is  rarely  prom- 
inent on  the  face;  and  the  disease  does  not  protect,  as  mild 
forms  of  small-pox  do,  from  a  subsequent  attack  of  variola. 
Sometimes  the  vesicles  may  be  found,  as  are  the  pustules  of 
small-pox,  on  the  roof  of  the  mouth  and  at  the  back  of  the 
throat.  But,  notwithstanding  they  may  be  everywhere  very 
plentiful,  the  disorder  is  not  a  grave  one.  Yet  I  have  known 
it  to  terminate  fatally. 

Dengue. — This  is  an  arthritic  fever  with  a  cutaneous 
eruption.  It  has  been  prevalent  in  the  form  of  epidemics 
chiefly  in  the  West  and  East  Indies,  as  well  as  in  Virginia 
and  South  Carolina,  and  others  of  the  Southern  States. 

It  usually  begins  with  pain,  stiffness,  and  swelling  of  some 
of  the  smaller  joints,  or  with  severe  muscular  pains,  aching 
in  the  back,  and  stiffness  of  the  muscles  of  the  neck.  Fever 
follows,  with  suffusion  of  the  eyes  and  headache ;  but,  as  a 
rule,  without  nausea  and  vomiting.  On  the  third  day  the 
fever  ceases  altogether,  or  subsides  very  markedly,  though 
the  muscular  and  arthritic  pains  do  not  pass  off  entirely. 
The  febrile  paroxysm  may  last  somewhat  longer,  or  only  six 
to  twelve  hours.  In  any  case  it  is  very  apt  to  be  succeeded 
by  an  interval  of  two  to  four  days  free  from  absolute  sufter- 


FEVERS.  779 

ing,  though  not  from  great  debility  and  some  pain.  Then 
the  pain  returns,  and  with  it  the  fever;  nausea  and  vomit- 
ing and  a  thickly-coated  tongue,  too,  are  noticed.  This  new 
phase  of  the  complaint  is  generally  relieved  by  the  appear- 
ance of  an  eruption,  which  shows  itself  on  the  fifth,  sixth,  or 
seventh  day  of  the  malady,  and,  therefore,  very  much  later 
than  the  rash  of  scarlatina,  which  it  resembles  often  in  hue 
and  aspect.  But  not  invariably  ;  for  it  may  occur  in  patches 
and  be  papular,  or  even  vesicular  or  like  urticaria.  The 
eruption  is  attended  with  a  sense  of  burning  and  of  itching, 
and  disappears  after  two  or  three  days'  duration.  Then 
convalescence  sets  in,  marked  by  considerable  muscular 
weakness  and  general  depression,  and  frequently  with  the 
rheumatic  stiffness  or  soreness  persisting  -for  some  time. 
Swellings  of  the  lymphatic  glands  of  the  neck,  axilla,  and 
groin  occur  in  many  cases,  and  may  continue  during  conva- 
lescence. 

The  cause  of  this  singular  malady — the  breakbone  fever  of 
parts  of  our  country — is  unknown.  It  is  a  harmless  disorder, 
clearly  epidemic,  and  contagious.  Such,  at  least,  is  the 
opinion  of  Dr.  Dickson,  to  whom  we  owe  one  of  the  best 
descriptions  of  the  disease,  and  from  whose  published  state- 
ments, based  on  epidemics  observed  in  Charleston,  I  have 
chiefly  drawn  this  sketch. 

Erysipelas. — This  is  an  eruptive  fever,  accompanied  by 
inflammation  of  the  integument  of  some  part  of  the  body, 
generally  of  the  head  and  face.  This  definition,  of  course, 
only  refers  to  such  cases  as  fall  into  the  hands  of  the  physi- 
cian, and  to  them  alone  the  following  remarks  apply. 

The  disease  begins  with  a  chill  and  fever.  Soon  a  portion 
of  the  face  is  noticed  to  be  red  and  hot.  The  redness  spreads, 
a  clearly-defined  edge  marking  its  onward  march ;  and  gen- 
erally it  does  not  stop  mitil  it  has  occupied  the  whole  of  the 
face  and  a  considerable  portion  of  the  scalp.  The  features 
are  then  so  tumefied  as  to  be  hardly  recognizable.  The 
patient  is  very  restless,  has  high  fever,  and  not  unfrequently 
enlargement  of  the  glands  at  the  angle  of  the  jaw,  and  sore 
throat.  By  the  seventh  or  eighth  day  the  disease  is  over, 
and  large  patches  of  cuticle  fall  from  the  no  longer  swollen 
and  disfigured  countenance. 


780  MEDICAL    DIAGNOSIS. 

This  is  simple  erysipelas ;  but  we  may  have  to  contend  with 
more  dangerous  forms  and  somewhat  different  symptoms. 
Thus  the  affection  may  extend — as  is  in  truth  always  its 
tendency — from  the  true  skin  to  the  subcutaneous  areolar 
tissue,,  and  give  rise  there  to  collections  of  pus,  which  reveal 
their  presence  by  chills  and  an  obscure  sense  of  fluctuation, 
and  keep  up  an  irritative  fever  until  they  are  discharged. 
Irrespective  of  this,  the  tumefaction,  while  the  complaint  is 
at  its  height,  is  much  greater  in  this  phlegmonous  variety  of 
the  malady,  and  there  is  more  constitutional  disturbance; 
but,  on  the  other  hand,  not  so  much  local  irritation,  for  the 
morbid  action  travels  less  rapidly,  and  often  remains  more 
circumscribed.  In  some  cases  the  inflammation  extends  to 
the  brain,  and,  instead  of  the  wandering  at  night,  always  a 
very  common  symptom,  we  have  violent  delirium,  soon  suc- 
ceeded by  coma  and  rapid  sinking.  In  other  cases,  again, 
and  they  are  generally  very  bad  ones,  we  may  find  these 
active  cerebral  symptoms,  and  yet  not  be  able  to  detect,  after 
death,  sims  of  inflammation  in  the  brain  or  its  membranes. 
Now  and  then  the  disorder  passes  to  the  throat,  reaches 
'the  larynx  and  bronchial  tubes,  and  places  life  in  imminent 
peril  from  oedema  of  the  glottis,  or  from  a  most  hazardous 
form  of  capillary  bronchitis.  In  some  instances,  a  highly 
asthenic  state  becomes  developed,  and  the  patient  dies  ex- 
hausted. 

The  diagnosis  of  erysipelas  is  not  beset  with  difiiculties. 
Erythema  resembles  it  most  closely;  but  there  is  this  mani- 
fest difference :  in  erythema  there  is  scarcely  any  swelling, 
not  much  tendency  to  spread,  and  almost  no  constitutional 
disturbance.  The  ordinary  exanthematous  fevers  may,  at  an 
early  stage,  be  mistaken  for  erysipelas.  But  all  of  them,  even 
scarlatina,  have  a  longer  period  of  febrile  invasion  ;  in  all, 
too,  although  the  eruption  takes  its  origin  at  one  spot,  and 
generally  on  the  face,  it  is  not  limited  there.  The  thickly- 
clustered  blotches  of  commencing  confluent  small-pox  and 
the  swelling  attending  them  give  at  times  to  the  face  the 
look  of  erysipelas.  But  here,  also,  evidences  can  be  found 
of  a  rash  about  to  appear  all  over  the  body;  and  should 
doubt  still  exist,  it  is  soon  dispelled  by  the  progress  of  the 


FEVERS.  781 

eruption.  Sometimes  vesicles  and  even  irregular  pustules 
form  in  erysipelas,  and  occasion  some  misgivings  as  to 
whether  the  malady  be  not  a  chronic  disease  of  the  skin, 
such  as  eczema,  pemphigus,  or  impetigo ;  but  these  affec- 
tions lack  the  constitutional  symptoms  and  the  history  of  a 
recent  acute  disease,  and  in  reality  the  likeness  is  not  a 
very  striking  one,  if  the  inflamed  surface  be  carefully  ex- 
amined. 

Erysipelas  maybe  confounded  with  mumps.  This  does  not 
seem  at  first  sight  very  likely,  but  I  have  known  the  error  to 
have  been  committed.  It  was  mainly  caused  by  too  much 
stress  being  laid  on  the  redness  which  is  frequently  found 
beneath  one  or  both  ears  in  parotitis ;  but  which,  unlike  ery- 
sipelas, is  attended  with  much  pain  on  moving  the  jaw,  and 
with  decided  glandular  tumefaction.  The  redness,  more- 
over, shows  no  tendency  to  spread,  and  rarely  continues  for 
the  four  or  fi.vc  days  during  which  mumps  lasts.  In  very 
young  children,  however,  there  may  be  some  difficulty  in 
diagnosis.  I  have  seen  the  glands  at  the  angle  of  the  jaw 
much  swollen  for  one  or  two  days  prior  to  the  slight  dis- 
coloration over  them  taking  on  a  deeper  blush,  and  then 
spreading  rapidly  as  marked  erysipelas  over  the  whole  face 
and  part  of  the  scalp,  reaching  the  other  jaw,  where  sub- 
sequently the  glands  began  to  swell.  In  such  cases  great 
weight  must  be  attached  to  the  history  of  the  case,  to  deter- 
mine which  disorder  was  primary,  and  whether  the  glandular 
complaint  was  or  was  not  the  complication.  If  the  conta- 
gion of  mumps  can  be  traced,  the  matter  is  easily  settled. 


CHAPTER  XII. 


DISEASES    OF    THE    SKIN. 


To  facilitate  tlie  discrimination  of  diseases  of  the  skin, 
they  have  been  grouped  into  classes.  These  have  been  ar- 
ranged b}^  some  authors  in  accordance  with  the  obvious 
characters  of  the  eruption,  by  others  in  accordance  with  its 
presupposed  cause  and  attending  structural  alteration.  The 
former  classification  is  that  of  Willan  and  Bateman,  and, 
with  such  modifications  as  the  knowledge  of  the  day  has 
necessitated,  is  the  one  still  generally  followed.  In  compli- 
ance with  its  main  features,  cutaneous  afiections,  omitting 
some  of  the  less  important  ones,  may  be  thus  grouped : 

Diseases  of  the  Skin. 


MACULiE. 


Ephelides. 

Vitiligo. 
I   Chloasmata. 
(^  Naevi. 

{Erythema. 
Roseola. 
Urticaria. 

Papular  Diseases /  ^'^^^^• 

1.  Prurigo. 

{Eczema. 
Herpes. 
Pemphigus. 

Acne. 
Impetigo. 
Ecthyma. 
Eupia. 

Lepra. 
Psoriasis. 
Pityriasis. 
Ichthyosis. 


Pustular  Diseases. 


Squamous  Diseases. 


(782) 


DISEASES    OF    THE    SKIN.  783 

MoUuscum. 


(ivioiiuscum, 
Lupus. 
Elepliantiai 


TUBERCTJLATED  DISEASES. 

Elephantiasis  Grsecoruni,  etc. 

Scabies. 

Phthiriasis. 

Pakasitic  Diseases -j  Favus. 

I   Mentat^ra. 

I  Pityriasis  versicolor,  etc. 


Another  system  of  classification  which  has  much  to  recom- 
mend it,  and  which  takes  for  its  basis  the  anatomical  seat 
and  arrangement  of  the  cutaneous  malady,  is  that  of  Hebra. 
As  developed  by  him,  it  is,  however,  not  a  purely  anatomical, 
but  a  mixed  system.  All  diseases  of  the  skin  are  arranged 
in  twelve  classes:  Hyperaemiae;  Anaemias;  Morbid  secre- 
tion of  the  cutaneous  glands ;  Exudations ;  Hemorrhages ; 
Hypertrophies;  Atrophies;  N^eoplasms;  Pseudoplasms ;  Ul- 
cers ;  Nervous  affections ;  Parasites. 

The  fourth  class  is  the  most  comprehensive,  and  is  divided 
into  an  acute  and  chronic;  the  acute  being  subdivided  into 
a  contagious  class — the  exanthemata,  and  a  non-contagious — 
erythemata,  dermatitis,  phlyctaenoses.  The  chronic  exuda- 
tions are  the  squamous  affections — psoriasis,  lichen,  pityriasis 
rubra;  the  pruriginous  affections — eczema,  scabies,  prurigo; 
the  acneform  affections — acne,  sycosis;  the  pustular  affections 
— impetigo,  ecthyma;  and  the  bullous  affections — pemphigus. 

But  in  this  sketch  of  cutaneous  affections,  we  shall  adhere 
to  the  first  classification  ;  and  in  accordance  with  it,  when 
a  disease  of  the  skin  is  presented  for  examination,  we 
must  first  endeavor  to  ascertain  the  group  it  belongs  to;  for 
instance,  is  it  vesicular,  pustular,  or  erythematous  ?  Having 
determined  this,  we  next  fix  which  one  of  the  group  it  is. 
When  this  has  been  accomplished,  we  inquire  into  the  his- 
tory of  the  disorder  and  its  duration,  whether  acute  or 
chronic ;  take  into  account  the  presence  or  absence  of  fever 
and  the  general  condition  of  the  patient;  search  for  the  evi- 
dences of  a  cachexia  or  of  some  visceral  disturbance ;  and 
trace,  as  far  as  possible,  the  cause  of  the  aftectiou  and  its 
exact  seat.  Having  done  all  this,  we  have  a  groundwork 
upon  which  to  institute  a  suitable  treatment. 


784  MEDICAL    DIAGNOSIS. 

Most  diseases  of  the  skin  are  again  subdivided  into  several 
varieties,  based,  for  the  most  part,  on  their  duration,  situa- 
tion, form,  feel,  and  color.  Thus  we  have  constantly  recur- 
ring the  terms  fugax,  inveterata,  capitis,  facialis,  palmaris ; 
or  punctate,  guttata  or  guttate,  when  like  a  drop  on  the 
skin;  nummular,  when  like  a  coin;  larvaris,  like  a  mask, 
etc.;  the  qualifying  words,  Iseve,  indurata;  and  the  adjec- 
tives of  color,  nigrum,  rubrum,  versicolor.  But  these  divi- 
sions are  all  of  secondary  importance;  and  I  shall  not,  in 
this  outline,  regard  them.  Premising  this  statement,  let  us 
briefly  examine  the  characteristics  of  the  various  cutaneous 
affections  of  more  common  form.  The  class  oimaculx  com- 
posed chiefly  of  the  ephelides,  comprising  freckles,  called 
also  lentigo,  and  large  patches  of  a  yellowish-brown  color, 
attended  with  slight  desquamation ;  and  nsevi  or  moles, 
spots  of  congenital  origin,  need  not  be  further  considered. 

Exanthematous  Diseases. — This  group,  regarded,  too, 
as  rashes,  is  often  made  to  include  rubeola,  scarlatina,  and 
erysipelas ;  but  these  belong  more  strictly  to  idiopathic 
fevers  than  to  diseases  of  the  skin,  and  have  been  described 
already.  There  are  onl}^  three  affections  which,  strictly 
speaking,  come  under  this  division  of  cutaneous  complaints : 
erythema,  roseola,  and  urticaria.  In  all  of  these  the  skin 
is  more  or  less  red,  and  its  surface  unbroken. 

Erythema  is  characterized  by  a  uniform  and  continuous 
redness  of  the  skin,  occurring  in  irregular  patches  of  some 
size,  and  attended  with  but  slight  swelling,  if  with  any. 
The  afiection  may  or  may  not  be  associated  with  disturbance 
of  the  general  health  ;  usually  it  is  acute,  and  connected 
with  some  visceral  disorder.  There  is  only  one  variety  apt 
to  be  combined  with  decided  febrile  symptoms — the  hard, 
painful  protuberances  most  commonly  seen  on  the  legs,  and 
constituting  the  so-called  "erythema  nodosum."  This  form 
of  the  complaint  is  chiefly  observed  in  those  of  rheumatic 
diathesis. 

Roseola  consists  in  circumscribed  spots  of  a  rose-red  color, 
and  of  a  more  or  less  circular  form.  The  spots  are  smaller 
than  those  of  erythema.  There  is  slight  fever,  and  at  times 
redness  of  the  fauces.     The  aftection  is  generally  acute,  and 


DISEASES    OF    THE    SKIN.  785 

bears  a  certain  resemblance  to  scarlatina  ami  measles;  but 
it  is  not  contagious,  its  constitutional  symptoms  are  much 
milder,  and  we  find  neither  the  marked  sore  throat  of  scarlet 
fever  nor  the  catarrh  of  measles. 

Urticaria,  or  nettle-rash,  gives  rise  to  prominent  and  per- 
fectly smooth  patches,  the  color  of  which  is  either  redder  or 
whiter  than  the  surrounding  skin.  Tlie  wheal-like  eruption 
is  attended  with  more  itchins:  and  tina;lino;  than  the  other 
exanthemata,  and  is  much  more  evanescent,  generally  disap- 
pearing in  two  days  at  furthest.  It  may,  however,  exist  in  a 
chronic  form.  Its  cause  is  irritation  of  the  gastro-pulmonary 
or  gastro-urinary  mucous  membrane.  Certain  kinds  offish, 
especially  shell-fish,  are  particularly  prone  to  produce  it. 
Urticaria  is  thought  generally  to  be  an  exudative  disease  of 
the  skin;  but  there  are  those  who  believe  that  it  is  only  a 
spasmodic  contraction  of  the  muscular  tissue  of  the  cutis;* 
and  it  seems  to  me  most  probable  that  it  is  wholly  a  reflex 
phenomenon  caused  chiefly  by  reflected  irritation  of  the 
cutaneous  vaso-motor  nerves. 

Papular  Diseases. — A  papula,  or  pimple,  is  a  small  eleva- 
tion of  the  cuticle  with  an  inflamed  base  ;  it  does  not  contain 
any  fluid,  and  usually  terminates  in  desquamation. 

Lichen  furnishes  the  best-marked  example  of  a  papular 
eruption.  It  consists  of  minute  conical  papulfe,  generally 
of  reddish  color,  and  occurring  in  clusters.  It  is  most  fre- 
quently encountered  in  the  summer  months  and  in  adults, 
and  often  in  persons  of  good  health,  but  who  have  been  ex- 
posed to  much  fatigue  or  anxiety.  Sometimes  it  is  evidently 
connected  with  disordered  digestion.  It  is  very  commonly 
chronic.  "When  assuming  a  circular  form,  it  is  designated 
as  a  species  of  ring-worm.  The  lichen  of  young  children 
and  infants  is  called  "strophulus."  There  is  often  a  mix- 
ture of  papulae  with  an  eczematous  eruption ;  indeed,  there 
is  a  close  relationship  existing  between  the  two  disorders. 

Prurigo  is  a  papular  afiection  of  the  skin  attended  with 
excessive  itching.  The  pimples  are  generally  torn  by  the 
finger-nails,  and  are  surmounted  by  black  scabs.     They  are 


*  Gull,  Guy's  Hosp.  Rep.,  3d  Series,  vol.  v. 
50 


786  MEDICAL   DIAGNOSIS. 

not  red,  as  those  of  lichen  so  usually  are,  and  are,  as  a  rule, 
larger,  and  accompanied  by  much  more  pruritus  and  by 
thickening  of  the  skin.  The  affection  may  or  may  not  be 
attended  with  constitutional  symptoms.  It  is  very  distress- 
ing and  obstinate,  especially  when  happening  in  old  persons. 
It  generally  affects  more  particularly  the  arms  and  legs,  very 
rarely  the  face  and  neck.  The  skin  of  the  anterior  and  outer 
part  of  the  leg  is  most  changed ;  that  over  the  flexors  in  the 
forearm  is  always  healthy.  The  distressing  disorder  may  be 
purely  local,  occurring  around  the  anus,  or  on  the  scrotum 
and  root  of  the  penis,  or  on  the  pudenda.  Some  of  these 
cases,  however,  though  called  prurigo,  present  no  papulae, 
and  the  disorder  is  really  due  to  perverted  sensibility  of  the 
cutaneous  nerves  alone. 

Prurigo  can  often  be  traced  to  want  of  personal  cleanliness. 
It  is  frequently  found  to  be  connected  with  deterioration  of 
the  health,  and  is  indeed  essentially  an  affection  of  the  nerves. 
It  may  last  a  lifetime,  beginning  in  childhood.  Its  local  forms 
are  associated  with  irritation  of  the  bladder,  rectum,  or  uterus. 

Vesicular  Diseases. — These  are  characterized  by  an  eflu- 
sion  of  a  clear  fluid  beneath  the  epidermis,  which  is  generally 
raised  in  small  elevations.  To  the  class  of  vesicular  dis- 
eases belong  especially  eczema  and  herpes.  Along  with  them 
pemphigus,  usually  grouped  with  the  bullse,  will  be  described; 
for  bullae  difter  from  vesicles  only  in  size. 

Eczema  consists  of  minute  vesicles  collected  together  in 
irregular  patches.  The  vesicles  are  often  confluent,  and  it 
then  appears  as  if  the  whole  surface  were  secreting  fluid. 
This  may  harden,  from  exposnre  to  the  air,  into  scabs  of 
various  thickness  and  color.  The  skin  itself  is  often  of  a 
vividly  red  hue. 

Eczema  may  aflect  the  whole  bod}',  but  is  ordinarily  limited 
to  some  portion  of  it.  It  is  acute  or  chronic.  The  former  is 
generally  seen  as  the  eftect  of  local  instants,  and  may  be 
met  with  in  young  and  healthy  persons.  Chronic  eczema  is 
oftener  the  consequence  of  constitutional  disturbance,  and 
is  very  frequently  found  to  be  associated  with  some  disorder 
of  the  digestive  system.  Dentition  and  unhealthy  milk  are 
common  sources  of  the  aft'ection  in  very  young  children.     In 


DISEASES    OF    THE    SKIN.  787 

tliem  the  disease  is  extremely  apt  to  attack  the  scalp  and  face, 
forming  the  complaint  often  described  as  "  crusta  lactea ;"  or, 
if  the  secretion  be  partly  purulent,  and  dry  into  large,  dark 
scabs,  the  malady  is  designated  as  "eczema  impetiginodes." 

In  some  of  the  forms  of  eczema,  especially  in  its  chronic 
varieties,  the  vesicles  supposed  to  characterize  the  disorder  can 
often  not  be  found.  This  and  other  reasons  have  caused  sev- 
eral recent  dermatologists,  especially  Hebra*  and  Anderson, f 
to  deny  that  eczema  need  be  vesicular  at  all.  Intiltration  of 
the  skin,  exudation  on  its  surface,  the  formation  of  crusts, 
and  itching  are  held  to  be  its  distinctive  signs,  while  the  erup- 
tion is  at  its  height;  but  the  eruption  may  consist  of  clusters 
of  papules,  vesicles,  or  pustules,  or  there  may  not  be  a  vestige 
of  any  of  these,  the  skin  being  red  and  smooth  and  secreting 
a  sticky  discharge  or  covered  with  green  or  gummy  crusts. 

Eczema,  particularly  when  it  affects  the  scalp  and  face, 
must  not  be  confounded  with  the  morbid  secretion  from  the 
sebaceous  follicles  giving  rise  to  soft  crusts.  This  disease,  or 
"seborrhea,"  by  preference  attacks  the  parts  mentioned,  but 
its  crusts,  as  Hardy  has  shown,  are  unlike  those  of  eczema  in 
the  readiness  with  which  they  are  detached,  and  susceptible 
of  beino;  moulded  between  the  fins^ers.  The  surface  beneath 
the  crusts,  too,  is  dissimilar.    It  has  an  oily,  glistening  look. 

Herpes,  like  eczema,  is  classed  as  a  vesicular  affection,  and 
differs  from  the  obviously  vesicular  form  of  the  latter  disorder 
by  the  larger  size  of  the  vesicles.  These  are  generally  of 
globular  form,  and  are  arranged  in  clusters  upon  an  inflamed 
patch  of  skin.  Each  vesicle  is  distinct,  and  remains  so 
throughout  its  course.  It  lasts  from  about  eight  to  twelve 
days,  and  often  terminates  by  the  formation  of  a  thin  incrus- 
tation. 

Herpes  has  seldom  a  longer  duration  than  three  weeks. 
It  happens  usually  in  persons  of  delicate  skin ;  is  generally 
very  local,  having  its  seat  on  the  lips,  eyelids,  prepuce,  or 
pudenda;  and  is  almost  invariably  associated  with  an  internal 
disease,  especially  with  irritation  of  some  portion  of  the  gas- 


*  Hautkrankheiten  ;  or  Translation  by  Sydenh.  Soc. 
f  A  Practical  Treatise  upon  Eczema.    London,  1863. 


788  MEDICAL    DIAGNOSIS. 

tro-pulmonary  mucous  membrane.  It  often  appears  at  the 
termination  of  fevers.  Its  most  distressing  form  is  that  ex- 
tending around  one-half  of  the  trunk, — "  herpes  zoster,"  an 
acute  disorder,  which  may  show  itself  over  the  course  of  any 
of  the  superlicial  nerves.  Indeed,  herpetic  or  bullous  erup- 
tions often  happen  over  the  course  of  nerves,  and  a  nerve 
lesion,  the  result  of  disease  or  of  an  injury,  will  produce  them 
over  the  disordered  nerve. 

Herpes  and  eczema  may  both  be  confounded  with  scabies, 
which,  like  them,  occasions  a  vesicular  eruption  which  is  apt 
to  be  found  on  the  inner  surface  of  the  limbs  and  flexures  of 
the  joints.  The  distinction  consists  in  the  severe  itching; 
in  the  small,  conical  vesicles,  torn,  as  they  so  usually  are,  by 
scratching;  and  in  the  presence  of  the  acarus,  which  may  be 
removed  from  its  burrow  with  the  point  of  a  needle  or  any 
sharp  instrument. 

Pemijhigus  is  a  disease  not  often  met  with.  It  appears  in 
very  large  vesicles  or  bullae,  surrounded  by  a  zone  of  erythe- 
matous redness.  The  blebs  occur  in  crops,  and  look  like 
small  blisters  filled  with  serum.  The  disorder  may  be  acute 
or  chronic.  It  is  ordinarily  chronic,  and  happens  in  persons 
of  enfeebled  constitutions.  The  chronic  form  is  also  called 
"  pompholyx." 

Pustular  Diseases. — These  are  marked  by  circumscribed 
elevations  of  the  cuticle  which  contain  pus.  Acne,  impetigo, 
and  ecthyma  belong  to  the  group.  Rupia,  too,  although  often 
classed  among  the  vesicular  or  the  bullous  disorders,  apper- 
tains more  strictly  to  the  pustular. 

Acne  is  an  eruption  of  hard,  isolated,  red  elevations,  due 
to  chronic  inflammation  of  the  follicles  of  the  skin.  At  the 
apices  of  many  of  these  elevations  pus  forms,  which  is  dis- 
charged, leaving  a  hardened  base,  which  only  gradually  disap- 
pears. Acne  is  generally  seen  on  the  face  and  shoulders. 
Men  of  sedentary  occupations  and  drunkards  are  very  liable 
to  it.  In  women  it  is  frequently  associated  with  uterine  dis- 
turbances. 

Impetigo  presents  small  pustules  occurring  in  successive 
crops  and  arranged  in  clusters.  The  pustules  are  but  little 
raised  above  the  surface,  soon  break,  and  a  thick,  yellowish 


DISEASES    OF    THE    SKIN.  789 

or  greenish  crust  is  developed,  "When  the  disorder  attacks 
the  scalp  and  face,  especially  in  infants  and  children,  it  gives 
rise  to  very  extensive  incrustations,  and  constitutes,  particu- 
larly if  conjoined  with  eczema,  the  atfection  designated  as 
"porrigo  larvalis." 

Ecthyma  differs  from  impetigo  by  the  larger  size  and  greater 
prominence  of  the  pustules  and  their  inflamed  base.  When 
the  crust  that  forms  on  each  pustule  falls,  a  highly-congested 
surface  or  a  superficial  ulceration  is  seen,  which  leaves  a 
cicatrix.  The  disorder  is  apt  to  be  connected  with  a  cachec- 
tic state  of  the  system.  It  bears  a  certain  resemblance  to 
sycosis;  but  the  limitation  to  the  hairy  portions  of  the  face, 
the  yellow  color  of  the  pustules,  their  conical  form  and 
smaller  size,  and  the  brown  crusts  they  occasion,  distinguish 
this  malady. 

Bupia  produces  very  large  pustules,  that  desiccate  into 
thick,  brownish  crusts,  often  of  conical  shape  or  resembling 
the  shell  of  an  oyster,  and  which,  when  thrown  off,  expose 
ulcerations  of  various  depth  that  are  slow  to  heal,  and  on 
which  fresh  crusts  arise.  The  disease  runs  a  chronic  course. 
It  occurs  especially  on  the  lower  extremities,  is  almost  always 
syphilitic,  and  coexists  with  a  deteriorated  constitution.  It 
is  very  like  ecthyma,  and  can  be  distinguished  only  by  the 
history  of  the  case,  the  persistent  ulcerations,  and  the  promi- 
nent, peculiarly-shaped  crusts. 

Squamous  Diseases.— Here  the  predominant  character- 
istic is  the  formation  of  small,  whitish  patches  of  unhealthy 
cuticle  covering  red  papular  elevations,  or  a  deep-red  surface. 
Lepra  and  psoriasis  are  the  main  disorders  belonging  to  this 
group.  Pityriasis  is  included  by  many  authors,  while  others 
regard  it  as  merely  a  variety  of  chronic  erythema.  It  differs 
from  lepra  and  psoriasis  by  the  production  of  minute  squamae, 
which  are  constantly  thrown  off  and  re-formed,  and  which  are 
seated  on  a  reddened  integument. 

Lepra  and  psoriasis  may  be  described  together,  since  there 
is  very  httle  real  difference  between  them.  In  both  we  find 
patches  of  red  hue  raised  above  the  surrounding  integument 
and  covered  by  scales  of  dried  epidermis.  In  lepra  these 
patches  have  a  circular  or  circumscribed  shape,  the  scales  are 


790  MEDICAL    DIAGNOSIS. 

large  and  well  defined.  In  psoriasis,  on  the  other  hand, 
while  the  scales  more  completely  cover  the  morbid  portion 
of  skin,  they  are  finer,  and  the  patches  are  large  or  consist  of 
very  small  ones  which  have  coalesced  into  a  single  large  one, 
are  not  of  an  annular  form,  and  not  separated  by  healthy  skin. 

Lepra  and  psoriasis  occur  most  frequently  among  the  poor 
and  uncleanly,  and  are  sometimes  evidently  hereditary.  They 
are  chronic  afliections,  and  often  extremely  obstinate.  They 
are  both  liable  to  be  mistaken  for  lichen,  especially  lepra. 
The  latter  is,  however,  distinguished  by  the  distinct  scales 
and  by  the  smooth,  red  skin,  which  is  at  once  perceived 
when  the  scales  are  detached.  Psoriasis  has  a  predilection 
for  the  vicinity  of  the  joints.  Sometimes  it  appears  exclu- 
sively on  the  palm  of  the  hand. 

Ichthyosis,  or  fish-skin,  is  also  a  squamous  disease;  but  it 
difiers  from  the  others  of  this  class  in  being  much  more  gen- 
eral,  affecting  as  it  does  often  the  whole  integument,  and  in 
the  absence  of  reddening  or  any  signs  of  inflammation  of  the 
surface.  The  skin  is  drj^  and  rough,  and  covered  with  thick- 
ened and  exfoliating  cuticle.  Ichthyosis  is  almost  always  of 
congenital  origin. 

Tuberculated  Diseases. — These  are  hard,  indolent,  su- 
perficial, and  generally  permanent  tumors  of  the  skin.  Mol- 
luscum.  Lupus,  and  Elephantiasis  of  the  Greeks  illustrate 
this  group. 

Molluscum  presents  numerous  globular  or  flattish  tubercles, 
sometimes  seated  on  a  broad  base  or  attached  to  a  peduncle. 
They  occur  chiefly  in  groups  on  the  face  and  neck,  are  filled 
with  a  peculiar  atheromatous  matter,  vary  in  size  from  a  pea 
to  a  pigeon's  Qgg,  show  no  tendency  to  inflame  or  ulcerate, 
and  are  not  attended  with  increased  sensibility  of  surface. 
They  are  of  the  color  of  the  skin  or  of  brownish  hue.  They 
may  last  during  life  and  grow  very  slowly  without  affecting 
the  general  health.  There  is  a  variety  met  with  specially  in 
children,  which  has  at  the  top  or  side  of  each  tubercle  a  small 
orifice  from  which  a  creamy  fatty  fluid  can  be  pressed.  This 
variety  is  regarded  as  contagious ;  though  there  are  many 
who  still  doubt  the  contagious  nature  of  "molluscum  conta- 
giosum." 


DISEASES    OF    THE    SKIN.  791 

In  lupus,  the  tubercles  mayor  may  not  ulcerate.  They  are 
of  a  dull-red  color,  and,  if  they  ulcerate,  are  apt  to  destroy 
the  tissues  in  which  they  are  situated.  The  ulcers  also 
spread,  and  may  occasion  much  devastation.  Wlien  they 
heal,  they  leave  a  strongly-marked  whitish  cicatrix  and  an 
unhealthy-looking  skin.  The  disorder  occurs  in  syphilitic  or 
scrofulous  persons.  There  is  a  form  of  lupus  occurring  only 
in  strumous  subjects,  and  characterized  by  warty  formations. 
This  "  lupus  verrucosus  "  is  without  pain  or  itching,  but  cica- 
trices form,  though  there  has  been  no  previous  ulceration.* 

Elephantiasis  of  the  Greeks  is  distinguished  by  tubercles, 
from  the  size  of  a  pea  to  that  of  a  walnut,  of  reddish,  or 
whitish,  or  bronzelike  hue,  which  may  ulcerate,  and  which 
are  preceded  by  erythematous  patches.  Often,  too,  there  are 
symptoms  of  defective  innervation,  especially  deficient  sen- 
sation of  the  surface,  and  the  blood  is  seriously  affected. 
The  face  is  frequently  the  seat  of  the  malady,  and  becomes 
very  much  thickened  and  disfigured. 

The  Barbadoes  leg,  or  elephantiasis  of  the  Arabs,  is  an 
enormous  increase  in  size  of  the  limb,  usually  dependent 
upon  an  indurated  swelling  of  the  subcutaneous  tissues,  with 
some  alteration  of  the  skin  proper.  The  tumefaction  may  be  in 
swellings  separated  by  deep  furrows,  giving  somewhat  of  a 
tuberculated  look  to  the  part,  or  it  may  be  uniform.  It  is 
similar  in  the  structure  it  principally  afifects  to  the  extraor- 
dinary induration  of  the  cellular  tissue,  to  which  the  name 
of  sclerema  or  sclerodermia  has  been  given.  I  had  some  years 
since  a  marked  case  of  this  strange  affection  under  my  charge 
at  the  Pennsylvania  Hospital,  in  a  woman,  forty-two  years  of 
age,  who,  admitted  with  oedema  of  the  feet,  was  at  the  same 
time  noticed  to  have  a  swelling  of  both  wrists  and  forearms 
as  well  as  of  the  cheeks.  The  swelling  was  firm  and  resistant, 
and  did  not  pit  on  pressure.  The  skin  covering  it  was  very 
smooth,  and  of  redder  hue  than  at  other  portions  of  the 
body;  there  was  well  preserved  sensibility.  The  csdema 
disappeared  from  the  feet,  but  the  signs  of  the  indurated 
cellular  tissue  did  not  leave  the  afi:ected  parts.     On  the  con- 


*  McCall  Anderson,  Journal  of  Cutaneous  Medicine,  vol.  i. 


792  MEDICAL   DIAGNOSIS. 

trary,  the  condition  of  these  parts  became  worse,  though 
the  general  health  was  excellent,  all  the  internal  viscera 
being  in  a  normal  state.  Gradually  the  hands,  particularly 
the  fingers,  were  found  to  be  more  and  more  resisting  and 
immovable,  and  she  could  scarcely  bend  them ;  occasionally 
they  were  the  seat  of  pain.  The  skin  lost  all  suppleness,  and 
could  not  be  raised  up.  At  no  time,  while  under  observation, 
was  albumen  present  in  the  urine.  She  left  the  hospital  un- 
improved by  the  sulphur  baths,  the  bichloride  of  mercury, 
and  the  various  other  alteratives  she  took;  and  I  have  since 
learned  that  she  died  of  an  acute  pleurisy  succeeding  an 
attack  of  acute  meningitis,  from  which  she  had  not  wholly 
recovered.  Prior  to  her  death,  so  great  was  the  pressure  ex- 
erted by  the  dense  and  contracting  cellular  tissue,  that  dry 
gangrene  of  a  finger  ensued,  as  well  as  of  a  toe,  the  disease 
having  also  been  noticed  in  the  lower  extremities.  In  truth, 
the  progress  of  the  whole  affection  was  in  its  eflects  on  the 
adjacent  muscles  similar  to  that  produced  in  cirrhosis  by  the 
increased  and  indurated  cellular  tissue.  She  died  about  one 
year  from  the  beginning  of  the  complaint.  Examined  after 
death,  the  skin  over  the  diseased  parts  was  firmly  united  by 
the  dense  and  augmented  areolar  textures  to  the  muscles  be- 
neath; thus,  of  necessity,  their  motions  had  been  interfered 
with. 

There  is  a  form  of  enlargement  of  the  leg  which  we 
may  here  briefly  refer  to — one  in  which  the  overgrowth  of 
the  affected  limb  is  associated  with  disease  in  the  lymphatic 
system.  Vesicles  form,  which  are  connected  together  by 
ridgelike  elevations,  and  which  from  time  to  time  discharge 
a  chylous  fluid.*  The  subcutaneous  lymphatics  near  the 
groin  are  usually  found  to  be  distended. 

Parasitic  Diseases. — These  may  be  caused  either  by  the 
presence  of  parasitic  animals  or  of  plants.  To  afi'ections  of 
the  former  origin,  or  to  the  epizoa,  belongs  especially  sca- 
bies; though  the  various  forms  of  lice  producing  the  ail- 
ment, presenting  for  the  most  part,  a  pruriginous  eruption 
— phthiriasis,  must  be  alluded  to.     The  other  animal  para- 

*  W.  H.  Day,  Transactions  of  Clinical  Society  of  London,  vol   ii.,  1869. 


DISEASES    OF    THE    SKIN.  793 

site,  the  entozoon  or  demodex  folliculorum,  inhabits  the 
sebaceous  and  hair  follicles,  but  does  not,  so  far  as  is  known, 
cause  disease. 

The  complaints  associated  with  the  vegetable  parasites,  the 
epiphytes,  or  as  those  on  the  skin  are  called,  the  dermato- 
phytes, are  chiefly  favus,  mentagra,  pityriasis  versicolor,  and 
some  of  the  forms  of  ring-worm,  tinea  circinatus,  and  tinea 
tonsurans.  Pellagra,  also  supposed  to  be  due  to  a  vegetable 
parasitic  growth,  is  not  an  atfection  met  with  in  this  country, 
!N"or  does  the  presumed  parasitic  fungus  lodge  in  the  skin. 
It  is  said  to  be  found  in  diseased  Indian  corn  or  maize, 
which,  when  eaten,  causes  the  general  cachexia  and  cuta- 
neous eruption  which  characterize  the  malady,  of  which  the 
eruption  moreover  is  determined  by  exposure  to  the  sun. 

Scabies,  or  the  itch,  is  owing  to  the  acarus  scabiei.  This 
burrows  into  the  skin,  particularly  between  the  lingers  and 
between  the  toes.  The  channels  produced  are  generally 
somewhat  curved,  and  may  be  traced  as  whitish  or  black 
streaks  of  several  lines  in  length,  in  the  situations  just  indi- 
cated. The  disease  is  attended  with  excessive  itching,  and 
the  eruption  of  conical  vesicles,  or  even,  in  some  cases,  of 
pustules. 

At  the  close  of  the  late  war  we  had  a  form  of  itch  very 
prevalent  in  this  country,  and  which  was  spread  far  and 
wide,  as  is  presumed  by  contact  with  the  troops — the  so- 
called  Army  itch.  It  was  a  very  chronic  and  very  distressing 
atfection,  and  no  age  or  social  state  w^as  exempt  from  it. 
Indeed,  so  prevalent  was  it  that  it  almost  appeared  as  an 
epidemic.  The  itching  was  intense,  the  eruption,  as  by  far 
most  frequently  met  with,  was  like  prurigo,  but  vesicles, 
or  even  an  eczematous  condition  of  skin,  or  pustules  attended 
the  intolerable  itching;  and  in  cases  of  very  long  duration 
the  appearance  of  the  skin  was  altered,  and  all  trace  of  a 
distinctive  eruption  was  gone.  The  eruption  was  seen  on 
the  arm,  forearm,  chest,  abdomen,  and  lower  extremities, 
particularly  on  the  ulnar  side  of  the  forearm  and  inner 
aspect  of  the  thigh.  It  was  sometimes  found  on  the  scalp, 
but  very  seldom  in  the  groins,  axillte,  on  the  hands  or  be- 
tween the  fingers.     It  was  benefited  by  sulphur;  for  almost 


794  MEDICAL    DIAGNOSIS. 

all  the  preparations  recommendecl  for  it  contain  sulphur. 
Whether  it  was  due  to  the  same  acarus,  as  ordinary  scabies, 
or  to  a  ditFerent  species,  I  am  unable  to  say. 

Faims  gives  rise  to  bright-yellow  umbilieated  crusts,  of 
circular  shape  and  smooth  surface,  which  often  form  yellow 
rinses  around  the  hair  follicles  and  are  not  much  elevated 
above  the  skin.  There  is  no  discharge.  The  disease  very 
rarely  atfects  any  other  part  of  the  body  than  the  scalp.  In 
cases  of  doub.t,  the  microscope  furnishes  us  with  a  certain 
means  of  diagnosis,  by  exhibiting  the  cryptogamic  plants.* 

The  vegetable  origin  of  mentagra,  or  sycosis,  is  not  so  sat- 
isfactorily proved  as  that  of  favus.  The  distinctive  marks 
are  the  development  of  yellowish  pustules,  having  a  bright- 
red  base,  around  the  roots  of  the  hair  of  the  beard.  The  tri- 
cophyton  tonsurans  is  the  parasite  said  to  be  found  in  sj'cosis, 
and  it  is  also  met  with  in  tinea  circinatus,  the  ring-worm  of  the 
body,  and  in  tinea  tonsurans,  the  ring-worm  of  the  scalp. 

Pityriasis  versicolor  occasions  those  yellow  or  yellowish- 
brown  discolorations  which  maybe  not  unfrequently  seen  on 
various  parts  of  the  body.  The  affection  is  common  in 
women,  especially  in  pregnant  women.  The  microsporon 
furfur  of  Eichstadt  is  the  parasite  present  in  this  disorder. 
In  pityriasis  affecting  the  scalp,  we  may  also  find  parasitic 
growths  of  vegetable  nature;  and  they  are  often  the  cause  of 
baldness,  as  in  porrigo  decalvans. 

The  disorders  of  the  skin  which  we  have  been  considering 
do  not  always  occur  isolated  ;  they  may  be  combined.  Again, 
they  are  altered  by  the  existence  of  a  special  taint,  as  by  the 
syphilitic.  Now,  without  making  any  attempt  to  describe 
syphilitic  diseases  of  the  skin,  I  may  briefly  state  that  they 
ditfer  chiefly  by  their  copper-colored  tint,  and  by  the  stained 
aspect  they  leave.  Then,  syphilitic  lichen  has  more  distinct 
pimples,  and  a  well-deflned  scab  on  each.  The  ulcerations  in 
the  pustular  aflections  are  deeper;  while  in  the  squamous 
disorders  the  scabs  are  smaller  and  the  papules  larger  than 
in  the  non-syphilitic  eruptions. 

As  regards  the  treatment  of  cutaneous  affections,  we  should 


*  For  a  good  description  of  these,  see  Bennett's  Clinical  Lectures. 


DISEASES    OF    TUE    SKIN.  705 

always  recollect  that  manv  of  them  require  hoth  constitutional 
and  local  treatment.  Constitutional  treatment  is  carried  out, 
to  speak  in  general  terms,  by  purgatives,  diaphoretics,  and 
diuretics,  in  the  acute  cases  and  where  febrile  excitement  is 
present;  by  tonics,  especially  by  arsenic,  cod-liver  oil,  iodine, 
and  iron,  in  the  chronic  disorders.  Local  remedies  may  be 
used  for  a  twofold  purpose :  either  to  soothe  the  irritated 
surface  and  protect  it  from  external  injury,  or  to  produce  a 
stimulating  and  alterative  action.  The  latter  is  effected  by 
the  application  of  mercurial  ointments  and  lotions,  of  the 
preparations  of  tar,  of  sulphur,  of  carbolic  acid,  and  of  alka- 
line washes  ;  but  we  must  be  careful  not  to  employ  such  agents 
in  the  early  stages  of  cutaneous  disorders,  as  they  only  aggra- 
vate them.  Simple  cerate,  glycerin  in  a  diluted  form,  solu- 
tions of  lead,  and  the  oxide  of  zinc  ointment, — in  fact,  reme- 
dies which  are  soothing  or  sedative  rather  than  stimulating 
are  far  more  appropriate,  and  may  be  often  advantageously 
resorted  to  even  in  the  chronic  diseases  of  the  skin. 


CHAPTER   XIII. 

POISONS   AND    PARASITES. 

In  disorders  due  to  poisons  or  parasites,  the  morbid  phe- 
nomena are  clearly  occasioned  by  causes  introduced  into  the 
system  from  without.  Thus  they  agree  in  being  affections 
of  external  origin  ;  and  as  regards  both  the  diagnosis  and 
treatment,  our  chief  aim  is  to  ascertain  precisely  to  what 
foreign  substance  the  symptoms  are  owing. 

POISONS. 

Cases  of  poisoning  are  presented  to  the  physician's  notice 
under  various  circumstances.  Sometimes  they  are  the  result 
of  accident  or  carelessness;  sometimes  the  life  of  the  patient 
has  been  attempted  by  himself  or  by  others.  In  either  case 
it  may  be  a  matter  of  the  greatest  moment  to  make  out  a 
correct  diagnosis  as  the  starting-point  for  prompt  and  skilful 
treatment. 

I  cannot,  of  course,  enter  here  at  any  length  into  the  sub- 
ject of  poisons,  but  shall  merely  endeavor  to  set  forth  the 
main  signs  by  which  the  consequences  of  the  most  common 
of  them  may  be  recognized  and  distinguished.  And  for  this 
purpose,  it  will  be  convenient  to  consider  cases  of  poisoning 
as  divided  into  acute  and  chronic,  subdividing  these  two 
classes  again  according  to  the  character  and  effects  of  the 
different  noxious  substances.  Now,  as  regards  their  charac- 
ter and  effect,  various  arrangements  of  poisons  have  been 
made  by  toxicologists,  as,  for  instance,  into  irritant,  narcotic, 
narcotico-acrid,  and  septic ;  into  metallic  and  non-metallic ; 
into  animal,  vegetable,  and  mineral.  In  the  following  sketch, 
I  shall  not  adhere  closely  to  any  of  these  arrangements,  but 
shall  be  guided  by  them  only  to  a  certain  degree  in  grouping 
the  poisons  to  be  discussed. 
(796) 


POISONS    AND    PARASITES.  797 

Acute  PoisoDing, 

The  attack  comes  on  suddenlj^,  the  patient  having  been 
previously  in  perfect  health,  but  having  taken  some  food, 
drink,  or  medicine  which  has  been  followed  b}'^  the  urgent 
symptoms.  And  it  is  always,  in  a  case  of  suspected  poison- 
ing, of  the  utmost  importance  to  be  able  to  make  out  these 
points. 

Irritant  Poisons. — The  chief  articles  which  give  rise  to 
acute  poisoning  belong  to  the  class  of  irritant  poisons.  The 
symptoms  vary  somewhat,  but  they  are  generally  those  of 
acute  gastritis,  attended  often  with  more  or  less  intiamma- 
tion  of  the  mou-th,  fauces,  and  oesophagus.  Sometimes  tiie 
air-passages  maybe  involved,  either  directly  or  bysympathy, 
and  we  iind  hoarseness  and  cough.  Convulsions  are  occa- 
sionally observed,  and  collapse  is  apt  to  occur  sooner  or 
later. 

The  acute  pain,  the  tenderness,  and  the  vomiting  come  on 
shortly  after  a  meal,  or  at  least  after  something  has  been  swal- 
lowed. This  distinguishes  the  acute  gastritis  caused  by  pois- 
ons from  idiopathic  acute  gastritis.  And  sometimes  several 
persons  are  similarly  afi'ected,  a  circumstance  always  strongly 
in  favor  of  the  idea  of  poisoning.  From  perforation  of  the 
stomach  or  intestines,  irritant  poisoning  is  discriminated  by 
noting  that  the  acute  signs  in  the  former  case  follow  upon 
the  manifestations  of  some  gastric  or  intestinal  trouble;  and 
the  attending  phenomena  of  collapse  are  not,  as  in  poisoning, 
associated  with  cramps  or  convulsions.  Cholera  resembles 
poisoning  in  the  suddenness  and  violence  of  the  attack,  but 
is  distinguished  by  the  rice-water  discharges  and  by  its  epi- 
demic character.  In  strangulated  hernia,  the  comparatively 
gradual  onset,  the  pain,  the  tumor,  and  the  absence  of  diar- 
rhoea will  be  significant.  As  regards  the  separation  of  those 
cases  of  poisoning  in  which  blood  is  ejected,  from  ordinary 
hemorrhage  from  the  stomach,  we  find  that  pain  and  purg- 
ing are  both  absent  in  the  latter,  while  in  irritant  poisoning 
they  are  apt  to  be  well-marked  symptoms. 

Let  us  now  examine  some  special  poisons.  Strong  acids 
are  frequently  used  to  destroy  life.     Nitric  acid  stains  the 


798  MEDICAL    DIAGNOSIS. 

lips  and  mouth  orange  yellow  wherever  it  touches  them ;  the 
matters  vomited  are  very  acid,  and  act  upon  copper  or  tin, 
with  the  disengagement  of  reddish  fumes  of  nitrous  acid. 
Sulphuric  acid  stains  the  skin  or  mucous  membrane  white  or 
grayish ;  the  pain  is  excessive,  and  if  the  vomited  matter  be 
mixed  with  a  solution  of  nitrate  of  baryta,  a  dense  white 
precipitate  of  sulphate  of  baryta  is  thrown  down.  Muriatic 
acid  is  less  irritant  and  corrosive  than  sulphuric  acid.  It  is 
recognized  in  the  ejected  substances  by  causing  a  white  pre- 
cipitate with  nitrate  of  silver.  Oxalic  acid,  when  concen- 
trated, is  very  rapidly  fatal.  If  vomiting  occur,  the  matter 
ejected  may  be  tested  with  a  solution  of  lime,  when  the  oxa- 
late of  lime  will  form  a  white  and  insoluble  deposit. 

The  strong  alkalies,  when  taken  into  the  stomach,  cause 
inflammation  of  the  organ.  Ammonia  may  induce  violent 
nervous  symptoms,  similar  to  those  of  tetanus;  its  vapor 
sometimes  acts  powerfully  on  the  air-passages. 

Iodide  of  looiassium,  iodine^  bromiiie,  and  chlorine  are  all  ca- 
pable of  destroying  life  by  their  intensely  irritant  eflfect. 
Phosphorus,  which  is  not  unfrequently  taken  as  a  poison,  im- 
parts to  the  breath,  the  feces,  and  even  to  the  urine  an  allia- 
ceous smell,  and  makes  them  luminous  in  the  dark.  It  acts 
as  an  irritant,  causing  obstinate  vomiting  and  purging,  pain 
at  the  epigastrium,  rapid  and  weak  pulse,  jaundice,  and  un- 
quenchable thirst.  The  local  pain  and  inflammation  are 
usually  extreme,  and  collapse,  with  or  without  convulsions, 
comes  on  early.  In  some  cases  painful  cramps  in  the  limbs 
occur  and  various  disturbances  of  sensibility,  and  later,  vio- 
lent delirium  and  convulsions  eventuating  in  coma  and  death. 
In  other  cases  hemorrhage  is  a  striking  feature,  the  blood  is 
very  fluid,  and  it  issues  from  all  the  passages,  and  petechise 
form  beneath  the  skin. 

Jaundice  is  a  very  constant  symptom;  it  seldom,  however, 
comes  on  before  the  third  day  and  is  never  intense.*  The 
spleen  increases  in  size  simultaneously  with  the  liver.  Al- 
bumen is  occasionally  present  in  the  urine,  and  the  biliary 

*Schraube,  Schmidt's  Jahrb.,  quoted  in  New  Syd.  Society's  Bieii.  Rep.  fur 
1867-8,  p.  449. 


POISONS    AND    PARASITES.  799 

coloriog  matters  usually.  In  cases  of  phosphorus  poison- 
ing, acute  and  extreme  fatty  degeneration  of  the  tissues 
happens.  It  occurs  with  astonishing  rapidity.  It  has  been 
seen,  in  the  bodies  of  persons  poisoned  by  phosphorus, 
within  so  short  a  period  as  forty-eight  hours,  and  has  been 
found  to  affect  the  heart,  liver,  kidneys,  glands  of  the  stom- 
ach, and  the  voluntary  muscles.* 

Various  salts  of  pofassa,  copper,  zinc,  silver,  lead,  and  iron  oc- 
casionally cause  death.  They  act,  for  the  most  part,  as  irri- 
tants merely;  but  some  of  them  are  powerfully  astringent, 
and  even  caustic,  as,  for  instance,  the  chloride  of  zinc  or  the 
nitrate  of  silver.  If  the  toxical  phenomena  are  due  to  the 
nitrate  of  silver,. the  staining  of  the  lips  may  afford  a  clue  to 
the  nature  of  the  case.  There  are  no  really  distinctive  symp- 
toms produced  by  large  doses  of  arsenic,  antimony,  mercury,  or 
their  compounds,  which  are  among  the  best  known  of  irri- 
tant poisons ;  the  peculiar  effects  of  each  of  these  substances, 
when  insidiously  introduced  into  the  economy,  will  be  pres- 
ently alluded  to. 

Amonor  animal  substances,  canikarides  has  sometimes  been 
productive  of  poisonous  effects ;  strangury,  and  in  male  sub- 
jects priapism,  are  the  most  marked  symptoms  in  such  eases  ; 
wdiile  the  shining,  green  particles  of  the  drug,  if  taken  in 
substance,  have  been  detected  in  the  vomited  matters. 

The  vegetable  irritants  are  mainly  articles  commonly  used 
as  purgatives.  l!h\x%,  elateriuni,  aloes,  colocynih,  and  colchicum 
have  all  proved  fatal  when  taken  too  freely.  The  symptoms 
do  not  differ  materially  from  those  caused  by  other  poisons 
of  this  class.  Tobacco  and  lobelia  are  very  powerful  local  ex- 
citants, occasioning  emesis  and  purging,  with  a  speedy  col- 
lapse of  the  system.  Savin  not  only  produces  inflammation 
of  the  alimentary  canal,  but  is  apt  also  to  give  rise  to  stran- 
gury; it  is  most  frequently  resorted  to  with  the  view  of 
bringing  on  abortion. 

Narcotic  Poisoning.— The  symptoms  of  narcotic  poison- 
ing vary  more,  according  to  the  special  article  taken,  than 
those  caused  by  irritants.    Narcotic  poisons  affect  chiefly  the 

*  Tardieu,  Etude  Medico-Legale  sur  rEmpoisounement,  1867,  p.  445. 


800  MEDICAL    DIAGNOSIS. 

nervous  system  and  the  circulation.  Many  of  them  produce 
phenomena  like  apoplexy  and  intoxication,  from  which  they 
need  to  be  most  carefully  distinguished.  Narcotic  poisoning 
is,  for  the  most  part,  of  the  acute  form. 

Ophon  is  by  far  the  most  important  of  narcotic  poisons.  It 
induces  giddiness,  stupor,  and  lethargic  sleep,  from  which, 
however,  the  patient  can  at  first  be  roused,  if  sharply  spoken 
to.  Subsequently  this  sleep  deepens  into  coma,  and  cannot 
be  broken ;  the  skin  is  relaxed  and  perspiring;  the  face  is 
usually  pale;  the  pupils  are  contracted  and  insensible  to  light. 
A  more  or  less  evident  odor  of  opium  may  often  be  perceived 
about  the  person  or  on  the  breath.  No  distinction  can  be 
drawn  between  the  effects  of  different  forms  of  this  poison ; 
the  stronger  the  preparation,  however,  the  more  marked  and 
the  more  rapid  will  be  the  progress  of  the  case.  Morphia, 
narcotina,  and  the  other  alkaloids  give  rise  to  similar  symp- 
toms;  but  the  smell  of  opium  is,  of  course,  absent,  and  it  is 
said  that  convulsions  are  more  likely  to  occur  as  the  result 
of  their  operation. 

The  diagnosis  of  opium  poisoning  from  apoplexy  and  from 
the  coma  of  ureemia  has  been  discussed  in  a  former  chapter. 
We  may  merely  recall  that  the  contracted  pupil  caused  by 
opium  is  of  very  great  significance,  and  does  not,  with  the 
exceptions  there  referred  to,  exist  in  the  other  states.  More- 
over, the  coma  of  apoplexy  is  at  once  developed ;  while  in 
narcotic  poisoning  it  is  not  sudden,  but  is  preceded  by 
drowsiness  or  stupor,  which  gradually  passes  into  coma. 
These  phenomena  occur  also  in  the  same  sequence  in 
ursemia;  but  they  are  even  slower  in  their  progress,  and  are 
frequently  associated  with  convulsions  and  with  dropsy. 

Alcohol,  if  taken  in  large  quantities  and  not  much  diluted, 
produces  symptoms  very  much  like  those  caused  b}'  opium. 
The  effect  would  not  always  seem  to  be  due  to  the  absorption 
of  the  poison,  since  the  breath  may  be  quite  free  from  spirit- 
uous odor.  This  absence  of  odor  of  the  breath  may  give  rise 
to  a  confusion  between  alcoholic  poisoning  and  apoplexy, 
and  the  discrimination  of  these  conditions  must  then  depend 
in  some  measure  upon  evidence  furnished  by  the  history  of 
the  occurrence  of  the  insensibility,  and  the  presence  or  ab- 
sence of  the  signs  of  palsy. 


POISONS   AND    PARASITES.  801 

Belladonna  and  hyosnjamus  produce  a  more  marked  excite- 
ment of  the  brain  than  opium  does,  often  causing  delirium 
of  an  active  kind,  with  convulsions.  The  pupil  is  dilated 
and  vision  is  singularly  deranged;  there  is  intense  tliirst, 
v^^ith  spasm  and  burning  in  the  throat.  Coniwn  occasions 
stupor,  or  paralyzes  the  muscular  system.  Aco7iiie  has  a 
powerfully  sedative  influence  upon  the  action  of  the  heart, 
brain,  and  spinal  cord,  as  well  as  an  irritant  action  upon 
the  alimentary  canal ;  slow  pulse,  giddiness,  delirium,  nanib- 
ness,  and  tingling  of  the  skin,  loss  of  power  in  the  legs, 
with  vomiting  and  purging,  are  followed  by  syncope  and 
death. 

Digitalis  causes  great  dilatation  of  the  pupil,  sometimes 
vomiting  and  purging,  and  suppression  of  urine;  its  chief 
eftect,  however,  is  upon  the  pulse,  which  is  strikingly  lessened 
both  in  frequency  and  force.  Veratrum  viride,  or  American 
hellebore,  now  so  extensively  used  in  this  country,  closely 
resembles  digitalis  in  its  action. 

Hydrocyanic  or  prussie  acid  is  a  well-known  poison  ;  it  usu- 
ally leads  to  convulsive  contractions  of  the  muscles  of  the 
limbs  and  trunk,  and  destroys  life  by  stopping  the  circulation 
and  respiration.  Sometimes  the  odor  of  the  acid,  resembling 
that  of  bitter  almonds,  is  perceptible  in  the  patient's  breath  ; 
but  too  much  reliance  must  not  be  placed  upon  this  point. 
Unfortunately,  the  diagnosis  of  this  poison  has  generally  to 
be  made  after  death,  for  medico-legal  purposes. 

The  gases  arising  from  burning  coa^,  and  the  fumes  of  char- 
coal, may  lead  to  death  by  asphyxia;  and  a  knowledge  of  this 
fact  has,  particularly  in  France,  led  to  many  suicides.  In 
those  cases  in  which  the  asphyxia  has  not  a  fatal  termination, 
yet  has  been  decided,  disorders  in  the  peripheral  nerves  may 
show  themselves,  manifest  either  bv  the  signs  of  neuritis,  or 
by  pain  and  swelling  simulating  a  phlegmon,  or  by  vesicular 
eruptions  in  the  course  of  an  atiected  vaso-motor  nerve.  The 
peripheral  disturbances  may  appear  immediately,  or  not  until 
after  some  days.  The  signs  of  disorder  of  the  vaso-motor 
nerves  do  not  last  long ;  those  of  the  motor  or  sensitive  nerves 
have  a  longer  duration;  may  be  incurable,  extending  from 

51 


802  MEDICAL    DIAGNOSIS. 

the  centre  to  the  periphery,  or  in  the  reverse  direction;  or 
lastly,  cause  an  ascending  acute  paralysis.* 

Calabar  bean  acts  as  a  direct  sedative  to  the  spinal  marrow, 
and  produces  muscular  debility  or  relaxation  or  even  paral- 
ysis, extending  to  the  heart  and  respiratory  muscles.  The 
mental  faculties  remain  unafl'ected,  and  in  this  it  ditters  from 
the  action  of  the  cerebral  sedatives.  It  is,  however,  irritant 
to  the  alimentary  canal,  causing  vomiting  or  purging,  and  a 
peculiar  epigastric  sensation  is  generally  experienced.  Cal- 
abar bean  contracts  the  pupil  and  also  the  ciliary  muscle, 
thus  making  the  eye  myopic. f 

Strychnia  and  brucia,  the  active  principles  of  nux  vomica, 
and  of  several  allied  plants,  give  rise  to  phenomena  strongly 
resembling  those  of  tetanus.  A  very  short  time,  however, — 
from  a  few  minutes  to  an  hour  or  two, — will  determine  the 
issue  of  a  case  of  poisoning;  while  tetanus  may  run  a  course 
of  several  weeks.  The  first  symptoms  of  strychnia  poisoning 
are  apt  to  be  a  sense  of  suftbcation  and  dyspnoea,  followed 
by  starting  and  twitching  and  rigidity  of  the  arms  and  legs, 
but  not  by  lock-jaw;  tetanus,  on  the  other  hand,  comes  on 
with  setting  or  locking  of  the  jaws,  and  the  limbs  are  not  at 
first  afiected  with  spasms,  indeed,  the  arms  remain  through- 
out nearly  free  from  them.  Again,  idiopathic  tetanus  is 
extremely  rare;  almost  always  there  has  been  some  wound 
or  injury  as  a  proximate  cause  of  the  malady.  But  we  need 
not  pursue  these  points  of  diagnosis  further;  they  have  been 
already  mentioned  in  connection  with  tetanus. 

Chronic  Poisoning. 

When  the  patient  has  been  subjected  to  the  continuous 
action  of  a  noxious  substance,  the  case  is  said  to  be  one  of 
chronic  or  slow  poisoning.  Any  of  the  irritant  poisons, 
given  in  small  and  repeated  doses,  will  keep  up  a  morbid 
condition  of  the  stomach  and  bowels  much  like  ordinary 
chronic  inflammation. 

The  narcotics,  taken  in  the  same  manner,  act  primarily 

*  Leudet,  Archiv.  Gener.  do  Med.,  May,  1865. 

f  T.  A.  Eobertson,  Ediiib.  Med.  Journ.,  March,  18C8. 


POISONS    AND    PARASITES.  803 

upon  the  cerebro-spinal  system,  and  through  this  upon  the  ali- 
nientarv  canal,  so  deramyinsr  dio-estion  and  nutrition  as  even 
indirectly  to  cause  death.  Opium  is  the  most  important  of 
the  articles  thus  used;  it  is  often  administered  to  infants,  for 
the  purpose  of  quieting  their  cries,  and  the  frequent  repeti- 
tion of  the  dose  induces  a  series  of  phenomena  closely  allied 
to  those  observed  in  the  adult.  With  the  eflects,  on  the 
mind,  of  opium  taken  persistently  for  the  sake  of  intoxica- 
tion, the  reading  world  is  familiar  through  the  published 
experiences  of  De  Quincey  and  Coleridge. 

The  habit  is  here  and  in  Europe  generally  acquired  only 
by  persons  who  have  begun  the  practice  for  the  relief  of 
some  painful  affection  ;  in  the  East,  opium  is  used  much 
more  commonly,  and  in  many  Oriental  countries,  to  smoke  it 
is  a  favorite  amusement.  Those  who  employ  it  constantly  are 
pale,  or  have  a  sallow,  haggard  countenance  and  a  dull  eye. 
They  are  troubled  by  loss  of  appetite,  sleeplessness,  and 
low  spirits,  which  they  remove  by  resorting  to  the  opiate. 
Though,  in  spite  of  the  pernicious  custom,  their  general 
health  may  remain  for  many  years  good,  yet  sooner  or  later 
it  gives  way,  and  the  opium-eater  dies  w^orn  out;  or  death 
may  be  the  consequence  of  disease  of  the  liver,  palsy,  or 
inveterate  diarrhoea,  produced  by  long  addiction  to  the  vice. 
Persons  who  consume  large  quantities  of  opium  are  very 
apt  to  have,  from  time  to  time,  attacks  of  extreme  nervous 
prostration,  attended,  perhaps,  with  violent  headache,  and 
requiring  free  stimulation  for  their  relief. 

Mher  and  chloroform,  habitually  made  use  of,  also  cause 
serious  disturbance  of  the  nervous  system:  and  so  does  alco- 
hoL  The  abuse  of  spirituous  liquors  gives  rise  to  a  disorder 
of  the  mental,  motor,  and  sensory  functions,  producing  sleep- 
lessness, headache,  giddiness,  hallucinations;  as  well  as  to 
a  sensation  of  choking,  a  diminished  vitality,  a  tendency  to 
fatty  degeneration,  especially  of  the  liver  and  kidneys;  in 
short,  to  the  symptoms  often  met  with  in  drunkards,  and 
constituting  the  state  so  graphically  described  by  Huss*  and 
Marcetf  as  chronic  alcoholism. 

*  Alcoholismus  Chronicus,  or  Chronic  Alcohol  Disease. 
t  On  Chronic  Alcoholic  Intoxication.     London,  18G0. 


804  MEDICAL   DIAGNOSIS. 

Tobacco  used  in  excess  gives  rise  to  tremors,  impaired 
digestion,  intermittence  in  the  pulse,  with  irregular  cardiac 
action  and  palpitations,  which  may  become  very  annoying, 
and  originate  the  belief  of  an  organic  disease  of  the  heart. 
Like  the  persistent  abuse  of  alcoholic  drinks,  tobacco  may  oc- 
casion amaurosis;*  and  it  is  also  affirmed  that  an  insidious, 
obstinate  form  of  otitis  is  developed  in  inveterate  smokers, 
and  is  attended  with  very  minute  granulations  of  the 
pharynx,  nasal  fossse,  tubes,  and  middle  ear.f  When  em- 
ployed in  large  quantities  by  those  previously  unaccustomed 
to  it,  tobacco  produces  emaciation,  weakness,  sleeplessness, 
dull  hearing,  cold  sweats,  feeble  action  of  the  heart,  and  will 
even  cause  death. 

Let  us  now  examine  some  of  the  features  of  slow  poison- 
ing by  the  metals. 

3Iercury  in  any  of  its  preparations,  may  lead  to  chronic 
poisoning.  The  mouth  is  inflamed,  the  gums  sore  and 
swollen,  the  salivary  glands  act  inordinately,  and  the  breath 
is  very  ofiensive.  Colicky  pains,  and  sometimes  diarrhoea 
occur.  Tremors  of  the  limbs,  when  any  motion  is  attempted, 
evince  disorder  of  the  nervous  centres :  they  are  particularly' 
frequent  in  cases  where  the  poison  has  been  inhaled  in  the 
form  of  vapor,  and  come  on  by  degrees,  and  are  associated 
with  loss  of  power  of  locomotion  and  with  digestive  disturb- 
ances. The  tremors  may  be  incessant  and  the  movements 
involuntary,  like  those  of  chorea,  and  so  rapid  as  to  prevent 
the  patient  from  obtaining  rest  at  night. |  In  some  cases,  an 
eczematous  aflection  is  observed. 

Poisoning  by  mercury  is  generally  the  result  of  the  expo- 
sure to  its  action  incidental  to  certain  occupations,  such  as 
glass-plating,  gilding,  and  working  in  quicksilver  mines. 


*  Sichel,  Annalcs  d'Oculistique,  Mars,  1865,  quoted  in  Brit,  and  For.  Mcd.- 
Chirurg.  Eev.,  July,  1865. 

f  Triquet,  quoted  ib.  Le  Briert,  Gazette  des  Hopitaux,  quoted  in  Ed.  Med. 
Journ.,  Aug.  1864. 

J  As  in  a  case  reported  by  Dr.  Taylor,  in  wbich  the  patient  died  from  the 
effects  of  the  poison,  without,  however,  liaving  presented  salivation  or  mer- 
curial fetor  of  the  breath,  or  a  blue  line  on  the  gums.  Guy's  Hosp.  Eep.,  3d 
Series,  vol.  x. 


POISONS   AND    PARASITES.  805 

Lead  poisoning  is  by  no  means  uncommon  among  painters, 
plumbers,  and  other  workers  in  lead.  Sometimes  it  may  be 
caused  by  accidental  circumstances,  as  when  the  patient  has 
drunk  water  passed  through  leaden  pipes,  or  taken  snutf 
which  has  been  impregnated  with  lead  for  the  purpose  of 
coloring  it;  poisonous  properties  are  said  also  to  be  acquired 
by  snuff  wrapped  in  lead-foil,  and  lead  poisoning  has  been 
observed  among  those  engaged  in  the  manufacture  of  lucifer 
matches  or  working  in  glass  powder.* 

In  such  cases,  the  physician  may  have  to  depend  entirely 
upon  a  correct  appreciation  of  the  symptoms  for  the  diagno- 
sis. Pain  and  uneasiness  in  the  course  of  the  colon,  consti- 
pation, loss  of  appetite,  and  emaciation  are  the  earlier  signs. 
A  metallic  taste  is  sometimes  perceived;  the  breath  is  fetid, 
and  the  tongue  pale  and  funded;  the  gums  are  almost  always 
edged  with  a  blue  line.  Colicky  pains  are  felt  from  time  to 
time,  and  a  severe  and  long-continued  attack  of  colic  may 
form  the  culmination  of  the  disease.  Occasionally  wrist-drop, 
or  paralysis  of  the  extensor  muscles  of  the  forearm,  so  well 
known  as  a  phenomenon  of  lead  poisoning,  occurs  among  the 
first  symptoms ;  but  it  is  more  generally  preceded  by  one  or 
more  attacks  of  colic.  "We  also  find  at  times  lesions  of  the 
tendons  in  saturnine  palsy. f  Yet  as  regards  this  palsy  we 
must  bear  in  mind  that  paralysis  of  the  extensors  may  occur 
which  is  not  due  to  lead.| 

Sometimes  there  is  evidence,  in  cases  of  saturnine  poison- 
ing, of  very  grave  cerebral  disorder;  epileptiform  convul- 
sions, attacks  resembling  apoplexy,  or  general  tremors  and 
extended  paralysis  of  the  muscles,  with  amaurosis  and  other 
signs  of  nervous  disturbance,  are  noticed.  Of  course  the 
diagnosis,  under  these  circumstances,  will  be  materially  as- 
sisted by  an  accurate  knowledge  of  the  previous  historj'  of 
the  patient  as  regards  exposure  to  the  action  of  the  poison. 
The  tremors  are,  like  those  caused  b}'  mercury,  mostly  pecu- 
liar in  ceasing  when  the  limbs  are  supported  or  at  rest. 


*  Lacharriere,  Archiv.  Gener.,  December,  1859. 

t  Med  Times  ami  Gazette,  May,  1868. 

X  St.  George's  Hospital  Eeports,  1868,  p.  86. 


806  MEDICAL    DIAGNOSIS. 

Another  result  of  lead  poisoning  is  that  it  leads  to  the 
form  of  Bright's  disease  known  as  granular  degeneration  of 
the  kidneys.  This  is  very  apt  again  to  coexist  with  a  gouty 
condition,  which,  as  Garrod  has  shown,  is  one  of  the  results 
of  the  absorption  of  lead.  But  the  kidney  trouble  may  be 
found,  whether  or  not  the  joints  are  markedly  affected.  The 
intertubular  or  fibrous  tissue  of  the  organs  becomes  thick- 
ened by  a  sort  of  chronic  inflammation,  and  depositions  of 
urate  of  soda  between  the  tubes  are  not  uncommon. 

Arsenic,  admmistered  in  small  doses  for  a  lengthened 
period,  produces  a  state  of  chronic  inflammation  of  the  ali- 
mentary canal.  (Edema  of  the  face  and  limbs,  in  some 
instances  associated  with  albuminous  urine,  irritability  of 
the  stomach,  diarrhoea,  and  increasing  nervous  derangement 
mark  the  progress  of  these  cases;  the  hair  and  nails  occa- 
sionally fall  out,  and  there  is  much  frontal  headache.  Simi- 
lar efl:"ect8  are  noticed  to  follow  the  pernicious  habit  of 
arsenic-eating;  and  will  be  also  encountered  among  per- 
sons employed  in  making  artificial  flowers  and  toys,  in 
dyeing  cloths,  in  manufacturing  and  hanging  green  papers, 
or  engaged  in  the  sublimation  of  arsenical  ores.  Besides 
the  phenomena  of  internal  poisoning,  cutaneous  eruptions 
occur. 

The  inhalation  of  the  fames  of  zinc  gives  rise  to  a  peculiar 
form  of  poisoning,  characterized  by  a  sense  of  weariness, 
a  feeling  of  tightness  in  the  chest,  and  by  attacks  of  shiv- 
ering, followed  b}^  heat  of  skin  and  a  profuse  sweating 
stage.  This  irregular  form  of  ague  is  common  among  brass- 
founders,* 

Sulphuret  of  carbon  produces  toxical  efl:ects  of  a  singular 
character,  conspicuous  among  which  are  gastric  disturb- 
ances, a  cachectic  condition,  impotence,  and,  in  severe  cases, 
amaurosis,  hallucinations,  and  complete  perversion  of  the 
intellect.!  These  phenomena  are  met  with  among  work- 
ers in  India-rubber. 


*  Greenhow,  Medico-Chir.  Trans.,  1862. 

f  Dclpech,  Mem.  de  I'Academ.  de  JVIedeoine.  1856;  and  Heurtaux,  Rccueil 
do  la  Societe  Medicale  d'Observation,  1860. 


POISONS    AND    PARASITES.  807 

Phosphorus  is  often  seen,  particularly  among  those  who 
work  in  lucifer  match  factories,  to  produce  very  serious 
lesions.  It  may  occasion,  as  acute  phosphorus  poisoning 
does,  alteration  of  the  composition  of  tlie  blood  and  a  hem- 
orrhagic diathesis,  and  a  fatty  degeneration  of  several  organs, 
as  well  as  of  the  voluntary  muscles.*  It  also  produces  necrosis 
of  the  jaw,  for  which  the  whole  lower  jaw  has  been  removed. f 
It  leads,  when  taken  internally  in  doses  that  graduall}'  exert 
a  poisonous  effect,  to  chronic  inflammation  and  thickening 
of  the  stomach,  to  colicky  pains,  to  diarrhoea,  hectic  fever, 
general  emaciation,  falling  out  of  the  hair,  and  palsies, 
which  are  generally  the  precursors  of  a  fatal  termination. 

Animal  yoisons  may  give  rise  to  chronic  as  well  as  to  acute 
poisoning.  We  find,  for  instance,  syphilis,  and  gonorrhcca, 
hydrophobia,  dissecting  wounds,  snake-bites,  and  acute  glan- 
ders and  farcy,  —  all  disorders  exhibiting  the  effect  of  an 
animal  virus.  But  we  have  already  discussed  some  of  these, 
so  far  as  is  admissible  in  a  work  of  this  kind ;  and  of  the 
others,  it  need  only  be  said  that  the  antecedent  circumstances 
generally  place  the  diagnosis  beyond  a  doubt. 

Yet  there  are  a  few  illustrations  of  animal  poisons  and 
their  effects,  which  must  here,  however  briefly,  be  men- 
tioned. 

One  of  these  is  the  malignant  'pustule,  a  terrible  malady, 
which  is  the  cause  of  many  deaths  on  the  continent  of 
Europe,  and  which  is  identical  with  the  charhon  of  animals. 
The  disorder  is  also  prevalent  in  New  Mexico.f  It  is  com- 
municated to  man  by  direct  inoculation  ;  or  by  means  of  the 
skin  or  hair  of  the  diseased  beast,  or  by  eating  its  flesh  ;  or 
by  insects  which,  sucking  the  poison  from  the  sick  animal, 
implant  it  on  the  skin  of  man.  The  poison  produces  a  red 
speck,  which  develops  into  a  vesicle,  under  and  around 
wliich  an  extremely  hard  spot  forms  that  becomes  gangren- 
ous.    The  surrounding  skin  inflames,  new  vesicles  or  pus- 


*  Lancei-aux,  I'Union  Medicale,  1863,  quoted  in  Br.  and  For.  Med.-Chir. 
Eev.,  April,  1864. 

f  Cases  of  Hunt  and  Boker,  Araer.  Med.  Journ.,  April,  1865;  Wells,  New 
York  Med.  Journ  ,  Jan.  1866. 

J  A.  H.  Smith,  Amer.  Journ.  Med.  Sciences,  April,  1867. 


808  MEDICAL   DIAGNOSIS.  / 

tules  spring  up,  and  the  gangrene  spreads  rapidly,  the 
patient  speedily  sinking,  or  the  death  of  the  parts  is  ar- 
rested, and  separation  takes  place  between  the  living  and 
gangrenous  textures.  It  is  remarkable  how  little  local  pain 
attends  the  grave  constitutional  disturbance,  and  signs  of 
low,  irritative  fever.  The  disease  is  found  on  the  exposed 
portions  of  the  bodj',  as  on  the  neck  and  hands.  Though 
due  to  a  poisonous  influence  communicated  from  a  diseased 
animal  to  man,  it  has  been  affirmed  to  have  been  traced  to 
the  presence  of  the  filiform  infusoria,  called  bacteridia,  which 
have  also  been  found  in  the  charbon.* 

There  is  another  form  of  animal  poisoning  which  may  be 
in  this  connection  briefly  considered,  namely,  milk-sickness. 
Now,  its  phenomena  are  so  variously  described  by  writers, 
that  its  characteristic  signs  are  difiicult  to  define.  It  prevails 
only  in  the  southern  and  southwestern  portions  of  iSTorth 
America,  and  is  brought  on  b}'  drinking  the  milk  or  eating 
the  flesh  of  cattle  which  have  been  exposed  to  certain  influ- 
ences, the  nature  of  which  is  as  yet  unknown.  Gastritis  and 
enteritis  seem  to  be  more  or  less  blended  in  the  early  stage 
of  this  disorder,  which,  at  a  later  period,  is  said  strongly 
to  resemble  typhus  fever.  The  symptoms  more  especially 
dwelt  upon  are  lassitude,  nausea  and  vomiting,  with  a  sense 
of  burning  at  the  epigastrium,  great  oppression,  intense 
thirst,  hot,  dry  skin,  obstinate  constipation,  and  obvious 
abdominal  pulsation.  If  at  all,  recovery  takes  place  very 
tardily,  the  tone  of  the  stomach  being  often  left  impaired  for 
life. 

The  treatment  of  this  affection  consists  in  overcoming  the 
very  obstinate  constipation  apt  to  exist,  in  remedying  the 
local  irritant  action  of  the  poison,  and  supporting  the  powers 
of  the  system.  Mercurials  pushed  to  salivation  would  seem 
to  have  proved  beneficial  in  some  cases. 

Besides  these  forms  of  animal  poisoning,  which  are  pro- 
duced by  the  direct  contact  with  the  virus,  or  at  all  events 
by  its  introduction  into  the  system  through  the  stomach,  we 
find  morbid  states  occasioned  by  animal  poisons  which  arise 

*  Davaine,  Gazette  Medicale,  July,  1865. 


POISONS   AND    PARASITES.  809 

from  decomposing  bodies  or  excretions,  or  from  the  crowding 
of  many  together,  particularly  of  those  of  uncleanly  habits, 
or  of  wounded.  These  poisons  reach  the  blood  for  the  most 
part  by  the  lungs,  in  the  shape  of  poisonous  exhalations.  They 
are  very  depressing  in  their  action,  may  lead  to  low  fevers, 
or  to  septicaemia,  and  in  the  case  of  the  wounded  to  pyaemia 
and  hospital  gangrene.  Persistent  nausea,  too,  and  a  lower- 
ing of  all  vital  energy  are  not  uncommonly  observed  in  those 
who  breathe  continuously  tlie  foul  air  under  the  circum- 
stances alluded  to — as  in  hospitals  and  in  prisons,  in  which 
thorough  cleanliness  is  not  enforced,  and  due  regard  is  not 
paid  to  ventilation. 

In  some  persons  deleterious  emanations  from  the  human 
body  give  rise  to  a  form  of  toxeemia,  one  of  the  chief  features 
of  which  is  the  marked  anorexia  which  attends  the  great 
debility.* 

The  exposure  to  animal  effluvia  may  also  excite  violent 
diarrhoea,  or  even  symptoms  like  those  of  cholera,  certainly 
like  those  of  severe  attacks  of  cholera  morbus.  Of  the  occur- 
rence of  the  former  we  have  an  illustration  in  the  dissecting- 
room  diarrhoea,  which  is  usually  attended  with  very  fetid 
discharges,  and  may  be  accompanied  by  colicky  pains,  by 
nausea  and  vomiting,  and  headache.  The  same  kind  of 
diarrhoea  also  happens  in  those  who  clean  privies,  or  who  are 
exposed  to  the  emanations  arising  from  sewers  ;  or  dysentery 
or  choleraic  attacks  may  follow  the  exposure.  ISTay,  as  in 
instances  recorded  by  Becquerel,  the  instant  disengagement 
■  of  large  quantities  of  putrid  gases,  arising  from  bodies  far 
advanced  in  decomposition,  where  coffins  have  been  opened, 
has  caused  sudden  deaths,  or  resulted  in  so  serious  a  state  of 
poisoning  as  to  have  given  rise  to  very  grave  illnesses,  having 
mostly  a  fatal  termination. f  In  individuals  Avho,  in  conse- 
quence of  their  vocation,  are  habitually  brought  in  contact 
with  animal  effluvia  and  liable  to  inhale  noxious  gases,  be- 
sides the  attacks  of  diarrhoea  referrrd  to,  chronic   disturb- 


*See  Dr.  Hunt's  case  described  by  himself  in  Pennsylvania  Hospital  Ee- 
ports,  vol.  i. 

f  Traite  d'Hygiune,  third  edition,  p.  218. 


810  MEDICAL    DIAGNOSIS. 

ances  of  the  stomach  and  liver,  with  marked  impairment  of 
the  general  health,  may  happen. 

PARASITES. 

Parasites,  properly  speaking,  are  organisms  which  hecome 
secondarily  implanted  within  or  upon  the  body.  There  is 
much  room  for  doubt  concerning  several  of  them,  as  to 
whether  they  cause  disease  or  are  merely  its  concomitants. 
Some  parasites  give  rise  to  no  symptoms  at  all ;  many  occa- 
sion phenomena  closely  resembling  those  of  other  irritations. 
In  any  case,  however,  the  only  absolutely  convincing  evi- 
dence of  the  presence  of  a  parasite  is  obtained  by  seeing  it. 

Vegetable  Parasites. — The  chief  vegetable  parasites  have 
been  mentioned  in  connection  with  diseases  of  the  skin  ;  the 
oidium  albicans,  present  in  thrush,  and  stated  to  have  been 
met  with  in  diphtheria,  as  well  as  the  sarcinee  ventriculi,  have 
also  been  alluded  to.  All  these  vegetable  growths  can  only 
be  detected  by  the  microscope ;  and,  particularly  in  those 
involving  the  skin  or  hair,  it  is  of  the  utmost  use  to  employ 
the  liquor  potassfe,  under  the  action  of  which  the  structures 
become  transparent. 

One,  and  so  far  as  is  known  only  one,  fungus  penetrates 
the  internal  tissues — the  chionyphe  Carteri.  This  gives  rise 
to  that  terrible  disease  known  as  podelcoma,  or  the  fungus 
foot  of  India, — a  complaint  confined  to  the  natives  of  India 
who  go  about  with  naked  feet.  The  fungus,  introduced  either 
through  a  scratch  or  passing  through  the  pores  of  the  skin, 
soon  spreads,  eating  its  way  into  the  bones  of  the  tarsus, 
metatarsus,  and  into  the  lower  end  of  the  tibia  and  fibula, 
producing  a  species  of  caries,  or  rather  a  breaking  up  and 
absorption  of  the  osseous  tissues.  The  fungus  particles  or 
masses  are  generally  of  deep  black  color,  firm  and  globular, 
and  in  size  varying  from  a  pea  to  a  pistol  bullet ;  or  the  fun- 
gus presents  the  appearance  of  sloughing  tissue,  and  exhibits 
chiefly  white  granules;  or  it  consists  of  particles  of  pinkish 
color.  In  any  case  the  foot  is  enlarged  about  the  ankle  and 
over  the  instep;  and  on  either  side  of  the  ankle-joint,  and  on 
the  dorsum  as  well  as  on  the  sole  of  the  foot  are  small,  soft 


POISONS    AND    PARASITES.  811 

swellings,  having  pouting  openings  that  lead  to  fistulous 
canals  communicating  with  the  bones,  which  they  perforate 
in  every  direction.  The  fungus  ^iiass  is  for  the  most  part 
situated  in  the  cavities  in  the  bones,  and  from  the  canals 
passing  to  them  transudes  a  discolored,  glairy,  or  purulent 
and  fetid  fluid.  The  toes  are  distorted,  and  the  muscles  of 
the  leg  iitrophied  ;  but  the  fungus  does  not  spread  up  the  leg. 
The  tendency  of  the  disease  is  to  cause  death  by  exhaustion; 
the  only  remedy  is  amputation.* 

Animal  Parasites. — When  speaking  of  the  affections  of 
particular  structures,  I  have  already  alluded  to  some  of  these 
intruders, — those  found  in  the  skin  or  liver,  for  instance.  I 
have  now  to  consider  chiefly  such  as  inhabit  the  hollow  vis- 
cera and  certain  solid  organs  or  the  muscles,  noticing  the  phe- 
nomena caused  by  them  and  the  main  points  by  which  they 
may  be  distinguished  from  one  another.  But  in  so  doing  I 
shall  only  mention  those  of  greatest  import,  for,  as  there  are 
at  least  thirty-one  distinct  animals  which  in  some  phase  or 
other  of  their  existence  infect  man,  and  as  a  number  of  these 
reside  in  the  structures  just  alluded  to,  it  would  not  be  pos- 
sible to  describe  them  all  in  detail. f 

Intestinal  loorms  are,  perhaps,  the  most  common  of  all  para- 
sites. The  general  symptoms  induced  by  them  are  those  of 
intestinal  irritation  with  disordered  digestion.  The  appe- 
tite is  capricious ;  the  bowels  are  very  irregular,  sometimes 
constipated,  sometimes  relaxed;  the  abdomen  is  frequently 
swollen  and  hard,  and  the  seat  of  distressing  uneasiness  or 
of  colicky  pains;  the  tongue  is  furred;  the  breath  fetid;  and 
there  is  constant  itching  about  the  nostrils  and  anus.  The 
patient,  furthermore,  grits  his  teeth  during  sleep,  and  is  very 
often  annoyed  by  nightmare.  Phenomena  indicative  of  a 
ojreater  or  less  des-ree  of  nervous  disturbance  are  also  met 


*  See  Carter,  in  the  Transactions  of  the  Bombay  Medical  and  Physical 
Society;  and  Aitkon,  Practice  of  Medicine,  vol.  i. 

f  See,  for  their  full  description,  the  excellent  works  of  .Joseph  Loidy,  A 
Flora  and  Fauna  within  Living  Animals,  Smithsonian  Publications,  vol.  v.; 
of  Davaine,  Traite  des  Entozoaires  et  des  Maladies  Vermineuses  ;  of  Cobbold, 
Entozoa;  of  Lcuckhart,  Die  Menschlichcn  Parasiten,  Leipzig;  and  Kiichen- 
meister.  Manual  of  Parasites,  Sydenham  Society's  Translation. 


812  MEDICAL    DIAGNOSIS. 

with ;  they  may  range  from  mere  fretfuhiess  up  to  delirium, 
convulsions,  chorea,  epilepsy,  or  even  insanity. 

There  are  many  kinds  o^  worms  known  to  infest  the  ali- 
mentary canal  of  man,  and  they  belong  to  the  orders  oinema- 
toda,  or  round  worms,  or  to  those  of  cesioidea,  or  tape-worms. 

The  round  worms  are  parasites  of  an  attenuated  and  cylin- 
drical form,  and  present  these  varieties  : 

1.  The  ascaris  hmibrkoides,  or  round  worm,  bears  a  consider- 
able resemblance  to  the  common  earth-worm,  from  which  it 
is,  however,  anatomically  different.  It  inhabits  the  small 
intestine,  sometimes  finding  its  way  into  the  stomach,  or 
even  into  the  oesophagus,  or  being  discharged  through  the 
abdominal  parietes.*  When  it  ascends  to  the  stomach  and 
oesophagus,  it  causes,  before  it  is  expelled  by  the  mouth,  sud- 
den attacks  of  fever  and  gastric  derangement,  with  nausea 
and  vomiting;  and  even  at  times  marked  delirium. f  The 
worms  have  been  known  to  be  so  numerous  as  to  obstruct 
the  intestine.  Calomel,  pink-root,  chenopodium,  and  other 
purgatives,  given  singly  or  variously  combined,  will  dislodge 
or  destro}'  the  parasite. 

2.  The  oxyuris  vermicidaris,  thread,  or  seat-worm,  is  very 
small,  the  male  being  about  two  lines,  the  female  about  five 
lines  in  length.  The  parasite  is  white,  slender,  and  extremely 
active ;  is  found  in  the  anus,  and  causes  intense  itching  of 
this  part.  The  annoyance  is  sometimes  such  as  to  excite  a 
suspicion  of  the  existence  of  piles.  It  may  creep  into  the 
vagina,  giving  rise  there  to  profuse  discharges  ;  or  into  the 
urethra.  It  affects  children  frequentl}^  but  is  not  uncommon 
in  adults.  Enemata  containing  vinegar  or  turpentine  gen- 
erally afford  relief. 

3.  The  ascaris  mystax,  a  parasite  which  inhabits  the  cat, 
may  also,  as  Bellingham  and  Cobbold  have  proved,  infest 
the  human  body.  It  is  a  moderate-sized  nematode,  from  two 
to  three  inches  long,  though  the  female  may  reach  about  four 
inches.     Its  head  end  is  spear-shaped. 

4.  The  trichocephalus  dispar,  or  long  thread-worm,  is  detected 


*  Garnier,  rUnion  Medicale,  Oct.  1861. 
t  Schmidt's  Jahrb.,  No.  10,  1868. 


POISONS    AND    PARASITES.  813 

in  very  large  numbers  in  the  ilium  near  its  termination,  or  in 
the  colon,  particularly  at  its  head.  It  has  been  found  in  per- 
sons laboring  under  typhus  or  typhoid  fever,  or  dying  from 
cholera  or  diarrhoea.  It  is  from  an  inch  and  a  half  to  two 
inches  in  length,  and  is  characterized  by  the  hairlike  appear- 
ance of  the  head,  which  is  generally  buried  in  the  mucous 
membrane  of  the  intestine.  It  is  not  a  very  common  para- 
site, and  it  is  doubtful  whether  its  presence  gives  rise  to  any 
marked  derangement.  The  trichina  spiralis,  belonging  also 
to  the  round  worms,  was  formerly  stated  to  be  the  immature 
brood  of  the  thread-worm  ;  but  this  is  now  known  to  be 
incorrect. 

The  tape-worms,  or  cestoidea,  are  jointed  entozoa,  of  a 
ribbon-like  form.  They  embrace  the  true  tape-worms,  or 
tseniadpe,  and  the  bothriocephali.  Of  the  former  there  are 
eight  varieties,  all  of  which  have  been  found  in  man,  though 
only  two — the  solium  and  the  mediocanellata — are  at  all 
common.  The  bothriocephalus  latus  is  the  usual  species  of 
bothriocephalus  met  with  in  the  human  intestine. 

The  tsenia  solium,  or  common  tape-worm,  consists  of  an  im- 
mense number  of  joints  in  connection  with  a  single  head. 
It  may  attain  an  enormous  length,  and  inhabits  chiefly  the 
small  intestines.  The  researches  of  Klichenmeister,*  Von 
Sieboldjf  and  others  have  shown  that  its  eggs  become  devel- 
oped into  the  cysticerciis  cellulosx  discerned  in  the  muscles  of 
the  pig,  rabbit,  and  other  animals  whose  flesh  is  used  as  food. 
Cysticerci  have  also  been  detected  in  the  muscles,  cellular 
tissue,  brain,  and  even  in  the  eye  of  man ;  being  once  intro- 
duced into  the  alimentary  canal,  they  find  there  a  nidus  in 
which  to  undergo  development  into  the  tape-worm. 

The  parasite  is  nourished  from  its  head,  the  newly-created 
segments  pushing  those  already  formed  before  them,  so  that 
the  caudal  extremity  is  the  oldest  portion  of  the  animal. 
Each  segment  is  flat  and  rectangular,  and  contains  both  a 
male  and  female  organ,  the  orifices  of  which  are  joined  at 

*  See  Manual  of  Animal  and  Vegetable  Parasites.     Translation  published 
by  Sydenham  Society,  1857. 

I  Origin  of  Intestinal  Worms,  ibid.  1857. 


814 


MEDICAL    DIAGNOSIS. 


Fig.  4G. 


the  apex  of  a  lateral  papilla.     In  the  tfenia  solium,  the  papillce 
are   arranged   alternately  at  one  side  and  the  other.     The 

size  of    the    se2:nients    in- 
creases    gradually    toward 
the    caudal    extremity,   the 
largest  heing  three  or  four 
lines    in    breadth.      There 
may  be  upwards   of  eight 
hundred  segments,  and  the 
worm  may  measure  above 
ten  feet ;   nay,  it  has  been 
stated    even    to    be    above 
thirty.      Upon     the     head, 
which  is  about  as  large  as 
that  of  a  pin,  is  a  double 
circle  of  hooks  contained  in 
sacs,  and  around  this  circle 
are  arrans-ed  four  suckinc:- 
cups  or  mouths.     The  slen- 
der neck   exhibits  no  seg- 
mentation.     The    sucking- 
disks  in  the  tienia  inedioca- 
nellaia  are  much  larger  than 
those  of  the  taenia  solium, 
but  the  head,  which  is  large, 
of  blackish  appearance,  and 
obtuse,  has  no  hooks. 

Taenia  occasions  disor- 
dered digestion,  colic, 
cramps,  a  feeling  of  uneasiness  in  the  abdomen,  irritation  of 
the  mouth,  nose,  and  anus,  anaemia,  headache,  dizziness,  dis- 
turbed sleep,  mental  depression,  cough,  fainting  tits,  and 
various  cerebro-spinal  atfections,  such  as  convulsions  and 
epilepsy ;  yet  there  are  no  absolute  data  for  the  diagnosis  of 
this  parasite,  except  its  appearance  in  the  discharges.  In 
order  that  relief  be  permanent,  the  head  must  be  expelled. 
Many  remedies  have  been  recommended  for  ettecting  this, 
among  whicli  may  be  mentioned  pomegranate  bark,  extract 
or  oil  of  male  fern,  kousso,  powdered  zinc  or  tin,  and  pump- 
kin seeds. 


TaMiia  solium.     Drawn  from  a  S)icciiiicn. 


POISONS    AND    PARASITES.  815 

The  bothriocephahts  latus,  Ucnia  lata,  or  1)road  tape-worm, 
difters  from  the  common  tape-worm  in  having  no  lateral  pa- 
pillae alternately  arranged,  hut  a  single  one  at  the  centre  of 
each  segment;  the  segments  themselves  are  much  broader, 
and  with  the  breadth  greatly  preponderating  over  their 
length  ;  the  head  is  of  elongated  form,  has  no  hooks  upon 
it,  and  only  a  pair  of  fissures  instead  of  the  four  mouths  of 
the  tsenia  solium,  and  we  find  no  traces  of  joints  until  about 
three  inches  from  the  head.  The  parasite  is  of  yellow  or 
grayish-white  color. 

Echinococci  belong  also  to  the  family  of  the  tfeniadse.  They 
may  take  up  their  abode  in  the  substance  of  almost  any 
organ  in  the  body,  and  are  the  immature  brood  of  a  species  of 
tsenia.  They  consist  of  a  vesicle  having  at  one  portion  of  its 
wall  a  head,  upon  which  are  six  booklets  circularly  arranged. 
The  whole  animal  is  surrounded  by  an  investing  membrane, 
which  may  burst  and  allow  it  to  escape ;  the  term  h}datid 
designates  the  enveloping  cyst.  It  forms  when  the  taenia 
embryo  has  bored  its  way  to  its  resting-place  in  the  liver,  or 
has  been  carried  with  the  circulation  to  other  organs.  The 
echinococcus,  unlike  other  larval  tsenise,  retains  a  more  or 
less  globular  figure,  in  place  of  exhibiting  a  head,  neck,  and 
body.  When  the  echinococci  are  arrested  in  their  normal 
development  and  barren,  not  attaining  to  the  production  of 
scolices,  they  give  rise  to  cysts  with  walls  consisting  of  very 
distinctly  developed,  concentric  layers,  and  having  a  peculiar 
gelatinous  trembling — the  so-called  acephaloci/dts ;  and  the 
same  may  be  said  of  abortive  cysticerci,  embryonic  forms  of 
tseniee,  which,  some  suppose,  may  also  occasion  the  hydatid 
cysts  ;  though  others  maintain  that  the  hydatids  proceed  from 
only  one  form  of  tsenia — the  taenia  echinococcus. 

The  family  of  the  disiomidse,  belonging  to  the  order  of  fluke- 
like parasites,  is  not  at  all  uncommon  in  man. 

A  species  of  distoma,  measuring  from  eight  to  fourteen 
lines  in  length,  called  the  distoma  hepaiicwn,  very  usual  in 
the  liver  and  gall-bladder  of  the  sheep,  has  been  seen  in  the 
human  liver  and  gall-duct,  and  also,  it  is  said,  in  abscesses 
of  the  scalp.  Other  species  of  distoma  have  been  found  in 
the  portal  vein,  ureters,  kidneys,  and  bladder,  and  upon  the 


816  MEDICAL   DIAGNOSIS. 

intestinal  mucous  membrane ;  yet  in  the  portal  vein  and  its 
larger  branches — a  common  seat  of  the  distoma — the  para- 
site produces  little  or  no  appreciable  derangement;  but  when 
in  the  intestine,  it  may  give  rise  to  congestion  of  the  mem- 
brane, extravasation  of  blood,  and  the  symptoms  of  dysentery. 
This  has  been  specially  noticed  of  the  distoma  htematobium, 
or  Bilharzia  htematobia,  a  worm  very  common  in  Egypt,  and 
which  has  also  been  found  to  be  the  cause  of  the  hpematuria 
so  prevalent  at  the  Cape  of  Good  Hope*  and  at  the  Mauritius. 

A  worm  called  the  sirongylus  gigos  has,  in  one  or  two  in- 
stances, been  observed  in  the  kidneys ;  it  need  not,  however, 
be  more  than  alluded  to. 

The  parasites  which  chiefly  occupy  the  areolar  tissues  or 
the  muscles  still  remain  to  be  described.  Of  these  there  are 
two  of  special  importance. 

One  is  the  filaria  medinensis,  or  Gidnea-ioorm.  This  is  a 
very  slender,  flat,  finely-ringed  w^orm,  which  introduces  itself 
into  the  subcutaneous  cellular  tissue :  here  it  grows  rapidly, 
and  gives  rise  to  swelling,  with  more  or  less  inflammation ; 
and  severe  constitutional  disturbance  is  sometimes  mani- 
fested. After  a  time  the  swelling  points,  breaks,  and  the 
worm  may  be  laid  hold  of  and  carefully  twisted  around  a 
little  piece  of  stick  or  a  quill  until  it  is  extracted  entire ;  if 
broken  off,  the  eggs  with  which  it  is  filled,  getting  into  the 
wound,  will  become  the  agents  of  fresh  mischief  Very 
many  of  these  worms  may  be  found  in  the  same  patient, 
occasioning  great  annoyance  and  distress,  even  fatal  ex- 
haustion; but  it  is  stated  that  there  is  often  only  one  present. 
The  number  may  vary  between  this  and  fifty.  Some  worms 
are  twelve,  others  forty  inches  long,  or  even  more.  Accord- 
ing to  Busk,  the  parasite  grows  in  the  human  areolar  tissue 
at  the  rate  of  about  an  inch  a  week.  Thouo^h  it  is  most  fre- 
quently  found  in  the  lower  extremities,  it  has  been  observed 
to  appear  in  the  socket  of  the  eye,  the  mouth,  the  cheeks,  in 
the  ears,  and  under  the  tongue  and  the  scalp.  It  migrates 
rapidly  from  one  part  of  the  body  to  another.  Where  it  ex- 
ists, a  pricking  or  an  itching  heat  is  felt;  a  vesicle  forms 


*  John  Harley,  Medico-Chirurg.  Transact.,  vol.  xlvii. 


POISONS    AND    PARASITES.  817 

when  the  worm  is  about  coming  to  the  surface,  and  this 
vesicle  opens,  leaving  an  angry-looking  ulcer,  in  the  centre 
of  which  the  parasite  shows  itself.  The  period  of  incubation 
is  about  twelve  months ;  thus  a  year  elapses  before  the  Guinea- 
worm  makes  itself  manifest  in  the  human  body.*  The  dis- 
order, common  in  Asia  and  Africa,  is  fortunately  one  with 
which  we  are  unacquainted. 

Trichina  spiralis. — This  parasite,  which  is  now  known  to 
be  of  not  unfrequent  occurrence  in  the  muscles  of  man,  and 
to  give  rise  to  a  very  grave  disorder,  occasioning  much  pain 
and  very  often  death,  was  formerly  supposed  to  be  perfectly 
harmless.  It  was  discovered  by  Owen  in  1835  in  human 
muscles  taken  from  the  dissecting-room,  and  was  named  by 
him,  as  it  was  as  tine  as  a  hair  and  always  coiled  up  in  a  more 
or  less  spiral  line,  trichina  spiralis.  The  same  parasite  was 
subsequently  found  in  animals,  as  by  Leidy  in  the  animal 
which  it  most  infests, — the  pig.  But  in  the  observations 
made,  certainly  in  those  made  on  man,  the  trachinse  were 
only  detected  in  their  cysts,  and  as  these  cysts  become,  after 
a  certain  period,  filled  with  a  calcareous  deposit,  which  leads 
to  the  extinction  of  the  worms,  the  whole  subject  of  their 
presence  in  the  human  body  was  scarcely  looked  upon  as 
other  than  one  of  curiositv,  until  in  1860  Zenker — the  same 
pathologist  who  discerned  the  altered  and  granular  condition 
of  the  musculd;r  tibres  iu  low  fevers — proved,  by  a  series  of 
splendid  observations,  that  trichinae  may  exist  free  in  the 
muscles  of  man,  that  they  are  encapsuled  only  after  som^ 
time,  and  are  the  cause  of  what  may  be  a  very  fatal  disease. 
The  first  case  was  that  of  a  servant-girl,  who  died  in  the  hos- 
pital at  Dresden  with  symptoms  like  those  of  typhoid  fever. 
She,  together  with  several  members  of  the  family  in  which 
she  lived,  and  the  butcher  who  had  killed  the  pigs,  had 
swallowed  their  meat  uncooked,  and  had  soon  afterward 
been  taken  sick.  At  the  autopsy,  her  muscles  were  found 
to  be  full  of  trichinae,  which  were  not  yet  encapsuled.  One 
of  the  hams  and  some  of  the  sausages,  portions  of  which  she 
had  eaten,  contained  numerous  encysted  trichinae.    Thus  the 


*  Aitken's  Practice  of  Med.,  vol.  i. 
52 


818  MEDICAL    DIAGNOSIS. 

connection  between  the  symptoms  and  their  originating  cause 
was  clearly  traced.  It  was  soon  veriHed  by  other  observa- 
tions ;  and  it  has  since  been  well  understood  that  the  cases 
previously  examined  were  cured  cases,  which  had  falsely 
given  rise  to  the  belief  of  the  supposed  innocuous  character 
of  the  parasite,  and  that  in  the  trichina  disease,  or  trichiniasis^ 
we  find  one  of  the  most  dangerous  maladies  to  which  the 
human  frame  is  liable;  so  dangerous  that  whole  families 
have  perished  from  its  effects  amid  great  suffering,  and  that 
in  the  small  village  of  Hedersleben,  of  2000  inhabitants,  300 
were  affected,  of  whom  80  died.* 

The  parasite  is  always  introduced  into  the  body  by  eating 
ham,  pork,  or  sausages  made  from  the  flesh  of  pigs  contain- 
ing trichinae.  It  is  very  probable  that  the  hogs  themselves 
obtain  them  from  rats,  in  which  they  are  extremely  common. 
It  has  also  been  stated  that  trichinae  may  exist  in  beef,t  but 
this  is  not  generally  admitted. 

The  trichina  spiralis  is  the  juvenile  condition  of  a  small 
nematode  worm.  It  is  incapable  of  generation,  and  becomes 
fruitful  only,  whether  encapsuled  or  not,  when  introduced 
into  the  intestine.  After  being  swallowed,  if  it  be  encysted, 
the  capsule  is  dissolved,  and  the  parasite  remains  in  the  in- 
testine, where  it  rapidly  grows  to  three  or  four  times  its 
former  size,  and,  within  two  days,  attains  its  full  sexual 
maturity.^  By  the  sixth  day  the  female  trichina  contains 
an  abundance  of  living  young,  and  begins  to  throw  off" 
minute  embryos,  which  are  born  without  any  covering  from 
the  Qgg,  and  at  once  begin  to  migrate  to  the  muscular  struct- 
ures. When  they  reach  these,  they  grow  there,  but  do  not 
generate  others.  A  single  female  trichina  may  remain  in 
the  intestine  for  three  or  four  weeks,  or  even  longer,  and 
may  give  birth,  it  is  estimated,  to  from  two  hundred  to  two 
thousand  embryos,  which  find  their  way  to  the  muscles; 
while  the  trichinae  that  have  been  swallowed  never  pass  be- 
yond the  intestine.     In  six  or  eight  weeks  at  furthest  the 


*  Virchow,  Die  Lehre  voii  den  Trichinen,  p.  33. 

t  New  York  Med.  Journal,  July,  1866. 

J  Leuckhart,  Uutersuchungen  iiber  Trichina  Spiralis.     Leipzig,  1806. 


POISONS    AND    PARASITES. 


819 


intestinal  trichinge  have,  as  a  rule,  died  and  left  the  intes- 
tinal canal ;  four  to  iive  weeks  may  be  stated  to  be  their 
average  life.* 

When  the  young  trichina  arrives  in  the  muscles,— wliicli 
it  does,  according  to  the  current  view,  by  piercing  the  intes- 
tinal walls  and  passing  directly  to  the  muscles,  or,  according 
to  one  of  our  own  observers,  Dr.  Dalton,t  by  being  conveyed 

Fig.  47. 


Trichina  iu  n-riiit  liiiiiiiui  niii-rlr,  lakun  tin;  tliateijiitli  day  ol'  illness.  (Alter  Dalton.) 


there  by  the  circulating  current, — it  begins  to  destroy  the 
muscular  texture.  It  penetrates  the  sarcolemma,  feeds  on 
the  fibre,  particularly  on  the  primitive  fibrilles,  and  on  the 


*  Leuckhart,  op.  cit. 

t  Transactions  of  the  New  York  Academy  of  Medicine,  18G4. 


820 


MEDICAL    DIAGNOSIS. 


granules  and  disks  of  the  contractile  matter,  or  syntonine ; 
and  irritates  the  sarcolemma,  leading  to  its  gradual  thicken- 
ing, also  to  an  increased  development  and  multiplication  of 
the  nuclear  elements,  and  to  an  exudation  which  finally  fixes 
the  worm  to  a  particular  spot.  Thus  is  formed  the  cyst, 
which  encapsules  the  worm,  and  which  plays  such  an  im- 
portant part  in  the  subsequent  destruction  of  the  parasite. 
This  cyst  in  the  human  subject  is  oval,  or,  more  generally 
still,  spindle-shaped,  the  prolongations  having  a  rounded  end, 
and  in  its  centre  the  worm  lies  coiled  up.  It  takes  a  month 
or  months  for  the  cyst  to  form  completely,  though  at  the  end 
of  the  third  week  after  migration,  the  inflammatory  irrita- 
tion has  reached  its  highest  point,  and  the  trichina  is  by  that 
time — Leuckhart  says  in  less,  in  fourteen  days — nearly  or  en- 
tirely full  grown.  Several  trichinae  may  wander  in  the  same 
track,  and  ultimately  be  inclosed  in  the  same  mass  of  exuded 
matter.  Two  are  not  unfrequently  seen  intimately  coiled  up, 
and  the  number  may  rise  to  five.* 

After  the  perfect  formation  of  the  cyst,  further  changes 
take  place  in  it.     The  masses  of  nuclei  in  the  spaces  at  both 

extremities  of  the  capsule  become 
of  greenish  hue ;  dark  or  black 
particles  of  carbonate  of  lime  and 
magnesia  are  deposited.  The  cal- 
careous mass  extends,  and  gradu- 
ally covers  the  whole  parasite, 
while  around  the  prolongations 
of  the  cyst  fat  cells  are  deposited. 
The  whole  process  is  very  de- 
structive to  the  flesh-worm,  and  it  is  thus  that  the  disorder 
is  cured.  But  it  is  apt  to  be  months  before  this  result  is  ac- 
complished. Nay,  as  we  know  from  two  cases  recorded  by 
Virchow,  neither  the  encapsuling  nor  the  calcareous  trans- 
formation kills  the  worms,  of  necessity,  at  all  speedily;  for 
in  the  one  case  they  had  remained  alive  for  eight,  in  the 
other  for  thirteen  and  a  half  years  after  the  infection. f 


Fig.  48. 


Trichina  capsule  with  shell-like  calca- 
reous deposits.  (After  Leuckhart.) 


*  Thudichum,  Blue   Book. 
Privy  Council,  p.  367. 
f  Virchow,  op.  cit.,  p.  40. 


Seventh  Report  of  the  Medical  Officer  of  the 


I 


POISONS   AND    PARASITES. 


821 


Fig.  49. 


halky  concretions  in  niusclc-, 
due  to  dead  trichina;.  Magnified  about 
thirty  times.   (After  Leuckiiakt  ) 


The  appearances  described  are  not  to  be  recognized  by  the 
naked  eye.  Indeed,  the  cysts  can  scarcely  be  said  to  be 
visible  excepting  after  the  cal- 
careous matter  has  been  de- 
posited in  them,  when  they  ap- 
pear as  very  small  gritty  sub- 
stances scattered  over  a  piece 
of  muscle.  For  the  study  of 
the  cyst  a  low  magnifying 
power  only  is  requisite.  To  in- 
vestigate the  structure  of  the 
worm  requires,  however,  one  of 
at  least  300  diameters.  The  par- 
asite, which  is  truly  a  micro- 
scopical animal,  being  only  J  to 
J  line  in  length,  and  about  ^2  of 
a  line  in  thickness,  will  be  seen 
wnth  this  power  to  have  an  an- 
terior extremity  that  is  narrow  and  pointed,  and  where  an 
alimentary  canal  commences  by  a  mouth,  followed  by  an 
oesophagus  surrounded  by  cells.  The  cellular  body  extends 
through  a  very  considerable  portion  of  the  animal,  and 
passes  into  the  less  complex  intestinal  canal,  which  ter- 
minates with  an  anus  at  the  rounded  and  comparatively 
thick  posterior  extremity  of  the  worm.  In  the  posterior 
third  of  the  trichina  lies  the  generative  apparatus,  which  in 
part  presents  a  dark,  granular  mass,  but  nothing  else  very 
marked,  since  in  the  trichinae  found  in  the  muscles  there  are 
no  developed  sexual  organs.  The  internal  structures  are 
protected  by  a  thin  but  strong  and  elastic  integument  with 
minute  grooves.  The  male  intestinal  trichina  is  only  about 
two-thirds  the  length  of  the  female,  and  the  body  is  more 
transparent. 

The  number  of  trichinae  in  the  muscles  may  be  from  several 
hundreds  to  as  many  millions.  Now,  in  accordance  with  their 
number  in  the  muscles,  with  the  character  of  the  changes 
which  there  take  place,  and  the  quantity  in  the  intestines,  will 
vary  the  extent  of  constitutional  derangement  and  the  signs  of 
local  irritation.     Thus  the  symptoms  and  the  dangers  of  tri- 


822 


MEDICAL   DIAGNOSIS. 


ehiniasis  are  not  always  the  same  :  we  find  indeed  all  degrees 
of  the  malady.  When  merely  a  few  thousand  trichinse  occupy 
the  muscles,  there  is  chiefly  muscular  pains  with  stifiiiess  and 
general  debility;  signs  which  gradually  cease  as  the  worms 
become  fully  encapsuled,  and  cretaceous  alterations  occur. 


Fig.  50. 


Tnclmiii  tpiralis.      Maymliud  ^UU  tiuies.      (_AUi;i-  Niuciiuw.) 


When  the  muscles  are  occupied  by  millions  of  the  flesh- 
worms,  the  local  phenomena  are  much  more  severe;  there 
may  be  almost  complete  immobility  of  the  whole  body,  the 
muscles  of  respiration  and  deglutition  are  implicated,  irrita- 
tive fever  and  the  general  cachexia  are  very  marked,  and  the 
patient  is  apt  to  perish  by  gradual  exhaustion,  or  in  conse- 
quence of  the  disordered  respiratory  function,  or  some  pul- 
monary complication.  The  presence  of  large  numbers  of 
trichinfe  in  the  intestine  produces  diarrhoea,  vomiting,  ab- 
dominal pain  and  tenderness;  or  the  worms  may  shortly 
after  being  swallowed  give  rise  to  a  kind  of  cholera  morbus. 
Speaking  generally,  we  may  recognize  in  trichiniasis  three 
stages:   the  first,  lasting  about  a  week,  during  which  the 


POISONS    AND    PARASITES.  823 

trichinae  are  being  generated  in  the  intestines ;  the  second, 
the  passage  of  the  brood  through  the  intestinal  walls  into 
the  muscular  textures  and  the  disturbances  it  there  occasions; 
the  third,  the  retrogressive  formation  which  fairly  sets  in 
about  three  or  four  weeks  after  the  beginning  of  the  second. 
Now,  it  is  this  stage  which  yields  the  most  striking  mani- 
festations of  the  malady: — loss  of  appetite;  nausea;  dry, 
somewhat  coated  tongue;  diarrhoea;  abdominal  pain  and 
meteorism ;  prostration ;  fever,  with  a  quick  pulse  and 
copious  sweating ;  edematous  swelling  of  the  face,  followed 
in  grave  cases  by  almost  general  anasarca ;  sensitiveness  of 
the  muscles  to  the  touch,  or  painfulness  when  moved,  and 
their  contraction  or  difficult  motion;  dyspnoea;  sleepless 
nights;  and  emaciation. 

Let  us  examine  some  of  these  phenomena  more  in  detail : 
The  fever  is  a  very  marked  symptom.  It  sets  in  early, 
owing  to  the  intestinal  irritation,  though  it  is  not  until  the 
end  of,  or  after  the  first  week,  after  therefore  the  migration 
of  the  young  trichinae  has  fairly  begun,  that  it  is  strikingly 
developed.  It  is  then,  excepting  in  those  cases  in  which  fresh 
importations  of  trichinae  from  the  intestine  in  considerable 
numbers  produce  exacerbations,  a  continuous  fever,  with  a 
pulse  ranging  from  100  to  130,  with  scanty  urine  and  profuse 
perspirations  having  a  very  unpleasant  odor,  and  which  may 
continue  in  certain  parts  of  the  body  after  the  general  sweat- 
ing has  entirely  ceased.  The  temperature  is  increased  to 
about  101°  Fahr.,  though  it  may  pass  beyond  this;  but  it 
does  not  reach  the  high  heat  which  is  observable  in  other 
continuous  fevers,  particularly  in  grave  cases.  In  this  com- 
paratively low  temperature,  joined  to  the  profuse  perspira- 
tions, the  absence  of  enlargement  of  the  spleen  and  of  an 
eruption,  the  swelling  of  the  face,  the  muscular  symptoms, 
and  a  very  red  color  of  the  visible  mucous  membranes,  lie 
the  points  of  difference  between  the  febrile  excitement  of 
trichiniasis  and  typhoid  fever, — a  malady  which,  on  account 
of  the  continuous  fever,  the  prostration  and  diarrhoea  and  the 
sudamina,  it  resembles. 

The  oedema  marks  the  distinct  beginning  of  the  second 
stage  of  the  affection.     It  manifests  itself  first  in  the  eyelids, 


824  MEDICAL   DIAGNOSIS. 

and  is  very  apt  to  be  attended  with  a  catarrhal  state  of  the 
conjunctiva,  dilated  pupils,  great  susceptibility  to  light,  di- 
minished power  of  accommodation,  and  pain  in  moving  the 
eye.  The  swelling  may  extend  over  the  whole  face.  It  is  un- 
influenced either  by  the  sweats  or  the  diarrhoea;  but  lessens 
generally  very  much,  after  lasting  eight  or  nine  days,  or 
even  disappears ;  at  the  same  time,  too,  the  diarrhcea  is  apt 
to  diminish,  or  even  gradually  to  cease.  But  instead  of  the 
oedema  subsiding,  it  may  extend  to  the  chin,  arms  and  legs, 
and  the  back ;  or  it  may  show  itself  in  the  extremities  sub- 
sequently to  the  disappearance  from  the  face,  and  shortly 
afterward  become  perceptible  over  the  trunk.  In  some  cases 
an  anasarcous  condition,  commencing  at  the  ankles  and  ex- 
tending upward,  occurs  during  convalescence,  and  is  of  long 
duration.  It  is  then  probably  connected  with  the  state  of  the 
blood ;  whereas  the  cedema  happening  earlier  in  the  malady 
is  thought  to  be  due  to  the  pressure  upon  the  arteries,  exerted 
by  the  parasites  and  the  exudation  of  plastic  material  they 
produce,  or,  in  accordance  with  the  observations  of  Thudi- 
chum,  their  presence  within  the  lymphatic  spaces,  vessels  and 
glands,  and  blood-currents.*  It  is  a  very  striking  fact  con- 
nected with  the  dropsical  swelling  of  trichiniasis  that  it  is 
not  associated  with  albumen  in  the  urine,  for,  excepting  an 
increased  quantity  of  uric  acid,  the  urinary  secretion  contains 
no  abnormal  ingredient.  Boils,  acne,  and  ecthyma  are  often 
noticed  after  the  oedema  has  passed  away.f 

The  muscular  sym'ptoms  begin  in  the  second  stage  with  pain 
and  stiffness  in  the  limbs.  Soon  at  all  parts  of  the  body  the 
muscles  give  the  impression  of  being  swollen ;  they  are  ex- 
tremely painful  when  touched  or  moved ;  and  the  patient  lies 
in  consequence  as  quiet  as  possible,  or,  in  very  severe  in- 
stances of  the  aft'ection,  like  a  paralyzed  person.  The  im- 
mobility is  partially  also  due  to  the  retracted  state  of  the 
muscles  which  occurs  in  bad  cases,  and  which  produces  a 
condition  similar  to  a  true  spasm,  manifest  for  instance  in  the 
semiflexed  position  of  the  extremities,  and  in  the  occasion- 


*  Thudichum,  loc.  cit.,  pp.  362  and  386. 
f  Meissner,  Schmidt's  Jahrb.,  No.  4,  1868. 


POISONS    AND    PARASITES.  825 

ally  present  rigid,  trismus-like  setting  of  the  jaws.  The 
disturbance  of  function  of  certain  muscles  becomes  particu- 
larly evident.  The  disorder  of  the  muscles  of  the  eye  has 
already  been  alluded  to;  we  encounter  besides,  impaired 
hearing  and  difficulty  of  deglutition  and  loss  of  voice,  from 
the  muscles  of  the  ear,  of  the  pharynx,  and  the  larynx  being 
filled  with  trichinse.  The  respiratory  muscles  are  commonly 
very  much  aflfected,  and  we  find  hurried  and  shallow  breath- 
ing, and  at  times  considerable  distress  in  respiration.  The 
muscles  of  the  heart  very  usually,  and  the  unstriped  muscles 
of  organic  life  constantly,  escape  infection  ;  and  as  the  tri- 
chinae wander  to  the  front  of  the  body  rather  than  to  the  back, 
the  muscles  anteriorly  are  more  infested  than  those  posteriorly. 

The  marked  muscular  pain,  the  stiffness,  the  fever,  the 
profuse  sweats,  the  acid  urine,  simulate  the  signs  of  acute 
rheumatism ;  but  we  find  in  trichiniasis  diarrhoea,  no  artic- 
ular swelling,  and  no  heart  complications.  It  is  only  as  re- 
gards cases  of  acute  muscular  rheumatism — which  is  by  no 
means  frequent  as  a  general  state  or  associated  ordinarily 
with  obvious  febrile  phenomena — that  error  is  likely  to  arise. 
The  signs  of  prostration  are,  however,  here  wholly  wanting. 

The  condition  of  the  respiratory  muscles  gives  rise,  as  al- 
ready stated,  to  the  embarrassed  respiration,  but  it  is  not  the 
only  cause  of  the  'pulmonary  symptoms.  Yet  whether  it  alone 
leads  to  congestion  of  the  lung  and  to  bronchitis  or  pleu- 
ritis,  or  other  causes  concur  in  producing  them,  it  is  certain 
that  these  states  are  very  usual.  They  are  also  not  uncom- 
monly combined  with  pneumonia,  which  appears  suddenly, 
and  selects  the  lower  portion  of  the  left  lung  by  preference, 
occurs  about  the  twenty-sixth  day  of  the  disease,  and  is  very 
apt  to  prove  fatal.  The  sputa  consist  of  dark  unmixed 
blood;  and  the  pneumonia  is  thought  to  be  due  to  a  trichi- 
nous  embolism,  the  clots  being  derived  from  thrombi,  which, 
forming  in  the  venous  system,  are  sent  through  the  heart  into 
the  lungs.* 

If  the  patient  escape  a  serious  pulmonary  complication,  if 


*  Rupprecht,  Die  Trichinen  Krankheit  im  Spiegel  der  Hettstiidter  Endemie 
betrachtet,  1864. 


826  MEDICAL    DIAGNOSIS. 

he  has  strength  enough  to  withstand  the  weeks  of  irritative 
fever  and  exhaustion,  he  enters  at  the  end  of  a  month  of  suf- 
fering upon  a  gradual  convalescence.  The  fever  declines  ;  the 
respiration  is  less  accelerated  ;  the  perspirations  are  far  less 
copious;  the  urine  increases  in  quantity;  the  pains  decrease; 
and  by  about  the  sixth  week  of  the  malady,  the  patient  is 
sufficiently  free  from  pain  to  lie  on  his  side,  and  is  thus  able 
to  sleep.  The  pallor  of  his  countenance  gives  way  to  a 
healthier  hue  ;  his  appetite  becomes  insatiable  ;  and  he  moves 
his  limbs  with  more  and  more  freedom.  But  it  is  a  long 
time  before  he  reo-ains  his  full  strength  or  his  muscular 
power.  Indeed,  the  latter  may  be  always  somewhat  impaired  ; 
though  we  have  the  authority  of  Rupprecht  for  the  statement 
that  it  may  entirely  return,  and  perfect  health  be  recovered. 
In  some  cases  the  convalescence  is  greatly  retarded  by  boils, 
inflammation  of  the  lymphatic  glands,  and  the  very  gradually 
yielding  drops3\  The  reduction  of  the  power  of  accommo- 
dation of  the  eye  to  distances  may  also  alter  but  slowly. 
Children  are  apt  to  convalesce  more  quickly  than  adults. 
They  suffer,  in  truth,  less  from  the  disease,  and  are  not  so 
subject  to  it. 

Xow  the  diagnosis  of  the  strange  malady  has  been  made 
evident  while  discussing  the  symptoms.  It  need  be  but  fur- 
ther pointed  out  that  its  early  manifestations  might  be  mis- 
taken for  irritant  poiso?iing,  and  that  we  can  only  tell  their 
meaning  prior  to  the  development  of  the  phenomena  in  the 
muscles  by  the  detection  of  trichinae  in  the  stools.  Again,  it 
must  be  borne  in  mind  that  in  some  cases  the  first  manifesta- 
tions of  the  complaint  do  not  happen  for  two  or  three  weeks 
after  the  infected  meat  has  been  eaten;  and  that  others  show 
a  very  chronic  course,  and  the  whole  disease  is  ver}-  pro- 
tracted. The  so-called  ^^  sausage  poisomig,"  not  dependent 
on  trichime,  differs  from  trichiniasis  in  its  rapid  course  and 
the  quick  appearance  of  the  symptoms  after  the  spoiled  sau- 
sages have  been  partaken  of.*  There  is  a  peculiar  disease  of 
the  arteries,  periarteriitis  nodosa,  which,  with  the  signs  of  a%ute 
desquamative  nephritis  and  fever,  gives  rise  to  small  swell- 


*  See  Falck,  in  Virchow's  Handbuch  der  Path,  und  Therap.,  vol.  ii.  p.  328. 


POISONS   AND    PARASITES.  827 

ings  under  the  skin,  to  ra}>i(i  loss  of  muscular  power  with  de- 
ficient electro-muscular  contractility,  and  to  such  severe  mus- 
cular pains  that  they  are  readily  mistaken  for  those  of  the 
trichinous  ailection.*  But  the  history  of  the  ailment,  the 
signs  of  the  thickening  of  the  vessels,  and,  if  necessarj-,  an  ex- 
amination of  the  muscles,  will  throw  light  on  the  cause  of  the 
muscular  distress.  Indeed,  in  any  instance,  no  matter  what 
be  the  complaint  trichiniasis  may  simulate,  there  is  but  one 
means  of  determining  the  presence  of  the  flesh-worms  posi- 
tively— to  examine  a  piece  of  muscle.  This  may  be  effected 
by  cutting  down  upon  a  muscle  and  removing  sufficient  of 
its  structure  for  a  microscopical  examination,  or  by  using 
Middeldorpfi"'s  harpoon  or  Duchenne's  trocar  to  accomplish 
the  same  purpose, — modes  of  diagnosis,  it  must  be  confessed, 
of  an  aggressive  kind,  not  likely  to  be  readily  submitted 
to:  though  where  they  become  necessary,  I  would  suggest 
atiffisthesia,  general  or  local,  as  a  preliminary  measure. 

Tlie  chief  epidemics  of  trichiniasis  have  occurred  in  Ger- 
manj- ;  but  we  have  not  escaped  in  this  countrj'.f  Nor  can 
we  claim  that  our  hogs  are  not  infected.  On  the  contrary, 
the  report  of  the  Chicago  Academy  shows  that  about  1  in  50 
contains  trichinae  in  the  muscles.l  Our  comparative  immu- 
nity from  the  affection  is  due  to  the  })ork  being  much  more 
generally  cooked  thoroughly  before  it  is  eaten  ;  for  the  only 
prophylactic  is  thorough  cooking,  prolonged  exposure  to  high 
temperature  killing  the  trichinae.  Salting  and  smoking  are 
preventive  means  of  some  value,  but  do  not  insure  safety. 
Pickling  has  little  if  any  effect. 

In  the  treatment  of  trichiniasis  we  have,  unfortunately,  no 
agents  in  orr  possession  which  kill  the  worms  or  prevent 
their  rapid  development.  The  ordinary  vermifuges,  crea- 
sote,  picrate  of  potassa,  turpentine,  arsenic,  and  benzine,  have 

*  Kussmaul  and  Maier,  quoted  in  Schmidt's  Jahrb.,  No.  8,  1868. 

t  See,  for  instance,  Dalton,  op.  cit.,  and  Medical  Record,  vol.  iv.  p.  82  ; 
Krombcin,  Bufialo  Med.  and  Surg,  .lournal,  June,  1864;  also  epidemic  in 
lowu  Med.  and  Surg.  Rep.,  July  14,  1866;  and  Ristini,  Med.  Record,  1866, 
vol.  i.  p.  249;  Buck,  ib.  1869,  vol.  iv.;  Hun,  Transact,  of  New  York  State 
Med.  Society.  1869. 

+  Chicago  Medical  Examiner,  May,  1866 ;  quoted  in  Med.  and  Surg.  Re- 
porter, June  2,  1866. 


828  MEDICAL    DIAGNOSIS. 

been  employed  in  vain  to  destroy  the  dangerous  parasites ; 
nor  is  it  certain  that  carbolic  acid  has  any  more  effect.  The 
most  useful  treatment  at  present  known  consists  in  removing 
as  many  of  the  intestinal  trichinae  as  possible  by  purgatives, 
particularly  by  scruple  doses  of  calomel,  to  be  repeated  two 
or  three  times  in  as  many  days,  unless  the  first  dose  produce 
mucous  evacuations.  Besides  this  treatment  by  large  doses 
of  calomel,  we  must  support  our  patient's  strength,  relieve 
his  more  prominent  symptoms,  so  far  as  they  can  be  relieved 
by  medicinal  means,  and  be  careful  not  to  check  the  diar- 
rhoea by  opiates.  When  the  intestinal  irritation  subsides, 
which  it  generally  does  at  the  beginning  of  the  third  week, 
quinine,  and  in  convalescence,  iron,  should  be  administered. 
Iron  has  been  found  of  essential  service  in  relieving  the 
oedema  dependent  upon  anaemia,  which  comes  on  at  a  late 
stage  of  the  malady  or  during  recovery. 


INDEX. 


A. 

PAGE 

Abdomen,  diseases  of 413 

abscess,  in  wails  of 493 

auscultation  of 421 

general  enlargement  of. 562 

inflammation  of  muscles  of,  con- 
founded with  peritonitis...  483 

inspection  of. 413 

palpation  of.  415 

percussion  of. 416 

tumors  of 569 

Abscess  of  abdominal  walls  con- 
founded with  peritonitis...  483 

hepatic 541 

lumbar,  confounded  with  aneu- 
rism    584 

of    brain    distinguished    from 

softening 156 

distinguished  from  tumor 159 

of  the  kidney 631,  633 

of   thoracic   walls   confounded 

with  chronic  pleurisy 309 

perityphlitic 493 

psoas,  confounded   with  aneu- 
rism    584 

pulmonary,    confounded    with 

phthisis 272 

retropharyngeal 409 

confounded  with  croup 189 

Acidity  of  the  stomach  as  a  symp- 
tom  ". 423 

Acids,  gastric 424 

Acne 788 

Acute  diseases  presenting  pain  in 

cardiac  region 345 

Addison's  disease 681 

JEsthesiomcter 59 

Air-passages,  upper,  diseases  of...  173 

Albumen  in  the  urine 626 

tests  for 626 

Albuminuria,  simple,  confounded 

with  Brigbt's  disease 645 


PAGE 

Alcoholismus 99,  803 

Alvine  discharges 458 

Amphoric  voice 226 

Anaemia 680 

confounded  with  JBright's  dis- 
ease   652 

Anaesthesia 57 

from  disease 57 

from  poisoning 57 

hysterical 84 

in  affections  of  nervous  centres..     58 

localized ,     59 

trigeminal 59,  167 

Anajsthetics,  employment  of,   in 

feigned  aphonia 193 

in  phantom  tumors 574 

Anasarca 675 

Aneurism,  abdominal 581 

confounded  with  colic 471 

of  abdominal  aorta  confounded 

with  aortic  pulsation 583 

with  colic 583 

with  disease  of  the  spine 583 

with  lumbar  and   psoas   ab- 
scess   584 

with  neuralgia 583 

with  non-aneurismal  j)ulsat- 

ing  tumors 584 

with  rheumatism 683 

of  aorta  confounded  with  chro- 
nic laryngitis 191 

of  ascending  aorta 386 

of  descending  aorta 394 

of  innominate  arter}- 394 

of  pulmonary  artery 390 

thoracic 385 

Angina  pectoris 335 

pseudomembranous,  confound- 
ed with  croup...  400,  406 

simple  acute 399 

ulcero-membranous 404 

Animal  parasites 811 

(829) 


830 


INDEX. 


Aorta,  aneurism  of  abdominal  ...  581 

aneurism  of  tliDracic 386 

confounded  with  laryngitis...   191 

inflammation  of 351,  703 

pulsation  of 581 

Aphasia 133 

Aphonia,  feigned 193 

nervous,  confounded  with  chro- 
nic laryngitis 191 

of  hysteria 192 

Aphthte 397 

Apoplexy 124 

and  sunstroke,  treatment  con- 
trasted    137 

attended  with  paralysis 127 

cerebellar 127 

confounded  with  acute  soften- 
ing  , 130 

with  asphasia 133 

with  asphyxia 129 

with  catalepsy 138 

with  cerebral  hysteria 132 

with  epilepsy 128,  142 

with  insensibility  from  drinii..  128 
with  insensibility  from  nar- 
cotics   128 

with  meningitis 128 

with  obstruction  of  the  cere- 
bral arteries 131 

with  protracted  sleep 132 

with  sudden  paralysis 130 

with  sunstroile 128,  136 

with  syncope 129 

with  tumors 128 

with  uremic  coma 128 

hemorrhage  a  cause  of 124 

pulmonary 287 

mistaken     for     acute     pneu- 
monia   286 

serous 126 

spinal 126 

Appendix  casci,  diseases  of 488 

Appetite,  loss  of,  as  a  symptom...  422 

Arcus  senilis 366 

Arteries,    cerebral,    obstructions 
of,   confounded  with  apo- 
plexy   131 

Artery,  ligation  of,  as  a.  cause  of 

paralysis 72 

Ascites 562 

confounded  with  chronic  peri- 
tonitis    565 

with  chronic  tympanites 567 

with  distention  of  the  blad- 
der   566 

with  gravid  uterus 567 

with  ovarian  drojisy 564 

Asphyxia  distinguished  fr(jm  ajio- 

plexy "." 129 

Asthma 232 

cardiac 234 


Asthma  diagnosticated  from  dysp- 

ncea 233 

from  pressure  of  tumors 234 

Ataxia,  progressive  locomotor 95 

Atrophy,  acute  yellow 537 

of  liver,  chronic 561 

of  optic  nerve 68 

of  spinal  cord 82 

progressive  muscular 90 

Aura  epileptica 140 

Auscultation 210 

cerebral 109 

immediate 210 

mediate 210 

of  abdominal  viscera 412 

of  children 229 

of  the  voice 225 

rules  for  practice  of 227 


B. 

Bell's  palsy 87 

Bile  in  the  urine 615 

Biliary    passages,    inflammation 

of 535 

Bladder,    distended,    confounded 

with  ascites 566 

with  peritonitis 482 

inflammation  of 661 

confounded  with  peritonitis..  482 
spasm     of,     confounded     with 

colic 468 

Blood,  diseases  of 680 

effusion  of.     See  Hemorrhage. 

in  the  urine 624 

Bowels,  hemorrhage  from 515 

morbid  discharges  from 508 

Brain,  abscess  of. 156 

and  spinal  cord,  table  of  dis- 
orders of 106 

congestion  of 155 

diseases  of. 50 

headache  as  a  symptom  of 61 

dropsy  of 162 

hardening  of 156 

hemorrhage  into 155 

hypertrophy  of. 16o 

distinguished  from  dropsv  of 

bram 162 

from     enlargement    of     the 

head ^ 163 

inflammation  of. 158 

confounded  with  pericarditis..  358 

meningitis  of  base  of. 112 

softening  of. 153 

table  of  diseases  of. 106 

tumor  of. 158 

Brain-power,  exhaustion  of. 157 

Brass-founders'  ague 806 


INDEX. 


831 


Breathing,  condition  of,  in  laryn- 
geal diseases 172 

See  albo  Respiration. 
Bright's  disease,  acute, confounded 

with  acute  nephritis 644 

witli  coma 647 

with  convulsions 647 

with  dropsy 647 

with  htematuria 645 

witli  pericarditis 646 

with  pleurisy 646 

with  pulmonary  oedema 64() 

with  purulent  urine 645 

with  simple  albuminuria. 645 

with  suppurative  nephritis...   645 

chronic 649 

confounded  with  anaemia 652 

with  cancer 655 

with  cardiac  dropsy 653 

with  chronic  bronchitis....  658 
with  chronic  rheumatism..  653 

with  cysts  of  kidney 654 

with  gastro-intestinal  dis- 
orders   654 

with  neuralgia 653 

with  tubercle 655 

table  of  clinical  differences  in..  659 
Bronchial  glands,  tuberculization 

of 237 

phthisis 237 

Bronchitis,  acute 242 

diagnosticated  from  capillary 

bronchitis 245 

from  hooping-cough 237 

physical  signs  of. 243 

sputa  in 243 

capillary 245,  246 

confounded  with  lobular 

pneumonia 245 

chronic 247 

confounded  with  Bright's  dis- 
ease  '; 653 

with  phthisis 263 

sputa  in 243 

plastic 248 

Bronchophony 225 

Broncho-pneumonia 246 

Bronchorrhcea 247 


C. 


Ca3cum,  affections  of. 488 

appendix  of,  diseases  of 488 

cancer  of 492 

inflammation  of 488 

distention  of. 491 

Calculi,  renal 641 

Cancer  of  caicum 492 


Cancer    of    kidney    confounded 

with  Bright's  disease 654 

of  liver 547 

confounded  with   acute  con- 
gestion    549 

with  acute  hepatitis 549 

with  cancer  of  omentum 553 

with  cancer  of  stomach 552 

with  chronic  congestion 549 

with    diseases    of    gall-blad- 
der   551 

with  enlarged  kidni^y  553 

with  fatty  liver 549 

with  syphilitic  liver 551 

with  waxy  liver.. .549 

of  lung 269 

confounded  with  chronic  j)leu- 

risy 311 

with  phtliisis 269 

of  Ivmphalic  glands  by  side  of 

vertebrie 577,  584 

of  omentum   confounded  with 

cancer  of  liver 5-53 

of  peritoneum 580 

of  stomach 451 

confounded    with    cancer   of 

liver 552 

with  chronic  gastritis.  447,  453 

with  gastric  ulcer 447,  453 

Cardialgia 435 

Cardioscope  of  Alison 320 

Carditis 360 

Catalepsy-  accompanying  hysteria  138 
confounded  with  apopUixy...    138 

with  ecstasy 138 

daymare  form  of. 139 

Catarrh,  gastric 443 

suffocative 246 

Cavernous  voice 225 

Cerebellum,  diseases  of 99 

Cerebral  affections 106 

pain  in.  distinguished  from  he- 

micrania 168 

Cerebritis  confounded  with  men- 
ingitis     108 

Cerebro-spinal  dist)rders 98 

Ciiest,  alterations  of   form,  size, 

etc.  of,  in  disease 199 

dilatation  of,  di.scases  present- 
ing   209 

diseases  of. 196 

mapping   out   of,   for   j)hysical 

diagnosis 197 

motions  o\\  in  diseases  of 198 

retraction  of,  diseases  attended 

with 310 

Chest-measurer  of  Sibson 200 

Chickon-pux.  778 

Childbed  fever 478 

Children,  auscultation  of. 229 

respiration  in 229 


832 


INDEX. 


Chlorides  in  the  urine,  pathology 

of 609 

Chlorosis 681 

Cholera 519 

infantum 517 

morbus 518 

Chorea 144 

attended  with  salaam  convul- 
sions    147 

distinguished  from  epilepsy 145 

from  facial  spasm 147 

from  convulsive  tremor 146 

from  mercurial  tremor 146 

from  paralysis  agitans 146 

from  tetanus 146 

from  writer's  cramp 147 

relations  of,  to  rheumatism 145 

Chylous   fluid,    discharged    from 

leg 792 

Circulation,  condition  of,  in  dis- 
ease      34 

derangements    of,    in    cardiac 

disease 333 

paralysis  from,  interfered  with.     72 

Cirrhosis  of  liver 557 

confounded  with  chronic  peri- 
tonitis    561 

with  cancer  of  stomach 561 

of  lung  confounded  with  chro- 
nic pleurisy 312 

Clots,  fibrinous,  in  the  heart 350 

Coifee-ground  vomit 432 

Colic 460 

as  a  symptom 464 

bilious 462 

confounded  with  abdominal  an- 
eurism   471,  583 

with  abdominal  neuralgia....  470 

with  eiiteritis 471 

with  gall-stones 466 

with  gastralgia 465 

with  hernia 466 

with  nephralgia 467 

with  perforation  of  the  intes- 
tine   465 

with  peritonitis 471,  486 

with  sjiasm  of  the  bladder. ...  468 

with  spinal  disease 471 

with  tumors 471 

with  uterine  colic 469 

flatulent 462 

lead  463 

metallic 463 

nervous 463 

spasmodic 461 

uterine 469 

Collapse  of  the  lung 252 

confounded  with  chronic  pleu- 
risy   312 

Colon,  dilatation  of. 580 

Coma 64 


Coma  occurring  in  Bright's  dis- 
ease   647 

ursemic 128,  647 

Congestion  of  brain,  discrimina- 
ted from  softening 155 

pulmonary 286 

Congestive  fever 753 

Consciousness,    diseases    marked 

by  sudden  loss  of 124 

Constipation  as  a  symptom 505 

habitual 505 

Consumption.     See  Phthisis. 

galloping 278 

Convulsions 101 

See  also  Spasms. 

diseases  marked  b}' 139 

distinguished  from  epilepsy 142 

in  Bright's  disease 647 

salaam 147 

Cord.     See  Spinal  cord. 

Cough 235 

in  laryngeal  afifections 173 

Countenance,  expression  of,  as  a 

symptom 32 

Crackling,  diagnostic  of  tubercle 

of  lungs 222 

Cramp  of  the  stomach 435 

writer's,     distinguished     from 

chorea 147 

Creatine 611 

Creatinine 611 

Crepitation 222 

Croup 184,  186 

catarrhal 184 

confounded  with  diphtheria....  189 

with  laryngitis 188 

with  pseudomembranous  an- 
gina   189 

with     retropharyngeal     ab- 
scesses    189 

diseases  confounded  with..  188,  189 

false 184 

membranous,  confounded  with 

diphtheria 189,  406 

spasm  of  glottis  in 185 

true 184,  186 

Cystitis,  acute 661 

chronic 662 

confounded  with  peritonitis 482 

Cysts  of  kidney  confounded  with 

Bright's  disease 654 


D. 

Daymare 139 

Debility  confounded  with  typhoid 

fever 723 

Delirium 51 

accompanying  insomnia 65 


INDEX. 


833 


Delirium,  active 57 

confounded  with  delirium  tre- 
mens    120 

feigned 53 

hysterical 54 

in  children 52 

of  inanition 53 

mistaken  for  insanity 52 

passive 51 

prominent  as  a  symptom,  acute 

affections  with 100 

tremens 120 

confounded  with  acute  mania...   123 

confounded  with  meningitis 121 

Dengue 778 

Diabetes 608 

Diagnosis,  by  exclusion 23 

dilfferential 23 

methods  of  arriving  at 21 

physical 198 

sources  of  error  in 24 

Diaphragm 234 

inflammation  of. 235,  534 

paralysis  of 234 

rheumatism  of 235 

Diarrha?a 508 

acute .508 

bilious 509 

choleraic 520 

chronic .509 

fatty 510 

intermittent 502 

membranous 512  ; 

of  soldiers 511 

strumous 512 

tubercular 511 

Dilatation,  bronchial,  confounded 

with  phthisis 270 

of  heart 364 

confounded  with  fatty  degen- 
eration   366 

with  pericardial  effusion....  368 

Diphtheria 401 

confounded  with  croup 189,  400 

with  erj-sipelas  of  the  fauces..  405 
with  pharyngitis  and  tonsil- 
litis  ". 403 

with  scarlatina 400 

with  ulcerative  stomatitis 404 

with  ulcero-membranous  an- 
gina   404 

intercurrent 407 

nasal 407 

Diphtheritic  paralysis 85 

Discharges,  alvine 458 

as  a  symptom 458 

Displacements  of  heart 884 

Diuresis,  chronic 669 

Drink,  insensibility  from 128 

Dropsy 674 

abdominal 562 


Dropsy,  active 678 

acute 678 

after  scarlatina 768 

cardiac 333,  677 

chronic 677 

hepatic 077 

of  brain 162 

ovarian 564 

pericardial  368 

confounded  with  cardiac  dilata- 
tion   368 

renal 647,677 

Duodenum,  ulcer  of 4.50 

Dysentery 513 

acute 513 

chronic 515 

Dyspepsia  as  a  symptom 439 

Dysphagia 411 

Dyspnoea 231 

diagnosticated  from  asthma 234 


E. 

Echinococci 553,  815 

Ecstasy 138 

distinguished  from  catalepsy....  138 

Ecthyma ",....  789 

Eczema 786 

Effusions,  pleural 305 

Egophony 225 

Electricity  as   a  test  in  paraly- 
sis   75,  84 

Elephantiasis 791 

Emaciation  as  a  symptom 32 

Embolism 688 

of  pulmonary  artery 691 

Emphysema 249 

confounded  with  chronic  pleu- 
risy    306 

diagnosticated    from    pneumo- 

"thorax 301 

interlobular 251 

Empyema,  pulsating,  confounded 

with  aneurism 389 

Endocardial  murmurs 346,  383 

Endocarditis,  acute 346 

confounded  with  pericarditis...  356 

Endoscope 029 

Engorsrements,  pulmonary,  in  fe- 

"vers 286 

mistaken  for  acute  pneumonia..  286 

Enteritis 472 

acute 472 

confounded  with  colic 471,  473 

with  peritonitis 481 

with  typhoid  fever 725 

Epigastrium,  tumors  of 572 

Epiglottis,  swelling  of,  as  a  diag- 
nostic sign 193 


53 


834 


INDEX. 


Epilepsy 104,128, 

aura  preceding 

central  or  centric 

distinguished  from  apoplexy  128, 

from  chorea 

from  convulsions 

from  hysteria 142, 

eccentric 

feigned 

followed  by  hemiplegia 

idiopathic 

of  retina 

peripheral 

sequelae  of 

sj'mptomatio 

vertigo  previous  to 

Epistaxis 

Eructation  as  a  symptom 

Erysipelas 

confounded  with  mumps 

of  the  fauces  confounded  with 

diphtheria 

Erythema 

Examination  of  patients,  methods 

of 

analytical 

synthetical 

Exanthematous  fevers 

Expiration,  prolonged 

See  also  Respiration. 

Eye,  appearance  of,  in  disease 

condition  of  pupil  of,  in  cere- 
bral disease 


139 
140 
141 
142 
144 
142 
148 
141 
143 
140 
140 

68 
141 
140 
141 

63 
239 
424 
779 
781 

405 

784 

28 

28 

28 

784 

216 

64 

65 


F. 

Pace,  spasm  of 167 

Facial  paralysis 87 

Earcy,  acute,  confounded  with 

pj^semia 686 

Fat  in  the  urine 632 

Fatty  degeneration  of  heart 366 

confounded  with  dilatation 366 

Fauces,  diseases  of 399 

erysipelas  of 405 

inflammation  of 399 

pseudomembranous,  inflamma- 
tion of 400 

ulcers  of 408 

Favus 794 

Focal  discharges 459 

Feces,  accumulation  of 571 

Feigned  aphonia 193 

delirium 53 

diseases 24 

epilepsy 143 

hysteria 149 

rheumatism 707 

sciatica 170 


Fever,  catarrhal 715 

Chickahominy 758 

congestive 753 

enteric 716 

intermittent 742 

miasmatic 742 

nervous 716 

relapsing 738 

remittent 746 

scarlet 765 

simple  continued 714 

spotted 736 

syphilitic 745 

typhoid 716 

typhus 727 

urethral 745 

yellow 759 

Fevers 711 

classification  of 713 

continued 713 

head  symptoms  of,  confound- 
ed with  meningitis 109 

eruptive 764 

exanthematous 764 

periodical 742 

Fibrin,  clots  of,  in  the  heart 351 

Fifth  pair,  painful  anesthesia  of. .  166 

Fire  measles 769 

Flatulency  as  a  symptom 424 

Follicular  pharj'ngitis 408 

Fremitus,  friction 204 

rhonchal 204 

vocal 226 

Friction,  pleural 223 

Friction  sounds  of  pericarditis....  353 

of  pleuritis 223,  295 

Fungus  foot  of  India 810 


G. 

Gall-bladder,    diseases    of,    con- 
founded   with     cancer    of 

liver 551 

inflammation  of 535 

Gall-ducts,  inflammation  of. 535 

Gall-stones,  passage  of,  confound- 
ed with  colic 466 

Galvanic   battery  as  a  means  of 

diagnosis 88 

Gangrene  associated  with  paralv- 

sis .:..     72 

pulmonarv,    confounded    with 

phthisis 273 

Gastralgia 435 

confounded  with  colic 465 

Gastritis  confounded  with  perito- 
nitis   480 

acute 440 

chronic 445 


INDEX. 


835 


Gastritis  confounded  with  gastric 

cancer 447 

with  gastric  ulcer 447 

of  young  children 440 

Gastrodynia 435 

(•onfounded  with  colic 465 

Gastro-intestinal  disorders  con- 
founded with  Bright's  dis- 
ease   654 

Glanders,  acute,  confounded  with 

pyjemia 686 

Glands,  bronchial,  tuberculiza- 
tion of 237 

Glottis,  oedema  of 183,  189 

spasm  of,  an  element  of  false 

croup 185 

Gout 707 

rheumatic 709 

Guinea- worm 816 


H. 

Hffimatemcsis 240,  431,  450 

Hsematocele,  periuterine 579 

Ha^maturia 625 

confounded  with  Bright's  dis- 
ease   645 

renal 627 

vesical 629 

Hasmoptysis 238 

Hardening  of  the  brain 156,  161 

distinguished  from  softening  of  156 
Head,    enlargement    of,    diseases 

characterized  by 162 

shapes  of,  in  disease ;..  164 

Headacbe 61 

from  ])oisoning 62 

in  diseases  of  the  brain 61 

nervous 62 

neuralgic. .. , 62 

sympathetic 62 

Hearing,  sense  of,  derangement  of     70 
Heart,  anatomy  and  physiology  of  314 

auscultation  of. 322 

chronic  diseases    of,   with    in- 
creased percussion  dulness  361 

clots  of  fibrin  in 350 

dilatation  of. .' 364 

diseases  of. 314 

diseases  of,  .symptoms  of 332 

displacements  of. 384 

dropsy  caused  by  disease  of.....  333 

fatty  degeneration  of. 366 

functional  disorders  of 340 

hypertrophy  of. 361 

inflammation  of. 346,  360 

inspection  of 318 

irregularity  of  action  of. 341 

malformations  of 370 


Heart,  organic  diseases  of. 345 

palpation  of. 319 

percussion  dulness  of 361 

percussion  of 320 

physical  diagnosis 317 

rupture  of 368 

valvular  affections  of. 370 

Heart-burn 424 

Hemicrania 167 

distinguished  from  pain  of  or- 
ganic cerebral  afi'cctions. ...   168 

from  periostitis 168 

from  rheumatism  of  the  scalp..   168 

Hemiplegia 73 

appearance  of  muscles  in 77 

cerebral 74 

electricity  as  a  test  of. 75 

following  epilepsy 140 

right-sided,  associated  with  loss 

of  articulate  language 135 

seat  of  lesion  in 73 

spinal 75 

Hemorrhage  a  cause  of  apoplexy  124 
between  the  membranes  of  the 

brain 128 

cerebellar 127 

cerebral 127 

from  aneurism 240 

from  the  bladder 629 

from  the  kidneys 627 

from  the  larynx,  trachea,  etc...  239 

from  the  lungs 240 

from  the  oesophagus 239 

from  the  stomach 239,  430,  450 

from  ventricles  of  brain 127 

in  apoplexy,  seat  of 127 

into  the  subarachnoid  spaces...   127 

of  the  bowels 515 

relations  of,  to  softening  of  th(^ 

brain 156 

Hepatic     diseases,    chronic     and 

acute,  confounded 533 

Hepatitis,  acute 530 

confounded  with  acute  non- 
hepatic  diseases 534 

with  acute  yellow  atrophy  535 

■with  cancer  of  liver 549 

with  chronic  hepatic  disease 

with  acute  symptoms 533 

with  diaphragmatic  pleurisy  534 
with  inflammation  of  portal 

veins 532 

with  inflammation  of  the 

bi  liary  passages 535 

with  perihepatitis 531 

with  pigment  liver 532 

chronic 539 

Hernia,  diaphragmatic,  con  fdund- 

ed  with  pneumothorax 303 

strangulated,  confounded  with 

colic 466 


836 


INDEX. 


Hernia,  with  intestinal  obstruc- 
tion    497 

Herpes 786 

Hiccough,  in  diaphragmatic  pleu- 
risy   534 

Hip-joint    atJl'ctions    confounded 

with  sciatica 170 

Hodgkin's  disease 684 

Hooping-cough 236 

diagnosticated  from  bronchitis.  237 

Hydatids  of  the  liver 553 

multilocidar 556 

Hydrocephaloid  disease 114 

Hydrocephalus,  acute 113 

chronic. 113,  162 

Hydronephrosis 667 

Hydrojjhobia  confounded  with  te- 
tanus     150 

Hydrothorax     confounded    with 

chronic  pleurisj^ 310 

Hyperesthesia 56 

hysteria  as  a  cause  of. 56 

relations  to  inflammator}' 56 

Hypertrophy  of  brain 163 

of  heart 361 

Hypochondrium,  right  and  left, 

tumors  of. 569,  570 

Hypogastric  region,  tumors  of 579 

Hysteria 147 

abdominal  confounded  with  pe- 
ritonitis     485 

as  a  cause  of  hyperiesthesia 56 

associated  with  catalepsy 138 

cerebral,     distinguished     from 

apoplexy 132 

distinguished  from  chorea 144 

from  epilepsy 145,  148 

feigned 149 

Hysterical  complaints,  local 149 

delirium 54 

locomotor  ataxia 99 

paralysis 71 

pseudo-maladies 149 


I. 


Ichthyosis 790 

Icterus 524 

catarrhalis 535 

neonatorum 528 

Iliac  fossa,  diseases  attended  -with 

pain  in 488 

region,  tumors  of. 578 

Impetigo 788 

Inflammation,  local,  confounded 

with  neuralgia 165 

Influenza 715 

Innoniinata,  aneurism  of 394 

Inosite 621 


Insanity  confounded  with  delirium    52 

form.sof. 123 

Insensibility  from  drink    distin- 
guished from  apoplexy 128 

from     narcotics    distinguished 

from  apoplexy 128 

Insomnia 55 

with  delirium 55 

Inspection    in    diagnosis    of   dis- 
eases of  lungs 198 

Inspiration,  jerking 216 

See  also  Hespiraiion. 
Insufficiency  of  aortic  valves  con- 
founded with  aneurism 389 

Intellection,  deranged 50 

Intermittent  fever 742 

Intestines,  diseases  of 457 

inflammation  of. 472 

intussusception  of 500 

invagination  of 493,  500 

obstruction  of 495 

percussion  of. 416 

perforation  of,  confounded  with 

colic 465 

Intoxication,  ursemic 647 

Itch 793 

army 793 


J. 


Jaundice 524 

of  the  new-born 528 


K. 

Kidney,  abscess  around 664 

abscess  of. 663 

cancer  of 654 

chronic  enlargement  of 656 

inflammation  of 657 

contracted 658 

cysts  of. 655 

enlarged,  confounded  with  can- 
cer of  liver 553 

confounded  with  ovarian  tu- 
mor   578 

fatty 656 

hydatids  of 667 

inflammation  of 635 

pelvis  of. 665 

movable 575 

neuralgia 637 

pain  in 637 

pain  of,  confounded  with  colic.  467 

percussion  of 418 

suppurative  inflammation  of....  663 

tumors  of. 492,  667 

wa.xy 657 


INDEX. 


837 


L. 

Larvni^cal  affections,  acute 181 

stridor 172 

Laryngitis,  aneurism  of  aorta  con- 
founded with  191 

confounded  with  altered  voice...  191 

witli  hysterical  aphonia 191 

with  nervous  aphonia 191 

acute 181 

confounded  with  croup 188 

chronic 190 

combined  with    syphilis 191 

confounded  with  aneurism...  392 

diseases  confounded  witii 191 

chronic,  with  tuberculosis 191 

pseudomembranous 186,  188 

secondary,    of    the    exanthem- 
ata..!   189 

spasmodic 185 

stridulous 185 

Laryngoscopes 174 

Laryngoscopy 174 

Larynx,  acute  diseases  of 181 

affections  of  nerves  of. 192 

changes   in   breathing   in   dis- 
eases of. 170 

in  voice  in  diseases  of 172 

chronic  diseases  of 190 

cough  in  diseases  of 173 

diseases  of. 172 

inflammation  of. 182 

organic  diseases  of. 181 

pain  in  diseases  of 173 

stethoscope'  in  diseases  of. 187 

table  of  diseases  of. 180 

tumors  of. 194 

Lead  poisoning 805 

paralysis  from 84,  805 

Lepra 789 

Leucocythajmia G83 

Leucine G14 

Leuktemia G83 

Lichen 785 

Liver,  abscess  of. 541 

acute  affections  of,  confounded 

with  pyicmia G87 

acute  congestion  of. 530 

confounded    with    cancer   of 

liver 550 

acute  inflammation  of. 530 

acute  yellow  atrophy 537 

cancer  of 547 

chronic  atrophy  of. 561 

chronic  congestion  of. 539 

confounded    with   cancer   of 

liver 549 

chronic  inflammation  of 541 

cirrhosis  of 657 

enlargement     of,     confounded 

with  chronic  pleurisy 308 


Liver,  fatty 545 

confounded    with    cancer    of 

liver 549 

hydatids  of 553 

movable 57() 

percussion  of. 416 

pigment,  confounded  witli  acute 

hepatitis 532 

syphilitic,  confounded  with  can- 
cer of  liver... 551 

table  of  diseases  of 529 

waxy 545 

waxy,  confounded  with  cancer 

of  liver 549 

Lock-jaw.     See  Tetanus. 

Locomotor  ataxia 95 

of  syphilitic  origin 100 

Lumbago 705 

Lumbar  region,  tumors  of 577 

Lungs,  diseases  of. 198 

acute  affections  of,  in  tvphoid 

fever \ 72C 

cirrhosis  of 312 

collapse  of. 252 

fistulous  opening  into  312 

scrofulous  disease  of 276 

symptoms  of  diseases  of. 230 

syphilitic  disease  of. 269 

Lu{)U5 791 


M. 

Malignant  pustule 807 

Malaria,  poisoning  by 749,  757 

Malformations  of  heart 370 

confounded  with  valvular  affec- 
tions   370 

Mania,  acute 123 

confounded  with  acute  menin- 
gitis    123 

with  delirium  tremens 123 

Mania  u  potu     See  Deliriu7n  Tre- 
mens. 

Measles 770 

confounded  with  scarlet  fever..   77G 

with  small- pox 776 

fire 769 

Mehena 515 

Memory,  disordered,  as  a  sym})- 

tom 50 

Meningeal  disease,  pain  in 62 

Meningitis,  acute 106 

confounded  with  acute  mania  .    123 

with  apoplexy 128 

with  cerchritis 108 

with  delirium  tremens 121 

with  head  symptoms  of  acute 

rheumatism Ill,  702 

of  continued  fevers..  109 


838 


INDEX. 


Meningitis,  with  head  symptoms 

of  pericarditis Ill 

of  jmeumoniiv Ill 

with  typhoid  fever 726 

cerebro-spinal 116,  736 

confounded  with  myelitis 119 

diseases  confounded  with 119 

chronic,  distinguished  from  tu- 
mor   l-)9 

of  the  base  of  the  brain 114 

spinal 116 

tubercular 112 

diseases  confounded  with 115 

Mensuration  of  chest.  199 

Mentagra 794 

Mental  faculties,  diseases  charac- 
terized by  gradual  impair- 
ment of. 153 

Mercurial  tremor 804 

Metritis  confounded  with  peri- 
tonitis    481 

Milk-leg  confounded  with  acute 

rheumatism 700 

Milk-sickness 808 

MoUuscum 790 

Motion,  deranged 70 

voluntary,  diseases  marked  by 

sudden  lossof 124 

Mouth,  diseases  of 396 

Mumps 400,  781 

Murmur,  vesicular 213 

absence  of. 216 

causes  of 213 

changes  in 213 

respirator}^ 215 

Murmurs,  cardiac 326 

dynamic 327 

endocardial 326 

hiemic 327 

pericardial 381 

without  valvular  lesion....   371,  384 

Muscse  volitantes 64 

Muscles,  appearance  of,  in  paraly- 
sis      73 

morbid  states  of,  paralysis  from     72 
Muscular    movements,   irregular 

forms  of 98 

Myalgia 706 

Myelitis  81 


N. 


Narcotics,  insensibility  from  128 

poisoning  by 799 

Nausea  as  a  symptom 425 

Nephralgia 637 

confounded  with  colic 4(57 

Nephritis 635 


Nephritis,  acute,  confounded  with 

Bright's  disease 644 

acute  desquamative 642 

chronic  non-desquamative 657 

supi)urative 645,  663 

Nerves,  diseases  of 50 

paralysis  from  alFections  of...  71,  72 
N(>rvous  atlVctions,   classification 

of 106 

centres,  disease  of,  anaesthesia 

a  symptom  of 57 

deranged  nutrition  and  secre- 
tion in 103 

paralysis  from 71 

system,  diseases  of 50 

Nettle-rash 785 

Neuralgia 165 

as  a  cause  of  headache 62 

Neuralgia,  cerebral 168 

confounded  with  aneurism 583 

with  local  inflammation 165 

with  pain  of  rheumatism 165 

epileptiform 167 

facial 166 

intercostal 166 

confounded  with  acute  pleu- 
risy   298 

lumbo-abdominal 470 

of  bladder 423,  662 

of    spinal    nerves    confounded 

with  colic 470 

of  the  stomach 434 

reflex 165 


O. 

(Edema 675 

of  the  glottis 183 

diagnosticated  from  croup....  189 

of trichiniasis 822 

pulmonary 286 

occurring    in    Bright's    dis- 
ease   646 

mistaken  for  acute  pneumo- 
nia   286 

CEsophagus,  inflammation  of 410 

stricture  of 410 

Omentum,  cancer  of 553 

Opisthotonos 150 

Ophthalmo.scope  in  diseases  of  the 

nervous  system 660 

Optic  neuritis 67 

Orthopncea 231 

Ovarian  drop.«y  confounded  with 

ascites 564 

Oxalate  of  lime  in  the  urine,  pa- 
thology of 612 

Oxaluria 613 


INDEX. 


839 


p. 

Pain  as  a  symptom 44 

cardiac 335 

gastric,  as  a  symptom 433 

in  diseases  of  liver 524 

in  laryngeal  aflections 173 

paroxysmal,  diseases  character- 
ized by 164 

Palpation  of  the  chest 203 

friction  and  rales  detected  by 

fremitus 204 

Palpitation 338 

cardiac  diseases  attended  with..  340 
Palsy.     See  Paralysis. 

Bell's 87 

shaking 100,  146 

Pancreas,  diseases  of. 572 

Paralysis 70 

acute  ascending 80 

agitans 100 

distinguished  from  chorea....  146 

associated  with  gangrene 72 

clinical  points  in  regard  to 89 

creeping 71 

diphtheritic 85 

essential 92 

facial 87 

from  affection  of  nerves  at  tlieir 

extremities 71 

from  apoplexy 127 

from  chronic  softening 154 

from  interference  with  the  cir- 
culation       72 

from  lead  poisoning 84 

from  lesion  of  nervous  centres..     71 

in  the  course  of  a  nerve 71 

from  morbid  state  of  the  mus- 
cles       72 

from  poisoning 72 

from  ])rogressive  muscular  atro- 
phy      90 

from  reflex  action 71 

from  locomotor  ataxia 162 

general 70,  101 

confounded  with  softening...   161 
distinguished  from  other  pal- 
sies    162 

glossopharj'ngeal 89 

hysterical..' 71,'  83 

intermitting 72 

local  87 

malarial 72 

partial 70 

perij)heral 71 

pseudo-hypcrtrophic,  muscular     93 

rheumatic 84 

sudden,  distinguished  from  apo- 
plexy   130 

syphilitic 85 

Paraplegia 78 


Paraplegia  from  various  diseases.     79 

gradual 80 

reflex 82 

seat  of  lesion  \\\ 78,  94 

spinal 79 

varieties  of. 78,94 

Parasites 810 

animal 810 

vegetable  810 

Parotitis 781 

See  also  Mumps. 
Paroxysmal  pain  in  nervous  dis- 
eases   164 

Pectoriloquy 225 

Pemphigus 788 

Percussion 204 

clearness  of,  as  a  diagnostic  sign  242 
dulness   of,   diseases    accompa- 
nied by 255 

hammer 205 

immediate 205 

mediate 205 

of  abdominal  viscera 416 

of  healthy  chest 208 

results  of 208 

sounds  elicited  by 206 

Perforation,  intestinal,  confound- 
ed with  colic 405 

Periarteriitis  nodosa 826 

Pericarditis,  acute 352 

diagnosticated  from  endocardi- 
tis   356 

gastric  irritation 358 

inflammation  of  the  brain 358 

pleuritis 357 

friction  sounds  of 353 

head  symptoms  of,  confounded 

with  meningitis 108 

in  Bright's  disease 646 

Pericardium,  dropsy  of 358 

effusion    of,    confounded    with 

chronic  pleurisy 309 

Perihepatitis     confounded     with 

acute  hepatitis 531 

Perinephritis 004 

Periosteum,  rheumatism  of 706 

Peritoneum,  diseases  of 457 

Peritonitis  confounded  with   ab- 
dominal hysteria 485 

with  colic 471,  486 

with  cystitis 482 

with  distention  of  the  bladder  482 

with  enteritis 481 

with  gastritis 480 

with   inflammation    and   ab- 
scess of  abdominal  muscles  483 

with  metritis 481 

with  rheumatism  of  abdomi- 
nal walls 485 

with  typhoid  fever 725 

acute 474 


840 


INDEX. 


Peritonitis,  chronic 487 

confounded  with  ascites 565 

local 479 

puerperal 478 

Perityphlitis 490 

Phantom  tumors 573 

Pharj'ngitis     confounded      with 

diphtheria 403 

Pharynx  and  oesophagus,  diseases 

Jf 409 

Phlegmasia  dolens 675 

confounded     with     rheuma- 
tism   700 

Phosphates  in  the  urine,  patholo- 
gy of 606 

Phthisis 255 

acute 278 

bronchial 237 

chronic  pulmonary 255,  279 

confounded  with  bronchial  di- 
latation   270 

with   bronchial  phthisis 238 

with  chronic  bronchitis 263 

with  chronic  pleurisy 268 

with  chronic  pneumonia 264 

with  emphysema 264 

with  pulmonary  abscess 272 

with  pulmonary  cancer 269 

with  pulmonary  gangrene  ...  273 

cough  in 256 

temperature  in 257 

Phj'sical  diagnosis 198 

exploration 198 

signs 196,  228 

Pigment  liver 532 

Pityriasis  versicolor 794 

Plague  confounded  with  typhus 

fever 735 

Pleura,  cancer  of 311 

effusion  into 310 

fistula  of 312 

Pleurisy,  acute 292 

confounded  with  acute  pneu- 
monia   296 

with  intercostal  neuralgia.  298 

with  pericarditis 357 

with  pleurodynia 297 

bilious 291 

chronic 304,  308 

confounded   with  abscess  in 

thoracic  walls 309 

with  cancer 311 

with    chronic    pneumonic 

consolidation 311 

with  cirrhosis 312 

with  collapse  of  lung 312 

with  emphj'sema 306 

with  enlargement  of  liver.  308 
with  enlargement  of  spleen  309 

with  hydrothorax 310 

with  intra-thoracic  tumor.  307 


Pleurisy,     chronic,     confounded 

with  pericardial  efi'usion...  309 

with  phthisis 268 

with  pneumothorax 306 

with  tubercle  .  311 

diseases  confounded  with.  306,311 
dia})hragmatic,  confounded  with 

acute  hepatitis 534 

double 268 

occurring  in  Bright's  disease...  646 

Pleurodynia 297 

confounded  with  acute  pleurisj'  297 

Pleximeter 204 

Pneumonia 282 

acute 282 

auscultation  in 283 

confounded  with  acute  pleurisy  296 

with  bilious  pneumonia 290 

with  pulmonary  apoplexy....  287 
with      pulmonary     engorge- 
ment in  fevers 286 

acute,  confounded  with  pulmo- 
nary oedema 286 

with  typhoid  pneumonia...  288 
head  symptoms  of,  confound- 
ed with  meningitis Ill 

bilious 290 

chronic,  confounded  with  chro- 
nic pleurisy 312 

with  phthisis 264 

lobular 245 

mistaken  for  bronchitis 288 

malarial 290 

typhoid 288 

Pneumothorax 299 

diagnosticated   from  emphyse- 
ma   301 

from  chronic  pleurisy 306 

from  diaphragmatic  hernia...  303 

Poisons 796 

animal 799,  807 

irritant 797 

Poisoning,  acute 797 

arsenic 806 

calabar  bean 802 

chronic 802 

followed  by  coma 54 

lead 805 

malarial 749,  752,  756 

mercurial 804 

narcotic 799 

insensibility  from,  confound- 
ed with  apoplexy 128 

opium 800,  803 

phosphorus 798,  807 

producing  anaesthesia 57 

headache 62 

paralysis 72,  84 

prussic  acid 801 

strychnia 802 

confounded  with  tetanus.  152, 802 


INDEX. 


841 


Poisoning,  zinc 80G 

Portal    veins,    inflammation    of, 
confiiuiicled      witli      acute 

hepatitis 532 

Position  as  a  symptom 31 

Prurigo 785 

Pseudo-tabes  mesenterica 423,  575 

Psoriasis 789 

Pulmonary  artery,  aneurism  of...  390 
diseases.     See  Lung,  diseases  of. 

Pulsation,  abdominal 581 

aortic 581 

confounded  with  aneurism  of 

abdominal  aorta 583 

Pulse,  condition  of,  in  disease 30 

respiration — ratio,  perverted...  282 

study  of,  as  a  symptom 35 

Pupil  of  eye,  condition  of,  in  cere- 
bral disease 65 

Purging,  diseases  attended  by 517 

Purpura 696 

Purulent  urine  confounded  with 

Bright's  disease 645,  664 

diseases  associated  with 661 

Pus  in  the  urine 630 

Pyaemia 685 

arterial 687 

chronic 688 

confounded   with    acute   aflec- 

tions  of  liver 687 

with  acute  glanders 686 

with  intermittent  fever 745 

with  rheumatic  fever 686 

Avith  typhoid  fever 686 

Pyelitis 665 

Pyonephrosis 667 


Quinsy 400 

Quinoidine,  animal,  in  malaria...   752 


R. 

Kales 220 

Kecords  of  cases,  plans  for 30 

Regions  of  chest 197 

Relapsing  fever 738 

Remittent  fever 746 

infantile 115,  753 

Respiration,  amphoric 220 

bronchial 218 

cavernous 219 

feeble 214 

harsh 217 

in  children,  peculiarities  of 229 

jerking 210 

metallic 220 


Respiration,  puerile 214 

prolonged 216 

sounds  of,  in  health 212 

suppl(!mentary 214 

vesiculo-  broncliial 217 

Respiratory  movements 198 

Retropharyngeal  abscesses 409 

Rheumatic  gout 709 

paralysis 84 

Rheumatism 699 

acute 099 

confounded  with  acute  syno- 
vitis   700 

with  milk-log 700 

v,'ith  trichiniasis 825 

head  symptoms  of,  confound- 
ed with  meningitis.   Ill,  702 

heart  symptoms  in 702 

chronic 7U3 

confounded  with    abdominal 

aneurism 583 

with  Bright's  disease 653 

with  neuralgia 165 

with  sciatica 168 

feigned 707 

gonorrhoeal 701 

muscular 704 

confounded      with        trichi- 
niasis   825 

of  abdominal  walls  confounded 

with  peritonitis 485 

periosteal 706 

relations  of,  to  chorea 145 

subacute 703 

Rhinoscopv 179 

Rhonchi...'. 220 

See  also  Rales. 
Rhythm  of  respiration,  changes  in  216 
Rigidity,  local,  confounded  with 

tetanus 152 

Roseola 784 

Rubeola 769 

notha 773 

Rupia 789 

Rupture  of  heart 308 

S. 

Salaam  convulsions 147 

Sarcin;c  ventriculi 427 

Scabies 793 

Scalp,  rheumatism  of,  confotmded 

with  hcmicrania 108 

Scarlatina 705 

confounded  with  diphtheria....   400 

with  sraall-pox 769,  770 

Scarlet  fever 765 

Sciatica 169 

distinguished     from     hip-joint 

afi'ections 170 


842 


INDEX, 


Sciatica  distinguished  from  irri- 
tation of  the  kidiipj" 170 

from  rheumatism 170 

feigned 170 

pressure    of     fluid     on     nerve 

in 169 

rheumatic 169 

Sclerema 791 

Scrofula,  pulmonary 277 

and  tubercle 277 

Scurvy 695 

confounded  with  purpura 697 

Sediments  in  the  urine 633 

Sensation,  deranged 55 

impaired 55 

perverted 55 

Sensations  of  patients 44 

Senses,  special,  derangement  of...     64 

Septsemia 688 

Serum,  effusion  of,  in  serous  apo- 
plexy   126 

Signs,  physical .' 197 

Skin,  condition  of,  as  a  symptom     34 

Skin  diseases 783 

classification  of 783 

exanthematous 784 

papular 785 

parasitic 792 

pustular 788 

squamous 789 

syphilitic  794 

tuberculated 790 

vesicular 786 

Sleep,    protracted,    distinguished 

from  apoplexy 132 

Small-pox 773 

confounded  with  measles 776 

with  scarlet  fever 776 

Softening  of  the  brain 154 

acute,   distinguished  from  apo- 
plexy   128 

chronic 153 

discriminated  from  abscess...   156 

from  congestion 155 

from  exhaustion  of  brain- 
power   157 

from  hardening 156 

from  tumor 158 

paralysis  from 155 

red 154 

relations  of,  to  hemorrhage 155 

white 154 

Sore  throat 399 

chronic 407 

clergyman's 408 

Sound';  bronchial 212,  218 

elicited  by  percussion 206 

Hippocratic  or  succussion,  de- 
tected by  palpation 204 

in  chest,  adventitious 220 

tubular 212 


Spasm  of  bladder  confounded  with 

colic '. 468 

bronchial 232 

facial 167 

distinguished  from  chorea....   147 

masticatory,  of  the  fiice 152 

of  glottis  in  croup  185 

Spasms 101 

See  also  Cojivulsions. 

clonic 101 

diseases  marked  by 139 

tonic 101 

Sphygmograph  of  Marey 39 

Spinal  cord,  diseases  of. 50,     78 

inflammation  of 87,  119 

morbid  conditions  of,  as  a  cause 

of  paraplegia 81 

sclerosis  of. 82,  721 

softening  of 82 

tumors  pressing  on 82 

Spine,  disease  of,  confounded  with 

aneurism 583 

with  colic 471 

Spirometer  of  Hutchinson 202 

S{)leen,  afiections  of 570 

displacement  of 576 

enlargement      of,    confounded 

with  chronic  pleurisy 309 

percussion  of. 418 

Spotted  fever 736 

Sputa  of  bronchitis 243 

nummular 255 

of  acute  pneumonia 282 

of  phthisis 255 

Stetho-goniometer 201 

Stethometer  of  Quain 200 

Stethoscope 210,  211 

application  of,  to  larynx  and 

trachea 173 

Stethoscop}'  of  heart 322 

Stomach ,  acidity  of,  as  a  sj'mptom  423 

acute  diseases  of 440 

acute  inflammation  of 440 

cancer  of. 451,  .5-52 

catarrh  of. 443 

chronic  aflections  of 445 

cramp  of 432 

diseases  of. 421 

fibroid  thickening  of. 455 

gout  in 708 

hemorrhage  from 431 

irritation  of,  confounded  with 

pericarditis 358 

neurnlgia  of. 434 

percussion  of. 416 

softening  of. 444 

ulcer  of. 447 

Stomatitis 396 

ulct'rative,     confounded     with 

diphtheria 404 

Stools  as  symptoms 4'58 


INDEX. 


843 


Stricture  of  the  oesophagus 410 

Stridor,  laryngeal 172 

Sti-yclinia  poisoning 802 

confounded  with  tetanus...  152,  802 

Stupor 54 

in  uremia 647 

St.  Vitus's  dance.     See  Chorea. 

Sugar  in  the  urine G17 

tests  for 617 

Sulphates  in  the  urine,  pathology 

of 610 

Sunstroke 136 

distinguished  from  apoplexy.,.  1-37 

Supra-renal  capsules,  diseases  "of..  681 

Sycosis 794 

Symptoms,  disguised 25 

feigned 24 

ohscure 24 

pathognomonic 21 

similarity  of,  in  diseases 26 

study  of..". 27 

Syncope  distinguished  from  apo- 
plexy....'.   129 

Synovitis,  acute,  confounded  with 

acute  rheumatism 700 

Syphilis  combined  with  laryngi- 
tis   190 

of  liver 551 

Syphilitic  disease  of  the  lungs....  269 

fever 745 

of  the  skin , 794 

Sweating,  excessive 104 

T. 

Tabes  dorsalis 

mesenterica 

pseudo-tabes  mesenterica..  423, 

Tactile  sense,  impairment  of. 

Tape-worm 

Temperature  of  body  as  a  symp- 
tom  

in  Bright's  disease 

in  hectic  fever 

in  intermittent  fever 

in  measles 

in  phthisis 257, 

in  pyaemia 

in  relapsing  fever 

in  scarlatina 

in  small-pox 

in  trichiniasis 

in  tj'phoid  fever 

in  typhus  fever 

Tenderness  as  a  symptom 

Tetanus 

confounded  with  hydrophobia.. 

with  local  rigidity 

with  spasms  in  scarlet  fever., 
with     strychnia    poison. 


152, 


distinguished  from  chorea. 


98 
575 
575 

60 
813 

45 

649 
744 
744 
776 
281 
685 
740 
776 
776 
823 
718 
729 
44 
150 
152 
152 
151 

802 
146 


Tetanus,  hysterical 151 

idiopathic l.^O 

symptomatic 1.51 

traumatic 1.50 

Thermometer,  clinical  use  of 45 

See  also  Temper aiure. 

Thirst  as  a  symptom 423 

Thoracic  aneurism 381 

confounded  with  chronic  laryn- 
gitis   391 

with  dilated  auricle 389 

witli  insufficient  aortic  valves  389 
witii    null  formation    of    the 

chest ....  390 

with  morbid  growths 387 

with  pulsating  empyema 389 

with  pulsation  of  pulmonary 

artery 390 

Thorax.     See  Chest. 

Thrombosis ., 688 

Thrush 397 

Tic  douloureux 57 

Tinnitus  aurium 70 

Tongue,    condition    of,    in    dis- 
ease      41 

inflammation  of. 398 

Tonsillitis 400 

confounded  with  diphtlieria  ...  403 

Torticollis 706 

Trachea,  affections  of 172,  195 

symptoms  of  diseases  of...  172,  173 

Tremor 100 

mercurial,  distinguished   from 

eiiorea 146 

Trichina  spiralis 817 

Trichiniasis 818 

Trismus 150 

Tube-casts  in  the  urine 643,  658 

Tubercle 255 

and  scrofula 276 

calcareous  transformation  of....  275 
confounded  with  chronic  pleu- 
risy   268 

Tubercular  meningitis 112 

Tuberculi/catiou    of    bronchial 

glands 237 

Tuberculosis  of  lungs 255 

See  also  Phthisis. 
combined  with  laryngitis..  191,  193 
confounded  witli   IJi-ight's  di.s- 

ease 655 

physical  signs  of 258 

Tumors,  abdominal 569 

confounded  with  colic 471 

cerebral 158 

intra-thoracic,  confounded  with 

chronic  pleurisy 307 

mediastinal 387 

non  -  aneurismal,      confounded 

with  abdominal  aneurism..  584 
of    brain,   distinguished   from 

softening 158 


844 


INDEX. 


Tumors  of   brain,  distinguished 

from  apoplexy 

of  larynx 

of  spinal  cord  a  cause  of  para- 
plegia  

ovarian 

Tympanites,  chronic 


128 
194 

82 

578 
508 


confounded  with  ascites 50/ 

Typhlitis ■•••  ^^^ 

Typhoid    conditions   confounded 

Avith  ty|ihoid  fever 724 

Typhoid  fever  confounded   with 

enteritis ; !■;„ 

with  general  debility ■ 

■with  meningitis ■ 

■with  peritonitis 

with  lailnionary  alfections....  71i() 

with  remittent  fever 748,  756 

with  trichiniasis ^-3 

with  typhoid  conditions 724 

spinal  symptoms  in 

Tvphus...'. •;•: 

'and  typhoid  fever,  diflferentuxl 

diagnosis  of 

cerebral  symptoms  in 720 

confounded  with  plague  .... 
Tyrosine 


72G 
725 


721 

727 

70  0 
t»0 


G14 


Urine,  specific  gravity  of. o93 

suppression  of. 624,  671 

table  exhibiting  action  of  tests 

upon 634 

Urticaria •/••  '^^5 

Uterus,  colic  of,  confounded  with 

ordinary  colic ..-.•  469 

gravid,  confounded  with  ascites  567 

V. 

Valves  of  heart 370 

See  Valvular  affections. 
Valvular  affections  of  the  heart..  370 
confounded  with  functional  car- 
diac disease 

with  malformations  of  heart., 
with  misdirection  of  current.. 

table  of. 

Variola • 

Varioloid ••••• 

Veins,  portal,  inflammation  of.... 

Vertigo 


U. 

Ulcer,  gastric 

confounded   with  chronic  gas- 
tritis  

with  gastric  cancer, 


447 

453 
453 


with  ulcer  of  duodenum 450 


Umbilical  region,  tumors  of 

Ura-mia ;•• 

distinguished    from    ammonio- 

semia 

UrsBmic  coma  distinguished  from 

apoplexy 

Urates,  pathology  of. 

Urea,  pathology  of. 

Uric  acid  in  gout 

detection  of. 

pathology  of. •• 

Urinary  organs,  diseases  of..  586 
Urine 

acid  free  in 


o74 

047 

649 

128 
604 
597 
708 
708 
602 
635 
586 

^^  _    _ 595 

abnormal  constituents  of 612 

albuminous  conditions  of. 041 

alkaline 5^6 

analysis  of ^°^ 

changes  in  constituents  of o97 

color  of,  changes  in 590 

estimate  of  solids  tn 593 

increased  discharge  of 6(0 

pigment  in •••••   591 

quantitative  examination  ot....  o»/ 

reaction '^'I'l 

retention  of. 6<- 


371 
370 
371 
379 
773 
777 
532 
63 

precursor  of  epilepsy 63 

Viscera,    abdominal,    percussion 

and  auscultation  of....  412,  421 

Vision,  derangement  of 64 

Vocal  fremitus • 226 

resonance ^■^'^ 

Voice,  altered,  with   or   without 

chronic  laryngitis 191 

amphoric 226 

auscultation  of. ^^^ 

cavernous ;••  ^^'^ 

changes  in,  in   laryngeal  dis- 

eases ^^- 

Vomit,  conee-a,  round '*^^ 

ditierent  forms  of 4-/ 

Vomiting  as  a  symptom 42o 

diseases  accompanied  by 51* 


W. 


429 


Water-brash ■ 

Womb,    inflammation     of,    con- 
founded with  peritonitis...  481 

Worms,  intestinal ^\l 

Writer's  cramp ).■*' 

Wry-neck '^6 

Y. 

Yellow  fever "^^ 

confounded    with    remittent 

fever ; ^6;> 

diseases  confounded  with <6- 


Z. 


Zinc  poisoning. 


806 


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