PAIN
ITS CAUSATION AND DIAGNOSTIC SIG-
NIFICANCE IN INTERNAL
DISEASES
BY
DR. RUDOLPH SCHMIDT
ASSISTANT IN THE CLINIC OP HOFRAT VON NEUSSER, VIENNA
TRANSLATED AND EDITED BY
KARL M. VOGEL, M.D.
INSTRUCTOR IN PATHOLOGY, COLLEGE OF PHYSICIANS AND SURGEONS, COLUMBIA
UNIVERSITY; CLINICAL PATHOLOGIST AND ASSISTANT ATTENDING
PHYSICIAN, ST. LUKE'S HOSPITAL
AND
HANS ZINSSER, A.M., M.D.
INSTRUCTOR IN BACTERIOLOGY, COLLEGE OF PHYSICIANS AND SURGEONS,
COLUMBIA UNIVERSITY; ASSISTANT PATHOLOGIST,
ST. LUKE'S HOSPITAL
PHILADELPHIA & LONDON
J. B. LIPPINCOTT COMPANY
COPYRIGHT, 1908
BY J. B. LIPPINCOTT COMPANY
Manufactured, by J. IS. Lippincoft Company
The Washington Square Press, Philadelphia, U. S. A.
WB
17*
S3S3A
HO*
Translators' Preface
IN undertaking a systematic analysis of pain
Dr. Schmidt lias performed a useful service. The
great difficulties attending such an analysis hardly
need to be emphasized to the general practitioner,
who is so often called upon to interpret the sub-
jective complaint in terms of the temperament and
individuality of the patient. In fulfilling his task
the author has throughout tempered his deductions
from actual pathological processes with a careful
critical consideration of the functional elements
which, in the phenomena of pain, so frequently
cloud the clinical picture. Wherever possible, how-
ever, he has based his conclusions upon the more
exact factors of anatomical structure and patholog-
ical change. It is self-evident that in the considera-
tion of a symptom so purely subjective, composed of
such complex psychological and pathological ele-
ments, the final interpretation can be made only on
the basis of careful clinical observation. The subtle
differences, too, which may exist between individual
cases of similar conditions preclude the possibility
of formulating absolute rules. The author can but
point the way to correct analyses and logical deduc-
tion. Dr. Schmidt, in the performance of his task,
calls upon the experience of many years with a huge
clinical material. The thoroughness and concise-
5
6 TRANSLATORS' PREFACE
ness with which he has presented his subject have
seemed to the translators to justify the preparation
of the little volume for the use of American mem-
bers of the profession. For the sake of complete-
ness they have added a chapter (X) embodying
a brief presentation of Head's researches on re-
ferred pains and a series of diagrams showing some
of the commoner seats of pain or tenderness in
visceral disease.
Preface
THE manifestations of disease that are apparent
to the senses of the examiner, and therefore sus-
ceptible of objective estimation, are, naturally, espe-
cially valuable for diagnostic purposes. Modern
medical research accordingly strives to facilitate
the solution of diagnostic problems by investigations
tending in this direction, such as the study of serum
pathology and radiology. It may therefore appear
almost like a step backward to lay as much stress
on a phenomenon that is so purely objective in
nature, and so dependent on the observations of the
patient himself, as will be done in the following
discussion of the symptom of pain.
In this undertaking I have been actuated by the
following considerations: In the first place, the
objective evidences of disease often do not appear
until the malady has reached a certain degree of
development, whereas pain is not rarely present at
its very inception. Furthermore, under the condi-
tions of actual practice a comprehensive investiga-
tion of all the objective symptoms is frequently a
matter of great difficulty owing to the absence of the
necessary facilities, and therefore a careful consider-
ation of the patient's own sensations is absolutely
essential. Lastly, it is frequently this very symp-
tom of pain that impels the patient to seek medical
7
8 PREFACE
advice, and it will therefore be the starting point
of the diagnostic train of reasoning, while its correct
interpretation is the first requisite to the institution
of a suitable form of treatment.
On the other hand, both during the ten years of
my service in the clinic of my honored instructor,
Hofrat von Neusser, which brought me in constant
contact with the younger members of the staff, and
in the course of my long-continued activity as a post-
graduate instructor, I have convinced myself that
even among those having satisfactory command of
the methods of objective examination there is a great
deficiency in the ability to make use of the infor-
mation conveyed by the manifestations of pain. A
realization of this lack was another reason for the
preparation of the present volume.
The work is intended especially to afford a gen-
eral view that will enable rapid orientation in the
individual case, and I therefore did not deem it
advisable to impair its continuity by the introduction
of references to the literature or of polemical dis-
cussions. The adoption of a more or less dogmatic
method of presentation seemed justified by my long-
standing hospital connection, which has also involved
much experience in teaching.
In discussing the manifestations of pain it has
seemed to me that in addition to the organic proc-
esses to which they were due and the topographical
factors underlying their projection externally, their
relationship to function was especially important
PREFACE 9
from the standpoint of facilitating diagnosis. The
investigation of painful conditions from this point
of view leads to- a more* intimate, comprehension of
their pathogenesis and therefore to greater success
in treatment.
May the book fulfil the purpose for which it was
written, of serving as a guide in the rapid and
correct interpretation and successful treatment of
the pain occurring in internal diseases.
SCHMIDT.
Contents
PAGE
TRANSLATORS' PREFACE 5
AUTHOR'S PREFACE 7
CHAPTER I.
THE SENSATION OF PAIN 15
CHAPTER II.
THE FUNCTIONAL MODIFICATION OF PAIN 22
The Influence of Position 22
The Influence of Motion 26
The Influence of Pressure 29
The Influence of Food 33
The Influence of Drugs and Chemicals 38
The Influence of Organic Function 41
CHAPTER III.
TOPOGRAPHY IN ITS RELATION TO PAIN 47
The Shoulder 48
Retrosternal Region 50
Scapula and Interscapular Region 51
The Epigastrium 53
' The Abdomen below the Umbilicus 56
The Lumbar Region (symmetrical) 57
The Lumbar Region (unilateral) and the Flanks 58
Atypical Abdominal Pains 59
CHAPTER IV.
QUALITY AND TIME OF OCCURRENCE 65
Colicky Pains 65
Nocturnal Pains 67
CHAPTER V.
THE NERVOUS SYSTEM 69
Headache 69
Due to Elevations of Intracranial Pressure 71
Caused by Chemical Poisons 76
Of Reflex Nature 78
Neuralgias Involving the General Nervous System 83
The Face 88
The Occipital Region and Nape of the Neck 90
The Arm 91
Intercostal Spaces, including Upper Abdomen 92
Flanks and Lower Abdominal Region 94
Lower Extremities 95
Neuralgias, Sympathetic System and Vagus 97
11
12 CONTENTS
CHAPTER VI.
PAGE
ORGANS OF MOTION 103
Joint Pains or Arthralgias 103
Muscular Pains or Myalgias 108
Bone Pains or Ostalgias 115
CHAPTER VII.
DIGESTIVE SYSTEM 123
Gastralgias 123
Irritable Weakness of Nervous System 126
Direct Causes 126
Pieflex Causes 128
Gastric Ulcers 133
The Colic of Pyloric Stenosis 153
Gastric Cancer 164
Intestinal Ulceration 174
Diseases of the Appendix 182
Lead Colic 192
Malignant New Growths of the Intestines 197
Liver 206
Gall-Bladder Colic 209
Pains without Colic 226
Distention and Inflammation Capsule 228
Pancreas 240
CHAPTER VIII.
URINARY SYSTEM AND SPLEEN 249
Kidney 249
True Kidney Pains 249
Muscular Spasm, Urogenital Tract 262
Urinary Bladder 272
Spleen 276
CHAPTER IX.
RESPIRATORY AND CIRCULATORY SYSTEMS 282
The Lungs 282
Aorta 292
Peripheral Vessels 314
CHAPTER X.
CUTANEOUS TENDERNESS IN VISCERAL DISEASE . 319
List of Illustrations
(At End of the Text)
FIG.
1. Diagram, anterior view of the human body showing seg-
mental distribution of referred pain and tenderness in
visceral disease.
2. Diagram, posterior view of the human body showing seg-
mental distribution of referred pain and tenderness in
visceral disease.
3. Diagram, lateral view of the human body showing seg-
mental distribution of referred pain and tenderness in
visceral disease.
4. Diagram of head and neck, showing areas of referred pain
and tenderness related to visceral disease or to affections
of the head and neck.
5. Possible areas of pain or tenderness in diseases of the nervous
system, etc.
6. Possible areas of pain or tenderness in diseases of the nervous
system, etc.
7. Possible areas of pain or tenderness in diseases of the abdom-
inal organs, etc.
8. Possible areas of pain or tenderness in diseases of the abdom-
inal organs, etc.
9. Possible areas of pain or tenderness in diseases of the abdom-
inal organs, etc.
10. Possible areas of pain or tenderness in diseases of the abdom-
inal organs, etc.
11. Possible areas of pain or tenderness in diseases of the abdom-
inal organs, etc.
12. Possible areas of pain or tenderness in diseases of the lungs
and pleura.
13. Possible areas of pain or tenderness in diseases of the lungs
and pleura.
13
14 LIST OF ILLUSTRATIONS
FIG.
14. Possible areas of pain or tenderness in diseases of the lungs
and pleura.
15. Possible areas of pain or tenderness in diseases of the heart
and vessels.
16. Possible areas of pain or tenderness in diseases of the heart
and vessels.
17. Possible areas of pain or tenderness in diseases of the heart
and vessels.
18. Possible areas of pain or tenderness in diseases of the heart
and vessels.
PAIN
ITS CAUSATION AND DIAGNOSTIC SIGNIFICANCE
IN INTERNAL DISEASES
CHAPTER I.
THE SENSATION OF PAIN.
IN order to combat successfully a painful sen-
sation manifested by a patient, of whatever sort it
may be, it is necessary first to obtain a clear insight
into its sources of origin. The more deeply we are
able to penetrate into these the more successful and
to the point will be our therapeutic measures. A
fundamental principle in such an objective study is
the analysis of the 'painful sensation into its various
elements, its relations to space and to time, its char-
acteristic qualitative shading, its area of distribu-
tion, associated manifestations, etc.
TOPOGRAPHY. The analysis of a pain may most
suitably be commenced by determining its topo-
graphical characteristics. In order to do this it
should be made a rule always to have the patient
point out exactly the spot or the region in which
the pain is felt, and specify whether it is superficial
or deep seated. Vague statements, such as pain in
the stomach, in the liver, etc., are of little value and
are frequently associated with totally erroneous con-
15
16 PAIN
ceptions regarding the situation of the organ in
question, so that they serve only to lead astray.
Where the pain is a radiating one it is necessary
to differentiate between the painful focus and its
peripheral radiations. In such cases it will usually
be found that the focus often from the diagnostic
point of view the most important point coincides
with the area in which the pain was localized at the
beginning of the attack. Of no less significance than
the location of the painful focus, which ordinarily
is at least in proximity to the etiological point of
origin, are the radiations of the pain, especially in
cases in which there is no ground for assuming a
neuropathic tendency in the patient. If the opposite
should be the case, however, it is advisable not to
attach undue importance to the direction of radia-
tion from the standpoint of differential diagnosis.
Under these conditions one must be prepared to
encounter atypical and wholly irregular, bizarre radi-
ations. The extent of the area involved by the
radiation of the pain in paroxysms such as those of
biliary and ureteral colic, etc., frequently appears
to be directly proportional to the intensity of the
neuropathic tendency.
In considering the topography it is also essential
to take into account multiplicity or symmetry of the
pain, if present. These features in connection with
neuralgias, arthralgias, and ostalgias indicate a
broader etiological basis, such as a disorder of meta-
bolism, and speak against a purely local causation.
TIME. A natural sequel of a consideration of
ANALYSIS OF THE SENSATION 17
the location of the pain is that of the time of its
appearance. Not infrequently the onset of the pain
is associated with some definite hour of the day, or
exhibits a regular dependence on certain occur-
rences, such as the ingestion of food. Or it may
appear at some stated time of the day (for example,
nocturnal pain), and it is then our task to determine
the factors underlying this regularity in recurrence.
Now and then a relation to larger units of time, such
as the seasons, or distinct phases in bodily develop-
ment, may be observed and open up perspectives
in the direction of the manner of causation. The
duration of the painful sensation must also receive
due attention.
INTENSITY. The purely quantitative variations,
of course, depend on the intensity of the stimulus
in question, but not less so on the sensitiveness of
the registering apparatus, that is, the patient's
psychical characteristics, so that the same etiologi-
cal stimulus may appear endurable to one, but may
seriously disturb the psychical equilibrium of an-
other. This double dependence of the intensity of
the painful sensation on stimulus and irritability,
and the impossibility of projecting externally the
physicochemical events in the sensory nerve sub-
stance that take place when pain is experienced, ren-
der illusory attempts at the quantitative estimation
of the sensation for diagnostic purposes. None the
less, we are not entirely without means of control,
and can make use of these in cases in which doubt
arises regarding the credibility of the patient.
2
18 PAIN
SIMULATION. Experience shows that intense and
persistent pain in the course of time nearly always
leads to more or less serious disturbances in the con-
dition of the body as a whole, so that disorders of
nutrition are produced and loss of weight results.
In some cases, therefore, systematic observations
of the patient's weight may serve as a means of
control in this regard. When paroxysmal pain is
complained of, the determination of the blood pres-
sure by means of the tonometer [or, preferably, the
sphygmomanometer] is to be recommended in sus-
pected cases. This should be done both in the in-
terval when the pain has subsided and at the height
of the paroxysm. From analogy with the labora-
tory experiment of stimulating the sciatic nerve
an elevation of the vascular tension during the
paroxysm is to be expected, and in fact this phe-
nomenon may often actually be observed. In deal-
ing with patients suspected of malingering I would
suggest that if pain is complained of on pressure,
the size of the pupils be observed in order to detect
any possible increase in dilatation that may follow
the painful stimulus (sympathetic reflex). If this
reflex is present there is no doubt of the veracity
of the patient in stating that he is experiencing pain.
It is advisable, however, to obtain some insight into
the patient's susceptibility to reflexes of this sort
by the production of an artificial pain, e.g., by pinch-
ing. Theoretically, this procedure even offers the
possibility of obtaining an insight into the intensity
of the original pain by observing the degree of
ANALYSIS OF THE SENSATION 19
stimulation necessary to evoke the same reflex,
assuming that equal stimuli produce reflexes of equal
intensities. Reflex phenomena may be used in other
ways as means of control in this direction. Such
a one is the unilateral increase in the abdominal
reflex which leads to the symptom of muscular rigid-
ity (defense musculaire] occurring in abdominal
conditions.
QUALITY. Patients accustomed to close self-
observation often supply information in regard to
the quality of their pains. Not infrequently light
may be thrown on the pathogenesis or nature of
these pains through the description which the patient
gives of them as being boring, piercing, colicky, etc.
Pain resulting from muscular spasm is often experi-
enced as a " cramp" or "griping." In cases of
overdistention of hollow muscular organs this phe-
nomenon may give its characteristic shading to the
pain, and the pain of aneurysmal erosion, for ex-
ample, is often described "as if something was
boring" or as being "pounding" in nature. Ab-
dominal pains must always be considered with re-
gard to the presence of a colicky character. The
distinctive feature of this lies in its wave-like in-
crease and decrease, frequently accompanied by a
sensation of griping, "tying up in a knot," or a
feeling of overdistention.
MODIFYING FACTOKS. The exact analysis of the
pain furthermore demands the accurate determina-
tion of all of the factors which influence the inten-
sity of the sensation, either in the positive or the
20 PAIN
negative sense. Such modifying factors are inti-
mately connected with the causative condition and
are therefore of the greatest importance from the
diagnostic point of view. In this connection stimuli
of general nature must especially be considered.
a. Psychical. Excitement, diversion of atten-
tion, suggestion either in the waking condition or
under hypnosis, etc. It is evident that painful sen-
sations that have what may be termed a psychical
origin and from this center are projected to some
one zone of the periphery, such as some of the pains
of hysteria, are particularly susceptible to psychical
modification. The same thing is true of pains which
are peripheral and organic in origin but which are
brought prominently into the foreground only as the
result of abnormal irritability of the central recep-
tive organs. In such cases diverting the attention
through suitable occupation or pastimes, change of
surroundings, etc., has an anodyne action. It is
never permissible, however, from such an observa-
tion alone to consider a pain as being of purely
psychical nature. At the most it is justifiable only
to assume the existence of a contributing component
of this character.
b. Mechanical. Position of the body, motion,
solid food, percussion, massage, pressure, concus-
sion, etc.
c. Thermic. Changes of weather, draughts, etc.
d. Electrical.
e. Chemical. 1. Dietetic.
2. Eemedial : local or general.
ANALYSIS OP THE SENSATION 21
Whenever the pain appears to be dependent on
certain organic conditions or organic functions it
will nearly always be possible on careful considera-
tion to discover the primary causative factor, either
in the group of the mechanical or of the chemical
cell stimuli.
ACCOMPANYING MANIFESTATIONS. Finally, it must
not be forgotten that attention should be directed
to any possible associated manifestations, whether
these are of a purely subjective nature or are also
susceptible of objective study. Frequently, of
course, these are only remote in nature, such for
example as the vomiting or constipation accompany-
ing painful abdominal seizures of the most varied
types, but sometimes they may also be interpreted
as actual local symptoms (peristalsis, diarrhoea,
dysuria, icterus, bleeding from the genitals, etc.).
By following the preceding scheme it will often
be possible to make a rapid diagnosis and to obtain
a point of departure for therapeutic measures. At
least the diagnostic possibilities will be narrowed
and the physical examination or the laboratory
investigations may be concentrated in a smaller
domain. This is as it should be, for not only accu-
racy but also promptness is desirable in diagnosis.
CHAPTER II.
THE FUNCTIONAL MODIFICATION OF PAIN.
THE INFLUENCE OF POSITION.
IN discussing the pain associated with the
various organs it is often desirable to emphasize
its dependence on definite positions of the body,
such as the dorsal, the lateral, etc., which fre-
quently appear to bear a distinct relationship
to the sensation. Observations of this sort lead
to the characterization of certain "positions of
maximum pain," which term may be applied to
those positions which give rise to a pain which
previously did not exist or which increase the inten-
sity of a pain already present. In so far as the
painful position depends on tenderness to pressure
of superficial structures, as in joint affections, etc.,
it has little diagnostic interest, and only those in-
stances are to be discussed in which such external
causation of the pain is not involved. In gastric
ulcer the existence of a painful position has been
accorded a somewhat unjustifiable degree of im-
portance from the standpoint of differential diag-
nosis, and for this reason the interpretation of the
symptom is not always clear cut. This subject will
be discussed later on in its proper place.
As a matter of fact, painful positions may be
discovered in connection with the pain complexes
of the most varied organs, and this therefore points
22
FUNCTIONAL MODIFICATION 23
to uniformity in the mechanism of their origin. For
example, in the discussion of special organs refer-
ence will be made to the occurrence of painful posi-
tions in diseases of the gall-bladder, of the appendix,
in abdominal tumors, aneurysms, pericarditis, etc.
I have found that even in intracranial processes, such
as cerebellar tumors, there may be painful position
in regard to the headache, which occurs on the side
opposite to that of the hemisphere in which the
tumor is situated and may depend on the pressure
of the growth on the vena magna Galeni or the
aqueduct of Silvius. In the majority of cases the
most general cause of pain is to be sought for in
a change of position of the diseased organ, such as
occurs in certain positions of the body. All the
organs, including new growths, are rather loosely
packed in the body cavities, and the firmness of their
fixation is very variable, as is shown in enteroptosis
for example.
Painful traction on diseased organs is likely to
result (especially in cases of inflammatory processes
in the immediate neighborhood of the structures
involved, as in perigastritis, appendicitis, periaor-
titis, etc.) in those positions of the body in which the
organ is deprived of its firm support. This is ordi-
narily the case in the position on the side opposed to
the lesion, and the resulting pain will depend on
the degree of sensibility caused by the inflammation
and on the intensity of the traction, i.e., on the weight
and mobility of the displaced mass. Of course other
factors also come into play, such as pressure on
24 PAIN
neighboring nerve trunks, as in aneurysms, tumors,
etc., as well as secondary pressure effects on mus-
cular hollow organs like the stomach, intestine,
ureter, etc. A special mechanism depending on
the local peculiarities of the tissues involved under-
lies the position of maximum pain in certain diseases
of the aorta or the coronary arteries. It is well
known that in some cases of these the horizontal
position may give rise to the onset of painful attacks
of angina pectoris. In these affections the causa-
tive factor is probably to be found in the alterations
in the circulation produced by the change in position,
such as the slower but more powerful cardiac con-
tractions with a possible rise in arterial pressure
and greater lateral tension of the chronically in-
flamed aorta.
What light is thrown on the problem of differ-
ential diagnosis by the discovery that there is in
a given case a position of maximum pain ?
1. If the problem presenting itself for decision
is whether the pain is organic or functional in
nature, the existence of a painful position is in favor
of an organic lesion. Thus in cases of mediastinal
new growth, including carcinoma of the oesophagus,
aneurysm of the thoracic and abdominal aorta, gas-
tric ulcer, etc., the nature of the attendant pain is
not rarely misunderstood and is considered as being
a functional manifestation of a neurosis. Under
these conditions the demonstration that there is a
distinct position of increased pain may be of deci-
sive moment.
FUNCTIONAL MODIFICATION 25
2. The presence of a painful position always in-
dicates the advisability of a search for the organ
or new growth causing it, and the location of the
sensation attending the painful position will corre-
spond to the situation of the organ or new growth
in question. The detection of deeply situated
tumors involving, for example, the pancreas or
oesophagus, is often a matter of difficulty and in
these cases the presence of a painful position may
be taken as being corroborative of doubtful palpa-
tory evidence. The occurrence of a painful position
points toward a localized process, especially in deal-
ing with the abdomen, even when the pain appears
to be diffuse, as in appendicitis, intestinal cancer,
cholelithiasis, nephrolithiasis, etc., and so may be
of service in differentiating an ordinary intestinal
colic from similar painful sensations originating in
appendicular disease or localized carcinoma.
The lateral posture is a painful position par ex-
cellence, for it involves the most favorable condi-
tions for abnormal displacement and traction. The
dorsal position (e.g., retroperitoneal processes) or
the sitting posture may also come into question,
however. In the latter case the symptom is usually
difficult to interpret. Pain in the small of the back
and in the flanks is not infrequently caused after
long sitting, especially if the body is inclined for-
ward, by swollen abdominal organs like the kidney,
spleen, liver, etc. These pains do not, however,
appear very promptly, but only after long contin-
26 PAIN
uance of the position, and the pain may sometimes
also be explained as being the result of fatigue of
the dorsal musculature.
THE INFLUENCE OF MOTION.
Under this heading only those forms of pain will
be discussed that are modified in clearly recognizable
fashion through bodily motion, either general or
local. In these cases the pain may be produced
or aggravated as if by carefully planned experi-
mentation, and the differential diagnosis is facili-
tated by tests in this direction. A more or less
superficial connection between pain and bodily mo-
tion in the sense that rest has a beneficial effect
is very widespread and may, to some extent, be
explained through the steadiness of the circulatory
conditions (headache), and in the absence of me-
chanical insults (gastric ulcer) when the body is at
rest. On the other hand, there is a group of painful
sensations that appear on motion as the inevitable
result of the general pain mechanism.
1. DISORDERS OF THE ORGANS OF MOTION. These
are maladies usually involving the extremities, which
are accessible to careful and extensive physical ex-
amination so that special difficulties are not likely
to be encountered. The greatest source of error is
to be found in the fortunately comparatively rare
diffuse diseases of the osseus system, such as osteo-
malacia and disseminated lesions of the bone-
marrow. These possibilities must therefore always
be kept in mind.
FUNCTIONAL MODIFICATION 27
2. DISORDERS OF THE CIRCULATORY APPARATUS.
The intimate relationship existing between the vas-
cular and muscular systems has as a result, that in
disorders both of the central and peripheral portions
of the circulatory system, motion may appear as a
potent source of pain. The circulatory system is
also one of the channels through which the physical
and objective act of motion transforms itself into
the subjective sensation of pain. Every muscle,
whether it is striated or smooth, when in action
makes increased demands on the vascular system as
a whole, and also on its own peripheral district. In
this way it is easy to understand on the one hand
the possibility of the causation of local pain on
locomotion in local disorders (crural, mesenteric, and
coronary vessels), and on the other hand it is clear
that muscular action may produce pain indepen-
dently of peripheral demands through the indirect
effect on the central portions of the circulatory sys-
tem, as in aortitis, aneurysm, etc. It is therefore an
easily explainable fact that all of the symptoms
produced by aneurysms or chronic inflammation of
the aortic walls, and especially pain, may be in-
creased or brought about by bodily motion. If, for
example, retrosternal or epigastric pain is caused
as the result of severe muscular exertion, such as
climbing stairs, running, or battling against the
wind, the possibility of the presence of disease of
the circulatory system must always be suspected
(atheroma of the thoracic and abdominal aorta, scle-
rosis of the coronary arteries, hepatic congestion).
28 PAIN
The same is true in regard to pain in the shoulder,
or brachial neuralgia (aneurysm).
3. ABDOMINAL DISOEDEKS. In these there is not
rarely an exquisite interdependence between pain
and motion. This is especially true of acts that are
accompanied by simultaneous exercise of the abdom-
inal muscles, such as lifting weights, stooping, rais-
ing the head, defecation, backward or lateral inclina-
tion of the body, coughing, sneezing, etc. Undoubt-
edly it is the accompanying elevation of intra-
abdominal pressure that gives rise to the painful
paroxysms in already congested organs (ureteral
and biliary colic, etc.), either directly or through
the interference with the venous flow. Before the
onset of typical attacks of pain and also after the
subsidence of these the appearance of distinctly
localized pain as the result of efforts of the sort just
mentioned may direct attention to a local disorder
in the nature of latent appendicitis or cholecystitis,
etc. Pain in the neighborhood of the appendix, for
example, is not rarely elicited during defecation,
in drawing on the shoes, lifting the head, bending
the trunk to the left, on sitting down, etc. Pain in
the epigastrium on bending the body backward would
suggest the presence of an epigastric hernia.
The pain produced through forcible motion at
the hip joint in inflammatory and suppurative proc-
esses in the neighborhood of the ileopsoas muscle
involving the appendix, caecum, kidney, and para-
metrium finds its explanation in the local pressure
caused. Under these conditions it is important not
FUNCTIONAL MODIFICATION 29
to make the examination in the horizontal position,
in which the abdominal muscles are relaxed, but to
have the patient standing, as then the pressure
effects are more pronounced. Of course it is also
necessary to think of inflammatory processes involv-
ing the joint itself. The pain accompanying certain
movements of the thigh in incarcerated hernia (ob-
turator hernia) must not be overlooked in this con-
nection. The jar communicated to the abdomen
along the lower extremity on putting the foot to
the ground may give rise to pain ; for example, in the
neighborhood of an inflamed appendix, a movable
kidney, or in cholecystitis. This pain appears when
the foot of the same side strikes the ground, and
is more pronounced in walking down hill owing to
the greater force of the concussion.
THE INFLUENCE OF PRESSURE.
The influence of pressure, especially pressure
from within, is of great importance in the mech-
anism of spontaneous attacks of pain. An elevation
of intracranial pressure gives rise to most severe
headache. A rise of tension in the arterial system
may produce extremely painful paroxysms; in-
crease in the internal pressure in the liver, spleen,
or kidney may cause acute pain through the tension
of the capsule of the organ, and the same thing is
true of localized distention in the gastro-intestinal
canal.
Pressure from without exerted for the purpose
of testing a painful condition is usually not effective
30 PAIN
from all directions, as in the above instances, but
only from a given point. Nevertheless, under some
conditions spontaneous pressure effects in all direc-
tions may be experimentally imitated and made use
of for differential diagnosis ; for example, in dealing
with the digestive tract. I remember one case in
which the nature of a tumor below the left costal
arch was in doubt until the colon was inflated. At
once pain, localized strictly to the tumor region, ap-
peared, and at the autopsy carcinoma of the splenic
flexure of the colon was revealed. In a similar way
in cases of carcinoma of the oesophagus with stenosis
the administration of effervescent draughts may
give rise to localized pain, evidently caused by the
tension from within.
PRESSURE FROM WITHOUT. When applied for
diagnostic purposes this may be used in order to
obtain more exact information in regard to the
location of already existing pain, or it may be re-
sorted to to discover a hitherto unrevealed area of
hyper algesia. In doing this it is well to remember
that, even under physiological conditions and accord-
ing to the degree of individual susceptibility, strong
pressure may be more or less painful, and it is advis-
able always to compare similar areas on the two
sides. It is further desirable always to outline the
zones of hyperaesthesia to pressure as accurately as
possible. The more deeply the pressure is carried
the greater is the loss of the resulting pain in local-
izing value, and this is particularly true of the
abdominal cavity.
FUNCTIONAL MODIFICATION 31
PERCUSSION. By means of this it is possible to
obtain an accurate estimate of the effect of pressure
and this method of examination should never be
omitted, especially in examining the abdomen. Posi-
tive results will generally be obtained by this proce-
dure in dealing with organs that touch the abdomi-
nal wall with even only a portion of their surfaces,
as the stomach, intestine, liver, and spleen in the
anterior parts and the kidney in the posterior parts.
The examination of the linea alba in this way for
its whole length, from the xiphoid process to the
symphysis, is especially to be recommended. If
there is any diastasis of the recti, pressure or per-
cussion in this region is not transmitted through the
abdominal musculature, as is the case over the recti,
but causes distinct manifestations of pain if one
of the' organic lesions in question is present.
In general it may be said that at every examina-
tion of the abdomen for purposes of rapid orientation
it is wise to test the sensibility to pressure of the
region of the pylorus and gall-bladder, the three
.flexures of the colon, the neighborhood of the appen-
dix, and the hernial openings. Any local sensitive-
ness to pressure in the rectum or vagina should also
be noted. The testing of local sensibility to pres-
sure also forms a useful method of rapid orientation
in cases in which accurate palpation is rendered
impossible owing to tension of the abdominal walls
as in ascites.
Among the pathological processes of a general
nature that underlie pressure or percussion pain in
32 PAIN
the abdominal region the first place must be given to
peritoneal irritation, either circumscribed or diffuse.
In addition, increase in the internal pressure also
plays an important role; for example, in such con-
ditions as hepatic congestion, and circumscribed or
diffuse gastro-intestinal distention, especially when
accompanied by ulcerative or peritonitic lesions.
Thus the hyperaesthesia of the congested liver dimin-
ishes in proportion to its decrease in size, and the
tenderness of gastric ulcer may decrease from an
excessive degree to a very slight amount within a
few hours owing to the subsidence of gastric disten-
tion. The sensitiveness of an inflamed appendix
may in the same way diminish suddenly on the expul-
sion of faeces and gas. "While in most cases it is
natural to associate any existing abdominal tender-
ness with the topographically related organs the
rarer possibilities must also be kept in mind. For
example, the symptom may have its seat in the ab-
dominal musculature itself, as in the epigastric
tenderness due to fatigue of the origins of the recti
following persistent attacks of coughing. If the
seat of the pain is situated behind the muscle the
contraction of the latter usually diminishes or abol-
ishes the effect of the pressure, and this may be of
value in differential diagnosis. The vascular system
of the abdominal cavity, particularly the aorta, may
also be the seat of tenderness in the epigastrium.
Furthermore, the possibility of neuralgic tenderness
of the sensory tracts should not be forgotten, as in
lead colic, gastric crises, etc. Sometimes in abdom-
FUNCTIONAL MODIFICATION 33
inal neuralgias of this sort intense pressure, over
the epigastrium for example, may seem to have the
effect of relieving pain. This sign may sometimes
be made use of in diagnosis, though caution is neces-
sary, as the same thing exceptionally occurs in
organic diseases.
I am inclined to consider the accurate localiza-
tion of tenderness of the sympathetic nerve fibres
and plexuses running deep down along the spinal
column as theoretically highly desirable but prac-
tically impossible, and the same thing may be said
in regard to the determination of tenderness of the
solar plexus.
THE INFLUENCE OF FOOD.
While the importance of the exact determination
of the alimentary causation or modification of pain
phenomena is very great, the difficulties attending
the demonstration of a relationship of this sort are
no less so. This is especially the case when the
evidence consists only of the biased or inaccurate
observations of the patient himself. Frequently the
connection between the two events is denied with the
statement that pain is present also when food is not
being taken and that the composition of the ingesta
has no noticeable effect. It is evident that both of
these conclusions are erroneous. In the first in-
stance, it is permissible to draw only the inference
that the ingestion of food is not the only pain-produc-
ing factor, and in the second that the quality of the
food is of slight importance. The difficulty of estab-
34 PAIN
listing a relationship of cause and effect is also
increased through the fact that in most cases the
pain, at least as far as it involves the gastro-intes-
tinal tract, appears only several hours after the
ingestion of food.
If the pain begins during the taking of the food
itself a deep-seated stenosis of the oesophagus, par-
ticularly carcinomatous, should be thought of even
in the absence of well-defined dysphagia and though
the pain be localized in the epigastrium. The pain-
ful sensations caused by the food masses that become
impacted above the stenosis are not infrequently
referred to the epigastrium, are accompanied by a
feeling of pressure, and usually disappear suddenly
at the moment that the bolus passes the obstruction.
Alimentary modification of the pain is ordinarily to
be taken for granted only when the pain follows the
ingestion of food with great regularity and after the
lapse of a uniform interval of time. In these cases
it is always advisable to determine the relationship
experimentally by modifications in the amount and
composition of the food.
The ingestion of food may serve to produce pain
in several ways, among which the most important are
as follows:
1. The increase in gastro-intestinal peristalsis
following the taking of food may serve mechanically
to induce pain. In this connection the effect of cold
appears to be especially noteworthy, as when cold
water is taken. The colicky pain sometimes appear-
ing in acute enteritis or appendicitis a short time
FUNCTIONAL MODIFICATION 35
after a drink of cold milk, for example, is certainly
caused in this way. When inflammatory ulceration
exists in the oesophagus, pylorus, intestine, etc., it
is natural to assume that the muscular contrac-
tions set in motion for the purpose of carrying
along the contents of the viscus form the cause of
the pain, so that it is easy to understand that the
composition of the food itself may not be of any
particular importance.
2. Chemical stimuli in the form of ingested acids,
spices, etc. The decomposition products resulting
from bacterial action on carbohydrates and fats must
also be. included under this head.
3. Local irritation due to the mechanical action
of substances like hard bits of meat and similar
bodies, distention of the gastro-intestinal wall
through the formation of gas due to the fermentation
of farinaceous foods, fruits, etc. This mode of
causation seems to play an especially important role
in cases of gastro-intestinal ulceration.
The factors mentioned above have a positive
action ; that is to say, cause* increase in pain, but
there is also the possibility of an influence in the
opposite direction. It is a fact that not only in
gastric neuroses but also in cases of ulcer and some-
times in gastric carcinoma the ingestion of food may
alleviate or entirely relieve previously existing pain.
Two possibilities must be considered in this connec-
tion: 1. The excessive and painful peristalsis is
relieved by the* entrance of food into the stomach
(the growling of a hungry stomach). In cases in
36 PAIN
which the nature of the food seems to be unimpor-
tant, so that even a piece of bread, for example, has
an anodyne effect, this appears to be the most nat-
ural explanation. 2. The food consumed, such as
milk, for example, combines with acid after the fash-
ion of an alkali.
In regard to the time of appearance of alimen-
tary pain phenomena the variability of the causes
explains the differences observed in the period of
their appearance, although in the same individual
the time intervals in cases of organic disease are
often very uniform. The painful attacks attending
lesions of the pylorus, for example benign stenosis,
appear with great regularity two or three hours
after the midday meal, probably in connection with
the expulsive period of digestion. Cases are ob-
served often enough, however, in which the interval
is as much as five or six hours. I consider that
attempts to draw inferences from such observations
regarding the position of the lesion, for example,
that it is a duodenal ulcer, are entirely unwarranted.
On the one hand the appearance of the pain of
pyloric ulcer may be much delayed as has been men-
tioned, and on the other, in duodenal ulcer and intes-
tinal affections including those of the colon (cancer
of the sigmoid flexure, appendicitis, etc.), the pain
may be felt a very short time after the food has been
taken. It is interesting that in some cases of pyloric
ulcer the onset of the pain is delayed if the quantity
of food taken is very large. This is probably due
to the fact that the expulsion of the gastric contents
FUNCTIONAL MODIFICATION 37
is retarded. When there is a clearly demonstrable
connection between the ingestion of food and the
pain, internal gastro-intestinal lesions, especially
those of an ulcerative and stenotic character, must
be thought of. In addition, the somewhat rarer
perigastritic processes should be kept in mind, such
as adhesions between stomach and liver in syphilis
of the latter organ, adhesions between stomach and
colon in carcinoma of the splenic flexure, etc. En-
largement of the organs in the neighborhood of the
stomach must also be considered, such as echino-
coccus of the liver or spleen, pancreatic cysts, etc.,
but these lesions are more apt to be accompanied by
a sensation of uncomfortable pressure rather than
by direct pain.
Organic lesions are particularly likely to be pres-
ent in cases in which there are no fluctuations in the
intensity of the symptoms, in which the effect of
psychical factors is slight or entirely absent, and the
alimentary factor is characterized by great consist-
ency. Owing to the close interrelationship between
the gastro-intestinal tract and the large abdominal
glands, the liver and pancreas, it is natural to expect
a priori that on account of the circulatory changes
in these organs attending the digestive act pain
from these districts also should be subject to alimen-
tary modification. Such interdependence is very
irregular in its manifestation, however, and fre-
quently cannot with certainty be demonstrated at
all. Equally irregular is the alimentary relation-
ship of the pain often observed after the subsidence
38 PAIN
of lead colic or gastric crises. In the former con-
dition painful attacks are not rarely the result of
a diet that tends to gas formation.
Pain resulting from disease of the circulatory
system is also susceptible of modification by the in-
gestion of food, as will appear later. Attacks of
angina pectoris may follow meals excessive in
amount or composed of food causing gastric and
intestinal distention. The phenomenon may prob-
ably be explained in part by the rise in blood pres-
sure and increased demand upon the heart. The
influence of food ingestion may also be observed in
cases of atheroma involving the gastro-intestinal
vessels.
THE INFLUENCE OF DRUGS AND CHEMICALS.
All forms of pain exhibit a widespread suscepti-
bility to modification by the administration of drugs,
quite independently of the effects of the narcotics.
Furthermore, there may be in some cases a specific
susceptibility obviously depending on more or less
fundamental factors in the mechanism of production
of the pain in question, and which may be made use
of for the purposes of differential diagnosis. It is
well known with what regularity the paroxysms of
angina pectoris respond to the administration of the
vasodilators. For this purpose I should especially
recommend erythrol tetranitrate in the form of pills
containing 0.01 g. each. In a case presenting indefi-
nite pain in the neighborhood of the heart or in the
epigastrium and where there are other reasons for
39
suspecting vascular disease, the resort to an erytlirol
tetranitrate test may be of great diagnostic value,
especially if the effect is more or less sudden and
the same result always follows a repetition of the
test. Obscure neuralgic pains in the left upper
extremity may also be unmasked in this way and be
found to depend on an irregular form of angina.
Reflex pain of this sort in the upper extremity
is sometimes relieved by the application of cold
to the precordium.
Local anaesthetics may be used for the purposes
of differential diagnosis in order to determine
whether the cause of the pain is peripheral or cen-
tral. The subcutaneous injection of cocaine has
been recommended for this purpose in trigeminal
neuralgia and a 5 per cent, ointment of morphine
has been used with a similar object. In testing the
gastric mucosa the use of ansesthesin in 0.5 g. doses,
or of cocaine (about 16 drops of a 1 per cent, solu-
tion), may be recommended. The pain of gastric
ulcer or of ulcerating carcinoma of the oesophagus
usually ceases within about a quarter of an hour
after the administration of these amounts of anaes-
thesin or cocaine. If this occurs in a case under
consideration, duodenal ulcer is improbable, and I
therefore suggest this anaesthesin test as a means of
differential diagnosis between gastric and duodenal
ulceration. A prompt result following the anaes-
thesin treatment in cases of epigastralgia usually
indicates a lesion of the gastric mucosa such as ulcer
or carcinoma and justifies the assumption of a local
40 PAIN
causation of the pain. If the pain is accompanied
by evidences of stenosis, such as increased gastric
peristalsis or dysphagia, a positive result of the test
would point to internal stenosis with changes in the
mucous membrane.
In order to decide the question whether a gastric
pain is partly or entirely caused by hyperaesthesia
to hydrochloric acid this may be given while fast-
ing in doses of 1-5 drops of the dilute acid to a
tablespoonful of water. The administration of
alkalis such as sodium bicarbonate forms a pendant
to this test. It must be borne in mind, however,
that sodium bicarbonate may bring relief and ces-
sation of pain by causing the stomach to expel any
gas that may be present. Epigastric tenderness due
to hepatic congestion is usually very amenable to
digitalis treatment. If it shows a tendency to in-
crease while the other evidences of congestion sub-
side the complication of gastric ulcer must be sus-
pected (ulcer in a congested stomach).
The rapid relief of headache or neuralgic pain
by the administration of iodine and mercury of
course suggests syphilis. In cases of headache, tri-
geminal neuralgia, sciatica, etc., accompanied by con-
stipation, it is advisable to resort to purgation in
endeavoring to obtain insight into the etiology of
the pain. While the intestinal condition is not very
frequently the sole cause of the pain, there is no
doubt that it sometimes is an important factor, and
the diagnostic and therapeutic aims may be united.
In gastric ulcer, the colic of pyloric stenosis, lead
FUNCTIONAL MODIFICATION 41
colic, etc., an important role in the pain formation
is often played by stagnation of the fecal masses.
Paroxysms of abdominal pain of the most varied
nature (gall passages, ureters, etc.) frequently re-
spond very directly to the cautious evacuation of the
intestine either through cathartics given by mouth
or through the rectum.
The hypodermic injection of distilled water may
be of diagnostic value in obscure pain, especially in
cases in which the patient's suffering is completely
or in part the result of autosuggestion. Even if
the pain diminishes there is always the possibility
that in addition to the functional element there is
also an organic causative factor, and in this way it is
possible to form an idea of the intensity of the latter.
Obscure pain about the thorax (shoulder, interscapu-
lar space, etc.) which is increased by the injection
of tuberculin probably is related to an underlying
tuberculous process.
THE INFLUENCE OF ORGANIC FUNCTION.
The coincidence of certain pain phenomena with
one or another organic function may form the start-
ing point of a diagnostic analysis. Sometimes such
a conjunction may afford appreciable assistance, but
it must be confessed that often there is danger of
its leading into error.
DEFECATION. The act of defecation, for example,
may exhibit the most varied relationships to pain
phenomena of widely differing origin. Coprostasis
of long .duration causes stagnation and abnormal
42 PAIN
decomposition in the entire digestive tract, includ-
ing the stomach, and it is not surprising, therefore,
that the pain accompanying many gastro-intestinal
conditions, such as appendicitis, intestinal stenosis,
lead poisoning, ulcer, stenosis of the pylorus,
etc., may be favorably affected by the cautious
production of an evacuation, a fact which de-
serves careful consideration from the standpoint
of therapeutics also. In dealing with inflammatory
lesions in the abdomen care must be taken, however,
that the act of defecation does not involve too great
a degree of exertion of the abdominal musculature.
Otherwise precisely during the act of defecation
strictly localized pain may be caused corresponding
to the position of the inflamed appendix or diseased
gall-bladder, or in the neighborhood of a carcinoma
of the colon or gastric ulcer. Such an occurrence
may have diagnostic value in determining the posi-
tion of the process in question. This localized pain,
accompanying abdominal straining, may be spoken
of by the patient and be of assistance in the diag-
nosis in cases of quiescent appendicitis, or on the
other hand, in the early stages of the disease. Back-
ache resulting from gastro-intestinal distention (in-
testinal stenosis, etc.) is usually perceptibly relieved
after a movement of the bowels. If the movement is
regularly preceded by pain immediately before the
act, deep-seated ulcerative processes such as carci-
noma of the rectum should be suspected.
In cases of latent angina pectoris severe abdom-
inal straining during defecation may cause the onset
FUNCTIONAL MODIFICATION 43
of a paroxysm, or slight retrosternal premonitory
sensations may be induced. The favorable effect of
defecation is often indubitable and even astonishing
in many cases of headache, especially, it appears
to me, in those types which are accompanied by
an elevation of intracranial pressure. A laxative
frequently is much more effective than large doses
of antineuralgics, even in cases of severe organic
lesions like brain tumors. In these cases the im-
provement must depend on alterations in the intra-
cranial circulation, for the effect is often very sud-
den. Meteorism may lead to stasis in the superior
vena cava and in the cerebral veins through the
restriction of the respiratory venous aspiration, and
the important part played by normal intestinal peri-
stalsis in facilitating the venous circulation in the
portal district must also be considered. In these
cases, too, the act of defecation may give rise to
temporary increase in the headache if it is accom-
panied by undue straining efforts.
The onset of gastric crises in tabes not rarely
occurs in conjunction with defecation and the evacu-
ation of fluid stools. It is likely, however, that the
act of defecation is in these cases only indirectly to
be associated with the gastric symptoms (increased
gastro-intestinal peristalsis). In enteroptosis, in-
testinal atony and neuropathic conditions persistent
constipation sometimes appears rather to have the
effect of deferring the onset of functional pains,
such as gastralgias.
44 PAIN
VOMITING. If vomiting accompanies abdominal
pain the coincidence of the latter with this common
symptom is more apt to lead astray than to be of
direct diagnostic service, unless it happens that the
nature of the vomitus (blood, sarcinae, lactic acid
bacilli, hyperchlorhydria, etc.) gives the necessary
clue. One may easily be deceived by the vomiting
in chronic intestinal stenoses, for example in tu-
berculous ulceration of the small intestine, and in
the absence of peristaltic movement be led to
assume a gastric lesion such as stenosis of the
pylorus as the starting point of the pain. Slight
alleviation of the pain after vomiting is sometimes
observed in painful seizures of the most varied
nature, such as angina pectoris, renal infarct, chole-
lithiasis, etc. Prompt and often complete relief to
the pain is particularly characteristic of attacks of
colic due to stenosis of the pylorus.
DEGLUTITION. Pain accompanying the act of
swallowing may depend on internal or external
causes. If the source of the sensation is in the
upper part of the oesophagus its detection will ordi-
narily not prove difficult. If the patient has fever the
possible existence of laryngeal tuberculosis should
not be forgotten. If the dysphagia is due to ulcer-
ation of some portion of the cesophageal mucosa an
increase in the pain is usually caused on taking acids
or spiced articles of food. On the other hand, the
administration of local anaesthetics like anaesthesin
will prove beneficial. This effect of food or drugs
is generally absent if there are other causes for the
FUNCTIONAL MODIFICATION 45
disturbance in deglutition, unless secondary ulcera-
tions have been caused. The deglutition pain of
aneurysm frequently radiates into the left shoulder
or below the clavicle.
MENSTKTJATION. While it is natural to refer to
the genital apparatus pains occurring together with
menstruation or at least, if they involve regions at
a distance such as headache or gastralgia, to asso-
ciate them with this function it must always be
borne in mind that the menstrual process leads to
increased irritability of the system in general.
Therefore, whenever there is already present an
irritative condition, such as cholelithiasis, appen-
dicular disease, ulcer of the stomach, etc., attacks of
pain may be brought on in these regions of lessened
resistance. This is especially true of the appendix,
owing to its topographical relationships and its
circulatory connections. In distinction to this many
obstinate abdominal pains such as gastralgias seem
to be checked during pregnancy. This is particu-
larly the case in enteroptosis, probably in part owing
to the diminution of the abnormal mobility of the
abdominal organs.
EESPIKATION. In dealing with shoulder pains in-
duced by respiration, it is always advisable to think
of the possible presence of apical tuberculosis with
secondary perineuritis of the brachial plexus (ten-
derness on pressure). Pain in the domain of the
thoracic muscles may of course be purely myogenic
in nature in spite of its dependence on the respira-
tory act. The retrosternal pain sometimes produced
46 PAIN
by deep respiration in cases of atheroma of the aorta
may be explained by the traction on the vessel.
Both local and diffuse peritonitic lesions such as
perihepatitis, perigastritis, etc., as well as lesions
of movable abdominal viscera in general, are fre-
quently the seat of pain on sudden inspiratory dislo-
cation, especially that caused by diaphragmatic
breathing.
CHAPTER III.
TOPOGRAPHY IN ITS EELATION TO PAIN.
WHILE in external diseases the site of pain nearly
always corresponds to tne lesion, this is true of
internal affections only with certain reservations
and in this connection there is found an unending
source of diagnostic errors. Even the general ques-
tion of whether the presence of local pain indicates
the existence of any disease of an internal organ and
is not due to an external lesion, may sometimes be
difficult to answer. Before arriving at the conclu-
sion that a certain painful sensation is caused by
internal disease, it will be found practically useful
to exclude the possibility of an affection of the
organs of motion joints, muscles, or bones- as well
as of disorders of the nervous system (v. Neural-
gias). The patient's own sensations and his de-
scription of the pain as being deep seated may some-
times, but not always, point to the existence of an
internal lesion.
The following discussion of pain in connection
with topography will be devoted only to those mani-
festations that are the result of disease of the inter-
nal organs. The inclusion of disorders of the
organs of motion and of the nervous system would
lead too far afield. Even with this restriction, how-
ever, completeness of exposition is out of the ques-
tion and therefore only certain districts of the body
47
48 PAIN
will be considered, which, may be regarded as nodal
points for painful sensations emanating from dif-
ferent directions. The obvious will be omitted and
only more unusual and easily overlooked phenomena
will be discussed, particularly from the therapeutic
standpoint. For the purposes of practical differen-
tial diagnosis it will not do to hold too closely to
purely topographical considerations. It is espe-
cially desirable to study the factors that influence
the pain; that is to say, the examination must in-
clude a test of function as well as of the accompany-
ing symptoms, as has already been pointed out in
detail in the section on the analysis of pain. In the
following pages I will be as brief as possible, as a
more detailed discussion of the various organic pains
may be found in the chapters devoted to each of
these.
I. THE SHOULDER.
The internal organs coming in question under
this head are as follows :
a. Lung. Affections of the pulmonary apices,
especially tuberculosis and new growths, not infre-
quently cause spontaneous shoulder pain as well as
tenderness of the brachial plexus, probably through
the development of perineuritis or direct involve-
ment of the branches of the plexus. I have found
that tenderness is particularly apt to occur at the
junction of the outer and middle thirds of the upper
border of the trapezius. TVTien pain in the shoulder
is complained of by persons of tuberculous appear-
ance this possibility should be kept in mind.
TOPOGRAPHY 49
b. Thoracic Aorta. Aneurysm and atheroma of
the thoracic aorta not infrequently are accompanied
from the very first by persistent shoulder pain.
This may be either bilateral or only on one side.
In addition to spontaneous pain there is frequently
also tenderness over the brachial plexus as well as
in the upper intercostal spaces in front. Of great
diagnostic importance is the fact that the pain is
increased by exertion, such as stair climbing, etc.,
as well as its coincidence with increased heart action.
Quieting cardiac activity by bodily rest and the
application of cold compresses generally relieves
this aortic shoulder pain. Motion at the shoulder
joint may be free and painless, but lifting the upper
arm from the side above the horizontal line is likely
to evoke pain (traction on the subclavian artery?).
It must be remembered that, especially in athero-
matous disease of the subclavian artery and in cases
of the arthritic diathesis, aneurysm of the aorta and
chronic aortitis may coexist with more or less inde-
pendent disease of the shoulder joint (rheumatic
joint lesions).
c. Subdiaphragmatic Organs. Inflammatory
processes occurring in the liver, spleen, or stomach,
or in their subphrenic surroundings. Shoulder
pains transmitted in this way through the phrenic
nerve of the same side usually do not attain particu-
lar intensity. The causative lesion, such as echino-
coccus of the liver, subphrenic suppuration, peri-
splenitis in leukaemic spleens, perigastritis in ulcer
of the stomach, etc., ordinarily causes much more
4
50 PAIN
acute local symptoms, so that if the possibility of
this connection is kept in mind the danger of misin-
terpreting the shoulder pain is not very great. The
shoulder pain may sometimes be latent and appear
only on pressure on the brachial plexus or on the
above-mentioned pressure point at the upper edge
of the trapezius.
II. RETROSTERNAL REGION.
a. Circulatory Apparatus. The pain accom-
panying such affections as aortic aneurysm, chronic
aortitis, and sclerosis of the coronary arteries, which
are the ones most often concerned under this head-
ing, is accompanied by a pronounced sense of con-
striction, and has the further peculiarity of being
promptly influenced and increased on exertion such
as running, climbing stairs, etc. The very intense
retrosternal pain that is sometimes seen in cases of
pericarditis is not paroxysmal but is persistent.
b. Mediastinum. Bifurcation of the trachea and
local affections of the mediastinum. The retroster-
nal pain often accompanying the cough in acute
bronchitis is usually to be explained by the inflam-
matory condition at the bifurcation of the trachea.
In some cases similar changes in the neighboring
lymph glands may contribute to its causation. The
more or less severe and persistent retrosternal pain
not rarely accompanying severe dyspnoea of long
duration may have a similar origin, and I have found
this symptom a not infrequent accompaniment in
cases of miliary tuberculosis. Mediastinal new
TOPOGRAPHY 51
growths, such as lymphosarcoma, etc., also not infre-
quently cause retrosternal pain that may be relieved
to some extent by leaning forward (transfer of the
pressure to the sternum and relief of the more sensi-
tive posterior structures). Such pain may be in-
creased by rapid walking, etc., probably through
the forced inspiration and consequent increase in the
motility of the trachea and traction on the surround-
ing structures. This observation may lead to the
erroneous diagnosis of angina pectoris.
c. (Esophagus, Stomach, and Liver. Fairly se-
vere retrosternal pain may be due to stretching of
the wall of the oesophagus on taking food if the lower
portion of the tube is stenosed. Pain of this nature
exhibits extreme dependence on alimentary condi-
tions. Retrosternal radiation of the pain is not
rare in ulcer of the stomach and pyloric stenosis,
although in these conditions the pain is rarely found
only in this situation. The same thing is true of
hepatic affections.
In the preceding, retrosternal sensations have
been considered only in so far as they reach the
point of actual pain. Sensations such as the feel-
ing of oppression sometimes occurring in nervous
asthma, tuberculosis, dilatation of the right heart,
or tabes, are not within the limits of the discussion.
III. THE SCAPULA AND INTERSCAPULAR REGION.
More than in any other part of the body pain in
this district suggests the possibility of disease of
the organs of motion (spinal column, dorsal muscles)
52 PAIN
as well as neuralgia. Only after these have been
excluded or on the demonstration of corresponding
organic lesions is it justifiable to consider the latter
as being responsible for the pain. In general the
possibilities are the same as those relating to shoul-
der pains, and here also pulmonary affections
like tuberculosis are not unimportant. Sometimes
chronic inflammatory changes in the pleura leading
to the formation of adhesions or glandular changes,
acting like the retroperitoneal glands in causing
backache, may manifest themselves subjectively by
interscapular pain. Secondary neuralgic conditions
of the intercostal nerves must also be thought of;
at any rate pains of this sort always indicate an
exhaustive examination of the lung.
Aortic lesions (aneurysm, chronic aortitis) also
not rarely give rise to pain in the interscapular
region, especially on the left side. Frequently there
is also a feeling of painful pressure and sometimes
a dependence on particular positions of the body.
A priori, an increase in such pain is to be expected
on exertion. The intimate relationship of the liver
and gall-bladder, spleen, and stomach to the shoulder
blades of the same side is well known, and reference
may be made to what has been said above.
Of gastric disorders it is particularly stenosis
of the pylorus that gives rise to painful attacks with
radiation into the left, or more frequently, both
shoulder blades. This radiation of the pain seems
to some extent to run parallel with the intensity of
the distention of the stomach during the paroxysm.
TOPOGRAPHY 53
The shoulder pains previously described repre-
sent a spatial prolongation of the radiation which
ordinarily rarely passes upward beyond the spine
of the scapula. It may also be mentioned that the
radiation of headache into the interscapular space is
generally associated with an increase in intracranial
pressure, as in brain tumor, meningitis, etc.
IV. THE EPIGASTRIUM.
The series of organic lesions manifesting them-
selves through pain in the epigastrium is so great
that from the standpoint of practical differential
diagnosis it seems more suitable in each case to
abandon promptly the purely topographical factor
and to turn the attention to certain characteristic
features of each type of epigastralgia, such as those
comprised in the modifying factors, accompanying
manifestations, etc. In this way more rapid orien-
tation is possible and the diagnostic possibilities may
rapidly be narrowed. Here again, as was pointed
out at the beginning of the chapter, lesions of the
organs of motion, such as the muscular pain follow-
ing persistent cough, muscular haematoma, etc., and
diseases directly concerning the nervous system, like
the neuralgia of spondylitis, the girdle pains of
tabes, or gastric crises, will not be discussed at
length.
The most important differential points to be dis-
cussed are as follows :
a. Tenderness to Pressure and Percussion. It is
true that most of the spontaneous pains in this dis-
54 PAIN
trict are accompanied by tenderness to pressure, but
the exact localization of this, and particularly the
determination of the point of maximum tenderness,
may be of importance. This is true, for example,
for the tender gall-bladder in cholelithiasis, pain on
pressure under the left costal arch in gastric ulcer
or carcinoma, or in syphilis of the left lobe of the
liver, sharply circumscribed tenderness in ulcer and
epigastric hernia, the relation of the sensitive point
to the edge of the liver, and so on. The absence of
tenderness in spontaneous attacks of pain would
suggest, though not without reservation, the diag-
nosis of gastric crises, essential gastralgia, or lead
colic. Its presence, however, is not sufficient to
exclude the latter affection.
b. Colic. In addition to the common paroxysms
of biliary colic and gastralgia, such conditions as
intestinal stenosis, new growths of the small intes-
tine, tuberculous intestinal ulceration, etc. as well
as particularly appendicular disease, pancreatic
colic, and angina pectoris must also be considered.
c. Collapse. The evidences of collapse may ap-
pear at the acme of any attack of colic, but such
severe general symptoms are especially suggestive
of perforation, as in gastric or duodenal ulcer,
acute intestinal obstruction, gastric crises, pancre-
atic necrosis, and angina pectoris.
d. Causation through the Ingestion of Food.
Under this heading may be included gastro-intes-
tinal lesions, processes in the neighborhood of the
stomach accompanied by progressive increase in
TOPOGRAPHY 55
size, such as echinococcus of the liver, splenic tumor,
deep-seated stenoses of the oesophagus, and more
rarely, angina pectoris and cases of painful intermit-
tent dilatation of the abdominal aorta.
e. Causation through Exertion. In this class
may be grouped diseases of the circulatory appa-
ratus, like sclerosis of the coronary arteries and
chronic aortitis. The sensation of painful pressure
due to hepatic congestion of course is also consid-
erably increased on motion.
f . Position. The existence of a position of maxi-
mum pain (v. p. 22) generally may be taken as indi-
cating an organic origin for the symptom.
g. The Influence of Drugs (v. p. 38). This con-
cerns particularly the internal administration of
local anaesthetics, of hydrochloric acid and alkalies,
as well as of erythrol tetranitrate.
Of much more importance than localization in the
epigastrium is the determination of asymmetrical
distribution of the pain. If this is more manifest
on the right or the left, either spontaneously or on
pressure, an organic condition is a priori more likely.
A. Localization on the Right Side. Below the
right costal arch : Spontaneous pain and tenderness
in disease of the gall-bladder, of the pylorus, the
duodenum (ulcer!), the hepatic flexure of the colon,
as in carcinoma or flatulence, renal infarct, etc. In
appendicular disease the tenderness is usually lower
down; in pleurisy and pneumonia of the lower lobe
there is usually only tenderness.
B. Localization on the Left Side. Below the left
56 PAIN
costal arch: Here both in spontaneous pain as well
as in tenderness to pressure ulcerative conditions
in the stomach should always be thought of first,
particularly as occurring in the middle region of the
organ, although gastric crises sometimes, even if
rarely, are distinctly left-sided. Furthermore, intes-
tinal carcinoma, particularly of the descending colon
(radiating to the anus) , should be thought of. When
there is a tendency to flatulence pain in this region
is also not uncommon. Lesions of the pancreas
(cysts), affections of the spleen, and left-sided pleu-
risy, if the pain is caused simply by pressure, must
also be considered.
V. THE ABDOMEN BELOW THE UMBILICUS.
In order to avoid error, it should always be taken
into account that in cases of enteroptosis organs
situated in the upper part of the abdomen, such as
the kidney, stomach, or gall-bladder with a corset
liver, may give rise to pain in the lower abdomen.
On the other hand, viscera originally situated in the
pelvis may in some conditions develop upwards
(urinary bladder, ovarian cysts, extrauterme preg-
nancy, etc.). In cases of bilateral tenderness tend-
ing toward the pelvis ovarian conditions and para-
metritic affections should be thought of in women;
also conditions in the colon and about the neighbor-
ing hernial openings. Pain on the left side suggests
the various affections of the sigmoid flexure, includ-
ing carcinoma, dysentery, membranous enteritis,
volvulus, foreign bodies introduced through the anus,
TOPOGRAPHY 57
etc. If on the right side, attention is directed to
lesions in the neighborhood of the caecum and the
appendix, including tuberculous glands or ulcera-
tions, intestinal perforation in typhoid fever, disten-
tion of the caecum in atony of the colon, etc.
VI. THE LUMBAR REGION (SYMMETRICAL).
Symmetrical lumbar pain is but little adapted to
furnish decisive diagnostic information. After ex-
cluding lesions of the musculature or fascia, such as
lumbago and diseases of the spine, like spondylitis,
osteomylacia, etc., there is a wide range of possibili-
ties in which nearly all the abdominal organs com-
pete, including particularly the female generative
system. The demonstration of alimentary modifica-
tion of the backache is of importance since it occurs
in ulcerative processes of the stomach or large intes-
tine. In these as well as in disorders of the colon,
for example carcinoma, the pain often appears
within even a few minutes after the ingestion of
cold fluids or solid food. This phenomenon is prob-
ably to be interpreted as the result of a reflex stimu-
lation of intestinal peristalsis. Accumulations of
gas above stenoses appear to be particularly prone
to induce backache. Very deep-seated carcinomas
frequently lead to pain in the neighborhood of the
sacrum, and the same may be said of haemorrhoidal
conditions. Backache occurring during pregnancy
and which is particularly severe on walking is of
great practical significance, as it is a symptom of
osteomalacia. A dependence on motion, particularly
58 PAIN
stooping, is also often present in backache not orig-
inating in the apparatus of motion itself, as in
hepatic, splenic, and renal processes, new growths
of the colon, etc.
The dorsal position is particularly likely to be
painful in cases of retroperitoneal tumor formation
through enlarged glands, aneurysm, pancreatic cysts,
etc., and it seems reasonable to explain this on the
ground of the increase in compression accompanying
this position. Prolonged sitting sometimes has the
same effect when there is swelling of abdominal
organs. A rather rare condition that I have ob-
served is backache occurring in chronic lead poison-
ing. This is sometimes accompanied by radiation
into both thighs and is followed by colicky pain in
the neighborhood of the umbilicus.
VII. THE LUMBAR REGION (UNILATERAL)
AND THE FLANKS.
The presence of spontaneous pain or tenderness
in the right or left lumbar region or in the flank has
much greater diagnostic value and restricts the pos-
sibilities much more than backache that is symmetri-
cal. Frequently there is no spontaneous pain, but
it is necessary to test for tenderness by pressure, or
preferably by light blows with the ulnar side of the
clenched fist. Under these conditions painful renal
affections must always be thought of, particularly if
the corresponding flank is also tender. Further-
more, on the right side: Appendicitis with retro-
csBcal abscess, hepatalgia, and especially choleli-
TOPOGRAPHY 59
tliiasis. On the left side : Gastric ulcer, perisplenitis,
and pancreatic lesions.
ATYPICAL ABDOMINAL PAINS.
"While the limits comprised under such a heading
as this are necessarily arbitrary, its introduction is
justifiable from the practical standpoint. For vari-
ous reasons abdominal pains not rarely offer unusual
difficulties in diagnosis. Frequently it does not suf-
fice simply to observe and to correlate the- observa-
tions to form diagnostic conclusions, but it is
necessary to go further and consider even the rarer
possibilities. The processes that most often lead
to diagnostic errors may perhaps be classified in the
following way :
1. Atypical Attacks of Colic and Thoracic Proc-
esses. The source of the pain is found in a more
or less characteristic and anatomically sharply cir-
cumscribed organic lesion, but the attacks of pain
are rudimentary or there is an absence of localizing
symptoms pointing to the organ in question. It is
well known, for example, that appendicular disease
or lesions of the gall-bladder frequently manifest
themselves by pain in the middle of the epigastrium,
and that biliary and ureteral colic and the pain of
pancreatic disease may appear in paroxysms embrac-
ing a wide area. Wrong diagnoses are to be avoided
only by the most careful search for a point of maxi-
mum tenderness, such as the testicle, gall-bladder,
etc., and possible attendant symptoms such as
dysuria, glycosuria, urobilinuria, etc. In this con-
60 PAIN
nection those cases should also be considered in
which the source of the abdominal pain is found out-
side of the abdomen, like the epigastric pain of
chronic thoracic aortitis or disease of the coronary
arteries and the tenderness under the costal arch
and in the flank in cases of pleuropneumonic disease
of the same side, etc.
2. Cystic New Growths and Foreign Bodies in the
Intestine. Under this heading cyst formations, such
as those of the" mesentery, pancreas, and ovaries,
must be considered. As will be pointed out in de-
scribing pancreatic pain the sensations attending
these are not susceptible of uniform interpretation.
For example, mesenteric cysts may on occasion give
rise to pain through the obstruction caused to the
passage of gastric and intestinal contents (direct
stenosis, volvulus?), or they may give rise to second-
ary neuralgia (solar plexus). The latter possibility
enters particularly into the question of pancreatic
cysts. The obstruction of venous trunks through the
torsion of the pedicle may lead to a rapid increase
in pressure in the interior of the cysts and therefore
give rise to pain through the augmented tension of
the cyst wall.
Pathological processes in the abdominal lymph
glands, both mesenteric and retroperitoneal, must
be thought of in cases of obscure spontaneous attacks
of pain as well as when tenderness to pressure exists
(typhoid, tuberculosis, neoplastic mesenteric glands,
etc.). Swollen glands, for example in leukaemia, are
particularly likely through compression of neighbor-
TOPOGRAPHY 61
ing nerve centers, such as the solar plexus, to cause
neuralgias of the severest type and resembling
attacks of colic. In this group may be included also
the pain accompanying the course* or termination of
a tubal pregnancy (v. the differential diagnosis of
appendicitis).
3. Visceral Neuralgias and Disorders of Circula-
tion. The cause of the pain lies not in the organ
itself, but in its nerve supply or in its vascular
system. Experience shows that cases of this sort
are particularly liable to misinterpretation because
through the law of probabilities lesions of the organs
themselves are more likely to be thought of.
The neuralgiform attacks sometimes occurring
in spinal diseases, particularly in tabes, cerebro-
spinal syphilis, etc., and manifesting themselves in
certain organs, such as the stomach, intestine, blad-
der, etc., as well as independent processes in the
abdominal sympathetic and its ramifications will be
taken up partly in describing the various organic
pains and partly in the discussion of the visceral
neuralgias. In order to avoid repetition, reference
is made to the chapters in question. On the other
hand, in the chapter on the vascular system we shall
discuss the manner in which anatomical changes in
vessels, like dilatation, constriction, occlusion, embol-
ism, and thrombosis, may occasion pain in the corre-
sponding organs, and reference will be made to the
importance of functional disorders like vascular
spasm. It is therefore to be recommended always
to keep this possibility in mind in investigating
62 PAIN
attacks of abdominal pain in which the necessary
underlying factor such as mitral stenosis, or athe-
roma with cardiac insufficiency is present. It is well
to remember, however, that these are more or less
rare and that, on the other hand, circulatory disor-
ders may give rise to abdominal pain in other, even
though indirect, ways. For example, patients with
portal obstruction are prone to meteorism and may
suffer from extremely severe pain from flatulent
colic, or there may be a secondary nephrolithiasis
due to sedimentation of urine in the renal pelvis of
a congested kidney, or complications like gastric
ulcer or cholelithiasis whose development appears at
times to be favored through the congestion.
4. Acute Intestinal Stenoses, Hernias, etc. In-
testinal affections from the borderland of surgery
and internal medicine. Here we should first con-
sider the pain often suddenly arising under severe
general manifestations, spontaneously or after ab-
dominal straining, and accompanying acute interfer-
ence with the passage of intestinal contents, whether
produced by external or internal incarceration,
strangulation, volvulus, or intussusception. Where
evidence is obtained pointing in this direction, such
as increased peristalsis with severe general symp-
toms, the subjective sensation of impeded intestinal
activity, acute meteorism, etc., the most careful study
of the nature of the pain is to be recommended.
While the diffuse colic attending these conditions is
not characteristic, the search after definite local
pain phenomena may be of decisive value. It is
TOPOGRAPHY 63
above all necessary to determine exactly the region
in which the pain began, as this may at least permit
conjecture in regard to the site of the lesion. Just
as in chronic intestinal stenosis the location of the
pain sometimes corresponds to the situation of the
obstruction, the same thing may be true in acute
cases. It is of equal importance to test for local
tenderness to pressure, and in this connection the
various hernia! openings should of course be most
carefully examined.
Gall-stones or foreign bodies impacted in the in-
testine may also occasion atypical local tenderness
which is difficult to interpret. In considering hernial
pain the position of the body must be taken into
account as well as the local tenderness, since it may
determine the intensity of the trauma acting at the
moment on the contents of the hernial canal or her-
nial opening. For example, the attitude of "Atten-
tion" or bending the trunk backward frequently
gives rise to pain in cases of the extremely small
and therefore easily overlooked hernias of the linea
alba, while on leaning forward the epigastric pain,
which is frequently interpreted as due to ulcer, is
relieved. Forcible bending forward may of course
also serve to bring on the pain. Abduction and for-
cible rotation inward of the thigh usually increases
the pain of incarcerated obturator hernia.
This group of easily misinterpreted atypical ab-
dominal pains also includes the more or less painful
sensations that accompany abnormal fermentative
processes in the intestinal canal. The neuropathic
64 PAIN
constitution, enteroptosis, and the tobacco habit not
rarely furnish the underlying groundwork of this
condition. The pain often involves the flexures of
the colon, is frequently characterized by great sever-
ity and a colicky nature, and may also be accom-
panied by local tenderness. The examination of the
stools is of great importance and often reveals a
strongly acid reaction and an abnormal flora with
the presence of leptothrix-like rod forms which give
the starch reaction. The pain frequently subsides
rapidly immediately after the discharge of flatus or
feces.
CHAPTER IV.
QUALITY AND TIME OF OCCURRENCE.
COLICKY PAINS. The classification of pains from
the standpoint of their quality, as a rule, has but
little practical diagnostic value. One group stands
out distinctly, however, and that is the one compris-
ing the pain of colic. This is characterized by a
gradual onset and subsidence, that is, a wave-like
curve of intensity with summits and valleys, and by
the sensation of spasmodic contraction. The first
peculiarity is also manifested by the pain of neural-
gia, and therefore in abdominal cases the recognition
of the nature of the symptom may be attended by
considerable difficulty. In such instances the pres-
ence of the spasmodic element, as well as possible
accompanying manifestations such as active peri-
stalsis or borborygmi, may give the necessary clue.
Pathogenesis of the Pain of Colic. How does the
pain of colic originate! It occurs in regions where
there are muscular, hollow organs and is linked with
this anatomical structure. In regard to the general
pathogenesis of colic, from the purely clinical stand-
point I agree with those who explain the phenom-
enon by supposing that along the course of a muscu-
lar tube a band of spasmodic contraction approaches
another fixed contracted ring, driving before it the
contents of the organ. As a result of this there must
5 66
66 PAIN
beoverdistentionof the constantly shortening portion
lying between the two rings, and I regard this pain
of distention as being the chief factor in the mechan-
ism of the condition. It is a fact that the paroxys-
mal attacks of pain sometimes occurring in lesions of
the renal parenchyma (nephritis, tumor, etc.) as the
result of acute congestion, haemorrhage, etc., in their
qualitative shading are hardly to be distinguished
from the pains of colic. Here the distention of the
capsule is probably the only active factor. If the
stationary ring of contraction relaxes, the formerly
distended portion collapses, the tension of the wall
subsides and the contents move on. This may be
directly observed in cases of gastro-intestinal ste-
nosis. The advance of the contents is rendered evi-
dent by loud borborygmi, and with their onset the
pain usually subsides. Is the stationary contraction
ring itself a source of pain I It is a fact that cases
may be observed in which a spastic tumor at the
pylorus of an entirely empty stomach suddenly
appears under the palpating fingers, while at the
same time severe pain is felt by the patient. As the
tumor vanishes the pain also ceases. It seems out
of the question in such a case to assume the existence
of distention of the walls in view of the empty con-
dition of the stomach, and observations of this sort
appear to me to indicate that local spasm of the
nature of the ordinary sural cramp is also capable
of evoking the pain. In regard to the separate
forms of colic, the differential diagnosis, etc., refer-
ence may be made to the discussion of the individual
OCCURRENCE 67
organic pains as well as to the section on atypical
abdominal pains.
For the purposes of rapid orientation in doubtful
cases of colic it should be remembered that unilateral
tenderness of the testicle to pressure, disorders in
the evacuation of urine and in its nature, and pain on
pressure in the renal region are found in ureteral
colic. Elevation of temperature, ileocsecal pain, and
leucocytosis accompany appendicitis. The exami-
nation may also require a search for tenderness and
enlargement of the liver and gall-bladder, mesenteric
or ovarian cysts, extrauterine pregnancy, tenderness
about the hernial openings, gastro-intestinal peri-
stalsis, sarcinae in the stools and in the gastric con-
tents which occur in stenosis of the pylorus, lead line
on the gums, abnormalities of the pupillary and
patellar reflexes, glycosuria and the absence of indi-
can with peritoneal symptoms indicating pancreatic
disease, glandular masses in the neighborhood of the
solar plexus, menstrual irregularities, and cardiac
and aortic lesions pointing to angina pectoris with
epigastric localization.
The time of occurrence of the pain has differen-
tial value only if there is regularity in this, or if
there is a relationship to the ingestion of food or to
organic function. In this connection reference may
be made to what has been said above.
NOCTUKNAL PAINS. A special group is formed
by attacks of pain characterized by more or less ex-
clusively nocturnal onset. An undeniable relation-
ship in this regard is manifested by: (1) The pain
68 PAIN
of colic in general. As a physiological example
labor pains deserve the first place. With the inactiv-
ity of striped muscle there seems to be associated an
increased activity of the smooth muscle fibres, and
it may be said that at night smooth muscle is in the
ascendant. Colicky seizures of the most varied sorts
show a pronounced tendency to manifest themselves
during the midnight hours. (2) Pains due to a
dyscrasia. In this category may be included the
uraemic headaches, urasmic cramps of the calf
muscles, and gouty seizures. It seems to me natural
to assume that as a result of the diminution in
metabolic function through the absence of muscular
work and its attendant respiratory and cutaneous
activity, when a dyscrasia exists the toxaBmic curve
ascends at night and leads to nocturnal attacks of
pain. The connection between syphilis and noctur-
nal pain may accordingly be regarded only as a par-
ticular example of a connection actually having a
much deeper foundation.
CHAPTER V.
THE NERVOUS SYSTEM.
HEADACHE.
THIS designation, although it really connotes only
a topographical characteristic of the pain, is usually
employed when an organic pain is in question, that
is, cerebral pain. In order to justify the latter
assumption, it is necessary to regard the brain, to-
gether with its enveloping membranes, as an entity,
a principle that, by the way, will be found per-
fectly natural in the description of hepatic, splenic
or renal pains, etc. Paradoxical as it may seem at
the first blush to draw parallels of any sort between
organs that are so different in function and struc-
ture, it cannot be denied that the general basis of the
phenomena of pain in the organs just mentioned
possesses certain characteristics in common. Varia-
tions in the volume of the organs with the attending
tension of the capsule, and more or less independent
inflammatory processes of their enveloping mem-
branes, are important factors in the general pathol-
ogy of pain involving the organs in question. For
example, in proportion as the volume of a congested
liver diminishes under the action of digitalis its ten-
derness to pressure decreases, to reappear again
suddenly at a time when auscultation demonstrates
the onset of a perihepatitis. In this case the condi-
69
70 PAIN
tions are plainly evident, for the organ is accessible
to direct physical examination. It is different in
cases of cephalalgia, for although the ophthalmo-
scope may give valuable information, for the most
part we are confronted by the rigid bony cranium
which sets at naught our efforts in the way of physi-
cal examination. We are therefore forced to form
an opinion concerning the general mechanism of pain
from case to case, taking into consideration the modi-
fying factors and the accompanying manifestations.
Under these conditions it is hardly possible to avoid
reasoning by analogy.
FUNDAMENTAL CAUSES OF HEADACHE. The follow-
ing factors of general pathology may be grouped
as belonging to the fundamental causes of headache :
I. Mechanical factors, involving a rise in intra-
cranial pressure: (a) Chronic (new growths, hydro-
cephalus). (b) Acute. Under this heading vaso-
motor disturbances must be considered, such as
angioneurotic hydrocephalus and also interference
with the venous return, as in sinus thrombosis,
paroxysms of coughing accompanying congestion in
the superior vena cava in consequence of mediastinal
new growths, tricuspid insufficiency, etc.
II. Chemical factors: Anaemia, toxaemia, inflam-
mation.
III. Eeflex factors.
The meninges, receiving their innervation from
the trigeminal nerve, are to be regarded as the com-
mon point of attack of all these.
THE NERVOUS SYSTEM 71
I. Headache Due to Chronic or Acute Elevations
of Intracranial Pressure.
By way of preface, it may be pointed out that
increased pressure in the arterial system sometimes
occurs together with intracranial hypertension, and
may under certain conditions serve as a predisposing
factor. On the other hand, it is evident that intra-
cranial tension may also be increased in cases of
low arterial pressure.
BRAIN TUMOR AND HYDROCEPHALTJS. The ana-
tomical processes to be considered in this connection
are in the first place tumors, which may increase
cerebral pressure partly per se through the increase
in the bulk of the intracranial contents, but which
may also do this as a consequence of their relation-
ship to important channels such as the veins of Galen
or the aqueduct of Sylvius. The latter element par-
ticularly serves to explain the fact that of the intra-
cranial processes leading to headache tumors of
the posterior fossa deserve first place. Cerebral
abscesses, of course, behave in the same way. A
form of hypertension headache is caused in those
cases of acquired hydrocephalus of adults in which
the manifestations of increased cerebral pressure
arise, sometimes in stormy fashion with the symp-
toms of an infectious disease (serous meningitis), in
other cases in a more or less insidious manner, or
at least without evidences of acute infection. The
etiology of these cases of hydrocephalus running a
course like that of brain tumor is far from clear,
72 PAIN
and the assumption of the existence of chronic menin-
gitic processes is usually a mere hypothesis. Intes-
tinal processes such as constipation with acetonuria,
as well as anaemic blood changes like chlorosis, seem
to have some causative influence. The headache
arising under these conditions resembles, particu-
larly in the acute cases, the headache of acute menin-
gitis, and also, it is true, the hypertension headache
of brain tumors. The headache of acute meningitis
may also be included in this category.
POSITION OF THE HEAD. On careful observation
of such cases of hypertension headache, as I may
briefly call them, it is undeniable that the position
and motion of the head is of considerable influence
on the pain. The patient often succeeds in reducing
his suffering to a minimum by bending the head far
backward and burying it in the pillow. No doubt
this position produces a certain diminution of ten-
sion and may be compared to the midposition as-
sumed by inflamed joints. On the contrary, bending
the head forward appears to increase the pain, and
similarly, rotation of the head is often painful, the
sensation usually being experienced in the nape of
the neck and sometimes apparently on the side oppo-
site to that toward which rotation has taken place.
On lying down the patients not rarely fix the head
with the hand. Swallowing sometimes serves to
bring on pain. The patient therefore usually at-
tempts to bring the head into a certain "midposi-
tion" and to maintain it passively in this attitude
without innervation of the neck muscles. Another
THE NERVOUS SYSTEM 73
set of painful stimuli have in common the fact that
through increased heart action the blood supply to
the brain is increased but the venous return is in-
hibited. Of this description are various mechanical
factors like stooping, lifting weights, sitting up
rapidly or lying down quickly, the horizontal posi-
tion, hard straining at stool, etc. Extreme heat may
act in a similar way, and is usually not well borne.
Furthermore, various chemical stimuli of a dietetic
nature may be mentioned, such as the use of alcohol,
tobacco, coffee, tea, etc.
HEADACHE AND CONSTIPATION. Finally, I should
like- to call attention to the frequently very close re-
lationship between hypertension headache and con-
stipation. Practically this is of the greatest impor-
tance, but theoretically it is no less interesting.
When hypertension headache appears in conjunction
with constipation of long duration, for example, in
chlorotic persons, together with other symptoms of
intestinal intoxication like urticaria, acetonuria, etc.,
a causative connection immediately suggests itself,
and as a matter of fact calomel is a sovereign
remedy in these cases. I can also recall cases of
undoubted hypertension headache in cerebral tumor
in which the administration of a laxative gave
prompt relief and far surpassed the effect of the
antineuralgics prescribed. The connection between
constipation and headache is undeniable, but the ex-
planation of this is pure theory. The widely sup-
ported toxin theory seems to me to be not very satis-
factory, or at least not of itself all sufficient, in view
74 PAIN
of the extreme suddenness with which the pain often
ceases on evacuation of the bowels. In this connec-
tion the role played by intestinal peristalsis as an
accessory to the portal circulation might be thought
of as well as the interference with circulation in
the domain of the superior vena cava that results
through constipation and gas accumulation in the
abdomen, owing to the pushing upward of the
diaphragm.
TOPOGRAPHY AND ACCOMPANYING MANIFESTATIONS.
A topographical peculiarity of hypertension head-
ache appears to me to lie in its preference for the
nape of the neck, as well as in its tendency to radiate
along the spinal column, particularly in the region
between the shoulder blades. The patients fre-
quently complain of feeling "as if the head were
being split open," "as if the head would burst
open, ' ' sensations that may well be in harmony with
the underlying condition. Changes in the fundus
of the eye are particularly prominent among the
accompanying manifestations. They may be partly
of purely mechanical nature, such as dilatation of
the veins, or haemorrhages; partly inflammatory in
origin. In these cases there may be lymphatic con-
gestion with an accumulation of the products of
metabolism, and it may readily be assumed that not
only in the optic nerve but also in the trigeminal or
occipital nerves similar alterations may develop with
secondary neuralgia. Pressure points may often be
demonstrated over the distribution of the occipital
and trigeminal nerves. Hiccough, vomiting, and ab-
THE NERVOUS SYSTEM 75
normalities in pulse and respiration may be re-
garded as vagus symptoms. Not rarely symptoms
due to irritation of the optic and acoustic nerves
are observed, such as spots dancing before the eyes
or buzzing in the ears, as well as attacks of vertigo.
While the explanation on mechanical grounds of
the headache accompanying intracranial processes
that encroach on the available space is satisfactory,
the headaches caused in other ways are difficult to
understand. The thought suggests itself that the
same mechanical factor of elevation in intracranial
pressure that exists permanently and to an extreme
degree in the processes described above may also
occur intermittently and, so to speak, in rudimentary
form. Here consideration from case to case of the
mode of onset and accompanying symptoms may
serve to give the clue. For example, headache such
as occurs in persons with neurasthenic, irritable
weakness of the vasomotor system after psychical
excitement, mental exertion, straining the eyes
through reading, etc., may be explained in this way.
These are influences that, according to general
physiological conceptions, are associated with in-
creased blood supply to the organs in question, and
temporary intracranial elevations of pressure might
easily be produced, particularly if there is a condi-
tion of vasomotor ataxia induced through nicotinism.
The elevation of blood pressure which is so often
seen in neurasthenics may serve as a favoring factor,
and this condition always deserves consideration in
76 PAIN
the diagnosis and treatment of headache. In gen-
eral the neurasthenic headache is characterized by
the readiness with which it is influenced by the re-
moval of the exciting cause (mental exertion, sexual
habits, etc.).
II. Headache Caused by Chemical Poisons.
UREMIA. Albuminuric headache or the cephal-
algia caused by renal insufficiency may be taken as a
paradigm of this type, although here in addition to
the toxaemic element no doubt mechanical factors,
such as cerebral redema or hydrocephalus, together
with arterial hypertension, frequently play a not un-
important role in the pain production. The relief
to the pain that frequently follows epistaxis or
blood letting at the mastoid process may be ex-
plained on this basis. As with the headache of
hypertension, the seat of the uraemic headache is not
rarely the occipital region but in general it may be
said that there are no entirely characteristic fea-
tures, so that in every case of obstinate cephalalgia
the examination of the urine for serum albumin is
urgently demanded. The prompt effect frequently
following large doses of cerium oxalate (about
0.5 g.) is an interesting fact. It is difficult to deter-
mine to what extent the headache occurring in cases
of angiosclerosis without albuminuria depends on
arterio sclerotic renal insufficiency. Here again the
high blood pressure may come into play, as appears
to me to be shown by the relief not infrequently
afforded by an incidental nose-bleed, so that the
THE NERVOUS SYSTEM 77
advisability of producing this artificially may even
suggest itself.
LEAD POISONING AND GOUT. The basis of the
headache in chronic lead and metal poisoning in
general is probably not constant, and the same thing
is true of the uric acid diathesis and the peculiar
type of headache well known to the laity as migraine.
It is true nevertheless that Trousseau's classical
dictum, "migraine and gout are sisters," deserves
full consideration.
INFECTIOUS PKOCESSES. The relations between
infectious processes such as syphilis, malaria, tuber-
culosis, influenza, etc., and their associated head-
aches, are no less uncertain. In part, there may be
direct toxic action on the pain-conducting trigeminal
tract; in part, transitory elevations of intracranial
pressure incited through inflammatory hyperasmia
of the meninges and the intracerebral blood vessels.
This holds also for cases of suppurative or tubercu-
lous meningitis.
ANEMIA. It is undeniable that patients with
blood changes, such as chlorosis or pernicious
anaemia, not rarely suffer from headache, and it is
equally true that headache is often entirely absent
in cases of pernicious anaemia of the most severe
sort. It is hardly wise therefore to speak off-hand
of an anaemic headache. When headache is espe-
cially intense in anaemic patients, the idea of intra-
cranial rise in pressure through hydremic hydro-
cephalus suggests itself. In such cases elevating
the head is frequently of benefit, and the patients
78 PAIN
often behave in a manner similar to that discussed
under the heading of hypertension headache. Just
as hydremia appears to predispose to fluid exudates
in general, it seems sometimes to give rise to transu-
dation into the ventricles of the brain. This is not
intended to deny, however, that anaemic blood
changes may not cause headache without an inter-
mediate condition of hydrocephalus. These are
then susceptible to the same therapeutic measures
as the underlying condition and are relieved by a
more abundant blood supply, such as is caused by
lowering the head.
III. Headache of Reflex Nature.
Here irritative stimuli are concerned particu-
larly in the distribution of the trigeminal nerve
which under some circumstances may find an echo,
as it were, through radiation in the meningeal dis-
tribution of this nerve. Even in cases of restricted
localization the differentiation may be difficult be-
tween neuralgia and cephalalgia in the sense of cere-
bral pain. At any rate, in making the differential
diagnosis of headache, it is advisable not to leave
out of consideration any existing manifestations in
the distribution of the trigeminal nerve.
THE EYE, NOSE, AND EAR. This is especially
true of the eye; the combination of headache and
visual disturbances should always lead to the most
careful examination of the eye, including investiga-
tion of the tension of the eyeball, the visual field,
and examination for excavation of the optic disc.
THE NERVOUS SYSTEM 79
Furthermore, there is no doubt that other disturb-
ances such as weakness in convergence, hyperme-
tropia or presbyopia, astigmatism, etc., may furnish
the starting point of headache, especially in cases in
which a general predisposition to headache is
already supplied by other factors such as the
neuropathic constitution, disorders of nutrition,
etc. Overzealous treatment by specialists must
therefore be deprecated and the general pre-
disposing condition should receive full therapeu-
tic attention. This is equally true in regard
to the relations between headache and inflam-
matory and suppurative disease or swellings in the
nasal passages and their accessory cavities (frontal
headache in iodide coryza, etc.). Particularly con-
vincing are those cases in which months of anti-
neuralgic treatment of obstinate frontal headache
are suddenly permanently terminated by the dis-
charge of a quantity of pus through the nose. Proc-
esses in the frontal and sphenoid sinuses are of
particular significance in this connection. That the
ear should require full consideration among the
organs of special sense is evident through the pos-
sibility of otogenous cerebral abscesses, sinus
thrombosis, etc. The examination of the mastoid
process for tenderness should never be omitted.
STOMACH AND INTESTINE. Any existing gastro-
intestinal disorders (parasites, constipation, dys-
pepsia, latent cholelithiasis) must also be taken into
account. Just as cerebral processes like brain
tumors, meningitis, or migraine frequently evoke
80 PAIN
vomiting, constipation, or other secondary gastro-
intestinal disturbances, a similar influence seems to
be possible in the opposite direction also. Stag-
nation of fecal masses deserves consideration, as
has already been indicated. Even though the head-
ache may seldom be caused by constipation alone,
this often affords an important contributing cause,
the removal of which, as for example in cases of
brain tumor, may lead to an immediate and con-
siderable improvement in the pain. In women,
affections of the genital apparatus also require
careful attention.
DIFFERENTIAL DIAGNOSIS. In the differential
diagnosis of headache it is necessary first to deter-
mine the primary causes of the condition and to
determine its position in one of the three main
groups mentioned above. It is better not to label
the case at all than to resort to so inadequate a term
as "nervous headache," "habitual headache," etc.
TOPOGRAPHY. An exact inquiry into the details
of the pain frequently gives important clues in re-
gard to its causation. Localization of the pain at
the back of the head and the nape of the neck radiat-
ing downward along the spinal column between the
shoulder blades, would suggest particularly hyper-
tension headache or renal headache, if there is no
disease of the vertebral column itself or rheumatic
affection of the neck muscles (torticollis). Involve-
ment of the frontal region, on the other hand, would
direct attention to functional disorders of the eye
or diseases of the nose and nasal sinuses, particu-
THE NERVOUS SYSTEM 81
larly the frontal sinus. The depth at which the pain
is said to be situated is always of importance. Su-
perficial headache -points to trigeminal neuralgia or
rheumatic disease of the galea. A unilateral head-
ache indicates idiopathic migraine, if an appropriate
history is obtained of hereditary predisposition,
onset in youth, and typical accompanying manifesta-
tions like vomiting, scintillating scotoma, etc. If
hemicrania begins later in life, a secondary form
such as that due to tumor, nephritis, syphilis, etc.,
is suggested.
QUALITY AND INTENSITY. The quality and sever-
ity of the pain also deserve analysis. In general
the greatest intensity is exhibited by hypertension
headache, the attacks of migraine, and trigeminal
neuralgia. The quality of the pain of the first-men-
tioned type, which is often described as * ' splitting, ' '
harmonizes well with the underlying process, which
frequently no doubt involves a maximum of intra-
cranial pressure. The time of onset, too, may give
a clue. Headache appearing only by day is prob-
ably not of syphilitic o'rigin, but nocturnal increases
in intensity are also observed in non-luetic cerebral
processes, such as brain tumor or uraemia.
MODIFYING FACTORS. Most suggestive indica-
tions are generally afforded by a careful considera-
tion of the conditions under which the pain is modi-
fied. Headache primarily of psychical origin is the
most readily susceptible to psychical influences.
The greater the part played in the etiology by
mechanical factors, especially intracranial hyper-
6
82 PAIN
tension, the more will purely mechanical factors,
such as position of the head and body, movement of
the head, local bleeding, etc., have the power to in-
fluence the pain. In this connection reference may
be made to what was said above regarding hyperten-
sion headache. Palpation of the skull is always to
be recommended in order to discover any possible
pressure points corresponding to the emergence of
sensory nerves (trigeminal or occipital), syphilitic
periostitis, or rheumatic changes in the calvarium
or cranial aponeurosis. The effect of refrigeration
through draughts, cold, etc., comes in question par-
ticularly in neuralgia and rheumatic headaches or
those of extracerebral nature. Heat is frequently
badly borne in hypertension headache.
In this way the analysis of the pain itself will
frequently guide the examiner in one direction or
another, even though the diagnosis does not at once
follow. The careful and detailed general physical
examination is not to be avoided in this way, but may
be shortened. Certain tests are always to be recom-
mended for the purpose of rapid orientation :
1. Estimation of the blood pressure and of any
existing vascular changes (nephritis, angiosclerosis,
lead poisoning).
2. Pulse rate (bradycardia in tumors, hydro-
cephalus, meningitis).
3. Examination of the urine for serum albumin
and acetone. In intestinal autointoxication these
appear early, but in meningitis later.
THE NERVOUS SYSTEM 83
4. Testing the intra-ocular tension in order not
to overlook a case of glaucoma.
5. Ophthalmoscopic examination of the fundus
of the eye.
6. Testing the patellar reflex, which may be
absent in cerebellar tumors or meningitis.
7. Testing the pupils (syphilis and meningitis).
Among the cranial nerves the facial and hypo-
glossal ^deserve most attention, as slight disorders
of either of these do not give rise to complaint and
are therefore easily overlooked.
In taking the history, attention must be paid to
such accompanying manifestations as vomiting,
which suggests hypertension headache, migraine, or
glaucoma, and acute disturbances of vision indicat-
ing migraine, glaucoma, or nephritis. The matter
of preceding or still existing nasal or aural dis-
orders should also be investigated. Lacrimation
or secretory disturbances of the nasal mucosa or
salivary glands, accompanying the attacks of pain,
arouse suspicion of the existence of trigeminal
neuralgia.
NEURALGIAS INVOLVING THE GENERAL
NERVOUS SYSTEM.
Inasmuch as every stimulus requires transmis-
sion by the nerve trunks in order to be experienced
as a sensation, it at first seems rather paradoxical
to speak of "nerve pains" as a distinct variety.
Clinically, however, this term connotes the concep-
tion that the source of the pain is not to be found
84 PAIN
in the parenchyma of an organ, from which it is
transmitted to the sensorium through the special
nerve trunk belonging to the organ, but rather that
it acts upon the sensory trunk itself in its peripheral
portion. The first task of the diagnostician is to
discover, as far as possible, the seat and variety of
this cause. If this attempt is not successful the
assumption is warranted that there is present a
neuralgia in the more restricted sense; that is, a
nerve pain concerning whose etiological basis bio-
chemical information is not yet available and histo-
logical investigations will probably never enlighten
us fully. It is therefore necessary to keep in mind
that the diagnosis of neuralgia in its restricted sense
is a diagnosis by exclusion and that up to a certain
point it remains doubtful. Repeated reinvestigation
in regard to the etiology is accordingly extremely
desirable.
The point of attack of the neuralgia-producing
factor is probably in most cases to be found in the
course of the peripheral neurone. Nevertheless it
is desirable to remember that the central conducting
tracts, the medulla, pons, optic thalami, and their
surroundings, and probably also the cerebral cortex,
as well as the posterior portions of the gray matter
of the cord, may be the seat of the disease. In these
anatomical districts pain may be produced, not only
as the result of organic, but also from functional
disturbances. The neuralgias arising in hysteria,
cerebral tumors, tabes, syringomyelia, myelitis, etc.,
are probably to some extent to be interpreted as
THE NERVOUS SYSTEM 85
having a central origin of this nature. Much more
varied are the general and special factors that give
rise to neuralgias in the peripheral nervous system.
As it seems advisable to pass these in review in
every doubtful case, I wish to make at least the
attempt to arrange them in classified form.
A. DIEECT FACTORS.
1. Mechanical. These are principally pressure
effects through new growths, particularly glandular
swellings, aneurysms, inflammatory processes with
exudation in the neighborhood of nerves, hernias,
etc.
2. Thermic. This group includes the complex
of stimuli comprised under chilling, draughts, etc.,
the mode of action of which is difficult to analyze.
The underlying cause frequently lies much deeper
and the thermic stimuli have only an exciting effect.
3. Chemical Factors with Secondary Disorders
of Nutrition. Their point of attack is certainly
often indirect, involving the vascular system. Scle-
rotic and spastic conditions in the domain of
the vasa nervorum must not be forgotten in this
connection.
(a) Non-infectious exogenous toxins: Proto-
plasmic poisons of the most varied nature would be
included here, such as arsenic, lead, alcohol, nico-
tine, mercury, etc.
(b) Toxins infectious in nature: Syphilis, ma-
laria, influenza, tuberculosis, gonorrhoea, etc.
86 PAIN
(c) Dyscrasic endogenous toxins: Gout, carci-
noma, diabetes, nephritis, anaemia, adiposis dolorosa
of Dercum.
Here may best be included also those local dis-
turbances of metabolism that underlie the so-called
occupation neuralgias which result from the exces-
sive use of certain nerve tracts. Furthermore the
attacks of pain involving the distal portions of the
extremities and accompanied by vasomotor disturb-
ances, such as erythromelalgia, Raynaud's disease,
etc.
B. EEFLEX FACTORS.
The. stagnation of fecal masses, intestinal para-
sites, various visceral disorders involving the heart,
gall-bladder, genital apparatus, kidney, etc., may be
concerned in the causation of neuralgias, and it is
natural to assume a reflex element under these con-
ditions. On the other hand, neuralgias in certain
nerve tracts may incite neuralgias elsewhere as
through the sympathetic vibrations of musical
strings.
How is A NEURALGIA TO BE RECOGNIZED? As re-
gards the diagnosis of neuralgias as such, the recog-
nition of the fact that a pain corresponds topo-
graphically to a peripheral sensory nerve tract, and
like this exhibits a linear rather than a diffuse dis-
tribution, is frequently sufficient to establish the
nature of the case. Naturally it is not enough to
determine only the spatial limits of the spontaneous
pain, but the presence of painful pressure points
should also be sought for. This is the more impor-
THE NERVOUS SYSTEM 87
tant since in this way latent neuralgic conditions
not manifesting themselves spontaneously may be
detected for example, the tenderness to pressure
of the brachial plexus on the left or both, sides in
angina pectoris. The pressure points usually corre-
spond to those portions of the nerves which are sub-
ject to trauma through their superficial position, a
firm or bony substructure, etc., but as these are not
constant there is little wisdom in overloading the
memory with ballast of this nature and anatomical
knowledge is the best guide. In addition to the me-
chanical factor of pressure, traction may be used
for evoking the pain experimentally. This is true
for the trigeminal nerve (movement of the lower
jaw), the occipitalis major (rotation of the head),
and the sciatic nerve (flexion at the hip joint with ex-
tended knee) . The susceptibility to influence in this
way may also, however, lead to confusion with
muscle, joint, or bone pains, and caution is necessary
in interpreting the results. The anatomical unity
of the pain may be entirely upset through the in-
volvement of bone, periosteum, muscle, and joint
nerves in the neuralgic process, and these possibili-
ties must always be reckoned with. Paroxysmal
onset (frequently at night) is a common characteris-
tic of neuralgic pains. At any rate, the mere fact
of nocturnal occurrence does not justify the con-
clusion that syphilis is the underlying factor,
although in general the absence of nightly exacerba-
tions may be used with some probability as being
against syphilis. The periodical onset of the pain
88 PAIN
and its relief by quinine may find its explanation in
the malarial nature of the neuralgia, but this is not
necessarily so.
SITE OF THE LESION, WHETHER CENTRAL OB
PERIPHERAL. After a painful condition has been
identified as a neuralgia, it is always necessary to
determine the" site of the lesion. The possibility of
cerebrospinal localization (brain tumor, tabes,
syringomyelia, syphilitic spinal meningitis, etc.)
must always be thought of, and the reflexes and
possible disorders of motility, like flaccid or spastic
paralysis, ataxia, vesical or rectal disturbances,
should be considered. After determining the
peripheral character of the neuralgia the question
of etiology arises, and in regard to this reference
may be made to the classification given above. It
is of the greatest practical importance not to over-
look a beginning new growth, to think of the possi-
bility of cardiac or aortic lesions, and to guard
against failure to recognize some dyscrasic factor
by careful examination of the urine. The possi-
bility of reflex origin must also always be given due
weight.
THE FACE.
In order to determine the causative factor in
cases of trigeminal neuralgia, the course of the
nerve from the Gasserian ganglion onward should
always be kept in mind, so that such conditions as
tumors of the nerve itself, aneurysms of the internal
carotid, destructive processes of the meninges and
at the base of the skull, like tuberculosis, syphilis,
THE NERVOUS SYSTEM 89
carcinoma, actinomycosis, etc., may not be over-
looked. The distribution of the nerve must also
be considered and the processes in the. eye, teeth,
alveolar cavities, nose, ear, etc., that may come in
question. In infectious processes the discovery of
pronounced tenderness at the- point of emergence
of the supra-orbital nerve suggests influenza, typhoid
fever, or malaria. Under these conditions, however,
as well as in meningitis, it should not be forgotten
that the pain on pressure may be only a part of the
general hypersBsthesia. Of the reflex etiological
factors, reference may be made particularly to the
stagnation of fecal masses and disorders of the
female genital system. There is no doubt that at
times, as in cases of headache, a laxative is the best
antineuralgic remedy. Similar conditions also ob-
tain, both in trigeminal neuralgia and in headache,
in regard to the general pathological conditions, as
is not surprising when one considers that the dura
mater is supplied in part by the trigeminal nerve.
The underlying conditions that give rise to the
symptom complex of angina pectoris must also be
counted among the reflex visceral factors. It is
true, however, that isolated trigeminal neuralgia is
unusual under these circumstances, although unilat-
eral radiation in the districts of the third and second
branches, with pain in the teeth, is not of excep-
tional rarity. It seems to me that there is a possi-
bility of the radiation occurring through the vascu-
lar channels, perhaps owing to spasmodic conditions
due to the sclerosis.
90 PAIN
THE OCCIPITAL REGION AND NAPE OF THE NECK.
Of the sensory tracts supplying this region there
may be mentioned, toward the midline the occipitalis
major, more laterally the occipitalis minor, and still
further outward supplying the posterior surface of
the ear, the auricularis magnus. Diseases of the
vertebral column and of the meninges of the cervical
portion of the cord have a particular etiological
bearing. Since the second cervical nerve whose
posterior branches, as the occipitalis major nerve,
supply sensory filaments to the skin of the occipital
region passes between the atlas and axis, the occur-
rence of mechanical injuries in this region may be
readily understood through the great mobility of
the parts. At the same time, the fact is explained
that neuralgia of this region may restrict the move-
ments of the head, although the muscles and joints
themselves are not involved. Neuralgias in this
situation are probably also caused mechanically in
cases of elevation of the intracranial pressure, espe-
cially when due to processes encroaching on the pos-
terior cerebral fossa, as in hydrocephalus following
serous meningitis (Quincke) or due to chlorosis or
tumors of the posterior fossa.
Of the visceral diseases chronic nephritis seems
to me to be particularly prone to give rise to
occipital neuralgia, perhaps through intracranial
elevations of pressure. In addition, glandular proc-
esses (lymphosarcoma) and more rarely aneurys-
mal dilatations of the vertebral artery may come
in question.
THE NERVOUS SYSTEM 91
THE ARM.
The neuralgias occurring in the brachial plexus
and involving especially the ulnar and radial dis-
tricts, may be caused either through direct or reflex
factors.
1. Direct Causation. In addition to spinal dis-
orders like tabes, syringomyelia, etc., one should
think of vertebral disease, supraclavicular or axil-
lary compression by glands, aneurysmal dilatations
of the subclavian or innominate arteries, and the
presence of cervical ribs. The brachial plexus may
also be directly involved in cases of inflammatory
processes or malignant growths of the apical pleura,
and in this way spontaneous brachial neuralgia
or at least tenderness of the plexus may result.
I have formerly directed attention to this symptom
of "unilateral plexus tenderness" in incipient
phthisis, and have frequently made use of it to
good advantage. Abnormal exhaustion of the nerve
tracts through local overexertion, as in piano play-
ing, must also be kept in mind.
2. Reflex Causation. The neuralgic conditions
of the brachial plexus, whether spontaneously pain-
ful or existing only as a latent neuralgia manifest-
ing itself by tenderness on pressure, may overstep
the purely neurological limits since they not rarely
are accompanying evidences of visceral lesions.
Sometimes, though less often, they present a certain
degree of independence, or may be accompanied by
mild motor manifestations of a paretic or spasmodic
92 PAIN
nature. A neuropathic constitution undoubtedly
affords a favorable soil for radiations of this sort.
The thoracic viscera, particularly the heart, peri-
cardium, and large vessels, as well as the diaphragm
and the abdominal organs coming in contact with it,
are likely to be concerned in this way. The side of
the organic lesion then usually corresponds to the
side of the plexus neuralgia. There is no doubt that
the phrenic nerve is the reflex tract in many such
cases, and therefore tenderness over the third and
fourth spinous processes should always be looked
for.
Particular emphasis may be laid on the fact that
sometimes spontaneous pain may be absent while
the pressure tenderness is constant, as in angina
pectoris or perisplenitis. In discussing the separate
organic pains, these reflex arm and shoulder neural-
gias will be explained in detail, and in order to
avoid repetition reference is made to the sections
in question.
INTERCOSTAL SPACES, INCLUDING THE UPPER ABDOMEN.
The intercostal nerves, whose lower branches
send sensory fibres also to the upper portion of the
abdominal wall, very frequently cause spontaneous
pain, but still more often occasion tenderness to
pressure. In addition to localized central processes
like spondylitis, tabes, syringomyelia, etc., it is espe-
cially internal diseases that are accompanied by
either tenderness or spontaneous pain in the regions
supplied by the intercostal nerves.
THE NERVOUS SYSTEM 93
Diseases of the lung, and particularly of its
pleural covering, deserve first place in this connec-
tion. In nearly all cases of pneumonia and pleurisy
the intercostal spaces are sensitive to pressure, nota-
bly in the axillary region, although it must remain
an open question whether the tenderness does not
depend on direct mechanical trauma to the inflamed
pleura and whether there may not also coexist an
inflammatory condition of the intercostal muscula-
ture transmitted through the lymphatics. It is sug-
gestive that the tenderness in cases of pulmonary
infarct and tuberculosis frequently corresponds ex-
actly to the site of the infarct or infiltration, and
shows no relation to the usual pressure points of
intercostal neuralgia. Suppurative pleural exu-
dates are likely to be accompanied by special
tenderness, while pleural processes accompanied
by contraction only rarely give rise to severe
neuralgias.
Diseases of the circulatory apparatus, such as
mitral stenosis, are frequent causes of intercostal
neuralgia. Usually the pain is located on the left
side in the neighborhood of the apex beat. The
mode of origin of intercostal neuralgia in dilatation
of the aorta and mediastinal new growths demands
no explanation; no doubt in addition to direct
trauma reflex stimuli also come into question just
as for the brachial plexus, especially for the upper
intercostal spaces. The aneurysmal neuralgias of
direct causation are not rarely characterized by
dependence on exercise and position, owing to
94 PAIN
stronger pulsation of or dislocation of the sac. Dis-
eases of the subdiaphragmatic organs like choleli-
thiasis, perihepatitis, pyloric ulcer, and perisple-
nitis are also prone to cause tenderness of the axil-
lary portions of the lower intercostal spaces on the
corresponding side. If the liver or spleen is in-
volved the area of tenderness often coincides with
the dulness, and this may be of diagnostic impor-
tance. Here, no doubt, reflex stimuli are concerned
similar to those causing the hypersesthesia of cer-
tain spinous processes that is frequently also
present. In pyloric ulcer and cholelithiasis this
tenderness to pressure and percussion often occurs
over the twelfth thoracic vertebra. In cases of sud-
den intense intercostal neuralgia the imminent
onset of herpes zoster should be thought of.
THE FLANKS AND LOWER ABDOMINAL REGION.
Leaving aside the neuralgias of spinal origin
which have already been spoken of several times,
idiopathic conditions of this sort are rare in the
present regions. Of the intra-abdominal causes,
retroperitoneal processes such as glandular masses,
aneurysm of the abdominal aorta, and renal diseases
at once suggest themselves. The renal causes in-
clude tumors pressing on the nerve trunks passing
over the posterior surface of the organ, inflamma-
tory and suppurative processes, or perinephritic
cicatrization following infarct, etc.
Another etiological factor is formed by hernias
which may induce neuralgia through pressure along
the hernial canal.
THE NERVOUS SYSTEM 95
LOWER EXTREMITIES.
1. Anteriorly and Internally (Crural Nerve).
Pain of the same linear distribution as that of neu-
ralgia may sometimes be caused by phlebitic proc-
esses in the internal saphenous vein. It may also
be the result of femoral hernia and may stand in
relation to diseases of the kidney such as nephro-
lithiasis, and of the appendix. Beyond this, refer-
ence may be made to the general underlying causes
of neuralgic pain (v. classification on page 85).
2. Externally. The neuralgias occurring in the
district of the external cutaneous nerve, and there-
fore involving the external and posterior surface
of the thigh from the iliac crest to the knee, are not
usually founded on causative factors specific for the
locality. The etiological possibilities coincide with
those of neuralgia in general, and therefore include
trauma, gout, syphilis, tabes, pernicious anaemia, etc.
As the nerve traverses a fibrous canal in the fascia
lata of the thigh, it is not astonishing that tension of
this structure, such as is caused on standing or
walking, easily produces exacerbations of the pain,
whereas rest brings relief.
3. Internally. Neuralgias involving the* region
of the adductors of the thigh always suggest the
presence of a possibly incarcerated obturator hernia,
especially if the thigh cannot be approached to the
midline.
4. Posteriorly. (The sciatic plexus.) The pain
that is principally concerned under this heading is
linear in distribution and often extends down the
96 PAIN
entire posterior side of the lower extremity. Even
the laity usually interpret this correctly as a " nerve
pain." If there is in addition tenderness over the
course of the nerve and pain on stretching it by
forcible flexion at the hip with extended knee, there
is little room for doubt. Diseases of the hip joint
differ in that flexion of the hip is painful even when
the knee is kept flexed. It is the duty of the
physician not to rest content with the diagnosis of
sciatica, which may already have been made by the
patient, but to investigate the particular source of
the trouble, and here as in neuralgias in general I
think that I may formulate the rule: If nothing is
found, search further. The scheme of causes given
above may serve to aid in the general task of orien-
tation. Examination of the rectum and vagina
should never be omitted in order that any possible
pelvic lesions, such as new growths of the intestine
or pelvic bones, may be detected, and the patient's
general condition (emaciation, etc.) should be care-
fully considered.
The degree of fulness of the rectum should also
be taken into account; there is no doubt that a
connection exists between fecal stagnation and pain
in the sciatic plexus, though it is difficult to ex-
press an opinion in regard to the details of the
relationship. Usually the condition is merely a pre-
disposing and not a causative factor. Before decid-
ing to accept the assumption of a purely mechanical
direct action of fecal masses on the nerve plexus, it
is advisable to think of the association that may
THE NERVOUS SYSTEM 97
exist between headache or trigeminal neuralgia and
constipation, and of the fact that fecal accumula-
tions probably also serve to increase pain through
the interference with venous return (vasa ner-
vorum). The possible existence of external or inter-
nal varicosities (involving the nerve sheath) with
phlebitic or thrombotic processes must always be
thought of. In this respect conditions are of course
much more unfavorable in the lower extremities
than in the upper. Bilateral pain always suggests
median lesions involving the vertebral column or
spinal cord, or diffuse dyscrasic disorders like dia-
betes. Pain of maximum intensity that is refrac-
tory to all treatment sometimes is encountered in
tumors of the cauda equina. A careful examination
of the nervous system, with special attention to the
tendon reflexes of the lower extremities, bladder dis-
turbances, atrophies, etc., should never be omitted.
NEURALGIAS INVOLVING THE SYMPATHETIC
SYSTEM AND THE VAGUS.
A priori the assumption suggests itself that the
neuralgic manifestations just described for the
cerebrospinal system may also, in the presence of
the corresponding etiological factors, occur in the
separate portions of the sympathetic system and the
viscera supplied by it. This view is fully confirmed
by the clinical observations. The task of correctly
interpreting visceral neuralgias of this sort is, of
course, much more difficult. In this case one is deal-
ing not with the anatomically distinct, simply con-
7
98 PAIN
stmcted, and directly accessible nerve tracts of the
cerebrospinal nervous system, but with plexuses and
groups of ganglia for the most part inaccessible to
physical examination. The problem is further com-
plicated by the fact that the separate networks have
as end stations organs like the stomach, intestine,
ureter, genitals, etc., in which painful lesions may
originate primarily. Theoretically three possibili-
ties may be_ considered and in practice these are
shown to be well founded.
(a) Simple Neuralgia. The pain-producing
process is a neuralgic condition in one of the im-
portant tracts of the vegetative nervous system, and
the corresponding organ is anatomically intact.
Gastric crises may be regarded as an example of
this sort and a pendant in the province of the
cerebrospinal system would be neuralgia of the sec-
ond and third branches of the trigeminal nerve
without any disease of the teeth.
(b) Simple Organic Pain. The pain has exactly
the same character in regard to localization, quality,
accompanying manifestations, etc., but is the result
of an anatomical or functional disorder of the organ
itself. As a paradigm reference may be made to
the pain of gastric ulcer. Recently an attempt has
been made to argue away the existence of stomach
pains as such and to regard the cause of every
gastric pain as being a sympathetic neuralgia. This
is entirely inadmissible and in opposition to the facts
of clinical observation. One has only to think of
the stomach-ache that is promptly checked by a dose
THE NERVOUS SYSTEM 99
of alkali or by the administration of local anaes-
thetics such as anaesthesin or cocaine. The same
thing is true of pyloric stenosis, and the explanation
offered by the advocates of the theory just men-
tioned to the effect that the sympathetic nerves are
compressed by the distended stomach is extremely
improbable. The existence of true gastralgia, re-
sulting from purely local anatomical and functional
disturbances, is as certain as the occurrence of pain
in dental caries.
(c) Mixed Forms. I believe that a combined
form of visceral pain is not at all rare in which both
the sensory-conducting tract and the organ in ques-
tion play a distinct role in the causation of the pain ;
as an example, trigeminal neuralgia and painful
dental caries may be mentioned. Such a combined
origin of pain in the sympathetic and vagus districts
is probably commoner than is ordinarily supposed,
particularly in neuropathic individuals. It is con-
ceivable that the anatomically or functionally active
organic process might arise only secondarily as the
result of atrophic disturbance due to a primary
neuralgic condition, but the reverse is also probable,
as well as coincident causation. When such mixed
forms of visceral neuralgia are in question, it is
clear that, to continue the example chosen above,
the extraction of the decaying tooth may bring relief
commensurate with its component of painful sen-
sation, but the pain will continue as long as the
neuralgic condition of the trigeminus does not im-
prove. In the same way, in other cases of mixed
100 PAIN
form, the same attacks of pain may recur after the
removal of gallstones or the treatment of a pyloric
stenosis by gastro-enterostomy. Through exact
analysis of the conditions, as well as the study of
the psychical make-up of the patient, it is possible
from case to case to interpret these mixed forms
correctly and to determine approximately the rela-
tive proportions of the two components. The prog-
nostic and therapeutic importance of an analysis of
this sort is self-evident.
ETIOLOGY. As far as the etiological sources of
the visceral neuralgias are concerned it may be said
that there is a far-going, deep-seated correspondence
between the cerebrospinal and sympathetic nervous
systems. In this connection reference may be made
to the scheme of causes given above as well as to the
section on gastralgia.
HOW MAY A VlSCEEAL NEUKALGIA BE EECOGNIZED?
The diagnosis of a visceral neuralgia is probably
one of the most difficult of differential problems and
can never be made with absolute certainty, as it is
nearly always a diagnosis by exclusion. For ex-
ample, what is known concerning the positive symp-
toms of a neuralgia of the cosliac plexus is so inade-
quate and so vague that a conscientious clinician
would never venture to make this diagnosis directly.
The cause of pain induced by deep pressure over the
abdomen is difficult to determine. Whoever is
anxious to discover tenderness to pressure of the
sympathetic fibres or of the solar plexus will usually
succeed in doing so ! If the psychical equilibrium is
THE NERVOUS SYSTEM 101
intact, there is no neuropathic tendency, and etiologi-
cal factors of the variety in question are absent, one
should be very reluctant to think of a visceral neural-
gia. But in this neurasthenic age cases that comply
with these requirements are very rare, while on the
other hand, even serious nervous disturbances do not
exclude the possibility of an organic lesion as the
basis of the pain, the more so as they may be second-
ary. The important general rule of unity of etiology
in disease is open to many exceptions in. this prov-
ince, and painful states due to a combination of
functional and anatomical components are certainly
very numerous.
TOPOGRAPHY. The topography of the pain usu-
ally has no differential significance. The distri-
bution of the pain in a neuralgia of the ureter de-
pending on chronic lead poisoning is the same as that
caused by the passage of a concretion, and hysteri-
cal angina pectoris radiates in the same way as the
true organic type. Essential gastralgias, it is true,
are rarely asymmetrical in their localization, in con-
trast to the pain of ulcer and pyloric stenosis, and
this is particularly true of the tenderness to pres-
sure. Gastric crises, however, with their tendency
to a left-sided localization, at least so far as the
spontaneous pain is concerned, form an exception
to the rule.
MODIFYING FACTORS. A careful study of these is
always of great importance. Whenever reflex in-
volvement is evident, as, for example, in cases of
gastric pain at the time of menstruation, it is per-
102 PAIN
missible to think of a simple visceral neuralgia, but
it should not be forgotten that the pain of ulcer or
biliary and appendicular colic may be induced
through the profoundly disturbing process of men-
struation. In general, it may be regarded as posi-
tive evidence of the existence of a pronounced func-
tional component if a sedative regime comprising
general hygiene and psychical rest, the diversion of
the attention, and administration of quieting drugs
like the bromides or valerian, has a notable and per-
sistent effect on the intensity and frequency of the
pain. On the other hand, it is fair to assume a
prominent local component when purely topical
treatment like the administration of alkali in gastric
pain is promptly effective. Serious consideration
must be accorded to mechanical factors and their
effect. If a given position of the body always causes
prompt increase in the pain, it is natural to think
of a localized anatomical lesion of the organ in
question (cf. p. 22). The most exhaustive physical
and functional examination of the organ that appar-
ently is involved and the consideration of its secre-
tions or excretions is of course of the greatest
importance in reaching a decision.
CHAPTER VI.
ORGANS OF MOTION.
I. JOINT PAINS OR ARTHRALGIAS.
TOPOGRAPHY. In view of the clearness of the
topographical relations and the ease of accurate
functional examination, it is ordinarily not difficult
to identify an arthralgia as such. Only when the
joints concerned are difficult of access, like those of
the vertebral column or of the sacro-iliac synchon-
drosis, or are abnormal (manubrium-corpus), are
difficulties to be expected. Sometimes, however, the
topographical considerations themselves may lead
astray, as an illustration of which may be cited the
pain in the knee that so often precedes coxitis in
young persons. On the other hand, it is always our
duty not to remain satisfied with the general diag-
nosis of arthralgia but to determine which anatomi-
cal component of the articulation is the seat of the
pain. Accordingly, the articular extremities of the
bones, the fibrous capsule, the neighboring tendons
and tendon sheaths, and adjoining muscles must all
be tested as regards painfulness. The examination
must include all structures standing in anatomical
relationship to the joint capsule, such, for example,
as burssB, nerve trunks, vessels, or fibromas in the
subcutaneous tissues. It is also necessary to distin-
guish between deep-seated and superficial pain.
Functional arthralgias of the sort that sometimes
103
104 PAIN
occur in neuropathic individuals are not rarely ac-
companied by marked cutaneous hyperaesthesia with-
out deep-seated tenderness, so that in functional
coxalgia forcible pressure of the head of the femur
against the acetabulum is easily borne, although
even gentle touching of the skin gives rise to pain.
In general it may be said that arthralgias do not
radiate. The necessary conducting tracts are want-
ing, a condition in contrast to the joint pains of
neuralgic origin, such as the shoulder pain of angina
pectoris. An exception to this rule is formed by
coxalgia; in this the pain may radiate down the
thigh toward the knee. The same thing is true for
the ankle joint in flat foot. In other articular
conditions radiation is generally to be expected only
in cases of neuritic or spinal complications, such as
tabes or syringomyelia, or if the pain is purely
functional in nature.
INTENSITY. Assuming a normal nervous system,
the severity of the pain seems to depend on the
degree of acuteness in onset as well as the intensity
of the inflammatory process, and therefore many
cases of acute polyarthritis, gonorrhoeal joint affec-
tions, and gout are highly painful. When the ner-
vous system is in a state of hypersensitiveness
(hysteria) a disproportion may be observed between
the objective conditions and the subjective sensa-
tions, but this by itself may not be sufficient to ex-
clude the organic nature of the affection. Where,
however, the pain-conducting tract is damaged, as in
tabes and syringomyelia, one must be prepared to en-
ORGANS OF MOTION 105
counter very slight degrees of pain or even the total
absence of this symptom in spite of anatomical
changes of considerable extent, and this discrepancy
may direct the attention into the proper channel.
KELATIONS IN REGARD TO TIME. The relation of
joint pains to time can be made use of only with
great caution in differential diagnosis. The occur-
rence of nocturnal exacerbations is frequently
pointed out in cases depending on syphilis in the
secondary or tertiary stages. The absence of noc-
turnal increase may in general render syphilis less
likely, but its presence is far from rare in non-
syphilitic conditions also, and may occur often
enough in cases of ordinary acute polyarthritis and
especially in gouty arthralgias. Only the functional
arthralgias of neuropathic nature seem never to be
accompanied by nocturnal increase in pain. The
occurrence of arthralgias during pregnancy or in the
puerperium always suggests gonorrhoea (lighting up
of old foci) or sepsis.
MODIFYING FACTORS. Among the most important
characteristics of a joint pain is its susceptibility
to mechanical influences. These may vary in nature,
and the two most important are (1) pressure in the
neighborhood of the joint (effect on the bone ends,
capsule, etc.) ; (2) active and passive motion.
1. In examining joints, particularly when the
larger ones are involved, one should never omit to
investigate the possibility of a bone process, such
as tuberculosis, syphilis, or osteomyelitis, as the
underlying cause of the joint affection, and for this
106 PAIN
purpose the articular extremities of the bones should
be carefully palpated and be pressed against each
other. No less care should be used in examining
the fibrous capsule and tendon sheath.
2. The production of pain through active and
passive motion is of course one of the chief evidences
of an arthralgia. It should be remembered, how-
ever, that motion of a joint may also give rise to pain
through traction on inflamed muscles, nerve trunks,
or vessels (e.g., the shoulder pain in aortalgia) with-
out there being any lesion of the articulation itself.
If, however, even slow motion of very slight extent
causes pain the diagnosis of arthralgia receives
greater justification. These are cases in which im-
mobilization of the joint is the best analgesic, but in
functional arthralgias fixation is very badly borne.
This fact may be of differential diagnostic value as
well as the noteworthy difference between superficial
and deep tenderness. The mechanical factor of
trauma may be the inciting agent of both functional
and organic arthralgias.
THERAPEUTIC INFLUENCES. The mechanical fac-
tors are supplemented in their action by chemical
agents. This is especially the case from the thera-
peutic standpoint, but may also be made use of in
differential diagnosis. Only in exceptional cases are
gonorrhoeal joint affections and the arthralgias of
rheumatoid arthritis and gout favorably influenced
by the salicylates. Mercury and iodine again
are particularly effective in cases of syphilitic
arthralgias.
ORGANS OF MOTION 107
ACCOMPANYING MANIFESTATIONS. Not rarely the
pain may be practically the only manifestation of
the joint affection, and this is not exclusively the
case in functional arthralgias, but may occur in
organic lesions. The harmful agents attacking the
joints may also invade the muscular and nervous
systems (neuritis), and such complications must be
thought of in testing for tenderness on pressure.
Possible involvement of the bones, as in syphilitic
periostitis, the growth of osteophytes, erosion of the
articular surfaces, etc., must be thought of. Where
fever is an accompanying symptom the bacteriologi-
cal cause of this should be determined if possible and
efforts be made to discover the primary focus of in-
fection. This may be sought for in the tonsils, acces-
sory nasal cavities, the middle ear, the urethra, pros-
tate, parametrium, etc. Particular attention should
of course also be given to endo-, peri- and myocardial
changes.
ETIOLOGY. In the foregoing the recognition of
an arthralgia as such has been discussed, and from
a consideration of the facts elicited in this way much
light will often be thrown on the etiology of the
process. A definite conclusion in this regard can
of course be arrived at only from a complete investi-
gation of the disease process. To begin with, the
adoption of the following classification is suggested :
1. Arthralgias of infectious origin: a, acute; b,
chronic.
2. Arthralgias due to disorders of metabolism.
3. Arthralgias of neurogenous nature.
108 PAIN
1. The streptococci require special consideration
under this head as the inciters of the ordinary acute
polyarthritis, or of sepsis. Other organisms of
importance are gonococci and the pus-producing
cocci in general (staphylococci, diplococci, and men-
ingococci), and of less frequent occurrence ex-
cepting the tubercle bacillus bacilli such as 'those
of typhoid fever, dysentery, leprosy, and influenza.
Diseases like scarlatina, variola, parotitis, and
syphilis are also to be thought of in this connection.
2. Under this heading are grouped the arthri-
tides of the uratic diathesis and its variants, the
arthritis of lead poisoning, and the joint processes
sometimes accompanying psoriasis, as well as many
cases of chronic polyarthritis, although in these the
possibility of an infectious etiology must always be
kept in mind. The cases of intermittent hydrops of
the knee and the joint conditions of haemophilia may
also be included in this class. The position of
arthritis deformans is not yet clear.
3. The arthralgias of neurogenic nature, such as
those of tabes and syringomyelia are ordinarily char-
acterized by slight intensity which may diminish to
almost nothing. They therefore offer a striking con-
trast to the arthralgias sometimes occurring in
neuropathic individuals and forming an articular
manifestation of hysteria.
II. MUSCULAR PAINS OR MYALGIAS.
Tenderness on pressure over a muscle and pain
whick is increased on passive stretching or active
contraction, form the most important indications for
ORGANS OF MOTION 109
the diagnosis of a myalgia. In dealing with the
extremities and with the musculature of the head and
neck the problem does not ordinarily present great
difficulties, providing that there are no painful in-
flammatory conditions of the overlying skin and
subcutaneous tissues.
SOUBCES OF ERROK. It is hardly necessary to
point out how puzzling it may be to interpret cor-
rectly pain in the region of the diaphragm. Diffi-
culties may also be encountered in investigating the
musculature of the chest, the back, and abdomen,
since functional examination may not give satisfac-
tory results or may be hard to carry out, and the
pain on pressure may be referable to underlying
organs. In this regard it is important, particularly
in dealing with the abdominal muscles, to ascertain
whether, when the muscle is in a state of contraction,
it is equally or even more tender. If the sensitive
point is situated beneath the muscles a decrease or
disappearance of the tenderness may be expected,
as the contracted muscle yields but little to the pres-
sure. Reference may also be made at this point to
the myalgias frequently occurring in laborers
through muscular fatigue or the effects of exposure.
These are particularly frequent in the thoracic
muscles, and as the pain is increased by respiration
owing to the functions of the muscles involved, sus-
picion of pleural processes is easily aroused. In
these cases it is important if possible to raise _the
muscle from its underlying structures and test it for
tenderness by taking it between two fingers. In gen-
110 PAIN
eral the tenderness is increased when the muscle is
contracted. I should also like to call attention to the
tenderness of the abdominal muscles, particularly
in the epigastrium, which is not uncommon after
severe protracted coughing, as in phthisis. If there
happen to be at the same time abdominal symptoms
such as gastric disorders, diarrhoea, etc., confusion
may easily arise and the pain of gastric ulcer or
peritoneal irritation be thought of. The same thing
is true in regard to myalgia coming on acutely after
the lifting of heavy loads, which may persist for
months. In cases in which the diseased muscle be-
longs to the deeper layers, e.g., the deep muscles
of the neck, diagnostic difficulties may present them-
selves, and there is danger of confounding the con-
dition with a bone lesion.
GENERAL, PATHOLOGY AND ETIOLOGY. In discuss-
ing the general pathology of muscular pain, the fact
must be emphasized that the chief site of the sensa-
tion is probably to be found less in the parenchyma
than in the connective tissue framework. This is
most highly developed in the tendons and aponeu-
roses, and the pain may extend to these, so that in
considering the myalgias these structures must also
be taken into account. The pain of cramp, such as
that of the calves of the legs, is etiologically among
the most easy to understand. In this the purely
mechanical factor of pressure is concerned, a form
of pain mechanism that is also encountered in organs
composed of unstriped muscular fibre, like the intes-
tine and uterus. Otherwise inflammatory processes
ORGANS OF MOTION 111
are the most fundamental causes of myalgias, both
those of endogenous nature due to disorders of
metabolism and those of exogenous origin depending
on toxins in general, and especially those of bacterial
nature. The myalgias that are more or less physio-
logical in nature and follow over-exertion through the
accumulation of fatigue toxins may also be grouped
in the class of endogenous origin. It must always be
taken into account that the real cause of the myalgia
may be found extramuscularly in a primary painful
affection of the peripheral nervous system, such as
neuritis, provided that sensory intramuscular fibres
are involved; an example of this is the tenderness
to pressure of the calves of the legs of drunkards.
MODIFYING FACTOES. As has already been
pointed out tenderness is an important aid in the
diagnosis of myalgia. It must be ascertained
whether this symptom is locally limited or is diffuse
throughout the muscle and tendon. Local lesions
such as traumatic or spontaneous haematomas,
abscesses, tubercles, gummas, muscular cicatrices,
echinococcus cysts, new growths, etc., frequently are
characterized by local tenderness. Where the mus-
cular inflammation is diffuse, as the result of infec-
tion or through causes of a general type, the tender-
ness will also be diffuse in nature. Such a condition
might be due to infection with the pus-producing
cocci, acute infectious polyarthritis, typhoid fever,
influenza or gonorrhoea. Other processes that may
be mentioned are intestinal autointoxication, Unver-
richt's dermatomyositis, haemorrhagic myositis, and
1 12 PAIN
parasitic diseases, especially trichinosis. In contra-
distinction to the neuralgias spontaneous exacerba-
tions of pain are very rare ; the symptom is caused
through pressure, or active and passive motion. Of
other modifying influences climatic conditions such
as dampness, draughts, etc., may be mentioned, par-
ticularly in connection with myalgias localized in the
muscles of the shoulder, neck, and lumbar region.
If the process is situated in the muscles of respira-
tion the movements of deep breathing, coughing,
sneezing, defecation, etc., give rise to pain. The
same is true of swallowing if the muscles of deglu-
tition are involved. Of therapeutic influences men-
tion may be made especially of the effect of salicy-
lates and preparations of iodine and mercury.
ETIOLOGY. Owing to the great variety of the proc-
esses giving rise to myalgias, it is difficult to
arrange them in a scheme of classification. The
distinction of most service in differentiation is be-
tween, on the one hand, the type running its course
as a local and afebrile condition, and on the other,
the type diffuse in nature and presenting the picture
of a severe infectious disease.
1. MUSCULAK AFFECTIONS CHIEFLY LOCAL IN NATUKE.
Traumatic hasmatomas and hernias of muscle
(the adductor group) ; haematomas following pre-
ceding vascular damage (typhoid fever, sepsis,
phosphorus poisoning, arsenic poisoning, jaundice,
etc.) ; rheumatic affections due to cold, for ex-
ample, in the shoulder or lumbar aponeurosis ; mus-
ORGANS OF MOTION 113
cular cicatrices following fibrous myositis through
local venous thrombosis, for example, deep-seated
varicosities in the muscles of the calves; atheroma
of the muscular arteries (intermittent claudication) ;
muscular abscesses and infarcts, gummas, tubercles,
echinococcus cysts, new growths.
2. MUSCULAR AFFECTIONS CHIEFLY DIFFUSE IN
NATUKE.
1. In general infectious processes through pus
organisms, acute articular rheumatism, typhoid
fever, influenza, syphilis, etc., Unverricht's der-
matomyositis, haemorrhagic polymyositis, acute
delirium.
2. In constitutional disorders, such as the rheu-
matic diathesis and ossifying myositis. The latter
is unlikely after the twentieth year.
3. In parasitic diseases, particularly trichinosis.
4. Periarteritis nodosa. This is most often seen
between the twentieth and thirtieth years.
DIFFERENTIAL DIAGNOSIS. As has already been
pointed out the diagnosis of myalgia in general is
founded on the symptoms of tenderness to pressure
and of increase in pain on active and passive motion.
Alterations in the volume and consistency of the
structures concerned have a corroborative value, but
are not a conditio sine qua non for the diagnosis.
If the symptoms mentioned are noted as well as the
absence of spontaneous exacerbations the danger of
confusion with neuralgia is ordinarily not very
great. It is well to keep in mind the pains that are
114 PAIN
often associated with the milder states of weakness ;
for example, in the shoulder girdle in cases of aortic
disease, processes in the liver and spleen, or in apical
tuberculosis. The connection of lesions of the kid-
ney, such as calculus and new growths, as well as of
the prostate or parametrium (metastasis of carci-
noma), with pain in the thigh, also deserves con-
sideration. Involvement of the neck muscles may
simulate meningeal rigidity or spondylitis, though
the contrast between the intensity of the apparent
stiffness of the neck and the absence of other menin-
geal symptoms, and especially the tenderness of the
muscles, will guard against error. Similar consid-
erations will serve to exclude tetanus when the
muscles of mastication come in question. In differ-
entiating between pleural pain and rheumatoid affec-
tions of the thoracic muscles the chiefly, and often
exclusively, axillary localization of the former seems
to me to be of significance. In order to guard
against mistakes it is always advisable to pay par-
ticular attention to the presence of tenderness of
nerve trunks and of joints, and it should be remem-
bered that the simultaneous occurrence of disease in
these structures is not impossible.
ACCOMPANYING MANIFESTATIONS. In addition, the
temperature and the general condition should receive
careful scrutiny. Serious illness with typhoid-like
symptoms suggests the not rarely fatal cases of
Unverricht's dermatomyositis whose etiology is still
uncertain, haemorrhagic polymyositis, or in the pres-
ence of the appropriate initial intestinal symptoms,
ORGANS OF MOTION 115
trichinosis. In the latter case', the combination of
multiple myalgia with eosinophilia is of particular
importance. The presence of cutaneous oedema is
also significant. It is brawny and firm, with non-
involvement of the joints in Unverricht's dermato-
myositis, and involves the eyelids in trichinosis. If
the swelling is limited to one lower extremity, local
thrombotic conditions come in question, such as those
occurring in the cachexia of malignant disease or as
post-infectious complications.
III. BONE PAINS OR OSTALGIAS.
The danger of misinterpreting pain caused by the
irritation of sensory fibres in the bone-marrow and
periosteum and of ascribing to it a different nature
(rheumatic or neuralgic) is shown by experience to
be no slight one. This is in part explained by its
comparative rarity, and in addition there is no dis-
tinct localization in the affected part, particularly in
diffuse skeletal disease, such as osteomalacia, new
growths of the bone-marrow, etc. Furthermore, as
far as the factor of motion is concerned, the symp-
toms correspond to those of many commoner and
therefore better known painful conditions. For ex-
ample, if the bone exhibits periosteal changes at the
point of insertion of muscular masses, contractions
in these will naturally be painful and there will be
danger of confusion with muscle or joint pain.
Spontaneous exacerbations, which may be nocturnal
in character and occur, for example, in osteomalacia,
new growths of the bone-marrow, and post-typhoid
116 PAIN
osteomyelitis, may simulate neuralgic or spinal
processes, and this the more so if alteration in gait,
increased reflexes, etc., are present, as in osteo-
malacia. If one further reflects that infectious and
dyscrasic factors, as well as malignant processes,
play a particularly important role in the etiology of
ostalgias, it is to be expected a priori, that compli-
cating muscle, joint, and nerve pains may appear
both primarily and secondarily. From this it is easy
to understand that errors in diagnosis may readily
occur.
ETIOLOGY. It is advisable to begin by passing in
review the various general and specific disease
processes associated with bone pain.
1. Infectious processes, such as typhoid fever, in-
fluenza, sepsis, etc. The lesions of the bone-marrow
in these conditions may be manifold in nature and
run through all the stages from simple hypersemia
to fibrous exudation, necrosis, and the formation of
specific granulation tissue such as a gumma or a
tubercle. The scale of subjective pain sensations
corresponds to this range of anatomical changes,
running the gamut from slight pain evoked only
through strong pressure to the most severe spon-
taneous paroxysms. Usually the primary lesions
run their course in the bone-marrow itself and the
periosteal involvement is secondary, although the
possibility of an initial affection of the latter cannot
be excluded.
The infectious process may be principally or
entirely localized in the bone-marrow and give rise
ORGANS OF MOTION 117
to local, exceedingly intense pain (acute osteomye-
litis), or the lesions may be very slight and be dis-
covered only when special search is made for them.
For example, in the course of typhoid fever and far
into the convalescence it is wise not only to watch
for spontaneous ostalgia (often manifesting noc-
turnal exacerbations), but also to look for tender-
ness in the portions of the skeleton frequently in-
volved in osteomyelitis of this type. These are par-
ticularly the tibia, ribs, femur, and clavicle, and
especial attention should be given to the epiphyseal
regions. The bone processes due to syphilis and
tuberculosis and the ostalgias associated with them
fall within the province of the surgeon, and are
therefore only mentioned. Tenderness pointing to
irritation of the bone-marrow, particularly in the
sternum, is not infrequently encountered in infec-
tious processes like malaria and pneumonia if it is
looked for, and the ostitic symptoms sometimes ob-
served in biliary cirrhosis may also be placed in this
class. Some of the cases at least, of Marie's hyper-
trophic osteoarthropathy, associated with clubbed
fingers, may be included in the same group, in so far
as they occur in empyema of the pleural cavities.
The status of the disease of mother-of-pearl workers
is still uncertain.
2. New growths, involving especially the bones
of the trunk and of the proximal portions of the
extremities. This localization is characteristic for
the more or less diffuse lesions of the bony frame-
work, such as multiple myeloma,lymphadenia ossium,
118 PAIN
ehloroma, etc., which therefore exhibit somewhat the
course of an internal disease. The correct interpre-
tation of the not uncommon pain in these conditions
is an essential for the early recognition of the true
state of affairs. This is no less true for the cases
of metastatic new growths which are often associated
with neoplasms of the breast, prostate, thyroid, and
adrenal body. Given a history of the removal of a
carcinoma of the breast even some years previously,
the occurrence of indefinite pain always suggests the
possibility of ostalgia. Paradoxical as it may sound,
it is precisely the indeterminate nature of a pain
that suggests the possibility of its originating in the
bone.
3. Blood diseases. It is very tempting to explain
the tenderness in the lower part of the sternum that
is so often observed in the grave blood diseases like
pernicious anaemia, myelogenous leukaemia, and
pseudo-leukaemia as being associated with hyperas-
mic and inflammatory changes in the bone-marrow.
Sometimes this symptom is one of the earliest sub-
jective disturbances. On leaning against the edge
of the table in writing, on resting against the win-
dow sill, or in bending over the washtub, the patients
experience pain in the portion of the sternum pressed
upon, and on examination pronounced tenderness is
discovered, particularly in the lower half of the bone.
An interesting observation is that the sternal pains
are controlled by arsenic, and as I have convinced
myself in numerous cases, are least troublesome dur-
ing the acme of the drug's action. In the myeloge-
ORGANS OF MOTION 119
nous forms of leukaemia they may run parallel to the
rise and fall in the number of leucocytes. These
pains never occur spontaneously, but are always
produced only by pressure over the lower half of the
sternum. In exceptional cases there is also tender-
ness in other portions of the skeleton, like the
humerus or ilium.
4. Dyscrasias. Bone diseases of dyscrasic and
trophic nature. For the sake of completeness ref-
erence may be made to the extremely rare condition
of ostitis deformans (Paget) and of leontiasis ossea
(Virchow). The pains occurring about the head in
cases of the latter are probably neuralgic in origin
rather than ostalgias, and are due to pressure on
the nerves through the proliferation of bone. In
acromegaly ostalgia is not ordinarily observed and
the condition may be dismissed with simple mention.
OSTEOMALACIA. In this disease ostalgia appears
in its purest and most concentrated form. It must
always be our aim to make the correct diagnosis at a
time before palpable changes in the skeleton have
developed, but this is rendered possible only by
familiarity with the initial pain symptoms. The
lumbar region and the lower extremities are usually
indicated by the patients as the chief seats of dis-
comfort, at least in the puerperal forms. Whenever
pains having this localization appear in the course of
a pregnancy the possibility of a beginning osteo-
malacia should be thought of. In contradistinction
to the pain due to neuralgic disorders or spinal
affections, like myelitis, the pains of osteomalacia
120 PAIN
usually subside completely during rest, and their
onset is intimately connected with mechanical fac-
tors. Active and passive movement, coughing,
laughing, sneezing, yawning, etc., either become im-
possible or cause pain, even in far distant parts such
as the lower extremities. Active motion, such as
walking, stooping, and rising after being seated for
some time, usually causes the patients great discom-
fort. On getting out of bed they carefully lift out
each leg in turn, holding by the thigh. Deep respira-
tion often gives rise to pain in the ribs, and descend-
ing^ stairs is sometimes still more uncomfortable than
the ascent owing to the jarring of the body that it
occasions. While moving about is exceedingly
arduous, remaining in the same position for any
length of time, either sitting or lying, results in an
increase of the pain, so that the patients are obliged
to change their position constantly, and sleep is
therefore very broken. The movement of abduction
at the hip joint is particularly prone to cause
paroxysms of pain, as well as rapid dorsal flexion
at the ankle joint. In the latter case a pain is not
rarely caused which runs the entire length of the
lower extremity, radiating to the pelvis and some-
times accompanied by dorsal clonus. Lateral com-
pression of the thorax, or of the pelvis at the level
of the trochanters or the iliac crests, promptly causes
pain. Wearing a corset and tight lacing sometimes
appear to relieve the subjective symptoms, evidently
through the support given to the spinal column.
ORGANS OF MOTION 121
It is clear that the mechanical factors influencing
the pain of osteomalacia are not deficient in charac-
teristic qualities. If in spite of this, confusion with
other affections, particularly those of rheumatic
nature, is not rare, this may partly be explained by
the fact that to some extent they respond in the same
way to therapeutic measures. My experience leads
me to speak of the prompt relief to pain afforded by
the diaphoresis caused by hot-air baths, as well as
of the improvement often spontaneously occurring
during the hot summer months. Complications such
as myalgias of the adductors and calves, joint pains
of arthritic nature, and neuralgias like sciatica also
sometimes occur and may contribute to render the
picture of typical osteomalacia indistinct as regards
its pain phenomena. As suggested above, accom-
panying symptoms like ankle clonus, together with
the apparent weakness of the lower extremities, may
even give rise to confusion with spinal affections.
The intimate relationship between the pain of osteo-
malacia and mechanical factors like motion, as
opposed to the more spontaneous onset of the
paroxysms of spinal pain, should be sufficient for the
purposes of differentiation. The absence of bladder
disturbances is also an important diagnostic point.
The differentiation from spondylitis in the dorso-
lumbar region with secondary neuralgia of the pel-
vis in which I have found that there may also be
tenderness of the pelvic bones owing to involvement
of the perio steal nerves is ordinarily not difficult.
It is sufficient to think of this possibility in order to
122 PAIN
avoid error by a careful examination of the spinal
column. Where typical bony changes already exist
an extended analysis of the pain phenomena may of
course be dispensed with. In its onset, however, the
disease belongs to the subjective ostalgias discussed
above.
FUNCTIONAL OSTALGIAS. It may be assumed
a priori in view of the analogous observations in the
province of joint and muscle pains that ostalgias
may sometimes appear as manifestations of a gen-
eral neurosis, like hysteria. In fact, there are obser-
vations on record showing the possibility of the
simulation of osteomalacia by that great artist in
imitation, hysteria. In such cases error is to be
avoided by a careful study of all the attendant symp-
toms, but it must be borne in mind that the existence
of hysteria does not exclude osteomalacia and that
the latter disease in a hysterical subject will present
confusing symptoms due to this tendency.
REFLEX OSTALGIAS. Reflex sensitiveness to pres-
sure and percussion over the spinal column may
occur in abdominal processes without any anatomical
lesion of the bone itself. This is particularly the
case in gastric ulcer and cholelithiasis, in which the
hyperalgetic spot is often over the twelfth dorsal
vertebra at the level of the lower pulmonary border,
or in the interscapular space. The local tenderness
to pressure and percussion sometimes exhibited by
areas of the skull overlying cortical cerebral tumors
may be due to slight degrees of periostitic irritation
(internal erosion).
CHAPTER VII.
DIGESTIVE SYSTEM.
GASTRALGIAS.
IN this section those paroxysms of pain are to be
described which are colicky in nature, are localized
in the epigastrium, are frequently accompanied by
objective gastric symptoms, such as vomiting, eruc-
tations, etc., and which in the absence of anatomical
disease of the stomach are usually interpreted, and
misinterpreted, as "nervous gastralgia."
GENEKAL PATHOGENESIS. In view of the negative
nature of the condition, it is not astonishing that
even the existence of gastralgia as a painful sensa-
tion arising in the stomach itself is sometimes denied,
and the sensation in question is assumed to arise
entirely outside of the organ in the vagus and sym-
pathetic nerve tracts. According to this view gas-
tralgia would be sharply differentiated from the
pains occurring in other muscular hollow viscera,
such as the gall-bladder, intestine, ureter, uterus,
etc., and would be brought into association with the
neuralgias. For the same reason that it would be
improper in the case of a tumor of the Gasserian
ganglion, accompanied by pain in the teeth, to speak
summarily of toothache, the term gastralgia should
be avoided and be supplanted by the expression
sympathetic or vagus neuralgia, with the addition
of the underlying cause. In analogy to the condi-
123
124 PAIN
tions existing in neuralgias of the cerebrospinal
nervous system the occurrence of tenderness along
the nerve tracts in question, the vagus, the sympa-
thetic nerves, and the solar plexus might be ex-
pected. It is clear, however, that owing to the topo-
graphical relations tenderness to pressure in the
neck or over the anterior surface of the spinal
column, in the abdomen, etc., is far from comparable
in diagnostic value to the demonstration of distinct
tenderness over the sciatic nerve, for example, and
it is especially necessary under these circumstances
not to allow the wish to become father to the
observation.
Of course the occurrence of gastralgia is per-
fectly possible as a purely neuralgic disturbance in
the course of the sensory tracts without the exist-
ence of any causative motor or secretory disorders
in the organ itself. This is especially the case when
the attacks of pain persist even when the stomach
is empty and are not influenced by alkalies, local
anaesthetics, or the ingestion of food. The gastric
crises of tabes may serve as a paradigm of this
group, and the similar conditions appearing in
syringomyelia, multiple sclerosis, cerebrospinal
syphilis, vagus lesions, etc., may also be pointed
out.
VAGUS GASTRALGIA. For example, in a case of
gastric crises under my observation, the patient was
able to cut short mild attacks by inserting the finger
deeply into the left external auditory meatus (vagus
DIGESTIVE SYSTEM 125
fibres), but the act was accompanied by violent
coughing. Starting with this observation of the
patient's, to the effect that it was possible to inhibit
the painful process evidently situated in the left
vagus by a sort of counter-stimulation such as is
applicable to the act of sneezing, I prescribed with
good effect the application to the left auditory
meatus of a pledget of cotton moistened with a mix-
ture consisting of three drops of oil of mustard, one
gram of menthol and ten grams of liquid petrolatum.
It would be interesting to repeat this experiment
in other cases of suspected vagus gastralgia.
GASTRALGIAS OF GASTRIC ORIGIN. In addition to
these gastralgias which are, so to speak, extra-
stomachic, there are also undoubted essential gas-
tralgias which probably preponderate, and in which
the underlying cause is formed by the motor element ;
that is, pyloric spasm alone or in combination with
coincident dilatation of the gastric wall at the antrum
of the pylorus, as well as secretory disturbances such
as hyperacidity and acid hyperaesthesia. From the
latter point of view especially, the alkali test should
be made in every case of gastralgia by giving a pinch
of sodium bicarbonate during the attack. This test
is of value in differentiating the various gastralgias,
but even in case prompt relief is afforded it must be
remembered that the effect may be the result of the
combined action of various factors.
ETIOLOGY. The causes of gastralgia may be
classified as follows :
126 PAIN
I. IKRITABLE WEAKNESS OF THE NERVOUS SYSTEM.
This factor is in most cases the fundamental
cause of the essential gastralgias. Without the in-
creased susceptibility to pain that it involves, no
doubt many of the special factors, for example those
of alimentary nature, would be inadequate to cause
actual painful phenomena. In these cases the appli-
cation of the therapeutic lever is particularly effec-
tive, and improvement may often be secured even
in the persistence of the specific cause of the pain.
The most varied influences and processes may com-
bine to produce the condition of irritable weakness
of the nervous system, mental overexertion, psychi-
cal emotions, sexual aberrations, anaemias, the arthri-
tic diathesis, chronic infections such as tuberculosis
with possible secondary sympathetic and adrenal
lesions, syphilis, chronic intoxications such as nico-
tinism, plumbism, alcoholism, arsenic poisoning, etc.
These conditions contribute their part in giving rise
to essential gastralgias ; they are factors that occur
also in the causation of neuralgias in the cerebro-
spinal nervous system (cf. classification on p. 85).
Frequently they simply prepare the soil for the
subsequent action of more specific causes.
II. DIRECT CAUSES.
A. ACTING CENTRALLY. This heading comprises
especially diseases of the central nervous system,
such as tabes, syringomyelia, multiple sclerosis, cere-
brospinal syphilis, etc. It is difficult to decide to
DIGESTIVE SYSTEM 127
what extent disturbances of metabolism such as the
arthritic diathesis, diabetes, and the chronic infec-
tions and intoxications mentioned in the preceding
paragraph, have a central or a peripheral effect.
In this class may also be included the gastralgias,
often accompanied by vomiting, sometimes occurring
in cases of vascular lesions such as atheroma of the
abdominal aorta, of the coronary arteries, the cceliac
axis, etc., and concerning whose exact mechanism
we are still ignorant.
B. ACTING PERIPHERALLY. Here the point of at-
tack lies in the sensory nervous apparatus of the
stomach itself. Organic lesions of the gastric
mucosa, such as ulcerative or inflammatory proc-
esses, may serve to induce gastralgias, especially if
there is. an already existing predisposition. The
actual mechanism of pain production frequently de-
pends on a pyloric spasm of reflex nature; that is,
on a pathological increase in motor activity which
of course may reach its maximum when there is a
permanent tendency to abnormal peristalsis, as in
pyloric stenosis. Among the chemical factors
whose existence in a given case is indicated by the
prompt temporary effect of the administration of
alkalies are to be counted the inorganic and organic
acids, contact of which with the gastric mucous mem-
brane may induce gastralgias of the most severe
type. In view, of what was said above under section
L, it may be expected that in hyperaesthesia small
amounts of acid will be effective, while the variety
of the acid is also not without importance.
128 PAIN
ACIDITY. The complaints usually ascribed to
hyperacidity and capable of being modified by the
administration of alkali might therefore more cor-
rectly be spoken of as due simply to acidity, since
frequently they result not from an excess of acid but
through an increased susceptibility to acids. Here
again those gastralgias might be mentioned that
sometimes occur with an anatomically intact stomach
after the ingestion of strongly acid foods or those
forming acid on decomposition (animal fats, milk)
or strong spices, coffee, etc. Mechanical factors,
such as insufficient mastication, overeating, and foods
tending to gas formation, also come in question.
HUNGER PAIN. Just as quantitative and qualita-
tive abnormalities in the ingestion of food, including
poisoning, may lead to gastralgiform attacks, pro-
tracted fasting may have a similar effect. This
appears rather paradoxical, since apparently noth-
ing becomes a cause. In reality it is probably the
physiological increase in peristalsis (growling of the
empty stomach) that accompanies the sensation of
hunger, and sometimes perhaps also the gastric juice
secreted under these conditions that causes the pain,
and this is particularly likely to occur if the predis-
position already spoken of in section I. exists
or the stomach has become a locus minoris resis-
tentia through ulcerative processes (particularly
ulcer, rarely carcinoma).
III. REFLEX CAUSES.
The gastralgias comprised under this heading in-
clude those sometimes occurring in diseases of the
DIGESTIVE SYSTEM 129
appendix, disorders of the female genital apparatus,
sometimes even in nasal affections, hernias of the
omentum in the linea alba, movable kidney, etc. In
such cases it is always necessary to determine
whether factors from groups I. and II. are not also
concerned, and accordingly one-sided special treat-
ment must be avoided. I consider it very probable
that the epigastric pains often accompanied by gas-
tric symptoms such as vomiting, eructations, the
feeling of peristaltic unrest, etc., which sometimes
occur in cases of more or less latent gall-bladder
disease as well as in pancreatic conditions and dis-
eases of the aorta and coronary arteries, are, as a
matter of fa,ct, to be regarded as reflex gastralgias.
DIFFEKENTIAL DIAGNOSIS. Colicky pains in the
epigastrium associated with gastric symptoms of
course always suggest gastralgia, but a satisfactory
diagnosis can be made only through the proper inter-
pretation of the causative factors. For this purpose
it is necessary to pass in review the possibilities sug-
gested under headings L, II., and III., unless defi-
nite peculiarities of the pain give the necessary clue.
TOPOGKAPHY AND TIME. Attention may be called
to the purely left-sided character of the pain that is
sometimes observed. Biliary colic is never re-
stricted to the left half of the epigastrium leaving
out of account the possibility of transposition of the
viscera. Primary gastralgias ordinarily do not
radiate into the upper extremities, particularly not
as opposed to cholelithiasis into the right shoulder
and arm. Eadiation into the left upper extremity
9
130 PAIN
is also very rare as compared to the epigastric form
of angina pectoris. For a consideration of the ten-
dency to radiation exhibited in the colic of pyloric
stenosis reference may be made to the section in
question. It is also advisable to try to ascertain the
depth of the pain from the surface in order to avoid
erroneously interpreting intercostal neuralgias in
the epigastrium as gastralgias. For this reason it
is always wise to test the cutaneous sensibility of the
epigastrium. The regular daily recurrence of the
attacks, particularly if a relationship to the taking
of food can be demonstrated, suggests the possibility
of the conditions discussed in group II. B, such as
ulcer, pyloric stenosis, etc. On the other hand, great
irregularity in the appearance of the pain points
more to the central diseases spoken of under group
II. A, and perhaps the reflex factors of group III.
MODIFYING FACTOES. In order to avoid errors in
drawing conclusions from the causative factors, it
is always necessary to remember that these are
occasionally multiple in nature.
Not without reason was the group included under
the heading of irritable weakness placed first in the
list of etiological factors, for gastralgias of the most
varied origin may be founded on this basis. This
indeed is true of attacks of pain in general, and the
occurrence of a gastralgia under the influence of
emotional excitement, such as anger or grief, is far
from justifying the exclusion of an organic cause.
Among the mechanical factors I should attach a
not unimportant role to the matter of bodily posi-
DIGESTIVE SYSTEM 131
tion. If the gastralgia is merely the result of func-
tional or organic disease of the nervous system the
effect of position will in most instances be hardly
perceptible. The reverse may be the case to a very
pronounced degree, however, if organic lesions of
the stomach (II. B) or reflex stimuli from abnor-
mally movable organs (III.) are concerned. If
gastralgic seizures occur in connection with rapid
motion, stair-climbing, etc., masked forms of angina
pectoris must always be thought of. Pronounced
tenderness, particularly on percussion of the epi-
gastrium or on pressure, renders the existence of an
organic condition likely, especially if asymmetrical,
but exceptions in this regard may be encountered
both on the organic and on the functional side.
Particular attention must of course be given to
the effect of diet. The mechanical, chemical, and
thermic factors concerned in the ingestion of food
tending to gas formation, strongly acid, spiced, or
fatty foods, cold fluids, etc., are of importance, espe-
cially in dealing with the organic processes spoken of
under group II. B. The effect of acids and the
opposite test with alkalies is also of importance.
In the same way it seems to me that the action of
local anaesthetics, such as cocaine, alypin, and anass-
thesin is of importance from the diagnostic stand-
point. If the administration of such agents causes
rapid decrease in the discomfort the presence of
local pain-producing factors such as ulcer, carci-
noma, haemorrhagic erosion, or hyperaesthesia of the
gastric mucosa may be regarded as demonstrated,
132 PAIN
and in making the otherwise difficult decision be-
tween gastric and duodenal ulcer the prompt produc-
tion of relief in this way points in favor of the
former lesion.
A possible interdependence between the onset of
gastric pain and constipation of long duration should
not be overlooked. In hydrochloric acid hyper-
sesthesia or hyperacidity, as well as in ulcer and
pyloric stenosis, there is no doubt in regard to a
connection of this sort, and it probably depends on
interference with the emptying of the stomach and
secondary stagnation and fermentation of its con-
tents. The effect of menstruation should also be
considered.
ACCOMPANYING MANIFESTATIONS. Although in
cases of gastralgia the best advice that can be given
is to make a complete physical examination involv-
ing all the organ systems, in addition to the analyt-
ical study of the paroxysms in the manner just
indicated and keeping in mind the possibilities sug-
gested in the introductory classification, it may be
helpful to emphasize several points that aid in rapid
orientation, although not of great importance per se.
Among these may be mentioned the possible coinci-
dence of bladder disturbances or pains in the lower
extremities (tabes). The syndrome gastralgia and
distended bladder always awakens suspicion of gas-
tric crises. High blood pressure, accompanied by
arteriosclerotic pallor of the face and dyspnrea, even
though slight, suggests an arterial starting point
such as angina pectoris. Gastralgia and sarcinae
DIGESTIVE SYSTEM 133
in the vomitus or in the feces point to ulcerative
stenosis of the pylorus. The same thing is true of
visible gastric pefistalsis or marked gastric meteor-
ism (not to be confounded with distention of the
epigastrium through an enlarged liver in choleli-
thiasis). Examination for a palpable or painful
gall-bladder, for the presence of a hernia in the
linea alba, or for tenderness of the appendix and
parametrium, should never be omitted.
GASTRIC ULCER.
TOPOGRAPHICAL CONSIDERATIONS. It might be
assumed a priori that in ulcerative processes of the
gastric mucosa the pain, whether spontaneous or
produced artificially through pressure or percussion,
would have a more or less asymmetrical left-sided
localization corresponding to the position of the
organ. As a matter of fact, this is true in a large
number of cases, at least so far as ulcers in the
neighborhood of the cardia or the central part of the
stomach are concerned, and may be made use of in
differential diagnosis. Exclusively or principally
left-sided spontaneous pain or tenderness to pres-
sure, either in the epigastrium or in the anterior or
posterior lower thoracic region, renders painful
processes of the right side of the abdomen and par-
ticularly gall-bladder affections improbable, and
therefore limits the diagnostic possibilities from the
very beginning.
The painful area to be outlined by pressure or
percussion is not rarely situated on the left side
134 PAIN
anteriorly, just below the costal arch, somewhat to
the median side of the mammary line. It is also
sometimes possible to discover another point of ten-
derness on the left side posteriorly, close to the verte-
bral column, at about the level of the twelfth dorsal
or first lumbar vertebra. Concussion of the left
lower portion of the thorax with the fist at about
the level of the lower pulmonary border is also often
exquisitely painful as compared with the right side.
Even when the pain is median in onset it frequently
radiates in the direction of the left costal border
and to the left scapula. This is particularly likely
in cases with perigastritic adhesions to the dia-
phragm, the transmission probably taking place
through the phrenic nerve into the shoulder. There
may then also be a pressure point over the outer and
middle third of the upper border of the trapezius
muscle. While the left-sided position of the pain is
not pathognomonic of gastric ulcer its diagnostic
significance is the result of the position of the organ
in the abdominal cavity and cannot be neglected.
The great frequency with which the smaller median
and right-sided prepyloric and pyloric portion of
the organ is the seat of ulcerative lesions causes the
pain to occupy a similar position in a great propor-
tion of the cases. Not only is the spontaneous pain
experienced in the middle portions of the epigas-
trium, but on testing the sensibility by percussion
the maximum point of tenderness is frequently found
on a line connecting the xiphoid process with the
umbilicus. I must caution, however, against draw-
DIGESTIVE SYSTEM 135
ing conclusions in regard to the site of the ulcer from
this position of the area that is painful on percus-
sion. It is easy to convince oneself, for example,
that in cases of hepatic congestion in which the
hypersensitiveness of the organ to mechanical insult
is no doubt the same throughout, percussion is
always most painful in the midline of the epigas-
trium, while on the right and left sides it may cause
little or no discomfort. This may be explained as
follows : On either side of the midline the recti blunt
the force of the blow through their contraction, but
in the center, where, especially in cases of ulcer,
diastasis of the recti may exist together with enter-
optosis, this defense musculaire is wanting and
the impact is received unaltered by the stomach.
This is apt to be overdistended with gas and the in-
creased tension may result in pain production quite
independently of the actual position of the ulcer. In
most cases the lesion appears to be near the pylorus
on the lesser curvature. The tenderness to percus-
sion frequently begins about four finger breadths
below the xiphoid process and extends to the neigh-
borhood of the umbilicus. If it begins immediately
below the xiphoid and corresponds to an area of dul-
ness, the possibility of hyperalgesia of the liver, per-
haps through congestion, or following an attack of
gall-stones, must be seriously considered. It must
also be remembered that hepatic congestion and ulcer
may occur coincidently and that the development
of an ulcer may be favored by the vascular and cir-
culatory disturbances. Therefore in cases of myo-
136 PAIN
cardial degeneration, mitral stenosis, etc., with pain-
ful congestion of the liver and accompanied by symp-
toms suggesting gastric ulcer, the relations of the
tender area to the liver edge should be carefully
studied. If it is situated below this the possibility
of ulcer must always be thought of. Just as spon-
taneous pain and tenderness to percussion or pres-
sure may occur in the midline anteriorly, symmet-
rical backache or hyperalgesia of one or more
thoracic or lumbar vertebrae (usually the twelfth
dorsal or first lumbar) may sometimes be encoun-
tered. Ulceration of the pylorus itself not rarely
causes exquisite tenderness on the right side, which
may be either just to the right and above the um-
bilicus or nearer to the costal border and therefore
in unpleasant proximity to the gall-bladder. The
radiation of the pain of pyloric ulcer is less inti-
mately associated with the ulcer as such than with
the pyloric stenosis, and will therefore be discussed
with the subject of colic due to this condition. At
present only the retrosternal radiation sometimes
observed in ulcers of the lesser curvature will be
mentioned. Ordinarily only the lower part of the
sternum is involved, but sometimes the sensation
extends upward toward the neck, and when it is
accompanied by the sense of oppression and is de-
pendent on motion (traction), confusion with angina
pectoris may result.
The pain of ulcer is nocturnal in a considerable
proportion of cases, the paroxysms frequently occur-
ring during the midnight hours (from 11 to 1 o 'clock)
DIGESTIVE SYSTEM 137
and lasting into the early morning. The relation
between the ingestion of .food and the onset of pain
varies greatly from case to case, and I should never
venture from this to draw conclusions in regard to
the localization of the ulcerative process. Often the
pain begins immediately after eating, but sometimes
it does not occur until hours after the last meal. In
pyloric ulcer, particularly if there is also stenosis,
there is more regularity in this regard and the pain
customarily begins two or three hours after the
midday meal, as will be explained at greater length
in discussing the subject of pyloric colic.
THE NATURE AND PATHOGENESIS OF THE PAIN.
The nature of the pain is very variable. Sometimes
the feeling of a "sore spot" is complained of; fre-
quently there is simply a diffuse sense of pressure
in the epigastrium, a sensation of heaviness "as if
there were a stone in the stomach. ' ' Sometimes it is
described as being cutting, piercing, burning, or
gnawing, or it may be spasmodic or throbbing in
character. The intensity of the pain, and especially
also the tenderness, may vary in a short time between
wide limits so that while at one moment even deep
pressure may not be painful, a few hours later even
the contact of the shirt may seem unbearable. It is
evident that the ulcerative process itself undergoes
no change within so short a lapse of time, but gastric
distention may develop, and I think that this
accounts for the rapid fluctuations so often encoun-
tered. The more the ulcerated gastric wall is
stretched by gas formation the greater will be the
138 PAIN
tenderness to pressure and percussion. Before be-
ginning to discuss the actual causation of the pain,
it may be well to say a few words in regard to its
pathology. It is evident that the conditions are
rather more complex than in ulcerations of the
buccal cavity, for example, for here we have an
organ whose wall may sometimes be abnormally
distended through the accumulation of gas, and
which, on the other hand, is subject to spasmodic
contraction. Furthermore, one must take into ac-
count its peritoneal covering, which may become
inflamed over the ulcerated area (perigastritis), and
also the production of acid gastric juice which may
serve as a source of irritation. Every one of these
factors, and of course to a much greater degree
their combination, may occasion pain.
At this point I should like to touch briefly upon
the question as to why the deep ulcerations of the
gastric mucous membrane caused by carcinoma
rarely give rise to painful seizures similar to those
of the benign simple ulcer. The acidity of the car-
cinomatous stomach is also often high owing to the
formation of organic acids, such as lactic, acetic, and
butyric. In the explanation of this apparent para-
dox two factors play a large part. (1) The carcino-
matous stomach is much less prone to spastic con-
traction than is the stomach with simple ulcer. The
latter in spite of the frequently existing moderate
degree of motor insufficiency is still undoubtedly
in a state of motor hyperexcitability (irritable weak-
ness), and every spasmodic contraction of the ulcer-
DIGESTIVE SYSTEM 139
ated gastric wall may serve to cause pain. (2) In
ulcer the stomach is more liable to meteorism, espe-
cially if there coexists pyloric stenosis, either func-
tional through spasm, or organic through cica-
tricial contraction. The resulting tension of the wall
of the organ is a very active source of pain. At any
raie the two- mechanical factors of contraction and
overdistention play an exceedingly important part
in the pathogenesis of the pain of ulcer.
Not rarely psychical factors, such as excitement
or anger, are adduced by the patients as initiating the
attacks of pain. If one takes into consideration
the interdependence between the emotional state and
the motor and secretory functions of the stomach,
and on the other hand, the fact that the intensity
of stimulus necessary to evoke pain in an emotionally
excited person is reduced, the demonstration of such
a relationship will probably never be regarded as
by itself sufficient reason for assuming the existence
of a functional disorder. It is especially necessary
to be on one's guard since gastric ulcer is not rarely
associated with the neuropathic constitution and a
tendency to enteroptosis.
The mechanical factors in the process of pain
production are of the greatest differential value in
dealing with the pain of ulcer as opposed to that of
other gastralgias, such as those occurring in organic
or functional nervous disorders like tabes or neuras-
thenia, or those due to secretory anomalies or to
intoxications (lead, nicotine). It is clear from what
has been said above that the way in which mechanical
140 PAIN
factors act will not be uniform and that the position
of the ulcer and any existing adhesions will be of
importance. A peculiarity frequently observed in
cases of ulcer is that during the paroxysms, and
sometimes also at other periods, the position of the
patient while in the horizontal posture, whether on
the face, back, or side has an undoubted effect on the
intensity of the pain. It may at once be pointed
out that similar observations may be made in painful
affections of other organs, such as the liver, kidney,
appendix, etc. I do not therefore agree with the
generally accepted explanation that in certain posi-
tions the eroded surface is exposed to the impact, so
to speak, of the gastric contents, while in others this
is not the case. Assuming that the material in the
stomach is pultaceous and therefore not easily mov-
able, as must often be the case, this explanation
seems somewhat forced. At the most, it could be
claimed only that the weight of the overlying
layer, which, however, cannot vary very greatly,
may have a pain-increasing effect, though this
seems to me rather improbable. I should regard it
as much more natural that, just as in the case of
other painful abdominal organs, displacement, trac-
tion, or kinking at the pylorus takes place and in-
creases the pain. When the stomach is full it is par-
ticularly liable to displacement of this sort as a
whole and in part, and this can hardly be without
effect in the presence of the inflammatory adhesions
usually existing. Such displacement in different
positions of the body is the more likely to occur in
DIGESTIVE SYSTEM 141
ulcer since not rarely the condition is associated
with enteroptosis and lax abdominal walls. This
imperfect fixation of the abdominal organs as a
whole is further contributed to by the considerable
reduction in intra-abdominal padding due to the
absorption of fat commonly seen in cases of ulcer.
Therefore I should consider the effect of the painful
position as due less to a displacement of the gastric
contents than to that of the stomach itself (cf. page
22). The patients themselves often complain, for
example, that when lying on the left side ' ' a weight
seems to pass to the left. ' ' The pain accompanying
the lateral position is sometimes experienced on the
same side, but may also be contralateral, so that
when lying on the right side it is felt to the left of
the epigastrium, and often conveys the impression
of traction to the right. The painful position may
be noted only during the spontaneous paroxysms and
frequently appears to depend on overfilling of the
organ, which, of course, would predispose to dis-
placement. It does not seem to me justifiable to
draw conclusions, as is often done, in regard to the
localization of the ulcer from the relations between
the position of the body and increase or decrease in
pain, since the connection evidently does not depend
on simple displacement of the gastric contents due to
gravity alone. A fairly constant though not invari-
able rule is that painful lesions of the pylorus, par-
ticularly if accompanied by stenosis, make the right
lateral position uncomfortable during the spontane-
ous attacks of pain, but more will be said on this
subject in discussing the pain of pyloric stenosis.
142 PAIN
So far only the horizontal position has been con-
sidered. In walking, the body is frequently held in-
clined forward, at least at the time of the paroxysm.
Belief is sometimes afforded in the sitting or crouch-
ing position, but in other cases these attitudes in-
crease the patient 's discomfort. Movement of vari-
ous sorts is also effective as a mechanical factor.
Many patients complain of an increase in symptoms
on walking, and it may be assumed that the traction
and vibration to which the stomach is subjected,
particularly if the abdominal walls are relaxed, is
responsible for the pain production. A misstep may
give rise to severe momentary pain in the epigas-
trium. Exertion while stooping, calling into play
the abdominal muscles, as in lifting heavy loads, is
a frequent cause of pain, and may bring on a haemor-
rhage. I recall an instance in which a patient after
lifting a heavy load experienced for the first time a
burning sensation below the left breast, which was
followed by the development of typical ulcer symp-
toms. Violent straining at stool may act in the same
way.
The respiratory movements may also cause pain,
usually on the left side of the epigastrium just below
the costal border, particularly if perigastritic com-
plications are present. In these cases the sensation
may radiate from the epigastrium to the left along
the axillary portions of the thorax into the shoulder.
It is hardly necessary to indicate that efforts such
as those of coughing and sneezing may also be pain-
fuL Under these conditions the sensation may be
DIGESTIVE SYSTEM 143
located in the thorax. Straining at stool sometimes
causes pain in the pyloric region, and in one case
of mine about the sternal end of the third rib. The
dependence of the pain of ulcer on mechanical
stimuli, such as pressure and percussion, is among
its most useful diagnostic peculiarities, but the im-
pression appears to obtain that, as in the case of an
ulcer in the mouth, the sensitive area corresponds
to the anatomical lesion and depends on this alone.
Pain on pressure and on percussion are, however,
undoubtedly dependent on the degree of tension of
the stomach wall. If the organ is greatly dilated,
as may occur without true cicatricial pyloric stenosis
through pyloric spasm and secondary stagnation,
pressure and percussion will be particularly painful.
This will be the case over a considerable area, and
even when the trauma does not correspond to the
situation of the diseased spot. This view is further
borne out by the enormous fluctuations in sensitive-
ness often occurring within a few hours and running
parallel to the degree of distention of the organ.
The possibility of determining the position and size
of the ulcer by outlining the painful area by percus-
sion seems to me to exist only when the stomach is
not distended. The percussion must be very gentle,
as if forcible it acts as a strong vibration, such as
that caused by coughing, for example. Tenderness to
percussion over the epigastrium should be looked for
in the following situations: (1) From the xiphoid
process to the umbilicus. (2) In the apex of the
angle on each side between the outer border of the
144 PAIN
rectus and the costal arch. (3) At a point about
2 cm. to the right of and above the umbilicus. (4)
The lower part of the sternum. In the back hyper-
algetic areas are. not rarely found in the neighbor-
hood of the spinal column, particularly between the
shoulder blades in the neighborhood of the twelfth
dorsal vertebra. The left flank may also be sensitive
to percussion with the clenched fist, less rarely the
right, in contradistinction to cholelithiasis. In rare
cases the epigastrium, and still more rarely the dor-
sal regions just indicated are so hyperalgetic that
simple contact and slight pressure (the weight of the
bed-clothes, for example) are sufficient to cause pain.
Overdistention of the stomach through diagnostic
inflation (caution is necessary) may give rise to
acute spontaneous pain and tenderness to pressure.
So far we have discussed factors concerning
whose purely mechanical nature there can be no
doubt. The effect of diet presents a much more
difficult problem. Here one is dealing with a com-
plex of mechanical, chemical, and thermic factors,
and this may explain the great variability in the
effects of dietary regulation, although certain under-
lying principles always stand out clearly from the
chaos of inconsistencies. The mere fact that the
pain is subject to alimentary modification at all
seems to me of greater diagnostic importance than
the exact manner and nature of the effect produced.
The pain-inducing factor may be regarded as purely
mechanical when it is the result of the use of foods
causing gas formation. Here, as has already been
DIGESTIVE SYSTEM 145
pointed out several times, it is the gastric meteorism
which is predisposed to by the atony of the ulcer-
ated stomach and its tendency to pyloric spasm that
produces the paroxysms of pain through tension of
the walls of the organ. This explains the prompt
relief that often follows the evacuation of gas and
the beneficial effect of the local application of an
ice bag. The act of vomiting sometimes checks the
pain abruptly. Some foods (e.g., pork) may have a
purely mechanically irritating effect through their
indigestibility and act as foreign bodies. Acid foods
and strong spices, including salt and pepper, are
nearly always badly borne. Of beverages, hot tea
with milk, and milk to which an alkali like lime water
or vichy water has been added, seem to agree the
best. Coffee, beer, wine, and cold water often in-
duce paroxysms of pain. In exceptional cases the
ingestion of coffee or whiskey may bring relief to the
pain, possibly through hastening the emptying of
the stomach or through an antifermentative. action.
Meat sometimes also has a favorable effect which is
ordinarily explained as due to the neutralization of
the excess of hydrochloric acid. For my part, as the
result of numerous observations, I consider that
hydrochloric hyperacidity is very far from frequent
in ulcer and have furthermore been able to convince
myself that in undoubted cases of the lesion even
large doses of dilute hydrochloric acid have not in-
creased the pain and have sometimes even seemed to
have a favorable effect, possibly through an anti-
fermentative action. I should always advise testing
10
146 PAIN
the effect of acid and alkalies experimentally in
cases of gastric ulcer. If the administration of alka-
lies relieves the pain the proof of hyperchlorhydria
has not been furnished, for there may exist what
I think is rather frequent, namely, a hypersesthesia
to hydrochloric acid accompanied by even subnormal
HC1 values. In addition, the discharge of gas and
consequent reduction of gastric meteorism sometimes
produced must be taken into consideration. That
the ingestion of meat and milk frequently does not
act exclusively through the neutralization of hydro-
chloric acid is shown by the fact that not rarely a
piece of bread will have the same- effect.
Increased peristalsis is likely to attend the sen-
sation of hunger caused by prolonged abstinence
from food. This is evidenced under physiological
conditions by the " growling of the* stomach," and
the ingestion of food of any sort appears to have a
quieting effect on the spasmodically increased motor
activity. The effect of tobacco in causing pain,
which is not only common in essential gastralgias but
also in cases of ulcer, may be due in a similar way to
the increased peristalsis.
It is not possible to formulate distinct rules in
regard to the effect of thermic stimuli on. the pain
of ulcer. In most cases moderate warmth, both in-
ternally through beverages such as warm milk or
tea, as also externally by means of fomentations or
hot water bottles, appears to act favorably on the
pain, but cold (a swallow of cold water, or an ice bag
to the epigastrium) not infrequently relieves in
DIGESTIVE SYSTEM 147
cases in which heat increases the discomfort of the
patient.
Among the interrelationships between the pain of
ulcer and the condition of other organs or their func-
tions, constipation, which is so frequently seen in this
disease, appears to me to be of importance particu-
larly from the therapeutic standpoint. Constipation
is undoubtedly a pain-producing factor, for when
it has persisted for any length of time the intensity
and frequency of the attacks nearly always increase,
only to subside again after evacuation of the intes-
tine. Occasional enemas of oil or glycerine and pos-
sibly the regular administration of mild laxatives,
such as cascara sagrada, are therefore urgently indi-
cated. It appears most likely that the blocking of
the fecal masses reacts upon the stomach and causes
stagnation in this organ, thus increasing the ten-
dency to meteorism. The effect of the latter upon
the pain of ulcer has already been discussed at
length. It is hardly necessary to point out that a
condition of "irritable weakness" of the nervous
system is unfavorable, particularly if accompanied
by anaemia, and therapeutic measures must be
directed along these lines. No less undesirable is
the effect of enteroptosis, which is not infrequently
encountered in neuropathic individuals. If gas-
troptosis exists, the resulting kinking at the pylorus
leads to stagnation and abnormal fermentation
of the gastric content, while at the same time pain-
ful traction on the organ is also likely to be caused.
When pregnancy has a beneficial effect on ulcer
148 PAIN
and its pain, as was the ease in some instances that
I recall, it is possible that among other factors the
relief to the condition of enteroptosis produced
by the elevation of the abdominal viscera through the
enlarging uterus is of importance.
ACCOMPANYING SYMPTOMS. Among the symp-
toms associated with exacerbations of pain the most
characteristic are those standing in close relation-
ship to the mechanism of pain production. For ex-
ample, the distention of the stomach is often evident
from the presence of a rounded swelling, or at least
an air-cushion-like resistance, in the left (as con-
trasted with cholelithiasis) side of the abdomen.
Pressure over this sometimes occasions pyrosis
through regurgitation upward, sometimes there is
distinct, easily produced succussion.* Frequently
there is audible and palpable gurgling owing to the
increased peristalsis, or there may be acid eructation
or belching of gas smelling like putrid eggs (SH 2 )
and vomiting followed by the immediate cessation
of the pain (as opposed to cholelithiasis). Chills
occur only rarely and then in neuropathic persons
with abnormal vasomotor excitability; the superfi-
cial abdominal reflex is sometimes increased on the
left side, headache and attacks of vertigo are often
seen, as well as the feeling of great heat and sweat-
ing, especially during a haemorrhage. Microscopi-
cally the examination of the vomitus or of the feces
*In cases of gastric ulcer it is desirable, in order to avoid local
injury in testing for splashing in the stomach, to shake the whole
abdomen by grasping the two sides of the pelvis with both hands.
DIGESTIVE SYSTEM 149
may reveal the presence of sarcinae, which is a find-
ing of importance. As noted above, I do not regard
hyperchlorhydria as a frequent concomitant of ulcer.
DIFFEBENTIAL DIAGNOSIS. If the existing pain
phenomena are analyzed in detail in this way, pay-
ing special attention to the causative factors, mis-
takes in diagnosis will be unlikely. In distinguish-
ing the paroxysms of gastric ulcer from those of the
gastralgias of "nervous" nature, such as may be
caused by organic lesions of the nervous system,
tabes, multiple sclerosis, syphilis, etc., and which are
often dependent on a neuropathic basis, as in hys-
teria, exophthalmic goiter or nicotinism, the inter-
mittent character of the pain in the latter may be
emphasized. In these conditions, in addition to the
sporadic nature of the attacks and the lack of sus-
ceptibility to influence by mechanical factors, such
as position, motion, or pressure, there is also the
absence of permanent or consistent modification
through diet. In difficult cases it is advisable to
make careful dietetic observations in order to deter-
mine the degree of tolerance for articles of food
badly borne in ulcer. The lack of response to
dietary changes will also prevent confusion in cases
of epigastric intercostal neuralgia. As opposed to
the more occasional attacks of gall-bladder colic, the
pain of ulcer is characterized by greater persistence
and the action of local anaesthetics is of importance
(cf. pyloric stenosis colic). The existence of a
hernia of the linea alba, which may exhibit the same
epigastric tenderness as ulcer, is easily recognized
150 PAIN
by palpation while the patient coughs. Still, even
after the discovery of a hernia the possibility of the
simultaneous occurrence of both conditions must
be kept in mind. The epigastric tenderness some-
times seen in chronic bronchitis as a muscular phe-
nomenon involving the insertions of the recti and
comparable to the pain in the calves after fatiguing
marches, is likely to lead to error only if the exam-
ination is superficial and gastric symptoms happen
to coexist, as in tuberculosis.
Hepatic congestion with tenderness seems to offer
a possibility of mistakes in diagnosis. In cases of
ulcer, associated with cardiac insufficiency and
hepatic congestion in which the gastric lesion may
be predisposed to by the circulatory disorders the
epigastric pain is likely to be ascribed summarily to
the hepatic condition, and the stomach symptoms
are explained in the same way. It may be that not
until perforative peritonitis intervenes, as in a case
I have seen, is the true state of affairs recognized.
It is important to demonstrate that there is also a
spot painful to percussion below the edge of the liver
and that the pain does not subside under digitalis as
is the case in the hepatic condition. Of course, care-
ful study of the attendant circumstances is also
necessary. Angina pectoris, especially in its graver
forms induced through lesions of the aorta and coro-
nary arteries, may simulate the symptoms of ulcer
if the pain is localized in the epigastrium and evi-
dence of gastric disturbance like vomiting is present.
This is the more likely to be the case if the epigas-
DIGESTIVE SYSTEM 151
trium is tender to pressure, as the result of inflam-
matory atheroma of the abdominal aorta. In deal-
ing with persons over forty, of stocky build and pale
complexion, with a tendency to dyspnoea, thick arter-
ies, and high blood pressure, one should always be
slow to make the diagnosis of ulcer, particularly if
it is found that rapid motion, stair climbing, etc.,
give rise to the epigastric pain. The characteristic
anguished facies of the patients during the attack
also gives a hint as to the true state of affairs. If
the dietary has no particular effect on the pain, as
is usually the case, the distinction is not difficult to
draw. The conditions are more- difficult when the
ingestion of food also induces attacks in coronary
or aortic angina. In such cases the nature of the
food is frequently without significance ; for example,
in one case the attacks occurred no matter whether
the patient took milk or pork and sauerkraut; it was
the ingestion of food as such irrespective of its qual-
ity that caused the pain. Those cases should also
be borne in mind in which gastric ulcer affords the
reflex starting point of hysterical angina pectoris,
particularly if aortic lesions are present, such as
aortic insufficiency. Neuroses are most apt to occur
in anatomically damaged organs.
In all cases of suspected ulcer the region of the
appendix should be examined for tenderness. Just
as appendicular colic not rarely begins in the epigas-
trium, chronic appendicitis may be associated with
epigastric symptoms simulating ulcer. The possible
combination of both conditions must als.o be consid-
152 PAIN
ered. In cases of achylia gastrica, such as occur in-
dependently or as part of the picture of a pernicious
ansemia, ulcer-like symptoms, sometimes even asso-
ciated with the apparent symptoms of hyperacidity,
may occur. The demonstration of the absence of
hydrochloric acid will give the necessary clue. The
same thing is true of gastric carcinoma, which some-
times begins with typical ulcer symptoms. In
chronic gastritis tenderness over the pylorus may
be present, though this is usually slight. There may
also be similar dietary symptoms, though seizures of
severe pain are almost never observed. The possi-
bility of ulceration in other portions of the gastro-
intestinal canal must also be taken into account.
These exhibit similar and therefore confusing die-
tary symptoms. I believe that it is impossible to
distinguish with any degree of certainty between the
pain of gastric and of duodenal ulcer. The appli-
cation of the ansesthesin test has already been de-
scribed (cf. page 39). If the pain of intestinal
ulceration, for example, of tuberculous nature, is
accompanied by symptoms such as vomiting, gastric
splashing, etc., and is localized in the epigastrium, it
is very difficult to make the distinction, particularly
in view of the similar behavior of the two affections
in regard to the ingestion of food. The case- is ren-
dered still more complex if, as in an instance ob-
served by me, intestinal symptoms such as diarrhoea
and increased peristalsis are absent. Under these
conditions the appearance of pain in the lower abdo-
men, as well as of tenderness in the ileocaecal region,
DIGESTIVE SYSTEM 153
seems to me of great importance; At any rate, great
caution is necessary in making the diagnosis in
patients having pulmonary tuberculosis.
THE COLIC OF PYLORIC STENOSIS.
Just as stenosis of the intestine may give rise to
attacks of colic more or less independently of the
nature of the obstruction, paroxysms of similar eti-
ology are occasioned when the pylorus is narrowed.
As is the case in the intestinal canal, internal ste-
noses induced by lesions of the mucosa produce the
most intense attacks of pain. Fresh pyloric ulcera-
tions are not necessary for this ; it is rather chronic
cicatricial inflammatory changes or malignant new
growths that are at fault. In short, the causes of the
obstruction may vary, but the pain phenomena in-
duced are the same. It therefore seems to me justi-
fiable to classify separately the paroxysms of this
type and to give them the new designation of pyloric
colic. In the pathogenesis of this it appears to me
that as in the stenotic colics in general the factor
of overdistention is of greater importance than that
of muscular spasm. The quality of the pain itself
and particularly the accompanying symptoms in ad-
vanced cases, such as visible peristalsis, leave no
doubt in regard to the underlying causes. At the
acme of the paroxysm the patients nearly always
complain of pain that is exquisitely colicky and grip-
ing in character and is associated with the sensation
"as if there were something alive in the stomach
region," "as if the stomach were contracting vio-
154 PAIN
lently and there were an obstruction to the exit of
its contents." The spasmodic attempts of the gas-
tric muscles to force the contents of the organ
through the stenosed pylorus manifest themselves
in this way and sometimes even the direction of peri-
stalsis from left to right is manifest to the sufferer.
The distention that is ordinarily also present gives
rise to an extremely disagreeable or even painful
feeling of fulness.
OBJECTIVE SYMPTOMS. Although the subjective
sensations of the patient depending on the underly-
ing conditions of spasm and overdistention give a
sufficiently clear picture of the actual condition, the
other objective symptoms banish all doubt, at least
in well-marked cases. The cardinal phenomenon is
the fact that the contours of the stomach are ren-
dered visible and palpable. At the same time gur-
gling and rumbling sounds may be heard. This so-
called rigidity of the stomach is often observed by
the patient himself as a " hardening" of the epigas-
trium, which is likely to be most marked on the left
side. It corresponds in time fairly closely with the
paroxysm of pain. The distended stomach does as a
matter of fact become harder to the touch and is
palpable as a mass resembling an inflated air-cushion
in consistency. This is a symptom that deserves
consideration in all cases of gastric pain in which
pyloric stenosis is suspected. If the abdominal
muscles are well developed and the stomach is not
greatly dilated the abnormal increase in peristalsis
may not be visible, but can be detected on palpation
DIGESTIVE SYSTEM 155
as a rapid change in the degree of tension of the
organ. In testing for this it is advisable to palpate
with the outspread fingers pressing vertically against
the abdominal wall, especially over the left half of
the epigastrium and below the left costal border.
In some cases, particularly if there is no gastric dis-
tention, an increase in the pyloric resistance may be
felt at the onset of the pain. The sausage-like trans-
verse mass so formed disappears again as the pain
subsides. If the stomach is more dilated and ap-
proaches the vertical in position peristalsis is often
most marked in the neighborhood of the umbilicus
and little eminences appear at either side of this.
More rarely the protuberance is in the neighborhood
of the gall-bladder. A similar observation is some-
times made by patients with gall-stones and is due
to a specie of erection of the gall-bladder. The
auscultatory manifestations have the same origin as
the visible and palpable phenomena and correspond
to the loud borborygmi accompanying intestinal
stenosis. They are caused by the gurgling of gas
through the narrowed pylorus and are ordinarily
followed by decrease of the tension of the gastric
wall and subsidence of the paroxysm of pain. The
evacuation of gas upward through the cardia has the
same effect. The violent peristalsis battling against
the pyloric obstruction also often produces eructa-
tions of sour material accompanied by retrosternal
pyrosis which may extend up into the throat.
Finally, there may be vomiting of an abundance of
material that is not bile stained, the act being usually
156 PAIN
followed by cessation or considerable diminution in
the pain, as opposed to the vomiting of biliary colic.
Although in the typical cases with marked dilatation
the large quantity of the vomitus, which comes up in
great gulps, and the facts that the material brought
up is almost never bile stained, frequently contains
old food particles and sarcinae, and is often hyper-
acid, usually make the recognition of the underlying
conditions easy, there are other instances in which,
in spite of years of stenosis, there is never vomiting,
no sarcinae are to be found in the gastric contents,
and there may also be no food residue in the fasting
stomach. In these cases there is probably a compen-
satory change without extreme stenosis, and instead
of dilatation there is rather a concentric hypertrophy
of the muscular layers. The absence of vomiting
may also be caused by perigastric adhesions, and in
such cases the careful study of the attacks of colic
may be of great diagnostic importance. Of other
symptoms frequently observed there may be men-
tioned the belching of gas having the odor of putrid
eggs (SH 2 ) ; the microscopical pendant to this is the
discovery of sarcinae. Another typical manifesta-
tion is the presence of gastric splashing, which may
be elicited at any time, and is often noticed by the
patient in walking. It is only rarely (in neuropathic
patients with an excitable vasomotor system) that a
short chill accompanies the attack of colic. Eleva-
tions of temperature do not go with the seizures of
pyloric stenosis, as opposed to biliary colic. Con-
stipation is a regular concomitant in almost every
DIGESTIVE SYSTEM 157
case of well-marked pyloric stenosis and is aggra-
vated at the time of the attack. The urine is often
reduced in quantity owing to the loss of fluid through
vomiting and is darker in consequence of its
concentration.
TIME OF ONSET. The time at which attacks of
pyloric colic occur is fairly regular. In most cases
the pain begins two to three hours after the midday
meal; more rarely after the lapse of one to four
hours. At this time the expulsion of the gastric con-
tents through the narrowed pylorus, or an attempt
at this, takes place. Gastric rigidity sets in and
gurgling sounds are audible, while' gas is belched up
and there are eructations of sour fluid. In short,
in typical cases there appear the various manifes-
tations of increased but ineffectual peristalsis. The
attacks often last from two to three hours and are
ordinarily terminated by the onset of copious vomit-
ing. These afternoon attacks depending on the in-
gestion of the midday meal are in many cases fol-
lowed by nocturnal seizures that are regular in
recurrence but do not exhibit a distinct connection
with the evening meal and have a greater resem-
blance to the more isolated and sporadic paroxysms
of biliary colic. In some cases this nocturnal type
even predominates. As in colic of other sorts the
attacks are most likely to occur at about midnight,
lasting several hours until copious vomiting relieves
the tortured patient from his pain.
TOPOGRAPHY. In regard to the situation of the
pain I should like to consider especially the ten-
158 PAIN
dency to radiation, which is also prominent, as is
well known, in gall-bladder colic. This appears
to depend in part on the degree of tension of the
stomach wall. On the evacuation of gas by belching,
there- is often abrupt cessation of the radiating pain ;
for example, that passing into the back. Several
types may be recognized from the topographical
standpoint, but they all have a stenosis of the pylorus
(cicatricial) as underlying cause.
1. Type of Pseudo- gall-stone Colic. The pain of
the attack begins in the epigastrium or in the pyloric
and gall-bladder region, and radiates into the right
lumbar region and right shoulder. It accordingly
simulates that of biliary colic, and error is to be
avoided only by a careful analysis of the attendant
circumstances, time of onset, etc. The difficulties
may be still further increased in those fortunately
rare cases in which pyloric ulceration through in-
fection, secondary duodenal catarrh, or adhesions
leads to lesions in the gall-bladder or gall passages,
and therefore causes jaundice.
2. Type of Gall-stone Colic tvith Left-sided Pain.
The pain begins on the left side of the epigastrium
and radiates into the left lumbar region, left shoul-
der, and possibly left breast. Owing to the left-
sided position of the distended organ this type
appears to be commoner than the preceding.
3. Type of Pseudo-girdle Pains. The pain be-
gins exactly in the middle line of the epigastrium
and extends in girdle form with equal intensity to
each side to the back. It may also radiate retro-
sternally and into both shoulder blades.
DIGESTIVE SYSTEM 159
4. Type of Diagonal Radiation. The pain be-
gins, for example, in the right half of the epigastrium
in the immediate neighborhood of the gall-bladder,
but radiates backward, especially into the left shoul-
der. Such left-sided radiation is of value in differ-
entiating the condition from the ordinarily right-
sided biliary colic.
MODIFYING FACTORS. In this connection mechani-
cal factors are of great importance, particularly in
regard to the position of maximum pain (cf. page
22). Lying on the right side is very likely to bring
on the pain or to increase it if already present. Dur-
ing the intervals between attacks this position is
often well borne, however. I have already indicated
my doubts in regard to the assumption that the ex-
planation is to be found in a simple settling or dis-
placement of the stomach contents on to the surface
of the ulcer or the cicatricial tissues. This view is
also opposed by the observation that in some cases
of ulcerative cicatricial pyloric stenosis the right
lateral position is well borne, but the left is accom-
panied by nausea, belching, etc., so that the patients
turn on the right side during the attack. Sometimes
in the course of the disease a change in the position
of maximum pain is observed so that for a time it
may be the right and later the left side. It has been
pointed out above that it is therefore much more
rational to consider that the effect of position de-
pends on kinking, traction, inflammatory adhesions,
etc. The part played by the overdistention of the
stomach in bringing on the attack is demonstrated
160 PAIN
by the fact that the belching of gas and vomiting
relieve or cut short the paroxysm. Many patients
instinctively massage the distended epigastrium or
they furnish a support to the anterior stomach wall
by pressure with the fist, and in this way favor the
evacuation of gas.
It is often possible to demonstrate the presence
of pyloric tenderness by percussion and deep palpa-
tion. Frequently it is more or less limited to a
point in the linea alba between the navel and the
xiphoid process. Sometimes there is tenderness of
the spinal column to percussion between the shoulder
blades. The influence of diet manifests itself in the
same way as spoken of under the heading of ulcer.
It is hardly necessary to emphasize the fact that
owing to the narrowing of the pylorus the ingestion
of foods tending to produce distention or fermenta-
tion is very likely to cause gastric meteorism, and
that these are particularly to be avoided. The fol-
owing articles are nearly always very badly borne:
Potatoes, turnips, uncooked fruit, cabbage, smoked
meat, and fatty foods in general, as well as pastries
prepared with yeast, and alcoholic beverages, espe-
cially sour wines. Foods that agree well are thick
rice soup, spinach, potato puree, tea with milk, milk
dishes, chopped ham, etc. The drinking of large
quantities of fluid is always of untoward effect.
In speaking of thermic stimuli I wish only to
point out that in those cases of pyloric colic accom-
panied by considerable distention of the stomach,
DIGESTIVE SYSTEM 161
the application of cold, possibly through its tonic
effect in encouraging contraction, seems to be more
beneficial than the various warm applications ordi-
narily used in attacks of colic. In some such cases I
have seen heat not only unproductive of relief but
the patients have even complained of increase in
their sufferings. Internally, lukewarm drinks are
to be recommended.
What was said concerning the effect of the func-
tions of other organs on the pain of ulcer is also ap-
plicable here. The indication for careful regulation
of the intestinal functions is the more important
since the tendency to gastric meteorisin is evidently
more pronounced than in cases of ulcer not accom-
panied by stenosis. There is no doubt in regard to
the effect of constipation in increasing pain. Psy-
chical factors, such as overwork or excitement, fre-
quently cause the attacks to recur at shorter
intervals. Disregard of this fact might make con-
fusion with functional conditions likely.
DIFFERENTIAL DIAGNOSIS. The possibility of mis-
taking pyloric colic for biliary colic is particularly
great in those cases in which the characteristic evi-
dences of pyloric stenosis, such as gastric rigidity,
very copious vomiting, etc., are absent, or in which
jaundice appears as a result of secondary duodenal
catarrh. Sometimes, though fortunately rarely, the
two conditions occur in combination. Some of the
more important differential signs may be summar-
ized in the following table:
11
162
PAIN
PYLOBIC COLIC.
Active borborygmi in the epi-
gastrium.
Distention, most marked below
the left costal border.
Acid eructations with heart
burn; copious vomiting of
strongly acid material that
is not bile stained but con-
tains sarcinae and possibly
particles of old food.
Eructations smelling of SH 2 .
Copious vomiting or eructations
of gas are followed by a
marked diminution in pain.
Usually no chill.
The fasting stomach contains old
food.
Attacks are very numerous,
often occurring daily for
weeks and months.
The pain tends to radiate to the
left.
The attacks regularly begin two
to three hours after the
midday (or largest) meal.
Foods causing gas formation
tend to increase the pain.
Attacks of colic are sometimes
brought on by lying on the
right side.
Local anaesthetics relieve the
pain.
BILTABY COLIC.
Swelling in the gall-bladder
region.
Vomiting of bitter material that
is bile stained and is not
very great in amount.
Vomiting has no noteworthy
effect on the pain or it may
even increase it.
Often a chill followed by eleva-
tion of temperature.
Attacks are sporadic, frequently
with intervals of several
months.
Tends to radiate to the right.
Irregularity in time of onset, or
a longer interval after eat-
ing (about 5 hours).
The nature of the food is of
comparatively slight effect.
The left lateral position is often
badly borne and is accom-
panied by a feeling of pain-
ful traction on the right.
Urine contains bilirubin or uro-
bilinogen.
Numerous as the differential signs are, it may in
some cases be exceedingly difficult to distinguish be-
tween these widely separated pathological condi-
tions. On the one hand, there are cases of very slight
DIGESTIVE SYSTEM 1C3
pyloric stenosis in which there is good compensation
and the objective cardinal symptoms are absent or
few, but in which, possibly in consequence of gen-
eral irritability of the nervous system, the attacks
of pain may be extremely severe ; while on the other
hand cholelithiasis may be accompanied by symp-
toms such as gastralgia, or pain due to-' adhesions
between gall-bladder and duodenum, which arouse
the suspicion of a pyloric stenosis due to ulceration.
Finally, of course, the two conditions may coexist.
Tuberculous Intestinal Ulceration. Ulcerative
processes in the small intestine causing stenosis
may give rise to error, particularly if the intestinal
symptoms are not well marked. So in one case
observed by the author which came to operation, the
stools were normal, gastric symptoms, comprising
dilatation with persistent splashing, vomiting, etc.,
were prominent, the effect of diet was as in pyloric
stenosis, but the condition was one of very slight
chronic intestinal stenosis due to tuberculous ulcera-
tion. In this connection attention should be directed
to pain in the lower abdomen, which generally does
not occur in pyloric colic. On the other hand, I
attach little diagnostic value to visible intestinal
peristalsis of slight degree, particularly if the ab-
dominal wall is relaxed and thin. I have frequently
seen this at the acme of gastric peristalsis in un-
doubted cases of pyloric stenosis, and regard it as
being due to a sort of sympathetic activity. Further
differential points may be found in the chapter on
gastric ulcer.
164 PAIN
GASTRIC CANCER.
In view of the various anatomical lesions accom-
panying the development of gastric carcinoma, such
as pyloric stenosis, ulceration, perigastritis, meta-
stases in the liver, retroperitoneal glands, etc., as
well as direct extension to neighboring structures,
it might well be expected that the course of the dis-
ease would be accompanied by pain. As a matter
of fact this is true in a certain number of cases, and
the character of the pain as well as its modifying
factors often indicate the manner of its causation.
PAIN AS AN EARLY SYMPTOM. While pain not
rarely begins very early, often at a time at which
anorexia has not yet set in and the general condition
is good, this is to be explained by the fact that in
most such instances the growth has commenced very
near the pylorus and is causing obstruction at that
point. This stricture of the pyloric region, which
at first is probably purely spasmodic, manifests itself
in a series of subjective sensations which, according
to the degree of stenosis and other circumstances,
such as the motility and total acidity, closely re-
semble those described in the section on pyloric colic.
At any rate, these subjective sensations precede the
objective evidences of pyloric stenosis, such as gas-
tric rigidity, by a considerable period of time, and
this very fact gives them a distinct importance.
This spontaneous pain due to the early onset of
pyloric stenosis may be contrasted with other arti-
ficially evoked pains that indicate ulceration and are
the result of the anatomical process (new growth
DIGESTIVE SYSTEM 165
formation and ulceration) per se. We must there-
fore- discuss :
I. Pain due to the local process, which usually
leads to pyloric stricture.
II. Pain caused by the local invasion of other
organs, or distant metastases.
III. Pain resulting from inflammatory complica-
tions, such as perigastritis and local or diffuse
carcinomatous peritonitis.
I. A priori it might be expected that the phe-
nomena comprised under this heading would be iden-
tical with those described in the section on pyloric
stenosis which was devoted to the benign cicatricial
stenosis. One would suppose that the malignancy
of the ulcerative process would not alter the char-
acter of the pain. In fact, there are cases of gastric
carcinoma which during their entire course are ac-
companied by just such painful phenomena, pecu-
liarities of radiation, etc., as were described in the
chapter referred to. In general, however, the inten-
sity of the spontaneous attacks is less and the
progress of the stenosis and increased activity of
peristalsis are often accompanied by a marked de-
crease in the pain, so that it may be said that be-
nign pyloric stenosis is much more painful than the
malignant form. The rather paradoxical-appearing
fact that the malignant stenosis is exceeded in pain
by the benign process is readily explained on more
careful consideration. The mere decrease in appe-
tite accompanying carcinoma causes dietary errors
which are so often responsible for attacks of colic
166 PAIN
in benign stenosis to be much rarer. In addition
the musculature of the carcinomatous stomach early
becomes atonic, whereas in ulcer it is more likely
to be hypertonic, or at least in a condition of irritable
weakness, which renders it easily excitable and prone
to spasm. At the very beginning of the affection
the pain in carcinoma may present great similarity
to that of ulcer. While the appetite is still good, the
dietary is not appropriately restricted, and therefore
the early stages of a carcinoma are sometimes accom-
panied by very intense pain. One of the most fre-
quent initial symptoms of cancer of the stomach is
a sensation of pressure in the epigastrium, usually
occurring about half an hour after eating. Some-
times this is simply a disagreeable, uncomfortable
feeling, but in others it already has the quality of
pain. The patients often speak of "a heaviness in
the stomach." This sensation of fulness, tension, or
pressure in the epigastrium, sometimes accompanied
by " burning," appears to correspond to the first
degree of commencing narrowing of the pylorus, and
may be the result of a functional spasmodic stenosis,
for at this time other objective symptoms of perma-
nent organic stricture are usually absent. Some-
times it is possible at the moment of appearance of
this sensation, which frequentty lasts for only a
short time, to detect a momentary air-cushion resist-
ance in the epigastrium due to a wave of contraction
of the organ. If the stenosis increases, stronger
contractions striving to overcome the obstruction
appear, and these are manifested to the patient as
DIGESTIVE SYSTEM 167
pains of a knife-like boring and twisting character.
Sometimes the sensation is described "as if a ball
were rolling around." These are true colic pains
and the spasmodic contraction in the epigastrium
may become exceedingly violent; in such cases it is
usually followed by vomiting.
ACCOMPANYING SYMPTOMS. These variously
graduated sensations, ranging from a simple feeling
of pressure to colicky pain, may be accompanied
by other manifestations also differing in intensity.
The slight initial grades of stagnation and the sub-
jective sensation of simple pressure, which often is
not really painful, may be accompanied by eruc-
tation of small quantities of acid fluid, frequently
accompanied by heartburn, or there may be belch-
ing of odorless gas; while in benign stenoses the
gas has the odor of putrid eggs (SH 2 ). Copious
vomiting, or indeed vomiting at all, does not usually
occur during this initial stage of epigastric pressure
after eating. It has already been pointed out that
not infrequently advanced malignant stenoses ex-
hibit a contrast between the intensity of the stenosis
and the slightness of the pain, and an explanation
for this has been offered. If a benign stenosis be-
comes malignant an apparent improvement may re-
sult, as the attacks of pain sometimes become less or
cease entirely. It may also be mentioned that in
malignant stenosis bile-stained, yellow-colored vomi-
tus is more frequent than in cases of benign stricture,
owing to the absence of marked pyloric spasm in the
former condition.
168 PAIN
The vomiting of a coffee-ground character, which
occasionally accompanies the benign stenoses, has
been mentioned above. In the stage of simple epi-
gastric pressure, anorexia is not usually present.
On the other hand, there is a certain amount of intol-
erance for meat and solid food, especially cooked
food, and, even earlier, intolerance for vegetables
and for beer. Sluggishness of the bowels deserves to
be mentioned as a symptom which is occasionally
very early in its occurrence and is rarely absent in
the later stages.
Chemical and microscopical examinations of the
stomach contents are rarely decisive during this
initial stage of subjective symptoms. It is always
well to note the presence of slight bulging of the
epigastrium, especially in its left half, which repre-
sents a rudimentary peristalsis and is present espe-
cially after the taking of food. This symptom, of
course, as well as the rigidity of the epigastrium
which comes a little later, depends more or less upon
the development and natural stiffness of the abdom-
inal muscles.
Occasionally the colicky pains occur two or three
hours after meals. In other cases they show a de-
cidedly nocturnal type (eleven o'clock at night, last-
ing until about two A.M.). Frequently, however,
they follow directly upon the taking of food. The
feeling of heaviness, especially, occurs either imme-
diately upon, or within a half hour after, the taking
of food. Only in very rare cases are these pains
postponed for a longer interval than six to seven
hours after a large meal.
DIGESTIVE SYSTEM 169
In regard to the abdominal regions involved, a
great similarity with the previous conditions may be
observed. In many cases, for instance, there is a
definite relation between the posture of the patient
and the pain. When the patient lies on the right
side, there is commonly an increase of pain, abdom-
inal bulging, and nausea. Here, as in the case of the
pain accompanying pyloric stenosis, the suffering is
immediately ameliorated by the belching of gas and
by vomiting. In every respect where the mechanical
agencies are involved the analogy of this condition
with pyloric stenosis is so close that the subject can
be dismissed by referring to the chapter on pyloric
stenosis.
There is a marked similarity also in regard to the
influence of diet upon the pain. The sensations of
pressure and of hunger which so frequently occur
in neuroses of the stomach, in which the pain is
alleviated by the taking of food, occur but rarely in
this condition. It is an almost invariable rule that
food increases or begins the pain, and in this respect
the quality of the food plays a very important role,
the most troublesome articles of food being boiled
beef, heavy vegetables, rye bread, and fluids of all
kinds, especially beer and acid wines.
We have still to consider th'e localization of the
pain, and in this connection we must differentiate
between
(a) Subjective pains, and
(b) Objective pains produced by pressure and
percussion.
170 PAIN
(a) Subjective Pains. The pain is usually pro-
jected forward into the epigastrium. More rarely
it is situated retrosternally under the lower half of
the sternum. In the epigastrium there may be vari-
ations in the position of the pain just as in gastric
ulcer. In some cases the left side of the epigastrium
becomes the most painful area; in other cases the
mid-line is the seat of greatest pain; and, again,
in other cases, the suffering is chiefly localized over
the pyloric region. The subjective pain may remain
localized here, or, just as in benign stenoses, it may
radiate especially into the loins and back, toward
the hypochondriac regions, and occasionally even
into the shoulder blades. The pain which occa-
sionally is noticed as radiating up behind the ster-
num into the throat is usually accompanied by re-
gurgitations of the acid stomach contents, and may
easily be controlled by small doses of alkalies.
Those pains in the back which are produced by a
pyloric stenosis and secondary dilatation of the
stomach as such, and not by metastases, are in
direct proportion to the epigastric pains, are in-
creased and decreased with these, and are simply
backward radiations of these pains. Their appear-
ance seems to be favored by constipation and they
disappear with thorough emptying of the bowels.
Such pains may occasionally be produced when the
stomach is artificially inflated, a fact which may be
regarded as important in clearing up the mechanism
of such sensations.
DIGESTIVE SYSTEM 171
(b) Objective Pains. Not infrequently it is pos-
sible to map out by palpation, and occasionally even
by percussion, a definite hyperaesthetic zone in the
epigastrium, which frequently corresponds to the
position of the tumor. In those cases where a tumor
is impalpable on account of its small size or of great
muscular development of the epigastrium, the local-
ization of such a hyperaesthetic area may, if cau-
tiously interpreted, give much diagnostic aid. If
such a zone be placed asymmetrically on the left or
right side below the costal border, it will be more
worthy of notice than if placed mesially.
As in gastric ulcer, the vertebral column in its
interscapular and dorsolumbar regions, as well as
in the left lumbar region, is frequently painful to
percussion.
II. Following the classification proposed above,
we are now about to deal with those painful sensa-
tions which depend upon local extension of the proc-
ess as well as upon metastases into other regions.
These are, of course, of much less importance, since
we are no longer dealing with early symptoms ; on
the other hand, they will find further mention when
we reach the discussion of organic pains of other
regions (hepatalgia, etc.).
These pains, in contradistinction to those dealt
with above, are differentiated in general by their per-
sistence and by their independence from digestive
influences, so that even when localized in the epigas-
trium (metastases into the liver, pancreas, and
glands), they are easily separated from the pains
previously described.
172 PAIN
III. Tnfla.TnTna.tory complications are often the
basis for the pains occurring with gastric carcinoma ;
these may be more or less local, as in fibrinous or
purulent perigastritis, or diffuse, as in carcino-
matous peritonitis.
The new growth itself does not seem to be par-
ticularly sensitive to pressure. In cases where a
more severe sensitiveness to pressure exists, we are
usually dealing with a superimposed inflammatory
process in the ulcerated tumor mass. A localized
peritonitis may occasionally be evidenced by a
noticeable leather-like creaking brought out by pal-
pation. The motion of the tumor mass in such cases
produces pain by rubbing against the inflamed por-
tions of the peritoneum. This may be brought about
by coughing, bending forward, pressure during defe-
cation, deep breathing, etc.
Eapid changes of position also (from the dorsal
position to the right or left) may in the same way,
by producing sudden motion of the tumor, give rise
to local pain. Whenever the perigastric process
extends, giving rise to subphrenic abscesses or to
pleurisy, which seems to occur usually on the left
side, pain will occur, on this side in the lower inter-
costal spaces, in addition to the epigastric pain.
But in cases where the peritoneum, as a whole,
is involved in the carcinomatous process inflamma-
tory changes usually take place and give rise subjec-
tively to general abdominal tenderness, and to a
painful sensation of general distention.
DIGESTIVE SYSTEM 173
The pain which depends upon peritoneal involve-
ment may frequently be influenced by local treatment
(sapo kalinus, tincture of iodine, alcoholic com-
presses, etc.) ; on the other hand, lavage, which fre-
quently relieves pains due to stagnation in the
stomach and overdistention of its walls, increases
the pain when we are dealing with a perigastric con-
dition, in that it is contrary to the first principle
of treatment in inflammatory processes, i.e., immo-
bilization.
It is only after a careful consideration of all the
elements involved, and a careful physical examina-
tion, that we can reach the conclusion that certain
pains are due to the development of a gastric carci-
noma. Of the most practical importance are the
epigastric sensations which have been described un-
der I., and which appear at a time when other symp-
toms, such as anorexia, progressive emaciation,
achlorhydria, etc., are still absent, and the patient
is as yet unaware of any severe illness.
In this connection all those conditions which have
been mentioned under gastric ulcer and pyloric
stenosis must again be considered in making the
differential diagnosis. The greatest difficulty will
be encountered in the exclusion of gastric ulcer, both
in its development and in its recurrence. Suspicions
of carcinoma will be strengthened when the general
symptoms of gastric ulcer and anorexia persist, in
spite of rest in bed and regulation of the diet. Diffi-
culty may occasionally be experienced in separating
carcinoma of the stomach from the dyspepsia which
174 PAIN
accompanies cases of chronic tuberculosis. This
may occur with but slight involvement of the lungs
and may give rise to such extreme anorexia and
progressive emaciation that the suspicion of early
carcinoma is aroused. These cases, however, are
rarely accompanied by the attacks of spontaneous
epigastric pains which characterize gastric carci-
noma. Even in tuberculosis it is not rare to find
epigastric tenderness, and this is easily explained
by oversensitiveness at the points of insertion of the
rectus muscle, produced by severe paroxysms of
coughing.
INTESTINAL ULCERATION.
Ulcerations of the gut give rise to more or less
characteristic phenomena of pain, though they do
this less regularly than do ulcerations of the
stomach. Tuberculous ulcerations are the most fre-
quent, and they may be taken as an example of
intense intestinal ulcerative and obstructive condi-
tions throughout. Tuberculous ulcerations, how-
ever, give rise to attacks of pain more characteristic
than those arising from other intestinal ulcers (for
instance, those of typhoid and dysentery). The ex-
planation for this may be easily found in the fact
that they have a greater tendency to produce ste-
nosis, and that during their existence the pain is
less definitely under dietetic control than is gener-
ally the case in typhoid and dysentery.
Similarly to gastric ulcers, the tuberculous ulcera-
tions of the gut may remain entirely latent. This,
DIGESTIVE SYSTEM 175
however, is not frequently the case. The production
of stenosis is here, as in conditions of the stomach,
one of the chief causes of pain; added to this, of
course, are the conditions of enteritis, abnormal fer-
mentation, and the peritoneal lesions produced by
perienteritis.
The pain accompanying stenoses is closely analo-
gous to the colic resulting from pyloric stenosis.
Even the localization of the pain is occasionally very
similar, so that the patient when consulting the
physician describes it as epigastric. Spontaneous
pains frequently begin in the epigastrium. Badia-
tion, in these cases, towards the ileocaecal region is
of considerable importance, since such radiation is
very uncommon in gastric conditions. This may be
due to the anatomical position of the lesion, since
the ileocaecal region is involved with special
frequency.
Pain is noticed in the umbilical region rather
more frequently than in the epigastric ; here it may
occur to the right or left of the mid-line, and may
extend to both sides, encircling the body. The most
common seat of the pain, however, is the hypogastric
region, and here it occurs especially in the right side.
The pain is usually projected forward ; it rarely
is localized in the back ; but when it is, the posterior
pain is always accompanied by the anterior pain,
and is directly dependent upon the taking of food.
The objective pains produced by pressure or per-
cussion generally correspond, in localization, with
the subjective ones; therefore the ileocaecal region
176 PAIN
is almost always sensitive. This is likewise true
of the hypogastrium, especially when there is dis-
tention. There is frequently a well-localized pain-
ful zone in the neighborhood of the umbilicus which,
especially if situated above the umbilicus, gives rise
to a suspicion of gastric ulcer. In such cases it is
important to determine whether or not this area of
pain is situated above or below the major curvature
of the stomach.
The time of occurrence of the pain is, in many
cases, in direct relation to the taking of food. This
is especially noticeable in connection with the large
meal in the middle of the day, which is followed,
with more or less regularity, within one half to one
hour, by attacks of pain which may last for several
hours. While the length of this interval between
the meal and the onset of pain varies greatly in dif-
ferent individuals, there is great constancy in the
duration of the interval in the same individual, in
that attacks occur in one case with great regularity
in from three to four hours, in other cases in from six
to seven hours after meals. Whenever a very short
time elapses between the meals and the appearance of
the pain, we are undoubtedly dealing with a stimula-
tion of intestinal peristalsis produced by the food
still remaining in the stomach; and it is this peri-
stalsis which produces the pains in the ulcerated
area. It is important to note that patients with this
form of intestinal ulceration may experience entire
freedom from pain during intervals often lasting
for months. As the disease progresses, these free in-
DIGESTIVE SYSTEM 177
tervals become shorter and shorter, until the attacks
are of daily occurrence ; this is due, of course, to the
constantly increasing stenosis.
Mechanical Considerations. Since the condition
is most frequently localized in the ileocascal region,
the pain is usually most severe in this region. Thus
the patients, when lying on the left side, complain of
feeling as though something were being drawn from
the ileocsecal region into the left side, while when
lying on the right side the pain is directly localized
in this region. In general, the position on the left
side is less painful than that on the right. This is
undoubtedly due to the traction brought about by
the weight of the diseased gut and of the involved
glands, a traction which is the more painful because
peritoneal inflammations and adhesions are com-
paratively frequent.
The condition may be confused with cases of
acute and chronic appendicitis where the same pecu-
liarities as to the relation of pain and position are
present. This error is more easily made because
in both of these conditions the patient will be re-
lieved by flexion of the right leg at the hip through
relaxation of the abdominal muscles during the
attacks.
The pain which is elicited in circumscribed areas,
especially the hypogastric and umbilical regions, by
jarring of the body, as in coughing, walking down-
stairs, rapid turning and deep inspiration, is easily
explained by the correspondingly localized inflam-
matory processes in the peritoneum,
12
178 PAIN
A number of other minor symptoms unquestion-
ably depend upon the fact that the intestinal pain
is frequently accompanied by local or general dis-
tention. Thus the patients, during their attacks,
rub the hypogastrium, place their hands upon their
hips and turn the trunk upon the pelvis in an in-
stinctive attempt to cause a general distribution of
the local distention. The same fact explains the
relief produced by enemata, by vomiting, or by the
discharge of gas per os or per anum, all of which
bring about a relief of the distended intestinal wall.
The influence of the diet upon the pain is depen-
dent upon this very question of distention; and the
same conditions which we considered in speaking of
gastric ulcer and of pyloric stenosis must be taken
into account here. In the first place, those articles
of diet which give rise to fermentation will cause
pain. Chief among these are cabbage, turnips, len-
tils, potatoes, pastries prepared with yeast, rye
bread, beer, not infrequently milk, and furthermore
all those articles of diet which are apt to constipate.
Great pain can be produced by those articles of
diet which produce active peristalsis when present
in the stomach; this probably explains the attacks
of pain which regularly occur a few minutes after
the ingestion of ccld beverages (water, milk), strong
coffee, and certain drugs, as thiocol; on the other
hand, these very articles which stimulate peristalsis
may aid in relieving local distention and thus have
the opposite effect. Direct chemical irritation of
the ulcerated areas probably occurs very rarely;
DIGESTIVE SYSTEM 179
but if it does occur this may explain the production
of pain by very acid food such as salad. More fre-
quently mechanical injury may be caused by the
ingestion of solid food, especially raw fruit ; so that
in general a fluid or semi-solid diet is to be preferred.
It is self-evident that the quantity of food intro-
duced may, by its filling of the intestine, become a
serious consideration in the production of pain.
Just as the introduction of cold substances may
produce pain by their active stimulation of peri-
stalsis, so also thermic influences brought to bear
from without may play a similar role.
Chilling of the feet seems to have special in-
fluence in initiating attacks of pain. Thus attacks
may be brought on by walking upon a cold floor with
bare feet. This is, in general, a peculiarity of pains
due to intestinal peristalsis and may have a certain
amount of differential value. Applications of cold
compresses to the abdomen, in that they relieve dis-
tention, usually have a favorable influence; while
the application of heat often increases the pain.
The secondary symptoms are especially impor-
tant because they so frequently give rise to errors
in diagnosis.
The importance of this fact is well illustrated by
those cases of tuberculous ulceration which are
accompanied by gastric symptoms, vomiting and
belching. The vomiting is often in large quantities,
and in the vomitus there are frequently particles
of food which have been ingested several days be-
fore. In these cases we are unquestionably dealing
180 PAIN
with stagnation in the stomach, secondary to the ob-
struction in the gut. The very facts that the vomit-
ing is copious, that the microscopical examination
points to stagnation, and that the clinical signs
obtained on palpation indicate moderate dilatation,
may give rise to the erroneous diagnosis of pyloric
stenosis. This error may be more easily made since
the pain in these cases is often localized in the epi-
gastrium, and occasionally there may be an entire
absence of symptoms referable to the intestines,
such as diarrhoea, or even irregularity of the bowels.
We have already pointed out the great similarity
which may exist between the two conditions in re-
gard to the influence exerted upon the pains by the
diet.
In doubtful cases it is particularly important to
remember that, in contrast with pyloric stenosis,
the vomitus frequently contains bile, and the pains
are radiated either into the hypogastrium, or, more
frequently, into the ileocsecal region. The discovery
of sarcinae in the vomitus is pretty positive indica-
tion of the gastric nature of the condition.
Diarrhoea, especially the very foul variety which
occasionally accompanies tuberculous ulcerations, is
almost unknown in cases of pyloric stenosis. These
are almost invariably accompanied by constipation..
For this reason, too, the succussion noticed occasion-
ally in cases of tuberculous ulceration is extremely
rare in pyloric stenosis. Withal it must not be for-
gotten that both conditions may occasionally be pres-
ent at the same time.
DIGESTIVE SYSTEM 181
It is sometimes extremely difficult to distinguish
the condition under consideration from acute or
chronic appendicular inflammations. This is true
particularly because the point of maximum tender-
ness may often be located in the right ileocaecal re-
gion, and parsBsthetic sensations may occur on the
inner surface of the right thigh. Flexion of the
right leg at the hip during the attacks and slight
distention of the right ileocaecal region aid in confus-
ing the picture. Occasionally bladder symptoms are
present, due to pressure of the full bladder upon the
inflamed parts.
Great help can be derived in such a confusion of
evidence from a positive diazo reaction ; in contrast
to appendicitis, too, ulcerations of the gut even dur-
ing the colicky attacks may be entirely free from
temperature. Added to this we may have a previous
history of long-continued symptoms of slight intes-
tinal obstruction and the general evidences which
point to tuberculous trouble, night-sweats, pul-
monary symptoms, etc.
In those cases in which the stenosis is slight, vis-
ible peristalsis is often limited, and is noticeable par-
ticularly in the ileocsecal region and in the immediate
neighborhood of the umbilicus. The peristalsis is
often accompanied by crackling sounds produced by
the passage of gas through the stenosis, which is fol-
lowed by relief from pain as the pressure upon the
overdistended gut is diminished. While occasion-
ally slight chilly feelings, or in severe cases even col-
lapse, may occur in this condition, a true shaking
chill is extremely rare.
182 PAIN
It would be impossible to review all the condi-
tions which make a differential diagnosis in this con-
dition difficult. It is, however, advisable to be sus-
picious of tuberculous ulceration of the gut in all
those cases of abdominal pains of colicky nature in
which there are any other factors in the history or
in the physical examination which point to a tubercu-
lous tendency in the patient.
DISEASES OF THE APPENDIX.
It is not wise to speak in a vague way of ' ' appen-
dicular colic." The acute or chronic inflammatory
conditions of the appendix originate from a variety
of causes, and it is necessary to understand clearly
the pathological basis of the pains which occur in
each of these conditions in order to draw diagnostic
conclusions from them. It is generally assumed that
the colicky pains in appendicular conditions are
primarily due to the intra-appendicular pressure of
inflammatory exudates, which cause contractions of
the musculature, and a condition not unlike neural-
gia. This is an assumption which has much in its
favor and cannot be dismissed lightly. This explan-
ation of the pains, however, is entirely insufficient
for the more chronic conditions where the appendix
is well imbedded in the surrounding inflammatory
thickenings. Here, of course, distention of its
lumen and contraction of its muscular walls are
quite out of the question. I should like to suggest
that it is quite possible that many of these so-called
cases of appendicular colic are nothing more than a
DIGESTIVE SYSTEM 183
simple intestinal colic reflexly initiated in the appen-
dix. In these cases intestinal inflammations seem
frequently to have preceded, the attack of appendi-
citis occurring during an acute exacerbation of
these. This assumption would be supported by
the frequency with which the parasitic flora of the
feces is changed from the normal in cases of appen-
dicitis, and would explain the previous diarrhoeas
which often are present during the early develop-
ment of appendicitis.
Comparison of the pains in appendicitis with
those in tuberculous ulceration of the intestine
shows many points of similarity. Distinction be-
tween the conditions would be almost impossible, as
far as the pains themselves are concerned, were it
not that in contrast to the intestinal pains of other
diseases, in appendicitis we have added the pains
due to peritoneal inflammation, and from this a
number of important differential symptoms can be
deduced.
The early pains of appendicitis rarely corre-
spond in localization to the position of the appendix.
Usually the pains begin diffusely in the umbilical
and hypogastric regions, occasionally in the epigas-
trium, and differ in nothing from the pains of ordi-
nary intestinal colic following errors of diet, or
acute gastro-enteritis. The suspicion of appendi-
citis at this stage is not aroused by the character of
the pains but depends upon the secondary symptoms,
such as temperature, etc., and the absolute absence
of the usual causative agents of intestinal colic. It
184 PAIN
is only the rare cases which begin with a localized
pain over the appendix, or even with a distinctly
right-sided pain. Occasionally, there may appear
radiations of the pain into the right inguinal or
lumbar regions, and this seems to depend upon a
retrocaecal position of the appendix. It is extremely
important in these cases to determine whether or
not there is radiation into the right thigh. This is
not often found, but when present may be regarded
as characteristic of true appendicular colic, since
it never occurs in the ordinary pains of intes-
tinal peristalsis. The more irregularly localized
pains which occur in this condition are probably
never entirely of appendicular origin. In contrast
to them, however, we have pains which are due to
the localized peritonitis or peri-appendicitis, and
these are situated more exactly over the position of
the appendix. Extension of such processes and the
formation of abscesses will lead to pressure pains
in the right inguinal region, as well as to extreme
tenderness upon rectal examination (abscess in the
pouch of Douglas). These local peritonitic pains
are very sharply denned, and are of extreme im-
portance in differential diagnosis.
There are three principal elements which under-
lie the causation of pain in such conditions, which
will have to be discussed in greater detail.
1. PRESSURE. There is, almost invariably, pain
upon pressure in the ileocsecal region corresponding
to the location of the disease. This pain is subject
to wide variations in intensity. It is usually great-
DIGESTIVE SYSTEM 185
est during the stage of abscess formation, when
the abscess wall is subject to great distention. In
such cases the slightest pressure, even the weight of
the bed-clothes, will be marked by extreme agony.
Pain upon pressure may occasionally exist in the
right flank as well, especially in cases where abscess
formation occurs retrocsecally. When the tender-
ness is situated high up under the right costal bor-
der, it is probable that the pain is chiefly of peri-
toneal origin. It has frequently come to my notice,
however, that when the bowels have been freely
moved by an enema (for instance, five grams of glyc-
erin) the sensitiveness diminishes immediately upon
reduction of the distention. This indicates unques-
tionably that the pressure of the distended intes-
tinal walls upon their inflamed serous coverings
may play an important role in the mechanism of
these pains; this may also explain those less fre-
quent cases in which the sensitiveness to pressure
is greater over the left half of the abdomen above
Poupart's ligament, than on the right, intestinal
distention being more intense on that side. When
the appendix itself is pressed upon, radiation of the
pain often occurs towards the epigastrium and into
the left hypogastrium.
We have already considered the more or less
traumatic pains produced by examination. Spon-
taneous movements of the patient produce pain in
the same way, especially contraction of the abdom-
inal and pelvic muscles. Thus the first pains fre-
quently occur in the ileocaecal region when the
186 PAIN
patient stoops, sits down, sits up in bed, lifts a
weight, or bends the body back upon the hips.
Sometimes even the lifting of the head when in the
prone position will give rise to pain. More particu-
larly, however, pain is caused by contracture of the
right ileopsoas (produced by the bending of the right
leg upon the hip). This motion gives rise to pain
in the ileocascal region, especially severe when the
abdominal muscles are contracted. The pains,
therefore, would be greater when, the patient is
standing, walking, or climbing stairs than when he
is lying down, for in these positions the diseased
tissues are compressed between the contracting ileo-
psoas and the contracting abdominal wall. It is
important to remember this when testing pain on
flexion of the right leg, for even during the exist-
ence of an appendicitis such motion of the right leg
when the patient is lying down may be entirely with-
out pain, while the same motion may be very painful
when the patient is standing or walking. Thus this
symptom of hip flexion is entirely dependent upon
the position of the body. In some cases it can be
elicited only when the patient is lying on his left side.
The first indication of appendicular pain has often
occurred during the drawing on of shoes, and here
again it is unquestionably a pressure pain, since the
patient in carrying out this motion lifts the right
leg and produces a contraction of the corresponding
pelvic muscles. While this symptom is apparently
trivial, it is so frequently the first indication of early
appendicular trouble that it may become extremely
important in differential diagnosis.
DIGESTIVE SYSTEM 187
In some cases of early appendicitis the pain is
markedly increased when the patient is lying on the
right side, and this again is due to pressure upon the
inflamed parts. Because of the pain caused by these
muscular contractions, the patient involuntarily re-
laxes these muscles and thus many patients with
appendicitis bend forward when walking or bend
toward the right side, or, when lying down, draw up
the right thigh and arouse by their very position the
suspicion of appendicitis.
2. JARRING. For diagnostic purposes the most
practical way of producing jarring of the abdomen in
the ileocaecal region is by percussion. With its help
a very exact demarcation of the area of pain can be
made, and it is much to be preferred for this purpose
to simple palpation. The pathological basis of pain
produced by jarring is probably the same as that of
the pressure pains. Percussion in the mid-line is
often more painful than on either side of the line be-
cause of the absence in this location of muscular
defenses. Other forces which actively cause jarring
of the abdomen are coughing, stepping on the right
leg in going downstairs, jumping, etc. In all these
cases pains are produced in the appendicular region
which are of a sharp, boring nature. This method
of pain production is frequently possible before
other symptoms have occurred.
3. DISPLACEMENT. Under this heading we will
consider chiefly those tearing pains which are pro-
duced in certain positions of the body by the weight
of the diseased organs. It is not surprising that the
188 PAIN
slightest displacement of this kind should cause pain
when we consider that we are dealing with fresh in-
flammatory adhesions. This must be our interpre-
tation of the pains complained of by patients who
are unable to lie upon the left side, and who inform
us that, in this position, they feel a painful drawing
as though something were falling from the right to
the left side. When the peritoneal process has ex-
tended into the left side the same variety of pain
may be caused by the right-sided position. It is
clear that such pains must be primarily influenced
by two factors :
(1) The closeness with which the abdominal
organs are held together. For instance, when the
abdominal muscles are flabby and weak, and the
viscera are in consequence very loosely packed to-
gether, even the slightest change of position will
give rise to displacement.
(2) The formation of a tumor in the ileocaecal
region, either in the form of exudate or of enlarged
glands. When the patient is lying on the left side
the weight of the tumor mass will exert considerable
traction, a traction which may, however, be exerted
by the weight of the intestinal contents themselves.
The pains described in the foregoing paragraphs
are all referable to the localized peritoneal inflam-
mation.
The general intestinal pains which are added
to those of more purely appendicular origin are
difficult of interpretation. It is not easy to say
whether the basis of these lies in the appendix itself,
DIGESTIVE SYSTEM 189
or whether they are to be regarded as an accompany-
ing intestinal colic. The localization of these colicky
pains aids us but little in determining this. At any
rate, it seems wise to restrict the term " appendicular
colic ' ' to those cases only in which, with other symp-
toms of appendicitis, sudden colicky pains occur
spontaneously without previous reference to pre-
vious dietetic errors or other causes.
More frequently, however, the beginning of the
colicky attacks is directly dependent upon intestinal
disorders, especially those following errors in diet,
and it would be hard to understand how such influ-
ences could affect the appendix itself. The fact that
diarrhoea frequently occurs in these cases points to
the likelihood that we are often dealing with an acute
or an exacerbated chronic enteritis in the course of
which changes in the appendix and its peritoneal sur-
roundings may occur.
The diarrhoea is of great differential importance
since it occurs frequently in early appendicitis,
whereas constipation is the rule in cases of lead
colic, gall-bladder colic, and the pains of pyloric
disease and diseases of the ureters. This is likewise
true of most of the gastric pains (ulcer and hyper-
chlorhydria) which may in other respects have a
superficial similarity to appendicitis. In differen-
tiating the condition from the ordinary acute inflam-
mations of the small and large intestines, our most
important aid lies in the localized peritoneal pains
which have been spoken of above; of special impor-
tance is the hip-flexion symptom. Help may be de-
190 PAIN
rived from the bladder symptoms, which aid us in
determining the existence of a local peritonitis.
These often consist of pains during micturition;
strong pressure is required to expel the urine, and
occasionally retention of urine occurs.
In differentiating the intestinal pains produced
by the ingestion of irritating substances or by flatus,
we are aided particularly by the temperature.
Occasionally errors are made in cases where for-
eign bodies, introduced per os or per anum, give rise
to a suspicion of appendicitis, the similarity being
more marked because of the increased temperature.
It is often extremely difficult to differentiate appen-
dicular pains from those produced in inflammatory
diseases of the female genitals (parametrium, tubes,
and ovaries) ; this is especially true because often
disease of the adnexa and appendicitis occur to-
gether. In such cases only a very exact analysis of
the pains will lead to a correct interpretation.
The pains of peritoneal origin in both of these
conditions show great similarity. In a general way,
however, the symmetrically bilateral location of the
pain, and the deeper, pelvic position of the tender-
ness will point more directly to parametritis than to
appendicitis. The influence of menstruation upon
the pains must be carefully considered, without for-
getting that it is not rare for adhesions to have
formed between the appendix and chronically in-
flamed ovaries, and that the existence of a parame-
tritis by no means excludes the existence of an
appendicitis.
DIGESTIVE SYSTEM 191
Furthermore, in differentiating between these
two conditions we can be guided by the fact that
enteric pains are almost never present in diseases
of the genitalia, and that the diet is entirely without
influence upon the pain.
Appendicular colic may occasionally be simulated
by right-sided ectopic pregnancy. During rupture,
pain occurs which radiates into the right thigh and
is accompanied by collapse and sensitiveness of the
abdomen. The absence of temperature, however,
the presence of acute anasmia, and occasionally bleed-
ing from the genitals, with a previous history of
pregnancy, and the discovery of a periuterine tumor,
lead us in the right direction.
Occasionally we will have to consider in the dif-
ferential diagnosis torsion of a right-sided ovarian
cyst, hydrosalpinx, etc. In women, too, in the ab-
sence of fever and leucocytosis, it is necessary to
search carefully for signs of hysteria, especially in
the abdominal regions (viz., analgesia of the umbili-
cal region). It is absolutely necessary, however, to
analyze carefully the various factors which influence
the pain in these cases, for, unquestionably, a true
appendicitis may occur in an hysterical individual.
When we consider that the appendicular pains are
distinctly due to two components, on the one hand
a local peritonitis, on the other hand a colic, it is
plain that other inflammatory processes occurring
in the ileocaecal region may give rise to the same
symptom complex, chief among these being tuber-
culous, actinomycetic, and malignant processes.
192 PAIN
Similarly localized tenderness may occasionally
occur in diseases of the kidney and gall-bladder, in
psoas abscesses, in right-sided pleurisy, and in
pneumonia.
LEAD COLIC.
When sudden attacks of colic occur in an anaemic
individual who gives a history of dyspepsia, ano-
rexia and constipation, and when these attacks are
localized in the epigastrium and are accompanied
by retraction and rigidity of the abdominal walls,
our first thought must be of chronic lead poisoning.
On the other hand, it would be hasty to conclude
from the coincidence of colicky pains and the signs
of chronic plumbism that we are necessarily dealing
with a neuralgia of the mesenteric plexus due to lead.
Occasionally, other toxic conditions must be consid-
ered, to which patients with lead poisoning are par-
ticularly predisposed. Chief among these is nico-
tine poisoning. It is not rare, also, to find tubercu-
losis in individuals with lead poisoning, and in such
cases we may well be dealing with tuberculous ulcer-
ations. Again, ulcerative processes in the stomach
and duodenum are not infrequent during the course
of lead poisoning, and may be especially favored by
the condition of the vessels and by a tendency to
spastic contraction in the stomach and intestinal
canal. Furthermore, I should like to call attention
to the fact that in cases of chronic lead poisoning
there is sensitiveness to pressure in the region of
the appendix, and for this reason also the question
of appendicitis must be considered. It goes without
DIGESTIVE SYSTEM 193
saying, furthermore, that chronic lead poisoning
does not protect against the colics of gall-stones and
renal calculi. It becomes necessary, therefore, in
each case, to consider carefully the individual symp-
toms and to analyze the pains as they occur.
In regard to the factors modifying the pains we
can assume that, because of the nervous origin of
the disease, dietetic influences do not come under
consideration; and, as a matter of fact, this con-
clusion is justified by actual fact. The pains in this
condition are independent of dietetic influences.
This is in contrast to the state of affairs found in
the case of most intestinal pains (tuberculous ulcera-
tions and stenosis of the gut) and therefore is of the
greatest differential importance. It would, how-
ever, be silly to expect that the hyperaesthetic gut of
chronic lead poisoning may not react forcibly to
errors of diet, and all those articles of food which
cause much flatus may in these cases give rise to true
colic. This, of course, would not represent a true
case of lead colic, but would simply consist of a
colica flatulenta favored by the existing lead poison-
ing. It is probable that in a great many cases of
so-called lead colic the pains are caused by the pres-
ence of stagnated fecal material and abnormal quan-
tities of gas, and thus are explained the frequent
prompt results gained therapeutically by high ene-
mata, and the observation frequently made by
patients that the passage of gas immediately relieves
the colic; in some cases, too, relief may be experi-
enced from vomiting.
13
194 PAIN
Excessive use of tobacco is unquestionably an
important factor in the initiation and increase of
the colicky pains, a consideration which is worthy
of notice therapeutically. Alcohol in concentrated
forms, such as brandy, in many cases causes diminu-
tion of the pains. Mechanical agencies, because of
the neuropathological basis of the pains, have little
influence.
Changes of position do not influence the pain in
these cases as they do in ulcerative processes or in
the localized peritoneal inflammations. It is fre-
quently claimed that pressure upon the abdomen is
not painful in cases of lead colic, but on the contrary
often relieves pain. This is true in a great many
instances, but cannot be regarded as a rule. Pain
on pressure may frequently be due to the fact that
there exists a severe neurasthenia which is accom-
panied by general hyperaesthesia. In those cases
where gas collects, locally or diffusely, in the intes-
tinal tract during the attacks, it is perfectly natural
that there should be a certain amount of tenderness
to pressure over the distended intestinal coils. The
sensitiveness of the abdomen to pressure, therefore,
can give us little help in differentiating this condi-
tion from the peritoneal processes. Flexion of the
thighs upon the abdomen frequently gives relief;
but it is important to notice whether both thighs are
flexed or whether the right thigh simply, as would
be the case in appendicitis or in the tuberculous
ulcerations of the intestine.
The application of heat usually influences the
colic favorably. The application of cold often ini-
DIGESTIVE SYSTEM 195
tiates an attack. Emotional excitement may fre-
quently give rise to a severe attack of pain.
The pains, which are chiefly of a sharp, boring or
cutting character, and which are almost invariably
paroxysmal, are located principally about the um-
bilicus. Occasionally, however, they occur in the
epigastrium. When the attack is at its height it is
hard to refer the pains to any particular region, and
they may cover the abdomen diffusely. The pain is
as a rule limited to the abdominal region and
only in the rarest cases radiates into the sternum,
the chest and the shoulders. On the other hand,
pain frequently occurs in the lumbar region, and may
radiate into the genitals or bilaterally into the thighs
(lead colic of the ureters). There is no radiation
into the ileocaecal region, as is so frequently the case
in tuberculous ulcerations. This region, however,
and occasionally the region of the sigmoid flexure
are often quite sensitive to pressure. This can be
easily explained by the fact that in these two regions
especially there is apt to be stagnation of the feces
which, with slight inflammatory changes, leads nat-
urally to tenderness.
As far as the time of occurrence of these pains
is concerned we are able to gather no facts of differ-
ential importance. The very irregularity of the at-
tacks, which often show prolonged intervals between
separate seizures, should give us some clew. Attacks
occur more frequently during the night than during
the day ; but this peculiarity is common to all varie-
ties of abdominal colic.
196 PAIN
The most important of the secondary symptoms
which accompany the colicky attacks are the follow-
ing: Nausea and vomiting, often an absolute intol-
erance for solid or fluid food, constipation preceding
the attack, sometimes with tenesmus, usually with
retraction of the abdominal wall. Visible peristalsis
and succussion are rarely present, and are found
only in those cases where the constipation is of a
very chronic order and where the abdominal walls
are extremely flabby. There are practically no
alarming general symptoms. The diagnosis, of
course, will be much strengthened by the discovery
of other symptoms of chronic lead poisoning, such
as a lead line, weakness of the muscles supplied by
the radical nerve, and high blood pressure. The
high blood pressure itself is by no means constant
in these cases, since it may even be diminished in
cases where the anaemia is severe or where tubercu-
losis exists as a complication.
There are other conditions which, resting on a
purely neuropathological basis, may also produce
gastro-intestinal colic, and from these we must occa-
sionally differentiate lead colic. Chief among these,
of course, would be the intestinal crises of tabes,
and hi such cases the nervous system must be care-
fully examined in order to make the differentiation.
Ulcerations of the gut with stenosis may give
rise to difficulty in diagnosis. Lead colic is ex-
cluded in such cases by the close relation of the pains
to the taking of food, their constancy, and their
definite variation upon changes of position. The
DIGESTIVE SYSTEM 197
discovery of sarcinae in the vomitus or in the feces
during an attack would point quite distinctly to the
existence of pyloric stenosis.
In distinguishing lead colic from appendicitis
and peritonitis, our chief strongholds are the afebrile
course and the absence of a leucocytosis. These two
conditions carry with them also voluntary immo-
bilization of the abdomen and the patient usually
assumes a supine position, whereas in lead colic the
constant restlessness is characteristic, and the
patient may walk about or remain in a sitting posi-
tion, pressing his hands upon his abdomen. The
indifference of the patient to mechanical disturb-
ances of the abdomen is quite characteristic and
helps very much in differentiating lead colic from
other conditions. This aid is lost, however, in those
cases mentioned above of neurasthenic patients, who
occasionally show abdominal sensitiveness.
In closing, it is necessary to call attention again
to the fact that, even when chronic lead poisoning
can be definitely diagnosed, the possibility of a com-
plicating gastric ulcer or renal calculus must not
be overlooked.
MALIGNANT NEW GROWTHS OF THE INTESTINE.
There is nothing absolutely characteristic about
the pains occurring in the conditions we are about
to discuss. They may be caused by organic changes
and mechanical stenosis of the gut, and the disten-
tion and increased peristalsis dependent upon these.
Or, again, their pathological basis may rest chiefly
198 PAIN
upon peritoneal involvement. The pains are impor-
tant, nevertheless, from a diagnostic point of view,
in that they frequently occur during the very early
stage of the condition when other physical signs are
entirely lacking.
These pains are frequently regarded as harmless
manifestations of intestinal indigestion such as fol-
low errors in diet or exposure to cold, and yet if the
phenomena of the pains are carefully analyzed we
may often find distinct reasons for believing that
there is a well-localized cause for the attacks.
Whenever this can be accomplished an important
diagnostic advance has been made.
Corresponding with the localized process from
which they arise, there is a tendency in such cases
towards a localization of the pains. This is par-
ticularly true of the neoplasms of the large intestine
where frequently, at the very beginning of the at-
tacks, the pain is felt in the seat of the lesion, and, in
consequence, usually occurs in the cascum or in the
three flexures of the large gut. At the height of such
an attack the pain is generally diffuse, but centers
chiefly in the region of the umbilicus, and is fre-
quently accompanied by pain in the lumbar regions.
Whenever the obstructing process lies in the neigh-
borhood of the splenic flexure there may be distinct
radiation into the lower half of the thorax and occa-
sionally, though rarely, into the left leg (one case
of hysteria). When the neoplasm occurs in the
hepatic flexure the condition may strikingly simulate
gall-bladder colic. The pains begin in the neighbor-
DIGESTIVE SYSTEM 199
hood of the gall-bladder, radiate backwards into the
small of the back, and frequently reach even to the
right shoulder blade. Radiation towards the anus is
a phenomenon of extreme importance, for it indicates
most frequently a deep-seated carcinoma of the sig-
moid flexure. Occasionally it may accompany new
growths which are situated higher up in the colon,
but whenever it is present it appears to the writer
to be a most important sign of stenotic processes
in the large intestine. In carcinoma of the sigmoid
flexure and rectum a more distinct localization can
often be made. When the process is situated in
these regions there are frequently dull pains in the
left inguinal region which radiate into the left tes-
ticle. Again pains may arise in the left half of the
epigastrium and radiate towards the anus ; radiation
into the left inguinal region and along the outer
aspect of the left thigh occurs and seems to be a
particular accompaniment of left-sided tumors.
Pains in the back are rarely present, or when occur-
ring are simply added to the sum of the other pains.
The same may be said of pains in the region of the
left sciatic nerve.
Not less important than the topographical consid-
erations are those symptoms which give us a clew
to the factors influencing the pains, and these aid us
particularly in differentiating the localized carcino-
matous processes from those occurring in acute or
chronic enteritis.
It appears to me of special importance, when-
ever intestinal colic occurs in older people, to deter-
200 PAIN
mine whether there is a "position of the greatest
pain, ' ' such as that which we have considered in the
discussion of the pains accompanying ulcers. When
we are dealing, for instance, with a carcinomatous
process in the region of the hepatic flexure, the
patients will frequently tell us that they cannot lie
comfortably upon the left side because in this posi-
tion they have pains in the right side which give
them the impression of a mass dropping from right
to left. This is unquestionably in many cases due
to traction upon peritoneal adhesions and therefore
points strongly towards the extension of a local
process. The occurrence of such an extremely im-
portant diagnostic position of pain is not infre-
quently noticeable at an earlier stage than the occur-
rence of any local sensitiveness to palpation. It is
always important to examine the abdomen carefully
for sensitiveness to local pressure, since in many
cases pains may be produced in this way, which then
give an important clew. Absence of abdominal ten-
derness does not, of course, exclude absolutely the
condition under consideration, for sensitiveness to
pressure may be absent in those neoplasms which
are situated in the pelvis, in the neighborhood of the
rectum and in the lower half of the sigmoid flexure.
Local sensitiveness corresponding to the seat of the
tumor is occasionally felt during strong contraction
of the abdominal muscles, such as that produced by
lifting a weight or in defecation. Deep diaphrag-
matic inspiration may give rise to such pain, espe-
cially in cases where peritoneal inflammations are
DIGESTIVE SYSTEM 201
present. The same kind of pain may be elicited by
careful inflation of the rectum. Whenever pains
are present in the lumbar region these are increased
by stooping.
The peculiarities of the pain in cases of malig-
nant tumors which we have so far enumerated, have
a diagnostic significance chiefly because they lead
us to suspect a localized cause for the attacks of
colic, and therefore considerably limit the diagnostic
field. For, by reaching such a conclusion, we are
able to exclude a great many of the more generalized
causes for intestinal colic, such as the conditions
caused by flatulence and the ordinary intestinal in-
digestion. The differentially significant phenomena
in the case of neoplasms are based upon the early
occurrence of a local peritonitis, giving rise to the
occurrence of a position of the greatest pain, and to
local sensitiveness. No specific or characteristic
factors, of course, can be ascribed to those phenom-
ena which depend upon flatulence and consequent
distention of the gut, or upon the increased peristal-
tic contractions of the intestinal muscles. If the
symptoms depending upon these conditions are par-
ticularly prominent they lead easily to confusion
with other conditions. However, these general pains
will aid very much in differentiating the conditions
we are speaking of from colicky attacks occurring
with diseases of other organs. This would be par-
ticularly important in cases such as carcinoma of
the hepatic flexure where the confusion with gall-
bladder colic is very easy, and where such general
202 PAIN
intestinal symptoms protect us from mistaking one
condition for the other. This becomes especially
significant when we consider how frequently even
the secondary symptoms of these' two conditions
(fever and slight jaundice) are common to- both.
When, in intestinal new growths, the attacks of
pain are dependent chiefly upon the general intes-
tinal condition, their onset may frequently be directly
related to some thermic stimulation, such as the
application of cold, walking with bare feet upon a
cold floor, sudden throwing off of the bed-clothes or
drinking cold fluids. The reason for this is a stimu-
lation of peristalsis. Again, the attacks of pain may
be incited by articles of diet which increase the pro-
duction of gas in the intestine, such as certain vege-
tables, bread, etc., and frequently in the history of
intestinal carcinoma the first attack of pain is
directly referable to such errors of diet. It is well
to remember these things in order to protect our-
selves against mistaking the early symptoms of a
carcinoma for simple intestinal colic, and it is espe-
cially desirable when dealing with older individuals
to search carefully for the existence of a new growth
even when the colicky pains seem to have been
directly connected with an error in diet.
It frequently happens that the positive physical
signs are delayed for a long period after these first
subjective symptoms have been noticed. In those
cases where the above-mentioned subjective symp-
toms are absent, but where we have some other
reason to suspect the existence of a neoplasm, it is
DIGESTIVE SYSTEM 203
well to attempt by palpation and by changes of posi-
tion to produce artificially the conditions most favor-
able to the production of the pains ; and in this way
we may be led to a clearer comprehension of the
case.
An important symptom which is frequently pres-
ent in these cases is prolonged constipation. The
passage of feces or gas from the intestine is usually
followed by an immediate diminution of the pains.
The patients themselves frequently, during the at-
tacks of colic, massage the abdomen in the region
corresponding to the position of the tumor in order
to diminish their pains. Thus the distribution of
the distention which is probably the cause of the
pain actually leads to great relief. Occasionally,
even, the definite localization of the spontaneous
massage carried on by the patient will be of diag-
nostic aid.
While there is generally no distinct relation be-
tween the attacks of pain and the taking of food,
occasionally there does exist some regularity in their
occurrence in relation to the large meal. In some
cases attacks occur within two to three hours after
the meal, and are probably directly dependent upon
the occurrence of powerful peristalsis during this
time. This same interpretation may be given to the
frequency of nocturnal attacks. During early car-
cinoma there are usually intervals of several months
between the attacks of pain. As the disease pro-
gresses the intervals become shorter and shorter,
a fact which may have much diagnostic significance,
204 PAIN
since these intervals depend upon the nature of the
process. Frequently the pains occur a short time
before defecation. This is chiefly the case in those
carcinomata which are situated well down under the
sigmoid flexure.
The symptoms which occasionally accompany the
pains due to intestinal neoplasms are often of such
a nature that their erroneous interpretation might
well lead to false localization of the disease in the
stomach, the gall-bladder, the kidneys, etc. Thus
vomiting is frequently present at the height of the
attack, and, with it, appear epigastric pains. The
suspicion of gastric disease aroused by these symp-
toms can be allayed by remembering that whenever
vomiting occurs in intestinal neoplasms we may pre-
suppose a considerable degree of stenosis and may,
therefore, expect such vomiting to be accompanied
by visible or palpable intestinal peristalsis. When
the vomitus is bile-stained, is foul, or contains B.
coli, we will, of course, be led to recognize the intes-
tinal character of the condition.
In carcinoma of the splenic flexure pains fre-
quently occur immediately after the taking of food,
and are caused either by inflammatory adhesions to
the stomach, or by direct invasion of that organ.
In such cases careful distention of the rectum will
usually give rise to immediate pains in the region
of the splenic flexure. The pains of carcinomata of
the hepatic flexure are frequently confused with
gall-bladder colic, especially when the pain is local-
ized over the gall-bladder, because of adhesions or
DIGESTIVE SYSTEM 205
direct metastatic growth. Icterus is often present
in these cases, and a sensation of resistance in the
neighborhood of the gall-bladder may be felt. In
such cases, as we have mentioned before, especial
attention must be paid to- the influence which the
application of cold exerts upon the production of
peristalsis and to the presence of visible peristalsis
or succussion in the ascending colon. The tendency
to diarrhoea, the occasional foul stools containing
mucus, and the presence of blood or of an abnormal
flora in the feces, are additional evidences pointing
to carcinoma. The local bulging which might occur
in the neighborhood of the gall-bladder when the
intestine in this vicinity is abnormally distended
could very easily be misinterpreted as a large gall-
bladder. Chills occur in this form of intestinal
carcinoma also, just as they occur in gall-bladder
colic. In some cases, especially in carcinomata of
the sigmoid flexure or the caecum, difficulty in urina-
tion, pain in the bladder, frequent micturition, and
even radiation into the testicle may be present, and
these may easily lead to false conclusions. In this
connection it is simply necessary to remember the
danger of error and to avoid it whenever the tumor
is impalpable and visible peristalsis is absent by
careful examination of the stools and the peculiari-
ties of defecation, such as tenesmus and distention
of the descending colon.
In differentiating carcinomatous disease of the
intestine from the other more distinctly enteric
causes of colic (flatulence, intestinal indigestion, etc.)
206 PAIN
we have already called attention to the fact that a
careful analysis of the pain alone may give us much
basis for a sharp localization of the pathological
condition. A distinct recognition of this, if we con-
sider the relatively limited number of such localized
processes in the intestinal tract, will make the fur-
ther differential diagnosis quite simple, for there
are few ulcerative or stenotic conditions with well-
localized symptoms which are of practical impor-
tance. Thus, in the ileocascal region we have, outside
of carcinoma, to deal almost exclusively with
tuberculosis; in the sigmoid flexure, almost exclu-
sively with dysentery or occasionally membranous
enteritis.
LIVER.
There are three chief factors which give rise to
pain in the region of the liver. These may be dis-
cussed in three groups, as follows :
I. CONDITIONS OF SPASM OK DISTENTION IN THE
BILE-PASSAGES AND GALL-BLADDER.
The pains occurring in this region are closely
analogous to those occurring in the gastro-intestinal
tract a fact which is not surprising when we con-
sider the great similarity between the two systems
functionally and anatomically. As in the intestinal
tract, a simple narrowing in the system of bile ducts
is followed by spasm and overdistention in front of
the stenosis, which consequently give rise to colicky
pains. Thus here, too, colicky pains may be caused
without absolute anatomical occlusion of the lumen.
DIGESTIVE SYSTEM 207
While such attacks of gall-bladder colic are usually
associated with, the presence of gall-stones, this is
not by any means necessary, and it is illogical to
speak invariably of such attacks as gall-stone colic.
Further analogy to the conditions in the alimen-
tary canal is found in the fact that inflammatory
processes without any existing organic stenosis may
be accompanied by the same attacks of pain, the con-
ditions for such attacks being especially favorable
in the appendix to the gall-duct system the gall-
bladder. Here a colicky attack may be initiated by
an inflammatory exudation with a rapidly increasing
intravesical pressure and overdistention of the walls.
In discussing the conditions in the biliary system
which can give rise to spasms and overdistention,
with their consequent attacks of colic, we shall have
to consider :
(a) Stenosis due to carcinoma at the papilla of
Vater or in the head of the pancreas, ascarides in
the ductus choledochus, aneurysms of the hepatic
artery, intrahepatic carcinoma, cysts and gummata,
kinking of the cystic duct in enteroptosis by adhe-
sions, etc.
(b) Inflammation, as in cholangeitis with or
without biliary cirrhosis, acute yellow atrophy,
cholecystitis with or without the formation of stones,
carcinoma, etc.
It is hardly necessary to mention that occasion-
ally attacks of colic may be initiated by a combina-
tion of (a) and (b). It is a universal rule that
wherever secretions accumulate because of the for-
mation of a stenosis the opportunity for infection
208 PAIN
and for the development of a "stagnation-flora" is
particularly favorable.
It would probably be very advisable to drop the
expression gall-stone colic entirely, and to substitute
for it the words, gall-bladder colic or gall-duct colic,
terms which imply no premature anatomical diag-
nosis. This may seem pedantic, because in the ma-
jority of these cases stones are actually present, but
this slow method of diagnosis seems to the writer
extremely desirable, since by its use we may often
avoid overlooking other and rarer causes for these
attacks.
II. DiSTENTION OF THE LlVEB CAPSULE.
Whenever a free flow of blood out of the hepatic
veins is prevented, a swelling of the liver results
which leads to painful distention of the peritoneal
coverings. A similar condition is caused by obstruc-
tion to the flow of bile. The presence of cysts in the
liver tissue, and the growth of neoplasms, may give
rise to a similar result. Distention of the capsule
of the liver may also be produced by active hyper-
semia. Thus in malaria, pernicious anaemia, par-
oxysmal haemoglobinuria, leukaemia, diabetes, this
occasionally occurs. In the last-named condition,
however, the sensitiveness to pressure is usually of
very moderate degree.
III. INFLAMMATORY PROCESSES IN THE CAPSULE OF
THE LIVER (LOCAL AND DIFFUSE PERIHEPATITIS).
The general diagnosis of a hepatalgia is based
chiefly upon the discovery of sensitiveness to pres-
DIGESTIVE SYSTEM 209
sure or percussion, upon the size of the organ as
determined by the liver dullness and upon a close
analysis of the subjective pains.
It now becomes our task to analyze more closely
the details of the mechanism of these pains. In
doing this we shall find that the groups which we
have just discussed will often act in combination.
I. Gall-bladder Colic.
It is plain, from the very pathological conditions
underlying the pains occurring in diseases of this
organ, that the general phenomena must frequently
be of an extremely complicated nature. Thus, ad-
hesions between the gall-bladder on the one hand, and
the duodenum or colon on the other, may give rise
to entirely independent attacks of pain ; the develop-
ment of peritonitis, the occurrence of septic throm-
bosis in the lower extremities, with the pains that
occur in them simulating radiation from the original
seat of trouble, offer extreme difficulties to inter-
pretation. It must also be remembered that, at the
height of the attacks, neurasthenic patients may
experience most unusual radiations of pain into
the left arm or into the right leg, so that in judging
of the condition it is especially important to pay
attention to the pains which have occurred at the
very beginning of the attack.
The usual locations of the earliest pains are in
the epigastrium, in its middle portion or just below
the right costal margin. Whenever the attack of
colic is localized chiefly on the left half of the epi-
14
210 PAIN
gastrium we will be much more apt to think of a
simple gastralgia (excepting, of course, in cases of
transposition of the organs). The natural explana-
tion of this right-sided position of the pain is found
in the topography of the gall-bladder and the liver.
The pain most usually radiates from the epigas-
trium upwards, in rare cases up to the right half
of the neck and to. the right acromion process. More
often, however, it radiates, in front, up to the right
nipple and backwards into the shoulder blade and
into the right lumbar region. The radiations which
occasionally occur into the right arm and leg, or even
into the left arm, are present only at the height of
very intense attacks of colic, and only in patients
who are of unusually neurotic constitution. The
paraesthesias which occur occasionally in the arms are
probably of a vasomotor nature. "Whenever the
radiations into the left arm are prominent we must
consider the possibility that the attack of gall-
bladder colic by increasing the blood pressure has
brought on secondarily an attack of true functional
or organic angina pectoris.
Radiations into the genitals with retention of
urine and severe pains above the symphysis occur
but rarely, but when they do occur usually depend
upon the development of the peritonitis which occa-
sionally accompanies the gall-bladder inflammation ;
pains in the lower extremities, especially those which
occur in the nerves of the legs, are frequently due
to septic thrombi. Such complications must be very
carefully considered in order that we may avoid any
DIGESTIVE SYSTEM 211
confusion with renal calculi. It is only at the very
height of the attacks that the pains are diffuse or
lack definite localization.
While the localization of these subjective pains
is extremely important, just as much help can be
obtained by a careful determination of those areas
which are tender to palpation and percussion.
1. THE GALL-BLADDER ITSELF. This organ is
often enlarged and is usually markedly tender to
palpation and percussion. There are certain pecu-
liarities connected with this tenderness, the pres-
ence of which confirms the diagnosis of gall-bladder
tumor and aids in distinguishing it from the lower
pole of the kidney. Pressure upon the gall-bladder
frequently produces radiation of the pain along the
phrenic nerve towards the acromion. Radiations
backward towards the left half of the epigastrium
and towards the ensiform process are quite frequent.
This artificially produced radiation is an important
adjunct to the spontaneous radiations.
2. THE MID-LINE OF THE EPIGASTRIUM FROM THE
ENSIFORM TO THE EDGE OF THE LIVER. In this region,
corresponding to the area of liver dullness, limited
below by the edge of the liver, there is in almost all
cases of early gall-bladder colic marked tenderness
to percussion. In those cases which are accompa-
nied by icterus, this tenderness may remain for a long
while after the end of the attack of colic and may,
by its diminution, indicate an improvement in the
accompanying pathological changes. This symptom
of tenderness to palpation in the mid-line which
212 PAIN
occurs in cases- of gall-duct colic is directly referable
to increase of intrahepatic pressure, and will receive
further attention in the section on hepatic conges-
tion.
3. THE BIGHT LUMBAR REGION (LIMITED ABOVE BY
THE BASE OF THE LUNG). Here we are dealing with
a symptom which frequently remains for some time
after the attack proper has ended, and has probably
the same etiological causes as the symptom just
described under 2. In order to determine the pres-
ence of this symptom it is best to tap lightly with
the ulnar surface of the fist upon both lumbar re-
gions in order to compare the tenderness of the two
sides.
In addition to these well-localized areas of pain
there are other varieties of pain which undoubtedly
are of reflex origin (phrenic nerve, etc.).
(a) Tenderness in the area of the shoulder
girdle. There is great tenderness to pressure in the
right brachial plexus ; this symptom is rare. More
frequently there is a point of sensitiveness situated
along the upper portion of the trapezius muscle,
about three fingers' breadth distant from the acro-
mion. Pressure at this point causes pain which
radiates towards the gall-bladder. Pressure upon
the gall-bladder, on the other hand, may cause pain
radiating towards this point. There exists thus a
mutual radiation from one point to the other.
The pains we have just discussed are not fre-
quent in their occurrence, but when they are present
they may be of considerable importance in differen-
DIGESTIVE SYSTEM 213
tiating these conditions from other similar attacks
of colic, such as those of pyloric stenosis, etc. They
are also found, however, in cases of liver abscess,
and in general in all cases of subdiaphragmatic
inflammations.
(b) Tenderness to palpation along the vertebral
column. There is no localized tenderness over any
one particular spinous process. The hyperassthetic
zone extends usually over several spinous processes
and is commonly subject to great variations, but, in
general, it occurs between the fourth and the twelfth
thoracic vertebrae. Occasionally there may be ten-
derness to pressure in the ileocsecal region. This,
when present, is not easy to interpret. Probably in
most cases it is a direct transmission of the pressure
upwards, and thus in reality a true gall-bladder pain.
On the other hand, we must remember that in
patients with gall-stone disease, and liver disease in
general, there are usually intestinal disturbances,
chiefly chronic constipation, and it is necessary for
us therefore to think of chronic inflammatory con-
ditions of the appendix.
In order clearly to differentiate between gall-
bladder colic and attacks of paroxysmal pain from
other causes, it is necessary to pay very close atten-
tion to the gradual increase and decrease of the
attacks and to the cramp-like, sharp character of
the pain. In those cases in which stone formation
is present this characteristic of a rapid rise to a
climax and gradual decrease, is especially marked,
and the intensitv of the attack seems to reach its
214 PAIN
maximum at the time when the stone is expelled.
There are cases which have a more chronic and
latent character and which in the course of years
may have no sharp attacks, but in which there is a
constant sensation of soreness in the epigastrium.
Such cases of gall-stones without actual colic usually
occur together with enteroptosis, and these run their
course with constant parassthetic sensations in the
region of the epigastrium. The weakness of the
abdominal muscles, as well as possible relaxation of
the musculature of the gall-ducts may be responsible
for this.
The attacks of colic may occasionally be preceded
and followed by pains of another nature. These are
usually sharp, cutting sensations which are directly
dependent upon deep breathing and coughing, and
which are due to inflammatory changes about the
gall-bladder. In these cases auscultation may re-
veal a leather-like creaking over the gall-bladder,
and the patient may have a distinct sensation of the
gall-bladder being pressed against the abdominal
wall, or of an inflated stomach.
As regards the influence of the taking of food
upon the attacks of gall-bladder colic, we may say
that a marked contrast exists between this condition
and cases of pyloric stenosis. There is no injury
done to the affected parts by the food, as is the case
in gastric ulcer, and peristalsis of the gall-ducts, if
at all excited by the taking of food, is certainly not
so deeply influenced as is intestinal or gastric peri-
stalsis. We may thus say that, in these cases, the
DIGESTIVE SYSTEM 215
relation of the taking of food to the beginning of
an attack is entirely unimportant, and, as a matter
of fact, this is true in all those cases where chole-
lithiasis occurs in patients of otherwise normal
gastro-intestinal tracts. The taking of food is im-
portant in relation to the attacks only in those cases
where we are dealing with delicate, anaemic individ-
uals, often with some degree of enteroptosis, espe-
cially those with gastroptosis and general atony of
the stomach. These cases are chiefly limited to the
female sex, and in them a differential diagnosis be-
tween a gastric condition and gall-bladder colic is
extremely difficult.
It is not at all out of the question that in some of
these cases following an error in diet, a gastralgia
with cramp-like contractions of the stomach is
started which may secondarily give rise to an attack
of colic in the gall-ducts, the muscular activity of
the two systems being functionally so closely allied.
The influence of diet upon gall-duct colic is similar
in many ways to its influence upon the pains of
pyloric stenosis, and it is not at all unlikely
that, accompanying some cases of gall-stone, there
actually does occur slight obstruction at the pylorus
or in the duodenum itself. On the one hand, gas-
troptosis, which is so often present, may readily
lead to kinking of the duodenum and subsequent
stenosis; on the other, it is not infrequent to find
adhesions between the pylorus and the gall-bladder
which may cause similar obstruction.
The articles of diet which are especially apt to be
responsible for the attacks are all those which lead
216 PAIN
to distention, vegetables, carbohydrates, bread, etc.;
also fat, meat, cheese, acid food, beer, etc. Attacks
are occasionally inhibited by strong alcohol in the
form of brandy. The quality of the food is often
less important than the quantity, in that the attack
is initiated simply by the mechanical overfilling of
the stomach.
Just as in the case of the pain accompanying
ulceration of the pylorus, in these cases the position
of the patient has an important influence upon the
course of the attacks. The pain is especially severe
when the patient is lying on his left side. In this
position he may complain of a drawing sensation
which gives the impression of something being
tugged from the right hypochondriac region toward
the left. This pain, in the left-sided position, is
especially severe whenever there is great flabbiness
of the abdominal walls, and therefore corresponding
mobility of the abdominal organs. Mechanically the
explanation is extremely simple since, in this posi-
tion, the swollen organs are freely suspended from
their inflamed peritoneal attachments. It is true
that in some cases there is pain also in the right-
sided position, and this is easily explained by the
fact that greater pressure is exerted upon the liver
and gall-bladder ; but when this does occur the pain
is not accompanied by nausea and belching, as is
almost invariably the case when the right-sided pains
occur with ulceration and stenosis of the pylorus.
Inflammatory changes in the neighborhood of the
gall-bladder and in the serous coverings of the liver
DIGESTIVE SYSTEM 217
give rise to other secondary symptoms. Thus the
jarring accompanying speech, rapid walking, run-
ning down hill, coughing and sneezing, gives much
discomfort during the attack and for a long time
afterwards. Likewise those motions are very pain-
ful which are accompanied by pressure upon the
abdominal organs in general, such as stooping, put-
ting on the shoes, lifting a weight. Bending for-
ward occasionally causes pain in the back, and owing
to this the patients often instinctively relax their
abdominal muscles by walking in a stooping position
or shoving a pillow under their backs.
Like the stomach and intestine, the gall-bladder
has an important functional dependence upon the
central nervous system, and it is thus not surprising
that observations have been made which would indi-
cate that attacks of gall-stone colic have been initi-
ated by psychic or emotional impulses.
It is at least worth considering whether such
attacks cannot be reflexly initiated from other
organs, the kidney, the genitals, the stomach, or the
intestine, either in th'e presence of gall-stones or
with any other lesion of the bile passages. Abnor-
mal irritability of the nervous system may certainly
be regarded as a factor favoring the attacks.
There is a very definite connection between gall-
stone colic and conditions of obstruction in the
alimentary canal. Thus, prolonged constipation
may occasionally start an attack, probably by pre-
venting the free expulsion of bile, and occasionally
an attack of colic may be interrupted by a free evacu-
218 PAIN
ation of the bowels by enema or otherwise. Such
close interrelation is logically to be expected when
we consider the close functional relationship of the
gut and the bile passages.
As regards the time of attack, there is unques-
tionably a greater frequency during the night or
evening, but this is not striking and attacks may
occur at any time during the day.
In differentiating gall-stone colic from pyloric
stenosis, we may be helped by remembering, first,
the long, free intervals occurring between attacks
of the former condition, in contrast to the almost
uninterrupted suffering of the latter. When attacks
occur daily for weeks we may usually conclude that
we are dealing with stones which are immovably
lodged in the cystic duct or with one of those cases
of enter opto sis mentioned above. Stones which are
situated further down, in the less narrow common
duct, usually give rise to very little peristaltic unrest
in the gall-duct system.
The most important of the secondary symptoms
which are to be considered is vomiting. This symp-
tom especially may lead to confusion in pointing
towards a gastric condition, such as ulceration at the
pylorus; but the character of the vomiting is quite
different in the two conditions. In the case of
pyloric ulceration or stenosis the vomiting is usually
very copious, does not consist of bile, has a sour
taste, and is usually followed by immediate relief
from pain ; in gall-stone colic it is usually full of bile,
is bitter in its taste, and in most cases increases the
DIGESTIVE SYSTEM 219
pain because the jarring of the act, as well as the
pressure of the abdominal muscles, causes consider-
able pain in the sensitive liver and gall-bladder.
If the physician is present during the attack,
examination of the urine will quickly determine
whether obstruction of bile exists or not. Such
a decision is much more difficult when we have to
make, up our minds simply by means of the state-
ments of the patient. We must not lay too much
weight upon the patient's statement that his urine
was dark during the attack, for in the attacks of the
colic of gastric ulcer we often notice the excretion
of a dark concentrated urine. If the patient is able
to tell us that the urine has left yellow marks upon
the linen or that there has been pruritus, the likeli-
hood of the existence of true icterus becomes very
strong. Jaundice is occasionally absent in diseases
of the liver and, on the other hand, is often present
in other diseases, chiefly in gastric and appendicular
disease, in duodenal ulcer and in carcinoma of the
hepatic flexure ; nevertheless, when icterus has never
been present in patients whose disease has existed
for a considerable period, extreme caution must be
used before a diagnosis of hepatic disease is made.
Shaking chills and rises of temperature are fre-
quently present during the attacks themselves, but
are of much less importance than increased tempera-
ture which is present for some length of time after
the attacks. The chills and rise of temperature dur-
ing the attack may be present in many other condi-
tions in persons who have irritable vasomotor sys-
220 PAIN
terns. The temperature which occurs after attacks,
however, is usually an expression of an infection,
such as that which is frequently present in gall-
bladder colic, and is therefore of much more impor-
tance in clearing up the diagnosis. Herpes is rarely
present.
The symptoms which appear on physical exam-
ination are chiefly tumor of the gall-bladder and
liver, creaking friction sounds over the gall-bladder,
crepitant rales over the base of the right lung, and
occasionally also over the base of the left lung
(splenic enlargement).
There are a number of conditions which may
simulate gall-bladder colic. Chief among these are :
1. Cicatricial and ulcerative processes of the
pylorus (see page 162).
2. Duodenal Ulcer. The localization of the at-
tacks may be very similar in the two conditions. In
a general way the same distinguishing characteris-
tics may be drawn between these two conditions
as are useful in differentiating gall-bladder colic
from pyloric stenosis. In duodenal ulcer there is
almost immediate relief after vomiting because of
the evacuation of the distended stomach.
3. Appendicitis. The danger of false, diagnosis
is especially due to the fact that many cases of
cholelithiasis show tenderness to pressure in the
ileocsecal region ; this is usually caused by an abnor-
mal position of the gall-bladder on account of a
sinking and rotation of the liver.
In a great many cases also there may be a chronic
inflammatory process of the appendix directly re-
DIGESTIVE SYSTEM 221
lated to the chronic constipation accompanying gall-
stone disease. A superficial examiner might there-
fore easily misinterpret attacks of colic with sensi-
tiveness in the ileocaecal region as appendicular colic.
On the other hand, cases of true appendicitis may
simulate gall-stone colic when the appendicular pain
is situated high up, because of an abnormal position
of the appendix. Careful analysis of the pains, to-
gether with most painstaking examination of the
liver for enlargement, tenderness, etc., can alone
give us clearness.
4. Carcinoma of the Colon. Another condition
which it is difficult to differentiate from the pain
under consideration is carcinoma of the hepatic
flexure of the colon, with adhesions to the gall-blad-
der and liver. In these cases there are colicky at-
tacks with localization and radiation similar to those
of true gall-stone colic. Added to these, slight
jaundice is present, due to adhesions to or metas-
tatic infiltration of the bile passages. The difficulty
may be further increased by the presence of a
rounded sensitive tumor which cannot be separated
from the liver.
While the examination of the feces and other
subjective signs will clearly differentiate these con-
ditions, the writer would like to call attention, for
the purpose of rapid diagnosis, to the great differ-
ence which exists in the reaction of the pains of
these two conditions to thermic influences. When-
ever the attacks of pain are easily brought on by the
application of cold (cold drinks, exposure of the
222 PAIN
abdomen, etc.), gall-duct colic is extremely unlikely,
this characteristic being peculiar chiefly to the
paroxysmal pains occurring in the intestines.
Eises of temperature occur in ulcerating carci-
noma of the colon and therefore give us no differ-
ential help. However, chills at the time of the attack
would point more particularly to gall-stone colic.
In addition, it is important to consider the con-
stancy of the pain, its dependence upon dietetic
influences, its relief by the expulsion of flatus, etc.
As far as objective symptoms are concerned the
most important are those which point to obstruction
of the gut. These, of course, may be absent for a
long time. Most important among them are bor-
borygmi in the region of the tumor and succussion
sounds along the ascending colon; it must not be
forgotten, however, that even disease of the gall-
bladder may secondarily lead to slight obstruction
in the region of the hepatic flexure.
Diarrhoea when present would point towards an
intestinal origin of the pains, for gall-duct colic,
especially when due to stone, is almost always accom-
panied by constipation.
5. Movable Kidney. Errors are very easily
made, because it is not infrequent that, together with
an irregular cholelithiasis, there exists a movable
kidney which is assumed to be the cause of the entire
trouble. This combination is quite usual, and there-
fore errors often occur. A mistake is most easily
made when we are dealing with cases of chole-
lithiasis which run their course with constant pain
DIGESTIVE SYSTEM 223
in the epigastrium, without the real colicky attacks
and without icterus. The pain in these cases is
influenced by jarring and motion, and it is not at
all unlikely that when the kidney is movable and at
the same time gall-stones are present, the tugging
of the loose kidney may reflexly lead to peristaltic
unrest in the bile-duct system.
If the colicky pains occur while the body is in
complete rest, for instance, during sleep, of course
the assumption of movable kidney is quite out of
the question.
6. Hysteria. This error can be made only when
the existing cholelithiasis is of an atypical kind.
Here also one must not forget that the conditions
may frequently coincide. Whenever, of course,
purely mechanical methods, such as the position of
the patient, exert an influence upon the pain, we can
hardly assume that the condition is entirely of a
functional nature. So, too, it is important to know
whether there is a lack of harmony between the gen-
eral nervous condition and the severity of the local
pain, for with an improvement in the general ner-
vous condition, the local pains in the epigastrium
are rather more likely to increase than to decrease
when gall-stones are present. General rules can-
not be made for cases of this kind, and it is of the
greatest importance to consider carefully the in-
dividuality of the patient in order to make a correct
diagnosis. When, together with the existence of
gall-stones, severe hysteria is present, even opera-
224 PAIN
tive interference will not always guarantee complete
cessation of the pains. It seems that in these cases
we must consider that we are dealing in part with
a visceral neuralgia (solar plexus? cf. page 97),
in which the gall-bladder pain has the same relation
to the neuralgia that a carious tooth would have to
the ordinary trigeminal neuralgia. The extraction
of the tooth might bring about a temporary improve-
ment, but the neuralgic foundation would remain.
It is an open question whether or not pure neural-
gia of the liver may exist by itself without organic
foundation. According to some observers such
cases may occur with all the attributes of a true gall-
stone colic, except fever and inflammatory changes.
7. Syphilis of the Liver. Attacks of pain may
occur in the train of rapidly developing liver gum-
mata, the causes of the pain being sudden tension
of the liver capsule and local peritonitis. The con-
fusion of this condition with gall-stone colic seems to
be all the more likely because these cases are fol-
lowed by jaundice and increase of temperature, and
palpation of the liver reveals enlargement and ten-
derness. However, more careful examination will
frequently show unevenness of the liver surface,
and, on the other hand, syphilitic processes occur
frequently in the left lobe of the liver; thus
there may be a peculiar left-sided localization of the
pains, a localization which hardly ever occurs in gall-
stone colic. In every difficult case the prompt im-
provement under iodides may be decisive. Similar
DIGESTIVE SYSTEM 225
symptoms may occur with primary or secondary car-
cinoma of the liver.
In our introduction we have already called atten-
tion to the fact that while gall-bladder colic is usually
caused ,by the existence of gall-stones, there may
nevertheless exist cases of true gall-bladder colic
without the presence of gall-stones. These cases,
as it was pointed out, are chiefly dependent upon
inflammatory stenoses along the bile ducts.
The occasional combination of a gall-stone colic
with haematemesis and melaena would lead us to
think of aneurysm of the hepatic artery. Likewise
we would have to consider ulcerative-stenotic condi-
tions at the papilla of Vater.
In patients who are suffering from marked en-
teroptosis mild attacks of such colicky pains would
suggest kinking along the cystic duct. When other
symptoms point to biliary cirrhosis the possibility
of an inflammatory colic of the gall-ducts must be
thought of.
It is a point of practical importance that in pa-
tients who have their first attack of gall-stone colic
at an advanced age, or in those in whom such attacks
are repeated only after prolonged intervals, we may
be dealing not with gall-stones but with a developing
carcinoma of the gall-bladder, or possibly with both
conditions together. An early operation for carci-
noma of the gall-bladder is made possible only on the
basis of the subjective phenomena, and even then
only upon a diagnosis of probability.
15
226 PAIN
Gall-bladder Pains without Attacks of Colic.
In all the preceding conditions we have spoken
of attacks of colicky pain which are probably caused
by the more or less sudden increase of intravesical
pressure or by tonic contractions along the muscu-
lature of the bile ducts.
There are still those cases to be considered in
which the same etiological factors may give rise- to
more gradual pathological changes, and therefore
express themselves in more constant local pains over
the gall-bladder rather than in paroxysmal attacks.
Here, too, we must consider stenotic processes which
lead to an overdistention of the gall-bladder. The
chief conditions which must be thought of in this
connection are diseases of the pancreas of an inflam-
matory or malignant nature, and inflammatory proc-
esses of the gall-bladder itself, either of a local
nature (gall-stones, typhoid) or of an ascending
nature (duodenal catarrh, cholangeitis, biliary cir-
rhosis). Added to these conditions there frequently
occur inflammatory changes in the peritoneal cover-
ings of the organ, a pericholecystitis ; and this gives
us a third factor which, together with the distention
and the muscular contractions, adds to the general
picture of gall-bladder pains. Such lesions are for
many reasons extremely unsatisfactory for physical
examination, and the subjective pains, therefore,
assume especial diagnostic importance.
Generally the pains are localized in the gall-
bladder region itself; in cases of enteroptosis or
corset liver the pains may be close to the ileocaecal
region.
DIGESTIVE SYSTEM 227
The peculiarities of the pains which can be pro-
duced by physical examination have already been
spoken of in the section on gall-bladder colic.
Sharply localized, stabbing pains in the gall-bladder
region may be caused by percussion in the right loin,
by coughing, by sneezing, and by the pressure ex-
erted in strong contraction of the abdominal muscles
such as vomiting, straining at stool, and rising from
a horizontal position. Deep respiration causes pain
over the gall-bladder, especially in those cases where
pericholecystic complications exist. Spontaneous
pain is very slight in many cases ; and often the fact
that there is localized pain in the gall-bladder region
is brought out only by one of the methods just
described.
Similar sensations might occasionally be caused
by an abnormally movable right kidney. Findings
of such a nature, of course, cannot be decisive,
since gall-bladder disease is frequently coexistent
with movable kidney. It would be much more im-
portant to find an enlarged gall-bladder. Increase
of the temperature (cholecystitis) and persistence
of the pain during the prone position would point
towards the gall-bladder as the origin of the pains.
Pains due to flatulence, which so frequently occur
with atony of the gut, as in chronic nicotine poison-
ing and neurasthenia, are occasionally localized over
the gall-bladder region (hepatic flexure), but can be
easily distinguished from gall-bladder disease by
the fact that they vary in their localization.
228 PAIN
II. and III. Distention and Inflammation of the
Capsule of the Liver.
Up to the present time we have spoken only of
liver pains which have their seat in the biliary sys-
tem, and its appendix, the gall-bladder. Here we
had in addition to the factor of distention the cramp-
like peristalsis of the muscular elements. In the
following paragraphs we will deal with conditions
localized in the peritoneal coverings of the liver.
In these, pains are caused both by distention, when
the liver is enlarged, and by inflammatory processes
about the liver (perihepatitis).
It is more practical and useful not to separate
these two varieties of pain, since, although they are
distinct etiologically, they very frequently occur
together.
(a) Hcematogenous Congestion of the Liver.
Such cases are usually caused by cardiac lesions,
especially by insufficiency of the right heart. Never-
theless occasionally extracardial causes must be con-
sidered, such as narrowing of the inferior vena cava
by aneurysms, thrombi, fibrous changes of the peri-
cardium, fluid exudate in the right pleura, right
pneumothorax, and narrowing of the hepatic veins
through perihepatitis.
Next to the regularly present enlargement of the
organ the most constant symptom of these anomalies
of the circulation, at least in their acute and sub-
acute stages, is the characteristic pain. There can
hardly be any reason for doubting that the mechan-
ism of the pains in these cases depends upon the
DIGESTIVE SYSTEM 229
stretching of the liver capsule. The quality of these
pains is almost always that of a feeling of pressure
in the epigastrium which varies in degree from, sim-
ple discomfort to actual pain, so that the patients
speak often of ' ' stomach-ache. ' ' Radiations do not
occur in this kind of pain. The patient frequently
feels as though there were a constant and heavy-
weight upon the stomach.
The most characteristic quality by which this
species of pain can be recognized is the increase in
its severity which occurs whenever more work is
laid upon the heart. This, of course, is natural in
that it increases the actual cause of the pain. The
patient who is suffering from a congested liver com-
plains of an increase of the pain when he walks up-
stairs, whereas it is very much less marked when he
is walking downstairs. Struggling against the wind,
running, in short, every physical exertion increase
the suffering.
Percussion of the liver is painful, and it is not
surprising that in the face of the diffuse and even
stretching of the liver-capsule the pain, on percus-
sion, should have an analogously diffuse and even
distribution. As a matter of fact, however, the
maximum pain is felt in percussion along the linea
alba and extends in this line from the tip of the
ensiform down to the liver margin. This close cor-
respondence of the zone of greatest pain with the
liver dullness in the line of the linea alba is particu-
larly important in differentiating this condition from
other epigastric pains. For this reason examina-
230 PAIN
tion by percussion is more important in this condi-
tion than examination by palpation.
The explanation of the fact that in spite of the
diffuse nature of the process the maximum pain, on
percussion, extends along the linea alba probably
lies in the circumstance that here the muscular de-
fense is least effectual, especially in cases where
there is some separation of the recti. Probably the
same explanation holds good for a similar localiza-
tion of the greatest tenderness along the linea alba
in gastric ulcer.
Whenever, therefore, one wishes to examine for
pain in cases suspicious of hepatic congestion, it is
advisable to percuss along the linea alba.
If cases dependent upon uncompensated cardiac
lesions are examined in this way while they are
under treatment with digitalis, it is often possible
to notice that the pain will diminish from day to
day if approximately the same force- of percussion
is used. In this way we have a very simple means
of controlling the processes of compensation of the
right heart. At the same time the influence exerted
by the therapy upon the tenderness throws definite
light upon the etiology of the condition.
The position of the body has a definite influence
upon the intensity of the suffering. The upright
position naturally leads to a greater stagnation of
blood in the liver, while the horizontal position
allows of a better outflow of blood.
Dietetic conditions also may have a definite effect
upon the hyperaemia of the liver and therefore upon
the pains (spices, large quantities of meat, etc.).
DIGESTIVE SYSTEM 231
Occasionally mechanical and dietetic conditions
may be combined (bodily exertion immediately after
meals).
The physical signs accompanying increase of the
pain are chiefly enlargement and firmer consistency
of the organ. The latter condition is frequently
noticed by the patient himself, who may observe
a diffuse firmness in the epigastrium after exertion.
In many cases, of course, the congestion of the
liver is merely a secondary factor in the general
clinical picture, and it may be easy to explain the
enlargement of the organ without paying much at-
tention to the character and quality of the pains.
The enlargement of the liver falls in naturally with
the cyanosis and the redema. On the other hand,
there are cases in which the hepatic congestion and
the suffering resulting from it may be predominant.
The cases chiefly to be considered in this con-
nection are especially those of acute pericarditis,
which are frequently characterized by epigastric
rather than by cardiac symptoms ; and these epigas-
tric symptoms, on closer analysis, can be recognized
as being due to. hepatic congestion. The same is
true of the- symptoms accompanying many cases of
adherent pericardium, and in these often the diag-
nosis of hepatic congestion can be made before the
condition of the heart is recognized.
Again there are cases in which, even when the
signs of an insufficiency of the right ventricle are
perfectly clear, there- may be. much doubt as to
whether the existing enlargement of the liver is to
232 PAIN
be explained by simple congestion, or whether other
pathological processes, for instance cirrhosis, may
have a part in it. In just these cases the examina-
tion of the organ for its sensitiveness and the zones
of distribution of these pains, as determined by
physical examination, may lend invaluable aid.
The pathological basis of the pain of congestion
lies in the acute or subacute distention of the organ
and its peritoneal coverings. This, however, pre-
supposes the possibility of distending the organ
itself. In cases where there has been much forma-
tion of fibrous tissue, as in cirrhosis, distention is
not possible, and even an acute cardiac insufficiency
is unable to produce any marked degree of pain.
Therefore, whenever acute general congestion ex-
ists without any marked degree of pain in the liver,
we must always be suspicious of a preexisting cir-
rhosis. It is well, however, to be cautious in those
cases where the cardiac lesion has developed in very
chronic stages and has carried in its train a consid-
erable degree of connective tissue formation (car-
diac cirrhosis).
Occasionally inflammatory factors, such as acute
perihepatitis, may contribute to the production of
the pain. Such complications are characterized by
a sudden increase in the subjective pain without
a corresponding exacerbation of the cardiac condi-
tion. In contradistinction to the dull, aching pres-
sure produced by stretching of the capsule, this pain
is acute and stabbing, and because of its peritoneal
and inflammatory nature it is increased upon deep
DIGESTIVE SYSTEM 233
respiration (rubbing of peritoneal surfaces). This
pain is independent of digitalis treatment, but on
the other hand is rapidly and effectually controlled
by local treatment. "When perihepatitis is present
it is almost impossible to lie upon the painful side.
Friction sounds accompany the pains only when
there is a fibrinous exudation of considerable quan-
tity and the fibrinous masses are of favorable con-
sistency.
Further details of the pains accompanying peri-
hepatitis will be discussed when speaking of syphilis
of the liver.
(b) Biliary Congestion. In the same way that
an overfilling of the blood vessels may lead, by a
secondary stretching of the capsule, to liver pains,
so the condition of congestion in the bile ducts may
give rise to a very similar state of affairs. The
suffering produced by biliary congestion, however,
rarely equals in intensity that produced by conges-
tion in the blood vessels, largely because of the
differences of pressure in the two conditions.
Nevertheless pain over the liver upon percussion
along the linea alba is not uncommon in those dis-
eases which are accompanied by congestion of bile
(catarrhal jaundice, Hanot's cirrhosis, carcinoma of
the head of the pancreas, etc.).
These conditions are also accompanied by the
gall-bladder pains which we have mentioned above,
which occur without true colicky attacks. These
may exist in varying degrees, from the simple sensa-
tion of pressure to conditions approaching gall-
234 PAIN
bladder colic. It is therefore always important to
percuss along the linea alba as well as over the gall-
bladder itself.
Since stagnation of the bile is often directly the
result of inflammation of the mucous membrane of
the passages, and since, on the other hand, biliary
congestion favors inflammation of these passages,
it is not surprising that these conditions are fre-
quently accompanied by perihepatitis and the pains
characteristic of this condition. Therefore the pa-
tient who is suffering from Hanot's cirrhosis often
complains of a sharp pain along the right costal
margin or in the region of the right hypochondrium.
This pain is often dependent upon movements which
cause peritoneal friction, such as running, coughing,
sneezing, or deep respiration. Sometimes, though
rarely, it radiates towards the right shoulder.
Such variation is entirely consistent with its sub-
diaphragmatic position. The pains which occur in
the back and are increased by stooping must be
explained by the distention of the liver capsule.
We have already mentioned that gall-bladder
colic may, though rarely, be part of the clinical
picture of a Hanot's cirrhosis.
Tenderness on percussion over the liver, along
the linea alba and over the gall-bladder as well, is
occasionally found in cases of catarrhal jaundice,
and is directly proportionate to the degree of biliary
congestion.
In cases where the inflammatory processes are
not limited to the larger passages alone but extend
DIGESTIVE SYSTEM 235
into the bile capillaries, extension takes place into
the peritoneal coverings, and thus a new reason
for tenderness is added. Therefore, whenever the
pain is extremely acute without great enlargement
of the organ, it is logical to think of an inflamma-
tory perihepatitis. In such cases also the gall-
bladder becomes involved and there is local tender-
ness to palpation and percussion, and local pain in
the gall-bladder region upon jarring of the body.
"When this occurs it is important to think of the pos-
sibility of preexisting lesions in the gall-bladder,
such as gall-stones, since ordinarily the gall-bladder
pains are not an accompaniment of catarrhal icterus.
In considering conditions which lead to abnormal
stretching of the liver capsule, special attention is
due to the cystic new growths of the liver, and par-
ticularly to the development of echinococcus cysts.
The pains which occur in this condition remind us in
many of their peculiarities of the phenomena con-
sidered under the heading of gall-bladder colic.
In rare instances the passage of small cysts
through the bile ducts may give rise to attacks of
pain. More frequently, however, pains in this con-
dition are due to pressure and consequent stenosis
of the gall-ducts. Likewise, sudden changes in vol-
ume of the echinococcus cysts frequently occur, and
these give rise to inflammatory swelling of the liver
tissue surrounding the growth. The attacks of pain,
which often occur suddenly, are usually localized
in the right hypochondrium under the right costal
border, and radiate towards the right shoulder blade
236 PAIN
and the sternum. The pain may also begin in the
back and radiate forward on both sides; more or
less constant pain in both scapulae and in the back
may be present.
The similarity to gall-stone colic may be accen-
tuated by the occurrence of nocturnal attacks. The
attacks may be colicky, often severe enough to cause
syncope ; again they may be of a more constant dull
character. Mechanical factors materially influence
the pains. Thus the pain is often at its maximum
when the patient lies on the left side, and in this
position has a sensation of a heavy mass being
dragged from right to left. Jarring of the body
increases the pain. Thus sneezing, coughing, per-
cussion upon the right loin, or any exertion causes
pain. Motions which are dependent upon contrac-
tion of the abdominal musculature, bending, lifting,
etc., lead to stabbing sensations over the liver. The
echinococcus cyst itself is sensitive in but few of the
cases. Accompanying the attacks of pain, syncope
may occur ; sensations of suffocation and rise of tem-
perature are not rare. Singultus may occur and
give a clue to the subdiaphragmatic nature of the
condition. Great attention must be paid to those
symptoms which emanate from the stomach and
often lead to an erroneous diagnosis of gastric
disease. These are due in most cases to the crowd-
ing of the stomach by the cystic sac, which produces
the symptoms of slight obstruction and gastric peri-
stalsis. This error can be well guarded against
if, on principle, in all cases of apparent gastric dis-
DIGESTIVE SYSTEM 237
ease, we examine the liver and the spleen as well
as the stomach.
The statements made in regard to the pain
accompanying distention of the liver capsule are
hard to reconcile with those cases of carcinomatous
infiltration of the liver which are unaccompanied
by pain, even when the liver is enormously enlarged.
The same is true of most cases of fatty or hyalin
infiltration of the liver. The strange behavior of
these diseases is probably explained by the more
gradual enlargement which the liver undergoes. In
carcinoma., especially, the liver is not enlarged in
toto but in different places at different times, so that
the peritoneal coverings have an opportunity to
adjust themselves to the changed conditions. If car-
cinoma of the liver is accompanied by pains at all,
they are usually traceable directly to stenosis along
the bile-ducts (carcinoma of the pancreas or the bile-
ducts) or to' the perihepatitis. Occasionally, too,
carcinoma of the liver may be complicated by gall-
stones, which then would account for the pain. The
sharp pains which indicate perihepatitis seem to be
associated chiefly with secondary carcinoma of the
liver, especially when the primary growth is an ulcer-
ating neoplasm of the gastro-intestinal tract. It
stands to reason that in such cases the conditions are
favorable for secondary inflammatory processes. In
cases of this kind occasionally sharp and prolonged
attacks of pain occur, and these are dependent upon
all those motions which give rise to peritoneal fric-
tion, thus pointing to the peritoneal cause of the
238 PAIN
suffering. Pain is caused especially by those carci-
nomatous nodules which lie subperitoneally and
secondarily involve the peritoneum.
There are many cases in which it is important to
determine whether, with the existence of a gastric
carcinoma, the liver has already been involved or
not. In these we are forced to pay particular atten-
tion to the existence of pain in the right hypochon-
drium, since it is hardly ever possible to discover
by physical examination carcinomatous nodules sit-
uated under the dome of the diaphragm; the same
applies to circumscribed tenderness over the palpa-
ble liver surface. Acute and paroxysmal attacks of
pain of a moderate colicky nature are characteristic
chiefly of neoplasms which have caused stenosis of
the bile passages. Chief among these are the neo-
plasms situated in the pancreas.
Carcinoma of the gall-ducts occasionally runs its
course without either subjective or objective pain.
Local pain involving the gall-bladder and in part the
right lobe of the liver accompanies all those cases,
however, in which inflammatory changes have taken
place within or about the gall-bladder. In these
cases, too, mild attacks of gall-bladder colic may
occur even without the existence of a gall-stone.
The fact that the left-sided position is particu-
larly painful in many cases of carcinomatous en-
largement of the liver is explained upon purely me-
chanical grounds. In this position the heavy organ
drops towards the left side and the patient feels
a drawing pain which extends from right to left. If
DIGESTIVE SYSTEM 239
the capsule of the liver is inflamed this change of
position of the liver gives rise to extreme pain, and,
in such cases, the patient voluntarily prefers to lie
flat upon his back; thus immobilizing the organ.
Very frequently stooping gives rise to great pain
in the back.
Attacks of pain of intestinal origin are not rare
in carcinoma of the liver. These are due, on the
one hand, to direct infiltration of the colon from the
gall-bladder and consequent moderate obstruction.
On the other hand, there frequently exists a tendency
to meteorism which leads, by a local collection of
flatus, to attacks of a colicky nature. These attacks
are easily controlled by emptying the bowels.
Much more marked than in carcinoma of the liver
are the pains which accompany liver gummata, and
these are so regular that in all cases where pains
occur in the liver region it is necessary to think of
this possibility.
A local perihepatitis is almost regularly present
because of the inflammatory nature of the new
growth, and in this secondary phenomenon lies the
causes of the pain. This is made particularly evi-
dent by the factors which influence the pain. Pain
is initiated or increased by deep respiration, by
rapid walking, by jarring of the body, by walking
downstairs, by slipping of the right foot, and by
laughing or coughing.
Just as direct pressure upon the painful area
increases the pain, so motions which indirectly give
rise to greater pressure increase it as well. Occa-
240 PAIN
sionally, too, the taking of food will cause increased
suffering (perihepatic adhesions).
A great deal of differential knowledge may be
gained by the therapy. The pains are almost imme-
diately relieved by iodides and (in one of the
author's cases) by arsenic. If the pains are situ-
ated on the right side under the costal margin, there
is radiation into the right shoulder blade and into
the back. If the pain, in addition to this radiation,
assumes the nature of a colicky attack and is accom-
panied by vomiting, slight fever, and icterus, the
danger of confusing it with gall-bladder colic is
plain. Here only an exact physical examination can
make the differentiation, by revealing a circum-
scribed tumor upon the liver surface. Very fre-
quently, however, the pains are situated along the
left costal margin, because of the frequent involve-
ment of the left lobe of the liver. They are then
more constant in their nature, without colicky at-
tacks. They may be sharp or dull without giving
rise to radiation, and tenderness over the gall-
bladder region may be entirely absent.
In contradistinction to echinococcus, in the syphi-
litic condition the tumor itself is markedly sensitive.
PANCREAS.
In this organ, in which we have neither the
mechanism of muscular contraction nor the intimate
relation to the peritoneum found in the liver, there
would seem to be very little basis for the develop-
ment of characteristic pains. On the other hand,
DIGESTIVE SYSTEM 241
experience tells us that certain lesions of the pan-
creas are accompanied regularly by attacks of pecu-
liarly intense pain. The most important among
such lesions are pancreatic cysts.
In accounting for this it is of primary impor-
tance to consider the intimate relations which the
pancreas holds to the nervous system in general
and to the solar plexus in particular ; and it is quite
likely that, occasionally, we are confronted with
purely neuralgic conditions. This, however, does
not exclude the possibility that occasionally pains
may be produced in the pancreas by exactly the same
mechanism by which they are produced in the liver ;
that is, by cramp-like contractions and increased
pressure in the excretory ducts. Because of the
disproportionate structure of the muscular appa-
ratus of these ducts, however, it is hardly possible
to explain in this way any of the very intense
paroxysmal attacks.
Again, it is quite easy to understand that many
of the pains occurring with pancreatic lesions may
emanate from neighboring organs, rather than from
the pancreas itself.
In this connection the very intimate topographi-
cal relation of the terminal end of the ductus chole-
dochus to the head of the pancreas is important;
the close apposition of these two structures makes
it self-evident that any pathological changes in the
head of the pancreas would lead to compression of
the common bile duct; and this, of course, would
lead to stenosis with consequent colicky attacks in
the gall-ducts.
16
242 PAIN
We must remember, however, that frequently
diseases of the gall-passages and of the pancreas
may be present at the same time. In cysts of the
pancreas, the pancreatic nature of the disease may
be particularly obscured by pressure upon portions
of the gut, giving rise to paresis, peritonitis, and
their consequent train of symptoms. Because of the
very intimate relationship of vascular disease to the
general pathology of the pancreas, we must occa-
sionally think of pains arising in the vessels.
From these considerations it naturally becomes
clear that any attempt to separate purely local pan-
creatic pains from those depending upon the neigh-
boring organs must be extremely difficult.
The law which states, in a general way, that
organ pains correspond in localization to the organ
from which they emanate, is borne out by pancreatic
conditions. So, because of the chiefly left-sided posi-
tion of the pancreas, the pains which arise in it are
situated in the left half of the epigastrium, to the
left of the umbilicus, or even in the left loin. Occa-
sionally with these, radiations may be observed
which are symmetrical with 'Lliose occurring in gall-
bladder colic.
It has been mentioned above that occasionally
the colic accomparying pyloric stenosis may behave
in the same way. This left-sided character of the
pain in pancreatic lesions, therefore, might under
certain conditions be of gastric origin, in that the
pathological changes in the pancreas have second-
arily produced a pyloric stenosis by compression
DIGESTIVE SYSTEM 243
and spasm. At all events it is necessary to pay very
close attention to the presence of gastric distention,
peristalsis, or sarcinae in the vomitus or feces.
It is easy to understand that, corresponding with
the retroperitoneal position of the organ, pains in
the back should frequently occur. These pains
sometimes radiate forward and around the waist.
Sensitiveness to pain will change in its localization
according to the position of the lesion in the pan-
creas. Since it is necessary, in palpating, to exert
deep pressure towards the vertebral column, the
localization of the tenderness is of little diagnostic
value. It is important also to look for sensitiveness
to pressure and percussion along the upper lumbar
vertebrae, a symptom which I have had occasion to
notice in several cases of diabetes. This is proba-
bly to be regarded as a reflex manifestation corre-
sponding to the phenomena occurring with gastric
ulcer and gall-bladder inflammations.
Whenever the sensitiveness is in the epigastrium,
it is necessary, owing to the close relation of vascu-
lar disease to disease of the pancreas, to think of
the possibility of purely vascular pain (haemor-
rhages or atheroma of the aorta). When sensitive-
ness occurs along the right costal border, even when
sure of the presence of pancreatic disease, we must
not neglect to search carefully for tumefaction of
the gall-bladder. This may easily follow constric-
tion of the common bile-duct in the head of the
pancreas.
A regular relation of the pains in diseases of the
pancreas to the taking of food could logically be
244 PAIN
assumed since the food, passing out of the stomach
two or three hours after a meal, may readily cause
pain by reflexly inciting pancreatic secretion, and
therefore producing hyperaemia of the organ ; but, of
course, whenever such a direct relation between the
meal and the attack of pain occurs it would be more
reasonable to think of secondary pyloric stenosis
or gastralgia.
It has frequently been noticed that the pain in
the back emanating from the pancreas occurs with
especial frequency at night; and this is explained
by the fact that the dorsal position is most apt to
cause discomfort.
The quality of the pain is of great diagnostic
importance, in that it frequently occurs with great
suddenness and severity and is accompanied by signs
of collapse.
The factors influencing the pain are naturally
dependent upon the mechanism underlying each in-
dividual attack. In cases in which we are dealing
with true neuralgia without the presence of other
factors, it is quite impossible to influence the* pains
in any way except by occasionally effectual narcotics.
In cases where the pain is due to pressure of
tumors (cyst or neoplasms), or is caused by peri-
toneal adhesions to the surrounding organs (as in
pancreatic abscesses), the conditions are quite dif-
ferent. In such cases purely mechanical causes,
jarring and tugging upon compressed nerves in
rapid change of position, stooping, coughing, or deep
breathing, may exert a very marked influence upon
DIGESTIVE SYSTEM 245
the pains. Thus in the case of cysts and neoplasms
the dorsal position is very painful, and turning
upon the side brings almost immediate relief. When-
ever we are sure of the presence of a pancreatic
lesion and we can obtain immediate relief from the
pains by the belching following the administration
of alkaloids, we may conclude that there is present
a secondary stenosis of the duodenum with conse-
quent distention of the stomach.
"When the pains have a purely vascular origin we
may expect them occasionally to be initiated by
the hyperaemia accompanying digestion.
Since, in a general way, the diagnostic aid given
us by the pain in these cases is extremely small, it
is very important to consider closely all other pos-
sible clues. We must remember that a large propor-
tion of the cases of pancreatic disease occurs in very
stout alcoholic individuals ; and that these are espe-
cially prone to arteriosclerosis and therefore to
hsemorrhage and necrosis.
It is well also to think of the possibility of a
pancreatic lesion in all cases of apparent peritonitis,
or intestinal obstruction. The same holds true of
all cases of colicky abdominal pains which follow a
trauma, blows in the epigastrium, etc. If in these
cases no indican is found in the urine, but glycosuria
appears spasmodically or constantly after the attack
of pain, the suspicion of a pancreatic lesion becomes
strong. This opinion is much strengthened if, in
addition to these signs, the stools show an insuf-
ficient digestion of albumins and fats, and physical
246 PAIN
examination justifies the consideration of pancreatic
disease.
In spite of all these things it will often be impos-
sible to distinguish diseases of the pancreas from
peritonitis, acute intestinal stenosis, cholelithiasis,
gastralgia, etc.
Some of the lesions of the pancreas are accom-
panied by pains of definite quality which, while not
entirely characteristic, may still give much diag-
nostic aid.
(a) Carcinoma of the Head of the Pancreas.
Pain in the back with occasionally definite relation
to the position of the body may occur. This is by
no means a rule. The first pains seem frequently
to occur in the neighborhood of the gall-bladder be-
cause of the overdistention or stenosis of the com-
mon bile-duct. The pains seem to be dependent
chiefly upon mechanical conditions, such as the posi-
tion of the body, and are similar in this respect to
those occurring in the gall-bladder. Again the first
pains may be dependent entirely upon the local
perihepatitis which accompanies the subperitoneal
metastases.
In this way, in some cases, the entire attention
of the physician may be concentrated upon the liver
and gall-passages, and the pancreatic lesion may
escape detection. In the same way the attention
may be directed chiefly toward the pylorus or duode-
num when subjective or objective symptoms of ste-
nosis occur in these places. When this occurs, how-
ever, the pains are much less severe than in the
DIGESTIVE SYSTEM 247
primary ulcerative or stenotic processes of these
organs.
(b) Pancreatic Cyst. In this condition very sud-
den attacks of pain occur, sometimes under the left,
sometimes under the right costal border, accompa-
nied by syncope, collapse, vomiting and diarrhoea.
These attacks may in part be due to sudden increase
of tension whenever the cyst contents rapidly in-
crease in volume. Again, they may be neuralgic
in their nature, or may consist in the colic following
secondary stenosis of the gut.
(c) Suppurative Pancreatitis. Not rarely the
acute attack of pain which occurs in these- cases is
followed by icterus. This would naturally lead to
the danger of confusing the condition with choleli-
thiasis. The error can be guarded against only by
very careful palpation and localization of the sensi-
tive point.
(d) Hemorrhages. When we are dealing with
drunkards, very fat people, or individuals with
marked arterial changes, all sudden attacks of epi-
gastric pain accompanied by collapse and dangerous
symptoms must be considered as possibly due to a
haemorrhage into the pancreas. It is almost never
possible to make this diagnosis with certainty.
(e) Pancreatic Calculi. Attacks of pain which
are due to stones in the pancreatic duct usually be-
gin in the left half of the epigastrium and radiate
over the left shoulder. This left-sided localization
occasionally permits their differentiation from the
very similar attacks of gall-stone colic, a differen-
248 PAIN
tiation which is rendered very difficult by the fact
that occasionally pancreatic concretions are accom-
panied by icterus. The- absence, too, of sensitiveness
to pressure over the gall-bladder would be of great
aid. Differentiation from ulcerations similarly
localized, for instance those occurring in the py-
lorus, can be made by considering the independence
of the pancreatic pains from the quality and quan-
tity of the food. The greatest weight in making
these difficult diagnoses must, of course, be laid
upon the secondary symptoms.
Diarrhoea must be very carefully inquired for,
since it is rather a rare symptom in the other
varieties of colic. In addition to this careful exam-
ination must be made for the detection of glycosuria
and of excess of fat in the stools. The stools, too,
should be searched for bile-free concretions consist-
ing of carbonates and phosphates of calcium.
CHAPTER VIII.
URINAKY SYSTEM AND SPLEEN.
KIDNEY.
IN discussing the factors which produce pain in
the urogenital system, we may avoid much repetition
by calling attention to the close analogy existing
between this system and that of the liver and gall-
ducts. The pelvis of the kidney, the ureter and the
bladder find close analogies in the gall-bladder, the
gall-passages and the duodenum, and in a general
way the conditions producing colicky pains along
these hollow muscular organs are the same. It may
be assumed that conditions which produce an in-
crease of pressure upon the capsule of the liver,
such as congestion of blood or bile, or tumor forma-
tion, may find close analogies in the kidney itself.
The same holds good of perihepatitis and peri-
nephritis. For this reason we can follow approxi-
mately the same classification.
I. True Kidney Pains.
Here the pain is caused by acute or chronic
tension upon the kidney capsule or inflammatory
changes in the surrounding tissue. In some cases
also there may be direct injury by destructive proc-
esses of the renal plexus. At any rate it is never
correct to speak of renal colic; for in the kidney
itself the conditions for the production of such
249
250 PAIN
colicky pains are absent, such pains occurring only
in hollow organs.
While it is impossible to differentiate by their
pains alone the various conditions which produce
such stretching of the capsule of the kidney, it is for
practical reasons better to consider the conditions
separately.
(a) Embolism of the Renal Arteries. It is ex-
tremely rare for this lesion to be accompanied by
pain. In the year 1901 I was able to find in the
literature only seven reported cases, and therefore
it may seem wrong to begin our considerations with
this condition. But in kidney infarcts the pain
occurs in such a characteristically sudden way that
it furnishes a most clear-cut subject for study.
The pain in this condition is distinguished from
all other true kidney pains only by the great sudden-
ness of its onset (apoplectiform). In other respects
every one of the details which are observed in kidney
pains occurs, and for this very reason a close de-
scription of the condition will serve most excellently
to illustrate the others.
Subjective pains, as well as the objective ones
produced by pressure, palpation and percussion, cor-
respond in a general way to the position of the
organ in front and behind. The kidney extends
vertically from the middle of the eleventh thoracic
vertebra to the lower limit of the body of the second
lumbar vertebra. In an upward direction, therefore,
it extends to above the twelfth thoracic vertebra.
Its posterior surface for a short distance is apposed
URINARY SYSTEM AND SPLEEN 251
to that part of the diaphragm at which the lumbar
and costal portions of this organ join. The greater
part of it lies against the quadratus lumborum.
Since the kidney varies much in its localization we
must occasionally be prepared to find abnormal local-
ization of the pain. Thus a low position of the kid-
ney may give rise to pains in the ileocsecal region.
It must be remembered also that in some cases the
kidney may have projections towards the median
line (horse-shoe kidney), or occasionally in the pel-
vis, or the sacrum, along the position of the sacro-
iliac junction. These abnormal positions would
naturally bring with them abnormal positions of the
pain.
The kidney pain is especially easy to recognize
when we are dealing with the right kidney and the
pains are projected forwards. This occasionally
happens in- renal infarcts. If we consider the sec-
ondary symptoms, such as vomiting, pain in the liver
due to congestion, tenderness along the gall-bladder
and appendix, and fever, the danger of confusion
with gall-bladder or appendicular pain is extremely
probable.
It seems to the author especially important to
note that the pain in disease of the kidney is located
particularly in the flank; while along the mammary
line in front, or in the lumbar region behind, the
tenderness to pressure or percussion is much less
marked.
Another source of frequent error lies in the fact
that pressure of the abdomen often gives rise to a
252 PAIN
very diffuse pain (especially when the infarction is
bilateral). This is explained by the fact that the
pressure reaches the diseased organ indirectly
through the interposed organs. For the more exact
localization of the pain in these cases percussion is
more useful than palpation.
The patient in cases of true kidney pain almost
always localizes the pain deeply, away from the
abdominal wall, a fact which often helps greatly in
differentiating it from neuralgia or myalgia.
Very occasionally there is sensitiveness in the
lower intercostal spaces as far up as the scapular
angle posteriorly, and about four centimeters above
the costal border anteriorly. This must be regarded
as merely a reflex pain, since it occasionally occurs
in pyelonephritis without the existence of a second-
ary pleural inflammation.
Sensitiveness to pressure is found chiefly in:
(1) the flank, in the axillary line; (2) the angle
between the lateral border of the erector spina* and
the twelfth rib; (3) anteriorly in the region below
the gall-bladder corresponding to the position of the
kidney.
A characteristic radiation does not accompany
these true kidney pains and therefore is not present
with renal infarcts. This is due to the absence of a
path of transmission (ureter) ; yet in rare cases
there may be sensations in the thigh. When these
do occur, they can be regarded as due to pressure
upon the twelfth dorsal nerve and branches of the
lumbar plexus, by thickening of the capsule.
URINARY SYSTEM AND SPLEEN 253
The factors influencing the pains of renal inf arct
are chiefly mechanical. Normally the kidney is sup-
posed to be entirely immovable. This is quite theo-
retical, however, and practically we may find all
degrees of mobility. It is not surprising, therefore,
that in cases of inflammatory changes within the
kidney or about the capsule (partial necrosis of the
renal tissue, tuberculosis, etc.), forcible manipula-
tion of the organ is accompanied by more or less
pain; thus, too, a definite position of greatest pain
is developed quite acutely in cases where enterop-
tosis and weakness of the abdominal walls are pres-
ent. The patients are unable to lie on either side
without suffering, and it is peculiar that pain is
most severe when lying upon the healthy side. In
this position they have the sensation of a painful
tugging extending from the diseased side towards
the healthy. The actual descent of the kidney
downwards toward the side upon which he lies is
felt acutely and distinctly by the patient.
In the same way definite painful positions are
present in tuberculosis, in renal tumors and in pyelo-
nephrosis; only occasionally does the position of
greatest pain correspond with the diseased side. If
change of position and slight tugging by reason of
the weight of the organ itself are able to cause pain,
it is all the more reasonable to believe that forcible
jarring would cause localized pain in the neighbor-
hood of the kidney; and this actually occurs with
coughing, vomiting, riding in a carriage, jumping,
or making a false step. All motions which call for
254 PAIN
contraction of the ileopsoas muscle, such as rising,
and stretching of the flexed thigh, will of course
give pain because of the close apposition of the
kidney to the muscle.
It is hardly necessary to mention that pressure
in the kidney region, or percussion with the clenched
fist would cause pain. Strong percussion is espe-
cially helpful in localizing the exact extent of the
pain and in demonstrating its diminution during con-
valescence. It is worth mentioning, too, that in
cases of renal infarct the objective pain is present
for some time after the subjective has disappeared.
The pain accompanying renal infarct resembles,
in the suddenness of its onset, colic of the ureter,
but is sharply differentiated from the latter condi-
tion by the fact that the pain itself, after the onset,
is not colicky but stabbing, aching and constant.
In attributing any pain to renal infarction, we
must consider the condition of the heart (existence
of a mitral stenosis). "We must note particularly
the sudden onset of the pain and the subsequent
absence of any paroxysmal quality. Most abdom-
inal pains are of a colicky nature, and the absence
of the paroxysmal element is of great differential
importance.
It is, furthermore, very important to determine
whether or not there is difficulty of micturition.
Urination becomes difficult (renal dysuria) and can
be accomplished only in the standing position and
with great exertion; occasionally there are symp-
toms of moderate incontinence. The quantity may
URINARY SYSTEM AND SPLEEN 255
be at first diminished or there may even be complete
anuria. The frequent desire to urinate seems to
be absent in these cases, a feature which is of great
differential value since pains arising in the excretory
passages are usually accompanied by this symptom.
The characteristic features of the urine analysis,
I have found to be the following :
There is often a sudden and copious albuminuria,
as high as 2 per cent., which very rapidly diminishes.
There is occasionally a very slight hsematuria, often
discovered only by microscopical examination. Oc-
casionally, also, epithelial casts may be found in the
sediment.
The consideration of these secondary symptoms
which point to the urogenital system will guard us
against confusion with the colics of the gall-bladder
and appendix, an error which is the more easily
made when the embolus is situated on the right side.
The vomiting and hiccoughing which occur with
the onset, can lead easily to the false diagnosis of
acute peritonitis. This is especially so when the
infarct is bilateral and in consequence the abdom-
inal tenderness is very diffuse.
The pain accompanying renal infarct is sharply
differentiated from the pains which occur along the
ureter (nephrolithiasis) by the complete absence
of paroxysms,, the continuous character of the pains,
and the slight tendency to radiation. In ureteral
colic the pain is of a remarkably intermittent type
and radiations are very frequent. In renal infarc-
tion the kidney is especially sensitive to pressure,
256 PAIN
whereas in the other condition tenderness may occur
only along the course of the ureter.
It is quite impossible to differentiate the pain of
renal infarct from that accompanying other intra-
renal conditions. All other diseases which occur
in this location may give rise to similar pains, and
for that reason the description just given may serve
as a type for all true "nephralgia." I will there-
fore spend little time in discussing the other patho-
logical conditions which occur in the kidney and are
accompanied by pain.
(b) Acute and Chronic Nephritis, Pyelitis, and
Paranephritis. Acute paroxysmal pains may occa-
sionally, though rarely, accompany the non-suppura-
tive inflammations of the kidney. These are then
due to pericapsular inflammation, and damming back
of the urine, with acute congestion and increase in
the capsular tension. Thus acute hyperaemia, as it
occurs in cases of nephritis, may give rise to intense
pains which are similar to those just described in
renal infarct, and these pains may be one-sided in
spite of symmetry in the pathological process. It
is therefore advisable to be very cautious in the
diagnosis of calculus when sudden- colicky pain
occurs in the neighborhood of the kidney in acute
nephritis, even when, as in one of my own cases,
radiation occurs into the thigh. Such an occurrence,
while it must be thought of, is nevertheless extremely
rare in all cases of non-suppurative nephritis. I
have seen onlv one such case.
URINARY SYSTEM AND SPLEEN 257
Of much greater frequency are those uncertain
dull back-aches, the relation of which to the kidney
is subject to great doubt and must be judged individ-
ually in each case. It is very rare that we have any
definite factor which points to the kidney as the
source of the pain. I have seen cases, however, in
which the patient has stated that excessive drinking
has increased the pain, while, on the other .hand,
discharge of the urine has decreased it considerably.
In contrast to lumbago, the pain in nephritis and
pyelonephritis is not at all influenced by stooping;
while, on the other hand, walking about, severe exer-
tion, and pressure increase the pains, just as in the
case of lumbago. In these conditions, too, the pain
is occasionally one-sided. As a matter of practical
importance it is well to examine the urine for al-
bumin in all cases where a pain suggestive of lum-
bago exists, and this, especially, when no other
clearly rheumatic pains are present.
It is also important, whenever albuminuria has
been discovered, to examine the kidney for tender-
ness. Occasionally, hypersemia of the kidney and
consequently increased intracapsular pressure will
give rise to sensitiveness on palpation. Percussion
in the loin is best made with the clenched fist. By
palpation in front it is often possible to press
directly upon the lower pole of the kidney. When-
ever slight pressure in the loin or slight jarring in
this neighborhood causes pain and we can determine
the presence of hyperaesthesia along the ileohypo-
gastric and genitocrural nerves, we must think of
17
258 PAIN
the possibility of paranephritic suppuration. In
such cases the patient often lies with the thigh flexed
and adducted, has chills, and suffers great pain upon
change of position.
(c) Renal Congestion. Just as the liver is the
seat of pain when it is congested in consequence of
cardiac insufficiency, so the kidney may be the seat
of pain under similar conditions. This, however,
occurs much more rarely. The pains in the back
are then very promptly relieved by digitalis.
(d) New Growths of the Kidney. Pain in the
lumbar region and the flank, when unilateral, must
occasionally arouse suspicion of an early neoplasm
of the kidney and should lead to a careful palpation
of the organ.
Increase in the intracapsular tension in conse-
quence of the enlargement of the new growth, con-
gestion or haemorrhage into the tumor, may give rise
to pain, even in the early stages. In these cases, too,
the pains havethe characteristics of true kidney pains
in the special sense of the word, and correspond to
the pains described for renal infarct. In conse-
quence of the increased weight of the organ the tug-
ging pains accompanying change of position will be
more noticeable than in infarction, so that the patient
cannot bear to lie on the side opposite to that of the
diseased kidney. The pain is often provoked by
bending, lifting, or the carrying of a heavy weight.
This may be due either to temporary passive hyper-
semia or to direct pressure by the contracting abdom-
inal muscles. In these cases, too, there may occa-
URINARY SYSTEM AND SPLEEN 259
sionally be sensitiveness to pressure in the corre-
sponding thigh.
When the new growth penetrates into the pelvis
of the kidney and secondary haemorrhage occurs, a
new source of pain arises ; but then we are dealing
with the colicky pain belonging to the urinary pas-
sages which will be spoken of in a later section.
(e) Tuberculosis of the Kidney. In many cases
tuberculosis of the kidney occurs without local pain.
Nevertheless cases occur in which pain is one of the
earliest symptoms. Whenever considerable capsu-
lar or pericapsular inflammation occurs, nephralgia
will be present, and such pains, in the presence of a
tuberculous tendency or of tuberculosis in other
parts of the body, must always arouse suspicion.
The pain seems to be in many cases extremely
acute, and is described as boring like that of a boil.
Just as in new growth, so in tuberculosis of
the kidney sudden paroxysmal attacks may occur.
These occur whenever by ulceration and erosion of
a blood vessel a haemorrhage takes place into the
pelvis from one of the papillae.
The localization of the subjective and objective
pains in this condition corresponds more or less
closely to that described for renal infarct. The
painful sensations which occasionally occur in the
bladder and urethra, without any disease in these
organs, must be explained by radiation, and consist
chiefly in a painful desire to urinate, and burning
pain before and after micturition; so that these
pains may simulate a cystitis.
260 PAIN
(f) Paroxysmal Hcemoglobinuria. In this con-
dition there is occasionally an acute hyperjemia of
the kidney with consequent intracapsular pressure;
the pain in the back which occurs is probably to be
interpreted upon this basis.
The subjective pain which occurs in one or both
kidneys is often accompanied by sensitiveness.
The pain is then dependent upon motion, such as ris-
ing from a stooping position, bending forward and
turning towards the painful side.
(g) Movable Kidney. It must be remembered,
in considering movable kidney, that many patients
in whom an enormous amount of freedom of motion
of the kidney exists are almost entirely free from
pain. This fact ought to be considered very seri-
ously, because it is a quite common error that when
a movable kidney is present in a patient, this is taken
as the cause for any existing pain. In most cases
it is not the wandering kidney which causes the
pains. The individuals in whom they are present
are usually of an extremely neurasthenic type, and
suffer from a general enteroptosis. These are the
conditions which should be treated rather than that
of the movable organ itself. It stands to reason that
in this condition there is a constant tugging on the
renal plexus and indirectly therefore upon the solar
plexus. This leads naturally to hyperasthesia in
the abdominal sympathetic system and consequent
irritability of the stomach, gall-bladder and genitals.
In this sense, a movable kidney and enteroptosis
may be very disagreeable complications of gastric
URINARY SYSTEM AND SPLEEN 261
ulcer or cholelithiasis. Whenever an abnormally
movable kidney is also tender and sensitive to pres-
sure, it is well to think of diseases of this kidney,
such as calculi, pyelitis, or tuberculosis.
In referring any existing pain to the mobility of
the kidney, it is important to determine whether
motions which directly result in tugging or jarring
of the organ, such as walking downstairs, rapid
change of position, etc., are the ones which cause the
pain; and it is never just to attribute pains which
are present during absolute quiet to this cause. It
must be remembered, however, that other diseases
which are often accompanied by enteroptosis, such
as ulcer, chronic appendicitis, and gall-bladder dis-
ease, may also be dependent upon such jarring
movements.
The exact diagnosis in these cases is often ex-
tremely difficult, and it is better, therefore, to let
the therapeutic interference precede the diagnosis
rather than vice versa. Whenever the pain is re-
lieved when the kidney is immobilized by bandages,
the diagnosis, of course, is cleared up.
It is surely very rare that torsion of the pedicle
of a movable kidney occurs; and it is well to think
of this only after the exclusion of other causes for
the attack. Whenever this does occur the pain that
accompanies it can be explained in two ways:
1. Acute venous stasis. 2. Acute development of
ureteral obstruction with secondary hydronephrosis.
In both cases local sensitiveness would be easily ex-
plained. In the second case, however, an attack of
262 PAIN
polyuria would theoretically be expected towards
the end of the attack. On the other hand, it is well
to remember that in neurasthenic individuals, among
whom the large majority of movable kidneys occur,
polyuria is not a rare symptom.
II. Pains Caused by Distention and Muscular Spasm
along the Urogenital Tract (Renal
Pelvis and Ureter).
The pains which are considered in this connec-
tion are in their genesis closely related to those
occurring in the gall-bladder system, and may easily
be classified in the same way. The pelvis of the kid-
ney may be regarded as analogous to the gall-
bladder and the urinary bladder to the duodenum.
The characteristics which distinguish the pains
in these passages from the true kidney pain (ne-
phralgia) are the marked tendency to colicky attacks
and the tendency to radiation ; for we have here in
contradistinction to the kidney itself a channel for
radiation along the ureter and bladder. The chief
causes which may give rise to colicky attacks in the
genito-urinary ducts are analogous to those which
give rise to similar pains in the gall-duct system.
1. Stenotic Processes. The most important
causes for stenosis are : (a) Calculi, blood clots, par-
ticles of new growth, and aortic aneurysm (on the
left side), (b) Kinking and torsion, (c) Carci-
noma of the bladder at the points of entrance of the
ureters. (This would be analogous in the bile pas-
sages to a carcinoma at the papilla of Vater or in
the head of the pancreas.)
URINARY SYSTEM AND SPLEEN 263
2. Inflammatory Processes, Ascending and De-
scending. Pyelitis with or without the formation
of calculi ; this may or may not extend into the small
tubules of the kidney (pyelonephritis). Ureteritis
is entirely analogous to cholecystitis and cholan-
geitis, while the pyelonephritis can be compared with
Hanot's biliary cirrhosis.
All these conditions, and especially the formation
of calculi in the kidney pelvis, give rise to colicky,
paroxysmal pains. On the other hand, they may
also give rise to more constant pains, not colicky in
their nature, the understanding of which is of ex-
treme importance. These more constant pains are
probably due to a moderate degree of distention
along the ureters or pelvis. It must be remembered,
too, that any pathological process in the renal pelvis
easily involves the kidney itself, even when it is only
a temporary damming back of urine or an active
hypersemia; and this, in its turn, can give rise to
the true kidney pain which we have spoken of before.
As a practical matter it is almost impossible to
separate the purely stenotic and the inflammatory
processes which occur along the renal pelves and the
ureters. They often occur at the same time, for
stagnation, as is well known, carries with it the
predisposition to infection. For this reason we
may disregard this purely artificial distinction in
the consideration of the pain.
(a) THE FORMATION OF CALCULI IN THE PELVIS OF
THE KIDNEY. Just as in describing the true kidney
pain, the pain caused by infarct of the kidney was
264 PAIN
used as a type, so the pains occurring in the pelves
and ureters are well typified in a general way by the
pains caused by a calculus in the renal pelvis.
For practical reasons it is well to divide such
pains into (1) spontaneous attacks of paroxysmal
pain or colic, (2) more constant pains not colicky
in their character and often elicited by physical
examination.
(1) The localization of the colicky pains is rather
apt to be confusing to the diagnostician. Sometimes
these pains occur first in the region of the gall-
bladder along the right costal border. Occasionally
they have their seat more deeply in the ileocascal
region or, if left-sided, just above the left Poupart's
ligament. In comparatively rare cases the lumbar
region may be the starting point of the pains. This
is not at all surprising when we consider that the
lesion upon which the pain is based has its seat, not
in the kidney itself, but in the ureter.
More important than the actual location of the
pain is the radiation, which unfortunately is not
always present. This occurs into the thigh of the
same side, chiefly radiating down the anterior or
external surface, and rarely extending further down
than the knee.
We must be on the watch, too, for radiations into
the bladder and the genitals, with occasional cramp-
like sensations in these organs. It is very important
to remember that painful sensations in the testicles,
ovaries and thighs may for a long time precede the
first attack. These pains occur especially at night
URINARY SYSTEM AND SPLEEN 265
and their diagnostic importance must not be under-
estimated.
The pain not infrequently radiates into the lum-
bar regions; upward it rarely reaches higher than
the angle of the scapula. Whenever the attacks
occur spontaneously they seem to be dependent upon
mechanical agencies rather than upon digestive
causes.
Motions which give rise to a sudden stiffening
of the abdominal walls, lifting, or throwing, seem
frequently to have a causal relation to the begin-
ning of an attack. On the other hand, I have seen
cases in which attacks have been initiated by the
drinking of sour wine, the taking of sour food, such
as vinegar, and occasionally the drinking of beer.
Such digestive influences upon the attacks occur nat-
urally in cases in which, in addition to calculus for-
mation, there is an inflammatory change of the
mucous membrane of the pelvis and ureter which
is irritated by the reaction of the urine passing
through it.
Whenever a paroxysm ceases with great sudden-
ness we are led to believe that a calculus has been
discharged into the bladder.
The secondary symptoms chiefly to be consid-
ered are those which arise from the urogenital sys-
tem and therefore point directly to the origin of the
colicky attack. Chief among these are the desire for
frequent micturition and retention of urine. In
tuberculosis of the kidney, kidney infarct, and other
conditions of nephralgia or true kidney pain, the
266 PAIN
desire to urinate may occasionally entirely disap-
pear.
Sometimes there is definite sensitiveness of the
testicle on the affected side with occasional swelling.
Swelling and sensitiveness in the urethra may be
the premonition of an attack. Very definite clews,
of course, are given by haematuria, albuminuria, ura-
turia, phosphoturia, oxaluria, and cystinuria.
Eeflex symptoms, aroused in other organs by
the renal condition, may considerably cloud the diag-
nostic picture. Meteorism with constipation, diffuse
distribution of the pains, with collapse, may simu-
late acute intestinal obstruction and, in just such
cases, the extreme sensitiveness of the testicles is of
distinct diagnostic importance. The distended ab-
domen itself is often sensitive to pressure, and in
such cases distention and sensitiveness are usually
localized more on one side than on the other. Occa-
sionally there may be no pain in the kidney region
itself. Gastric symptoms, such as nausea and vomit-
ing, occasionally occur, but are much less frequent
than in connection with the colics of the biliary sys-
tem, and, during the attacks of renal pain, the diges-
tive system is often entirely normal, not even the
appetite being changed. In many cases there are
subjective sensations, such as a sensation of cold,
etc., in the thigh of the same side. There may also be
motor symptoms, such as spasm in the muscles of the
calf or the thigh of the same side.
Sensitiveness to pressure along the ureter on
external examination per rectum or pervaginam is of
URINARY SYSTEM AND SPLEEN 267
the greatest importance, and from this examination
alone the diagnosis of an obstructing calculus can
often be made.
(2) More constant pains (without paroxysmal
quality). Under this heading we include chiefly
pain which is not subjectively present but is discov-
ered on palpation. We have already called atten-
tion to the sensitiveness of the testicle. In addition
to this there is usually sensitiveness of the ureter,
leading on the right side to pain in the neighborhood
of the appendix; on the left side in the neighbor-
hood of the sigmoid flexure.
The sensitiveness to pressure in the flank and to
percussion in the lumbar region is of great impor-
tance. The maximum point of sensitiveness is often
located just above Poupart's ligament. Occasion-
ally when the condition exists on the right side the
gall-bladder is very sensitive and errors may arise
from this fact. When this is the case, however, very
often sensitiveness in the gall-bladder radiates
towards the urinary bladder and this, of course, is
of great importance.
These more constant pains may often be started
by the patient's lying on one side. When the
process is bilateral lying on either side is painful.
In some cases no fixed position can be held for any
length of time without great pain. We spoke of
such positions of greatest pain when dealing with
cholecystitis, and here again symptoms of this kind
are due probably to changes in the pelvis of the
kidney; they may also be caused by secondary in-
268 PAIN
volvement of the kidney in the form either of an
acute damming back of the urine, or an acute conges-
tion of the kidney itself. Coughing, deep breathing,
and jarring of any kind may give pain in nephro-
lithiasis.
The unilateral neuralgia of the testicle which
occurs chiefly at night, and the so-called rheumatic
pains in the thigh, may often precede the true colicky
attacks by many years. The sensations of weakness,
nausea, etc., which usually accompany the colicky
attacks may be present by themselves frequently,
and are then, almost invariably, wrongly interpreted.
Under this heading, too, we must consider that
pain in the lumbar region which frequently accom-
panies the condition. This is present especially in
the lying and sitting postures, and is less marked
when walking. Alone, of course, the recurrence
of such a pain can give us no diagnostic clue ; but, in
connection with other symptoms, such as testicular
pain and parsesthesia of the thigh, it may give much
additional support to our diagnosis.
(b) PYELITIS. Of chief importance are the
ascending catarrhs of the urinary passages, usually
preceded by a history of an old gonorrhoea, so that
in many cases the ureter and the bladder itself may
be regarded as diseased together. This variety of
pyelitis is the most frequent. The pain occurring
in this condition is almost identical with that occur-
ring in cases of calculi. This fact is of particular
pathological interest, since it lends support to the
opinion that pains of this description are, in these
URINARY SYSTEM AND SPLEEN 269
cases as well as in gall-bladder condition, caused by
the inflammatory lesions rather than by the mere
mechanical presence of calculi.
Changes of the kidney in all their transitions
from a simple inflammatory hypersemia to a fully
developed pyelonephritis may accompany this con-
dition. A part, therefore, of the clinical picture is
made up of the true kidney pain itself. The local-
ization of the pain is much the same as that men-
tioned above. Occasionally, however, cases occur
in which the pain and sensitiveness take place in the
region of the gall-bladder and appendix and thus
lead to error in diagnosis.
The radiation is identical with that which occurs
in calculi of the renal pelvis. Radiation may occur
at the same time as the colicky attacks or may be
entirely independent of them. It may be localized
chiefly on the outer side or occasionally on the inner
side of the thigh of the same side. Prolonged sit-
ting occasionally initiates these radiating pains.
In isolated cases it is not so much the sensation
of pain as the sensation of weakness and fatigue in
the lower extremity of the same side as the disease
which gives rise to a suspicion of a lesion in the
renal pelvis.
Sometimes sensitiveness occurs along the dorso-
lumbar portion of the spinal column. Pain occur-
ring while the patient is lying on his side is located
usually in the side opposite to that of the lesion.
Frequently the pain which occurs in this posture is
present only during the acute attack and disappears
when the attack is over.
270 PAIN
There is often a tendency towards relaxation of
the abdominal muscles on the diseased side. The
patients lean toward that side while walking or sit
in a cramped position. Sudden stretching of the
abdominal muscles often brings about an attack of
intense pain and syncope, in cases which have been
before that almost free from pain. In doubtful
cases it is often advisable to test cautiously the
influence of lifting or carrying weights on the back.
Violent jarring, such as is produced by stamping
the foot, jumping, etc., will frequently give rise to
pain. In contradistinction to lumbago, the pain is
not increased by stooping, even when there has pre-
viously been severe pain in the lumbar region.
Catching cold and exposure to wet often give rise
to attacks of pain. This is probably due to the fact
that these conditions may provoke an acute exacer-
bation of a chronically inflamed condition of the
mucous membrane.
It need hardly be emphasized that careful micro-
scopical examination of the urine and careful atten-
tion to the temperature are desirable. Pyemic tem-
perature frequently occurs and the individual par-
oxysmal attacks may be accompanied by a chill and
subsequent sweating. Fever may precede the at-
tacks for some time, for the infectious agent, which
not infrequently is B. coli or staphylococcus, plays
an important role in these cases.
The most important secondary symptoms are fre-
quent desire to micturate and ardor urinae.
URINARY SYSTEM AND SPLEEN 271
(c) HEMORRHAGE FROM THE KlDNEYS. Bleeding
from the kidney can unquestionably give rise to
paroxysmal attacks of pain, so that the expression
Nephralgie hcematurique is fully justified.
It is very important to remember that cases of
prolonged and constant haematuria exist, so-called
1 'essential haematuria," without a lesion in the kid-
ney and without any accompanying pain. Haema-
turia, therefore, gives rise to pain only when other
underlying factors are present. The most impor-
tant of these is the presence of blood coagula
(malignant tumors, ulcerative erosions of renal
capillaries, as in tuberculosis of the papilla, etc.).
The clots in these cases produce the same patholog-
ical condition in the ureters as calculi, and occa-
sionally cause obstruction. In addition to this, sud-
den profuse bleeding may cause severe distention
and in this way give rise to paroxysmal pains.
It is a general fact that under suitable conditions
bleeding into hollow muscular organs may by acute
distention give rise to paroxysmal pains. The
writer has seen one case at autopsy in which bleed-
ing had taken place into the stomach from an
cesophageal vein. In this case severe paroxysmal
pains in the epigastrium had occurred.
A true kidney pain, that is, nephralgia in the true
sense of the word, is occasionally caused by bleeding
from -vascular tumors of the kidney, by " essential
haematuria," or by acute exacerbations of chronic
nephritis ; such pains may be due either to distention
by the haemorrhage or to acute congestion.
272 PAIN
URINARY BLADDER.
The chief characteristic of pain in the bladder
is the direct relation which it has to the function
of the organ, that is, urination. The problem of
diagnosis is simpler by far in this organ than in
any of the other hollow muscular organs, since
pathological changes in micturition can be closely
observed by both patient and physician. The
mechanism of the pain, therefore, can be more ex-
actly studied, and the conditions prevalent here can
serve to throw light upon similar pains occurring
in the gall-bladder and stomach.
The conditions which give rise to bladder pains
are the following:
1. CATARKHAL AND ULCERATIVE CHANGES IN THE
Mucous MEMBRANES OF THE BLADDER AND THE URE-
THRA. These are chiefly caused by acute and chronic
forms of cystitis following urethral infections, in-
flammatory conditions due to calculi, foreign bod-
ies, tuberculosis, neoplasms, etc. Urethral stric-
tures and enlargement of the prostate, benign or
malignant, are important in that they predispose to
cystitis.
2. PERIVESICAL INFLAMMATIONS. These are
chiefly diseases of the female genitals and diseases
of neighboring parts of the intestine (rectum and
appendix).
The pain is often directly related to the contrac-
tion of the bladder muscle and reaches its maximum
at the height of contraction, that is, during the end
of micturition and immediately after it.
URINARY SYSTEM AND SPLEEN 273
Distention o-f the bladder wall whenever sudden
may also cause great pain. This is closely analo-
gous to conditions existing in the gastro-intestinal
tracts and the bile-ducts.
The localization of the pain, both subjective and
objective, corresponds to the location of the organ,
occurring behind the symphysis. In prostatic dis-
ease it is occasionally located in the pierineum. Ra-
diation occurs along the urethra and into the glands,
into the .testicles, and into the inguinal regions.
Sometimes the pain radiates into the anus and the
perineum. When this happens it may be explained
by the common innervation of these regions by the
sacral plexus.
Reflexly radiation may occur upwards into the
hypochondriac regions, downward into both thighs,
and into the regions innervated by the sciatic and
the anterior crural nerves. This, for instance, is
the case in prostatic tumors.
It must not be forgotten that in rare instances
prostatic tumors may occur without pain. The gen-
eral condition of the nervous system seems to have
great bearing upon this feature.
As we have said, bladder contraction is the most
important factor in producing the pain. The more
forcibly, therefore, this contraction occurs (as in
stricture, enlargement of the prostate, and calculi),
and the more severe the inflammation of the mucous
membrane, the more violent will be the attacks. In
cases where the mucous membrane of the bladder
itself is intact, and the pain is due only to tugging
18
274 PAIN
on the perivesical adhesions, the attacks are never
very severe.
Jarring and sudden changes of position, when
they have any relation to the pain at all, point
toward the existence of calculi. It is always neces-
sary to examine by palpation above the symphysis
and per rectum or vaginam.
Cold drafts, wetting the feet, etc., may reflexly
give rise to bladder peristalsis.
The physical and chemical properties of the urine
may also exert marked influence upon the pain.
Concentration of the urine, as in fever with serous
exudation (as in tuberculous peritonitis) or in con-
sequence of severe perspiration, may give rise to
pain in an irritable bladder. Spicy food and certain
drugs, such as urotropin, in large doses, give rise
to similar sensations.
The most important secondary symptoms to be
considered are pyuria and bacteriuria. Whenever
these two conditions are absent, we should suspect
calculi or perivascular inflammations ; haematuria,
too, for obvious reasons, is not rare. Whenever this
occurs, together with pains in the bladder, a vascu-
lar origin of the pain is most likely. Frequent mic-
turition is, next to pyuria, the most usual of the
secondary symptoms.
The fact that the pains are usually in direct rela-
tion to the bladder function, makes an error in diag-
nosis rather rare ; yet it is well to remember that the
symptoms of disease of the bladder itself are so
similar to those of disease of the prostate and pos-
URINARY SYSTEM AND SPLEEN 275
terior urethra, that a separation from these is almost
impossible without the aid of objective symptoms.
Examination of the prostate is, therefore, essential.
Differentiation of these conditions from a'ttacks
of pain which, like gastric crises, have their origin
in the central nervous system, may be neglected
because of the extreme rarity of such attacks.
On purely theoretical grounds, we may say that
conditions dependent upon the nervous system would
be independent of micturition. Sensitiveness of the
bladder upon examination per vaginam or per rec-
tum would point to organic disease. The pains occa-
sionally radiate into the rectum and are in direct
relation to defecation. This occurs chiefly in dis-
eases of the prostate and in vesical calculi, and may
lead to an erroneous diagnosis of intestinal disease.
Radiations into the genitals and thighs may occa-
sionally be misconstrued as ureteral colic. Only
careful physical examination can guard us against
these errors.
In the section on true kidney pains, we called
attention to the fact that neoplasms of the bladder
may, by obstruction to the ureters, give rise to
ureteral colic and sensitiveness of the kidneys them-
selves on one or both sides. Conversely, tubercu-
lous disease of the kidney may frequently be accom-
panied by the subjective symptoms of cystitis, and,
even when the bladder and urethra are entirely nor-
mal, pains may be produced in them by pressure
upon the diseased kidney.
276 PAIN
SPLEEN.
Pathological processes in the spleen often give
rise to pain at extremely early stages of their de-
velopment, and, in correspondence with the position
of th^ organ, such pain is localized in the left hypo-
chondrium. Since we are dealing with a ductless
gland the pains produced here cannot possess the
manifold variety of those occurring in organs with
muscular ducts. Here there are but two factors to
be considered:
1. Distention of the spleen capsule with enlarge-
ment of the organ.
2. Inflammation of its. peritoneal coverings
(perisplenitis).
The conditions which a-re accompanied by pain
in the spleen are chiefly:
(a) Myelogenous Leukcemia. In this condition
the pain in the spleen is frequently one of the first
symptoms. Sudden and intense pain is caused by
inflammation of the capsule with or without the
formation of infarcts. Pseudoleukaemia and polycy-
themia also give rise to pain in the spleen ; chlorosis
and pernicious anaemia more rarely.
(b) Cirrhosis of the Liver. Splenic involve-
ment is most frequently found in cases of syphilitic
cirrhosis, and in such cases the perisplenitis goes
hand in hand with the existing perihepatitis. Many
of the so-called Banti's cirrhoses (hereditary lues)
come under this heading. Splenic pains occasionally
accompany Hanot's cirrhosis, but are hardly ever
present in the atrophic variety of Laennec.
URINARY SYSTEM AND SPLEEN 277
(c) Paroxysmal Hamoglobinuria. During at-
tacks of paroxysmal hsemoglobinuria splenic pains
may occasionally be noticed.
(d) Infectious Processes. The infectious proc-
esses which are most commonly accompanied by
splenic pain are typhoid fever and malaria.
Occurring in the left axillary line, the splenic
pains in these diseases are often erroneously re-
garded as evidences of a pleurisy or a, lower lobar
pneumonia. This error is more easily made since
in cases with splenic swelling fine crepitant rales
often occur along the line of separation between the
lung and the spleen, due to atelectasis of the margin
of the lung.
Whenever we are attempting to obtain a history
of a previous attack of malaria, it is well to inquire
whether at the time of the chill there* were pains in
the splenic region. Sharp pains along the right
costal border often occur together with these and
are due to hepatic swelling.
Pain on palpation along the left costal border
in a patient who is running a temperature and in
whom we can exclude pleurisy and subphrenic ab-
scess, usually points to marked swelling of the
spleen.
(e) Heart Disease. In patients with heart le-
sions (mitral stenosis, etc.) acute pains occurring in
the region of the spleen or sensitiveness in the inter-
costal spaces corresponding with the position of the
spleen, should always arouse the suspicion of splenic
infarction. This suspicion is strengthened by symp-
toms of emboli in other regions (renal arteries, etc.).
278 PAIN
Progressive increase of the pain in a case of
recent endocarditis points to the possibility of sec-
ondary abscess formation.
Since the position and size of the spleen are
subject to great variation in the different patho-
logical conditions, it is natural that the exact topog-
raphy of the pains should show corresponding varia-
tion. In all cases, however, the pain is felt in the
left side along the lower thoracic and upper abdomi-
nal regions. Whenever pain occurs in this situation
examinations should be made for sensitiveness under
the left costal border and in the lower intercostal
spaces from the eighth downward.
Splenic tumors may occasionally give rise to
dorsal pain, especially after prolonged lying on the
back. When the spleen is so large that it sinks for
any considerable distance below the costal border,
as in leukaemia, for instance, it is important to deter-
mine whether the sensitiveness is of diffuse or cir-
cumscribed nature. Circumscribed pains of this de-
scription are occasionally due to splenic infarct or
local perisplenitis.
Every now and then pain occurs along the angle
of the left scapula or between the shoulder blades.
In some cases there is marked pain in the left shoul-
der, often so severe that motion of the left arm
becomes difficult.
Such radiations may occur spontaneously or may
be caused by sudden stooping, trauma, or lying on
the left side. In such cases localized points of sensi-
tiveness can be determined. The most common situa-
URINARY SYSTEM AND SPLEEN 279
tions of these are over the acromion process and at
the junction of the external and middle third of the
upper edge of the trapezius muscle. The conditions
prevalent here are exact counterparts of those exist-
ing in the right shoulder with perihepatitis.
The quality of the pain is usually described by
the patient as stabbing or tearing. Mechanical
motions often initiate attacks of pain. The mechani-
cal factors to be considered are :
1. Compression of the organ produced by stoop-
ing, quick turning to- the left of the trunk upon the
hips, lifting of the left arm, etc. In contrast to this,
relaxation of the abdominal muscles relieves the
pain, and in consequence patients often walk in a
stooping position. Palpation and percussion in-
fluence the pain in a similar way.
2. Change of Position of the Organ. Lying on
the left or right side usually produces pain and a
sensation of tension in the left side. This is espe-
cially the case when the stomach is empty, the full
stomach acting as a sort of cushion. For obvious
reasons deep breathing will cause pain when peri-
splenitis is present.
3. Sudden Jarring. All varieties of jarring will
give rise to pain, prolonged walking, running, riding
in a carriage, hiccoughing, sneezing, etc.
Occasionally, besides the mechanical means of
starting the pain, digestive conditions will influence
it. Abnormally large quantities of food will give
rise to pain by causing secondary hyperaemia of the
organ. This is especially the case when inflamma-
280 PAIN
tory adhesions exist between the stomach, and the
spleen.
The influence of drugs on the diagnosis is not
negligible since the pain caused by increased tension
of the capsule is diminished by all those drugs which
produce a diminution in the size of the spleen. Such
are arsenic and quinine.
The most frequent secondary symptoms occur-
ring with splenic pain are increased size of the
spleen as detected by percussion and palpation, fric-
tion sounds produced by perisplenitis, and a systolic
murmur heard over the splenic vessels.
The most important condition to be* considered
in differential diagnosis is pleurisy. Differentiation
is especially difficult in the case of acute disease,
such as malaria and typhoid fever. The pains in
these cases are felt in the axillary and intercostal
regions. They are dependent upon deep breathing.
Lying on the left side is usually painful and occa-
sionally produces a cough. There are fine crepitant
rales over the area of pain, due to atelectasis caused
by the large size of the spleen. By these signs one
is led to suspect pleurisy or early pneumonia and to
forget the fact that the pain may be due to an
increased tension upon the splenic capsule.
In the same way infarcts of the lung and spleen
may often be mistaken for one another in patients
with heart disease. In such cases examination of
the spleen reveals its sensitiveness. Much informa-
tion, too, can be gathered by careful examination of
the intercostal spaces in the axillary line in order to
URINARY SYSTEM AND SPLEEN 281
determine whether or not they are sensitive. When
the condition is one of splenic pain the sensitiveness
in the intercostal spaces is limited pretty well to
the area of dulness of the organ.
Splenic pains are occasionally misinterpreted as
arising in the stomach, since, as has already been
mentioned, the taking of food often increases the
pain or initiates an attack. In a general way this
can be avoided by remembering that in splenic con-
ditions the quantity of the food, entirely independent
of its quality, gives rise to the attack. In cases
where radiation of the pain into the left shoulder
takes place, a diagnosis of articular rheumatism
is occasionally made. The absence, however, of
change in the joint itself, the entire freedom of
motion, and the determination of the above-men-
tioned points of tenderness (at the acromion and
along the border of the trapezius) will aid in the
differentiation.
CHAPTER IX.
RESPIRATORY AND CIRCULATORY SYSTEMS.
THE LUNGS.
PAIN may unquestionably occur in the trachea
and the two main bronchi. At any rate, it is cus-
tomary to interpret the retrosternal pain occurring
almost regularly with acute bronchitis during the
stage of dryness and congestion, as emanating from
these organs. On the other hand, distinctive proc-
esses which involve the air vesicles of the lung, such
as lymphosarcoma and pulmonary abscess, may run
their entire course without any pain. It is, there-
fore, perfectly safe to claim that lesions occurring
in the parenchyma of the lung itself do not give rise
to pain.
The production of pain in disease of the lung is,
therefore, dependent entirely upon involvement of
the pleura. This, of course, is most frequently of
an inflammatory nature.
These simple facts give the key to the compre-
hension of all pains which occur in connection with
pulmonary disease and permit us to understand their
nature and radiations.
It must not be forgotten that the visceral and
parietal pleura are in very intimate relation with
many nerves (brachial plexus, intercostal and
phrenic nerves), and that they likewise have close
anatomical relation to the intercostal muscles and
282
RESPIRATION AND CIRCULATION 283
diaphragm. For these reasons the occurrence of
secondary neuralgias and myalgias is more than
likely.
Since, therefore, the pains accompanying all the
various lesions of the lung are dependent upon the
inflammatory pleurisy, it is simplest to describe them
all together in a general way, pointing out, as we
proceed, the various features of differentiation.
As regards localization, these pains correspond
almost exactly with the situation of the pleural in-
flammation, and the greatest intensity of the pain,
both subjectively and objectively, coincides with the
most marked auscultatory sounds.
Disease of the pleura over the upper lobes (tu-
berculosis and neoplasms) evidences itself chiefly
by pain in the region of the shoulder, in the supra-
and intraclavicular fossae and in the supraspinous
regions. These pains should be looked for espe-
cially in cases in which we suspect early tuberculosis.
The pains in the shoulders, which so often occur
in tuberculous patients at the very beginning of the
disease, are probably caused in most cases by the
adhesions at the apex of the lung found so fre-
quently at autopsy. The inflammatory process oc-
curring along the summit of the pleura may involve
secondarily the brachial plexus and the upper inter-
costal nerves. For this reason tenderness along the
brachial plexus and along the upper intercostal
spaces is frequently present in cases of tuberculosis
and is in many cases one of the first symptoms. The
point of tenderness which was mentioned as a reflex
284 PAIN
symptom of hepatic and splenic enlargements (at the
junction of the outer and middle thirds of the upper
border of the trapezius muscle) can occasionally be
demonstrated in these cases as well.
It need hardly be mentioned that carcinoma de-
veloping in the apex of the lung might give rise to
secondary injury of the brachial plexus and conse-
quent neuralgia in the arm.
When the pleura are diffusely diseased, as in
pleurisy and pyopneumothorax, the subjective pain
and tenderness often fail to show a correspondingly
diffuse character. On the contrary, they are usually
located in the axilla or in front, rarely posteriorly,
and, when this does occur, only in the last intercostal
spaces.
This is due to a number of causes. Chief among
these, probably, is the fact that the respiratory
excursions of the lung reach their greatest develop-
ment at the bases and thus the greatest motion of the
pleural leaves upon each other takes place in the
costophrenic sinuses.
Whatever the reason may be, the facts remain
that pains which arise in the pleura are frequently
found only in the axillary line, and that sensitive-
ness to pressure is limited to the area below the fifth
intercostal space. The latter fact may in part be
due to the absence of a muscular covering over these
spaces.
Occasionally, cases of diffuse pleurisy and
pleuropneumonia of the lower lobe occur, in which
the tenderness is limited to the abdomen, just below
RESPIRATION AND CIRCULATION 285
the costal border. This may lead to errors in diag-
nosis. In such cases upward pressure in the flank,
hypogastrium, and (in right-sided cases) even the
ileocaecal region, will give rise to pain.
This peculiar distribution of the pain is probably
due to involvement of the diaphragmatic pleura.
The diaphragm forms a sort of bridge across which
the thoracic pain enters the abdominal regions.
Even the subjective pain in pleurisy may in a good
many cases be localized along the costal border.
One of the favorite seats of pain in left-sided
pleurisy is the region of the heart apex. This may
be due to the fact that during systole the apex of
the heart, by friction, increases the inflammation
and, therefore, in spite of the diffuse nature of the
pleurisy, may give rise to circumscribed pain.
Retrosternal position of the pain is rare. It does
occur, however, and is usually associated with in-
flammation of the mediastinal pleura and with le-
sions of the mediastinal lymph nodes. In such
cases, however, it would also be necessary to think
of pericarditis.
The pains occurring in the interscapular space in
pulmonary tuberculosis may also occur in diffuse
pleurisy.
The quality of the pain is rarely characteristic,
and it is very difficult to differentiate it from that
of intercostal neuralgia or myalgia. As a general
rule we may say that the pain is of a sharp and
stabbing character.
286 PAIN
Special characteristics of the pain are present
only in rapidly developing pneumothorax, where the
pain, just like the pain accompanying perforation
of the gut into the peritoneum, is extremely acute
and diffuse, and involves the entire half of the
thorax. Added to this there is a peculiar sensation
of internal soreness or tearing. Similar pain, how-
ever, may be observed in subpleural cavities without
perforation, and the confusion may be increased by
the occurrence of collapse. Similar acute attacks
of pain occasionally accompany the perforation of
an empyema.
The factors most markedly influencing the pleural
pain are:
1. Pressure. There are cases of pleurisy in which
even a light touching of the skin of the thorax with
a needle, with the bare hand, or with the bed-cover,
may give rise to the most intense pain (empyema).
On the other hand, there may be all transitions from
this extreme condition of sensitiveness to an absolute
lack of pain. The factor determining this, of course,
is the degree of acuteness and severity of the inflam-
matory process. The condition is unquestionably
analogous to a similar condition in the peritoneum.
The area of sensitiveness to pressure is usually much
more diffuse than the area of subjective pain. In
every individual case it is important to observe the
zone of sensitiveness and to observe its increase or
decrease during the course of the disease. In
pleuropulmonary disease the pain which occurs in
the abdomen is hardly ever spontaneous and is dis-
RESPIRATION AND CIRCULATION 287
covered only by examination. While the dia-
phragm, as mentioned above, is usually the means
of transmission of such pain to the abdomen, in
right-sided lesions it is always necessary to consider
the possibility of secondary liver pain due to peri-
hepatitis or hepatic congestion.
Sensitiveness to pressure is limited chiefly to the
axillary and anterior aspects of the thorax, and
favors the lower intercostal spaces. This is true
at any rate of cases of acute pleurisy. In apical
tuberculosis when pleural adhesions are developing,
the sensitiveness to pressure is usually localized in
the subclavicular or subspinous fossae, and in the
upper anterior intercostal spaces. The same is true
of cavity formation in apical tuberculosis. These
objective pains are of especial importance for early
diagnosis, since they may appear when subjective
pains are still absent.
The pain may be definitely ascribed to a pleural
lesion whenever sensitiveness to pressure and crepi-
tant rales are found in one and the same spot. It
is occasionally difficult to exclude intercostal neural-
gia. (For a discussion of this refer to the chapter
on the subject.)
"Whenever pressure upon the rib itself is painful,
it is obvious that (having excluded periostitis) we
must assume the existence of a secondary intercostal
neuralgia.
In pericarditis the pain seems to be chiefly sub-
jective, modified little, if at all, by pressure; it is
288 PAIN
located more anteriorly and retrosternally, rather
than in the axilla.
2. Position and Motion. Lying upon the dis-
eased side causes pain by direct pressure. For a
consideration of this position, therefore, the remarks
made in the preceding paragraphs may be consulted.
When the patient lies on the healthy side, how-
ever, different conditions prevail. In this position
the patient frequently suffers great distress, which
gives him the impression that the pain is drawing
over into the healthy side.
Such sensations are chiefly present in cases of
pleural exudate, more rarely with cavities, and must
be ascribed to a shifting of the organs in the media-
stinum. When the patient lies upon the healthy
side, also, the work of the diseased side is increased
and the pain occurring with respiration is neces-
sarily greater. In some rare cases lying upon the
abdomen relieves the pain. (This was the case in
a patient with pleural pain in the neighborhood of
the heart apex.)
The pain is increased when the patient is upright
and his head is bent forward. This is due to the
increased costal respiration. Stooping occasionally
gives rise to pain.
3. Inspiration and Expiration. Coughing and
sneezing come under this heading, since all these
forcible movements in the pleura presuppose an
analogous action of the muscles of inspiration.
In cases of pyopneumothorax, however, there is
no increase of the pain with deep inspiration. This
289
is, in part, due to immobilization of the correspond-
ing half of the thorax, and in part to a lack of con-
tact between the leaves of the pleura.
Whenever a chill or any febrile movement is fol-
lowed by sharp pain in the axillary regions, the diag-
nosis of pleural pain is obvious, and the first sus-
picions are, of course, of pneumonia or pleurisy.
Yet it is important to remember that occasionally
a malarial chill is accompanied by pain in the lower
intercostal regions and in the axillary portions of
the left chest. These pains we have already referred
to as emanating from the spleen and due to tension
in the splenic capsule. The presence of herpes and
the fine crepitant rales of atelectasis at the base of
the left lung (pushing upward of the diaphragm
by the enlarged spleen) increase the possibility of
error.
Whenever pains occur along the lower portions
of the thorax it is wise to think of the subdiaphrag-
matic organs and their appendages.
The sensitiveness which accompanies acute right-
sided pneumonia and pleurisy is occasionally local-
ized in the ileocsecal region. This is especially fre-
quent in children and may lead to a false diagnosis
of appendicitis.
The interpretation of thoracic pains is far more
difficult in chronic conditions which run their course
without fever. In such cases it is always difficult
to decide whether the pains have a pleural origin
(such as the chronic pleural adhesions so often
found in tuberculous individuals) or whether we are
19
290 PAIN
dealing with an absolutely independent neuralgia
or myalgia.
When there have been very severe coughing
spells it is always well to think of myalgia due to
fatigue (analogous to the pains in the calves of the
legs following long walking tours). It is perfectly
obvious that the pain due to a muscular or nervous
cause may be initiated by the same factors that give
rise to pleural pain (respiration, etc.). On the one
hand, there may be absolutely no physical signs in
the chronic adhesive pleurisies; on the other, the
pain in intercostal neuralgia, by limiting respiratory
excursion, may lead to secondary atelectasis with
crepitant rales. It is very important, therefore, to
determine whether the lower border of the lung
moves properly with respirations. Examination of
the domes of the diaphragm with X-ray is also
advisable.
Careful differential diagnosis in all these cases
is almost impossible, but there are a number of
points which may be of great help.
1. One-sided objective or subjective pain, local-
ized in the axilla, points with great probability to a
pleural origin.
2. The same is true of one-sided pain limited
to the apex of the lung, especially when this is accom-
panied by ana?mia, emaciation and neurasthenia,
even when the physical examination of the lung is
negative.
3. Careful investigation of the previous history
must be made as regards overexertion of the muscles
RESPIRATION AND CIRCULATION 291
of the arm or chest, and exposure to draughts. In-
quiry must be made as to rheumatic or neuralgic
tendencies, and symptoms of these diseases in other
parts of the body must be looked for. These, when
present, point toward neuralgic or myalgic origin
of the pain.
4. Whenever lying on the diseased side causes
coughing, it is obvious that the pain emanates from
the pleura.
In the preceding section we have differentiated
pleural pains from those not localized in the pleura,
but we have paid no attention to the differentiation
of the specific pleural lesions which may produce
such pains.
In cases in which there is unquestionably a lesion
of the lungs and the pleura, the exact nature of the
lesion can be determined only by careful analysis
of the pain. The very absence of pain in such cases
is of great diagnostic significance. Thus, whenever
large areas of dullness occur entirely without sub-
jective or objective pains, although it is not possible
absolutely to exclude inflammatory pleurisy, never-
theless it is advisable to think of neoplasms, echino-
coccus, dermoid cysts, and pulmonary abscesses,
processes which are not necessarily accompanied by
severe inflammations along the pleura and may
therefore develop with little or no pain. Dullness
along the base of the lung without sensitiveness over
the lower intercostal spaces points to the existence
of a subphrenic abscess.
292 PAIN
Symptoms of pneumonia with infraclavicular
pains should lead us to think immediately of a begin-
ning apical pneumonia.
Analysis of the pain often aids in differentiating
a cavity from a pneumothorax, a differential diag-
nosis which is sometimes extremely difficult. This is
true, too, of cases in which we are trying to decide
whether a sudden profuse expectoration is due to
the evacuation of a cavity or to the rupture of a sac-
culated empyema. In the latter case the act of
rupture is accompanied by intense pains and the
sensitiveness along the intercostal spaces corre-
sponding to the sacculation is immediately dimin-
ished, just as after the incision of an abscess.
Cavities, on the other hand, since they are more
centrally situated, hardly ever lead to much sensi-
tiveness of the corresponding costal spaces, and give
rise to no attacks of pain during the act of evacua-
tion.
AORTA.
The phenomena which have occupied our atten-
tion in the preceding chapters, pains occurring in
the alimentary tract, liver and kidney, have had
three fundamental factors in common:
1. Local spasm in a hollow muscular organ.
2. Local distention of its capsule or walls.
3. Inflammatory processes in their serous cover-
ings.
The second and third of these factors, as we have
seen, may combine in many of these conditions.
RESPIRATION AND CIRCULATION 293
It is beyond doubt that diseases of the thoracic
or abdominal aorta (such as aortitis or aneurysm)
may give rise to pain. The question naturally
arises, therefore, whether the mechanism of this
pain is entirely a new one, or whether it is caused
by factors similar to those occurring in the other
conditions.
Anatomically, the severe inflammations of the
aorta may involve the vessel wall in toto or in part.
Such inflammatory conditions are comparable with
the third factor given above.
It is a matter of fact, too, that added to the in-
flammatory processes constant or paroxysmal over-
stretching of the inflamed aortic wall may occur
(by aneurysm or increased tension). The condition
of tension may be chronic (arteriosclerosis), or there
may be a sudden increase of pressure with increased
action of the heart and increased resistance in the
capillaries (vasomotor disturbances, such as cramps
or paresis). These conditions are comparable to
those mentioned under the second group (see above)
which dealt with overdistention.
Since, therefore, we have the two elementary
factors, two and three actually present and fre-
quently acting in unison, the question arises whether
the sympathetic nerve endings embedded in the vas-
cular wall are capable of conveying painful sensa-
tions. This question can be answered decidedly in
the affirmative. Definite affirmative evidence is
offered by the pressure pain which is found in in-
flammatory processes of the peripheral arteries
294 PAIN
(carotid, etc.). Similar support for this opinion
is found in the tenderness which unquestionably
occurs in the suprasternal fossa over the aortic arch
or. over the abdominal aorta, in conditions of chronic
aortic inflammation.
The etiological factors in aortic pain are, there-
fore : 1. Inflammatory and degenerative processes in
the aortic wall. 2. A condition of hyperaesthesia
of the sympathetic network embedded in the aortic
wall. 3. Chronic or temporary, local or general, in-
crease of internal pressure in the aorta.
These factors need not necessarily occur in com-
bination, but when present in combination, of course,
produce the most favorable conditions for the occur-
rence of pain. Thus, a priori, we may assume that
two and three together would be sufficient to produce
attacks of pain in individuals of a neuropathic tem-
perament.
The fact that occasionally aortic processes may
run their course without pain does not contradict
these statements. One might just as well say that
articular inflammation is not the cause of the pains
of arthritis because occasionally a case of arthritis
runs its course without pain.
The conditions of primary importance in this con-
nection are usually spoken of as "angina pectoris."
The name is purely symptomatic and has no relation
to the etiology.
The mechanism which gives rise to the pain in
these cases may be subject to considerable variation.
The anatomical basis underlying the pains of angina
RESPIRATION AND CIRCULATION 295
pectoris (excluding, of course, all those cases which
are essentially neuralgic) seems to consist of two
main features. These are disease of the wall of the
aorta itself (the ascending aorta and arch espe-
cially) and disease of the coronary arteries.
There can be little doubt about the production
of pain by disease of the aortic wall. Such pain may
be of many kinds, and angina pectoris is, in a way,
only a special form of aortic pain. Chronic dilata-
tion of the ascending aorta or of the aortic arch fre-
quently gives rise to constant pain which, in its
localization and radiation, is entirely similar to that
which characterizes attacks of angina pectoris.
We have already called attention to the fact that
the general etiology of the aortic pains stands in
close analogy to the pains produced in other organs.
Quite frequently severe attacks of angina pectoris
can be explained at autopsy by gross pathological
lesions either of the coronary arteries themselves or
of their mouths (usually narrowing of the entrances
to the arteries by atheroma or vegetations). Etio-
logical relationship unquestionably exists between
these lesions and the attacks. Nevertheless, in many
cases there is, at the same time, gross pathological
change of the aorta itself, and it is hard to decide
which of the symptoms are due to the aortic lesions
and which are more directly referable to the disease
of the coronary arteries. Generally speaking, it
is quite likely that the coronary arteries are more
directly responsible for the attacks, for it is proba-
ble that, during these, ischemia of the heart muscle
296 PAIN
occurs, resulting in a condition more or less analo-
gous to intermittent claudication. It seems to me,
for this reason, that whenever attacks of angina pec-
toris are accompanied by signs of cardiac insuffi-
ciency, irregular pulse and general collapse, it is
logical to think primarily of disease of the coronary
arteries.
The problem is much more difficult when with
severe attacks of pain there is no cardiac insuffi-
ciency. In such cases the heart is usually regular,
the pulse is full and of good force, and it is likely
that, when this occurs, the pain is of purely aortic
origin, without coronary involvement.
GENERAL SYMPTOMS. The pains which accom-
pany aortic lesions are, in a general way, alike, in
spite of the variety of pathological conditions upon
which they depend.
They are situated usually over the diseased
organ, and, therefore, are felt in most of the cases
retrosternally. Sometimes there is only a feeling of
slight discomfort; in other cases there may be an
extremely painful sensation of oppression.
The conditions for diagnosis are very much more
difficult here, of course, than in other organs, because
direct examination by palpation is impossible. This
should, however, be attempted as well as practicable
by pressure into the suprasternal fossa and upon the
abdomen.
Acquaintance with the most common directions
of radiation is important, since radiating pains may
occasionally occur without other symptoms. Eadia-
RESPIRATION AND CIRCULATION 297
tion is usually along arterial channels, especially
when the aortic process is continued, as in arteritis,
into other vessels (carotid and subclavian). In such
cases the vessels involved are sensitive to pressure.
Tugging on the vessels by turning the head or
lifting the arm is painful, and subjective pain pos-
sibly due to vascular spasms may be felt to extend
even as far as the branches of the larger trunks.
When the carotid artery is the channel of radiation,
symptoms may occur in the parts supplied by this
vessel. There are occasionally unilateral or bilat-
eral pains in the teeth of the upper and lower jaws.
Eadiation may occur into the temporal artery and,
in addition to pain, may give rise to buzzing in the
ears. When the subclavian is involved similar
symptoms may occur in the upper extremities.
It is quite reasonable, therefore, to assume that
the radiations accompanying aortic pain occur along
vascular channels. This, however, does not exclude
the possibility that radiations may occur along the
brachial plexus and the intercostal nerves as well.
Frequently the left brachial plexus is exquisitely
tender, both during and between attacks. This may
in pa.rt be a reflex pain, but in part certainly it is
due to direct mechanical injury of these plexuses
(large aneurysms).
Pains in the brachial and cervical plexus, of
course, can hardly be explained by direct mechanical
injury.
Again, pains in aortic <lisease can be explained
on the basis of localized nutritive disturbances,
298 PAIN
brought about by diminished blood supply. This is
especially probable when fever or metabolic disease
is present. Such nutritive changes may be caused
by independent lesions in the arteries branching
out from the diseased aorta, and then would be
simply accidental incidents in the clinical picture.
But they may also be more directly related to the
aortic lesion, in that the mouths of the large branches
may be narrowed. Such narrowing occurs quite
frequently at the mouth of the left subclavian artery
in cases of chronic aortitis, and occasionally leads
to complete stenosis. In patients who are at the
same time suffering from rheumatism and gout,
these localized nutritive changes are of especial im-
portance. The two conditions together metabolic
and aortic disease bring on pains in the region of
the shoulder girdle and in the thoracic walls; and
while the pain is actually caused by the secondary
condition (gout and rheumatism), it finds its ulti-
mate explanation in the aortic disease. Such an
analysis may seem a trifle overrefined, but it is ex-
tremely important in the treatment of the pains.
In a large majority of the cases of aortic disease,
a definite history of syphilis can be elicited. This is
especially true in patients who are still below middle
life. Whenever apparently rheumatic pains occur
in the shoulder or along the upper extremity in such
individuals, the pains are probably, as a whole or in
part, dependent upon atheroma of the thoracic
aorta; such suspicions are definitely strengthened
by the discovery of other symptoms of aortic disease,
RESPIRATION AND CIRCULATION 299
such as increase of arterial tension, aortic pulsation
in the suprasternal fossa, etc.
The radiating pains considered above are usually
associated with more centrally situated pains which
correspond in their localization with the diseased
portion of the aorta. Along the ascending aorta they
occur chiefly as deeply situated sensations of pres-
sure along the lower end of the sternum. When the
arch of the aorta is diseased the pains are situated
along the manubrium, while disease of the descend-
ing aorta causes pain chiefly in the back between the
two scapulas. These last pains are situated usually
to the left of the vertebral column. Disease of the
abdominal aorta occasionally gives rise to pain in
the left loin or in the epigastrium.
There is thus great variety in the topographical
characteristics of the aortic pains. Although in
general they are localized in the thorax they are
present occasionally in the neck, head, and upper
extremities, following in part the vascular channels
and in part the nerve trunks.
The factors which give rise to attacks of aortic
pain are very few, and for this reason they are of
extreme importance diagnostically.
"While the causes leading to an attack may seem
to be of many kinds, yet, upon closer analysis, they
will all be found dependent upon a temporary in-
crease of the strain put upon the aortic wall either
by an absolute or by a relative increase of the intra-
arterial pressure. The causes initiating an attack
may be of an extremely transitory nature, just as a
300 PAIN
single forcible clenching of the teeth may give rise
to a prolonged paroxysm of trigeminal neuralgia.
The chief factors to be considered are :
1. Increased muscular exertion, such as rapid
walking, lifting a weight, walking upstairs, rapid
turning in bed, playing the piano, etc.
2. The position of the body. The horizontal posi-
tion, for instance, produces slowing of the pulse, and
is usually accompanied by a greater volume of car-
diac contraction, and consequently increased pres-
sure. Sitting up in these cases usually brings relief.
3. Unusual distention of the stomach and intes-
tine. Improvement occurs usually after vomiting
and the expulsion of gas or feces. Severe attacks
of aortic pain can unquestionably be caused by
chronic constipation and meteorism, by excessive
meals, especially when taken in the evening, and by
the ingestion of flatulent food. These considera-
tions are of extreme importance prophylactically
and therapeutically.
The explanation of this, in many cases, probably
lies in the high position of the diaphragm accom-
panying abdominal distention. In consequence of
this there is diminished respiratory suction upon the
large veins, which leads to stasis. This, reflexly, by
way of the medulla, acts upon arterial conditions
which naturally affect the aorta. Prolonged and
rapid expiration, as in continued speaking, seems
occasionally to act in the same way.
4. Chemical poisons : Alcohol, nicotine, lead, gout
and rheumatism are important etiological factors.
RESPIRATION AND CIRCULATION 301
5. Temperature. The extremes of temperature
act in the same way. Hot rooms or cold draughts,
cold sponging, cold bed, etc., may give rise to aortic
pain or may occasionally alleviate existing aortic
pain; in some cases the harmful influence of cold
weather is undeniable.
6. Psychic influences (excitement, bad dreams).
While these influences are chiefly important in their
relation to the functional aortalgias, they may never-
theless be of significance also in pains of true aortic
lesions. Here, however, they are of less importance
than other influences, though every organic disease,
and especially that connected intimately with circu-
lation, is more or less in close functional relation to
the nervous system.
7. Pains in other organs which lead to consequent
increase of blood pressure. Such are cholelithiasis,
gastric ulcer, etc.
There is no characteristic time for the occurrence
of the attacks of angina pectoris. Whenever the
condition is based upon actual organic disease, at-
tacks can often be produced with the regularity of
well-planned experiments, if any one of the factors
just mentioned is exerted with sufficient energy.
This regular dependence upon the causative factors
is the chief differential characteristic between the
functional and the organic angina pectoris.
In rare cases attacks may occur regularly at
night or during the early morning hours, and these
may be explained by the horizontal position of the
body and the sudden change of this position during
302 PAIN
sleep. The occurrence of distressing dreams may
also have quite an important bearing upon this.
In patients suffering from metabolic disease the
attacks are especially frequent at night and during
the early morning. In many cases they occur during
the hours of the first physical activity and decrease
during the course of the day. This is probably due
to the fact that occasionally the pathological lesion
in the aorta is actually caused by the metabolic con-
dition (gouty arthritis).
As the disease progresses the free intervals be-
tween attacks seem steadily to decrease in length.
Chief among the secondary symptoms found with
aortic pains is increased arterial tension. In cases
where the attacks are characterized by collapse and
where they are dependent more directly upon coro-
nary arteriosclerosis, this does not hold good. The
pulse and respiration may be either increased in
frequency or slowed.
Pulmonary oadema does not form part of the
typical clinical picture, but is not an infrequent
complication in cases where there is a tendency
toward pulmonary congestion.
The patients themselves during the attack may
seem slightly frightened, or they may go into col-
lapse, with nausea, trembling, and severe perspira-
tion. The characteristic aspect of patients with the
most severe attacks is silent terror and an expres-
sion of the greatest alarm. Such cases are often
complicated by disease of the coronary arteries, and
are in marked contrast to the loud, melodramatic
RESPIRATION AND CIRCULATION 303
behavior of patients suffering from the functional
forms of aortic pain.
The paroxysmal attacks of vascular pain which
we have just considered may be regarded as the most
severe development of the disease. All degrees of
pain, however, may be found accompanying the
various aortic lesions. These are best considered
in direct connection with the various pathological
processes.
ANEURYSM OF THE AORTA. The pain produced
by aneurysm is at first probably due to the stretching
of the diseased aortic wall. On the other hand, it
may also be due to the progressive nature of the
process, an extension quite analogous to that occur-
ring with malignant new growth. The diffuse and
even distention of the aorta may give rise to pain
independently of further extension. The cases of
chief interest to us here, however, are the progres-
sively extending ones.
The mechanism of these pains is the same as that
which we described in speaking of aortic pains in
general ; but here we have, in addition to other fac-
tors, the element of progressive extension of the
aneurysmal sac and consequent pressure upon sensi-
tive structures. This source of pain must especially
be considered in cases which are accompanied by
constant pain, and a recognition of this will, of
course, materially influence prognosis.
Patients suffering from aneurysms occasionally
suffer from a pain in the shoulder or in the upper
extremity, which comes and goes irregularly. Such
304 PAIN
variation makes us question the correctness of our
diagnosis. The irregularity can often be explained,
however, by temporary exacerbations in the in-
flammatory process of the aorta and the perivascu-
lar inflammations. These pains usually correspond
absolutely with the position of the aneurysmal sac.
Therefore they are located with especial frequency
along the clavicle and are accompanied by sensitive-
ness in the corresponding brachial plexus, the upper
intercostal spaces and ribs. Occasionally pain may
occur opposite the coracoid process in Mohrenheim's
fossa. When it extends into the back, it is usually
situated over the left scapula, in the space between
the scapula and the vertebral column, or just below
the scapula angle. Occasionally there may be pain
in the supraspinous fossa.
Retrosternal pain in the region of the heart, in
the shoulder and upper extremity and in the inter-
costal spaces, however, is so common in simple
chronic aortitis that it is hardly necessary always to
think of aneurysm when this occurs. It is logical
to think of aneurysm only when the symptoms are
constant and no free intervals occur. The same con-
siderations apply to the pains radiating into the neck
and occipital region. It is the constancy of the pain
rather than its localization which makes the differ-
entiation between chronic aortitis and aneurysm.
The factors modifying the pain in aortic aneurysm
are the same as those mentioned in speaking of
simple aortic pains.
RESPIRATION AND CIRCULATION 305
Whenever pain in the shoulder is complained
of, diagnosis should be made with extreme care.
Such pains often occur as an early symptom of
aneurysm, but are frequently interpreted as rheu-
matic, and the treatment to which the patient is sub-
jected (massage, gymnastics, and hot baths) directly
aggravates the aneurysmal dilatation. Especial
care should be taken to determine whether the pain
is increased by forcible exertion, rapid walking, or
running upstairs, and improved by rest ; or whether
a paroxysm is accompanied by cardiac symptoms,
such as palpitation, etc. When the pain is due to
aneurysm, too, the motions of the shoulder joint are
usually free ; this, however, is not a very useful point
since there are many exceptions, cases in which this
reflex pain in the shoulder joint leads to limitation
of movement. Eotatory movements of the shoulder
in such cases, especially abduction of the arm from
the chest above the horizontal position, often lead
to pain in Mohrenheim's groove. This may possibly
be due to direct tugging upon the subclavian artery.
Similar tugging upon the carotid by turning and
backward bending of the head may produce pain in
the neck and occiput.
The error of confusing the shoulder pain pro-
duced by aneurysm with rheumatic pain is especially
frequent because exposure to cold and draught often
produce an exacerbation, and a local counter-irrita-
tion is often followed by distinct improvement. It
is not at all out of the question that in many of these
cases there may actually be rheumatic or gouty pains
20
306 PAIN
in the joints, since there is often such a diathesis
underlying the vascular disease. The shoulder joint
is unquestionably in such cases a point of least
resistance because of the diseased arteries which
supply it.
A very important diagnostic feature of the pains
accompanying aortic aneurysm is their reaction to
changes of position of the body.
In speaking of general aortic pains, we called
attention to the fact that there is a marked differ-
ence between the upright and the prone positions in
their influence upon arterial pressure. There are,
on the other hand, cases of aneurysm in which mere
shifting of position when the patient is lying down
will influence the pain ; these are entirely analogous
to similar phenomena occurring in the abdominal
conditions, such as gastric ulcer and renal disease.
Lying upon the side is often accompanied by great
pain, which is usually present when the patient is
lying on the side opposite to the lesion. This gives
him the sensation of something sinking toward the
healthy side. This is unquestionably due to the
change of position of the aneurysmal sac and traction
upon the periarterial adhesions. It is very impor-
tant, therefore, in cases suspicious of aneurysm, to
observe the influence of changes of position upon the
pains.
Theoretically it is quite obvious that any agencies
which would exert traction upon the sac, such as deep
breathing, coughing and sneezing, would give rise
to pain, and practical experiments bear this out.
RESPIRATION AND CIRCULATION 307
The pain may be especially dependent upon respira-
tion, and it is of particular diagnostic significance
when deep breathing gives rise to extrathoracic
pains (for instance, in the back of the neck).
The pain occasionally accompanying the act of
swallowing is probably explained by the motion of
the larynx during this act, and consequent traction
upon the left bronchus and tugging upon the aorta.
This pain occasionally radiates into the shoulder
blade or into the intraclavicular region.
Percussion and palpation over the intercostal
spaces, the ribs and the vertebral column in the
region of the aneurysm occasionally produce great
suffering.
While the aneurysmal process is an entirely con-
stant state of affairs, the pain need not be entirely
constant. Variations are especially frequent in
those pains which are based upon reflex causes
(brachial and cervical plexuses, subclavicular and
carotid regions).
Variations, too, in the pathological conditions
underlying the pains explain such changes. These
are chiefly changes in dilatation of the aneurysmal
sac and fluctuations in the inflammatory process
occurring in the aorta. These fluctuations may be
very similar to those occurring in rheumatic condi-
tions. Changes in the pain may be due, on the other
hand, directly to variations in the occasionally com-
plicating rheumatism.
The quality of the pain is not at all uniform.
Usually the patients complain of pulsating, boring
308 PAIN
pains, or, again, of a shooting or stabbing as with
needles. Almost invariably they localize their pains
deeply.
We may frequently be led in the right direction
by considering the regions secondarily involved in
aneurysmal pain, the shoulder pains being particu-
larly important. In this connection special atten-
tion must be paid to the mechanical influences of
motion or body position, which will help us tremen-
dously even when other secondary symptoms are
absent.
Other important symptoms which are occasion-
ally associated are variable hoarseness, which is
directly dependent in its intensity upon physical
exertion, difficulty in swallowing, especially the swal-
lowing of cold fluids, and associated especially with
particular positions of the head. There are often,
too, a dry hacking cough, which is influenced defi-
nitely by the position of the body, cardiac palpita-
tion, and increase of the shoulder pain following
rapid walking, variations in the pulse, sometimes
referable to the sympathetic system, and dilated
veins.
For rapid diagnosis it is always important to
examine the aorta carefully in the suprasternal fossa
and in the intraclavicular space on both sides by
palpation and inspection.
CHRONIC AORTITIS. In cases of aneurysm of the
aorta we had to deal chiefly with a constant pain.
In the cases of chronic aortitis, on the other hand,
we deal with a characteristic paroxysmal pain. The
RESPIRATION AND CIRCULATION 309
chief condition under consideration here is that
which is known commonly as angina pectoris, and
which is unquestionably often accompanied by dis-
ease of the coronary arteries. In order to avoid
repetition we may refer to the section upon aortic
pains in general. We have already called attention
in that section to the secondary pains and to their
channels of radiation.
The considerable variations in the localization
of the attacks may be due to the varying localization
of the disease in the aorta. The central point of
these attacks of pain, that is, the locality from which
the attack emanates, is frequently below the sternum.
Often the pain is in the lower portion of the sternum
and extends symmetrically on both sides, covering
thus an oval area; more rarely it extends to the
suprasternal fossa. Occasionally, again, the attack
may begin with stabbing pains in the heart itself or
in the right mammary line.
The point of origin does not, however, occur
always in the thorax. It may be located in the epi-
gastrium, and these cases are the ones which are the
most easily misinterpreted. Radiation most fre-
quently occurs retrosternally in an upward direction.
Whenever the epigastric type of angina pectoris
occurs it is well to seek an explanation in two proba-
bilities: (1) involvement of the abdominal aorta, es-
pecially at the point of origin of the eceliac axis;
(2) coincident disease of the stomach itself (chronic
gastritis, ulcer, atony, etc.).
The possibility of sclerosis of the gastric arteries
must also be considered.
310 PAIN
It is important to determine whether or not the
initial epigastric pain is truly gastric or hepatic in
nature (as by hepatic congestion or cholelithiasis)
and whether the angina pectoris is thereby second-
arily initiated.
There are two chief types of radiations, which,
by the way, may be entirely absent at the beginning,
and occur only later in the disease.
1. The symmetrical type. Radiations which are
equally severe in both shoulders, both arms (espe-
cially the ulnar surfaces) in the scapular region, both
sides of the neck, both sides of the jaw and both
temples.
2. The asymmetrical type, which involves chiefly
the left side of the body; radiations occurring into
the left shoulder and the left arm, the back be-
tween the vertebral column, the left shoulder blade
and the left side of the neck.
While there are cases in which there is a complete
absence of radiation there are, on the other hand,
cases in which the attack begins in the peripheral
zone and centers towards the aorta (for instance,
from one carotid artery or from one arm).
These unusual peripheral types (sensations in
the regions of the teeth, wrist, olecranon, etc.) are
of the greatest practical importance, since they are
so easily misinterpreted, and may in many cases be
the forebodings of sudden death.
In the histories of the patients with chronic
aortitis and coronary sclerosis we may often trace
the earliest beginnings of the fully developed attacks
RESPIRATION AND CIRCULATION 311
to stages where there were centrally localized pains
only. These early stages consist usually in slight,
hardly noticeable, sensations of pressure behind the
lower part of the sternum, or occasional mild, stab-
bing pains in the heart produced by rapid motion,
occurring especially in the morning. From these
very slight beginnings gradually the terrible picture
of a severe angina develops. The intervals between
the attacks become shorter and shorter, and the
stimulus necessary for their occurrence becomes
slighter.
As far as the causes giving rise to attacks are
concerned we may refer to the section upon aortic
pain in general.
The basis for these causal factors consists in the
increased blood pressure and secondary distention
of the diseased aortic walls, and upon the nerve end-
ings embedded in them. The more frequently the
attacks occur, the more slight the stimuli necessary
for attacks become, the more serious is the prog-
nosis. The prognosis is especially bad in cases
where the attacks are accompanied by great nausea.
The secondary symptoms which are most important
in rapid diagnosis are an accentuated ringing second
aortic sound, increased tension in the arteries, and
angiosclerotic pallor of the face.
DISEASE OP THE AORTIC VALVES (ENDOCARDITIS)
WITHOUT DISEASE OF THE AORTIC WALL. There are
unquestionably cases of aortic pain corresponding
in their localization and general behavior with the
pains which we have described, without the presence
312 PAIN
of any traceable disease of the aorta itself or the
coronary arteries. In some of these cases there
may be simply diseases of the aortic valves, in others
even these may be absent. Such cases give striking
proof of the nervous origin of angina pectoris and
aortic pain in general. The origin of the pain in
such cases is unquestionably in the cardiac and
aortic plexuses of the sympathetic system. In or-
ganic disease of the aorta these may be the sites of
actual neuritis and, therefore, react acutely to in-
jury, to disturbances of the circulation in the vasa
vasorum, or especially to distention of the aortic
walls. They may, on the other hand, without trace-
able anatomical reason, be the seats of neuritis,
especially in persons who are subject to general
irritability of the nervous system. Such attacks of
pain may be known as functional angina or false
angina ; but we must clearly understand that while
the special pathological changes in these conditions
are very different, the general origin of the pains
may be much the same.
The stimulus initiating such attacks of functional
aortic pain, therefore, may often be increase of blood
pressure, due to spasms in the peripheral vessels.
It is certainly not a chance occurrence that func-
tional angina is found most frequently in young
neurasthenic individuals with disease of the aortic
valves. The neurotic disposition prepares the field
and the pathological pressure in the aorta gives
the actual stimulus.
\
RESPIRATION AND CIRCULATION \313
The differentiation between functional and 6r-
ganic angina pectoris is of extreme prognostic ini-
portance and is recognized by the analysis of the
factors initiating an attack and of the secondary
symptoms. As far as the initiating stimuli are con-
cerned, however, it is quite important to remember
that both the conditions have many of these in
common.
As for angina pectoris which is based upon actual
organic disease, we may say that we are dealing with
an exact problem. The patient himself knows that
if he runs a certain distance at a definite speed he
will have an attack. He can make a definite calcu-
lation, as it were, of the factors which will give rise
to the attack.
The functional angina, on the other hand, is en-
tirely beyond control, is irregular, and is uncertain.
In all respects functional angina pectoris is a sort
of farcical parody of the tragic true angina. Even
the most severe cases lack the serious character of
the true organic angina. The blood pressure is not
usually increased; the face is often flushed instead
of pale. Instead of seriousness and quiet, there is
restlessness and noise. The heart action is usually
rapid.
The extremes of the two cases, therefore, are not
hard to differentiate; but unfortunately a mixture
of the two conditions is very common. There are
cases in which a general neurosis becomes localized
in the diseased aorta and adds the characters of a
well-developed functional condition to the early
314 PAIN
symptoms of a true angina. Such cases are often
f jlsely diagnosed and are taken for pseudo-angina
until sudden death occurs. No general differential
symptoms can be formulated for these. Only the
most careful individual study of the symptoms and
the most concentrated analysis of the problem can
guard us against error.
Functional angina is especially likely when we
are dealing with neurasthenic patients below thirty,
when syphilis can be excluded, and especially when
there is excessive use of tobacco. This is likely even
when an aortic valvular lesion is present. Above
thirty, and especially above forty, the differential
diagnosis becomes particularly difficult.
True angina must always be considered most
seriously, even in the presence of neurotic symp-
toms, when there is arterial tension, a history of
syphilis, or when gout or rheumatism is present.
PERIPHERAL VESSELS.
It is well known and based on many clinical ob-
servations that severe pains may be caused by disease
of the peripheral arteries, veins, or lymph vessels.
It would be quite incomprehensible if this were not
the case, since the nerve trunks themselves possess
their own vessels, and it goes without saying that
when these are diseased, either primarily or second-
arily, errors of nutrition must occur in the nerves,
and these therefore become the seats of pain.
In this connection the very intimate relations
between the vessels and the nerves must be carefully
\
RESPIRATION AND CIRCULATION 315
considered. On the other hand, changes in the ves-
sels and circulation may cause disease in the nerves,
while disease in the nerves may cause disease in the
vessels. The pathogenesis of the pains, therefore,
is extremely difficult to determine.
Clinical experiment alone can lead us to the cor-
rect interpretation. It is a fact that subjective and
objective pains occur along the peripheral vessels
when they are involved in inflammations (phlebitis,
lymphangitis, arteritis), and there is no reason for
not interpreting such pains as irritability of the
sensory fibers supplying the vessel walls. In some
cases, of course, it is necessary to think of a direct
extension of the inflammatory process from the ves-
sels to the nerves which accompany them. Many
cases of neuralgia are probably traceable to such
changes in the vessels accompanying the involved
nerves.
It is unquestionable that sclerotic changes in the
peripheral arteries, both in the extremities and in
the internal organs, may give rise to acute neuralgic
attacks of pain. The most striking and fundamen-
tal example of this is Charcot's intermittent claudi-
cation, since this can be directly observed.
After a few minutes of walking the patient has
pains in his calves which force him to stand still.
The pain then disappears ; the patient continues his
walk, but in a few moments the same symptoms
occur; and with the absolute regularity of a well-
planned experiment the same symptoms follow the
same exertion again and again.
316 PAIN
Physical examination in these cases shows scle-
rotic changes in the vessels, either local with the
formation of aneurysm, or diffuse changes in the
iliac arteries extending downward with or without
stenosis, or more or less severe vasomotor phe-
nomena (coldness, pallor, redness and cyanosis of
the toes) ; death finally occurs with gangrene of the
toes.
The mechanism of the pain in these cases is not
easy to explain. Are we dealing with chronic nutri-
tional disturbances in the sensory nerves which
reach their greatest height during the circulatory
changes accompanying muscular action, or are we
dealing with acute ischemia of the active masses of
muscle due to arterial spasms 1
The mechanism of the pain is not necessarily
uniform. But, at any rate, it is certain that the
clinical observations cannot be explained without the
assumption of vascular spasms, to which sclerotic
vessels are always subject. Otherwise the constancy
of the anatomical changes would have to be fol-
lowed by a constancy of the clinical symptoms, while
as a matter of fact clinical experiment teaches us
that proper treatment may often give the most
remarkable results in a short time. Improvement
may even occur spontaneously.
This unquestionably functional factor in the
causation of intermittent claudication makes it
almost impossible to deduct the cause of a given
pain from definite anatomical conditions of the arter-
ies. Unquestionably severe atheroma may be pres-
RESPIRATION AND CIRCULATION 317
ent in the vessels of the leg without the existence
of any pain. For this reason, even in cases where
angina pectoris has been observed during life, it is
not always a foregone conclusion that the finding
of c6ronary sclerosis at autopsy absolutely explains
the symptoms.
The pains occurring in intermittent claudication,
too, find their analogy in diseases of the viscera.
It may be considered an established fact that
diseases of cardiac, gastric, or intestinal arteries
may give rise to painful interferences with function.
In order to draw an intelligent parallel, however,
between the intermittent claudication of the lower
extremities and the pathological conditions of inter-
nal organs, we must consider only those cases in
which there is real similarity between the existing
stimulus and the therapeutic influences. The at-
tacks of pain must occur at the height of the mus-
cular exertion, that is, at the height of digestion,
as in arteriosclerotie intestinal pains, and be accom-
panied by disturbance of motility in the sense of
spasm and loss of function.
In the heart this might become evident by cardiac
insufficiency with arhythmic feeble pulse. In the in-
testine it might be noticed as a stenosis or distention
which could simulate peritonitis ; and this, as a mat-
ter of fact, actually occurs in a number of cases.
It is true, too, that cases of this order can be
therapeutically influenced (erythrol tetranitrate) .
Probably in all these conditions the organic basis
of the pains consists in an active intermittent spasm
of the vessels.
318 PAIN
Either in the last stages of these conditions or
even as an entirely independent condition, pains may
occur in which the vessels play a more passive role.
Closure of the vessels by thrombosis or embolus
may give rise to pain in consequence of anaemic
necrosis of the sensory nerve endings and their
dependent tissue regions.
The severe pain occurring in gangrene of the
toes and the sudden pains which occur in the lower
extremities, with embolus or thrombosis of the lower
portion of the abdominal aorta, would belong to this
order.
The accompanying symptoms, coldness of the
affected area and a loss of the motor and sensory
functions, will usually clear up the diagnosis.
Similar processes in the chest, abdomen and vis-
cera will, of course, give rise to great diagnostic
difficulties.
Stenoses of the mesenteric arteries frequently
lead to the erroneous diagnosis of intestinal obstruc-
tion and peritonitis. "Whenever sudden colicky
pains, either with or without bloody diarrhoea, occur
in patients with noticeable arterial disease, it is
always important to think of the possibility of dis-
ease of the mesenteric vessels.
Closure of the veins as well as of the arteries may
give rise to severe pains. A notable example of
this is the headache accompanying thrombosis of
the lateral sinus, and the phlegmasia alba dolens
following closure of the large veins of the leg.
CHAPTER X.
CUTANEOUS TENDERNESS IN VISCERAL DISEASE.
WHILE the fact that diseases of the internal
organs may be accompanied by areas of cutaneous
tenderness or pain more or less remote from the
actual seat of disturbance had previously been com-
mented on by various observers, notably Hilton,
Dana, Boss, and Mackenzie, it is largely through the
brilliant researches of Henry Head that the real
significance of this phenomenon has been made clear.
His explanation for this transference of sensation
is that a painful stimulus to an internal organ causes
centripetal impulses, ordinarily below the threshold
of consciousness, to be conducted to a certain seg-
ment of the spinal cord. Here a more or less diffuse
disturbance is induced which involves also the fibres
connecting a definite district of the surface of the
body with the same segment. As the function of
sensation has been very highly developed in the skin
its sensory and localizing power is enormously in
excess of that of the viscera, so that the painful
sensation is referred in consciousness not to its true
source, but to the site from which such messages
are habitually received, i.e., the surface of the body.
According to the intensity of the visceral stimulus,
actual pain may be experienced, or there may result
only a state of hyperaesthesia or hyperalgesia which
319
320 PAIN
manifests itself by an increased susceptibility to
stimuli, so that contacts which would ordinarily evoke
only sensations of touch now give rise to actual pain.
In order to discover the presence of such areas of
tenderness and ascertain their boundaries, the exam-
iner may use a pin with a round head of such size
as to feel blunt when applied to normal skin. Pres-
sure is made with this here and there over the sus-
pected region, and if hyperalgesia exists the patient
complains of a sensation as if a bruised spot were
touched, while if the point of the instrument is
applied the pain is far in excess of that normally
produced.
Head was led to investigate the subject by the
observation that the distribution of the lesions in
cases of herpes zoster corresponded with the areas
of cutaneous pain or tenderness occurring in certain
visceral disorders, and by comparing the areas in-
volved in a large number of cases of herpes zoster
with the disturbances of sensation in a series of
cases of nervous disease with gross lesions of the
spinal cord, he was able to map out on the surface
of the body the skin units or dermatomes in com-
munication with the various segments of the cord.
These areas correspond, not to the peripheral distri-
bution of the posterior roots, but to the segments of
the cord itself from which the roots in part arise.
The skin areas as traced by Head on the trunk
form more or less horizontal zones of irregular out-
line, while about the neck and on the limbs their
eccentricity of contour is still more pronounced. The
VISCERAL DISEASE 321
whole area is not necessarily involved in every case,
but each segments! district possesses one or more
maximal points in which the tendency to exhibit pain
or tenderness is most acute and which give the clue
to the area concerned.
Subsequent observers have Verified Head '* con-
clusions in most particulars, and while f ' ne limits
of the various areas as given by differ?*^ authors do
not in all cases coincide absolutely, ^ is probable that
the maximal points on Head's digrams are correct.
For practical purposes, at anv rate, the chief interest
attaches to these, so that fr>^ this reason, and for the
sake of greater clearness, on the following figures
/only the so-called m? *ima are indicated. It must be
remembered, however, that for the present at least,
the evidence sdt-ord&l by the demonstration of areas
of cutaneouat tenderness or pain is valuable chiefly
in the positive sense and that their absence does not
preclude tlr- existence of visceral disease. Further-
more, in /Any given cases these areas do not neces-
sarily preserve their integrity indefinitely, but as
the nenp^HS system becomes impaired as the result
of prolonged illness, first, the corresponding dis-
trict ( 'he opposite side of the body may become
' m , ul later on still more marked generaliza-
tion i y occur until the pain and tenderness invade
iiat bear no relation to the affected organ,
pc nt of practical importance is that counter-
j r :ritntion over the cutaneous area may have thera-
Hpeutic value, not only in the immediate relief of
Bpain, but also in influencing the underlying condition.
322 PAIN
SEGMENTAL DISTRIBUTION OF REFERRED PAIN AND
TENDERNESS IN VISCERAL DISEASE.
(Compiled from Head.)
See diagrams figures 1, 2, and 3.
.Third cervical and first, second, and third dorsal seg-
.._Third and fourth cervical and first to ninth [sometimes
-al seenient*, especiallv the third, fourth, and fifth.
Breatr
"-urth and fifth dorsal segments.
(Esophagr*
fth, sixth, and eighth dorsal segments.
Stomach. Th,. ' ,, . JL,
-d fourth cervical and sixth, seventh, eighth,
and ninth dorsal segn, . , . , .-.
Cardiac end from the sixth and seventh,
and the pyloric end froi;
r ninth.
Intestines. Down to the , T . ,, .-.
-*er part of the rectum: Ninth, tenth,
eleventh, and twelfth dorsal st,. , ,,. -, *
' <ts. Rectum: Second, third, and
fourth sacral segments.
Liver and Gall-bladder. Seventh,'*: ,, j^_ aQ f
*h, ninth, and tenth dorsal
segments, and perhaps the sixth.
Kidney and Ureter. Tenth, eleventh, a. i ., , , > _
ments. The nearer the lesion lies to the kia ,, x^
pain and tenderness associated with the tenth i. rm,-
lal segment. Ine
lower the lesion in the ureter the more does the fi*'.^ i segment
tend to appear.
Bladder. Mucous membrane and neck of the bla<? . -p'r^i, ec-
ond, third, and fourth sacral segments. Overdistenti ^ ^pffpc-
tual contraction: Eleventh and twelfth dorsal ana , i,. ,,v.nr
nrs L i it ill u*i r
segments.
Prostate. Tenth, eleventh, and twelfth dorsal, first, ond an( j
third sacral, and third lumbar segments.
Epididymis. Eleventh and twelfth dorsal and first ,
ments.
Testis. Tenth dorsal segment.
Ovary. Tenth dorsal segment.
Uterine Appendages. Eleventh and twelfth dorsal and first,
bar segments.
Uterus. In contraction: Tenth, eleventh, and twelfth dorsal ai,
first lumbar segments. Os uteri: First, second, third, and fourth
sacral segments, and very rarely the fifth lumbar.
VISCERAL DISE
323
PAINFUL AREAS ABOUT THE HEAD RELATED
TO VISCERAL DISEASE.
(Head.)
See diagram figure 4.
S Area on Body.
Associated Area on
Head.
Organs in Particular Relation with
these Areas.
Bervical 3 and 4
worsal 2 and 3 .
Btorsal 4
Fronto-nasal
Mid-orbital
Doubtful
Apices of lungs, stomach, liver,
aortic orifice (?)
Lung, heart, arch of the aorta.
Lung.
Jporsal 5
Fron to- temporal .
Lung and occasionally the heart.
4)orsal 6
Fronto- temporal.
Lower lobe of lung, and heart.
Dorsal 7 .
Temporal
Bases of lungs, heart, and stomach
Dorsal 8
-Vertical
Stomach, liver, and upper part of
Dorsal 9
Parietal
the small intestine.
Stomach, and upper part of the
t
Dorsal 10
Occipital
small intestine.
Liver, intestine, ovary, and testicle.
324
AIN
AREAS OF REFERRED PAIN AND TEwSX?? 8 IN AFFEC '
TIONS OF THE HEAD AND NEC
(Head.)
See diagram figure 4.
Organ Involved.
Maximum Point
of Referred Pain and
Tenderness.
Organ Involved.
Maximum P n(1
of Referred T'aiii
TendernesSBB
Ciliary muscle.
(Disorders of
accommoda-
tion.)
Cornea
Midorbital.
Frontonasal.
Frontotemporal ,
temporal, and
maxillary.
Temporal.
Vertical.
Hyoid.
Vertical and be-
hind the ear.
Upper teeth . . .
Lower teeth. . .
Tongue, ante-
rior part.
Tongue, lateral
part.
Tongue, poste-
rior part.
Tonsil
Frontonasal, naso-
labial, temponi
maxillary, or
mandibular.
Mental, hyoid, 8Kb
perior laryngeklj
and in the ear. "X
Mental.
Hyoid, superio^
laryngeal, and in
the ear.
Superior laryngeal,
hyoid, occipital.
Hyoid and in the
ear.
Frontonasal and
midorbital.
Nasolabial (occa-
^ionally) .
Superior and in-
ferior laryngeal
(in destructive
lesions) .
^
Iris
Vitreous body
(Glaucoma.)
Retina
Tympanic mem-
brane.
Middle ear ....
Nose, olfactory
portion.
Nose, respira-
tory portion
and poste-
rior nares.
Larynx
D 11
FIGURE 1. C S and C 4 .third and fourth cervical; D 1 to D IS, first to
twelfth dorsal ; L / and L 2, first and second lumbar ; 5 3 and S 4, third and
fourth sacral.
C 3
D 11
S 2
D 10
D 12
S 1
FIGURE 2. C, cervical ; D, dorsal / L, lumbar ; S, sacral.
D 2
L 1
L 5
FIGURE 3. D, dorsal ; L, lumbar.
Neuritis of Bra-
chial Plexus.
Neuritis.
Neuralgia.
Progressive Muscu-
lar Atrophy
Syringomyelia.
Disease of Verte-
' brae.
Occupation Neu-
roses.
Tabes.
steomalacia.
Disease or Injury
of the Cord (es-
pecially Tabes).
FIGURE 5. POSSIBLE AREAS OF PAIN OH TENDERNESS IN DISEASES OF THE NERVOUS
SYSTEM, ETC.
Neurasthenia.
Meningitis.
Cerebellar Disease.
Sub-occipital Neu-
ralgia.
Disease of Cervical
Vertebra.
Affections of Naso-
Pharynx. Nose,
and Middle Ear.
Uremia.
Syphilis.
Osteomalacla
Hypertension
Headache.
Neurasthenia.
Neuritis of Bra-
chial Plexus.
Neurasthenia.
Railway Spine.
Meningitis.
Myeli ti s or Tu-
mors of Cord.
Disease of Vert e-
brae.
Typhoid Spine.
Spondylitis Defor-
mans.
Lumbo-abdominal
Neuralgia.
Lumbago.
FIGURE 6. POSSIBLE AREAS OF PAIN OR TENDERNESS IN DISEASES or THE NERVOUS
SYSTEM, ETC.
Hepatic Conges-
tion.
Gallstone Disease.
Intestinal Ulcera-
tion.
Ulcer of Stomach.
Lead colic.
Pancreatic Dis-
ease.
Appendicitis.
Renal Affections
Ulcer of Stomach.
Gallstone Disease.
Intestinal Ulcera-
tion.
Pancreatic Disease.
Appendicitis.
Hernia.
Affections of Rec-
tum.
Vertebral Disease.
Constipation.
Gastric Disorders.
Constipation.
Colitis.
Gastric Disorders.
Gastralgia and
Functional Disor-
ders of Stomach.
Gastric Distention.
Ulcer of Stomach
or Duodenum.
Carcinoma of Sto-
mach.
Ulcer, New Growth
or Stricture of
Esophagus.
Punctional Disor-
ders of Stomach.
Gastritis.
Ulcer and Carcino-
ma of Stomach.
Pyloric Colic.
Enteroptosis.
Splenic Disease.
Movable Kidney.
Renal Colic.
Ulcer of Stomach.
Colitis.
Testicular or Ovarian Affections.
Renal Colic.
Hernia.
Constipation.
FIGURE 7. POSSIBLE AREAS OF PAIN OR TENDERNESS IN DISEASES OF THE ABDOMINAL
ORGANS.
Pregnancy.
Uterine or Ova-
rian Disease.
Head's Triangle in
Ulcer of Stomach.
Gallstone Disease
and Affections of
Gall-bladder.
Pancreatic Disease
Appendicitis.
Ureteritis.
Gastralgia.
Ulcer of Stomach.
Carcinoma of Sto-
mach.
Flatulence.
Enteroptosis.
Dietl's Crises.
Lead Colic.
Peritonitis.
Tuberculous Peri-
tonitis.
Intestinal Obstruc-
tion.
Intestinal Ulcera-
tion.
Enteritis.
Hernia.
Pancreatic Disease.
Tabes.
Spinal Disease.
Gout.
Ovaritis.
Cystitis.
Tuberculosis or
Carcinoma of Bladder.
Vesical Calculus.
Prostatic or Adnexal Disease.
FIGURE 8. POSSIBLE AREAS OF PAIN OR TENDERNESS IN DISEASES OF THE ABDOMINAL
ORGANS, ETC.
Splenic Affections.
Gastric Disorders.
Constipation.
reinoma of Colon or
Pancreas.
Movable Kidney.
Pyelitis.
Subphrenic Abscess.
Renal Colic.
FIGURE 9. POSSIBLE AKEAS OF PAIN OR TENDERNESS IN DISEASES OF THE
ABDOMINAL ORGANS.
Gallstone Disease and Af-
fections of Gall-bladder.
Hepatic Disease: Cir-
rhosis.Cqngestion, Syph-
ilis, Carcinoma, Abscess,
Echinococcus etc.
Subphrenic Abscess.
Carcinoma of Pylorus or
Colon.
Movable Kidney.
Pyelitis.
FIGURE 10. POSSIBLE AREAS OF PAIN OK TENDERNESS IN DISEASES or THE
ABDOMINAL ORGANS.
Gastric Affections.
Constipation.
Ulcer of the Sto-
mach.
Spleen.
Pancreas.
Lumbago.
Flatulence. ,
Constipation.
Renal Calculus or
New Growth.
Movable Kidney.
Pyelitis.
Acute Nephritis.
Lumbar Abscess.
Vesical Calculus.
Cystitis.
Prostatic New
Growth or Sup-
puration.
Ischiorectal Ab-
scess.
Fever, (Acute In-
fectious Dis-
eases etc.) .
Anemia.
Gout.
Coccygodynia.
Anal Fissure.
Hemorrhoids.
Rectal Fistula.
Ischiorectal Abscess.
FIGURE 11. POSSIBLE AREAS OF PAIN OB TENDERNESS IN DISEASES OF THE ABDOMINAI
ORGANS, ETC.
Esophagus: In-
fl animation,
Stricture, New
"rowths, Ulcer-
atiqn, etc.
Gastric Affections.
Flatulence.
Pancreatic Disease.
Liver and G a 1 1-
bladder.
Ion.
.Kidney.
Renal Affections.
Relaxation of
Sacro-iliac Lig-
aments.
Disease of Pelvic
Viscera.
Rectal Carcinoma
or Ulceration.
Hemorrhoids.
Ischiorectal A b -
scess.
Diaphragmatic
Pleurisy.
Mediastinal
Growths.
Enlarged Bron-
chial Glands.
Bronchitis.
Miliary Tubercu-
losis.
Pneumonia.
Empyema.
Pneumonia.
Pleurisy.
Pleurisy.
Apical Lesions.
New Growths.
leurisy.
New Growths of
Lung or Pleura.
Diaphragmatic
Pleurisy.
Pneumonia.
eurisy.
Prolonged C^ugh-
ing or Vomiting.
Pneumonia.
Pleurisy.
Diaphragmatic
Pleurisy.
FIGUHE 12. POSSIBLE AREAS OF PAIN OK TENDERNESS IN DISEASES OF THE LUNGS AND
PLEURA.
Pleural Affections.
Muscular Pain after Pro-
longed Coughing or
Vomiting.
Pneumonia.
Tuberculosis.
Empyema.
Pleurisy.
New Growths of Pleura or
Mediastinum.
Enlarged Bronchial
Glands.
Pleurodynia.
FIGURE 13. POSSIBLE AREAS OP PAIN OR TENDERNESS IN DISEASES OF THE LUNGS
AND PLEURA.
Diaphragmatic
Pleurisy.
Tuberculosis.
Pleural Adhesions.
Glandular Enlarge-
ments.
Pleurisy.
New Growths.
Apical Lesions.
Mediastinal
Growths.
FIGURE 14. POSSIBLE AREAS OF PAIN OR TENDERNESS IN DISEASES OF THE LUNGS AND
PLEURA.
Atheroma of Aorta
and Large Ves-
sels.
Aneurysm of In-
nominate.
Arch of Aorta.
Ascending Aorta.
Valvular Lesions.
Pericarditis.
Angina Pectoris.
Aneurysm of Ab-
dominal Aorta or
Coeliac Axis.
Spasm of Mesen-
teric Vessels.
A neurysm of
Aorta.
Atheroma of
Aorta.
Aneurysm ot
Aorta.
Angina Pectoris.
Coronary Sclerosis.
Valvular Lesions.
Atheroma of
Aorta.
Aneurysm of
Aorta.
Coronary Sclerosis.
Angina Pectoris.
Pericarditis.
Myocarditis.
Endocarditis.
Valvular Lesions
(especially Aor-
tic).
Functional Dis-
ease of the
Heart.
Anemia.
Gout.
FIGURE 15.-
-POSSIBLE AREAS OF PAIN OR TENDERNESS IN DISEASES OF THE HEART AND
VESSELS.
Pericarditis.
^Aneurysm of Thoracic
Aorta.
FIGURE 16. POSSIBLE AREAS OF PAIN OR TENDERNESS IN DISEASES OF THE HEART
AND VESSELS.
Atheroma of Aorta.
Aneurysm of Aorta or
Coeliac Axis.
Valvular Lesions (espe-
cially Aortic).
FIGURE 17. POSSIBLE AREAS OF PAIN OR TENDERNESS IN DISEASES OF THE HEART
AND VESSELS.
Pericarditis.
Descending Aorta
Abdominal Aorta.
Atheroma of Aorta.
Aneurysm of Aorta.
or Innominate.
Atheroma of Aorta.
Aneurysm of Tho-
racic or Abdom-
inal Aorta.
FIGURE 13. POSSIBLK AREAS OF PAIN on TENDERNESS IN DISEASES OF THE HEART AND
VESSELS.
INDEX
Abdomen, 56
Abdominal disorders, 29, 41, 59, 94
Adhesions, peritoneal, 244
^Esophagus, 51
Anaemia, 77
Aneurysm of aorta, 303
Angina pectoris, 38
Aorta, 49, 292
Aortitis, chronic, 308
Apices, pulmonary, 48
Appendicitis, 220
Appendix, 182
Arm, 91
Arthralgias, 103
Biliary congestion, 233
Brain tumor and hydrocephalus,
71
Calculi, 247, 263
Cancer, gastric, 164
Carcinoma of colon, 221
of gall-ducts, 238
Catarrhal and ulcerative changes,
272
Circulatory apparatus, 27, 50
Cirrhosis of the liver, 276
Colic, 54
and thoracic processes, 59
doubtful cases of, 67
Colicky pains, 65
Collapse, 54
Congestion, hsematogenous, 228
Cysts, 241
Defecation, 41
Deglutition, 44
Drugs and chemicals, 38, 280
Embolism of the renal arteries, 250
Epigastrium, 53, 54, 243
midline of, 211
Epigastric pain, 27
Face, 88
Food, influence of, 33, 54
Gall-bladder, 211
colic, 209
Gall-stones, 63
Gastralgias, 123
Gastric crises, 43
disorders, 52
pain, 40
Hemorrhage, 247, 271
Headache, 69
and constipation, 73
caused by chemical poisons,
76
of reflex nature, 78
Hsemoglobinuria, paroxysmal, 277
Heart or epigastrium, 38
Heart disease, 277
Hernias, 62
Hysteria, 223
Infectious processes, 277
Inflammations of aorta, 293
Intercostal spaces, 93
Intestine, malignant new growths
of, 197
Intestinal stenoses, 62
ulceration, 174
Kidney, 222, 249, 258, 269
Lead colic, 192
325
326
INDEX
Lead colic, individual symptoms
and analysis, 193
Lesions, abdominal, 42
aortic, 296
of lungs, 291
organic, 37
Liver, 49, 51, 206
capsule, distention of, 208
inflammatory processes,
208, 228
Lumbar region, 57, 58, 212
Lungs, 282
Mediastinum, 50
Menstruation, 45
Motion, organs of, 26
Myalgias or muscular pains, 108,
112, 113
Myelogenous leukaemia, 276
Nephritis, 256
Neuralgias, 61, 83, 97, 100
New growths, cystic, 60
Nocturnal pains, 67
Obstruction, intestinal, 245
Occipital region, 90
Osteomalacia, 119
Ostalgias or bone pains, 115, 122
Pain, sensation of, 15-21
of colic, 65
Pancreas, 240, 246
Percussion, 31
Peripheral vessels, 314
Perivesical inflammations, 272
Pleura, 284, 291
Pleural pain, 286
Pneumonia, 292
Position, 22, 55, 72
Pressure, 29, 252
Pyelitis, 268
Pyloric stenosis, colic of, 153
Renal infarct, 253, 256
Respiration, 45
Retrosternal region, 50
Scapula, and intrascapular region,
52
Shoulder, 48
Spasm in bile passage and gall-
bladder, 206
of the urogenital tract, 262
Spleen, 276
Stenotic processes, 262
Stomach, 51
and intestine, 79
Suppurative processes, 28
True kidney pain, 249
Tuberculosis of the kidney, 259
Ulcer, duodenal, 220
gastric, 133
Ulceration, gastric and duodenal,
39
intestinal, 174
tuberculous intestinal, 163
Uremia, 76
Urinary bladder, 272
Urination, 254
Vagus, 97
Valves, aortic, 311
Visceral disease, 319-324
Vomiting, 44
UNIVERSITY OF CALIFORNIA LIBRARY
Los Angeles
This book is DUE on the last date stamped below.
Form L9-Series4939
