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BOSTON
Medical Library
8 The Fenway
PAIN
PAIN
ITS ORIGIN, CONDUCTION,
PERCEPTION AND DIAGNOSTIC
SIGNIFICANCE
RICHARD J. BEHAN, M.D.
Dh. Med. (Berlin)
WITH ONE HUKDRED AND NINETY-ONE
ILLUSTRATIONS IN THE TEXT AND
MANY DIAGNOSTIC CHARTS
NEW YORK AND LONDON
APPLETON AND COMPANY
1914
7 £^S
COPTBIOHT, 1014, BT
D. APPLETON AND COMPANY
'<$
:o-
^ MEdTq;
L JUN 16 1963 *
LIBRAE"!
Printed in the United States of Ameriea
IT IS WITH THE GREATEST OF PLEASURE
THAT I DEDICATE THIS BOOK TO ONE
WHO HAS EVER BEEN AS A FATHER
TO ME AND TO WHOM I OWE THE
MOST OF WHAT I AM — TO MY UNCLE
MALACHY O'DONNELL
PREFACE
During many years I have been impressed with the necessity
of a thorough understanding of pain phenomena in the making
of a diagnosis. Pain is universal, and is present in practically
every disease, and in most diseases it is the one symptom which first
attracts the patient's attention and causes him to become aware
of some change in his physical well-being. The patient then
comes to the physician, who, unless he is well versed in the inter-
pretation of pain phenomena, may be at a loss to interpret the
symptoms which are presented to him. To do so he needs to
know not only the various factors to which a certain pain may
be due, but also the reasons why it should be produced and the
different diseases giving rise to pain of similar character and loca-
tion. To understand thoroughly these latter factors the physician
must needs be versed in all the essentials and components of which
a pain consists, its causes, character, varieties, its localizations
and the changes induced by its presence.
It was with the idea of supplying easily accessible informa-
tion along these lines that I imdertook the composition of this
book. To those, who, like myself, have felt the need of such a
book, I offer it with the hope that it may be of some help to them.
To make it as complete as possible has been my endeavor, and to
do so I have thoroughly searched the literature and culled from it
all that I thought might be of use. I believe credit has l)eon
given in all cases to the authors of my references, but if, through
• •
vu
viii PREFACE
an unintentional oversight, this has been neglected, I beg that my
attention may be called to it so that it can be remedied.
It is with the greatest pleasure that I express my thanks to
Dr. T. L. Disque, Dr. Wm. H. Glynn, Dr. E. C. Stuart, who so
kindly granted me the use of an abundant material from his
surgical service; to Goldsmith of Vienna, who reviewed the
anatomical section of my work ; to Dr. Frankel of the same city,
who reviewed my gynecology section; to Dr. Smith Ely Jelliffe,
who has reviewed the entire work; to Mr. Sander of Vienna; and
Dr. Frenzel and Dr. Powers of Berlin ; to Miss Esther TIrubesky
of Berlin, who has aided me in revising my proofs and illustrations.
R. J. Behan.
212 South St. Clair Street
Pittsburg, Pa.
CONTENTS
CHAPTER I
GENERAL CONSIDERATION OF SENSATION
PACB
Sensation in Lower Animals 1
Reaction op Animals to Pain 3
General Consideration of Sensation 4
Properties op Sensation 6
Centers for Sensory Perception and the Sense Organs . . 7
Sense Perceptive Organs 11
Stimuli 12
Interprstation op Sensation . 12
CHAPTER II
THE NATURE OF PAIN
Depinition 18
Metaphysical Consideration op Pain 20
Memory Centers for Pain 24
Causative Factors in the Production op Pain .... 25
Apparatus for Receiving and Conducting Pain ... 28
Pain and Mental States 30
Relation op Pain to Other Sensations 31
Conveying Channels for Sensations 35
CHAPTER III
DISTRIBUTION OF THE SENSATION OF PAIN
Distribution of the Sensation op Pain 4(i
CHAPTER IV
PERCEPTION OF PAIN SENSATION
Analgesia ... 61
Anesthesia 63
Hyperalgesia 67
iz
X CONTENTS
rAOB
Tenderness 70
Paresthesia 73
CHAPTER V
CLASSIFICATION OF PAIN
SuBjECTiVB Pains 74
Emotional pains ......... 76
Hysteria 76
Hypnosis 80
Habit pains .......... 80
Monomania pains ......... 80
Occupation neuroses . . . . . . . .80
Objective Pains 82
Central objective pain ........ 82
Peripheral objective pain ....... 83
CHAPTER VI
CLASSIFICATION OF PAIN (Continued)
Peripheral Objective Pains 89
Propagation of pains ........ 89
Character of the pain ........ 108
Persistency of pain ........ 109
Time of the pain 110
Sensitiveness to pain ........ Ill
Individual susceptibility . . . . . . .112
CHAPTER VII
THE INTENSITY OF PAIN
Factors upon Which Intensity Depends 114
The stimulus 114
Sensitiveness of the patient ....... 115
Irritability of the nerves ....... 115
Extent and number of nerve fibers involved .... 115
Factors Modifying Pain Production ...... 115
Psychical factors ......... 115
Physical factors . . . . . . . . .116
Estimation op the Intensity of Pain 120
Blood-pressure elevation ....... .120
Motor reflexes ....*..... 122
Comi)laints of patient compared with his susceptibility . . 123
Vasomotor signs ......... 124
CONTENTS xi
PAGE
Dilatation of the pupil ..... .125
Amount of morphine necessary to overcome pain . . . 125
Appearance of patient ........ 125
Patient's description ........ 128
Mechanical factors ........ 129
Conditions Associated with Severe Pain 132
Respiratory system ........ 134
Circulation 134
Loss of equilibrium ........ 134
Trophic changes ......... 134
Preprotective functions . • . . . . ... 135
Elevation of temperature ....... 135
Method of Recording Pain 135
CHAPTER VIII
PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
Affections of the Nerve Terminals and Nerve Trunks . . 140
Etiology 142
Symptoms .......... 143
Duration of neuralgia . . . . . . . . 146
Diagnosis of neuralgia ........ 146
Types of neuralgia according to localization .... 147
Central Nervous System 172
Anatomy .......... 173
Origin of headache ........ 175
Headache in disease of the brain and meninges . . . 178
Diagnosis of headache in diseases of the brain and meninges . 190
Differential diagnosis ........ 195
CHAPTER IX
DISEASES OF THE SPINAL CORD
Cord Conditions Which Cause Pain 208
Meningeal apoplexy ........ 209
Hematomyelia ......... 210
Caries of the vertebral canal ...... 210
Tumors of the spinal cord and vertebrae, .... 211
Acute spinal meningitis ....... 212
Pachymeningitis spinalis hypertroi)hica ..... 212
Myelitis 212
Poliomyelitis of children ....... 212
Syphilis of the meninges and of the cord .... 213
Multiple sclerosis ......... 213
zu
CONTENTS
PAGE
Syringomyelia
. 214
Tabes dorsalis
. 214
Neurasthenia
. 215
Hysteria
. 216
Traumatic neuroses
. 216
General smnmary .
. 216
CHAPTER X
PAIN IN THE TISSUES
Muscular Tissues 218
Voluntary Muscles 219
Myositis 219
Acute polymyositis ........ 220
Myositis hemorrhagica ........ 221
Myositis fibrosa . . . . . . . . . 221
Myositis ossificans ........ 221
Myalgia 221
Involuntary Muscles 222
Colics 222
Fatty Tissues 224
Adiposis dolorosa ......... 224
CHAPTER XI
BONE PAINS— THE OSTALGIAS
General Considerations 226
Types op Pain 227
Continuous pains ......... 227
Intermittent pain 227
Diurnal variation of the pains 228
Character op Bone Pain 228
Localized Bone Pain 228
Periosteal lesions 229
Traumatism .......... 229
Fracture 229
Contusions . . . . . . . . . . 230
New growths 230
Septic involvement ........ 231
Generalized Bone Pain 232
Osteomalacia 232
Diseases of the hemopoietic system ..... 233
Sarcoma and carcinoma ....... 233
Myeloma, lymphadenoma ossium, and chloroma . . . 233
CONTENTS xiii
PAGE
Osteitis deformans ........ 233
Leontiasis ossea ......... 233
Spurs 233
Differential Diagnosis of Bone Pain 233
Joint Pains — ^Arthralgia 234
Classification 234
Radiation of joint pains ....... 236
Intensity of the pain . 236
Symptoms 236
Diagnosis of inflammatory joint pains ..... 239
Hip joint 240
Tension pain of intra-articular hip-joint abscess . . . 244
CHAPTER XIT
THE CIRCULATORY SYSTEM
Pain Caused by Changes in the Blood 247
Pains from increase in blood supply ..... 247
Pains from diminution in blood supply .... 248
Arterial Diseases Causing Pain 249
Inflammation . . . . . . . . . 250
Increase of blood pressure . ..... 251
Intermittent claudication ....... 251
Erythromelalgia ......... 252
Embolism and thrombosis of the mesenteric arteries . . 253
Aneurysm .......... 254
Diseases of the Veins Causing Pain 255
Inflammation of the veins ...... 255
Thrombosis 256
Varicose veins . . . . . . . . . 256
CHAPTER Xm
THE GLANDULAR TISSUES
The Glands 257
The Mammary Gland 257
The Adrenals 259
The Mesenteric Glands . 261
The Thymus and Thyroid 261
CHAPTER XIV
REGIONAL PAIN
The Head 262
Sense of pressure in head ....... 264
Head pain . 265
Diagnosis of headache ........ 281
xiv CONTENTS
PACE
Pain in the Back 296
Lungs . . . . 300
Heart and aorta . . . . . . . . . 301
Stomach 301
Intestines 302
Liver and gall-bladder 302
Kidney 302
Pancreas, spleen, etc. ........ 303
Anemia and chlorosis ........ 304
Pain in the Limbs 304
Pain in the Abdomen 307
Chest Pain 310
CiiAvicuiiAR Pains 310
Neck Pains 312
Summary 312
CHAPTER XV
THE SIGNIFICANCE OF PAIN IN DISEASE OF THE EYE
Etiology 317
Localization op Pains 318
The eyelids 318
Surroundings of the eye ....... 322
Conjunctiva and cornea ....... 322
The iris and ciliary body 325
Sclerotic coat 327
Choroid, retina and optic nerve ...... 328
Glaucoma 329
Panophthalmitis 330
Asthenopic disorders 330
CHAPTER XVI
PAIN IN DISEASE OF THE EAR
External Ear .
• « 4
332
External Auditoey Canal .
. 333
Tympanum
335
Middle-ear Disease
• *
. 335
Middle-ear Catarrh ,
• *
. 339
Otosclerosis
» • i
. 339
Labyrinth
► • • «
. 331*
Referred Pain .
* • s *
■ •
. 340
CONTENTS XV
CHAPTER XVn
PAIN IN DISEASES OF THE NOSE
PAGE
The Sbnsobt Nerves op the Nose 341
Diseases Which Produce Pain and Their Manner op Production 342
Nasal Stenosis 342
Empyema 343
Headache prom Disease op the Sphenopalatine Ganglion . 345
Tumors 347
Diagnosis 348
CHAPTER XVni
PAIN IN DISEASES OF THE THROAT
Pain in Diseases op the Pharynx 351
Pain in acute diseases .••..... 351
Pain in chronic diseases ....... 354
Pain in the Larynx 356
Pain in acute affections . . . • ' . . . 357
Chronic processes 358
CHAPTER XIX
ABDOMINAL PAIN
Classipication 360
Subjective Pain 360
Objective Abdominal Pain 360
Inflammations op the Peritoneum 364
Tumors op the Peritoneum 367
Nature op Pain from Adhesions 367
Nature op Pain in Hernla . . . . . • 371
CHAPTER XX
PAIN IN ABDOMINAL VISCERAL DISEASE
History 377
Location op Pain 383
Transference op Pain 384
xvi CONTENTS
CHAPTER XXI
DIAGNOSIS OF ABDOMINAL PAINS
PAGB
Nature op Various Abdominal Pains . . . ■ ^ , 390
Examination for Pain 394
Localization of pain ........ 394
Localization of oi^an producing pain ..... 395
Lesions causing epigastric pain 396
Pain due to functional processes 400
Pain due to intestinal diseases 401
Abdominal tenderness ........ 403
Posture in Abdominal Diagnosis 406
Forms of Abdominal Pain 408
Functional pains 409
Care in diagnosis 410
CONDITIONS Associated with Abdominal Pain .... 413
Spasm and rigidity of muscles ...... 413
Visceromuscular reflex ........ 413
Toxemia 414
Indicanuria .......... 414
Polyuria 414
Relationship of hysterical to abdominal pain .... 414
Abdominal incisions ........ 415
Post-operative abdominal pain 415
Pain referred to extra-abdominal regions .... 416
Absence of pain ......... 416
CHAPTER XXII
PAINS OF THE ALIMENTARY TRACT
Lips 418
Cheeks 418
Teeth 419
Tongue 421
Salivart Glands 422
Pharynx and Tonsils ^ . . 423
Esophagus 424
CHAPTER XXni
THE STOMACH
Areas op Referred Pain Caused by Stomach Disorders . . 427
Pain in Gastric Areas 429
Character of gastric pain . . . . . • . . 429
Time and manner of its appearance ..... 430
CONTENTS xvii
PAGE
Relationship to ingestion of food 430
Duration of pain 430
Previous attacks 431
Associated symptoms ........ 431
Pain reflected or referred to gastric areas .... 431
LESiONa OP Stomach Causing Pain ' . 431
Displacement of the stomach (gastroptosis) .... 431
Crastralgia or gastromyalgia ....... 431
Hyperchlorhydria ........ 434
Pyloric or cardiospasm ....... 436
Acute dilatation of the stomach 439
. Acute gastritis 440
Chronic gastritis ......... 442
Gastric erosions 442
Gastric ulcer 442
New growths of the stomach ...... 455
Perigastric adhesions ........ 459
Referred Pains Confused with Those of Gastric Origin . . 461
CHAPTER XXIV
INTESTINAL PAIN
General Considerations 463
Etiology of pain 463
Location of pain 469
T3rpe of pain 470
Manner of onset 471
Relation of the position of the patient to the pain . . . 472
Relation of the ingestion of food to the pain . . . 472
Duration of pain ......... 473
Result and history of the pain ...... 473
Tenderness 474
Symptoms associated with the pain ..... 474
Lesions of the Intestines Causing Pain 476
Enteralgia 476
Pain due to functional disturbances ..... 477
Type of pain in colic 483
Inflammation of the bowel 484
Ulcers of the intestine 487
Distention of the bowel 491
Adhesions .......... 491
Obstruction of the intestine ....... 492
The rectum 505
The anus 509
xviii CONTENTS
CHAPTER XXV
THE APPENDIX
PAGE
Varieties op Appendiceal Pain 516
Tenderness in Appendicitis 529
Symptoms Associated with Pain Production in Appendicitis . 535
Differential Diagnosis 537
CHAPTER XXVI
THE LIVER, GALL BLADDER AND DUCTS
General Considerations 540
Nerve supply •....,... 540
Pain of the Liver 545
Character of the pain . . 545
Relation to the ingestion of food and drink .... 545
Relation to the movement of the body ..... 547
Position of the body . . . . . . . . 547
Relationship to other diseases and processes .... 548
Time of appearance of pain ...... 549
Neuralgia .......... 550
Pains due to the disturbance of the liver substance proper . 550
Gall Bladder 562
General etiology ......... 562
Diagnosis .......... 563
Diseases causing pain ........ 568
Gall-duct Pain 572
Etiology 572
Location of pain .....•••. 573
Character of pain 573
Associated symptoms ........ 576
Differential diagnosis 577
CHAPTER XXVII
THE PANCREAS
General Considerations 580
Nerve supply 581
Structure of the pancreas 582
Peritoneal covering ........ 583
Relationship to other parts 584
Character of pain ......... 585
Location of pain ......... 585
CONTENTS xix
PAGE
Tondemess 586
Position of the patient 587
Diseases op the Pancreas Causing Pain ..... 587
Pancreatitis 587
Pancreatic calculi . . 589
Cystic disease of the pancreas 591
Cancer of the pancreas 591
CHAPTER XXVni
THE SPLEEN
General Considerations . . , 593
Anatomy 093
Nerve supply .■)93
Position of patient 596
Tenderness .......... 596
Factors influencing pain ....... 596
Disorders of the Spleen Producing Pain .... 598
Displaced or movable spleen ...... 598
Congestion 599
Perisplenitis 000
Abscess of the spleen ........ (301
Infarct GOl
Rupture of the spleen ........ ()02
Tumors of the spleen 002
Cysts of the spleen 002
CHAPTER XXIX
THE KIDNEY
General Considerations 604
Nerve supply 604
Etiology of kidney pain 005
Character of renal pain 607
Localization of kidney pain ....... 607
Tenderness 615
Factors influencing production of pain ..... 617
Absence of pain in kidney lesions ..... 618
Symptoms associated with pain phenomena .... 618
Pain in diagnosis of kidney lesions 619
Differential Diagnosis of Kidney Diseases Causing Pain . 620
Movable kidney ......... 620.
Renal infarction ......... 026
Hematuric nephralgia ........ 029
Inflammation of the kidney 629
CONTENTS
PACE
Perinephritis ......... 637
Rupture of the kidney .
¥ • « 1
. 641
Tuberculosis of the kidney ,
. 642
New growths
. 644
Pyelitis . . . ^ ,
. 647
Hydronephrosis
. 653
Renal calculus
. 655
CHAPTER XXX
THE URETER, BLADDER AND URETHRA
The Ureter . . . 670
The Bladder 672
General considerations ........ 672
Bladder aflfectious causing pain ...... 683
The Urethra 605
Urethral caruncles ........ 695
Calculus 696
Rupture of the urethra . . . . ' • • . 696
Transferred pain in urethral disease ..... 696
Pain on urinating ........ 696
CHAPTER XXXI
THE MALE ORGANS OF GENERATION
The Testicles 698
Epididymis, Vas Deferens, and Seminal Vesicles . . . 699
The Prostate 700
Cong^estion and inflammation ...... 700
Lesions .......... 701
Hypertrophy ......... 701
Tumors of the prostate 702
Tuberculosis 702
Associated symptoms ...••••. 702
The Penis 703
Urethritis 703
Inflammation of the prepuce . v . . . . 703
Inflammation of Cowper's glands ...... 703
CHAPTER XXXn
PAIN IN THE FEMALE GENITALIA
General Considerations 705
Anatomy .......... 705
Nerve supply ......... 705
CONTENTS
xxi
PAGE
Diagnosis of pelvic and hysterical pain .... 709
Varieties of pain ......
. 712
• Character of uterine pains
. 716
Diagnosis of the pelvic diseases
. 722
Utekixe Pain .....
. 724
Character of uterine pains .
. 724
Neuralgfia .....
. 726
Displacement of the uterus .
. 726
li'unctional disorders of the uterus
. 728
Inflammation of the uterus .
•
. 740
New growths of the uterus .
. 743
Fallopian Tubes ....
. 744
Tubal conditions causing pain
. 744
Extrauterine pregnancy
. 746
Ovary
. 747
Local point of pain
. 748
Causes of pain ....
. 748
Neuralgia of the ovary
. 749
Displacement of the ovary .
. 749
Hernia of the ovary .
. 749
Hyperemia of the ovary
. 749
Abscess of the ovary .
. 751
Tuberculosis ....
. 752
Enlarged uterus ....
. 752
Relationship of ovaries and parotide
3
. 752
Cysts of the ovary
. 753
The Vagina
. 755
Nerve supply
. 755
Affections causing pain .
. 755
Sexual connection ....
. 756
CHAPTER XXXra
PAIN IN THE CHEST
The Thoracic Walls 760
The skin 760
Muscles, fascia and nerves ....... 762
Nerve and muscle pain ........ 762
Bone pain 764
Pleural pain 764
Referred and Reflected Pains of the Thoracic Walls . . 764
Localization of pain on the chest wall ..... 767
Pains within the Thorax 769
The pleura 769
xxu CONTENTS
CHAPTER XXXIV
HEART DISEASE
PAGE
General Considerations 773
Nerve supply of the heart 774
Diagnosis by means of location of referred pain . . . 774
Intracardiac lesions as causes of pain ..... 782
Angina Pectoris 783
Etiology 783
Character of the pain in angina pectoris .... 784
Location of the pain ........ 785
Local tenderness ......... 787
Associated symptoms 787
Disease of the Pericardium 788
CHAPTER XXXV
THE RESPIRATORY ORGANS
The Lungs 790
General considerations ........ 790
Diseases of Thoracic Organs Causing Pain .... 795
Acute bronchitis ......... 795
Pneumonia 797
Tuberculosis 800
The Medustinum 802
BIBLIOGRAPHY 805
INDEX 869
LIST OF ILLUSTRATIONS
FIG. PAGB
1. — Right cerebral hemisphere seen from the outside . . 9
2. — dinner surface of right cerebral hemisphere .... 9
3. — Schematic illustration showing how the various sensations are
transmitted from the periphery to the brain cortex and
from thence to the two brain centers .... 23
4. — Diagram showing how changes in the cell metabolism may
produce changes in the irritability of the cell and a de-
parture in its reaction to external stimuli, either making
it more or less sensitive to peripheral irritation . . 27
6. — Areas of epicritic and protopathic sensibility ... 38
6. — Effect of injury to the pain-conduction paths in the cord . 39
7. — Unilateral complete lesion on one side of the cord producing a
narrow band of anesthesia on the same side at the level of
the lesion and a broader zone of anesthesia on the opposite
side slightly below the level of the lesion ... 39
8. — Cross section of the spinal cord ..... 40
9. — Diagram showing intraspinal course of sensory fibers . . 43
10. — Course of the different sensory (peripheral) fibers, according
to Head 44
11. — Cutaneous sensory nerve supply to the lower limbs. (After
Toldt.) 49
12. — Cutaneous distribution of peripheral nerves. (After Fowler.) 50
13 and 14. — Cutaneous nerve supply, showing the distribution areas
of the different plexuses. (Toldt.) .... 51
15. — Distribution areas of the nerves (from lumbar plexus) distrib-
uted to the anterior surface of the thigh and abdomen . 52
16. — Distribution of the nerves derived from the sacral plexus . 53
17. — Dorsal nerves 54
18. — Cord zones according to Kocher ...... 55
19. — Cutaneous areas related to spinal cord segments and cutaneous
distribution of nerves 56
20. — ^Areas of anesthesia and paralysis corresponding to affected
vertebraB 57
21. — ^Distribution of the lumbar segments according to Thorbum 57
22. — ^Distribution of lumbar and sacral segments as outlined by
Starr .57
• • •
XXUl
xxiv . LIST OF ILLUSTRATIONS
FIG. PAGE
23. — Relationship of the segments of the spinal cord and their
nerve roots to the bodies and spines of the vertebrae . 58
24. — Cord zones and areas of maxirauni tenderness according to
Head 59
25. — Cord zones and areas of maximum tenderness according to
Head 59
26. — Cord zones and areas of maximum tenderness according to
Head 59
27. — Areas of anesthesia on leg due to depressed fracture of skull 64
28. — Method of eliciting hyperalgesia .' . . . . .67
29. — Areas of analgesia in hysteria . . . ... .78
30. — Method of pain production in inflammation . . .85
31. — Varieties of pain: Origin and transmission ... 89
32. — Scheme showing how the different varieties of pain may arise
and how the different musculo-sensory reflexes may occur 90
33. — Varieties of pain: Origin and transmission ... 91
34-36. — Case illustrating upward reference of pain ... 99
37. — Hand pressing on the abdomen, very characteristic of colic,
i.e., of the uterus or intestine ..... 126
38. — ^Position assumed in uterine colic, intestinal colic, and distended
urinary bladder ........ 127
39. — Lacing shoe position ........ 128
40. — Pain on hyperex tension of the body ..... 120
41. — Pain on going uj)stairs ....... 129
42. — Marking code of Dr. Harris ...... 136
43. — Figures showing the application of the marking code of Dr.
Harris ......... 137
44. — Areas of neuralgic pain ....... 148
45. — Brachial plexus ......... 151
46. — Areas of distribution of nerves derived from the brachial
plexus ......... 152
47. — Areas of distribution of nerves derived from the brachial
plexus ......... 152
48. — Distribution areas of the cutaneous nerves of the upper limbs 154
49. — Areas of distribution of the different cords of the brachial
plexus ......... 155
50. — Distribution of sensory disturbances in a lesion of the fifth
cervical nerve ........ 156
51. — Area of distribution of pain in lesions of the sixth and seventh
cervical nerve ........ 156
52. — Distribution of sensory disturbances in lesions of the cervical
: plexus . . ... . . . . ,. 157
53. — Area of anesthesia in a lesion of the first dorsal nerve . . . 157
54. — !Method of eliciting pain in brachial neuralgia i . . 158
region
LIST OF ILLUSTRATIONS
FIG.
55. — ^Method of eliciting the points of tenderness in intercostal
neuralgia .........
56. — Cutaneous distribution areas of small and greater sciatic
57. — ^Method of eliciting pain in sciatica
58. — ^Distribution of the plantar nerves
59. — Pain in skin over back and shoulder due to disease of shoulder
joint
60. — Obturator and accessory obturator
61. — Pain areas in the head
62. — Pain areas in the head
63. — Figure illustrating tlie places where induration takes place
64. — Locations of the principal headaches
65. — Locations of the principal headaches
66, — Occipital headache ' .
67. — Fron to- temporal headache .
68. — Temporal headache
69. Frontal view of Head's zones
70. — Lateral view of Head's zones
71. — ^Lateral view of Head's zones
72. — ^Posterior view of Head's zones
73. — Figure showing the modifications of pain in the lumbar
by change of position .....
74. — Pain areas in trunk and lower extremities .
75. — Pain areas in breast and abdomen
76. — Pain areas in neck, chest, clavicular region and abdomen
77. — Pain areas in the back ....
78. — ^Pain areas in spinal column
79. — Pain areas in back .....
80. — Posture assumed in earache
81, — Scheme of innervation of abdominal viscera
82. — Figure showing the anterior distribution of the ninth,
eleventh and twelfth dorsal nerves
83. — Anterior view of abdominal zones with corresponding
84. — Posterior view of abdominal zones
85. — Areas of local tenderness, when the inflammation of the appen-
dix, gall bladder, and Fallopian tube and ovary has spread
to the peritoneum and Irns produced a localized peritonitis
86. — Posture of abdominal protection present in peritonitis .
87. — Position in abdominal colic, assumed on lying . . .
88. — Pcteition in abdominal colic, assumed on sitting .
89. — Areas of referred pain as given by Head
90. — Nervous supply of the stomach .
91. — ^Location of the pain symptoms in a case of
92. — ^Pain radiation . : . .
93. — ^Location of pain in actite gastritis
tenth,
organs
XXV
PAGE
164
167
168
169
235
240
263
264
266
278
279
280
280
281
291
292
293
294
298
308
309
311
313
314
315
335
379
385
395
396
hyperchlorhydria
404
406
407
407
427
42^
435
43G
44i
LIST OF ILLUSTRATIONS
FIG PAGE
94. — ^Location of pain in gastric ulcer 443
95. — Sites of tenderness in gastric ulcer, ulcer of pylorus and ulcer
of duodenum 446
96. — Sites of tenderness in gastric ulcer, posterior view . . 446
97. — Hyperalgesic zones in cancer at cardiac end of stomach . 456
98. — ^Point of tenderness and the area of pain in a case of peri-
gastric adhesions ........ 460
99. — Anterior view of areas of referred pain in intestinal diseases 466
100. — Posterior view of areas of referred pain in intestinal diseases 466
101. — Points to which pain is referred in lesions of different parts of
intestinal tract ........ 467
102. — Pain areas in colonic colic ....... 481
103. — Pain areas in intussusception ...... 498
104 and 105. — Areas of pain in diseases of colon .... 500
106. — Irritation at external sphincter referred to skin over coccyx . 510
107. — Cutaneous and muscular distribution of eleventh and twelfth
thoracic nerves ........ 515
108. — ^Areas supplied by the posterior branches of the eleventh and
twelfth thoracic nerves ...... 520
109. — ^Areas of pain referred from the appendix .... 521
110 and 111. — Areas of cutaneous hyperalgesia in appendicitis cor-
responding to the eleventh dorsal area of Head . . 522
112. — Reflected pain in appendicitis. Triangle of cutaneous tender-
ness 523
113. — Reflected pain in appendicitis. Small area of cutaneous ten-
derness occasionally present ...... 523
114. — ^Reflected pain in appendicitis. Rounded patch of cutaneous
tenderness in lumbar region ...... 523
115. — ^Location and radiation of sympathetic reflected pain in appen-
dicitis ......... 524
116. — Location and radiation of sympathetic reflected pain . . 524
117. — Areas of hyperalgesia in the eleventh dorsal visceral s^ment
due to appendicitis of the catarrhal type . . . 525
118. — ^Areas of increased sensitiveness to pain and to touch in appen-
dicitis ......... 526
119-121. — Pain in the left side in appendicitis .... 528
122. — ^Areas of referred pain in liver diseases: Anterior view . 541
123. — ^Areas of referred pain in liver diseases: Posterior view . 541
124. — ^Areas of referred pain in liver diseases: Lateral view . . 542
125. — Relationship of nerve supply of liver to cerebrospinal and sym-
pathetic systems ........ 543
126. — Area of greatest tenderness in diseases of the gall bladder
and appendix ........ 564
127. — Method of eliciting gall-bladder tenderness .... 565
128. — ^Radiation of gall-bladder pain as given by Schmidt . 566
LIST OF ILLUSTRATIONS xxvu
FIG. PAGB
129. — ^Nerve supply to pancreas .... . . 681
130. — Distribution areas for pain due to pancreatic lesions . . 582
131. — ^Relation of pancreas to posterior abdominal wall . . 583
132. — ^Pain areas in disease of pancreas 590
133. — ^Points of pain and tenderness in diseases of the spleen . 595
134. — Points of pain and tenderness in diseases of the spleen . 595
135. — ^Method of palpating for splenic tenderness . . . 596
136.— Location of the kidney 597
137. — Areas of referred and reflected pains in diseases of the urinary
apparatus 609
138. — Nerves involved in referred pain from kidneys . . . 611
139. — Distribution of cord zones (according to Head) and of
nerves ......... 613
140. — ^Areas of reflected hyperalgesia, in tenth, eleventh and twelfth
dorsal, and first lumbar visceral segments (according to
Head) 614
141. — ^Method of palpation in eliciting tenderness in the kidneys . 615
142. — Position assumed in kidney disorders, ureteral and kidney
colic, lumbago, uterine and tubal adhesions and drag on
back, enteroptosis, especially after removal of corset . 617
143. — Area of hyperalgesia in congestion of kidney . . . 631
144. — Areas of hyperalgesia in congestion of kidney associated with
liver congestion : Anterior view ..... 634
145. — ^Areas of hyperalgesia in congestion of kidneys associated with
liver congestion: Posterior view ..... 634
146. — Area of hyperalgesia in kidney and liver congestion . . 635
147. — ^Area of hyperalgesia in nephritis ..... 636
148 and 149. — Areas of tenderness present in renal tuberculosis . 643
150. — ^Areas of distribution of anterior spinal nerves . . . 660
151. — ^Areas of distribution of posterior spinal nerves . . . 660
152. — Head zones of hyperalgesia usually associated with kidney
lesions: Anterior view ....... 661
153. — Head zones of hyperalgesia usually associated with kidney
lesions : Posterior view ....... 661
154. — ^Area of cutaneous hyperalgesia in severe renal colic in which
the stone was in the ureter 662
155. — Pressure made upon ureter in endeavor to obtain local ten-
derness 663
156. — Toumier's points of pressure in kidney and ureter lesions . 664
157. — ^Relationship existing between pain and other sensations arising
in the urinary bladder 673
158. — ^Pain areas associated with diseases of bladder . . . 674
159. — Relationship of rectal tenesmus to vesical tenesmus . . 675
160. — ^Areas of referred pains usually associated with disease of
urinary bladder ........ 676
xsviii LIST OF ILLUSTRATIONS
FiG. PACB
161. — Referred pain in disease of bladder ..... 677
162. — ^Referred pain in disease of bladder ..... 677
163. — Referred pain in disease of bladder ..... 677
164. — ^Referred pain in disease of the bladder due to involvement of
the pudic nerve ........ 679
165. — Areas of cutaneous tenderness in disease of the epididymis . 699
166. — Areas of distribution of the tenth and eleventh dorsal segments,
and the first, second and third sacral segments on the
right side ......... 701
167. — Nen'e supply of female genitalia ...... 706
168. — Area of distribution of cord segments involved in uterine,
ovarian, and tubal diseases ...... 714
169. — Points of tenderness as elicited by Donald and Lickley in
ovarian, tubal, and uterine diseases .... 720
170. — Areas of hyperalgesia in a woman two months pregnant . 736
171. — Phenomena accompanying tubal disorders .... 738
172. — Areas of referred pain in a case of labor .... 740
173. — Areas of cutaneous distribution of the thoracic segments . 761
174. — Points at which the intercostal nerves become superficial . 763
175. — Location of tenderness in various diseases of the chest and
abdomen ......... 765
176. — Location of hyperalgesic zones and the areas of pain in cardiac
and aortic lesions ....... 775
177. — An ai*ea of hyperalgesia corresponding to portions of the sec-
ond, third and fourth dorsal zones .... 776
178. — Areas of cutaneous and deeper hyperalgesia in a case of acute
dilatation of the heart, accompanied by acute distention of
the liver ......... 777
179. — Hyperalgesic area in a case in which the myocardium is prob^
ably in a state of intoxication ..... 778
180. — Areas of pain in a case of mitral and aortic regurgitation . 779
181. — Area of sensorj' disturbances in a case of angina pectoris . 785
182. — Communication between spinal accessory and vagus . . 786
183. — Emergence of the spinal accessory from under the sterno-
mastoid . . . . . . . - . . 787
184. — Conducting paths for impulses from the heart . . . 788
185. — Points of emergence of the dorsal nerves (anterior) . . 791
186. — Arms of hyperalgesia in a case of diaphragmatic pleurisy . 793
187 and 1S8. — Areas of referred pain in ])leurisy . . . .' 794
189 and 190. — Figures showing, on the left side, the areas of distri-
bution of pain in a case of diaphragmatic pleurisy with
effusion; on the right, the areas before the effusion ap-
peared . . . . . . . . * 796
191. — Some of the areas of pain and tenderness in Ciirdiac and pul-
' monary disease . . . . . . . . 801
PAIN
CHAPTER I
GENERAL CONSIDERATION OF SENSATION
To those who are interested in the study of disease, it is
scarcely necessary to emphasize the value of the correct apprecia-
tion of pain as a s\Tnptom. The importance of its interpretation
must be obvious. Almost ninety per cent, of all diseases either
begin with, or have, pain as a prominent symptom at some time
during their course. Therefore, a correct diagnosis can hardly be
made without an intensive study of the various forms of pain.
Sensation in Lower Animals. — We may, therefore, take up
with profit a consideration of sensation, of which pain, as a psycho-
logical entity, is but a part. In fact, to gain a comprehensive
idea of pain, it is necessary to begin our studies with those organ-
isms in which sensation emerges from that simple state in which
all stimuli are responded to by reflex protoplasmic movements, of
which the organism has no perception.
Thi3 movement according to Loeb would be the result of che-
motropism. All protoplasm is attracted by certain substances and
repelled by certain other substances, the attraction and repul-
sion depending upon the construction of the protoplasm and the
stress of its need or avoidance of the constituents of which the
other body is composed. Such a state we find in the ameba. In
a higher organism, as the medusa, an aggregation of cells possesses
the same threshold of irritabilitv for certain substances and thus
they respond to irritation by coordinated motion and this seems
to be due to the presence or absence of certain ions in the stimu-
1
2 GENERAL CONSIDERATION OF SENSATION
lating substance. (Na ions start or increace rhythmical contrac-
tions; Ca diminish the rate or inhibit such contractions.) Or
should the cells all not come into contact with the exciting factor,
the one coming into contact can transmit its stimulus to other
adjacent cells and in them produce a similar reaction to its own.
This propagation by contraction is better exampled in the
Ciona intestinalis, where as a means of communication a set of
cells are specially differentiated so that they can better and more
quickly carry stimuli from one structure to another. In other
words, conduction is their function. These cells arrange them-
selves into special groups, etc., and form what is termed the nerv-
ous system. But in the lowest forms of life the nervous system
is not a necessity, but only an auxiliary in the life economy of the
animal, as demonstrated by Loeb. He removed the central
nervous apparatus of the Ciona intestinalis and found that it
still responded to a mechanical stimulus of one group of muscles
by contraction of other groups, but that this response was much
slower than when the central nervous system was intact. From
this he concluded that while the central nervous system was not
absolutely necessary (in this animal) still it served a useful pur-
pose in that the stimuli were conducted more quickly and that
therefore the threshold of response was greatly lowered. In the
earthworm, which is composed of segments, each segment has its
own special nerve supply. Forward motion in this animal is due
to the alternate action of the longitudinal and the circular mus-
cles. Friedlander found that removal of its central nervous sys-
tem had no effect on the coordination of progressive motion.
This is explained by Loeb, who says that when the forward piece
is elongated and attempts to shorten itself by contraction of the
longitudinal muscles, the skin of the aboral piece is stretched and
that this stretching produces a stimulus to the longitudinal mus-
cles of the posterior piece which then contracts and causes the
animal to move forward. Thus at this stage of biologic advance-
ment, motion is not the result of sensation, but is only a reflex of
a very simple nature. In animals of a higher order the same
stimulus exists, but the stimulus of origin is in some cases far
REACTION OF ANIMALS TO PAIN 3
removed from the stimulus of eifect. The conduction from place
of origin to point of effect being through nerve paths, the motion
is still the result of a reflex, and this reflex either causes the ani-
mal to move to or draw away from the source of the stimulus
either as it is beneficial or destructive to its economy. When it
does so withdraw or when it responds to excitor stimuli by rapid
and irregular motion, are these an indication of a disagreeable
sensation or of pain ?
Reaction of Animals to Pain.— Many have assigned to the
lower organisms the same pain sensation as that possessed by man.
The reason assigned for this hypothesis is that reactions take
place to injurious stimulation, by various reflex movements, and
that these reflex movements are the motor manifestation of pain.
This interpretation is contested by Norman ("American Journal
of Physiology," Vol. Ill, p. 271, 1899), who states that in many
animals, ranging from the simple worm to the higher vertebrates,
such as fish, he has cut off segments of the body and otherwise
insulted the integrity of the structure, without, in some instances,
producing any movement at all, or, if movement occurred, with-
out producing any which was greater than that caused by ordinary
and slight stimuli. He maintains that the movement of an ani-
mal is not due to impulses caused by the sensation which we design
nate as pain. Should excessive reflex movements be produced,
they are the result of an excess of stimuli, not necessarily destruc-
tive. His experiments were varied and numerous. In one in-
stance, he cut an earthworm in two ; and while the posterior part
performed very rapid twisting and squirming movements, the
anterior half simply elongated and went on crawling, the same as
before the experiment. Is it possible that pain would be felt in
the posterior part, and that the anterior segment, in which the
main ganglia are located, would be free of pain? Norman
elaborated his experiments further. He cut in half a leech, which
was swimming in the water, and observed that both segments
continued their motion without interruption. Starfish and crabs,
as well, showed no reaction to division. He cut away the posterior
part of the abdomen of a bee, while it was engaged in sucking
1
\
4 GENERAL CONSIDERATION OF SENSATION
honey, without any interruption to its activity. He also men-
tions the fact that sharks may be cut and operated upon without
the slightest movement on their part. Experiments of this nature
tend to show that one must ascend rather high in the vertebrate
scale before true pain phenomena make their appearance. In
fact, it is only in mammals that this sensation is developed to its
highest degree. In our study of pain, therefore, we must bear in
mind that motor response to an irritant is not always an indi-
cation of pain, but is only a reaction to stimuli (not necessarily
sensory). However, before proceeding further in our considera-
tion of pain phenomena we shall study sensation and its attributes.
(General Consideration of Sensation. — Sensation itself is
the perception of an impression conveyed to the brain as the result
of the activity of some peripheral sense-organ. These sense-organs
may give rise to both subjective and objective sensations. Sub-
jective sensation is the result of activity of those forces of the
body which are concerned with its integrity and well-being. It
gives rise to hunger, satiety, nausea, thirst, physical or mental
depression, or exhilaration, joint sensation, and the like, and may
be called an organo-protective sensation. It also produces the
feeling of fatigue and exhaustion. Objective sensations primarily
depend, for their perception, upon the presence of external re-
ceptors, such as those of sight, touch, smell, hearing, taste, tem-
perature, etc. Therefore, in order to have sensation, that is, to
be capable of perceiving and interpreting stimuli, and of classi-
fying them under certain empirical divisions as belonging to one
domain or another of feeling, it is first necessary that our sense-
receptive organs be intact, the sense-conveying organs normal, the
sense-interpreting centers active and the associative memory cen-
ter (consciousness) intact. Should the latter be disturbed, as oc-
curs during certain mental diseases, anesthesia, etc., sensory stim-
uli, irrespective of their character, either will fail to be perceived,
or, if they are, will be greatly modified. Since we speak of con-
sciousness it may be well to briefly consider it. It has been de-
fined as the ability, power, faculty, or mental state of being aware
of one's own existence, thoughts, feelings, actions and sensations,
I
I
GENERAL CONSIDERATION OF SENSATION 5
whether intellectual, moral or physical (Sudduth, 472), and must
be present to take up and correlate the different stimuli reaching
the brain from the periphery.
Consciousness has been divided into two classes: (a) subjective
and (b) objective. Subjective consciousness tells us of things
which originate in the mind (we shall have occasion to use this
concept later in our study of hysteria). Objective consciousness
tells us of things perceived through the senses.
Of the senses we distinguish two varieties', the internal and
the external. The internal senses are those which are concerned
with the well-being of the organism, and the relation of the dif-
ferent parts, one to another. They include muscle sense, joint
sense, hunger sense, etc. The external senses are those which
are concerned with the interpretation of external objects, and in-
clude, generally speaking, touch, smell, sight, hearing, taste, mus-
cular and temperature sense. Each of these senses has a complete
nerve apparatus of its own, consisting of sense-receptive, sense-
conveying, and sense-perceptive organs. The sense-receptive or-
gans are the terminal filaments of the sensory nerves. The sense-
conveying organs are the axis cylinders of the sensory ganglia cells
(the nerves) and the sense-perceptive organs are the sensory cor-
tical cells.
We now have the apparatus; all that is lacking is the force.
The question now arises, what is this force, and what varieties of
stimuli produce the changes which give rise to sensation ? The two
most prominent hypotheses are that the stimulus is of a chemical
or electrical nature or is a mechanical force in the form of vibra-
tion. The chemical hypothesis is that the external stimuli produce
some chemical change in the cell, which reaction is propagated
into other adjacent cells until it reaches the perceptive center.
Engelman (377) advances the idea that the impulse which cre-
ates sensation is of an electrical nature, but does not exactly de-
fine what he means by electrical nature. By many, however, it
is held that all sensation is the appreciation of arrested motion
(vibration), this motion being the result of a mechanical, a chem-
ical or an electrical contact. It is the motion of the ether mole-
6 GENERAL CONSIDERATION 01' SENSATION
cules upon the retina which produces the "formation or decom-
position of certain substances and it is the chemical processes of
the formation and decomposition of these substances which deter-
mine light and color sensations" (Loeb, 104 C, p. 291) ; the mo-
tion of the air molecules upon the drum membrane of the ear
which "causes vibration in endings of the auditory nerve by which
new molecules dre brought into contact with each other and
sound is produced" (Loeb) ; the impact of the odoriferous parti-
cles upon the olfactory nerve terminals in the mucous membrane
of the nose which creates smell (chemical action). For taste, it is
essential that the sapid substance shall come in contact with the
taste-buds of the tongue (chemical action) ; for touch, that matter
must come in contact with the nerve terminations in the skin. Thus
we see that all sensation depends upon contact, and that contact
gives rise to motion. This motion is in the form of vibration
(molecular), and the sensation produced depends upon the sense-
organ against which the vibration impinges. Each terminal sense-
organ takes up only the vibrations produced in a particular me-
dium. For instance, in the normal state, sound is perceived only
when the air is in vibration against the cochlear apparatus ; light
depends wholly upon the vibration of the ether upon the retina ;
smell upon the impingement of minute physical particles upon
the olfactory terminals, etc. It is also of great interest to know
that the sense perception of these organs in man is limited to the
perception of vibrations which lie within certain limits. For
example, the human ear is unable to hear if the vibration is
below two per second, or greater than thirty-three thousand per
second. Thus man is unable to hear the calling of a whale, be-
cause the tone of the whale's voice vibrates only two per second ;
as he also frequently is unable to hear the humming of a swarm
of gnats, a sound which is produced by a vibration of about thirty-
five thousand per second.
Properties of Sensation. — Sensation possesses the following
properties: quality, intensity, and duration. (
(1) Quality gives us an idea as to the cause of the sensation.
For instance, the quality of the sensation of sound is entirely dif-
SENSORY PERCEPTION AND THE SENSE-ORGANS 7
ferent from that of the sense of taste, and it is this difference
which enables us to correctly determine the source of origin
(whether from a peripheral sense-organ of taste, hearing, smell,
etc.). It also enables one to distinguish variations in the same
sensation.
(2) Intensity enables us to distinguish differences in the
strength of stimuli producing the same sensation, and indicates,
also, the receptive state of the organism to the sensation. At cer-
tain times pain is much more acutely felt. This is due to the
fact that at these times the organism is weaker, being either re-
duced by exhaustion or disease, and therefore it is more acutely
affected by all irritative stimuli.
(3) Duration of a sensation depends, first, upon the inten-
sity, and second, on the rapidity of the impulse. If the impulse is
very intense, the sensation in the sense-perceiving centers persists
for some time after the stimulus has ceased. For example, if a
bright light is placed before the eyes, the sensation of light per-
sists for some time after the light stimulus has been removed ; also
if we gaze at a bright light and then close the eyes, the sensation
of light still continues for a few seconds. The rapidity of the
repetition of stimuli also influences the duration of the sensation.
If the stimulus is repeated too frequently, we find that a continu-
ous instead of an interrupted sensation is felt. This is due to the
fact that the sense perception of all stimuli persists for a short
time after the stimulus has ceased to exist. Thus, if the stimuli
follow each other at short intervals, the sensation is that of a con-
tinuous stimulation. At times, remissions in sensation occur, and
are due to fatigue of the central sense-perceiving center.
Centers for Sensory Perception and the Sense- Organs — It
has been observed by Goltz, II. Jhmk and others (Tigerstedt's
"Physiology," p. 651), that in the dog the destruction and
removal of the motor region and the cortical layers adjacent
thereto cause a variety of derangements of sensation and of mo-
tion. These cortical layers, then, must in some manner be con-
cerned with the perception of sensation. It has been found that if
the entire cortical area for the posterior extremity is removed the
8 GENERAL CONSIDERATION OF SENSATION
muscles of the opposite leg can no longer execute finely graded
movements; that for some days after the operation a complete
insensibility in this extremity exists; and that a certain blunt-
ness of sensibility becomes permanent.
With still more extensive destruction, the finer movements of
the hand and foot are permanently arrested in the monkey,
and for some time after the operation the sensitiveness of the
paws is somewhat reduced, so that the animal reacts only to very
painful stimuli. In fact, the sensitiveness of the hand and foot
becomes permanently so slight that a severe pinch produces no
reaction at all (Mott). On the other hand, Schaffer has found
that a monkey which does not react at all to a painful pinch im-
mediately notices a slight tactile stimulus applied to the para-
lyzed extremity. The monkey from which Goltz had removed
the entire motor region of the left hemisphere took no notice of
the gentle tactile stimuli applied to the right extremity.
Stronger pressure stimuli were always felt Motor sensations
were also somewhat diminished.
From this it will be observed that generally, except in the
case mentioned by Schaffer, in which pain sensation was lost
but tactile sensation was present, it will be found that, in case
of destruction of the motor area, the sensation in the skin over
the paralyzed part will also be reduced for touch, but present
for pain. This might be accounted for on three hypotheses: (1)
that the impulse which would produce pain is so intense that it
spreads over a considerable area of the cortex, and is communi-
cated to parts which are not destroyed and which still have the
power of pain perception; or (2) that, owing to the strength
and volume of the impulse, it is transmitted to the cortical area
in the opposite hemisphere, and is there perceived; (3) that
the center for pain sensation is not in the cortex, but lies proximal
to it in one of the forwarding structures of the sensory apparatus,
namely, in the optic thalamus. The first supposition gives weight
to the argument that it is the extent of the cortical reaction which
produces the relative sensations, either of touch or of pain, a small
area giving rise only to touch, a large area to pain. This possibly
Hearing
Fio. 1. — RioBT CxRBBBAi;, Hkuibphsbii Sibn rRou THB OimmiL
FiQ. 2. — Innek Subtace of Riqht Cerebkai, Hebosphebe.
figures 1 and 2 show the areas of sensory distribution according to Tiger-
stedt (p. 654), modified from Flechaig. Dots indicate senaory areas.
Areas where dots tire thickest are the re^ona where most of the sensoiy
pathways end.
10 GENERAL CONSIDERATION OF SENSATION
can be explained from the inhibitory action of the cortex, the
destruction of a small area being not sufficient to abolish the in-
hibitory impulses sent from the cortex to the optic thalamus and
their acting as controls over the sensory perceptions.
It has been found that general sensation and touch are lost
by destruction of the central and parietal convolutions, paracen-
tral lobules, and possibly the posterior part of the frontal convo-
lutions, and that, for the most part, the sensory area consists of
post central and parietal convolutions (Leszynsky, 498; May,
397, p. 793).
Many sensory fibers enter the post central convolution. Some
also enter the precentral convolution. The first and second frontal
convolutions also receive some fibers; they chiefly are, however,
sensory fibers connected with the cerebellar system.
Upon destruction of these areas, the different sensations are
differently affected, namely: (1) pain sensations suffer least,
because a wider area is required for their destruction; (2) pres-
sure and temperature sensations are somewhat reduced, but by
no means abolished; (3) power of localization is profoundly
affected; (4) motor sensations are much disturbed.
The areas for sensation are probably bilateral in their loca-
tion. Mills claims that they are also found in the limbic and
quadrate lobes. While Dana admits that this is possible, he
also holds that the motor areas are also sensory (Church and
Peterson, 506, p. 367). The sensorimotor area, in the optic
thalamus (the so-called associative memory center of Loeb), is
probably a depot for memory of sensation as it passes on its way
to higher centers, in the limbic or quadrate lobes.
According to Horsley (ibid., p. 162), the different cell areas
for motion and sensation are superimposed in strata. Most super-
ficially the tactile sense, then the muscular sense, and finally the
pure motor sense elements are found. It appears that in these
areas the granular cells are the active agents in sensory percep-
tion, since lesions in this cell layer cause disturbances of touch,
pressure, localization, muscular sensibility (sense of passive posi-
tion and of movement), and, less frequently, of pain and tem-
SENSE PERCEPTIVE ORGANS 11
perature. This disturbance occurs in the opposite side of the
body, and, when a limb is involved, the sensation is first lost in,
and is last to return to, the distal portion and outer margin (W.
Page, May, 397, p. 796).
The small pyramidal cell layer may also be concerned indi-
rectly in pain production, since these cells are atrophied in
dementia, and may, therefore, be indirectly associated with sensi-
bility; because it has been found that sensibility varies almost
directly in proportion to the mental development of the individual,
and that the pyramidal cells vary directly in proportion to the
mentality.
It has also been claimed that the cerebellum is the seat of all
pleasure and pain activities (F. Courmont, "Le Cervelet et ses
Fonctions"), and also of those connected with the emotions
(Marshall, p. 25). Modern anatomical research, however, has
shown that the cerebellum is the chief central organ for the senses
of equilibrium, muscle tonus, and orientation in space. And al-
though it is preeminently a sensory organ, the cortex being a
sensory cortex, it is not such for pain, for light touch, heat, or
cold.
Sense Perceptive Organs. — Recently the sense-organs, the
stimulation of which causes sensation, have been divided into
three classes: (1) the visceral sense-organs of the internal organs
and their derivatives, (2) the extroceptor, or somatic, sense-organs,
which receive the impressions from the outer world, and (3) the
proprioceptors, which receive impressions from the muscles, ten-
dons, etc., and report to the sensory area the exact position of the
body and the relationship of parts to each other.
The researches of Head, Holmes, and Sherrington have served
to show that the constituents of sensation are extremely complex.
So far as the visceral receptors are concerned, we know vei*y little
about them. T^re are chemical, touch, heat, and cold receptors,
and undoubtedly receptors which have to do with the forces of
gravity. Most of these receptors Head has placed within his pro-
topathic system. They belong, phylogenetically speaking, to old
systems; are almost automatic, and for the most part are passed
12 GENERAL CONSIDERATION OF SENSATION
over to the autonomic sympathetic nervous system. Their spinal
representations are present largely in the lateral processes of the
cord. Their central paths are not as yet definitely determined.
The extroceptor or somatic sense organs are divided by Head
into the epicritic and protopathic systems. The ability to dis-
tinguish light touch (cotton wool), two points of a compass (at
small intervals varying with the part), and to discriminate slight
variations in temperature, are held by Head to be specific and in-
dividual entities. Together they constitute his epicritic system.
Their spinal, medullary, thalamic, and cortical distributions have
been fairly well defined. To the protopathic system on the
other hand belong the faculties to distinguish ordinary touch, deep
pressure, extremes of heat and cold. Finally, according to Sher-
rington, there exists another system, the proprioceptive. Its re-
ceptors are found in many places in the body, chiefly in the ten-
dons, muscles and bones, and also most characteristically in the
labyrinth. Its chief sensations are those connected with the orien-
tation of the body in space; the vestibular nerve being its chief
cephalic ganglion and the cerebellum its chief central organ.
StimiilL — The stimuli necessary to produce a sensory-reaction
may be mechanical, chemical, thermal or electrical. Any of these,
when applied in normal quantity, and with normal force, produces
a normal reaction ; but when applied with excessive intensity, all
are capable of stimulating the specific pain receptors.
Interpretation of Sensation. — If we consider for a moment
the embryological development of the human body, we find that
the external organs of sensation develop pari passu with the in-
ternal organs, but that the external ones are practically without
function until the fetus is bom. During the period of intra-
uterine existence, the external senses are lying dormant; but as
soon as the fetus is bom, and feels the touch of air upon its sur-
face, it has entered upon a new life, and one vast complex of
sensations reaches it from every side. Embryologically the vesti-
bular system develops very early.
These sensations are for three purposes: (1) to provide pro-
tection for the organism; (2) to provide for its development; and
INTERPRETATION OF SENSATION 13
(3) to provide for its reproduction. We find that in general
everything which reacts unfavorably to the organism causes dis-
tasteful and disagreeable sensations. These, when of a peculiar
quality and intensity, give rise to the sensation which we term
pain. It is also found that everything which acts or aids in the
growth, development and reproduction of the organism causes
pleasure. Between the two extremes of pain and pleasure there
exists a neutral state, where, because of the weakness of sensory
stimulation or perception, a state neither of pleasure nor of pain
is produced. This we term the state of indifference. Therefore,'
we may be said to have three states of sensory mental activities,
namely, pain, indifference and pleasure.
Definition of Pain. — Pain is distinctly a mental interpre-
tation, and cannot be strictly defined. It is the interpretation of
some abnormal and generally harmful process which is occurring
in the organism. It cannot be classed as a sensation, but rather
is the result of the perception and interpretation of sensation by
the mind. Our consideration of pain will naturally lead us into
a discussion of its antithesis, pleasure, since the two are inti-
mately connected in their perception and in their interpretation.
Both are the result of mental activity.
Mental Activity. — ^According to many authors, three divi-
sions of mental activity have been assumed: intellect, or the
faculty of thought ; sensibility, or the faculty of feeling, and voli-
tion, or the faculty of voluntary action. This is manifestly a
purely artificial division. While we are primarily interested with
the second division, it is my purpose to show that it is intimately
bound up with the first (intellect). I shall also point out that the
intellect can, by the exercise of memory, recall to mind the ob-
jective sensations classified as pain, and, by making them perti-
nent to the moment, cause them to appear real, as if experienced
at the time. In other words, intellect is able to produce, without
any objective means, the sensation of pain. This class of pain-
sensation, which seems to appear without any definite causative
factor, is frequently called subjective pain.
The crudest mental impressions consist of the primary sensa-
14 GENERAL CONSIDERATION OF SENSATION
tiojTS of touch, sight, hearing, taste, smell, and temperature, which
are objective, and muscle sense, joint sense, hunger sense, etc.,
which are subjective. These, when carried to and interpreted by
the brain, result either in pleasure sensation, neutrality, or pain;
and as a result of these mental interpretations there arise certain
mental states, such as joy, sadness, pleasure, and happiness, which
in turn may give rise to mental activities, such as anger or its
converse.
Mental States. — I do not mean to say that all sensation
must definitely be interpreted either as painful or as pleasant, in-
asmuch as there are sensations which are neither painful nor
pleasant. These are referred to as neutral sensations. For in-
stance, the sight of a tree may be neither pleasant nor painful,
but the recollection of certain facts associated with that particu-
lar tree may recall, at the sight of it, certain thoughts that induce
a painful or rather unhappy emotion; and here it is well to dif-
ferentiate emotion, which is a mental state, from pleasure-sense
or from pain, which are but sensations. Ideas or thoughts may
give us pleasure, but it requires an external stimulus to arouse
the pleasant sensation that may accompany thought, such as is
found in reading, in listening to sounds which are pleasant when
grouped in the form of harmony, in hearing beautiful ideas well
expressed, or in seeing wondrous productions of blended colors
in the form of a beautiful landscape. Therefore, the use of the
word pleasure should be restricted, I think, to the mental state
following upon pleasant or agreeable sensations, which, in turn,
should be called pleasure-sensations. Thus we have the emotional
condition of pleasure and of its converse, displeasure.
Mental Resultants. — From every mental state, certain de-
rivatives arise; for instance, anger is often evolved from dis-
pleasure, while pleasure gives rise to elation. It is the affective
state which we are in that colors our perception and guides our
acts; and it is particularly fitting, in this connection, that physi-
cians should bear in mind that the fundamental cause of an ill-
behaved, crabbed disposition very often is to be found in the
elementary sensations coming from the periphery, acting as ex-
INTERPRETATION OF SENSATION 15
citors to a possibly already overwrought and abnormal nervous
system. How easy it is, on this hypothesis, to account for the
sour and surly disposition of the dyspeptic, or the forbidding as-
pect of the chronic sufferer. They are worthy of our kindest con-
sideration, for their disposition and their evil manners are often
due to causes over which they have little control.
Relation of Pain and Pleasure to Mental States. — Ac-
cording to Marshall, pleasures and pains are but differential quali-
ties of all mental states. To this I must take exception, for, to
my mind, they are but interpretations of sensations which are
perceived as arising in the periphery.
It would seem more fitting that pleasure, when applied to sense
perception, should be spoken of as pleasure-sensation. For in-
stance, a cool bath taken on a warm day gives rise to a pleasant
sensation and at the same time produces pleasure; but thoughts
of an absent one, or of some joyous past event, may give pleasure,
while at the same time we have no pleasant sensation.
Next it behooves us to ask, can both pleasure-sensation and
pain be perceived at the same time, and, if they are not perceived
and factors which ordinarily produce them are present, is their
non-perception due to the fact that they neutralize each other?
It is inconceivable that two such opposites as these could exist in
consciousness at the same time ; and it is entirely improbable that,
should such a state exist, their contra-action would produce a con-
dition of neutrality, which is the result of two active, equal and
opposing forces. For instance, the distress which comes from an
ulcerated stomach or an irritated sore cannot be neutralized by
the physical pleasure derived from epidermic sources. We experi-
ence either pleasure or pain ; there is no halfway stop where the
one counteracts the other, giving rise to a state neither of pleasure
nor of pain, but of neutrality. Yet, in some cases a transition
from pleasure to pain-sensation may occur, for it is found that
sensations which ordinarily are interpreted as pleasant may, from
frequent repetition and excessive stimulation, become painful, as
in pericementitis, in which at first a pleasant sensation is pro-
duced on lightly pressing the teeth together, but which, if the
16 GENERAL CONSIDERATION OF SENSATION
pressure is continued or increased, results in pain. Another ex-
ample is priapism, in which the distention, which at first is pleas-
ant, if continued, soon becomes painful. Gtentle friction over the
body, especially over the nape of the neck, is pleasant (to most
people) ; yet, if the friction becomes excessive, and the nerve-
endings are irritated, the pleasant sensation is transformed into
a painful one. Again, a harmonious play of colors is soothing and
pleasant to the eye ; but let the colors be exceedingly brilliant, the
pleasant sensation is transformed into a disagreeable and painful
one. Another example may be deduced from the sense of hear-
ing. We all know how pleasant to the ear are the tones of a harp ;
but change them into the shrill notes of the siren and we almost
shriek with pain, or rather let us say distress. Yet, if now we
modify the vibrations and reduce them in number, the distress
disappears; and the sound, while neither painful, nor pleasant,
may become pleasant if we place among its components some half
tones which increase the fullness and volume. These are examples
of sensations changing from pleasant to painful, and then back
again from painful to pleasant. The changes which bring this
about are the result of variations in the force and rapidity of the
impulses impinging on the nerve terminals.
Certain laws have been deduced from this transitional inter-
pretation of impulses from pleasure to pain, of which the two
following are taken from Moher ("Psychology," p. 226), who
says that:
(1) Pleasure is an accompaniment of the spontaneous and
healthy activity of our faculties, and pain is either the result of
their restraint or of their excessive exercise.
(2) Pleasure increases with increasing vigor in the opera-
tion, up to a certain normal medium degree of exertion, and pro-
gressively diminishes after that stage is passed. Farther on,
pleasure disappears altogether, and beyond this line pain takes its
place.
Whether this interpretation is correct is not yet apparent. If
the receptors for light and sound, for example, have specific pain
receptors, which have a definite threshold value and only react
INTERPRETATION OP SENSATION 17
when the intensity of the stimulus has reached a definite point,
then the older hypothesis that assumes that pleasure passes into
pain fails. By bearing in mind the analogies in skin sensibility,
it would appear that such specific receptors are probably present,
and recent studies of sensation tend to show that they are pres-
ent and are independent of others of a lower threshold value.
Should this principle hold «true for the sensory systems through-
out, epicritic and protopathic, our conceptions of pain and its re-
lation to pleasure will be markedly altered and simplified ; we then
may discard much of the metaphysical speculations regarding the
relations of pleasure and pain. These, however, will be discussed
more fully in another chapter.
CHAPTER II
THE NATUBE OP PAIN
Definition. — Various definitions of pain have been given by
diflFerent authors. Meade says that pain is an indication of inter-
ference with the power of nutrition of the organism; pleasure,
of the elevated power of nutrition of the organism. Gilman thinks
that the source of all pleasure is the renewal, on the part of the
nerves, of the activity that has already become familiar to them,
while pain has its source in the violation of nervous habitude.
Meynert and Gilman think that the effective working of the
psychic functions is the cause of pleasure, while any obstacle to
these functions is the cause of pain. Sidney E. Mezes says that
pleasure is attention without difficulty or obstruction, while pain
is attention with difficulty. This applies to mental pleasure par-
ticularly, as close attention with deep thought is pleasant, while
obstruction to this attention and thought, due to internal conflict,
distress of mind, or other causes, is painful (Bianchi, p. 346).
Bianchi further says that whenever there is internal emotion, or
exteriorization, in response to the needs of life, there is pleasure ;
when the movement is hindered or obstructed, there is pain. This
applies particularly to hunger pains.
The aspect theory, as held by C. D. Strong (473), regards
pain as the highest degree of displeasure, and holds that the pain
of a cut or of a bum can always be analyzed into a tactile or tem-
perature sensation, on the one hand, and a feeling of displeasure
on the other. Kulpe evidently was the inspiration for this idea,
for he is quoted by Strong as saying that "the characteristic fea-
ture of pain is not the sensational quality, which is never absent,
but the feeling of the disagreeable, of which pain is the highest
18
DEFINITION 19
degree.^* On tke other hand, Lehmann does not entirely lose
sight of the sensational element of pain when he says : "A feel-
ing, whether of pleasure or of pain, never occurs apart from a
sensation, however weak, and in every case where such an isolated
feeling is supposed to have been observed, the sensational element
has merely been overlooked.''
Meyers (122, p. 744) says that pain is a beneficent reaction,
through the nervous system of altered structure or disordered
function, against threatening forces. Dunglison, in 1857, defined
pain as '^a disagreeable sensation which scarcely admits of defi-
nition"— truly a very indefinite definition. Quain (471), not
more clear, said that "it is the representation in consciousness of a
change produced in a nerve center by a special mode of excita-
tion." Sudduth says that "pain is a mental state, an element of
consciousness, due to the perception of an injury to the body or
to the feelings." By this definition it is seen that Sudduth holds
that there must be a condition of mental aptitude or perception,
for otherwise it is not possible to decide as to whether or not an
injury is painful.
Schopenhauer turns to scholastic philosophy and the intro-
spective method of deduction, for he believes that "pains are
positive and pleasures are negative experiences ; pleasures are due
to the absence of pain, and the intensity of one is often in propor-
tion to the other feeling that preceded it." Another definition,
of somewhat the same character, is given by Spinoza, who says
that "pleasure is an emotion whereby the body's power of activity
is increased or helped, and pain is an emotion whereby the body's
power of activity is diminished or checked. Therefore, pleasure
in itself is good." (Spinoza's "Improvement of the Understand-
As one retreats farther into the past, it will be seen that the
physical properties of pain were not perceived, and that only
a metaphysical interpretation was taken into consideration.
The early Celts and Teutons had a mythological representation of
disease, called Hela, a ghastly form who received all who died
of disease into her residence, Niflheim. In this were the Hall
20 THE NATURE OF PAIN
Elidnir (pain), her bed, Koer (disease), and the table, Hungur
(Allen, 510). Cicero described pain as a disagreeable move-
ment in the body (35) ; Gambuus called it a disagreeable sensa-
tion which the mind would rather not experience ; while Sauvage
spoke of it as a disagreeable sensation originating from any lesion
of nerve fibers (5). Valentine (507), Wundt (508) set forth the
idea that too great an intensity of stimuli may cause pain ; Erb
held that every increase of sensory stimuli is capable of producing
pain as soon as it attains a certain intensity; Eulenburg (509)
states that it is a gradual increase in the feeling which accom-
panies every sensory process.
From the preceding, we see that there are two ideas underly-
ing the various definitions for pain ; the one physical and the other
metaphysical. The older writers dwelt upon its psychological as-
pect, namely, that it is a disagreeable sensation, while the modem
thinkers add that the disagreeable sensation is the result either
of lessened nutritive activity in the cell (receptive or perceptive),
or is the indicator of the reaction against whatever tends toward
the destruction of the organism.
Universality of Pain, — As an evidence of the universality of
pain, we find words expressing it in all languages ; and as an evi-
dence of the antiquity of its existence, we find that the word ex-
pressing it is practically the same in all languages having a com-
mon origin. In the English language, the name is probably de-
rived from the Middle English, and is a term used to convey the
idea of suffering. This, in turn, like a similar expression
found in all modern languages, was probably derived from
the Latin poena, which means a punishment, and which no doubt
originated in the Greek word irooo, also meaning a pimishment or
penalty.
Metaphysical Oonsideration of Pain. — Thus far we have been
considering pain as a sensation. This, according to Marshall
("Pleasure and Pain," p. 25), is untenable, for the following
reasons :
A sensation must have a receptive, a conducting, and a per-
ceptive organ and
METAPHYSICAL CONSIDERATION OP PAIN 21
(1) No center for pain has ever been defined or located.*
(2) No special means for pain production are present, as in
the case with other sensations.
(3) Pain is aroused by the most varied stimuli, while sensa-
tions are aroused by well-defined and limited stimuli, which must
be exerted upon a special sensory-perceptive apparatus.
(4) Sensations are themselves both painful and pleasant;
therefore, pain and pleasure are but attributes of sensation, and
cannot exist by themselves as separate sensations. For instance,
heat, cold, taste, smell, hearing, and sight may all be painfully,
as well as pleasurably, perceived.
(5) Pain may exist in the intellect without any peripheral
cause, but in this case it generally acts as a qualifying factor in
emotion, which is a mental state. It is extremely difficult to say
whether an abstract idea can or cannot be painful. Perhaps the
most we can say is that it is either agreeable or disagreeable.
(6) Another argument sometimes advanced against pain be-
ing a distinct sensation is that we can draw up in the imagination
a representation of sensation without its actual presence ; but we
cannot, by any stretch of the imagination, conjure a picture of a
pain, but must always associate it with some sensation, such as
touch, heat, cold, etc.
Newer research has shown that Marshall's position is abso-
lutely untenable, but we shall for a moment disctiss its merits and
demerits, with the hope of adding light to the whole subject With
regard to Marshall's first proposition, that no center for pain has
ever been defined or located, it may be said that while, as a rule,
physiologists and psychologists do not limit pain perception to a
particular region of the brain, they hold a rather unanimous belief
that the sensations, of which pain constitutes a part, have their
centers in the postcentral gyri. Calkins speaks more definitely.
He holds that the centers for pleasure and pain are in the frontal
lobes, and that it depends upon the state of nutrition of these •
cells whether the excitation which comes from the motor areas of
1 At the present time, however, most physiologists hold that the pain center
is located in the optic thalamus.
22 THE NATURE OF PAIN
the Rolandic fissure produces pleasure or pain. If the cells are in
a building-up process, that is, in the stage of anabolism, the result
is pleasure; if they are fatigued, the result is pain. If the state
of nutrition exactly corresponds to the state of need, the result
will be neither pleasant nor painful, but will be one of indiffer-
ence. This is a purely speculative hypothesis. What, in the
first place, produces the nutritive derangement in the frontal
lobes ? It is a fact that a patient who is fatigued, either mentally
or physically, will feel painful stimuli more acutely than one who
is not in such a state of fatigue; but it is also true that fatigue is
not necessary to the perception of pain, since even those who are
in the best of health may suffer from it.
More recently it has been held that the pain perceptive cen-
ters lie in the cortex of the postcentral convolutions, but Thomas
and Gushing (512) found, during an operation, that the post-
central convolutions could be manipulated without pain, the pa-
tient at this time being perfectly sensible and alert to all sensory
phenomena. The operation consisted of incision of the cerebral
cortex and removal of a tumor, all without pain. During the
operation, the patient had not the "least sensation of any descrip-
tion, though the operative technic required the cutting across and
the breaking up of many fibers, as well as the irritation of the
gray matter." It is interesting to observe that these areas cred-
ited by many with pain production were, when irritated, entirely
insensitive. This, however, may not entirely negate their pres-
ence because painful stimuli are effective only in the receptor
end of the neuron or in the course of the neuron, and it is likely
that the center of perception, since it possesses no adequate ap-
paratus to receive a pain stimulus, would be unable to perceive it.
Centrally projected pains, as from thalamic lesions, are of an-
other type. Here the associative memory centers lie and at the
same time it is the region where the third neuron of the sensory
nerves arises — and thence passes to the periphery. However, if
centers for pain perceptions are admitted, there must be more than
one; and at least two must be separated: (a) centers where the
sensations are received, and from whence they are projected to
METAPHYSICAL CONSIDERATION OF PAIN
23
the perceptive centers, as the thalamus, for instance (see tha-
lamic lesions), and (b) centers which record the painful impres-
sions in memory, and in the future, either upon some subjective
or peripheral irritation, project them into the perceptive centers,
where they give rise, in consciousness, to the sensation called pain.
The following diagram exemplifies the meaning of this :
HcAHirvg
"RcCEpTlON CCNTEH
Taste
TbUCH
MeN\oH3
Cemter
lD6ATAOri.
Center
Pig. 3. — Schematic Illustration, Showing How thb Various Sensa-
tions ARE Transmitted from the Periphery to the Brain Cortex
AND from thence TO THE TwO BrAIN CENTERS.
(1) The ideation center where the different perceptions are correlated into
thoughts and ideas (objective sensation), and (2) the memory center,
where the separate perceptions are stored until again they are called into
consciousness. A block at a would occlude all senary perception of
stimuli and the memory storage of the same. A block at b would occlude
the transmission of present acting sensory stimuli, so that they would not
be perceived in consciousness. However, the center still receives im-
pulses from the memory center, which it may evolve into consciousness,
where they are perceived as acting in the present (subjective sensation).
If the path to the memory center is destroyed, all recollections of prior
sensations are lost, and the ideation center, owing to lack of comi)arison
with previous sensations, would be unable to correctly interpret the ones
it then receives and may interpret cold as heat, or touch as pain, etc.
(paresthesia).
24 THE NATURE OF PAIN
Memory Centers for Pain. — ^It is further evident that all of
the energy received in the areas for painful impressions is not
transferred to the areas of perception of pain, but that some of
it is transmitted to the memory areas, from whence, in the future,
it may be transferred to the areas of mental perception of pain,
thus giving rise to pain which is subjective in consciousness, and
therefore called subjective pain.
In regard to Marshall's second point, it will be shown later
that special fibers for pain conduction do exist in the peripheral
nerves, cord, and brain (cortex), and that these fibers carry im-
pulses from pain receptors existing in special areas, and have the
single function of carrying pain impulses and no others. Head
has done more than any other observer to establish the fact that
the different sensations have separate receptive organs, which re-
ceive stimuli peculiar to them and to no others.
Marshall's third objection is harder to meet, in the present
state of knowledge, for it may be true that certain irritations,
exerted to excess on some sense organs, may produce pain. While
as yet no specific pain fibers have been discovered to be present
in the retina of the eye,^ it is not improbable that such fibers
exist; or, should they not exist, that the reaction which excess of
stimulus produces in the receptive optic cells in the brain causes
fatigue of those cells and that this is transmitted to the fibers of
adjacent cells, in which a reaction interpreted as painful is pro-
duced. That such a hypothesis is not entirely without basis, may
be seen from the assertion that ''there are special pain nerves run-
*In this respect, Poster ("Physiology," 5th edn., Part IV, pp. 281,
282) agrees with Goldscheider (473, "Ueber den Schmerz," p. 8), and in
speaking of the pain from stimulation of the retina says: "We have no evi-
dence that simple stimulation of the retina, however excessive, will give rise
to pain, meaning, by pain, tha kind of sensation we feel when the skin is cut
or burnt. We have no evidence that an auditory, or an olfactory, or a
gustatory sensation can, through mere intensity, become converted into a sen-
sation of pain. We may assume that the pain which we feel when the finger
is cut is a wholly different thing from the pain which is given to the most
delicately musical ear by even the most horrible discord." These considera-
tions suggest to Foster that cutaneous pain is not simply an exaggeration of
tactile and temperature sensations, but a separate sensation developed in a
different way.
CAUSATIVE FACTORS IN THE PRODUCTION OF PAIN 25
ning parallel to and in the same trunk with the sensory nerves,
having a special sense of perception in the brain, and operating
only under the influence of intense irritation." Matzinger's (328,
p. 138) statement, that "it is unlikely, and contrary to natural
laws, that there should be an elaborate mechanism of highly or-
ganized tissue which is destined never to come into use in some
individuals, or at least only in a very limited way," will have to
undergo modification, for it has been proven that there are such
tissues in the form of special nerves (pain, etc.) for certain types
of sensation (Edinger, Head, Strumpell, etc.).
As to the fourth objection, that pain must be an attribute of
sensation because each sensation may be both painful and pleas-
ant, it is rather difficult to formulate a proper answer. Were it
not for its clear separation, in the skin, from all other
sensations, one would be forced almost naturally to the con-
clusion that pain really is only a qualifying factor in sensation.
Yet it is possible that the pain sense which one finds in the
periphery is a highly differentiated touch-sense; that pain is
present in other organs from a too great stimulation of their
sensory end organs ; and that pain is present in their centers from
overactivity.
The fifth and sixth arguments are not supported, in view of
the general hypothesis that there are specific pain sensations.
Oansatiye Factors in the Production of Pain. — The produc-
tion of pain depends upon the presence of a proper stimulus and
the integrity of the receptive, the conveying, and the interpreting
apparatus. The stimuli may be divided into those due to me-
chanical changes in pressure, to toxemia, to chemical changes, and
to electric or thermic reactions. The stimuli due to mechanical
changes are exerted either upon the terminal filaments of the
nerve, or on some of the neurons extending from the brain to the
periphery. This mechanical irritation may be due to pressure
from an inflam^matory exudate (see Inflammatory Pain), to pres-
sure by new growths, or to prolonged, strong contraction of a hol-
low organ (Mackenzie). Hemorrhage in the body tissues will
almost invariably cause either deep pressure pain, or epicritic pain
26 THE NATURE OF PAIN
(Head), unless the rupture is an areolar tissue, when, owing to the
looseness of the tissues, pain is not present until the local dis-
tention becomes excessive, or until pressure is made on adjacent
structures. In regions where the tissues are denser and more com-
pact, pain is very severe, even from the beginning of the hemor-
rhage, as in hemorrhagic pancreatitis. In cavities, also, hemor-
rhage is often provocative of the most intense distress. This is
particularly true of the peritoneal cavity. The cause of this ex-
cessive pain is rather hard to determine, in view of the fact that
in this location the resistance to the hemorrhage is almost nega-
tive. It may be that blood possesses some substances which are
particularly irritating to the peritoneum, and that this irritation
is transmitted to the body wall as pain. Even as hemorrhage
causes pain, so also in some cases of congestion, it eases the pain,
as in swollen turbinates, premenstrual congestion of the
uterus, etc.
The extent of the surface stimulated is important in the pro-
duction of certain kinds of pain. If the area of stimulated sur-
face is too small, no pain is felt. It seems that, in certain areas,
only an aggregate of stimuli can produce pain (Tigerstedt, 483,
p. 467).
The stimulus which causes pain may not be of any greater
magnitude than that which is daily experienced by the organism ;
yet, from frequent repetition, a condition is reached in which,
before recovery from one stimulus, the cell receives another, and
so on. Each stimulus leaves a little of its irritative quality,
until the tension from the accumulation of these irritative
remnants becomes too great, and release of nervous energy
takes place in the cell, the pain threshold is reached and the
sensation of pain results. After once having overcome
the threshold, secondary discharges take place on a slighter provo-
cation.
Sudden alterations of blood pressure create pain, as is seen
when a tourniquet, which has been on a limb for several hours,
is removed.
Toxemia is a cause of pain, particularly in severe anemia of
CAUSATIVE FACTORS IN THE PRODUCTION OF PAIN 27
a part, such as is found in emboli of the arteries.* James re-
ported a ease of complete obstruction in circulation of the aorta,
in which, after the ligation, the patient had the most severe pain
(D. W. Mitchell, 263, p. 52). The causes of this, ^^Brown-
Sequard thought to be an accumulation of COj in the tissues.
Vulpian regarded it as being due to the lack of oxygen, while W.
Mitchell thought that it might be due to sudden annihilation of
nutrition, osmosis and conditions of pressure."
Pain may also be due to the accumulation of toxic products
ncl«boiism '^AMiiniU^on* \. Twit Pr^jwcb
Abnormal — \^ Complett X V,-Mp»Ko^«
Abnormal
^ D<»lrucTion ^ »u-..*«-uu
Non-cofriplcU
elimination
T>ii» mas account for ctrlam of the p«in» which v»« find in hijfttcrkal con4iiioM
Fig. 4. — Diagram showing How Changbs in the Cell Metabolism May
Produce Changes in the Irritability op the Cell and a Depar-
ture IN ITS Reaction to External Stimuu, Either Making it
More or Less Sensitive to Peripheral Irritation.
in a part, as exemplified in the fatigue pains of muscle, wherein
the products are the result of metabolic waste; or else the toxin
may be derived from exogenous sources, as from the alimentary
tract or from an outside toxic agent, alcohol, etc. It may also be
the result of toxins from bacterial organisms. The toxin acts
upon the receptor cells, or on the sensory nerve substance to
which the irritant may be transferred.
As to chemical causative factors, there may be many, princi-
pally in bums, severe ischemias, etc. From the nature of the
condition, toxemias might also be classed among chemical agents,
inasmuch as in toxemia the poison or irritant is of a chemical
nature.
* Very eevere pain is felt in infarct kidney (Halperin). Pain is also
extremely severe in arteriosclerotic thrombosis (Buerger and Geis). Intense
pain is also felt in arteriosclerotic thrombosis of the lower limb, a disease
which is especially prevalent among the Russian Jews. The pain is so agon-
izing and constant that the poor sufferers will consent even to the extreme
remedial measure of amputation rather than bear longer suffering.
28 THE NATURE OF PAIN
Decreased alkalinity of the blood, as suggested by Sir Lauder
Brunton,^ may also produce pain. This may explain the cause
of the generalized aching pain that is present in infectious
diseases.
Photochemical changes in the rods and cones of the retina of
the eye are produced by light. When the light is too severe, these
changes are excessive, and the stimulation of the optic nerve
is stopped or modified, so that vision is obscured and pain results
(Matzinger, 328, p. 139).
In some cases trophic changes in the skin may also produce
pain. This may be peripheral, due to irritation of the sensory
receptors (protopathic), or central, due to changes in the sensory
cell distribution in the cord.
Electrical reactions cause pain, as may be proven by the use
of the painful, interrupted electrical current (Head, 519). This
is one way of testing sensitiveness to pain (see Intensity of Pain).
Heat and cold are frequent causes of pain production, the
reason evidently being some chemical change in the region of the
sensory receptors. This, however, will be more fully considered
in the section devoted to the relation of pain to temperature.
Freezing of a nerve will cause such an irritability of the nerve,
below the point frozen, that the least pressure upon it causes pain
in its distributive area (Weir Mitchell, 263, p. 18).
Apparatns for Receiving and Oondncting Pain. — The various
forms of receptive apparatus are not, as yet, well defined. Special
terminal filaments are present for certain forms of stimuli, but
their distribution is little known. From the universal presence of
pain, it would seem that the sense-receptive organs for pain are
*Sir Lauder Brunton (516) states that he became infected with the
staphylococcus pyogenes aureus, and that numerous boils developed which had
a stinging, burning pain, generally worse about three or four hours after
eating — a time when digestion would be most active, the absorption of the
acid-formed contents of the stomach greatest, and the alkalinity of the blood,
from their absorption, least. From this he concluded that the pain was due
to a decreased alkalinity; and, proceeding on this assumption, he took fairly
large doses of alkalies, with a resulting diminution of pain. He then tried
the effect of the bicarbonates, applied directly to the boils, with a consequent
diminution of pain. In toothache, also, the application of bicarbonate of soda
to the cavity of the tooth has a beneficial effect.
APPARATUS FOR RECEIVING AND CONDUCTING PAIN 29
widely diffused. These receptors are capable of receiving pain
stimuli of various kinds, touch, deep pressure, heat, cold. Their
action may be abrogated by excessive cold, cocain, vibration, elec-
tricity, etc. These terminal filaments in the skin have been
called noci-ceptors (nocuous ceptors) by Sherrington (522). He
classifies as receptors all organs in the skin and mucous mem-
branes which have developed by a long series of evolutionary
changes, and which have the ability to distinguish stimuli arising
from different sources, such as temperature, pressure, or touch.
Those portions of the body most subject to injury should, there-
fore, have a more numerous supply of noci-ceptors than those
portions which are not so exposed. If this is true, we should
find the fingers, which are exposed to injury, better supplied with
these ceptors than the brain, which, because of its inclosure in the
skull, is prevented from injury. Such is the case; for in the
brain, the cortex is found to be relatively insensitive to many
stimuli which ordinarily cause pain sensations (Crile and Sher-
rington).
The pain-conducting apparatus consists of the nerve fibers
leading from the periphery to the sense-perceptive centers. Any
irritation to the axis cylinders of the sensory nerves in this path-
way will be transmitted to the periphery and be felt as pain. Irri-
tation may be in the form of inflammation of the nerve (neuritis),
of the ganglion (herpes), of the post roots (tabes) within the cord
(transverse myelitis), or in the thalamus. Various agents may
act upon the axis cylinder processes (nerves), such as tetanus
toxins, arsenic, alcohol, etc. The headaches of toxic origin, fa-
miliar to all, are usually due to stimuli, acting upon the dural
distribution of the trigeminus.
Pressure on the conducting fibers causes, as a rule, a severe
pain reaction. Yet, it is possible for pressure, when equal and
constant, to be very severe without producing any pain reaction.
It seems most potent for pain production when it varies in in-
tensity; the more variable the pressure the greater the severity
of the pain. Such a pressure we see exerted by new growths, as
tumors or cysts, or by inflammatory changes, as in meningitis.
30 THE NATURE OF PAIN
The sense-perceptive centers in the brain may, from oft-
repeated stimulation, become hypersensitive. It is often the ease
that, after the original cause has ceased, the hypersensibility re-
mains, so that stimuli of ordinary intensity, when they reach these
centers, may be interpreted as painful. Whether this is due
to a hyperactivity of cortical cells, or to a lowering of the thresh-
old values in the receptors, has not as yet been definitely estab-
lished. The so-called occupation neurosis, in which pain is pres-
ent when the patient attempts to perform some accustomed task of
manual dexterity, may serve as an example of this. Here the
pain, as well as the spasm which accompanies it, may be said to
represent a rebellion on the part of the overused cortical centers.
This rebellion does not seem to be so much upon the part of iso-
lated centers as due to fatigue in the association of certain stimuli,
which are carried to the affected area from other centers, and which
have the power of producing certain coordinate actions. The same
centers may be called into play to make other movements of the
same muscles without producing pain. Thus, a person who is un-
able to write without pain may be able to sew without any trouble
(Walton, 517, p. 261). It should not be overlooked, however,
that such acts are only apparently similar. In reality they are
quite diverse.
We have spoken of the lowering of the threshold to pain. In
neurasthenia it would appear that, for reasons as yet unknown,
such a reduction takes place so that the body is more capable of
reacting to stimuli (including pain) than when it is in a normal
state.
Shock, anxiety, apprehension, have an effect in lowering the
pain thresholds for various stimuli. Just what the molecular
factors may be underlying this change no one knows. Clouston's
phrase, "disturbance of molecular equilibrium," is as good as any
other, whatever it may mean.
Pain and Mental States. — Emotions, like anger and fear,
sometimes give rise to severe nervous attacks which are typified
by headaches; and in this relation it is an odd coincidence that
only the unpleasant emotions give rise to disagreeable sensations,
EELATION OF PAIN TO OTHER SENSATIONS 31
for surely no olie has ever heard of a pain (headache) being pro-
duced by joy or happiness. Hypnosis may also have the power of
bringing into the patient's consciousness an intense perception of
pain. Some blindfolded persons will experience what they think
to be pain, if, prior to running a cold instrument across the skin,
they are told they were going to be cut. In the dream state, also,
vivid sensations of pain may occur. One of my patients, a non-
pregnant woman, has been aroused frequently by apparent labor
pains, of which she had not the slightest perception upon awak-
ing. The modus operandi of this perception was described when,
in speaking of consciousness, the method of transference of im-
pulses from the receptive center to the perceptive center was il-
lustrated. There has been some controversy as to whether it is
possible to imagine pain. The answer seems to be simple; for
how else would it be possible for the hysteric to draw from mem-
ory's store, and present to vivid view, sensations which are as
realistic as though they were actually taking place ? And is not
imagination, of which the hysteric unconsciously makes abundant
use, but the power of transferring sensation from the warehouse
of past experiences to the mart of present change ?
Belation of Pain to Other Sensations. — ^We now approach the
most difficult part of our subject, namely the consideration of
pain in its relationship to other sensations. Pain is so inextricably
mixed up with other sensations that at first it would seem almost
impossible to unravel the skein. Yet, the riddle is not so difficult
to solve if we only recognize one factor, and always consider it in
our study of this subject. This factor is evolution. If we reflect
that our nervous system is the development of nameless thousands
of ages ; that from a most simple form it has developed to a most
complex system; and that during this development its structures
and functions have constantly been modified by and adjusted to
the changes in environment, it is easy to understand how, by these
constant changes and innumerable modifications, it has reached its
present complex and intricate form. The nervous system at first
(in our progenitors) was very crude, being little more than that
which was essential for the carrying on of the two great functions
32 THE NATURE OF PAIN
of the organism, namely, growth and reproduction. As the or-
ganism developed, it became more and more susceptible to external
influences, and more and more cognizant of its environment and
the physical state of its being. At the same time, the means of
defense were improving, so that the organism was better able to
protect itself from injury and the external dangers of which it
was just becoming aware. Probably it was at this time that the
various external senses were called into activity. An analogue of
this is seen in the human embryo, in which it is held (Mackenzie,
69) that the cerebrospinal system is a later development than the
sympathetic, the sympathetic being concerned with the essential*
processes of life, while the cerebrospinal is concerned only in
communicating to consciousness the relationship to surrounding
objects, the relationship of different portions of the body to each
other, and the intensity and variety of stimuli which are received
from different sources. In other words, cognition is dependent
upon this exterior system. So, it is held that the development of
the cerebrospinal system is for the purpose of defense against
injury, and that the principal means of communicating the exist-
ence of such an injury to consciousness is by a series of disagree-
able stimulations which, by long association, have been grouped
into various groups and are called pain.
Yet, pain to touch is not the only sensation which, because of
ancestral necessities, has been developed from the primal sensi-
bilities of a simple organization. In the same class are tempera-
ture, light touch, and deep sensibility. Light touch, as it was prob-
ably the last to develop, is the most vulnerable ; so that, in lesions
of the peripheral nerves it generally is found to be one of the first
sensations to disappear. Touch and pain have been regarded by
some as variations of the same sensation. From the following
facts, however, these two sensations cannot be considered the same :
(1) The distribution areas of touch and pain are not identi-
cal. Were they but modifications of the same sensation, their
localizations would be exactly similar, and both would be present
at the same time. The exact opposite of this was present in a
case reported by Head and Thompson (206, p. 553), where, in a
RELATION OF PAIN TO OTHER SENSATIONS 33
lesion of the spinal cord, an area on the limb was insensitive to
pain, while it was sensitive to light touch and pressure.^
(2) Another illustration in point is given by Biemacki
(Witmer, 527), who states that pain and temperature sense can be
made to disappear by pressure on the ulnar nerve, while the other
sensations, as touch, localization, and muscular sense, remain.
This would argue either for special nerves of pain, or else for the
reduction in the conductivity of individual fibers ; so that if pain,
in the case of touch, is due to increased molecular vibration, the
fibers would not be able to carry the stimulus. Yet, such a suppo-
sition is hardly tenable, from the fact that disease of the cotd,
and of a certain area of it, will produce a loss of pain conduction,
but not of light touch; and, vice versa, lesions in the cord may
produce a disturbance of light touch perception and not of pain
perception.
In a case reported by Gowers a unilateral hemorrhage into the
lateral columns and gray substance of the upper cervical cord pro-
duced analgesia and thermoanesthesia. In this case there was a
complete loss of pain on the opposite side of the body, without
disturbance of light touch.
From the above it would seem that the pain and temperature
senses are more closely related than are pain and touch. In
other conditions the senses of touch and pain appear intimately
related, as is shown, when by gradually increasing the pres-
sure on a part, the sensation produced changes from that of touch
to actual pain. Witmer found that a maximal pressure of
1.0 gm. or 2.0 gm. will give the sensation of touch greater in-
tensity. The same stimulus, ranging from 20.0 gm. to 15.0 kgm.,
produces a sensation of pressure, while at times a pressure of 5.0
kgm. to 15.0 kgm. will give rise both to pressure and pain sensa-
tions. A maximal stimulus above 15.0 kgm. gives rise to pain
only. This Head has shown is due to specific receptors of deep
* This is frequently found in dissociation paralysis, which is conspicuously
present in syringomyelia. It is also founds less marked, but much more fre-
quently than is usually assumed, in neurotic processes, in tabes and in
paralysis, as well as in alcoholic and hysterical persons. (Osier's ** Modem
Clinical Medicine," ** Diseases of the Nervous System," p. 194).
34 THE NATURE OF PAIN
sensibility whose threshold values are approximately stated by
Witmer.
In tabetics, also, it is very common for some dissociation be-
tween pain and touch to be present, as frequently the patient will
feel the touch of a pin point much sooner (one or two seconds)
than the pain caused by its penetration into the skin. The term
delayed pain sensation is given to this state.
A dissociation between pain and touch sensations may also be
present under the action of cocain, chloroform, tabes dorsalis, hys-
teria, hypnotism, etc. During operations, when anesthesia is not
complete, it is rather common for the patient to complain that he
feels the touch of the knife, but no pain. Should pain be present
and touch be absent, the patient will be unable to localize the pain ;
and, inversely, it is found that the more acute the tactile sense of
a part is, the more accurate is the localization of pain in that
part (Hall, p. 442).
Of the sensations, pain and temperature seem to be the ones
most closely connected — at least, this holds true in regard to
the cord, for lesions here more frequently produce a dissociation
between the other sensations than between pain and proto-
pathic temperature. That they represent degrees of the same
sensation cannot be held, because, in the first place, the tempera-
ture sensation may remain when all the others are absent (Head
and Rivers, Ref. 86). In such cases, the patient does not respond
to painful tactile stimuli, but to painful heat or cold stimuli.
This would apparently show a diflFerence either in the origin of or
in the conduction of these two sets of stimuli. Yet, pain can be
produced by a temperature of 36.3° C. to 52.6° C, and cold
pain by a temperature of + 2.8° C. to — 11.4° C. (Dana,
529), when the tactile sensibility and the cutaneous pain sensa-
tion are lost.^ This diflFerentiation of sensation can occur only
'According to Weber, "the pain produced by heat and cold is very dif-
ferent from the sensation of heat or that of cold. If the pain is not extreme
we feel at the same time the heat or cold which causes it, and can then dis-
tinguish pain due to heat from pain due to cold. But if it is extreme, the
sensation is the same, whether caused by heat or cold*' (Strong, 473). The
pain sensation is located deeper in the skin than the terminal filaments which
transmit cold, because, ''on contact of a cylinder, slightly heated, with the
CONVEYING CHANNELS FOR SENSATIONS 35
when the superficial nerve is diseased, and deep sensibility
remains ; for the part of the nerve conveying deep sensibility runs
with the muscular branch of the superficial nerves, and so may
escape injury in case of destruction of the cutaneous sensory
branch. The sensibility to temperature changes is not equally
distributed, it being greater in some places than in others. That
heat and cold sensations have separate receptors can be deduced
from the fact that one may be present in the absence of the other.
Rivers and Head (86) report a case where the sensation to cold
was independent of any other sensation. It has been known for
some time that heat and cold sensations have special areas on the
skin where they alone, of all the sensations, are present (Gold-
scheider). Thus it will be seen that, in the course of development,
certain nerve elements, becoming more highly specialized, liave
arrogated to themselves special functions, one of which is the
power of being stimulated by hot and cold objects. These recep-
tors, devised for temperature, are insensitive to electrical and
mechanical stimuli (Rivers and Head, 86, p. 385). It has also
been found that stimulation of temperature points or spots by a
needle will not produce pain (Tigerstedt, 483). Excessive stimu-
lation by heat or cold may produce only the sensation of pain.
While it is probable that the correlated senses are present, they
are not felt because of the overwhelming of the consciousness by
the intensity of pain sensation. Hyperalgesia to temperature
may be present without hyperalgesia to touch (Stern, "Archiv fur
Psychiatric," 1886) ; and it has also been noted that hyperal-
i^esia for heat mav not be as marked as it is for cold.
Conveying Channels for Sensations. — It is apparent that while
skin, on which a blister had been applied and the epidermis removed^ a painful
stimulus without a trace of heat sensation was felt" (Mettler, 505).
A case in point is reported by Barker, wherein, because of pressure of a
cervical rib, certain conditions occurred in the area of distribution of the
nervi cutanei brachii et antebrachii mediales of the left arm. He found that
in some areas careful testing showed that pricks with a fine needle gave onlj
pain, without calling forth previous touch or pressure symptoms. Ice at first
gave no sensation, then pain. Heat gave rise only to heat pain, without pre-
vious heat sensation. A stimulus of 47** C. (116.6** F.) and upward quickly
caused pain, but no sensation of warmth. Barker claims that the pain was
due to. stimulation of pain organs. (Witmer, 527.)
^
36 THE NATURE OF PAIN
the sensations of touch, temperature, pain, and deep pressure pain
are closely related, they are separate entities, and that each is
carried by its own specially differentiated and functionating
nerves.^ We have already referred to these, bilt will discuss
them again more at length.
^ There has always been considerable discussion among physiologists as
to the presence of pain nerves and pain tracts. Advocating the existence of
pain nerves are Strong (533), Krehl (534), Von Frey, Piersol (537), Nichols,
Bianchi (* 'Psychiatry,'' p. 358), Funke, Head, Goldscheider, etc. Opposing
the idea are Hall, Marshall, Mantegazza (536), Dana, BrownS^quard, Mun-
sterberg, James, Ziehen and Weir Mitchell (263, p. 40), who says:
"Do you suppose that there always exist in these organs pain nerves, and
that only once, perhaps, in a lifetime, these filaments are to be roused into activ-
ity? " He further says: -**As regards the skin, how shall we deal with the like
difficulty if we choose to believe that everywhere are peculiar nerve fibers de-
voted only to transmitting painful sensations f So he concludes that pain is
not a "distinct sense, with afferent tracks peculiar to itself," but that it is
"the central expression of a certain grade of irritation in any centripetal
nerve." He goes on to say (p. 48) that if a nerve is cut, and "the nerve ends,
having been allowed to cicatrize without union, should be constantly irritated
by imprisonment in the hard tissue of stumps or scars, or by a neuritis, a great
variety of peculiar sensations are felt, such as the feeling of being tickled, of
motion in the lost or disconnected part, heat, cold, etc. These facts seem to
prove that some peculiar peripheral arrangement for the production of touch,
sense of movement, and the like, is without firm physiological foundation."
The last example is hardly to the point; yet, at the time of writing, it
was well taken. To-day it is recognized that, upon irritation of a nerve, the
pain is referred to the peripheral distribution of that nerve because the brain
cells have learned to interpret such a stimulus as coming from a particular
area, and will so continue to interpret it when the direct communication with
that area is interrupted; so that irritation applied in the course of a nerve
is always felt as though it were coming from the peripheral distribution.
One of the strongest advocates of special nerves of pain is von Frey, who
gives the following reasons for his belief:
(1) "By observing certain precautions, mechanical stimulation of the
skin with a bristle produces a pure sensation of pain, without any prelimi-
nary or accompanying sensation of pressure.
(2) "If a bristle be placed over a pressure point, the sensation appears
immediately, but at once fades away again, and usually becomes unnoticeable
after a short time. Over the pain point, the effect appears later, gradually
increases in strength, and decreases again after reaching a maximum.
(3) "When the head of a pin is pressed for a moment into the skin there
follows very often, after the sensation of pressure, and separated from it by
an appreciable interval, the sensation of pain."
Von Frey claims that on the back of the hand, over the metacarpus of
the ring finger, sixteen pain points can be demonstrated as against two
pressure points. The nerve endings which convey pain are, he t)elieves, prob-
ably the free intraepithelia nerve endings (Tigerstedt's "Physiology," p. 467).
CONVEYING CHANNELS FOR SENSATIONS 37
The channels for conveying sensibility are divided into super-
ficial and deep sets (Head and Thompson, 206). The superficial
set is again divided into two others, the protopathic ^ and the epir
critic. These differ from each other principally in their power of
conveying degrees of stimuli, the epicritic being finer, and capable
of conveying slighter degrees of stimuli. It is probably a later
evolutionary development than the other. Pitt (530) states that
it is developed after birth. According to Head, Rivers, and
Sherren (85), Head and Sherren (86), and Head and Thompson
(206), the systems for conveying sensations, with the stimuli
which they carry, are as follows:
I II in
System of System of System of
Deep Sensibility Pbotopathic Epicritic
Sensibility Sensibility
Deep pressure, which, Painful cutaneous Light touch.
when excessive, is stimulations. Character of touch.
interpreted as pain. Extremes of heat and Xumber of points of
Localization of pres- cold (below 20° C. pressure.
sure. and above 45° C). Distance points are
Alterations in the Visceral sensation. apart.
positions of the Painful sensation Character of surface
joints, muscles and from a prick. touched.
tendons. Electrical stimula- Slight differences in
tion. temperature.
Wiindt (Strong, 437) assumes that in the peripheral nerves the paths of
pain impulses are the same as those of touch, heat and cold impulses. When
tactile or temperature impulses reach the cord they find two paths open: a
primary path, leading through the white matter, and a secondary path, or
paths, leading through the gray matter. Impulses of moderate intensity take
the primary path, and this path can accommodate only moderate impulses.
When excessive impulses come, they overflow into the secondary paths and
pass upward through the gray matter. Funke and Goldscheider (**t)ber den
Schmerz," p. 19) agree with the assumption that each nerve carries two sets
of impulses, one giving rise to the ordinary correlated sensations, and the other
producing pain.
The very full discussions of Head and Holmes (Lancet, January, 1912)
give the latest summary of these studies.
1 (Goldscheider (62b) holds that the protopathic system does not exist, and
that the so-called protopathic sensibility is but an expression of the lessened
functional power of the nerve apparatus.
38 THE NATURE OF PAIN
According to Head and Rivers, the fibers conveying deep sensi-
bility accompany the muscular branches of the nerves, and are
distributed, in many cases, to the deeper tissues and the tendons
of the muscles. This is in accordance with the anatomical find-
ings of Sherrington (205, pp. 255-256), who says that "macro-
scopic nerve trunks are not purely motor, but are sensorimotor
or purely sensory. Such nerves as the phrenic, hypoglossal, re-
current laryngeal, and posterior interosseous contain an abundance
of fibers from sensory ganglia." In muscles, the special end
organ for root ganglia fibers is called a muscle spindle (Kuhne).
The nerve fibers conveying these different sensibilities do not
all converge into the same nerve or roots, although the fibers con-
veying the same sensation from the same part of the skin do so, as
a rule. For instance, the protopathic fibers from the same area
converge and are all found in the same posterior roots. As a con-
sequence, in root injury (diagnostic point for root injury) they
do not overlap, while the epicritic fibers do, being conveyed, prob-
ably, by several roots and first being merged in the cord.
^% Deep, eplcritlo and pro>
topatlilo seoflatlon.
Epiorltlc Ep\orltlc and
senatbUlty protopathic sensl-
FiG. 5. — ^Areas of Epicritic and Protopathic Sbnsibiuty.
In the accompanying drawing is seen the effect of injury of
the sacral plexus below the point where it is joined by the second
sacral nerve. The third sacral nerve had been destroyed, and the
nerves were bound up in a dense mass of fibrous tissue (Head
and Thompson, p. 552). This illustrates the effect of injury to
the peripheral nervous system before the fibers have been joined
into separate conduction paths in the cord. These conduction
paths for pain, muscle sensibility, touch, and pressure are separate
and distinct. This is illustrated in Fig. 6, taken from Head and
COKVEYING CHANNELS FOE SENSATIONS 39 '
Thompson, which shows the effect of injury to the pain-condue-
tion paths in the oord.
The painful impulses from the ekin enter the cord by way of
the protopathic system. They probably become combined at once>
Fio. 6. — Effict of Injury to
THE PaIN-CONDDCTION PaTHB
IN THX Cord.
In the shaded area the parts
were insenffltive to all painful
stimuli, while at the same time
they were sensitive to light
touch and pressure. (From
Head and Thompeon, 206.)
Fio. 7. — Unilateral Coicplete Lesion
ON One Side of the Coro Produc-
iNO A Narbow Band of Anesthesia
ON the Same Side at the Level of
THE Lesion and a Broader Zone of
Anesthesia on the Opposite Side
Slightly Below the Level of the
Lesion. (From Edinger, Nerviisen Zen-
tralorgane,6 Auflage, p. 377, Fig. 263.)
and enter the intramedullary system at the level of their entrance.
The fibers from the <leep system <lo not enter by the same posterior
roots as those conveying painful cutaneous stimuli. Thus, more
than one segment of the cord is required before all the painful
impulses from any one part of the body can be gathered together
and recombined. After being recombincd, they pass across the
commissure to the opposite side, where thoy ascend in the tractus
spinothalamicus et tectalis. The decussation takes place in the
course of four or five spinal segments (Piltz, 407). According
to Camp, it may take six to eight. This peculiarity of structure
aecounte for the irregular distribution of pain sensation in uni-
40
THE NATURE OF PAIN
lateral lesions of the spinal cord. If the lesion is not extensive
enough to involve all the fibers coming from a part, there may
be a very indefinite loss of sensation ; but if the lesion is extensive,
there is a definite loss of sensation in an area above and an in-
definite loss below the lesion, while on the opposite side of the
body the sensations are entirely abolished below the level of
the lesion. Fig. 7, from Edinger, shows nicely the sensory results
following a unilateral lesion of the cord.
In the accompanying drawing an effort is made to illustrate
the course of the sensory fibers. The fibers for all the sensations
enter the posterior root separately, and pass from thence to the
cord. In the ganglion, these fibers come into relationship with
the ganglion cells, with which they are connected, some of the
^ AnteritM* cr motor root.
- - -Postflrtor gmnsUon oeU.
Fig. 8. — Cross Section of the Spinal Cord.
This represents on the left side the views of Dogiel and Snuf on the course
of the sensory fibers in the posterior root; while on the right side is illus*
trated the view of Donaldson in regard to the division of the sensory
neuron.
ganglion cells being connected with more than one afferent fiber
(Head and Thompson, 306). It is in these ganglion cells that
the afferent fibers from the viscera have their origin. According
to Warrington and Griffith (414), not more than two per cent, of
all the cells in the spinal ganglion are connected with the viscera.
This accords with Langley's statement that the total number of
CONVEYING CHANNELS FOR SENSATIONS 41
sensory fibers distributed to the viscera about equals the number
of sensory fibers present in a posterior root. Dogiel and Onuf
found the axis-cylinder processes of certain cells of sympathetic
ganglia terminating around cells of a spinal type.
Ludlum suggests that the visceral nerves may give off col-
laterals in the spinal ganglia, and that tBese, coming in contact
with a spinal neuron, may transmit the stimulus to it This
stimulus would then be perceived as coming from the peripheral
distribution of the neuron, in the distribution area of which the
pain would be perceived. On the other hand, Donaldson be-
lieves that the peripheral branch of a spinal ganglion nerve splits,
and that one of the branches is carried to the somatic distribution,
while the other, through the ramus communicans, is distributed
to the viscera. In this case, any irritation of the viscera would
so alter the ganglion cell that, if the irritation were strong
enough, it might give rise to pain; or if it were not severe
enough to cause pain, it might produce such an alteration in
the cell that a state of hypersensibility would ensue, and the
slight irritation in its peripheral distribution would then be per-
ceived as pain.
After the entrance of the sensory fibers into the cord, they
are joined into well-defined bundles, all the fibers of a single
bundle having the same function. The fibers entering the poste-
rior comua may be defined as follows (May, 397, p. 759) :
(1) Fibers which enter the post-columns, and then divide
into ascending and descending branches from each of
these collaterals, pass at various levels of the cord and
end in gray matter (Schultz Col., 430).
(2) Fibers which pass forward and end around the cells of
the anterior horn (Edinger, 421).
(3) Fibers passing to Clark's column (Edinger, 421).
(4) Fibers which go to the cells of the posterior horn, lat-
eral colunm, then end in the gray matter of the poste-
rior column of the same side, but do not cross (Rus-
sell, 428, Mott, 429). These fibers terminate in the
42 THE NATURE OF PAIN
medulla (post-column nuclei), but during "their
course collaterals and some main fibers terminate in
gray matter" (397).
(6) Fibers which pass to the post-column. Collaterals are
given off and pass to cells of the gray matter, and end
generally around cells of posterior horns. The fibers
themselves terminate around cells in the posterior col-
umns, and some extend as far as the columns of GoU
and Burdach in the medulla (397^ p. 760).
Fibers arising in cells of gray matter are :
(1) Fibers running in antero-lateral columns, same side.
(2) Fibers running in post-colunms, same side.
(3) Fibers branching, one part running in the antero-lateral
coliunn of same side, and the other branch passing over
in anterior commissure to run in antero-lateral column
of opposite side.
The above are primary paths. Secondary paths are also pres-
ent in the cord. They are represented by:
(1) Fibers which arise in Clark^s column of the same side,
and run to the dorso-spino cerebellar tract (path of
Flick and Foville) lying exterior to the crossed pyram-
idal tract, and anterior to the post-root fibers. "In
the medulla they are joined by a bundle of fibers from
the crossed inferior olive, and pass directly into the
restiform body, and thence to the cerebellum" (397,
p. 763).
(2) The ventro-cerebellar tract forming part of Qower's
tract, in which the fibers arise : (a) In the cells of the
posterior horn and intermediate gray substance of the
opposite side, (b) In the cells of the posterior col-
umn of the same side. Both pass up in the cord and
brain, and terminate in the cerebellum.
crfmiDBtlw
R — F1b«n flTlBf
rka to reneHd
F— Tonob and
Fia. 9. — DuoRAu Showing Intbabpinal Coubsb of Sbnboby Fibbrb.
\ !i 1
I'iH /!■' -W
I I
ii
It
i
i. i. 1 % Si . 1 1. Ii li 1
CONVEYING CHANNELS FOR SENSATIONS 46
(3) The fibers of the tractus spino-thalamicus which arise
in cells in the posterior horns, cross over in anterior
commissure to the spino-thalamicus tract, and pass
' upward to end in the thalamus. Collaterals are sent
to:
(a) The lateral fillet of the same side.
(b) The post-corpora quadrigemina of the same side
and the opposite side.
(c) The anterior corpora quadrigemina of both sides.
The ascending path in the anterior column consists of:
(1) Long and short intersegmentary fibers, the exact origin
and terminations of which are obscure.
(2) One set of fibers which arises from the lateral bundle,
passes into the anterior columns, and thence up the
cord to terminate in the inferior olive (May, 397,
Dydynski, Bechterew).
Figures 9 and 10 will give a diagrammatic idea of the course
of these fibers.
After passing through the mesial fillet the fibers enter the
thalamus (May, 397, pp. 789-791), from whence they are dis-
tributed to the cortex, some, at least, posterior to the central fissure
of Kolando (397).
CHAPTER III
DISTRIBUTION OP THE SENSATION OP PAIN
The sensation of pain is either deep-seated or superficial.
When deep-seated, it is carried, as a rule, by the nerves of deep
sensibility from the tendon receptors. These are termed the ten-
don spindles (tendon organs) of Golgi (Howell, 539). They do
not degenerate after section of the anterior roots, and therefore
must be derived from the posterior roots and are sensory in origin
(Sherrington, 540). They are particularly irritated by anything
which disturbs the relationship of the subcutaneous structures,
such as deep pressure, or the rolling of the tissues over each other.
Pressure made on the skin, raised in a fold, the base being held
tightly between the fingers, will not be felt. This shows that
this type of sensation (pressure sense) resides in the deeper struc-
tures, the muscles and tendons (Striimpell).
Superficial pain (protopathic system) is carried by the cutane-
ous nerves. Here the pain fibers are associated with those carry-
ing sensations of heat, cold, and light touch. These sensations are
all separately received upon special nerve receptors, found in
the skin in well-defined minute areas, each area being associated
with a particular specific sensation. That tlie nerve fibers for
temperature and pain are closely associated in the same nerve
bundle is seen from the fact that, if either of them is irritated,
the pain, if referred to a distant area, is felt in the same area
(Rivers and Head, 86, p. 417). These local areas of sensibility,
in which the pain fibers originate, **vary greatly in activity and
threshold." According to von Frey, the pain points are those
pain spots of lowest threshold in any particular area of the skin.
Landois (541) states that the pain points do not coincide with
46
DISTRIBUTION OF THE SENSATION OF PAIN 47
the pressure points which are present on the same area, but are
about one thousand times more numerous.
The epicritic differs from the protopathic system, in that it
does not transmit pain, but seems to be concerned with the dis-
crimination of the finer variations of sensation. It is the last
sensory system to appear, being developed after birth. Following
an injury to a cutaneous nerve, epicritic sensibility does not return
until some time after the recovery of the other types of sensibility.
For instance, pain returns before the sensations of light touch,
warmth, coolness and the discrimination of two points of a com-
pass. According to Head and Sherren (295, p. 163), the time
necessary for the return of sensibility in the following systems
after section of a cutaneous nerve is as follows :
Peotopathic Epicritic
Begun Completed Begim Completed
Ulnar, with dorsal
branch intact ? days 133 days 183 days 320 days
Complete ulnar nerve. 109 days 171 days 169 days 278 days
Median nerve 65 days 190 days 262 days 387 days
Median and ulnar
nerves 101 days 217 days 271 days 470 days
A peculiarity of pain sensibility is that, in the absence of ther-
mal sensibility, a temperature between 40° and 44° C. will cause
pain ; but as soon as the thermal sense returns it requires a higher
degree of stimulation to overcome the inhibition of the convey-
ance of the pain stimulus by the conducting apparatus normally
resident in the part. The protopathic nervous system gives rise
to hyperalgesia, but the areas of hyperalgesia derived from dif-
ferent nerves so overlap that they are useless as a means of
defining the distribution of any peripheral nerve. On the other
hand, the epicritic nervous system gives well-marked, delimited
areas which may be used to define sensory nerve-distribution areas.
This means of discrimination can only be used when the lesion
is in the course of a nerve. When it is in the nerve root, the
48 DISTRIBUTION OF THE SENSATION OF PAIN
regions of distribution greatly overlap (Tigerstedt and Sher-
rington), so that the "lateral aspect of the body is provided with
a twofold, or even a threefold nerve supply."
Pain Localization. — To localize pain, it is necessary that the
sense of touch remain intact. When it is diminished, there is a
tCTidency for the sensor ium to refer the pain sensation to a part
where the touch sensation is more acute. An aid which the patient
instinctively uses, in his attempt to localize sensation, is motion.
Let the sense of touch in a finger be dulled, for instance. One
may then prick the finger, and the patient will not be able to tell
from where the pain comes ; but grant him the privilege of mov-
ing the finger, ever so little, and the touch upon his finger, and the
pressure against it of the pricking object, will enable him correctly
to localize the site of the irritation. This localization is explained
in the work of Head and Sherrington (263, p. 185), who find that
the muscles have a slightly different sensation from the skin,
and also that the muscles are not supplied by the same nerve
fibers which supply the skin, so that, by means of this involved
muscular supply, a correct localization can be made. When a
lesion is on the nerve circuit, a correct localization of the in-
jury is made by means of the nervi nervorum, as in a case re-
ported by Mitchell (263, p. 193), wherein "a blow had fallen
on the ulnar nerv^e at the elbow. The pain was felt in the
fingers, but there was also a well-defined sense of hurt at the point
struck."
However, every portion of the body is not equally supplied
with pain filaments. The abdomen seems to be most liberally
supplied,* then the chest, extremities, neck and back (Crile, 521).
The structure which is probably the most sensitive to pain is
the conjunctiva of the eye.
When the patient himself subjectively localizes a pain, one
should always insist upon his being definite in his statements, and,
if possible, have him indicate with his hand the area affected. In
some cases, the pain occupies an extensive, but rather indefinite,
area, so that the patient is unable to delimit it exactly. In these
cases (Schmidt) the focus is generally at the point where the pain
1
1
\
li'S
1 ji
U,
ii5
i
1
s
1
1
1
1
1
1
III
a
J,
I
i
i
fill
11
ill
!
1
f
1
50 DISTRIBUTION OF THE SENSATION OF PAIN
first occurred (infiammatory pain). This is true only of local
pains; other varieties will be described later in the text.
According to Tigerstedt, Pryer and Krauae have asserted that
the skin covering any given muscle is supplied with sensation by
the same spinal nerve which supplies the muscle.* This was also
a dictum of Hilton; but it has been shown to be untrue by Sher-
rington. He found that, during development, certain displace-
ments occur, causing the skin regions to be situated somewhat
more distally than the muscles with which they are related through
a common nerve supply.
Fia. 12. — Cutaneous Disteibdtion or Periphbral Nerves. (After
Fowler.)
The sensory nerves of a muscle probably belong to the same
cord segment as the motor nerves of the same muscle.
In the peripheral distribution of the sensory fibers, four dif-
ferent areas must he defined, namely:
' Tigerstedt gives the flexor surface of the thigh &Dd foreleg wid the an-
terior tide of tb« ann sa the onlj' esceptlons to this rale.
DISTRIBUTION OF THE SENSATION OP PAIN 51
(1) The areas of distribution of the peripheral nerves.
(2) The areas of distribution of the difFerent plexuses.
(3) The areas of distrihution of the posterior roots and their
corresponding segments.
(4) The areas of distribution of certain areas related to
visceral disease, as defined by Head and his associates.
FiGB. 13 ANn 14. — Cutaneous Nerve Supply, Sbowing the Distbibution
Abeab op the Diffkrent P1.EXU8ES. (Toldt, Fart VI, p. 811.)
The area of distribution of the sensory fibers in the peripheral
nerves, because of their overlapping, is rather difficult to outline.
This accounts for the great variation in boundaries, as given by
the leading workers in this field. Figures 13-17 are a composite
of the description and the drawings (see figures) of the principal
authors consulted.
Any lesion causing irritation in the course of a peripheral sen-
sory (pain) nerve would cause the pain to be referred to the dis-
tribntion area of this nerve. Care must be taken, however, not to
allow the overlapping of the distribution areas to render the de-
ductions misleading.
The distribution areas of the sensory fibers in the posterior
roots and in the corresponding segments of the cord, as given by
Flo. 16. — DiBTRiBinioN 07 THE Nerves Derived frou the Sacral
Plexus.
54 DISTRIBUTION OF THE SENSATION OF PAIN
different authors, difiFer even more widely than do those of the
peripheral nerves. The distribution, as given by Thorbum, Starr,
and Kocher, is shown in Figures 18-23. Figure 23 shows the
relationship between the cord segments and the different nerves.
f4.^
Fig, 17, — Oobsal Nbbvbs.
There are also on the body surface certain well-defined zones
which are related to visceral diseases ; they were first described
by Head, who, while working in the London Hospital, noticed
that, in different diseases of the viscera, areas or zones of cu-
taneous hyperalgesia were found which coincided rather closely
with the areas of distribution of herpes of the different re^ons.
Since herpes was due to a disease of the posterior root ganglion
(Head and Rivers; Church, 542, etc.), be concluded that in the
ganglion certain stimuli must be transmitted from the visceral
fibers to those going to the somatic areas, and produce an irritar
FiQ. IS. — Cord Zones According to Kocher.
Hiese represent the cutaneous areas involved in lesions of different segments
of the cord. The circles represent the areas of maximum tenderness
according to Head. Head's zones and these do not entirely coincide
because Head worked out his zones from a study of visceral lesions and
somewhat arbitrarily defined them, while Kocher used the peripheral
disturbances occurring in lesions of the cord as the means of defining his
segments. These really represent the distribution areas of the posterior
BatnebiTindar. 1, 4, 0.
B, «. 7. », O.
lUalikculiul, 1. Im
OnllooninU. I. 2. L.
Modlin. 1. T. S. O. I. □.
Surul lutumn. 3. I, I.
tm
Fig. 19, — Cutaneous Areas Related to Spinal Cord Segments (Church and
Peterson, p. 56, after Starr) and Cutaneous Distribution of Nerves
(Church and Peterson, p. 52, after Fowler).
Si i'iiitiiiii-is
11
jBS
i| i1lll^l|3ii
skills, -isSslilS
SSs
Fia. 23. — Relationship of the Segments of the Spinal Cord and
Thbih Nerve Roots to the Bodies and Spines of the Vertebra.
Thiti ia the reation for the location of the distributiuii si^gmeuts lower than oae
would Daturally expect. (Keen's System, Vol, II, p. 843.)
FlO. 24. — COBD ZONBB
AJ«D Areas of Max-
iHUU Tendernebs
AccoBDiNO TO Head.
Fia,25. — Cord Zones AND Areas Fig. 26.— Cord Zones
OF Maximum Tenderness Ac- and Abbas of Max-
CORDINQ TO Head. imum Tenderness
According to Head
60 DISTRIBUTION OF THE SENSATION OF PAIN
tion of these fibers, so that lighter than ordinary stimnli give rise
to pain. These areas are given in Figs. 24-26. At the present
time, they are acknowledged, in the main, as correct; and while
many have slightly modified the areas, the modifications are so
slight and so varied that it has been thought better to reproduce
the original drawings of Head.
/ ■•
CHAPTER IV
PEBCEPTION OP PAIN SENSATION
There are two states of perception, or rather, degrees of inter-
pretation, of pain-sensation, namely: (1) The condition or state
in which sensation is almost or entirely absent, anesthesia (when
the sensibility to pain alone is absent, it is called analgesia) j and
(2) the state in which sensation is more acute than normal, and
in which the slightest irritation will produce a more pronounced
reaction, or hyperesthesia (if the pain reaction alone is increased,
it is called hyperalgesia). Intermediate between these two is a
class of conditions producing symptoms not severe enough to be
classed as hyperesthesia, but which, because of their peculiarity,
cannot be classed as normal. These are the paresthesias, in which
creeping sensations, etc., are present over a part
Analgesia. — ^Analgesia may be either central or peripheral.
When central, the lesion may be in the brain, or spinal cord.
When it is in the brain, it may be either endogenous or exogenous.
Endogenous analgesia is present during severe emotion, such as
great joy, anger, . and fear, as is seen in the disappearance of a
*
toothache as soon as the patient enters the dentist's office, or the
cessation of pain when the patient is in mortal terror. It may
be present during arduous mental work which requires great con-
centration of thought, and also in states of mental exaltation,
such as exhibited by religious zealots, examples of which are the
Buddhist fakirs. In such cases, a perversion of sensation, from
strong religious excitement, seems to have taken place, so that,
while undergoing the most severe tortures, no pain is felt. In-
stead even a sensation of pleasure is experienced. Just what
factors underlie this type of phenomena is far from being satis-
61
02 PERCEPTION OF PAIN SENSATION
factorily explained. Some have assumed states of localized
anemia or hyperemia consequent upon variations in hlood pres-
sure. Others assume changes in the resistance to the passage of
nervous energy in completing nerve paths. Others assume a
"spill" hypothesis, namely, that emotional excitement lowers the
tension in certain nerve paths, and thus drains off the sensory im-
pulses, so that the nerve is not able to properly conduct the stimu-
lus, and radiation takes place into the adjacent tissues. Again,
others assume blocking processes which shut the sensory percep-
tions out of consciousness. Thought along these lines is in a
state of flux. Nothing is definitely known.
Toxic Analgesia. — Certain forms of toxemia are powerful
in retarding the perception of pain. They produce a dulling of
consciousness, varying all the way from cloudiness of intellect
to unconsciousness. Such toxemias are found in many states
and diseased conditions of the body, as acute infectious diseases,
the terminal stages of malignant processes, uremia, acute yellow
atrophy of the liver, etc. They are also present in cases of failing
circulation, such as occur prior to death, in fainting, and after
severe hemorrhage. This is hardly the place to speak of the
mentally defective, who, because of retarded development of the
perceptive faculties, are backward in their ability to experience
pain. These states are found in idiocy. In psychoses of various
types, also, the pain-perceptive centers are dulled.
VoLUNTABY A N ALGESIA. — In somc cascs, there seems to be
an ability to inhibit pain-perception, as is seen in a case reported
by Witmer, of a '^professional painless man." In this case, pins
' and needles could be pushed into the skin ; also, he could hold a
red-hot half-dollar in his hand without wincing, until it had
burned itself deep into the flesh. Witmer, from a consideration
of the circumstances of the case, believed that the subject inhibited
the sensation of pain, and not its external manifestations; that
is, that he did not perceive the pain, and was not stoically en-
during it. The patient was possibly a syringomyelic. Many of
us, by sufiicient training, are able to inhibit the sensation of pain.
According to Mitchell, some women remain for years without the
ANESTHESIA 63
peripheral pain sense, though the general health is unimpaired,
while the internal organs are still sensitive to pain, and all forms
of skin sense are as keen as ever.
The extrinsic or exogenous causes acting to produce analgesia
are all those conditions which produce a lowered pain perception.
Chief among these are drugs, morphin and ether probably taking
the highest place among them. Both act by obtunding conscious-
ness, although either may cause analgesia before consciousness
has entirely disappeared.
Anesthesia. — It is often a subject of controversy whether or
not a patient feels pain while under an anesthetic. It seems
foolish that such a controversy should arise, when we know that
pain is a concept of the higher sensorium, and that as soon as
consciousness is dulled the sensorium becomes inactive, and the
body is imable to perceive pain, although it may be able to per-
ceive touch. To illustrate this, I will recount a little personal
experience of several years ago. After using ethyl chloride suc-
cessfully upon a patient. Dr. Henry Hall suggested that I try
some. This I did, and after a few seconds the surroundings
seemed to become distant, and, while I could see and hear, I
was unable to move. When the doctor touched me and asked
me to tell him when he did so, I was unable to intimate by word
or gesture that I did not feel him, although I could see him
touching me.
Anesthesia is in reality an inhibition of perception. The physi-
ologists are agreed that the first phenomenon which is abolished
during anesthesia is that of voluntary movement, after which come
the loss of spinal reflexes, loss of pain, and finally loss of con-
sciousness. It is also agreed that loss of pain-perception precedes,
by a noticeable interval, loss of consciousness. Crile is not in
accord with this, for he believes that the only result of an anes-
thetic (ether) is obtunded consciousness. The disturbing stimuli
from the irritated area are carried to the brain, just as though
the patient were conscious, and exert the same irritative action.
The only difference is that the patient is not aware of their
presence.
64 PERCEPTION OF PAIN SENSATION
Interference with the areas of pain-perception will also cause
a loea of pain-perception. This is seen especially in all those cases
in which pressure is made upon the pain-centers, as in tumors,
hemorrhage, or pressure from a depressed fracture of the skull. A
case of this kind was reported hy Leszynsky (KSO), in which,
. after a fracture of the
i I skuH, there developed,
along with motor symp-
toms, an anesthesia ex-
tending around one leg.
It reBemhled an hysterical
anesthesia in that its boun-
daries were transverse,
and did not in the least
... Q .- resemble the boundaries of
the areas of distribution of
either the peripheral sen-
sory nerves, the pwterior
roots, or the cord s^
mental zones (Fig. 27).
In this case, "there was
an area of complete anes-
thesia, extending from the
toes to about two and a
FiQ. 27.-AIIBA8 OF Anesthesia on Lko ^^^^ j^^jj^g ^j^^ ^^
Due to Dbfbxbbbd Fracturb or '
Skcll. tella anteriorly, and to
o. ThennoaneatheMa; b. tactile and thermo- about three inches below
aDesthesia; c. complete anesthesia. . ,,^ ,
the popliteal space poste-
riorly, with a circular band of dissociated sensory disturbance
above this. For two inches above the level of the complete anes-
thesia, the tactile and temperature sensibility were abolished and
the pain-sense was preserved. For one inch and a half farther up,
thermoanesthesia persisted without impairment of other forms
of sensibility. The patient stated that about one week be-
fore entering the hospital he noticed beginning loss of sensi-
bility in the leg, and that about two weeks later the loss was
ANESTHESIA 65
complete. The losa of sensibility to the application of the f aradio
wire brush extended from the toes to about three inches below
the level of the area of complete anesthesia. The senses of po-
sition and of localization were normal in the toes and foot. The
senses of localization and of pressure were absent in the leg.
The upper extremities and the other lower extremity were nor-
maL There was no astereognosis. The visual fields as measured
with the perimeter were practically normal." This case brings
the point prominently to the mind that there are alreas in the
cerebral cortex which are connected with the sensory distribu-
tion of different regions of the body. This is important in the
etiology of hysteria.
Paresis frequently gives rise to anesthesia, which, according to
Clouston, is due to loss of inhibition ( ?) in the cortical areas.
It would seem more likely, from the pathology of this condition,
to be a loss of perception in the cortical areas.
Passage of an electric current of 1,000 volts through the body
will cause anesthesia, probably due to encephalitis causing
inability of centric perception (Hoover, 554).
The peripheral causes of anesthesia are all those conditions
arising in the nerve pathways which act as obstructions to the on-
ward progress of the pain stimulus, chief of which, of course, is
severance of the pathways by section of the nerves or spinal cord.
This may be the result of accident or of design, excepting that, in
the case of the cord, it is never in man the result of design. In
some cases the peripheral nerves are sectioned by the surgeon in
an attempt to cure neuralgia. This is an operation which for-
merly was frequently performed for trifacial neuralgia. Broken
back (fracture of the vertebra) frequently acts as an interrupter
of conduction, though, unless it is accompanied by a dislocation,
it generally does not cause a complete severance of the cord; so
that the anesthesia may not be symmetrical nor complete. Cord
tumor, however, is almost invariably accompanied by anesthesia.
Indeed, Bailey (544) says that no cord tumor can be diagnosed
with certainty if sensibility is intact. The only exception Bailey
makes is in tumors of the cauda equina. Syringomyelia fre-
66 PERCEPTION OF PAIN SENSATION
quently produces changes which interrupt the conduction of touch,
pain, and temperature. In other disorders, as in transverse myelir
tis, a local interruption of the sensory tracts in the cord also
results in anesthesia. In tabes the sensory fibers are affected just
as they enter the cord, and analgesia is produced here, although
touch and temperature conduction may remain intact. Practi-
cally the only lesion of the posterior roots which causes anes-
thesia is severance, which generally occurs as the result of frac-
ture of the vertebra.
Lesions within the nerve itself may cause an anesthesia. An-
esthesia may also be the result of pressure within the nerve sheath,
as illustrated in the case cited by Babcock (549), of a patient
who had sustained a small incision of the median nerve from a
piece of flying glass and had an area of anesthesia corresponding
to the sensory distribution of this nerve. On exposure of the
injured nerve it was found that it was not divided, but was the
seat of a marked fusiform enlargement Upon incision of the
affected area, a gelatinous, serous fluid flowed from between the
nerve fibers. A free longitudinal incision was made into the
nerve. Four days later, upon testing the hand, it was
found that the area of anesthesia had decreased one-third,
and that there was a distinct increase in the ability to
flex the fingers.
Should a nerve trunk be pressed upon by a tumor, a complete
interruption of the conduction of nervous impulses may occur,
and the area of skin distribution cut off will lose all sensibility.
At the same time the irritation occurring at the level of the lesion
may cause severe pain, which is referred to the peripheral distri-
bution of the nerve. A similar condition, called anesthesia dolo-
rosa, is often associated with cancer of the spine, the mass press-
ing upon and irritating the sensory nerves entering the interver-
tebral spaces (Eichhorst, 553, Landois, etc.).
Freezing of a sensory nerve trunk also causes anesthesia.
This is due to ischemia because, when ischemia is present in a
part (Kofman, 478), anesthesia generally results. This, in turn,
may be a result of mechanical pressure or of a chemical reactioii
HYPERALGESIA 67
to toxic factors. In the Glasgow Medical Journal of 1898
(VoL L, p. 467) are mentioned the following instances of opera-
tive procedure withoHt pain, the only anesthetic measure being
the production and retention of complete ischemia by means of an
Esmarch bandage. By this method, a ganglion was resected from
the dorsum of the right wrist without pain, a needle was also re-
moved, and a ganglion in the popliteal region was resected. In
Buch cases it is necessary that the ischemia be complete, and that
a short time shall elapse between the application of the Esmarch
and the beginning of the operation.
Certain toxic agents (as cocain) will produce a terminal anes-
thesia. Cocain first destroys the pain-conduction power of the
fiber, and finally touch sensation. In the tongue, according to
Schree (201, p. 207), the order in which sensation is lost in
general anesthesia is taste (bitter, sweet, then acid), pressure lo-
calization, and lastly tactile perception. Temperature sense is also
abolished (Met-
■tler, 505). Car-
bolic acid (5 per
cent solution on
the tongue) weak-
ens the sense of
pressure and pain,
but destroys the
sense of taste and
temperature. Ar-
senic and bella-
donna produce an-
esthesia to touch
and pain, but not
to temperature. Sa-
ponin produces an-
esthesia to touch,
but does not aflfect pain in any way (Rebot, Mettler, 505).
Hyperalgesuk is a condition in which there is an abnormal
painfol sensibility to irritative processes of any kind. Since
68 PERCEPTION OF PAIN SENSATION
pain-perception is the specific performance of a definite kind of
nerve fiber, hyperalgesia may be regarded as a hypersensitiveness
of the pain nerves (Sahli, p. 771).
Hyperalgesia of a part may be tested in three ways :
(1) A rather sharp pin, or pointed instrument, is drawn
across the surface imder examination, the instrument being pre-
ceded by the finger, as shown in the drawing. The reasons for
the finger preceding the instrument are: (a) that the sense of
touch may be somewhat removed, in order that the patient may
not be so likely to confuse touch sensation with pain sensation,
and (b) that, by using the second finger as a support, more
equable pressure with the pin can be made, while at the same
time all folds of the skin which might cause inequality of pres-
sure will be pressed out
(2) A second method, in which the skin is pinched between
the fingers, is also a good one, but does not show the slight changes
in sensibility which are found by the first method; nor does it
permit of such fine judgments on the part of the patient as to
the presence or absence of pain, or of variations in the degree
of pain, because of the inability of the examiner always to exert
the same amount of pressure in each individual pinch. As far
as personal choice goes, I have always preferred the first method.
(3) The head of a pin is sometimes used instead of the
point This really gives one hyperesthesia instead of hyperalgesia,
hyperesthesia meaning an increased sensitiveness to all sensation,
and hyperalgesia meaning only an increased sensitiveness to pain.
(4) Instrumental. — Various forms of instruments (esthesio-
meters, or algometers) have been devised for the purpose of accu-
rately recording changes in sensory or pain perception.
In judging of the hyperesthesia of a part, special attention
should be paid to each of the tissues composing the part^ namely :
(1) The skin (hyperalgesia sought by running the point of a
pin over the skin).
(2) The subcutaneous tissues (hyperalgesia sought by grasp-
ing lightly the structures of the skin between the
thumb and first finger).
HTPERALGESIA 69
(3) The muscular tissues (hyperalgesia sought by movement
of muscles).
(4) The osseous tissues (hyperalgesia sought by deep pres-
sure and tapping).
(5) The serous membranes, such as the pleura or peritoneum
(hyperalgesia sought by deep pressure, respiratory or
cardiac movement). (McKenzie.)
The areas of hyperesthesia of any two of these tissues may
not be coextensive. The area of tenderness of the subcutaneous
tissues is generally more extensive than the areas of any of the
other tissues. Sometimes the areas of the subcutaneous tissues
which are sensitive may be at some distance from the hyperal-
gesic areas of the skin. This is explained by the fact that both
of these areas are supplied by nerves coming from the same seg-
ments of the cord, but having different distributions (McKenzie).
Head has made a special study of hyperalgesic zones of the
skin; that is, hyperalgesia due to pricking with a sharp instru-
ment, or by pinching a fold of skin between the fingers. Should
the underlying tissues be grasped, or pressure be exerted upon
them, the results of the examination are apt to be deceiving, from
the fact that the sensibility of the subcutaneous tissues is mixed
with that of the skin. A reflex associated with these hyperalgesic
zones is dilatation of the pupil. When the irritation is severe
enough to cause pain, this dilatation is especially noticed on the
side which is hyperalgesic. Pinching of the areas which are not
hyperalgesic may, if the pinching is severe enough, cause a dila-
tation of both pupils, but more marked on the side pinched. The
hyperalgesic areas are particularly insensitive to deep pressure.
In many cases touch is not painful, while in others it produces
the most severe pain. Deep pressure over these areas will also
produce a dilated pupil more pronounced on the affected side. In
these areas the sensations of heat and cold are also exaggerated.
These hyperalgesic areas are sharply defined, while the hyper-
algesic areas due to a lesion of a nerve or nerve trunk are rather
vague and indefinite, and overlap. As a consequence, they cannot
70 PERCEPTION OF PAIN SENSATION
be used to delimit the boundaries of nerve distributicms. The
mere fact that these areas of hyperalgesia (Referred Pain, Head)
and of extremes of temperature (Forsyth, 26, p. 173) do not
overlap, seems to show that they have their origin in the cord,
and bear some relationship to the pain pathways, or at least that
they arise in the spinal ganglion before the nerve roots unite and
form plexuses, for it seems that it makes no difference how many
nerve plexuses and nerves the spinal roots form; the areas of
hyperalgesia are still distributed on the body in a segmental form.
This is well illustrated in injuries of the spinal roots, or of the
cord. Langley (131, p. 235) thinks that a sli^t rearrangement is
required in Head's areas, in order to bring the anatomical and
clinical evidence in accord. He savs that "a white ramus alwavs
has sensory fibers." If so, it could carry sensory impulses, which
would be so interpreted by the brain. We will not discuss this
further, but will leave it for consideration imder Sensibility of
the Internal Viscera.
In some cases of anemia, malaria, and infections of various
kinds, painful areas are present in the skin. This is particularly
true of influenza, which sometimes causes a severe general hyper-
esthesia; so much so that the slightest touch is painful. The
scalp may be so affected that the combing of the hair is almost
unbearable. In some cases lesions of the internal viscera give
rise to no hyperalgesia until an intercurrent infection, such as
pneumonia, or possibly appendicitis, occurs. This increases the
irritability of the cells in the cord, and then the irritation from
the diseased focus is felt and is referred to the peripheral distri-
bution, and continues after the intercurrent affection has disap-
peared.
Hyperalgesia and hyperesthesia do not increase the accuracy
of localization. Rather, they seem to multiply and duplicate the
number of sensations (Mettler, 505), so that the patient, on at-
tempting to delimit his pain areas, becomes greatly confused.
Tenderness. — Tenderness is slightly different from hyperal-
gesia. It means a painful condition produced by pressure. Hy-
peralgesia, when severe, will also give rise to tenderness, but it
TENDERNESS 71
may also be present and not give rise to pain on pressure. In some
cases, even a strong, firm pressure is found most gratifying.
Sometimes there is a dissociation between the tenderness and the
subjective pain, the tenderness being present over the site of the
lesion, while the subjective pain may be limited to this area or
may be referred to a distant area.
As a rule, pain of equal intensity cannot be felt in two places
at the same time, for the mind is capable of only a single impres-
sion at one time. Then, it will be asked, how are we aware of
the pains over different parts of the body during the course of
certain diseases (as influenza) ? The answer is very simple. As
no stimulus can always maintain the same intensity, at times its
strength will be reduced. At such a time, another and lighter
stimulus will gain the ascendency, and will impress its location
and character upon the brain, and be perceived. This perception
lasts only a short time, when the first, or some other, stimulus
again gains the ascendency and impresses its character upon the
mentality. Thus the localization of the pain varies, from day to
day, from hour to hour, and from minute to minute, the stronger
impression being the only one of which the mind is cognizant.
This also accounts, in some instances, for the variability of pain,
and for its frequent change of location. In other cases, the ten-
derness may be felt in a part distant from the lesion. This is par-
ticularly true when disease or pressure on a nerve is present.
When such is the case areas of tenderness are generally at the
points where the nerves emerge from the deeper parts and become
superficial. To them the name Valleix's points has been given.
According to Bennett (475), there are three painful reactions
to pressure. In the first, the pain is increased by pressure of any
kind. The lightest touch causes the most severe distress. Infec-
tious diseases of the nature of influenza produce this condition.
In the second, the pain is increased by deep pressure only. It
generally indicates some deep inflammatory lesion which is not
disturbed by the superficial pressure, but is aggravated by deep
pressure. For instance, in phlebitis, slight pressure over the most
painful part is not resented, but deep pressure produces pain.
72 PERCEPTION OF PAIN SENSATION
In the third reaction, pain is increased by superficial pressure.
In this condition, Bennett believes that a vasoneurosis is present
and causes a dilatation and engorgement of the vessels, especially
marked in the muscles ; the pain is severe and is relieved by pres-
sure and massage. On the contrary, if the engorgement is in-
flammatory, and an exudate is present, the pain will be increased
rather than decreased on pressure.
Tenderness may be present over the area in which pain is
complained of, but which is not the area of the lesion, or it may
be entirely absent over that area and be found at some distant
point. A few cases of disease in which the tenderness and its re-
lation to the location of pain differ are given below (Bennett) :
Disease Location of Pain Location op Tbn-
DEBNESS
Tabes dorsalis. Epigastrium (com- Over the spinal verte-
monly). bra.
Sciatica. Often back of thigh Over the great sciatic
and knee. notch.
Intercostal neuralgia. In epigastrium or in Over the intercostal
the middle line of spaces.
the body.
Gastric ulcer. Opposite the eighth oi Over the gastric re-
tenth dorsal ver- gion.
tebra.
Gall-bladder disease. In the back at the an- Over the gall-bladder
gle of the scapula. region.
Rigidity of the underlying muscles is, as a rule, associated
with tenderness. This is a good confirmative sign that pain is
present (of some diagnostic value in malingering). Points which
aid in differentiating the malingerer from the actual sufferer are
the changes in respiration and pulse, both in the rate and rhythm,
when pain is produced* These are not absolute, because in some |
cases where there is actual physical objective tenderness no change :
in the pulse or respiration is noticed in making pressure upon the |
PARESTHESIA 73
tender point or points. Changes in the pupil, however generally
they occur, should also always be sought, for pain causes dilatation.
Paresthesia. — This is a term used to describe a group of symp-
toms simulating pain, yet not of sufficient intensity to be so
classified. Under it are grouped such feelings as numbness, prick-
ing, and tickling. They are probably due to a lesser degree of
irritation than that which produces pain. For instance, pres-
sure upon the ulnar nerve at the elbow will produce tingling and
numbness, while a sharp blow will produce actual pain. Like-
wise, it is conmion when one knee is' crossed over the other to
have the foot of the crossed leg go to sleep from pressure on the
sciatic nerve. A fractured lower end of the humerus may also
press upon the ulnar nerve and cause paresthesia in the ulnar
distribution.
CHAPTER V
CLASSIFICATION OF PAIN
Several different classifications of pain might be made, but
the one most generally used is that which classifies them accord-
ing to origin, namely, subjective and objective.
SUBJECTIVE PAINS
Subjective pains are those which have no physical cause for
existence, but are a product of mental action arising from some
changes of the coordinating centers of the sensorinin.
There are a variety of conditions in which subjective pains
play a great role. The most frequent of these are emotional states,
hysteria, habitual reactions, depressions of various types, com-
pulsion neuroses, etc. In hysteria, wherein, owing to intense
mental concentration on the subject of pain, with the fixed idea
that it can be and is present in a certain place (ovaries, for in-
stance), it happens that, subjective to the patient, to all intents
and purposes, pain is present in such an area or point. Hysterics
are noted for the rapid changes in the location of their pains;
for the great variety of pains with which they are afflicted, and
their sudden change from those of mild character to those of
great severity. These pains may have no organic basis for
their presence, but may be the product of deranged mentality,
the result of disordered mental equilibrium wherein impulse is
misinterpreted, and the stimulus which ordinarily would be rec-
ognized as only a slight irritation is magnified, enlarged, and
changed in its journey to the sensorium, so that it is felt by the
centers as pain ; or else the centers themselves are diseased, se
that they interpret normal, non-painful phenomena as painful.
74
SUBJECTIVE PAINS 75
It 18 manifest that these ideas of pain, or the subjective impres-
sion of pain, are the result of impressions stored up in the mem-
ory centers, which are recalled when the proper associations are
aroused. These recalled sensations may be either autosu^estive
or heterosuggestive.
In autOBuggestive sensations the suggestive stimulus arising
in the organism itself is due to some pathological change, while
in the heterosuggestive sensations the stimulus arises outside the
organism, as in hypnosis, wherein pain can be felt in response to
a suggestion made by the hypnotizer. Subjectively-excited pain
can be made to appear and disappear at the will of the operator.
Also, sensations which normally are pleasant may, by the sugges-
tion of the operator, be interpreted as painful, thus showing how
a functional misinterpretation may occur without any organic
basis. These su^ested pains often are localized in a particular
organ, as in the hip joint in cases of so-called hysterical hip-joint
disease. Here the area corresponds to the terminal distribution
areas of several nerves, and is not localized to the area supplied by
the terminal filaments of a single nerve. The projected idea of
pain comes from the intellectual coordinating center acting in con-
junction with the memory center. In this respect, the question has
often been asked, can we conjure up in our dreams the sensation
and impression of pain ? From recollection of my own dreams, I
am incapable of answering in the affirmative; but several of my
patients have informed me that they have dreamed of being in
severe pain, which proved to be a myth upon awaking, there being
present no perceptive irritation which might act as a subconscious
cause of the pain. This dream-pain has been described as similar
to the sudden acute and agonizing pain associated with the cut
of a dagger, or contact with fire, and the sensation is as real as
though actually occurring. In these cases, it seems as though all
the tracts from the reception center to the memory center are
blocked, except those for touch and pain, and from the memory to
the ideational center all the tracts except those for pain are blocked.
Therefore, the ideational center perceives only impressions which
by the mdmory center are interpreted as painful.
76 CLASSIFICATION OF PAIN
Emotional Pains. — The emotional pains are those which are
the result of excessive emotion of any kind. They are felt in
great anger, great sorrow or distress, and kindred feelings. The
sensation experienced is not in reality a pain, but rather a feeling
of unpleasantness. That it is an actuality may be deduced from
the fact that, upon its disappearance, the body is left in the
greatest fatigue. Another and a related sensation is the sense of
depression felt in cardiac disease (angina pectoris). This in-
creases to anxiety, then progresses through the stage of distress
until the actual pain is apparent.
Hysteria. — Hysteria probably includes the largest number of
subjective pains. It is only recently that hysteria has been recog-
nized as an entity, and as a disease worthy of the most pains-
taking attention. Heretofore, when a patient complained of pain,
and no objective lesion was found, he was dismissed with the diag-
nosis of hysteria ; but this did not always prevent death from the
disease with which he was suflFering. The absence of a pain in a
complex of symptoms where ordinarily it would be may also
lead to a wrona; diajmosis of hvsteria. Roch mentions the case
of a patient who had stercoraceous vomiting, without the presence
of pain and tympany, and who was permitted to die without
operation because of the diagnosis of hysteria. This case illus-
trates how, because of the absence of pain, hysteria might be
diagnosed. The same would apply just as well if pain had been
present and the other symptoms absent. That some change which
accounts for the pain is present in hysteria cannot be doubted;
and that the pains of hysteria are imaginary and have no basis is
ridiculous. As remarked by W. H. Thompson, how is it possible
for a patient, through imaginary means, to cause a paralysis
of one vocal cord, when perhaps she does not even know that she
has such an apparatus, or that it is connected with the formation
of the voice ?
Explanation of Hysterical States, — It may be of some service
to glance over rapidly some of the suggestions made by various
authors as to the possible explanation for these states. Clevenger
(40, p. 195), for instance, believes that the anesthesia of hysteria
SUBJECTIVE PAINS 77
is due to deficient nutrition from improper vascularization, the
r^ult of localized anemia from constriction of the vessels. This
anesthesia is followed by a return of sensation, and in some cases
by hyperesthesia or even by hyperalgesia, upon the resumption of
the blood supply to the part with a consequent engorgement of the
vessels. The action of suggestion in relieving pain can be ex-
plained by the lessening of the blood supply to the affected part.
Sharkey (456) points out, as an argument in favor of the
central origin for anesthesia in hysteria, that when anesthesia is
due to an organic disease the patient is aware of his loss, but that
when it is due to hysteria he is unaware of it. This, according to
Sharkey, shows that in the first case the psychical centers are in-
tact, and that in the second case they must be involved so that the
patient cannot feel pain, and at the same time is unaware of his
loss.^
However, the most likely cause of hysteria is some disturbance
of brain metabolism due to vasomotor changes. In some cases
there is a transference of the hemianesthesia or hyperesthesia
from one side of the body to the other. "In these subjects, the
feeling on the affected side ic restored when small metallic plates
or compresses are applied to the skin. At the same time that
the affected part recovers its sensibility the corresponding part of
the opposite, healthy side or limb becomes affected. It was
thought that the application of the plates produced a galvanic
current and that this was instrumental in causing the transfer-
ence ; but it is now believed that it is due to the same thing which
causes the application of cold plates to one side of a healthy per-
*The cause of this Joss may be due to the fact that the nerve cells seem
to contain a substance of the nature of neurin, which can be transferred from
one cell to another, in case of exhaustion of one set of cells from hyperactivity.
Should the cells be unable to replenish their supply of this activating substance,
they are unable to appreciate impulses, and anesthesia results. Should the acti-
vating material be in excess, the cells become irritated and respond to less than
normal stimuli, giving rise to hyperesthesia and hyperalgesia. In some cases
there are small areas of anesthesia or hyperesthesia over the body. These are
explained by Sharkey by the fact that after the sensory fibers leave the inter-
nal capsule they separate and are distributed to widely-separated areas of the
cortex, so that it would be possible for some of these areas to be affected, and
thus give rise to areas of changetl sensibility.
CLASSIFICATION OF PAIN
son to increase the sensibility of tlie oppoaife side" (Landois,
"Physiology'," p. 936, American translation, 1904),
Distribution of Hysterical Pain.— The area of distribution of
analgesia in a hysterical subject may follow the distribution of
Flo. 29.— Areas or Analgkbia in Hysteria.
A is a case of tlie cerebrospinal type. B ia a cose of a pure cerebral type.
In A all superficial reflexes to painful slimuli and to hot and cold sensa-
tion were lost over tiie shaded areas. Loss of seoaation to touch was
lees extensive. In B the shaded areas indicate the loss of sensation to
touch, pain, heat and cold. (From Head, Brain, Vol. XVI, p. 116.)
the cord zones, or of tlie cerebrospinal areas. The cerebrospinal
areas generally have sharp boundaries, and have a transverse
delimitation, as shown in the accompanying figures (Fig, 29, A
and B), which are taken from Head. These states are inde-
pendent of any nerve or nerve lesion, even section. They are not
influenced by inflammation. Frequently these pains make their
first appearance after the examination of the physician, who, too
often, by the eare with which he goes over an area, and his oft-
repeated query as to the presence of sensory changes, rather sag-
SUBJECTIVE PAINS 79
geats the pain to the patient. Hysterical pain is also frequently
induced by emotional shock. Cold, heat, pressure, and irritation,
as a rule, have no effect upon it. Pressure points — that is, areas
which are particularly painful to pressure — are frequently found
in hysteria. According to Dercum (150, p. 849), the most fre-
quent hysterical areas are: (1) the inguinal region (women), (2)
the inframammary region, (3) above the spines of the scapula,
(4) to the sides of the dorsal, cervical and lumbar vertebra, (5)
over the sacrum, and (6) over the coccyx.
Diagnosis of Hysterical Pain. — In the diagnosis of such a con-
dition, the limitations of the fields of vision and the loss of the
pharyngeal reflex are of considerable weight Diller (557) classi-
fies the evidence as negative and positive. Under the negative
evidence, he cites the facts that the pain does not conform to any
one organic disease, and that it is very contradictory in its charac-
ter, time, appearance, and duration. Under the positive evidence
is the fact that suggestion often relieves pain. The patient gener-
ally is very detailed in his description of the location, time of
appearance, type, and intensity of the pain. The sufferer from
real pain, on the contrary, makes but few remarks concerning his
pain, and when he does so they are generally brief and to the point
(Thompson). Hysterical pains are not, as a rule, relieved by
drugs, such as morphin, while organic lesions are so relieved.
While in many cases a patient may seem to be complaining
of a pain in order that he may arouse the sympathy of those inter-
ested, we, as examining physicians, should not conclude because
we are unable to find an organic basis for the pain that it does
not exist. The diagnosis of hysterical pain is often but a cloak
under which the physician hides his ignorance. When we con-
sider that the nervous system is of considerable volume and
weighs about six pounds, and that it is subject to the same varia-
tions of nutrition and change as are the other tissues of the body,
it is easy to appreciate how it may be subject to the vicissitudes
of the other tissues, and therefore subject to irritation and fatigue,
the same as are these tissues. In children, hysterical pain is very
rare, because they are too young to have experienced much pain.
80 CLASSIFICATION OF PAIN
and hence are free from pain memories, and, as a consequence,
are also free from hysterical pain.
Hypnosis. — Hypnosis is sometimes capable of bringing into con-
sciousness the storcd-up pain experience of the subject. It causes
those dim and forgotten sensations which have been present in
the past to dawn into consciousness. It is only the drawing away
of the veil from the subconscious state and the forcing of it into
view. The hypnotizer can suggest the idea of pain to the hypno-
tized, and can make him feel pain in every act and every move-
ment. He reproduces, as it were, the states which are present in
hysteria.
Habit Pains. — A condition closely related to the forgoing is
that of the so-called habit pains. This is the name given to that
great class in which the pathways for pain have been so grooved
from frequent repetition that on the least provocation the stimulus
travels over them and gives rise to pain sensation. These fre-
quently follow a trauma which has occurred some time previously.
Such a trauma may cause abnormal or unusual susceptibility to
pain production, and what otherwise would be felt as a non-
painful stimulus gives rise to pain. Habit-pains frequently per-
sist after operations of various kinds which have been undertaken
because of the pain, and continue in spite of the fact that all the
abnormalities have been corrected. The persistence can only be
accounted for upon the habit-pain hypothesis. The pain is par-
ticularly apt to persist when opiates, such as morphin, have been
given before the operation.
Monomania Pains. — Brissaud (Progres Med., XIX, No. 2)
mentions another variety of habit-pain, in which the pain recurs
as a habit at a certain time, or in connection with certain objects.
Brissaud believes that patients subject to such pain are suffering
from an obsession, and that they have a delusion of pain when none
is present. The pain resembles that due to occupation neuroses,
and represents a variety of pain caused by overactivity of a certain
neuromuscular apparatus, and nature's attempt to hinder excessive
action.
Occupation Neuroses. — Dr. Walton ('^International Clinics,"
SUBJECTIVE PAINS 81
Vol. IV, p. 261, 17th series) recites several cases in which, in-
stead of the muscular spasm (found in certain neuroses, such as
writer's cramp), severe pain is felt, not localized to the distribu-
tion area of any nerve, but rather extending over the area of the
muscle and its insertion. This pain is induced only by making
the occupation movements, and is not invariably produced even
then. If the occupation is continued, every repetition of the act
causes pain. By this time, the pain is produced by other move-
ments than those of the occupation, and finally spontaneous and
paroxysmal pain is apt to appear in the same region, not generally
following the exact tract of any nerve, but rather distributed over
the area involved in the muscular action, and perhaps radiating
therefrom. Tenderness may or may not be present. Examples:
(1) Physician, laryngologist ; pain in the side of the neck
and back of the ear; comes on when the head is placed
in the position for operating; relieved and finally
cured by rest.
(2) Golf player; pain in the arm in the region of inser-
tion of the deltoid, produced at each swing of the
club.
(3) Pain in arm ; persistent with paresthesia ; due to sewing.
(4) Music teacher (piano); pain in right arm; numbness
and easy tiring of the fingers ; relieved on stopping the
piano-playing.
(5) Pain in the entire forearm ; due to overwork of the arm ;
moderate tenderness over the entire forearm present.
(6) Ticket agent; pain and tenderness on the radial side of
the first phalanx of the ring finger of the right hand,
due to pressure made by the corners of the tickets
against the spot in stamping.
As is remarked in an editorial in the Journal of the American
Medical Association (LVI, 12, 898), all of the occupation pains
may be avoided by proper precautions — and as examples are given
the cure of the pains in the bricklayer's back by placing the bricks
on a proper platform easy to be reached, or of the hammerer who
82 CLASSIFICATION OF PAIN
is relieved of the pains in his arm by using the opposite arm in
his work.
OBJECTIVE PAIN
By objective pain is meant that pain which is excited by some
cause or agent foreign or abnormal to the area in or near which
it is excited. Such a pain may be produced: (1) in the centers,
as the brain or cord, and (2) in the nerves, as the trunk or its
terminations. It always is the result of some demonstrable patho-
logical change.
CENTRAL OBJECTIVE PAIN
The cortical brain tissues contain no known pain-receptors.
Pains in the head, about the head, etc., are due to peripheral action
usually upon the receptors of the trigeminus, widely distrib-
uted in the meninges covering the cerebrum. The pain of
pressure within the head, as in hydrocephalus, brain tumor,
lead encephalopathies, etc., is probably also carried through the
trigeminus.
Purely cortical lesions are not known to produce pain, nor are
they known to bring about any increase or decrease of sensibility
to measured painful stimuli. Only in the case of recent lesions,
or in those accompanied by epileptiform seizures, has there been
foimd to be any reduction in pain sensibility. The cortex as a
place of origin for central pains may be excluded. The role of the
cortex in the analysis of other forms of sensibility does not lie
within the province of this chapter.
Central pains, however, may be present and due to lesions
in the optic thalamus, which is the chief sensory organ of the
brain ; the major relay station.
Two features stand out in thalamic lesions so far as sensations
are concerned. One consists in the excessive response to affective
stimuli. There is, as Head and Holmes express it, an "overload-
ing of the feeling tone.'' It has been present in the thalamic
syndrome cases reported by Roussy and others (Jelliffe, "Tha-
lamic Syndrome," N. Y. Med. Jour., 1910)., This excessive re-
sponse— explosive laughter, explosive crying — bears no relation
OBJECTIVE PAIN 83
to the quantity of painful stimuli. It is an interesting feature
that such variations in effective response may be unilateral.
Thalamic pains are usually very severe and intractable. They
are not infrequently seen in hemiplegics who also suffer from
thalamic lesions. Lesions of the thalamus seem to permit all
sensory stimuli to be felt as painful. Most of the reported tha-
lamic pains have been located in the upper extremities.
Lesions about the cord, meningeal exudates, pressures, tabes,
tumor, give rise to pain. Such are, for the most part, due to
action upon the peripheral sensory neuron. They are not, prop-
erly speaking, intracordal lesions, and do not, as a rule, give rise
to local pain. Pain tracts may be cut off, as in syringomyelia,
hematomyelia, intracordal tumors, etc., but do not give rise to pain.
They cause hyperesthesia, and may lower the threshold to painful
stimuli, but apparently do not cause spontaneous pain.
PERIPHERAL OBJECTIVE PAINS
Peripheral pains are those which are due to action on the axis
cylinder, the ganglia cells or the receptors, and are objective in
that some definite lesion (as a rule) acts as the producing factor.
They may be classified as to cause, manner of propagation, time,
constancy, and character.
Causes. — The causes of peripheral objective pain may be di-
vided into organic and functional. The organic causes are those
which are due to changes in structure, or in the relationship of
different anatomical elements to each other. They may in turn
be divided into intrinsic and extrinsic. The intrinsic causes give
rise to parenchymatous pains, and include inflammation, new
growths, muscular contraction, or displacement of parts, as in
those cases where teeth have not erupted and are still in the
maxilla, and where, by pressure upon the adjacent structures,
they cause great pain. The extrinsic causes include all lesions
making pressure upon the nerves or nerve terminals, as displace-
ment and pressure by adjacent organs, new growths, etc., and
stretching of the nerves, ligaments, or other attachments, in dis-
placement, or in new growths of different organs.
84 CLASSIFICATION OF PAIN
The functional pains are due to excessive activity of an organ
(generally the activity is transitory), as in the stomach (pyloric
obstruction) ; in the intestines (obstruction) ; in the testicles (hy-
persexual activity); and in the brain (excessive mental work).
Parenchymatous Pain. — Parenchymatous pain is due to
some pathological condition that involves the sensory nerve termi-
nations. It may be due to local irritation, such as occurs (1) in
inflammation, (2) in torsion or stretching of the fibers by muscu-
lar contraction, (3) in thermic irritation, as in burns, and (4)
in chemical changes due to acidg.
(1) Inflammatory Pain. — An organ consists of: (1) the
essential structure, such as cells; (2) the supporting structure,
consisting of connective tissues, in which are found (a) lymph
channels, (b) blood vessels (arteries, capillaries, and veins), and
(c) nerves (sympathetic and cerebrospinal); (3) the encapsulat-
ing structures (capsules) ; and (4) the adjacent structures (lymph
glands, nerve plexuses). Therefore, when the pain is parenchy-
matous, it must occur in one or more of the structures enumerated
above.
In inflammation we know that the first sign of the beginning
process is in the blood vessels, which dilate and thus bring an
additional supply of blood to the part. It is, no doubt, the vast
increase in the blood supply and the greatly increased force of
the systolic impulse in the diseased arep that cause the throbbing
pain, recognized as the early stage of an active, inflammatory
process. It is, however, very difficult to say exactly through what
channels or means the knowledge of this increased blood supply is
conveyed to the sensorium. It may be conveyed by the following
means: (1) nerve fibers distributed to the vessel walls which are
associated with the vasomotor nerves ; ( 2 ) nerve fibers distributed
to the cellular substance; and (3) nerve fibers distributed to the
capsules of the gland.
We know that the lumina of the vessels in inflamed areas are in-
creased much beyond their normal size, so that the combined area of
the lumina of the vessels within the inflamed area is several times
the area of the lumina of the vessels entering the part; and the
OBJECTIVE PAIN 85
systolic pressure is as much greater in the part as the area of the
vessels in the part is greater than the area of the vessels entering
it. This is according to a well-known principle of mechanics. To
be more definite, we may assume the area of the lumina of the
entering vessels to be one square foot, and the area of the lumina
of the contained vessels to be twenty square feet. The pressure
on every square foot of the enlarged area is the same as that on
the small area. Therefore, it will be twenty times the smaller
pressure (for example, if the smaller is one pound, the larger will
be twenty pounds). Thus, it is easy to understand how the in-
creased area of the vessels will indirectly cause the sensation of
VesBel entering part
Area thirty times that of
small veowl entering
tlie iMut
Area of vessels In Inflamed part
Fig. 30. — Method op Pain Pkoduction in Inflammation.
throbbing. It would, further, cause compression of any nerve
fibers which are found in the organ, and would also undoubtedly
exert a great pressure upon the capsule. Both of the factors would
produce pain.
The cause of the throbbing in severe inflammation may be
the impulse of the blood in the dilated vascular paths in the
inflamed area, or the result of a nervous vasomotor reflex, caus-
ing an alternating dilatation and contraction of the vessel walls.
Personally, I am inclined to the belief that it is due to the
propulsion of the blood into the part without any means of re-
turn, the capillary paths being blocked, and permitting but slight
venous return from the inflamed area, or that the return is so
slow that the blood accumulates in the part. As a consequence,
the force exerted through the small vessels entering the area
acts as in a hydraulic force-pump, and the pressure and force
are increased in the much larger area which the vessels supply.
Thus, this magnified force is seen by the alternate pallor and
J
86 CLASSIFICATION OF PAIN
flushing of the part. The nerves in the part are stimulated by
the dilatation of the vessels in the area adjacent to the inflamma-
tion, and impulses are sent to the cord, which sends them back
again as reflexes, which act as vasomotor dilators. Thus, there is
dilatation at each systole and a consequent contraction at each
diastole.
In the later stages of inflammation the throbbing pain which
was originally present is changed to a dull ache. This is due to
the fact that, at this time, the vessel walls and the capsule are
dilated to their fullest extent, and will not admit any more blood;
and, instead of the intermittent, systolic pressure that is found in
the early stages, there is present a pressure that is constant and
unvarying. Again, as the inflammation begins to subside (pro-
vided the extravasated blood does not block the channels) the
former throbbing pain may recur.
Sometimes it is found that the inflammatory reaction is not
limited to the confines of the organ in which it is found, but ex-
tends beyond these limits and progresses in the course of the
adjacent lymph paths, finally reaching some of the neighboring
lymph glands, where the inflammatory process becomes active,
thus producing further pain.
In some cases parenchymatous pain radiates in various direc-
tions from its place of origin; this radiation may be explained
upon one hypothesis: that the painful impulses are conveyed
from the organ to an adjacent nerve plexus where they be-
come diffused. From the plexus the impulses are carried to
the brain, and give rise to the impression that the pain arises
in the entire area to which the nerves forming the plexus are dis-
tributed.
Parenchymatous pain, due to inflammation of viscera, seems
to be more of a myth than an actuality, for, since it is a fact
that no sensory nerves are distributed to the parenchyma of vis-
cera, it is difficult to understand how, in the organ itself, painful
sensations can be present. The following are instances (Mc-
Kenzie) illustrating the absence of pain in diseases of certain
viscera :
OBJECTIVE PAIN 87
(1) Kidney inflammation, especially the chronic variety, is
entirely painless.
(2) Disease (inflammatory) of the liver is without pain, as
a rule, and the pain which is present in hepatitis is often due
either to involvement of the capsule or to the tractions made upon
the abdominal wall by the pull of adhesions passing between
the liver and its parietes. The only exception is hepatitis syphi-
litica (Neusser).
(3) Lung tissue lacks pain-sensation, and in disease such as
pneumonia the patient is entirely unaware of the baneful changes
occurring in the lung until the pleura becomes involved and pain^
is produced.
(4) The testicle is also without pain-sensation. Yet orchitis
is a condition which is very painful ; but it seems that the painful
reaction in this disease is due to an extension of the inflamma-
tory process to the adjacent structures (epididymis).
(5) The heart is also without a local pain reaction. It seems
that in painful cardiac diseases the painful condition is due to
an inflammation of the myocardium producing pain which is re-
ferred to the anterior thoracic wall.
Characteristics of inflammatory pain are: (1) the pain is
produced on pressure; (2) movement of the part affected or of
any adjacent part, causing pressure on the inflamed area, causes
pain; (3) the function of the part (because of pain) is abolished,
as the rigidity of the hip, which occurs in hip-joint disease (see
Ryder, 35). It has been observed that inflammatory pain is
more intense in colon-bacillus and streptococcic infection than in
most other infections.
ParenchymatoxLS pain in glandular organs^ such as the lymph
glands, may be due to stretching of the capsule or to involvement
of the nerves which accompany the arteries into the part. In
glandular tissue there does not seem to be any parenchymatous
nerve supply other than these filaments which accompany the
blood vessels to their ultimate divisions in the depths of
the tissue. In acute infectious diseases the pain is due to irrita-
tion of the terminal nerve filaments by the toxic substances circu-
88 CLASSIFICATION OF PAIN
lating in the blood. The reason for the pain being localized in a
particular area is that in this area the tissues are in a state of
lessened resistance and any toxic change taking place will be local-
ized in the less resistant region.
(2) Traction, that is, stretching or pulling on the nerve
fibers by muscular contraction, may cause pain. This is exempli-
fied in the contractions of the stomach, intestines, gall-ducts, ure-
ters, and uterus. It seems that the most severe pains felt by
patients are those due to contraction of hollow viscera, such as
the intestine gall-ducts, ureters, etc.
Torsion of the nerve fibers, such as occurs in twisting of the
pedicle of an ovariai^ cyst, also causes severe pain.
(3 and 4) Thermic and Chemical Irritations. — Burns, from
heat or chemical agents, cause pain by exposing the sensory ter-
minal filament to irritation by external agents. Even exposure
of these filaments to the air causes the most excruciating pain.
The reason for this, in all probability, is that, because of their
sudden change from a medium where temperature and surround-
ings are equable to a location where these conditions are not favor-
able, a great change in their state of irritability is produced, so
that they respond to a greater degree than normal to all stimuli,
and especially so to stimuli to which they had not been previously
accustomed.
CHAPTER VI
CLASSIFICATION OF PAIN (Continufd)
PESIPHEaAL OBJECTIVE PAINS
Propagation of Paina. — The second part of our classification
deals with propagated pains. These pains are felt in areas
other than those in which they are produced. They may be
divided into associated, referred, projected, reflex, and trans-
ferred pains.
Fig, 31. — Vakietteb of Pain: Orioin and Transmission.
flO CLASSIFICATION OF PAIN
AssociATEi> Pain. — The associated pain depends, for its
production, upon the transference of stimnli from one nerve cell
Fig. 32.~-Scheue Showing Howthe Different Varietieb of Pain May
Arise and How the Different MtsciLOBENSORT Reflexes May
Occur.
lo another. In some eases it is impossible to tell by what means
the stimnli are transferred, as in the following cases:
92 CLASSIFICATION OF PAIN
(1) A pain in the top of the head occurred with rectal fis-
sures. Upon the curing of the fissures, the pain disappeared.
(2) Pain under the heart, associated with labor pains. In
this case there was also cutaneous tenderness, which came and went
with the labor pains.
(3) Epigastric pain associated with gastritis.
(4) Pain in knee in a case of putrescent pulp of the lower
second bicuspid. Upon drawing the tooth the pain was relieved.
Upon sealing it again, after it had been opened and drained, the
pain returned. This experiment was made several times with like
results (P. V. McFarland). This pain reference is also present in
those cases where two adjacent centers are involved.
If the original stimulus is very severe, and is continued long
enough, adjacent centers become irritated, owing to the central
stimulation by the overlapping or spilling of stimuli from the ad-
joining centers to which the stimulus is conveyed. This is exem-
plified in the ear pain which follows toothache, or in the pain in
the inframaxillary branch of the fifth nerve when the stimulus is
in the superior maxillary branch. In some cases the pain be-
comes very diffuse, and is felt over wide and scattered areas of the
body. The diffusion is accounted for in two ways:
(1) By the crossing of the fibers. Some of the sensory
fibers evidently pass over fronj one side of the cord to the other,
conveying impulses which stimulate the sensory cells (in the cord)
supplying the opposite half of the body.
(2) By the diffusion of the stimuli. Some of the nerve cells
in the cord are in close relationship with those cells to which the
stimuli from the painful parts are carried. When there is an ex-
cess of stimulus, some passes over into the neighboring cells and
gives rise to painful sensations, which are interpreted as coming
from the area supplied by the stimulated cells. This tendency to
diffusion may be due :
(a) To reduction of the resisting power of neighboring seg-
ments, "general constitutional diseases reducing the body powers
generally, and the nervous system in particular, as in anemia and
pulmonary tuberculosis."
PERIPHERAL OBJECTIVE PAINS 93
(b) Increasing excitability of the involved segment, as in
fevers.
(c) Prolonging or augmenting the stimulating power unduly,
as in chronic ovaritis and chronic metritis.
These diffusely distributed pains should not be mistaken as
manifesting hysteria or hypochondriasis. In some cases the diffu-
sion is so great, and the pains so general, that they are spoken of
as generalized pains. (This is particularly so in the various in-
fectious diseases.) In other cases, when a distant segment of the
cord, or even the pain centers in the brain, have a reduced resisting
power, or have had the pain habit, irritation in any part of the
body may sensitize these centers and cause the pain to appear to
come from their areas of distribution. From Fromentel's studies
(Monro, 556) it appears that the relationship between the irri-
tated point and the sympathetic point is very constant and that
the sympathetic point is generally on the trunk on the same side
of the body. Cases in point are :
(1) "Mrs. H., aged 44; married late in life and never was
pregnant. Health has been fairly good. Several years ago she had
an attack of acute otitis media, the result of chronic otitis media
in the right ear. For some time the patient has suffered from
dysmenorrhea, but the pain from which she suffers has been in
the right ear and has been very severe. I was called to see the
patient, but before I got to her house the pain had ceased. The
patient visited me at my office. Bimanual vaginal examination
showed an enlarged and very tender left ovary, pressure upon
which caused quite severe pain in the ear" (personal communica-
tion from Dr. Torrey, Olean, New York).
(2) Pain in the chest, right side anterior, from rubbing the
back of the right forearm. A touch on the back of the forearm
or any part of a strip of surface extending from below the elbow
to the four inner metacarpo-phalangeal articulations was felt both
locally and in the area described on the anterior of the chest.
Firm pressure on the part of the arm described caused no pain
locally, but caused severe tearing pain in the chest front (Monro,
32, p. 9).
94 CLASSIFICATION OF PAIN
(3) Pain in the chest, due to pressure at the front of the wrist,
at the root of the thumb, or at the flexure of the elbow on the left
side. The pain caused was not local, but was felt in the left lateral
region of the chest (Monro).
(4) Pain was present in the chest on the right side, over the
second right costal cartilage, during each dressing of an appendi-
ceal abscess wound.
(5) Painful stimulation of the thigh produced a pain in the
back of the head (Monro, 32, from Do Fromental, *^Les Synalogus
et les Synalgia'^).
(6) Mitchell quotes a case where stimulation of a mole on
the leg produced pain in the chin.
(7) The headache which occurs after eating ice cream is also
an illustration of this variety of pain.
(8) The headaches which occur in various diseases are also
illustrative of this condition.
(9) Alger (560) reports a case of severe abdominal pain,
resembling that due to appendicitis, caused by eye-strain. Upon
the adjustment of glasses, the pain disappeare<l. Three years
later the patient lost his glasses, and the pain immediately re-
turned.
In some cases the associated areas are physiologically related,
as the breast and uterus (see mammary gland). It is very com-
mon for women to have pain in the breast during the period of
menstruation. In many cases it occurs just prior to menstrua-
tion. This pain-localization may be duo to lessened resistance
or increased irritability in the nerve-conducting paths, the stimu-
lus which in one gives rise to pain, in another produces no reac-
tion; or there may be some unusual nerve connections between
these different parts, or some cryptogenic process may lie dormant
in the parts and announce its presence by pain on irritation of
some related part. In woman, the spinal area offers least resist-
ance to pain at the sixth dorsal (mammary) ana the tenth dorsal
(ovarian) vertebra.
Misreference of pain phenomena, because of the instability
PERIPHERAL OBJECTIVE PAINS 95
of the nervous system and the imperfect development of the local-
izing apparatus, is very common in children. Examples of this
are seen in the pain present over the appendix area in cases of
pneumonia and hip-joint disease.
Referred Pain. — Referred pain is the name given to that
class of pain in which the irritation occurs along the course of
the nerve fibers, and the pain is felt as being produced in the
somatic peripheral distribution of the affected nerve or nerves.
There are three places where the irritation may cause referred
pain, namely:
(a) The cord.
(b) The posterior roots or ganglia.
(c) The nene trunks or nerves.
When the irritation occurs in the cord, the pain sensation is
referred along the pain paths connected with the same side of the
body. When it is transferred across the cord, and is felt on the
opposite side, it is called transferred pain. Among referred
pains, due to disturbance in the cord, are the well-known girdle
pains, which are almost pathognomonic for tabes dorsalis, trans-
verse myelitis, cord tumors, etc. Referred pains from lesions on
the posterior roots may be due to pressure from fragments of a
fractured vertebra, tumors, or inflammation, as in meningitis and
herpes. The principal causes of referred pain, however, are
lesions occurring somewhere on the nerve circuit. They may
occur on the nerve trunk or on one of the branches (see illustra-
tion). When a lesion occurs on the trunk, it is always referred
to a point on the periphery distal to the area at which it occurs;
but if the irritation is on a branch, it may be referred to the
periphery in an area proximal to that at which it occurred. This
is due to its reference along a collateral branch. Bennett (48)
gives a number of cases in which pain in the groin was due to
both downward and upward reference.
The following is a table taken from Dr. Bennett's article
(p. 269) :
96
CLASSIFICATION OF PAIN
Incidents of Pain in Groin
Incidents of Pain in Groin
Apparently from Above
Apparently from Below
Cases
Cases
Prolapse of ovary
1
Small omental hernia. . . .
1
Omental umbilical hernia .
1
Small femoral hernial sac.
1
Tumor of the pelvis . . . . ;
1
Obturator hernia
1
Stone in the bladder
1
Saphenous varix
4
Stone in the ureter
3
Osteoma of the tibia
1
Stricture of the urethra . .
2
Femoral atheroma
2
Movable kidney
Cyst of the testicle
1
Osteoarthritis
1
2
Rider's sprains
4
Retained testicles
3
Polypus of the rectum. . . .
2
Intestinal diverticulum . . .
1
Piles
2
Incomplete inguinal hernia
Traumatic lumbar hernia
2
Flat foot
1
1
Popliteal sarcoma
1
Varicocele
3
Old fractured tibia
2
Lateral curvature of the
Melanotic mole on the sole
spine
Sninal abscess
2
of the foot
1
1
Varicocele
2
Undetermined
2
Dr. Bennett also speaks of a case of osteoma of the tibia, in
which a sharp spicule of bone sprang from the inner surface of
the bone, about four inches from its lower end. Pressure upon
this caused acute pains in the left groin, rather to the inner side.
Pain also occurred when the limb was being flexed, as well as
when it was rotated outward. Kicking also caused pain. It was
due to involvement of a filament of the saphenous nerve.
Another case mentioned by Dr. Bennett is that of a pain in
the knee caused by a com. In this case, a loose semilunar car-
tilage was diagnosed, and the advisability of an operation was
considered. The patient had sudden attacks of acute pain, most
marked when he would suddenly turn around. These pains were
present when he wore boots or shoes, and were entirely absent
at other times.
A most peculiar case was one in which pain in the groin was
PERIPHERAL OBJECTIVE PAINS 97
caused by a mole on the foot. Pressure upon the mole, which
was on the inner side of the foot, caused pain in the front of the
groin. Other cases of upward reference are:
(1) Pain in the back caused by a wound of the testicle (Wit-
mer, 527, p. 930).
(2) Pain and tender areas over the fourth and fifth spinal
s^ments in painful disease of the breast (Treves's "Applied An-
atomy," p. 176).
(3) Pain in the left clavicle in volvulus of the small intes-
tine; condition verified by autopsy (Haworth).
(4) Pain in the back, due to a wound of the testicle (S. W.
Mitchell,. 559).
Cases of downward reference are :
(1) Pain in the arm and hand from pressure on the brachial
plexus by a supernumerary rib.
(2) Pain in the little finger due to pressure on the ulnar
nerve from a growth on the first rib (Forsyth, 126, p. 1470, quot-
ing from Hilton).
(3) Pain in the left leg, in a case of tubercular disease of
the spine, with a sinus opening in the lumbar region. Upon
passing a sound into the sinus, the patient complained of severe
pain shooting down the leg (St. Francis Hospital Dispensary).
(4) Pain in the hand, along the outer (radial) side, from
irritation of the musculospinal nerve due to fracture of the upper
part of the middle third of the humerus (Estes, 555). Estes
also mentions the pain felt on the ulnar side of the hand, especially
in the little finger, in cases of bone excrescences, etc., about the
inner condvle of the humerus.
(5) Pain in the thigh (anterior and posterior) and in the
groin, from a psoas abscess. This case I shall give in detail be-
cause of classical reference of the pain.
The patient had been sick for some weeks, and recently com-
plained of pain in the posterior region of the leg. The point of
maximum tenderness was beneath the crural fold in the crural
crease. He also complained of pain in the area outlined in Fig. 34.
There was a fullness present in the inguinal region, which was
98 CLASSIFICATION OF PAIN
tender to the touch. On irritation of a narrow area of the skin
next to the scrotum, a reflex contraction of the abdominal wall
was noted in the area indicated in Fig. 35. This reflex was pres-
ent on both sides. There was also noted rigidity of the spine,
Sayre's test positive, Bryant's angle normal. When lying on the
back or side, the knee was flexed and the thigh but slightly flexed ;
there was fullness in the left inguinal space glands, as indicated ;
the circumference of left thigh was 1.5 inches more than the
right one. This condition gradually progressed until opera-
tion, several days later, wh* a large collection of pus was
found in the inguinal region, which apparently came from the
region of the spine. After operation, the patiejit quickly col-
lapsed, his temperature became high, and he died in twenty-eight
hours.
It is interesting to speculate upon the reason why pain should
be felt in the area indicated. A study of the anatomy shows that
the area of pain is the area of distribution of the small sciatic
nerve, which was involved by the abscess cavity as. it gradually
crept downward into the thigh. The reflex contraction of the
lower abdominal wall occurred in the area of distribution of the
first lumbar segment, and the irritation which produced it was
made in the area of distribution of the ilio-inguinal, which is also
derived from the first lumbar segment (Fig. 36). Therefore,
the first lumbar segment of the cord in this instance acted but as
a reflex station for the nerves which derived their origin from it
The sudden death of the patient, in this case, could only be
explained by the supposition that the system was overwhelmed by
toxins which were more easily absorbed when the pressure was
taken away from the cavity walls on the opening of the abscess.
Still, this is a rather far-fetched explanation.
Other cases of downward reference are:
(1) Pain in the epigastrium, due to disease of the spine,
with a slight displacement between the sixth and seventh ver-
tebrae. In this condition, the pain increased when the patient
assumed an erect position, and, as a consequence, he walked with
the body inclined forward (Hilton).
CO
o
o
<
o
E
PS
t
O
J?
CO CO
I
99
100 CLASSIFICATION OF PAIN
(2) Pain in the chest, in the distribution of the fourth and
fifth dorsal nerves, from an aneurysm of the aorta (Hilton).
(3) Pain in the penis from ureteral colic and from cystitis.
In one case the patient, who had a stab wound one inch below the
umbilicus, complained of pain in the penis each time the gauze
packing, which touched the bladder, was removed. The rectum
and the neck of the bladder are supplied from the second,
third and fourth sacral nerves. From the same nerves the
pudic nerve, supplying the penis, is derived, and thus is ex-
plained the pain in the penis, due to rectal or vesicle disorder
(Monro, 32, p. 7).
(4) Pain in the great toe on the left side, in a patient suf-
fering with perinephritic abscess, the sinus from which opened in
the lumbar region a half inch from the second lumbar vertebra.
Pain was noticed only when the cavity was full of solution
(E. C. Stuart, personal report).
(5) Disease of the anterior third of the tongue frequently
causes pain in the auditory canal, because the auditory canal, the
teeth, and the anterior part of the tongue are all supplied by the
fifth dorsal nerve (Monro, 32).
(6) Pain in the legs, which was very unresponsive to treat-
ment, was found to be due to a tumor of the cauda equina.
(7) Monro (32, p. 7) also gives an example of a case of hemi-
plegia in which the patient, who had almost complete anesthesia
of the genitals, suffered pain in the great toe every time he passed
urine. This is explained by ifonro as due to the common origin,
from the first sacral nerves, of the nerves supplying the dorsimi
of the great toe and those supplying the prostate and the mucous
membrane of the neck of the bladder.
(8) Pain in the calf of the leg may be present in prostatic
disease (Head, *'Brain,'' 16, p. 29).
(9) Severe earache may also be found occasionally in ton-
sillitis.
(10) Pain on the inner side of the ankle was due to a tumor
in Scarpa's triangle.
The following are characteristics of pain due to pressure upon
PERIPHERAL OBJECTIVE PAINS 101
a nerve trunk by a tumor, enlarged and displaced organs, or other
causes :
(1) The pain is continuous, and does not intermit, as in
neuralgic pain.
(2) It is not increased upon pressure or movement.
(3) It does not produce muscular stifiFness, difiFering in this
respect from inflammatory pains.
(4) It may interfere with function, as in brain tumor or
brain abscess. In the former there is no fever, while in the latter
fever is present.
(5) It radiates very widely, especially when large trunks or
plexuses of nerves are involved. A characteristic of radiating
pains is that they vary greatly in intensity and location, but that
they are always associated with other pains which are due directly
to the lesion or radiate from it. A study of the different varieties
of radiated pain will give us a clew to the focus of the disease.
(6) Tumor involving the trunk of a nerve sometimes causes
trophic changes at the peripheral distribution of the nerve on the
skin, in the form of an intractable ulcer, or as a herpetic eruption
followed by persistent local anesthesia.
(7) Cramps in the muscles may be associated with pressure
pains.
(8) A point of interest in connection with these pains is that
morphin does not ease them for any considerable time, but "anti-
pyrin, phenacetin, and other coal-tar derivatives are of consider-
able service, either combined with an opiate or with bromids.
This is especially true in pains caused by aneurysm" (Thompson,
561).
In cases of section of nerves, J. K. Mitchell remarks that occa-
sionally, after union of the segments has taken place, the sensa-
tions of touch and pain are referred to the wrong areas. He sug-
gests, by \vay of explanation of such cases as depend upon nerve
injuries, that possibly, in the union of the several nerve trunks,
the axis-cylinders in the proximal part do not always succeed in
joining the proper axis-cylinders in the distal portions. For in-
stance, after a lesion of the nerves in the upper arm, nerve fibers
102 CLASSIFICATION OF PAIN
from the proximal stump, which normally convey sensations from
the elbow lesion, may unite with fibers from the distal part and
with nerves which are anatomically connected with the hand.
Thus, the impression due to a touch on the hand will, on reaching
the seat of injury, be shunted to the path which has hitherto
been that for impressions from the elbow. However, the sensorium
soon learns to orient the sensations so they are referred to their
proper source.
A differential diagnostic point between referred pain and neu-
ralgia is that in referred pain no nodal points are present (J. H.
Musser, 558). Apropos of this subject, and bearing upon the
production of pain, Carleton (123) reports cases of referred,
transferred and reflex pain, in which relief was obtained by the
local application of adrenalin, either over the terminal nerve
filaments or in the course of the nerve. It is difficult to under-
stand the modus operandi of this relief, because it is not reason-
able to suppose that adrenalin, when locally applied, can have any
but a local action ; and if it does have only a local action, how is
it possible that it can affect the seat of production of the pain,
which may be some distance away, on the same nerve or on an
entirely different nerve, either on the same or on the opposite side
of the body? It may be that the application of adrenalin pro-
duces some effect on the nerves, so that the transmission of pain-
ful impulses is inhibited. Carleton supposes the effect to be due
to a regeneration of the nerve force, or rather the restocking of
the nerve with kinetoplasm, the substance consumed in the nerve
cells during their activity. How it does so is to me incompre-
hensible.
Sympathetic Pain. — Closely resembling transferred pain is
sympathetic pain. It is really a transferred pain, with the dis-
tinction that in sympathetic pain a painful sensation is present
in the organ originating the pain, while in transferred pain there
may be no painful impression or sensation in the area or organ
in which the pain originates. In other words, sympathetic pain
is an overflow phenomenon, while transferred pain is due to con-
veyance of the stimulus through collateral fibers from one cord
PERIPHERAL OBJECTIVE PAINS 103
segment to another which is either adjacent to or at a distance
from it. As an example of sympathetic pain, we have the pain
in the axilla passing down to the arm and hand, due to angina
pectoris. The axilla, arm, hand, and heart are supplied by con-
tiguous nerve roots, the third, second, and first dorsal (McKen-
zie), and thus a stimulation of one segment is conveyed to the
adjacent segment and the sensation is referred to the peripheral
distribution of these segments.
Pbojection Pain. — Closely allied to referred pain is projec-
tion pain, a term given to pain which is felt as being present either
in a part which has no sensation (as in locomotor ataxia), or in
a part which, because of amputation, no longer exists. In the
case of projection pain in an amputated limb, the pain seems
to be due to the inclusion of the nerve in the cicatrix of the stump,
or a neuritis, or a neuroma. It is also related in some way to
the circulation. Otherwise how can the relief derived from eleva-
tion of the stump be explained? Gordon (562) enters into the
psychology of the subject to a considerable degree. Every con-
ception of a limb is due to a visualization of the peripheral stim-
uli which have been received. When irritation is present in the
periphery of any amputated nerve, the visualization is still pres-
ent, and from old association produces a picture of the absent
limb. It is along this limb to the former distribution area of
the various nerve fibers that the pain is referred.
Gordon illustrates the visualization of an amputated arm, in
which pain finally developed, in the case of "a railroader who
met with an accident twenty-seven years previous, in which his
left arm was crushed and amputated. Since the operation he has
always felt the presence of the left arm. Soon pain developed,
which was localized, mentally, so to speak, in the left limb. The
severity of the pain gradually disappeared, though the pain itself
did not cease. Upon examination, the stump appears to be cov-
ered with a cicatrix. The latter is tender, and pressure upon it
causes a sharp pain, which extends downward along the absent
limb. The prick of a pin will also cause pain to be referred
down the limb. If cold or hot water is applied to the stuiiip, a
104 CLASSIFICATION OF PAIN
sensation of cold or heat, respectively, will be felt by the patient
down the absent limb, as far as the tips of the imaginary fingers.
He also has spontaneous sensations of the absent limb, and con-
stantly feels the presence of the arm. He feels it hanging along-
side of the body ; he feels the arrangement of the fingers and some-,
times their movements. There is a constant unpleasant feeling,
a numbness in the absent limb. He also has at times a spontane-
ous, sharp pain, of neuralgic character, which makes him flinch
and double up. This pain, he says, runs through the ulnar side
of the arm. A few months ago, the patient suflFered an apoplectic
seizure, following which a left hemiplegia developed. Since this
cerebral disturbance, the former stump phenomenon became ag-
gravated. The spontaneous pain in the absent arm is more fre-
quent and intense, the nimibness causes him more discomfort than
previously, and finally the response to stimulation of the stump is
decidedly greater.''
Reflected Pain. — The next variety of pain which we shall
consider under reflected (deflected) pain is that in which the stim-
ulus is carried to the sensory ganglia or to the cord and then trans-
ferred from the sensory filaments of the neuron primarily affected
to those of a secondary neuron. The stimulus is then carried, in
this neuronic pathway, to the brain, and is perceived as coming
from the distribution area of the second neuron. This variety of
pain differs from referred pain in that in reflected pain there is a
transfer of painful stimuli from one neuronic system to another,
while in referred pain there is no transfer but only a misreference
of the pain by the sensorium. A better term to express the true
characteristic of this variety of pain would be "deflected," instead
of "reflected" or "reflex." "Deflect" means to turn aside, or to
shunt, while "reflex" means to turn back; and, since the pain is
not turned back, but is only swerved into another pathway, it
seems that "deflection" would characterize the change more than
would "reflection." Besides, in physiology "reflection" is gener-
ally used to indicate a reaction produced in some portion of the
body by a change in another part ; and for this reaction "afferent
and efferent fibers are necessary. The former are of a necessity
PERIPHERAL OBJECTIVE PAINS 105
sensory; the latter may be motor, vasomotor, vasoinhibitory, car-
dioinhibitory, or secretory. They are never sensory, for the simple
reason that a sensory nerve is always aflFerent, and there can be
no reflection without descending fibers" (Hart, 273, p. 344), so
that it would seem to be better to use deflection instead of reflec-
tion. These deflections probably have an anatomical basis. Re-
cent researches show that the nerve cells (in a segment) of the
cord undergo degeneration as a result of any lesion in the corre-
sponding segmental distribution area (Lickley, 138, p. 438).
This confirms the hypothesis that stimuli causing pain arise from .
direct irritation from pathological changes in the cord, and are not
due simply to a transfer of stimuli from one set of cells to another.
The most numerous and important of reflected (deflected)
pains are those due to pathological changes in the internal viscera.
The viscera of themselves have no sensation of pain, as elicited
by ordinary pain-producing stimuli. They can be cut, torn and
sutured without the production of pain ; likewise, they are insensi-
tive to heat and cold, but have a sense of their own which tells
the sensorium of their well-being with a sensation akin to that
Tvhich we term muscle-sense, or joint-sense. When the viscera are
irritated, the stimuli are carried to the cord and react on the cord
cells ; and impulses are produced and sent out as motor impulses,
or are carried to the brain by the neurons of these cells, where
they are perceived as painful. At the same time, the adjacent set
of cells become irritable, and react abnormally to all stimuli reach-
ing them from the periphery. Thus, we have the origin of the
hyperalgesic zones of Head. These zones are not always present
over the area of the involved viscera, and the reason for this, as
given by McKenzie, is that in the course of development the tis-
sues, which in a low form of life must immediately have covered
the organ, became displaced. In this way, several peculiarities of
pain-production may be explained. For instance, the pain in the
testicle in ureteral colic is felt, because, in early fetal life, the
testicle was very high in the abdomen, and was supplied by the
first lumbar segment Then it began to journey through the ab-
dominal ring and into the scrotum; but it always retained its
106 CLASSIFICATION OF PAIN
nerve supply. The ureter, likewise, receives its nerve supply from
the same segment, so that when irritation occurs in the ureter the
pain is often referred to, and is felt as arising in the testicle,
which at the same time is tender. In renal colic the skin of the
scrotum is never hyperalgesic, because the scrotum is supplied by
the sacral nerves; but the deep coverings of the testicle are always
hyperalgesic, because they are in relation with the same cord seg-
ment as the kidney (McKenzie).
The method of localizing the viscus causing the reflected pain
is given below:
(1) Determine if, in connection with it, there is an asso-
ciated area of hyperalgesia.
(2) Delimit the area of hyperalgesia as nearly as possible,
and orient it with a cord segment.
(3) Find out what organs are supplied by this segment
(4) Examine the organ or organs for disease.
(5) See if the pain can be reproduced by manipulation of
the organ.
The general lowering of the vitality of a patient often aids in
the production of reflected pains by reducing the resistance and
increasing the irritability of the affected cord segment.^
Sometimes reflected, referred, or transferred pains are con-
fused with neuralgia ; from this they can be differentiated by the
injection of cocain, which will ease the pain of a neuralgia, but
will have no effect on referred pain.
Tbansferked Pain. — Transferred pain is the name given to
that variety in which the stimulus passes from the neuron in which
it is originally present, over an intermediate neuron, to a third
neuron, in the area of distribution of which it is perceived as
being present.
In other cases the sensorium may mistake the peripheral dis-
tribution of the pain, as in degeneration of the posterior roots
(tabes), or of the ganglia and posterior columns, or cornu of the
* For a more complete exposition of this subject, see under Head 's Zones,
Visceral Sensibility.
PERIPHERAL OBJECTIVE PAINS 107
cord. It is very likely that in certain conditions the sensory im-
pulses which are carried by the sensory fibers and the gray matter
are not entirely obtunded or destroyed by the pathologic processes
which have taken place, so that touch can be conveyed to a minor
degree, and localizing sensations, such as those which tell us of the
position of a limb, may be present only in a very restrictive sense.
Therefore, an impulse propagated through the sensory pathways
is very weak, and on its perception by the brain (there being little
or no localizing stimulus accompanying it), is perceived as coming
from the opposite side where the localizing neurons are intact.
When the transference occurs in the cord, the segment affected
may be homologous to the segment in whose area the impulse was
originally received, or it may be higher, or it may be lower. In
the latter cases the impulse is transmitted to the perceptive (third)
neuron through some of the collateral branches.
Examples of pain transferred to a homologous segment in the
same relative position on the opposite side of the abdomen are
found in appendiceal and ovarian diseases, pneumonia, and
pleurisy. Examples of higher and lower reference are found in
those cases in which the pain of pneumonia is transferred to the
appendiceal region, or in which the appendix causes pain which
is transferred to the thorax. Mitchell (559) cites two instances
of this variety of pain. In the first case a window fell on a finger
upon which there was a felon. The pain was felt in the finger,
and at the same time in the face and neck on the opposite side
of the body. The second case is that of a patient who had a heavy
weight fall upon his right foot, striking the toes. The great toe
and the one next to it were injured. Immediately pain was felt
on the antero-intemal aspect of the opposite leg, at the junction
of the upper and middle thirds. The pain was of a burning char-
acter, fairly constant, and worse at night. It persisted for three
weeks longer than the pain in the injured part. The case has also
been cited of pain in the left thumb caused by a felon on the right
thumb. In another instance a wound on the right side of the
neck caused paralysis and pain in the left arm (Mitchell, 559).
Mitchell also mentions a case in which a shell wound in the right
108 CLASSIFICATION OF PAIN
leg caused the patient to complain of a burning pain in both the
left and the right arm and in the right pectoral region.
In regard to the cause for the persistence of these pains, I shall
quote from Dr. Mitchell (559), who says that "one can, in a meas-
ure, comprehend that a violent stimulus to a sensory nerve can be
switched off on to other nerve tracks or centers, as if it were the
escape of an overcharge ; but even if we hazard such a hypothesis,
it is still difficult to explain the persistency of these transferred
impressions, for it is a law of the receiving centers for painful
impressions that when the cause of the pain ceases to be active
the feeling of being hurt ends. But in some of these examples
of false reference of pain there must have been made in the center
some more or less permanent change that continuously represents
the effect to which any pain-producing agency usually gives rise.''
I have noticed that pain is more likely to be referred to the
opposite side from that on which the lesion is located, in elderly,
unmarried females. What, if any, bearing their social state has
upon this fact I am unable to say.
Character of the Pain. — Another classification of pain is that
founded upon the description furnished by the patient. This is
most varied. A patient with a lively imagination can, of course,
give a more vivid description of pain than those of a somewhat
duller mentality. Naturally, the pain is likened to some sensa-
tion which has been experienced in the past; hence the terms:
burning, gnawing, cutting, pinching, smarting, lancinating, bor-
ing, shooting, screwing, gripping, stabbing, grinding, sharp, dull,
aching, lightning, tearing, creeping, throbbing.
In earlier times this method, founded on the description of
the patient, was the one usually employed ; and, with the tendency
of the age to scholasticism, pains were elaborated and defined until
a celebrated physician of the time of Trajan recognized thirteen
varieties, and, not to be outdone, Halmeman, another early physi-
cian, distinguished seventy-five. Avicenna, in the tenth century,
A. D., wrote a work on medicine, in which, among other matters,
he distinguished fifteen varieties of pain (Allen, 563).
This method of classification, however, proves very unreliable,
PERIPHERAL OBJECTIVE PAINS 109
because of the difference in susceptibility of different people, and
of their varied powers of expression. Yet, it is of some value in
diagnosis, for certain pains, as described by the patient, are
characteristic of certain disease (Church and Peterson, p. 960),
as the lightning pain in tabes, the gnawing pain in rheumatism,
the burning pain in neuritis, the girdle pain in spinal disease, the
lead-cap pressure pain in neurasthenia, the sharp, cutting pain in
neuralgia, and the dull, aching pain in infectious diseases.
Persistency of Pain. — Pain is divided, according to persist-
ency, into constant, intermittent and remittent. Each of these
may again be divided, according to the subjective feeling, into
dull, aching, etc. Likewise each may be classed under some
variety of the anatomical divisions of pain, as referred or re-
flected. When a pain is constant, it is necessary to investigate
those conditions which act constantly and which produce pain.
Among the most common causes of constant pain are new growths
pressing upon the nerve fibers somewhere in their course. This
pain is referred to the peripheral distribution of the affected fibers.
Should the pressure be produced by an inflammatory mass, the
pain is constant, but is marked by periods of lessened severity.
These periods indicate the intervals in which the inflammatory
congestion is diminished. In other cases the remission may be
complete, and the patient may be free for a shorter or longer inter-
val, as happens in salpingitis and oophoritis, in which frequently
the pain is absent during the intermenstrual periods, and reap-
pears when the menstrual congestion occurs and the blood pres-
sure and internal congestion in the affected organs are again
increased.
Under certain conditions, pain may occur in paroxysmal at-
tacks of great severity, to which the term crises has been given.
According to Fenwick, who quotes from H. C. Moore, a pain crisis
consists of a paroxysm of pain as violent as human nature can
endure, accompanied by excessive functional activity of the part
attacked, but disappearing as rapidly as it appeared, and is asso-
ciated with a condition of undisturbed functional activity of the
affected viscera between the paroxysms (Fenwick, 569).
110 CLASSIFICATION OF PAIN
Time of the Pain. — Pain may be further divided into diurnal
and nocturnal. Diurnal pains are worse in all those condi-
tions which are aggravated by activity, either mental or physical.
For this reason neurasthenics and those afflicted with diseases of
the locomotor apparatus suffer more during the daytime. Such
conditions are found in rheumatism, neuralgias (as sciatica), flat
foot, joint disease, etc. Pain is also greater during the day in
eye-strain and diseases of the eye, and also, as a rule, in diseases
of the gastrointestinal tract. This is due, in both cases, to the fact
that during this time the organs are most active. Yet, as a rule,
it seems that nocturnal pain is more frequent than diurnal pain.
When pain is present during both periods, it is more severe at
night, because during the day the mind has so many other affairs
to occupy its attention that it does not perceive the i)ain sensations
as acutely as it would if it were free of oth(»r impressions. At
night everything is quiet, the other senses are in abeyance, and the
l)ain-sensation enters and alone occupies the mentality.
Among pains which are prominent at night are tliose due to
syphilis, uremia and gout. Schmidt (564, p. G8), in speaking of
these conditions, says: "It seems that, as a result of the diminu-
tion of the metabolic fimction, through the absence of muscular
work, there is a decrease in respiratory and cutaneous activity.
Therefore, when a dyscrasia exists, the toxic curve ascends at night
and leads to nocturnal attacks of pain. The pain of tuberculous
hip-disease is also most pronounced during the night. In this
disease when night comes on and tlie })atient is asleep he often
cries aloud and awakens complaining bitterly of the pain in his
hip. It is claimed that the pain is due to a relaxation followed by
a sudden contraction of the muscles around the joint. During the
day they are contracted and hold the limb in such a position that
the least possible injury can be done to it. During the night these
muscles relax and the limb falls away until slight pain results.
Then the muscles sharply contract and draw it again to the posi-
tion of least pain ; but as they do so, they also throw the head of
the b(mc forcibly into contact with the acetabulum, and thus cause
the sudden, sharp, acute pain, of which the patient so complains."
PERIPHERAL OBJECTIVE PAINS lU
Colics are ako most pronounced during the night. Schmidt
(564, p. 64) says: **It seems that a relationship exists between
smooth muscle fibers and striped ones, so that when one set is
active the other is idle. During the day the striped muscle fibers
are active, and, as a consequence, the smooth ones are idle, while
the smooth ones become active during the night, when the striped
ones are idle."
Gall-stone and appendicitis pains are frequently present at
night, many hours after the ingestion of food. (For fuller dis-
cussion, see Gall Stones and Appendix.)
When a patient gives a history of pain occurring at particular
times one should inquire as to his habits of life, what his routine
of work is, how and when he eats, and if the pain seems to be asso-
ciated with the ingestion of food. If it does, one should ascertain
if it follows the ingestion of all varieties of food, or only certain
varieties, and inquire whether the pain is relieved by the ingestion
of food. Hunger headaches and hyperacidity pains in the stomach
areas and pains of duodenal ulcer are eased by the taking of food,
particularly albuminous foods.
In some cases the pain-sensation travels more slowly than is
normal, the so-called delayed pain. In these the touch-sensation
is present some time previous to the pain-perception. Tabes dor-
salis gives such a pain-reaction. It may be observed by pricking
the patient with a pin and having him say ''Now" when he per-
ceives the sensation of touch, and "Oh" when the sensation is pain-
ful. He will say **Xow" much earlier than "Oh," showing that
the pain-perception is delayed. It is hardly possible that the
delay occurs in the transmission, for it seems that all impulses
travel along the nerve with equal speed ; yet, such is the explana-
tion given by Landois (* 'Physiology," p. 936, American trans-
lation, 1904).
Sensitiveness to Pain. — It seems that sensibility to painful
impressions is present in early infancy, but is not as acute as in
later life. The infant, at the time of its birth, I have no doubt,
is able to receive the impressions which later it interprets as
painful ; but it requires time to learn to coordinate the sensory
112 CLASSIFICATION OF PAIN
impressions and classify them as beneficent or harmful, so that at
this early age pain-perception has not as yet entered into its con-
sciousness. We may say that the infant has an instinctive dread
of all sensations which betoken an act or condition detrimental
to its welfare. This protective and defensive instinct is an in-
herent and non-cognitive factor in its development, arising not
from previous experiences, but from some inherited and latent
consciousness which awakes under the stimulus of external life
and takes upon itself the defense of the organism through the
perception of all pernicious impulses as disagreeable sensations
(principally as pain) from which it is wise to be dissociated. As
the infant develops, it becomes more sensitive to all painful im-
pressions until, in adult life, it probably has reached the acme
of sensitiveness. From this period until middle age the perceptive
powers probably are stationary. Then, as age advances, they
again become reduced, until in old age they are once again at a
minimum. As the ability to withstand pain differs at different
ages, it also differs among races and individuals of the same race.
Among races, it is claimed that the Hebrew stands pain less easily
than any other race (Editorial, British Medical Journal, April
14, 1006, p. 880). Such general statements, however, smack of
the feuilletonist and are not to be taken too seriously.
Individual Susceptibility, — Among individuals, the ability to
withstand pain varies markedly. It seems that those of a fair
and very delicate skin are most susceptible. In these people the
pain-receptors, because of the lack of protection which is given by
a thick epidermis, are more exposed and possibly more subject to
irritation than in those of a thicker integiiment. Such people are
not only very susceptible to pain, but also to cutaneous irritability
of any kind. Others, because of lack of mental development, are
incapable of acute perception of pain ; while still others, because
of intense will power, or of some inherent inability to perceive
pain, are comparatively immune. Bennett mentions such a case
of stoical disregard for pain. A celebrated French surgeon was
performing an amputation, and, seeing the look of distress on
the face of the patient, said: ''I fear I am causing you great
PERIPHERAL OBJECTIVE PAINS 113
pain," to which the patient replied: "No, the pain is nothing;
but the noise of the saw sets my teeth on edge."
Ottolenghi (449), who made records of cases of six hundred
and eighty-two women, foimd that women were less sensitive than
men, and draws the following conclusions in regard to pain in
women at different ages. He states that the sensitiveness is less
in early life, increases to the twenty-fourth year, and then de-
creases. This sensitiveness is greatest in the nineteenth year.
The higher the type, the greater the sensibility. The left temple
and left hand are more sensitive than the right. Luxury seems
to increase susceptibility to pain-perception. The divisions of
womanhood, in order of susceptibility to pain, are: (1) girls of
wealthy classes; (2) self-educated women; (3) business women;
(4) university women; and (5) washerwomen. We have here a
generalization which must be taken "cum grano salis."
Tissue Susceptibility. — Tissues vary in susceptibility to pain.
Metzinger (328, p. 141) claims that the blood supply of an organ
often determines its sensitiveness to pain, as the organs which are
the richest in blood supply generally suffer the greatest pain, and
that organs poor in blood supply have little, if any, pain. This is
in accordance with the theory of Oppenheimer, who claims that
the pain is created and carried by the vasomotor system. As ex-
amples of the effect of blood supply, he cites the lack of pain in
cartilage, nails, and hair, and the slight pain in pneumonia, while
pain is present to an enormous degree in the periosteum, perimy-
sium, pleura, peritoneum, etc. He gives bone as an example of a
tissue which is free from pain,^ but he says that this is due to the
fact that when blood-vessels enter the compact structure of the
bone they discard their muscular coat and so lose the vasomotor
nerves and the pain sense. These sympathetic vasomotor fibers
are supposed to issue by the post root, with the sensory fibers, and
enter the spinal ganglia. . In the cord they can be traced to the
antero-lateral ascending tract. Some fibers pass to the anterior
horn, and stiU others to higher or lower ganglion cells.
1 In recent experiments we have found that the medullary cavity of bone
is very sensitive.
chaptp:r VII
THE INTENSITY OF PAIN
It is always interesting, and in some cases it is important
for the diagnosis, to know the intensity of the pain suflFered by
the patient. The patient should always be interrogated, there-
fore, regarding this point. Very often the answer is of consid-
erable importance in enabling the clinician to make a diagnosis;
but when the physician takes the word of the patient he is ai)t
to be misled, perhaps not intentionally, yet misled, nevertheless,
because in the great anxiety of the patient to give a proper im-
portance to his complaints, he is apt to magnify his symptoms.
However, there are certain means of checking the patient's state-
ments so that it may be ascertained whether or not he is speaking
the truth.
FACTOKS UPON WHICH INTENSITY DEPENDS
Before going into details concerning these means, we must first
study the factors upon which the intensity of pain depends. These
factors are: (1) the stimulus; (2) the sensitiveness of the
patient; ('3) the irritability of the nerves; and (4) the extent and
number of the nerves involved.
The Stimulus. — The stimuli may be of different degrees and
strength, and they may be exerted continuously or intermittently.
A stimulus that is exerted continuously will be felt, at first, as
much more severe than one of equal force which is not so exerted.
As the stimulus continues, the reaction becomes weaker, until the
perception center is dulled and does not react at all. Likewise,
a constant stimulus alternately weak and strong will be more pain-
114
FACTORS MODIFYING PAIN PRODUCTION 115
ful than one which is constant, but of equal force. The reason for
this is that when the stimulus is constant, either the conducting or
the perceptive apparatus becomes fatigued, and the stimulus is not ^
perceived as acutely as when intermissions take place, since during
these intermissions the nerves have time to recover their sensitive- .
ness.
Sensitiveness of the Patient. — Susceptibility to pain varies
among different individuals. Some react to a painful stimulus
much more readily than do others. My experience has shown
that those of a thin and neurotic build suffer much more severely
than do the heavier and more robust. There seems, also, to be a
certain relationship between the degree of mentality and suscep-
tibility to pain. The higher the development and the more vivid
the imagination, the greater is the susceptibility. Those who are
not particularly affected by pain or emotion we call phlegmatic.
All their sensibilities seem dulled and inactive.
Irritability of the Nerves. — The trigeminus, the sciatic, and,
it is said, the splanchnic nerves are, as compared with others, ex-
tremelv irritable.
Extent and Nnmber of Nerve Fibers Involved. — The severity
of the pain depends upon the number of fibers which are involved.
The greater the number of fibers the more intense the pain.
FACTOKS MODIFYINO PAIN PRODUCTION
The factors modifying pain production are psychical and
physical.
Psychical Factors. — The psychical factors may be divided
again into emotion, consciousness, suggestion, diversion of atten-
tion, and expectation of pain.
Emotions greatly modify pain-sensation. For instance, vio-
lent anger or great joy preempts the sensorium to such an extent
that sense-perception is dulled and may become absolutely nega-
tive. Consciousness, of course, is necessary for the perception of
pain, and the more acute the consciousness the greater the pain.
Those who are worn out with physical work will often suffer less
116 THE INTENSITY OF PAIN
from an injury than their more vigorous fellow- workers. Sugges-
tion is also of considerable importance in pain phenomena. Many
modem cults have made capital out of the fact that pain may
often be eased by concentration upon some other object, or by self-
persuasion (auto-suggestion) that pain is not present. Yet this is
not new, for physicians have made use of this principle even as
far back as the time of Pharaoh. Diversion of attention is im-
portant, for the reason that when a patient's attention is drawn
to some object, and is entirely engrossed with it, he has two cen-
ters (sensory) which are active, as a consequence of which neither
is apt to be as sensitive as if acting alone.
Physical Factors. — Physical factors influencing pain may be
divided into the intrinsic and the extrinsic. Among the intrinsic
factors are digestion, motion, urination, defecation, menstrua-
tion, respiration, and position of the body. Among the extrinsic
factors are pressure, heat, cold, electricity, and drugs.
Inteinsic. — Digestion, as a rule, causes pain only when dis-
ease of the alimentary tract or some of its related organs is pres-
ent. The severity of the pain depends upon the kind of food
taken, and the variety of the lesion. In all cases indigestible
food increases the pain. When the pain comes on immediately
after eating, one would naturally think of gastric ulcer ; if in an
hour or two, of duodenal ulcer ; and if in three or four hours, of
gall-bladder or common duct disease. Also, at about the same
interval pain due to appendiceal or colonic diseases makes its
appearance, although that from colonic disease generally occurs
somewhat later, say in five or six hours. Should the entrance of
food into the stomach ease the pain, carcinoma, duodenal ulcer, or
a pure neurosis is probably present (Schmidt). Should the pain
come on during the ingestion of food, it indicates some disturb-
ance in the esophagus, such as ulcer, stenosis, or a lesion at the
cardiac entrance to the stomach, such as cardiospasm.
In all inflammatory states, when motion causes pressure to be
made upon the inflamed area, pain results. When a patient com-
plains of pain upon moving a part, careful investigation should
be made of the muscles, bones, joints, and nerves composing that
FACTORS MODIFYING PAIN PRODUCTION 117
part. In connection with the muscles the most common painful
affections are inflammations, as myelitis or abscesses. In some
cases, while the lesion is not in the muscle itself, it is adjacent
thereto, and contraction of the muscle will produce traction and
pressure upon the inflamed area. Such a condition is found fre-
quently in appendicitis. The appendix lies over and is joined to
the psoas, so that each time the limb is flexed, and the psoas con-
tracted, pulling and traction on the inflamed tissues occur, and
pain is felt. Therefore, whenever pain is complained of in
connection with muscular movement, not only the muscle but all
of its adjacent and related structures should be investigated.
Should the muscle prove negative the bone may give some infor-
mation as to the cause of the pain. In this direction the first
line of inquiry will be as to the condition of the periosteum, and
if it is found to be healthy, the bone may be excluded as a
cause of the pain. After careful investigation of these structures,
the joints should be examined, and flexion and extension tried.
Especially in disease of the articular cartilages pressure made
by forcibly pressing the two articular surfaces against each other
is provocative of the greatest pain.
Pain may be caused by change of position. This occurs espe-
cially in those organs which are held in position by "ligaments and
end attachments, such as the stomach." Here a change of posi-
tion produces a disturbance of their relationship to surrounding
organs, and in some cases a derangement of their functional
economy. It may produce, also, pressure or traction on an in-
flamed area. All of these factors lead to an increased amount
of irritation and pain. The occurrence of a painful lesion upon
a change of position of the patient indicates a local disorder.
Certain positions are characteristic of certain classes of disease
(see Positions of Pain).
Pain associated with defecation occurs at the time of the
movement, or a little later. If it occurs at the time of the move-
ment one would naturally think of some lesion involving the
sphincter or the anus. Of these, inflammation, from simple in-
filtration to abscess formation, is very painful. As much so, or
118 THE INTENSITY OF PAIN
even more painful, is fissure or ulcer of the anus. When the
pain persists for some time after defecation an abscess may be
present. Pain coming on immediately before the act indicates
deep-seated ulceration, such as would occur in carcinoma of the
rectum (Schmidt, p. 42). Abdominal pain, the result of strain-
ing accompanying bowel movement, may indicate some quiescent
inflammatory process in the appendix or the gall-bladder. By
constipation the pain of enteroptosis, intestinal atony and neu-
ropathic conditions is retarded.
Extrinsic. — Of the extrinsic physical factors modifying pain,
pressure is by far the most important. In many instances it is
the underlying factor of pain-production. Structures are so
joined and related to each other that pressure is constantly ex-
erted by the one upon the other, and any disarrangement of this
adjustment may cause the pressure to become excessive, and re-
sult in pain.
Electricity causes pain by stimulating the pain receptors. The
pain may also be due in part to muscular contraction and to sud-
den changes in the relationships of the parts, caused by opening
or closing of the circuit. The faradic current is probably the
most painful. The static spark is also quite painful.
Extremes of heat and cold both cause pain, and, most pecu-
liarly, the sensations caused by excessive degrees of either are
almost identical. Thus it is that one speaks of the burn due to
excessive cold. In case of pain due to freezing of a part addi-
tional pain is produced by placing the hand in hot water, which
is due to the dilatation of the vessels and engorgement of the
tissues of the part. This engorgement increases the pressure
upon the pressure-pain receptors, and thus causes an increase of
pain. Cold acts in an opposite manner. It causes contraction
of the vessels and a lessened blood supply in the part. Metabolism
is interfered with, and toxic products^ accumulate in the tissues.
These act upon the sensory receptors in the part and cause pain
in addition to that caused by the action of cold upon the cold pain
1 Toxic products also in some cases produce anesthesia. See under
Toxemia.
FACTORS MODIFYING PAIN PRODUCTION 119
receptors. In either of these cases the pain is due to the stimula-
tion of the temperature receptors, plus the stimulation of the
deep sensibility receptors. In some cases of heat pain, for a short
time two different sensations are felt, one being that of heat,
and the other that of pain. Then the sensation of heat disappears
and only that of pain persists. The only reason that both cannot
continue is that the pain sensation soon becomes paramount, and
preempts the sensorium. Another argument in favor of the sepa-
rate origin of temperature sensation and of pain sensation from
excessive degrees of heat or cold is that pain may be present from
hyperstimulation of either, in the absence of temperature sense.
That is, excessive degrees of heat or cold produce pain, while
moderate degrees of either cannot be recognized, or, if they are,
the one is confused with the other.
Drugs modify pain by various means. They usually block
the carrying power of the nerves peripherally (morphin or co-
cain) or centrally (morphin or ether). They may create changes
in the organs in which pain arises, and thus cause changes in the
pain. For instance, alkalies reduce the acidity of the stomach and
decrease the pain caused by a hyperacidity. Mercury and the
iodids frequently relieve pain due to syphilis. On the other hand,
tuberculin increases the pain, if it is due to tuberculosis (Schmidt,
p. 40). Emptying the bowels relieves certain headaches. The
withdrawal of morphin, in the case of a person who is accustomed
to its use, very frequently causes great pain.
Weather, — Pain also seems to be influenced by temperature
changes, for it has been observed that a lessened barometric pres-
sure causes a weakened resistance to pain. Evertt (566), from
a study of a number of cases, found the period of greatest pain
to be from nine to eleven a. m. A period of less severe suffering
is between eight and ten a. m. Barometric changes influence
the production of pain much more than does the actual presence
of storms. Damp, musty weather also influences pain production
(Head and Rivers, 201, p. 54). Evertt believes that the cause of
this increase in pain is that the electricity in the air, is increased
during these periods of atmospheric unrest.
120 THE INTENSITY OF PAIN
ESTIMATION OF THE INTENSITY OF PAIN
It is necessary, not only to know that a person has pain, but
also how to estimate and measure its intensity. This knowledge
is important in order to check the many misunderstandings that
occur, sometimes intentionally, sometimes unconsciously, between
the physician and his patient. It is also of value occasionally, in
deciding upon the progress of a disease. The different means of
measuring the intensity of pain are: (1) blood-pressure eleva-
tion; (2) motor reflexes; (3) complaints of the patient, com-
pared with his ability to withstand pain; (4) reflex vasomotor
signs, as syncope; (5) dilatation of the pupil; (6) amount of
morphin necessary to overcome the pain; (7) appearance of the
patient; (8) patient's description of the pain, and (9) mechanical
factors.
Blood-pressure Elevation. — Blood-pressure elevation is an im-
portant means of estimating the intensity of a pain. Studies
along this line have been made, particularly in Germany, where
the question of simulation is so important, because of indus*
trial insurance. Curschman (567) found that in eighteen out of
twenty people with normal sensibility the blood pressure rose
eight or ten mm. of mercury under stimulation with a faradic cur-
rent (on the upper part of the thigh). In the other two persons
the rise was somewhat higher (ten to fifteen mm.). In nine cases
of hysteria and in five cases of disease of the spinal cord, the pres-
sure was unaffected. During the gastric and intestinal crises of
tabes, and in lead colic, a pressure of 170 to 210 is common, but
quickly subsides to normal, 115 or 120 mm., when the attack is
over. In other painful abdominal affections only a very moderate
increase in pressure, ten mm., occurred. Janeway reports the
following cases: (1) A woman of twenty-eight, with a blood
pressure of 70-80 mm. between the paroxysms of pain, had 170 to
190 mm. in moderate and 240 mm. in very severe attacks. (2)
A man thirty years old had a blood pressure of 65 mm. between
paroxysms and of 140 mm. during the paroxysms. The climax
of hypertension and pain seemed to coincide, and both passed
ESTIMATION OF THE INTENSITY OF PAIN 121
away together. Morphin caused sleep and a lessening of the pain,
but no fall in pressure. Chloral caused a hypotensive, as well as
an analgesic, effect.
'*Of special interest (again to quote Janeway's words) was the
alternation of the abdominal and the lancinating pains. When the
latter came on, the pressure promptly fell, and the visceral crises
ceased. Therefore, Pal assumes that a spasm of the splanchnic
vessels is the cause of pain in a gastric crisis, and that the irrita-
tion which causes the lancinating pains affects depressor fibers
in the posterior roots, and the stimulus is sufficient to interrupt
or cut short an abdominal crisis'' (Janeway, 568, p. 247).
In this connection it is of value to know that an arterioscler-
otic condition of the abdominal arteries will at times, when the
pressure is high, cause a dull, aching pain in the abdomen. This
increase in the blood pressure is due to the stimulation of the vaso-
motor nerves (the vasoconstrictor part), and is produced princi-
pally in the splanchnic area. During labor pains, also, the blood
pressure is raised. Coincident with each pain it becomes higher,
and varies directly as the pain. As labor continues there is a
constant increase in pressure until the child is expelled, when
there is a drop to a point slightly below normal. This increase of
blood pressure is not due to the psychic influence of pain, for it is
present even when the patient is unconscious from the administra-
tion of an anesthetic. It may be due to the following causes:
(a) uterine contractions; (b) muscular contractions of the abdomi-
nal wall, causing an emptying of the splanchnics and a consequent
increase of the peripheral pressure; (c) excitement when the
patient is conscious. Worry may also have influence. It seems
hardly reasonable to suppose that the small increase in the quan-
tity of blood thrown into circulation at each contraction of the
uterus would be sufficient (when we consider the great adapta-
bility of the circulatory system to accommodate great or sudden
increases in the amount of circulation fluid) to cause any appre-
ciable increase in the systolic blood pressure; though the asso-
ciated contraction of the abdominal muscles, and, in fact, of
nearly all of the musculature of the body, it is reasonable to
122 THE INTENSITY OF PAIN
suppose, will produce a great elevation of blood pressure. We
must bear in mind, also, the fine supply of sympathetic nerve
fibers to the uterus and adnexa. After all, the increased vascular
tone is, in all probability, due to this elaborate nerve supply and
its irritation.
Motor Reflexes. — The reflexes produced by pain are protective
in their tendency, in that they are a means of defense instituted
by nature against injury. In every instance, if possible, they
tend to remove the organism from the source of danger. They
are very active and are constantly exerted. For instance, when
the hand comes in contact with a heated object, it is immediately
drawn away by a quick, automatic muscular movement, even be-
fore the individual becomes aware of the contact. In sleep many
reflexes are active, and in some diseases of the cord (transverse
myelitis) they may be present even when pain sensation is absent
Even in light anesthesia, this reflex-protective action is present,
as is seen in abdominal operations when the parietal peritoneum
is somewhat roughly handled. Although sensation is not present,
the reflexes are, and, acting immediately, produce such a sudden,
strong contraction of the abdominal muscles, that it is almost im-
possible for the surgeon to do his work. The defensive power of
the reflexes is best exemplified in consciousness when the patient is
under the influence of pain. The centers for voluntary muscles
are throwTi into activity, so that the organs, the seat of deleterious
changes, may be protected from injury. Every physician is aware
of the rigid contraction of the abdominal muscles in pelvic or peri-
toneal disease, and of the extent to which the administration of
an anesthetic simplifies and renders easy a manual examination.
Can anyone doubt that the higher automatisms, with appreciation
of pain, are active in causing this rigidity? Almost innumer-
able examples of the same kind might* be cited, for instance, the
contraction of the muscles surrounding a joint, and its consequent
fixation, in those cases in which articular inflammatory states are
present, or the rigidity of the head in disease of the soft struc-
tures at the base of the skull in meningitis, etc.
In view of the universality of these defensive reflexes, it is
J
J
1j
ESTIMATION OF THE INTENSITY OF PAIN 123
fitting that we should be a little curious as to the reason for their
presence. We know that nature is always purposeful. Every
act is conservative, and we may be sure that when pain, with
its attending reflexes, is present, there is a good reason for its
appearance. This reason is protection against further injury.
For this purpose are called into play the only reflex organs in
the body capable of resistance, namely, the muscles. As a result
of their stimulation and consequent contraction either rigidity or
motion, or both, follow. Rigidity is best seen in the cases of
abdominal diseases above mentioned; motion is best illustrated
by the quick withdrawal of the hand from a source of injury.
Two of the special senses, taste and smell, owing to their func-
tions, have developed a special sensation which is termed nausea.
It is of a disagreeable, sickening nature; and finally, if suffi-
ciently prolonged, causes a protective reflex action in the
form of vomiting. This reflex, as one would judge from its inti-
mate dependence upon the sympathetic system, is practically an
involuntary act, though sometimes it can be produced by conjuring
up in the mind pictures of disagreeable or disgusting objects.
Hearing, also, is somewhat different from the other senses.
Here an excessive stimulant gives rise to a sensation, which, if it
cannot be accurately classified as pain^ is closely akin to it, be-
cause of its intensely disagreeable nature. When this sensation
is present, protection from the causative agents (noises, etc.) is
sought by placing the hands over the ears, so that the distressing
sounds may not enter.
All of these reflexes are accompanied by certain well-marked
and clearly defined changes in other systems, as the circulatory,
digestive and pulmonary systems.
Complaints of Patient Compared with His Susceptibility. —
A comparison of the complaints of the patient with his ability to
withstand pain often gives an indication of the severity of the
pain. This ability varies in different people. Some, especially
those of a phlegmatic temperament, seem to be capable of bearing
pain of much greater intensity than those of a nervous, active
nature. Blondes, also, seem to be more sensitive than brunettes.
124 THE INTENSITY OF PAIN
Personal idiosyncrasies, however, are of great value in estimating
the severity of pain.
To determine the sensibility of the patient, the skin on an un-
affected part of the body should be pinched between the fingers.
When the abdomen is not affected, it is best, because of its great
sensitiveness, to use it as a control. By the response to various
degrees of pressure, an estimation can often be made of the
susceptibility of the patient.
Vasomotor Signs. — Vasomotor signs, as pallor and syncope,
often give an indication of the severity of the pain. These
changes are due to a reaction of the pain stimuli upon the vaso-
motor system, and it is necessary to inquire into their cause.
The vasomotor system consists of centers to which two sets of
fibers are connected, namely, the inhibitory fibers and the con-
strictor fibers. The inhibitory fibers convey impulses which hin-
der the contraction, and the constrictor fibers convey impulses
which stimulate the contraction of the muscular coat of the blood-
vessels. It is very difficult to say in what way mental states have
an action on the physical processes of the body; but that they
have is evident, and that the action is a powerful one can be
seen from the persistence of the induced physical changes. How
the vasomotors are influenced it is very difficult to say. Yet we
know that they may be influenced by many mental processes.
For instance, pallor is induced by fear, fatigue, nausea, or severe
pain. Redness is induced, in the process called blushing, either
by a stimulation of the vasomotor inhibitory fibers or by a
paralysis of the contracting fibers, producing a paralysis and
dilatation of the blood-vessels of the face and neck. The vaso-
motor fibers pass up the cord in the lateral tracts, and pain sen-
sation is also conveyed by the lateral tracts; so it can easily be
seen how any change in the fibers conveying pain sensation would
react on the vasomotor fibers and produce changes in them.
Pallor and syncope may be the indication of shock due to
intense irritation of the sensory terminal filaments. According
to Henderson, this shock is the result of the rai)id resi)iration al-
ways induced by peripheral sensory irritation. In his experiments
ESTIMATION OF THE INTENSITY OF PAIN 125
consciousness was abolished by the use of ether and morphin, so
that the results were not due to consciousness of suffering, but to
nerve irritation. It seems that consciousness of suffering is a
mere accompaniment and not a causal element in the production
of shock, which is of a reflex nature. Among other signs of shock
are rapid and feeble pulse, vomiting, drawn, anxious features,
and excessive perspiration. The susceptibility to shock varies.
In those of a well-marked nervous temperament shock from a
small injury is greater than in those of a more phlegmatic nature.
Some women are almost prostrated with the pain of menstruation,
while others hardly seem to mind it. The same may be said of the
parturient state (Lazarus-Barlow, 571, p. 478).
Dilatation of the Pupil. — Dilatation of the pupil is produced
by irritation of the sympathetic nervous system, particularly in
the splanchnic area. This reaction can be made use of when
estimating the tenderness of a part. Yet, in using it, one must
not forget that pressure alone will produce dilatation of the
pupil, especially when exerted on the abdomen, and that dilata-
tion may also be produced by stroking or pinching the neck
(Schmidt). Some idea of the dilatation due to pressure alone
should be gained by stimulation of a non-painful part. Then, with
this as a standard, an estimation of the dilatation due to pain can
be made. This method is not available after the use of drugs, such
as morphin, cocain, and belladonna, which have an action on the
pupil.
Amount of Morphin Necessary to Overcome Pain. — The
amount of morphin necessary to ease pain is a good indication of
its severity. Colic requires more morphin than many other vari-
eties of pain. This is especially true of gall-duct or pancreatic
duct colic, and renal colic is especially noted for its persistence and
severity.
Appearance of Patient. — The appearance of the patient fre-
quently is a reliable index of the variety and severity of his pain.
As a rule, pain of great severity produces a cessation of muscular
movement To this there is one great exception, namely, the pain
of colic. Here, whether the colic is of urinary, biliary or intesti-
THE INTENSITY OP PAIN
nal origin, the patient writhes, squirms and assumes all conceiv-
able positions, at the same time crying out or moaning. These
attacks come in paroxysms, a period of quiet following each
attack. In colic, also, the patient presses with his hands, or with
a bolster, upon the abdomen, and frequently lies with his limbs
drawn up (see Figs. 87, 88). Here the tendency to exert pres-
sure is seen in the characteristic way in which the hands are joined,
the fingers being interlocked so that greater pressure may be ex-
erted.
This picture ia the exact opposite to that seen in peritonitis,
where the patient is absolutely qiiiet, lying flat upon his back
FiG. 37. — Hand PiiEasiNn on the Abdomen is Very Characteristic of
Colic, i. e., of the Uterus or Intestine.
1. Area of referred pain in phlebitis (femoral). Also area of distribution
of ant. crural and area of pain reference in crural neurolt^ia.
2. Localized tenderness in phlebitis,
3. Phlebitis (femoral vein).
Hip joint disease.
Psoas abscess (low).
4. Ovary inflammation. )
Salpingitis. Mt ia more characteristic for patient in these con-
5. Appendicitis. ) ditions to lie on back.
with his limbs drawn up and hands frequently placed lightly
upon his abdomen. He is very atloutive, and is ever ready to
ward off any touch or pressure with the other hand {^ec Fig. 8C).
To this posture the term "abdominal jiroteetive position" has been
given. Other characteristic postures are illustrated in Figs. 37,
38. Headaches also give rise to characteristic postures, as may be
seen in the Figs. (Iti, G7, 08.
ESTIMATION OF THE INTENSITY OF PAIN 127
In pleurisy or intercostal neuralgia the patient assumes a rigid
chest position, and, on close examination, it is noticed that the
thoracic respiration is hindered. This is exactly opposite to what
happens in abdominal inflammatory disease, in which the breath-
ing is of the thoracic type,
abdominal breathing hav-
ing ceased entirety.
When the patient moves
with considerable pain and
refuses to stand on a limb,
and holds the joint in a
flexed position, inflamma-
tory disease of the joint
should he suspected. The
position assumed in dis-
tention of the vesical blad-
der is one in which the pa-
tient inclines slightly for-
ward, his back straight and
rigid, pressing both hands,
which are interlocked.
over the lower segment of
the abdomen. Tumor or
aneurysm is indicated as a
rule by pressure over the
diseased area. In men-
ingitis the patient r<
rigid because of the pain
(Kyder, 35).
The facial expression
also is frequently a reliable index of the severity of pain. One
expression which is indicative of the most severe pain is
the so-called Hippocratic facies, in which the brow is con-
tracted, the lips drawn back, the eyes fixed and the entire
attention focused upon some intrinsic phenomenon. This is the
characteristic facies of peritonitis, and when present is of s
Fig. 38, — PosmoN Assumed in Uterine
Couc, Intestinal Colic, and Dis-
tended Urinary Bladder.
128
THE INTENSITY OF PAIN
import. In some patients, especially among those who have
trained their features to express emotion, simulation is often prac-
ticed; vet, under close obsen-ation, one will notice, at times, some
relaxation or change in ex-
pression, especially when
the patient thinks he is not
being watched.
Gestures indicative of
pain are principally those
in which the patient tries to
ward off an imaginary or an
actual injury. Motion as
an indication of the severity
of pain is of some value,
but is chiefly of (ise in
pointing to the structures
which are involved. As a
rule, all pains of moderate
severity cause a loss of
function of the part, and the
patient usually lies quietly
ill bed, attentive but mo-
tionless, except in cases of
F.o^SS.-Lacing Shoe PCTom. ,Mominal colic, in which
In lumbago, spinal cancB, hip joint dis-
ease, Hi;iatica, appendicitis and pelvic each paroxysm is indicated
peritonitis, pain is experienced on the by sudden and explosive
patient assumine this position. . 1.11
movements. In cnudren,
according to Eustace Smith, pain in the head is indicated by a con-
traction of the brow; in the chest by a sharpness of the nostrils,
and in the abdomen by a drawing in of the upper Hp (Musser,
p. 79).
Patient's Description. — A patient's description of his suffer-
ings is not of much practical assistance in deciding upon the ■
severity of a pain, IHs descriptive ability, powers of imagination,
and vocabulary cause it to vary greatly. One factor of im-
portance is the persistence with which the attention of the patient
ESTIMATION OF THE INTENSITY OF PAIN 129
is devoted to the pain, to tlie exclusion of other topics. Should
he be consistent, and persist in his statements of its character and
severity, and should his attention be not easily drn\vn away or
Fig. 40. — Pain on Hyper extension
OF THE Body.
Hyperextension of the body produces
pain in inflammalioa of the ab-
dominal viscera, adhesions, peri-
tonitis, etc.
occupied to the exchiaion of the
pain, it may be concluded that a
pain of considerable intensity is
present.
Heohanical Factors. — Pinching,
chanical factors which are of slight
gree of pain or tenderness. Those
Fig. 41. — Pain on Going Up-
stairs.
When, on going upstairs, pain is
present in the right limb, it in*
dicatCB appendiceal abscess or
pelvic inflammation, and is
due to the tension of the
psoas muscle producing pres-
sure or traction on the in-
flamed area. The pain is
greatest at the moment of
raising the foot off the ground
slrokinfi, pressing are me-
value in determining the de-
are of little value because of
130 THE INTENSITY OF PAIN
the variations, both of pressure and of the resistance of the
patient. The best mechanical aids are electricity, the von Frey
hairs, algometers, and needles.
In testing pain by means of electricity, two electrodes are
used. They should be about the size of a knitting needle, and are
placed from one to two cm. apart. In the following table, taken
from Bernhardt, the figures showing the distances of the cylinders
of the induction apparatus represent the minima of sensation, and
the figures in parentheses represent the minima of pain in a
healthy person :
Tip of the tongue 17.5 (14.1)
Palate 16.7 (13.9)
Tip of the nose, eyelids, back of
tongue, gums, lips 14.8 — 14.4 (13 — 12.5)
Acromion, sternum, nape of neck.. 13. 7 — 13 (11.5 — 12.2)
Back of the arm, buttocks, occiput,
loin, neck, forearm, vertex, coccyx,
thigh, back of the first phalanx,
back of the foot 12.8—12 (12 — 9.2)
Back of the second phalanx, back of
the metacarpal bone, back of the
hand, leg, distal phalanx, knee. . .11.7 — 11.3 (10.2 — 8.7)
Palmar aspect of the head of the
metacarpal bone, tip of the toe,
palm of the hand, palmar aspect of
second phalanx, hypothenar emi-
nence, plantar aspect of the first
metatarsal bone 10.9—10.2 ( 8 — 4 )
These tables are of value in that they enable one to compare
the relative sensibility of the different areas. Any decrease in
the distance of the cylinders would indicate, of course, an increase
in the sensitiveness of the part.
Von Frey's hairs, also used in the estimation of sensibility,
are hairs which have been so selected that they bend at different
ESTIMATION OF THE INTENSITY OF PAIN 131
pressures. They are fastened to a small wooden rod at right
angles. Previous to use, the weight necessary to cause them to
bend is ascertained.
In Head and Thompson's experiments, hairs sent by von
Frey were used. Xo. 8 would bend at 830 mgms. pressure ; No.
5 would bend at 360 mgms. pressure; No. 4 would bend at 230
mgms. pressure; and No. 2 would bend at 100 mgms. pressure.
In the intervals between use, they should be kept in a box, with
the rods supported in such a manner that the hairs do not come
in contact with anything (Head and Thompson, 206, p. 642).
Algbmeters have been described by Head and others. A
pointed instrument (as a needle) is made to press against the skin,
and the amount of pressure is indicated by a scale which is
attached to a resisting spring. This is the manner in which most
of these instruments work. They are of considerable value, but
are not yet in general use.
Needles and pins are also employed in estimating sensibility,
but their use involves several drawbacks. First, the pressure
exerted by them is variable and cannot be controlled. Second,
the sense of touch is apt to be confused with the feeling of pain.
To avoid the latter, it is well to precede the pin with the tip of
the finger, so that touch may be felt first, and later hyperalgesia,
if the sensibility is increased.
In making a thorough sensory examination according to Head's
methods the following rules should be observed : Have the patient
in an easy position and see that he is without physical discomfort,
i.e., that the bladder and rectum are empty, and that he is neither
hungry nor thirsty. The time of day best suited to the examina-
tion is morning, when the patient has not entered upon the work
and worry of the day. Weather conditions, also, are of some im-
portance. A bright, sunshiny day will bring more uniform and
reliable results than an examination upon a dismal day. The
surroundings must also be propitious. The room must be quiet,
and no loud noises or talking should be permitted in the immediate
vicinity. Above all, in testing the sensibility of a part, screen it
from the observation of the patient. At the time of the examina-
132 THE INTENSITY OF PAIN
tion the external temperature should be warm, for anything which
produces goose-flesh detracts from the value of the results.
During an examination for sensibility both sides of the body
should be compared. If a certain organ has been decided upon as
the cause of the pain phenomenon it is necessary, in order to be
sure that the decision is accurate, to reproduce the pain by trac-
tion, pressure or manipulation of the organ. Should the proper
organ be engaged, a reproduction of the pain will result. Unless
this can be done, and in the absence of definite pathology, it is
not wise to make too positive a diagnosis. On forming a conclu-
sion, one should not forget that the ventral aspect is less sensitive
than the lateral aspect, and the lateral aspect less sensitive than
the dorsal aspect of the body.
The sensations allied to pain having their basic principles in
touch sensation are: (1) pleasant sensations; (2) agreeable sen-
sations; (3) normal quiescent states; (4) disagreeable sensations;
(5) pain sensations. At one end of the series we have pleasure,
and at the other pain, while between the two we have all degrees
of pleasant and unpleasant sensations. As the sensation becomes
exaggerated at either end, we have a condition of unendurable-
ness, for intense pleasure is just as unendurable as intense pain,
and both manifest their intensity by promptly causing uncon-
sciousness, from which the patient awakes, generally after the
passing or subsidence of the causative sensation. Sometimes, fol-
lowing unconsciousness from pain, the patient awakes, and, the
pain being present, may become unconscious again. This pro-
cedure may be repeated many times, until finally the pain-per-
ceptive centers become fatigued or the pain disappears.
CONDITIONS ASSOCIATED WITH SEVERE PAIN
Associated with severe pain are certain symptoms which
indicate to us the vast influence which a severe subjective con-
scious irritation may produce upon the physical entity. With
extremely severe pain there are often syn^ptoms of collapse, such
as cold sweats, weak pulse, and an anxious look. These are prac-
CONDITIONS ASSOCIATED WITH SEVERE PAIN 133
tically tlie same phenomena as those which accompany any great
emotion, such as fear, in which, owing to the induced fright, a
vasomotor collapse takes place, the patient faints and is cold and
clammy, with weak and very often rapid pulse. Happiness is
also potent to cause somewhat the same condition, for we all know
of the state of a man fainting from joy. In fact, in any great
emotional exaltation a temporary loss of consciousness may occur,
as in the sexual act, where in some cases the irritation to the
glans or clitoris may produce such a succession of imi)ulses that
the receptive centers are overcome from the unaccustomed fre-
quency and a temporary loss of consciousness results. The cause
of this unconsciousness may be that the stimuli which are trans-
mitted to the refraction center are referred to the periphery, and
cause a vasomotor paresis which gives rise to lessened circulation
in the brain. ^ As soon as unconsciousness occurs, the sensory per-
ception is lost and the peripheral impulses to the vasomotors cease.
The patient now regains consciousness, and is able again to per-
ceive the exaggerated impulses (pain), whereupon he promptly
relapses into unconsciousness. Thus an almost endless cycle is
formed. The same phenomena occur in the case of extreme fear.
Cases are quite common in which persons, who have become un-
conscious at the sight of some grewsome object, are, on recovering,
rendered unconscious a second time at the sight of the same
object.
It is amazing how much one can suffer and still show no signs
of it by physical deterioration. It is certain that every practi-
tioner has seen sufferers from the most severe and constant neural-
gias who are robust, and otherwise seem to be in perfect health.
* According to Gowers ("Clinical Lectures," third series, p. 7), sudden,
intense pain, especially if felt in the abdomen or in the vicinity of the heart,
may produce unconsciousness. The mechanism is supposed to be a direct action
on the centers of the vagus, but syncope (unconsciousness) is only known to
result if the pain is perceived. In man a cause of pain adequate to produce
syncope, while the patient is under the influence of an anesthetic, has not been
known. Hence, it seems doubtful whether the effect is due to a direct action
on the vagal center. The facts suggest that it may be the result of a profound
influence on the sensory regions of the cortex, focused on the cardiac center in
the medulla.
134 THE INTENSITY OF PAIN
After long periods the sufferer seems to acquire a tolerance for
pain, so that he can, with a minimum of discomfort, withstand
very severe attacks. On the other hand, all have seen cases in
which the constant, steady and increasing pains of tubercular
disease, trigeminal neuralgias, etc., have, completely exhausted
the patient, so that he has become thin, haggard, careworn and
prematurely gray. In many cases worry and mental anxiety seem
to have as much to do with the deterioration in physical charac-
teristics of the patient as does the original pain. While the pain
may not produce any apparent physical disturbance, the mental
disturbances are manifold and remain more or less persistent even
after the pain has entirely ceased. These mental changes are
shown in irritability of temper, neurasthenia, etc.
Bespiratory System. — During severe pain the respiration, as
a rule, is increased, and at the same time becomes very shallow.
If the pain is due to inflanmaatory lesions in the abdomen, tho
breathing is of the costal type, while if it is due to disease of the
thorax, the breathing is principally abdominal in character, and
the chest is fixed as though it were in splints. These conditions
exist even when the patient is unconscious, showing that they arc
reflex acts and not in any way the result of inhibitory voluntary
action.
Circulation. — An acute pain is almost always associated with
an increase of the pulse rate, while a chronic pain is not so fre-
quently associated with rapidity of the pulse.
Loss of Eqnilibrinm. — Pain may be so severe that a loss of
equilibrium may result, as in the case reported by Erdman (Medi-
cal Record, 1906, Vol. 69, p. 94), of a girl thirty-two years old,
who, while at Mass, was taken with sudden, excruciating pain in
the abdomen. Although she fell, she did not become unconscious.
This loss of equilibrium may have been due to the fact that the
stimulus produced by the pain was so great that it monopolized
the entire sensorium, so that the equilibrizing perceptions from the
sight, the aural, and the remaining peripheral senses were not
perceived.
Trophic Cliaiiges. — Certain disturbances in niiscles, joints
METHOD OF RECORDING PAIN 135
and bones may be associated with pain. These disturbances are
either (1) functional or (2) metabolic.
Both result in atrophy; the first the so-called atrophy of dis-
use, which results from inactivity caused by the pain, and the
other an atrophy due to lack of metabolic interchange in the cells
of the part. This metabolic disturbance may be in the nature
of a lack of constructive power, or an increase of destructive
change. In either case, the final result is a wasting and a diminu-
tion in the power of the muscle.
Preprotective Functions. — Associated with pain is what may
be called the preprotective function, as exemplified in stom-
ach disease, when the skin over the epigastrium, as well as the
upper segment of the rectus abdominus, becomes somewhat tender.
At the same time the rectus is in a state of partial contraction, and
acts as a guardian, even before danger threatens. But as soon as
pressure is exerted upon it the muscle hardens, and the pain, which
may have been light before, now becomes acute. This illustrates
how weU designed is the protection of the viscera, for if the stom-
ach itself were sensitive violence would reach and injure it before
pain could be experienced; but by the interposition of sensitive
structures, which are coupled to a powerful muscular reflex exter-
nal to the stomach, the diseased organ is effectually guarded
against external violence.
Elevation of Temperature. — There is no doubt that elevation
of temperature is frequently produced by pain. There also is a
close relationship between the conducting paths for pain and for
those of the special senses, for hemianesthesia is sometimes ac-
companied by impairment of the senses of smell, taste, and hear-
ing, and amblyopia is sometimes associated with concentric con-
traction of the visual field on the same side of the body.
METHOD OF RECORDING PAIN
For a thorough and productive study of pain it is necessary
that some reliable and simple means of recording pain phenomena
should be found. This condition seemingly has been met by
136
THE INTENSITY OF PAIN
Harris (84), whose method is one of the best, and, at the same
time, the simplest that has so far been devised.
In his marking code, four primary characters are used: (1)
a simple, unbroken line; (2) a broken line, or dashes; (3) a dot;
and (4) a dot and dash. After the fourth marking Arabic
0 I
I-
0:
k.
V^
u
i
Or
D
8
J
X
I
X
c « f I
^
Q:
r
u
ONE.
TV#0
/
^ ^
• • •
THIWe • tt
• • •
• • •
• 7
• 7 •
• -, •
' A *
•o
M
••••i»
• tt •
• • •
• IS •
CHART B
Fig. 42. — Marking Code of Dr. Harris.
numerals are used to indicate areas, centers, and radiations of
pain, the numeral being placed at the point of the most intense
pain and also on the line inclosing the pain area or indicating the
pain radiation. Thus it may be seen that the primary characters
can only be used in every fourth marking, but that the number
of markings may be multiplied indefinitely. Figure 43 illustrates
this.
"Figure I, in Fig. 43, shows the first marking upon a patient,
who we assume complained of a painful area, a center pain within
the area, and a radiatiou of pain. It will be seen that the area of
pain, its more- painful center, and the radiation of pain from the
area of pain are constructed from the first primary character.
"Figure II, in Fig. 43, shows the second marking upon the
patient who complained of a painful area with a more painful
point within, which we designated as a center pain. The boun-
METHOD OT RECORDING PAIN
137
Fig. I
(
V
J
V ^ ^
Fig. n
F19. m
•
•
\
1 \
•
—•—•—»-'• F19. IV
(
S
^ Fii^. Y
/
/
\
\
\
\
/
/
. - "^ Fuj.Vt
5f . ^ ^v^ ^ ^ ^ ^ ^-^ \, • • ^ * «x^
r* ^
Fig.Vn
>^^_/ R9. vra
Q..
^ s
V N. _ -*
> »
w ^
F19. IX
•
^^ / R9. X
Fig. 43. — Figures Showing the Appucation of the Marking Code of
Dr. Harris.
dary of the painful area is formed from the second primary char-
acter, as is also its center of pain shown by the Greek cross.
"Figure III, in Fig. 43, shows the third marking upon the
patient who complained of simply a painful point. The four dots
138 THE INTENSITY OF PAIN
arranged in equi-latero-quadrangular formation show the manner
of marking a painful point or a center of pain from the third
primary character.
"Figure IV, in Fig. 43, shows the fourth marking upon the
patient, illustrating a painful area and a center of pain. The
markings are constructed by using the dot and dash, which consti-
tute the fourth primary character.
"Figure V, in Fig. 43, demonstrates a painful area and a
center pain.
"Figure VI, in Fig. 43, shows the sixth marking. The dashes
are employed, as in the case of the second marking, but here the
insertion of the Arabic numeral 6 indicates the number of the
marking.
"In Figure VII, in Fig. 43, the Arabic numeral at the begin-
ning of the dotted line shows the painful point, and the dotted
line indicates the direction of radiation.
"In Figure VIII, in Fig. 43, the boundary of the pain area is
constructed from the fourth primary character, the insertion
of the numeral 8 distinguishing it from the fourth marking.
The location of the figure 8 at three different points indicates
the location of the pain at three distinct points.
"The Arabic numeral 9 in the ninth marking of the patient
indicates a painful point, while the continuous arrowed line, con-
structed from the first primary character, illustrates a radiation
of pain from the marked painful point.
"Figure X, in Fig. 43, shows a recurrence of pain in the
same region as shown by the second marking of the patient In
this tenth marking of the patient the boundary of the area of
pain is constructed from the second primary character. The
number 10 in the outer boundary line of the area distinguishes
this boundary line from the boundary line of the second marking,
which occurred in the same region having a longer and narrower
area. The number 10 in this tenth marking shows the location
of the center of pain, and distinguishes it from the center of
pain indicated by the Greek cross of the second marking of this
patient."
METHOD OF RECORDING PAIN 139
A permanent record may be made on the patient^s chart by
transferring the outlines on the patient's body to a stamped figure,
being careful that the relative positions of the outlines correspond
both with the bony landmarks on the figure and on the patient's
body.
CHAPTER VIII
PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
The nervous system, since it is the carrier of impulses from
one portion of the body to another, and since its organization is
much more delicate than that of any other structure of the body,
suffers from disturbances, which, when affecting the sensory ele-
ments, are, as a rule, announced by pain. For systematic consid-
eration the following divisions may be made: (1) nerve terminals;
(2) nerves or nerve trunks; (3) nerve plexuses; (4) nerve roots;
(5) cord lesions; and (6) pontine, mid-brain and cortical
lesions.
AFFECTIONS OF THE NERVE TERIOINALS AND NERVE
TRT7NES
Affections of the nerve receptors are due, as a rule, either to
inflammation, to toxemia, or to pressure. These have been con-
sidered in part in the section on parenchymatous pain (q. v.).
Affections of the nerves or nerve trunks are due, as a rule, to
the following causes: (a) congestion; (b) inflammation; (c) in-
jury (traumatism, pressure) ; and (d) toxemia. The milder
grades may, for purposes of convenience, be termed neuralgias;
the more severe affections, neuritis.
The distinctions between neuralgia and neuritis are quantita-
tive rather than qualitative. It is largely a matter of degree. A
severe neuralgia may be termed a neuritis ; a mild neuritis a neu-
ralgia. We cannot, therefore, insist upon a separation of the two
conditions. One finds one or all of the causes operative in pro-
ducing either a neuralgia or a neuritis and the resulting lesion de-
140
AFFECTIONS OF THE NERVE TERMINALS 141
pends largely upon the severity of the action of the exciting factor.
Thus exposure to cold may set up a neuralgia in the facial from
involvement of its sensory roots (the geniculate ganglion), or it
may cause a true neuritis, involving the motor components, as well.
Similarly an inflammatory reaction in* a mixed nerve may cause
only slight pain, the sensory components being involved but
slightly, or it will bring about both sensory and motor disturbances
with distinct neuritis symptoms ; slight traumata, as well as tox-
emias, cause quite similar pictures.
Certain meningeal diseases of the cord, as well as ganglion
affections, give rise to exquisite neuralgic symptoms without any
of the usual motor complexities of a neuritis.
We shall here discuss the so-called neuralgia, although it
should be remembered by the reader that one is continually stray-
ing into the field of neuritis.
Anstie, in his classical work on "Neuralgia and the Diseases
Which Eesemble It" (1871), gave one of the first English presen-
tations of the general subject Bernhardt, in NothnagePs large
system, has given the most extensive of recent discussions of the
whole subject. However, he was incorrect in regarding neuralgia
as a separate entity. It should not be so regarded, with the pos-
sible exception of a few conditions, for instance, those which
cause such a change in the conducting apparatus that a light
stimulus is interpreted as painful, or pain is produced without
any apparent stimulus. Such a condition may follow slight chill-
ing of the surface, or the lodgment in the nerve or its sheath of
toxic substances, either heterotoxic (phosphorus or mercury), or
autoxic, the result of deranged metabolism. Such a condition is
present in influenza, and also in old age, when, because of im-
paired circulation, the tissues are not properly nourished. To
these pains the term neuralgia may be applied. As early as 1873,^
Loomis also applied the term to conditions in which there is a
disturbance of nutrition. Neuralgia seems to be without recog-
nizable pathology ; at least, no uniformity exists as to the kind of
pathology which is present By some it is thought to be a form of
1 Loomis, Med. Becord, N. Y., 1873, p. 473.
142 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
neuritis (neuritis of the nervi nervorum, Thompson, 352), but it
differs considerably from neuritis in its pain phenomena.
Etiology. — By many authors neuralgia is the name given to
a nerve-pain which is produced by any of the following causes :
Exciting Causes. — Intraneural, in which the exciting cause
is found in the nerve fiber or its central origin. This cause may,
in many cases, be the presence of toxic materials producing irri-
tation and pain somewhat akin to the action of rheumatic poisons
in rheumatic myalgia, in which the poisons act upon the terminal
filaments of the sensory nerves distributed to the muscles. Under
this heading we would include all those pains of infectious origin
which do not result definitely from an inflammatory change in
the nerves, such as occur in acute infectious diseases (influenza,
tonsillitis, common colds), malaria, gout, nephritis, anemia
(chlorosis), diabetes, syphilis, typhoid fever, small pox, constipa-
tion, and gonorrhea. Many consider copper, lead, arsenic, alco-
hol, nicotin, and mercury causes of neuralgia; others class them
rather as irritant poisons with the production of neuritis. Other
causes are molecular changes in the nerve itself, the character of
which we do not know, although many regard them as a mild de-
gree of inflammation. Also included under the heading of mole-
cular disturbance pain are pain caused by exposure to cold (we
are all aware of the headache produced by going against the wind
on a cold day) and post-hoc-neuralgia, a term given to those con-
ditions in which, following the removal of the cause of the neu-
ralgia, there is a persistence of the pain, due, perhaps, to continued
molecular change in the nerve substance or ganglion, which time
alone can, but does not always remove. As an instance of this
may be mentioned the pain persisting after removal of gall stones,
after the removal of carious teeth, and after cure of a gastric ulcer.
Sometimes these are called "habit pains" (q.v.).
Extraneural, under which we would include pressure by new
growths, tumors, or bony processes, by foreign bodies, soft tissues,
glands, bone (especially when the nerves pass through bony fora-
men), cicatrices, misplaced viscera, hernia, aneurysms, enlarged
uterus, etc., upon the nerve.
AFFECTIONS OF THE NERVE TERMINALS 143
Traumatism, 8uch as injury of the nerve by a blow, by forcible
contact with a foreign body, by the pinching of a nerve between
two bones, as pinching of the intercostal nerves between two adja-
cent ribs. Fractures by pressure from fragments, or from the
callus, cause nerve pain. Dislocation of a bone may also cause
pain.
Infection has been mentioned as one of the causes, and perhaps
it is the chief one. Cases of epidemic intercostal and of supra-
orbital neuralgia have been described, as well as the neuralgia
associated with typhoid fever and rheumatism. It is reasonable
to suppose that the infective germs can lodge and grow in nerves
as well as in blood and interstitial tissues, for it has been defi-
nitely proven by many observers that typhoid fever germs are,
in the later stages of the disease, freely circulating in the blood.
Pneumococci, streptococci, and various other germs have also been
isolated in pure culture from the blood; and these wandering
hither and thither in the tissues locate themselves where there is
the least resistance, be this in bone, tendon, nerve, or muscle.
Should the nerve be the habitat, a mild neuritis is produced
and this causes pain.
Predisposing factobs leading to the production of neuralgia
are inherited predisposition, the use of alcohol, tobacco and
drugs, neurasthenia, and excessive sexual indulgence. Age seems
also to act as a predisposing factor, those of advanced age being
more susceptible than those who are younger. The other so-called
pains are classified under referred, projected, sympathetic pain,
et ceterUf under which they will be described (q. v.).
Symptoms. — In the case of pain occupying any restricted
area it is well to make an examination for local inflammatory
changes in the skin and subjacent tissues. Should they be absent,
with the skin very sensitive to light pressure and the deeper tissues
not so sensitive, we may conclude that the cause of the pain is
either a neuralgia or a neuritis.
If neuralgia is present there are points of hyperesthesia and
the course of the nerv^e is not painful to pressure, while in neuritis
the course of the nerve is tender to pressure, and there are no
144 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
painful points. Should neuralgia be suspected, we must seek
the cause, and consider acute infections, reflex irritations, as the
cephalgias due to visceral disorders ; referred pain, as earache due
to decayed teeth; projected pain, as in the head after Gasserian
ganglion resection, and sympathetic pain, when one sensory center
is affected by changes in another center, and pain is felt as coming
from the area of distribution of nerves arising in this center.
The pain of neuralgia may be constant and dull, or there may
be periods of freedom from pain and then times of sudden and
severe pain. These paroxysms of pain occur at intervals varying
from a few seconds to as many weeks. The duration of an indi-
vidual paroxysm varies from a few seconds to as many minutes.
Sometimes, after the pain reaches its acme it becomes almost con-
tinuous and may last for weeks. The onset in many cases seems
to be without any causal condition, and may be sudden or grad-
ual. Abortive attacks may come quickly and quickly disappear.
Sensations of cold, itching, and numbness in the areas of the skin,
which subsequently are affected by the neuralgia, are premoni-
tory signs of an attack. The pains are of a burning, darting, bor-
ing, cutting, piercing, biting, or pulling character. In some cases
there is an intermittency in the paroxysms, whiqh may come every
day or every second or third day. When this occurs examine for
malaria. The pain generally follows the course of a peripheral
nerve. It may remain confined to one nerve area throughout its
course, or it may suddenly shift from one area to another. At
times it is confined to a small area, but most often it radiates
through large areas and may run toward the periphery (neural-
gia descendens), or from the periphery inward toward the cen-
ters (neuralgia ascendens).
Anesthesia dolorosa (q. v.) sometimes is present in these con-
ditions, especially when the nerve trunk is subject to pressure due
to an irritative lesion. In neuralgia tactile sensation also is some-
times lost.
Local Points. — Pressure points, first described in 1841 by
Valleix, are called Valleix's points. Light pressure on these points
sometimes aggravates the pain, while heavy pressure relieves it.
AFFECTIONS OF THE NERVE TERMINALS 145
In other cases the reverse is noticed. Pain may be elicited by pres-
sure with a single finger-tip.
The galvanic current sometimes produces pain when finger
pressure fails to produce it. (Technique: Place the positive pole
on any part of the body, preferably over some part of a nerve;
hold it stationary, and run the negative pole along the course
of the nerve.) In neuralgia Valleix's points are found at the
point of emergence of the nerve trunks, at sections where a nerve
trunk traverses a muscle to reach the skin, at the point where
a nerve fiber breaks up into branches, and at points where the
nerve becomes very superficial. The painful points along the
course of nerves in neuralgic affections may be due to irritation
of fine terminal-sensory filaments, which are distributed to the
sheath of the nerves (Jelliffe).
Distant Points, — "Points douloureux apophysaires" of Trous-
seau, or distant painful points, are also found in neuralgia.
These are located in the spinous processes of the vertebra, be-
tween which the roots of the affected nerves leave the verte-
bral canal. The spinous processes in the region of the middle
cervical vertebra are very sensitive in neuralgia of the trigeminal
nerve.
While painful points vary greatly and sometimes are recog-
nized only at the time of the paroxysm, they may exist all the
time and become more painful only at the time of the paroxysm.
Pressure on the painful points may in one case produce an attack,
while in another case it may abort the attack. The effect is some-
times lessened, sometimes intensified, depending upon whether the
pressure is light or heavy. Light pressure sometimes produces a
paroxysm, while heavy pressure sometimes causes its disappear-
ance. After the neuralgia has existed a certain length of time,
atrophy of the nerve may occur and the pain may subside, espe-
cially when it is due to pressure along the course of the nerve.
Vasomotor Changes. — In acute and recent attacks, because of
the contraction of the vessels and stimulation of the vasomotor,
there may be at first pallor of the affected area, followed by flush-
ing. In chronic neuralgia there is chronic flushing, due to vaso-
146 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
motor paresis. In later attacks there is generally flushing of the
skin on the affected area. In trigeminal neuralgia there may be a
pulsation of the temporal artery on the affected side. In some
cases a swelling of the affected side occurs, and this in time leads
to chronic thickening.
Trophic Changes. — The skin is sometimes thicker than nor-
mal; or, as a rarer condition, it may be thinner, due to cutaneous
atrophy. The hair on the affected side of head in trigeminal neu-
ralgia sometimes becomes coarse or rough, and falls out, or it may
become gray. Areas of gray hair may alternate with the natural-
colored hair. In some cases the hair grows profusely. Other
changes, as herpes, desquamation, eczema, and pemphigus, are
fairly common. The secretory and excretory apparatus are also
affected. Saliva and tears are often increased on the affected side
in trigeminal neuralgia. Sweating is common over the affected
part, and urine is often excreted in abnormal amounts. The nas^l
secretion in a trifacial neuralgia is at times tinged with blood.
MiLsculur Changes. — Atrophy of the muscles on the affected
side is common. It is due to lack of motion, because of pain.
This is very slow of onset, and after a certain time remains sta-
tionary. Trophic muscular changes generally indicate a more
extensive involvement (protopathic system).
Muscular contractions occur ; at times they are clonic, at other
times tonic. Slowing of the heart's action has been observed dur-
ing a neuralgic attack. Movement is often impossible, because of
the irritation produced in the sensory nerves. Walking and flex-
ing of the thigh will often produce pain in cases of sciatica. Eat-
ing will frequently produce pain in cases of trigeminal neuralgia.
Pupils are often dilated, the dilatation being unequal. Associated
neuralgia may be present in some cases. Here the pain gradually
appears on the opposite side of the face, and may then entirely
disappear in the region where it commenced.
Duration of Neuralgia. — Sometimes the disease ends after
one or two attacks, or it may persist for long years, even for an
entire lifetime.
Diagnosis of Neuralgia. — Neuralgia can only be diagnosed
AFFECTIONS OF THE NERVE TERMINALS 147
by exclusion, and is only justifiable when all other causes having
an anatomical basis for the pain production have been excluded,
such as pressure from growths, inflammatory exudates, misplaced
fragments of bone, etc. The term neuralgia is often only a cloak
for ignorance. It indicates that the diagnostician has not been
able to localize the cause of the painful condition. It is the same
as calling a pain in the head headache, or a lesion of the heart
heart disease.
Differential diagnosis of neuralgia should be made from
painful muscular lesions. Here the muscle is tender to pressure,
and there are swelling and thickening. Pain never extends be-
yond the region of the muscle. Inflammation of the bones or
periosteum is also to be distinguished. Xn these there are swell-
ing and tenderness in the bones affected. Inflammation of the
joints sometimes is mistaken for neuralgia; it is differentiated
by the swelling and tenderness of the joints and the pain on mov-
ing them. Neuritis from a differential diagnostic standpoint
offers the greatest diflSculties. It is different from neuralgia, in
that neuralgia is but the name of the sensory condition, while
neuritis is the name of the pathological entity which is present.
Syphilitic Neuralgia, — This form of neuralgia, because of the
frequency with which it is entirely overlooked, merits separate
consideration. Neuralgia may occur during any of the three
stages of syphilis. During the first stage it is manifested princi-
pally by fugitive transitory pain over the entire body. It is
rather an aching than a well-defined pain. In the second stage,
the pain also is fugitive, is worse at night, and shows remarkable
improvement under syphilitic treatment ; while in the third stage
the pains are more fixed and are due to pressure from syphilitic
changes in the surrounding tissues (gumma, exostosis), or they are
produced by changes in the nerve itself, due to syphilitic processes
such as are found in locomotor ataxia.
Types of Neuralgia According to Localization. — The principal
types of neuralgia, according to localization, are: (1) trigeminal;
(2) brachial; (3) intercostal; (4) circumflex; (5) sciatic; (6)
peroneal; and (7) visceral.
148 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
Teioemisal Neuraloia (Tie Douloureux). — Neuralgia may
occur in any of the branches of the fifth nerve. In some cases
lesions have not been demonstrable, but in the majority of in-
stances some disease of tlie Gasserian ganglion has b<'en found in
intractable cases of tic douloureux.
Fio. 44. — Areas of Neuralgic Pain.
The first brtmch involvement is seen most oft«n by physicians; the second
and third division involvemeut are seen most frequently by dentists.
The dote indicate Valleix's points of tenderness in neuralgia of the
fifth nerve. The crosses indicate the points of tenderness in cervico-
occipital neuralgia.
The most important of the }>eripheral trigeminal pains due to
lesions of the nerve are in the teeth. In some cases the pain is
referred to areas supplied by a different branch of the nerve than
that which supplies the particular tooth. The reasons for this are
not known exactly. In other cases a central pain is referred to
the teeth. One of the moat frequent mistakes of dentists is to
consider a tic douloureux as being due to teeth disorders. The
result is the extraction of all the teeth for a lesion which really
is in the Gasserian ganglion.
AFFECTIONS OF THE NERVE TERMINALS 149
The nose in many cases acts as a primary cause for neuralgia
(referred pain) of the upper branch. Thompson mentions a case
of trigeminal neuralgia which was caused by a piece of necrosed
bone in the nose.
Lange calls attention to neuralgia being mistaken for incipient
tabes. Diagnostic differentiation in tabes is the lack of sensitive-
ness of the nerve trunks, and generally the simultaneous affection
of the trigeminal and occipital nerves. On the other hand, a tabes
may have its initial symptom in a trigeminal neuralgia.
Blair give3 the following as characteristics of trigeminal neu-
ralgia: (a) The pain is generally sudden in one branch of the
fifth nerve; (b) it is paroxysmal and always returns in the same
spot ; (c) it is spontaneous, or is produced by certain definite stim-
uli peculiar to the individual ; (d) no primary anesthesia is pres-
ent over the involved nerve; (e) there is no tenderness of the
trunks of the involved nerve.
When trigeminal neuralgia is present in any or all branches
of the fifth nerve, examine the branch involved from its area of
distribution to its point of emergence on the face. True trigemi-
nal neuralgia is due to a lesion of the Gasserian ganglion, and
should not be confused with the nerve pain arising from inflam-
mation of the nerves, tumors of the nerves, injury of the nerves,
pressure upon the nerves from new growths (as aneurysm of the
carotid artery), tuberculosis of the bony foramen through which
the different branches pass, gummata, and malignant growths. In
infectious diseases, as influenza, malaria, and typhoid fever,
the severest pain is felt at the supraorbital foramen (Schmidt).
The pain of trigeminal neuralgia is probably the most severe
of any to which man is heir. As a rule it is unilateral. When
at its worst the sufferer may cry out, roll, and toss in his agony.
With a constant, steady pain, there occur paroxysms of greater
severity, which are so intense that the patient would welcome any
event, even death itself, if it would relieve him. If the inferior
or middle branches are involved, eating becomes an utter impossi-
bility, and drinking is only accomplished with great distress. The
patient is in constant dread, for when the pain is somewhat les-
150 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
sened the slightest touch, even the vibration from a slammed door,
will again cause a paroxysm. These attacks last from a few
minutes or hours to several days.
Valleix's points, which are present, are described by Jelliffe:
(a) for the first division of the fifth nerve, as being located at
the supraorbital notch, the external angle of the upper lid, the
upper, outer aspect of the nose, and the globe of the eye ; and (b)
for the second division at the infraorbital notch, the molar bone,
opposite the upper last molar, at the outer angle of the mouth,
and on the roof of the mouth. The points of tenderness (c) in the
inferior maxillary involvement are just in front of the auditory
canal, the side of the tongue, the border of the chin, and Trous-
seau's points over the first and second cervical vertebral spines.
Brachial Neuralgia. — Brachial neuralgia, or neuritis, is
due to a lesion of the brachial plexus. The brachial plexus arises
from the anterior roots of the lower four cervical nerves and the
upper half of the first dorsal nerve. These then unite into trunks,
the fifth and sixth uniting to form the upper trunk, the seventh
nerve forming the middle trunk, and the eighth cervical and one-
half of first dorsal nerves uniting to form the lower trunk (Fig.
45). These trunks then divide into an anterior and a posterior
part, the anterior portion of the upper two trunks again uniting to
form the upper cord, and the posterior divisions of the upper and
middle trunk uniting to form the middle or posterior cord. The
inferior trunk continues as the inferior or lower cord. Each of
these cords is made up of both motor and sensory nerves.
The sensory cutaneous nerves arising from the upper cord of
the plexus are the musculocutaneous, from the fifth, sixth and
seventh cervical roots. Those arising from the lower or inner
cord are the lesser internal cutaneous, which arises from the first
dorsal ; the internal cutaneous, arising from the eighth cervical
and the first dorsal ; the ulnar, receiving its fibers from the eighth
cervical and first dorsal roots; and the meridian (inner head),
arising from the sixth, seventh, and eighth cervical and the first
dorsal nerves. From the middle cord arises the circumflex, re-
ceiving fibers from the seventh and eighth cervical ; and the mus-
AFFECTIONS OF THE NERVE TERMINALS 151
eulospiral, radial branches receivinp: fibers from the seventh, eighth
cervical and first dorsal roots. A lesion in any one of the cords
of the brachial plexus may produce pain in the area of distribution
Fig. 45.— Brachial Plexus.
of any of the nerves arising from it, A lesion on any of the
nerves derived from the brachial plexus will cause pain in the
area of distribution of the nerves involved. The areas of distribu-
PAIN IN niREASEfi OF THE NERVES, BRAIN, AND COED
Fia. 46.— Areas of Distribution of Nbkves Derived from the Brachial
Plexus.
tioii are shown in the accompanying figures (Figs. 46, 47).
Should the lesioii occur above the cords, and be in one of the trunka,
it is very easy to define it by referring to the figures showing the
Fio. 47. — Areas of Distribution of Nerves Derived frou the Brachial
Plexus.
AFFECTIONS OF THE NERVE TERMINALS
153
distribution areas of the nerves forming the brachial plexus. It
is only necessary to remember that the upper trunk is formed by
the fifth and sixth cervical, the middle trunk by the seventh cer-
vical, and the lower trunk by the eighth cervical and the first dor-
sal nerves. These figures (Figs. 46, 47) clearly show the areas
of pain in lesions of the different cervical nerves. The accompany-
ing outlines (compiled from Piersol and Gray) show the nerve
Posterior thoracic —
Suprascapular
External anterior tho-
racic
Internal anterior tho-
racic
Subscapular
Circumflex
Musculocutaneous . . .
Median
Lesser internal cuta-
neous
Internal cutaneous. . .
Ulnar
Circumflex
Musculospiral
5 cervical
5 cervical
5 cervical
5 cervical
5 cervical
5 cervical
5 cervical
6 cervical
6 cervical
6 cervical
6 cervical
6 cervical
6 cervical
6 cervical
6 cervical
6 cervical
7 cervical
7 cervical
7 cervical
7 cervical
7 cervical
7 cervical
7 cervical
8 cervical
8 cervical
8 cervical
8 cervical
8 cervical
8 cervical
8 cervical
8 cervical
8 cervical
8 cervical
1st D.
Ist D.
Ist D.
Ist D.
1st D.
1st D.
Ist D.
1st D.
roots from which the divisions of the brachial plexus are derived,
and are very useful in localizing neuritis, which affects both the
motor and the sensory fibers of the nerves involved.^
These primary distribution areas are represented in the out-
lines in such a manner that they clearly define the area of distri-
bution of the different nerves forming the brachial plexus. Dia-
1 The table may be used to define the cer\'ical nerve, root or cord zone in-
volved; for instance, suppose pain was felt on the ulnar side of the arm and
over the shoulder, on referring to the figure one sees that the pain is in the
area of distribution of the ulnar and circumfiex nerves, and on referring to
the table one sees that while the circumflex arises from the seventh and eighth
cervical and the first dorsal, the ulnar arises only from the eighth cervical and
first dorsal. The lesion may involve the seventh and eighth cervical, and the
first dorsal, but if it involves the first dorsal, the lesser internal cutaneous would
also be involved. Since it is not, the first dorsal must be excluded. Examina-
tion of the internal anterior thoracic will show whether the eighth cervical or
the seventh cervical are the ones affected. If it is involved in the pain phe-
nomena also the eighth cervical is the nerve affected.
154
AFFECTIONS OF THE NERVE TERMINALS 155
grammatic outlines of the distribution area of the cords compos-
ing the brachial plexus are shown in Figures 48-53, A lesion on
one of these nerves would produce a disturbance in the entire
distribution area of the nerve below the point involved.
FiQ. 49.— Areas of Distribution of the Diffebent Cords of the
Brachial Plexus.
The areas marked U are supplied by the upper cord. Those marked M by
the middle or posterior cord, while those marked L derive their supply
from the lower or inner cord. The area containing crossed lines and
marked U M is supplied by both the upper and lower cords.
When the pain is bilateral, and aiTecta the ureas of one or
more segments (see figure showing cord zone distributed) of the
cord, disease of the vertebra or tuberculosis should be looked for;
or, if it affects the cord itself, tabes should be sought The asso-
ciation of herpes indicates involvement of the posterior ganglia.
Unilateral pain occurring (a) within the boundaries of a par-
ticular cord-distribution area, (b) within the distribution area of
a cord trunk, or (c) of one of the cervical neires, or (d) even of
the nerves given off from the brachial plexus, shonhl always
156
/
I
Q 55
1 *-t
157
ISA PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
cause a !*earcli to he made for the lesion in the special nerve seg-
ment in which it ha-i been localized. Lesions causing such a condi-
tion are those producing pressure, aa axillary tumors, sarcoma,
aneurysm of the subclavian or axillary artery, abscess, and en-
largement of the cervical and axillar\' lymph glands. Owing to
the close relationship of the trunks and cords forming the brachial
plexus, it is very ■
unusual for one to
be affected to the
exclusion of the
others.
A method of
making pressure
on the brachial
plexus and so
causing pain to ap-
pear in the distri-
bution areas in-
volved is shown in
the figure.
All of the in-
stances given here
are not, in the
strict sense of the
Via. 54.— Method of Kucitinq Pain in Brach- . . r
., won , true cases of
lAL NeiiBALaiA.
neuralgia. The
term neuralgia should be used only to define those lesions of the
nerves giving rise to pain and in which there is no apparent pathol-
ogy. Such a condition is found in anemia and toxemia. In other
cases pain produced by ]>ressure is referred to the area of distribu-
tion of the nerve, and is a referred pain, while pain resulting from
an adjacent inflammation is due to a neuritis or to pressure from
the inflammatory exudate, lioth cases resemble referred pain ; but
since it is common to consider these pains under neuralgia, and
neuralgia itself means pain, they have been placed under this
beading. In cases in which inflammation is the cause of the
AFFECTIONS OF THE NERVE TERMINALS 159
neuralgia a considerable part of the local pain is as much the
result of the inflammatory invasion of the connective and muscu-
lar tissues of the affected part as it is of nerve involvement;
indeed, it is probable that every one of the above so-called neu-
ralgias will be found to be a neuritis.
The pain in brachialgia is similar to all other neuralgic affec-
tions. It generally occurs in sharp paroxysms, in the intervals
between which there is no pain ; yet, in some cases, the pain may
be constant, and of a dull, aching type. In all cases sharp
paroxysms of greater severity occur at regular intervals. In the
early stages of the disorder, the pain is a dull, generalized ach-
ing, and involves the entire arm; then, as the attack persists, it be-
comes localized to the distribution area of one or more of the
cords of the brachial plexus (page 155). The pain may be so
severe that the patient cannot sleep, and even though he should
momentarily doze he is awakened by sharp paroxysms of pain.
All sudden and forcible motions make the pain worse, but
gentle manipulation is painless. In brachial neuralgia, stretch-
ing of the arm causes pain in the region over the posterior
margin of the scapula. The paroxysms frequently come on
at night and it is nothing unusual for the patient to awake
in the morning suffering from arm pains of the greatest
intensity.
The attacks may last for a short time, a few minutes, or a
few hours ; then again, they may be present for weeks or months,
during which time the pain may be interrupted by periods of rest
or aggravated by paroxysms of great severity. An individual
attack lasts, on an average, almost two or three weeks. The pa-
tient seeks rest, and it is common to find him sitting in an arm-
chair, nursing the diseased arm with the sound one. In some
cases the patient lies down and places the arm across his chest
or abdomen.
Location of the Pain. — In brachial neuralgia the pain may in-
volve the entire arm, but generally only the upper part of the
arm and the shoulder are most severely affected. The reason for
this is that the circumflex and the internal cutaneous nerves sup-
160 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
ply the shoulders and the upper part of the arm, and are the most
subject to injury.
Should the pain be entirely above the shoulder, it is due to
involvement of the acromial and clavicular branches of the fourth
cervical. If the pain is over the shoulder, or is at its anterior and
outer aspect, it indicates involvement of the circumflex (Figure on
page 154). Since the shoulder joint is also supplied by the cir-
cumflex nerve, movement of the joint may cause pain in the dis-
tribution area of this nerve. If the circumflex is involved the pain
is confined to the cutaneous area of the distribution of this nerve ;
but should the pain be the result of a lesion of that part of the
cord from which the circumflex arises, the pain is felt also down
the arm in the area of distribution of the musculospiral nerve
which arises from the posterior cord in common with the circum-
flex. Should the pain in the area of distribution of the circum-
flex be associated with pain over the scapula, under the clavicle or
in the neck, it indicates that it is the fifth root which is involved.
In disease of this root pain may also extend down the arm in the
distribution of the musculocutaneous nerve.
Pain on the ulnar side of the arm, extending almost half-way
around and involving the hands and fingers, except the dorsal
and external surface of the thumb, the index finger, and the adja-
cent surfaces of the index and the ring fingers, indicates involve-
ment of the middle cord of the brachial plexus. Pain in the radial
side of the forearm generally indicates involvement of the upper
cord of the brachial plexus. Depending on the location of the
lesion, the muscles may or may not be involved. A square block
has been placed on the upper trunk of the brachial plexus, just
before it divides into the musculocutaneous, and the branch help-
ing to form the median. A lesion at this point would not disturb
the muscular and cutaneous supply of the nen^es given off above
this level, while the supply given below this portion would be
disturbed in the manner described above. By placing a block
on any part of the nerve, the resulting disturbance can easily be
ascertained.
In the early stages of brachialgia the pain is diffused over
AFFECTIONS OF THE NERVE TERMINALS 161
the entire arm, forearm and hand, and runs down into the fingers,
though it usually involves only the first, second and third fingers
(Dana). According to Dana, neuralgic pain in the forearm is
very rare.
Tenderness. — Neuralgia, in the absence of neuritis, causes
little or no tenderness along the course of the nerves, nor over the
site of the brachial plexus, though there are well-defined tender
areas in which points of maximal tenderness are located. Accord-
ing to Dana, these areas of maximal tenderness do not always
correspond with the tender points of Valleix. It is common for
patients to rub those tender areas with some form of liniment in
the endeavor to ease the pain. It is needless to say that this pro-
cedure is productive only of irritation and inflammation at the
site of the rubbing, without any alleviation of the pain. Others
engage masseurs, who put the patient through a course of treat-
ment, generally with a negative result, though in some cases they
irritate the nerves, and increase, instead of decrease, the pain.
The tender areas are located on the anterior and posterior
surface of the arm and shoulder. Those on the anterior surface
are found over the outer third of the clavicle and infraclavicular
fossa, over the deltoid, at the outer surface of the arm, over the
inner surface of the arm just above the elbow, over the middle of
the forearm, and (one) over the wrist (Growers). On the pos-
terior surface the areas are found over the scapula in the supra-
spinatous fossa, over the posterior margin of the scapula, over the
upper surface of the arm where the arm and the shoulder join,
over the middle of the arm, and over the middle part of the fore-
arm. The areas along the posterior margin of the scapula are in
close relation with the points of tenderness of occipital neuralgia.
They lie over the second and third cervical spines. They are also
closely related to the points of tenderness of cervicobrachial neu-
ralgia, which lie over the first or second dorsal spines (Trousseau),
and of brachial neuralgia, whose points of tenderness lie over
the third and fourth dorsal spines.
Associated symptoms may be present, but they are not com-
mon unless a neuritis is present. When that is present there are
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164 PAIN IN DISEASES OF THE NEEVES, BRAIN, AND CORD
generally some miiacnlar paralysis and atrophy. At first the elbow
jerk is a little exaggerated, and then becomes decreased, and anes-
thesia is absent In brachialgia these changes, if present at all,
are a later development. In the early stage no physical change
can bo noticed in the arm except a slight swelling and some flabbi-
neas of the tissues.
Circumflex Neuralgia. — Circumflex neuralgia is more com-
mon than one would naturally suppose, and of all neuralgias it is
probably the most frequently wrongly diagnosed, and often mis-
taken for rheuma-
tism of the shoul-
der joint. From
this it is to be dis-
tinguished by the
absence of swell-
ing in the joint,
the more or less
intermittent pain,
presence of exacer-
bations, etc. Per-
verted sensations
are also present,
as tingling, burn-
ing, and numb-
ness. Tenderness
over the deltoid
and teres muscles
Fig_^55.-Method of liLiLiTiNU the Points or -^ ^^g^^, ^^^ jg
Tenderness in Intercostal Neuralgia. '^ '
very severe over
the line of the ner\e. The causes of circumflex neuralgia, accord-
ing to Disna (598), are toxic materials (as arsenic), infections
(as tubennilosis), diabetes, rheumatism, gout, draughts, injury
to the shoulder, blows across the deltoid muscle, fracture of the
surgical neck of the humerus, and dislocation of the shoulder
joint
Intercostal Neuralgia, — Intercostal neuralgia occurs, eb a
AFFECTIONS OF THE NERVE TERMINALS
165
rule, rather suddenly, and comes on after exposure to cold, etc.
It appears in paroxysms, which are very severe while they last,
the pain seeming to extend around the chest. Any exposure to
cold excites a paroxysm. Pressure pain over the nerve is present,
and it is specially marked (a) near the spinous process of the
vertebra ; (b) near the mid-axillary line ; and (c) behind the left
margin of the sternum. Herpes zoster is frequently confused with
this condition. The pain may last from one to several days, then
gradually becomes less and less severe, and finally disappears.
Frequently after its disappearance a feeling of soreness remains.
Pleurisy without effusion is often confounded with intercostal
neuralgia. A point of difference is that in intercostal neuralgia
the pain increases when the patient bends over toward the affected
side, while in pleurisy the pain decreases (Schepelman, 24b, p.
1078).
Differential Diagnosis Between Intercostal Neuralgia
AND Pleurisy (Schepelman)
INTERCOSTAL NEURALGIA
Character
of Pain —
Radiation
of Pain —
Sticking, burning or
lancinating — paroxys-
mal.
Often to the inner side
of the arm.
Location of Pain — In intercostal spaces.
Pressure Points — (a) Near to the verte-
bra at the back of
origin of the inter-
costal nerves.
(b) Axillary line.
(c) Sternal line.
Pressure — Touch and pressure are
very painful on the
affected nerves.
DRY PLEURISY
Sticking and lanci-
nating, but occurs
on breathing.
None.
Over an infected area
of the pleura.
Over the infected
area of the pleura.
Painful over the area
of the diseased
pleura.
166 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
INTERCOSTAL NEURALGIA DRY PLEURISY
Oalvanization — Reduction of the pain. Xo change.
Herpes — Often occurs. None.
Rubbing Sounds — Absent Present.
{Friction Fremi-
tus)
Breathing, ) -.^. • p ^ tt ' ^ ^
^ C A ot so painful Very painful.
Coughing — \
Sciatica. — ^By many sciatica is thought to be a neuritis, while
others consider it a form of reference pain from some lesion, oc-
curring along the course of the sciatic nerve. In some cases the
sacroiliac joint becomes diseased ; and since the lumbo-sacral nerve
passes over it, any disturbance of the joint will affect the nerve.
Sometimes, also, a spicule of bone from an osteoarthritis of the
spine may press on the nerve. Pressure by a tuberculous abscess
will also cause this condition (Adams, 603). Sciatica often fol-
lows a fall or an injury, and is the result of infections, consti-
pation, sudden changes of temperature, etc. Women are less fre-
quently affected than men, in the proportion of one to four. It
is most frequent after the age of forty, and up to sixty years of
age (Duckworth, 604).
The Pain. — The pain is constant, with severe paroxysms,
which generally occur at night. At the time of the paroxysms
the pain is sharp and lancinating. Between the paroxysms it is
dull and aching. Frequently it comes on after exposure to cold,
or following an injury. As a rule it does not last longer than a
few months, though it may persist for a year. Because motion
increases the pain, the patient tries to ease the weight on the
affected side, and holds up the pelvis toward the sound side, thus
flexing the trunk toward the diseased side and producing a static
scoliosis.
Location of the Pain, — The pain is felt principally in the
back of the thigh, and runs down the leg, following the course of
the sciatic nerve. Sometimes it is over the sacral or lumbar
area. Frequently, on motion, pain is felt at the sciatic notch.
AFFECTIONS OF THE NERVE TERMINALS 167
The cause of this pain is the pressure of the nerve against the rim
of the sciatic notch by the inflamed and contracting pyriformia
muscle (Eashinger, 601). The tender points (Valleix'a points,
FiQ, 56. — Cutaneous Distribution Areas of thb Siaali. and Greater
Sciatic.
SS=Bmall sciatic; EP=extemal popliteal; PT=poBt tibial; S = sciatic; IS=
internal saphenous; EP and PT are branches of the great sciatic. These
drawings are composites from those given by Head and Thompson and
represent the areas in which sensation was lost after division of their
respective nerve supply, consequently they would also represent the
areas in which pain would be felt in any painful lesion of the nerve.
These areas correspond rather closely with those given by McKenzie (599).
according to Edinger) are located: (1) over the anterior superior
spine of the ilium; (2) in the center of the posterior surface of
the thi^; (3) just inferior to the lower margin of the gluteus
maximus; (4) in the middle of the calf of the leg; (5) under the
168 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
head of the fibula; and (6) in the popliteal space. Dana also
gives the back of the foot and the sciatic notch as points of ten-
derness. In pome cases the paifi is referred, and it is found in
the area of distribution of the sciatic nerve (see figure). Bruce
(502, p. 511) advances an original claim wben he states that
sciatica is due to disease of the hip joint. He has found wasting
of the gluteal muscles (59 per cent) and obliteration of the
gluteal folds (30 per ccni.) in nearly all the cases which he has
examined. Lameness was also most constantly present. Diag-
nostic of sciatica is pain running up the back of the thigh when
pressure is made on the posterior part of the knee with the leg
extended a little more than i right angle (Dana, from Gowers).
Kernig's sign is that hip motions are free as long as the knee is
flexed, but become limited if the leg is straightened and flexion
of the thigh is attempted. Sciatica should be diagnosed from
hip-joint disease, disease of the cord (tumors of the cauda equina^
Fig. 57. — Method of Euciting Pain in Sciatica.
new growths (sarcoma), lione formations, etc. Gordon (608)
reports two eases of tnmor of the sacrum which had beon mistaken
for sciatica. Tabes has sometimes bt^cn mistaken for sciatica, but
the presence of tlie knee jerk in sciatica will exclude tabes. In
relation to sciatica, Faber (616) mentions several eases, in which,
in addition to the sciatica, there was also present a well-marked
degree of adiposa dolorosa. After the reduction of the adipose
APTECTIONS OP THE NERVE TERMINALS 16»
tissue, the patients felt very much better. In cases of this kind,
patients may have at the same time well-developed symptoms of
both adiposn dolorosa and sciatica, and the one should not be
treated to the exclusion of the other. In all eases of sciatica
examine the pelvis carefully (per vagina and rectum) and the
hip-joint both bimanually and by the X-ray.
In Figure 57 is shown a method of eliciting pain in sciatica
by making pressure on the nerve as it emerges from the sciatic
notch.
Pla^jtae Neuealqia. — Plantar neuralgia is due to a lesion
of the plantar nerve, and anesthesia or paresthesia frequently ac-
companies the pain. In the accom-
panying figure the area of distribu- mt. pudm i h a.
tion of the nerve is outlined, and Bn.Fiuuriv. v
it ia in this area that the pain
occurs.
Morton's neuralgia, due to pres-
-tire on the digital branch of the
external plantar nerve, is found in
early stages of flat-foot disease.
In some cases of typhoid fever the
toes become very tender. This, ac-
cording to McCrae (607), ia due to
a local neuritis. It closely resembles
a plantar neuralgia. The first com-
plaint of the patient is of pain from
pressure of the bed-clothes.
Sacral oe Liimbar-cobd Ned-
RALoiA. — Sacral or lumbar-cord neu-
ralgia is betrayed by pain in practically the same regions as
Head has outlined as the distribution areas of the different cord
zones. In Kocher's figures the boundaries are, as a rule, held to
be somewhat too high, the true areas in reality being one or two
zones lower.
It is useless to reiterate what has been said in regard to lumbar
or sacral root neuralgia, because the symptoms are exactly similar
Fio. 58. — Distribution of
THE Plantar Nerves.
The plantar nerves are branches
of the tibial which is a
branch of the sciatic (modi-
fied from Cunningham's An-
atomy; also from Gerrish's
Anatomy).
170 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
to those found in brachial root neuralgia, to which the reader is
referred. With this reference, and by the aid of the accompany-
ing figures (Head zones; and Figs. 1889, 1890, Toldt), the reader
should be able clearly to differentiate this condition.
When a root or a root ganglion is involved, a continuous area
of the skin is always affected, even though the fibers derived from
this root unite with others to form a plexus. These regions of dis-
tribution overlap so that when a root is diseased, sensation (epi-
critic) is not completely destroyed over the entire area of the root
distribution (Tigerstedt). It is entirely absent only in a central
area. It increases gradually toward the periphery until it be-
comes normal in the areas of divStribution of the unaffected roots.
This border zone is not present, as a rule, for protopathic sensation.
For this the cord zones seem to be more definitely marked. There
is greater overlapping in the distribution of the nerve in the
peripheral part of a limb than in the proximal part (Buzzard,
"Brain," Vol. 25, p. 308). This is due to a spreading out of the
nerve fibers in the periphery of the limb. These border areas
react to a much greater degree than normal to painful stimuli, but
the strength of the stimulus to produce a reaction must be much
greater than that applied to normal skin.
In regard to loss of sensation. Head and Sherren say that "it
would seem that division (disease) of the posterior roots abolishes
sensation to prick over an area larger and more sharply defined
than that which becomes insensitive to light touch. Moreover, this
insensibility to prick is accompanied by an inability to appreciate
temperatures below 15° C. and above 60° C, although 40° C.
and 23° C. may appear definitely warm and cool." In lesions
of the peripheral nerves the opposite is the case, the epicritic sen-
sation lK»ing lost in a larger area than is the protopathie; i.e., the
sensation to fine touch was absent in a larger area than was the
sensation to prick (Head and Sherren, 244, pp. 310-311). Buz-
zard (613), in a case of injury to the cord roots, found the sensi-
bility to pain and temperature abolished, but the tactile sensibility
partially retained. When sensation returns, the first to recover is
the sensibility to prick, and to the more extreme degrees of heat
AFFECTIONS OF THE NERVE TERMINALS
171
and cold (Head and Sherren). In some cases lesions of the
posterior roots are present, and sensations are lost without the
patient being aware of their absence.
When the posterior ganglia are affected, herpes generally ac-
companies the neuralgia. When it is present, a copious eruption
of vesicles appears over the affected area. These, when they dry
up and desquamate, leave a brownish spot. The pain does not
disappear upon the disappearance of the eruption, but may con-
tinue for some time longer. A diagnostic sign of value in differ-
entiating cord lesions from root or nerve lesions is the dissociation
of sensation. When the cord is diseased, pain, touch, tempera-
ture, etc., may be individually or collectively abolished; but in
nerve lesions they are always collectively abolished (Sherren,
612).
The following is a differential diagnosis, compiled chiefly from
Sherren :
Cord Lesion.
Loss of pain perception.
Temperature sense is changed,
so that (a) sensibility to heat
may be abolished without any
change in respect to the sensi-
bility for cold (the inverse
may be the case) ; (b) all dis-
tinctions between the minor
and extreme degrees of tem-
perature are lost ; and (c)
"insensitiveness may be pres-
ent to all forms of heat and
cold, the lightest touch may
be felt, and discrimination of
the points of a pain may be
present.''
Peripheral Lesion.
Pain produced by excessive
pressure as long as there is
any touch sensation.
All sensations are affected, but
not to the same extent, the
epicritic being affected in a
greater area than is the proto-
pathic sensibility.
172 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
Cord Lesion.
Both superficial and deep touch
are usually unaffected, but
when absent they usually dis-
appear together.
The patient may have touch sen-
sation, but be unable to appre-
ciate pain^ heat and cold.
Peripheral Lesion.
Absent in a peripheral lesion.
Passive movement and position
of the limb are not apparent
to the patient.
Spasticity of muscles on the
same side below the level of
the lesion.
Paralysis and wasting of mus-
cles at level of the lesion.
Reflexes having origin below
the level of the lesion are in-
creased.
Pupillary reflex may be affected
if the lesion is in the cervical
cord, on account of affection
of the cervical sympathetic.
Muscle atrophy may not occur.
"Light touches over the distri-
bution area with cotton wool
are usually not appreciated,
though deep touch and pres-
sure evoke a response."
Passive movements and position
of the limb apparent.
No spasticity.
Paralysis of the muscles sup-
plied by the affected nerve.
Reflexes originating in the af-
fected area are decreased.
Pupillary reflex is not affected.
Muscular atrophy of the muscles
supplied by the affected nerve
is always present
CENTBAL NERVOUS SYSTEM'
The discussion of diseases of the central nervous system re-
quires a recapitulation of the normal anatomical relations, which
will be given, as briefly as possible, in the following paragraphs.
1 Written by Dr. Alfred Neuman, Vienna.
CENTRAL NERVOUS SYSTEM 173
It will be entered upon here only so far as appears necessary for
the understanding of the subject.
ANATOMY
The surface of the brain is supplied with furrows and convo-
lutions, which, though of many varieties, show a certain regularity
through which it is possible to differentiate them in every case.
A few of them have special importance, and will be more minutely
discussed.
The central convolutions on the convex side of the brain, the
paracentral lobe, and the median wall of the hemisphere with the
adjacent part of the frontal lobe, represent the motor region. Far-
thest below is the center for the facial and hypoglossus; in the
middle is found the center or centers for the movements of the
upper extremity; and in the uppermost third those for the move-
ment of the lower extremity of the opposite side of the body.
The centers innervating the musculature for the act of eating,
for talking, for trunk movements, and for the closure of the
eyes, are connected with the corresponding muscles of
both sides, so that in case of a unilateral destruction of a
center, the ability to perform these movements still per-
sists. The speech center occupies the posterior part of the
third frontal convolution, as well as the first temporal con-
volution. In right-handed individuals it lies in the left hemi-
sphere. In the third frontal convolution occurs the transforma-
tion of ideas into words. The motor speech center in the tem-
poral convolution is the seat for word sounds (sensory speech
center). The centers for the sensation coming from the body lie,
apparently, in the region of the motor centers, and, as it seems,
are practically identical with them. However, the entire poste-
rior central convolution^ as well as the parietal lobe, evidently be-
longs to the sensory sphere. The centers for vision lie in the oc-
cipital lobes, viz., in the fissure calcarina and in the cuneus, per-
haps, also, in the neighboring adjacent portions of the lingual
globe. The recollections of sensations of sight (the field for optic
memory) are said to lie on the convexity of the occipital lobe.
174 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
The olfactory center is supposed to lie in the gyrus hippocampus
and uncinatus. The auditory center occupies the upper convolu-
tions of the temporal lobe. From these centers, on the one hand,
pass the centrifu<]^ally conducting fibers to the periphery; on the
other hand the centripetal conducting fibers enter them. Of
course, it is neither possible nor necessary to discuss all the con-
ducting tracts ; only the two most important ones will be discussed
here.
Passing inward and downward from the motor centers, the
motor fibers are gathered in the posterior limb of the internal
capsule, near the knee. They pass then into the brain peduncle,
and from here the central portion passes through the pons into
the medulla oblongata, where a part undergoes decussation and
enters the lateral column of the spinal cord, from whence it goes
over into the anterior roots of the peripheral nerves. The smaller
part, non-decussated, descends in the anterior column of the spinal
ccird, and undergoes partial decussation farther below, and finally
enters tlie anterior roots.
The fibers for the motor nerves, which spring from regions
lying adjacent to each other, run to the capsule in front of the
pyramidal tract, decussate in the pons and in the medulla, and
reach the corresponding nuclei.
The course of the sensory conducting fibers is more complicated,
but it shows in many respects a resemblance to that of the pyram-
idal fibers. These sensory fibers, entering through the posterior
roots, run for a part of the time (uncrossed) in the funiculus
gracilis and cuneatus to their nuclei, also to the nucleus of the
funiculus gracilis and the nucleus of the funiculi cuneati in the
posterior surface of the fourth ventricle. From here they pass
through the fibers of the arciformis internis, between the olives,
to the opposite side (lemniscus decussation), which lies above the
pyramidal decussation. One other [)art of the sensory fibers which
ascends in the ground bundle of the anterior and lateral colunms
of the cord, and has previously crossed, joins with the first ones,
after their crossing, and then again enters in common with them
and passes through the crest of the peduncle to the brain cortex,
CENTRAL NERVOUS SYSTEM 175
on the way undergoing, in the optic thalamus, another interrup-
tion by relaying cells. Besides this, on the part of the lemniscus
tract (the median), there is another portion, namely, the lateral
lemniscus, which is composed of the fibers of the acousticus and
the sensory fibers of the cranial nerves, and which lies more later-
ally. It also arises in the upper half of the pons, out of a collec-
tion of ganglia which communicate with the corresponding sensory
cranial nerves, and passes, partly decussated, into the corpora
quadrigemina, and from thence to the cortex.
The pains which are due to diseases of the nervous system or
its sheath are localized, on the one hand, in the head, in affections
of the brain, and on the other hand in the back and the extremi-
ties in diseases of the spinal cord, f Exceptions to this general rule
occur. Thus, there are pains radiating into the extremities in
affections of the sensory tracts in the brain (Edinger) and head-
ache in spinal-cord diseases (tabes, multiple sclerosis). Although
these exceptions are not very frequent, yet we cannot attribute
every headache to an affection of the brain substance, nor every
back pain to an affection of the spinal cord. Both symptoms also
belong to other diseased organs, and we are obliged to include in
our discussion those forms of headache, or of pain in the back,
which are caused by injuries which are indirectly elicited or pro-
duced by changes in the substance of the central nervous system
or their sheaths (through the circulation or by reflex means) ; for
instance, headache in anemia, constipation, abnormalities, or in
refractive errors of the eye.
ORIGIN OF HEADACHE
Now we should first ask ourselves where the sensations desig-
nated as headaches arise, and in which tissue layer they are local-
ized. It has been shown by clinical observations that both the
brain substance and all its sheaths may be the seat of the pain;
for instance, the outer skin, the aponeurotic layer of the cranial
muscle, the skull with the periosteum, the meninges, and the brain ?
itself. Concerning the membranes, it is seldom questioned that
pains can originate therein; indeed, frequently they have been
176 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
considered as the only bearers of headache, since they are supplied
with cerebrospinal nerve fibers, which seem alone to be capable
of pain conduction. The cortical origin of headaches, on the
ground of the observations of Lennander, would be declared im-
possible, because of his observation, by operation, that the brain
cortex may be sectioned without the patient feeling anything.
Because of this, all intracranial headaches were attributed to
irritation of the dura mater. Against this theory, Nothnagel ob-
jected that the mechanical irritation employed on the brain was
not suflScient to produce a reaction because another sort of irrita-
tion (toxic, infectious) was needed to produce pain, as the head-
aches from poisoning, infectious diseases, and anemia prove. L. R.
Miiller remarks, further, that symptoms of loss of function which
accompany migraine, as the shrinking of the field of vision, prove
that certain parts of the brain are functionless for a short time.
The observations of Oppenheim also speak in a very instructive
way, opposing the view that only the dura mater can be looked
upon as a source of pain, be it the result of direct or indirect irri-
tation, through the intervention of brain pressure.
Before it can be certain that pain which is felt as headache
may arise in the brain substance itself, we must know the nerves
which conduct these painful stimuli to the cortex. The only per-
ipheral nerves known to be present in the brain are of the sympa-
thetic system. If it could be shown that these fibers are able to
carry stimuli in a centripetal direction, we would be justified in
ascribing to the brain substance itself the power of originating
painful stimuli. The circumstances are similar in regard to the
sensibility of the abdominal organs. Here, also, are found nerves,
which, only with the vagus or with the sympathetic, enter into
the viscera. To both, only the motor functions were ascribed, and
therefore it was concluded that the viscera possess no special sensi-
bility.
However, it has been demonstrated that the sympathetic nerves
carry sensory filxTs which convey irritations from the viscera to
the central nervous system (Xeuman) ; and this removes the most
important objection to the acceptance of the idea that each organ
CENTRAL NERVOUS SYSTEM 177
possesses its own sensibility. The fact that the cerebral cortex is
insensitive to the touch of the fingers, or of instruments, only goes
to prove that it is insensitive save to these types of stimuli, which
never occur normally. Just as the eye receptors act for light
only, so there are probably receptors in the brain tissues which
react only to special forms of stimuli. Just what these are is not
as yet definitely known. The further conduction of the irritation
may then be described as being through the rami communicans into
the posterior roots and then through one of the above-described
sensory tracts over the cord back again to the cortical brain sub-
stance. The conduction of the painful irritation from the cover-
ings in diseases of the meninges, of the cranium, of the aponeu-
roses, or of the skin is over the trigeminus to the terminal cells of
the same in the mid-brain ; from there to the corpora quadrigemina,
to the thalamus, and finally to the brain cortex ; in a similar way,
by the upper cervical nerves through the median portion of the
lemniscus (Edinger).
Headache also appears as a symptom of disease of the brain
substance and the meninges, and in diseases which certainly
have nothing to do with these organs. As an example of the for-
mer may be mentioned the headaches of brain tumor or of menin-
gitis ; as an example of the latter, the so-called rheumatic or indu-
rative headache may be mentioned. Not only have we to con-
sider diseases of an organic nature, but also those in which purely
chemical substances cause molecular alterations, and thus, perhaps,
cause headaches. Uremia, the different metal poisonings, or the
infectious diseases are examples. Here, also, belong the headaches
of anemia, of congestive states, and possibly of migraine.^
In a similar manner, also, in the headaches of neurasthenia
or of hysteria, we must think of a hitherto undemonstrated change
in the central nervous system. The elicitation of pain through
mighty efforts, irritation or fright, as well as some accompanying
disturbances (for instance, dizziness), can hardly permit of an-
other explanation.
If we would, with the help of headaches, try to arrive at a
*This as yet has not been demonstrated. For another view, see pp. 189 and 190.
178 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
diagnosis of diseases of the brain and its membranes, we must
determine first whether they do not also occur in other dis-
eases, and, second, whether they possess certain special peculiari-
ties which would be characteristic of different diseases of the brain
or of the brain membranes. Unfortunately, we have no such cri-
teria. Keither are headaches limited to diseases of the central
nervous system ; nor are they of as many forms as their causes are
numerous. One can certainly say that there is no form of head-
ache which would be pathognomonic for a certain disease, with the
single exception, possibly, of a luetic headache. We must not per-
mit ourselves, in making a diagnosis, to be guided by the character
of the headache alone, but must utilize the other symptoms. Nev-
ertheless, in the character of the headache there are several pe-
culiarities, which, if they do not speak for a certain disease, may
still give a hint as to the nature of the trouble. Since, here, only
those forms of head pain come into question which are connected,
first of all, with diseases of the brain, or its membranes, all other
kinds of pain belonging to the symptom complex of other diseases
will be excluded.
Should headache be present, we must, in our diagnostic in-
vestigation, first search for disease of the outer coverings of the
central organ ; that is, of the bony skull, of the aponeurotic layer,
of the scalp muscle, and of the scalp itself. These are treated in
Chapter XIV. Should these be excluded the brain and its cover-
ing should next be examined.
HEADACHE IN DISEASE OP THE BRAIN AND MENINGES
Those diseases of the brain and the meninges in which head-
ache forms an essential part of the symptom complex now will
be described ; and in conclusion an analysis of these headaches will
be given.
First of all let us remember that not all pathological changes
of the central nervous system are accompanied by pain, and gross
lesions of the brain are found (post mortem) without the patient
having complained of headache. Therefore, an extensive dis-
turbance of the brain may occur, as in cerebral hemorrhage, with-
CENTRAL NERVOUS SYSTEM 179
out the patient making any complaint Even laceration may
occur so slowly that the patient either does not lose consciousness
or docs not at once become unconscious. The same is the case in
brain-softening, in encephalitis, in infantile cerebral palsy, in
general paresis, etc. Nevertheless, headaches are also found in
the course of these diseases, either as a prodromal sign, as in
hemorrhage, or in the later stages ; but they are not characteristic
of the disease.
In other diseases, however, headache forms an important symp-
tom. Here must be included pachymeningitis interna, leptomen-
ingitis, brain-abscess, brain tumor, aneurysm of brain arteries,
syphilitic diseases of the brain and the meninges, migraine, neuras-
thenia, hysteria, and circulation disturbances in the brain. We
shall not discuss the latter.
Pachymeningitis Interna H»morrhagica (Hematoma of the
Dura Mater). — From a pathological, anatomical standpoint we
have to deal with the formation of a fibrinous membrane on the
inner surface of the dura mater, into which there occur from
time to time smaller or larger hemorrhages. Headache may pre-
cede or follow a developing coma, or, if there is no coma, the
pain in the head may be the chief symptom of the disease.
It may be associated with nausea and vomiting. Generally the
pain is very intense. It may be felt as a circumscribed area, and
then sensitiveness to percussion, circumscribed, unilateral, or dif-
fuse, is present When the hematoma is located on the convexity,
the pain on the diseased side frequently predominates. When
the hematoma is localized at the base of the skull trigeminal neu-
ralgia occurs, with other symptoms due to pressure upon the
cranial nerves. The remaining symptom-picture of pachymen-
ingitis is not at all characteristic. The etiology (alcoholism, in-
fectious diseases, trauma, general paresis, senility, lues, and blood
diseases, pernicious anemia, leukemia and scorbutus) is, above all,
important. In classic cases an irritative stage, with delirium,
precedes, and this is followed by the attack with coma, during
which signs of increased brain pressure can be demonstrated.
There are slowing and irregularity of the pulse, changed breath-
180 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
ing, vomiting, contracted, sluggish or nonreacting pupils, choked
disc, general cramps, bilateral deviation, etc. (see page 271).
Symptoms which depend upon the location of the hemorrhage
are hemiplegias, monoplegias, and unilateral and disseminated
twitchings. The gradual increase and frequent change of the phe-
nomena, with remissions and recurrences, are considered a charac-
teristic. Hyperidrosis and elevation of temperature to 41° C.
(105.4° F.) frequently occur.
Leptomeningitis Punilenta. — Here there is an infiltration of
the pia mater, especially on the convexity. This is at first serous
and later purulent. There is also a serous infiltration of the
superficial layers of the cortex. In the tuberculous form a gela-
tinous, rarely purulent exudate first spreads on the base between
the brain and the peduncles and extends from here in all direc-
tions, especially in the sulci, reaching a marked degree, however,
only on the convexity. Headache is so characteristic in this dis-
order that one should not make a positive diagnosis if headache
is absent. It is extremely severe, mostly continuous, but pa-
roxysmally increasing. The headache is, as a rule, located (by
the patient) in the entire skull, sometimes more in the forehead
or in the occiput. The patient manifests signs of pain, even in
coma, in spite of the deepest stupor. He grasps his head, and at
times cries out loudly, especially, however, if one tries to move
the head.
In tuberculous meningitis the pain in the beginning has a dif-
ferent character. It occurs only temporarily, is not so great in
intensity, and only later reaches the great severity just men-
tioned. Gradually there appear disturbances of the consciousness,
delirium, and eventually coma. Stiffness of the neck (the head
being drawn backward), stiffness of the muscles of the back, and
boat-like retraction of the belly occur. Hyperesthesia of the skin
and the muscles, restlessness, and jactitations are characteristic.
Not uncommonly we find unilateral convulsions, and, less fre-
quently, general ones. The patients conspicuously and rapidly
become emaciated. In extensive involvement of the base of the
brain, involvement of the cranial nerves occurs, the oculomotoriue.
\
I
CENTRAL NERVOUS SYSTEM 181
the optic and also the acoustic being especially implicated. The
fundus of the eye often shows the signs of neuritis. The tendon
reflexes, which may be increased at first, are later usually lost,
as are also the skin reflexes. Paralysis of the bladder and the
rectum occurs only just preceding death.
Chronic Anemia of the Brain (Chlorosis, Pernicious Anemia,
Leukemia, etc.). — The headache in these diseases is usually not
very severe, often consisting only in hyperesthesia of the head.
It can be recognized, sometimes, by the fact that it grows worse
"when the patient is in an upright position, and decreases when
he lies down. Other signs due to anemia of the brain are the
occurrence of fatigue, both mental and physical, after a small
amount of work. Drowsiness, humming in the ears, stars before
the eyes, vertigo, and an apathetic state may be present. All
these conditions improve when the patient lies down (see page
272).
Hyperemia of the Brain. — Congestions which consist of a sud-
den afflux of blood to the head cause pressure and sometimes
pain, which increases with the pulse beat. Other symptoms con-
sist of a feeling of heat, of throbbing in the face, vertigo, and
disturbance of consciousness. These attacks, however, usually
last only for a few minutes, sometimes an hour, and, in rare
cases, several hours. The headache in venous congestions of the
brain, ear lesions, struma, etc., is made worse by coughing and
sneezing, as well as by the patient assuming the horizontal posi-
tion, especially with the head drooping. The rest of the symp-
toms are not unlike those in chronic anemia, i.e., apathy, drowsi-
ness, vertigo, and slight mental confusion.
Brain abscess originates from a suppuration transmitted from
the skull. It may be of traumatic or otitic origin, or may arise
from remote organs. In regard to the latter, a lung abscess, lung
gangrene, or a pyemia may form the primary starting point.
Headache is one of the earliest and most constant symptoms of
brain abscess. It increases, especially during the development
and the growth of the pus focus, to such a high degree that the
patient constantly groans and behaves like a maniac. In the latent
182 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
stage the pain may be slight These paroxysms of pain often last
only for a few hours; sometimes, however, they persist for days.
The pain is of a boring, throbbing character, mostly dull, either
spread over the whole head, or is more severe on one side, prin-
cipally on that which is the seat of the abscess. However, the
localization of the pain does not always correspond to that of the
focus. An abscess of the cerebellum, for instance, may cause
frontal headache. A circumscribed area of sensitiveness, on per-
cussion, furnishes a much more important clew to the localization
of the focus. Coughing, sneezing, stooping, as well as fever,
make the headache worse. Other symptoms of brain abscess due
to the suppuration, are elevation of temperature, which does not
show any characteristic course, and the not very infrequent chill.
Retardation or irregularity of the pulse, changed breathing, optic
neuritis (which occurs here more frequently than choked disc,
and, indeed, more frequently on the same side as the focus), gen-
eral convulsions and mental disturbances, chiefly in form of
stupor, depression, delirium, and eventually coma are later symp-
toms. Rapid emaciation is often very conspicuous.
Brain Tumor. — Headache is one of the most frequent signs
of this disease. In accordance with the gradual growth of the
tumor, the pain is moderate in the beginning and variable in its
intensity. Later it becomes very severe, but still shows exacer-
bations, which occur generally in the morning. They may be
partly spontaneous, and partly due to an increase of blood pres-
sure from pressing, coughing, sneezing, stooping, etc. During
such paroxysms the patient may either lie in bed, groaning, often
perfectly apathetic, or he may run about in the room, pushing
and knocking his head against the wall, and behaving like a
maniac. Stupor that occurs in the later stage dims the severity;
yet even then one observes that the expression of the face is dis-
torted, and the seizing of the head by the hands proves the con-
tinuance of pain. The pain is, as a rule, diffused over the entire
head; sometimes it is unilateral, more in the occipital, or more
in the frontal region. Sometimes the localization depends upon
the position of the tumor, as tumors of the posterior cranial fossa,
CENTRAL NERVOUS SYSTEM 183
for the most part, cause occipital headache, which may radiate
into the shoulders. One must, however, not depend upon this
entirely. More stress should be laid upon the circumscribed
sensitiveness on percussion, which, however, does not regularly
occur, but only when the tumor lies quite superficial.
Trigeminal neuralgia, especially of the first branch, is ob-
served in tumors of the chiasma, cerebello-pontine angle, and pons,
and may later be followed by loss of function of the nerve. Signs
of pressure on the optic nerve are rarely lacking. Papilledema
(choked disc) is seldom missed. It may be absent in tumors of
the central convolutions, and of the first and second frontal con-
volutions, but it is almost never present when foci are in the pons.
Otherwise, however, choked disc, or its forerunner, optic neuritis,
is one of the cardinal symptoms. It is mostly double sided, fre-
quently more intense on the affected side. Not less important are
the changes of intelligence and of the psyche. The patients think,
speak aud act more heavily. Soon they become stupid and drowsy.
They fall asleep while they are still speaking, or in the midst of
a meal. At such times they pass feces and urine involuntarily.
Delusional ideas, ideas of persecution, and finally delirium may
be present. Very frequently vomiting (of a cerebral type) oc-
curs, with retardation of the pulse, which may here assume a high
degree, and, after some time, usually passes into pulse accelera-
tion (vagus paralysis). Giddiness is frequently complained of.
It has not, however, been accompanied by rotatory nystagmus,
which occurs principally in tumors of the cerebellum. Convul-
sions and' loss of consciousness occur paroxysmally, together or
separately. Parallel with these general symptoms are the so-
called focal symptoms. By direct focal symptoms we mean those
phenomena which are the result of pressure on that area of the
brain in which the new growth develops.
Focal Symptoms of the Motor Region. — Here are found
the results of irritation-, paresthesias and spasms, which are fol-
lowed later by paralysis. These three phenomena generally begin
in one particular place, and then spread over the neighboring
areas, for the most part in regular order (Jacksonian fits). The
184 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
order in which the individual groups are affected is a regular
one, and extends from center to center, beginning, for instance,
in the right foot, and extending to the knee, hip, shoulder, elbow,
hand, and distribution area of the facial nerve. Consciousness
is intact, at first, and only later becomes cloudy in attacks of
greater intensity and longer duration. Correct observation of the
muscle groups initially involved is of importance for the localiza-
tion of the tumor.
As a sequence of such a spasmodic seizure, but also unaccom-
panied by a seizure, paralyses arise, which, in the beginning, are
transient, but which later become permanent, and attack (like
cortical epilepsy), little by little, wider areas, until finally they
present the complete picture of a hemiplegia, with all its char-
acteristics, namely, increase of the tendon reflexes, spasms, ab-
sence of skin reflexes, Babinski, clonus, etc.
TuMOKs OF THE FRONTAL LOBE producc motOT aphasia if they
lie in the left inferior frontal convolution. In tumors of the left
second frontal convolution one sometimes sees, as a result of
the disturbances of the innervation of the muscles of the buttock,
uncertainty in walking and standing, and in turning toward the
crossed side. As a remote effect upon the motor region, Jack-
sonian epilepsy may occur. When the tumor lies in the temporal
lobe, disturbances of hearing, such as buzzing and whistling, may
occur. There may, also, be disturbances of smell and taste.
Finally, tumors of the left first temporal convolution produce
word-deafness, memory aphasia and paraphasia. Here, as a dis-
tant result, are observed Jacksonian epilepsy; and further, from
the action on the occipital lobe, crossed hemianopsia, hemianes-
thesia, and hemiplegia.
Tumors of the parietal lobe give rise to little that is char-
acteristic (disturbances of muscle sense, crossed hemiataxia). In
fact, as a rule, they produce only distant effects, by pressure
upon the motor region (Jacksonian spasms), or on the occipital
(hemianopsia), etc.
Still more uncertain is the diagnosis of tumors of the cor-
pus CALLosuM, which, according to Ziehen, have paraparesis as
CENTRAL NERVOUS SYSTEM 185
the only sign of any value. Apraxia is often present in tumors of
this region.
Tumors of the central ganglion characterize themselves
by disturbance of the inner capsule. Therefore, they cause hemi-
plegia, which gradually arises if more of the anterior part of
the capsule is affected, and hemianesthesia if more of the posterior
part is affected. Hemichoreas, hemianesthesiae, and unilateral
tremors may result.
When the corpora quadrigemina are the seat of the tumor,
sight disturbances, hearing disturbances, and double-sided
paralysis of the eye muscles of a muscular character form the
clinical picture. With the disease, also, come disturbances of
equilibrium on walking and on standing.
Tumors of the pedunculi cerebri produce paralysis of the
oculomotor of the same side, and of the extremities of the oppo-
site side (hemiplegia alterans superior), oculomotor paralysis,
with tremor, similar to that in paralysis agitans.
If the CEREBELLUM is the seat of the tumor, this can be
recognized, in most cases, by a few important signs. The most
characteristic is cerebellar ataxia. The patient sways from one
side to the other. Frequently, also, he complains of a genuine
dizziness, in which objects seem to be moving around him, espe-
cially upon sitting up. With this dizziness nystagmus is fre-
quently combined. Vomiting is very common. It is also an im-
portant symptom that the headache is localized, especially in the
occipital region, possible in the nape of the neck, and that the
choked disc, which is mostly bilateral, is seldom absent. Along
with this are opisthotonic and tetanic contraction of the muscula-
ture of the neck. As indirect local symptoms, the affections of the
different cranial nerves, of the pyramidal tract (paraparesis,
crossed hemiparesis, intentional tremor) and also the occurrence
of hydrocephalus interna must be considered.
Tumors of the pons show slight development of general
symptoms, and the absence of a choked disc almost as the rule.
The most classic symptom is the hemiplegia alterans inferior.
There is paralysis of the extremities of one side, with paralysis
186 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
of the facial, trigeminus, or abducens, of the other side, in which
case, of course, all three of the above-mentioned cranial nerves
may be affected. Very frequently, before the paralysis, very
severe attacks of trigeminal neuralgia occur. Further, associated
eye-muscle paralysis of the right rectus internus on the side of
the tumor must be mentioned; also in right-sided paralysis there
is a simultaneous disturbance of hearing, through pressure on the
acoustic nerve at its place of origin.
Tumors of the medulla may run a symptomless course, but
when they produce symptoms they are similar to those of tumors
of the pons, with the exception that they injure deeper-lying
cranial nerves, namely, the eighth and twelfth, causing disturb-
ances of hearing, speech and deglutition, as well as paralysis of
the extremity on the other side, singultus, diabetes insipidus,
breathing changes, etc.
If the tumor is seated in the third ventricle, drowsiness
and change of intelligence are usually prominent.
Tumors of the base of the brain give rise to few general
symptoms. According to Oppenheim, choked disc and vomiting
frequently fail. Pain, on pressure, occurs in the bones which are
in relation to the base of the brain. Bleeding from the nose and
pharyngeal cavities also occurs ; and, above all, is to be considered
the involvement of brain nerves in a certain combination corre-
sponding to their topographical arrangement.
Tumors of the hypophysis also produce few general symp-
toms. Here, also, choked disc is frequently absent, and headache
may be very slight. On the other hand, the eye symptoms (bi-
temporal hemianopsia, amaurosis, eye-muscle paralysis, exoph-
thalmos) and certain disturbances in development (hypoplasia of
the genitalia, feminine habitus), as well as adipositus universalis
and myxedematous skin, form the most striking symptoms.
Tumors of the posterior cranial fossa often begin with
humming in the ears, difficult hearing and disturbances of equi-
libriunL Associated with these is irritation or paralysis of the
trigeminus, with absence of the corneal reflex (Oppenheim). In
relation to this, as a result of the pressure on the surrounding
CENTRAL NERVOUS SYSTEM 187
region, cerebellar ataxia, nystagmus and sight paralysis (Oppen-
heim) occur. The patient complains of occipital and frontal
headache and vomiting. Objectively, one very frequently finds
choked disc and localized sensibility on percussion.
Aneurysm of the Brain Arteries. — Here the headache is also
one of the general symptoms. It is generally described as throb-
bing, and may be half-sided, as in heraicrania, diffuse, or be felt
more in the occiput (in aneurysm of the basilar artery). Vomit-
ing, dizziness and stupor (corresponding to the reduction of brain
space) are present, while, on the contrary, choked disc is infre-
quent. A pulsating vessel murmur, heard over the skull, is con-
sidered an especially characteristic symptom. However, this is
found in other diseases, and also in normal children. The develop-
ment of the process is often very rapid. The localization is to be
inferred from the local symptoms.
Parasites of the Brain {Cysticercus Cerebri), — Headache^
with dizziness, is a frequent symptom; but the characteristic
signs are localized attacks of cramps, due to the location of the
cysticercus in a circumscribed area of the motor region. At-
tacks of an epileptiform character, with psychic disturbances (im-
becility, confusion, irritability), are present. The local symp-
toms differ according to the seat of the parasite. Frequently
there is a conspicuous change in the intensity of the clinical
symptoms. A cysticercus tumor may be diagnosed if the possi-
bility of infection has existed (association with infected individ-
uals, ingestion of raw pork, etc.), or if the cystieerci are found in
another portion of the body. The echinococcus also produces
tumor phenomena. However, it is very seldom that one can suc-
cessfully diagnose it, since, in order to do this, an echinococcus
cyst must be found somewhere else in the body.
^7drocephalllS Intemiis. — Headache, in this case, is usually
constant. For the rest, the disease picture is similar to that of
meningitis purulenta, with the exceptions that the fever is not so
high, the headache is less severe, and frequently a perfect cure
occurs, with sequelse of eye disturbances. The differentiation is
easiest made through spinal puncture. Chronic hydrocephalus
188 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
progresses, in most instances, under the symptom-complex of a
brain tumor, or a tumor of the cerebellum. According to Oppen-
heim, two points for the differential diagnosis are to be taken
into consideration: (1) whether there exists a deficient congenital
development (abnormal size and form of the skull) ; and (2) the
occurrence of remissions or of intermissions of a month's or of a
year's duration.
Syphilis of the Brain. — Anatomically the process consists
either in the formation of tumor-like gummata or in changes of
the vessel walls, especially of the basilar artery. A tubercular
basilar, gummatous meningitis, starting in the region of the
chiasm, is even more frequent. Headache is one of the earliest
symptoms. It may occur months or years before other signs.
Nightly exacerbations, recurring at a certain hour, and disappear-
ing at a certain time, are characteristic. During the exacerbation
the patient suffers considerably by reason of the severity of the
pains. In the intervals, however, the pain is bearable. It is
mostly felt as a diffuse pain, situated deep within the skull.
Sometimes it has a circumscribed border, if the process reaches
the convexity. In these cases, also, a circumscribed percussion
sensibility may be present. Other constitutional symptoms be-
long to the picture of cerebral lues ; for instance, vomiting, dizzi-
ness, attacks of unconsciousness, psychic disturbances, dementia,
stupor and states of irritability occur in a paroxysmal manner,
alternating with periods of normal consciousness. In addition to
these, there is paresis or paralysis of the cranial nerves, especially
the optic, and oculomotor-ptosis is especially frequent. Any of the
other cranial nerves may be involved in differing combinations.
The repeated change in the intensity and the final complete dis-
appearance of all the synii)t()ms are typical. The onset of hemi-
plegia, which develops in the course of one or two days without
disturbances of consciousness, is a frequent symptom.
Hysteria. — The headache, frequently felt as a dull pressure
in the entire area of the skull, may often be localized to. a cir-
oumscribed place on the vortex, in the occiput, or in the temple.
It is, as a rule, associated with hyperesthesia of the scalp, so that
CENTRAL NERVOUS SYSTEM 189
the slightest touch or the least disturbance of the hair causes a
pain which increases on pressure. Bodily and mental exertion
and emotion may also produce increased irritation. The condition
is improved by diverting occupations and during quiet and dark-
ness. It may last for hours, days or months, and does not leave
the patient even during sleep. The remaining hysterical symp-
toms are of so many forms that they cannot briefly be given here.
Neurasthenia. — Here, also, the intensity of the headache is
not very great. It appears mostly as pressure and constriction
of the entire head, the feeling often being strongest in the region
of the forehead, and not seldom in the occiput. The patient also
complains of a contraction, as though the head were bound with
an iron band. The headache of neurasthenia is also produced or
increased through great bodily or psychic irritation, or by emo-
tions.
Hemicranic Headache (Migraine). — The real attack of
headache is often preceded by symptoms which bear a certain re-
lationship to it Some patients, previous to the attack, feel lan-
guid, exhausted, and are without appetite, or, on the contrary,
manifest great hunger. As aura, Moebius designates certain
paresthesias, which may or may not precede the attack, namely,
eye symptoms, flying bodies, glittering, narrowing of the field of
vision (especially hemianoptic), and glistening scotomata; these
may occur, for instance, as a light point in one or both eyes, which
is diffused or travels across the field of vision in a zigzag line.
Other forms of the aura are unilateral paresthesia, aphasia, con-
fusion, states of anxiety, etc. The attack itself consists in head-
ache of the severest degree. Generally it occurs after waking,
with slight intensity, and gradually increases to an unbearable
degree. It lasts for a few hours to a few days. Frequently it
stops during sleep. There are patients in whom migraine attacks
are of slight severity, and in whom light and severe paroxysms
interchange. In the intervals, which may last for weeks and
months, the patient feels perfectly well. The pain is mostly
one-sided, but is also double-sided, usually in the forehead and
eye region. Less frequently the occipital region is attacked. As.
190 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
a rule, the pain is located by the patient as deep in the skull,
and is of a boring or tearing character. The patient may say he
feels as though his head were in a vise, as though it were bursting
asunder, or as though it were being belabored with a hammer.
The countenance of the patient during the attack is, in most
cases, pale, although in some instances the face and conjunctiva
are reddened. During the attack, also, the patient is very sensi-
tive to all forms of stimuli. Noises, smells and lights increase
the pain. Nausea and vomiting sometimes are accompanying
symptoms, and, in most cases, the attack concludes with them.
DIAGNOSIS OF HEADACHE IN DISEASES OF THE BRAIN AND
MENINGES
The character of the headache alone rarely permits an accu-
rate diagnosis to be made.- Yet each and every one of the cranial
lesions enumerated have some features which predominate
more or less. Thus, in cerebral lues, our attention is drawn to
the night attacks. This is rare in other forms of brain disorder.
Intensity. — The intensity of the pain varies greatly in dif-
ferent cases. The severest degrees of headache are most frequently
observed in leptomeningitis, then in brain-tumors, in abscess,
brain-syphilis and hemicrania. Tolerable, though still severe,
headache is found in pachymeningitis hsemorrhagica interna^ in
some forma of headache in hysteria, and in aneurysm of the basilar
artery. Headache due to neurasthenia and disturbances in the
circulation of the brain is naturally not very severe. In the
first-named group of cases (pachymeningitis interna haemorrhage
ica) paroxysmal exacerbations occur, giving rise to very con-
spicuous manifestations of pain. The patient groans, whines,
and either shows dull apathy or jumps out of bed, runs about
and presses his head. Pain of this severity, however, is only
temporary, and the very manner of its occurrence, as well as the
character of the free intervals, is important for the diagnosis in
some cases.
It has been noted that the paroxysms of pain in cerebral syph
ilis may be expected with great probability during the night.
CENTRAL NERVOUS SYSTEM 191
The pain appears at a certain hour after the patient has gone to
bed, usually at the same hour every night. In the periods be-
tween the paroxysms the headache is either of little intensity or
disappears entirely.
The typical form of hemicrania is also characterized by its
paroxysmal occurrence. After an aura of short duration, or
perhaps without an aura, there appears the most severe pain,
compelling the patient to lie down and keep absolutely quiet.
Usually sleep puts an end to the attack, but frequently the pain
appears in the morning after awaking. In this point, therefore,
the pain differs from that in lues cerebri. Another feature may
be used for the diagnosis of hemicrania, namely, that the pauses
between paroxysms, which may last for days, weeks, even months,
are perfectly free of pain. During these periods the patient feels
absolutely well.
Paroxysmal exacerbations occur in other affections; for in-
stance, purulent leptomeningitis, abscess, tumor, etc. These exac-
erbations, however, appear irregularly, and the periods between
the paroxysms are by no means free from pain. It is important
to know that in cases of brain abscess the paroxysmal exacerba-
tions of the headache appear usually during the development and
growth of the pus foci; and, obviously, for this reason they are
frequently connected with fever-elevations.
Between the varieties of headache characterized by their great
intensity and the headache which is described by the patient as
hyperesthesia of the head (pressure or heaviness) there are
scarcely any intermediate forms. The latter sort of headache is
seen in neurasthenia, hysteria, and disturbances of circulation in
the brain. It is characterized in most cases by its continuous
course; although variations in intensity may occur, they do not
show any feature characteristic of the condition. In most cases
direct spontaneous paroxysms of pain do not occur, neither are
there any periods perfectly free from pain; yet the feeling of
pressure in the head does not leave the patient, even in his sleep.
Moderate degrees of headache occur in pachymeningitis in-
terna, prior to, or after a comatose attack, and also without any
192 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
coma. Here, also, there are intermissions of pain of varying
duration, which cease on the onset of another bleeding. The
headache in aneurysm and the paroxysms of headache in hysteria,
which, as a rule, occur in the parietal region, are somewhat simi-
lar to those in pachymeningitis, so far as their intensity is con-
cerned.
Localization of Pain. — Localization gives but few clews for
diagnosis. True, there are diffuse headaches, unilateral headaches,
headaches involving only the frontal region, as well as those of the
occipital region. Finally a headache may have a circumscribed
area ; but there is scarcely one of those localizations which might
be looked upon as characteristic of any definite affection. Kot
infrequently one finds all of these localizations involved in one
and the same disorder. This may be the case in a brain tumor,
for instance. Nevertheless, some affections predilect a certain
region of the cranium. We know, for instance, that in migraine
headache occurs most frequently unilaterally. Moebius states that
among patients of his from whom he could obtain reliable state-
ments fifty-seven had almost constantly unilateral headache,
whereas twenty-five declared that they had felt it on both sides.
Moebius doubts the reliability of the second statement. On the
other hand, there are diseases in which unilateral headache is,
comparatively speaking, seldom present ; for instance, in leptomen-
ingitis, neurasthenia and in disturbance of the cerebral circulation.
Frontal headache is observed in neurasthenia comparatively fre-
quently, and the unilateral headache in migraine is often most in-
tensely felt in or behind the eye. Pressure in the parietal region
is frequently met with in hysteria, is mostly circumscribed and
is accompanied by sensitiveness on pressure. In a comparatively
large number of diseases the painful area is sharply circumscribed,
a fact often noted in pachymeningitis, in brain abscess and in
cerebral syphilis. This circumscribed pain is generally, also,
associated with a circumscribed sensitiveness on pressure (the so-
called sensitiveness on percussion).
The tension of the pain helps less frequently than its localiza-
tion in making a diagnosis. Certainly even here the greatest
CENTRAL NERVOUS SYSTEM 193
caution is necessary; for cases in which a tumor in the occipital
region causes frontal headache are by no means rare ; and it also
happens that a tumor of the left side may give rise to pain felt
in the right half of the cranium. If, however, a pain is con-
stantly felt in one place, or, when generally diffused, it originates
from one place, no mistake will be made if one locates the cause
of the disease, be it a tumor or an abscess, in that region. Pain
in the occiput or neck, radiating into the back, justifies one in
assuming that the focus lies below the tentorium. We may as-
sume, with great probability, that a lesion exists in the same
area in which pain i& present, if we have to deal with a pain con-
stantly confined to one side, or to the frontal region. Of course
one should strictly avoid depending upon pain, alone, in forming
conclusions. To form a diagnosis, which often implies a great
responsibility, all the other observations and examinations (which
will be discussed later) must be resorted to.
Character of the Pain. — The character of the headache tells
us very little concerning its cause. Patients describe various
kinds of headache in quite different ways, most frequently as
dull, pressing, drawing, cutting, lancinating, constricting, driving
asunder, roaring, pulsating, and throbbing. Since every form
may occur, in very different intensities, there result an exceed-
ingly large number which are of only very little value for the
diagnosis. If there is a kind of headache to which we may
ascribe a characteristic feature, it is the pulsating and throbbing
variety. It is found most clearly pronounced in an aneurysm of
the cerebral vessels, but also in hyperemia, and sometimes in
cases of abscess.
A knowledge of those external influences which may cause
an exacerbation of an already existing headache, or which are
capable of producing headache, is more important for the diag-
nosis than are the location and the character of the pain. It has
been emphasized that, in those affections in which the sensitive
area is circumscribed, an increase of the headache can be brought
about on pressure, with the finger, or by striking with the percus-
sion hammer. These affections are pachymeningitis, brain abscess.
194 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
cerebral syphilis and hysteria. There are other cases in which
the headache grows considerably worse by the increase of
internal brain pressure, such as occurs in coughing, sneezing,
pressing, stooping. This is the case in brain abscess, brain
tumor, and passive congestion. Sometimes movement of
the head increases the headache, especially in meningitis and
migraine.
In the latter, according to Moebius, movements of the eye
have a much more unfavorable effect than those of the whole head.
The upright position of the body has an unfavorable influence
upon anemic headache, whereas horizontal position increases an
hyperemic headache. Headache due to abscess, tumor and hemi-
crania may be increased by alcoholism. In conclusion, it may be
added that mental exertions and emotions are able to elicit and
to increase headache in neurasthenia, hysteria and hemicrania,
and the same factors may aggravate the headache in case of
tumor.
Influence of Therapy. — Diverting occupation, eating, and
rest influence headache in a favorable way, especially nervous and
hysterical headache. According to !Moebiu8, however, they may
alleviate, also, less severe attacks of migraine. This latter often
may be cured or alleviated, without any other treatment, by
removal of irritants (light, noise, etc.).
By the observation of these circumstances, it will often be
possible to draw, from the character of the headache, a conclusion
as to its cause. A severe pain, for instance, which appears
paroxysmally on one side, and which is favorably influenced by
rest and ends with vomiting, may be looked upon with great prob-
ability as hemicrania ; nightly exacerbations point to cerebral lues,
whereas headache that occupies the cortex makes us think first of
hysteria. It is not the task of the diagnostician, however, to
make the diagnosis from one single symptom, but eventually he
will utilize, in making the diagnosis, all the signs of the disease.
In the following lines, therefore, we will discuss all those factors
by which the individual affections of the brain and spinal cord
may be differentiated; and for the sake of completeness those
CENTRAL NERVOUS SYSTEM 195
affections will be discussed here which are not accompanied by
pain.
DIFFERENTIAL DIAGNOSIS
Brain Abscess. — If the analysis of the pain has shown that
we have to deal with a brain abscess, the following conditions
will come into consideration for the differential diagnosis:
Beain Tumoe. — Against this would speak the etiology (with
the exception of traumatism, which also may cause a tumor),
the fever, the chills, and the comparatively more rapid course
(weeks to months). A well-marked, choked disc (optic neuritis
occurs also in an abscess), as well as the better-marked phenomena
of pressure, in general, would indicate tumor.
Leptomeningitis Pueulenta. — This takes a course even
more rapid than abscess — days and weeks. It shows high fever
and acceleration of the pulse (in case of abscess only low grades
are observed), hyperesthesia of the organs of sense, of the skin
and muscles, involvement of the cranial nerves, scaphoid retrac-
tion of the abdomen, and rigidity of the muscles; whereas optic
neuritis, retardation of the pulse, less stupor and a negative result
of lumbar puncture, i.e., a clear puncture-fluid, rather speak in
favor of a diagnosis of brain abscess.
Leptomeningitis Seeosa. — This occurs either as a primary
affection, or as an accompanying symptom of an otitis media.
It may heal spontaneously. In addition to this, the greater fre-
quency of a choked disc and of disturbances of sight would speak
against brain abscess.
Otitis Media. — This may cause diagnostic difficulties by the
occurrence of cerebral symptoms, but can be recognized by the
disappearance of the latter on removal of the pus.
ExTEADUEAL Abscess {In Sequeucc to a Suppuration of the
Ear), — This is indicated by the presence of focal symp-
toms and the absence of local signs, i.e., the absence of
the inflammatory swelling and painfulness in the region of the
mastoid process.
Sinus Theombosis. — Here are found, in contradistinction to
brain abscess, pyemic fever and acceleration of the pulse, com-
196 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
plete absence of any disturbance of consciousness, more frequent
occurrence of choked disc, and externally a thrombosis of the
jugular vein in the neck. On the other hand, focal symptoms
speak for the presence of an abscess.
• Hemobbhaoes into the Meninges. — ^When caused by trau-
matism, they proceed without any fever, and follow directly after
the injury.
MioBAiNE. — Against it speak both etiology and absence of
fever.
Tbaumatic Neuboses, Hystebia and Neubasthenia. —
They may occur as concomitant symptoms of a brain syndrome,
or may be independent affections, and only simulate these.
Bbain Syphilis. — This is mostly accompanied by the loss of
pupillary reaction to light, and can be surely diagnosed by the
positive result of Wassermann's reaction and of antiluetic treat-
ment.
Leptomeningitis. — In the differential diagnosis of leptomenin-
gitis quite a number of diseases come into consideration in which
focal symptoms always decide in favor of meningitis.
Pneumonia, Typhoid Feveb and Pyemia. — Rusty sputum
and dullness over the lungs speak for pneumonia; gradual devel-
opment and the positive result of Gruber-WidaFs reaction speak
for typhoid fever ; retardation of the pulse, stiff neck and paraly-
sis of the cranial nerves, as well as the intense headache, continu-
ing also during the coma, speak for meningitis; frequent chills,
skin and rectal bleeding, and joint swelling speak for pyemic
condition.
Bbain hemobbhaoes, embolus and thbombosis, as well as
encephalitis hjemobbhaoioa never cause fever-elevations of
such a duration as seen in meningitis.
Otitis media is confused with meningitis principally because
the ear trouble is followed by a serous leptomeningitis. As such
a serous meiiingitis often can be differentiated from a purulent
one only with difficulty, a differential diagnosis can be made in
most cases only by the disappearance of the meningeal symptoms
after the evacuation of the otitic focus.
CENTRAL NERVOUS SYSTEM 197
In uremia, albumin and formed elements, as a rule, are
found in the urine.
The SEROUS form of meningitis is, as above mentioned, diffi-
cult to differentiate from the purulent form. In most cases the
fever is less.
Delirium; Tremens. — Stiff neck and the extremely severe
headache speak against it
Tuberculous meningitis occurs in early childhood (2 to 14
years). It does not set in in such an abrupt manner, and shows
frequent remissions (of temperature, stupor, etc.).
In children the stomach and intestinal disturbances may
cause symptoms similar to those of leptomeningitis, and may give
rise to confusion in diagnosis. However, the influence of the diet
and the action of a purgative will soon clear the diagnosis.
Brain Tumor. — Hysterla may be differentiated by its head-
ache, spasmodic attacks and hemiplegic paralysis. Choked disc
and focal symptoms will guide us here, but it must not be for-
gotten that both affections may occur together. The possibility
of influencing the condition psychically speaks for hysteria. In
case of a tumor we find also, during the acme of the pain, retarda-
tion of the pulse and vomiting. These are found in hysterical
headache, only when it occurs on one side.
Concerning migraine, which might give rise to confusion by
the severity of the headache and vomiting, we must be guided by
the history (heredity in migraine) and by the presence of choked
disc and focal symptoms in tumor of the brain.
Paresis often comes into review in the diagnosis of brain
tumor. The clinical symptoms may be very similar. A positive
Wassermann, a positive cell count, and a positive globulin reac-
tion almost certainly speak for paresis and against a brain tumor.
In paresis choked discs are not frequent. The attacks of cortical
epilepsy occurring in both, and which in the external manifesta-
tions are similar, usually leave little permanent palsy in paresis.
Multiple sclerosis comes into consideration in affections of
the cerebellum, of the pons, and of the corpora quadrigemina,
which likewise produce intention tremors, nystagmus, spastic
198 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
ataxia, as well as paretic symptoms in the extremities. To these
must be added the occurrence of atrophy of the optic nerve, if
they are accompanied by brain symptoms. However, the general
symptoms of the tumor, such as severe, continuous headache, the
retardation of the pulse, vomiting and stupor, do not belong to the
clinical picture of multiple sclerosis. In epilepsy, which has a
certain similarity to tumor in its paroxysmal character, the gen-
eral symptoms will facilitate the differential diagnosis.
Pachymeningitis Haemorrhagica Interna. — Differential diag-
nostic points speaking against pachymeningitis are either the en-
tire absence of stiff neck or the presence of a slightly stiff neck,
as well as the rare involvement of the basal cranial nerves; how-
ever, both signs occur also in pachymeningitis, if it is located at
the base of the brain.
Ceeebral hemobbhaoe frequently is with difficulty differen-
tiated from pachymeningitis. The absence of the above-described
symptoms would lead to a consideration of a hemorrhage into the
brain substance; and the change of symptoms, the choked disc
and the intercurrent appearance of convulsions to that of pachy-
meningitis.
In EMBOLISM and thrombosis elevation of temperature is
rare in the later stages, and phenomena of brain pressure are
absent.
Migraine may also come into question in the basal form of
pachymeningitis. Inherited predisposition, as well as a rapid
course without fever, speaks for migraine.
THALAMIC PAINS AND THE THALAMIC FUNCTIONS*
While central pains, probably due to lesions in and about the
basal ganglia, were first suspected by Nothnagel, it is chiefly to
the studies of Dejerine and Roussy that we are indebted for the
clearing up of the question of pains due to lesions of this region.
Dejerine and his students have shown that lesions of the
thalamus, especially of certain of its nuclei, produce a character-
' Written by Dr. Smith Ely Jelliffe, New York, U. S. A.
CENTRAL NERVOUS SYSTEM 199
istic picture, the thalamic syndrome (Jelliffe). in which severe
and persistent pains form a prominent part.
These pains usually involve the side of the body on which
the lesion takes place, and are noted for their severity, their per-
sistency, and their resistance to analgesics.
The entire picture of the thalamic syndrome is so character-
istic that its somewhat — at first sight — anomalous symptoms
should be given in detail. This is all the more important since
many patients with the thalamic syndrome are thought to be ma-
lingerers or hysterical.
The usual thalamic syndrome begins, as a rule, with a mild
apoplectiform attack. It may be severe, or it may be so mild as
to escape ordinary observation. After a certain length of time,
the motor weakness of the early slight or severe hemiplegia disap-
pears entirely, or to a greater or less extent. The patient has some
difficulty in managing his hand and leg, and it appears to be dif-
ferent from the hand of the well side. Then pains are felt on the
affected side. They may at first have been only uncomfortable
sensations in the skin of the side ; they usually take the form of
acute shooting pains, and may be in the entire half of the body, or
may be limited to the face, to the upper extremity, or to the lower
limbs. They rarely cross the middle line, although in double
thalamic lesions both sides of the body show painful distributions.
The nerve trunks are absolutely painless; they are not swol-
len, and careful search for Valleix's or Trousseau's points is
unavailing. There is nothing to point to a neuralgic or a neuritic
process.
These pains stab and jump and throb, and are complained of
as excruciating. The ordinary analgesics do not touch them ; even
morphin is unavailing, at times, in checking their severity.
Notwithstanding these severe pains, it may be that careful
sensory examination shows that the patient is unable to distin-
guish pain at all. This anomalous condition is further compli-
cated by the fact that a pin prick which cannot be recognized as
a pin prick, the patient being unable to tell the difference between
the head and the point of a pin, is nevertheless felt as a disagree-
200 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
able sensation. Here, then, is the apparent absurdity of a patient
who cannot tell pain, yet has a disagreeable sensation when
pinched, still suffering excruciating pain. Not only may the
patient be unable to tell a pin point from a pin head, but he
cannot recognize the difference between heat and cold, and burn-
ing sensations, recognized on the sound side, are translated as dis-
comfort only on the thalamic side. He also loses superficial sensi-
bility. The touch of cotton wool is lost Furthermore, these pa-
tients have lost their deep sensibility. The position sense is gone,
and they fail to recognize objects placed' in the hand. The rough-
ness of a lump of sugar may be interpreted as a disagreeable sen-
sation, but is not recognized as roughness.
Moreover, these patients show slight motor incoordination
in the hand or leg; they are ataxic, and more or less choreiform
or athetoid-like movements are present in the afflicted side.
In some patients there are residual signs of a hemiplegia;
slight spasticity, perhaps; slight clumsiness, increased radius-
periosteal reflexes, triceps reflexes ; perhaps lost abdominal reflexes
on that same side; increased patellar reflex, a clonus and exag-
gerated Achilles jerks. A Babinski extension of the great toe is
often absent, but may be present. Chaddoch, Gordon and Oppen-
heim's signs vary considerably. The motor synergistic phe-
nomena, described by Babinski, Grasset, and Hoover, are all apt
to be present.
One feature of special moment found in thalamic lesions and
which has been emphasized by Head and Holmes is an excessive
response to affective stimuli and the change in behavior in states
of emotion of the abnormal half of the body. Thus, in many
cases of pure thalamic lesion, if a pin be lightly dragged across the
face or trunk, from the sound to the affected side, the patient
exhibits intense discomfort when it passes the middle line. He
not only complains that it hurts him more, but the face may be-
come contorted. Notwithstanding this, he is unable to tell
the difference between the point and tlie head of the pin. The
same type of over-response is found to other forms of stimuli.
Thus deep pressure, which cannot be measured at all, also evokes
CENTRAL NERVOUS SYSTEM 201
an over-response ; the same is true for extremes of heat and cold,
in spite of the fact that the patient is unable to distinguish be-
tween them. Visceral sensibility, scraping, roughness, vibration
and tickling all show this over-response in the affected side.
Not only are painful stimuli over-reacted to, but pleasurable
stimuli occasion a like over-response. Furthermore, in states of
emotion, there may be different manifestations on the two sides
of the body, just as painful and pleasurable stimuli may produce
a stronger reaction on the affected side. Thus some patients can-
not hear music without its causing sensations in the affected side,
or even causing motor unrest, movements of the leg with shaking.
The choreiform movements, which are notable motor features,
under the influence of emotional stimuli may be markedly in-
creased.
From this it can readily be seen that the thalamic syndrome
is a most important clinical picture, and that its more -careful
study is bound to throw considerable light upon the whole ques-
tion, not only upon the subject of pain-perception, but also upon
emotional attitudes to all forms of stimuli. In fact, it opens the
way to the most important of all of the questions taken up in this
book. Through the study of the thalamus the entire sensory side
of the human organism will be revealed, and it may readily be
seen that sensory neurology will be the neurology and possibly
the psychiatry of the next decade.
Thus far the study of the thalamus has shown that it contains
the terminations of all of the secondary sensory paths. In it
sensory impulses of every kind are regrouped and again redis-
tributed. This redistribution takes place not only within the
thalamus itself, giving us thalamo-thalamic paths, but it also goes
to the cortex in a fairly large series of thalamo-cortical paths.
The thalamo-thalamic paths seem to pass to important centers,
constituting what Head and Holmes have termed the "essential
organ" of the thalamus which forms the main center for certain
fundamental elements of sensation. It is a center which is com-
plementary in function to the sensory cortex, and has distinct
though related functions. The lateral part of the thalamus con-
202 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD
tains the corticothalamic paths through which the cortex influ-
ences the essential center, controlling and checking its activity.
Analogous, in a way, is the activity of the motor cortex upon the
anterior horn nuclei of the medulla and spinal cord. The ex-
cessive response to affective stimuli, pain as well as others, is
due to a removal of this cortical control, just as an excessive
motor reflex reaction recurs when the pyramidal tract does not
bring down cortical stimuli from the motor area.
The activity of the thalamic center is of special import in our
study of pain, for it has been pointed out that in lateral thalamic
lesions there is an actual overloading of sensation with feeling
tone.
The pains and paresthesise, found in many thalamic cases,
have been thought to arise from "irritative'' lesions, but this is
probably not so. It would seem that the thalamic center is a true
center for perception of sensations, including pain, and that the
cortex has a definite relationship to these, so that it may modify
the affective response and naturally, thereby, the motor responses.
The essential thalamic organ is a center for conscious perception
for certain elements of sensation. It responds to those stimuli
which are capable of evoking pleasure and discomfort or con-
sciousness of a change in state. The feeling tone of the body,
which has often been termed the somatic or visceral tone sensa-
tion, is a thalamic function.
What the interrelations between the thalamus and the cortex
are, so far as sensation is concerned, need not detain us at this
point. We have chosen to isolate, for the purposes of our treatise,
that sensation known as pain, therefore a discussion of the whole
question would be somewhat out of place. Yet, a word should
be added as to the cortical function in sensation.
The sensory cortex permits a concentration of attention on
any part of the body which is stimulated. Such stimuli are
passing through sensory paths to the thalamus. Many of low
threshold value pass to the cortex or are automatically taken care
of by the thalamus. Those of high threshold value pass into
the essential organ of the thalamus and into consciousness, where
CENTRAL NERVOUS SYSTEM 203
they bring about a tendency to excessive reactivity, just as the
anterior horn cells of the cord react excessively if uncontrolled.
The sensory cortex gives a quick reacting mechanism to dampen
down the affective response to thalamic over-activity.
This leads us to an interesting deduction made by Head and
Holmes, in the study herein freely made use of, that the aim of
human evolution is the domination of feeling and instinct by
discriminative mental activities. This struggle on the highest
plane of mental life is begim at the lowest afferent level, and the
issiies become more sharply outlined the nearer sensory impulses
approach the field of consciousness.
In the accompanying table an attempt is made to simplify the
diagnosis between a cerebral (sensory) cortex lesion and one of
the thalamus. The defining factors are obtained principally from
the work of Head.
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206
CHAPTER IX
DISEASES OP THE SPINAL COBD
Diseases within and about the spinal cord produce principally
two different kinds of pain, namely, back pains and radiating
pains. The former are more or less continuous, extending
either along the entire vertebra, or occurring in certain regions.
The latter occur in the extremities and in the nerve trunk along
the peripheral portions of the sensory nerves. It would be of
great value in the diagnosis of spinal cord diseases if the pains
were at all definitely characteristic. Unfortunately, this is not
the case. Moreover, there are a number of diseases of the spinal
cord in which pain is usually absent. Here may be mentioned
acute poliomyelitis, amyotrophic lateral sclerosis, progressive mus-
cular atrophies of the nuclear type, multiple sclerosis, and various
defect anomalies. On the other hand, affections of the cord or of
the meninges, especially in the initial stages, are apt to result in
pain. Pains localized in the back are also found in diseases of
other organs, and there are also in the back radiating pains which
are not characteristic of diseases of the cord or its membranes.
It will also be important to consider here those visceral dis-
eases, chiefly of the musculature of the back, whose pains must be
differentiated from those originating in tlie cord or its immediate
coverings. Not until disease of other organs, which may give
rise to back and radiating pains, is excluded, can the pain be uti-
lized for the diagnosis of disease of the spinal cord. One must,
above all, be able to recognize neck, back and pelvic pains, the
causes for which are outside of the central nervous system.
There is an entire class of organs, internal and external, which
207
208 DISEASES OF THE SPINAL CORD
can cause such pains. This class chiefly composes almost all the
internal organs of the thorax or of the abdominal cavity. For a
consideration of the back pains due to visceral diseases, see page
300.
It will be necessary, in every case of back pain, to exclude
the entire class of visceral complaints before one sets to work to
indicate the pain as originating from the spinal cord or its men-
inges. Above all, in doubtful cases a systematic examination of
the internal viscera must be undertaken. If these are found un-
changed, we must refer the pain to disease of the spinal cord or
its membranes. If, however, in connection with back pain one
of the internal organs is found to be diseased, the object of the
examination will then be to ascertain whether the pains are con-
nected with these organs or with the central nervous system.
OORD CONDITIONS WHIOH CAUSE PAIN'
In certain cord conditions pain is an important factor. We
will discuss some of these seriatim :
Luxation and Fracture of the Vertebra, — Luxation and frac-
ture of the vertebra produce severe radiating pains in the arm,
trunk or leg, according to the site of the injury. If it lies in the
cervical vertebra, it may, through compression of the occipital
nerves, cause pain in their area of distribution. If it lies in the
thoracic vertebra, it will cause pain by pressure upon the inter-
costal nerves. The remaining symptoms depend upon the situation
and remote effect of the lesion. In addition to the sensory signs
there is paralysis below the site of the injury. The loss of sen-
sation begins usually at about the same level, though, as a rule,
somewhat lower than the lesion.
No attempt will be made in this chapter to present a complete
summary of the clinical pictures of the various forms of spinal
luxation or fracture. Such must be sought in special works upon
the subject. We can give only a brief summary of the symptoms,
laying stress upon the sensory side of the picture :
1 Written bj Dr. Alfred Neuman, Vienna.
CORD CONDITIONS WHICH CAUSE PAIN 209
The most classical pictures are produced by cervical, dorsal,
lumbosacral and cauda equina lesions.
The most frequent cause for the first type is direct injury,
diving, falls, falling of heavy weights. Either dislocation or frac-
ture may occur. One finds forward displacement of the head,
there are usually myosis of the pupils, greatest on the side most
injured, narrowing of the palpebral fissure, retraction of the eye-
balls— which eye signs are due to involvement of sympathetic cen-
ters in the first dorsal region of the cord (Dejerine, Klumpke).
There may be no pain, but there are usually anesthesia and anal-
gesia below the level of the lesion. The muscles affected indicate
the level of the lesion in the cord.
Movement of the head or neck, however, is apt to create sharp
radiating pains at about the level of the injury. Local pain on
pressure is present.
Dorsal injuries cause similar pictures lower down. They are
usually very severe.
Lumbosacral and caudal lesions affect the movements of the
legs and the functions of the bladder, rectum, and sexual organs.
Lesions here are apt to result in much pain, especially in injury
to the cauda equina. In isolated cord lesions, pain is apt to be
missing, but in caudal involvement, especially later in the disease,
pain is frequent and very often severe.
A study of the anesthesiae and the muscles involved is neces-
sary to locate the precise site of the injury.
Meningeal Apoplexy. — Likewise in spinal cord hemorrhage,
as the result of a trauma, pains occur. They may be very severe ;
are localized in the back, and are limited either to a part of the
same (pelvis, interscapular region, or the neck), or spread over the
m
entire vertebral column. Pressure on the vertebra causes a slighter
increase of pain than does motion ; consequently, the vertebral col-
umn is held in a stiff position. In like manner radiating pains
occur in the upper or lower extremities, according to the location
of the lesion. The remaining symptoms of the disease present
themselves in cramps, tremors, and contractures in the arms and
legs.
210 DISEASES OF THE SPINAL CORD
Hematomyelia. — Sudden hemorrhage, occurring within the
spinal cord, in the majority of cases causes pain. Some hemato-
myelias run a painless course. The location of the pain corre-
sponds to the level of the affected area, and appears either as back,
shoulder, pelvic or leg pain. Stiffness of the vertebra and pressure
sensibility of the same are present in involvement of the meninges.
The patient presents a sudden interruption in the conduction
paths. The remaining symptoms, produced through the position
and the spreading out of the area, are disturbances of sensibility,
bladder and rectal paralysis, atrophies, participation of the arm,
or half-sided paralyses, etc.
Caries of the Vertebral Canal. — In this disease pain plays an
important part. It appears very often as local pain, increased on
motion, and limited to the diseased vertebra. The result is that
the patient guards against exercise involving the diseased part,
and holds it in a stiff position. He also avoids displacement of
the diseased vertebra. With the local pain, radiating pain ap-
pears, earlier or later, and has different localizations, according to
the vertebrae involved. In disease of the highest cervical vertebra
the pain radiates, through the occipital nerves, to the head (neu-
ralgia). If the cervical cord enlargement is damaged by bone dis-
ease, the pain radiates into the arms. In compression of the dorsal
cord girdle or intercostal pain occurs; and, finally, there is lan-
cinating pain in the limbs in affections of the lower enlargement
of the cord. The pressure sensibility of the spinous processes of
the diseased vertebra* is especially characteristic. It is very pro-
nounced, and is proportional to the amount of pressure used.
On the contrary, in neurasthenia and in hysteria (diseases in
which pressure sensibility of the vertebral column is observed),
there is greater sensitiveness to a light touch of the skin, on the
elevation of a fold, than to a strong pressure. In hysteria, pres-
sure pain is often greater lateral to the spinal process than it is
over it, and is influenced by suggestion. As characteristic of
caries, the readiness with which the skin lying over the diseased
vertebrae responds to pain, to electrical and thermal irritation is
especially pronounced. The other most important symptoms are
CORD CONDITIONS WHICH CAUSE PAIN 211
the acute kyphosis, through collapse of the diseased vertebrae, the
descending abscess (on the posterior pharyngeal wall, along the
psoas muscle, or into the inguinal fossa or on the back), and the
symptoms referred to the spinal cord or the spinal roots.
Tumors of the Spinal Cord and Vertebrae. — For the diagnosis
of these conditions, local painfulness of the vertebral column
and radiating pain must be differentiated. The former corre-
sponds to the location of the tumor, and is increased, especially
upon bending forward and on shaking the head. This symptom,
however, is not always present. It is possible that an
inequality exists between the strong, spontaneous pain and
the lighter pressure sensibility. According to Petren, only a
diffuse painfulness of the vertebral column can be a symptom of
cord tumor.
More frequent and more clearly pronounced are the neuralgic
pains which arise from pressure on the posterior roots. As a rule,
they are described as intermittent or remittent, and may be
present, according to the location of the tumor, in different parts
of the body. If the tumor is present at the cervical enlargement,
it causes radiating pains in the areas corresponding to the thoracic
vertebral column, girdle pains around the thorax, and shooting
pains in the region of the stomach or bladder. When the tumor is
located still lower, sciatic pains, on one or both sides, are often
the first symptoms of the not yet apparent disease.
In addition to tumors involving the cord itself, as causes of
pain, one should also bear in mind those affections of the vertebrae
which either themselves encroach upon the cord, or which produce
such changes in the bones that they make pressure upon, or cause
involvement of the cord. The most important of the bony dis-
orders of the vertebrsB is tuberculosis. Here there is found
localized tenderness over the spinal vertebrae, usually sharply lim-
ited to one or two segments. The general meningeal pain develops
later, whereas the more severe pressure pain originating from the
pressure on the roots accompanies the settling of the vertebrae, i. e.,
more or less synchronous with the kyphosis. In caries, also, there
is no Wassermann, in the fluid the number of cells is rarely high.
212 DISEASES OF THE SPINAL CORD
the globulin content nil. (See Caries of the Vertebral Column
above.)
Gummatous masses act like timiors at times, and cannot be dif-
ferentiated clinically.
Acnte Spinal Meningitis. — If a spinal meningitis is added to
a cerebral meningitis the symptoms of the spinal trouble arc the
more prominent. Intense pain is frequently observed. There is
also a local painfulness of the spinal column, especially pro-
nounced in the lumbar region. The pains are increased by pres-
sure and shaking (coughing, sneezing), but especially by active
and passive motion. In the same manner the simultaneously oc-
curring pains radiating into the arms and legs are increased. For
this reason the patient holds the vertebral column in a rigid posi-
tion.
Paohjrmeningitis Spinalis Hypertrophica. — In this disease we
find pains in the neck, in the occipital region between the shoul-
ders, and along the spinal column; the point of localization de-
pending upon the location of the diseased areas. In addition to
the local symptoms radiating pains in the extremities and in the
trunk occur. In the cervical variety the neuralgic pains corre-
spond to the course of the ulnar and median nerves.
Myelitis. — Pain, which is not the most important symptom in
this disease, is found especially in the beginning stage, or as a pro-
drome. In the chronic stages pain is not a constant sign. Back
pains, varying according to the location of the diseased areas,
girdle pains, corresponding to the upper boundary of the disturb-
ances of sensibility, or lancinating pains in the extremity, gener-
ally not of great intensity, are present. Pressure sensibility, as
well as percussion sensibility, is almost never found.
Poliomyelitis of Children. — In the prodromal stages of the
disease pains are present in addition to fever, convulsions and
vomiting. These pains are apt to be very diffuse, but are especially
severe about the neck and occiput, often being more suggestive of
a cerebrospinal meningitis than a poliomyelitis. Diffuse pains of
the extremities and marked hyperesthesia, resembling these signs
in influenza, are extremely frequent, especially in some epi-
CORD CONDITIONS WHICH CAUSE PAIN 213
demies. A poliomyelitis may run a course indistinguishable from
a polyneuritis, save that in the latter bony sensibility is apt to be
involved. It is rarely implicated in poliomyelitis. Associated
with poliomyelitis is paralysis, which generally occurs suddenly
in the course of the night, in from two to seven days, and affects
either one or more extremities, generally one or both limbs. The
paralysis is flaccid, and the skin and tendon reflexes are absent.
After a short time atrophy of the muscle and reaction of degen-
eration are demonstrable. Then the affected limbs feel cold and
are livid in color. Atrophy and secondary contractures ensue in
many cases.
Syphilis of the meninges and of the cord causes pains in dif-
ferent parts of the vertebral column, which are increased through
movement and pressure, are of great severity, with nightly exacer-
bations, and are combined with radiating pains in the extremities
and the trunk (girdle pain). Through compression of the ante-
rior roots there also occur atrophic paralyses of the extremities
and of the abdominal muscles. The participation of the spinal
cord can be seen through an interruption (very incomplete)
of the conduction. Spastic paralysis of one or both extremities
is also of frequent occurrence. Babinski's and Oppenheim's signs
are then present, as well as disturbances of sensibility in the rec-
tum and bladder. The frequent change of the disease picture is
characteristic. Paralysis may be present one day and then disap-
pear, and it may frequently be observed that paralysis and per-
fect motion follow one another in the same region.
Multiple Sclerosis. — The pains are similar to those found in
tabes, but are much less frequent. Some pain is observed along
the spinal column. The remaining symptoms are familiar,
namely, spastic paretic symptoms in the extremities, intention
tremor, scanning speech, nystagmus, passing disturbances of sight,
with paleness of the papilla, headache, dizziness, and mental signs.
In the later stages, marked by intense contractures, pain is often
very intense. It is due to the contractures and may also appear
early in the disease as short stabs, occurring at the time of a con-
tracture cramp of the extremities, principally the lower.
214 DISEASES OF THE SPINAL CORD
Sjrringomyelia. — The pains which are most often observed in
this disease are similar in character to the lancinating pains of
tabes dorsalis. They are often very severe, and radiate into the
limbs (sometimes into all four) and around the trunk. The other
symptoms concern the development of atrophic paralysis, princi-
pally, at first, in the upper extremities, beginning in the small
muscles of the hand. The sensory syndrome consists in a retention
of epicritic touch sensibility, but a loss of pain and temperature
sensibility. Vasomotor and trophic disturbances are frequent
from involvement of protopathic conduction fibers.
Tabes Dorsalis. — The pains in tabes dorsalis are localized
sometimes on the surface of the body, sometimes in the hollow vis-
ceral organs. The former appear as lancinating pains in the ex-
tremities, or as girdle pains around the trunk. These pains form
one of the first symptoms, and often appear nlany years previous
to other symptoms of the disease. They come on abruptly, while
the patient is in the best of health, and soon reach a great in-
tensity. They are situated, as a rule, less frequently in the upper
than in the lower extremities. In the former case, they are
usually not so severe. In the legs they may reach their greatest
intensity. The pain suffered by different patients, however, varies
in intensity. It is seldom felt in the skin, but, instead, usually
deep in the muscles or in the bones. The attack itself may last
for a few seconds at first, then, later in the disease, a few minutes,
then, in the final stages, may persist for hours. The incidence of
the attacks seems to at least partly depend upon outside factors,
as weather, worry, wine, and women. The girdle sensations indi-
cate only different localizations of the lesion. They appear as
pressure, tightness on the breast, as though the patient were
bound by an iron band, or as pressure sensation of the stomach
or bladder. Pains in the maxilla, teeth, or ear may occur in
tabes, in fact, in the distribution area of any sensory nerve. The
pains which arise in tabes in the internal organs (stomach, blad-
der, intestines) occur paroxysmally, and are often of extreme
severity, when they are termed tabetic crises. Such crises are not
infrequently very early. The best known are the stomach crises.
CORD CONDITIONS WHICH CAUSE PAIN 216
A patient in perfect health suddenly has excruciating pains in the
stomach, usually accompanied by uncontrollable vomiting. Ra-
diations into the shoulders occur. Some patients scream, sigh, and
toss in bed, while others remain perfectly quiet. This condition
lasts a few hours, or days, rarely longer. Then the picture
changes. The pains and vomiting disappear, and the patient is
able to eat everything without distress, the same as though he were
in perfect health. These intervals of freedom last for different
periods, sometimes months or years. Then other crises occur. In
the intestines the crises arise as colicky pains associated with
diarrhea ; kidney crises, with pains similar to those of renal colic,
also occur; bladder crises, ureter crises, and clitoris crises, corre-
sponding to pains in these organs ; eye crises, sudden pains arising
in the eyes, joined with redness, lancination and contraction of the
lids ; laryngeal crises, sneezing crises, etc., also occur.
Tlie associated symptoms are so numerous that only the
most important can be mentioned, namely :
(1) Disturbances of sensibility, and, in addition to the pain,
paresthesias, especially in the extremities, paralysis of sensibility
of the skin, of the muscles, and of the joints.
(2) Disturbances of the reflexes with absence of the patellar
reflex or of the tendon achilles reflex, the tendon reflexes of the
upper extremities, and of the pupil reflexes (Argyll-Robertson).
(3) Ataxia of the extremities, shown by the finger-nose test,
finger-finger test, knee-heel test and by Romberg's test.
(4) Bladder and rectum disturbances, especially inconti-
nence.
(5) Trophic disturbances leading to spontaneous fracture,
atrophies of the joints, arthropathies, falling out of the teeth, and
perforating ulcer.
(6) Eye symptoms, which are often temporary, ptosis, oph-
thalmoplegies, optic nerve atrophy.
Neurasthenia. — Pain in the back of the head is a frequent
complaint of many neurasthenics. It is localized to a circum-
scribed part of the vertebral column, or spreads out over the
entire circumference. One finds pressure sensibility in a lesser
216 DISEASES OF THE SPINAL CORD
or greater part of the spinal column corresponding to the loca-
tion of these pains. It is characteristic that strong pressure is
often felt to be less painful than light pressure. The pains are not
as severe as they are described, as may be seen by the ease with
which the patient's attention is distracted from the pain. Radiat-
ing pains in the trunk and in the extremities are also frequently
described. In regard to the other symptoms of neurasthenia, they
are so numerous that the mere enimieration would be too exten-
sive. They may be found in text-books of neurology.
Hysteria. — The pains of hysteria are similar to those of neu-
rasthenia. Pressure sensibility in the back, over one or more
spinous processes, as well as the other peculiarities of neuras-
thenia, are present in hysterical back pain.
Traumatic Neuroses. — If the trauma strikes the spinal col-
umn directly or indirectly, pain which hinders the patient from
making active movements may occur in the involved area.
General Summary. — It is even far more difficult to draw diag-
nostic conclusions from the character of spinal pains than it was
from headache pains. They have little of characteristic pecu-
liarities. The nightly exacerbation of luetic pains, as a single
exception, is almost the only one pointing directly to an etiological
factor. In spinal-cord affections, local pain, local pressure sensi-
bility, and radiating pains are singly or in combination diagnostic
criteria of value. They may occur separately, but are usually
found together. Diagnostic conclusions can rarely be drawn from
the severity of the pains alone. The highest degree of radiating
pain is found in caries and tumors pressing upon the spinal cord,
as well as in meningeal apoplexy, meningitis, and meningomyelitis.
The severity of the pain depends more upon the extent and the
degree of the process than on its nature, so that the intensity of
the pain, in the diseases described, may be greater or less, accord-
ing to the stage of the disease. It should be obsen^ed that pains in
the back, along the entire spinal cord or a greater part of it, in
neurasthenia are almost always of a minimum intensity, though
they are described by the patient as being very severe. Observa-
tion of the patients, however, shows that they are bearable pains.
CORD CONDITIONS WHICH CAUSE PAIN 217
In most cases of localized spinal affections the pains are not spread
out over the entire vertebral column, but affect only circumscribed
parts of one or a few vertebrse. A pain limited to a circumscribed
area frequently is valuable for a diagnosis; not so much for the
recognition of the trouble itself, as for the determination of its
location. The sudden darting pains of tabes are almost pathogno-
monic, as are also the crises pains.
CHAPTER X
PAIN IN THE TISSUES
UUSCXTLAB TISSUES
Muscles are subject to pain and seem especially to be affected
in the acute infectious diseases, or in those conditions which go by
the rather loose term "colds.'' The majority of these diseases are
due to bacterial invasion, with the production of toxins, and it is
these toxins which seem to have a selective action on the sensory
nerve receptors distributed in the muscles.
For a long time it was not definitely known that sensory nerve
receptors existed in muscular tissue. Sherrington, however, dem-
onstrated the existence of such organs, and Head, by his thorough
technique, showed that the origin of deep sensibility was undoubt-
edly muscular and tendinous. As yet, though we know that they
exist, the sensory end organs in the muscle tissue have not been
definitely isolated. In some cases these end organs, or sensory
nerve filaments, become hypersensitive. The hypersensitiveness
may be confined to the muscles alone, the overlying skin being
uninvolved or both the skin and muscle may be involved. Tender-
ness of the muscles may be elicited by grasping them between the
fingers, or by making pressure on them. At the same time pinch-
ing the skin may give no reaction, for the reason that the deep sen-
sory system may alone be aflFected, the skin systems not being im-
plicated.
In a consideration of the pain-producing diseases of the
muscles it is better to divide them into the voluntary and invol-
untary, for what would produce a painful reaction in the volun-
tary often has absolutely no effect in involuntary muscle; for
218
MUSCULAR TISSUES 219
instance, inflammation in voluntary muscle gives rise to very
severe pain, while in involuntary muscle it may not produce the
least sign'of its presence. In either case the stimuli which react
to cause pain are the same, but those in the voluntary muscles
act upon sensory termini which are accustomed to respond to
inflammatory irritative stimuli by pain, while in the involuntary
muscle the sensory termini have had no such training, and react
only in response to an entirely different set of stimuli. In the
voluntary muscles the pain syndrome may be produced in a
flaccid muscle by the action of bacterial toxins on a sensory nerve
terminal, while in the intestine it is necessary that to the bacterial
invasion a contraction of the muscle fibers also be added before
pain is produced.
A condition in which all voluntary movements have been asso-
ciated with great pain has been described by McCarthy (Osier's
System, VI, 569). He terms it Akinesia Algera.
VOLUNTARY MUSCLES
The diseases of voluntary muscle causing pain are myositis,
acute polymyositis, myositis fibrosa, myositis ossificans and my-
algia.
Myositis. — ^When inflammation of a muscle (myositis) occurs,
the pain is found in definite areas corresponding to the muscular
distribution. The pain may be so severe, and every movement
so provocative of pain, that the patient is unable to move, and
lies in bed like one paralyzed. Different groups of muscles may
become involved successively. The involved muscles, as a rule,
are greatly swollen. The pains are described as drawing, tear-
ing, or boring (Steiner). In other cases, no definite inflamma-
tory state can be defined, but severe pain is produced on move-
ment of a certain group of muscles. This is very common in
women of feeble muscular development, and is ^*folt at the attach-
ments of the abdominal muscles to the ribs, or along the attach-
ments of the erectors of the spine. These, in reality, are stretching
pains, and are due to an abnormal pull upon the tendinous struc-
220 PAIN IN THE TISSUES
tures from deficient muscular support" (Thompson, 36). In
these cases the skin may be very hypersensitive over the insertion
of the involved muscles (MouUin, 226). In other cases pain is
present in the skin over the entire extent of the involved muscle.
This would seem to lend credence to that part of Hilton's law
which states that skin over involved muscles is tender in disorders
of these muscles, because both have the same nerve supply. This
cannot always be true, however, because, as already explained,
while the muscle and overlying skin might originally have been
supplied by the same nerve or nerves, yet, owing to development
and consequent change in the relative position of both the skin and
its underlying muscle, it frequently happens that the skin is dis-
placed to a considerable distance away from its original position
over its nerve-related muscle.
Of the acute forms of myositis the suppurative variety soon
lends itself to ready diagnosis, not from the pain, which at first
resembles that of a generalized neuralgia, or is of a rheumatic
type, but from the rapid localization in the involved muscle of
the characteristic tender indurative swellings, hard and board-like
in character. Muscular contractures are the rule. Softening and
fluctuation soon determine the true nature of the pain. Suppura-
tive myositis may be multiple or isolated.
Acnte Polymyositis. — The form of myositis which has just
been discussed is largely a local affair affecting one muscle or a
small group of closely related muscles. In persons of early or
middle life there exists, however, a form of acute generalized in-
flammation of the muscles — a polymyositis — in which pain is a
prominent symptom.
This disorder, frequently a complication of other infectious
disease, also of generalized toxemic states, usually begins with
acute constitutional symptoms, malaise, headache, nausea, vomit-
ing. Dragging pains then occur, with frequent cramps in the
entire musculature. At first the sore spots are fairly well local-
ized, tender to pressure and to passive motion. Then a period of
inflammatory edema makes its presence manifest by swelling and
hardness of the parts. These swellings may at times give the
MUSCULAR TISSUES 221
muscles a somewhat grotesque appearance. The skin is tense,
often reddened, and may show exanthemata, erythema, urticaria,
or vesicles. The electrical excitability diminishes, and atrophy
takes place after the hypertrophy has disappeared. The epicritic
sensibility is unimpaired. Careful search should always be made
of the blood picture, as certain forms of polymyositis are associated
with eosinophilia, which not infrequently has as its underlying
cause a localized or generalized trichinosis. Other parasites are
described.
Myositis Hsemorrhagica. — In myositis hsemorrhagica pain is
the first symptom. It is usually sharply circumscribed to a spot
in the muscle where a small nodular, palpable tumor usually de-
velops. Edema soon sets in and hemorrhagic areas are observed,
which soon show the familiar yellow-green discoloration.
myositis Fibrosa. — Myositis fibrosa often shows itself in sharp
pains in the muscles, the lower extremities usually being first im-
plicated. The disorder advances slowly, going from one muscle
to another, and the patient, after several months or years, is un-
able to move about because of the pain and rigidity. Contractures
occur, but sensory disturbances are rare. Palpation is usually
painless in this particular variety, and much weight is laid by
Lorenz upon this feature in diagnosis. The muscles get harder,
but the spontaneous pains become less pronounced.
Myositis Ossificans. — In myositis ossificans the pain often
masks the case as one of "rheumatism." In some pain is lacking
in the early stages. The usual signs of myositis are present in
most cases, with radiating pains. Following an attack, the pain
subsides, but the muscles remain hard and indurated. Other
attacks come and go, the indurations becoming harder and harder,
until bony masses are evident. The disorder is found most fre-
quently in the muscles of the back and neck, the face and upper
extremities less frequently, while the muscles of tlie lower ex-
tremities are rarely involved. The gradual rigidities that develop
with the deformities are very striking.
Myalgia. — Torticollis and lumbago are the most classical of
the myalgias, although any muscle of the body may show this
222 PAIN IN THE TISSUES
peculiar disturbance. Myalgias are very frequent, yet, notwith-
standing, the cause is very obscure. Exposure to cold and trau-
matism are among the most frequent etiological factors.
The pain is usually sharp, especially when the parts are moved
and the muscles forced to functionate, actively or passively. In
torticollis, in which the sternocleidomastoid is affected, the pa-
tient holds the head to one side, and the pain is very
severe and is usually unilateral. In lumbago the pain is
in the back. The onset is usually sudden, often following a
muscular strain ; every movement becomes extremely painful, and
the position adopted by the patient is very characteristic. He
walks with a stiff, short tread. Lumbago may be confused with
spinal arthritis, with sacroiliac disease, with malignant spinal
growths, or even tuberculosis of the spine. Other muscles (pleu-
rodynia, scapulodynia, dorsodynia) afford other special pains and
special postures.
The muscles are often somewhat painful to pressure, and occa-
sionally they are indurated ; at times the induration is soft, again
it is hard. Counterirritation and massage often relieve the con-
dition very rapidly.
INVOLUNTARY MUSCLES
Colics. — Thus far only voluntary muscles have been consid-
ered. Involuntary muscles, also, are the site of pain sensation,
especially those which are present in the hollow viscera. Here
the pain is associated with contractures or spasms. Tliese con-
tractions or spasms, when they occur in the intestinal, genito-
urinary, or biliary tracts, are called colic. The pain in colic is
constant, as a rule, but may have periods of greater or less in-
tensity. Of all colics, perhaps, that of the common gall-duct is the
most severe.
Colicky pains show variations. In some cases there is a sudden
increase of pain, which persists for a longer or shorter period and
suddenly disappears. In another type the colicky pain comes on
suddenly, then remits, and in a few hours returns and becomes
MUSCULAR TISSUES 223
very severe. This may be repeated many times. In a third variety
the pains at first are light, but become of gradually increasing
intensity, with an incomplete remission between the paroxysms
until a paroxysm of maximum intensity occurs, when there is a
gradual remission and return to the normal.
Several factors enter into the causation of colicky pain.
(1) The pains may be due to the overdistention of a portion
of the canal lying between a distal, non-moving, contracted part of
the canal, and a movable, contracting part, the movable part gradu-
ally approaching the stationary part until the contents in the in-
tervening canal are put under great pressure and consequent dila-
tation and overdistention of the canal take place. This over-
distention causes a stretching and pressure on the nerve terminal
filaments in the wall, and pain results. Normally this overdisten-
tion does not occur, for it is a rule, in all hollow muscular viscera,
that contraction of one portion is followed by relaxation of the
next adjacent portion. It is only when this law, called by Meltzer
(105b) the "law of contrary innervation," is at fault that colic
occurs.
(2) Pressure may be made upon the terminal nerve fila-
ments by the contracting muscles.
(3) Traction and pull is made on the mesentery by the in-
equality in position of the contracted and noncontracted seg-
ment
(4) During contraction of the bowel it tends to straighten
out and this causes a pulling and stretching of the mesentery.
In fact, it seems that this is the most reasonable hypothesis. This
is contrary to the idea of Hertz that tension is the only true
cause of hollow visceral pain. In intestinal colic, relief almost at
once follows the onward passage of the feces. The pain of intes-
tinal colic is not felt so much in the viscera, but is referred to
the anterior abdominal body wall, and follows the law of seg-
mental distribution (Head). Hertz, on the contrary, claims that
the referred pain is rarely present alone to the exclusion of a triie
visceral pain, but that the visceral pain is often present to the ex-
clusion of the referred pain.
224 PAIN IN THE TISSUES
FATT7 TISSUES
Adiposis Dolorosa. — In this condition, first described by Der-
cum in 1888, pain is a prominent feature. It is a pain, however,
that is more the result of pressure than spontaneous, although there
usually are burning, lancinating sensations present in the fatty
masses, which form the characteristic features of the disease.
Diffuse collections of fat, scattered over the body, are found
in several conditions. Adiposity shows itself under several forms ;
chief of these are the adiposis tuberosa of Anders, adiposis cere-
bralis of Frohlich, formerly prophyseal or epiphyseal disease
(Marburg, Jelliffe), symmetrical adenolipomatosis, multiple lipo-
matosis and adiposis dolorosa. These are probably closely related
conditions, and pathologically some relationship to the ductless
glands, particularly the hypophysis, is probable.
Adiposis dolorosa varies from the others by reason of the pain
and tenderness of the fatty masses. This pain is probably the re-
sult of an associated neuritis, since neuritic lesions have been found
in a number of cases. Furthermore, tender nerve trunks, trophic
changes, and sensory symptoms go to round out the picture of a
neuritic involvement.
The fatty areas, as they develop on a basis of a general adipos-
ity, are usually edematous and tender. Pressure induces an ex-
quisite painfulness, and leaves behind it burning, lancinating
sensations. The areas have a tendency to disappear, leaving in-
durated spots; then recurrences take place, and nodular tumors
develop. These nodules, which are very sensitive — even to the
slightest touch — often giving rise to exquisite pain, are found
principally over the trunk and extremities. The face, hands and
feet are free. Cases are also met with, with no nodules. Here
there are large indurative areas, sensitive to touch and palpation.
There is a tendency for these areas to become less sensitive, but
nodules which remain in the fat retain an exquisite tenderness,
and are the centers for neuralgic-like radiating pains.
• Pain is present usually at all times. It may be an initial
symptom, coming on before there are any fatty nodules. It may
FATTY TISSUES 225
be dull, lancinating, or burning; rarely is sharply localized to
any nerves, but is usually associated with tender nerve trunks.
Asthenia, querulous irritability, mental apathy, and depres-
sion are frequent associated conditions, while general neuritic
signs, such as anesthesiae, hyperesthesia, vasomotor disturbances,
hypersecretion, cyanosis, demographia, ulcers, ecchymoses, all con-
tribute to the general evidence to show some implication of the
protopathic system.
In all cases of adiposis dolorosa examination should be made
for hypophyseal symptoms. In many cases of this disease an
adenoma of the posterior lobe of the hypophysis has been found
(Pick).
CHAPTER XI
BONE PAINS— THE 0STALGIA8
OENEBAL CONSIDEBATIONS
When pain occurs in a limb over a region where bone involve-
ment is a possibility, it is necessary to consider lesions of struc-
tures overlying the bone, as well as those of the bone itself. It
is only when pathological lesions in the overlying structures have
been eliminated that the bone should be considered as at fault.
When a patient complains of pain in bony structures it is neces-
sary first to obtain a history of the pain, its type, manner of onset
and character, and then to proceed to a physical examination of
the aflfected region. Of the physical methods of examination
made use of in the elucidation of bone symptoms, palpation is
productive of the best results. If palpation over a limb or a part
where bone is a prominent structural component discloses only
superficial pain, the bone can be disregarded as the chief cause
of the pain ; yet it should always be borne in mind that a lesion,
which at first may have commenced in the bone, may progress so
that adjacent tissues are involved and secondary lesions ensue.
These may be far worse, and produce symptoms of much greater
severity than the original disorder, so that often in the medical
survey the secondary lesion intrudes itself to such a degree that
the original primary condition is overlooked. As a rule, however,
if tenderness and pain are both superficial, and there is no his-
tory of a previous deeper pain, the bone may be disregarded and
the superficial tissues considered as being at fault (bone lesions
are tender and painful on deep pressure).
226
TYPES OF PAIN 227
TYPES OF PAIN
In our examination as to the cause of the bone pain, inquiry
must be made as to its type, i.e., whether it is continuous or inter-
mittent.
Oontinnous pains are due to persistent acting causes, such as
new growths, inflammation or aneurysm. New bony growth gen-
erally produces a dull, aching pain, which, as a rule, is fairly well
localized to the area affected. Inflammation of bone produces
a continuous pain, which is interrupted at times by paroxysms
of greater intensity. Pressure on a bone by a growing tumor or
an aneurysm (with gradual erosion of the bone) causes a dull,
aching pain of great severity. In this condition there is a sharply
defined area, exquisitely tender to the touch, corresponding to
the site of the bone involvement. Other signs of tumor or
aneurysm are also present
Intermittent pain in bony lesions is divided into two classes ;
in the first, the pain occurs spontaneously, without any excess of
local irritation, and generally indicates a more severe process than
in the cases where pain is felt only on pressure. When pain is
only felt on pressure (if the bone is only slightly involved) it
disappears from the part as soon as the pressure is removed; but
in more severe cases it may persist for some time after the re-
moval of the pressure.
In some cases there are recurring attacks of very violent
pain, with great tenderness at the point where the pain is felt.
When this pain and tenderness are accompanied by local swell-
ing, fever, and a rapid pulse, osteomyelitis should be considered.
Pains of this type, spontaneously occurring at intervals without
any apparent existing causes, are called spontaneous intermittent
pains. The other forms which can be produced by pressure are
called pressure intermittent pains. These occur generally in
association with an inflammation and are either mild or severe,
depending upon the amount of pressure which is necessary to be
exerted on the part to produce pain. Among the pressure inter-
mittent pains are those due to osteomalacia and osteomyelitis.
228 BONE PAINS— THE OSTALGIAS
Dinmal variation of the pains is of great value in the diag-
nosis of bone lesions. Pains due to certain diseases seem to appear
at regular and definite periods of the day. Syphilitic and tubercu-
lous bone pains are generally worse at night. A point of impor-
tance is that luetic pains are always relieved by mercury and the
iodides, and tuberculous lesions give tuberculin reactions and the
serological test (Wasserraann's) is present in lues. Nocturnal
ostalgia is very common in typhoid fever, especially in patients in
whom the bone marrow is involved, so that when a limb pain is
present in those convalescing from typhoid fever the bone should
always be examined.^
OHARAOTER OF BONE PAIN
According to its severity bone pain may be classified as sharp,
piercing, dull, or aching. When the pain is sharp, it is generally
of sudden onset, and comes without warning. If it is very severe,
and is sharply localized, osteomyelitis is most likely to be present.
Piercing pain is not common in bone disease, and, when present,
neuralgia should be sought.
Dull and aching pain is characteristic of syphilitic lesions.
When present an examination for past or present syphilis should
be made. It is also present in periostitis, in which at the point
of periosteal thickening a dull pain, with at times more or less
acute exacerbation, is felt. When the periosteum is diseased, a
well-marked, localized thickening will be found on X-ray exami-
nation.
LOCALIZED BONE PAIN
With reference to extent, bone pains may be classified either as
localized or diffuse. Localized bone pains are due to periosteal
lesions, traumatism, new growths, and inflammation.
1 It seems that the medulla of bone, perhaps the cndosteum, is much more
sensitive than the periosteum, for recently in our (Dr. Schultze and myself)
work on bones we have found that the cutting of the periosteum or the tre-
phining of the cortex was not especially noticed by the morphinized dog, but
as soon as the drill penetrated the medullary cavity he became restless and
whined very much. Later in the experiment, when it became necessary to in-
troduce a sound or curette into the narrow cavity, he again showed signs of
apparent pain.
LOCALIZED BONE PAIN 229
Periosteal Lesions. — The periosteal lesions causing pain are,
as a rule, inflammatory. If the inflammatory changes occur at the
point of the insertions of muscles or tendons, any activity of the
muscles or movement of the tendons will cause pain, and in some
cases this may be confused with pain produced in the bone itself.
In periosteal inflanunation tenderness is sharply limited, which, as
a rule, is not the case in lesions of the bone itself. The tender-
ness is nicely defined by running the finger do^vn to and over the
inflamed area. In lesions of superficial bones like the tibia
marked pain is evinced as soon as the finger crosses the border of
the inflamed area.
Should swelling of the periosteum occur without pain, it may
be due to a new growth which causes pain only when the sub-
periosteal distention becomes so great that pressure is made upon
the sensory nerve filaments terminating in the periosteum.
In children the so-called growing-oiit pains are often the result
of slight septic processes in the periosteum. They often appear
after acute infection, tonsillitis, etc.
Traamatism. — Here the pain is of sudden onset and immedi-
ately follows the injury. If the part is too tender to palpate, an
anesthetic may be used, so that a proper diagnosis of the condi-
tion can be made. If possible a skiagraph of the part should be
taken. This will save considerable manipulation of the injured
region, and will lessen the necessary pain to the patient. I . tL:
X-ray is not available the presence or absence of fracture should
be determined from crepitus and false motion. If a fracture is
foimd its probable direction and extent should also be determined.
Following an injury, if localized tenderness is present and the
bone has not been broken, bruises and contusions must be consid-
ered. These may also occur in the periosteum, in which case the
tenderness is present as a rule only on deep pressure. It is neces-
sary to consider fractures, bruises and contusions separately. In
some severe injuries all these may be included in one lesion, which
is called a crush.
Fracture. — In fractures pain may be entirely or almost en-
tirely absent, particularly when the fracture is an impacted one.
230 BONE PAINS— THE OSTALGIAS
This occurs only in the absence of laceration of the adjacent parts.
Pain may also be absent when the fractured ends of the bone are
separated by a considerable interval. In fractures pain is elicited
by two methods : First, by passive motions, to produce which the
limb is grasped so that one hand is above the line of fracture and
the other below it, and to and fro movement is made so that there
is motion between the fragments ; when a fracture is present, pain
is felt, sharply localized at the point of fracture. Second, if pres-
sure be now made over the point of greatest pain, a well-marked
area of tenderness, corresponding rather closely to the line of
fracture, is found. In some fractures the line of the fracture may
be outlined by the sharply defined area of tenderness immediately
above it. This line of tenderness is very useful in diagnosing a
greenstick fracture in which crepitation and false movement are
absent In certain cases of impacted fractures, for instance, those
of the femur, great care should be exercised in the manipulations,
so as not to break up the impaction ; otherwise, especially in old
people, a condition in which union does not occur will result. A
point of considerable importance to remember in the diagnosis of
fracture is that tenderness persists for a considerably longer period
in a fracture than in a simple contusion. If the pelvis should be
injured and a fracture suspected the crests of the ilium should be
forcibly pressed toward the middle line. When a fracture is pres-
ent there is a well-marked and sharply defined pain at the point
of fracture.
Contusions. — Bruises and contusions generally are the result
of direct violence, and are localized in extent. The periosteum is
markedly elevated and under it a blood clot, felt as a soft, fluctu-
ating mass, may be present. If in a lesion of this kind in which
the swelling is beneath the periosteum the pain increases, instead
of decreases, it is likely that infection has occurred, particularly
if th^. Swelling' coptiimes, to lincr^se in size and becomes softer.
. Hew CUrflwJtbB.T^A^ » ^tmIo, mewigrowths of bone are not pain-
ful ( ?) until the periosteum is involved, or until pressure is mada
uppnadj^eiit ti^^pies, when ffce^ give yis^ hptblto local and re-
fecred pain,. Iteseipblipg new ,gTo^rtbs^ t^berc^loiAS; di&eaae ofi tte
LOCALIZED BONE PAIN 231
boile may be present for some time without producing pain, but,
as a rule, it soon gives rise to a dull aching, which, if the adja-
cent joint is involved, is interrupted by sharp paroxysms.
Septic Involvement. — Septic involvement of the osseous sys-
tem is frequently encountered during pneumonia and malaria. It
also is common during the course and convalescence of typhoid
fever, the bones must frequently affected being the ribs, tibia,
femur and clavicle. This septic involvement, and, in fact, all in-
flanamatory changes, can occur only in the bone marrow and
the cancellous tissue, because the hardness and density of the cor-
tex inhibit inflammatory reactions. To these inflammatory
processes the name osteomyelitis has been given. The pain of
acute osteomyelitis is of the greatest intensity. According to
Nichols, it is the most intense of any pain with which we are
familiar. Osteomyelitis of the long bones often commences
with a sharp, sudden pain in the vicinity of the epiphyseal line.
A sign of great significance in the diagnosis of osteomyelitis is that
continued, gentle pressure on the shaft of the bone, at a distance
from the area of greatest pain, will at first produce no pain, and
then, very suddenly, there will occur a sudden short exacerbation
of great severity. Acute osteomyelitis generally gives acute symp-
toms, but it must not be forgotten that, either following such an
acute attack or arising de novo, a chronic osteomyelitis may be
present and give rise only to a dull aching, in some cases, gnawing
pain in the affected area.
Changes in the structure of a bone not only may be the result
of germ infection, but may also be produced by diseases of the
hemopoitic system, such as leukemia and pseudoleukemia. In
such conditions pain is frequently present in the lower part of the
sternum. It is produced by pressure against the bone. Such pres-
sure may occur while leaning against the edge of a table, in writ-
ing, on resting on the window-sill, or on bending over the washtub.
Pain of this type is often the first manifestation of leukemia or of
a pseudoleukemia.
Schmidt has made the interesting observation that in leukemia
and pseudoleukemia the sternal pains are controlled by arsenic.
232 BONE PAINS— THE OSTALGIAS
and that during the period of greatest activity of arsenic the pains
are less troublesome. He has also found that the bone pains in-
crease and decrease with the increase and decrease in the number
of the leukocytes.
QENEBALIZED BONE PAIN
The diseases causing generalized bone involvement and giving
rise to pain are: Osteomalacia, diseases of the hemopoitic system,
and new or abnormal growths.
Osteomalacia occurs most frequently in association with preg-
nancy. The pain is usually found in the lumbar region and in
the lower extremities. It is produced by any action which causes
motion in the affected bones. Such actions as walking, stooping,
rising from a sitting to a standing posture, laughing, sneezing and
coughing produce great distress. Schmidt well describes it thus:
^*0n getting out of bed, the patient subject to osteomalacia care-
fully lifts out each leg in turn, holding it by the thigh." Deep
respiration often gives rise to pain in the ribs. Descent of the
stairs is sometimes more uncomfortable than the ascent, because
of 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. The patients are thus obliged to change .their positions
constantly, and their sleep is very broken. Abduction as well as
rapid dorsal flexion of the hip causes paroxysms of pain located at
the ankle joint. In the latter case the pain often runs the entire
length of the lower extremity, radiates to the pelvis, and is some-
times accompanied by dorsal clonus. Lateral compression of the
thorax, or of the pelvis at the level of the trochanters or iliac crest,
promptly causes pain. The wearing of a corset and tight lacing
sometimes' appear to relieve the subjective symptoms, evidently
through the support given to the spinal column. Osteomalacia
should be carefully diagnosed from spondylitis of the dorso-lumbar
region, in which, during the early stages, the character of the
pain may be somewhat similar.
DIFFERENTIAL DIAGNOSIS OF BONE PAIN 233
Diseases of the hemopoitic system, as leukemia and pseudoleu-
kemia, also cause aching pains in the long bones. (See above.)
Xew growths of bone are sarcoma, carcinoma, myeloma,
lymphadenoma ossium, and chloroma.
Sarcoma and Oarcinoma. — Should pains be associated with a
tiimor mass and at the same time with cachexia, search should be
made for malignant bone disease, and one of the best methods of
diagnosis is the X-ray. In suspected cases the adjacent lymph
glands should also be examined for swelling and the skin should
bo inspected for the red lines caused by affected lymph radicles
(running from the site of the disease to the nearest lymph gland).
Myeloma, Ijrmphadenoma ossium, and chloroma cause diffuse
pain and are associated with the symptoms of internal lesions.
Malignant metastatic growths also are frequently found in bone,
and cause pain which at first may be delimited and localized ; but
finally, with the involvement of the entire bone, the pain also
becomes diffuse.
Abnormal growths of bone causing pain are osteitis deformans,
and leontiasis ossea.
Osteitis Deformans. — In case of long-continued pain in the
legs, with occasionally tender points over the bone, osteitis de-
formans, or Paget's disease, may be found. Its presence is further
indicated by the constantly increasing size of the head.
Leontiasis ossea is also a rather frequent cause of bone pain.
Spurs growing out from bone are also a cause of pain. When
they grow out of the os calcis, they are often the cause of the
so-called painful heel.
DIFFEBENTIAL DIAGNOSIS OF BONE PAIN
•
Bone pain should be differentiated from that due to bursitis, in
which a painful swelling is located over the site of a bursa. Pain
is present only in acute bursitis. In the chronic form it is absent
unless an acute process is engrafted upon the chronic one. Of
somewhat frequent occurrence are the neurotic ostalgias, the so-
called functional pains. In some cases the diagnosis from the or-
234 BONE PAINS— THE OSTALGIAS
ganic form of pain is very difficult, but on examining under
anesthesia in those suffering from neurotic ostalgia no loss of func-
tion is apparent and no abnormal change in the tissues can be felt
An X-ray examination also shows no pathological change ; at the
same time there is no definable change in the relationship of the
bone to the surrounding parts.
Hysteria may be differentiated by associated areas of anes-
thesia and hyperesthesia, as well as by the eye symptoms. Nerve
lesions, such as neuralgia and neuritis, are distinguished by their
characteristic symptoms. Referred nerve pain is sometimes pres-
ent in a bone, but this is not so difficult to diagnose. Local symp-
toms of disease are absent, while diseased areas are present at
a distance. Pains may also be referred from a bone to a distance ;
such pains referred are often found in diseases of the vertebrce,
however, in which case pressure over the spinal column is very
painful.
JOINT PAINS— ABTHBALQIA
Olassiflcation. — Joint pains are of two classes: organic, in
which the pains are due to structural changes, and non-organic,
in which no apparent structural change can be found. In the
former the pain appears when the affected organ begins to func-
tionate. Under the latter class are included the hysterical and
functional pains.
Organic joint pains may be due to injury or to disease of any
one or more of the following structures: namely, the bone, car-
tilage, synovia, capsules, muscles, tendons, subcutaneous tissues,
and the skin. The pain in the bone may be due to involvement
of the epiphysis, in which case it is elicited by direct pressure over
the epiphysis. On the other hand, if the articular cartilage is dis-
eased, the pain is best elicited by suddenly jolting the articular
cartilages, one against the other. If pain is present from the on-
set of the swelling in a moderately enlarged joint, and then if a
sudden enlargement of the joint occurs, with a concomitant in-
crease of the pain, the condition is most likely a chronic arthritis,
with an acute reinfection and consequent synovitis. If such is the
case, it is accompanied by the symptoms found in acute synovitis,
JOINT PAINS— ARTHRALGIA 235
guch as a rise of temperature, chill, and marked redness of the
skin. If pain and swelling are found firat, in an area adjacent to
Fio. 59. — Pain in Skin Over Back and Shoulder Dub to Disbase op
Shoulder Joint.
In this drawing of the brachial plexus is shown how in injuries to the shoulder
joint the pain may be carried back through the suprascapular and circum-
flex nerves to the anterior branch of the fifth cervical, where it is trans-
ferred to the posterior branch of the fifth cervical and thence is further
propagated backward until it is distributed to the skin over the back
(trapezius muscle).
the joint, and then spread to the joint and cause it to become very
much swollen, sensitive, and lender, it indicates that an inflamma-
tory process has extended from the adjacent tissues to the joint,
236 BONE PAINS— THE OSTALGIAS
causing an acute arthritis. Inflammatory processes of this nature
are characteristic of extension from an osteomyelitic area in the
bone into the joint, and also of an inflammation of the adjacent
soft parts, such as occurs in erysipelas, abscess, lymphangitis,
and bursitis with consequent extension into the joint
Osteom;yiBlitis is tender only on deep pressure, while cutaneous
and subcutaneous inflammation is exquisitely tender on super-
ficial pressure. Inflammatory changes also give other character-
istic symptoms.
Radiation of Joint Pains. — Joint pains, as a rule, do not
radiate. There are few exceptions, however, as exemplified in the
pain of the knee and the inner side of the leg, which occurs in
the hip-joint disease, and the pain in the ankle and calf of the
leg present in flat foot. Pain due to disease of the shoulder joint
is sometimes felt in the skin over the back and shoulder (see
Fig. 59). There may also be a radiation of pain to joints. This
is found in primary or associated nervous lesions, as tabes or
syringomyelia.
Intensity of the Pain. — The intensity of the pain gives some
indication of the rate of development of the lesion, for it has been
found that the severity of the pain depends to a great extent on
the suddenness of the onset of the disease; the more acute the
onset, the more severe is the pain. The reason that pain is not
very severe in disease of gradual development is that, in this type
of disease, the body becomes accustomed to the pathological
changes, and is not so radically affected as it would be if they were
of sudden origin. Therefore they do not cause such sudden re-
adjustment of tissues and consequently do not cause much pain.
When joint pains are of extremely sudden onset, they are usually
the result of an acute synovitis.
Sjrmptoms. — In involvement of a joint the pain, as a rule, is
accompanied by certain more or less specific symptoms, such as
muscular sp^sm, and swelling or loss of function of the part
affected. In deep joints, as the hip, muscular spasm is the best
indication of joint trouble; whereas, in superficial joints, as the
knee, swelling is the surest indication.
JOINT PAINS— ARTHRALGIA 237
The CESSATION OF FUNCTION in a hypersensitive joint may be
explained on the following hypotheses :
(1) That a balance exists between the external muscles and
the internal resistance of a joint. When the muscular action be-
comes excessive, and too much pressure is exerted upon the in-
ternal structures of the joint, pain is produced. This inhibits
further action of these same muscles, and causes inactivity.
(2) Where excessive pressure is present, there also seems to
be, according to Hilton, a lessened amount of synovial fluid, which
produces more difficult movement, a tendency to pain productioUj
and a consequent inhibition of motion.
(3) Muscles surrounding or associated with, an affected or
painful joint are hypersensitive, and are easily thrown into con-
traction, in which state they are better able to repel any attack
upon the integrity of the joint. This hypersensibility also causes
them to contract to a lighter stimulus than usual. In some cases
the slightest touch causes the most pronounced reaction.
(4) A position of flexion is generally taken by an affected
joint, because even though both the flexor and the extensor muscles
are equally involved, the flexors being the stronger, overcome the
weaker extensors, and draw the limb into the position of flexion.
It is possible that the associated tenderness and loss of muscular
power present in a limb in which the joint is diseased and painful
may be explained by the association of the nerve supply of the
joint with its surrounding muscles and overlying skin. From
these premises Hilton has deduced the following law: The
same trunk or nerves whose branches supply the groups of
muscles moving a joint, furnish also a distribution of nerves to
the skin over the insertion of the same muscles, and the interior
of the joint receives its nerves from the same source. This law
does not always apply, for it has been partially controverted by
Sherrington.
After the patient has described his pain and its characteristics
it is necessary to verify his statements. This is done by palpation
and manipulation. Of the symptoms resulting from manipulation
the most important one is tenderness. In all inflamed joints this
238 BONE PAINS—THE OSTALGIAS
is always present. It is also well to note whether the tenderness
is superficial or deep. If superficial, the lesion may be in the skin,
muscles (myalgia), or nen^e (neuralgia), but if it is deep and is
noticed only on deep palpation, it indicates that the lesion is
probably associated with the bones forming the joint, or with the
synovial membrane of the joint itself. Then if the tenderness is
not too great, manipulation of the joint is performed (passive
motion being made). Some idea of the intensity of the pain may
be derived from the resistance to motion. Tenderness in a joint
may also be elicited by knocking the opposing joint surfaces to-
gether with a sudden shock. If they are denuded or inflamed,
pain is produced. Both of those signs can be elicited in the
presence of fluid if the quantity is not too large, or if the internal
tension is not too great. If still in doubt as to the origin of the
pain, it is necessary (after all these diagnostic means have been
exhausted) to use a so-called therapeutic test. Mercury and iodin,
as a rule, will cause syphilitic joint pains to cease, and salicylates
ameliorate those due to rheumatism.
Of the symptoms associated with pain in joint disease swell-
ing of the joint and redness are the most important. Redness
usually is associated only with acute processes, which may be of
two kinds: (1) traumatic, in which, in addition to swelling of the
joint there is present a history of an injury; (2) infectious, when
infection is added to traumatism, the pain and swelling increase
and fever makes its appearance. If, following traumatism, there
occur in a joint pain and swelling, it indicates that an acute
synovitis has developed. If fever is also present, infection should
be thought of, and septic organisms should be sought. In cases of
subacute urethritis, the gonococcus is a frequent cause of joint in-
volvement. However, gonorrheal arthritis should always be con-
sidered in case of an apparent idiosyncratic inflammation in the
joint, when it is borne in mind that septic involvement of a joint,
without external communicating injury, is very rare, and that
when, in the presence of gonorrhea, joint involvement occurs, the
gonococcus is probably the causal agent. In gonorrheal arthritis
the pain is slight at first, and is accompanied by swelling and stiff-
JOINT PAINS— ARTHRALGIA 239
ness of the joint, with a slight temperature. A history of such
joint difficulty may also show that the joint symptoms followed the
passage of a sound.
Eisendrath gives the order of frequency of involvement of the
joints in eight hundred and fifty-five cases of gonorrheal joints, as
follows: In the knee, in 158 cases; in the ankle, in 125 cases;
in the wrist, in 76 cases ; in the elbow, in 53 cases ; in the shoulder,
in 44 cases ; in the hip, in 42 cases ; in the temporo-maxillary, in
16 cases; in the small joints of the foot, in 46 cases; in the heel
and toes, in 21 cases ; in the small joints of the hands, in 50 cases,
and in other articulations, in 24 eases.
Diagnosis of Inflammatory Joint Pains. — Septic. — All in-
flammations of a joint are not septic. The presence or absence of
infection may be denoted by the temperature of the patient.
Fever, as a rule, is an indication of infection. Where infection is
present, either rheumatic or septic, the original site of entrance
should be sought. In rheumatism it frequently is the tonsils; in
gonorrhea, the urethra; in sepsis, the endometrium. Less fre-
quently the infection may originate from typhoid fever, menin-
gitis, and pneumonia.
If the inflammation of the joint is non-septic and fever is
absent, the metabolic and eliminating organs of the body should
be examined. Pain and redness of a joint are very common in
lead poisoning, joint disorders accompanying psoriasis and in the
so-called uric acid diathesis, the sodium urate deposits in the joint
causing pain. In children scurvy is a frequent cause of joint
disturbance. In a suspected case of rickets the gums should be
examined for sponginess, and the body for the hemorrhagic skin
eruptions which are so characteristic of this disease.
In rheumatic inflammation the pain is most severe, and is
accompanied by an excessive degree of joint swelling. If cardiac
involvement is also present, and a rapid amelioration takes plaqp
under the use of salicylates, the diagnosis is rendered certain.
Should redness be absent and temperature little marked, tuber-
culosis may be present. Tuberculosis of a joint (especially of the
knee) is frequently present without redness, and in many cases
240
BONE PAINS— THE OSTALGIAS
without pain. A tuberculin reaction or tuberculous foci else-
where in the body would aid in clearing the diagnosis.
Acute synovitis is characterized by chills, swelling, tenderness,
loss of motion and redness of the overlying skin. Stiffness is a
frequent sequela of synovitis. WTieu it occurs, pain on motion is
excessive. Stiffness with pain may also be the result of immobi-
lization for long periods.
PECTONEUS
ADD. MAO.
ADD. BUEV.
/Ba.KNEE.
ADO MAG.
SYNOV.
MEM.
HIP JOINT
^^-^i9li^if^^
Fig. 60. — Obturator and Accessory Obturator.
This shows the relation of different thigh muscles to the hip joint.
Hip Joint.^ — Tn diseases of the hip joint, we have occasion
to observe many different forms of pain, the varieties of which
doubtless depend upon the peculiar relationship of the nerves to
the joint. The nerves of the hip joint are mostly derived from
^By Dr. Werndorf, Assistant to Professor Lorenz, in Vienna.
JOINT PAINS— ARTHRALGIA 241
the lumbar plexus. They are: (1) a median skin branch from
the femoral nerve, and (2), the obturator nerve, which through
its posterior branch supplies the anterior and median parts of the
capsule, and through other branches supplies the intraarticular
ligament and the acetabulum. Many other nerves reach the hip
joint, either by way of the nervus ischiaticus or the quadratus
femoris from the sacral plexus.
Radiating Pains. — The pains observed in the hip joint are,
for the most part, either radiating or local. Radiating pains are
observed in the early stages of all classes of hip-joint disease.
They are frequently the first signs of the so-called voluntary lame-
ness, and are also an early symptom of beginning tuberculous dis-
ease of the hip. They are also observed in acute and chronic in-
flammations of the hip joint, and in growing joints. The most
frequent point of radiation is the knee. It is very probable that
the pains propagated to the knee arise through suffusion into the
obturator nerve, which runs in the immediate neighborhood of the
joint. Indeed, the pathology of the hip joint offers an important
point for this sort of explanation of the so-called knee pains, for
anatomical examinations show that the synovial form (most fre-
quent) starts with proliferating tuberculous granulation tissue in
the acetabular fossa, and also in the part of the joint cavity occu-
pied by the intraarticular ligament. A branch of the obturator
nerve, supplying the joint, accompanies the ligament and enters
the joint through the incisura acetabuli. Branches from this
nerve also supply the upper half of the knee joint, and the median
side of the thigh, in which locations the referred pain is most fre-
quent. Radiating pains are frequently also felt in the lower half
of the knee joint, or in the popliteal space.
Functional Pains. — Another variety of pains observed in
the hip joint, which are of great interest, are the functional pains
resulting from movement and weight bearing. The principal
difference between these two forms of pain has generally been
overlooked. Lorenz was the first to show, on the foundation of his
interference therapy, the fimdamental differences between the
movement and the weight-bearing pains. The so-called move-
242 BONE PAINS— THE OSTALGIAS
ment pains arise on movement of the head of the bone in the artic-
ular cavity; the weight-bearing pains, on the contrary, arise
through the (functional) weight-bearing stress on the bones con-
stituting the joint.
Movement Pains. — If a synovial diseased joint is opened, the
synovial membrane is found to be considerably swollen, it being
three or four times thicker than normal, and, at the same time,
reddened and infiltrated. The cartilage of the head of the bone
may be perfectly normal. Its shining whiteness is in striking
contrast to the redness of the synovia. Now, by the least move-
ment of the head of the femur in the acetabular cavity, the dis-
eased, and therefore very sensitive, synovial membrane is pinched
and squeezed into folds. It soon becomes injured, and this trau-
matism chiefly affects the numerous and multiple divisions of the
nerves running in the synovia. Therefore the pain felt on move-
ment occurs through the irritation of the intraarticular nerves of
the svnovial membrane. It is understood, without further ex-
planation, that in this stage of the disease weight-bearing, that is,
the pressing of the head of the bone against the articular cavity,
is without pain. Therefore, on examination, very often the re-
markable symptom occurs that a child with coxitis walks entirely
free from pain, and that, on examination of a joint previously
painful on to and fro motion, the weight-bearing test proves en-
tirely negative. A light blow on the sole of the foot of the diseased
and outstretched limb produces no pain, while the least attempt at
movement of the thigh against the pelvis produces the most severe
pain. The irritation (on movement) of the intraarticular nerves
produces a reflex spasm of the muscles which surround the hip
joint. The joint is at once, when fixed through the resulting
muscular action, rendered free of pain, since the injury of the
sensitive internal covering of the joint is prevented. So it hap-
pens that a muscular fixed joint is insensitive against weight bear-
ing, while for the same reason night cries are a constant symptom
in the history of a coxitis patient. In sleep the muscular spasm
which fixes the hip joint relaxes, and with it the fixation of the
synovial membrane disappears and any involuntary movement of
JOINT PAINS— ARTHRALGIA 243
the patient produces the greatest pain. He is aroused from sleep
by the pains. The muscular spasms recur, and again protect the
joint from painful movement, so that the patient again falls to
sleep.
Should any doubt remain as to the truth of this explanation of
the causation of these pains, it will disappear on viewing the
resulta of treatment by early fixation by means of a plaster cast.
The plaster cast takes the role of the fixating muscles, and
the joint will remain insensitive to weight bearing, so insensitive
that the coxitis patient is able to walk on his diseased limb, and
frequently can even jump on it without producing pain.
Weight-hearing Pains, — The pains observed on allowing the
hip joint to bear weight are of an entirely different kind. They
are mostly local, are seldom radiating, and disappear if the patient
rests in bed. Movement of the thigh of the diseased side against
the fixed pelvis produces no noticeable increase of the pains. They
arise through traumatism of the ligaments and muscles, as the
result of a changed direction of weight-bearing. Therefore, they
are almost always observed when adduction and flexion contrac-
tions are present in the hip. When, as may frequently be observed,
a genu valgum, or recurvatum occurs in addition to the adduction
flexion contraction, weight-bearing pains are present in the knee
joint. They are similar to the pains arising from static deformi-
ties, and can be well differentiated from the radiating pains pre-
viously mentioned. Trauma of the soft parts of the joint is caused
by the stretching of the muscles and tendons on the adduction side
of the joint. The bony structural inhibition itself produces very
little pain, except when destruction of the joint itself is present.
Physiological investigation (Dubois Raymond) has shown that
equilibrium in walking and standing occurs not so much through
the action of the bony elements of the joint as through the play of
musculature related to the joint and the tension of the ligaments.
The knowledge of these facts is of the greatest value in the treat-
ment of a tuberculous hip joint, for it shows us that a hip joint,
once fixed and therefore protected against joint movement, may be
subjected to weight bearing. The functional irritation (friction)
244 BONE PAINS— THE OSTALGIAS
of the weight-bearing is suitable to stimulate the end of the bone to
grow, and in this way to produce an ankylosis of the hip joint,
which is the object sought.
Tension Pain of Intraarticular Hip- joint Abscess Besides
movement and weight-bearing pains, we recognize in the hip joint
an especial form of pain which has been observed exclusively in
intraarticular abscess of this joint. It is classified as tension pain,
and is produced through the progressive hypertension of the joint
capsule, due to an increase in the intraarticular pressure. The
pain, for this reason, may be almost unbearable. The weight-
bearing pains are felt especially on walking, and the movement
pains are elicited on gross movements of the joint; and while in
both many intervals of rest are granted to the patient, the pain
of intraarticular abscess is continuous. Pressure of the bed
clothes alone often causes intolerable pain; and, as a rule, a
child with an intraarticular abscess cries and screams incessantly.
The tension pains of an intraarticular abscess defy every form of
mechanical treatment, and it is precisely this negative result of
an otherwise efficient therapy which gives very frequently an im-
portant point for the diagnosis of an intraarticular abscess. How-
ever, the greatest difficulty underlies the diagnosis, especially of
a beginning intraarticular abscess. One is unable to determine
the presence of fluid in the joint, owing to the cavity of the hip
joint being very slight, and because the thick, muscular infundib-
ulum surrounding the joint makes it inaccessible to the sense of
touch. Fluctuation is felt only after the abscess has penetrated
the capsule and has become extraarticular.
The diagnosis, however, can be made by close attention. A
coxitis patient who has been treated a short time with mechanical
treatment, that is, with the plaster trousers or the soKjalled com-
bined bandage (Lorenz plaster hose with leg apparatus), may re-
main for a short time without pain. ITe then conmaences to cry
out a couple of times in the night, but by day he is usually free
of pain. In a few days painful attacks occur also in the daytime;
the night cries become more frequent, and in a short time the
pains are continuous, so that the patient presents a picture of
JOINT PAINS— ARTHRALGIA 245
the greatest distress. In spite of all the bandages, the pains
increase, and evening fever sets in. This condition per-
sists many weeks with a constantly increasing severity, until
suddenly, over night, the pains entirely cease, and the very
sick patient appears again as though given back to life. The
intraarticular abscess has broken through and has become
extraarticular, and will, finally, be palpable as a subcutaneous
abscess.
A little trick, which is suitable to establish objectively a
beginning intraarticular abscess, may be brought into play. With
the patient in an abdominal posture, normally, the medium-size
trochanter can be touched in a small depression corresponding to
the retrochanteric fossa. This part of the posterior and upper sur-
face of the neck and of the femur is not normally inclosed by the
joint capsule, but in the early stages of an intraarticular collection
of fluid, the dilated capsule is swollen and covers the otherwise
free and extraarticular part of the posterior part of the neck of
the femur, so that, by close investigation, a circumscribed fluctua-
tion may at this point be determined.
The knowledge of the beginning of an intraarticular abscess
is, therefore, of a significance not to be depreciated, because in a
positive diagnosis the early opening of the joint (arthrotomy) re-
lieves the patient with one stroke from all his suffering.
According to William Bruce {Scottish Med. and Surg, Jour.,
1904, XIV, 297-304), gouty deposits may occur in the hip joint.
These, he claims, irritate the articular (nerve) branch which,
arising from the fourth, fifth L. and first S. segments, causes irri-
tation to these segments, and gives rise to pain, referred to the
areas of distribution of the sensory nerves derived from them.
These areas of distribution almost coincide with the area of distri-
bution of the pain in cases of sciatica. He differentiates the gouty
joint from sciatica, however, in that, in this condition: (1) There
is a wasting of the gluteal muscles. This is absent in sciatica, be-
cause these muscles are not supplied by the sciatic nerve. (2) In a
gouty hip joint there will also be noted impairment of motion —
also (very frequently) a grating and roughness on movement.
246 BONE PAINS— THE OSTALGIAS
(3) There is also lameness of the hip and (4) tenderness to pres-
sure over the hip joint. Both of these are absent in sciatica.
These considerations also hold true for an arthritis deformans of
the hip. In all cases, however, an X-ray picture should be taken^
and the diagnosis made certain
CHAPTER XII
THE CIBCULATORY SYSTEM
The circulatory system consists of the heart, the arteries,
capillaries, and the veins. The heart is considered under its ap-
propriate heading (q. v.). At the present time we shall consider
the blood vessels (arteries and veins). The capillaries can hardly
be said to cause pain, except possibly in inflammatory states, where
undoubtedly they have a slight influence in giving rise to the
throbbing pain felt in those conditions.
PAIN CAUSED BY 0HANOE8 IN THE BLOOD SUPPLY
In circulatory disturbances, pain is produced either by a too
great (disproportionate) increase or decrease in the blood supply.
When the blood is increased in quantity, congestion results, and
pressure is made upon the terminal filaments. This congestion is
of two varieties, namely, active and passive. The active variety
has been considered under inflammatory pain. The passive vari-
ety (passive congestion) we will now consider.
Pains from Increase in Blood Supply. — First of all, what is
meant by passive congestion ? By this, we here understand a con-
dition in which there is an excess of blood in a part, due to back-
ward pressure. This pressure can never become excessive ; so that
the most to be expected in this condition is pain of a dull, aching
character. This pain is always felt directly in the congested area
or is referred to the skin region associated with the congested
organ. In static congestion a part of the pain undoubtedly is due
also to toxic products, which must, of necessity, accumulate in the
tissue when the exit from the affected part is obstructed. Such
stasis pains are produced in the liver and spleen when the right
247
248 THE CIRCULATORY SYSTEM
heart circulation fails. These are probably the two best examples
of this condition, because in both cases inflammation can be abso-
lutely excluded. The cause of the pain is the stretching of the
capsule of these organs, with possibly, at the same time, some pull
and drag on the ligaments. Of course, as a cause of passive ob-
struction, tumors or displaced organs pressing upon the returning
veins must not be forgotten.
Pains from Diminntion in Blood Snpply. — A diminution of
the blood supply to a part causes pain by the starvation of the
tissues which results; and, as the nervous tissues are by far the
most sensitive, disturbance in them is first produced, and sudden,
sharp pain is produced. This is well illustrated in Raynaud's
DISEASE^ the symptoms of which are due to a contraction of the
smaller arterioles in an extremity (generally the hand). In this
disease sudden, sharp pain occurs in an extremity, increasing with
the elevation of the part. The surface is cool and white, and sen-
sation is diminished, the part being numb to the touch. This
symptom complex appears (and disappears) at irregular intervals,
imtil finally a small, atrophic ulcer develops on the most distal
part of the limb affected. This may progress upward, or a portion
of a finger or toe may become gangrenous. In other cases the pri-
mary contraction is followed by a dilatation of the vessels, and the
part becomes swollen and purple (Sachs, 622). In these cases,
when the limb is elevated, the pain, which is of a drawing, burn-
ing type, disappears. Raynaud's disease — which is, after all, a
fairly ample syndrome — is in reality a dual affair. The cells in
the spinal cord, usually termed sympathetic and trophic, and regu-
lating the vessels, are those primarily affected. The pains are
largely due to implication of this system of nerves, and are
grouped by Head with the general group of protopathic and deep
sensibility pains. Buerger has recently described a state in which
the arteries of the lower limbs become thrombosed or obliterated
(endarteritis obliterans. See intermittent claudication.). Here the
pain is most intense and is constant while the limb is dependent,
but disappears on the elevation of the limb. No medicinal treat-
ment can alleviate the pain of the unfortunate sufferer, and the only
ARTERIAL DISEASES CAUSING PAIN 249
means of easing his agony is high amputation of the diseased limb.
This condition has been called thrombo-endarteritis obliterans.
In PUKPURA H^MOEEHAGiCA the pain is also caused by obstruc-
tion to the onward circulation. The cause can be explained more
explicitly if we examine the cause of the hemorrhage in a case of
purpura hsemorrhagica due to syphilis (reported by Sabrazes and
Duperin, 573). In this case the hemorrhages were due to the
rupture of capillaries, due to mechanical obstruction by the intes-
tinal granulomatous lesions of the disease. These lesions will ex-
plain the pain felt in these conditions, for it is a noticeable fact
that the pain, not only in this, but in most rheumatic purpuras,^ is
very great until the hemorrhage appears, when it is eased. In
other words, during the period of distention of the vessel, there is
pain, while on rupture and removal of the intraarterial tension the
pain disappears. In any case, when an artery is affected, the pain
follows the distribution area of the affected artery.
Functional activity^ because of the increased demand made
upon the arterial system, often causes severe pain when the blood
supply to the active part is deficient. This is illustrated in cases
of aortitis, stenosis of the coronaries, passive congestion of the
liver and spleen, and in arteriosclerosis of the mesenteric vessels.
ARTERIAL DISEASES OAUSINO PAIN
The principal arterial diseases causing pain are arteritis,
thrombosis, embolism and aneurysm. It has been claimed by
Granville that the vasomotor nerves have a component of sensory
fibers. Should such be the case, one can easily understand why,
in disturbances of the vessels, pain should result. That a comple-
ment of sensory fibers accompany vasomotor nerves may in part
be true, for in performing abdominal operations under a local
anesthetic, it has been found that the ligating of vessels is very
painful. Yet it seems that, in most cases, especially in the pres-
ence of inflammation of the vessels, the pain is due to the in-
il am not aware of any work done as yet which would prove that the
cause of obstruction of the vessels in purpura hsemorrhagica is either emboli
or thrombi, but reasoning from analogy such would seem to be the case.
250 THE CmCULATOEY SYSTEM
flammation which has extended to the adjacent nerves. This has
been set forth by Buch as the cause of pain in aortitis.
Inflammation. — ^When inflammation occurs in an artery the
tima is the part first affected. Up to this point no pain results;
then the inflammation spreads to the media, and finally to the ad-
ventitial in which it seems that the receptors for pain sensibility
may lie. The arteries of smaller caliber are not as sensitive as the
larger ones. Perhaps the best place to study arterial changes and
the sensory results is in the aorta. Here the inflammation, as long
as it remains in the aorta, produces no pain, but it soon passes out
and involves the neighboring cords of the sympathetic. Ordinarily
the sympathetic is not painful, but, according to Buch (171),
Wutzler, Flourens, Bruchet, Valentin, and Longet have found
that the sympathetic becomes sensitive through inflammation or
congestion. Confirmation of the fact that inflammation may be
communicated to the sympathetic from an aortitis can be found in
the writings of Debove and LetuUe (384), Rigal and Juhel-Rinon
(386), Weber (386), Lanceraux (387), Dutil and Lanny (388),
Lapinsky (389), Duplaix (390), and Holsti (391), who have
found that inflammation of the aorta was communicated through
the adventitial coat to the aortic and celiac plexus. Buch agrees
with these observers, and discredits the view of Potain (380) that
the pain is due to inflammation of the arterial wall. Engleman
(381), like the previous observers, believes that the pain is due to
hyperalgia of the aortic plexus. Buch (p. 291), in affirming these
views, claims that he not only has found the aorta hyperalgesic,
but also the two bordering sympathetic cords, or at least one of
them.
The pain of aortitis is sudden in onset, occurs in the epigas-
trium, and resembles angina pectoris in its severity and sudden-
ness. It is produced by exertion and by the ingestion of food, the
kind seeming not to be so important as the quantity. The pain
comes on in paroxysms, each individual paroxysm lasting only a
few minutes. Paroxysms seem to be especially produced by eleva-
tion of the arterial pressure, particularly when it is accompanied
bv contraction of the superficial vessels. A cause of this contrac-
ARTERIAL DISEASES CAUSING PAIN 251
tion may be excessive functioning of the suprarenals (Buch). In
this relation it seems that when the blood is thrown into the deeper
vessels because of their stiffness th6y are unable to dilate and
acconmiodate it. As a consequence, congestion of the sympathetic
occurs. This gives rise to pain, because of its previous irritability.
A reflex dilatation of the vessels then takes place, change of the.
blood flow occurs, and the congestion and pain are relieved. It is
characteristic of these cases that the pain is relieved by strophan-
thufl or diuretin.
The time of onset is variable, and often seems to be the result
of exertion. Yet exertion is not the cause, in all cases, for, in some
instances, the pain appears in the middle of the night while the
patient is sleeping quietly. The position of the body of the patient
seems to make a difference only in an individual case. With some,
the pain comes on when they are standing, while with others it
appears when they are lying down (Brunton, 11). Kreuzfuchs
(572) claims that the pain is most liable to develop when the
patient is lying down. Brunton calls attention to the distention of
the bowel with flatus, which frequently comes on some time
during the attack. During the attack tenderness of the aorta and
neighboring nerve trunks is present, and, according to Brooks (93,
p. 784), persists for some time afterward.
In some cases, as related by Rossback (623), symptoms of
gastric disturbances may be present for years without a typical
attack. These are the cases which are frequently diagnosed as
stomach disorders. Arteriosclerosis of the aorta seems to be more
common in men than in women, and most frequent in the years
from forty to fifty.
Increase of Blood Pressure. — That increase of blood pressure
alone may cause pain is afiirmed by Pal (674), who, in examining
cases of lead colic, found the blood pressure in the intestinal ves-
sels increased from one-half to twice the normal pressure. This
increased pressure irritates the terminal nerve filaments, or re-
duces the circulation in the intestine, thus causing pain.
Intermittent Claudication. — There is a peculiar and compara-
tively rare condition, especially frequent in male Russian
252 THE CIRCULATORY SYSTEM
Hebrews, in which pain in the lower limbs is associated with vas-
cular alterations. It was first described by Charcot. There is, in
this disorder, a sensation of numbness, fatigue and pain, which
comes on in one or both legs on walking. It increases in severity
after a short time — fifteen minutes to half an hour — and renders
locomotion impossible. On resting, the pain disappears, to ap-
pear again after walking. In advanced cases the pains occur
spontaneously, from time to time, or they are persistent.
The pains resemble those of a sciatica, although they are apt
to be more diffuse, involving the entire calf, or thigh, rather than
following a nerve trunk. Cyanosis, pallor and coldness are fre-
quent accompanying symptoms. They can be induced by having
the patient walk briskly, when the sole of the foot will be observed
to be waxy and cold. The absence of pulsation in the dorsalis
pedis and posterior tibial arteries is a marked feature of many
cases. Arteriosclerosis is a constant accompaniment, and X-ray
examinations of the legs will often show the presence of hardened
calcified blood vessels. An obliterating arteritis alters the nutri-
tion of the muscles and may be the cause of the pain on walking.
At times a spastic vascular condition may rest at the bottom of
the disorder without ftny pronounced organic vascular lesions,
although these are probably early cases. It may also be due
to congenitally small blood vessels. In the majority of these cases
the organic vascular changes come along later.
An intermittent claudication of the arm may be present.
Erythromelalgia. — Here the chief features are pain and red-
ness of the skin, particularly of the feet, less often of the hands,
still more rarely of all four extremities. Pain is an early sign. It
comes on after over-exertion, and is usually abrupt in onset, al-
though occasionally gradual in its development. The balls of the
toes and the heels are the sites of maximum involvement. Rarely
the whole extremity, upper or lower, is invaded. There is, in addi-
tion to the pain, redness, and the tips of the fingers or toes are
swollen. There is a sensation of exquisite pain, with burning,
and, as a matter of fact, the local temperature is raised. The
blood vessels pulsate, small nodules appear, and marked sweating
ARTERIAL DISEASES CAUSING PAIN 253
is apparent. Other sensory changes are slight, and consist of a
mild hyperesthesia or hypesthesia.
The pain varies. In the more advanced cases it is severe tor-
ture, but may vary from a mild discomfort to agonizing pain.
Cold and the recumbent posture relieve it, while lowering the af-
fected part, standing or walking (if the feet are affected), or the
application of heat, increase its severity. On walking (feet be-
ing affected), the swelling is increased, and the redness becomes
successively more marked.
This condition is probably more than a single entity, since it
may be associated with disease of the sympathetic cells (in the
cord), or with disease of the peripheral nerves. Again it is allied
with vascular disorders. It is probably a vasomotor neurosis of
central origin.
Embolism and Thrombosis of the Mesenteric Arteries. — The
mesenteric arteries merit separate consideration; and it is espe-
cially necessary to review the two most important causes of pain
in lesions of these vessels, namely, thrombosis and embolism.
In both of these conditions the blood supply to the intestine is
cut off and paralysis (absence of peristalsis) occurs in the affected
segment of the bowel. This paralyzed bowel acts as a barrier to
the forward movement of the feces, and all the signs and symptoms
of obstruction take place. In embolism these symptoms are, as a
rule, sudden in onset, while in thrombosis they develop more
slowly. As in intestinal obstruction from other causes, generally
the first sign of the disease is pain, which is sudden, sharp, acute,
and is referred to the epigastrium, if the superior mesenteric ar-
tery is affected, while if the inferior is the one involved, the pain
is referred to the region of the abdomen, below the umbilicus.
Shock is a constant symptom, accompanying the pain. After the
first acute pain, there is often a lulling of the pain-sensation, but
the pulse continues rapid (the effect of the shock). In a short time
the pain again becomes prominent, and is of a colicky character.
The primary gain is regarded as due to the sudden shock to the
mesenteric nerves, the secondary as due to the pull and drag upon
the mesentery. As soon as the segmental bowel paralysis becomes
254 THE CIRCULATORY SYSTEM
complete, signs of obstruction, such as vomiting, intervene. The
vomitus consists, at first, of the contents of the stomach; later,
of the bowel down to the point where the obstruction has occurred.
The bowel movements at this time often contain blood, which is
bright scarlet and somewhat fluid, in obstruction of the inferior
mesenteric. It is dark in color and somewhat clotted in lesions of
the superior mesenteric artery. A tumor composed of gas also
makes its appearance in the abdomen. This tumor is generally
more marked on the left side in lesions of the superior mesenteric,
while in lesions of the inferior mesenteric it is more marked on
the right side and across the abdomen. This tumor mass quickly
becomes of great extent, and soon occupies the entire abdomen. At
the same time a transudation takes place, and on celiotomy a
bloody peritoneal fluid is found. Should the obstruction be more
gradual, such as occurs from an arteriosclerosis, pain is a marked
symptom. It is not constant, but is of a flitting character, such
as we find present in another location in angina pectoris. Pain
of this character, without any well-defined, apparent pathology,
should always cause us to examine the arterial system for arterio-
sclerosis.
Aneurysm. — When the coats of an artery are abnormally di-
lated, singly or en inasse, we have a condition called aneurysm. In
this the pain is constant and gnawing as a rule. In some cases it
is paroxysmal, though often in the early stages of aneurysm it may
be entirely absent. In many cases the patient localizes the pain
over the tumor mass by pressing over the affected area with his
hand; and a characteristic of the disease is that deep pressure is
always very grateful. Should any sensory nerves be pressed upon
by the tumor mass, pain is referred to their peripheral distribu-
tions. These referred pains vary with the situation of the tumor.
When the arch of the aorta is involved, the local pain is felt to the
right of the sternum at about the junction of the second or third
rib with the sternum, and the referred pain is felt in the inner side
of the right arm, and extends as far down as the elbow. Fre-
quently in an aneurysm of the thoracic aorta the pain does not
follow the distribution of the intercostal nerves, but is located over
DISEASES OP THE VEINS CAUSING PAIN 255
the back in the distribution area of the spinal nerves. It may also
radiate into the left shoulder and arm. The aneurysms of the
thoracic aorta, however, do not produce as much pain as do those
of the abdominal aorta. In this latter pain is very severe, and is
felt in the back, as a rule. At first it is somewhat paroxysmal, and
then takes on a dull, boring character. When this occurs, the diag-
nosis of bony involvement may be made with absolute certainty.
Certain positions, namely, those in which pressure is made upon
the vertebrae, cause extreme, almost unbearable, pain. Hyperal-
gesia, corresponding to Head's zones, is often present. These
areas of hyperalgesia should be carefully sought for and mapped
out. In all cases of suspected aneurysm careful inquiry should be
made as to the presence of pain, because the patient frequently
neglects to mention it.
*
DISEASES OF THE VEINS OAUSINO PAIN
The lesions of the veins causing pain are inflammation, throm-
bosis and varices.
Inflammation of the Veins. — Inflammation of the veins (phle-
bitis) causes a very severe pain, which is more likely due to an
associated involvement of the surrounding tissues than to the in-
flammation in the vein itself. Nevertheless, irrespective of the
cause, the pain is most severe, constant and aching in character,
and is greatest when the limb is in the dependent position. The
pain is increased by pressure. By means of the tenderness on
pressure, the entire distribution area of the vein can be defined.
Phlebitis is very common in the femoral distribution following
child-birth, during which a slight infection of the iliac vein has
taken place. It is also very frequent in the femoral veins follow-
ing typhoid fever. When so affected, the patient voluntarily lies still,
because the pain is increased by the slightest movement. The con-
dition persists for a varying period of time, and then disappears,
although slight soreness lasts for some time. In some cases of
phlebitis, the pain is referred to distant areas. This is due either
to pressure on an adjacent nerve by the inflamed vein, or to a
266 THE CIRCULATORY SYSTEM
communicated infection. In cases of pressure or inflammation of
the sciatic, or of the lumbosacral cord, the pain is referred into
the area of distribution of the sciatic (Peterson, 625). It is most
intractable, and is curable only on the amelioration of the causa-
tive lesion.
Thrombosis. — Since thrombosis of a vein is, in nearly all
cases, nothing more than an inflammatory process, the above de-
scription of phlebitis will equally well apply to it.
Varicose Veins. — Of varicosities it is only necessary to speak
of those of the lower extremities. Varicosities in other regions
are entirely, or almost entirely, painless. When varicosities occur
in the lower extremities, the external and internal saphenous are
the veins principally affected ; and it seems that the internal is, as
a rule, more severely involved than the external. Consequently,
the local symptoms will be more marked on the inner than on the
outer side of the leg. This agrees well with the histories, for
most of the patients complain of pain beginning above the knee
and running around to the inner side of the leg, thence down on
the posterior surface of the calf, extending, in some cases, even as
far as the ball of the foot. Usually the pain is worse at night.
During the day the patient, as a rule, has been standing on his feet
more or less, and a certain amount of inflammatory congestion re-
sults from this. In many eases of varicosities of the internal
saphenous if pressure be made on the anterior crural, pain radiat-
ing into the inner half of the thigh and the leg will be felt. After
the formation of an ulcer, the pains are very severe, and make the
patient's life miserable. They are eased by the application of
firm pressure, which would seem to indicate that they are due
either to traction from the excessive granulations, which, when
filled, drag upon and stretch the terminal nerve filaments, or to
exposure of the nerve endings in the floor of the ulcer, which
follows upon the removal of the ordinary protective layers of the
skin. In any case the pain is extremely severe and is much worse
when the limbs are in a dependent position.
CHAPTER XIII
THE GLANDULAR TISSUES
The Olands. — The principal glandular structures are the
glands with ducts, as the mammary and those found in the ali-
mentary tract (salivary, pancreas), and those without a duct, the
so-called ductless glands, as the lymphatic glands, the thymus,
thyroid, pituitary and the adrenals. There are also numerous
small secreting glands found in the mucous lining of the alimen-
tary, respiratory and genitourinary systems, but these are of such
minor importance that they do not merit a consideration. When
pain is located in a glandular structure, it is due, as a rule, to dis-
tention of the capsule of the gland. This distention, in its turn,
is usually the result of inflammation.
In those cases in which distention has occurred gradually pain
may be absent. As a rule, it is present only when the distention is
acute. The pain of large, glandular abscesses or of tumors of the
glands is further increased by the pressure of the tumor mass
upon adjacent organs or nerves. In case of pressure upon nerves,
the pain is referred, as a rule, to the peripheral distribution area
of the nerve or nerves involved.
A special consideration of the most important of the glandular
structures is in order. We shall commence with the mammary
gland, after which we shall consider the adrenals, mesenteric, thy-
mus, and thyroid.
The Mammary Oland. — The mammary gland is situated in
the lower part of the anterior lateral surface of the thorax. The
sensory receptors of the gland are found in the alveoli, from which
the fibers collect to ultimately join the fourth, fifth and sixth
257
258 THE GLANDULAR TISSUES
intercostals, in which they run to the cord. The sympathetic
associations are with the thoracic branches. The skin over the
gland receives its nerve supply from: (1) the supraclavicular
branches of the cervical plexus, and (2) the anterior and lateral
cutaneous branches of the second to the fifth intercostals.
Pains in the breast may occur at certain physiological periods
of a woman's life, such as in infancy (shortly after birth), pu-
berty, during menstruation, and at the beginning of pregnancy.
These pains may be pure reflex, or rather transferred, pains, and
are probably due to stimuli carried through the nervous system,
probably by the same well-defined paths through which other
stimuli are carried when, in pregnancy, the breast begins to per-
form its fimction, and lactation commences. It is a moot question
whether there is, or is not, objective cause for this phenomenon,
for it seems that the stimuli transferred to the breast from the
genital organs cause some slight tumescence in the breast^ prob-
ably enough to produce a subjective sensation of pain, but not
enough to be perceived objectively. A peculiar thing about this
pain, which seems to verify its nervous genesis, is that it may be
spread over a wide area, so that it sometimes involves the side of
the thorax and the arm. This might be accounted for by the over-
flow phenomenon which has been described in a previous chapter.
The intensity of the pain varies from a slight, hardly noticeable
sensation, to one of most intense distress. The hyperalgia is not
always confined to one breast, but may involve both. In the
newly-born infant, an inflammatory change sometimes occurs in
the breast. This is probably painful, but we have no means of
drawing positive conclusions. (See Uterus and Mammary Pain in
Uterine Disease.)
Pain in the breast may be due to the following pathologic
causes:
(1) Inflammation: (a) lactation mastitis; (b) stagnation
mastitis; (c) pyogenic mastitis (extension from neighboring struc-
tures, lymphatics, blood) ; (d) small abscesses which form in
the areola from a fissured nipple.
(2) New growths: (a) malignant, as in oarcinoma and sar-
THE ADRENALS 269
ooma (pain and tenderness are not marked, but may be present
periodically) ; (b) benign, as fibroids.
Tumors of the breast, as a rule, do not give rise to referred
pain. Fissure of the nipple is very painful, the same as is a
fissure at any of the other openings of the body; for example,
the anus, the mouth, or the urethra. Simple cysts of the breast
generally give rise to considerable pain, especially if they are of
rapid growth.
Most of the pain produced by mammary changes is local, but
retention of milk, suckling (forcible), and pulling on the nipple
often give rise to referred pain in the area of the fourth and fifth
dorsal segment. It seems to be an invariable rule that traction
upon the nipple produces pain over the angle of the scapula pos-
teriorly. Sometimes it is referred along the side to the anterior
part of the chest, and is felt beneath the breast.
Pain and discomfort during menstrual periods should cause
the diagnosis to lean toward mastitis. Carcinoma in the early
stages is generally not tender, while mastitis, as a general rule, is
tender.
The breast may also be subject to referred pain from the
female sexual organs, for which, see p. 715.
The Adrenals. — The most common, in fact the only, condition
in the adrenals which we are sure of as a cause of pain is hemor-
rhage. The hemorrhage comes on suddenly and causes a great dis-
tention of the capsule of the gland. This, of course, produces
pain, sudden in onset, and most intense. It is, as a rule, localized
in the epigastrium, but may radiate to the hypochondrium, or to
the lower abdomen. Digestive disturbances in the form of per-
sistent vomiting and diarrhea are associated with this pain, while
at the same time a fall of blood pressure, rapid, weak pulse, and
reduction in temperature occur. The skin gradually assumes a
yellowish or brownish color. Debility, coma and death finally
ensue. In regard to the debility, Murdock (627), quoting from
Neusser, says that the "permanent sei^se of weakness and exhaus-
tion, the lack of power and debility frequently present a striking
contrast to the relatively good general appearance and the abun-
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THE THYMUS AND THYROID 261
dance of abdominal fat." On examination of the abdominal wall
one is sometimes impressed with the excessive tenderness which is
present.
The Mesenteric Olsnds. — The mesenteric glands, even though
enlarged, do not of themselves cause much pain, unless the enlarge-
ment is excessive, when, by encroachment upon neighboring struc-
tures and interference with their function, they may indirectly
be the cause of pain production. In tuberculosis, when the mesen-
teric glands reach an enormous size, the patient often complains
of aching and distress, or, as frequently expressed by negro sub-
jects, '^a misery in the abdomen.'' This misery becomes an acute
pain, should the gland, becoming degenerated and caseous, sud-
denly rupture and cast its contents into the peritoneal cavity. The
pain now assumes the characteristics of that due to general peri-
toneal irritation.
The Thymus and Thyroid.— The thymus and thyroid are en-
tirely without pain production, unless they become acutely in-
flamed, when pain phenomena appear. Frequently in thyroid
tumors and in disease of the gland pain is felt in the occiput, in
the shoulder and back of the ear, due to irritation (pressure) of
the posterior auricular. In one case pain was complained of over
the second dorsal spine.
In Hodgkin's disease pain in the arms is very common, be-
cause of the pressure exerted upon the nerves in the axilla. In
the same way pain may be felt in the lower limbs from pressure
upon the anterior crural nerve by enlarged inguinal glands.
CHAPTER XIV
REGIONAL PAINS
As an aid to a quick orientation of the cause of pain which is
felt in a special area, the body may be divided into different re-
gions, aa the head, neck, arms, chest, abdomen, and the extremities.
Each of these will be fully discussed under special headings, but •
at first a brief, general review of the different pains in these
regions and their significance will be imdertaken.
THE HEAD
The head is a most important localizing center for pain, for it
seems that here all the aches and ills of the human body converge •
to bring torment and suffering to the unfortunate individual.
Head pain is partially considered under headache, which includes
the pains felt in the cranial part of the head, but headaches do
not include face pains. These are very important, as they in-
clude one of the most sinister of all human ills, namely, trigeminal
neuralgia (tic douloureux). Its pains occur in the forehead, the
cheek and over the lower jaws. There are well-defined spots of
maximum tenderness, which are shown in the drawings. Of
other important causes of face pains, sinus disease probably ranks
next. These sinus diseases include the frontal, ethmoid and an-
trum of Highmore. When any of these structures is affected,
pain is complained of by the patient, and at the same time tender-
ness is marked over the diseased area. Should tenderness not be
present in the area in which the patient complains of pain, it
indicates that the pain is a referred pain from some distant region.
262
264
REGIONAL PAINS
A good example of this is pain in the temples, referred from
carious teeth. Reference to Figures 61 and 62 will do more to
localize these different pain areas and their significance than an
entire volume of description. Head pains referred (reflected)
lathemU
Anemia
Neurasthenia
Ovarian
Mental tire
Infectious diseases
Tyjplhoid
Innuensa
Malaria
Small-pox
Meningitis
Brain tumor
Corysa
Toothache
Supramaxillary
inflammation
Neuralgia
Inf. dental branch
Fig. 62. — Pain Areas in the Head.
Epilepsy
Uterine disease
Pregnancy
Anemia
Meningitis
Ovarian disease
Hysteria
5
Migraine man-
ner of radia-
tion
6
Arteriosclerotic
headache
■7
Ethmoid. Ar-
rows indicate
the direction
of radiation
8
Orbital headache
Typhoid fever
Eye strain
Anemia
Inflammation of
eye
9
Point of ten-
derness in in-
f ra-orbital
neuralgia
10
Antrum disease
11
Point of tender-
ness in mental
neuralfi%
Periostitis inf.
max.
from abdominal and thoracic organs are described in the chapters
under their respective headings.
The most important of the local head pains is headache, or,
as it should be called, head pain. When a patient complains of
headache, he should always be asked, "Is it a pain, or is it only a
sense of pressure ?'' If it is a sense of pressure, the consideration
will be entirely different from that of true head pain.
Sense of Pressure in Head. — Edinger has graphically dis-
cussed this condition, especially in its relation to neurasthenia. He
notes that **the pressure is felt in the top of the head, and is espe-
cially severe in the morning. It generally continues all day,
though it may lessen toward night. This head pressure, which is
THE HEAD 265
not a pain, is particularly a characteristic of tired persons ; those
who have overworked, either physically or mentally, and those
whose hours of labor are too long or too continuous; those who are
hereditarilv weak : and those who have suffered from severe dis-
ease (influenza) and have exerted themselves too soon thereafter.
If the sensation is described by the patient as a pain, head-
aches should then be considered.
Head Pain. — In the diagnosis of headache it is well to ascer-
tain first whether the pain is unilateral or bilateral. If it is bi-
lateral, it generally is an indication that the underlying cause
is of systemic origin, while if it is unilateral, as a rule it is an in-
dication that the cause or causes acting to produce it are also uni-
lateral in their origin. Where headache is unilateral, it is always
wise, before making a more extended search, to examine the head
for local causes, such as inflammations, or to examine the organs
located in or associated with the skull, such as the eye, the ear, the
nose, the teeth, and also the throat, which in many cases is at
fault.
The following outline of the principal causes of head pain
may be of value in the diagnosis. The classification
used is based upon an anatomico-physiologic basis. Accord-
ing to this, head pains may be divided into two great
classes: (1) those of extracranial origin, and (2) those of
intracranial origin.
Head Pains of Extracranial Origin, — Extracranial head pains
are caused by lesions of the skin, muscles, tendons, bones, and
nerves. The shin includes the epidermis and subcutaneous tis-
sues, and is the seat of pain in neuralgia and superficial inflam-
matory lesions. Excessive weight of hair may be the cause of
severe and chronic headache.
The muscles are the seat of pains, the result of such metabolic
disorders as occur in rheumatism, gout and diabetes. Inflamma-
tion likewise may be a cause of local pain. In this connection
it is well to mention a condition described by many writers, in
which headache is due to indurative processes, occurring in the
muscles of the head and neck. Edinger claims that, though
266 REGIONAL PAINS
almost unknown, the indurative variety of head pain is probably
the most common of all headaches. In those suffering from it, it
is found that at the insertions, or within the bodies of the muscles
of the head and neck, there appears a thickening which at first is
transient and then later becomes constant. This thickening, prob-
ably of chronic inflammatory
origin, irritates the sensory
nerve fibers supplying the
part, and thus produces pain.
The pain occurs in parox-
ysms, which may be brought
on by emotional disturbances,
physical or mental fatigue,
sudden exposure to cold, in-
sufficient drying after wash-
ing the hair, a stay in bad-
ly ventilated places, and the
approach of damp or chilly
weather or storms. The par-
oxysms are least common in
summer and most frequent
■ Fig. 63.— FiQUBE Illubtoatinq the in the fall and the spring.
In the development of the
induration three stages can
be defined. In the first stage
a swelling of a soft, yielding consistency, often present in the
bodies of the muscles, makes its appearance. A pufBness to the
touch is now felt at this point; then, iu a short time, a slightly
elastic resistance develops, as though some organization had taken
place; and finally an induration, in which there is an absence of
elasticity, occurs. Organization has now advanced to the stage
at which a substance of cartilaginous consistency presents itself to
the examiner. The older these thickenings are, the harder they
become and the more resistant they are to treatment.
The symptoms are characteristic. Attacks of pain occur,
which at first are slight and infrequent, and then gradually be-
Plac£s Where Induration Takes
Place.
These areas are tender to pressure.
THE HEAD 267
come more frequent, greater in severity and longer in duration.
Sometimes they are of a dull, aching type, and are almost con-
stant ; again, they are sharp and fleeting. They occur in various
parts of the head, the location depending upon the site of the
local enlargements, over which they are usually found. They may,
however, radiate to other parts. Local pressure often gives relief.
Before an attack the enlargements become swollen and sensitive.
The symptoms associated with this disorder are the marked
susceptibility of the patient to colds, depression of spirits, and to
mental torpor. Gastrointestinal disturbances, toxic in character,
occur, and spasms in the leg-muscles and myalgia in different
parts of the body take place. Hypersensitiveness of the teeth and
a pyorrhea alveolaris are also seen, and on forcible twisting or
turning of the neck there is intense pain at the insertions or along
the bodies of the neck-muscles. Local tenderness over the sites of
the enlargements almost always is present. It is most common
at the insertions of the trapezii, scaleni, splenii and sternomastoid
muscles. Hypersensitive points are often found round the base
of the skull, from one mastoid process to the other, and on the
spinous process of the cervical vertebrse, particularly the upper
cervical vertebra?. The supraorbital region also is often involved.
These indurative headaches are to be diagnosed from: (1)
Meningitis, in which fever is present and induration and hyper-
sensitiveness are absent
(2) Migraine, in which sensitive aura are present, indura-
tion and local hypersensitiveness are absent, nausea and vomiting
are present, and no relief comes from massage. While hereditary
migraine begins in early youth, indurative headache appears in
later life.
(3) Bone diseases, such as inflammation, caries, gummata
and tuberculosis should also be carefully diagnosed, as they often
give rise to local head pain and indurative areas. A careful study
of the general symptom-complex will often clarify the situation.
As a rule, though, the indurative headaches are very common.
They are very easy to differentiate, because of their local
character.
268 REGIONAL PAINS
That long-continued contraction of a group of head-muscles
may cause pain is possible. Thompson (630) describes such
headaches which arise from the long-continued contraction of the
occipito-frontalis muscle, as the result of a strong sensory impres-
sion, coming from the eyes, ears, or other channels of sensation.
They may, however, be produced only as a result of the irritation
of cold and strong winds.
Nerves. — The head pains due to nerve involvement are to be
classed under neuralgias and neuritidcs. There is also a local
irritation which has not progressed to the stage of inflammation.
Neuralgia, which means nerve pain (for a complete descrip-
tion see under Xeuralgia), is a rather frequent cause of pain in
the head. In it pressure points can be found, corresponding to
the emergence of sensory nerves from the skull. The nerves most
frequently involved are the trigeminal and the cervico-occipital
branches of the cervical plexus. Xeuralgia is frequently the result
of wasting diseases, malnutrition, exposure, poor hygienic condi-
tions, rheumatism, gout, diabetes, anemia, chronic malaria and
acute infectious disease.
Xeuritis, a somewhat allied condition, differs from neuralgia
in being a much more active inflammation of the nerves or nerve
sheaths. In it the nerve is painful to pressure, muscular twitch-
ings occur, and, if the condition continues hmg enough, a final
atrophy and paralysis of the related muscles may result.
Head pain may also be induced by the products of metabolism,
which act locally upon the muscles of the scalp and produce pain
by irritation of the sensory nerves in the same manner as it is
produced in gout and rheumatism. Especially is this liable to
happen should the resistance of the muscles have been i)reviously
reduced by exposure to cold or drafts. In neuralgias and inflam-
mations there is always a certain amount of associated hyperes-
thesia, the affect(d part l)eing, in many cases, excpiisitely tender.
In addition to headaches due to local causes are those which
are the result of conditions present at a distance from the area in
which pain is felt. These are classified as projected, reflex, or re-
ferred headaches. Projected headache is the result of pressure
THE HEAD 269
upon the cranial nerves, either in their extracranial or intra-
cranial course. Such pressure may be due to tumors, caries of
bone (especially caries or periostitis of the bone at the foramina
of exit) and to foreign bodies.
Reflex headache is due to a stimulus carried through the
nervous system from some distant organ. In these headaches the
action is upon the nerve centers, or nerves, either indirectly
through adjacent nerve centers, or directly by the action of irri-
tating bodies (toxins of disease and organic or inorganic
poisons). The fifth nerve seems to be especially subject to irri-
tation from extraneous causes, and the part that seems to be most
commonly affected is the Gasserian ganglion.
Referred headache is the result of a reference of stimuli along
associated or related nerve pathways, as is exemplified in the
frontal headache following immediately after the drinking of ice-
water, etc.
Head Pains of Intracranial Origin. — The intracranial
causes of headache are: Meningeal changes, functional and or-
ganic; cerebral toxemia; cerebral anemia; cerebral congestion;
increase of cerebrospinal fluid.
Meninges as a Cause of Headache, — Stretching and pressure
exerted on the meninges is the most important cause of headache,*
and produces the most severe and persistent pain, as in cere-
bral tumor; here, owing to the general increase of pressure from
the growi:h, the headache is apt to be diffuse. However, when
the cortex membranes are involved, the pain becomes localized;
and this localization is of the utmost value in defining the site of
the tumor.
The general cause of meningeal stretching and traction is
pressure from underlying structures. The piaarachnoid is prob-
ably not supplied with sensory nerves, and it is very likely that
its only nerve supply consists of those supplying the blood vessels.
Therefore, in cases of leptomeningitis, it is the congestion inci-
1 The meninges seem to be almost insensitive to the ordinary stimuli,
as when the skull is opened under local anesthesisB they may be touched,
pinched or cut, without the patient complaining much of pain.
270 REGIONAL PAINS
dental to the inflammation that causes pressure upon the dura
and its nerve filaments, and so produces pain.
Stretching and pressure on the meninges may also be caused
by an increase in the cubical contents of the cranial cavity, such
as occurs by an increase in the brain substance from new growths,
abscesses, and increase in the fluids of the brain (blood and cere-
brospinal fluid).
Increase in brain substance is found in new growths, such as
timiors of the brain. These cause pain by increasing the intra-
cranial pressure. This they do in two ways: (a) by an increase
in the intracranial contents, which, owing to the pressure of their
mass, cause an increase in the intraventricular pressure, and (b)
by raising the intraventricular pressure, either by shutting oflF
the means of exit of the intraventricular fluid by blocking the
foramina of communication between the ventricles and the suba-
rachnoid spaces, or else, by pressure on the veins of Galen. A
loose fibroma in the lateral ventricle may also act as a plug and
thus prevent the escape of cerebrospinal fluid, and cause intoler-
able headache, optic neuritis, coma and death.
. Pain, in some cases, in which the tumor is cortical or sub-
cortical, is produced by the growth pressing directly upon the
meninges, and in this way squeezing the terminal nerve filaments
incorporated in its substance. Tumors of the posterior fossa of
the cranium probably cause the most pain.
Diagnostic symptoms of tumors of the brain are pain, which,
in cerebral tumor, owing to the general increase of blood pressure
from the growth, is as a rule diffused. When the cortex mem-
branes are involved, the pain becomes localized, and this locali-
zation is of the utmost value in defining the site of the lesion.
When the pain becomes circumscribed, it is most often confined
to the forehead or to the occipital region. Accompanying the pain
there are disturbance of sensation and motion, choked disc, rigidity
of the pupils, vomiting of a projectile character (with an entire
absence of gastric symptoms) and dizziness. Sometimes symp-
toms of headache may be almost entirely absent in brain tumor,
as in a case reported by Edinger, in which, on autopsy, a tumor
THE HEAD 271
was found in the Island of Keil of a patient, who had had head-
ache only a short time before death.
Brain tumors may be syphilitic, tuberculous, hydatid, carci-
nomatous, sarcomatous, or osseous formations withili the cranial
vault
Brain abscess causes headache in the same manner as do
tumors.
Organic Meningeal Changes, — Organic meningeal changes
due to adhesions, inflammations and hemorrhages cause head-
aches. Adhesions between the dura and the cranium are often
the cause of severe pain, localized over the affected area. Local-
ized head pain may also be caused by syphilis and trauma, or it
may be the result of inflammation. The inflammations causing
these headaches are of two types :
(1) Pachymeningitis interna, which is very common in old
people, and quite frequently accompanied with small and minute
hemorrhages. The headache frequently is introduced by vomit-
ing, which sometimes occurs in paroxysms, with brief intervals.
Occasionally it is combined with a disturbance of consciousness
or of paralysis of some cranial nerve (see page ISO). (2) Acute
meningitis gives rise to an increased blood pressure, which, in
turn, causes an outpouring of serous fluid into the meninges. This
produces pressure on this membrane and on the terminal sensory
nerve filaments. It may also cause headache by involving the
nerve filaments and meningeal endings in the inflammatory
process.
Toxemic Headaches, — These are due to: (1) Exogenous
poisons, as alcohol, lead, iron ether, nitroglycerin, amyl nitrite, or
arsenic, and (2) endogenous poisons, as the toxins of pneumonia,
typhoid fever, influenza, small-pox, chronic gastritis, chronic
Bright's disease, diabetes, cirrhosis of the liver, cerebral syphilis,
gout, hyperthyroidism, starvation, and possibly diseases due to
alimentary disturbances. Toxins act by altering the intracerebral
pressure through their action on the vasomotors and possibly also
directly upon the sensory filaments in the meninges. In addition
to the reflex head pain, some slight sluggishness of intellect is gen-
272 REGIONAL PAINS
erally associated with these conditions, and this may progress to
delirium.
Of the toxemias the starvation products due to nutritional
defects, caused by anemia, are the most frequent cause of head
pain. The head pain which they produce is mostly of local origin
and has been ascribed to a lack of nutrition of the trigeminal
nerves, or, according to Neuman, to a disturbance of the brain
cortex. This disturbance leads to pain. This manner of pain pro-
duction explains why the headache is relieved when the patient
reclines, for, in doing so, he increases the blood supply to the
brain and incidentally the nutrition.
Anemia. — The diagnostic criteria associated with anemic
headaches, which, in a way, are starvation headaches, are pain,
generally vertical, and made easier on the patient reclining; pal-
lor, especially marked on the lips; disturbed sleep; drowsiness;
edema of the ankles; drooping of the eyelids; and feeble carotid
pulsation, a symptom which is of great diagnostic importance.
Lenhartz (Munich Med. Woch., 1876, Xos. 8-9) showed that the
headache and dizziness of chlorosis are associated with an in-
crease in the subarachnoid pressure; therefore, it is this increase
in pressure and (in many cases) not the anemia which is the
cause of the headache.
Congestion. — Cerebral congestion seems to be a true cause of
headache. Edinger claims that the headache of migraine is of this
type, i. e., that it is due to a vasomotor congestion. For the expla-
nation of the causes of these headaches, see under Vasomotor,
Paralytic Headache, which is described under Headache of
Chronic Origin.
Cerebral congestion leads to an increase in the amount of fluid
in the brain. This increased amount mav be the result of an
increase in the amount of blood in the brain substance (edema),
or in the quantity of the cerebrospinal fluid. The increase in the
amount of blood in the brain is the result of an increase in the
intracranial blood pressure, or of venous congestion.
Increased arterial pressure in the cranium may or may not
be associated with increased (systolic mean) arterial pressure.
THE HEAD 273
In some cases an increased arterial supply to the brain is due both
to an increased heart action and to an interruption to the return
flow through the venous channels. Some causes of increased intra-
cranial blood pressure, which may, in certain conditions, incite
head pain, are the following: stooping, lifting weights, sitting up
suddenly, lying down quickly, the horizontal position, hard strain-
ing at stool, physical exertion, running and extreme heat
Predisposing Factors, — There are certain factors which reflexly
act upon the blood vessels or the vasomotor centers and cause such
a lessening in control that slight causes, which otherwise would
have no action, act upon the cerebral centers, and lead to a cerebral
^'ongestion. These factors are mental excitement, anger, or men-
tal labor (severe), acting as a reflex cause of neurasthenia, which
in turn acts principally as a predisposing factor in headache pro-
duction. Other reflex and clinical factors are found in alcoholics,
coffee and tea drinkers, and in those suffering from fevers. Sun-
stroke and rapid chilling of the surface, as in colds, also have the
same effect. In come cases there is a further lessened resistance
to the above acting causes, because of a vasomotor ataxia due to
nicotinism (Schmidt). In headache due to increased intracranial
arterial pressure the pain generally is of a throbbing nature,
the throbbing being due, perhaps, to' a backward and forward flow
of the cerebrospinal fluid. The pain is accompanied by a fulness
of the head especially marked on coughing or on any sudden
exertion. A flushed face, injected eye grounds, general irrita-
bility, sensory disturbances and increased heart action also accom-
pany this condition. There is also a form of arterial congestion
due to a vasomotor paralysis in which pain is present in all parts
of the head, but is especially severe on the top and in the temples,
where it seems as though the head would burst. There is also a
painful sense of pressure behind the eyes, which seem to bulge
forward. Periods of freedom from pain intervene; then there
are recurrences, often just before the menses, or when the atmos-
phere is heavy.
In headache due to ironeral hypor hlood-icnsion, ^fatthew
{Quarterly Journal of Medicine, 1909, II, 2G1) found that a
274 REGIONAL PAINS
reduction of about 30 mm. Hg iu the blood pressure was almost
invariably followed by an alleviation of the head symptoms.
Another cause of hypertension headache is the local increase in
blood pressure, the result of inflammation, as in meningitis. Here
the pain is generally associated with a slow, strong pulse, though
no rise in the mean arterial pressure may be noted. In this it
differs from aortic regurgitation, which also causes headache, but
in which, although there is a sudden strong pulse (high systolic
pressure), the mean arterial pressure is reduced. A third cause,
the result of cerebral arteriosclerosis, is the elevation in the
cerebral systolic pressure, which may be high, though the mean
arterial pressure may be normal.
Moleen writes : "Of the general symptoms of cerebral arterio-
sclerosis, headache stands first. It is usually dull, not throbbing,
and quite often is described as a feeling as though a tight band
were compressing the head. It occurs most frequently in
the morning after walking about, and diminishes as the day
advances, except in syphilitic arteriosclerosis, in which it is
usually most severe at night. Dizziness, or vertigo, as a symptom,
is next in importance to pain. Numbness, tingling, twitching,
weakness in a limb, or in one-half of the body, and disturbances
in articulation are also common."
Headache may be caused by increased venous pressure, as well
as by increased arterial pressure ; or both may interact to produce
increased intracranial pressure. Headaches of the first type are
present when there is any obstruction to the return circulation, as
in tricuspid regurgitation (-.vhich produces back pressure),
thyroid enlargement (producing static back pressure), sinus
thrombosis, and paroxysms of coughing. Tight neck bands and
epilepsy (Knowlton) may also cause headache.
General Consideration of Hypertension Headaches. —
Hypertension headaches are very severe and usually are badly
borne. It is most likely that in all hypertension headaches there
is a supersensibility of the nerves supplying the dura, and thus
more cognizance than normal is taken of chans^s in intracranial
pressure. In these headaches the pain is eased by the patient draw-
THE HEAD 275
ing his head far backward and burying it in the bed clothes. If
the neck-muscles are in a state of tonic contraction, we may pre-
sume the lesion causing the condition to be of an inflammatory
nature, probably one affecting the meninges. If this is the case,
bending the head forward seems to increase the pain, and rotation
is also painful, the pain being in the nape of the neck, and fre-
quently on the side opposite to that toward which the rotation has
taken place (Schmidt). Swallowing, as well as lying down, at
times causes pain. The patient often attempts to fix the head
with the hands, so that movement cannot take place. Hyperten-
sion headaches are quickly relieved by the taking of a purgative.
This would hardly happen if the headache were due to a toxemia,
in which case the headache would last for some little time, un-
til the toxic material could be removed. Now, it behooves us to
ask, how a purgative so quickly relieves the headache. It is rea-
soned by Schmidt that intestinal stasis causes meteorism, and that
this in turn causes "stasis in the superior vena cava and in the
cerebral veins through the restriction of the respiratory venous
aspiration''; and purgation causes a revulsion in this condition,
and a normal respiratory circulatory activity. He also remarks
"that the important part played by normal intestinal peristalsis in
facilitating the venous circulation in the portal district must not
be forgotten. The headache may be temporarily increased if the
act of defecation is accompanied by considerable straining"
(Schmidt, p. 43). A point of value in diagnosing increased ven-
tricular pressure is that the pain of increased ventricular pressure
is always referred — while that due to meningitis or tumor (menin-
geal), etc., is always localized to the area involved.
Associated with hypertension headaches are changes in the
fundus of the eye, such as dilatation of the veins, hemorrhage into
the retina, and choked disc, all of which are due to mechanical
agents. There are also present mild inflammatory lesions, partly
due to obstruction of the lymphatic return flow.
Pressure points (see Neuralgia, Fig. 44) can often be dem-
onstrated in the area of distribution of occipital-trigeniinal nerves.
Hiccoughs, vomiting, abnormalities in pulse and respiration, pos-
276 REGIONAL PAINS
sibly due to vagiis involvement, are also found. The spots seen
dancing before the eyes are due to optic nerv^e involvement, while
the buzzing in the ears is the result of involvement of the audi-
tory nerve.
Increased intracranial pressure is often evidenced by a visible
distention of the veins of the brow or of the scalp. The degree
of stasis may be fairly well judged by the magnitude of the dila-
tation of the venules of the upper eyelid (Gushing). Where in-
creased intracranial pressure is present, repeated examination of
the urine should be made in order to detect, if possible, the
presence of a nephritis.
Among other associated symptoms of tension headaches are
great debility, disinclination for any kind of work, anorexia, and
distressing dreams with fright on awakening. Actual hallucina-
tions are occasionally present; edema of the cortex of the skull
sometimes occurs; red blotches at times cover the entire surface
of the body, and the strife of the skin, which are produced by
stroking with the finger, often persist much longer than tlie normal
time. Thunderstorms aggravate or initiate the pain. Headaches
of this variety should be diagnosed from those due to brain tumor
by an eye examination. Choked disc is present in tension (tumor)
headache, and is absent in vasomotor paralytic headache.
Head pain may also be due to an actual, as well as a relative,
increase of the cerebrospinal fluid. This increase may be local-
ized to either the meninges or the ventricles. Increase in the men-
ingeal fluid without an accompanying inflammation may be due
to anemia (such as chlorosis or constipation with acetonemia).
Increase in the ventricular fluid may be caused by an increased
production of the fluid, or, if the production of the fluid is normal,
by a blocking of the foramina of exit (Foramen ilagnus or the Ac-
queduct of Sylvius), which causes an accumulation of fluid in
the ventricles. Accumulation of fluid may occur in any of
the cavities of the brain, from a blocking of their foramina of
exit by new growths, inflammatory exudates, or foreign bodies.
That a foreign body may cause such an obstruction is proven by
the many reported cases in which the removal of an extraneous
THE HEAD 277
substance, such as a bullet from a position in the brain where
it was producing obstruction, relieved the pressure and cured the
headache. Angioneurotic hydrocephalus is also a cause of head
pain which is due to an accumulation of the cerebrospinal fluid
in the ventricles. Cerebral compression may also be the cause of
an internal hydrocephalus, and thus cause head pain. Gushing,
in speaking of cerebral comjiression the result of tumor growth,
says that he succeeded in demonstrating, in the dog, that the
longitudinal sinus may completely collapse at an early stage of
compression with a venous stasis of high degree. If there is
increased tension, from any source, a similar collapse may be pro-
duced in the sinus rectus, with stasis in the vena galena, and this
produces an internal hydrocephalus witlior.t direct implication of
these vessels by pressure from a neighboring growth. This in-
ternal hydrocephalus produces pressure and traction on the dura
mater which results in head pain.
Reflex causes of headache are the last to be considered, but
they are not by any means the least important. Reflex headaches
are due principally to organic disturbances of the uterus, ovary,
eyes (iritis, glaucoma, chronic eye strain), sinus disease (nasal
and frontal), hemorrhoids, decayed teeth, digestive disturbances,
and toxic disturbances. The reflex headaches are due to irrita-
tion of the nerve centers, and owe their presence to circulatory
changes in the brain.
Under reflex headaches it is also proper to consider headaches
which follow intense irritation of the organs of special sense, for
in many cases headaches follow a loud iioi.-e, exposure to an in-
tense light, or a strong and disagreeable odor. These headaches
are probably reflexes from the centers affected to the centers of
the cutaneous area in whi( h the pain is felt.
Hunger headaches are due to a lack of nutrition in the brain
cells of the cerebral cortex (in reality toxic headaches). This
condition is common in children.
Headaches which follow excessive venery are probably due
to cerebral fatigue. To the same class belongs the headache
which follows loss of sleep, such as occurs in those who have been
278 REGIONAL PAINS
Tip all night, or in those who have missed an accustomed mid-
day nap.
Disturbance of the brain substance from worry, etc., may
cause some change in the molecular structure of the cortex,
and this, in turn, produces reflex circulatory disturbances,
which may be the cause of pain. Associated symptoms of such a
state, according to Drein, are malaise, irritability, digestive and
visceral disturbances, nausea, confusion of ideas, and vertigo.
ehuyngoal dJKHAr
rouUdiKHW
roDiiUv sknd ii i
Fig. 64. — Locations of the Principal Headaches,
Neuralgia of the cortex is also given as a cause of headache.
As neuralgia means but an increased irritability of llic si-nsory
centers, or of the nerves conducting seiii^ation and is used more
to define a functional lesion, it may nol be entirely proper to
apply the term to the condition lu which pain is produced by a
cortical organic irritative lesion leading to lessened resistance
and increased susceptibility. We find an increased suscepti-
bility of this kind in neurasthenia and allied depressive states,
in which a bright light, a thunderstorm, etc., will produce
THE HEAD 279
headache. It is also held that there is a headache caused by an
irritation of the cerebral cortex by toxic materials, such as was
claimed by the older writers (Boerhaave, Van Sweten) to occur
. Aaeurjva of verubral ftrter>-
(1) HydrcMKphalus
[ (2) Nflpbritu
FiQ. 65.— Figure Illustrating the Locations oftbe Principal Head-
aches.
Thebackof the head and the nape of the neck are supplied by: 1. OccipitalU
major, which lies toward the mid-line and which is a branch of the 2d
■cervical nerve which passes through between the axis and atlas, and
may be easily injured, owing to the great mobility of theae part^; it is
also affected in tuberculosis of this region; therefore pain would be felt
in the occipitalis major area of distribution in disease of either the atlas
or axis. 2. Occipitalis minor, which lies more laterally. 3. Auriculahs
magnus, which supplies the posterior surface of the ear. Occipital head-
ache pain begins at the junction of the skull and the cranium and runs
up the back of the head to the vortex or laterally tu the back of the cars.
in rheumatic headaches. These headaches are of a mobile char-
acter, and occur at various parts of tlie cranium, being especially
common in the occipital and frontal regioue. The pain seems to
be well within the skull, and pressure on the surface does not
modify its character as is the case in rheumatism of the scalp.
280 ' REGIONAL PAINS
The muscles of the neck are more or less rigid, and the movement
of the head is painful. Conditions of eold and dampness influence
Fig. 66. — Occipital Heaoachb.
the head symptoms tlio siime as tlicy inflnence rheumatic affec-
tions of the joints.
Fig. 67. — Fbontotemporal Headache.
In many painful lesions of the brain the skin over a ce
tain area of the head is very sensitive to pressure. This i
THE HEAD 281
thought to be due to the relations existing between the nerve
filaments of the meninges and those of the aealp overlying the
affected area.
Diseases pro<lucing reflex headaches are: brain abscess,
chronic appendicitis, gall stones, chronic gastritis, intestinal de-
rangements, etc. The menstnial period also is often nshered in
with a severe headache.
In the accompanying drawings the locations of the principal
headaches are given; and since these locations can be illustrated
much better than described, the latter has been thought unnec-
easary. (Figs. 61, 62, 63, 64, 65.)
Fio. 68. — Temporal Headache.
In almost every case of lieadaclic the patient tries to ease the
pain by making pressure on the head. This is illustrated in
figures 66, 67, 6S.
Diajfnosis of Headache. — The following may be of use in the
diagnosis of headaches:
Qmoiif. — First, ascertain if the headache is of recent or of
remote origin. If it is of recent origin, examine for:
(1) Acute infectious diseases in which the pain may be the
reault of a direct action on the pain-conducting trigeminal tract,
282 REGIONAL PAINS
or due to an elevation of the intracranial pressure. The most
common infectious diseases causing head pain are influenza, ty-
phoid fever, tonsillitis, and the acute exanthemata (measles and
scarlet fever).
(2) Injury (traumatism).
(3) Toxemia: (a) endogenous (hepatic torpor) ; (b) exogen-
ous (constipation, drugs).
(4) Intracranial lesions (meningitis), either tuberculous or
septic. In either case, the characteristics are a constant pain, in-
terrupted by paroxysms of greater severity, and increased by
movement or on the taking of food or drink. Vomiting and
nausea occur in the absence of the ingestion of food. In some
cases, when the intracranial pressure becomes high, optic neuritis
follows. Tuberculous meningeal headaches, as a rule, are frontal
or occipital (Taylor, 632).
Prpbably the headaches of all the acute diseases are due to
toxic causes. While headache is a common accompaniment of all
acute infectious diseases, yet some, as pneumonia, may be entirely
free of headache throughout their whole course.
Remote Origin. — If the headache has been of a chronic type,
a knowledge of the relative frequency of the diiferent forms of
chronic headacheunay aid greatly in forming a diagnosis. Accord-
ing to Edinger, two-fifths of the chronic headaches are of the in-
durative type, two-fifths are of the migraine type, and one-fifth
consist of other types. The majority of all headaches are in the
frontal region. In our examination of structural changes, as a
cause for chronic headache, we begin an examination of the dif-
ferent organs in the following order:
(1) The eyes produce the so-called ocular headaches. In
these headaches the pain is, as a rule, more severe on using
the eyes. Brooks thinks that the principal eye conditions giv-
ing rise to headaches are errors of refraction, by which an
excessive amount of work is thrown upon the ciliary muscles;
want of balance between the external muscles of the globe; and
retinal hyperesthesia, in which the retina is very sensitive to light.
Ocular headaches are usually located over the middle of the eye-
THE HEAD 283
brow and the pain radiates into the back of the eye (Jessop,
364).
(2) The nose ^ causes a pain that lies to the inner side of,
and extends higher on the forehead than the pain due to eye strain.
The nasal conditions causing headache are stenosis (chronic ob-
struction due to foreign bodies, rhinoliths, tumors, hypertrophy of
the turbinate, bending of the septum), vasomotor alterations, epi-
staxis, sinus involvement. lodid coryza should also be thought of,
especially in those who are undergoing treatment for syphilis.
The cause of the headaches in cases of nasal obstruction seems
partly at least to be due to the lack of oxygen, because it has fre-
quently been found that patients suffering from recurring head-
aches, or from neurasthenia, are immediately relieved of the
trouble by the removal of some obstruction in the nose or sinuses.
Turbinate headache is usually periodic, depending on the inter-
mittent swelling of the mucous membrane covering the surface of
the anterior end of the turbinate. Sinus involvement may
cause severe pain; for in one of Hartman's cases trigeminal neu-
ralgia, due to this condition, had persisted for weeks, the pain
being so intense that sleep had been impossible. The most
diverse treatment had given no relief. All pain vanished im-
mediately after the maxillary sinus was evacuated of the cheesy
matter with which it had been filled. In other cases supraorbital
neuralgia, which recurred every day at a certain hour, was the
result of inflammation in the frontal sinus, and was cured by
appropriate treatment The pain may be due to the inflamma-
tion itself, to compression from secretions, or merely to rare-
faction of the air in the sinus. The trouble may not be due to
an inflammatory process, but merely to the occlusion of the sinus,
by which communication with the air is shut off. This is a com-
paratively frequent occurrence, and is liable to cause distressing
pain. Opening a conununication into the nose banishes the pain
at once (Hartman). A particular variety, met most frequently
by Thompson (488), and associated with old fractures of the
nasal bones, seemed to begin at the roof of the nose and to pass
'See page 342, Nasa] Stenosis.
284 REGIONAL PAINS
horizontally backward to the occiput. It was always aggravated
by prolonged bending forward of the head, as in writing, and
had a special tendency to cause incapacity for mental work.
(3) Diseases in the accessory nasal sinuses are also causes
for headaches. The sinuses affected are the frontal, antral, eth-
moidal and sphenoidal. Headache due to disease of these sinuses
is generally relieved by the discharge of pus or mucus from
the nose. In these conditions, the seat of pain is generally frontal,
although most authors believe that it bears no special relation
to the site of the disease. Lack (623), however, holds that the head-
ache due to sphenoidal sinus involvement is * ^referred to the back
of the head and then radiates down the back of the neck." That
due to the ethmoid is found in the frontal region, in the eyes, and
deep in the head behind the eyes; while that due to the antrum
is found over the molar bone and may extend upward to the
temporal region. He also states that the frontal sinus headache is
most severe at the "top of the head over the posterior part of the
frontal bone." The original location of the pain is generally
continued throughout the disease.
(4) The ears,' in many cases, cause head pain. The prin-
cipal causes acting upon the ears to produce head pain are anemia
and mastoid disease.
(5) The alimentary tract gives rise to headache. Various
forms of mouth disease, gastrointestinal disorders, intestinal para-
sites, constipation, dyspepsia, and cholelithiasis may be the cause
of severe pain in the head. Dull, generalized headache and coated
tongue are due to indigestion.
(6) In kidney lesions the pain is felt particularly at the
back of the head, and radiates down the neck. Torticollis and
disease of the vertebrae should be eliminated.
(7) Brain tumors and abscesses are common causes of
headache. The location of the pain often corresponds with the
site of the tumor. Sometimes the pain is increased by pressure.
It may not be constant, but generally it is periodic. (Cerebellar
tumors commonly are on the side opposite to that in which the
headache is found. Tumor headaches are caused by tlie pressure
THE HEAD 285
of the growth obstructing the vena magna galeni or the aqueduct
of Sylvius (Schmidt), both conditions lead to increased intra-
ventricular pressure. The location of a brain tumor cannot be
diagnosed from the situation of the headache. For a fuller con-
sideration of these headaches, see page 182.
(8) Psychical strain will produce severe headache. This is
likely to be frontal, and generally is the result of long-continued
worry or severe mental effort A headache of this character is
influenced most by psychic states. Mental effort greatly in-
creases it. In this it differs from a headache due to increased
intracranial pressure, which is most influenced by mechanical
factors, such as change in position of the head and body, bleeding
from the nose, or blood-letting.
(9) Between lead poisoning and gout, and the uric acid
diathesis, probably there is a close relationship. All these pro-
duce headache.
(10) The headache of anemia is due to a hydremic hydro-
cephalus, with a consequent rise in the intracranial blood pressure.
Elevating the head often causes great relief.
(11) Cerebral arteritis: Of the general symptoms of cere-
bral arteriosclerosis, headache stands first. It is usually dull, not
throbbing, and quite often is described as a feeling as though a
tight band were compressing the head. It occurs most frequently
in the morning, after walking about, and diminishes as the day
advances, except in syphilis, in which it is usually most severe
at night. A peculiarity worth noting in this class of patients is
that, even though arteriosclerosis is present, there is also a lowered
blood pressure, which is probably the result of secondary cardiac
weakness. It averages from 110 to 130 mm. Hg. The causa-
tion of the headache can be explained from the fact that, since
the cerebral arteries are terminal arteries, a sclerosis of the coats
would cause a narrowing of the lumen, which would produce an
anemia of the cortex of the brain. The anemia, of course, would
then produce headache and giddiness. Wliy there should be a
systemic lowered blood pressure, is difficult to explain.
The patient should also be questioned in regard to the con-
286 REGIONAL PAINS
stancy of the headache; that is, whether it is intermittent or per-
sistent, and then, if it is intermittent, whether the intermittence
is regular (periodic) or irregular.
Inteemittent Headaches (Periodic Type). — According to
Edinger, two-fifths of all headaches from which patients suffer are
of the periodic type. The most important, as well as the best
known, of the periodic headaches is migraine. Two types of
migraine are recognized:
(1) The reflex migraine, which begins later in life than
does the true variety, and is dependent principally upon a non-
inherited, peripheral cause. In this class of cases there is no evi-
dence of a neurosis in the family, and the headache becomes
worse instead of better in middle life. A preliminary visual
spectrum is absent The headaches are warded off by purgatives
and laxatives, while, in contrast, the true migraine headaches are
not influenced by such means, but are lessened by phcnacetin.
The principal causes of reflex migraine are eye strain, constipa-
tion, and intestinal toxemia. These headaches may also be pro-
duced by peripheral factors, as injury to the nerve following a
blow on the head, or a fall, in which the third nerve has been
damaged. In some cases, after recovery from a head injury, a
patch of meningeal thickening may remain and cause head pain.
In this form there is sometimes a recurrent third nerve paralysis,
and the patient is attacked by severe headache lasting a day or
two. The third nerve recovers its functions in the course of some
weeks. A visual spectrum rarely develops.
(2) In the hereditary form of migraine there is a distinct
history of the heredity. Generally some member of the family
has been a sufferer from this condition. If none has been affected
with headaches often there is one member who is subject to attacks
of epilepsy, neuralgia, etc. Migraine appears in adult life and
may be caused by prolonged debilitating diseases. An individual
attack is frequently induced by the menses, which it may precede
or follow, a prolonged railway journey, a close, badly ventilated
room, great heat, emotion (as anger), excitement, the use of a
small quantity of alcohol or tobacco, unusually early awakening.
THE HEAD 287
omission of a meal, or strain of the eyes, especially if the strain is
on the ciliary muscles.
Migraine gives rise to a throbbing pain. It begins with dis-
comfort and gradually increases until it is agonizing in its
severity. It generally begins over one eye and then spreads to
the forehead and the side of the head. It is increased by bending
over, by noises, or by any sudden exertion. Eating may also in-
crease it. Drinking alcoholic beverages and smoking make it
worse. Strong light augments the distress. Because of all these,
the patient generally seeks a quiet and dark room and lies very
still.
A symptom almost pathognomonic of migraine is scintillating
scotoma, which appears before the pain commences. The scotomata
appear as floating dark spots in the visual field, the borders of
which are often serrated and illuminated. Some see only the
illuminated edges of the spots, and may complain of dulness of
vision.
The individual paroxysm of pain may last for a few minutes,
or an hour, while the period of attack may last for a few hours or
all day. The premonitory symptoms of migrane are lassitude,
irritability and incapacity for arduous work. They often appear
in the evening before the attack, while on the morning of the
attack the patient complains of numbness in the head and an ex-
tremely tired feeling. The pain begins gradually, and is felt
deep in the head, with a sensation as though the head were split-
ting. There are also a burning and a sense of pressure in and
behind the eyes. The pain, as a rule, is unilateral. It is asso-
ciated with a feeling of distress. Loss of appetite and cold feet
are often present. The physical signs associated with migraine
are: a generally pale face (though it may be red), injected con-
junctivae, narrowed palpebral fissure and contracted pupils. The
contraction of the pupils is an important differential sign, as in
all other conditions where severe pain is present the pupils are
dilated. Vomiting, as a rule, finally occurs, and when it does the
headache ceases.
True migraine is the most important and commonest of the
288 KEGIOXAL PAINS
forms of perio*Jic headache. The severe pain in the head seems
to be due to an increase of the intracranial pressure. The hemian-
opsia, the dimne^^s of vi-ion, tlie numbness in the tongue, cheek or
arm, and the temporary aphasia are all suggestive of sudden ar-
terial constriction in the cortex.^ Vomiting is also a most char-
acterLstic sign of elevation of intracranial pressure.
Bninton is also in accord with the arterial constrictive hypoth-
esis, for he claims that the pain of migraine is due to a con-
traction of the [>eripheral part of the temporal artery, and a dila-
tation of the proximal part lie noticed that in every case of
migraine the carotid was widely dilated, while in many cases the
peripheral part of the temporal artery seemed to be contracted,
and in other cases dilated ; but, in every case, the little branch
which turns upward on the forehead was found to be firmly con-
tracted. Pressure upon the carotid would oftentimes relieve the
pain, which ceased as long as the pressure was maintained, but
returned as soon as the pressure was removed. Pressure upon the
carotid artery of necessity produces pressure upon the pneumo-
gastric nerve, causing great disturbance to the respiration, with a
"feeling as though the entire chest were contracted, or as though
someone were pressing down with a giant's weight upon it"
Therefore, pressure on the artery, because of these symptoms,
cannot be long continued.
These views of Brim ton are in accord with the opinions of
Edinger and Harris, who also think that migraine is accompanied
and conditioned by a contraction of the peripheral arteries. While
as yet no vasoconstrictor nerves can be found in the brain, the
pale eyegrounds, the general vascular spasm which causes dizzi-
ness, and also the occasional disturbances of speech all seem to
confirm the anemic hypothesis. Another idea of the cause is ex-
pres8(»d by Jelliffe, who follows Spitzner in believing that migraine
is due to an absolute or relative stenosis of the foramen of Monroe.
According to the same authority, an occasional hyperemia of the
1 AU hough cerebral arterial constriction has been given by many
authorH as a cause of increased intracranial pressure, it seems to me that
the arterial constriction does not cause a congestion but an anemia, and that
^he primary condition is not an arterial constriction but a dilatation.
THE HEAD 289
brain leads to a hyperemia of the choroid plexus. This, in turn,
causes a greater narrowing of the foramen, and an increase of
tension in one or both ventricles. This causes a still further con-
gestion of both choroid plexuses, and increases the narrowing.
The vicious circle continues until the pressure is relieved or the
tension is reduced by a shock reaction, such as occurs in vomiting.
Or in the use of the vasodilators.
According to Levi and Rothschild, there is also a migraine
due to a diminished secretion of thyroidin. These doctors have
succeeded in ameliorating seven cases of migraine with thyroidin ;
and in their description of thyroid migraine they say that "the
existence of this affection is evident by the migraine being re-
lieved with thyroidin; by the hypothyroid signs we meet in people
suffering from migraine ; by the autotherapy of pregnancy ; by the
influence of female sexual life (puberty) on the appearance of
the affection; by the paroxysmal crises (during menstruation) of
the affection; and by their cessation at the menopause. Thyroid
migraine symptoms do not differ from those of common migraine.
It is either precocious or tardy, hereditary or acquired ; unilateral
or bilateral; syndromic or symptomatic. It may last only some
hours or days, but is always paroxysmic.''
Other causes of periodic headaches are, malaria, syphilis,
habit, hysteria, lymphatism.
If the periodic headache is due to malaria, there is some
malarial history. Chills, fevers and sweats occur, an enlarged
spleen can be palpated, and plasmodia can be found in the blood.
In headache due to syphilis, the pain, as a rule, occurs at
night, and is usual after excitement.
Habit Headache. — If a periodic headache occurs at the same
time of the day or week, examine for some disease or habit, in
the history of the patient, which would be likely to bring on
headache, or to act as a predisposing factor in its production.
Inquire into the manner of work, sleeping, eating, etc., of the
patient.
Hysterical headache may be present, in which case there are
other signs of the hysterical involvement.
290 REGIONAL PAINS
Ross speaks of a form of headache which he calls the lymphatic
headache. He describes it as having the following characteristics :
(1) It is present, and most severe, on walking, and tends to
lessen in intensity, or altogether disappear, in from one to six
hours.
(2) It usually manifests itself as a dull, heavy ache, or as
a frontal or temporal throbbing. Less frequently it is occipital,
vertical, or imilateral. Infrequently, also, it is neuralgic.
(3) In its typical form it is exceedingly chronic, often of
several years' duration, and most intractable. It is the common,
occasional headache to which most people are subject.
(4) It is associated with a deficient coagulability of the
blood.
The postures assumed by patients suflFering from the different
varieties of headaches are illustrated in Figs. 66, 67 and 68.
In all of these headaches, the principal factor sought by the patient
seems to be the application of pressure over the painful area.
This, in nearly all cases, relieves the pain; so it is possible that
in these headaches the pain is a superficial pressure phenomenon
(skin, muscles, etc., of scalp), and that pressure ai)plied over the
area of local pain removes the congestion and thus relieves the
pain.
Hyperalgesic zones of the head, according to llannsa (62b),
frequently occur in lesions at the base of the skull. The most
common of these are the result of bullet wounds of the skull,
basilar fractures, and concussion. The zones may lie in the area
of distribution of the second to fifth cervical segments — or in the
distribution area of the trigeminus. Hannsa, as well as Wilms,
Milner, Vorschiitz, Clairmont, etc., claim that the cause of these
zones is a lesion of the sympathetic.
In this connection, also. Head has observed that most of the
viscera cause pain which is referred both to an area in the body
and, in many cases, also, to one in the head, where it is expressed
as tenderness. Head found that these ^reas were associated with
certain visceral areas of tenderness. These associations are given
by Head in the table on page 295 (Head, Brain, 1894, p. 464).
"5
§
1 i
1
II
1
!
ill
■1
-I
il
il
bi
1
s i
la
1
to
5
^
"
llrt I,
JW liSll I'i
Sri jj ^q" *"' la
DiKue of Jut two lanltrt
Sunrior ImrvDceii]
L Di«ueo!wiHk>mti»tb
of donum of tooflue
FiG. 70. — Lateral View ok Head's Zones.
Solid black areas show points of niaximum teiidemesB.
THE HEAD 293
It seems that "all the thoracic and abdominal viscera, which
refer pain into the dorsal areas of the scalp, are supplied hy
what might be termed the vago-glosao-pliaryiigeal nerve — this con-
sisting of the vagus and the glosso-pharyngeal nerves. These two
^1 J DiseajR or poatanor portion of the avfl
" 1 EkvBiiim of IconoD in tbe middls w
Vrontolcmpor»l
ehuober td
'teetli
SMmoaucb*)
Fig. 71.^ — Lateral View of Head's Zones.
(From Head.)
nerves represent the visceral branches of a set of nerves whose
somatic sensory roots are to be fonnj in the sensory portion of
the fifth nerve. Therefore, it is possible to understand how the
impulses passing up the vagus may be referred to the distribution
area <rf the fifth nerve.
4 it.
mil
i
i
III
Area on Body
Cervical 3.
Associated Area on
Scalp
Cervical 4.
Dorsal 2.
Dorsal 3.
Dorsal 4.
Dorsal 5.
Dorsal 6.
Dorsal 7.
Dorsal 8.
Dorsal 9.
Dorsal 10.
Dorsal 11.
Dorsal 12.
Frontonasal.
> <
Frontonasal.
Midorbital.
Midorbital.
Doubtful.
Frontotemporal.
Frontotemporal.
Temporal.
Vertical.
Parietal.
Occipital.
Occipital.
Occipital.
Organs in Particular Relation
with Those Areas
' Apices of lung.
I liiver.
I Stomach.
[ Aortic orifices.
Limg.
'Lung.
" Heart (ventricles).
Ascendmg arch of aorta.
'Lung.
Heart (ventricles).
Arch of aorta.
Lung.
/Lung.
\ Heart (occasionally).
f Lower lobes of lungs.
\ Heart (auricles).
' Bases of limss.
Heart (auricles).
Stomach (cardiac).
' Stomach.
Liver.
^ Upper part of small intestine.
f Stomach (pyloric end).
\ Upper part of small intestine.
I Liver
Intestine.
Ovaries.
Testes.
Intestine.
Fallopian tubes.
I Uterus.
[ Bladder (contraction).
f Intestine (colon).
\ Uterus.
295
296 REGIONAL PAINS
PAIN IN THE BACK
This includes all pains from the base of the skull to the coccyx.
They may be the result of a lesion of the structural units of
the back (skin, muscles, nerves, or bone), or may be referred
from other regions. The skin of the back is hypersensitive in
many of the diseases of the internal organs — in these the zones of
Head are, as a rule, pronounced — and in all cases should be
sought. In many of the infectious diseases the skin is also very
sensitive, both to touch and to pricking.
In examining the back for the presence of pain phenomena first
try light touch and pin-point pressure. If these are not painful,
make deep pressure, or grasp the muscles between the fingers;
should the patient now complain of pain, we may conclude that it
is the muscles which are affected. The muscles most frequently
affected are in the neck, and the most common affection is rheuma-
tism, which in the neck produces torticollis, and in the small of
the back lumbago. These rheumatic affections are characterized by
a sudden onset, the great pressure sensibility over definite muscular
areas, the increase of the pain on movement, and the favorable
influence through massage, faradization and heat. In many cases,
also, the pain and tenderness seem to be influenced by the weather,
becoming much worse on rainy days. Only by their course do
the chronic rheumatisms of the back muscles differentiate them-
selves from acute forms. Johnson (Brit. Med. Jour,, 1881,
p. 221) mentions back pains, which lasted a long time, and which
appeared on bending forward. They were double-sided, and only
unilateral if the vertebra; were held crooked. These pains were
worse after their onset, and diminished after a little movement.
I have observed a similar case in a colleague. In this instance,
however, not the muscular but the tendinous structure was dis-
eased. The colleague complained of back pain, which would ap-
pear at certain parts of the vertebral column, upon motion or
fixation; for instance, it would appear if he stepped from the
pavement incautiously, and upon strong pressure. Examination
showed, in this otherwise healthy individual, a high degree of
PAIN IN THE BACK
297
sensibility of the vertebral spines of the two lower thoracic verte-
brae. Especially sensitive were the connecting fascial ligaments.
The overlying skin was also sensitive. Deformity was not pres-
ent, and sudden pressure over the vertebrae was not especially
painful. There was, therefore, no reason to think of a destruc-
tive process in the bodies of the vertebrae. I learned that the col-
league had worked with a microscope, in a somewhat uncomfort-
able position, several hours daily for many weeks, the microscope
being placed so low that he had to work with his back very much
bent. After working with the instrument in a better position, the
pain disappeared in a short time without further therapy.
Since lumbago is so frequently confused with that of neuras-
thenia the following table of diagnostic difference is appended.
Lumbago
Neurasthenia
Pain located.
In the region of the lower
lumbar vertebra and
spreads out sideward.
In the sacral region and
spreads upward.
Method of onset.
Sudden.
Very gradual.
Influence of motion.
Increases pain.
No action on the pain.
Points of tenderness.
Pressure on increases the
pain or also produces it.
No pressure points.
Psychical influence.
Mental states have no in-
fluence.
Is influenced ^atly by men-
tal states, uritation (psy-
chical) increai*es the pain,
diversion reduces the pain.
Vertebral column.
Often some change or de-
formitv present, such ae
scoliosis; this can be dif-
ferentiated from other
forms of scoliosis by hav-
ing the patient lie on the
affected side, in a sharp
angle, when the scoUosis
disappears.
No change or deformity.
Myalgia, due to toxemia, is nicely illustrated in those infec-
tious diseases in which backache is one of the most prominent
symptoms. In small-pox the pain in the back is so severe that the
patient, in many cases, is in the greatest distress. The nature of
this pain, however, does not long remain in doubt, for the presence
298
REGIONAL PAINS
of the eruption soon clarifies the situation. In the so-called break-
bone fever, of the Southern States, it is also most severe. Among
the other infectious diseases in which backache is a prominent
symptom are relapsing fever, influenza, tonsillitis, typhoid fever
and diphtheria.
CariPus Spine
^5rJ:IM2^^^
Fig. 73. — Figure Showing the Modifications op Pain in the Lumbab
Region by Change op Position.
The arrows indicate the direction of movement and + indicates increase
of pain, while — indicates decrease of pain in the diseases mentioned
when the motion is made as indicated.
In myalgia from sprain some history of injury is usually
obtainable, and in some cases evidences of traumatism are present
In myalgia due to fatigue the pain is more of an aching character.
Sitting upright or standing increases the pain. Ease may be
obtained, as a rule, by reclining. This condition is frequently
associated with neurasthenia, anemia and depressed mental or
physical states. Such a fatigued state is frequently experienced
by dentists, mechanics, barbers, surgeons, or comes on after cer-
tain forms of exercise, such as rowing. Pain may also be due to
PAIN IN THE BACK 299
inflanmiation in the 8ubcutane<5u8 tissues, as in perinephritic ab-
scess and inflammation of the retroperitoneal glands.
In the neck, the stemomastoid muscle, either as a result of
changes in its substance (result of toxic irritations), or as a re-
flex from other adjacent structures (neck glands, Ludwig's angina,
vertebral, or local lesions), or from neurotic influences (either
congenital or acquired, acute, or chronic), becomes so sensitive
that it remains in a state either of tonic or clonic contractions.
When the contractions are chronic they abate gradually but
quickly reappear on the least irritation or attempt at movement.
This condition is termed torticollis. For a fuller description of
this the reader is referred to special works on the subject.
After a consideration of the muscles as causative factors of
the back pain the vertebra and joints should next be considered.
Vertebral diseases^ as tuberculous caries (when inflammation
is acute), cause pain, elicited either by sharp spinal shocks made
by forcibly pushing the head downward, or by having the patient
stand with feet together and then, after elevating himself on his
toes, bring the heels down to the ground with considerable force.
When vertebral disease is present, pain will usually be felt in
the diseased area. Involvement of the third to the flfth vertebra
generally gives rise to more pain on bending forward or back-
ward than does involvement of other vertebrae, because it is at this
level that flexion and extension of the spine most frequently occur
(Cooper, 807).
Leukemia with vertebral myeloma may also give rise to back
pain, likewise, also, the vertebral metastatic growths, especially
prostatic, mammary, or adrenal tumors.
The sacrovertebral joints are also a frequent cause of back
pain, which may be either the result of inflammation, or of dislo-
cation. If of inflammation the same signs and symptoms of in-
flammations are found as in other inflamed joints (see page 239).
Dislocations also display here the same signs as when they
occur elsewhere. Here, however, should be mentioned the sacro-
iliac dislocation, the pain of which causes it frequently to be mis-
taken for lumbago and sciatica, llowever, in this condition the
300 REGIONAL PAINS
pain is in the sacroiliac region, and extends down to and over the
anus. There is also rigidity of the retrospinal muscles.
For the elucidation of this lesion Goldthwaite (800) has for-
mulated two tests (an anterior and posterior one), which are
known by his name. He describes them as follows (Anndls Surg.,
Vol. LI, Xo. 3, p. 420) :
"For the anterior test, place the patient on a bed with, say,
the right limb fixed on the bed ; then the left leg is lifted from the
bed without flexing the knee. If it does not go as high, if the
extension or flexion of the limb, when the limb is extended, is not
equal to that on the other side, and if the pain is acute, we suspect
an anterior displacement of the sacrum. The posterior test can be
made by extending the limb upward, with the patient lying on the
face." The diagnosis between muscular and ligamentous pain of
the spine (Cooper, 802) is that passive posturing will cause pain
if the ligaments are involved, while if the muscles are involved,
active posturing will cause pain.
Reynolds and Lovett (805) also speak of cases in which, owing
to an abnormal stooping-forward position, the center of gravity
is moved forward, and, as a consequence, considerable strain is
thrown upon the ligaments and back muscles, with the consequent
production of pain.
Osteomalacia is also productive of very severe back pain, but
the associated pregnancy and the typical pelvic and sacral de-
formity render its diagnosis easy.
Pain over the coccyx (the so-called coccydynia) may be due
to injury of the coccyx from a fall, or from over-distention of
the inferior pelvic outlet during childbirth. It is also found in
hemorrhoids, anal fissure, and proctitis. Lesions of the conus
meduUaris also may cause pain referred to this region.
Referred pain may be felt in the back and be present, either
as a result of disease of the viscera, or of some more distant organ
or region. The viscera lesions, most of which commonly give
rise to pain in the back, are : the lungs, stomach, intestine, liver,
and gall-bladder, kidney, pancreas, spleen, and pelvic organs.
Lungs. — Affections of the lungs, if they extend to the pleura,
PAIN IN THE BACK 301
frequently lead to pains which are felt in the back, especially as
the patients localize the pains in the upper part, in the intra-
scapular space and in the shoulder, if the area of disease is local-
ized in the apex or in the upper lobe. The more frequent cause
for such a condition may be a beginning tuberculosis. Pressure
sensibility of the skin and musculature, in the above-mentioned
region, is not often present. Increase of the pain in breathing,
and especially in coughing, gives an indication, and an exact
examination of the lungs makes the cause clear.
Heart and Aorta. — Just as frequent causes for back pains are
affections of the heart or of the aorta. Here the pain occurs not
only in the back, but also may be found as radiating pain in the
arm, especially in- the left arm and in the left shoulder. A fre-
quent complaint of such patients is a sensation of constriction of
the thorax, as though it were being pressed in a vise; but in this
case the hand of the corresponding part of the back, or the shoul-
der and the left arm, are oversensitive. It will not be hard to
differentiate these varieties of pain from those which are caused
by disease of the spinal cord or of the dura. Tlie circumstances
that heart pains almost always occur in paroxysms, and that these
attacks, in the first place, are called forth through bodily exer-
tion, psychical irritation, etc., indicate their origin in the heart.
An exact examination discovers changes in the aorta and the car-
diac muscle. Absence of signs of a spinal cord disease completes
the finding.
Stomach. — With the referred pains of gastrointestinal visceral
disease are associated the hyj>erseusibility of the skin and muscu-
lature of the painful region, and of the corresponding part of the
vertebral column, on the left side, in particular. But these pains,
as they are especially observed in ulcer of the stomach and in
pyloric stenosis, are not very difficult to connect with the stomach,
since their appearance and variations in intensity depend chiefly
upon the taking of nourishment, and especially upon the quality
of the food. It is unneeessarv to sav that the further examina-
tion of the stomach, in such a case, must yield signs of disease of
that organ. In many cases of total stenosis and cramp of the
302 REGIONAL PAINS
esophagus, a severe pain is frequently felt in the shoulder region,
and a girdle sensation is experienced in the thorax.
Intestines. — Pelvic pains are frequently due to diseased proc-
esses in the intestine. Gas collections in the large intestine pro-
duce pain in the pelvis and in the flanks, the cause of which
reveals itself upon the application of a purgative. Intestinal
ulcers do not so frequently cause pelvic pain. On the contrary,
pelvic pains in carcinoma are an important diagnostic phenomenon.
Very frequently they are associated with a radiation in the limb
and in the perineum, especially if the carcinoma is situated in a
deeper part of the colon. Yet, here the pains almost never appear
without accompanying symptoms. Very frequently they are asso-
ciated with intestinal symptoms, so that their recognition causes
no difficulty. Only an inflated colon can, as a single pathological
entity, produce dull pain in the back, usually on a level with the
kidneys. But here an exact anamnesis, with the fact that the onset
of the pain depends upon the passage of feces or of gas, makes the
diagnosis clear.
Liver and Oall-bladder. — One observes, very frequently, in
liver and gall-bladder troubles, pains in the shoulder, in the arm,
and in the back — almost always on the right side. There is often,
also, an excessive sensibility of the skin and of the correspond-
ing musculature. This can be demonstrated upon picking up
folds of the skin and pressing upon certain places (the region near
the tenth to the twelfth vertebral spine). When the remaining
signs of gall-bladder and liver disease are found, the diagnosis is
complete.
Kidney. — The spontaneous and pressure sensibility in diseases
of the kidney (inflammation, embolism, congestion, tuberculosis,
neoplasm) is situated in the flanks and pelvic region. Frequently,
also, hyperesthesia of the skin is found. Here chemical and
microscopical examination of the urine make an important dif-
ferentiation. In connection with pus inflammation (perinephritic
abscess) pain occurs in the lumbar region, which is increased by
touch and pressure, as well as by coughing, sneezing and motion.
In a similar manner, the pain of nephritis manifests itself. Radi-
PAIN IN THE BACK 303
ation occurs in the thigh or is present in the form of an intercostal
neuralgia. Patients with kidney stones complain of trouble and
pressure in the lumbar region. If the pain is intense, and takes
the form of colic, it radiates downward, as a rule (thigh, testicle,
ovary). Frequently, however, it is found in the lumbar region
and in the loins. The direction of this radiation, and the circum-
stance that the lumbar pain is increased, if one makes a journey
over a rough road, would lead one to think of a kidney stone,
further signs of which are disclosed upon examination.
Pancreas, Spleen, etc. — Of the pains of many pancreatic af-
fections, it is likewise known that they radiate in the back, or (in
girdle form) towards the front. Frequently diseases of the
female genitalia lead to severe pelvic pain, and finally the spleen,
also, under some conditions, produces pain which radiates into
the pelvis, the left shoulder, the left shoulder blade, and the inter-
scapular region. Spleen tumors, especially, produce pain, and
their presence will be thought of as an associated condition by
the presence of the above described pain.
The pelvic organs (uterus and ovary) are probably the most
frequent causes of backache in women. The principal lesions are
a malsituated uterus (retroversion, retroflexion, or the binding of
it down to the pelvic floor by adhesions, in which the pain is
worse just before the menstrual period) ; and inflammation of the
uterosacral ligaments (Garrigues, 803). Tender spots on either
side of the second sacral vertebra are due (Garrigues) to cellulitis
of the uterosacral ligaments. Pressure over the inflamed utero-
sacral ligaments produces pain at these places. The pain is worse
on exertion, especially in sweeping. Sexual intercourse is pain-
ful, as a rule. Examination will disclose the abnormal and pain-
ful ligaments. Pregnancy and menstruation are also potent causes
for backache; but in these conditions there is generally present
some previous disturbance of the lumbar structures which pre-
dispose them so that the addition of congestion or traction, result-
ing from pregnancy or menstruation, produces pain. In some
cases, during pregnancy, an actual relaxation of the sacroiliac
ligament is present (Andrews and Hoke, 806).
304 REGIONAL PAINS
Inflammations of the uterus may also cause backache. (For
a fuller consideration, see "Pain in the Female Genitalia," Chap-
ter XXXII.)
The genitourinary organs in the male (prostate, seminal
vesicles) cause lumbar pain. The urinary bladder, also, when
diseased, frequently gives rise to pain in this region.
Back pain may also be caused by static foot errors, hysteria,
anemia and chlorosis.
In static foot errors the pain is relieved on the patient lying
down, or on the correction of the errors of position.
"In hysteria the backache is usually referred to the lumbar and
sacral regions. It often extends upward over the dorsal area and
downward over the gluteal muscles" (Clara F. Dercum, 150).
Anemia and Chlorosis. — The anemic and chlorotic individual
very frequently complains of back pain. It occurs as rheumatic
pain, which is most severe in the morning, after arising, and im-
proves during the forenoon, if the patient moves about.
The lesions of the spinal cord causing back pain have been
previously considered, and will not be dwelt upon here.
PAIN IN THE LIMBS
After the consideration of back pains, it is next in order to
discuss the pains which usually are present in the limbs. The
upper limbs are probably not so frequently subjected to pain sen-
sation as are the lower limbs; and when they are, the causative
factor is more likely to be of a circulatory nature. The principal
pain areas are in the joints, which are frequently affected by
rheumatism. The shoulder joint, in particular, is subject to
gonococcus infection. Over the shoulder are also found the re-
flected pains from the liver on the right side, and from the spleen,
pancreas and stomach on the left side. On both sides pains re-
flected from the diaphragm, extrauterine pregnancy and pleura
are found. In the shoulder also is present the pain resulting
from inflammation of the deltoid bursa, which lies between the
humerus and the acromion process of the scapula. A characteris-
PAIN IN THE LIMBS 305
tic of this pain is, that it is caused by elevating the shoulder, and
is very severe until the arm becomes horizontal, when the pain dis-
appears. The pain is localized immediately below the acromion
process, between this process and the head of the humerus. Ten-
derness is also most marked at this point.
Generalized pains are usually neuralgic in origin (for which
the reader is referred to the section under Brachial Xeuralgia).
The LOWER EXTREMITIES arc greatly affected by circulatory
changes. A slight indication of the type the symptoms may as-
sume is given by the so-called sleeping pains which follow upon
the partial stopping of the circulation in a limb. Greneralized
pain of a paroxysmal character, more pronounced on the external
and posterior surfaces than on the internal surface of the limb,
is likely to be due to a sciatica (a complete description of which
is given in a separate section). When the pain is on the anterior
surface of the thigh, and runs down and to the inner side, it is
probably due to involvement of the anterior crural nerve. Should
neuralgia be present the pain is paroxysmal and is of great in-
tensity. If it is a referred pain from pressure on the nerve from
tumors or bowel accumulations (William Bruce, 502), it is more
of a steady, constant, dull ache.
In the lower limbs, the joints, especially the hip joints, are
very prone to tuberculous infection. The hip, when so affected,
at first causes a pain on the inner side of and somewhat posterior
to the knee; so that, in many cases, disease of the knee joint is
falsely diagnosed. Rheumatism is also common in these joints,
and frequently pain and swelling in the knee follow upon the
locking of the joint by a so-called rice body. The pain is due to
a stretching of the ligaments. It may be only a pinching pain, or
it may be excruciating, if the cartilages are caught (Barker).
Flat-foot, also, is a potent cause of pain in the regign of the
knee. The pain is on the inner side of the patella and may radi-
ate up and down the front of the leg. The pain is much in-
creased on active exercise of the foot, especially by running or
walking. Pain in the legs which is not influenced by position,
pressure, heat or cold is often the forerunner of brain hemor-
306 REGIONAL PAINS
rhage. When it occurs in persons of advanced years, with hard
arteries, it should be looked upon with suspicion (Musser).
At times the heel is very painful (pododynia) — so much so
that the patient is unable to walk. This pain may be due to local
conditions (exostoses on the surface of the os calcis). Those on the
posterior and inferior surfaces are the most frequent (Thomdike,
"Orthopedic Surgery," p. 164) ; there may also exist spurs run-
ning out from the under side of the os calcis ; bursitis of the bursa
imder the os calcis; or an associated flat-floot may be present
(Keen's "System of Surgery,'' Vol. II, p. 56). Painful swelling
may also be present on the posterior surface of the heel at the
insertion of the tendon-achilles into the os calcis. The patient
walks with the feet everted, while the use of the calf-muscles is
painful. Pain in the heel may also be caused by lesions which
are at a distance, as from urethral stricture (Luxmoor, Brodie,
Thompson, Van Buren, Keyes, and Gouley), vesicle calculus, cys-
ticoprostatitis, inflammation of the neck of the bladder, cystalgia,
or neuralgia of the neck of the bladder, which, in some cases, may
be mistaken for bladder stone (Von Pitha, 272), renal calculus,
gonorrhea (Fournier, 274), and locomotor ataxia (Segun and Buz-
zard). It is also present in pregnancy. Pain on the sole of the
foot may be caused by exostoses on the internal cuneiform or the
base of the first metatarsal, or at the junction of the scaphoid and
cuneiform (Thorndike).
A peculiar and painful affection of the foot, occurring only
in adults, and most frecpiently in women, is termed metatarsalgia
(Morton's disease).
"Typical cases of this affection have sudden cramp-like pains
starting in the third or fourth metatarsophalangeal articulation
and radiating to the tips of the toes and up the leg. The sudden
onset may be brought on by a misstep, or by the fatigue of stand-
ing a long time, and occurs almost invariably when the shoes are
worn. In some attacks are infrequent ; in others they practically
disable the patient and are provoked by inappreciable causes. The
pain is so great that the patient removes the shoe, rubs and com-
presses the front of the foot, flexes and extends the toes, and, after
PAINS IN THE ABDOMEN 307
a time, the pain ceases, leaving no sign, or only a very slight sore-
ness over the articulation on deep pressure. The cramp-like pain
may be referred to a single or to several adjoining joints or to all
the bones of the metatarsal articulation. It is due to a pinching
of the plantar nerve between the bones, or to an abnormal strain
on the ligaments connecting the heads of the metatarsal bones"
(Thomdike).
Tenderness is found on pressure over the heads of one or more
metatarsal bones, or on lateral pressure in the region of the meta-
tarsophalangeal joint (Forbes, Montreal Med. Joum., April,
1909).
PAINS IN THE ABDOMEN
If a pain is of a peculiar, dragging nature, increased on breath-
ing, and especially when deep inspiration or complete expiration
is performed, and if it runs round the chest from the ensiform
cartilage in a slightly downward direction to the tenth rib pos-
terior, it is generally the result of diaphragmatic traction. It oc-
curs in great cardiac and respiratory activity, dilatation of the
stomach, severe tympany, coughing, sneezing, or hiccoughing. A
pain slightly lower, and restricted to the area of the liver, may be
caused by hepatitis (see Liver). On the left side, over the
area of the spleen, a perisplenitis similarly will cause a pain.
Pain localized immediately in the middle of the abdomen, be-
tween the ensiform and the umbilicus, may be due to pancreatitis,
ulcer of the stomach, gall-stones, cardiac lesions (tricuspid regur-
gitation), liver and adnexal diseases, epigastric hernia, and duo-
denal ulcer. If the pain is located around the umbilicus, the
causative lesion may be a hernia of the linea alba, volvulus, em-
bolus of the superior mesenteric artery, meteorism, tympany, in-
testinal obstruction, swollen mesenteric glands, early stage of
appendicitis, ileocolitis and intestinal strangulation.
Pain downward and slightly to the right is very severe in
appendicitis, oophoritis and salpingitis. Pain on the left side is
severe in salpingitis and oophoritis. On either side pain running
from the back around to the anterior surface of the abdomen and
' Emboiua, ni
I Metcoriam
I Referred pun la h^ 1
Ttndgr point in lUt-
, Pds in Bat-foot
PojtcjIeaMal bnr-
—Pain Areas in Trunk a
Extremities.
IntuiauKeptioD i
PutCKAfl dueftfle
iver. mU-blul
Fio. 75 — Pain Areas in
Abdomen.
4
I-l- ...
Typhlid. .
Pun over BDtira *b>
domn
Pariianitu
ifflSr'^i
Inl«ti»i>] parfor-
Mian
Tympuilce
PDcumoniB (cfail-
(Inn)
ADButy™ C»bd-
310 REGIONAL PAINS
then down to the testicle or labia generally indicates a renal or
ureteral disorder.
Pain below the umbilicus in the mid-line is found in colonic
disease, rectal disease, embolus of the inferior mesenteric artery,
uterine disease, or disease of the urinary bladder.
Pain over the entire abdomen results from disease of the
abdominal wall (myalgia, neuralgia, rheumatism, peritonitis), in-
testinal perforation, tympanites, enteroptosis, referred pain in
pneumonia (in children), and aneurysm. For a more complete
discussion of abdominal pain, see Chapter XIX.
Pains due to tabes are very frequent in the abdomen.
CHEST PAIN
Pain over the chest in the sternal region may be caused by
diseased bone, mediastinal inflammation, changes in the medias-
tinal glands, aortic aneurysm, bronchitis and stomach disorders.
Over various areas in the chest are the pains from pneumonia
and pleurisy. Radiating around the chest wall and paroxysmal
in type are the pains of intercostal neuralgia and vertebral and
cord diseases. Pain localized to the pectorals and made worse on
raising and lowering the arm results from rheumatism of the
pectoral muscle. It can also be the result of invasion of the
pectorals in cancer of the breast.
Pain on the left side, over the cardiac region, indicates a
possible lesion of the heart, a^d this is confirmed, if it is found that
the pain runs down the uln>r side of the arm ; even as far as the
little finger. Pain in the breast is frequently present during
menstruation, in pregnancy, and in uterine and ovarian diseases.
It may, also, be the result of a local inflammation, in which case
the entire breast is markedly tender and signs of inflammation are
present.
CLAVICTJLAB PAINS
Pain in the clavicular region is frequently associated with
new growths (pleura, clavicle), aneurysm of the subclavian, and
pulmonary tuberculosis. In the supraclavicular region it may be
Thyroid diH
Tracheitii
LiwrdiMMo
Bitruitflrine pRff-
D I H □ hi a I m m t L fl
TSb^losL, I
pBriwtiti.
Mediuiinftl inSam- |
MedUatinHi ^ukIb |
HyiianbloihydTift
6
<^cBumSex neunl-
Peelonil nturaliJB
Relerrnl pain
Fia. 76.— Pain Areas in Neck, Chest,
Ci^vicuLAB Region and Abdoubn.
EpididymiB
SttDllea and
aiiine<l [d|
sJanda
312 REGIONAL PAINS
due (on the right side) to liver disease, or (on the left side)
to disease of the colon or stomach (in new growth of which also
search for metastatic glands in this region). In extrauterine preg-
nancy with rupture,, pain, when present, is on the same side as
the rupture ; in colonic disease and diaphragmatic pleurisy, pain,
as a rule, is on the diseased side. Pain over the shoulder is present
in deltoid bursitis and also, in a wider area, in neuralgia of the
circumflex.
NECK PAINS
When a patient complains of pain in the neck, the first idea
suggested to the physician is that he is suffering from some in-
flammatory disease of the upper respiratory passages. This idea
is increased almost to a certainty if, with the pain, there is also
present an inspiratory stridor. It may be a sign of laryngitis,
thyroiditis, or tracheitis. Should pain be felt only on turning
the neck to one side or the other, and should one of the sterno-
mastoids be in a state of tonic contraction, sternocleidoid disease
or wry-neck is indicated (see Fig. 69). This tendency to lateral
flexion and rotation is also seen at times in brachial neuralgia.
Pain above the sternomastoid and below the inferior maxillary is
found in tonsillitis, inflammation of the inferior maxillary gland,
or in inflammation of the floor of the mouth, the so-c»alled Ludwig's
angina. Pain over the os hyoides or larynx is a sign of inflarnma-
tion of the bone. In some cases an inferior maxillary neuralgia
may be present. Pain just anterior to the ear, on the side of the
face, indicates ear disease, parotitis, or diseased teeth (inferior
maxillary).
SXTMMARY
Pain in the back, over the entire vertebral column, indicates
neurasthenia, traumatic s[)ine or mediastinal disease; in the area
between the scapula it indicates pericarditis, lung disease, dia-
SUMMARY
313
phragmatic pleurisy and aortic lesions; over the scapula, lunji in-
volvement or pleurisy is indicateJ.
On the left side, between the vertebra; and the scapula, pain
Bplxm
IVricudiiis
Fig. 77.— Pain .\keas i:
HcuUche. bwk
d^'^
li
ILi
ordiH-^
Lu
nai-^pneu
S"jfc£"-
H
bdiHB«
;pi
urodynia
14
It«
ba. ](H»I-
iied memo.
*"i5
1 Li
« (porihep.
D
Ki
lni->Ti (pcri-
■bwna)
. Co
on in>i>srt?d
""
"ttu-;
Co
rvioitis
—
is present in aortic lesions and stomaeii disorders; at the apex o£
the scapula, on the left side, splenic disease ia indicated ; and, at
about the same level on the riirht side {in many cases a little
lower), liver disease is indicatol. Pnin freueralized over the hack
of the chest may be due to mynlpia, luns or pleural disease. Pain
radiatinf^ around the side of ihe ehest is due to intercostal neu-
ralgia. By reference to Fig. 78, the local points of tenderness in
brachial neuralgia and in the so-called diaphragmatic neuralgia
REGIONAL PAINS
are shown, as well as the points of tenderness in intercostal neu-
ralgia and in angina pectoris.
Pun is puInK
tuberculoaii
Douindicile p
Fig. 7S, — I'ain Akeas in Spinal Column.
Lower do\vn in the back, in the neighborhood of the lower ribs,
are found the areas which are painful in perihepatitis and dia-
phragmatic disease, while a little lower is found the area in which
pain is located in kidney disease. T^ower still, and in the neigh-
borhood of the sacrum, are the areas where pain is present in colon
involvement, retroperitoneal gland, and uterine disease. In the
entire small of the back are found the occupation-pain, uterine-
SUMMARY
315
disease pain, perinephri tic-abscess pain, lumbago, and lumbar-
abscess (tubercular) pain. In the same area, but extending over
the sacroiliac articulation, is the pain of sacroiliac disease. Over
tbe coccyx and adjacent regions is located the pain due to disease
3ud4
Tender polnta {
often preaeDt 1
RflDAtdiACAAft I
Tubrrculoui <M
Appendioitii
12
lUtenu
I guroUino dii
!
Fig. 79. — Pain Areas in Back.
of tbe coccyx, rectal disease, and cenix disease. Pain over tbe
buttocks, and running down the outer surface of the limb, is
especially frequent in ovarian and broad ligament disorders.
Pain in the inguinal region may be due to inguinal or femoral
adenitis, and if it radiates down toward the foot it may be due to
pblebitis, crural neuralgia, disease of the femur, femoral hernia,
abdominal tumors pressing on the crural nerve (aneurysm, uterine
or ovarian tumors, tuberculous abscess of the psoas).
Pain in a joint may result from rheumatism, tuberculosis,
acute synovitis, stretching of ligaments, or floating bodies.
CHAPTER XV
THE SIGNIFICANCE OF PAIN IN DISEASE OF THE EYE*
When sensitive and sensory impressions falling upon the
retina exceed a certain maximuui in intensity they become dis-
agreeable. If their intensity reaches a still higher degree the
sensation provoked is painful. Just what are the threshold values
for various forms of stimuli of the retina are not all determined.
Thus, the action of very strong light on the eye causes a painful
sensation, with blinding. Such sensations scarcely ever arise
spontaneously. They are nearly always the result of the action
of adequate stimuli which have been increast^d al)ove the normal
limits. These disagreeable sensations are to be distinguished from
others due to irritation of the nerves of common sensation. In
the descriptions to follow the latter will be simply called pain.
Under normal conditions an individual is not ordinarilv con-
scions of the normal retinal stimuli, and if the existence of this
organ intrudes itself upon consciousness this is usually a sign of
a pathological condition. This consciousness is usually brought
about through the medium of pain. As we do not possess any
objective method for measuring pain, we must rely upon the
information given by the suffering individual, which must be
checked up by our own experience. Self-training, self-control,
physical and psychical distracti^m are circumstances which con-
siderably influence the intensity of this pain ])erception, increas-
ing, diminishing, or even abolishing it completely.
The same uncertaintv which exists in tlu» estimation of the
intensity of the pain dominates the characterization of the quali-
1 By Decent Hans Lauber, M. D., and Olaf Ruttin, M. D., assistants of
the Eye Clinic, Vienna.
316
ETIOLOGY 317
ties of pains. In the same disease the same pain will not be
described in the same way by several patients, and will be diflFer-
ently described by the same patient at diflFerent times. The pain
may be described as blunt, dull, boring, burning, pulling, throb-
bing or tearing, but, unfortunately, there is no possibility of ascer-
taining whether the similar terms used by different patients
describe similar sensations.
As far as the duratic n of pain is concerned, we are in a far
better situation. We can more easily believe the correctness of
statements which describe pain as continuous, periodical, inter-
mittent, or periodically exacerbating. Under certain circum-
stances these characterizations can be of great diagnostic value.
ETIOLOGY
In examining the different factors that can cause or increase
pain in the eye, or its surroundings, we find that they may be
touch, pressure, atmospherical influences, temperature, light, and
tiring of the eyes by work.
The topography of the eye and its adnexa points to the rami-
fication of the first and second branches of the fifth nerve as the
source of the t^tile and consequently also of painful sensations.
The third bratich is of but secondary importance. All the other
nerves can be excluded from further consideration. As a conse-
quence of the very extensive ramification of the fifth nerve, it is
found that irritation of different branches of the nerve may pro-
duce a sensation of pain, or even other symptoms, in the ocular
region. It is important to emphasize, at the very beginning, that
irritation of any branch of the trigeminus may provoke a sensa-
tion of pain in its whole distribution, and, further still, reflex pain
can be elicited in all those nerves that are in close anatomical or
physiological relation to the irritated nerve — for instance, the in-
timate association of lachrymation to irritation of the trigeminus.
Mechanical influences, acting upon the cornea, elicit lachrymation,
just as easily as can the irritation of a tiny nerve stem in the pulp
cavity of a tooth, or the irritation of the nasal mucous membrane.
318 SIGNIFICANCE OF PAIN IN DISEASE OF EYE
which are likewise innervated by the fifth nerve. Irritation of
the bulbar terminal branches of the fifth nerve is generally accom-
panied by hyperemia, which extends from the immediate sur-
roundings of the irritated place to the neighboring parts, and can
lead to visible hyperemia of the conjunctiva. The numerous anas-
tomoses of the fifth nerve with the seventh and the sympathetic
explain the frequent reflex phenomena, such as sneezing, swallow-
ing, pupiUary dilatation, vasomotor and secretory disturbances.
All these reflexes can occur in association with pain in the realm
of the fifth nerve.
From a practical standpoint, pain is very important in a
double sense, first, as a symptom of partial disturbance, which is
often vague and allows many different explanations; second, as
the patient's prominent subjective complaint, by the removal of
which the physician can gain much credit.
LOCALIZATION OF PAINS
The exact localization of pains in the eye region may be of
symptomatic significance, yet here we encounter many uncertain-
ties. In a case of iritis, for instance, we firmly believe that the
pain originates in the ramification of the fifth nerve in the iris
itself, and yet many patients do not complain of pain in the eye,
but in the bone surrounding the orbit. The pain in glaucoma
has its source in the globe; nevertheless, many patients complain
only of headache or hemicrania until the tenderness of the globe on
pressure convinces them that the eyeball is the affected organ.
Notwithstanding the fact that the localization of the pain may
lead to false judgments, the following pages will attempt a diag-
nostic analysis of pain, based upon its localization.
The Eyelids. — The skin of the eyelids and their surroundings
may be a source of intense pain in cases of inflammation. This
pain may be spontaneous, and is generally very intense when the
inflamed skin is touched. This kind of pain which is localized in
the skin occurs in eczema, febrile herpes, herpes zoster, cases of
phlegmon and abscesses of this region. In many cases the pain is
LOCALIZATION OF PAINS 319
associated with swelling of the tissues, so that the real focus of
the disease can be found on palpation. In marked inflammatory
edema of the lids one finds on touch an increased resistance of
the tissue, which is considerably increased in some places. If the
region of the internal canthus ligaments be the seat of tenderness
to palpation the possibility of a beginning dacryocystitis or peri-
ostitis should be thought of. Pain and resistance at the margin
of an eyelid suggest a hordeolum; superficial pain of the skin,
accompanying movable resistance, points to the diagnosis of a
furuncle or an abscess, whereas an immobile resistance is an argu-
ment in favor of periostitis. It should be remembered that inflam-
mation or cicatrices in the region of the external canthus lead to
marked edema of the eyelids, so that the localization of the painful
spot and the accompanying resistance alone permits a diagnosis.
Tumors of these regions, which are exceedingly painful, are occa-
sional. Neuroma or neurofibroma are to be expected. Under cer-
tain circumstances ulcerated carcinomata occur. They are in-
tensely painful to touch.
The pain in herpes zoster has a special character. It, at times,
begins a few days before the appearance of an eruption; that is,
during a period when the patient complains of general malaise.
It is frequently impossible to explain such attacks of pain cor-
rectly until the appearance of the eruption shows the nature of
the disease. The pain in herpes zoster may persist with the same
intensity for weeks and months after the skin lesions are healed
and the accompanying keratitis and iritis have subsided. Nightly
exacerbations of the pain are not rare. The pain frequently irra-
diates into other branches of the trigeminus not apparently af-
fected by the herpes. Simultaneously with the appearance of the
intense pain there arises a hypo- or even anesthesia of the skin and
superficial parts of the eye, so that the characteristic symptom
complex of anesthesia dolorosa may appear. The sensibility re-
turns slowly. Hyperesthesia is rare. These cases of herpes zoster
represent the projection of a central lesion onto the peripheral
endings of the nerves. Investigations of Barensprung, Head and
Campbell, and Lanber have proved that the primary process is
320 SIGNIFICANCE OF PAIN IN DISEASE OF EYE
localized in the Gasseriau gauglion. The skin, conjunctival and
corneal changes are probably to be regarded as trophic lesions. In
some cases (Eisenlohr) a peripheral neuritis has been found, so
that "not only lesions of the ganglion, but also those of the nerve
are to be considered in herpes of this region.
From these statements it can be seen that the pain in herpes
zoster is a true neuralgic pain, as it is caused by a lesion of the
ganglion or of the perij)heral portion of the* nerve. It is of the
character of acute inflammatory neuritis, caused by some toxic
agent. It is a pathological process, occurring in the sensory gan-
glia, analogous to that in the motor gauglion cells in acute anterior
poliomyelitis or polioencephaloniyelitis. In addition to the virus,
«
the nature of which is as yet unknown, other causes of herpes zoster
exist. Such are traumatism, tumors, disease within the cavernous
sinus, aneurysms of the ophthalmic artery, pulsating exophthalmos,
poisoning by carbon dioxid and arsenic. All of these affect the
fifth nerve, and are of etiological importance.
A disease which resembles lu^rpes zoster in some ways is neu-
ralgic herpes of the cornea (her})es cormr neuralgicus of Schmidt-
Rimpler). This is a periodically appearing affection, often re-
curring at the same hour of the day. The attack begins by pain
in the supraorbital branch of the fifth nerve, and is characterized
by an eruption of small vesicles in the distribution area of this
branch. The whole attack passes off in a short time.
The pain which accompanies a febrile herpes of the cornea
is due solely to the epithelial lesions, and does not show the typical
neuralgic character of the two affections })reviously considered.
Several other forms of neuralgia of the same region are to be
distinguished from ty})ical trigeminal neuralgia, which is a
persistent and very torturing disease. They show the same symp-
toms, but are secondary affections of the trigeminus. Acute neu-
ralgias are caused by inflammatory ccmdititms, such as orbital
periostitis, empyenui of the accessory sinu<(\s of the nose, etc.,
and occasionally show rela})ses. Chronic neuralgias are due to
tumor, keloids, or to chronic forms of periostitis and euipyema.
Neuralgia of the fifth nerve can also be caused reflexly by lesions
LOCALIZATION OF PAINS 321
in distant regions, as by caries of the teeth or in nasal affections.
These can mislead the patient, as well as the physician. It is con-
sequently necessary, in cases of neuralgic pain of the fifth nerve,
to examine the entire distribution area of this nerve for causation
lesions before making a diagnosis of idiopathic or primary (essen-
tial) neuralgia.
A diagnosis of neuralgia is generally based upon the tenderness
of the nerve-stem to pressure. In the investigation of a case of
neuralgia, pressure should be applied to the nen'e exits ; i.e., over
the supraorbital foramen, the infraorbital, and mental foramina.
This excessive tenderness, accompanied by spontaneous periodi-
cally exacerbating pain, is very characteristic. Tenderness to pres-
sure is absent only exceptionally in neuralgia. This symptom
alone, however, is not sufficient to make a diagnosis of neuralgia,
as in hysteria, also, the branches of the fifth nerve are frequently
tender to pressure. Furthermore, tenderness to pressure may be
a symptom of a general poljTieuritis and not of an isolated affec-
tion of the trigeminus. Especial attention should be called to the
fact that neuralgic-like pains of the trigeminus may be sympto-
matic of glaucoma, or they may be precursors of this disease,
appearing a long time before the glaucoma can be recognized.
Another type of periodically returning pain in the trigeminus,
though generally affecting only its meningeal branches, is hemi-
crania, or migraine. Here the so-called scintillating scotomata,
with their characteristic features, are diagnostic. The attack be-
gins with eye symptoms, and, during this period, the patient no-
tices the scotomata with their luminous and generally moving
margins. These attacks are then followed, as a rule, by intense
unilateral headache, with frequent radiation of pain throughout
the entire fifth nerve area. The cause of the phenomena is prob-
ably a vasomotor disturbance, which, acting upon the meninges, is
felt in the peripheral branches of the nerve.
A very rare affection, likewise characterized by intense hemi-
crania, is a recurring third nerve palsy — ophthalmoplegic mi-
graine. Intense hemicrania introduces the attack, to which ptosis
und almost total immobility of the eye, nausea, or vomiting are
322 SIGNIFICANCE OF PAIN IN DISEASE OF EYE
added. Such attacks persist for from a half a day to two days
or more, and may recur at irregular intervals of a few weeks or
months. During the intervals of the attack the third nerve
paralysis recedes, but may not completely disappear.
Surroundings of the Eye. — Tender pressure points, so charac-
teristic of neuralgia, may exist in other affections of the surround-
ings of the eye. The cause of indefinite pain in the head, espe-
cially of dull pain in the forehead, can occasionally be found by
careful palpation, which reveals the nerve tenderness at a certain
place. Tenderness of the bone to percussion and tenderness in
the region of the trochlea are found in many cases of acute or
chronic affections of the frontal sinuses and the anterior ethmoid
cells. Thus, one may be guided to a correct diagnosis. Such
cases can be differentiated by the existence of delimited sensitive
areas from those other cases where the bone is sensitive through-
out to pressure or percussion, and at the same time is diffusely
thickened. These latter symptoms lead to the diagnosis of perios-
titis and osteoperiostitis. Indolent thickenings of the bone are
but rarely due to inflammation (lues, tuberculosis), and, as
a rule, represent tumor or protrusion of the bones by meningo- or
meningoencephalocele.
Oonjunctiya and Oomea. — Pain in the conjunctiva and its cor-
m
neal continuation is of the greatest interest to the oculist. The
abundant end ramifications of the nerve plexus of the super-
ficial layers of the cornea penetrate as far as the basal cells of
the epithelium and explain the great sensitiveness of this organ,
as well as the great intensity of the pain in superficial lesions
(erosions) of it. The conjunctiva is much richer in nerves than
other mucous membranes of the body. Inflammatory or traumatic
irritation of the nerve endings in the conjunctiva gives rise to
very severe pain, alike torturing to the patient and difficult for
the physician to abate. Great sensitiveness to thermic, atmos-
pheric, and light influences is present, and exposure to these in-
creases the pain to the highest intensity. While there is not the
least doubt, so far as thermic and atmospheric stimuli are con-
cerned, that the nerve terminations in the conjunctiva and cornea
LOCALIZATION OF PAINS 323
can transmit pain stimuli and cause such reflex disturbances as
lachrymation and blepharospasm, yet light can also give rise to
painful stimuli, and it is not so easy to determine how it acts and
causes pain in corneal and conjunctival lesions.
It is a fact, however, that in corneal erosions or in other super-
ficial lesions of the cornea, likewise in iritis, there exists a great
sensibility to light (photophobia), even when the patients keep
their eyes closed, thus excluding atmospheric and thermic in-
fluences.
In iritis, whether primary or secondary to keratitis, one is
inclined to attribute the pain caused by light to reflex contractions
of the sphincter, and to the irritation (on pupillary dilatation or
contraction) of the sensory nerves in the stroma of the iris. But
if the iris is normal, and its contractility is suppressed by means
of a mydriatic, it can no more be considered as a source of pain,
and other causes of the corneal irritation to light (photophobia)
must be sought. Wilbrand explains photophobia as follows:
'^Exposure to light leads to the formation of products of
metabolism in the pigment of the retina; if the forma-
tion of such products becomes increased, they may cause pain in
the ciliary nerves of the choroid, which contain filaments of the
fifth nerve. If those nerves are in a condition of pathological irri-
tation, even small quantities of these products .of katabolism can
cause considerable pain. This theory, however, does not explain
why the instillation of cocain into the conjunctival sac, in quanti-
ties which can act only upon the superficial endings of the nerves,
can in many cases quite suppress the photophobia. This would be
in favor of an explanation which attributes light sensibility to the
endings of the trigeminus in the cornea and conjunctiva, analogous
to the direct action of light upon the iris. This theory is, how-
ever, not satisfactory.
Hyperemia of the conjunctiva, infiltration of both conjunctiva
and cornea, detachment of the corneal epithelium in the form of
vesicles and blebs surely lead to mechanical and possibly also to
toxic irritation of the nerve endings. This explains why the
pain is so very severe in conjunctivitis and superficial keratitis.
324 SIGNIFICANCE OF PAIN IN DISEASE OF EYE
Superficial traumata, which expose the superficial and subepithe-
lial nervous plexi, are exceedingly painful. Deeper wounds,
which penetrate the substance of the cornea and sever the nerve-
stem, are less painful.
In an irritative condition of the cornea and conjunctiva,
tear-secretions retained in the conjunctival sac can cause consider-
able complaint. The accumulation of tears in the conjunctival
sac, when an eye is kept under a bandage after an operation, may
cause great discomfort, and even pain, which can be instantane-
ously relieved by removing the bandage and opening the eye.
Small quantities of mucus or muco-pus, on the surface of the eye,
are perhaps the cause of the sensation of a foreign body in con-
junctivitis.
In cases of gonorrheal or diphtheritic conjunctivitis the edema
of both conjunctiva and lids may lead to such stretching of the lid
that it can be the source of pain. However, this is easily re-
moved by simple canthotomy.
After foreign bodies of the cornea or conjunctiva have been
removed the sensation of their presence frequently persists for a
few hours and disappears, together with the subsidence of hyper-
emia and the reparation of the tissue lesions. Observations of
this kind prove that both hyperemia and the pressure of an almost
imperceptible exudate are able to irritate the nerve termination to
a high degree and cause pain.
In erosions of the cornea the pain often has a recurring char-
acter. According to von Reuss, two types of this affection can be
distinguished. In the first slight pain appears on first opening
the lids after sleep, or after they have been kept closed for a long
time. This soon ceases. In the second type, after a period of
apparent health, attacks of pain occur, having the same char-
acter and intensity as those following the original trauma. They
are caused by a plainly visible loss of epithelium in the same place
where the primary injury had originally led to the loss of sub-
stance. Both types of the affection are the consequences of an
abnormal condition of the epithelium established by the trauma.
Close examination of the cornea with a lens, or by the ophthalmo-
LOCALIZATION OF PAINS 325
scope, show minute opacities in the epithelium. In the first group
of cases the corneal epithelium, which during the night is in close
contact with the tarsal conjunctival epithelium, sticks fast to the
latter and is torn oflF when the eye is opened. In the second group
of cases (the recurring erosion in a strict sense) the epithelium
degenerates, is cast off, and exposes the nerve plexus lying in
the superficial layers of the cornea.
The pain associated with corneal herpes and punctate superfi-
cial dendritic and stellate keratitis is due to similar causes. Cor-
neal ulcers of various types all expose the nerve plexus of the
cornea, and can, therefore, cause more or less pain. The pain
becomes more intense when the exposed nerves are irritated by
the moving lids. For that reason a bandage is applied to prevent
the movement of the lids, and thus to diminish the pain. It
cannot relieve it completely, as the infiltration of the tissues exer-
cises pressure upon the nerves and stretches them. Toxins pro-
duced by bacteria also cause painful irritation of the corneal
nerves. Sudden pain arising in a case of ulcerating keratitis
frequently indicates perforation of the ulcer. The chief cause
of pain in perforation of the cornea is the mechanical irritation
of the iris. If the iris prolapses and cicatrizes, sudden and in-
tense pain may again arise. This is a symptom of secondary
glaucoma. The severe pain which frequently accompanies deep
keratitis is largely due to a concomitant iritis.
Referred pain is also present if the ulcer extends into the
deeper layers of the cornea. The area of reference is in the fronto-
nasal area, and also to some extent in the midorbital (Head). This
referred pain is probably due to a deepening of the anterior cham-
ber. Should a true cyclitis be present, the pain is referred fur-
ther to the side in the forehead than in corneal ulceration, the
midtemporal area being, as a rule, concomitantly involved with
the midorbital.
The Iris and Ciliary Body. — The existence of a dense nervous
plexus in the iris and the ciliary body fully explains the severe
pain found in diseases of these parts. The specific etiology of
iritis and iridocyclitis is also a factor in the origin of iritic and
326 SIGNIFICANCE OF PAIN IN DISEASE OF EYE
cyclitic pain. Its importance^ however, should not be exagger-
ated. The pain is frequently continuous, and may be localized in
the eyeball itself, or in the surrounding bones, even in the entire
half of the head corresponding to the affected eye. As in many
other diseases, so in iritis and iridocyclitis exacerbation of the pain
is observed toward the end of the night or in the early morning.
This is not only characteristic of syphilitic affections, but occurs
in the same way in rheumatic and traumatic cases of iritis. In
rheumatic iritis, more often than in those due to other causes,
severe pain during the night is a sign of a relapse or of an exacer-
bation of the inflammatory trouble. Examination of the eye the
next morning shows fresh fibrinous exudate in the anterior
chamber, or the presence of a fresh hyperemia. Such acute at-
tacks of pain are usually of short duration. Metastatic gonorrheal
iritis is a type of iritis which causes the most intense and obstinate
pain. The referred pain, as a rule, is in the frontotemporal,
maxillary and temporal areas. Should the tension in the vitreous
chamber rise, the pain has a tendency to be referred further back,
and also, in some cases, the teeth of the upper and even of the
lower jaw may become painful and very sensitive to pressure.
Rest in bed, atropin, warm applications, dionin, and diapho-
resis are serviceable for all forms of iritis. If the pain is very
intense aspirin, pyramidon, or morphin must be given, and even
these analgesics may prove insufficient to relieve the pain. In
chronic iritis and iridocyclitis the pain is generally very moder-
ate. Circumscribed areas in the region of the ciliary body, which
are tender to pressure, can be sometimes detected. They probably
correspond to small inflammatory foci which do not cause any
other clinical symptoms. It is important to ascertain their pres-
ence, as they direct attention to the possible recurrence of the
disease.
A sudden exacerbation of pain in an acute or a chronic iritis
should always arouse the suspicion that a secondary glaucoma is
developing. The pain caused by such an attack of secondary glau-
coma can reach the highest possible degree. The increase of intra-
ocular tension is diagnostic for acute glaucoma, although the dif-
LOCALIZATION OF PAINS 327
ferential diagnosis between a primary and a secondary glaucoma
may be very diflBcult, especially when the cornea is dull and
opaque.
A painful condition, which closely resembles iritis, and which
is in direct contrast to glaucoma, is an acute hypotonia of the
globe, complicating detachment of the retina. Hypotonia of this
kind can exist without any pain. In very pronounced and acute
cases, however, pain appears. To this subjective symptom there
corresponds an objective change, consisting of a slight ciliary in-
jection of the globe, a deepening of the anterior chamber and a
tremulous condition of both iris and lens. The vitreous is gener-
ally very turbid, and permits only indistinct recognition of the
increase of a preexisting or the first appearance of a retinal de-
tachment which previously had not existed. The pain, as a rule,
is mild and, together with other symptoms, slowly disappears.
In the course of retinal detachment there also occurs another
painful process, i.e., an iritis, which, similarly to the detachment,
is a consequence of the high myopia. If pain appears in the eye
affected with posterior staphyloma iritis might be present Such
myopic iritis seldom appears in posterior staphyloma without in-
volvement of the retina, and may be a precursory symptom of this
grave affection.
Sclerotic Coat. — Areas, tender to pressure, similar to those
previously described as occurring in chronic iritis, but correspond-
ing to hyperemic and swollen areas of the sclerotic, are characteris-
tic for scleritis. This affection may cause violent, spontaneous
pain, but may also be absolutely indolent. It is not exactly known
why some cases of scleritis are very painful and others are not.
This certainly does not depend upon the etiology, as both forms
may be caused by the same etiological factors. Anatomical inves-
tigation (Oatman) may explain it. In some cases the ciliary
nerves, as they pass through the foci of the scleritis, remain nor-
mal; while in others they are infiltrated by leukocytes. The in-
filtrated nerves show the anatomical picture of a neuritis, and
this is probably the cause of the pain.
Inflammatory foci of the scleritis may be invisible, on account
328 SIGNIFICANCE OF PAIN IN DISEASE OF EYE
of chemosis. If such is the case, palpation of the globe will easily
disclose the situation of the sclerotic foci. A sclerotic infiltration,
situated under one of the muscles, or at a muscular insertion, will
be irritated by contraction of the muscles and cause pain in move-
ments of the eye.
Similar pain following eye movements may be the sign of
rheumatism of an eye-muscle. The diagnosis of this condition is
based on the subjective symptom of pain without any visible
changes. Diplopia as a sign of impaired movement is, however,
not present in these cases of rheumatism.
Choroid, Retina and Optic Nerve. — Inflammation of the inter-
nal membranes of the eye, choroid and retina, as well as inflam-
mation of the optic nerve, generally does not give rise to pain.
Acute retrobulbar neuritis is an exception. Dull pain in the
orbit, increasing on extreme or violent movement of the eye, or
on pressure upon the globe, and associated with rapidly increasing
amblyopia and negative ophthalmoscopic findings, is the chief
symptom upon which the diagnosis is founded. A similar deep
pain on pressure occurs in posterior scleritis, which sometimes
shows an intermittent exophthalmos, and also in periostitis or em-
pyema of the posterior ethmoidal cells.
Bulb. — Pain originating in phthisic eyes deserves especial
attention and may arise from different causes. In most cases it
is due to increase of pressure of the process which originally
caused the phthisis, and is of the greatest importance, because a
reappearance of a previous inflanmiation may produce a sympa-
thetic affection of the other eye. Therefore, it cannot be expressed
too strongly that all phthisical globes which cause spontaneous pain
ought to be removed.
Up to the present time no symptom is known permitting a
differential diagnosis between an eye apt to induce sympathetic
ophthalmia from those which are harmless. Great attention must
be given to the other eye. Dull pain in the healthy eye may be
the first symptom of a sympathetic trouble. The suspicion of a
beginning process of this nature will be aroused, especially by the
appearance of photophobia, ciliary hyperemia, and diminution of
LOCALIZATION OF PAINS 329
the range of accommodation. These symptoms, which have been
described as sjTnpathetic irritations, may precede the outbreak of
an iridocyclitis for a varying period of time. Sympathetic
ophthalmia may also begin without irritative symptoms.
Sunken globes may become painful also from other reasons.
Such are ossification of the choroid, which causes pressure upon
the branches of the ciliary nerves, and folding of the sclerotic,
which acts in the same manner. Attention may be directed to
the fact that, even after the enucleation of a globe, the trunk of
the optic nerve or its surroundings may be very painful to pres-
sure, and is an indication for the resection of these parts in order
to enable the patient to wear a shell. The cause of this pain is
a neuroma of the ciliary nerves.
Olaucoma. — The most violent pain which can exist in eye dis-
eases is that found in acute glaucoma. The increase of intraocular
tension and the consecutive pressure upon the nerves in all the
tissues of the globe are given as the explanation of this pain.
Radiation of pain into different distributing areas of the trigemi-
nus is quite frequent, and has caused the condition to be mistaken
for a neuralgia, a hemicrania, a toothache, or, when vomiting is
present, even for a meningitis. It is unnecessary to analyze the
nature of an acute attack of glaucoma. It should be remembered
that inexplicable pain in the first branch of the fifth nerve is
frequently a symptom of glaucoma ; either prodromal or the devel-
oped disease. Xo doubt neuralgia may precede the outbreak of an
acute glaucoma by months or years. This pressure may be reduced
(with consequent relief of pain) by miotics. The diminution of
intraocular pressure due to miotics may be considerably enhanced
by the use of one per cent, solution of morphin, used as a collyrium
simultaneously with the miotics. Eserin is excellent in subduing
pain caused by glaucoma. If, however, it is instilled into a nor-
mal eye it is liable to cause considerable pain. This is due to
the compression of the nerve fibers by the tonic contraction of the
sphincter of the pupil. This pain may be quickly removed by
the use of a mydriatic.
Iridectomy and other operations devised to replace iridectomy
330 SIGNIFICANCE OF .PAIN IN DISEASE OF EYE
alleviate the pain rapidly when they reduce the ocular tension. If
after an operation for glaucoma intense pain arises, or an increase
of pressure is noted, it is a symptom indicating the malignancy
of the glaucoma, and forebodes the loss of the eye. If the eye
is blind and painful from glaucoma one may attempt to relieve
the pain by anti-glaucomatous operations, if they are possible;
otherwise, there remains only opticociliary neurotomy or enuclea-
tion of the globe. The operation first referred to is a dangerous
undertaking, as its results are doubtful, and in many cases it
must be followed by enucleation.
Paaophthalmitis. — Pain in panophthalmitis is caused in a
similar manner to that of glaucoma. The presence of a focus
of purulent inflanmiation in the globe, with the consequent pres-
sure, explains the painfulness of the disease. That the simple
opening of the globe by incision or spontaneous perforation at
once considerably relieves the pain proves that increase of pressure
due to the purulent exudation plays a great part in the etiology
of pain in panophthalmitis.
Asthenopic Disorders. — ^An entirely different group of painful
conditions is met with in the asthenopic disorders and the closely
related cases of eye-strain. In both accommodative and muscular
asthenopias, whether the latter be caused by exophoria or insuffi-
ciency of convergence, the phenomena are blurring of objects and
a dull pain in the forehead. This is accompanied by a feeling of
heaviness and pressure in the eyelids, lacrymation and a sensation
of heat in the eyes. If, in spite of these symptoms, the eyes
are used for work, headache may appear and continue even during
the next day. Asthenopic disorders manifest themselves, as
a rule, in the late afternoon or in the evening, when the
muscular apparatus is tired by the day's work. Proper glasses or
prisms can totally suppress the trouble, or at least alleviate it con-
siderably. In muscular asthenopia stereoscopic exercises can also
be of benefit.
How far a low degree of astigmatism may cause trouble is not
quite determined. Most of the European oculists are sceptical in
regard to this question, whereas English and American oculists^
LOCALIZATION OF PAINS 331
especially the latter, attribute a great number of subjective dis-
orders to uncorrected or insufficiently corrected astigmatism. They
also have created and developed the term "eye-strain," to which
disturbances in all parts of the organism are ascribed. Disturb-
ances due to hyperphoria are less frequent than simple asthenopic
phenomena, and differ from muscular asthenopia in exophoria, in
that they trouble the patient not only in close work, but cause
incessant aching. The prescription of corresponding prisms with
the apices upward and downward suppresses such disorders
promptly.
To Bielschowsky we owe the knowledge of a rare group of
painful disturbances related closely to asthenopia. This author
has discovered cases of disturbed innervation of binocular vision
leading to considerable subjective disturbances and simulating
squints. Their treatment either by operation or drugs is rarely
successful.
In hyperopics the over-strained accommodation leads to asthen-
opia. Disturbances caused by straining of the accommodation
do not occur in myopics, who, nevertheless, experience disagree-
able sensations. Myopics of the middle and higher grades fre-
quently complain of pain in their eyes when they use them for
close work. This pain, which is intermittent but not severe, may
yet be very troublesome to sensitive and neurasthenic individuals.
No generally accepted explanation of this kind of pain exists,
but it would seem quite plausible to connect it with the process of
stretching of the sclerotic, which may also affect the nerves lying
in the sclera. This pain cannot be influenced by the wearing of
correcting glasses, or by the extractions of the lens for removal
of the myopia.
CHAPTEK XVI
PAIN IN DISEASES OF THE EABi
It passes as current fact among the laity that ear pains can
scarcely be surpassed in severity by any pain elsewhere in the
body. Relief may be secured from pain occurring in any part of
the external or middle ear, but not from pain of labyrinthine
origin.
External Ear. — Trauma of the external ear is scarcely more
painful than trauma in other parts of the body, but it may be
followed by two troublesome conditions, namely, othematoma and
perichondritis. Othematoma is an exudate of serous, bloody fluid
between the cartilage and perichondrium of the ear. It results
from a blow, especially one from a fist. Consequently, we find
it frequently among prizefighters, and perhaps most frequently
among the Japanese wrestlers, because they use the head and neck
against the head of an opponent, and in this way the ear often
becomes subject to very great pressure, giving rise to the above-
mentioned exudate. It also is frequently seen among patients suf-
fering from acute mental disturbances.
The pain in hematoma is usually trifling. It is mostly of a
dull, aching character, worse at night. If, however, the othema-
toma becomes infected through unskilful surgery, a very painful
perichondritis may follow.
Such a perichondritis arises sometimes, also, after a radical
operation, as a result of infection of the cartilage. This cannot
always be avoided in plastic work upon the external ear. If the
bacillus pyocyaneus is present in the middle ear secretion, this
germ, which has a fondness for attacking cartilage, may bring
1 By Dr. Buttin, assistant in the Ear Clinic of the University of Vienna.
332
EXTERNAL AUDITORY CANAL 333
about a perichondritis. In fact, one can always grow the bacillus
pyocyaneus in pure culture from the perichondritic secretion.
Such a perichondritis advances very slowly, and lasts about
four weeks, when the disease has reached its highest point. The
suppuration then ceases, and the cartilage begins to shrink. Un-
fortunately, early and energetic incision does not shorten its
course. During the period of development, to the beginning of
the shrinking of the cartilage, extraordinarily severe pains exist.
It often requires much persuasion to convince the patient that
this distressing condition is not dangerous.
Of the tumors of the external ear, carcinoma and sarcoma
sometimes give rise to severe pains, but they often run a painless
course. The same is true of the inflammatory graniilomata of
lupus and lues, in which the slight pain may be completely over-
shadowed by the itching.
Pain of the external ear due to frostbite is especially note-
worthy. It is peculiar in that it is likely to recur with every
return of cold weather. The previously frozen parts often begin
to be painful again, even with a moderate fall of temperature.
A very painful disturbance in the pinna, which is, to be sure,
only a symptom of another disease, is herpes. The pain begins
even before the appearance of the herpetic vesicles, and continues
usually until they vanish. Gouty nodules, which have a prefer-
ence for the helix margin of the pinna, may be the cause of
pains which are of a very unstable and changing character, a
peculiarity of gouty nodules in general.
External Auditory Canal. — The external canal, with its nu-
merous hairs and glands, is directly predisposed to furunculosis.
The frequency of middle-ear suppuration, and the circumstances
that such a condition, after only a short existence, in most cases
shows a secondary infection with pyogenic staphylococcus, carries
with it the probability that during the necessary cleaning manipula-
tions of patient or physician the hair follicles become inoculated,
a procedure which, according to the researches of Schimmelbusch,
Garre and others, brings about furunculosis with tolerable cer-
tainty.
334 PAIN IN DISEASES OF THE EAR
Furuncle of the external canal manifests itself through a
special painfulness, because the pus, on account of the closely
woven, subcutaneous, connective tissues, is held under a high
degree of pressure. These pains are of a boring, sticking, throb-
bing nature, and radiate, by preference, toward the teeth. There-
fore, the patient can take only a very limited amount of nourish-
mentj since every movement of the mouth increases the pain.
This is due to the fact that the head of the inferior maxilla lies
against the anterior wall of the external auditory canal, and
movements of the jaw joint are accompanied by movements of
the adjacent aural tissues. The pain usually subsides with the
rupture of the furuncle, or with its opening.
The pain of diffuse inflammation in the external canal, the
so-called otitis externa diffusa, is of longer duration, and much
less certainly influenced by operation.
Foreign bodies in the external auditory canal cause pain
usually only by penetration, by woimds brought about by unskil-
ful attempts to dislodge them, or by the swelling or growing of
the foreign body in the ear. Peas, beans and fruit kernels
remaining for some time in the canal swell, and cause a
very noticeable pressure upon the canal wall, thereby producing
more or less pain. The larvae of the large meat-fly ("blue-bottle
fly^'), developing from eggs laid in the canal, often attain great-
ness, both in number and in size. They may cause such pressure
upon the external canal that it becomes widened to the breadth of
a finger. Since these maggots are provided with sharp hooks at
the ends of their bodies, and seek to attach themselves by sticking
these hooks into the skin, the pain which they produce is extraor-
dinarily severe. This becomes still greater, because the worm
masses are always in motion, and consequently the pain is of a
continuous, changing, undulating character. I have observed such
a case, in which twenty-six maggots had brought about a consider-
able widening of the canal, with very intense pain.
In lesions of the middle ear the patient assumes a position in
which the ear of the affected side rests in the palm of a supporting
hand, the elbow resting on a table, as is illustrated in Fig. 80.
MIDDLE-EAR DISEASE 336
^mpannm. — Pains ma; originate in the drum membrane.
One often speaks here of a mj^ingitis bullosa. This is, however,
not a bacterial invasion, but is only a herpes of the drum. Bac-
teriological examination in large numbers of such cases showed
the vesicles to be sterile. The sudden beginning of the pain is
very characteristic for myringitis. Often the patient is awakened
at night by a sudden, severe, sticking pain in an ear previously
entirely sound. The pain
lasts as long as the vesicle
remains, but ceases just as
suddenly as it began, ^
In lesions of the exter-
nal meatus from the tym-
panum outward the pain is
localized to the diseased
area, but from the drum in-
ward the pain is, as a rule,
referred to a distant area,
the most common reference
area being the hyoid, which
has two points of maximum
tenderness, the first in the
meatus and the second just
behind the angle of the jaw.
These areas are also asso-
ciated with the tonsil, the
posterior teeth of the lower -. „„ „ . „
Fio. 80. — Posture AasuissD in Earachb
jaw, and the lateral aspects
of the tongue (Head). When the tension in the middle ear is
raised pain may also be referred to the vertical and parietal area
of the scalp. (See pages 293 and 294.)
Hiddle-ear Disease. — Acute Otitis Media. — Most marked
are the pains of acute middle-ear inflammation. Here they are
not limited to the membrana tympani, and are most severe until
' Hunt, of New York, bas abown tbat this tTpe of berp«s is usuaUf
asaociated with diaeaae of the geniculate ganglioD.
336 PAIN IN DISEASES OF THE EAR
perforation of the drum takes place. We must, however, differ-
entiate two kinds of acute otitis, namely, that caused by capsulated
bacilli, and that caused by noncapsulated bacilli. While in the
first type the pain is usually trifling in nature, and only ^'stick-
ing'' in the first day of the disease, as in middle-ear catarrh, the
second type, caused by noncapsulated cocci, calls forth the most
capricious and troublesome symptoms. The pains begin with
moderate intensity and increase, within two or three days, to
quite unusual severity. They are, as a rule, of a boring, sticking or
tearing nature, and reach the greatest degree when the drum mem-
brane becomes deep red, shows no details, and is nearly ready to
rupture at some markedly bulging spot. After rupture the pain
for the most part ceases. Obviously one can shorten the patient's
sufferings by carrying out artificial rupture of the drum through
incision (paracentesis). It must be regarded as an unfavorable
sign, if, after perforation of the drum, the pains do not immedi-
ately subside. In such cases the mastoid process is likely to be
included, and if this comes to pass spontaneous pains of greater
or less severity manifest themselves. However, this symptom may
be completely lacking, or may only be elicited by pressure, either
upon the mastoid tip or over the antrum, in which latter case
the mastoid cells are undoubtedly involved. To be sure the prop-
agation of the inflammation to this degree must depend upon the
anatomical structure of the mastoid process. A pneumatic mas-
toid is always affected in the beginning of an acute otitis, and
this is the reason why tenderness at the tip in such cases is so
frequently seen. But this inflammation may at any stage retro-
gress without going on to suppuration and, therefore, in the begin-
ning of an acute otitis this symptom has no pathognomonic sig-
nificance. If, however, the tenderness or the spontaneous pains
last a relatively long time, or if, after having once vanished,
they reappear, then it is probable that we have to do with an
abscess in the mastoid process, and in this regard the symptom
becomes of great importance with respect to operative inter-
ference.
Chronic middle-eab disciiar(jk causes, as a rule, no pain;
MIDDLE-EAR DISEASE 337
but pain may arise, of course, as a result of an acute exacerba-
tion, or if the perforation in the drum is so small that opportunity
is given for retention of pus. Sometimes chronic middle-ear sup-
puration, which otherwise would give no pain, is, when accom-
panied by cholesteatoma, subject to manifestation of severe pain.
Complications of Middle-eak Disease. — If acute or
chronic middle-ear suppuration becomes complicated by extension
of the inflammation to neighboring regions, then the pain thus pro-
duced is usually quite significant, especially if suppuration takes
place in the mastoid, whereby the mastoid cells are broken down
and the excavated interior of this bone becomes filled by pus,
which, through gradual accumulation, exerts great pressure. If
this pus breaks externally through the bone cortex, it can dissect the
periosteum free from the bone to a very great extent. We then
find a large swelling behind the ear, which is covered by a much-
reddened, very tense epidermis, giving rise to great pain. This
swelling may become so great that the entire half of the head is in-
volved, especially in badly neglected cases. This subperiosteal ab-
scess formation is very frequent in children, because the pus passes
through the open fissura mastoidea in a very short time, and then
lies directly under the periosteum ; but here, on the other hand,
instead of producing pain, the pain may be actually lessened
after penetration to the periosteum for a time, at least, through
relief of pressure within the mastoid shell.
If, however, the pus burrows inward, the dura becomes ex-
posed through destruction of bone, either in the posterior or mid-
dle fossa, according to the direction which the destructive process
takes. The tough dura and, in the posterior fossa, the sinus lat-
eralis are fairly resistant structures, and may often be sur-
rounded by pus for a long time without becoming especially af-
fected. They become covered with granulations, which serve further
to protect them, and thus are brought about the conditions known
as pachymeningitis externa, or periphlebitis of the lateral sinus,
as the case may be. With this disease-picture at hand, the pain
is likely to be of a trifling, ill-defined, dull nature, but if the pus
extends outward between the dura and the bone, or between the
338 PAIN IN DISEASES OF THE EAR
sinus and the bone, we have the picture either of an extradural
or of a perisinus abscess. We speak of a "closed'' extradural
abscess if the opening through which the pus has penetrated to
the dura is so small as to be nearly undemonstrable ; but if, on
the other hand, the communication with the purulent mastoid
cavity is greater, we speak of such a condition as an "open"
extradural abscess. Naturally the pain in a closed extradural
abscess is much more severe than in the open type. If the pus
spreads out toward the tip of the petrous portion of the temporal,
then periorbital pains often arise, which Neumann holds to be
characteristic for this type of extradural abscess. On the con-
trary, if the abscess spreads more laterally in the middle fossa
of the skull, pain and swelling in the temporal region near the
zygomatic process simultaneously arise, as Ruttin has described.
Perisinus abscess may also cause very severe pain, especially
if the pus collects in the bony sinus groove between the mem-
branous and bony sinus walls, where it often remains under such
high pressure that, upon opening the mastoid process, it gushes
forth in a pulsating stream. Still greater may the pain become,
if, besides the pus, gas forms (gas abscess), and raises the pres-
sure to a very high degree. Perisinus abscess, like extradural
abscess in the posterior fossa, causes a more or less severe head-
ache in the occipital region. If the suppuration destroys the dura
mater, then intradural suppuration, meningitis, temporal lobe
abscess, cerebellar abscess, or sinus thrombosis may arise.
Intradural suppuration is such a rarity, and so seldom clinic-
ally pure in type, that with respect to pain as a symptom it offers
very little that is characteristic. On the contrary, otogenic men-
ingitis may produce a tolerably pronounced picture, since in it the
pain is extraordinarily intense, of a sticking or tearing character,
and accentuated in its last phase. I am accustomed to describe this
to my students in the following manner : The location of this pain
varies according to the extension of the meningitis. The basal type
usually causes occipital or frontal headache, but the head type, that
is, the form of suppuration which spreads out over the convexity of
the brain, produces pain at the vertex of the skull. Character-
LABYRINTH 339
istic, also, of meningitis are the remissions of pain, great suffering
being often followed by a period of comparative ease and comfort.
Brain abscesses may also exist in the middle and posterior
fossse. Headache is seldom lacking in these cases, and may be
referred, in both cerebellar and temporal-lobe abscesses, to the
frontal or occipital r^ons. In temporal-lobe abscess it is not
seldom localized at the vertex of the skull, but in both temporal-
lobe and cerebellar abscesses the pain is usually limited to the
half side of the head — ^hemicrania.
Middle-ear Catarrh. — Middle-ear catarrh is a frequent cause
of pain, especially in children. This pain, to be sure, is not
especially intense, but may, through its sticking character, be
quite disagreeable. It seems that such pains are induced
through the strong retraction of the membrana tympani ; at least,
this is true of those cases in which the drum is markedly re-
tracted, for they vanish after inflation of the tympanic cavity, or
after aspiration through the external auditory canal. High-
grade inveterate catarrh, with maximal retraction of the drum,
which is of a milky color, also causes pain, which is not, how-
ever, to be influenced through Politzerization, catheterization or
massage, because the drum is fixed in the retracted position and
cannot be corrected through these manipulations. In these cases
the pain, nevertheless, ceases immediately if one introduces a hook
with a straight shank just in front of the hammer and draws the
entire membrane outward, after the method which Ruttin has
described.
Otosclerosis. — In this disease, which consists of pathological
changes in the bony labyrinth capsule and which has an exquisite
hereditary anamnesis, but whose etiology is still unknown, pains
are seldom to be found. However, there exist, sometimes, in addi-
tion to diminished hearing, noises and manifold paresthesias
localized or diffused through the entire ear tract, as well as pain-
ful sensations in the external canal, and in the surrounding struc-
tures.
Labjnrinth. — Whether pains of distinctly labyrinthine origin
are to be recognized or not has hitherto not certainly been proven.
340 PAIN IN DISEASES OF THE EAR
However, pains in labyrinth disease scarcely come into considera-
tion in relation to the other extraordinarily troublesome and dis-
tressing symptoms, such as difficulty of hearing, noises, dizziness,
vomiting, etc.
Referred Pains. — First of all, there are pains due to diseased
teeth, which may so closely simulate aural pains that a typical
disease-picture is described as otalgia excarie dentium, since a
bad tooth is so often the cause of a pain described by the patient
as localized in the ear. Secondly, swollen glands in the neck
region may produce pains which the patient falsely refers to the
ear on the side affected. Especially, however, do inflammations
in or around the tonsils (peritonsillar abscess) produce pains
which the patient describes with great certainty as being situated
in the ear. These pains are increased by every act of swallow-
ing, because muscles of the Eustachian tube are thus brought into
action.
CHAPTER XVII
I
PAIN IN DISEASES OF THE NOSE i
The Sensory Nerves of the Nose. — The nose receives its sensi-
bility from the first two branches of the trigeminus. The lateral
wall receiving its sensory supply from the anterior and posterior
ethmoidal nerves, which take their origin from the first branch
of the trigeminus, while the infraorbital and sphenopalatine
nerves, which come from the second branch, participate in the
innervation of the other parts. The nervi septinarium, which
are the sensory nerves of the septum, also have their origin in
the second branch of the fifth nerve. Of the sinuses the frontal
sinus and the anterior ethmoidal cells receive their nerve supply
from the ophthalmic ramus (trigeminus I), while the posterior
ethmoidal cells and the sphenoidal sinus are supplied by the nervi
nasalis lateralis superiores and the nervi ethmoi dales poster iores.
The exact relations, according to the description of Zucker-
kandl, are the following: The nervus nasalis anterior passes
through the foramen ethmoidale anticum toward the anterior
cavity of the skull, where it extends to the edge of the cribriform
plate toward the anterior portion, and is there covered by the
hard sheath of the dura mater; then, after passing through the
ethmoidal canal, it goes to the nasal cavity, where it divides into
the ramus septinarium, the ramus lateralis, and the ramus an-
terior. The posterior nerves of the nose are derived from the
sphenopalatine ganglion, and after passing through the fora-
men enter the nasal cavity, where they are distributed to the
lateral and median wall. The nervus nasopalatinum scarpi, the
iBy Privat Joeent Dr. Emil Glas, assistant in th© University Clinic in
Vienna (Director Hofrat Chiari).
341
342 PAIN IN DISEASES OF THE NOSE
true septum nerve, which originates from the same source, sup-
plies the anterior mucous membrane of the palate after having
passed through the canalis incisorus.
Diseases Which Produce Pain and Their Hanner of Produc-
tion.— Introitics narium, folliculitis, eczema introitus, and the spe-
cific inflammations in the region of the anterior portions of the
septum produce pains such as one finds in all inflammatiops, and
need no special explanation. One should never forget, in acute
pains arising suddenly in the region of the introitus, closely to
inspect the anterior angle of the entrance of the nose, for in this
place one often finds a hidden folliculitis, or a small retention of
pus, which may easily produce severe pain. This is of
special importance in case of erysipelas, which not infrequently
begins at the introitus narium. It is well to mention the septum
abscesses, which are always accompanied by severe pains, and are
most frequently of traumatic origin. Pains in the region of the
cartilaginous portion of the nasal septum, combined with a sten-
osis of traumatic origin, at the nasal entrance, point to the forma-
tion of a septum abscess. The pains may be caused either
through inflammatory irritation of the terminal ramification of
the septal nerves, through compression or degeneration,' or through
pressure from the suppurating hematoma. Long, persistent
pains, after a discontinuation of suppuration, point to a fracture
or to a spreading of the fissures of the skull.
Nasal Stenosis. — The various headaches that are caused by
nasal stenosis deserve special consideration, for they are often
accompanied by other phenomena, such as psychical depression,
inattentiveness, loss of appetite, neurasthenic symptoms, and lack
of concentration. These phenomena, which were mentioned by
Piorry as symptoms of rhinostenoma, are caused by nasal polypi,
large hypertrophies, higher grade septum deviations, and tumors
of the nose, and can be cured by endonasal therapy.
Hartmann, in his work on "Xasal Headaches and Xasal Neu-
rasthenia," has given the following explanation for headaches
caused by nasal stenosis: If too little oxygen passes into the
lungs through a partly stenosed nose, and consequently a diminu-
EMPYEMA 343
tion of exhaled air, as is physiologically necessary, occurs, the
oxygen content of the blood is diminished and an accumula-
tion of carbon dioxid takes place in the blood. It is not only the
accumulation of carbon dioxid that is to be considered, but there
are other by-products formed that are classed as toxins. Hart-
mann states that, through partaking of poor nutritive matter, a
bad influence is produced upon the nervous organism, and that
only in this way is the appearance of headaches and neuras-
thenic symptoms to be explained. Just as neurasthenic condi-
tions appear in persons who are crowded into closed or poorly
ventilated apartments, so, also, difficulties are called forth through
lack of nasal breathing-space.
In children with adenoid vegetations Lichtwitz and La-
brayes have proven that the oxygen of the blood and the number
of red blood-corpuscles are considerably reduced, while the white
ones are increased; and that, upon removal of the adenoids, the
number of red corpuscles and the oxygen constituents of the
blood are heightened. This change, especially, should be consid-
ered by those who do not estimate highly enough the importance
of adenoids, and who deny the disappearance of a number of
reflex symptoms after the nasal pharynx has been freed of its
encumbrances. The headaches produced by nasal stenosis can,
in most cases, be cured through operative procedures. However,
one must not forget that quite a number of internal diseases may
also produce these cephalalgias, which fact should receive consider-
ation in applying therapeutic measures (see Headache, Chapter
XIV, page 262).
Empyema. — The headaches arising in empyemas of the sinuses
are found in acute as well as in chronic empyemas, and each has
a different genesis. Should it be possible that, at the same time
with the inflammatory changes of the sinus mucous membrane, the
terminal ramifications of the sensory nerve apparatus also suffer
inflanmiatory changes; or should it be possible that distant in-
flnences might also be acting as causative factors (the latter be-
ing classified in the group of referred pains), only after exclusion
of these factors is it proper to think of the neuralgic pains, which,
344 PAIN IN DISEASES OF THE NOSE
arising in cases of empyema, can be traced back to a stasis of
secretion and secondary pressure phenomena. The other neu-
ralgic pains caused by nasal affections will be considered in regular
order.
In his work on "The Significance of Rhinology for Internal
Diagnosis and Therapy" Glas has especially called attention
to and emphasized the fact that often the cause of these headaches
is not discovered for a long time, and that all possible measures
to relieve the sufferings may be utilized without result.
Other pains found in inflammatory states of the sinus are the
local pains that occur in the cavities themselves, as aching, boring
and piercing pains, and occasionally, as in cases of stasis,
severe and throbbing pains. These pains, which are similar to
sinus abscess pains, may also be produced by percussion of the
external wall of the suspected sinus, or, if previously existing,
may be increased. In this way in those sinuses whose walls are
percussible (as the maxillary sinus, frontal sinus and anterior
ethmoidal cells) one is able to decide, in some cases, even the
extent of the diseased area, and the size of the diseased sinus.
Occasionally, through the detection of percussion pains, one
can determine whether there are abscess formations and septum
deviations in the frontal sinus. These observations may be sub-
stantiated by X-ray examinations.
Finally, pains arising in other parts of the body may be
genetically related to diseases of the nose, especially to empyema,
as described by Flies in several cases. These phenomena belong
to the large group of reflex neuroses of the nose. A careful study
of these pain reflexes has also been made by Head, who finds
that diseases of the olfactory (upper part of the nose) cause re-
ferred pain and superficial tenderness over the nasal and mid-
orbital areas (q. v.): disease of the nasopharyngeal part of
the respiratory tract may cause pain and tenderness in the
nasolabial area. But, as a rule, the nasal affections do not
cause pain. Since the pressure pains are of value for the
localization of the diseased areas, the statement of the patient
in regard to the location of the headache would be of special diag-
DISEASE OF THE SPHENOPALATINE GANGLION 345
nostic importance, were it not for the fact that there are many
cases in which the subjective sensations do not coincide with the
objective findings. Similarly, one often finds that patients with
a disease of the sphenoid sinus or posterior ethmoidal cells often
refer the pains to the region of the anterior sinuses, which, upon
examination, are found perfectly healthy, and vice versa; so
that one cannot use pain localization as an absolute indicator in
the topical diagnosis of diseased sinuses.
That neuralgias may be produced by suppuration of the sinuses
has been proven by Peyre, who had a case of facial neuralgia,
which had been complicated by the removal of the Gasserian gan-
glion, and which disappeared after a septum and maxillary sinus
operation; or by Hartmann, who had a case of trigeminus neu-
ralgia, accompanied by insomnia of several weeks' duration, which
was completely cured after removing a caseous mass from the
antrum. The writer is at present observing a case of intensive
infraorbital neuralgia of several weeks' duration, which was
treated galvanically without result, and which completely disap-
peared after Cowper's alveolar operation of the maxillary sinus.
Also, cases of frontal sinus empyema, accompanied by supraorbital
neuralgias, are not infrequently cured by operation.
Headache from Disease of the Sphenopalatine Oanglion. — The
experiments of Greenfield Seiider, who believes that the spheno-
palatine ganglion is an important factor in the production of head-
aches of nasal origin, are of much interest. He believes that, sec-
ondarily, the ganglion is sympathetically affected in intranasal in-
flammation, and applies his therapeutic measures accordingly. He
has tried to anesthetize the ganglion by making cocain applica-
tion behind the posterior end of the middle turbinate, and suc-
ceeded in several of his cases. At the same time he describes
cases in which headaches have disappeared after cauterization of
these areas, a fact which seems to point to an affection of the
ganglion.
Obstructed Sinuses. — Here we may consider the observations
which convince the writer, as well as Hartmann, that also in cases
of nondiseased, but obstructed, sinuses, or in cases of poor com-
346 PAIN IN DISEASES OF THE NOSE
munication between the sinuses and the nose, severe pains may
exist, which, upon removal of the obstructions, are immediately
decreased. I know of a colleague whose left maxillary sinus
I must puncture four or five times a year, without being able
to detect at any time any inflammatory affection of the antrum.
However, I noticed at the first puncture that I made, on account
of the severe, one-sided beadache, that by the inflation of the
antrum with air the characteristic antrum murmur was missing,
and that it took more pressure than normal to inflate ; therefore, I
was forced to conclude that the ostium relations were unsatisfac-
tory, and were either injured or had been insufficiently developed.
Although there was no secretion to be found in the return solution
after douching the antrum, nevertheless the colleague felt well
after the rinsing. The headaches disappeared for some time, until
the conditions demanded another puncture, which had to be re-
peated four or five times a year. The patient has not accepted
my proposition to enlarge the communication and thus relieve him
of his sufferings, although this operation might free him of his
pains forever. Such cases indicate that the destruction of the
communication, or a hindrance between the sinuses and the nose,
can produce headaches even where there is no sinusitis present.
Hartmann has also made similar observations, and gives the
following explanation to prove the truth of his assertion: (1)
In those cases in which existing frontal headaches cause one to
believe that there is a frontal sinus disease, the frontal sinus may
be opened without finding any diseased condition. In such
cases the pains may disappear after opening the frontal sinus, to
reappear, however, when the external opening heals, unless in the
meantime a communication has been made with the nose. If a
communication has been made, the pains are absent as long as the
communication exists.
(2) There are cases in which, after an operation on the
frontal sinus, exacerbatory symptoms arise in the form of head-
aches without a real recrudescence of the disease, but only a clo-
sure of the opening into the- nose, and it is this closure which pro-
duced the frontal headaches. In such case it suffices to open the
TUMORS 347
thin scar on the forehead with a sound. This allows the entrance
of air> and thus relieves the headaches.
(3) The third deduction of Hartmann's is not absolutely
unchallengeable, for in those cases in which an empyema had ex-
isted (about eight), and which were cured, the reason that the
headaches disappeared after the formation of a communication
between the nose and the frontal sinus can be traced, possibly, to
a retention of secretion, and not to the exclusion of air in the sinus.
Tumors. — Headaches are, furthermore, a very important
symptom, and are often the most prominent phenomena observed
in the malignant tumors of the nose. Harmen and Glas have
shown that the headache was the most important symptom in nine
out of thirty-two cases observed.^ These headaches, in spite of
the better drainage of the pus, the result of an existing empyema,
continued in the same degree after the removal of the growth. This
showed that a deeper affection must have been the cause. The two
following cases may prove the truth of this assertion: (1) Pa-
tient Z came, for dispensary treatment, with severe pains of the
right cheek, accompanied by periodic, right-sided headaches.
Rhinoscopical examination showed pus in the right nostril, espe-
cially in the middle meatus. Considerable pain was present upon
pressure on the right maxillary sinus wall. The probable diag-
nosis made at the time was empyema of the antrum. Puncture
of the right maxillary sinus was positive. Since the suppuration
was not lessened by repeated douching through the ostium, the
maxillary sinus was opened, through the alveolar process. Re-
peated douching was given. Nevertheless, the pain did not cease.
The continuation of the pains, in spite of the opening and the
douching of the antrum, indicated that another process must be
present besides that of empyema. The histological examination
of the resected lower turbinate showed cylindrical-celled carci-
noma.
(2) A woman, fifty years of age, had a polypus removed
from the right nostril a year previous to her admittance. Eight
months later, on account of profuse suppuration, the maxillary
1 Deutsche restschrift fur Chirurgie.
348 PAIN IN DISEASES OF THE NOSE
sinus was opened through the alveolus. In this ease there were
two factors which indicated the probability of a malignant for-
mation of new tissue, namely, the intense pain and the fetid con-
dition of the returning fluid of the douching solution. The his-
tological examination of an excised mass then gave the diagnosis
of stratified epithelioma.
The cause of the headaches in malignant tumors of the nose
may be various. The origin may be one of the following: (1)
reflex irritability, (2) blood and lymph stasis, (3) nerve pressure,
(4) meningeal irritation, (5) the result of an empyema occurring
at the same time.
Zuckerkandl shows, in his anatomy of the nose, the superficial
position of the ethmoidal nerve in the anterior portion of the
skull, and adds that this exposed position allows approximating
swellings to cause pressure symptoms. That headaches some-
times arise as localized symptoms is shown in the second case,
cited by Harmen and Glas in their article on "Malignant Tu-
mors," in which right-sided, frontal headaches existed. Autopsy
showed penetration of the roof of the orbit and a growth of the
tumor into the right frontal sinus. We deduce, therefore, that,
after cleansing of the sinuses, constant pains should call forth
the suspicion of malignant neoplasms. In one of my last cases,
on autopsy, I found a meningeal hyperemia, which may have been
the cause of the violent and increasing cephalalgia during the
last days of the patient's life.
Finally, we cannot deny that those swollen areas in the interior
of the mucous membrane, found on section, may, by compressing
certain structures, very frequently be the cause of severe, continu-
ous headaches.
DIAGNOSIS
In cases of acute empyema the pains are sometimes very vio-
lent, and one cannot be reminded too often of the fact that, when
pains arise during a coryza, or an influenza, a thorough rhino-
logical examination should be made. The result of therapeutic
measures in empyema is often marvelous. A puncture through
DIAGNOSIS 349
the inferior meatus, or a douching through the natural opening
in sinusitis maxillaris, or the application of cocain on the
anterior end of the middle turbinate, in frontal-sinus affections,
can relieve the most acute pain. Unfortunately, even at the pres-
ent time, one finds many cases which are treated for weeks, either
galvanically, or faradically, are massaged, or receive other result-
less treatment, without the attending physicians even surmising
that the sinus is diseased.
A test of importance, which I have introduced into rhinology,
may frequently be applied. The principle of this test is the fol-
lowing: The tuning fork, which is held anteriorly in the median
line above the bridge of the nose, is lateralized to the side where
the diseased sinus exists. In case the ear is not affected the
patient hears the tuning fork only on the side, or more intensely
on the side in which the sinus is affected.
This method, which was tested in several hundred cases,
affords important service to one who is not thoroughly conversant
with exact rhinological technic, as he is able to state, in cases of
neuralgic headaches, whether they can be traced back to affections
of the sinuses. I have seen cases in which patients complaining
of severe neuralgias were sent to a rhinological specialist for
examination, in whom Glas's tuning-fork test proved to be nega-
tive (i. e., the tuning-fork was heard only at the point of appli-
cation, or, as the patients said, heard alike at all parts of the
head), and in whom, as a result of complete rhinological examina-
tion, empyema could be excluded as the cause of the neuralgic
pains. On the other hand, this test affords the rhinologist im-
portant service in a diagnostic and prognostic manner, in regard
to which Glas gave more explanatory details at the International
Rhino-Laryngological Convention in Berlin, 1911.
At the same time one must not forget those cases in which
there is no stenosis, but in which hypertrophy of the middle tur-
binate is the determining factor of the headaches, which disappear
after resection of this part. These headaches are classed by
some as symptoms of stenosis, but by others they are placed in
the group of Flies' reflex symptoms. At any rate the pressure of
350 PAIN IN DISEASES OF THE NOSE
the turbinates on the septi may cause reflex painsi The explana-
tion of Casali, however, is more reasonable. He assumes the
cause to be compression of the vessels of the nasal mucous mem-
brane, which are in communication with the veins of the dura
mater and the superior longitudinal sinus, the blood and lymph
stasis of the mucous membrane of the nose causing a stasis in the
dura covering the brain. There is no doubt that, in such cases,
the result of resection of the hypertrophy of the turbinate is strik-
ing. On negative internal findings, the diagnostic significance of
this therapy should not be forgotten. Here may be included those
cases in which severe neuralgias are relieved by endonasal opera-
tions. In regard to this point, I have expressed myself in my
work on "The Significance of Rhinology for Internal Diagnosis
and Therapy," in the following manner: Any one who has had
occasion to cure a severe neuralgia by an endonasal operation will
know how to emphasize the importance, indeed the utmost neces-
sity, of a rhinological examination in every case of neuralgia of
the fifth nerve. The following cases may illustrate the foregoing
statement :
(1) In the case of a patient who had suffered for years with
a neuralgia of the infraorbital nerve, I found, by rhinological
examination, a rhinolith lying under the middle turbinate and
pressing upon the processus uncinatus. On its removal the neu-
ralgia disappeared.
(2) A patient who had tried various therapeutic treatments
for a trigeminal neuralgia, in his despair consulted a rhinologist.
By chiseling a broad crista of the septum, which extended in an
especially sharp angle to the middle turbinate, relief of the neu-
ralgia was at once obtained. A single example of this kind is of
more value than a multitude of reflections, and proves the utmost
necessity of a rhinological examination of such cases.
In conclusion, it may be added that sometimes, after a radi-
cal operation on the frontal sinus, neuralgias of the supraorbital
nerve arise. Therefore, it seems rational that, while doing the
Killian operation, one should remember this fact, and resect the
supraorbital nerve.
CHAPTER XVIII
PAIN IN DIBBASES OP THE THBOAT
PAIN IN DISEASES OF THE PHARYNX'
The sensory nerve of the pharynx is the lingual. From it are
derived the sensory receptors of the anterior palatine arch, the
tonsils, the floor of the mouth, and the tongue. This and the
glosso-pharyngeal divide the supply of these parts, while the re-
gion of the gingiva is supplied by the alveolaris inferior.
Pain in Acute Diseases. — All the inflammatory processes in the
region of the pharynx contribute toward pain production, for in-
stance, the different forms of angina, the inflammation of the
pharyngeal tonsil, retropharyngeal abscess, and herpes, febrile and
zoster form. In this group of diseases phlegmonous angina, retro-
pharyngeal abscess, and diphtheritic inflammation are especially
prominent.
Phlegmonous angina often produces very severe pain, which
is increased by every movement of the mouth, and which has radia-
tions in the ear which are often unbearable. These are sometimes
produced through a pus area developing in the deeper tissues,
sometimes through an inflammatory edema of the surroundings.
The pains are sometimes boring, sticking, excessive, or trivial.
The localization of the pain is frequently inexact. When it is
located in the nasopharynx, in the ear, or in the region of the
ostium tubee, the increased pain upon pressure outside on the
anterior mandibular muscles is characteristic.
tTpon opening a peritonsillar abscess, the making of the inci-
sion in the right place, that is, at the point where the pus conies
* By Privat Decent Dr. Emil Glas, of Vienna University.
351
352 PAIN IN DISEASES OF THE THROAT
nearest to the surface, is of the utmost importance, since the inci-
sion and dilatation of the point of incision in an edematous
but not pus infiltrated area occasion very severe pains, which fre-
quently cause fainting. On the contrary, the incision in the in-
filtrated area is relatively painless, and causes an instantaneous
improvement.
Retropharyngeal abscess often produces pain similar to that
of phlegmonous angina, save that in the former the location cor-
responds to the deeper seat of the affection, which lies further
back and lower down. Deglutition also occasionally is difficult
and is associated with severe pain, which is increased by the swell-
ing of the corresponding glands of the neck. The acute process,
as a rule, does not affect the vertebra, but chronic retropharyngeal
abscess may cause necrotic processes in the vertebral column. Con-
cussion of the vertebral column, produced from above, causes no
increase of the pain in the acute form.
In diphtheria swallowing pains are usually severe. Fre-
quently, from the swelling of the velum, the taking of food be-
comes difficult and painful, although in many cases no trouble of
any sort is present. Generally there occurs a painful swelling of
the submaxillary glands; likewise, of the lymph glands lying
under the sternomastoid muscle; these frequently grow into a
large, very painful lump, especially sensitive to the touch. Here,
one must not forget, in pharyngeal diphtheria, the pains arising
(tlirough the general infection) in the head, neck, back and the
region of the buttocks, which often cause the patient very much
trouble.
The acute infectious diseases, especially influenza, which
causes very severe neck pain, with but little objective findings,
are of interest. Escat has described such cases and has diagnosed
them as pharyngod^^lia from influenza. Here one finds, at the
most, a slight degree of erythema. This painful angina is closely
related to thq herpetic angina and disappears in the course of a
few days.
The febrile herpes of the pharynx, which is often associated
with laryngeal herpes, appears very frequently in groups, occur-
PAIN IN DISEASES OF THE PHARYNX 353
ring, ako, in the form of small, diffuse, epidermic vesicles, and
is especially characterized by pain on swallowing. In a work
given out from the Chiari Clinic of the Vienna University, Glas
mentioned that frequently, after a short prodromal stage, severe
difficulties of swallowing and sticking pains occurred in the throat,
accompanied frequently by hoarseness and difficulties of breath-
ing. The dysphagia often reaches such a pronounced degree that
the patient is unable to take nourishment. Examination of
the mesopharynx very frequently gives an entirely normal pic-
ture. Laryngoscopic examination first shows on the base of the
tongue, in the region of the follicular papillae, on the vault of the
pharynx or on the pharyngeal wall, symmetrical vesicles. These
are very prominent, varying in size from a poppy seed to a
lentil, and are filled with white contents lying on a red base.
These vesicles may be scattered, without any arrangement, or they
may be gathered into groups. At this point it is time to emphasize
(as we shall do later, in our description of chronic affections) the
fact that one should always, in cases of pain on swallowing, ex-
amine the region of the hypopharynx, where these efflorescences
are likely to occur.
As an example of these interesting infections, in which severe
pain is always present, the following case is of note :
"The patient, fifty years of age, felt, for a few days, weak
and tired; three days previous, chills and high-grade dysphagia.
The patient gave the impression of being very ill, the head being
held as it is in peritonitis gravis. The temperature was 38.9° C.
(102.2° F.) and the pulse frequency was 110. The pharynx was
perfectly free, and the tonsils were not in the least inflamed.
The opening of the larynx (aditus) was greatly changed; the
epiglottis, the aryepiglottic folds, the vallicute in the recessus
pyriformis, were covered with vesicles of a somewhat similar size,
not very prominent, and filled with gold-colored contents."
Herpes zoster may, as I have frequently seen, give rise to
very special pain in the region of the pharynx, which assumes a
neuralgic character and reaches such an intensity that the other-
wise fairly resistant patient whines and complains. Kaposi has
354 PAIN IN DISEASES OF THE THROAT
described cases which correspond with the distribution of the
maxillary nerve, the pains at the same time occurring in the
cheeks, the palate and the pharyngeal mucous membrane of the
affected area. The herpes arises sometimes as a diffuse, painful
redness, sometimes as a group of efflorescences of a short duration,
or even as gangrene of the rami palatini and pharyngei.
Frequently with the significant difficulties of swallowing severe
toothache is present, with the resulting continuous neuralgi-
form pains. I have seen two cases of herpes zoster associated
with high-grade dysphagia. In these cases only the mucous
membrane of the mouth and pharynx was affected, and the efflor-
escence was interrupted sharply in the median line. Cases
have also been described in which it is almost impossible either
to speak or to chew, each movement calling forth a tic dou-
loureux.
Herpes zoster is occasionally mistaken for acute pharyngeal
affections. Here, also, phlegmonous inflammation of the base of
the tongue is to be considered, for it very often occasions unbear-
able pain, and, like peritonsillitis, makes deglutition impossible.
The pains, which are severe, sometimes radiate to the ear. These
diseases, because of the action of the inflammatory exudate on the
glosso-pharyngeus, give rise to stimuli which are conducted back
through the vagi, and are often associated with profuse salivation,
high-grade prostration, and difficulty of breathing.
Pain in Chronic Diseases. — Among chronic diseases of the
pharynx, which cause interesting pains, tuberculosis, lues, and
malignant neoplasms of this region are prominent
Tuberculous ulcers of the pharynx produce severe pain, which
is increased in swallowing. The pain frequently radiates to the
ear, and the deej>er the process extends the more severe it be-
comes. The maximum is reached in tuberculous affections of
the aditus laryngis, a very frequent disease. The ulcers located
in the epipharynx, especially those having their location near the
tuba of the ostium of the pharynx, are very painful, and, because
of their location, are noteworthy, since for their diagnosis an
exact posterior rhinoscopy is necessary (the unskilled rhinos-
PAIN TN DISEASES OF THE PHARYNX 355
copist, in order not to overlook these diseased parts, should use
a pharyngoscope).
Swallowing, in cases of pharyngeal tuberculosis, is often very
painful, and causes vomiting, which, in turn, aggravates the pain.
Very frequently otherwise active anodynes, such as cocain, mor-
phin, orthoform, etc., are entirely without eflFect, and the physi-
cian finds it necessary to resort to morphin injections. For the
severest laryngeal pain the alcohol anesthesia of the nerves is
especially to he recommended.
Luetic ulcers, at first, are not associated with very great pain,
the superficial mucous membrane plaques causing only slight
trouble; and attention should be called to the disparity between
the extensive process and the slight trouble as characteristic of
the first stage of syphilis. The first pain occurs on the deep exten-
sion of the process, and may (for example, in deep, ulcerating
gummata) reach a very high degree. Gummata of the base of the
tongue and of the epipharynx, lying principally on the roof of the
pharynx, may exist, in which the most prominent symptom is the
excessive pain. Diffuse pain, radiating chiefly into the ear,
accompanies this stage of the syphilitic process. It is also to be
emphasized here that, with this group of symptoms, an exact
retronasal examination should be made, and the region of the cir-
cimivallate papillse carefully examined, because it is exactly here
that the concealed seat of the affection is often to be found.
In carcinoma of the hose of the tongue there may be no pain in
the early stages. The patient experiences only a scratching or a
tickling in the neck. Often, upon pronounced movement of the
tongue, he has the sensation as of a foreign body in the pharynx,
and his complaint of this may lead to a false diagnosis. The deep
extension of the carcinoma first produces severe, often signifi-
cant pains radiating into the ear, the jaw, or the larynx. Pro-
fessor von Bergman held the hemorrhage and pain which are pro-
duced through the movement of the tongue, and through the con-
tact of the hard food, as characteristic features of carcinoma of
the tongue. He says : "They frequently are as pronounced as in
the flat, tubercnlons ulcers on the margin of the tongue. Fre-
356 PAIN IN DISEASES OF THE THROAT
quently they are neuralgic in character, and radiate toward the
ear, and the unhappy patients often complain fearfully" ("Hand-
book of Surgery").
Of the group of chronic infections with which severe pain is
associated pemphigi of the mucosa are conspicuous. Often they
suddenly burst open, or the vanishing vesicle, through hemorrhage
of the submucosa, may occasion an increase of the pain, especially
in the efflorescence of the mucous membrane lying adjacent to the
pemphigus follicle, which causes a diffuse epithelial desquama-
tion, produces a high degree of dysphagia, and, as a result of
inanition, quickly incapacitates the patient.
The NEURALGIAS OP THE PHABYNX, which, without demonstrable
organic changes, are found in hysterical individuals, are also to
be considered. The patient often, for hours, will complain of
lightning pains arising in the different parts of the mouth and
radiating into the pharynx. Here, one should always seek for the
pressure points, which are loc»ated in the region of the laryngeus
superior glosso-pharyngeus or the lingualis. Those affections
arising through tonic contraction of the swallowing muscles may
be designated as hysterical dysphagia. In these strong pressure,
accompanied by the closing of the teeth, produces a sticking or
tearing pain.
PAIN IN THE LABYNX
The sensory component of the vagus is the superior laryngeal
nerve, which, arising from the vagus, runs median to the internal
carotid as far as the thyrohyoid ligament. At the upper half of
the greater comu of the hyoid bone the nerve divides into an
outer and an inner branch, of which the outer has motor and the
inner sensory fibers. The latter passes through the thyrohyoid
ligament and reaches the recessus pyriformis, where it supplies the
mucous membrane covering the plica of the laryngeal nerve, and
ends in the mucous membrane of the larynx. At the same time it
forms an anastomosis with the laryngeus inferior, and concerns
itself with the delivery of sensory nerve fibers to the recurrens.
At this point, the observation made by Massei, of anesthesia of
PAIN IN THE LARYNX 367
the laryngeal entrance in recurrens paralysis, may be cited.
This he gives as a reason for his opinion that the recurrens really
conducts sensory fibers. My examinations, following those of
Massei, do not confirm his observation, so that I, as the result of
an enormous amount of clinical experience, and because of other
reasons, have reached the conclusion that the recurrens has nothing
whatever to do with the sensibility of the larynx.
Referred Pain, — Diseases of the larynx generally produce no
referred pain nor tenderness, but when pain does exist, it is gener-
ally felt in either the superior or inferior laryngeal area, the
upper area being particularly associated with disease of the epi-
glottis and aryteiio-epiglottidean folds, the lower area being par-
ticularly associated with disease of the cords (Head).
Pain in Acute Affections. — Laryngeal pain may be found in
all acute inflammations, chiefly in those associated with pus for-
mation. Here the intensity of the pain depends especially upon
the location of the process. The aditus laryngis, that is, the
epiglottis, aryepiglottidean folds in the arytone, is the region in
which inflammation produces the most severe pain. It depends,
on the one hand, upon the richness of the sensory nerves in this
region, and, on the other hand, upon its relation to the process
of swallowing. The bolus, gliding over the aditus, irritates the
inflamed area and produces, at the same time, an increased reac-
tion as well as i)ressure pain. A clear proof of the increased pain
sensibilitv in involvement of the aditus is found in acute affec-
tions; for examj)le, in herpes laryngis, involvements of the ary-
epiglottidean folds and the recurrens pyriformis are so painful
that swallowing becomes inij^ossible. Here the pain frequently
radiates into the region of the base of the tongue and the middle
auricular nerve of the vagus in the ear zone. On the side of the
larynx a clearly defined ulcer may frequently be present for a long
time without causing severe pain, because swallowing is not dis-
turbed. Here, upon manifestations of pain in these parts, I again
suggest a minute examination of the entrance of the larynx, espe-
cially of the recessus pyriformis, in order to avoid the overlooking
of a diseased process.
358 PAIN IN DISEASES OF THE THROAT
Chronic Processes. — Under the chronic processes are, again,
the tuberculous ulcers, as well as the crumbling carcinoma (extra-
laryngeal), which may give rise to an intense, often unbearable,
pain. The dysphagia of a patient suffering from a diffuse laryn-
geal tuberculosis often reaches such a high degree that he will
refuse to take food. The blowing in of orthoform, the instillation
of menthol, the insufflation of morphin, dysphagia tablets, paint-
ing with cocain, etc., very frequently fail, in the ulcerative form
of laryngeal tuberculosis, to relieve the pain, so that in a short
time after the onset of this affection one can do nothing for the
conditions.
The anesthesia of the entrance to the larynx, by Hoffman,
through injection of alcohol in the superior laryngeal nerve, at
its place of entrance through the thyrohyoid ligament, has given
a very satisfactory result in many cases, in that the dysphagia
diminishes and the otherwise rapid inanition is hindered. I can,
upon the basis of a large number of injections made in very sick
tuberculous patients, warmly recommend this treatment, and I
would like to emphasize the fact that, in a number of cases, I was
able to induce an anesthesia persisting through many weeks.
The pain in carcinoma of the larynx depends upon the locali-
zation of the tumor. Extralaryngeal tumors, lying in the region
of the aditus, give rise very early to pain on swallowing, while in
intralaryngeal tumors pain may not appear for a long time.
There are, then, because of the overgrowth of the tumor, severe
disturbances of swallowing. One may say, in regard to the early
diagnosis of carcinoma of the larynx, that the first symptom of the
extralaryngeal carcinoma is, as a rule, dysphagia and that the first
symptom of intralaryngeal carcinoma is hoarseness. Yet there
are cases, to which Leopold von Schroetter, especially, has drawn
attention, where, in spite of severe destruction in the region of the
aditus, pains are entirely absent. However, these are very rare.
The explanation lies in the fact that in these cases there are sen-
sory disturbances in the area of distribution of the superior laryn-
geal nerve. Generally the pains are spontaneous, on deglutition
as well as upon external pressure. The pain in carcinoma of the
PAIN IN THE LARYNX 359
larynx is explained through the simultaneous occurrence of in-
flammatory conditions, necrosis formation, and hardening, while
the pressure symptoms, or the propagation of the irritability,
occur from the involvement of the superior laryngeal nerve. Often
the pains assume the form of neuralgia, and radiate as lightning
pains into the region of the nervus auricularis vagi.
Labyngeal neuealgia is infrequent, and is observed in hys-
terical and neurasthenic subjects. The neuralgia often radiates
to the ear and frequently reaches an imbearable severity. Lemon
has reported a case in which a patient, in the climacteric period,
threatened suicide if freedom from her raging pain was not
obtained for her. In other patients, when the pain occurs on
speaking, it shows itself as a typical phonophobia. Finally, it is
mentioned that, in these glottis spasms which we so frequently
find in tabes dorsalis, the so-called laryngeal crises, hyperesthesia
and hyperalgesia, in the form of sensory aurae, are often found,
and introduce the cramp crises. The explanation of these forms
of pain is probably analogous to that of the adduction spasm, they
being due to an irritation of the sensory sphere. The typical
attack in such cases occurs as a peculiar sensation in the larynx,
in the form of a sticking, burning, lightning pain, accompanied
by states of anxiety or feelings of suffocation, after which the
spasm of the glottis follows.
CHAPTER XIX
ABDOMINAL PAIN
Classification. — There are two classes of abdominal pain : sub-
jective and objective.
The subjective pains belong to the class of symptoms usually
termed hysterical. For their production no organic basis can be
found. They seem to be due to the awakening into consciousness
of sensation-phenomena stored away in the subconscious mind.
Objective pains, on the other hand, have for their produc-
tion either some definite pathologic change, functional or or-
ganic, or a changed relationship of the organs as a whole to other
adjacent organs, such as occurs, for example, in a ptosis of the
stomach or of the liver.
Snbjectiye pain, in relation to the abdominal viscera, will
not be considered here. It has already been discussed in the
opening chapters.
Objective abdominal pain is important because of its rela-
tionship to changed pathology in the abdomen. It may be due to
a lesion of the skin, the subcutaneous tissues, the muscle, the peri-
toneum, or the viscera.
The SKIN is frequently painful, especially when it is the seat
of some inflammatory skin-disease, such as erysipelas. It is also
very painful in certain nerve lesions, as neuritis, or herpes.
The MUSCULAB LAYER OF THE ABDOMINAL WALL is Credited
by Mackenzie with pain production. He says: "It is the
muscular layer in the abdominal wall which is so exquisitely ten-
der in all affections of the viscera, giving rise to severe reflex
musculovisceral pain, as in appendicitis. Also, the abdominal
360
OBJECTIVE ABDOMINAL PAIN 361
muscles above the lesion are in a state of contraction and are
extremely tender to pressure." That Mackenzie erred and exag-
gerated the importance of the muscular coat in pain production is
proved by the researches of Lennander and others. Later, Mac-
kenzie (862) himself, modifying his previous statements, says
that the subperitoneal layer is the most sensitive, and, in confirma-
tion of his views, quotes Ranstrom, who has found many nerves
and nerve endings in this layer. The nerves are derived from
those supplying the muscular layer. All direct painful muscular
lesions in the abdominal wall are the result of inflammation,
neuritis, neuralgia, myalgia, or new growths.
Inflammation in the abdominal wall is accompanied by all
the signs and symptoms usually associated with inflammation in
general, such as swelling, redness, heat, and loss of function. The
pain is of a throbbing character. Tenderness on pressure is also
present. In some cases the inflammation precedes abscess forma-
tion. Such cases are described by Hitzrot (337). The pain was
localized, and was increased on assuming the erect posture and on
deep pressure. He quotes Fouquet (370), Sonnenberg (371),
Spellisy (372), Heller (373) and Allison (374), who have all
described similar conditions.
Neuralgia of the nerves of the abdominal wall occurs and is
frequently observed with or after infectious diseases. When it is
present the skin is exquisitely tender, and is very painful to the
pressure made by pinching it between the fingers. In this it dif-
fers from peritonitis, in which the skin is not so tender, and the
pain is produced only on deep pressure. In neuritic lesions of
the abdominal walls the pain is usually unilateral. When the
lumbar nerves are affected, the pain is commonly felt in the
hypogastric region, a little to one side of the median line. In
this area, too, there is localized tenderness on pressure. Tender
spots are also found, one a little to the outside of the first or
second lumbar vertebra, and another immediately above the crest
of the ilium. In women, who are by far the greatest sufferers
from this disease, there is also sometimes, about the middle of
the Fallopian tube, a spot, pressure upon which causes pain to
362 ABDOMINAL PAIN
be referred to the anterior abdominal wall. There is another
spot above the uterus. In men, points here and there on the scro-
tum are found which are painful to the touch. These points of
tenderness serve as characteristic signs of neuralgia. Neuralgia
is to be diagnosed, not only from colic, but from lumbago and
rheumatism of the abdominal walls. Diagnostic signs of neu-
ralgia are the absence of fever and the relief which is produced
by pressure and ordinary antineuralgic remedies.
Neuritis of the intercostal nerves is fairly frequent. This
frequency occurs because these nerves are particularly subject to
the deleterious influences of cold and traumatism, on account of
their exposed position. (For a more complete description see
under Neuritis.)
Myalgia is closely related, as far as etiology is concerned, to
the neuralgias. It seems to be due in very many cases to a dis-
ordered metabolism. This is the condition to which the term
"rheumatism of the abdominal wall" is given wrongly.
New growths, such as cysts and various kinds of tumors, may
occur in the abdominal wall. If of slow development, they cause
no great inconvenience, for by their slow increase in size they
gradually push the surrounding structures to one side, and the
tissues learn to accommodate themselves to the presence of the
foreign occupant. Should nerves be incorporated in the growth,
and pressure be exerted upon them, pain, generally of an aching
character, results. This pain may be localized to the region of
the growth, or may be referred to some distance in an area to
which the affected nerve is distributed. The size of the growth
bears no relationship to the amount of pain which it may pro-
duce, the smaller growths producing as much, if not more, pain
than many of the larger ones. The amount of the pain depends
upon the rapidity of the growth, the number of nerves incorpo-
rated in it, and the pressure exerted upon them by the inclosing
tissues.
Pebitoneum. — According to Mackenzie, the peritoneum of
itself is devoid of pain nerves. However, he claims that the sub-
peritoneal layer is plentifully supplied with pain nerves, and that
OBJECTIVE ABDOMINAL PAIN 363
it is here that the painful impulses arise. In its lack of pain
perception, the peritoneum, he says, is not unique among serous
membranes, for this is characteristic, he holds, of all serous mem-
branes, since they have no nerves which will transmit pain stimuli
of the kind found in the skin, the tunica vaginalis testis being the
only serous membrane which is sensitive to the usual tests for
pain sensibility. This is due to the fact that the tunica vaginalis
testis is innervated by a cerebrospinal nerve, the genital branch of
the genitocrural nerve.
Mackenzie's proofs that serous membranes are not the seat of
pain production were: (1) that the abdominal wall is very tender
in certain visceral colics in which there is no inflammation of the
peritoneum; (2) the skin of the abdominal wall generally is not
so sensitive in visceral lesions, for it can be pinched between the
fingers without producing pain; but if the muscles are grasped
between the thumb and fingers, acute pain is felt; (3) direct
stimulation of exposed pleura, pericardium, and peritoneum does
not produce pain. That this is not absolutely true will be shown
in the discussion of peritonitis.
The peritoneum is the lining membrane of the abdominal
cavity. It consists of two layers: (1) the visceral layer, which
covers the inclosed organs, and (2) the parietal, which lines the
external wall of the cavity. It has been held by many that the
visceral peritoneum is without pain sensibility, but, as will be
pointed out, much depends upon the type of stimulus. The adequate
stimulus in the viscera is deep pressure; that largely produced
by tension. It is the type of deep sensibility described by Head,
It was the belief of Lennander that "all painful sensations
within the abdominal cavity are transmitted only by means of
the parietal peritoneum and its subserous layer, both of which
are richly supplied with cerebrospinal nerves around the whole
of the abdominal cavity, with the exception of a small area in
front of the vertebral column lying below the crura of the dia-
phragm, and between the two chains of sympathetic nerves."
Here he found no cerebrospinal nerves, but only nerves running
more or less transversely between the two sympathetic chains.
364 ABDOMINAL PAIN
He found that within this area the patient does not respond to
hard pressure with a finger, or with an instrument, and that
stretching of the mesenteric attachments at this point is not pain-
ful. So far complete uniformity does not exist as to presence or
absence of pain sensibility in the peritoneum, though many ob-
servers are in accord with the deductions of Lennander.
Diseases of the peritoneum producing pain are inflammations,
hemorrhaire, and new growths.
Inflammations of the Peritoneum. — Inflammation of the peri-
toneum (peritonitis) causes pain only when acute. The chronic
inflammatory forms, as a rule, produce but little pain, except
as the result of adhesion formation. The seat of the pain in peri-
tonitis, according to Jklackenzie,^ is not in the peritoneum itself,
but in the subperitoneal tissue. This layer is exquisitely tender,
and Ramstrom found it richly supplied with nerve fibers, which,
in turn, are derived from the nerves of the anterior abdominal
wall. These nerves also supply the abdominal muscles, and thus
one can account directly for the reflex rigidity of these muscles
(supplied by the same nerves) when the peritoneum is affected.
In some cases, however, acute peritonitis may be present with-
out producing any pain phenomena. This is especially so in the
violent cases in which the abdomen contains a quantity of pus
(Bradford, 207). This lack of pain may be due to the rapid
destruction of the nerve endings, or to the impairment of their
efficiency. Such a state is frequently met with in puerperal
sepsis.
However, in all cases of sudden, sharp, exacerbating pain,
with rigidity of the abdominal muscles, generalized tenderness,
normal or subnormal temperature, and a rapid, rising pulse, peri-
tonitis should be thoughtfully considered (Richardson, 23).
Should the pain be dull and aching, the sub-peritoneal connective
tissue is probably involved.
1 It is also claimed by Mackenzie that the parietal peritoneum or nsert
is insensitive to pain; that it is the tiny nerve filaments, distributed in the
cellular tissue subjacent to the peritoneum, which are extremely sensitive,
and that the slightest traction or pressure on them produces the most ex-
cruciating pain.
INFLAMMATIONS OF THE PERITONEUM 365
Tuberculous Peritonitis. — In cases of tuberculous origin
pain may be an almost negligible symptom. The exceptions are
those conditions in which adhesions have developed, or in which
the tuberculous material has become encysted and has ulcerated
or suppurated. This gives rise only to a little pain on walking,
while obliterative, encysted, or sciatic forms may cause no pain
(Rolleston, 619). In case of tuberculous peritonitis Bainbridge
has found that the injection of oxygen into the peritoneal cavity
will relieve the pain. This may be due to the separation of the
two adjacent surfaces from each other, possibly to an anesthetic
action of the oxygen.
A common source of mistakes in the diagnosis of peritonitis
is the confusion of referred pain with that due to peritonitis.
Diagnostic criteria between the two conditions are: (1) The ten-
derness of referred pain is produced by slight stimulation of the
skin and the subcutaneous tissues, and seems to be relieved by
deep pressure; (2) the exact opposite is found to be the case in
peritonitis, deep pressure being painful, while light pressure is
not so distasteful; according to Lennander (618), the boundaries
of the hyperesthetic zones in peritonitis can be mapped out
almost to a centimeter; (3) in peritonitis proper there is gener-
ally no referred pain; this is given by Moullin (226) as a good
indication that no other viscera are involved, for as soon as the
viscera become involved hyperalgesia is present; (4) in perito-
nitis the abdominal reflexes are not exaggerated, while in referred
pain they are exaggerated.
Should a peritonitis be sudden in onset, as is the case in the
perforation of an ulcer of the stomach, or of the duodenum, the
pain is generally paroxysmal and is most severe. When the car-
diac end of the stomach is involved, the pain, as a rule, is under
the left scapula. When the pyloric end is the part affected, the
pain is under the right scapula (Mayo Robson, 619).
If the abdominal pain is associated with tenderness it is neces-
sary to distinguish between inflammation of the constituents of
the wall (skin, muscle, peritoneum), neuralgia and neuritis. In
peritonitis pain is produced only on the making of pressure on the
366 ABDOMINAL PAIN
abdominal wall, while in neuralgia or myalgia it may be necessary
to pinch the skin or muscle between the fingers before pain is
elicited. If peritonitis is present there is also pain on the patient
taking a deep breath, upon the making of a pelvic examination,
and also, in some cases, upon flexion of the body. Should the pel-
vic peritoneum be inflamed, pain is produced when the inflamed
peritoneum is pressed upon by the examining finger. Tilting up
of the uterus by pressure on the cervix will always cause pain,
and pain is also present on making deep, and, if the peritonitis
is severe, light pressure low down on the abdominal wall. Biman-
ual externovaginal examination will cause pain if the peritoneum
at the brim of the pelvis is inflamed. Defecation, micturition and
sexual connection (if a female) are also painful. The visceral
peritoneum is different from the parietal peritoneum in that pain
is not produced by pressure upon it; but it is very sensitive to
traction made upon it through the mesentery. The pain produced
by this traction is interpreted as coming from some zone of the
body and not from the affected viscera. This Mackenzie ex-
plained by the fact that the abdominal viscera are supplied en-
tirely by the sympathetic system, which has no sensory nerves.
When it is irritated its nerves carry impulses to the cord cells and
stimulate, in turn, adjacent sensory cells to activity, thus caus-
ing a painful impulse to be conveyed to the brain. This impulse
is projected as if coming from the peripheral distribution areas
of the sensory nerves, whose cells are stimulated.
Chronic peritonitis is somewhat different from the acute,
and is much slower in onset and duration. The pain is due to
the following causes:
(1) Traction and pull from adhesions, the result of the
chronic inflammatory process.
(2) Distention of the bowel from gas or fecal matter, owing
to obstruction of the lumen by adhesions which may be old or
recent
(3) Localized collections of fluid encysted by the peritoneal
adhesions. These localized collections may be either serum, pus,
or blood. After the fluid contents have reached a certain stage.
NATURE OF PAIN FROM ADHESIONS 367
they begin to exert pressure or traction on the adjacent structures,
and thus cause the pain. In some cases of slow, insidious peri-
tonitis, especially those of tuberculous origin, there may be no
pain of any moment until adhesions form, when pressure causes
tension pains.
The location of the pain may give an indication of the viscera
which are involved by the adhesions (for the points of reference
on the abdominal wall of visceral pain, see Viscera, Chapter XX,
pp. 383-389).
Hemorrhage. — In sudden, severe hemorrhage into the abdomi-
nal cavity, such as occurs in the rupture of an extrauterine preg-
nancy, pain is present; but in hemorrhages following operation,
pain, as a rule, is absent. This latter condition can probably be
accounted for by the previous insult to the peritoneum by the
operative procedures, with the consequent reduction in its sensi-
bility.
In some cases of excessive dilatation of the abdomen from
tympanites, or from obstruction, the abdominal tenderness is ex-
cessive, but at the same time the pulse and temperature are not
of a peritoneal character.
TiunorB of the Peritoneum. — Tumors of the peritoneum gener-
ally cause pain. When they are in the back, and lie posterior to
the peritoneum, they frequently cause pain by the pressure which
they exert upon the spinal nerves. This pain is referred to the
back or along the course of the nerves of the lumbosacral plexus.
It must be diagnosed from the pains due to aneurysm, vertebral
caries, or spinal tumor.
Nature of Pain from Adhesions. — As an end result of nearly
all processes, both inflammatory and otherwise, in the abdominal
cavity, is adhesion formation. These adhesions, as a rule, cause
pain, which is generally localized to one spot, at which point pain
is also produced by pressure.
The pain may come in paroxysms; when it does so, the
attacks resemble each other, and have the same train of symptoms.
The pain also is influenced by certain muscular movements or
positions of the body, and may be lessened or increased by mov-
368 ABDOMINAL PAIN
ing about or by turning over from one side to the other. It is
increased by peristalsis, especially if the adhesions are between the
stomach or intestine and the anterior abdominal wall. When the
adhesions are between the stomach and the anterior abdominal
wall, the pain is often increased after eating. Adhesion pain
is also increased by tension of the anterior abdominal wall, when,
by a backward motion of the upper part of the body, or hyper-
extension of the thigh, the distance between the ribs and the pelvic
bones becomes increased. In such cases the recti muscles become
rigid and traction is made on the adhesions. The magnitude of
the pain varies indirectly as the area of the adhesion. This is
due to the fact that, in extensive adhesions, the traction upon the
parietal peritoneum is not limited to any one spot, as it is in
very limited adhesions, but is spread out over a large area, and
consequently, not being perceived acutely in any single nerve
distribution, is felt rather as a dull, dragging pain, instead of a
sharp, pulling one.
Increased tension of the anterior abdominal wall also causes
pain in cases of hernia wherein stretching of the omentum is
probably present.
Adhesions pulling upon the peritoneum, as a rule, cause
greater pain if there is a sudden variation in the traction, such
as can occur when a hollow viscus of changing size and position,
such as the stomach, is attached to the anterior abdominal wall.
In this case the pain depends upon the variations in the force of
the traction, depending upon the amount of the stomach contents
and the state of its functional activity.
Adhesions of the omentum and the anterior abdominal wall
are a frequent cause of pain, because the bowel places the omen-
tum on the stretch, by forcing itself into th6 pocket between it
and the anterior abdominal wall. Adhesions between the viscera
if not connected with the anterior abdominal wall cause no
pain unless traction or pressure is made upon the mesentery or
other pain sensitive organs, by the changing relationships or the
hindered movements of the adherent viscera.
In this connection it might bo well to consider the causes of
NATURE OF PAIN FROM ADHESIONS 369
abdominal adhesions. They are the following: (1) tumors, which
form adhesions because of the pressure on, and consequent trau-
matism of, adjacent organs; (2) intestinal ulceration, which is
not an active cause of adhesion formation unless perforation has
occurred; (3) after laparotomies adhesion between the omentum
and parietal peritoneum; and (4) inflammation, particularly that
due to or associated with tuberculosis. Inflammatory lesions of
the gall-bladder are also potent causes of abdominal adhesion for-
mation.
Abdominal adhesions, according to Cumston, are divided into :
(1) A gastric group, including cholelithiasis; ulcer of the stom-
ach and duodenum; traumatism to the stomach, liver, pancreas,
and duodenum ; carcinoma of any of the above-mentioned organs ;
(2) the intestinal group, which is particularly associated with
the appendix and the sigmoid; (3) the pelvic group, which in-
cludes, lesions of the tubes, ovaries, and the uterus; and (4) the
peritoneal group, including all lesions in which primarily the
peritoneum is involved, as in tuberculous peritonitis.
Gastric Adhesions. — The diagnosis of adhesions may be made
easier if it is borne in mind that when adhesion of a viscus to
the anterior abdominal wall or to another organ occurs, pressure
or traction on the abdominal wall, so made that it will tend to
separate the two adhering surfaces, will produce considerable pain.
Thus, in gastric adhesions, if pressure is made on the anterior
abdominal wall in an upward direction, from the region of the
lower border of the stomach, the pain which is present on ordinary
manipulations is greatly increased. If the adhesions are on the
right or on the anterior border of the stomach, pressure made over
the epigastrium will cause the pain to shoot out from the right
over the area of the adhesions. If they are on the posterior gastric
wall, pressure over the first and second lumbar vertebrae will often
cause pain. Adhesions between the anterior abdominal wall and
stomach are not so frequent, and are very apt to be confused with
gastric ulcer. Pain due to intestinal adhesions, as a rule, is sud-
den and acute, and is the result of stenosis of the gut by the ad-
hesions; generally it is of short duration, disappears as quickly
370 ABDOMINAL PAIN
as it came^ and is frequently followed by a diacbaige of fluid feces
or flatus.
Intestinal Adhesions. — ^An interesting case of intestinal adhe-
sions is that of a young lady, whose history is as follows :
Nearly two years before admission to the hospital she began
having acute pains in the abdomen, of a spasmodic character.
During the past year these have become more frequent and are ac-
companied by vomiting and eructations of gas. The attacks
seem to be brought about by eating indigestible foods and exposure
to colds and dampness. She has had two attacks at night without
apparent cause. The menses are painless. The pains are always
relieved by a bowel movement. At first they are diffused over the
abdomen, but soon show a distinct right-sidedness. During the
last attack the pain was mostly toward the median line, slightly
to the right
Operation showed the cecum and adjacent intestinal coils all
matted together by dense adhesions, which, in some places, were
so thick that they had to be cut between ligatures. A tumor, cor-
responding in location to this mass, was felt on the right side
before operation.
Pelvic Adhesions. — Pain due to pelvic adhesions is present
(a) at stool, (b) during micturition, (c) during the menses, (d)
on moving, (e) on subjecting the body to light shock, and (f ) dur-
ing coitus.
A case in point is that of Mrs. X , whose ovary and tube
on the right side, and appendix were removed, drainage being in-
serted because of the pronounced gangrenous state of the appendix.
Some weeks after operation she complained of aching which was
worse after moving, after lying down at night, and on sweeping.
This aching begins in the lower right middle region anteriorly and
extends through to the back in the lumbar region.
Another case is that of Mrs. Y , in whom pain began in
the right side and was constant. She had a feeling as though a
knot were being tied inside her. On the same side a small mass
•was present. A year previous she had had an operation per-
formed, in which the ovaries were removed In this case there
NATURE OF PAIN IN HERNIA 371
was present a band of adhesion, extending from the uterus, its
appendages, and the intestines, to the lateral pelvic wall.
Oeneral Peritoneal Adhesions. — If the pain is due to general-
ized peritoneal adhesions, for instance those following a gastric
perforation, it is often present after eating, and comes on when
the stomach is full or when the patient assumes certain positions.
Pritchard (620) reported a case of abdominal pain, in which
the diagnosis was obscure, but on operation adhesions were found
between the stomach and the anterior abdominal wall. No previ-
ous symptoms indicating inflammation could be elicited ; no ulcer-
ated areas, nor indications of ulcer, could be found. After re-
viewing the case and excluding the gall-bladder, stomach, or duo-
denal ulcers as the cause of the adhesive formation, Pritchard,
because of the presence of an edema of the lower extremities,
without sufficient cause in the same patient a year or two previ-
ously, oflFered the novel explanation that the edema was due to
neurotic influences, and that the abdominal adhesions were the
result of the same influences acting in the abdominal cavity so as
to produce edema of the stomach and duodenum, and consequent
adhesive formation.
Nature of Pain in Hernia. — Because of the mechanical rela-
tionship of hernia to the abdominal structures, it has been thought
wise to consider it in this section. Pain is not a prominent
symptom of simple uncomplicated hernia, except in those cases
wherein the hernia is of sudden development. Here the pain is
due to: (1) Traction on the mesentery. This occurs in the
early stages of the condition. Later the pain is due to: (2) In-
flammation of the bowel, which is the result of deficient circula-
tion, edema, and the presence of toxins. This inflammatory
process causes the contents of the hernial sac to swell, and, if the
neck is small, the hernia becomes strangulated, and the traction
and pull upon the involved mesentery are increased. The inflam-
matory process may also extend to the parietal peritoneum, and
to the pain of the traction there is also then added the pain of
the peritoneal irritation. (3) Peritoneal irritation. The inflam-
mation may progress to such an extent that adhesions finally form
372 ABDOMINAL PAIN
between the peritoneum and the bowel, and then every movement
may be capable of producing pain of a dull, dragging character.
Thus pain of hernia may be due to involvement of the mesentery,
the bowel, or the peritoneum.
The mesentery as a factor in the pain production is generally
of little moment unless the onset of the hernia is sudden, when
there is present, in the majority of cases, a severe, dragging pain,
most frequently about or above the umbilicus, if the hernia is of
the small intestine ; while if it is of the lower bowel, the pain or
distress is generally below this level. The mesentery probably
also receives a few fibers from the cerebrospinal system; and,
when irritation to them occurs, the resulting pain is generally
referred to their somatic distribution. When this is the case, the
area of tenderness and of subjective pain is generally outlined by
the area of distribution of one or more of the spinal nerves.
The ilioinguinal nerve passes out of the abdomen at the exter-
nal abdominal ring, and is distributed to the ilioinguinal region
of the upper and inner part of the thigh to the scrotum in the
male, and to the labium in the female ; hernia, producing pressure
on this nerve, causes pain to be felt as coming from these parts.
Bowel pain proper differs from that of hernia, in that the pain
sensation is due to the carrying of stimuli to the cord, where some
of the cells of the spinal nerves, being stimulated, give rise to
pain sensation, which the brain interprets as coming from the
peripheral distribution of these fibers. The area of tenderness
and subjective pain felt in the distribution areas of these fibers
does not follow the plan of distribution of any spinal nerve or
nerves, but is located in the area of distribution of fibers arising
from certain cord segments, as marked out by Head. The points
of tenderness, which, in many cases, bear no definite relation to the
lesion causing the trouble, are but tlie maximal points of tender-
ness of these cord segments. If the hernia is in the small intes-
tine, the most common site of the referred pain is in the region
of the umbilicus, while in involvement of the large bowel the pain
is located as being below this point; if peritoneal irritation is
present, a local tenderness is felt at the place of the lesion. A
NATURE OF PAIN IN HERNIA 373
part at least of this bowel pain is due to distention of the involved
portion of the bowel by gas. When this factor is present, the
pains are generally paroxysmal, occurring at the time of the
bowel distention, and are eased as soon as the gas and the fecal
contents have passed on; but should the swelling at the neck of
the sac increase, the hernia then becomes strangulated, and to
the other factors producing pain is then added a third, namely,
peritoneal irritation.
In peritoneal irritation the pain at first is slight, and similar
to that described above ; but after it once develops, it is so much
more severe than the other two that they are of minor importance.
The tissues are now exquisitely tender, and are sensitive to the
slightest pressure. It is at this stage that, in case of femoral or
inguinal hernias, the patient instinctively draws up and rotates
inward the leg of the affected side.
The omental hernias are generally not very painful, because
the omentum, of itself, has little pain sensibility; but, in some
instances, as in a case of ventral hernia, where the patient had
suffered from cramps and severe abdominal distress, with vomit-
ing, an operation showed a small omental ventral hernia about
two and one-half inches above the navel and a little to the left of
the median line. There was no localized tenderness.
Pain, as a symptom of simple uncomplicated hernise, is gener-
ally of minor importance. Few of the cases of hernia are acute
in their onset, most of them being the gradual development of
years ; and even when the hernia is acute, the pain symptoms are
not of special diagnostic importance, only in so far as they indi-
cate the special region of the bowel attacked, and the magnitude
of the involvement. In chronic cases there may be a smarting
or burning, which De Garmo thinks most likely indicates an
omental protrusion. The most common pain is of a dragging
nature, and is worse in the evening and better in the morning,
because during the night the intraabdominal pressure is relieved.^
'Sir WDliam Bennett (Lancet, Feb. 2, 1907, p. 270) mentions a ease in
which the hernial sac had a very small opening; and he suggests that it was
due to the accumulation of fluid in the sac, as the day went on, which caused
the pain to be so much more pronounced toward evening.
374 ABDOMINAL PAIN
Anything causing a rise of the intraabdominal pressure, such as
coughing, sneezing, straining, or lifting, is likely to produce this pain.
Strangulated hernia generally gives rise to the greatest dis-
tress, very often present around the umbilicus, and when this is
associated with vomiting the diagnosis of gall-stone colic or gas-
tritis is very apt to be made, and the hernial condition neglected,
while the patient goes rapidly on to his death.
In some cases of steangulatbd hebnia the pain b^ns about
the umbilicus, and thence, as the severity of the lesion increases,
radiates to the region of the strangulation.
Umbilical hebnia is generally associated with considerable
local and referred pain, most of which is probably due to traction
on the stomach from the involved omentum, adhesions existing be-
tween either the stomach or the adjacent omentum and the an-
terior abdominal wall.
In INGUINAL HEBNIA forciWc exteusiou of the thigh is painful.
In some cases of inguinal hernia, also, the pain may be felt in
the epigastrium, and radiates to the back, as in a case reported by
Witherspoon (125, p. 219), in which the patient complained of
pain in the epigastrium radiating to the back, and of tender areas
on either side of the vertebral column opposite the eighth and
ninth thoracic vertebrse. Abrupt pressure over the epigastrium,
centrally, and to either side, over the recti muscles, excited severe
paroxysms of pain. Gradual pressure was well borne. Operation
relieved the condition.
The following is a case of pain due to inguinal hernia.
The patient complained of pain, or rather of a dragging sen-
sation, running from the region of the pubic spine downward and
inward to the scrotum. This pain was made worse by walking,
by lifting, or even by sitting, and was eased on lying down.
He would be all right in the morning, but as the day wore on he
would become so ill that he would have to give up his work, which
was that of a driver on a grocer's wagon. On releasing the
hernia, the pain entirely disappeared. The sac did not seem to
be adherent to the surrounding fascia.
Stockton, in speaking of inguinal hernia, describes a condition
NATURE OF PAIN IN HERNIA 376
in which the complaint is pain generally referred to the lower
quadrant of the abdomen ; it is of a colicky character, and is some-
times burning. There may also be present continuous suffering.
These symptoms are relieved when the patient lies down, and are
increased on active movements, also in lifting. They appear and
disappear at irregular intervals. Examination discloses a patu-
lous internal inguinal canal, not large enough to permit a well-
marked hernial protrusion, but sufficient to cause a bulging outward
of the peritoneum, which is made worse by coughing or straining.
Epigastbic Hebnia. — Epigastric hernias sometimes simulate
gaU-bladder or duct disease, or even a gastric disorder. They
are to be differentiated from the small subcutaneous tumors found
in the epigastrium, and are due to the protrusion of small, fatty
masses through openings in the anterior abdominal wall.
Hernias of the anterior abdominal wall sometimes produce
symptoms of pain which disappear on lying down. Examination
may elicit no apparent abnormality, and the physician is at a loss
to account for the persistent cryptogenic pain which recurs so regu-
larly on motion, or on the performance of tasks involving an in-
crease of the intraabdominal pressure. In many cases, while a
superficial examination shows nothing, a more thorough one may
reveal some slight thickening, or some little localized swelling of
the abdominal wall. When this is found, hernia should be
thought of. When small, there are no absolute diagnostic criteria
of a hernia of this character; but if it is large and reducible,
the gurgling accompanied by the disappearance of the tumor on
reduction indicates the condition. McEwen (919), in speaking
of small umbilical hernias, with a very narrow and distensible
sac, states that the pain (violent abdominal pain) frequently
comes on at an early stage, before any prominent external tumor
has appeared, and he attributes the pain in such cases, in part, to
the cupping of a portion of the bowel in the narrow mouth, and
in part to the distention of the narrow mouth, causing pressure
on, and irritation of, the peripheral nerves.
The pain of femoral hernia in the male may sometimes be
referred to the penis.
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CHAPTER XX
PAIN IN ABDOMINAL VISCEBAL DISEASE
History. — The question of the sensibility of the abdominal
viscera is one which has been much discussed, and, at the present
time, it cannot be stated with certainty that the problem has been
definitely solved. As long ago as 1753 Haller had noted that he
failed to obtain evidence that the internal viscera were sensitive
to painful stimuli, but it has become increasingly evident that the
nervous mechanisms of the visceral activities are exceedingly mani-
fold, and that no adequate explanation of their functions is possi-
ble without a searching investigation of their rich nervous supply.
The work of Lennander and Mackenzie seemed to point to the
fact of there being no pain fibers in these nerves, but that of Koss,
of Kast, and Meltzer has shown that the observations of previous
experiments were faulty and that the ordinary tests which they
used for the elicitation of pain phenomena in the viscera, which
were the same as those used to elicit pain response in the skin,
were not suitable, since the viscera, because of their structure and
position, are non-responsive to these stimuli, but may respond to
other forms of stimuli than do the skin and mucous membrane.
The ordinary facts of digestion prove the response to chemi-
cal stimuli, and also to those of heat and cold, and it is becoming
apparent that some modification of the earlier views must take
place.
The sensibility of the abdominal organs has been, for many
years, a question of debate between two opposing schools, the one
maintaining that the abdominal viscera of themselves were not
capable of producing pain phenomena, the other holding that they
were. Evidently both were right to some extent, for it has been
377
378 PAIN IN ABDOMINAL VISCERAL DISEASE
found that organs which under normal conditions do not produce
pain will, when inflamed, give rise to pain phenomena (Rosthorn).
However, in many cases it must be admitted that the sensibility
to pain shown by the abdominal organs is very unusual, for in
many cases operative interference may be undertaken without
excessive pain production, ovariotomies having been performed
by Riedel (865) and Johnnen without any especial pain. The
uterus is painful only when inflamed (Bernard, 867). AU varie-
ties of abdominal operations were performed by Lennander with-
out pain production, except when traction was made on the mesen-
tery.
For a better understanding of pain production in visceral
disease, it may be well to review the innervation of the abdominal
viscera. The innervation of the viscera is from both the cerebro-
spinal and the sympathetic system. The cerebrospinal or medul-
lated fibers are carried in the vagus and in the splanchnics, and
are distributed to the various abdominal plexuses. Where they
finally terminate is an undetermined question, but it seems likely
that they end in the mesentery. The sympathetic has its own
special nerve system — its fibers pass on farther than those of the
cerebrospinal system, and are ultimately distributed to the ab-
dominal organs, whose functional activities they coordinate and
regulate. They consist of vasoconstrictor, vasodilator, motor, and
inhibitory fibers, etc. (Tigerstedt). They originate in the lateral
horn on the same side of the cord in which they are found, pass
through the posterior ganglion into a nerve trunk, and finally end
in a ganglion, from which fibers are carried to the ultimate distri-
bution area. These ultimate ganglion cells have no connection
with each other. All the sympathetic fibers do not arise in the
cord, many of them arising in the posterior ganglia, or from the
abdominal ganglia themselves. Mackenzie, Peterson (72), and
others hold that the sympathetic system is oldest in origin, and
that the cerebrospinal system is merely an outgrowth of the sym-
pathetic, and has been built up for its protection. This may be,
as remarked by Mackenzie, the reason for its proneness to convey
pain, one of the functionally protective sensations. In this way
Fia. 81. — ScHKME OF Innervation or Abdominal Viscera.
The above diagnumnatic drawing shows the reason for the tendency of
diseases of the gall bladder, pancreas, duodenum, the pylorus and the
greater curvature of stomach, to cause pain on the right side of the
body; while lesions of the lesser curvature, fundus, spleen and pan-
creas have a tendency to produce pain on the left side of the bodj.
Drawing modified from Spaltebolz.
379
380 PAIN IN ABDOMINAL VISCERAL DISEASE
it guards, against injury, the internal organs supplied by the sym-
pathetic, which ordinarily has no direct pain-conducting sensi-
bility, as such is generally understood. The sympathetic contains
both afferent and efferent fibers, but it is only the afferent which
may, under unusual circumstances, be concerned in the conduction
of pain stimuli. Ordinarily, these nerves are incapable of con-
veying impulses which are interpreted as painful ; but under cer-
tain modifications, such as are produced by injury, a change of
irritability may take place, so that stimuli which ordinarily do not
produce pain now give rise to the most excruciating agony. Such
modifications have been observed, especially by Buch and Macken-
zie. Buch, on correlating the researches of Wutzer, Florens,
Brochet, Valentin and Longet with his own clinical findings, con-
cluded that a normal sympathetic nerve is incapable of carrying
pain-producing stimuli ; but that, when inflammation ensues,
some change in its excitability occurs, so that, instead of the dull
perception, whijsh it previously had, it acquires an exquisite sensi-
tiveness, so that pinching, pressing or dragging on it is very pain-
ful. This increase of sensitiveness can also be produced by con-
tinued electrical stimulation, or by stretching of or pressing upon
the nerve (Lemmering). Bitter, after experimenting on dogs,
concludes that the fibers conveying the impulses interpreted as
painful run in the nerves distributed to the blood vessels, for he
found that ligation of the vessels was much more painful than
irritation of the parietal jieritoneum or traction on the mesentery.
This is in accord with the statement made in a previous chapter,
to the effect that in the internal organs it is probable that the
sensory fibers accompany the vasomotor nerves. Should such be
the case, it is likely that the pain-conveying fibers are collected
into the same ganglia, or in the ganglia associated with those of
the vasomotor nerves. It has be(n found that the vasomotor cen-
ter for the stomach and upper intestine is in the plexus coeliacus
(Buch, 171; Pincus, 465; Budge, 406; Techlenburg, 467;
Lowen, 468, and Boer) while Laignel Levastine located the vaso-
motor center for the liver in the right semilunar ganglion, and the
vasomotor center for the spleen in the left semilunar ganglion^
HISTORY 381
and the vasomotor center for the small intestine and the upper
part of the large intestine in the superior mesenteric ganglion.
From the association of the vasomotor and sensory fibers, it
would seem that these ganglia also are the sensory centers for the
dependent organs. Lennander, however, states that it is traction
of the mesentery which, in turn, produces pull and traction on the
sensory (cerebrospinal) filaments in its substance that produces the
visceral pain. The apparent discrepancies between the statements
of Ritter and Lennander may be due to the fact that Ritter's ob-
servations were made during experiments on animals, while Len-
nander's were made during abdominal operations. On one fact
all observers are practically in accord, and that is that the
parietal peritoneum is very sensitive; and there is also concord
in the belief that the viscera themselves are but slightly sensi-
tive to pain. These latter views are in accord with observations
of physicians from time immemorial. Perhaps the oldest exam-
ple is in Xenophon's ^^Anabasis," wherein mention is made of
Xakarchos, the Arcadian, being wounded in the abdomen in battle,
and coming in flight, holding his entrails in his hands. Then, as
we pass down the ages, here and there examples are given of the
insensitiveness of the internal viscera. Haller, about one hundred
and fifty years ago (1753), noticed that the liver, spleen, kidneys,
heart and lungs possessed little sensibility; that the parietal peri-
toneum was slightly sensitive, while the visceral peritoneum was
entirely without sensation. He also states that the subcutaneous
coat is very sensitive, while the mesentery has no sensation. In
this connection, I shall quote in pxtenso from Meyers, who has so
well described the progress of our knowledge in this direction. lie
says that "Bichat noticed, at the end of the eighteenth century,
that electrical, chemical and mechanical stimulation of the organs
supplied by the sjTupathetic system do not produce pain." This
agrees with the clinical findings of Prony (343), who states
(1821) that Bichat had seen dogs devouring their own intestines
and tearing their own peritoneum, which had prolapsed through
abdominal wounds. Many observations have been made on man,
seeming to show absolute insensitiveness of the abdominal viscera
382 PAIN IN ABDOMINAL VISCERAL DISEASE
(Mitchell, 263, in the year 1872 ; Bier, 331 ; Mackenzie, 332 ;
Lennander, 380; Hofmeister, 869; Gushing; Block, 870; Mitch-
eU, 840; Partsch, 871).^
The absolute reliability of these deductions has been ques-
tioned by Kast and Meltzer, and more recently by Neuman. Kast
and Meltzer claim that the insensitiveness to pain present in the
abdominal viscera under local cocain anesthesia is due to the gen-
eral toxic action of the cocain, which so reduces the sensitiveness
of the internal viscera that they no longer respond to stimuli, to
which, without the cocain, they would respond and which, being
carried to the cerebrum, would be interpreted as pain. These
deductions are apparently controverted by Mitchell (155, pp.
200-201), who, under hypodermic subcutaneous injection of
normal salt solution, was able, after the peritoneum had been
opened and the intestine delivered, to seize it with a clamp, rub
it with gauze, and prick it with a needle, all without the produc-
tion of pain.
The pain sensations from the abdominal organs are probably
'It 18 claimed by Lennander that none of the abdominal viscera is sen-
sitive to pain, and that when pain occurs it is due to the following causes
(given by Kast and Meltzer, 134, pp. 1017-1019). (1) pressure, sliding or
pulling of the parietal peritoneum; (2) pulling of the mesentery, and thus
irritating the posterior wall of the abdominal cavity, which is provided with
pain fibers derived from the spinal nerves; (3) lymphangitis and lymphaden-
itis occurring and reaching the nerves of the posterior wall; (4) irritating
toxic products or chemicals, like HCl in gastric ulcer, reaching the lymphatics
of the posterior wall.
Maunsell Moullin says that the effect of traction on the mesentery is
the same, whether there is a "free mesentery or whether the peritoneum
is reflected from the sides of the viscera, leaving a portion of the circumfer-
ence of the bowel attached to the parietes by cellular tissue'' (Moullin). In
this case, besides the stimulation of the nerves in the peritoneum,' there would
be traction upon the nerves in the connecting tissue. These nerves are de-
rived directly from the cerebrospinal system, and any traction upon them
would be referred as pain to the distribution area of their somatic branches.
It is a well-known fact that the surfaces of the internal viscera are not
painful to pressure, pinching or squeezing, nor to heat and cold. Their
only function is reference of impulses having to do with the well-being of
the organism; and in cases of inflammation, as suggested by Lennander (23),
it is possible that toxins may be carried by the lymphatics to the nerve fila-
ments, thus rendering them more sensitive, so that they respond to stimuli
with a reaction which is called pain. Inflamed organs are slightly more sensi-
tive than organs not inflamed.
HISTORY 383
carried chiefly by the vagus and the greater splanchnics ; both con-
tain medullated fibers, found, according to Edgworth, in the vagus
at the level of the diaphragm. This view is opposed to that held
by Lennander and Meyers (122), that the sensory fibers of the
vagus do not e!xtend below its recurrent laryngeal branch. Edg-
worth also makes the observation that on the warming of the
vagus its conductivity seems to increase.
As to the manner of production and conduction of the visceral
pain impulse little is known, though it is held that the pain is:
(1) "due to induction of a current in adjacent fibers in a manner
comparable to the electrical induction in two adjacent but uncon-
nected nerves" (probably not correct) ; or (2) that the "nerve cen-
ter, spinal or cerebral, which receives the afferent impulses is so
unduly excited that in its disturbed condition it attributes the
afferent impulses to the wrong afferent nerve" ; or it may be possi-
ble (3) that "transference may take place in the sensorium."
Although the method of the production and conduction of the
impulse is in doubt, yet no doubt exists as to the actuality of its
presence. A peculiarity of its perception is that it is not felt in
the organ in which it is produced, but is referred or reflected to
the body wall, where it becomes either the so-called somatic pain,
or is perceived as a form of hyperalgesia.^
Location of Pain. — That the pain of visceral disease is not
necessarily located directly in the involved viscera may be seen
from the following :
(1) On movement of the involved organ there is no change
in the character or location of the pain :
(a) 'Movement of the heart produces no change in the char-
acter of the anginal pain. If the pain were in the heart itself,
each contraction of the heart would produce a change in the char-
acter of the pain.
(6) Peristaltic contraction of the stomach produces no change
in the type of the pain of gastric ulcer ; also, changes in the posi-
^ThiB view has recently been very strenuously opposed by Hertz, who
claims that pain sensation can reside in the internal viscera themselves
(Hertz, 106b, p. 48).
384 PAIN IN ABDOMINAL VISCERAL DISEASE
tion of the stomach due to respiration produce no change in the
location of the pain. If the pain were located in the stomach,
movement or change in the position of the organ would of neces-
sity produce a change in the character or location of the pain.
(2) The pain is not located directly over the diseased area
in the involved organ ; indeed, it may not even be over the organ
at all :
(a) Cardiac anginal pain may be felt down the arm or even
up in the neck.
(6) Pain of gastric ulcer is not directly over the site of the
ulcer, as has been proved, time after time, by operations.
(3) The area of hyperesthesia may be distributed over a
much wider area than that under which the organ is located.
Transference of Pain. — Because of the apparent non-location
of pain in the diseased viscera producing it, many attempts were
made to explain the relationship between the area of pain and
disease in the viscera. The most successful of these was by Head,
who, in a thesis read before the University of Cambridge, in June,
1892, and before the Neurological Society of London, November
10, 1892, first opened the way for the study of peripheral sensory
manifestations of visceral lesions. He claimed that the manner of
transference of pain sensation is this: that the stimulus affects
the peripheral distribution of a nerve distributed to a viscus, and
that this stimulus is carried to the cord and enters the sympathetic
system through the sensory root posterior to the ganglion. In the
cord the nerve cells of these fibers (from the sympathetic) come
into intimate contact with the cells of the fibers from the periph-
eral sensory system, and incite them to reaction, so that stimuli
occur, and are transmitted to the brain, so that the brain centers
perceive them as coming from the peripheral distribution of these
same somatic or body nerves.
By a reference to Figs. 31, 32, 33, it may readily be seen how
the stimulus can be reflected from one set of neurons to another
set ; and it is thus that the excessive irritative stimulus arising
in the splanchnic area is interpreted in some distant area as pain.
Head has laid down a law particularly applicable to this state,
TRANSFERENCE OF PAIN 385
namely, "that where & painful stimnlua is applied to a part of low
sensibility, in close central connection with a part of much greater
sensibility, the pain produced is felt in the part of higher sensi-
bility, rather than in
that of lower sensi-
bility to which the
stimulus is actually
applied."
Wilamowski'a
(109 b) experiments,
while confirm-
ing Head's deduc-
tions, show, in some
eases, areas of re-
duced sensibility cor-
responding in outline
to the areas of in-
creased sensibility in
other cases. He be-
lieves that this hypo-
algesia obeys the
same laws and
subject to the same
influences as the cor-
responding hyperal-
gesia, and that both are of the same origin.
In this relation it was noticed by Mackenzie that in but very
few cases does the hyperesthesia associated with visceral disease
occupy the entire area of distribution of a particular nerve, as
the area of cutaneous hyperesthesia associated with cardiac dis-
ease does not extend throughout the entire area of distribution of
the fourth dorsal nerve, but is generally confined to the skin on
the anterior surface of the chest. It does not pass around to Hie
posterior surface; also, it is sharply delimited at the clavicle, and
does not spread upward into the area of distribution of the fourth
cervical, which lies above the clavicle. It may extend down the
Fio, 82. — Figure Showing the Anterior Dsi-
TRiBunoN of the Ninth, Tenth, Eleventh
AND Twelfth Dorsal Nerves.
The shaded parts indicate the areas in which
pain is most frequently observed in abdominal
visceral disease.
386 PAIN IN ABDOMINAL VISCERAL DISEASE
inner side of the arm and forearm into the areas of distribution
of the second and third dorsal. Mackenzie (110b) claims that
these fields of hyperesthesia are not accurately defined, that they
may overlap each other, and that they are not particularly limited
to any definitely defined, special area. These areas of hyper-
algesia of Mackenzie are most likely nothing but the zone areas of
hyperalgesia, as described by Head, whose work at that time was
unfamiliar to Mackenzie.
In some cases the visceral lesion may produce an irritable
focus in the cord, so that stimuli coming to this place would be
perceived as pain, while normally they would not be so per-
ceived, or, in some cases, would not be felt at all. For instance,
the liver and the stomach receive their nerve supply from the
same segment of the cord. Liver disease may produce such an
irritation of this segment, that, on the entrance of food into the
stomach, the nerve impulses from the stomach to the cord, which
ordinarily are not painful, would then be perceived as painful.
Such examples we all have seen, and, in many cases, they lead to
a wrong diagnosis (Mackenzie).
Persistence of irritability of associated segmental areas of the
cord may explain the presence of hyperalgesia, due to excitation
of these associated areas. Thus, in a case of gall-stone colic (Mac-
kenzie), in which there was jaundice, there was also extreme hy-
peralgesia of the skin of the upper part of the abdomen, especially
marked in the epigastrium. This persisted for some days after
the stone had been passed and had been found in the stool. Dur-
ing the time the hyperalgesia persisted food taken into the stom-
ach produced severe pain in the epigastrium. With the disap-
pearance of the hyperalgesia of the skin the pain on taking food
ceased.^
Mackenzie, in continuing, says that "here there seems little
doubt that the stimulation, set up by the ingestion of food, which
passes to the spinal cord normally unperceived, reached that por-
tion of the cord which had been abnormally excited by the gall-
1 This association of pain with the ingestion of food may also be due
in many cases to the associated peristalsis set up in related organs by the
entrance of the food into the stomach.
TRANSFERENCE OF PAIN 387
stone colic, and had hjpersensitized the centers of the cutaneous
nerves for pain which supply the epigastric region,"
Shock, also, sometimes affects certain cord areas, as in per-
sons who experience pain in a certain area (hyperalgesic) when
startled, Mackenzie's explanation is that when startled a stimulus
passes down certain tracts in the spinal cord, affecting normally
the centers of the muscular nerve supply, as evidenced by the
sudden contraction of nearly all the muscles in the body. The
stimulus is not of sufficient strength to affect the sensory nerve
centers in a healthy cord, unless there are abnormally irritable
foci in the cord. However, if such should be present, the stimulus
in passing through them affects the excitable sensory nerve centers,
and pain arises and is referred to the peripheral distribution of
the nerves stimulated. It may also happen that pain is produced
by a stronger and more powerful contraction of the excitable and
hyperalgesic muscles.
Some mention should be made of the views of Hertz, who has
carefully discussed this whole question in his 1911 Goulstonian
lectures ("Sensibility of the Alimentary Canal"). He points out
that Lennander and Mackenzie did not take into consideration
the fact that a nerve ending may be sensitive to one form of stim-
ulation and may be insensitive to another. The one is an ade-
quate, the other an inadequate stimulus. The eye does not react
to sound stimuli, nor the taste buds to those of light. Thus, the
abdominal viscera, not being exposed to touch, are probably not
stimidated by touch stimuli, but that they react to adequate stim-
uli there is no question. All that the older observers showed
was that pinching, pricking, cutting were not natural, adequate
stimuli. The fact of the matter is that the abdominal viscera are
exquisitely sensitive to deep-pressure stimuli, such as th^se pro-
duced by tension. Thus, slight distention of the intestinal mus-
cular coat leads to discomfort, and marked stretching to severe
pain.
The normal stimuli reactions in the intestine are those of
contraction and relaxation; these two are going on continuously.
There is, as Meltzer has pointed out, a law of contrary innerva-
388 PAIN IN ABDOMINAL VISCERAL DISEASE
tion, which permits of this wave of contraction and relaxation,
and any interference with this law, such as occnrs in colic, in
obstructions, etc., gives rise to paroxysmal and severe pain.
The pains of gastric ulcer and duodenal ulcer are to be thus
interpreted. In colic an abnormally strong peristaltic wave
occurs in one part of the alimentary canal, the part immediately
below which should normally relax, following the law of con-
trary innervation, is unable to do so, owing to organic disease, or
to spasm; the intermediary segment is thus subjected to steadily
increasing pressure, which soon produces pain, the distention be-
ing the adequate stimulus.
Hertz believes that the only cause of true visceral pain is ten-
sion. Thus, a study of the visceral pains resolves itself into an
analysis of the two forms, the tension pains and the reflex pains,
which, as has been pointed out, are exceedingly rich and varied,
and of great diagnostic value topographically.
Even with the adequate stimulus, however, the intestines are
much less sensitive than is the skin to its adequate pain stimuli.
The inaccuracy of localization of the tension pains is no argu-
ment against them, since the brain is the perceiving organ and
it registers the general topography of an organ, not its variations
in location, as, for instance, in the movements of the stomach.
Thus, there is no valid reason why the pain of a gastric ulcer
should vary with every movement of that viscus. With the vis-
cera, however, which move the least, the localization of pain re-
mains the most stable, other things being equal.
Should the resistance of the patient be lowered from any
cause, such as occurs in the anemic and weakened state which
follows upon a severe fever or illness of any kind, it has been
found that reflected and referred pains are much more likely to
occur.
After the elicitation of referred or reflected pain, it is neces-
sary to localize the viscus producing it. The technic is the fol-
lowing: (1) delimit the area of hyperalgesia as nearly as pos-
sible, and orient it with a cord segment; (2) find out what or-
gans are supplied by this segment; (3) examine the organ or or-
TRANSFERENCE OF PAIN 389
gans for disease; (4) see if, by manipulation of the organ, the
pain can be reproduced.
The transmission of stimuli to the cord also affects the mus-
cular centers which lie adjacent to the sensory centers involved.
These stimuli augment that which is normally present in the
muscle, and, instead of the normal tonicity, cause a state of tonic
contraction. This contraction may be limited to a portion of a
muscle, may involve the entire muscle, or may affect several
muscles whose centers lie adjacent to each other. This muscular
center hypersensibility also accounts for the exaggerated reflexes
(principally abdominal) which are so often present in visceral
diseases.
As irritation of the viscera causes pain to be referred to
certain areas, it has been found that stimulation of these areas
also is referred back and causes reflex changes in the viscera.
CHAPTER XXI
DIAGNOSIS OP ABDOMINAL PAINS
NATURE OF VARIOUS ABDOIONAL PAINS
The lesions of the abdominal viscera producing pain are prin-
cipally those which cause contraction, active spasm, or excessive
passive dilatation of the involuntary muscle fiber in the walls of
these viscera. Inflammation of the viscera also causes pain ; but
in many cases ulceration of a hollow viscus may exist for years
without producing the slightest distress. This is well exempli-
fied in ulcers of the stomach, gall bladder and appendix (Moullin
and others).
In nearly all cases in which a severe and long contraction of
a hollow organ is present, there is, above the area of contraction,
an area of dilatation^ so that, at the junction of the contracting
segment with the dilating segment, a place is present where trac-
tion on the mesentery is severe and prolonged. It is likely that
this traction and pulling cause the excruciating pain of intestinal
and other hollow viscera colics.^ That excessive passive dilatation
of an abdominal organ may cause pain, is verified in many cases,
such as when tympany of the stomach or colon, with severe pain,
comes after operation. After relief of the dilatation by the pas-
sage of the stomach or rectal tube, the pain disappears. Many
have experienced the sense of discomfort and distention after the
ingestion of a hearty meal, and it is easy to understand how this
disagreeable sensation, if the distention of the stomach were pro-
longed beyond the limits of its normal capacity, might be in-
1 Hertz claims that coUc is due to an irritation directly on the sensory
terminal fibers in tbe muscle layer of tbe visceral waUs.
390
NATURE OP VARIOUS ABDOMINAL PAINS 391
creased to one of actual pain. There are many cases, also, in
which, during dilatation of the stomach for the purpose of record-
ing its capacity, the patient complains of a sharp pain in the
epigastrium. These are but isolated examples of conditions which
are very common.
In the spasmodic contractions and the dilatations of hollow
viscera the pain i% generally referred to the body wall, and hence
is called somatic. The point of reference, in many cases, is some
distance away from the location of the lesion. Thus, the pain
felt in stomach distention is in the epigastrium, immediately be*
neath the ziphoid cartilage, at a point that is somewhat remote
from the region of the stomach as projected on the abdominal
walL The logical way to explain the apparent non-association of
the area in which the pain is felt with the organ in which it is
produced is that these remote r^ons are in relation with one
another by means of nerve connections. An explanation of this
seeming inconsistency may be formed from a study of cord zones,
as elucidated by Head. It is known that the stomach is supplied
by the seventh, eighth and ninth dorsal visceral zones, and that it
is especially related to the seventh zone. It is also known that
the maximum point of tenderness and sensibility of the seventh
zone is in the epigastrium, immediately beneath the ziphoid.
Therefore, in any lesion of the stomach which may be painful,
the pain, as a rule, is reflected to this point, or to an analogous
area on the back opposite the ninth or tenth dorsal spine. These
pains are spoken of as reflected pains, and should more properly,
perhaps, be considered under the class of pains which are felt at a
distance from the lesions causing them, such as referred, reflected,
transferred and associated or sympathetic pains.
Referred pain is frequent in lesions of the nerves or of the
centers of these nerves, which supply the integument of the an-
terior abdominal wall.
Under referred pains are to be placed those due to tabes
dorsalis, tuberculosis of the vertebrae, fracture of the verte-
brae, osteoarthritis of the spine, insufficiency of the vertebrae,
spinal meningeal inflammation or tumor, neuritis of the lumbar
392 DIAGNOSIS OF ABDOMINAL PAINS
or dorsal nerves, pressure by growths, inflammatory products, or
broken ribs upon the nerves, pinching of the nerves (especially
of the last two intercostals) between the adjacent ribs, diaphrag-
matic pleurisy and rheumatism of the diaphragm, and aneurysm of
the abdominal aorta. Acute mediastino-pericarditis, from direct
extension, sometimes causes pain to be felt in the higher epigastric
and lower breast region. For a proper consideration of all these
pains, the reader is referred to the section under which referred
pain is considered.
Reflected abdominal pains are the most common variety, and
probably number fifty per cent, of all varieties of visceral pain.
They are the result of a stimulus applied either to a sympathetic
or to a cerebrospinal nerve. This stimulus is carried to the
posterior horns of the cord, and actively stimulates other asso-
ciated sensory fibers. The stimulus is then perceived as pain,
and the sensation is referred to the peripheral distribution of the
stimulated sensory neurons, and thus it occurs that the peripheral
distribution of the pain may be in an altogether different region
from that in which the stimulus originated.
Transferred abdominal pain is that form of pain in which the
impulse is transferred, either directly across the cord to the other
side, or to a higher or a lower level in the cord, thus changing
the location of its peripheral distribution to a higher or lower
level on the body wall. This is one of the most annoying pains
to interpret. It may be found in the opposite side of the abdomen
in appendicitis, pus tubes, diseased ovaries, renal calculus and
pelvic peritonitis. Pain transferred to a higher or a lower level
than that of the disease is illustrated by the abdominal pain in
pneumonia (q. v.), the clavicular pain in extrauterine pregnancy,
and the pains over the fourth costal cartilage (left side) in disease
of the common duct
The shoulder pain, which may be present in diseases of ab-
dominal organs, has been considered by Peter to be due to phrenic
nerve irritation, which carries the stimulus to the roots of the cer-
vical nerves, from whence the sensation is referred as pain to
their area of distribution (Mackenzie and Peter).
NATURE OF VARIOUS ABDOMINAL PAINS 393
Sympathetic pains are sometimes produced when the irrita-
tion of a center in the spinal cord is so great that other adja-
cent centers are stimulated and send impulses to the brain,
so that pain is also interpreted as coming from their distri-
bution areas. This may happen in acute appendicitis when
the cord segments above and below the segment connected with
the appendix are irritated and refer pain to their -area of dis-
tribution.
By reference to the diagram of pain paths, it may readily be
seen how the various paths are propagated and conveyed. It
SHOULD ALWAYS BE BORNE IN MIND THAT IT IS IMMATERIAL WHAT
PART OF A NERVE-CIRCUIT IS AFFECTED; THE PAIN WILL ALWAYS
BE INTERPRETED AS COMING FROM THE PERIPHERAL DISTRIBUTION
OF THE NERVE FIBERS WHICH ARE INVOLVED.
Regional Pains. — For the zone segments involved in disease
of the different viscera see Figures 24, 25, 26. Each zone segment
has one or more maximal points of tenderness which are
sensitive in any painful disease of the viscera supplied by this
special segment. It should be noticed that the term "painful"
diseases of the viscera is used ; for, as is known, every disease of
the abdominal viscera is not painful; and while the majority of
the visceral diseases at some period of their development become
painful, there is a well-defined percentage which never do. The
peculiarity of these nonpainful diseases may be accounted for
from the fact that, in the evolution of the disease, the parietal
peritoneum or the peritoneal attachments, as the mesentery, meso-
appendix or mesocolon, have never been involved. We have
already seen that Lennander explained all abdominal pain as a
result of pulling, pressure or traction upon the peritoneum. In
this relation, I would like, by means of an interpolation, to call
attention to the experiences of physicians of a previous genera-
tion, who frequently groped in the dark in a vain attempt to cor-
relate the symptoms and the disease seen in their patients. A
case in point is one in which pain extended from the midline
posterior above the hip to the midline in front, in which shingles
were present. The patient, a woman, died on tlie third day of
394 DIAGNOSIS OF ABDOMINAL PAINS
the disease, and on autopsy an inflammation of the peritoneum
and appendix was found. **During life it was quite impossible
to form a reliable opinion as to the nature of the lesion which
gave rise to the pain. In view of our later knowledge, we would
be able to diagnose the difficulty with ease'' (McCall Anderson,
860). A full discussion of these views will be given in a subse-
quent chapter.
One of the first results of abdominal pain is the crippling of
the respiration. This is noticed especially in men, who are accus-
tomed to use the diaphragm in respiration much more than
women. Where painful intraabdominal disease occurs, the dia-
phragm' partakes of the reflex of all other muscles, and becomes
rigid and motionless, so as to protect the diseased area. As a
consequence, abdominal respiration is hindered or abolished.
EXABONATION FOB PAIN
After this necessarily brief consideration of the pathology of
various abdominal pains, it is in order to consider more closely,
and in a more detailed manner, the routine examination for ab-
dominal pain and tenderness. After that, it may be permissible to
review the various divisions of the abdomen, and the pains which
lie within their borders. In the examination of the abdomen for
pain, the routine is as follows:
Localization of Pain. — The patient should be recumbent,
the shoulders raised, knees flexed, mouth open, and the breath-
ing regular and easy. The examiner's hand should then be laid
flat over the abdomen, at first with very slight pressure, to elicit
general tenderness; then the fingers should be pressed in with
more force, in order to elicit localized tenderness at special points.
The tips of the different fingers should now be successively de-
pressed, in order to define more accurately the localization of the
area of tenderness. After the location of an area of tenderness,
it is well to determine its extent by concentric palpation. Con-
centric palpation is made by starting from the periphery and
gradually making pressure towards the point of greatest tender-
EXAMINATION FOR PAIN
ness. In this way the area of hypersensitiveneas and the point of
greatest pain are determined.
Localizstioii of the Organ Producing Pain.— After deter-
13
Bnleriti.
Usd oollo
Fig. 83, — Antekiok View op Abdominai.
Zones with Corresponding Organs.
Midline pain may he due to hernia of the
linea alba. Pain over entire abdominal
wall with tenderness on pressure indicates
rheumatism of the abdominal muscles.
Pain over any part of the abdomen may
be found to be due to disease of the
vertebra (caries, sarcoma, etc.).
vfieeTDptoaii'
i-^ Rupluredeiln
13 H«rau
mining the presence of pain, it is in order to locate the organ pro-
ducing it. For the purpose of localization, the ahdomen is divided
into three regions: (1) the upper, (2) tlie middle, and {3) the
lower. The upper, which lies in tlie angle formed by the costal
margins and a line connecting the lowest points on the costal
arches, practically coincides with the epigastric area. The middle
396
DIAGNOSIS OF ABDOMINAL PAINS
area lies between this zone and another line connecting the two
iliac crests. Below this, and bounded at the base by the iliac
and pubic bones, is the lower zone. Each of these areas is divided
by a line extending from the ensiform cartilage to the pubes into a
right and a left region, and the middle zone is divided by an
Aneurysm of the^ ^
descending aorta
(Liver
■I Lungs
(Pleura
( Kidney
•I Spine
(Lumbago
— — —1— — — — - Sacroiliac disease
Fig. 84. — Posterior View of Abdominal Zones.
imaginary line passing down the extreme lateral aspect of the
body into an anterior and a posterior zone.
In the annexed figure an attempt is made to outline the organs
producing painful affections of each zone. In the upper zone,
which is included between the diaphragm and the zonal line divid-
ing the middle zone from the upper, two lateral zones are present
at either side beneath the ribs. They are called the hypochon-
driac zones. Reference to the figures will show the organs giving
rise to pain in each zone.
Lesions Causing Epigastric Pain. — In considering the re-
gional localization of abdominal pain it is well to pay at least
partial attention to the great variety of lesions to which pain in
the epigastrium may be due ; for, owing to the presence in the epi-
EXAMINATION FOR PAIN 397
gastrium of the solar-plexus, with its somatic peripheral distribu-
tion, pain in this region may be symptomatic of a lesion of almost
any of the abdominal organs. The organs most frequently causing
epigastric pain are:
(1) The Stomach. — The pain is very often associated with
vomiting, and generally bears some relationship to the ingestion
of food. It is found in acute gastritis, gastralgia, hemorrhage,
ulcer, perforation, injury, carcinoma, and obstruction from any
cause.
(2) The Intestines. — The pain is due to hemorrhage, rupture
from ulcer or injury, obstruction accompanied by increase of peri-
stalsis, and the formation of a tumor.
(3) The Appendix, — In all forms of acute appendicitis pain
is present at first in the epigastrium, but quickly radiates to the
right iliac fossa.
(4) The Liver, Gall Bladder and Ducts, — In acute peri-
hepatitis breathing is painful, and localized tenderness is present ;
biliary colic is often followed by jaundice ; in cholecystitis the en-
larged gall bladder can be felt, and chills and fever are generally
present; in rupture of the gall bladder or of the ducts symptoms
of peritonitis rapidly supervene; in carcinoma there are general
signs of the disease, such as emaciation, and a positive hemolytic
test. According to Kiedel, ninety-seven per cent, of epigastric
pains are due to gall-stones.
(5) The Pancreas. — In acute pancreatitis there generally is
a history of previous gall-stone disease, with no cholecystitis, and
no signs of a gastric lesion.
(6) The Kidney. — In renal colic, pyonephrosis and hydro-
nephrosis there are urinary findings, such as blood or pus in the
urine, to indicate the disease.
(7) The Spleen. — Splenitis, or traumatic rupture, may
cause epigastric pain.
(8) Ectopic Pregnancy. — Kupture of an ectopic pregnancy
sometimes causes epigastric pain.
(9) Locomotor Ataxia. — Locomotor ataxia causes a pain
which may be referred to the epigastrium. There are also present
398 DIAGNOSIS OF ABDOMINAL PAINS
other signs of the disease, such as Romberg incoordination and
Argyll-Robertson pupil.
(10) Pneumonia, — In pneumonia there are signs of lung
consolidation.
(11) Pelvic Lesions, — Embolism of either the superior or
the inferior mesenteric artery may be present, and produce epi-
gastric pain with all the symptoms of bowel obstruction, but of
much greater severity; in these cases some other grave disease,
from which the clot obstructing the vessel is derived, is also
present
(12) Adhesions between any of the organs underlying the
seat of pain may also be the cause of pain.
Character of the Epigastric Pain, — If the pain in the epigas-
trium is sudden and severe, and does not follow a straining effort,
examination should be made for:
(1) Appendicitis, which, if present, finally causes the pain
to become localized in the appendix area. Typhoid fever, which
in some cases, when it is of sudden onset, commences as a severe
abdominal pain, and has often been mistaken for appendicitis.
(2) Cholecystitis, in which the pain finally becomes local-
ized to the right hypochondrium.
(3) Acute hemorrhagic pancreatitis, in which the pain re-
mains in the epigastrium.
(4) Perforating ulcer, in which the ])ain remains where it
first appeared for but a very short time, and soon, because of the
development of peritonitis, becomes generalized ; or, in some cases,
owing to extension of the exudate may at first be most severely
felt in the pelvis.
(5) In obstructed intestines the pain, as a rule, has a ten-
dency to ascend toward the eiisiforni, until tympany becomes ex-
cessive, when it is felt over the entire abdomen.
(6) In perforated gall-bladder the pain remains in the
region of the gall-bladder, or passes down to the appendiceal
region, until generalized peritonitis develops, when the pain be-
comes diffused over the entire abdomen.
Sudden abdominal pain, following a straining effort and not
EXAMINATION FOR PAIN 399
confined to the epigastrium, may be due to: (a) hernial strangu-
lation; (6) ruptured extrauterine pregnancy; (c) ruptured ap-
pendix; (d) tearing of peritoneal adhesions; (e) rupture of
a cystic tumor; (/) twisting of an ovarian tumor or cyst on its
pedicle.
As they will not be extensively considered elsewhere, a little
time will be devoted here to cysts in which the pain is of sudden
onset, very severe, and paroxysmal, sometimes continuous. The
cause of the pain is torsion of the pedicle (ovarian cyst or tumor).
This causes an extravasation of blood into the tumor substance
and a consequent rise of internal cystic or tumor pressure with
tension and traction on the capsule. Such an increase is espe-
cially apt to occur when the return circulation through the veins
is obstructed. Should the capsule be lax, and the capacity of the
tumor great, the pain from extravasation may not be great, even
though symptoms of hemorrhage may supervene. Should the tor-
sion occur in the pedicle of a wandering spleen or of ^ prolapsed
kidney, the pain may be due to a beginning necrosis of the tissue,
although it would seem more logical to define the increased in-
tracapsular tension as being the active and potent cause. Pain,
while of the greatest use in the diagnosis of twisted pedicle, is not
of paramount importance. Richardson says that "a history of
tumor, a sudden enlargement and tenderness in that tumor, pre-
ceded or accompanied by pain, are sufficient to make the diagnosis
of twisted pedicle."
If the abdominal pain is due to irritation of the sympathetic
fibers, it is present at first, as a rule, in the central part of tiie
abdomen and later becomes localized more definitely to the area
associated with the diseased organ or organs. On the contrary,
if the cerebrospinal nerves are involved, from the development
of a peritonitis, the pain is localized directly over the aifected vis-
cera. Bed clothing cannot be tolerated, and the abdominal mus-
cles are rigid. The rigidity of the abdominal muscles over the
diseased area is the result of somatic muscular reflex contraction.
Hyperesthesia of the skin over the affected viscera is also present.
This sensitiveness is generally not so sharply delimited as is the
400 DIAGNOSIS OF ABDOMINAL PAINS
reflex tenderness from visceral disease. It is most severe at the
site of the most severe" inflammatory reaction, and diminishes
concentrically from this point.
Sudden abdominal pain is diffuse, or is localized in the umbili-
cal region (where the solar-plexus, the so-called abdominal brain,
the sensorium of the abdominal viscera, is located). This pain
may be associated with shock and collapse, which, when present,
are fairly certain indicators of a severe abdominal lesion. In
the condition of shock the associated symptoms of importance are
a rapid pulse, obliteration of the liver dullness (look for rupture
of a viscus), and rigidity of the abdominal musculature.^
Should the pain result from rapid and extensive extravasations
of septic material, it is sharp, sudden and overwhelming. It is
often ushered in by a feeling as though something had given
way. At first it is continuous, violent, and almost unbearable;
later it becomes paroxysmal and intermittent, or is dull and con-
tinuous. The pain, which at first is localized sharply in the
region of the extravasation, becomes generalized as the septic ma-
terial spreads throughout the abdominal cavity. When the peri-
tonitis becomes diffused and the bowel distention is excessive, pain
usually subsides, and when it does so, it is a sign of grave signifi-
cance (Richardson).
Pain Due to Functional Processes. — When abdominal pain
occurs, inquiry should be made concerning the following points:
(1) The relationship, if any, to the ingestion of food. If
' Lennander explains the diffuse abdominal pain present in the earlj
stages of so many infectious processes in the abdominal cavity as being due to :
(1) An increased sensitiveness of a large portion of the parietal perito-
neum, owing to lymphangitis or peritonitis.
(2) A considerable increase and irregularity of peristaltic action, which,
in addition to pain, often produces a feeling of sickness and vomiting, and
leads to one or more actions of the bowels at the commencement of these ill-
nesses.
(3) On account of increased sensitiveness, the movements of the stomach
and intestines against the parietal peritoneum, and the stretching of their re-
spective mesenteries, are felt as severe pains.
(4) In most cases, however, the general peritoneal irritation soon passes
away; only the part more especially infected remains in a condition of inflam-
mation, and the abdominal pain becomes localized at this spot.
EXAMINATION FOR PAIN 401
there is any such relationship examine (a) the stomach and in-
testine for a gastric or duodenal ulcer, or for adhesions, or the
intestine for a volvulus or obstruction, in which case the pain, at
first, is periodic and paroxysmal, and, later, continuous and of
an aching, dragging character. If the pain is sudden and intense,
especially if it commences in the umbilical region and gradually
becomes localized to the right side, examine for appendicitis. If
the pain is continuous and increasing, it indicates that the local
peritonitis is spreading. This is especially the case should there
be a synchronous increase in the tenderness, (b) In pancreatic
disease it may indicate a rupture of the duct or an acute hemor-
rhage and inflammation, (c) Biliary disease, as a rule, causes a
pain which comes on about the first or third hour after eating,
at the time of the greatest intestinal activity, and is especially
marked when percystic adhesions are present.
(2) Relationship of pain to defecation indicates: (a) hem-
orrhoids, which generally are associated with bleeding; (b) fis-
sures of the anus, which often are associated with itching; (c)
carcinoma of the rectum, in which bleeding is very marked and
sometimes is present previous to the onset of pain; (d) ulcera-
tions of the rectum, which, as a rule, are not painful, unless the
sphincter region is involved.
(3) If the pain occurs in conjunction with menstruation,
the genital organs should be examined, the uterus, tubes and
ovaries all being subjected to a close inspection. If they are
affected, the pain, because of the congestion then present, becomes
worse during the menstrual period. Sudden abdominal pain is
often premonitory of a miscarriage.
Pain Due to Intestinal Diseases. — A few facts worthy of
attention are: That increased peristalsis of the bowel may, in
case of obstruction, be a potent cause of abdominal pain. This
pain is located across the middle of the abdomen ; never below the
umbilicus in obstruction of the small intestine, but generally above
in lesions of the large intestine (Mackenzie). In obstruction of
the large intestine painful states arise. These are the result of
the obstruction to the forward peristalsis, and are called colics.
402 DIAGNOSIS OF ABDOMINAL PAINS
Of intestinal colics, there are those due to acute indigestion,
in which the pain is usually accompanied by vomiting; those
due to poisoning as by lead or brass. (These metals irritate and
<»ause constriction of the blood vessels in the intestinal walls, thus
indirectly irritating the sympathetic nerve filaments and causing
muscular contraction and colic. Pal claims that in lead colic the
blood pressure is increased from one-half to twice the normal, and
that this increased pressure irritates the terminal filaments of the
sympathetic, and thus causes pain) ; those due to hernia, which
are generally accompanied by vomiting ; those due to uremia, which
may precede other uremic symptoms by a considerable interval
(Musser) ; those due to gall-stones, which are probably the most
frequent cause of colic (here the pain, as a rule, is located in the
right epigastric zone, but may be felt in the right lumbar zone
anterior) ; and lastly, those due to renal calculus, which are very
severe, and sometimes are mistaken for intestinal obstruction,
chiefly because of the intestinal distention and inability to move
the bowels, a condition often the result of large doses of morphia
which the patient has been given.
In children painful paroxysms frequently occur in the course
of purpura. This disease, according to Guinon, is due to a toxic
infective agent, with special action on the nervous system ; so that
it seems very probable that the colicky pains are due to intestinal
cramps, the result of a deranged peristalsis, which in turn is the
result of malactivity of the nervous system. The ordinary colics
of children are accompanied by a great restlessness, throwing
about of the bodj% and interrupted cries. Relief comes on the
expulsion of flatus (Kerr, 861).
Perforation in typlioid is a cause of very severe and acute
abdominal pain. In Manges' series of nineteen cases of typhoid
perforation, abdominal pain was the first symptom to appear in
fourteen. In two of them, however, it was accompanied by a
chill, and in two others by vomiting. Though not the initial
symptom, it was present in seventeen of the nineteen cases. One
of the best descriptions of the pain due to typhoid perforation is
that given by Selby. What he says applies to perforation of any
EXAMINATION FOR PAIN 403
hollow abdominal viscus. He says that abdominal pain is a most
constant and reliable indication of perforation, depending, to be
sure, on the mental condition of the patient and his appreciation of
the sensation. The pain varies in degree, character and location.
It may be so severe as to force a cry from a comatose patient, and,
on the other hand, so mild as to attract but slight or no attention
from a conscious patient. It may begin as a sudden, sharp, stab-
bing and agonizing sensation, or may come on gradually. Its
duration varies also. It is usually circumscribed and is lo-
cated in the lower part of the abdomen near to the median line,
or towards the right side, and, generally speaking, the more cir-
cumscribed it is, the more keenly it is appreciated. Occasionally
it is referred to the umbilicus and other parts of the abdomen,
and even to the penis. If it be general at the start, as it some-
times is, it may, in the course of a short time, become confined
to the lower part of the abdomen. On the contrary, if primarily
it is localized, and later becomes generalized, it strongly suggests
progressive peritoneal infection. The value of pain, however, as
a symptom, lies not so much in its limits, its severity, the manner
of its appearance, and its persistence, as in the fact that it itself
is present. Its modifying features, when present, may be weighed
in proportion to their degree, but when absent may be ignored in
arriving at a diagnosis.
In one case of typhoidal perforation there was sudden pain
in the lower abdomen, causing the patient to cry aloud ; soon after-
ward there was intense pain in the penis (AUaben). The rela-
tion .of this penis pain to the perforation is difficult to determine.
Abdominal pain may be caused by adhesions, for a discussion
of which, see under Peritonitis.
Abdominal Tenderness. — Tenderness on pressure, being close-
ly allied to pain, may be considered in the light of a less-marked
manifestation of that sensation. It usually accompanies pain,
and not infrequently is present when actual pain is absent. It is
found within the same areas as is the associated pain, but is con-
fined within more narrow limits. Thus, diffuse pain is occa-
sionally associated with a localized tenderness. This feature
404 DIAGNOSIS OF ABDOMINAL PAINS
renders tenderness of value in the determination of the approxi-
mate location of the lesion. However, as such, it is not without
fallacy. A widening of the tender area may be taken as an indi-
cation of a spreading peritonitis, and, as siieli, is an indicator of
greater reliability than an increasing diffusion of the pain. "The
value of tenderness as a symptom is enhanced, needless to say,
by its characterizing features, but, as is true of pain, its real
value lies in its mere j
FiQ. 85. — Are.\s or LocAt Tenderness, when the Inflammation of the
Appendix, Gall Bladder, and Fallopian Tube and Ovary Has
Spread to ihe Peritoneum and Has Produced a Localized Pbbi-
T0N1TI8.
Morris's points are also shown, as well as the area in which pressure is made
best over an iuflamed ureter.
When abdominal pain is present, tenderness sliould always
be sought over the areas associated with the gall-bladder, the
pylorus, the appendix, and the hernial openings. Abdominal
tenderness ia sometimes due to a hypersensiiiyeness uf the abdom-
inal musciilalurc, such as is produced by proloiijicd coughing.
This tenderness is generally in the epigastrium in the region of
the recti muscles.
Percussion is of value in determining abdominal tenderness.
It often happens that, in percussing the abdomen, altention is
drawn to a particular region hy the wincing and involuntary
EXAMINATION FOR PAIN 405
shrinking of the patient from the percussing finger. This always
indicates tenderness. After the attention is drawn to a particular
area of the abdomen, more refined means of defining the degree
and extent of tenderness (palpation and pin-prick pressure) may
be used. Such measures have been described in earlier chapters.
Types of Tenderness. — Tenderness is of two types: tempo-
rary and permanent. Tenderness which is present temporarily
over an organ may be due to the distention of the organs (stom-
ach or intestines) with air or gas. As soon as the distention is
relieved pain and tenderness cease. Chronic tendermss is more
likely to be caused by inflammatory changes, especially in those in
whom the abdominal w^all or the parietal peritoneum is involved.
Should the tenderness be superficial, and so acute that even the
lightest pressure causes pain, it is probable that the condition
is one of superficial neuralgia, such as is common during infec-
tious diseases. On the other hand, deep tenderness is only of
relative value, since even in many normal cases the forcing of
the hand deep into the abdomen will cause pain.
Reflected Tenderness, — In the consideration of tenderness the
fact must not be lost sight of that tenderness is not always present
over the organ causing it; for in many cases pressure on or over
the inflamed or diseased organ will cause pain at some distant
area, and pressure over this area is painful, even though it is at
a distance from and has no direct connection with the organs
causing the pain. This is a most important point in the diagnosis
of disease, and should never be forgotten.
A point of tenderness in cases of pelvic adhesions is given by
Cumston, who says that *^a symmetrical point of tenderness on
the opposite side of the abdomen from McBurney's point will be
found in pelvic adhesions."
This point of tenderness, as given by Cumston, closely
approximates the point of tenderness defined by Morris as being
present in pelvic lesions. Morris gives his point as being one and
one-half inches from the navel on a line running from the navel
to the umbilicus. lie claims that when this point is tender on
the right side alone, appendicitis is present, and that when it is
406 DIAGNOSIS OF ABDOMINAL PAINS
tender on both aides, pelvie disease is present. This view has
been eontroveried by Hubbard, who ascribes to these areas of
tenderness, even in cases of chronic appendicitis, only secondary
iiD[>ortance. ilcBiimey's point, which is also a point of tender-
ness in appendicitis, is situated in the lower left quadrant of the
right lumbar zone anteriorly, on a line dra^m from the umbilicuB
to the anterior-superior spine of the ilium, and one and one-half
inches from the anterior-superior spine. It has not the signifi-
cance formerly ascribed fo it (see Appendix).
P08TUKE IN ABDOMINAL DIA0N08I8
The posture of the patient, in cases of severe abdominal dis-
ease, is characteristic. The patient assumes two general postitions:
in the first, the posture of abdominal protection, the patient is
alert, and while with one hand he attempts to ward off any ab-
FiG. 86.— Posture of Abdominal Protection Present in Pehitonit., .
Ill cholecystitis and appendicitis, the hands may be the reverse of what
they are in the figure: the right hand acts as guard and the left as pro-
tector. In salpingitis, the protecting hand is over the lower abdomen.
dominal interference (touch, palpjition), with the other hand he
covers (without making pn'ssuro ) the painful area. In the se<'ond
form the |mticiit, instead of warding off alKloniinal pressure,
seems to finil relief when pnssnrc i;i Hpjiiicd to the abdomen. Tie
is, as a rule, doubled up, with the Hmbs flexed on the abdomen,
POSTURE IN ABDOMINAL DIAGNOSIS
Fia. 87. — Position in Abdominal Couc, Assumed on Lying.
and the belly muscles tightly contracted. In some cases the pa-
tients make pressure on the abdomen with the hands, while in
other cases they 'use for this purpose some other object (pillows,
bolsters). la the first posi-
tion inflammation of some
of the abdominal organs is
indicated, and if the sensi-
tiveness is markedly in-
creased peritonitis probably
has already set in. The sec-
ond position indicates some
variety of colic, the parox-
ysms of which are indicated
by the exaggeration of the
position which the patient
assumes when the pain
comes on. The patient, as
a rule, lies down, or, if this
is impossible, assumes a sit-
ting posture, with the arms
folded and the body bent, so
that pressure is made on the
I n Fig. 88. — PosmoN in Abdominal Colic,
Assumed on Sittinq.
408 DIAGNOSIS OF ABDOMINAL PAINS
FORMS OF ABDOnnNAL PAIN
To complete this chapter a brief discussion of some of the
most common forms of abdominal pain is necessary. Among
those most frequently encountered is renal colic, the pain of
which is generally on the aflfected side, passes downward toward
the pelvis, and is often very acutely felt in the testicle on the
side of the disease. In the purpura of infants painful abdominal
paroxysms are common (455). According to Musser, abdominal
pain is often a precursor of uremia. This pain is usually situated
in the right or left hypochondrium, and, when in the left hypo-
chondrium, has been mistaken both for gastritis and gastric per-
foration. Enteroptosis, particularly gastroptosis, may produce
pain in the suprapubic region (Deaver).
Keen reports a case of rupture of the rectus muscle, in which,
at the time of the rupture, sudden, sharp pain was felt in the
abdominal wall. Such a rupture may occur in a typhoid patient
who is convalescing, and generally follows some sudden exertion.
The symptoms of rupture are sudden, sharp pain and tenderness
localized to the point of rupture. The rupture is generally accom-
panied by vomiting. Examination shows a depression in the
course of the muscular fibers, later accompanied by ecchymosis and
swelling.
If the pain is in the rectum, it may be caused by a pro-
lapsed colon.
Arteriosclerosis of the abdominal vessels also causes abdomi-
nal pain, which generally is severe and paroxysmal. For a full
discussion, see under Arteriosclerosis of the Mesenteric Arteries.
A condition is described by Depage in which pain is due to a
displacement of a rib. Examination will show that the eleventh
and in some cases the tenth rib is projecting over the iliac crest.
The pain is intermittent and is worse when the patient walks or
moves about. Pressure over the ends of the tenth and eleventh
ribs is painful, and pain is also experienced if the angles of the
ribs are brought one over the other. The condition is most fre-
quent on the right side.
FORMS OF ABDOMINAL PAIN 409
A rather rare and frequently overlooked cause of abdominal
pain is anemia (Musser, 6).
Functional Pains. — Kicbardson speaks of neuralgia of tbe ab-
dominal organs as a cause of abdominal pain. Tbis term, as a
rule, is a misnomer, for nearly all cases of supposed abdominal
neuralgia are due to some condition having a more definite patho-
logic basis than is found in neuralgia. The only reason that these
lesions are not properly diagnosed is that the search for their path-
ology has not been sufficiently prolonged nor assiduously enough
pursued. While neuralgia may and does occur as a cause of ab-
dominal pain, it is much less frequent than is supposed.
The so-called fimctional pains are frequently classified as neu-
ralgic, but in nearly all cases these pains can, by patient search,
be shown to be due to organic lesions, sometimes obscure, but .
present nevertheless. Under functional pains, Richardson gives
gastralgia, nephralgia, oophoralgia, and simple intestinal colic
from gas. All except the last are recognized entities, but not
in the same manner as is generally understood.
Gastralgia is only a term, usually applied to a painful state
of the stomach, having an unknown basic cause. In some cases,
when it is due to a painful condition of the muscular structure,
it should be called gastromyalgia ; on the other hand, if the nerves
are affected, it should be termed gastroneuralgia. However, all
painful conditions of the stomach, whatever the etiology, may be
classed under the generic term gastralgia. So likewise painful
states of the kidney and ovary may be called nephralgia and oophor-
algia. But often, alas, when we suffix "algia" to the name of an
organ, it means that we are but adding a cloak to conceal our
ignorance of the real cause of the pain which is present ; it means
that we are naming the diseased state from a symptom instead of
from the pathology. The careless use of these terms cannot be
too strongly condemned, and they would be seldom employed if
it were borne in mind that they frequently are but the indicators
of ignorance and sloth.
The presence of abdominal pain in neurasthenics should
always be a subject of considerable investigation before a defi-
410 DIAGNOSIS OF ABDOMINAL PAINS
nite diagnosis is made. The neurasthenic is frequently subject
to the delusion that there is something radically wrong in the
abdomen, and even though operation and removal of an ovary or
of an appendix may relieve the symptoms for a time, the pain
soon returns, and is found in a new location, so that it is almost
an impossibility to relieve this class of people, either with or with-
out operation. Psychotherapy in the form of reeducation is
probably at the present time the most efficient means at our com-
mand of producing relief.
After the review of pain, as given in the previous pages, it
may be well to consider the time of life at which the different
pains are most frequent. For this purpose, life may be divided
into four periods : infancy, childhood, adult life and old age. In-
fancy, with its sensitive and helpless condition, offers a double
hardship to the examiner, for he not only has to elicit symptoms,
but has to derive them without the patient's help. For this rea-
son, pain, as a symptom of disease in infancy, is a factor of
almost negligible value. It becomes important only as the infant
grows older, and, by intelligent cooperation, is able to tell the
examiner something of the type and character of the pain which
he experiences. Yet, with all these drawbacks, even in infancy
pain is of some little value. When the infant continuously cries
and cannot be hushed by its mother, as a rule, it is suffering from
some form of pain. The most common causes of pain in infancy
are colic, gastroenteritis, and intussusception. In children one
should look for these conditions, and, in addition, spinal caries,
gall-bladder disease, apj)endicitis and pneumonia. In adult life
all of the above, with the addition of gall-stones, gastroduodenal
ulcer, pancreatic disease, hernia strangulatiop, and, if the patient
is a woman, ovarian, tubal or uterine disease may be present. As
old age comes on, the tendency to malignant growths increases, and
in case of persistent pain one should seek for cancers.
Care in Diagnosis. — As previously mentioned, tabes dorsalis,
caries of the vertebrae and tumors of the spinal cord cause pain.
These three conditions should always be thought of in those cases in
which an abdominal pain is present without sufficient and definite
FORMS OF ABDOMINAL PAIN 411
cause. So often are they mistaken for disease of the intraab-
dominal organs that the physician must be very careful to exclude
them before he arrives at any definite conclusion. Howell (111b)
speaks of cases of tabes dorsalis being mistaken for cases of appen-
dicitis and operated upon. Lead poisoning should also be sought,
and when the patient with colic is a painter, the gums should be
inspected at once, to ascertain if the blue line at the edge is present
(Burt oil's blue lin«). In lead colic, the abdominal cutaneous
hyperalgesia is absent (Robinson, 265).
Intercostal neuralgia causes pain which is referred to the an-
terior abdominal wall, and is likely to be mistaken for an intra-
abdominal lesion. The presence of the pain points is a diflFeren-
tiating symptom (see Neuralgia).
Pneumonia frequently refers its symptoms to the abdomen,
and in some cases so strongly that an abdominal lesion has been
diagnosed. In many cases appendicitis operations have been
performed ivith negative results for appendicitis, and the oper-
ator, to his chagrin, has found pneumonia symptoms developing
during the course of the next few days. All cases of acute ab-
dominal pain, with rapid pulse, rapid respiration, and high
fever, should at once direct the attention to the chest. The ten-
derness, also, is characteristic, in that in pneumonia the skin
over the abdominal area in which pain is complained of is very
tender, but deep pressure is well borne (Howell, Hood, Bennett).
This is the opposite to the rule in severe abdominal diseases.
Pleurisy has also been mistaken for abdominal disease, and a
ease is cited by Bennett (144, p. 1005), in which operation would
have been performed for appendicitis had it not been that a band
of tenderness extending around the abdomen above the umbilicus
drew attention to the pleural involvement.
Hilton claims that the abdominal pains of thoracic visceral
disease are due to involvement of the parietal nerves, and a subse-
quent reference of the irritation to their distribution area. He
says that the pleura is supplied by the intercostal nerves, an opin-
ion which is disputed by Mackenzie. (See pleura.)
Abdominal pain may also occur with obstinate constipation.
am
mi^
ill
'Ml
111!
Pi
1,11
CONDITIONS ASSOCIATED WITH ABDOMINAL PAIN 413
When it does so occur, it may come on rather suddenly. It gradu-
ally increases with little or no increase in the temperature ; finally
vomiting of stercoraceous material occurs and the diagnosis is
made clear.
CONDITIONS ASSOCIATED WITH ABDOBONAL PAIN
Spasm and Rigidity of Muscles. — Spasm of the abdominal
muscles nearly always accompanies abdominal pain, especially if
the pain is severe. This symptom is lacking in those who have
very lax or atrophied abdominal walls, and it is also much less
marked in women than in men, because their muscular develop-
ment is generally much less than that of men. On the other hand,
severe rigidity of the abdominal wall may, in those of a very
muscular build, supervene upon a very slight intraabdominal irri-
tation. Localized rigidity is a good indicator of the region of the
abdomen involved, for the contraction generally takes place im-
mediately over the diseased viscus. Should abdominal rigidity
gradually become lessened, while the toxic state of the patient
gradually increases, it indicates that the lesion, whatever its
nature, is increasing in virulence, and is becoming dangerous to
the patient. This is particularly so if the leukocytosis, which has
been present, decreases to, or even below, the normal level. Spasm
of the abdominal muscles is of diagnostic value in differentiating
abdominal from pelvic lesions, it being marked in abdominal
lesions, and almost, if not entirely, absent in pelvic lesions.
Visceromnscnlar Reflex. — In abdominal lesions, also, the so-
called visceromuscular reflex (Mackenzie) may be present and
render the diagnosis more difficult, especially since, in the abdomi-
nal parietes, the muscles have the power of segmental contraction
over an area of inflammation or irritation. These segmental
masses of muscles are very deceiving to the palpating hand, and
have been mistaken by the examiner for: (1) enlarged ovaries,
(2) an enlarged and inflamed appendix, (3) tumors, intraab-
dominal and parietal, (4) inflammatory exudates, and (5) intes-
tinal tumors, due to volvulus, intussusception, etc.
414 DIAGNOSIS OF ABDOMINAL PAINS
During every abdominal examination, the possibility of con-
fusing these reflex muscular contractions with tumors, etc., should
always be borne in mind, and, since the rectus abdominis is mostly
at fault, its nodal points should be carefully mapped out. One of
these points occurs at the umbilicus and another between the um-
bilicus and the costal arch. Any swelling due to contraction of the
rectus would occur between these points and would be somewhat
oblong in shape.
In the diagnosis between these phantom and true abdominal
tumors it is well to observe: (1) that a tumor may vary in its
relative position to a fixed point (umbilicus) on the abdominal
wall, but a contracted part of the rectus muscles does not so vary ;
and (2) that while the tumor, which is the result of contraction
of the muscle, may be so persistent and constant that sometimes,
even under chloroform, it yields with difficulty, yet it always
does yield; while a tumor which is the result of organic disease
is more clearly defined when, as a result of the anesthetic action
of chloroform, relaxation of the rectus muscle occurs.
Toxemia also has a restrictive action on pain perception, and
if it is pronounced, abdominal pain is perceived very slightly, or
not at all. As Musser remarks, when a hyperleukocytosis is
present, with associated severe toxic symptoms, even though pain
is absent, a serious lesion should be considered.
Indicanuria, as an accompaniment of pain, is of considerable
value in localizing the lesion to the small bowel.
Poljmria. — Many painful conditions of the abdomen are asso-
ciated with polyuria, and Osier has remarked on the frequency of
polyuria in' the later stages of typhoid fever.
Relationship of Hysterioal to Abdominal Pain. — Hysteria as a
cause of abdominal pain is only mentioned to be condemned. It
seems to be a term with which many clinicians hide their ignor-.
ance and diagnostic distress. The more a physician sees of ab-
dominal pain, and the more frequently he follows his case to
operation or to autopsy, the less seldom he makes a diagnosis of
hysteria. It seems that nearly all so-called abdominal pains of
hysteric origin have for their basis something more than a disor-
CONDITIONS ASSOCIATED WITH ABDOMINAL PAIN 415
dered nervous system. Under the shadow of this name are hid-
den many cases of gall-stones, appendicitis and gastric nicer.
Many are the patients who go on to chronic invalidism or lie in
too early graves because of the ignorance or inattention of their
physicians to these facts.
Abdominal incisions are frequent causes of abdominal pain.
Since this is of vital importance to the surgeon, I quote from
Maylard, who, to avoid pain as a result of abdominal incisions,
recommends that the '^incision be made in the most favorable
part of the abdomen ; that is, the part that has the fewest nerves,
and that, during the operation, as little irritation or destruction
as possible to the tissues of the wound be made."
Post-operatiye abdominal pain, according to Maylard, is caused
by irritation of the nerve endings. If it follows immediately
after operation, it is due either to tight suturing or to the pres-
sure exerted by encircling ligatures. Tension is generally indi-
cated by a throbbing pain or ache. When the pain is due to tight
suturing or to the ligatures, it follows almost immediately upon
the operation, and generally is of a stinging, stabbing character.
In some cases a nerve may be transfixed with a suture or ligature,
and be a constant source of pain production. If the pain follows
twenty-four to forty-eight hours after operation, it is due to in-
flammation, with consequent swelling and pressure. When the
inflanmaation is mild, little or no pain results ; but should it be so
extensive that exudation is present, the pressure from the exudate
upon the terminal nerve filaments is productive of pain, in some"
cases very severe. The distress which at first was intermittent is
now continuous, and should a rise of temperature occur suppuration
will generally be found to be present. Inflammation of the skin
or subcutaneous tissues generally produces pain in the first twenty-
four to forty-eight hours, while inflammation of the deeper struc-
tures does not produce discomfort for longer periods. In case
the inflammation is of the peritoneum or subperitoneal tissues,
discomfort and pain do not make their appearance until about
the eighth day after operation. If the patient is very obese, a con-
siderable amount of effusion takes place into the wound, and, as
416 DIAGNOSIS OF ABDOMINAL PAINS
Maylard remarks, unless drainage is provided, tension, inflamma-
tion, and consequent pain will follow.
Pain Beferred to Extraabdominal Regions. — ^In disease of
abdominal organs the pain is sometimes referred to an extraabdom-
inal location. For instance, it is common to have pain in the shoul-
der in diseases of certain abdominal viscera. This pain has been
described as due to irritation of the phrenic nerves, which convey
the stimulus to the roots of the cervical nerves, to whose cu-
taneous distribution the pain seems to be referred. This pain,
along with an area of hyperesthesia of the skin of the shoulder in
lung inflammation, has been attributed to diaphragmatic irritation
by Mackenzie, although he also suggests that it may be due to the
vagus terminations being involved. It is probable that the shoul-
der pain, which is found associated with gall-stone and gall-blad-
der disease, is due to involvement of the diaphragm in the in-
flammatory process. Likewise, in certain cases of rupture of
extrauterine pregnancy, we find that pain is present in this area.
In these cases the pain may be due to pressure upon the diaphragm
by the accumulation of extravasated blood (for it is a peculiar
fact that, on standing, the pain often disappears).
Absence of Pain. — Should abdominal pain be absent when nat-
urally it should be expected, or if it should disappear before the
natural termination of the disease would warrant its cessation,
the patient should be examined for: (1) perforation of the viscus
involved, (2) gangrene of the diseased organ, and (3) increase of
toxemia to such an extent that the patient's faculties are dulled
so that he is unable to perceive pain.
When perforation of a viscus occurs, pain is temporarily re-
lieved ; but the relief is due only to the incapability of perception
which accompanies the shock produced by this condition. When
perforation takes place the pulse generally increases in rapidity
and becomes weak and thready. The temperature first falls and
then rises, as infection and a generalized peritonitis ensue. Any
localized tenderness which may have been present before the
perforation now becomes diffused, and muscular rigidity, which
before was restricted to one area, now becomes general. Should
CONDITIONS ASSOCIATED WITH ABDOMINAL PAIN 417
gangrene of an abdominal viscus occur, the temperature, because of
consequent toxemia, may fall. That this fall is not beneficent, may
be seen from the pulse, which is constantly increa3ing in rapidity,
and from the increasing stupor and somnolence of the patient,
whose appearance indicates that he is suffering from a most severe
disorder. The disappearance of the pain as an indicator of im-
provement is of value only if all associated symptoms improve con-
comitantly with it. In many, though not all cases, the rapid dis-
appearance of the cutaneous hyperalgesia occurs simultaneously
with the onset of gangrene (Bennett, 142, p. 1005). Toxemia can
be easily diagnosed by the increasing stupor and coma associated
with it. However, even in the most advanced stages of stupor and
coma, while the patient does not complain or cry out from pain,
a close examination will disclose the facial expression of the most
severe distress.
CHAPTER XXII
PAINS OF THE ALIMENTARY TRACT
Lips. — It 18 very rare for the lips to be afflicted with pain
without noticeable organic change, although sometimes neuralgia
of either the second or third branch of the fifth nerve seems to
be particularly confined to either the upper or the lower lip. In
this case we find that the lips are normal in appearance but ex-
ceedingly tender to pressure. The pain also comes in paroxysms,
between which there is no pain and absolutely no tenderness.
The principal organic changes in the lips producing pain are in-
flammation and fissure. Inflammation of the lips is generally
due to infection, which has entered either through an abrasion or
a pustule. When it is present there is considerable swelling, and
the pain is of a constant, throbbing character. The involved area
is very tender to the touch, and motion is almost if not entirely
abolished, so that it is very difficult to take food. When fissures
are present linear abrasions may be seen running across the mu-
cous membrane of the lip, and at the angles of the mouth, where
they are very common. Opening the mouth is very painful, and
the contact of the denuded surface with salty or acid substances
is also very disagreeable, so that the patient is averse to eating.
Herpes of the lips is very common in the early stages of in-
fectious diseases, and, as a rule, the vesicles are exquisitely ten-
der. Herpes of the lips is frequently complicated by infection.
Cheeks. — Pain in the cheeks may be due to inflammation or
to neuralgia. Inflammation is generally not of local origin, but
is the result of an extension from adjacent areas, such as the
gums, or alveolar processes. When it is present the cheeks are
kept at rest They feel as though they were stiffened, and are
418
TEETH 419
hard and board-like. There are also considerable swelling and
a glossy appearance of the skin. Neuralgia (trigeminal) here is
not different from neuralgia in other locations, and gives rise to
the same signs and symptoms. A condition of the cheeks that is
very painful is a vesicular formation on the internal mucous mem-
brane surface. This is very disagreeable and, though it does not
cause any subjective pain, the least irritation, such as the rubbing
against it of the tongue, or of solid or liquid food, causes a very
disagreeable sensation. These vesicles are either the result of nerve
involvement, such as is found in trigeminal herpes, or are but the
reflex herpetic eruptions of digestive disturbances. If on the
tongue an ulcer that is free or almost free from pain is found,
syphilis or tuberculosis should be sought. In mild inflammations,
such as those which accompany stomatitis, there is moderate pain,
which is increased on the ingestion of food. At the same time
there are thick, sticky saliva, impaired taste, and often a slight rise
of temperature.
Teeth. — Sometimes, in cases of toothache, the aching may be
due to hyperesthesia, a common accompaniment of pregnancy.
Ordinary toothache is due to an irritation of one of the branches
of the trigeminus by products of dental caries. At first the pain is
more or less localized to the point of origin, but it gradually may
become so accentuated that a general neuralgia results, and the
entire side of the face may become affected. This may increase
imtil the entire side of the head and n(»ck is tender and painful.
This extension can be explained by the rich collateral association of
the trigeminus with the cervical nerves. Because of this close rela-
tionship it is easy to understand how an excessive stimulation of
one nerve can produce reactions in adjacent nerv'es. In some
cases, after the extraction of teeth, ])ain may persist for several
days, especially if gum-boils are present before the extraction, in
which case the pain may persist for five or six days (Yosper,
896).
The most sensitive part of a tooth is the pulp and the agents
causing the greatest reaction are heat and cold. Head claims
that, until the pulp is involved, the pain remains local, but as
420
PAINS OF THE ALIMENTARY TRACT
soon as it is affected the local is changed into referred pain.
Thus, in the course of destruction of a tooth three different vari-
eties of pain are encountered:
(1) The local, sharp pain, associated with destruction of the
enamel and involvement of the dentine. It is easily produced
by the sensitive dentine coming into contact with very hot or cold
substances, drinks, etc.
(2) The referred pain from involvement of the pulp cavity.
It seems that each tooth has a separate area of pain reference;
for instance:
Tooth
Reference Area
Upper Jaw
(1) Incisors
Frontonasal region
(2) Canine
Nasolabial region
(3) First bicuspid
Nasolabial region
(4) Second bicuspid
Temporal or maxillary
(5) First molar
Maxillary region
(6) Second molar
"Mandibular region
(7) Third molar
Mandibular region
Lower Jaw
(8) Incisors
Mental
(9) Canine
Mental
(10) Bicuspid
Mental
(11) Second bicuspid
llyoid or mental
Ilyoid — also in ear and just be-
(12) First molars
hind angle of the jaw. The
(13 X Second molars
tip of the tongue on the same
side is also tender.
(14) Lower wisdom
Superior laryngeal area
(3) After the pulp is destroyed the referred pains cease and
there are only local pains, due to involvement of the periodontal
structures. For more detailed information, see Head, Brain,
1904, pp. 406-415.
Central trigeminus pain (tic douloureux), either from in-
TONGUE 421
volvement of the ganglion itself or its internal roots, or as a re-
sult of pressure (cerebello-pontine angle tumor, neuroma), often
leads to a faulty diagnosis of teeth pains. Many patients suffer the
loss of one tooth after another in the vain search for the affected
one. After the sacrifice of the teeth the dentist or physician
wakes up to the fact that the disorder is central, and that a grave
mistake has been made.
Tongue. — The lesions of the tongue which are apt to give
rise to pain are inflammation, fissures, ulcers, new growths, and
vesicles. Inflammation can generally be traced to some abrasion
or injury, or to an extension of inflammation from some adja-
cent area; however, there is a unilateral inflammation (hemiglos-
sitis) which is probably of neurotic origin. Fissures in the
tongue, as in all sensitive mucous membranes, are apt to be very
painful, because of the exposure of the sensory terminal filaments.
This is also true of ulcers, which in this location likevdse are
very painful. New growths in the tongue give rise to a sensation
of discomfort rather than to one of pain. Vesicles due to her-
petic disturbances may appear on the tongue, and when they do,
they cause great distress owing to their extreme sensitiveness.
They generally are an indication of a central lesion, central herpes,
though they may be, as are similar vesicles on the cheek, but
a manifestation of disturbed digestion (reflex herpes). When
due to herpes the vesicles generally appear on the posterior half
of the tongue, which derives its sensory supply from the glosso-
pharyngeal nerve. Tuberculosis and syphilis of the tongue are
not painful unless there is a breaking down of the lingual tissues,
with a consequent exposure of the sensory nerve filaments.
In many cases a hyperalgesia of the tongue is an indication of
hysteria, which, when present, generally gives rise also to para-
gusia or gustatory paresthesia (disturbances of the sense of
taste), the patient complaining either of the disagreeable taste
of that which would otherwise be agreeable, or of the persistence
of a bitter or of a sweet taste in the mouth when nothing has
been tasted. This is a fairly frequent condition in neurotics,
particularly those suffering from neurasthenia.
422 PAINS OF THE ALIMENTARY TRACT
The presence of small, painful lesions of the tongue may he
the first indication of a nocturnal epileptic attack.
There is an extremely painful condition of the tongue, due to
a papillitis, in which nothing abnormal can be found on the sur-
face; but, on magnification, small, ulcerating points are seen
hidden in the folds of the mucosa about the fungiform papillse
of the tip and the margin of the tongue.
Moeller's glossitis, or chronic superficial glossitis, is charac-
terized by bright red lines or patches at the margin or tip. The
pain, which is the principal lesion, is out gf all proportion to the
local involvement, and is much increased in chewing and speak-
ing.
According to Riesman (113b), pain in the tongue (glosso-
dynia) which arises without any apparent organic lesion, may be
divided into the following, which is the classification of Chaveau
(112b).
(1) Glossodynia secondary to trigeminal neuralgia, especially
the inferior dental branch of the trigeminal.
(2) Glossodynia of the insane, starting as a local paresthesia.
(3) Glossodynia of tabes, corresponding to crisis in other
organs.
(4) Glossodynia of hysteria.
(5) Rheumatism of the lingual muscles, or rheumatic glosso-
dynia.
(6) Glossodynia due to local causes. These may be classified
into the extrinsic and intrinsic. The extrifisic causes are: (a)
dental affections and artificial teeth, and (b) granular pharyngitis
and hypertrophy of the posterior pillars and of the lingual tonsil.
Among the intrinsic causes are: (a) lingual varices; (6) chronic
glossitis from tobacco, alcohol, spices, iodin, lead or gout, and (c)
papillary hypertrophy of the follicular region of the tongue.
Reference Areas in Diseases of the Tongue, — Disease of the
anterior portion causes pain to be referred to the mental area;
of the lateral portion, to the hyoid area ; of the dorsum, to the
superior laryngeal and the occipital area (Head).
Salivary Olands. — The salivary glands are subject to the ordi-
PHARYNX AND TONSILS 423
nary glandular pain-producing diseases, as inflanunation, etc.
There may be present also, in the ducts of the glands, some ob-
struction which gives rise to an intermittent colic with an asso-
ciated swelling and tumefaction of the gland. This condition
may sometimes be diagnosed by running the finger along the
course of the ducts, when an obstruction, if present, generally
may be felt. The most common form of obstruction is a salivary
calculus (Ranulus). The parotid gland sometimes becomes in-
flamed, and is very painful, giving rise to the entity called
"mumps." It also becomes tender after oophorectomy, and in some
cases where orchitis is present. Pain beneath the angle of the jaws,
in those who are convalescent from typhoid, should always lead
to investigation of the parotid as the possible cause of the pain.
Pharynx and Tonsils. — Pain in the pharynx may be present,
either objectively, on swallowing, or subjectively, without any
provocative act. In the first case we find that the causative
factors are slight, such as small ulcers and superficial inflamma-
tions; but when the infectious agents extend deeper, and the
surrounding connective tissues are involved, the pain is felt with-
out any exciting productive factor, and is continuous. This is
well exemplified in parenchymatous tonsillitis, in which the pain
extends to the angles of the jaws, also to the ears, even down the
neck, and in phlegmonous pharyngitis, which is extremely pain-
ful, there being a constant burning or aching pain, which in some
cases assumes a throbbing character. In the latter, the pain may
be of such, magnitude that the patient lives a miserable existence,
being unable to eat or to sleep until the abscess which has formed
ruptures and relieves the pressure.
The tonsils and posterior pharyngeal wall may be extremely
tender in certain forms of streptococcic sore throat, and the pain
often persists for a long period after the cessation of the acute
inflammation.
A so-called gouty throat causes a similar painful condition of
the pharynx and tonsils. There are few signs of inflammation;
the mucous membrane, however, is lax and edematous.
Various types of pharyngitis, granular, follicular, etc., cause
424 PAINS OF THE ALIMENTARY TRACT
pain. The diagnosis depends upon a special knowledge of the
various pictures. All of these conditions cause a certain amount
of referred pain. The pain in front of the ear, complained of so
much by patients with tonsillar affections, or by those who have
some tonsillar traumatism, operative or otherwise, is in the hyoid
reference area of Head (for which, see Fig. 60, p. 291). The
pain may also be referred to an area in the neck in the submaxil-
lary triangle. Palpation here will disclose an enlarged gland.
Esophagus. — The esophagus below the cricoid cartilage was
formerly considered to be non-responsive to tactile and other stim-
uli, but now it is known to be sensitive to heat, cold, tactile and
chemical stimuli, and it is also held that many apparent stomach
sensibilities are, in reality, esophageal sensibilities. Inflamma-
tion of the esophagus is, if severe, productive of considerable
pain. The pain is of a deep, burning character, and is felt
along the course of the esophagus. Pain is also felt on move-
ment of the esophagus, which occurs when the head is bent for-
ward or backward, and is also present when external pressure is
made through the overlying tissues upon the esophagus. Pain on
swallowing is very severe. In the severest cases of corrosive
esophagitis there may be no pain.
Pain felt in the esophagus, without any objective lesion, may
be due either to a hyperesthesia or a paresthesia. In the former,
pain is produced by factors which cause irritation, such as in-
flammation of the esophagus, or a neuritis of the nerves supplying
it. The latter (neuritis) gives rise to a perversion of sensation;
for instance, the act of swallowing, which ordinarily gives rise
to no sensation, is, in this condition, interpreted as painful. In
stenosis of the esophagus pain, as a rule, is absent. In cancer of
the esophagus there may be only a feeling of distress or of dis-
comfort under the sternum, generally localized to the area of the
growth. Sometimes severe pains, confined to the area of the
growth, or referred to the region of the xiphoid cartilage, may
also be present They generally are of a '^tearing, piercing char-
acter, and radiate widely to the back, neck, or shoulders." They
accompany the deglutition of food, but may be independent of it.
ESOPHAGUS 425
and are often nocturnal. Though generally present only late in
the disease they may be • the earliest manifestations of it
(McCrae).
Referred pains may be present in the intercostal spaces be-
tween the shoulder blades, in the epigastrium, in the throat and
head, in the ear, or in the extremities (Rosenheim).
Dyspnea and attacks of pain resembling angina pectoris also
occur. These are due to pressure on the trachea or upon both re-
current laryngeal nerves.
Localization within the esophagus is fairly accurate. Lamy,
in his study of one hundred and thirty-four cases of carcinoma of
the esophagus, found that four-fifths of the patients were able
to locate the lesion within an inch or two of the correct site; but
in the remainder a correct localization was impossible; often a
carcinoma of the lower third would be located by the pain-sensa-
tions in the upper third, or vice versa. Obstruction gives rise
to sensations for the most part in the middle line, deeply seated,
beneath the sternum, or, if the obstruction is low down, in the
epigastrium.
CTTAPTER XXIIT
THE STOMACH
After the review of the pain-producing diseases which are
located in the alimentary passages leading to the stomach, it is
next in order to consider the pains and pain-producing disorders
of the stomach. Of late years there has been considerable contro-
versy as to whether the stomach has pain-sensation or not. The
weight of the argument seems to be on the side of those who
claim that it has not. It is claimed that the sensations which are
felt in disease of the alimentary viscera are but referred sensa-
tions or impulses, carried to the cord in the sympathetic path-
ways, and thence referred again to the periphery throngh the
cerebrospinal nerves.
From the researches of Hertz in particular it would appear
that the gastric mucosa does not respond to tactile nor to chemi-
cal stimuli by pain. The stomach mucosa does not register
thermal stimuli, and the sense of warmth and coolness following
the ingestion of hot or cold liquids is largely due to the sensi-
bility of the esophagus to these forms of stimuli. The sensation
of fulness in the stomach is due to the deep-pressure sensibility of
the muscular coat, and is brought about by tension.
The sensation of hunger and emptiness is largely a matter of
habit, associated with malaise and weakness. It is conditioned
by the disturbance in the periodicity of the muscular hypertonus
and of neuronic excitability, normally the result of regular eat-
ing.^
* According to W. B. Cannon and A. L. Washburn (Amer, Jour, of Phy-
siology, March, 1912, Vol. XXIX, p. 455), hunger is due to the contraction
not only of the stomach, but also of the lower part of the esophagus and the
intestines. They were able to prove a relationship between rhythmic contrac-
tions of these organs and pain sensations.
426
PAIN CAUSED BY STOMACH DISORDERS
427
However, even though pain in the stomach is not, as a rule,
regarded as true visceral pain, yet it is closely related to it, for it
may be due to the tension already spoken of or to the spread of the
disease to surrounding sensitive structures, or to the traction of the
peritoneal connections. The accompanying tenderness is most
often due to hyperalgesia of the skin, voluntary muscles and con-
nective tissues supplied by that segment of the spinal cord which
receives the incoming stimuli from the stomach itself and its con-
tiguous structures.
AREAS OF REFERRED PAIN CAUSED B7 STOHAOH
DISORDERS
The areas to which the pain of stomach disorders* are re-
ferred are, first, the epigastrium, and (in many cases) the back,
in an area which, according to Cumiston and Maylard, is between
the posterior borders of both scapulae and opposite the spinous
Fig. 89. — Areas of Referred Pain as Given by Head.
A. One of the commonest situations for pain.
B. One of the commonest sites of gastric pain.
C. Maylard gives this point opposite the 5th dorsal spine as one of the
commonest locations of gastric pain.
process of the fifth dorsal vertebra. The pain also often circles
around from one of these artas to the other, and they are often
tender to the touch. The area spoken of by Cumiston and May-
lard as opposite the fifth dorsal spine is given by other authori-
ties as opposite the ninth or tenth dorsal spine. This agrees with
428 THE STOMACH
my own observations and coincides more closely with the deduc-
tions of Head, who places the maximum points of tenderness in
the seventh or eighth dorsal segments, opposite the ninth and
tenth dorsal spines. Boas, on the other hand, locates the area-
of maximum tenderness as opposite the eleventh and twelfth dor-
sal spines. When pain is produced in stomach disorders, it may
be felt in any of the areas supplied by the seventh, eighth, or
ninth dorsal segments, but it is more apt to be felt, and felt
PYLORIC PLC "
ORONAy PLCXUS
GASTRO— -
EPIPWC-
EPIPWOIC — QA5TKO-<PIPtOIC
OEXTRA
Fig. 90 — Nervous Supply of the Stouach.
more severely, in the maximal points of tenderness of these
areas.
In the accompanying drawing is shown the nerve supply to
the stomach. It is seen to be both sympathetic (splanchnic, celiac
ganglion) and cerebrospinal (vagus). True visceral pain is con-
veyed through the vagus, but it is of the deep-pressure sensibility
(tension) tyix- allied to Head's prolopathic system.
The areas of tenderness are of great diagnostic significance.
The hyperalgcrtic areas (Head) affected in stomach diseases are
the seventh, eighth, and ninth dorsal. The seventh and ninth
areas are those most freiiucntly affected. The upp<'r one, the
seventh dorsal, seems to be associated particularly with the stom-
ach diseases causing vomiting. When it appears, as a sequel to
vomiting, it is frequently accompanied by pain in the area
next to and above it, namely, the sixtli dorsal. The sixth dorsal
area is associated with disease in the lower part of the esophagus;
PAIN IN GASTRIC AREAS 429
consequently, when both the sixth and seventh areas are affected
the disease is somewhere near to and probably involves the esopha-
gus. In the same way the ninth dorsal area is shared by both
the stomach and the intestines, and when both are affected the
lesion is probably in the neighborhood of the pylorus. When the
seventh dorsal is involved, the pain, as a rule, comes on within
half an hour after taking food ; while, if the eighth dorsal is in^
volved, the pain generally comes on at least an hour later.
By stimulating the area in the hypogastrium, which is hyper-
algesic, a reflex contraction of the upper segment of the recti
takes place. While in some cases only a segment, in others the
entire rectus is thrown into contraction.
That the area in which pain is felt in stomach diseases does
not necessarily correspond to the site of the gastric lesion, may be
seen from th^ drawing (Fig. 98), where the projected outline of
the stomach is shown, with the dark circle indicating the area
of tenderness in gastric ulcer, the tenderness in no case being
directly over the stomach.
PAIN IN GASTRIC AEEAS
When pain occurs in the gastric areas, it is necessary to in-
quire into the following : (1) the character of the pain; (2) the
time and manner of its appearance; (3) its relation, if any, to
the ingestion of food; (4) the duration of the pain; and (5) pre-
vious attacks.
Character of Oastric Pain. — Certain types of gastric lesioi:c
have characteristic pains; for instance, that of gastritis is burn-
ing; that of spasm of the pylorus is sharp and sudden; that of
ulcer is very severe and is sharply circumscribed; that of per-
foration is sharp and agonizing, and quickly spreads from the
site of its original location; that of acute dilatation is severe
and constant, and is accompanied by symptoms of collapse.
It should also be borne in mind that the severity of the pain
has no proportionate relation to the gastric conditions, but often, as
in pain caused by lesions in other organs, depends upon the
430 THE STOMACH
susceptibility of the nervous system and the sensitiveness of the
pain-receptive centers of the individual patient.
Time and Manner of Its Appearanoe. — Should the onset be
sudden, without any apparent exciting factor and without any
previous history of pain, perforating ulcer or pyloric spasm is
to be considered. In perforating ulcer associated symptoms of
collapse and spreading peritonitis, with a diffusion and constant
increase of the pain, would be present, while in pyloric spasm
irregular paroxysmal pains that are sharply localized with no
tendency to spread or to become generalized would be present.
Acute gastritis is associated with the vomiting of indigestible
or fermenting substances; this generally tells the tale. If the
pain is of slow onset, and there are at first discomfort, and
then a gradually increasing distress until well-marked pain is
present, particularly if the pain is associated with the vomiting
of blood (coffee-ground vomitus), it is necessary to examine
for gastric carcinoma.
Relationship to Ingestion of Food. — If the pain comes on at
a definite time after eating, and is relieved by vomiting, gastric
ulcer is thought of. If it comes on immediately after eating, the
cardiac end is affected ; on the other hand, if it does not appear
for an hour or two after eating, ulcer of the pylorus is to be con-
sidered. If, instead of coming on immediately, it makes its ap-
pearance one-half to two hours after eating, carcinoma or hyper-
chlorhydria should be considered. In carcinoma the coffee-
ground vomit is distinctive, while in hyperchlorhydria the excess
of hydrochloric acid, with the absence of blood, is sufficient to
make a diagnosis. In early carcinoma, pain and coffee-ground
vomit are absent. Hyperchlorhydria may occur from gall-blad-
der disease, duodenal ulcer, or be purely functional.
Duration of Pain. — The duration of the pain in any of the
gastric disorders is variable. It seems to be present more con-
stantly and for a greater length of time in those disorders which
have an organic basis for their production. In carcinoma the
pain is steady and persistent, while in hyperchlorhydria and
pyloric spasm it is associated with the ingestion of food.
LESIONS OF STOMACH CAUSING PAIN 431
Previous Attacks. — A. history of previous attacks of pain may
be of value, in that it often is confirmative of the diagnosis which
the present symptoms would suggest
Associated Sjrmptoms. — Constipation is generally associated
with gastric ulcer, hyperacidity, and carcinoma.
Pain Beflected or Referred to Gastric Areas. — When pain is
present in the gastric areas, it may be not of gastric but of
nervous origin (intercostal neuralgia) ; or it may be projected from
the cord (locomotor ataxia, general paralysis, disseminated scle-
rosis), or it may be a reflex from other organs, as the uterus, kid-
ney, intestines, appendix, gall-bladder, pancreas, heart, or prostate.
LESIONS OF STOMACH OAUSINO PAIN
The commoner lesions of the stomach causing pain are: (1)
displacement; (2) gastralgia; (3) hyperchlorhydria ; (4) cardiac
or pyloric spasm; (5) acute dilatation; (6) acute gastritis; (7)
chronic gastritis; (8) gastric erosions; (9) gastric ulcers; (10)
perforating ulcer; (11) new growths, and (12) perigastric ad-
hesions.
Displacement of the stomach (gastroptosis) generally causes
no pain until it induces a dilatation. Then the sensation
produced is rather a disagreeable, nauseatiug feeling than
a true pain. It is increased by eating or by standing, and is
decreased on lying down or on supporting the abdomen by a
bandage judiciously applied.
Gastralgia or Oastromyalgia. — By many gastralgia is dis-
claimed as a misnomer, because it is said that there is no such
pathological entity. But why ? The stomach is an organ whose
walls consist of muscular tissue, and why should not this tissue,
even though it is involuntary, be subject to the same metabolic'
disturbances as are the muscles of the back, which under abnor-
mal metabolic changes give rise to lumbago? The only differ-
ence is that in the affected back muscle the changes act princi-
pally on the terminations of sensory nervTS in the muscles, while
in the stomach walls the nerve terminals affected are not sensitive
in the meaning that they convey pain or touch sensation. There-
432 THE STOMACH
fore, for this irritation to be perceived as harmful, that is, painful,
it must be carried to the cord, where, irritating some sensory
neuron, the stimulus is carried to the brain, where it is perceived
as coming from the area of distribution of this neuron. That such
a changed metabolic and at the same time pain-producing lesion
may exist in the stomach is in accord with the opinion of the
majority of observers. The condition, instead of being termed
gastralgia, which is only a general term, should be called gastro-
myalgia, although the term gastralgia is still in general use.
Schmidt claims that "the existence of true gastralgia result-
ing from purely anatomical and functional disturbances is as cer-
tain as the pain of dental caries." Maylard describes it as "oc-
curring generally in those of a neurotic taint ; and the pain may
be of the most excruciating character, seizing the patient in the
epigastrium, and striking through to the back, radiating some-
times round the chest or waist." It is most erratic in the time of
its appearance. Sometimes it follows the ingestion of food, while
at other times it appears without any known cause. It may
sometimes appear periodically at night, and at other times it may
follow upon any excessive draft upon the nervous system by
worry or excitement. The pain is "generally out of all proportion
to other physical symptoms of any suggestive physical disease.
The patient may also complain of a beating sensation, pulsating
sensation, a feeling of heat or cold. Periods of pain generally
alternate with periods of complete freedom from it."*
The symptoms usually associated with this condition are flatu-
* This consideration of the subject diflfers markedly from that given by
Schmidt, who classifies all gastralgias as neuralgic in origin. While it must be
admitted that stomach pain depends upon the irritation of nerve terminal fila-
ments for its production, yet, as mentioned above, in a somewhat though not
entirely similar condition in the voluntary muscles, the term myalgia is used.
It seems that an analogous term, such as gastromyalgia, should be used for
pain having its origin in the stomach musculature. The general term gastral-
gia, therefore, is ill-fitted, and is only to be used in a general way to include
those pains originating in the stomach, the etiology of which cannot be defi-
nitely determined.
On the other hand, neuralgia of the stomach is entirely different In its
etiology from gastromyalgia, but is included, as are all stomach-productive
pains of unknown etiology, under the generic term * * gastralgia. * '
LESIONS OF STOMACH CAUSING PAIN 433
lence, distention, anorexia, cravings for food, vomiting, and py-
rosis. The stomach pains frequently alternate with attacks of
migraine (same as in angina pectoris), neuralgia of the head, and
asthma. Women are more prone to gastromyalgia than men, in
the proportion of two to one, and it is most common between the
ages of twenty and forty-five.
In an entirely diflFerent class, but slightly related to the
pains we have just described, are those due either to a secretory
or a motor disturbance. These will be considered later under
their proper headings. In the meantime it is well to remem-
ber, in considering the cause of stomach pain, that the lessened
resistance of the nervous system to pain-production is of mani-
fest importance. Some people, owing to disease or inherited pre-
disposition, are abnormally sensitive to pain, so t^at the percep-
tion of sensations, which in others ordinarily would not even be
disagreeable, would be felt by them as sensations varying all the
way from distress to actual pain. In this connection it is helpful
to know that gastric pains not of purely nervous origin are influ-
enced by the ingestion of food and the position of the patient, while
those of purely nervous origin are not.
The diseases acting as predisposing causes of gastromyalgia
or gastroneuralgia are about the same as those which cause a
lessened resistance in the nervous system, and which are pro-
ductive of cerebrospinal neuralgia. Among them may be men-
tioned anemia (chlorosis), infectious diseases, rheumatism, syph-
ilis, influenza, tuberculosis, excessive use of stimulants (alcohol,
tea), sexual over-indulgence, gout, diabetes, uremia, and physical
depression.
The reflexes which are sometimes felt as pain in the gastric
reference area, and which in some cases are even accompanied
by vomiting, will be considered under the reflex pains of the appro-
priate viscera, though for clearness of conception they will also
be described in our consideration of the diagnosis of stomach
pains. These reflex pains in the epigastrium, associated with
vomiting are due to disease of the gall-bladder, pancreas, appen-
dix, uterus and appendages, etc., should not, as is done by some
434 THE STOMACH
authors, be placed under gastralgia, but should be considered
under the lesions of the diflFerent organs producing them. This
is sometimes very difficult, for, in many cases, it is not easy to
distinguish the origin of the different pains; for instance, gall-
stone colic is often confused with gastric pain, yet it may be dis-
tinguished from it by its paroxysmal character, its tendency to
become localized to the right and to extend around the right side
to the area underneath the right scapula. At the same time it is
associated with localized gall-bladder tenderness, and often there is
a well-marked enlargement of the gall-bladder and sometimes a
generalized jaundice. Angina pectoris has also been confused with
gastric pain. Here the pain, as a rule, follows exertion, and radi-
ates into the left arm and hand. The heart may be tumultuous in
action, and frequently there are severe depression and a fear of
death. The appendix, also, has in many cases been found to
cause epigastric pains; but here epigastric pain, with no tender-
ness over the epigastrium, but over the appendiceal region, is
present There may also be a palpable mass in the same region,
and the pain and tumor are associated with vomiting, eructation
of gas and constipation. Of diagnostic importance in differenti-
ating pain of local origin from referred pain is the administra-
tion of local anodynes, as cocain, alypin, menthol, and phenol.
These generally cause the pain to lessen or cease when it is of
local irritative origin, such as occurs when the lesion is in the
mucous membrane, namely, in ulcer, carcinoma, etc. When no
effect is noticed, after the administration of the local anodyne,
neurotic lesions should be considered. Of considerable diag-
nostic importance is the fact that gastromyalgia is frequently
relieved by pressure.
Hyperchlorhydria. — Hyperchlorhydria is the only secretory
neurosis of the stomach which products pain. This pain comes
on one-half to two hours after eating, and lasts a few hours, or
until more food is taken, being particularly relieved by the in-
gestion of proteids, and also by alkalies. It is much less after
large meals, especially those containing much meat and eggs and
deficient in carbohydrates. The pain differs from that due to
LESIONS OF STOMACH CAUSING PAIN 435
gastric uWr in being diffuse and extending over the entire abdo-
men. It seems to be frequent in persons of neurotic tempera-
ment, and is commonly associated with gall-stones. Hyper-
ehlorhydria is also frequently associated with neurotic motor
disturbances. The pain produced by it often is accompanied by
caoplucul oampoiiait ol
o«t*J ouiiUaewithtbe
Fia. 91. — Location or the Pain Symptomb in a Case of Htperchlor-
HYDRIA.
a considerable belching of gas, generally preceded by a burning
sort of pain, which seems to rnn up under the sternum to the
throat, and is accompanied by the regurgitation of acid-tasting
fluid. The pain may also radiate to the back, to the axilla, and
to the scapula. In some instances the pain seems to be due to
the presence, even in small quantities, of hydrochloric acid. In
these patients there is a pemliar antipathy of the stomach to the
presence of any acid. The examination of the stomach contents
often shows a normal or even a subnormal percentage of acid.
Hertz has shown that the gastric mucosa is not painfully
stimulated by excess of hydrochloric or other weak acids. It is
probable that the heartburn of so-called hyixTchlorliydria has
nothing whatever to do with acid production, and that the term
is a misnomer. The hot sensation is closely related to that felt
following the ingestion of alcohol, and is felt most often following
slight regurgitation due to the presence of excessive amounts of
gas. Hertz maintains that heartburn is an esophageal sensation,
436 THE STOMACH
not a gastric one, and is due to the stimulus of exceeeiVe carbo-
hydrate fermentation (hot bread — biscuit — causing the so-called
pudding heartburns). This causes the production of alcohols,
ethers, and organic acid in the stomach, which by regurgitation
FiQ. 92. — Pain Radiation.
Crosses indicate the ait«a of pain and the lines with arrows indicate the
direction of the p^n radiation.
act upon the lower end of the esophagus, thus giving rise to the
classical heartburn erroneously interpreted as a hyperchlorhydria.
For a further interpretation of the causes of pain in hyperchlor-
hydria, see gastric ulcer.
Pyloric or Oordiospum. — The stomach resembles other divi-
sions of the hollow abdominal viscera in that it is subject to colic;
but the parts chiefly affected are the pylorus and the cardia, as
the intervening portion has so great a lumen that it contracts en
bloc less readily. Then, too, this part of the stomach is so situated,
and its attachments to the adjacent viscera are so arranged, that it
may undergo considerable distention without any symptoms being
produced ; but as soon as the distention becomes excessive and trac-
tion is made on its peritoneal and diaphragmatic attachments,
pain results. The same is true, when, owing to the contraction
of the pylorus or cardia, a change in the relationship of these two
parts to the surrounding viscera results, and a pull on their peri-
toneal attachments occurs.
LESIONS OF STOMACH CAUSING PAIN 437
By reference to the anatomy it is seen how the cardia of the
stomach is immediately below the opening in the diaphragm, and
how, when it contracts, especially when the stomach is full, there
must be a stretching of the gastrophrenic ligament, with resulting
pain. The same is true of the pylorus, but here the pull is made
on the gastrohepatic omentum, and possibly also on the gastro-
colic omentum. Hertz claims that the pains in pyloric or cardiac
spasm are really tension pains, due to distention of a segment
of the stomach. In pyloric spasm a persisting contraction of the
pylorus occurs as a reflex from the presence of an excess of HCl
in the stomach. The peristaltic wave in the stomach, being ex-
cessive from the HCl stimulation, pushes the food onward until
it reaches the prepyloric part of the stomach; from here, owing
to the closure of the pylorus, it cannot advance further, and
tension is made upon the stomach walls at this point.
From this it would seem that not only is the small part of the
stomach at the pylorus involved, but that also a large part, if not
the entire stomach musculature, is involved in the contraction. It
is hardly probable that the contraction of the constricted part of
the bowel at the pylorus could so alter the relationship of this one
part to the gastrohepatic or gastrocolic omentum that the stretching
of it would be great enough to cause the severe and widely diffused
epigastric pain which is sometimes present. Another argument in
favor of the participation of the muscular wall is that the pain is
relieved by vomiting.
A somewhat similar cause exists for the pain in hour-glass
stomach. Here a portion of the stomach is contracted, and an hour-
glass stomach results. The food entering the upper compartment
is pushed forward by the peristaltic waves until it reaches the place
of contraction; here it is unable to progress further, and at this
point tension is made on the gastric walls, and pain results. As
would be expected, the pain is not felt when the stomach is empty,
but results only after ingestion of food and drink. It is relieved
by vomiting.
The cause of pain in cardiospasm is the dilatation of the ter-
438 THE STOMACH
minal portion of the esophagus. This is the result of stasis of
food, due to spasmodic closure of the cardiac sphincter. In cardio-
spasm the pain comes on immediately after eating, is fairly con-
stant, and seems to be located beneath the costal margin at the left
seventh costal cartilage, while in pyloric spasm the pain is localized
in the midline, about midway between the umbilicus and ensiform,
and comes on two or three hours after eating, i. e,, at the time of the
passage of the gastric contents through the pyloric opening. Both
pains have a typical paroxysmal gripping or twisting character,
and are equally severe. The pyloric spasm generally is relieved
by vomiting, while cardiospasm gradually passes off, no vomiting,
as a rule, occurring. In both midnight attacks are very frequent-
It seems also that in some cases the contraction of the cardiac and
pyloric sphincters alone can cause reflected pain, this pain being
due to the unusual squeezing of the nerve terniiuals in the muscular
tissue, the result of the abnormally severe contraction. For the
production of pyloric spasm pain it is not always necessary that
the stomach be full, for in many cases when it is empty the irrita-
tion of the gastric secretions (which in this condition are often
highly acid) will produce it. Also, it can be relieved by washing
out the stomach.
A similar contraction of the musculature of the pylorus and,
in some cases, of* the entire stomach and duodenum is the cause
of hunger-pain. This differs from cardia and pyloric spasm in
that it can be relieved by the ingestion of food, provided the
stomach mucosa and musculature are intact. The ingestion of
food will not relieve the associated hunger-pain present in ulcer
or carcinoma of the stomach, because the food, of itself, is an irri-
tant in such conditions, and aggravates instead of easing the
spasm.
In all these conditions, after the pyloric spasm has persisted
for some time, a dilatation of the stomach results. This dilata-
tion, in turn, causes gastric pain, because of the traction and
pull of the gastric walls on the omental attachments. The pain
is of the same kind as described in acute dilatation of the stom-
LESIONS OF STOMACH CAUSING PAIN 439
ach, only in dilatation the result of pyloric spasm the pain is
added to the previously existing spasm pain. In acute dilatation
also, the pain is. more generalized, and becomes constant, while the
pyloric-spasm pain is paroxysmal. In case of dilatation of the
stomach the epigastrium is distended, the outlines of the stom-
ach are plain, and visible gastric peristalsis can be seen; also,
on listening, borborygmi and bubbling noises can be heard.
Succussion sometimes gives rise to a splashing sound. Eructa-
tions of sour-tasting fluid are also present. These associated
symptoms generally come on when the pain is most severe. If
vomiting occurs, and the spasm has been of some duration,
large quantities of gastric contents are expelled. Sometimes
the attacks of colic are accompanied by a mild chill of
nervous origin, elevation of the temperature being entirely
absent.
Pressure on the distended stomach is well borne, and is fre-
quently applied by the patient, because it seems to aid in the forc-
ing on of the stagnated stomach contents. The pain is increased
by the eating of indigestible foods. According to Schmidt, cold
applications to the epigastrium seem to be better borne than hot
ones, and to be more beneficial to the patient.
Acute Dilatation of the Stomach. — Acute dilatation of the
stomach frequently is a cause of the most severe pain. It is prone
to occur after operations, especially those in which there has been
considerable handling of the abdominal viscera. It comes on,
as a rule, three or four days following the operation. By many
it is held to be only a symptom of a peritonitis, which, it is
claimed, is present in every case of such vomiting. At first there
is a feeling of distress in the epigastrium, which soon increases
until severe pain is felt. This is generally accompanied by the
vomiting of a greenish fluid, and by a gradual abdominal disten-
tion, with rise of pulse rate, and signs of severe systemic distress.
This state, unless relieved, is rapidly fatal. Acute dilatation also
occurs in many patients who have not been subjected to operative
interference, but generally it is not of as severe a form as in the
440 THE STOMACH
operative ones. In both of these conditions the pain is of a diffuse
nature, and is located in the epigastrium. Because of the acid con-
dition of the stomach contents, the pain may be partially relieved
by the ingestion of alkalies; but the only sure relief is from re-
peated stomach washing. Should stomach distention be suspected,
it can be confirmed or disproved by percussion and palpation, as
well as by the stomach tube, by which, if gastric dilatation is
present, large quantities of greenish fluid may be removed.
In some cases distention of the stomach may be associated
with distention of the duodenum, and, when this occurs, as in a
case reported by Torrance (577), there may be pain under the
right shoulder and over the eighth and ninth ribs to the right of
the spinal column.
The pain of gastric dilatation is also partially due to the trac-
tion which the diaphragm exerts on its costal attachments, owing
to the upward force exerted upon it and its consequent displace-
ment by the distended stomach.
Acute Qastiitis. — ^Although the stomach has no special tactile
sensory nerves, it reacts painfully to inflammatory lesions.
When inflammation is present in the stomach walls, the adjacent
lymphatics become involved, lymphangitis results, and this in-
flammation spreads to the parietal peritoneum through the im-
mediate attachments, and causes it to become hypersensitive. At
the same time the inflammation of its walls causes the stomach
to become very irritable, and to react much more strongly than
usual to stimuli; so that, on the entrance of food and drink, it
contracts to a greater than normal degree. This produces trac-
tion much greater than normal on the inflamed mesentery, and at
the same time causes tension within its own muscular coat and
pressure upon the nerves of deep sensibility with resultant pain.
In gastritis the subjective pain is felt in the epigastrium, and
at the same time the gastric areas of hyperalgesia (Head) may
be present. The subjective pain is of a dull, aching character,
increasing to a sharp, burning on the ingestion of foods. Another
characteristic of this pain is that it seems to run directly through
LESIONS OF STOMACH CAUSING PAIN
441
to the back, this being most probably the result of the irritation
of the inflamed peritoneum around the cardiac opening, which
lies very much closer to the back than it does to the anterior
abdominal wall. On making pressure over the epigastrium, pain
is elicited ; light pressure bringing out, in many cases, the hyper-
' Pain in epigaBtrium goes
directly through to the
back. Pain between
shoulders is also some>
^times present
Fig. 93. — Figure Illustrating the Location of Pain in Acute GASTRrris.
algesic areas of Head, while deep pressure brings to light the
tenderness of the subserous peritoneum, which, because of its
lymphatics, is frequently involved in the inflammatory process.
This pain varies in intensity and seems to have some relationship
with the severity of its lesion, so that the extent of the gastric
inflammation may partially be judged from the magnitude of the
pain.
The pain of acute gastritis is fairly sudden in its onset. It
may follow a night of alcoholic indulgences, or occur after the
eating of indigestible substances, and is associated with nausea
and vomiting. It may be so severe that morphin is required to
relieve it. In some cases there are an elevation of the tempera-
ture as high as 104 ° F. and an increased rapidity of the pulse.
The recti muscles of the upper abdomen are also contracted, espe-
cially on the left side, and are slightly tender on palpation.
442 THE STOMACH
Ohronio Gastritis. — Chronic gastritis is generally not painful^
though after eating there may be a feeling of discomfort. Kie-
gel, according to Gilbride, claims that in the atrophic forms of
gastritis the pain resembles that of the gastric crisis of tabes.
Qastric Erosions. — Gastric erosions, as pathological entities,
occupy a position intermediate to gastritis and ulcer. Pathologi-
cally they are less extensive than ulcers, and more intensive than
gastritis. The pain produced is of a dull aching character, and
seems to extend throughout the entire stomach area. It is not
affected by pressure or by change of position. It generally comes
on after eating, persists an hour or two, and then gradually sub-
sides; but it may be present irrespective of the intake of food,
and intervals may be present in which there is absolutely no pain.
The course of the disease is prolonged. Emaciation, loss of appe-
tite, and, in many cases, hematemesis may result.
Oastrio Ulcer. — Gastric ulcer, in its pain production, depends
upon practically the same factors as does gastritis. The lesion
in ulcer is circumscribed, while that of gastritis is diffuse. Both
are associated with lymphangitis, and it is this lymphangitis
which contributes greatly to the pain that is produced. That the
pain and tenderness which are felt on palpation are not present in
the stomach but in the abdominal wall can be demonstrated from
the following premises :
(1) The ulcer, in most cases, is on the posterior wall of the
stomach, and pressure upon it through the abdominal wall, rigid
because of the contraction of the rectus, is almost impossible.
(2) The pain and tenderness are constant, while the relative
position of the ulcer is always varying, depending upon move-
ment of the stomach due to respiration, peristalsis, distention
with food, liquids, gas, etc.
(3) On exposure of the stomach by exploratory laparotomy
the ulcer may not be found immediately beneath the area in which
the pain and tenderness had been felt.
In the following drawing, Mackenzie (586) illustrates the
relative position of the pain and the site of the ulcer. In his
LESIONS OF STOMACH CAUSING PAIN 443
cases the site of the ulcer bore no relationship to the site of the
pain ; but when the ulcer was near the cardiac end of the stom-
ach the localized pain and the cutaneous and muscular hyperal-
gesia were sitnated liigh in the epigaatrium, while if the ulcer
was situated near to the pylorus
it caused pain low down in the
epigastric region.
It is claimed that in some <
eases it is the contraction of the
pylorus which causes pain; in
othera that it ia the contraction
of the bundle of fibers which
surrounds the prepyloric r^ion
of the stomach and separates the
antrum pylori from the rest. In
one case Houllin reports a cure
from the ulcerated condition
and the pain by section of these "'
fibers (Mansell Moullin, 578,. F'"- 94.-Location of Pain in
In this case neither ulcer j^ ^^^f. gpjre the area A shows the
nor scar could be found when area of pMn when the ulcer waa
,, , 1,1. at the cardiac end of the stomach
the atomach was opened, so that ^. g ^^en the ulcer waa in the
it was probably only a case of middle of the leaser curvature b;
C when the ulcer was at the
pylorus c.
hypertrophied pylorus.
That the pain in gastric
ulcer ie not due to hyperacidity of the stomach contents can be de-
duced from the fact that increase in the hyperacidity, due to the
ingestion of acids, produces no increase in the pain. It has also
been shown that pain cannot be produced by irritation of the nor-
mal mucous surface of the stomach. The researches of Hertz also
tend to show that an ulcerated surface is insensitive to acids in the
strength found in the stomach.
In some patients an ulcer of the stomach causes no pain.
When this occurs the ulcer is generally situated on the anterior
surface, near to the cardia, no adhesions having formed between
it and the parietal peritoneum. C. W. Habershon, in 1859, was
444 THE STOMACH
one of the first to show that ulcer confined to the mucous mem-
brane alone was not painful. He likewise claimed that cancer
and other diseases, while restricted to the mucous membrane^
produce no pain.
The pain of gastric ulcer can generally be distinguished be-
cause of its several characteristics, as follows:
(1) Time of Onset — Pain generally begins immediately on
the entrance of food into the stomach, and gradually increases
until it reaches a climax (at the time the pyloric end is at work),
and then, as the stomach empties itself, it becomes less and less,
and gradually disappears. It is also relieved by vomiting, and
in many cases by the ingestion of alkalies. After an hour or two
it ceases. The longer the interval between the time of ingestion
of food and the appearance of the pain, the farther away from
the cardia and the nearer to the pylorus is the ulcer. If it has
occurred immediately after editing, the ulcer is probably near
the cardiac orifice or the lesser curvature; if two or three hours
after, it will be at the pylorus; and, if four hours after, and
relief ensues on taking food, the ulcer is probably in the duo-
denum.
(2) Character , — The pain, as a rule, is of a dull, boring char-
acter, and is generally localized to a small area in the epigastrium.
It may radiate to the back. Sometimes, instead of a pain, there
is present in the epigastrium a dull, disagreeable, constant sensa-
tion. When this is present, adhesions, peritonitis, and increased
continuous secretion of gastric juices are likely to be found. The
statement that the ulcer can be mapped out by percussion is mani-
festly absurd, as can readily be understood from a study of the
origin and propagation of gastric pain. A peculiarity worth
noting is that the pain is most severe when the ulcer is located
on the posterior surface, because, in this location, it is nearer to
the parietal peritoneum, upon which there is more drag than
would occur if the ulcer was situated upon the anterior surface.
In some cases there may be a burning sensation after eating, and
the pain may radiate to the sides of the chest and shoulder. The
sensation varies from a feeling of distress, that is hardly notice-
LESIONS OF STOMACH CAUSING PAIN 445
able, to a pain of the greatest severity. This pain has been
described as cutting, gnawing, piercing, or burning.
The pain of pyloric ulcer is, as a rule, greater than that of
cardiac ulcer.
A very strong reason why this should be so is that the pylorus
is relatively a fixed portion of the stomach, and in distention or
contraction of the stomach it does not change its position according
to the change in the position of the remainder of the stomach, con-
sequently pull is made upon it, and it is this pull upon the already
irritated structures that causes pain. This pain seems to occur
most frequently in the mid-hours of the night. In some cases psy-
chical disturbance, as anger or great emotion, seems to be conducive
to its onset.
(3) Tenderness. — In gastric ulcer, the tenderness which is
in the epigastrium, in many cases to the right of the median
line, may, because of adhesions, be localized in other parts of the
abdomen. Ulcer of the stomach differs from gall-stone and all
other colics, in that the patient is very sensitive in the upper
abdomen, so that in many cases he will not bear even the slightest
pressure, which is exactly the opposite to what occurs in colic, for
here pressure seems to give relief. The tenderness to palpation
and percussion associated with ulcer seems to vary according to
the degree of distention of the organ — the greater the distention
the more severe the associated pain.
The tenderness elicited on palpation is of two types, super-
ficial and deep. The superficial tenderness is merely an expres-
sion of the hypersensibility of the skin, while the deep tenderness
expresses the hypersensibility of the muscles, subserous perito-
neum, and the peritoneum (parietal) in immediate association
with the ulcer. When the tenderness is due to a hypersensibility
of the rectus muscle, it will be found that the muscle is in a state of
contraction, and that this contraction is localized to the upper
segment. The contraction is more marked, generally, on the
right side than on the left. This localized contraction, the so-
called visceromotor reflex of Mackenzie, has, in some cases, been
mistaken for a tumor. Sometimes, if the patient is very stout, it
iSi
^1
3 S S i
^ II
! Il
■si "bI
LESIONS OF STOMACH CAUSING PAIN 447
•
is difficult with ordinary palpation to elicit pain in the rectus. It
then becomes necessary to make very firm pressure, with the abdo-
men as relaxed as possible, so that the area of tenderness may be
defined. After having examined the abdomen it is well to examine
the back. Here a tender area to the left of the tenth, eleventh, or
twelfth dorsal vertebrae may be present. Percussion is frequently
used to exactly define the area of tenderness. The lymphatics
from the pylorus are in association with the upper abdominal
wall on the right side, while the lymphatics from the cardiac end
of the stomach are distributed to the upper abdominal wall on
the left side. Since ulcer is most common at the pyloric end of
the stomach, this >vill account for greater frequency of increased
rigidity of the right rectus.
(4) Diet. — Foods causing the production of pain, or increas-
ing the pain already present, are those which are of an irritating
nature or are difficult to digest. Of the first, are corn, crusts of
bread, some breakfast foods, as grape-nuts, cherries which have
been swallowed with their pits, etc. In the second class, pork,
fresh baked bread and hot rolls, boiled cabbage, cucumbers,
unripe fruits, strongly spiced foods, the various salads, and pota-
toes may be included. Of the liquids causing an increase of ulcer
pain, are those which are highly acid, or those which contain alco-
hol, as whiskey and beer. In many cases, also, those drinks
which in themselves are stimulating or irritating, as coffee and
tea, increase the pain. Cold drinks likewise sometimes induce a
paroxysm of pain. The foods which are well borne in ulcer are
meats, particularly scraped meat (beef), milk with lime water,
and farinaceous gruels. Smoking sometimes seems to induce
pain. Possibly this is a result of a stimulus to contraction known
to be caused by nicotin. If the ulcer is situated near the pylorus,
and the stomach is adherent to the pancreas, the pain is felt most
severely in the intervals of gastric digestion. It is temporarily
relieved by food or draughts of water.
(5) Change of Position, — If the pain is worse in certain posi-
tions it can be assumed that the position in which it is worst is
the one in which the stomach will be so situated that pressure
448 THE STOMACH
will be made upon the ulcer by the stomach contents and abdomi-
nal viscera, A change of position will also, in many cases, cause
a kinking or bending of the pylorus, and this, in turn, produces
traction upon the ulcer-bearing surface, thus causing pain«
It seems to be the rule that a right lateral position of the
body is most painful in ulcer of the pylorus. The opposite seems
to be true in cases of fundus ulcer. This rule, though, is true
only before adhesions have formed. After their formation such a
change of position of the body that the stomach will have a tend-
ency to drop away from and pull upon the adhesive surface, would
cause an excess of pain in the ulcer and adhesion area. In all cases
the pains due to change in the position of the body are increased
at the time of the spontaneous attacks common to ulcer. In many
patients, in whom the ulcer is on the posterior surface, relief is
found during the attack by lying on the abdomen. Lifting, strain-
ing, carrying heavy loads, jumping, and rowing, and, in some cases,
going up and down stairs, excessive respiratory movement, cough-
ing and sneezing, running and walking may be provocative of pain.
During attacks the patient may be crouched, the lower limbs being
flexed, and the body bent forward. He may lie on the back or
abdomen, or on either one or the other side, depending upon the
location of the ulcer.
(6) History. — Gastric ulcer generally gives a history of at-
tacks of left-sided pain, which may or may not be accompanied
by vomiting. This pain gradually passes off, and the patient may
be free for several weeks or months; but again the pain comes
on and lasts a little longer than in the first attack. Thus the
pain continues to come and go, each attack being of briefer dura-
tion than the previous one, and occurring at successively shorter
intervals.
Conditions accompanying and associated with gastric ulcer
are: (1) Vomiting, which comes on generally after the ingestion
of food, especially if the food be of an irritating kind. It occurs
one^half to two hours after eating, but may take place almost
immediately. The vomitus of an ulcer patient is somewhat char-
acteristic, in that it often contains pure blood.
LESIONS OF STOMACH CAUSING PAIN 449
(2) Constipation is frequently present*
(3) Anemia sometimes occurs, and is due to the loss of blood
in the vomitus or in the stools.
(4) Blood is sometimes seen in the stools after a meat-free
diet.
(5) Enteroptosis frequently accompanies pyloric ulcer. In
this case a properly adjusted abdominal supporter, the taking on of
fat, or the presence of pregnancy frequently eases the condition,
the cause of the relief in the latter instance being due, as Schmidt
suggests, to the elevation of the abdominal viscera by the rising of
the enlarged uterus.
(6) Pyrosis or regurgitation of sour-tasting fluids sometimes
occurs.
(7) Belching of gas and tympanitis are common. The belch-
ing of gas, with the accompanying sour-tasting eructations, is
almost pathognomonic of gastric ulcer.
Peeforating Ulcers. — The perforation of a gastric ulcer is
one of the tragedies of medicine. It is ushered in with pain
(Eisendrath, 579), which is severe and sudden, and of an intense,
agonizing, or stabbing character. If the ulcer is on the anterior
stomach wall, and is in intimate contact with the anterior abdom-
inal wall, the pain may be felt at first around the navel. In either
case, as the associated peritonitis extends down into the right
iliac fossa, it rapidly becomes diffused. The original pain is now
accompanied by the sharp, intense pain that is so characteristic
of a spreading peritonitis. The abdominal muscles become rigid,
and marked tenderness develops on the right side. A complica-
tion of this kind can be diagnosed from appendicitis in that the
muscular rigidity in appendicitis is more markedly localized to
the right iliac fossa, and also from the fact that in gastric ulcer
there is often a history of hematemesis, pain after eating, and
occult blood in the stools. If the case is first seen several hours
after perforation, it is almost impossible, because of the asso-
ciated peritonitis, to diagnose the origin of the pain.
Diagnosis of Gastric Ulcer. — The pain of gastric ulcer dif-
fers from that of gall-stone colic in the following ways:
460 THE STOMACH
(1) Pain in gall-stone colic is paroxysmal, and has a tendency
to radiate over the right side to the right scapula; also it is felt
in the right shoulder.
(2) Vomiting nearly always relieves the pain of ulcer, while
it may have no noticeable effect on gall-stone colic. In ulcer the
vomitus often contains blood. In gall-stone colic none is present.
(3) Local anesthetics and mild drinks often ease the pain of
ulcer. They would have no effect on gall-bladder colic.
(4) In gall-stone colic there is frequently a history of pre-
vious attacks, with an accompanying jaundice.
Cholecystitic pain is also often mistaken for ulcer pain; but
in the former the pain is constant, and the enlarged and very ten-
der gall-bladder can be felt. Pain of hepatitis has sometimes been
confused with the pain of gastric ulcer, but in the former there
is a tenderness beneath the right costal margin, and the liver is
generally enlarged.
From epigastric hernia gastric ulcer can be diagnosed by the
physical signs of the hernia which are present, and the impulse
on coughing and straining. Duodenal ulcer is hard to distinguish,
as the pain symptoms in the two conditions are almost identical,
but alypin and cocain often relieve the pain of gastric ulcer,
while they have no effect on that due to ulcer of the duodenum.
To distinguish pyloric from duodenal ulcer Mennier (66b) has
devised the following test He gives the patient one pint of
milk.
In Pyloric Ulcer In Diwdenal Ulcer
The pain is relieved after a The pain remains with the same
few swallows, and gradually intensity for 5, 10, or 15
disappears. minutes; then the patient
belches gas, and suddenly the
pain is relieved. This re-
lief is synchronous with the
opening of the pylorus, the
belching of gas, and the pas-
sage of the stomach contents
into the duodenum.
LESIONS OF STOMACH CAUSING PAIN 461
Acute pancreatitis often gives rise to symptoms similar to
those of gastric ulcer; but here there are generally an associated
shock and collapse. The pulse is considerably elevated, and a
tumor (enlarged pancreas) often develops and lies across the
uppLT abdomen.
Angina pectoris has also been mistaken for ulcer-pain; but
the associated collapse and fear of impending death, the presence
of unconsciousness, and the radiation of the pain to the left
shoulder and down the left arm make the diagnosis easy. In
angina pectoris vomiting does not occur, and diet, as a rule, has
no effect on the incidence of the pain; but exercise and violent
emotion seem to be inciting factors.
Appendicitis pain, especially if it occurs in the region of the
umbilicus and is associated with vomiting, has frequently been
mistaken for that due to gastric lesions. In appendicitis Morris's
and McBurney's points may be tender, and there may also be re-
flected visceral hyperalgesia in the area usually associated with the
appendix. These, with the absence of definite symptoms of stom-
ach involvement, make the diagnosis certain.
Eenal colic can hardly be mistaken for gastric-ulcer pain;
the peculiar radiation of its pain downward and inward to the
pubes makes its differentiation somewhat easy.
The pain of gastric carcinoma will be differentiated when it
is considered a few pages further on.
The diagnosis of chronic ulcer of the stomach is easy, and
when all of the classical symptoms are present can scarcely occa-
sion perplexity. When, however, this is not the case, it may be
exceedingly difficult, or even impossible, to make a positive diag-
nosis. Important diagnostic factors have already been indicated.
Two other diseases of the stomach, gastralgia, or gastrodynia (as
the expression of functional nervous disturbance), and carcinoma
resemble the symptom-picture of ulcer when ulcer deviates from
its typical course. It seems advisable to tabulate their important
points of difference, as follows : *
' Modified from ' ' Modem Clinical Medicine, ' ' Diseases of the Digestive
System, page 188.
452
THE STOMACH
NERVOUS GASTRALGIA
Tongue varies, is often pale,
and fissured at the borders
or upon the surface.
Frequent eructation of odor-
less gas.
Taste unaltered, dryness of
mouth frequent; sometimes
salivation.
Appetite irregular, capricious.
Eating brings relief.
Varying sensations in the
stomach, sometimes heat,
sometimes cold.
Spasmodic, burning pain, in-
dependent of food, often
ameliorated by the latter or
by pressure upon the stom-
ach. Pressure frequently
eases the pain, though it is
common for the anterior ab-
dominal wall to be hyper-
esthetic.
Often conjoined with hyster-
ical symptoms. Occurs at
all ages, more frequently in
women than in men.
ULCER
Tongue, dry, red, with
white streaks in the
center, or is smooth
and moist, or slightly
coated.
Eructations either rare,
or acid with pyrosis.
Taste unaltered.
Appetite good in the in-
tervals; thirst, eating
causes pain.
Burning sensation in
the stomach. Circum-
scribed boring pain,
often radiating pos-
teriorly.
Pains, gnawing, rare
upon an empty stom-
ach, usually appearing
after eating or upon
motion and on assum-
ing positions which af-
fect the stomach; in-
creased upon pressure.
Pressure points (hyper-
algesic) upon back.
Pressure over abdo-
men increases the pain.
Sometimes at the time
of parox3r8ms it will
relieve the pain. Pa-
tients sometimes pre-
sent the chlorotic type.
CANCER
Tongue, pale; in rare
cases, very red, dry.
Frequent fetid eructa-
tions.
Pappy, insipid taste.
Appetite decreased or
anorexia; early repug-
nance to meat; eating
causes pain.
Sensation of weight in
stomach ; drawing
pains of varying char-
acter, perhaps pain in
the shoulder.
Continuous sensations
of dull pain, period-
ically increasing t o
paroxysms, often pro-
duced by pressure or
increased by it.
Most frequent in middle
life; rare in children.
Accompanied by a
varying psychical con-
dition, frequently great
depression.
Most frequent between
the 40th and 60th
years. Psychical con-
dition that of depres-
sion; melancholia, but,
strange to say, less
profound than in se-
vere cases of ulcer.
LESIONS OF STOMACH CAUSING PAIN
453
NERVOUS GASTRALQIA
No tumor on palpation, un-
less, as rare exceptions, when
foreign bodies (hair, etc.)
have been swallowed. Chem-
ism varies; absence of lactic
acid.
ULCER
When the ulcer is situ-
ated at the pylorus
with consecutive hy-
pertrophy, an ovoid,
smooth tumor at the
right of the median
line may be palpated;
occasionally, in old ul-
cers with a hard base
and callous borders, a
palpable circumscribed
tumor may be felt.
Perforation of the
ulcer and consequent
adhesions with the
head of the pancreas,
the left lobe of the
liver, the spleen or
the omentum, causes
a tumor which does
not move with the
respiratory excursion.
HCl present and usu-
ally increased.
No symptom of perforation., Perforation into neigh-
boring organs with
characteristic, symp-
I toms may occur fre-
quently after apparent
I brief duration of the
disease, even occurring
without prodromes.
CANCER
Most frequent about the time Most frequent at from
of the menopause. 15 to 35 years.
History of nervous disorders, ^ History of anemia, vom-
as neurasthenia, hysteria,
neuralgia, etc.
No pain between attacks.
iting of blood, dyspep-
sia, tuberculosis, etc.
Pain attacks may bo
absent for years, only
to become again mani-
fest.
Distention of stomach pro- Distention produces
duces no pain. most severe pain, but
it is a very dangerous
procedure.
Tumor of varying size
and shape, nodular or
smooth, distinctly pal-
pable; as a rule, pas-
sively movable, occas-
ionally also showing
active excursions dur-
ing respiration. In the
majority of cases ab-
sence of HCl ; absence
of peptic digestion ; lac-
tic acid, lab-ferment
sometimes absent (can-
cer of the pylorus),
sometimes present
(cancer of the fimdus).
Secondary glandular
enlargement; metas-
tases.
Perforation ; implica-
tions of neighboring
organs only after pro-
longed existence of the
disease.
Most frequent late in
life.
History of cancer in fam-
ily, also of a gradually
progressive weakness.
Attack, when it comes
on, generally lasts till
cancer is removed or
till death occurs.
Distention is painful.
454
THE STOMACH
f^BVOUS GASTBALGIA
Very little effect on general
health.
The chemism of digestion not
especially altered.
Epigastric pulsation. Regu-
lation of diet has no effect.
Vomiting irregular, vomitus
sometimes contains only
mucus, sometimes more or
less digested stomach con-
tents, rarely mixed with bile.
No hematemesis, except as
accompaniment of very rare
compUcations.
Almost invariably stubborn
constipation; normal evacu-
ations very rare; occasion-
ally fluid mucoid dejecta, the
so-called pseudo- diarrhea.
Mucous colic, that is, colitis
' mucosa membranacea.
ULCER
General health greatly
affected.
Digestion of starches fre-
quently slow; that of
meat normal, or even
accelerated ; usually
hyperchlorhydria.
Alkalies and albumins
ease the pain.
Vomiting as a rule, im-
mediately or shortly
after eating, and fre-
quently the first symp-
tom of the disease;
it occurs very rarely
without the taking of
food, vomitus hyper-
acid.
Vomiting of light red
blood or coffee-ground
masses; usually re-
peated in a brief space
of time, occasionally
very profuse, followed
by extreme anemia and
collapse; compensation
with comparative rap-
idity; blood in the
feces; occult hemor-
rhages.
CANCER
General health greatly
affected.
Digestion insufficient ;
usually absence of free
HCl; and the forma-
tion of organic prod-
ucts of decomposition.
Epigastric pulsation
present with marked
emaciation. Regula-
tion of diet has no
effect.
Severe and frequent
vomiting, often period-
ic; occasionally, also,
before the ingestion of
food; vomitus is mu-
coid if acidity due to
the presence of organic
acids is present; vom-
itus shows but slight
progress of digestion;
sometimes cancer cells
are present. Also in
some cases the Boas-
Oppler bacillus.
Decomposed blood more
frequent than fresh;
quantity usually small,
but, vomiting having
once appeared, it re-
curs frequently at
short intervals.
Bowel discharges vary; Almost invariably bow-
not infrequently diar- els stubbornly consti-
rheal in consequence of
intestinal irritation ;
lientery if perforation
of the ulcer occurs into
the colon.
pated; lientery after
perforation of the ulcer
into the colon.
LESIONS OF STOMACH CAUSING PAIN
455
NERVOUS GASTRALOIA
X7LCER
•
CANCBR
No fever.
. Mild fever with adhe-
sive inflammation after
rupture of the ulcer,
or following profuse
hemorrhages.
Fever rare, and only
towards the termina-
tion of life; initial fever
quite rare.
Skin pale, rarely ruddy. Skin
of nonnal turgescence.
Skin usually ruddy, ap-
pearance good, anemic
only after profuse hem-
orrhages; frequently
the pallor is visible
in the mucous mem-
branes, and even in
the cheeks.
Skin sallow, yellow-
ish, dry, and flaccid;
marked cachexia.
New Orowths of the Stomach. — New growths of the stomach
cause pain, especially when they encroach upon the pylorus and
thus produce a partial obstruction with a consequent gastric dila-
tation. Carcinoma causes pain, particularly when it ulcerates,
and when infection takes place, which gives rise to lymphangitis.
According to Eisendrath, there is, in gastric carcinoma, at first
only a heaviness after eating, then later a pain of a dull, gnawing
character referred to the epigastrium. There is also a marked
local tenderness. In carcinoma, or other new growths of the
stomach, generally there are in some stage of their development
characteristic areas of cutaneous hyperalgesia. The figure on the
next page illustrates the areas mostly involved.
One of the earliest symptoms of carcinoma is the feeling of
pressure in the epigastrium, occurring a short time after eating.
There may also be sensations of burning, fulness, or of epigastric
tension. When the pylorus becomes stenosed the pains assume a
boring or twisting character, and are due to the spasmodic con-
traction of the stomach, which is attempting to force its contents
through the narrowed opening. When the cancer is at the fundus
pain is present, more especially when the stomach is full, and
may radiate towards the breast and back. In some cases it is
started by the ingestion of food, while in others it is produced by
mechanical shock or by change of position.
456 THE STOMACH
The pain in gastric carcinoma may vary in location, depend-
ing B great deal upon the site of the new growth. It seems as
though the nearer the growth is to the pyloric end of the stomach,
the farther to the right and the closer to the umbilicus will he the
pain. Sometimes this pain radiates around the sides to the back,
Fia. 97. — Htpeealgesic Zones in Cancer at Cardiac End of Stomach.
and rests between the shoulders, or runs anteriorly up under the
lower part of the sternum; or it may radiate backward into
the iliac regions. The reason for this is not clear. The appear-
ance of pain on the back seems to be favored by constipation
(Schmidt) ; it is relieved by purgation. Pain is also frequently
present in the supraclavicular region on the left side.
The pain in gastric carcinoma is greatly increased when in-
fection takes place, and a perigastric peritonitis results. The
local tenderness is also much increased, and extends over a wider
area. Creaking sounds, due to the movement of the inflamed peri-
toneal surfaces o^■c^ each other, may be lieard on auscultation, or
be felt on palpation. The pain is constant; and is increased on
the taking of food. Carcinoma, although having a resemblance
to gastric ulcer, should be distinguished in diagnosis. In gastric
ulcer pain comes on immediately after the ingestion of food; no
tumor mass is found; a localized area of extreme tenderness is
present in the epigastrium; and the stomach contents yield an
LESIONS OF STOMACH CAUSING PAIN 457
excess of hydrochloric acid with the absence of sarcinse and lactic
acid. The exact opposite of these conditions prevails in gastric
carcinoma. In gastric ulcer the pain generally occurs in attacks
at irregular intervals, and frequently a coffee-ground vomitus is
present, while in carcinoma the pain is more continuous, and coffee-
ground vomit is, as a rule, absent. In gastric ulcer the ingestion
of food increases the pain, while in gastric carcinoma this is less
liable to occur. In some cases of carcinoma, in which ulceration
has occurred, the pain has a character similar to that of gastric
ulcer.
The posture of the patient generally plays but a minor role
in the production of pain in gastric carcinoma, though the pain
is worse in that position in which there is an excess of pressure
upon the carcinomatous mass, or in which an abnormal degree of
traction is exerted upon the surrounding tissues. Generally, since
the carcinoma is most frequent at the pyloric end of the stomach,
lying upon the right side is more painful than lying on the left.
In case adhesions have formed, change from one position to an-
other may be very painful. Rapid changes of position are gen-
erally productive of pain, because of the sudden movement of
the tumor mass from one place to another.
It is claimed that benign stenosis of the pylorus is much more
painful than is carcinomatous stenosis, because in carcinomatous
stenosis the patients early lose their appetite, and there is no
great mass of irritating food clamoring for passage, as in a be-
nign pyloric stenosis. Also, owing to carcinomatous invasion and
lack of nutrition, the musculature of the stomach in carcinoma
soon becomes weakened, and is unable to exert as great a propul-
sive force upon the contained food mass as in pyloric stenosis.
These conditions are present only late in carcinoma ; early in the
disease, the diet being the same as in benign stenosis, the pains of
carcinoma may closely resemble those of the latter. Sometimes in
carcinomatous pyloric stenosis the colicky pains may come on sev-
eral hours after eating. They are common about one or two o'clock
in the morning. In this respect carcinoma resembles gastric ulcer.
The pain in gastric carcinoma is due to:
458 THE STOMACH
(1) The Local Disease. — In gastric carcinoma, although hy-
drochloric acid is not present, other organic acids, such as lactic
acid, etc., are formed, and these give rise to excessive peristalsis.
When the growth is at the pylorus, evacuation of the stomach is
hindered, and pain results from tension of that part of the
stomach which lies between the pylorus and the advancing peris-
taltic wave. Should ulceration occur, the fine nerve endings are
exposed in the bed of the ulcer, and are irritated by the excessive
amount of organic acids which are present in the stomach. This
irritation reflexly causes an increased peristalsis and very severe
pain. In the latter case the modus operandi of pain production
is exactly as in ulcer. Mansell Moullin, while he recognizes the
increase in peristalsis, however thinks that the pain of carcinoma
is due to a hyperemia of the peritoneum, which causes it to become
more sensitive and to react to peristaltic traction by pain produc-
tion.
(2) Lymphangitis. — This is very frequent in gastric car-
cinoma, and, according to Lennander and others, is the cause of
the pain felt in this condition. They hold that the inflammation
progresses into the mesogastrium until it reaches an area where
cerebrospinal nerves are encountered and are irritated, and pain
is produced. Naturally, when the inflammation is extending
backward along the lymph paths, the lymph glands would be in-
volved and become larger. Pressure may then be exerted upon
adjacent nerves and give rise to pain. Thus, the pain, radiating
around the chest wall, may be caused by pressure on the intercos-
tal nerves from the enlarged glands of the prevertebral area.
(3) Metastases. — Metastatic growths imdoubtedly cause many
of the radiating pains of gastric carcinoma. Metastasis may
either precede or follow the inflammatory swelling of the pre-
vertebral lymph glands, and alone, or in association with it, give
rise to the radiating chest and abdominal pains. The left shoul-
der pain, so often complained of by the patient with gastric car-
cinoma, may be due to pressure on the acromial nerve by the
enlarged lymph gland or glands in the supraclavicular region.
Diagnostic symptoms associated with cancer of the stomach
LESIONS OF STOMACH CAUSING PAIN 459
are: in the early stages a simple regurgitation of sour fluids;
in later stages the regurgitation is changed to a vomit, and the
fluid is of greater quantity, often fermented, and sometimes con-
tains blood and the Boas-Oppler bacillus. If the cancer is well
advanced, a definite tumor frequently can be located in the epi-
gastriuuL This tumor moves with respiration, and is tender to
the touch. In malignant disease of the pylorus bile may be present
in the vomitus. This may be accounted for by the lack of tone in
the pyloric sphincter, due to the atonic condition of the muscula-
ture. The ingestion of food almost immediately starts the pain,
which generally persists until the stomach is relieved of its con-
tents by vomiting or by exit through the pylorus. The kind of diet
influences the severity of the pain. Indigestible substances or those
hard to digest, as cabbage, corn, pork, tough meat, and rye bread,
generally are productive of great pain. Left-sided pleurisy is
often associated with gastric carcinoma, and frequently gives rise
to chest pains.
Pains due to metastases in other organs may follow upon
a train of symptoms indicative of gastric carcinoma; these pains
are most frequently located in the epigastrium, and are not in-
fluenced by the ingestion of food.
Schmidt claims that in many cases of tuberculosis with
dyspepsia the symptoms could be confused with those of gastric
carcinoma, because of the loss of weight, anorexia, and epigastric
pain due to coughing.
Perigastric Adhesions. — In case of long-continued inflamma-
tion and lymphangitis of the stomach, such as result from gas-
tritis or from ulcer, the pain which is present is, in almost all
cases, due to the adhesions which join the stomach to the adjacent
viscera. Adhesions existing between the anterior gastric wall, or
pylorus, and the parietal peritoneum are the most painful. A
factor of importance in the diagnosis of gastric-adhesion pain is
that the pain is made worse by change of position, though in the
change of position the location of the pain remains the same.
Another factor is that it is worse during active peristalsis or dis-
tention of the stomach, and is always located in the same area.
460 THE STOMACH
Palpation of the abdominal wall and stomach, as a means of
localizing the lesions, is useful, for if adhesions are present pres-
sure made in an upward direction from the lower border of the
stomach will increase the pain. If the adhesions are to the right
or are on the anterior border, pressure made over the epigastrium
Area Qfpftin in cutric ulcer
..Areaof paininpreeeiitCMe
l^-...y ,. Outline of stomach
Fig. 98. — ^Point of Tenderness and the Area op Pain in a Case op
Periqastric Adhesions.
will cause pain to shoot out from the right over the border of the
stomach. If the adhesions are on the posterior gastric wall pres-
sure over the first and second lumbar vertebrae will often cause
pain. When the adhesions are between the anterior abdominal
wall and the stomach they are very apt to be confused with gastric
ulcer (Cumston, 580). Erdman (581) claims that in gastric
adhesions no pain is complained of on any movement of the
stomach, only a sense of soreness being present. This is contrary
to the opinion of the majority of observers.
W. Langdon Brown (583) describes a pain situated just be-
low the costal arch and a little to the left of the middle line.
Its onset had no relationship to the ingestion of food, but came
on as soon as the direct posture was assumed. On operation a
firm adhesion to the anterior abdominal wall, about the size of a
half crown, was found midway between the greater and lesser
curvatures, and rather nearer the cardiac than the pyloric orifice.
REFERRED PAINS CONFUSED 461
The stomach was in direct contact with the anterior abdominal
wall. In some cases adhesions between the anterior abdominal
wall and the anterior wall of the stomach may cause such severe
symptoms that the patient is unable to assume the upright posi-
tion and remains bent forward (Gilbride, 582).
The following points, as given by Brown, are indicative of
perigastric adhesions:
(1) The symptoms have not infrequently been preceded by
those which are more characteristic of gastric ulcer or of gall-stone
colic; (2) local tenderness is very frequent; (3) pain is greatly
influenced by the position of the patient ; (4) vomiting, as a rule,
is not present; (5) careful dieting does not seem to have much
influence on the pain. Pressure over the last two dorsal verte-
brae and the first and second lumbar frequently causes pain in
adhesions of the posterior gastric wall.
BEFEBBED PAINS CONFUSED WITH THOSE OF OASTBIO
OBIGIN
After a consideration of the direct pains of gastric origin it
is necessary to consider these referred and reflected pains that are
so often confused with them. These pains are of nervous origin
and are due to neuralgia of the sympathetic or of the intercostals ;
or are projected pains from cord lesions, or are referred or reflected
pains from lesions in organs at a distance.
Neuralgia of the sympathetic or of the vagus, which supply
the stomach, may occur just the same as does neuralgia of other
nerves in other parts of the body. In neuralgia of the vagus
nen'e the pain is felt in the area of distribution of the sensory
fibers of the affected nerve, or is reflected through communicating
branches into the distribution area of the sensory part of related
nerves. In involvement of the sympathetic, pain is not felt in the
area of distribution of the sympathetic fibers, but the irritation
is referred to the cord and thence outward into the distribution
area of those spinal nerves whose cord-associated neurons have
been stimulated.
462 THE STOMACH
This neuralgic condition may exist in either one of the gastric
nerves, namely, the vagi and the splanchnics. Both may be sub-
ject to disorders causing pain. Schmidt reports a case of vagus
neuralgia in which pressure in the left external auditory meatus,
or irritation over the painful area with a combination of oil of
mustard, menthol, and liquid petrolatum, caused the pain to cease.
The pain of intercostal neuralgia is often confused with that
arising from the stomach, but, though the pain may be present in
the epigastrium, the diagnosis is easy if it is remembered that in
intercostal neuralgia there are tender points in the corresponding
intercostal spaces, one or two inches from the spine. These are
absent in gastralgia. The pain of intercostal neuralgia is also in-
creased on exposure to cold and to draughts.
Lesions of the cord are often mistaken for gastric disorders
because of the projected pain which they occasion ; but here there
is an absence of gastric symptoms ; the pain is generally bilateral,
and there are other well-defined symptoms of the nervous dis-
order. It is claimed by Schmidt that gastric crises (tabes) often
have a tendency to a left-sided localization. (Schmidt, 584, p.
101.)
It is also characteristic of tabes that at the time of the epi-
gastric pains, or crises, there is almost always an uninterrupted
and exceedingly painful vomiting. The vomit consists at first of
food, later of a mucous fluid which is sometimes mixed with bile
or tinged with blood. This is accompanied by marked nausea and
vertigo, as well as by cardialgic pains, which at times reach a
terrible degree of intensity. These attacks may appear at the
very beginning of the disease.
Referred pains to the epigastrium are often due to the ap-
pendix, uterus, ovaries, gall-bladder, in some cases, to aortic
aneurysm, the pancreas, spleen, even umbilical hernia, and Addi-
son's disease.
CHAPTER XXIV
INTESTINAL PAIN
GENERAL OONSIDEBATIONS
The value of pain in the diagnosis of intestinal lesions is of
more moment than is apparent from a cursory view of the sub-
ject. In a patient in whose case the diagnosis is obscure the cor-
rect interpretation of the pain manifestation is of vast importance,
and may be the means of eliciting the cause of otherwise inex-
plicable symptoms, and lead to effective treatment.
For convenience the intestine is divided into two portions,
namely, the large and small, both of which are united to the body
wall by a mesentery. The mesentery attached to the large bowel
is not as long nor as mobile as that attached to the short one, so
that when the large intestine is distended beyond its normal limit
it gives rise to more pain than does a proportionate increase in
distention of the small intestine.
Etiology of Pain. — The researches of Mackenzie, Lennander,
and well-known anatomists, physiologists, and surgeons have
shown that the intestinal mucosa, of itself, is insensitive to or-
dinary forms of tactile sensibility; that it can be pinched,
punched, and resected without producing pain, provided no trac-
tion is made upon the mesentery and that no* tension is exerted
on the muscular walls. There are, therefore, two distinct types
of intestinal pain — possibly more. The one due to the pull and
drag upon the adjacent peritoneal structures; the other a true
intestinal pain due to tension within the muscular structures.
This latter type of pain — deep sensibility pain — has often been
misinterpreted. As has been stated, the adequate stimuli for
463
464 INTESTINAL PAIN
visceral pain are not those of the ordinary tactile or thermal types
so well known for the skin and mucous surfaces. The adequate
stimulus here is tension and when the threshold of deep pressure
sensibility is reached pain results. It must be recalled that while
tactile, thermal, chemical, and possibly other forms of stimuli
may not be capable of exciting specific receptors in the intestinal
canal, nevertheless they are capable of inducing motor reflex ac-
tivities causing contraction, and that contractions which cause
tension to mount to the deep sensibility threshold result in pain.
Deep sensibility sensations may be transmitted by the sympathetic
fibers.
However, many do not believe that pain as a sensory entity
exists in the intestine. Since these hold that pain is not present
in the intestines, they must be asked how and in what manner it
is produced, since it undoubtedly is felt in lesions of the intestinal
viscera. It was formerly held that pain, as pain sensation, is
not transmitted by sympathetic fibers; therefore, the only nerve
fibers that could transmit pain directly were the fibers of the cere-
brospinal system, which, except the vagus (Bayliss and Starling),
are not in any way associated directly with the intestinal viscera,
although, in some cases, they are indirectly associated through the
phrenic, the lower six intercostals, the lumbar, the sacral nerves,
and the splanchnics (Lennander). The sympathetic cannot carry
stimuli which may be directly interpreted as painful, but do carry
stimuli which are reflected to the body wall and are there felt as
pain. According to Lennander, "all painful sensations within the
abdominal cavity are transmitted only by means of the parietal
f)eritoneum and its subserous layer, both of which are richly sup-
plied with cerebrospinal nerves around the whole of the abdominal
cavity, possibly with the exception of the small area in front of
the vertebral column, lying below the crura of the diaphragm and
between the two chains of sympathetic nerves." Here, he says, as
far as he is aware, no cerebrospinal nerves have as yet been demon-
strated. On a few occasions he has observed that within this area
the patient does not respond to hard pressure with finger or instru-
ment, nor, furthermore, does he experience any sensation when
GENERAL CONSIDERATIONS 465
a small portion of the mesenteric attachment at this point is put
on the stretch. This coincides somewhat closely with the views
of Mackenzie, that it is only the sub-serous peritoneal layer which
is the cause of pain in intraabdominal lesions. However, these
elaborate hypotheses devised by Mackenzie and Lennander, to show
why pain was felt in intestinal disorders when they were insensi-
tive to tactile sensibility, have all been swept away by the recogni-
tion of the fact that the adequate stimulus for intestinal pain pro-
duction is tension and not the well-known pain-producing stimuli,
touch, heat, pressure, etc., of the skin and the mucous membranes ;
that the intestinal pain belongs to the type of deep sensibility pain
and that it is conveyed through the sympathetic nerve fibers. It
had been held for a long time that the sympathetic nervous system
carried no pain fibers. Langley and Head hold the contrary
view. In any case, these sensations are conveyed to the cord,
where they stimulate certain cord segments, and thus cause pain to
be referred to the somatic distribution area of these segments or
zones.*
That pulling and stretching of the mesentery can cause pain
is shown by Lennander, who, in describing an operation, says that
"pain was occasioned by the placing or removal of gauze com-
presses between the viscera and the parietal peritoneum, by the
dragging forward of the cecum, of the appendix vermiformis,
or of any other organ whose normal attachment to the anterior
abdominal wall was put on the stretch." The same principle
applies to the stretching of abdominal adhesions, which may con-
nect the viscera with the anterior abdominal wall. On the other
hand, should a compress lie between the viscera without coming
into contact with the anterior abdominal wall the patient experi-
* Wilms (33b) believes that only the spinal nerves can convey pain sen-
sation. He says that the intestine of man has no sensory nerves, but that in
the mesentery the sensory nerves run almost to the intestines. The pain in
intestinal colic is caused by a pull on these nerve terminals and, therefore,
the pain is referred to the area where the mesentery is attached to the ver-
tebra— rather that the pain is referred out along the peripheral distribution
of the spinal nerves connected with the same segment of the cord as are the
nerves from the mesentery, so that, when irritation occurs in their distribution
area, the sensation (pain) is referred along the body wall.
GENERAL CONSIDERATIONS 467
enees no sensation when it is removed. Similarly no pain at-
tends the stretching or breaking up of adhesions Tvhich have no
connection with the abdominal parietes. The parietal perito-
neum along the thoracic aperture and around the foramen of
Winslow is especially sensitive to stretching and displacement.
Robinson (265) reports the absence of cutaneous hyperalgesia in
cases of acute intestinal obstnictiott.
Fio.101. — Points ToWmcH Pain Is Refbbbbd in LssioNa oy Different
Parts or Intestinal Tract,
The pain of intestinal origin is very imperfectly localized.
The reflex hyperesthesial and abdominal projections are better
capable of exact localization. They are therefore of great prac-
tical value.
If the lesions are of the small intestine the pain is reflected to
the anterior abdominal wall in the interval between the umbilicus
and the ensiform; if the disturbance is in the large intestine the
468 INTESTINAL PAIN
pain is felt slightly below the umbilicus. In lesions of the rec-
tum and sigmoid it is felt directly above the pubes. The drawing
on the previous page, according to Mackenzie, shows his deductions.
A peculiarity of referred somatic pain is that it seldom is felt
in the posterior distribution of the dorsal segments, but is almost
invariably present in the anterior distribution area. When re-
flected somatic pain is present in the posterior distribution, it is
always present at the same time in the anterior, though the an-
terior distribution may be present without the posterior involve-
ment.
Wilson (896) advances a hypothesis which, because of its
novelty, is quoted here. He says: "Muscle fiber has t\^o oppos-
ing types of activity: (1) the contractile activity, due to contrac-
tion of the longitudinal elements of the fibers; and (2) the ex-
pansile activity, due to contraction of the transverse elements of
the fibers, thus causing them to lengthen. Some pathological ele-
ments cause the bowel to expand instead of contract, so that there
is an active expansion." He thinks that the rigid arch of the
abdomen in peritonitis is due to the expansile activity of the
muscle fibers in the gut, for he cannot understand how a contrac-
tion of the abdominal muscles will produce an arched instead of
a straight line. He also claims that in some cases in which the
irritation causes a stimulation of the expansile activity a conflict
takes place between the two tendencies, resulting in pain, the so-
called colic.
Pain may also be referred to the peripheral distribution of
the genitocrural, the ilioinguinal, the iliohypogastric, the exter-
nal cutaneous, and the accessory nerve to the external cutaneous.
In these cases the pain is due to pressure made upon these nerves
by increase in size of the cecum or of the sigmoid. It is very fre-
quent in new growths of these organs.
Besides the above causes of pain, due to intestinal lesions, we
have two others which are generally forgotten, or, if not forgotten,
are thought to be of such slight importance that they are not
mentioned. These are the pain due to pressure upon adjacent
nerves by lymphatic gland enlargement, such as is found in tuber-
GENERAL CONSIDERATIONS 469
culous intestinal lesions and leukemia, and, second, the pain due
to irritation of the large ganglia of the sympathetic. The latter,
either by direct involvement in the inflammatory process or by
irritation from stimuli received through peripheral branches,
become supersensitive and react abnormally to normal stimuli.
By many observers the origin of the epigastric pain which
is felt in so many intraabdominal lesions is supposed to be due
to an irritation of the solar plexus. This is undoubtedly errone-
ous, for it seems that the solar plexus has a direct connection
with pain production, only in so far as it acts as a clearing house
for stimuli received through the different abdominal sympathetic
ganglia. From the solar plexus are derived the sympathetic
fibers which connect with the sixth to the ninth visceral segments
of the cord. Irritation to these fibers, arising either independ-
ently in the fibers or transmitted from the ganglia, is carried to
the cord, whence it is referred to the body wall as pain. The
maximum point of tenderness of the seventh dorsal segment is in
the epigastrium. Since it is generally in the area of maximum
tenderness that subjective pain is felt, it is in this area that pain
associated with most of the abdominal lesions is perceived.
Should intestinal disease be suspected as a cause of abdominal
pain there are certain characteristics of the pain-symptoms that
lead to a fairly definite decision, not only as to the involvement of
the intestine, but even to the segment of the bowel which is in-
volved. The characteristics aiding in the diagnosis are the loca-
tion of the pain, its type, manner of onset, variation (depending
upon the position of patient), duration, result, and history of the
pain, and the associated symptoms.
Location of the Pain. — Nearly all painful lesions of the in-
testine first betoken their presence by circum-umbilical pain. In
appendicitis this is very common, but, as the pathology progresses,
the site of the pain is changed from the umbilical region to the
right lower quadrant of the abdomen. In diseases of the large
intestine the pain is generally felt below the umbilicus, while in
those of the small intestine the pain is generally located above. A
peculiar characteristic, and one that is of great value in diagnosis.
470 INTESTINAL PAIN
is that in diseases of the large bowel pressure on the abdomen, over
the site of the colon (which, in its transverse division, is above the
umbilicus, and in its ascending and descending divisions to either
side of it), will produce pain in the mid-abdominal zone without,
in many cases, producing any pain at the point of pressure. In
lesions of the small intestine the contrary holds true, for pressure
in the area below the umbilicus generally causes pain in the supra-
umbilical zone. If the pain that is felt closely resembles that pro-
duced by stomach disorders, as is so often the case in duodenal
ulcer, and an examination of the stomach fails to reveal any abnor-
mality, the duodenum should then be suspected as the cause of the
pain. It is very common for the duodenum, because of its close
nervous relationship with the stomach, to produce symptoms sim-
ilar to those of gastric disturbances. In some cases the pain of
intestinal disease is felt in the back, in one or the other lumbar
region. Pain in the back generally alternates with the pain of the
anterior abdominal wall. As a rule both are not coincident
Visceral pain depends for its localization largely upon the
fixity or the mobility of the organ affected. The more fixed the
viscera, as a rule, the more constant the pain. Thus in the mobile
and freely moving small intestine the localization is diffuse, and
centralizes chiefly about the umbilicus. In the movable parts of
the colon pain is felt between the umbilicus and the pubes. In
diseases of the duodenum, the last few inches of the ileum and the
ascending and descending colon, and in lesions at the hepatic,
splenic, and pelvirectal flexures the pain is felt at the points where
these structures are joined to the abdominal wall.
Type of the Pain. — A sudden abdominal pain, associated with
vomiting, should always suggest an acute abdominal lesion, such
as an obstruction by volvulus, bands, strangulated hernia, foreign
body, intussusception, and appendicitis. If the vomiting persists,
and the pain becomes of*a gradually increasing intensity and
spreads over a wider area, it is certain that the intestinal lesion is
one of increasing gravity. At the same time, should a chill and
rise of temperature accompany or precede these symptoms, it is
very likely that the trouble is of an inflammatory nature. If the
GENERAL CONSIDERATIONS 471
pain is paroxysmal, with no rise of temperature, colic should be
thought of, or else an obstruction should be sought. Likewise, if
the pain is of a griping character, and is accompanied by diar-
rhea, enteritis is most probable. It is characteristic of patients
whose pain is due to lesions of the lower bowel that they try to
ease it by lying with the back bent and the lower limbs flexed.
In case the pain is due to a spasm of the intestinal muscles, pres-
sure and heat over the area affected will often give relief. If
the lesion is inflammatory, heat and pressure increase the pain,
while cold often produces ease and comfort.
Uanner of Onset. — Intestinal pain may be gradual or sudden
in its onset. When the onset is gradual with a slow increase in
the intensity, we know that the lesion is gradually increasing in
severity. The most common lesions which have gradually in-
creasing pain are those of an inflammatory origin, such as appen-
dicitis, enteritis, and those tuberculous lesions causing peritoneal
irritation, especially if these are of rapid progress. Should the
onset be sudden it generally indicates a rather severe and unusual
derangement of the intestinal viscera, such as may occur from
knots, kinks, and intussusception. Generally in these lesions, and
especially in all lesions which produce obstruction, enlargement
of the bowel proximal to the site of the obstruction occurs, so
that palpation of the abdomen will disclose a tumor mass, tym-
panitic on percussion. If in a case of acute intestinal pain, tumor
is absent and palpation reveals an area of exquisite sensitiveness,
gradually increasing in extent, it frequently is an indication of
a perforation of the bowel. This is especially true in those who
are suffering from intestinal tuberculosis or from typhoid fever.
Should the pain be acute in onset, and be relieved by vomiting, it
indicates an intestinal spasm. This spasm usually is caused by the
collection of gas due to fermentation or putrefaction of indi-
gestible food, and often is followed by a diarrhea which lasts
for a day or two. Should acute pain occur, followed by vom-
iting which finally becomes stercoraceous, it indicates an ob-
struction which, unless relieved, is sure to cause the patient's
death.
472 INTESTINAL PAIN
In those obstructive lesions in which a tumor formation is
present auscultation reveals exaggerated peristalsis over the tumor
mass, Mrith absent peristalsis below it in the area where the intes-
tines are collapsed. In these conditions pain is also very com-
mon after eating, coming on from one to seven hours after the
ingestion of food. Should it come on immediately after eating,
it is due to the stimulation of intestinal peristalsis by the en-
trance of food into the stomach.
Relation of the Position of the Patient to the Pain. — If the
pain varies in intensity, depending upon the position of the
patient, inflammatory lesions, either acute or chronic, should be
sought Change of position sometimes causes the most pain, espe-
cially after adhesions have formed. The pain is greatest in that
position in which the abdominal parietes are dragged upon by the
adherent bowel, and is always localized to the site of the lesion.
Colics are generally indicated by great restlessness and activity of
the patient, who often clasps his hands over the abdomen and
exerts pressure upon it ; on the contrary, inflammatory lesions are
generally indicated by the patient assuming a position in which
the intraabdominal pressure is lessened. To do this, he lies flat on
his back with his knees drawn up. In a case of inguinal or fem-
oral hernia the lower limbs are flexed and at the same time rotated
inward.
Relation of the Ingestion of Food to the Pain.— There are
three periods in which after the ingestion of food intestinal pain
occurs :
(1) The first period follows immediately after eating, and
lasts for a varying length of time. It is due to the excitation of
intestinal peristalsis by the entrance of food into the stomach,
and when present is a fairly good indication of an inflammatory
lesion in the bowel.
(2) The second comes on about one or two hours after eating,
and persists for a couple of hours. It indicates a duodenal in-
volvement, often an ulcer, or perhaps an inflammation. The
two hours mark the duration of the gastric digestion, and time
the Ix^ginning of the passage of the food from the stomach into the
GENERAL CONSIDERATIONS 473
duodenum. Pain may also be present immediately after the inges-
tion of food, but this pain only persists for a short time, and is then
followed by the duodenal pain. The presence of adhesions around
the duodenum, following common duct or gall-bladder disease,
will also give rise to this type of pain.
(3) When the pain is delayed, until four to seven hours or
longer have elapsed after the ingestion of food, it is a sign that
the trouble is low in the bowel. Appendiceal pain occurs from
four to seven hours after eating, and is very prone to come on
about midnight, provided the evening meal is taken around
six or seven o'clock. If it occurs at a longer interval than seven
hours it is an indication that the lesion is in the large intestine.
This is especially true if rather indigestible foods, as stewed cab-
bage, etc., have been eaten.
Dnration of Pain. — A pain of short duration, pathologically
speaking, is generally of but slight moment, while one of long
duration indicates a lesion of more or less severity. The more
constant the pain, and the greater its intensity, the more should
it merit our attention, not only because of the portent of harm to
the patient, but also because of the necessity for the individual's
ease and comfort to diagnose and relieve the symptoms as soon as
possible after examination has been made and charge of the case
has been assumed.
Bestilt and History of the Pain. — A pain that passes off with-
out any untoward result and is of a paroxysmal type generally is
due to colic. If the pain is of this character, the different colics,
such as hernial, foreign-body colics, volvular colics, and those due
to enteritis, should then be quickly passed in mental review. Pan-
creatic, biliary, urinary, and uterine colic also should not be for-
gotten. If there be a history of recurring attacks, associated with
vomiting and constipation, especially if a rise of temperature and
pulse rate is present at the time of the attack, and tenderness on
the right side is marked, appendicitis should be suspected. If the
attacks are spasmodic, and successively shorter intervals occur
between each successive attack, it is, in case of ulcerative lesion
of the bowel, an indication that the stenosis, which is the cause of
474 INTESTINAL PAIN
the attacks, is progressing, and that gradually the lumen of the
bowel is becoming more constricted.
Tenderness is of two types: (a) superficial, and (b) deep.
The superficial tenderness often exists in the form of a hyper-
algesia. This hyperalgesia is in well-defined zones, which have
been described earlier in the chapter. Deep tenderness frequently
is present over the area of the bowel involved, and is due to local-
ized peritoneal inflammation. When pain is felt at the site of
the irritation it is called direct pain or tenderness. When it is
felt in other areas it is called indirect pain or tenderness.
In the diagnosis of intraabdominal lesions, especially those
of the alimentary tract, tenderness may be of much importance.
Where the tenderness is direct it is due to inflammatory irritation
of the parietal peritoneum or of its subserous layer. An area in
which direct pain is present is tender only when, on palpation, the
pressure exerted is strong enough to irritate the peritoneal sub-
serous layer. An area in which the pain is indirect (hyperal-
gesia) is painful upon the slightest irritation. Even the drawing
of the tip of the finger or of the head of a pin across the surface
is extremely painful. This very marked superficial tenderness
may or may not be found at the point where the deep mural
tenderness, or tenderness on deep pressure would indicate the
site of the lesion.
Sjrmptoms Associated with the Pain. — Symptoms associated
with intestinal ^Dain are: vomiting, diarrhea, tumor (tympanitic
or dull on percussion), tympany, generalized or local, obstipation,
shock and collapse, rise or fall of temperature, changes in pulse or
respiration, diaphragmatic breathing, and inguinal glandular in-
volvement.
Vomiting is a symptom which, in obstructive disorders of the
intestine, follows shortly after the initial pain. The longer it is
in making its appearance the lower is the lesion in the bowel. In
nearly all intestinal lesions the vomit us consists at first of the
contents of the stomach, then, as the reversed peristalsis carries
the food from the lower segments of the bowel, it becomes more
and more fecal in character. From the time of the onset of the
GENERAL CONSIDERATIONS 475
vomiting to that of the appearance of the fecal material (if the ob-
struction is low in the bowel), a fairly good estimate of the location
of the lesion can be made.
Diarrhea^ following in a few hours the onset of a pain," gener-
ally indicates an enteritis, the pain being but an indication of the
bowel spasm which is present. Should diarrhea follow at a consid-
erable interval after the beginning of the attack, it is likely that
obstruction of the bowel is present, and has progressed to such an
extent that peritonitis has been produced. It must be remem-
bered, however, that diarrhea is not an invariable accompaniment
of enteric obstruction, constipation being present in all cases in
the early stages, and often persisting until the end. In localized*
bowel obstruction there is present a tympanitic tu^lor. If the
tumor is in the center, and somewhat to the left of the median
line, it indicates that the lesion is probably in the small bowel;
while if it is in either flank, the large intestine is very apt to be
at fault. A solid tumor associated with tympany may be due
either to tuberculosis or to a new growth (benign or malignant) ;
though, generally, neither of these causes any severe or marked
pain, and their progress is gradual.
Should shock and collapse be associated with severe abdominal
pain, it may indicate the rupture of the intestine into the abdomi-
nal cavity. The rupture may be due to previous ulcer formation,
either typhoidal or tubercular. Typhoid perforation occurs most
often during the third week of the disease, and is diagnosed by its
characteristic signs; while tubercular intestinal ulcers betoken
their presence by special symptoms. Intussusception and volvulus
are frequently associated at the time of their occurrence with con-
siderable shock. The rupture of an inflamed appendix causes
great shock, and generally occurs only after the disease has been
present for a few days. Temperature, pulse, and respiration are
of value in the diagnosis of tuberculosis, typhoid fever, appendi-
citis, and strangulated hernia. They are but slightly changed in
volvulus and hernia. Pain on deep inspiration, and the absence
of diaphragmatic breathing are often valuable in the diagnosis of
peritonitis originating from a perforated ulcer or a ruptured ap-
476 INTESTINAL PAIN
pendix. Glandular enlargement is of but slight diagnostic impor-
tance in clearing up the origin and cause of abdominal pains.
LESIONS OF THE INTESTINES OAUSINO PAIN
Because of the manner of origin and peculiarities, intestinal
neuralgia and colic merit a separate discussion. The lesions of
the intestines will be considered in the following order:
(1) Enteralgia.
(2) Neurosis.
(3) Inflammation.
(4) Ulceration.
(5) Adhesions.
(6) Intestinal obstruction.
(7) Diseases of special parts of the intestine, such as: (a)
appendix; (6) colon; (c) rectum; (d) anus.
Enteralgia. — That irritation which is interpreted as painful
may of itself arise in the intestinal walls without an associated
inflammatory state is very likely. Reasoning from analogy the
terminal nerve filaments in the walls should be subject to irritation
by toxic substances. This irritation sets up motor activities which
are interpreted as painful. The stimulus (resultant of excessive
motor activity) is carried by the sympathetic nerves to the cord,
where collaterals of the spinal nerves are involved. This causes
reflex hyperalgesia in the abdominal walls. Yet enteralgia, as a
pathological entity, is very rare. Pains of other abdominal lesions
are frequently mistaken for bowel pain, and the intestine is cred-
ited with their production, when it has no association with them.
Perhaps even more frequently organic lesions of the intestine are
mistaken for enteralgia. How many times appendiceal, gall-duct,
and pancreatic-duct colic are mistaken for it ! How often does the
patient go on for years suffering from distressing symptoms asso-
ciated with these disorders, when the cause could have been so
easily removed, and the individual restored to comfort and hap-
piness! Schmidt, who quotes from Hawkins, evidently mistakes
LESIONS OF THE INTESTINES CAUSING PAIN 477
other lesions for enteralgia, for he says that "the pain of enter-
algia is central, occurs in short, sharp attacks, quite as severe as
a biliary or renal colic, and is equally attended with sweating and
collapse." An analysis of the above should convince one that the
pain which he describes as enteralgic may be nothing more than
a colic of the intestine. In many cases the reason that
the generic term enteralgia is applied to abdominal pain colicky
in character is that a sufficiently painstaking observation has not
been made, and a general and non-specific term has been applied
to hide the confusion and diagnostic ignorance of the examiner.
Enteralgia should be given as a cause of pain only after all other
causes have been excluded ; and even then it may be possible that
some undiscovered cause, such as local irritative lesions of the
musculature, may be present. Besides the myalgic origin enter-
algia may be caused by some such similar change as produces
neuralgia in the cerebrospinal nerves, and we have, as it were, a
neuralgia of the sympathetic. When a probable enteralgic pain is
present, without any apparent lesion, the patient's general condi-
tion should be carefully studied, to find out if any of the disturb-
ances which are known to produce neuralgia are present. If they
are found a tentative diagnosis of intestinal neuralgia may be made
until something more definite is discovered.
Pain Due to Functional Distorbances. — The functional dis-
turbances of the intestine producing pain are either secretory or
motor.
Seceetoey Distukbances. — That it is possible for secretory
derangement of the intestine to cause pain cannot be disputed.
The disturbance that causes the most pain is a hyper- not a hypo-
secretion. It must be conceded, however, that an oversecretion of
intestinal juices cannot of itself cause pain, unless there is asso-
ciated with it some local lesion causing either an inflammation or
a circumscribed spasm. When the bowel is stimulated on its
internal surface by a local irritant it reacts by a hypersecretion of
mucus. This mucus, in its passage down the bowel, becomes
rolled into balls, or else adheres to the intestinal wall, so that a
greater than normal contraction of the musculature of the intes-
478 INTESTINAL PAIN
tine is necessary to force it on. Thus spasm, with its resulting
pain, is produced. It is not known whether a change in the chemi-
cal composition of the intestinal secretion can so occur that the
secretion may of itself become irritating.
MoTOE DisTUEBANCES — Enteeospasm. — Motor disorders,
such as spasm of the intestine, are a potent cause of pain. The
spasms are due to some local irritative lesion in the bowels or
are the result of referred stimuli. The local cause produces a
contraction, restricted, as a general rule, to a small area of the
bowel ; while the contraction spasm, due to a central stimulation,
may extend over a considerable section of the bowel. These re-
ferred stimuli may result from some disorder of the sympathetic
nerves or of their ganglia, or may possibly be due to a lesion in the
cerebrospinal system. Such causative factors are found in neu-
rasthenia, either of the sympathetic or of the cerebrospinal type.
The local lesions causing intestinal spasm are most frequently
the result of irritation from undigested food, irritative poisons,
and foreign bodies. The spasm resulting from this irritation
gradually progresses downward, following in its course the descent
of the irritating substance. Likewise the pain gradually moves
from the epigastrium down over the anterior abdominal wall, until
it becomes localized in the suprapubic region. In other cases
the irritation may be localized and non-progressive, and the pain
is stationary. When such a condition is present inflammation or
ulceration is most commonly the cause.
The pain of enterospasm is divided into two classes: (a) pri-
mary and (b) secondary.
(A) The primary pain is due to two causes: (1) the pres-
sure made by the contracting muscular walls upon the nerves ter-
minating between the muscle bundles. Lennander's experiment
on the intestine with electrical stimuli, which caused contraction
and no pain, is non-conclusive, as the adequate stimulus was ab-
sent, and the contraction one of an entirely different kind than
that which normally is present in the intestines.
(2) The pull and drag exerted upon the mesentery by irreg-
ularities in the size of the bowel.
LESIONS OF THE INTESTINES CAUSING PAIN 479
(B) Secondary pain is due to distention of the bowel proxi-
mal to the area of spasm. It is of the ordinary, colicky type, its
duration depending upon the kind and manner of the irritation.
Should the irritation be of a transient nature, as is found in dis-
turbances due to the passage of indigestible food, the pain is in-
termittent and varies in location, though it constantly progresses
toward the lower part of the abdomen. Should the lesion be or-
ganic the pain is permanently localized and is not progressive, but
remains at the point related to the bowel proximal to the point at
which the intestinal distention begins. The colon, owing to its
being most exposed to irritation, is most frequently the part of
the bowel involved in the spasm. In mucous colitis the attack is
typical (see Colon).
In a case reported by Hawkins and quoted by Maylard * a good
description of colon spasm is given: "In this patient attacks
came on once in about three or four years. They began as a con-
stipation, which was difficult to relieve; distention ensued, and
with it pain and vomiting. The pain was aggravated by the
taking of food and by defecation. At the operation, which was
performed for the relief of this condition, two areas of contrac-
tion spasm, without any associated lesions, were found. The first
was at the junction of the descending colon and the sigmoid flex-
ure. The second was in the small intestine. Both areas showed
a spasm of the musculature of such magnitude that nothing could
be passed through the lumen of the bowel. In both the narrowed
part of the bowel passed abruptly into the normal parts above
and below."
That such a localized spasm occurs is known to every practi-
tioner of medicine. Many and many a patient complains of fleet-
ing, colicky, abdominal pain, persisting off and on for years.
Operation, should it be undertaken, reveals conditions somewhat
like those described above, or shows nothing, in which case the
appendix is often blamed, and sometimes rightly, for many cases
of colic owe their origin to a fibroid appendix. This, because of
its constant irritation, produces abnormal excitability to stimuli
^ Herbert P. Hawkins, BHtish Medical Journal, January 13, 1906, p. 65.
480 INTESTINAL PAIN
in the sympathetic nerves and plexuses which supply it. This
excitability, in turn, is communicated to adjacent centers supply-
ing the small intestine, which may also become involved and be
thrown into a state of pathological excitability. When they are
in this condition, stimuli that ordinarily would produce no reac-
tion may cause pain, or else may reflexly produce spasms of the
bowel, which in turn cause pain.
In some cases, because of generalized abdominal symptoms,
enterospasm has been diagnosed as peritonitis. The following,
which are present in enterospasm and absent in peritonitis, aid in
the diagnosis: (1) The low temperature, pulse, and respiratory
rate; (2) the excess of peristalsis, even though the abdomen may
be rigid and tender; and (3) the absence of any tendency of the
process to increase in severity.
The intestine, because it has a lumen of a fairly constant size,
is subject to spasm-pain throughout its entire length. Because of
the progressive nature of the spasm, the pain is felt at different
points on the abdominal wall, depending upon the part of the
intestine which is involved.
In some cases spasmodic musculature contraction of the small
bowel occurs without any apparent organic cause, and is due to
abnormal functional activity. Those who are subject to these
spasms are so sensitive to irritative nervous influences of any kind
that the slightest change from the normal may cause a spasmodic
contraction of the bowel. This change also may be the result of
local changes (slight fermentation) in the intestine (producing a
local colic), or may be due to causes acting from a distance, such as
exposure to cold drafts, which produce an internal congestion,
etc. During bodily fatigue colic is also felt. The bowel contrac-
tion in the latter case is probably due to the irritation from the
toxic materials circulating in the blood. Excessive heat may aljo
act in the same manner.
All these disorders cause a derangement of intestinal secre-
tion, with consequent fermentation and putrefaction of the intes-
tinal contents. These, in turn, irritate the intestinal mucosa, and
this irritation may, in some cases, progress to an active inflamma-
LESIONS OF THE INTESTINES CAUSING PAIN 481
tion of the bowel. In any case diarrhea is a frequent accompani-
ment of this condition. It indicates that the changes in the mucosa
and bowel contents act as irritants and cause an excessive contrac-
tion and forcible propulsion forward of the bowel contents. How-
ever, the only structure particularly affected is the mucosa, which
at the time is in a state of weakened resistance. This reduction in
resistance is often caused by congestion incidental to the chilling
of the hody surface, in which a peripheral vasomotor contraction
occurs. A similar vasomotor spasm may also be caused by emo-
Tia. 102. — Pain Areas in Colonic Colic.
Colonic colic begins around the umbilicus and radiates in the directions
indicated. The pain ot all colics of the colon is generally referred at first
around the umbilicus and then later to the area below it. However, if the
lesion is in the small bowel the pain is referred above this level.
tional stress, such as is present in anger and extreme joy or
dejection.
Colics may be the result of some definite error in diet, such
as the eating of indigestible or bad foo<ls. Many persons cannot
indulge in whiskey, eat highly spiced foods, nor drink very cold
or unsuitable liquids without suffering from colic. People vary
somewhat in susceptibility, so that what one person can do or
take with immunity will in another cause colic.
Since these attacks of colic often follow a slight indiscretion
482 IKTESTINAL PAIN
in diet, possibly such an indiscretion as has occurred many times
previously without the production of colic, the patient is apt to
ask, and the physician himself should know, the reason of its
greater frequency at one time than at another. Its incidence is
probably determined by a lessened resistance due to changes in
atmospheric conditions, or to removal from one locality to an-
other, especially among those who are not accustomed to traveling.
In these the colic is probably due to change in habits and diet
Constipation, with irregular evacuation and overfeeding, is an-
other cause of this colic.
The most reasonable hypotheses as to the cause of colic are
those promulgated by Nothnagel, Lennander, and Wilms. Noth-
nagel says that colic is due to tetanic contraction of intestinal
muscles and the anemia produced by this contraction. Lennander
claims that in colic in the small intestine the pain is due to
pressure against the sensitized parietal peritoneum by the tetanicly
contracted loop of small intestine, and that pain from similar peri-
staltic action of the large intestine is due to traction on its short
mesentery. On the other hand, Wilms believes that colic in both
the large and small intestines is due to traction on the mesentery.
The simple explanation is that the pain of colic is that caused by
distention of the muscular walls. It is a special type of pain
conveyed by the sympathetic.
Colics generally are sudden in onset. The pain commences
around the umbilicus, and thence radiates either above (small in-
testine) or below (large intestine). The advance of the intestinal
spasm is often indicated by changes in the location of the pain.
When the spasm is in the small intestine, the pain is above the
umbilicus; when in the jejunum, cecum, and appendiceal region,
the pain is around the umbilicus; when the large bowel is in-
volved, the pain is below the umbilicus, and, as the spasm pro-
gresses toward the rectum and anus, the pain passes down toward
the pubes, and becomes lower and lower, until it rests just above
the pubes, which is a sign that the bowel contents have reached the
sigmoid. The pain now remains stationary until the fecal mass is
expelled.
LESIONS OF THE INTESTINES CAUSING PAIN 483
At the time when the colic is at its greatest intensity the pain
may be so severe as to cause the patient to cry aloud. He also
is very restless, moves constantly about, throws his limbs in all
directions, and often lies prone upon the bed or upon the floor.
Frequently he presses a pillow or his hands tightly over the
abdomen. This seems to relieve the pain (see drawing).
Type of Pain in Colic. — The pain may be either intermittent
or constant. When intermittent, it becomes lower and lower
in the abdomen, and finally ceases on the expulsion of flatus or
feces. Should the pain be constant, it shows that the obstruction
has become constant and persists at one place. An obstruction of
this kind is present in strangulated hernia and intussusception.
Intermittency in a colicky pain shows that the obstruction has
only been temporary. Such an obstruction may be produced by
kinks in the bowel, hardened fecal masses, and the like. Kelief
of the pain indicates that the obstruction has been overcome. An
onward movement of the bowel contents follows, and frequently
gives rise to a gurgling. If the obstruction becomes permanent a
considerable local distention takes place and causes tumor forma-
tion, excessive proximal peristalsis, and an absence of gurgling
over the tumor. If pain persists and is accompanied by diarrhea,
vomiting, and abdominal tenderness, it is a good indication that
inflammatory changes have taken place.
Tenderness is associated with enterospasm. The amount of
the tenderness depends on the location and the extent of the
bowel involvement. It seems to be the rule that disturbances at
either extremity of the small or large intestine give rise to a
greater degree of tenderness than do those of the middle part.
The tenderness may be indirect, as illustrated in involvement of
the transverse colon, where pressure on the abdomen above the um-
bilicus in the region of the colon will cause pain which is not felt
in the area over which the pressure is made, but in the anterior
abdominal wall below the umbilicus. If the small intestine is in-
volved, pressure on the abdominal wall, particularly kneading of
the abdominal contents, will produce pain in the epigastrium.
Local tenderness over the site of a bowel lesion is unusual, unless
484 INTESTINAL PAIN
the abdominal wall (parietal peritoneum and subserous layer) is
also involved.
Intestinal colic should be diagnosed from gall-stone, renal,
and uterine colic, pyloric spasm, perforation of the bowel, appen-
dicitis, acute pancreatitis, mesenteric embolus, and thrombosis;
from the referred pains due to thoracic diseases, as pleurisy, pneu-
monia; and also from the abdominal crises occurring in certain
diseases of the nervous system, as tabes, etc.
Should colic be present without any well-defined bowel lesion,
particularly if it occurs in a painter or in one who is accustomed
to handle considerable quantities of white lead, it is well to find
out if the cramp is due to plunibism, pathognomonic signs of
which are stippling in the red blood cells, the blue line on the
gums, and the wrist drop and foot drop (only occasionally, in the
early cases), or other signs of neuritis. Contraction and rigidity
of the abdominal muscles occur at the same time as the colic. In-
equality of the pupils and tenderness over the nape of the neck
are also to be noted.
The colicky pain, as a rule, is felt in the center of the abdo-
men, in the umbilical region. The sensation is that of the intes-
tine being twisted. Some describe it as a feeling in which it seems
as though the bowels were being tied in a knot. During the colic
the arterial tension is raised and the pulse is hard. Pal says that
the pain of lead colic is due to irritation and constriction of the
blood vessels in the intestinal walls, and that this indirectly irri-
tates the sympathetic nerve filaments.
There is also a colic associated with uremia. In this condi-
tion, beyond the colic, the only other symptoms are those of
the uremia.
Inflammation of the Bowel. — Inflammation of the bowel, as
a rule, causes little pain as long as there is no excess of motor
activity. When active peristalsis occurs there is a well-defined
pain ; and if the parietal peritoneum is invaded a local tenderness
is added which, as a rule, is confined to the involved area of the
abdomen. When all the coats of the bowel are involved in the
inflammatory process, pain is also reflected to the anterior abdomi-
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486 INTESTINAL PAIN
nal wall, and hyperalgesia is present in the cord zones associated
with the intestine.
In inflammatory states of the small intestine entrance of food
into the stomach may, by stimulating and increasing the peri-
stalsis, aggravate a pain already present, or initiate one, if none
is present. This inter-relationship of the stomach and intestine
can be explained upon the hypothesis of the close nervous connec-
tion between the two organs, so that a stimulation of gastric peri-
stalsis will likewise cause an increase of intestinal movements.
A confirmatory symptom of value in the diagnosis of inflam-
mation of the bowel is diarrhea, which in acute enteritis or colitis
is due to irritation by indigestible or fermenting substances. It
is of a foul odor and contains frothy material. In tuberculous
enteritis the stool is also foul, and contains blood and shreds of
tissue. The diarrheal stool of an inflammatory intestinal lesion
(enteritis) is generally acrid, and produces intense irritation
around the anus and buttocks, while other diarrheal stools, as a
rule, do not excoriate.
Since many of the inflammatory processes are accompanied by
fermentative changes in the intestinal canal, it follows that a
considerable distention of the bowel from gas frequently is a con-
comitant symptom. When it occurs, the pain of the distention is
engrafted on to that of the inflanmiatory process.
In some cases of inflammation of the bowels the inflammatory
process is very severe and extends to adjacent structures. In this
event, because of the involvement of the peritoneum, the sub-
jective pain is associated with considerable local tenderness, and
if the cecum or lower end of the ileum should be involved it may
be confused with appendicitis. This is all the more likely to
happen when the abdominal muscles over these areas are in a
state of rigidity, and vomiting and rise of temperature are present.
If the inflammation should be in the duodenum the abdominal
pain is constant, and there is an increased sensitiveness to pres-
sure in the right hypochondriac region. Duodenitis generally oc-
curs in a patient suffering from an acute gastritis, and in the
stools mucus, with or without blood, will be found. Duodenal
LESIONS OF THE INTESTINES CAUSING PAIN 487
digestion, according to O'Connell, occurs about three o'clock in
the afternoon and two in the morning; therefore, at these times
the pain would be most severe.
Ulcers of the Intestine. — The pain in ulcers of the intestine is
felt most often in the region of the umbilicus, though the exact
localization of the pain depends largely upon whether the lesion
is in the small or in the large intestine. In intestinal ulceration
the pain is more restricted than in inflanunation, and the area or
point of tenderness does not move about, as it does both in the
latter condition and in colics which are the result of eating indi-
gestible food. The pain of ulcer is frequently accompanied by
diarrhea, and occult blood can, in some instances, be demonstrated
in the stools. A factor of importance in the diagnosis of the loca-
tion of the ulcer is in the relationship of the attack of pain to the
time of the ingestion of food. Should the pain come on a few
hours after eating, the duodenum is most likely to be involved;
while if the interval is longer the lesion is apt to be lower in the
bowel. When an interval of seven or more hours elapses before
the commencement of the pain, the lesion is probably in the large
intestine. Another point of importance in diagnosing the loca-
tion of an ulcer is that the lower it is in the bowel the less is the
likelihood of diarrhea. If the pain becomes constant, and is asso-
ciated with a steadily increasing distention of the intestine,
stenosis of the bowel following an ulcer can be diagnosed.
In intestinal ulceration there are, at first, intervals of freedom
from pain ; but as the bowel lumen becomes narrowed from stric-
ture formation, the intervals of freedom become less and less, un-
til finally the pain is almost constant. This pain is relieved by
the passage of the gas present in the occluded bowel. Some-
times rubbing and massage, although they may temporarily in-
crease the pain by the extra intra-intestinal pressure which they
produce, will finally cause a passage of the gas and consequent
relief. Vomiting also appears, and, as the lumen continues to
narrow, gradually becomes worse, until complete obstruction oc-
curs. It is violent, persistent, and stercoraceous.
In ulcer of the intestine, food, particularly that which is hard
488 INTESTINAL PAIN
to digest, may act as a local irritant and increase the contraction
of the bowel, with a consequent drag and pull upon the ulcerated
area, and thus cause pain. Unripe fruit or vegetables, such as
corn and cabbage, are very likely to act as irritating factors.
It is claimed by Schmidt that the application of cold com-
presces to the abdomen will relieve the pain of intestinal ulcer,
while application of heat will increase it.
The pain of ulcers of the intestine generally is not very
severe, except when they occur in the duodenum, the sigmoid, or
the rectum. Large areas of ulceration in any portion of the bowel
are very painful, especially if the ulceration be deep enough to
involve the peritoneum. In these cases the areas of local tender-
ness over the abdomen are proportionate in size to the area of the
peritoneum which is involved. In ulceration of the rectum tenes-
mus is frequent. The different varieties of intestinal ulceration
are tuberculous, typhoidal, syphilitic, catarrhal, uremic, trophic
ulcers and those following burns.
Tuberculous Ulcers. — Non-progressive tuberculous ulcera-
tion of the intestine is often painless. Should the ulceration pro-
gress pain is present. It may be caused by an associated enteri-
tis, intestinal distention following a stenosis, a fermentation, or
peritoneal involvement. Tuberculous ulcers of the duodenum, be-
cause of the frequent location of the pain in the epigastrium,
are often confused with pyloric spasm or gastric ulcer. A diag-
nostic point of value between the two is that in pyloric spasm the
vomitus never contains bile, while in lesions of the small or large
intestine usually it is at least tinged with bile. Diarrhea of a very
offensive odor is frequent in tuberculous ulceration. Tubercle
bacilli may, in some cases, be found in the stools. Reaction to
tuberculin, signs of emaciation, night sweats, and probably some
lung involvement can also be detected.
Typhoidal Ulceratiox. — Typhoidal ulceration is generally
painless, though in typhoid fever it is common for the patient to
complain of discomfort in the lower abdomen, and in some cases
of tenderness in the right iliac fossa. If the onset of the fever is
sudden, there may be generalized body pain and headache. If
LESIONS OF THE INTESTINES CAUSING PAIN 489
the development is slow and gradual, and no acute toxic condition
is present, the only pain-phenomena may be a zone of tenderness
over the tenth or eleventh dorsal visceral segments.
Syphilitic Ulcebation. — Syphilitic ulcers of the bowel, as
a rule, are painless. Should constant pain in the abdomen occur
in a syphilitic, and be accompanied by diarrhea, and, in some
cases, by vomiting, a diagnosis of syphilitic intestinal ulcer would
be tenable.
Catakbhal Ulcebation causes no pain, unless the ulceration
is very deep. The same is true of the ulceration the result of
uremic and trophic changes.
Ulcebs Following Bubns. — Ulcers following burns are
common. They are most frequent in those cases in which the
burn is on the abdomen. When they occur they are most likely to
be in the duodenum (see Duodenal Ulcer), and give rise to no
special symptoms, other than those which occur in simple intes-
tinal ulceration. The pain produced by them is apt to be over-
looked by the patient, because of the much greater pain which is
the direct result of the burn.
Duodenal Ulcebs. — The pain of duodenal ulcer, like that of
gastric ulcer, is paroxysmal. It may be of intense severity, or
may be felt merely as a dull discomfort coming at certain inter-
vals following the ingestion of food. In other cases, whether
severe or dull, it is more lasting, and sometimes a constant sense
of burning or of sharp pain is experienced. This in many cases
is relieved by the ingestion of food, therefore it received the name
"hunger-pain." The pain is situated to the right of the middle
line, and usually a little above the level of the umbilicus. It
may radiate toward the right or the left side. Sometimes it is
described as having a deep-seated location, being rather unlike
the characteristic pain of gastric ulcer in this pajrticular. The
time of its appearance varies. It may follow immediately after
the taking of food, but most often does not appear or, if it does
appear, does not reach its maximum of intensity until two, three,
or four hours after eating. The character of the ingested food
has a certain relationship to the intensity and occurrence of the
490 INTESTINAL PAIN
pain. Generally speaking, heavy meals occasion a pain of greater
severity, although the pain is later in appearance than after light
meals. The drinking of copious draughts of water, or the taking
of other liquids, such as milk, beer, and wine, or the ingestion of
alkalies, may relieve the paroxysm for a time.
Tenderness and rigidity of the abdominal muscles in the right
upper segment of the abdomen may be met with. Pressure
usually increases the painful paroxysms, although not invariably.
That the site of the ulcer bears a relationship to the site of the
pain cannot be doubted, though the idea that the pain, localized
tenderness, and muscular rigidity occur directly over the site of the
ulcer is not tenable.
The pain in duodenal ulcer may be situated in the epigastrium,
near the mid-line, and may extend to the right so that it lies be-
tween the crest of the ileum and the ribs. In this condition there
is also often a tender spot to the right of the lower dorsal vertebra.
It is claimed by many (Deaver, among others) that the pain in
duodenal ulcer shows a tendency to periodicity, so that it may be
absent for long intervals and then occur in an attack of varying
intensity. The pain of duodenal ulcer is increased by moving,
eating, or pressure. In many cases there is also present in the
abdomen a feeling of gnawing or of boring.
Many theories have been advanced to account for the pain in
duodenal ulcer. Three suppositions underlie all these theories,
namely: (1) That the HCl, because of its reflex excess of secre-
tion, directly irritates the ulcer and thus causes the pain. But, if
this is so, there must be many exceptions, for a duodenal ulcer,
without an excess of HCl in the stomach, is frequently found. In
fact, it seems that the ulcer is the cause of this increase of secre-
tion, and that the only effect of the excess is that by irritating the
surface of the ulcer, it causes a reflex contraction of the pylorus.
This leads us to the second supposition, so actively championed
by Hertz, (2) that the pain is nothing more than a tension pain,
due to localized distention of the stomach walls, the result of
excessive stimulation from the HCl. It is known that the pylorus
remains closed while the duodenal contents are acid, and that it
LESIONS OF THE INTESTINES CAUSING PAIN 491
relaxes only when the contents become alkaline. In duodenal
nicer the duodenal contents are, because of the excessive secretion
of HCl in the stomach, seldom, if ever, alkaline. Consequently
the stomach is always in a state of hypertension, the result of
abnormal peristalsis. This hypertension, however, exists only on
the prepyloric portion of the stomach, because it is into this por-
tion that the food is forced by the peristalsis and, being unable to
advance because of the closed pylorus, accumulates and causes the
increase of tension and the so-called ulcer pain, which has about
the same location as that described under pyloric spasm. (3) A
third supposition is that advanced by Bier, who holds that a
stomach when empty has a tendency to pull to the left, and traction
(in case of duodenal ulcer) is made upon the ulcerated area, while,
on the contrary, a stomach, when full, is displaced to the right, and
the traction is diminished, with a consequent diminution of the
pain. Which of these (if any, or if all three) is the active
factor in the production of pain in duodenal ulcer is rather diffi-
cult to decide, though it seems as though all three may have a
more or less important influence.
Distention of the Bowel. — Uncomplicated distention of the
bowel will cause considerable pain, especially when the distention
is sudden in onset, such as is found in acute obstruction, strangu-
lated hernia, etc.
In chronic intestinal distention, pain, as a rule, is not a promi-
nent symptom, and only becomes so when there is a sudden in-
crease in the distention. The pain of distention is relieved by
the expulsion of gas, and frequently the patient feels a change in
the location of the pain following a gurgling and the forward
movement of the gas. Distention of the bowel is denoted also by
tympany, localized over the area of the bowel segment involved in
the distention. It frequently happens that when the large bowel
is distended its segments can be defined by palpation, and if the
abdominal wall is fairly thin, peristalsis, if at all active, may be
seen. In idiopathic dilatation of the colon (Hirschsprung's dis-
ease) pain is usually absent.
Adhesions. — Bands of adhesions, which are a common cause
492 INTESTINAL PAIN
of distention, occur most frequently in connection with the small
intestine, and are there a more common cause of obstruction than
in the large intestine. They usually do not produce pain unless
so placed as to cause, during intestinal digestion or on active
movements of the body, a pull or drag upon the parietal
peritoneum. They may also cause pain by causing obstruction of
the bowel.
Obstruction of the Intestine. — Intestinal obstruction is more
conmion in the small than in the large intestine. It may be acute
or chronic.
Acute Obstetjction. — There are two varieties of pain due
to acute bowel obstruction: the primary and the secondary.
Primary pain is sudden in onset, very severe, and of a griping
character. It is generally referred to the middle of the abdomen,
and is due to the change in the relationship of the parts of the
bowel, with a consequent drag or pull upon the mesentery or
mesocolon. Following this is the secondary pain. It is more
continuous than the primary pain, and, owing to the violent peri-
stalsis of the cut-off bowel, is interrupted with paroxysms of great
intensity. Gradually, as the result of paralysis, from exhaustion,
or from toxemia due to poisons generated in the obstructed seg-
ment, the pain becomes less.
If the pain has a tendency to spread from its primary location
and is accompanied by concentric spreading tenderness, it is an
indication that the peritoneum has become involved and that a
spreading peritonitis has ensued. When this occurs the pain is
sharp, stinging, and more constant.
The cause of the bowel obstruction may be one of the follow-
ing: (a) causes acting external to the bow.el, (a) twists, volvulus,
(6) adhesions, (c) intussusception, (d) hernial bands (see Her-
nia) ; or (b) those acting within the bowel, as (a) contractures,
(6) fecal contents, (c) foreign bodies.
In twists and intussusception the onset is sudden and the pain
is most severe. There is also present a well-defined and painful
tumor. This tumor, depending upon the part of the intestinal
tract which is involved, is located in different parts of the abdo-
LESIONS OF THE INTESTINES CAUSING PAIN 493
men. If the sigmoid is the part involved, the swelling first be-
gins in the left iliac fossa, and then gradually extends upward,
with a central tendency, towards the umbilicus. From the very
beginning there are pain and tenderness, which become more
severe as the lesion progresses. The pain gradually extends until
the entire abdomen is involved.
The pain in intestinal obstruction is due: (1) to inflammation
of the peritoneal surfaces and the consequent involvement of the
lymph nodes; (2) the traction which the inflated gut exerts on
the mesentery and mesocolon; and (3) irritation of the nerves in
the affected segment of the bowel by (a) pressure from the ob-
structing agent, (6) pressure from violent peristalsis.
In acute intestinal obstruction the history of a previous attack
of peritonitis would indicate that the obstruction might be due to
adhesions. The pain in these conditions at first is very great,
but gradually subsides if the obstruction persists. The tempera-
ture and pulse are both variable, though, as a rule, no remarkable
change is noted in either. Vomiting, though not constant, gen-
erally is an accompaniment of obstruction.
Sudden, acute abdominal pain, periodic in character, associ-
ated with the passage of blood per anum, occurring in young
children, should always lead to a consideration of intussusception
as a cause. Obstruction accompanied by periodic pain generally
means that a volvulus is the cause. This gives rise to almost the
same symptoms as intussusception, though the tumor has, as a
rule, a different shape and location.
In the early stages of intestinal obstruction light pressure
upon the abdomen will often give relief. If during the course
of the disease the pain suddenly subsides without improvement
in the pulse and the general condition, the case is serious. If,
after having ceased, the pain again commences and becomes rapidly
generalized, it is a sign that a generalized peritonitis has developed.
Cheonic Obstbuction. — Chronic intestinal obstruction is
due to adhesions, contractures, new growths, foreign bodies (gall-
stones, fecal concretions), and inflammatory processes. In these
the development is slow, and extends over long periods. At first
494 INTESTINAL PAIN
there is only a sense of discomfort, which gradually becomes
worse until it is merged into pain. This pain is intermittent and
occurs in cramp-like paroxysms. These pains arise suddenly,
and are relieved as soon as the stagnated fecal matter and gas
have been forced beyond the point of obstruction by the pressure
from the rear. The patient is also conscious of the "pain"
beginning in a certain spot and working in a screw-like fashion
up to another spot where it ends (Maylard). If the degree of
obstruction suddenly becomes greater the pain immediately in-
creases in intensity, sometimes so markedly and suddenly that the
diagnosis of an associated acute obstruction is made. What really
happens is that only an exacerbation of an existing condition has
occurred. After a time the pain again subsides, owing, perhaps,
to fatigue or to relief of the local conditions (Stengel).
Early in the course of intestinal obstruction the pain is mild,
paroxysmal and infrequent; but as the obstruction becomes more
complete, attacks of pain are more frequent, and are of greater
severity. Associated with the pain are tympanitis, vomiting (pos-
sibly fecal), visible peristalsis (should the abdominal walls be
thin), tumor, which is tympanitic, obstipation, and generally an
absence of fever. Previous attacks of localized peritonitis or the
history of an abdominal operation will suggest a band or kink
of the intestine as a cause of the obstruction. The history of a
tumor will suggest pressure and faulty position of an intestinal
coil; emaciation in middle life suggests malignant disease; ascites
should lead one to suspect tuberculosis (23, p. 220).
Maylard claims that pressure by hardened feces will also cause
pain, and he cites a case where severe pain and tenderness were
present in the right iliac region, and, on exploratory laparotomy,
only hardened feces could be found in the cecum.
Lesions of the sigmoid colon often cause pain of the most
racking kind. It is felt at a point usually about two inches to
the right of the umbilicus and at the upper part of the iliac fossa
at the level of the crest of the ilium.
Overloading of the colon does not seem to be the cause of any
LESIONS OF THE INTESTINES CAUSING PAIN 495
special pain. Constipated individuals rarely suffer from pain
due to this cause (see Constipation, p. 509).
The presence of indican in the urine is a point of considerable
diagnostic importance in locating the site of the obstruction.
Should indicanuria be present early in the disease, it is an indi-
cation that the obstruction is high up, generally in the small in-
testine. At the same time, in high obstructions there is a reduc-
tion in the quantity of the urine due to the loss of water from vom-
iting, which is much greater in lesions of the small than in those
of the large intestine.
In all cases of obstruction vomiting is constant, and is not
accompanied by nausea. The vomitus at first consists of the
contents of the stomach, then of the bowel, and finally becomes
fecal. The period at which the fecal transition occurs varies,
depending upon the segment of bowel involved. The lower
the involvement the longer is the fecal vomit in making its
appearance. Should the obstruction be as low as the ileum, one
or two days may elapse before it appears ; when it does appea/r it
is pathognomonic of obstruction.
The absence of pain in bowel obstruction may be due to the
obstruction being the result of paralysis of a portion of the bowel
distal to the obstruction, as in a case reported by Musser. Here,
the patient, five days after an operation for intussusception, de-
veloped vomiting, which was of increasing frequency and finally
became fecal, though no pain was present. On operation the
cause of the obstruction was found to be a paralyzed portion of
the bowel.
In resume it may be recalled that obstruction of the bowel
may be due to: (1) functional spasm (colic), the result of (a)
irritation, organic poisons, bacteria, and cathartics, (b) inorganic
poisons (lead) ; (2) obstruction of the lumen by (a) lodgment
of some substance, as enterolith, gall-stones, indigestible or fecal
material, foreign bodies, as gall-stones, (h) change in the relation-
ship of the parts to each other, as in twists (volvulus), invagina-
tion (intussusception), dragging and pulling (hernia) ; and (c)
496 INTESTINAL PAIN
the presence of new growths, which may be inter-, intra-, or extra-
mural.
VolvuliLS, — Pain in volvulus comes on as a sharp, sudden,
severe pain (cramp) in the epigastrium, or in the region of the
umbilicus. It is continuous, and at first is of a constant in-
tensity; but as soon as fecal stasis occurs, and distention of the
bowel segment proximal to the obstruction occurs, the constant
pain is interrupted by a series of cramp-like exacerbations.
These exacerbations are indications of the severe contractions
taking place in the intestine, in its effort to establish a passage
through the obstruction. Gradually, as the obstruction to the
circulation in the affected bowel becomes complete, inflammation
and gangrene supervene, and a generalized peritonitis, with its
accompanying pain and tenderness, occurs. As the gangrene
progresses, and the peritonitis becomes more severe, sepsis ensues,
and the patient, becoming toxic, complains less and less of pain,
until, in a state of somnolency and forgetful ness, the shadow of
death hovers over him and he passes into the land of eternal rest.
There is no relief for volvulus, unless the knot is reduced either
by natural or surgical means.
Associated with the pain of volvulus, as described above, there
is also present in tlie abdomen a rounded tumor mass, either tym-
panitic or dull on percussion. Obstinate constipation and vomit-
ing are also present, and generally, though not invariably, a rapid
pulse. If these symptoms are found, they are of sufficient mo-
ment to demand a laparotomy.
Volvulus is most frequent at the sigmoid. When the condi-
tion is acute and the obstruction is complete, a distention greater
than that which occurs with any other lesion of the bowels rap-
idly develops. Therefore, when sudden pain is followed by a
rapid distention, without signs of peritonitis, volvulus should be
considered. It is more frequent in men than in women, but
constitutes only about one-fortieth of all cases of intestinal ob-
struction.
Intussusception. — This is very frequent in infants, and,
while pain is undoubtedly pronounced, yet we are not able to
LESIONS OF THE INTESTINES CAUSING PAIN 497
make a definite assertion, because the infants, on account of
their immature age, are unable to express their distress. There-
fore, should evidence of colic occur in a baby (who, as frequently
happens, has had a previous diarrhea), followed, within a short
time, by the development and gradual increase in size of an
elongated tumor, with an associated constipation, a tentative diag-
nosis of intussusception may be made. If the disorder should
happen in those of more mature years, a more detailed account
will be given of the onset and the nature of the accompanying
pain. Bearing in mind the manner of production of this disor-
der (the sudden, acute invagination of one part of the bowel into
another part, with consequent pull and possible twist of the
mesentery), the reason for the sudden acute pain is apparent.
It is commonly stated that the pain in intussusception is
directly over the site of the tumor mass, but the fallacy of this
is clearly proved in the introductory remarks to this chapter.
The pain, which at first is of a well-defined, colicky type, gener-
ally is confined to the umbilical region or lies immediately below
it Since the lesion is located most commonly in the cecum and
the lower part of the ileum, the pain may finally become localized
in the right iliac fossa. This location of the pain can be ex-
plained from the fact that, when intussusception occurs, consid-
erable pull is made upon the mesenteric attachments of the ileum
and is reflected as pain to the anterior abdominal wall, generally
in the region of the umbilicus. As the intussusception progresses
an added pull is made upon the cecum, and through it traction is
exerted upon the parietal peritoneum, with pain referred to the
right iliac fossa, or to the lumbar region on the same side. Later
in the disease, owing to restriction of the blood supply and to
pressure, the inclosed segment of the bowel becomes necrotic.
Inflammation of the proximal segment then occurs, and is com-
municated to the adjacent peritoneum, with the production of
pain. This pain is referred to the area below the umbilicus and
across the lower portion of the abdomen. In pain-production the
pull and tension on the mesocolon also are of considerable mo-
ment
498 INTESTINAL PAIN
Id intussusception the lumen of the bowel is ohstnicted, and
the forward movement of feces hindered. Backward stasis
occurs, and distention of the bowel proximal to the obstruction
takes place. This distention then acts as an additional cause of
pain-production. In invagination of the ileum into the cecum
the etiological relationship of the lesion to the region where the
pain is felt is illustrated in the accompanying drawings.
Fic. 103. — Pain Areas in iNTUseuscEpnoN.
First st^^: Pull upon the mesentery. Second staKe: Pull on mesentery and
traction on parietal peritoneum connected with the cecum and colon.
Third stage: Inflammation has supervened and pain is also referred to
the colon area. Figure shows where the pain is felt as the bowel pro-
gressively becomes involved in the invi^nation.
After (he iiitussusceptum has sloughed off, provided the pa-
tient survives, there ia formed a considerable number of adhe-
sions which, because of their traction, are always a source of an-
noyance and pain-proiluction. The bowel is also shortened, and
the mesentery is constantly on the stretch; and, though in time it
may accommodate itself to its changed relations, at first every little
LESIONS OF THE INTESTINES CAUSING PAIN 499
(intestinal) distention is noticed much more and produces more
pain than it would in a normal subject.
If in the sloughing stage a generalized peritonitis supervenes,
the pain becomes much more acute and is diffused over the entire
abdomen. Tympanitis also becomes more marked, and tenderness
is excesdve. In eliciting the tenderness, the pressure exerted
upon the abdominal wall must be such that the parietal peri-
toneum is irritated ; pressure must be light but not deep.
That there is a somewhat intimate relationship between peri-
stalsis and the production of pain, and that an absence of peri-
stalsis may lead to an absence of pain, is seen from a case re-
ported by Musser, in which an intussusception was present with
an entire absence of pain. At the same time, peristalsis was
absent. At operation the intestines were found as limp and as
motionless as they are in a cadaver.
Hernia. — The obstruction due to hernia was considered under
hernia of the abdominal wall (q. v.).
New Growths of the Intestine, — New growths of the intestine
frequently occur without the production of pain, especially in the
early stages. When pain does occur, it is due: (1) to interference
with the local circulation, causing congestion, edema, inflamma-
tion, and adhesions; (2) obstruction to the bowels; (3) pressure
on the nerve filaments in the wall of the bowel or pressure upon
adjacent nerves ; and (4) dragging and pulling on the mesentery.
Interference with the local circulation does not produce any
pain until an active inflammation ensues; then pain becomes a
most marked symptom. It is localized to the region over the
affected bowel, and is of a peritoneal type. If obstruction to. the
bowel takes place the pain is of the type described under intesti-
nal obstruction. If it is due to pressure on the nerve filaments
in the intestinal wall, the pain may be reflected to the abdominal
wall, and be felt in the areas of distribution of the ninth, tenth,
eleventh, and twelfth dorsal visceral segments. The higher the
point of pressure in the bowel the higher the visceral segment
which is involved. If pressure should also be made upon adjacent
but extramural nerves, the pain is referred to the area of distribu-
500
INTESTINAL PAIN
tion of these nerves, either in the anterior abdominal wall or in the
lower limbs.
If a dragging and pulling on the mesentery occur, aching is
felt in the area of distribution of the related dorsal visceral seg-
ments.
Pain Due to Colonic Involvement. — The colon is supplied by
nerves derived from the superior and inferior mesenteric plexi,
which receive their supply from the solar and aortic plexi, re-
spectively. These, in turn, receive their supply from the ninth,
tenth, eleventh, and twelfth dorsal segments of the cord (accord-
ing to Wilson (896), from the seventh dorsal to the sec-
ond sacral) ; the segments most commonly involved are the tenth,
eleventh, and twelfth dorsal. The pain in colonic diseases seems
,^\
._.»>... p.::\
I
*' V V WW
V V V
XSKXKKXXVK .
V ixxxxx /
\ XXIIX •• — «..
\ XKX
...-->< y-;.'-
Fig. 104.
FlOS. 104 AND 105.-
Area in which pain is
felt when the inflamma-
tion progresaes alone the
gaatrocolic omentum
and causee inflamma-
tion of the stomach and
adjacent tissues
Area in which referred
pain is present
Fig. 105.
-Arbab of Pain in Diseases of Colon.
to be much more pronounced the nearer the lesion is to the anus.
When the lesion is high up, the pain is not very severe unless in-
flammation has extended to the peritoneal coat on either side of
the mesentery. If this has occurred, the infiltration may pro-
gress to the parietal peritoneum and thus cause pain, which, in
lesions of the ascending and descending colon, is felt in the right
and left lumbar regions respectively, or, in those of the trans-
verse colon, in the center of the abdomen. Should only traction
of the mesocolon occur, the pain is felt in the abdomen in the
hypogastric area.
This hypogastric pain comes under the class of reflected pains.
It is in the zone of distribution of the eleventh and twelfth dorsal
LESIONS OF THE INTESTINES CAUSING PAIN 501
visceral segments. The afiFections of the colon giving rise to pain
are: (1) acute and chronic inflammation, (2) displacements,
(3) obstruction, (4) new growths.
Inflammation of the Colon. — In inflammation of the colon
the pain is referred to the lower abdomen, and, in involvement of
the sigmoid flexure, generally to the left side. This reference can
only be explained by the fact that, because of the shortness of the
mesocolon and its intimate association with the peritoneum of the
left side, inflammation of the colon is quickly communicated
to the parietal peritoneum of the same side. The increase in
local tenderness on this side can also be thus explained.
Inflammatory diseases of the colon causing pain are of two
classes: (a) acute and (6) chronic.
Acute infective states of the colon are always painful, and
the pain is of a griping, burning, or boring nature. Pains the re-
sult of acute inflammation have a greater tendency to localize
themselves to the region of the affected bowel than do the pains
produced by chronic disease, which, as a rule, are reflected or
referred to distant areas. In inflammatory states of the colon
the patient is sometimes conscious of a relief of his pain follow-
ing movement of the bowels or the passage of flatus. Mild inflam-
matory states of the colon, as a rule, are not painful; but if the
irritation is prolonged, and the inflammation increases and be-
comes phlegmonous, a septic and generalized bowel involvement
or ulceration, with its somewhat mild but persistent symptoms,
may occur. In some cases of painful colitis the ingestion of food
brings on an attack of pain. This is due, probably, to activity of
the colon incited through sympathetic nerve connections.
According to Tuttle, there is in ulcerative colitis a "sudden
onset of sharp, lancinating pains in the course of the colon,
attended with griping and a tendency to frequent movements of
the bowels. These pains last for a short time, then disappear,
and the patient may have nothing more of the kind for several
days or weeks, when they again occur. They sometimes last an
hour or more; at other times they continue for two or three days."
If the attack is persistent, pus and blood finally appear in the
602 INTESTINAL PAIN
stools. The attacks are periodical, and the pain, which in the
early attacks was not severe, increases in severity with each at-
tack. The amount of the pain bears no relationship to the extent
of the ulceration, and is not influenced by the ingestion of food.
The cause of the pain seems to be the irritation of the ulcer by
the intestinal contents, which incite irregular peristaltic or spas-
modic movement of the bowel. In follicular colitis there may be
tenderness over the lower end of the spine, with vague pains
shooting down the legs.
In chronic colitis pain comes on at irregular intervals. It is
of a griping character, and generally precedes the passage of a
stool consisting chiefly of mucus or of shreds of membrane. After
the stool the pain may persist for several days. The onset of
the pain bears no relationship to the ingestion of food, nor does
it seem to be influenced by diet. Tuttle thinks that the formation
of the membrane is the result of a localized increase in the secre-
tion of mucus, this being the result of a localized hyperemia, which,
in turn, is due to a slight intussusception or volvulus. When the
spasm (localized), which has been the cause of the intussusception
or twist, relaxes, the mucus or membrane which has formed is
rapidly discharged. The patient, because of the synchronicity,
associates the passage of the membrane with the relief of the
pain.
Pain may be produced by spasm of the colon without any in-
flammatory lesion at the same time. Schiitz thinks that these
cases are most probably primary neuroses. Any systemic crisis,
such as that occurring at the menstrual period, may bring them
on. The pains occur as cramps in the sides and across the abdo-
men, at first only at stool, but gradually they become more con-
stant and are interrupted by exacerbations of agonizing intensity.
Constipation is pronounced. Loss of appetite, associated with
nausea, is present. This condition is found usually in those of
anemic and neuropathic tendencies. The lower in the colon the
disease is located the greater is the tendency to pain-production.
The reason for this is that filaments of the cerebrospinal nerves
are distributed to the lower part of the colon, so that, when this
LESIONS OF THE INTESTINES CAUSING PAIN 603
part is involved, pressure will be exerted upon these nerves and
pain will be produced in the area of their distribution. It is for
this reason that in diseases of the sigmoid flexure of the colon
pain has a tendency to be localized in the left lower abdominal
quadrant In sigmoiditis the patient flexes the left limb; the
abdomen over the sigmoid is very sensitive to pressure, and
the lower segment of the left rectus abdominis is in a state of
contraction. These symptoms are but indicators that the inflam-
matory process, localized at first to the walls of the lower bowel,
has spread by means of the lymphatics to the adjacent peri-
toneum. Such an extension would be very easy, for the sigmoid is
without a mesentery, and is connected to the body wall by a loose
meshed tissue. When peritonitis occurs all movements of the body,
especially those producing stretching or traction of the abdominal
wall, are very painful. These painful syndromes are present only
in acute cases, the chronic ones being entirely or almost entirely
free from pain.
Often in cases of mucous colitis considerable pain is present
previous to the discharge of casts of the bowel or of large shreds
of mucus. • This pain is relieved as soon as the bowel dis-
charge commences, but abdominal tenderness persists for some
time. Colicky pains in the lower part of the abdomen, on the left
side, followed by tenesmus and mucus-stained stools, are pathog-
nomonic of sigmoiditis. Inflammation of the sigmoid is very
rare without, at the same time, an associated inflammatory state
of the rectum. The latter produces symptoms similar in some par-
ticulars to those of inflammation of the colon and sigmoid, but
differing in many important details, because the lower position and
the nearer relationship of the rectum to the spinal nerves cause
the pain to be more that of a referred spinal type. The rectal
pain-producing diseases will be considered in a later section.
Displacement of the Colon. — A rather poorly understood
cause of pain in colonic disorders is displacement. That pain is
caused by displacement of the colon cannot be doubted, though,
at the same timej the opinion is widely held that displacements,
even of a major degree, may be present without producing the
504 INTESTINAL PAIN
slightest pain. The manner of the pain-production varies widely,
depending upon the portion of the gut involved. Should the dis-
placement occur on either the right or the left side, the pull is
upon the lateral mesocolon, and to some extent upon the kidney,
through the nephrocolic ligament If the displacement on the
left side is great enough, a pull upon the spleen also occurs
through the splenocolic ligament. If the lesion is on the right
side, traction is made upon the liver through the hepatocolic liga-
ment. When any of these conditions occur, aching and distress
are present in the regions associated with the organs secondarily
involved. Should the transverse colon be affected, the pull is
exerted upon the stomach and the organs closely connected with
it, as the pancreas, liver, and gall-bladder, and indirectly upon
the diaphragm, thus producing a symptom-complex involving all
these organs. As they are all supplied by the solar plexus, a
general aching and distress, sometimes amounting to actual pain,
with an ill-defined localization in the lower abdomen, result.
As a sequela, associated with displacement, is distention. It
occurs from the lodgment of fecal matter at one of the low places
in the distended gut with a consequent obstruction and distention
of the proximal segment of the bowel from gas. In some cases,
owing to the weight of the fecal matter, the bowel sags and a kink
results. The onward progress of the feces and gas is obstructed,
and, as a consequence, dilatation of the bowel occurs on the side
proximal to the obstruction. The signs and symptoms of disten-
tion (which are described under that heading) then appear.
In a brief resume it may be stated that the localized pull upon
the peritoneal attachments due to displacement produces signs
referable directly to the organs involved, while the pull upon
associated organs produces pain and symptoms referable to those
organs.
The consideration of the causes of colonic displacements is
beyond the scope of this work, but a brief review of the effects of
change of position, etc., upon the production and character of the
pain may be permissible.
If the displacement is of either the ascending or the descend-
LESIONS OF THE INTESTINES CAUSING PAIN 505
ing colon, the position of the patient lying upon the side opposite
to that in which the bowel is displaced will often cause consider-
able and lasting pain. The pain is of a dragging, aching charac-
ter, and may continue until the patient turns upon the opposite
(affected) side, and allows the displaced bowel to assume its
natural position, and permit the gas and fecal matter to have
an unobstructed passage.
Displacement also causes a tumor formation, which, as a rule,
is tympanitic, and varies in size, depending upon change in the
position of the patient. It can often be reduced by pressure,
the reduction being accompanied by audible gurgling, and by a
relief of the distress. An alteration of the diarrhea and constipa-
tion often occurs. When this symptom-complex is present it
should at once attract our attention to the colon. For other signs,
consult Distention (cf. p. 491).
Should the displacement be due to the drag of a tumor, pal-
pation will reveal the abnormal formation, and, at the same time,
the type of the displacement.
Obstruction. — Obstruction of the sigmoid by hardened feces
is a common cause of pain. In this condition there also may be
an alternate diarrhea and constipation.
New growths cause pain as a result either of displacement
or of obstruction.
The BecttinL — Rectal pain is of two classes : (a) local and
(&) referred.
Local pain is due to ulcers, new growths, strictures, etc. The
pains produced by these lesions are more frequently the result of
involvement of the neighboring structures than of direct irrita-
tion of the nerves ending in the walls of the rectum. In all these
conditions there is, in addition to the local pain, a referred pain,
which may be felt in the lower lumbar or sacral regions of the
back, on one or on both sides. These regions are supplied by the
fourth sacral nerve, which is distributed both to the rectum and
to the skin over the sacrum. In some cases, owing to associated
nerve involvement, the pain may be referred to the perineum,
down the back part of the thigh, and even to the penis, or to the
n
506 INTESTINAL PAIN
labia. The upper part of the rectum is without pain, and can be
greatly distended without distress. Because of its non-sensibility
it becomes the receptacle of the hardened feces.
Pain may be referred to the rectum from adjacent organs, as
the uterus, tubes, ovaries, prostate, posterior urethra, or trigone
of the bladder. In these Conditions the pain has more of an
aching character, and there is a constant desire to go to stool.
Nervous disorders also cause pain referred to the rectum.
The following nervous disorders, it is said, cause rectal referred
pain: epilepsy, locomotor ataxia, neuralgia, and hysteria. It is,
however, a disputed question if any nervous derangement can,
without some definite rectal pathology, cause local rectal pain.
The nerve supply of the rectum includes both sympathetic and
cerebrospinal nerves. The sympathetic supply is derived chiefly
from the inferior mesenteric and pelvic plexuses and from the
nerves accompanying the superior and middle hemorrhoidal ar-
teries.
The cerebrospinal nerve supply is derived from the second,
third, and fourth sacral nerves, which enter the sacral plexus and
are distributed to the rectum through the following nerves: (a)
the inferior hemorrhoidal, which supplies both the rectum and the
anus; (6) the superficial perineal, a branch of the pudic, which
supplies the levator ani and the skin in front of the anus. The
skin around the anus is supplied by the inferior hemorrhoidal
branch of the pudic (Piersol). The pudic nerve is derived from
the same segment of the cord as is the sciatic. Therefore, irrita-
tion of this nerve by ulcer or fissure of the lower rectum or anus
may be referred as pain down the leg along the course of the
sciatic.
The central origin of the nerve supply of both the rectum and
anus is located about the level of the first lumbar vertebra. This
is about the same level as that for the bladder and genitourinary
systems. Thus we have the explanation of the close sympathetic
bond existing between the two systems.
Inflammation of the Rectum. — Inflammation of the rec-
tum, called proctitis, as a rule, is of little moment, unless it passes
LESIONS OF THE INTESTINES CAUSING PAIN 507
the catarrhal stage and becomes of a dysenteric type. Proctitis of
the catarrhal type may give rise to no symptoms except a sense of
distress in the rectum, and, in some instances, an aching referred
to the back over the sacrum. Pathognomonic of catarrhal proctitis
are griping pains in the lower abdomen, with constipation, and,
in some cases, nausea and vomiting. In addition to these symp-
toms, there is at times the occasional passage of a small quantity
of blood-stained mucus. Should constipation be pronounced, the
stools hard and dry, and tenesmus and sacral pain marked, trophic
proctitis is most likely. Rectal tenesmus is present in all vari-
eties of proctitis.
In proctitis hemorrhoids are almost constantly present, and
should not be mistaken for the disease ; nor should pruritis, which
often is severe, lead one astray in making the diagnosis.
Dysenteric proctitis is the most severe form of rectal inflam-
mation. It causes the most pronounced aching in the pelvis and
about the anus, and also produces "burning and heat in the lower
part of the rectum, severe tenesmus, constant diarrhea, and rapid
exhaustion."
New Growths. — The new growths of the rectum causing
pain are carcinoma and gummata. Carcinomg, of the rectum, if
it is above the mucocutaneous folds, is generally painless. One
of the unfortunate things about this dread disease is that its onset
is so insidious and symptomless that its cryptic advance is not
suspected until it has progressed so far that treatment is of no
avail. Yet, because of the morning diarrhea and the discharge of
pus and blood, attention should be focused early upon the rectum
as the seat of the trouble.
Gummata of the rectum are painless. At the anus they are
inversely as frequent as are the primary lesions in the same loca-
tion. The probable reason for the lack of pain in gummata of the
rectum lies in the fact that they are seldom accompanied by inflam-
matory reactions, and pain, if it is present, is chiefly caused by
distention, and, because of the laxity of the tissues at this place,
is very hard to produce. Another reason for the absence of pain
608 INTESTINAL PAIN
is that gummata rarely suppurate, and, therefore, the nerves are
but seldom involved in an inflammatory process.
Ulceration. — The most common cause of rectal pain is ul-
ceration, and I cannot do better than quote from Tuttle, who
so thoroughly covers the subject. He says that in this condition
"pain is a very sharp, unreliable, and indefinite symptom. Cer-
tain individuals suffer greatly from it, while others have no pain
at all. If the ulceration is high up in the rectum, a sense of
weight and aching in the sacral region is the chief discomfort of
which most patients complain, while, if it is situated lower down
within the grasp of the sphincter and involves the mucocutaneous
fold, which is rich in sensory pain-receptors, pain of a sharp,
lancinating, burning character will be the chief complaint. This
pain is the result of contraction of the internal sphincter, which
makes pressure upon the exposed sensory receptors. The amount
of the pain varies considerably with the character of the ulcera-
tion. Tuberculous ulcers are almost entirely free from pain.
Syphilitic ulcers vary considerably in the amount of pain which
they produce. Sometimes they are very sensitive; at other times
the patient is almost entirely free from pain. This freedom de-
pends, to a considerable degree, upon the location of the ulcer.
As a rule, ulceration of the rectum is not an acutely painful affec-
tion."
Varicose ulcers of the rectum, because of their location above
the mucocutaneous fold, are a rather negligible quantity as a
cause of acute pain. However, there is present a dull aching in
the back, and sometimes shooting pains run down the leg or
around the pelvis. Should the sphincter be involved, the pain,
because of the excessive contraction of this muscle, becomes very
acute. If the varicosities are large enough to be termecl hemor-
rhoids, the pain is much more severe. It is especially marked
should the hemorrhoid be of such a size that it can prolapse
through the anus and be grasped by the sphincter. Hemorrhoids
may cause pain referred over the sacrum, in the back, and down
the limbs.
LESIONS OF THE INTESTINES CAUSING PAIN 509
Ulceration accompanying Bright's disease usually is without
pain.
Ischiorectal Abscess. — In ischiorectal abscess the infec-
tion is generally ushered in by a well-defined chill, and a feeling
of discomfort which is soon followed by a throbbing pain. Ex-
amination reveals an induration around the anus; redness may
or may not be present, depending upon the extent and severity
of the infection. The patient generally has difiiculty in urina-
tion, and defecation may be and usually is extremely painful.
In some cases a hematoma may simulate an ischiorectal abscess,
but on opening the swelling the only thing found is a collection
of blood. As soon as this is evacuated the pain disappears.
Paln^ Due to Constipation. — Neuralgia is often associated
with constipation. This is due in large part to direct pressure
by the fecal mass upon a nerve or a nerve plexus. Continued
pressure causes traumatism, and leads to a pressure neuritis.
Lowered vitality of the nerve-stem, due to pressure, also permits
infection. Thus, there may develop an infectious neuritis, as
well as a pressure neuritis.
Constipation. — Colicky pains are produced by constipation,
and are the result of the distention of the bowel by gas or fecal
matter, or they may be the result of enterospasm, due to irritation
from the stagnated feces, or their contained toxins. These pains
are, as a rule, localized in the central part of the abdomen. The
abdominal muscles are sometimes associated in the symptom-com-
plex and are strongly contracted. Frequently the contraction of
the muscle is confined to the portion which lies over the area of the
involved bowel.
The Amis. — The lowest part of the rectum, the anus, is the
part most subject to painful reactions. These are the result of two
factors: (1) the great sensitiveness of the sensory receptors in
this location, and (2) the presence of two powerful, constant act-
ing sphincters, whose contraction produces severe pressure upon
the exposed and irritated nerve filaments. Because of these con-
ditions, the slightest ulcer in this area is provocative of the most
extreme distress. The nerve stimuli from the anus areas are con-
510
INTESTINAL PAIN
veyed in the fifth sacral nerve, which also supplies the integu-
ment over the sides and the tip of the coccyx. This accounts for
the referred pain felt over this area in anal disorders.
InttfQ. Around
Anus
Fig. 106. — Iiuutation at External Sphincter Referred to Skin over
Coccyx.
Anal Fissure. — The most painful of the anal affections is
a narrow and deep ulceration of the mucocutaneous junction, the
so-called anal fissure.* The pain produced hy this lesion is of
two types, depending upon the stage of development. In the early
stages the nerve endings are exposed on the ulcerated surface, and
the pain is of a cutting, burning type, most marked after defeca-
tion. Later, as the sensitory fibers which have been exposed are
destroyed, the pain is more dull and constant. During the course
of the ulcer, owing to infection, and possibly traumatism of the
adjacent nerves, a peri- and, in some cases, an interstitial neu-
ritis may develop. There is then present a dull, throbbing ache,
which radiates to the back and dowTi the legs. This pain may
persist even after the ulcer has cicatrized, because, even though
the ulcer may heal perfectly, the neuritis will still remain.
' In anal fissure pressure upon the margin of the anus, just below the
ulcer, is always painful. A large part of the distress may be prevented,
should the patient lie down immediately after defecation. When the pain has
persisted for some time it may be permanently relieved by forcible divulsion
of the sphincter. The relief of pain by this means seems to be due, as de-
scribed by Tuttle, to the release of the nerves from inflammatory adhesions
with which they were surrounded, and to the removing of the pressure which
had previously been exercised by the tightly constricting sphincter.
LESIONS OF THE INTESTINES CAUSING PAIN 611
The description of the pain of anal fissure given by Tuttle
is worth quoting. He says, "The pain is very variable in time,
nature, and duration. It may come on at stool, immediately
thereafter, or half an hour or an hour after. It may be acute,
cutting, tearing, as if a woimd were being pulled asunder, or it
may be a burning, hot, irritating feeling, accompanied with spasm
and bearing-down sensation. Finally, it may have none of these
characteristics, but assume a dull, heavy ache, with throbbing and
distress similar to that of an aching tooth. The time during
which the pain lasts is also as variable as its nature. Sometimes
it lasts for only a few minutes, and the patient is then able to
go about his business without any further disturbance till the
next stool. At other times the pain and smarting are so severe
that he is unable to move from his position at the toilet, or he
must seek his bed, and lie there from one-half to three-quarters of
an hour until the acute agony has passed away. After this he is
comparatively comfortable for the rest of the day. In others, the
pain does not come on for some little time after the fecal move-
ment, when smarting and burning are felt in the anal region.
This sensation gradually changes to a throbbing, aching distress
about the anus and the sacrum, which may last for several hours,
or even, in some cases, all day long. Certain patients are never
entirely free from discomfort. There is a pretty clear relation-
ship between these pains and the character of the fissure.
"The acute pains, lasting only for a few moments, are ordi-
narily due to superficial fissures which involve the uppermost
layers of the mucocutaneous tissues, healing partially from day
to day, and recurring with each hard stool. They can be pro-
duced by forcibly stretching the anal folds apart. Such fissures
are frequently associated with atrophic catarrh and late syphilis.
The pains, which come on just after stool and last for one-half
an hour or more, are ordinarily due to an ulceration between
the radial folds of the rectum, especially in the posterior com-
missure. There is a slight red granulated base, thickening of the
edges, with a sentinel pile, or two little teats at its lower end.
The dull aching or throbbing pain, which comes on some time
612 INTESTINAL PAIN
after stool, is generally due to a fissure or ulceration in the upper
part of the anus, and involves the internal and the upper fibers
of the external sphincter. It is ordinarily of long standing,
deeper, and more indurated than the previous variety, but its
edges are not so elevated and thickened, and it does not involve
the skin at all, and can only be seen by the use of the speculum, or
by forcibly stretching the anus apart. The late pains, occurring
some time after a fecal movement, indicate that the ulceration
is high up, while those occurring immediately thereafter would
indicate a lower situation. In general, however, it may be said
that the acuteness and severity of the pain are in direct propor-
tion to the nearness of the ulcer to the anal margin. The more
the mucocutaneous tissue is involved the greater is the pain.
The reason of this is probably that the sensitive nerve fibers
approach the mucous membrane from below, and are distributed
in a gradually decreasing ratio as we ascend into the anal canal,
disappearing almost entirely after the mucous membrane has been
reached.^' ^
The reflex pains associated with anal fissure are:
(1) Dysuria. — This generally occurs at the time of or shortly
following defecation. This association is easily understood when
it is considered that the anus and the lower urinary system re-
ceive their nerve supply from the same segment of the cord.
(2) Uterine and bearing-down pains (in women).
(3) Backache and neuralgic pains shooting down the leg.
(4) Facial and occipital neuralgic pains.
The neuralgia may be but an indication of the reaction of the
nerves to the toxins which are circulating throughout the system,
because, in anal fissure, the bowels, on account of the pain, are
inactive, and the fecal matter accumulates, giving rise to a toxemia.
Perianal Abscesses. — Some perianal disorders are ex-
tremely painful. Of these abscesses are the most painful. Should
an abscess be present in the subcutaneous tissue around the anus,
and no pain be felt, it is a fairly good indication that the condi-
tion is due to tuberculosis. In such affections there is very little
*" Diseases of the Anus and Pelvic Colon,'* p. 300.
LESIONS OF THE INTESTINES CAUSING PAIN 513
inflammatory reaction, and swelling and redness are absent. The
discharge, thin and watery, passes out of a small opening which
leads from a boggy central mass. All cases of fistula, abscess, and
ulcer around the rectum, which have developed insidiously ivith-
out pain, are generally tuberculous. Should the abscess not be
tuberculous, but the result of an infection from a pyogenic organ-
ism, there is at first a preliminary feeling of discomfort, quickly
followed by sharp and severe pain. Examination will, in this
case, disclose a small, round, inflammatory area, which is hot
and red, and exquisitely tender to the touch. The patient also
has fever and an increase in the pulse rate.
CHAPTER XXV
THE APPENDIX
The appendix is located in the right iliac region at a point
about two inches from the umbilicus on a line running from
the umbilicus to the anterior superior spine of the ilium. It gen-
erally lies deep in the abdominal cavity, and has no direct connec-
tion with the abdominal wall. As a rule, it and the adjacent
loops of the bowels are covered by the omentum, which hangs
over and protects them from injury, either traumatic or infective.
It is, in the majority of cases, free, although its excursions
and movements are somewhat restricted by a short mesentery
which joins the right leaf of the mesentery proper and is called
the mesoappendix. Through this mesoappendix the appendix
derives its blood and nerve supply. The blood supply is derived
most frequently from the posterior branch of the iliocecal artery,
formed from the junction of a branch from the iliocolic with one
from the colica dextra. The nerve impulses are carried through
the superior splanchnic of the sympathetic.
The researches of Neuniann (127b) have definitely shown that
the splanchnics convey painful sensations to adequate (tension)
stimuli.
The pain ^ in appendicitis is, in the early stages of the attack,
found to be general, or, as it is termed, diffuse, being distributed
over the entire abdomen, though frequently it is first perceived
in the epigastric or umbilical region. Then it becomes localized
to the region of the appendix and, as the peritoneum becomes in-
volved, it again spreads. In gangrenous appendicitis there often
'The nervous aystem of woman reacts to pain more readilj than does
that of man (265, p. 408).
514
THE APPENDIX 616
is lack of pain, assumed to be due either to benumbing of the pain
receptors b; the toxemia, or possibly because there are no peristal-
tic waves set up in the appendix. The diffuse pain is probably due
to an explosion of nervous impulses, which are produced in the
appendix by the sudden distention and consequent traction thus
diThoru
Fig. 107. — Cutaneous and Musculab Distribution op Uth and 12th
Thoeacic Nervbb.
It is seen that the eleventh thoracic supplies principally the lower segment
of the rectus abdominis muscle. Thus since this segment is the one
usually connected with the appendix it is easy to understand the reason
for the local and segmental contraction of the rectus muscle in appen-
diceal inflammatory states.
induced upon the mesoappendix.^ It has been stated by Lennan-
der ^ that all pain arising from intraabdominal changes is due to
peritoneal traction produced by these changes. The secondary pain,
which becomes localized to the region of the appendix, may be due
'Moullin (226, p. 515) elaima that the initial pain of appendicitis is due
to the "periataltic action of the cecum or of the appendix dragging upon the
Bttachmsnt of the cecum to the atHlominal wall." When the inflftnunation
spreads to the muscular coat the latter can no longer contract, and ae a conse-
quence the pain cchb«b. Moullin also claims that such a relationship Is sbown
by the fact that the ceBsation of the umbilical pain is coincident with the
formation of a local swelling "due to distention of the bowel and the thicken-
ing of Its walla hj inflammatoi? exudate."
'Iiennander 'e explanations, however, as has been repeatedlj pointed out,
are not valid, because of the oversight of what constitutes au adequate stimu-
lus for tlie internal viscera.
516 THE APPENDIX
to involvement of the terminal sensory filaments of the spinal
nerves distributed to the appendix.* These refer the sensation to
their terminal somatic filaments and the abdominal wall and, since
the eleventh spinal segment (Deaver) is connected with the appen-
dix, the pain will be referred to the filaments of distribution of this
segment. The principal points of emergence of thepe nerves are
near McBumey's point, thus accounting for the pain in this neigh-
borhood.
It is also possible for an appendix to be inflamed and give
rise to no symptoms. For example, in many cases I have exam-
ined appendices where strictures were present, indicating an old
inflammatory reaction, and yet the patient was unable to recall
any attacks of pain resembling an appendicitis.
Varieties of Appendiceal Pain.— Pain in appendicitis may
be divided into the following classes :
I. Local pain due to:
(1) (a) Obstruction.
(&) Inflammatory swelling.
(2) Inflammation:
(a) Mural.
(&) Extramural.
(3) Adhesions:
(a) To other abdominal viscera.
(6) To the peritoneum.
II. Distant pain, which may be:
(1) Referred pain:
(a) To the abdominal wall of the same side.
(&) To the tunica vaginalis testis and also to the
sacroiliac region.
(2) Transferred pain:
(a) To the abdominal wall of the same side, at a
higher or lower level.
(b) Crossed to the abdominal wall of the other
side, at the same or at a higher or lower level.
' It is questionable whether the terminal filaments oi any spinal nerve
ever really reach the appendix.
VARIETIES OF APPENDICEAL PAIN 517
(8) Keflex:
(a) Headaches.
(&) Keflected pain.
Local Pains. — (1) Obstruction, — The local pains are due
to: appendiceal colic, the result of obstruction of the lumen of
the appendix by (a) some indigestible food, (fe) a foreign body,
(c) a kink in the appendix, or (d) constriction by adhesions.
(a) In some cases indigestible food, as the chaff of the wheat
grain, or of any other cereal, or the seeds of various fruits and
berries lodge in the appendix, and, because of diminished muscu-
lar power, it is unable to extrude them; consequently, they re-
main in its lumen and are a source of irritation. This irritation
is the signal for the gathering of germs which produce a mild
grade of inflammation; and, as a consequence of it, fermentation
and a slight dilatation of the lumen occur ; this in turn stimulates
contraction, and this causes the pain, (b) Foreign bodies may
lodge in the appendix, as fecal concretions, or seeds, (c) Kinks
may occur in the appendix. In these conditions the bend in the
appendix hinders the emptying of its lumen ; consequently, there
is an accumulation of secretion and fecal material on the side
distal to the obstruction. This causes distention, with a conse-
quent tendency of the appendix to straighten out, and there re-
sults a great pull and drag upon the segment of the mesoappendix
to which the distended segment is attached. This either initiates
a pain or adds to the pain which is already present. If the obstruc-
tion is near the end of the appendix, and the appendix is unable
to contract, there is little, if any, pain from the obstruction, (d)
The active causative factors of pain due to constriction by ad-
hesions are the same as when kinks are present.
Obstruction may be due to an inflammatory swelling, which
causes a blocking of the lumen of the appendix, distal to which
the distention occurs, with consequent pain production.
(2) Inflammation. — The pain of appendiceal colic is, in many
instances, due to an associated inflammation of the ileum, because
of which the peristaltic waves become painful. This adjacent in-
618 THE APPENDIX
flammation is more definitely indicated by the close association of
these attacks and the subsequent diarrheas.
Inflammation of the appendix may be divided into three
stages :
(a) Inflammation which is confined to the mucous and the
submucous coat Often, in this condition, no actual pain is pres-
ent; rather there is a sense of discomfort, which, as a rule, is
referred to the region of the umbilicus. This is the class of
cases in which the complaints are mainly digestive, such as pres-
ence of gas in the stomach and intestines, distress after eating, and
a tendency at times to nausea and vomiting. These symptoms
are but the reflex indications of a sympathetic involvement.
Should the onset of the inflammation be sudden, the shock to
the sympathetic system is greater, the above symptoms are in-
creased, and a well-marked, referred pain is present.
(&) Inflammation of the muscular coat follows closely upon
that of the mucous. To the above symptoms, well-defined local
pains are now added. These, following closely upon signs of
mucosal involvement, are a sure indication that inflammation is
spreading.
(c) Involvement of the peritoneal coat nearly always occurs
if the inflanmiation is severe. This happens, as a rule, only in
acute processes; that the peritoneal coat may be involved in a
chronic inflammation is possible ; but by far the vast majority of
peritoneal inflammations arise from an acute inflammation. If
the attack is acute and the inflanmiation has advanced to the
peritoneum, there is then present a greater intensity of the cuta-
neous hyperalgesia and referred pain. Following the onset of the
local pain, also, in some cases, in which the appendix is so situ-
ated that it lies in close contact with the parietal peritoneum,
this layer also becomes involved in the inflammatory process. The
local peritonitis is then manifested by exquisite local tenderness.
With peritoneal involvement the sympathetic reflex symptoms are
increased; nausea and vomiting occur, local peristalsis ceases,
constipation ensues, distention of the bowel comes on, and symp-
toms of toxemia appear. These are accompanied by an elevation
I
VARIETIES OF APPENDICEAL PAIN 519
of temperature and a rise of the pulse and respiratory rate. An-
other sign of importance (reflex in nature) is the cessation of dia-
phragmatic breathing as soon as the peritoneum becomes involved.
It is of importance, in deciding the extent of involvement, to
note the presence or absence of irritative peristalsis in the cecum.
The manner of obtaining this is suddenly and lightly to palpate
over the appendiceal region, having, at the same time, the bowl of
the stethoscope over the cecal region ; should the peritoneum be in-
volved, no peristalsis will take place; should the peritoneum not
be involved, peristalsis will immediately follow. This sign has
been elicited in many cases.
(3) Adhesions. — Should adhesions from the appendix drag
upon the parietal peritoneum, the pain is sharply localized to the
area of adhesion, is of a dragging nature, and is worse when cer-
tain positions are assumed by the patient A right lateral recum-
bent posture often seems to be conducive to the induction of this
pain. Active movements, also, as bending forward or backward,
will cause pain, if the appendix is adherent to the anterior abdom-
inal wall. Bowel distention, by dragging upon the adhering per-
itoneum, will cause pain, which ceases upon the passage of the
bowel contents. Adhesions between the appendix and the body of
the psoas muscle are often the cause of the pain felt by those suffer-
ing from chronic appendicitis when they attempt to climb stairs.
Distant Pains. — Pain in appendicitis is sometimes felt at a
distance from the site of the appendix. These pains are due to
stimuli transmitted from the site of the original lesion through
the nervous system to nerve collaterals. This stimulation is per-
ceived as pain, and is felt as coming from the area of distribu-
tion of the nerves originating in the centers irritated.
The distant pains may be classed as referred, transferred, and
reflected.
Referred Pain. — Referred pain is due to the transmission
of the stimuli along the splanchnics to the related spinal centers
in the cord, and the pain seems to be produced in the area of dis-
tribution of the latter. By a study of the figures following,
the location of the transferred pains may be seen. It is also
620 THE APPENDIX
shown how irritation to any division of the eleventh nene will
cause a contraction of the rectus, particularly the segment supplied
by the eleventh thoracic nerve. Should the irritation be strong
enough, the tenth nerve may also be irritated, and s^ments of the
muscle above the part supplied by the eleventh may also he thrown
into contraction. The figures also show how dorsal cutaneous ten-
PoMarior diniiim oT
11th domt nenr*
Poibirior divinoD of
Fia. 108. — Abeas Supplied bt the Posterior Branches of 11th and 12tb
Thoracic Nerves.
The figure illustrates how appcBdiceal pain may be felt posteriorly in the
diBtribution areas of these nerves. (Drawing modified from Totdt.)
demess and lumbar pain may be present, the areas in which they
are foand being marked off on the figure. Pain is, in some cases,
also referred to the vaginalis testis of the same side, or it may be
referred to the extreme lower part of the abdomen, or to the upper
part of the thi^.
This reference is through the first Inmbar nerve, which is
distributed to the lower abdomen and upper part of the thigh;
also, through a small branch to the tunica vaginalis testis.
Tbansfekbed Pain. — By fransferrod pain is meant that form
of pain which is felt on the opposite side or at a higher or lower
level of the body than the lesion causing it. It is due to the trans-
VARIETIES OF APPENDICEAL PAIN 521
mission, upward or downward in the cord of the stimulus from
the point of origin.
In the following drawing, modified from Toldt, it may be seen
how an appendiceal pain may be transferred across the cord and
be felt on the opposite side, the arrows indicating the origin of
the stimulus in the appendix, its conduction to the thoracic sym-
pathetic ganglion, and thence its transference either to the ante-
rior or to the posterior division of the nerve, the pain being felt
PAIN
•PAIN
Fig. 109. — ^Arbas op Pain Referred from the Appendix.
The arrows indicate the direction of the referred sensation. The two sets
of nerves are the superficial and the deep nerves of the abdominal wall.
At the point where they pass through the wall and become superficial
pain is felt. (Drawing modified from Toldt.)
either in the anterior or posterior abdominal wall. At its begin-
ning the anterior division of the nerve lies in close relationship
with the peritoneum, so that any irritation of the peritoneum
would cause pain, which would be felt either at the point of pro-
duction, or would be referred to the anterior abdominal wall.
Irritation at this point would also stimulate the motor fibers
in the nerve and segmental contraction of the rectus would result.
Reflected Pain. — The sympathetic nerve supply to the appen-
dix is derived from the superior mesenteric plexus, which re-
522
THE APPENDIX
ceives its supply from the ninth, tenth, eleventh,- and possibly
the twelfth dorsal segments. It seems, however, that the origin is
chiefly from the eleventh and twelfth dorsal segments, the eleventh
being the one most often involved in appendiceal lesions. In case
Fio. 110. I'M 111.
Figs. 110 and HI. — Areas op Cutaneous Hyperalgesia in Appendicitis
Corresponding to the Uth Dorsal Area of Head.
of very sudden onset, with severe toxemia, reflected pain may be
absent. It is also frequently absent in secondary attacks, because
of the destruction of the nerve endings, which has occurred in
the primary attack. In these cases of reflected pain the pain is
due either to inflammation or to distention of the appendix.
That the inflammation alone can cause it is well authenticated;
while the fact that the reflected pain may suddenly cease oil per-
foration of the appendix demonstrates that it also is caused by
appendiceal distention. Figs. 112, 113, and 114 represent a com-
plete drawing of many of the reflected pains felt in appendicitis.
Reflected cutaneous hyperalgesia is difficult, if not impossible,
to elicit, should ice or counter irritation have been applied to
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524
THE APPENDED
the patient a short time previously, because both reduce the cuta-
neous sensibility.
According to Maunsell MouUin (226, p. 516), "When hyper-
esthesia is definitely associated
with other evidence pointing to
an inflammation of the appen-
dix, it may be taken as a clear
indication that the wall of the
appendix itself is involved and
that, therefore, though the in-
flammation may subside, it will
in all probability leave some
permanent alteration in the ap-
Fio. 116. — ^Location and Radia-
tion OF Sthpathetic Reflected
Pain in Appendicitis.
1. Probably indicates some traction
on the splenocolic ligament from
pull on the colon.
2. Appendix is probably directed to
left side, mesentery being derived
from left.
3. Appendix being directed up under
the colon.
4. Referred pain in early stages of
appendicitis.
5. Referred pain in early stages pf
appendicitis.
Fig. 116. — Location and Radia-
tion OF Sympathetic Rbflbctbd
Pain.
1. Pain in this case was referred to
the sacroiliac synchondrosis.
2. Pain was present over the sacro-
sciatic notch and radiated down
the leg. Appendix was found
lying across the psoas muscle,
being entirely retroperitoneal.
No mesoappendix was present
except about ^ inch at extreme
tip of the appendix.
3. Same as 3 in Fig. 115.
4. Pain over left kidney due to
gangrenous appendix, no kidney
lesion.
J
VABIETIES OF APPENDICEAL PAIN
525
pendix^ which later will necessitate operation. Sudden cessation
of the hyperesthesia without at the same time any improvement
in the other symptoms often indicates that the appendix has be-
come gangrenous."
Figures 115, 116 and 117 show the location and radiation of
sympathetic reflected pain.
I
Fig. 117. — ^Abeas op Hyperalgesia in the 11th Dorsal Visceral Seg-
ment Due to AppENDicms of the Catarrhal Type.
The pain of appendicitis is well illustrated in the accompany-
ing case, in which the acute pain, present in the right side, was
associated with a well-marked hyperalgesia over the same area. As
the subjective pain decreased, the hyperalgesia also decreased,
so that when the subjective pain was gone the latter also was
entirely absent. Deep pressure over the appendix area still
caused pain, but no hyperalgesia, so that the patient was tender
but not hyperalgesic. This illustrates the independence of the two
symptoms. On operation the appendix was found enlarged, swol-
len, and very much inflamed. It extended along the right side of
the abdomen, running up in the direction of the liver. Adhesions
were not present.
The following photographs are of a boy ^ight years of age,
111
a.as3
nil
sill
ml
iiii
lire
■ili|
1111
VARIETIES OF APPENDICEAL PAIN 527
who complained of severe pain in the abdomen. Examination
showed the following area of tenderness (see Fig. 118) : the
shaded portion, which indicates the area of sensitiveness to pain,
such as to pinching; the cross-shaded portion, which indicates the
area of sensitiveness to touch, and the dark spots, which indicate
points of maximal tenderness (to touch), which were produced
by deep pressure. The circle around the umbilicus indicates the
region to which he referred his pain.
At first there was thought to be a possibility of malingering
in this case, as on a second examination the area of sensitiveness
had moved slightly, and on a third examination the area of
cutaneous hyperalgesia was much smaller than on the first exami-
nation, being about one-half inch smaller at all points. This idea
was dismissed later, as it was observed in several cases that the
area of hyperalgesia may change according to the change in the
position of the patient, and definitely according to that change;
also that it becomes smaller as the disease progresses toward a cure.
Pain on the left side in appendicitis may, in some cases, be
due to the position of the appendix on that side. Below are a
few of the positions which the appendix may take, owing to a
faulty rotation (Annals Surg., July, 1908, p. 137).
Left-sided pain may also be due, in some cases, to an inflamed
appendix situated in the pelvis on the left side.
Sympathetic pain, such as headache or generalized aching, so
common in appendicitis, is the result of the action of the toxins
(produced in appendicitis) on the centers supplying the areas in
which the pain is present.
In connection with aberrant pains in appendiceal inflamma-
tory states, it is a fact that, in many of these so-called pains, there
is a separate anatomical basis for the pain-sensation. Appendicitis
and colitis, says Lockwood (127b), are often closely related, and
in those cases which had pain over various parts of the colon
there was also associated a mucous colitis, which was the underly-
ing cause of this most prominent and distressing symptom.
In regard to involvement of the colon in appendicitis and its
relationship to pain-production, the reader is referred to the sec-
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528
TENDERNESS IN APPENDICITIS 629
tion on diseases of the colon, where the pain resulting from colonic
involvement is carefully reviewed.
In this connection it is well, also, to recall the fact that epi-
gastric pain, occurring at some late stage of appendicitis, or dur-
ing the course of the disease after the pain has been localized
in the right iliac fossa, is almost pathognomonic of a peritonitis
(W. D. Stanton).
Tenderness in Appendicitis. — The following are Eobinson's
(265, pp. 414-415) conclusions in regard to the presence of super-
ficial tenderness in disease of the appendix :
"In disease of the vermiform appendix, or in disease originat-
ing therein, cutaneous tenderness is sometimes present, most com-
monly in the skin innervated from the eleventh dorsal s^ment
of the spinal cord, but also sometimes in the territory of the
ninth, tenth, and twelfth dorsal, and possibly the eighth dorsal
and first lumbar segments.
"According to Sherren (266), there are three chief forms of
cutaneous tenderness. The first is in the form of a broad band,
extending from about the level of the first lumbar vertebra around
the anterior surface of the body, having a general downward
direction, and ending below the umbilicus. Its lower edge rides
over the crest of the ilium. The entire band closely corresponds
to the area of sensory distribution of the eleventh dorsal segment.
The second area is triangular, its upper boundary being on a
level with the umbilicus, its apex over the crest of the ilium, and
its base on the right side, toward the median linp of the body.
The third area is found about the middle of a line joining the
umbilicus and the anterior superior spine. A corresponding area
is on the back just above the iliac crest.
"A patient displaying an area of superficial tenderness of
one of these three defined varieties is, in the great majority of
cases, suffering from appendicitis. Nevertheless, many other
diseases may resemble appendicitis in this respect; for instance,
renal colic, perforated gastric ulcer, intestinal colic and perime-
tritis.
"Inflammation of nerve trunks is not the cause of this symp-
530 THE APPENDIX
torn, for the latter may occur in skin supplied by the post-primary
divisions of the spinal nerves. There is little evidence as to the
immediate cause of this reflex tenderness, but it is probably due
to irritation of the afferent nerves from the appendix. The irri-
tant is possibly, in some cases, tension; in others, it is almost
certainly something different. The symptom is found in a
minority only of the cases of appendicitis seen in hospital prac-
tice. It may, while a case is under observation, vary in charac-
ter or disappear altogether. During the progress of an attack, it
may appear in a patient in whom it has not originally been
present.
"Cutaneous tenderness is found as frequently in subsequent
as in first attacks of appendicitis. It may persist long after all
other signs of the disease have disappeared.
"The prognostic and therapeutic significance of cutaneous
tenderness, in cases of appendicitis, is slight. It is somewhat
less often found in cases of abscess than in other cases. When
the symptom and abscess coexist, the abscess is usually only a
beginning process.
"Cases of widespread peritonitis, set up by appendicitis, may
display large areas of cutaneous tenderness over the right side,
or over the whole of the ab3omen."
Tenderness as a Symptom in Appendicitis, — In two hundred
and forty-seven cases, reported by Sherrcn (267), and Robinson
(265), hyperalgesia was found in 66, or 26.7 per cent.: sixteen
times as a complete band; thirty-two times as a triangle; four-
teen times as a circular spot; and three times as a large, irregu-
lar area.
Sherren makes the statement that tenderness may be absent
in attacks after the first, if the first attack was of sufficient sever-
ity to destroy nerve tissue in the wall of the appendix (265, p.
398). The number of cases examined by Robinson was one hun-
dred and twenty-three, and the proportion of positive and nega-
tive cases was 21.1 and 78.9; but, as Robinson says, this does
not invalidate Sherren's statement, for the occurrence of previous
attacks may dispose the sufferer to superficial tenderness, and so
TENDERNESS IN APPENDICITIS 531
make np for the cases in which nerve tissue has been destroyed.
He further savs that the cases he has seen are the severe and
neglected ones; and that in the milder cases, which are seen in
private practice, the presence of pain is more common.
During its disappearance, as the other symptoms of the dis-
ease clear up, the areas of hyperesthesia assume many irregular
and migratory shapes.
Another conclusion of Sherren's is that the disappearance of
cutaneous hyperalgesia, without improvement in the general con-
dition of the patient, is a sign of perforation or gangrene, and
should be the sign for immediate operation. Bennett (142, p.
1005) questions the entire accuracy of this statement.
According to Sherren, also (265, p. 399), the presence of
cutaneous tenderness is no contraindication for operation. Ab-
scess may form and general peritonitis develop while it is pres-
ent. Of twenty-six positive cases, Robinson found abscess in
eleven ; gangrene in nine ; perforation in seven ; and general peri-
tonitis in three.
"However, absence of cutaneous hyperalgesia is of great im-
portance. Absence of cutaneous hyperalgesia in a patient coming
under observation early in the first attack of appendicitis is a
sign of gangrene of the appendix, unless the case is obviously mild
and is getting well rapidly. (Robinson is in accord with this state-
ment.) Cutaneous tenderness, as a rule, is absent in cases
of abscess of the appendix. (This is true in two out of three
cases.) The age of the patient and the position of the appendix
have no influence on the cutaneous hyperalgesia. Cutaneous
hyperalgesia is occasionally of use in the diagnosis of appendi-
citis. Cutaneous hyperalgesia, in the area which is associated
with appendiceal disease, generally is an indication of appendi-
ceal involvement, though of necessity it is not a pathognomonic
sign, for it has also been noted in other conditions, such as per-
forated duodenal ulcer, intestinal colic, and peritonitis. In a case
of perimetritis the area of hyperalgesia was in the form of the
small circular patch, already described. This may be the same
as Morris's point or area of tenderness" (Sherren, 265).
532 THE APPENDIX
Varieties of Tenderness. — Jn acute appendicitis two varieties
of tenderness are present: (1) tenderness to superficial irritation
in which over certain areas light pressure, as the drawing of the
point of a pin over the surface, produces pain. These areas of
tenderness are but reflexes from the viscera, and correspond to the
zones Head has worked out for the eleventh and twelfth dorsal
segments. Recently Elsberg, of New York, has confirmed to a
large extent the earlier observations of Head. The points of most
exquisite tenderness are but the maximal tender points of Head.
Robinson says (265, p. 392) that it is "remarkable, in all
definite cases of appendicitis, how definite is the line of tender-
ness between the tender and non-tender areas."
This superficial tenderness generally occurs during the first
attack, which may be a very mild one. In some cases the discom-
fort may be the result of a mild inflammation of the mucosa, while
in others for the pain production it is necessary that the perito-
neum be involved.
Sherren (267, 625, p. 390) thinks that a superficial tenderness
is due to stimulation of nerves within the appendix, the result of
intralumenary tension. This statement is disputed by Robinson,
who says that "inflammation and the products of inflammation
are capable of acting just as well." He says further, that "tension
may exist without tenderness, tenderness may be present without
tension, and the mere destruction of the afferent nerve fibers or
endings does not seem to abolish the symptom in all cases, any
more than tension on them of necessity produces it."
(2) Tenderness on deep pressure is always an indication that
the inflammation has spread to the peritoneum. It is generally,
also, an indication of an abscess formation, in which the parietal
peritoneum takes part. Should the peritoneal involvement be con-
siderable, subjective pain will also be associated with the tender-
ness, and the muscles over the painful area will be contracted.
This contraction is due to the beneficent reflex of Hilton, in which
the muscles over an (inflamed) area supplied by the same nerve or
nerves contract.
In chronic appendicitis the tenderness is due chiefly to the
TENDERNESS IN APPENDICITIS 533
adhesions which are present. In this condition palpation of cer-
tain areas seems to be particularly painful. The increased pain
is due to the much greater pull or drag upon the band of adhe-
sions, resulting from the palpation. Peristalsis of the bowel will
also cause pain. In examining patients for cutaneous tenderness
see that no poultices, compresses, fomentations, or ice have pre-
viously been used.
Tenderness may also be found:
(a) In the lumbar regions when the appendix is retrocecal.
Here the tenderness is probably due to direct pressure exerted by
the cecum upon the appendix.
(6) Vaginal palpation may produce pain if the appendix lies
in the pelvic cavity. It is very hard in this condition to distin-
guish by palpation an appendix from an inflamed fallopian tube.
However, the other signs and symptoms present in appendicitis
aid in the diagnosis. Should the appendix be in the pelvis, defe-
cation and micturition, due to the traction exerted upon the ap-
pendix by the adhesions which bind it to the bladder or to the
rectum, may be painful. Pain may also be present on bending
and straightening of the thigh. When this is the case, the appen-
dix lies on and is adherent to the psoas muscle, and the pain is due
to pressure and traction, the result of movement and contraction of
this muscle.
(c) Transabdominal tenderness. — In many cases a typical ap-
pendiceal pain can be produced in the area of appendiceal reflec-
tion by making pressure over the colon at the corresponding point
on the left side. This area corresponds rather closely with Mor-
ris's point of. tenderness in tubal and ovarian disease. Rovsing
(Ref. 190) makes no mention, however, of the presence of tubal or
ovarian disease, but states that in more than one hundred cases
it was never found imless there was some affection of the cecum
or appendix.^
^Dieulafoy had first indicated the contraction of the abdominal muscles
as an indicator of intraabdominal inflammatory states — the so-called muscular
defense, defense musculaire. This symptom is a good indication that gan-
grene or perforation, with beginning free or circumscribed peritonitis, has al-
ready taken place.
534 THE APPENDIX
Special Points of Teiyierfiess, — The presence of pain at Mc-
Burney's point has long been regarded as symptomatic of appen-
diceal involvement. This point is situated one and one-half
inches from the anterior superior spine, on a line running from
the anterior superior spine to the umbilicus. Pressure at this
spot has been held to be productive of pain in diseases of the
appendix. This area of pain is not constant, but it may be said
that in general its presence indicates appendiceal involvement,
while its absence is of no significance. In no case is its presence
in any way connected with the location of the appendix. In fact,
Lanz has shown that, as a rule, the appendix is some distance
away from the painful spot, and generally is below it.
Morris, of Xew York, has described a point of tenderness
about one and one-half inches from the umbilicus, on a line ex-
tending from the navel to the anterior superior spine of the ilium.
In reference to this point and its diagnostic value, the con-
clusions of Hubbard are pertinent. He says that, "this tenderness
is due to a tender lymph-gland, which has drained the region of
the appendix, and there is nothing absolutely diagnostic in its
presence. In acute appendicitis tenderness at Morris's point
is of less importance than the symptoms caused by the appendix
itself. However, in chronic appendicitis tenderness at Morris's
point may be of distinct diagnostic value. Tenderness at this
Perman (80b) had in a report of appendix cases (appearing in the Hy-
geia for 1904, p. 797) spoken of right-sided pain produced by pressure in the
left iliac region in a case of appendicitis. At the present time this symptom-
complex is known as Rovsing's sign. The best way to obtain the pain is to
lightly tap the abdo^ien on the left side, while the patient breathes quietly
and relaxes the abdominal muscles.
Perman argues with Hofman and Hausman that the pain is not due to the
stretching of the cecum due to thte pushing up of the colon contents, bdt rather
to the pressure carried directly from the palpated to the inflamed area. If the
sign is present, in qhronic or in interval attacks of appendicitis, it is due to
adhesions. When present in acute attacks, the app>endicitis is not simply a
catarrhal form, but is a pathological case of the most severe kind, either a
beginning phlegmonous aufiltrie^tion or gangrene with threatening perforation.
The sign may also be .praieUt^ in salpingitis. In a few of those cases and in
pelvic peritonitis Perman (80b) has observed it.
Lauenstein (53b) also doubts the value of this sign, and believes that
Bovsing also will in the future change his mind regarding its absolute sig-
nificance.
SYMPTOMS ASSOCIATED WITH PAIN IN APPENDICITIS 535
point, even though the only physical sign, by the rule of chance,
makes the diagnosis of appendicitis probable. When combined
with tenderness at McBumey's point the diagnosis becomes more
certain. Its absence does not rule out appendicitis, and its pres-
ence does not make the diagnosis of appendicitis absolute, for it
may occur in other conditions besides appendicitis. The point
has by no means the importance given it by Dr. Morris." (See
areas of reflex tenderness, Head's zones, in appendicitis.) In
hernia of the appendix the pain is more or less diffused around
the umbilicus, or lies in the lower abdomen. It is described as
colicky in character, sometimes as a dragging sensation which is
felt in the right iliac fossa. (See the relationship between the
dragging and the location of the pain, which is the same as in an
early case of appendiceal inflammation.)
Symptoms Associated with Pain Prodnotion in Appendicitis.
— Rigidity of the right rectus is an almost invariable accompani-
ment of appendiceal inflammation. It is most marked in the
muscular segments located immediately above the appendix.
Should rigidity suddenly increase, and become general over the
entire abdomen, with a sudden increase of pain, it is an indica-
tion of a rupture of the appendix, or of a sudden spread of the
inflammation, so that a generalized peritonitis has resulted.
Constipation is one of the associated symptoms of appendi-
citis. It is due to a reflex arising from the inflamed organ. Often
the reflex peristalsis can be aroused in a normal intestine by the
pressure of the bowl of the stethoscope. A weak or absent peri-
stalsis is an indication of the spread of exacerbation of the inflam-
mation.
Motion is generally interfered with ; climbing the stairs is a
source of pain, especially when the appendix lies upon the psoas
muscle. The reason of the much greater pain when the patient is
walking or climbing stairs is that, in these conditions, there is a
concomitant contraction of the psoas muscle and the abdominal
wall muscles, and the appendix, caught between the two, is sub-
ject to considerable pressure. Often the first indication of peri-
toneal pain has occurred during the drawing on of the shoes.
536 THE APPENDIX
Posture. — In appendicitis the patient usually assumes a re-
cumbent dorsal posture, with one limb, usually the right, drawn
up, and in some cases lies with the right limb thrown over the
left In many, especially after an abscess formation, or when
adhesions are present and the bowel segments are bound to-
gether, a left lateral posture is very painful; this is due to the
drag and pull upon the adhesions by the weight of the bowel in
this position. It is common for patients with appendicitis, when
walking, to bend the body forward and step lightly.
Jarring, such as occurs in running and jumping, frequently
causes pain. Any spasmodic movement of the diaphragm, such
as takes place in vomiting, coughing, and sneezing, also gives
rise to pain. Percussion of the abdomen also produces it, and it
is claimed by Schmidt that often by this means the delimitation
of pain is more accurate than by any other. The pain is greater
when percussion is made directly over the median line than when
it is made to either side, because here the protective action of
the muscles to the abdominal viscera is lacking.
During appendicitis pressure on the abdomen is very painful,
particularly so if to the appendicitis peritonitis has been added.
When this ensues vomiting generally occurs. In some cases of
appendicitis, pain can be produced by palpation upon the opposite
side of the abdomen. Another means of diagnosing appendicitis
is to distend the colon with gas. As soon as the gaseous distention
reaches the appendiceal region, pain is produced by disturbance
of the cecal relationship if peritonitis is present, or by appendi-
ceal distention should only the appendix be involved. However,
this is a dangerous procedure, and should be used, if at all, only
in chronic cases.
Sudden increase in the sensibility to pressure is indicative of
extension of the inflammation. The sensibility may be so great
that even the weight of the bed-clothes is unbearable. In some
cases distention of the bowel may also cause great sensitiveness to
pressure. Pain on pressure under the costal margin is chiefly
of peritoneal origin.
The pain of appendicitis, in many cases, seems to be induced
DIFFERENTIAL DIAGNOSIS 537
by peristalsis. Many a suflferer has been aroused in the middle
of the night by the most severe cramps, which the later progress
of the case proves to be of appendiceal origin. These come on at
the time intestinal peristalsis is most active, that is, from five to
seven hours after eating. In some cases the ingestion of cold
food or drinks will incite active peristalsis and thus cause pain
(Schmidt).
Differential Diagnosis. — The pain of appendicitis should be
diagnosed from: colitis, which generally is not productive of
pain; but if it is, the accompanying diarrhea, with its content
of mucus, is sufficient for a diagnosis; intussusception, in case of
tumor formation. It is very difficult, in many cases, particularly
when pain is very severe, to decide whether the condition is one
of appendicitis or intussusception, especially so should the condi-
tion be associated with vomiting and constipation.
OaUrbladder and gall-stone colic pain may be diagnosed by
the higher area of cutaneous hyperalgesia; also by the area of
local tenderness present in these conditions. Typhoid fever, espe-
cially when it is of sudden onset and commences as an acute ab-
dominal pain, has on more than one occasion been mistaken for
appendicitis, and the patient has been operated on under that mis-
taken diagnosis, in some cases with disastrous results. Generally,
in these diseases (typhoid), the pain, wbile severe, is still bearable,
and, as a rule, there is not present any considerable amount of
abdominal rigidity. The temperature also is of the ordinary
typhoid al type, high in the evening and low in the morning, while
in appendicitis it is more constant. The blood count in typhoid is
also low in leukocytes, while generally, in appendicitis, it is high.
Should the pain occur later in the disease (about the third week),
and be associated with abdominal rigidity, perforation should be
sought and careful inquiry should be made as to the type and
character of the pain. A constant, spreading pain, very sharp and
severe, generally indicates a spreading peritonitis.
Ovarian and Tubal Disease. — In the diagnosis of appendi-
citis from right salpingitis or oophoritis, the presence on the right
side of tenderness, which is increased and, at the same time,
538 THE APPENDIX
is associated with subjective pain at the menstrual period, is a
criterion of worth. In those conditions which closely simulate
both appendicitis and ovarian or tubal involvement, it must not
be forgotten that either or all may simultaneously exist, and that,
if they do so, symptoms of one or of all three may be present. If
all of these organs are acutely inflamed, adhesions will remain
after the inflammation subsides, and these adhesions will be a
potent cause for pain production in the future. A point of some
importance to remember is that pains due to involvement of the
genitalia are never, or very seldom, influenced by the ingestion of
food. Vaginal examination may help to clear the diagnosis,
though when the appendix is in the pelvis it may be difficult to
differentiate appendicitis from tubal disease..
Hydronephrosis has been mistaken for appendicitis, but the
urinary symptoms of the former, with the history of the disease,
should render easy the diagnosis.
Ureteral calcxdus has a pain that is very sharp and severe,
and soon after the cessation of the pain, or, if the attack is pro-
longed, during it, blood may be present in the urine.
Sciatica could hardly be mistaken for appendicitis, though
appendicitis with referred or reflex pain down the back of the
thigh has been mistaken for sciatica.
Carcinoma of the cecuvfi is a condition associated with tumor,
emaciation, and signs of a gradually increasing intestinal obstruc-
tion.
Lumbago can hardly be confused with appendicitis, even
in those cases in which appendiceal referred pain is felt in the
back.
Peritonitis has been mistaken for appendicitis. This can
hardly happen with a careful observer, for the bilateral and deep
tenderness, generalized, with tenderness on vaginal and rectal ex-
amination cannot but be interpreted as due to peritoneal
involvement. Tuberculous peritonitis, in which the lesions are
confined to the cecum, is very difficult to diagnose from chronic
appendicitis. The more chronic course, the tuberculin reaction,
the presence of a focus of tuberculosis elsewhere, the very slow
DIFFERENTIAL DIAGNOSIS 539
onset, with no history of an acute attack, are diagnostic criteria
of very great value.
Extrauterine pregnancy has also been mistaken for appendi-
citis, but the presence of fluid in the cul-desac of Douglas, the
history of pregnancy, the presence of anemia, and the passage of
some bloody discharge from the uterus help in the diagnosis.
Erythema exudativum multiforme sometimes causes a pain
resembling appendiceal crises.
Sagging loops of intestine, or omentum, by pressure upon the
external abdominal ring, produce pains that closely resemble those
experienced in chronic appendicitis.
Cheinisse (454, pp. 1-12) describes a condition which is fre-
quently associated with syphilis, influenza, or hysteria, in which
there is considerable pain around McBurney's point. The diag-
nostic differentiating points are: the absence of leukocytosis,
fever, and rapid pulse. Painful points may also exist at the exit
of certain nerves. The abdominal wall, also, is not rigid, and the
pain, as a rule, is not confined to one definite location. A variable
tumor is felt.
CHAPTER XXVI
THE LIVER, GALL BLADDER AND DUCTS
GENERAL CONSIDERATIONS
The liver is the largest gland in the body. It is subject to
diseases similar to those of other glands, and also to additional
disturbances, functional and anatomical, due to its different
structure and function and to its intimate relationship with the
digestive apparatus.
The painful disorders aifecting the liver as a glandular organ
are congestion, inflammation, adhesion, and displacement
The painful disorders affecting the liver and gall-bladder be-
cause of modified structure are inflammation of the gall blad-
der, inflammation of the ducts, obstruction of the ducts by foreign
bodies or new growths, adhesions, etc.
Nerve Supply. — The nerve supply to the liver is sympathetic.
It does not, as many have thought, derive through its convex sur-
face a partial supply from the branches of the intercostal nerves
distributed to the dome of the diaphragm, nor does it have any
connection with the phrenic, Ranstrom being unable to trace a
single branch of the phrenic nerve through the suspensorium liga-
ment to the capsule of the liver, also no twigs from the intercostals
could be found extending to the surface of the liver. The 8ymj)a-
thetic fibers are derived mostly from adjacent sympathetic plexi
and ganglia (coeliacum, etc.), which in turn are connected with
well-defined segments of the cord. The cord segments involved in
diseases of the liver proper are the eighth and ninth, and some-
times the tenth dorsal, while the fifth, sixth and seventh dorsal
segments are involved in disease of the gall bladder. The outlines
540
GENERAL CONSIDERATIONS 541
of the segments, with their maximal points of tenderness, are
shown in the annexed figures. The maximal points of tenderness
Fig. 122. — Areas op Referkbd
Paim in Lives Disease: An-
terior View. (According to
Head.)
. — Areas of Referred
Pain in Liver Disease: Pob-
TERioa View. (According to
Head.)
of these zones closely correspond with the areas in which pain and
tenderness are felt in diseases of the liver and gall gladder.
The vagus also assists in the liver innervation (Edgeworth).
In some cases of common duct disease, especially when the area
near the junction of the hepatic and cystic duct is involved, the
pain-producing stimulus is carried through the branch from the
adjacent sympathetic plexus to the left vagus, and thence to the
fourth and sixth dorsal segments, from whence it is reflected to
the chest wall in the distribution area of these segments. This
explains why pain is sometimes felt in the left anterior wall
of the chest, at about the level of the fourtJi or fifth costal
cartilage.
The accompanying sketch (Fig. 125) shows how pain irrita-
tive sensation may be carried from the vicinity of the hepatic
duct to the vagus, and thence he propagated through the sixth or
fourth ganglia of the sympathetic to the adjacent cord section,
542 THE LIVER, OALL BLADDER AND DUCTS
from whence it is carried to the brain, and is felt as coming from
;he somatic distribution area of these segments. The maximal
;ioiiit9 of tenderness in these segments are shown in Figs. 122
and 123.
Pain in the right shoulder in liver disease is transferred
through the right phrenic. This happens when the diaphragm is
involved by a lymphangitis spreading from
an inflamed liver or gall bladder. The draw-
ing on the next page shows the paths of com-
munication between the liver and the cord.
The liver itself is not very sensitive to
pain-producing stimuli, for Leunander was
able to apply a strong faradic or galvanic
current to the surface of the liver above the
gall bladder without exciting pain. He also
claims to have separated the gall bladder
from the liver as far as the cystic duct with-
out the production of pain. The sensations
of pressure, cold and heat are absent from
the liver, as well as from the stomach and
Fio. 124.— Areas of '"'e^'i"^^. However, tilting of the liver, or
Refersed Pain in pulling on the common duct, will cause pain.
Liver Disease: According to Mayo, the most sensitive
cording to Head.) '"■'^* •" ^^^ l'^^"" '^ i" ^^^ vicinity of the
common bile duct about the neck of the gall
bladder. This area receives filaments from the eleventh and
twelfth dorsal, and the first lumbar nerves. These nerves also
supply the diaphragm, and this relationship probably accounts for
the spasm of the diaphragm so often associated with gall-stone
colic. It also accounts for the disturbance of diaphragmatic action,
even under deep anesthesia, when in operating in this region pres-
sure is made on this area. Murphy's ' sign owes its presence to
this reaction; for as soon as the sensitive area around the gall
bladder is pressed against the examiner's fingers, there is a sudden
GENERAL CONSIDERATIONS
543
restriction of inspiration, and the characteristic grunt or groan as
described by Murphy occurs.
The liver, as has been shown, is supplied by both the sym-
pathetic and the cerebrospinal nerves. Its cerebrospinal nerve
supply is derived from the left vagus through a communicating
branch which passes from the nerve plexus on the anterior sur-
face of the stomach; thence it is distributed to the substance of
/>^--^— -LETT VAGUS
N. SPLANCHNIC
MAJOR.
N. SPLANCHNIC
MINOR.
QMMUN ICATING
»R..TO LEFT VACUS
SEMILUNAR. OANGUON
-COMMUNICATING BR.
--HEPATIC PLEXUS
Fig. 125. — Relationship op Nerve Supply op Liver to Cerebrospinal
AND Sympathetic Systems.
the liver through the ligamentum hepatico-duodenale to the trans-
verse fissure. The nerves accompany the arteries and are dis-
tributed in their walls. This is important to remember, for it
has a definite bearing on the production of pain in congestive
states of the liver.
Examination for Pain. — The grade of intensity of pain is of
little guiding moment in the diagnosis of diseases of the liver or
of its appendages. In many of these cases the patient is abnor-
mally sensitive and is most irritable, so that a variety of subjective
symptoms, either painful or otherwise, are experienced. Under
these circumstances, local tenderness is most useful in defining
544 THE LIVER, GALL BLADDER AND DUCTS
diseases of these organs. It may be elicited by: (1) palpation,
(2) percussion, and (3) sensibility examination. Palpation is of
the most value and is the method universally employed, the use of
the other two being, as a rule, confined to those who are accustomed
to employ in their examinations the refinements of modern tech-
nique. Palpation should be attempted only with the patient reclin-
ing, with the abdomen flaccid, and the knees drawn up.^
With the abdomen relaxed the hand is placed flat upon the an-
terior surface with the finger tips directed toward the liver. For
this purpose it is best to use the right hand and to stand at the
right of the patient. The tips of the fingers may now be pressed
into the abdominal wall below the costal arch at about the level
of the ninth or tenth rib, and the patient is requested to take a
deep inspiration. If, during or at the acme of inspiration, pain is
felt, it is an indication of either a perihepatitis or a gall-bladder
disorder. The fingers should then be removed to the area of the
gall bladder; the patient is raised to a sitting posture and another
deep inspiration is taken. Should there occur a sudden stopping
of the inspiratory movement, accompanied by a grunt, gall-bladder
disease is indicated. If nothing special is noticed on this proce-
dure the patient is again directed to lie flat, and the right hand is
placed on the back below the liver, while the left is placed above
and over the liver. Firm pressure is now made between the two
hands and at the same time the patient is instructed to breathe
deeply. Should a perihepatitis be present the patient will com-
plain of severe pain, which sometimes radiates to the front of the
right shoulder. Nodular growths on the surface of the liver,
tender on pressure, may often be felt in malignant disease of the
liver. They are present along the lower margin and the convex
surface.
Percussion is of less value than is palpation as a means of
eliciting pain phenomena in the diagnosis of diseases of the liver
or of its appendages. If the liver is involved, percussion is pain-
ful over the entire liver area, and, to a slight extent, beyond it.
"Should the patient be unable to relax the abdomen, because, perhaps
of an associated peritonitis, palpation is of no value.
PAIN OF THE LIVER 545
If the gall bladder alone is involved diffuse tenderness extends
around a much smaller area of maximum local tenderness as a
center, the maximum tenderness corresponding to the location of
the gall bladder. The cause of this considerable -extension of
tenderness is probably to be explained by the range of vibration
produced by the percussion stroke; for even though the blow
is made over an area which is not diseased the vibration may be
communicated to an adjacent diseased area, and thus cause pain.
In congestion of the liver, percussion in the epigastrium is
productive of pain. This pain extends from the ensiform
cartilage to the lower margin of the liver.
■
Sensibility Examination. — Examination to light touch, pin-
point and related sensory tests are of value in localizing the
areas of hyperalgesia, which are identical with the areas of re-
flected pain, as elucidated by Head. These areas are particularly
useful in defining lesions which do not give rise to any acute symp-
toms, such as abscess of the liver, cholecystitis not involving the
peritoneum and cirrhosis.
In some cases of liver, gall-bladder and duet disease the pain
persists after the removal of the pathological lesion originally
causing it. This persistence, the so-called habit-pain, is, no doubt,
due to some pathological change in the nerve supply to these
parts, by which the excitability to stimuli is increased to such an
extent that reaction to a painfully excessive degree occurs on the
slightest irritation. This excitability, which was originally due
to the pathological lesion, remains for some time as a habit-state
after the original cause has been removed.
PAIN OF THE LIVER
Character of the Pain. — In disease of the liver the pain, if
present, is generally of a dull nature, while in involvement of the
ducts the pain is of an intermittent, colicky character, and is much
more intense and severe than it is in disease of the liver proper.
Relation to the Ingestion of Food and Drink. — The ingestion
of food does not seem to have such an intimate relation to the
546 THE LIVER, GALL BLADDER AND DUCTS
production of pain in disorders of the liver and its appendages
as it does in disorders of the gastrointestinal tract proper, but that
it is not entirely without influence is apparent. In nearly all
of the diseases to which the liver, the gall bladder or its ducts
are subject the movement of peristalsis and the augmentation of
the circulation, which the ingestion of food produces, cause pain.
The degree of pain from these factors depends considerably upon
the extent to which the liver structures are involved and particu-
larly on the manner of the involvement. Should a perihepatitis
be present or adhesions have formed, increased peristalsis and
increase in the portal blood pressure in the liver will cause more
pain than if an abscess or a cirrhosis constitute the entire
pathology; consequently it is in the lesions of most acute and
recent formation that the pain variation is most influenced by
food ingestion.
The ingestion of food also causes pain in a simple inflamma-
tion of the gall bladder or of the ducts. The manner of the pain
production may be explained on two hypotheses:
( 1 ) That there is an intimate nervous connection between the
gall bladder, its ducts, the stomach and duodenum, so that when
peristalsis is excited in the latter organs there is, at the same
time, a reflex peristalsis produced in the gall bladder and ducts.
Should the ducts or gall bladder be inflamed pain is likely to
result.
(2) Owing to the intimate relationship of all the structures
in the upper abdomen, an increase of peristalsis in the stomach
or the duodenum will, by pressure or dragging (from adhesions
already formed), produce pain in the neighboring inflamed blad-
der and ducts. Therefore, if pain in the liver, gall bladder or
duct areas or zones is present after the ingestion of food, inflam-
mation or adhesions should at once be sought.
Schmidt (p. 215), in speaking of the relationship of food to
the production of pain in liver, gall-bladder, or gall-duct disease,
says that *'the taking of food is im])ortant only in those cases
where we are dealing with delicate, anemic individuals, often witli
some degree of enteroptosis, especially those with gastroptosis and
PAIN OF THE LIVER 547
general atony of the stomach." It does not seem that the kind
and character of the food, except when it is so indigestible that
it leads to vomiting, have as much influence on the production of
gall-bladder and duct pains as does the quantity, where it acts
more as a mechanical agent, producing pain from its proximal
pressure. In case the pain is of inflammatory origin, cold drinks
seem to ease it.
Eelation to the Movement of the Body. — It may be stated as
an axiom that when, in disease of the liver or its adnexa, pain is
produced by movement, such as bending, stooping, and rapid or
forcible breathing, inflammation is present; while, should these
movements, including change of position, not produce or increase
the pain, it may be accepted as a fact that inflammation is absent
and that any spontaneous pain which may be felt is due to stone,
or to some disease causing a slow tissue change, as cirrhosis. It
seems that in inflammatory diseases of the hollow viscera deliber-
ate movements and change of position are not particularly pain-
ful, but that rapid movements, especially those involving a jar, are
productive of great pain. Movements such as occur in running,
jumping, riding horseback, traveling in springless wagons, going
up or down stairs, and some movements connected with respira-
tion, such as sneezing, coughing, and yawning, are very painful.
Positions causing intraabdominal pressure are also painful ; for
example, the bending of the body, stooping, and defecation.
Position of the Body. — In inflammatory diseases of the liver
the patient tries, as much as possible, to inhibit motion and to
avoid everything which causes dragging upon the liver and its
attachments, as this causes pain. To. do this he generally lies in
bed upon his right side. It might be urged that this is a very poor
position for him to assume in order to acquire ease, for in it the
pressure from the abdominal viscera is greatest upon the inflamed
liver, gall bladder, and ducts, and consequently one would think
that the pain should be greatest. It is very true that in such a
posture there is great pressure on the liver, etc., but it should be
recalled that the assumption of the left lateral posture would put
considerable traction upon the ligaments, which, being inflamed.
548 THE LIVER, GALL BLADDER AND DUCTS
Avould cause prono.unced pain. This pain is so mnch greater than
the pain produced by the intraabdominal pressure, when the
patient lies upon the right side, that naturally he assumes the
posture of relatively greatest ease. In general, it may be said that
more comfort is obtained in reclining than in the upright or sit-
ting posture. This, according to Schmidt, is due to the much
better draining of the liver when the body is in a reclining posi-
tion.
Likewise in malignant disease of the liver, or in hepatic hyper-
trophy or enlargement from any cause, the patient has the greatest
ease in the right lateral position, for turning upon the left side
causes a great increase in the pull and drag upon the ligaments
by the enlarged and weighty organ. This is especially noticeable
in multipara?, because of the relaxation of the abdominal wall.
Generally, in these conditions, the patient likes to lie upon his
back, because this is the posture of greatest ease. If nausea and
vomiting also occur on change of position, some additional patho-
logical process in the stomach or intestine should be sought.
Relationship to Other Diseases and Processes. — Gall-bladder
colic is often initiated by psychic and emotional disturbances.
It is also suggested that it may be reflexly started by impulses
arising in other organs, such as the kidney, genitals, stomach, or
intestines. Constipation also seems to initiate an attack. Should
pain occur in the liver area during pregnancy, or shortly after
its termination, either the gall bladder or the liver may be
affected. It seems to be fairly common that the gall bladder, im-
mediately after labor, becomes intolerant of its gall-stone contents,
and tries to force them out through the narrow duct, thus produc-
ing pain and distress, the so-called gall-duct colic. During preg-
nancy, also, the liver is subject to metabolic and toxic changes. A
degeneration of liver tissue leading to atrophy may result in the
well-known yellow atrophy. While the pathologic changes asso-
ciated with this disease are, as a rule, painless, yet in many cases,
because of parenchymatous or peripheral inflammation, pain may
be a prominent symptom.
Typhoid fever, at times, in its early stages produces symp-
PAIN OF THE LIVER 549
toms resembling cholecystitis, and, in some instances, gall-bladder
inflammation very likely is present. When symptoms of cholecys-
titis do occur in typhoid fever they last only for a few days, and
then become merged into those typical of the fever. During con-
valescence pain and tenderness over the gall-bladder area may
also occur, and in these circumstances they indicate gall-bladder
infection. Should the inflammation become so severe as to re-
quire operation, the gall bladder is found to be inflamed, and in
many cases filled with pus.
Liver disorders occurring during the course of dysentery, par-
ticularly that due to amoeba coli, should at once cause a search to
be made for liver abscess. Enteroptosis may be associated with
gall-duct disease, and the pull and drag upon the liver and its
appendages, produced by jarring, running, or jumping, may,
especially if a movable right kidney is present, incite a gall-duct
colic in one who is subject to such attacks.
Time of Appearance of Pain. — Liver and appendage pain is
generally incited or at least made worse by the onset of digestion,
particularly after the food passes through the pylorus and enters
the small intestine. This, as a rule, occurs from two to four
hpurs after eating.
Gall-stone pain generally occurs in paroxysms. The pain
paroxysms may be incited by vomiting and by excessive motion.^
Should a colic resembling gall-stone colic appear in a person of
advanced age, it is more likely that the condition is one of carci-
noma of the gall-bladder than a cholelithiasis. Gall-stone colic,
like all other colics, seemingly has a tendency to occur most fre-
quently at night This possibly is only a supposition (see Diurnal
Variation of Pain). If the pain is due to a hepatitis it may last
for a long time, the constant pain being interrupted by exacerba-
tions, which indicate the flaring up of a dormant infection. In
gall-stone colic, on the other hand, the pain is not so continuous,
* Gall stones may lie latent in a ^all bladder for years until, suddenly,
the patient has an attack of indigestion and the latent disturbance at once
becomes active. The violent retching and vomiting which accompany the indi-
gestion have dislodged the calculi from their resting place in the bladder and
one or more are forced into the cystic duct, thus causing the pain.
550 THE LIVER, GALL BLADDER AND DUCTS
but occurs in paroxysms, which disappear on the passage of the
stone or on its retrogression into the gall bladder. In these cases
there is generally a history of a previous attack, with a similar
pain, accompanied by vomiting, jaundice, light-colored stools, bile
in the urine, and constipation. A history of gastric disturbances,
associated with pain in the right hypochondrium, should, in all
cases, lead to the suspicion of gall stones as the cause of the dis-
order.
Neuralgia. — Sometimes the nerves supplying the liver, it is
said, are subject to what is called neuralgia. Allbut describes
such a state of the liver, but Maylard doubts its existence. The
latter observer quotes a case, but the signs and symptoms which
he noted seem to be rather those of a hepatitis than of a neuralgia.
The case quoted by Maylard from Allbut is as follows:
"Mr. W. A. , aged 32, whose habits are temperate,
whose health is exceptionally good, and who presents no obvious
disorder of function, has called upon me at intervals for three
years. Four months before his first visit he was taken with a
pain which he refers precisely to the seat and extent of the liver.
This pain has often recurred, and observes no period of recurrence,
except that it always attacks him at night. It is a 'miserable
pain.' He arises and paces the floor for hours. He maps out the
liver, of whose seat he was previously ignorant, with curious ex-
actness. He has had no jaundice, nor does he suffer from consti-
pation. The pain does not stab nor radiate as spinal pains do.
On bromid and arsenic he recovered and was well for twelve
months, when worry and overwork recalled the attacks. The
family history points to rheumatism.'^
Pains Due to the Disturbance of the Liver Substance
Proper. — The pains due to disturbance in the liver proper are
either extra- or intraparenchyniatons in origin.
(1) Extraparenehymatous pains are caused by (a) distention
of the capsule; (b) inflammation of the capsule by inflammatory
products, etc. ; (c) traction from adhesions joining the capsule
PAIN OF THE LIVER 551
to adjacent organs, or to the parietal peritoneum; (d) traction by
the liver on adjacent organs through its ligaments, because of dis-
placement.
(2) Intraparenchymatous pains are produced by irritation
of the nerves in the liver substances by inflammatory products,
tumors, etc. The stimulus is carried by means of the sympathetic
fibers, whence, depending mostly upon the strength of the stimu-
lus, it is generally reflected to the body wall and is there per-
ceived as pain.
Intbaparenchymatous Pain. — Distention of the liver causes
pain, especially when the enlargement is acute. Chronic disorders
of the liver causing an increase of the parenchyma (of substance
mass) are, as a rule, not painful.^
The principal causes of acute distention of the liver are
passive and active congestion. Passive congestion is due to a
backward stasis, either in the blood circulatory system (hepatic
or portal vein), or in the bile circulatory system, such as is pro-
duced by closure of the lumen of the bile ducts from inflammatory
swelling or gall stones. Acute distention, the result of active
congestion of the liver with involvement of the parenchymatous
nerves, occurs in abscesses (toxic or pyemic), in rapid-growing
cancer and sarcoma, and in acute generalized inflammation of
the liver substance. In these conditions there is present an inter-
stitial hepatitis, and this adds considerably to the pain content by
irritating the local nerves. Acute distention of the liver may also
be caused by active hyperemia of the liver, the result of over-
eating.
Patients subject to a hepatic congestion, due to a stasis, gen-
erally complain of a sense of pressure in the liver region. Pain,
if present, is more of a dull ache around the costal arch of the
right side. Referred pains are not common in this class of dis-
orders. The pain is made worse by any exertion of the patient,
such as going up stairs, running, and walking, while it markedly
' It is claimed by Schmidt that distention of the liver capsule is a cause
of pain production in malaria, pernicious anemia, paroxysmal hemoglobinuria,
leukemia, and diabetes.
552 THE LIVER, GALL BLADDER AND DUCTS
decreases when the patient, and consequently the heart, is in a
state of rest. The pain is also worse when the patient is in an
upright position, and is increased by deep breathing, by the inges-
tion of certain kinds of food, such as albumins, and by the drink-
ing of alcoholic liquors. It is also made worse by a sudden change
of position and by lying on the right side.
According to Murchison there are present in congestion of the
liver: (1) a feeling of tightness in the liver region ; (2) more or
less tenderness, rarely acute on pressure below the margins of the
ribs on the right side; (3) a pain which may extend up to the
right shoulder and which is increased after meals. According to
the same author, lying on the left side produces a feeling of drag-
ging or weight in the hepatic region. Pressure on or percussion
over the liver area is painful. According to Schmidt 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. lie
also claims that the tenderness to percussion, in a case of back-
ward congestion from a non-compensating lieart, will, when under
treatment w^ith digitalis, become less as improvement occurs.
Another differential point is that the pain of congestion, un-
like that of hepatitis, is rarely referred to the right shoulder or
scapula. When acute congestion occurs the liver becomes larger
and harder. The patient may be aware of this change, the exact
nature of which he does not understand, for he often complains
of the increasing hardness of the abdomen.
In passive congestion of the liver, pain and tenderness are not
prominent factors, unless the congestion is sudden in its onset, for
the passive congestions of slow onset gradually distend the cap-
sule, which, without pain, accommodates itself to the increase in
the intracapsular bulk. A pathognomonic sign of backward
(stasis) congestion is expansile pulsation of the liver, systolic in
time.
A liver which already is afflicted with cirrhosis cannot become
congested. Therefore, if passive congestion is general and it does
not appear in the liver a diagnosis of cirrhotic liver may be made.
Should perihepatitis ensue during passive congestion of the liver
PAIN OF THE LIVER 553
the pain of the congestion is aggravated by the much more acute
and severe pain of the perihepatitis (q. v.).
Besides the congestion due to the backward stasis of blood,
a biliary stasis may also occur, but this is not of such a type that
pain is common. The pressure from the retained bile generally is
not sufiicient to distend the liver capsule and cause pain. It acts
especially as a predisposing cause for pain production, for the
biliary stagnation produces a condition favorable to inflammatory
reaction, which may ensue and turn the passive congestion into
an active inflammation.
Congestion due to acute inflammatory lesions causes both a
distention of and an irritation of the capsule. This irritation
may be productive of a very mild or a very severe inflammation,
which in turn may result in the formation of adhesions. There is
also a great tendency for infectious inflammatory diseases of the
liver to form abscesses. The abscesses are of two types: (a)
pyemic and (b) tropical. The pyemic abscesses are generally
smaU and multiple and are painful only because of the secondary
changes which they induce.
Some of the abscesses are near the peritoneal surface, and as
a consequence they involve this membrane. Adhesions quickly
form, and much of the pain is due to the traction exerted upon
them by the liver. A description of the pain due to a single abscess
and its complications is given by Hotchkiss, New York Surgical
Society, March 10, 1909. He says :
"The onset of the condition began as a pain in the epigas-
trium, which lasted for two days without relief; but after this
it was less severe and lasted for two years, being modified by the
kind of food which the patient ate. It came on in the morning
when he woke up, was confined to the epigastrium, did not radiate,
and was often relieved by a cup of hot fluid, such as tea. The
pain always returned after the other meals, but was not as severe,
and generally was relieved by pressure and hot drinks. It was
worse when lying on the side; also, after the taking of solid food
and after exercise. On physical examination there was an area
of tenderness and muscular spasm over the upper segment of the
554 THE LIVER, GALL BLADDER AND DUCTS
right rectus muscle. An abscess was found in the central part of
the liver, adhesions to the diaphragm being present."
The pain in these conditions in which the liver is bound to the
diaphragm or to the abdominal wall by adhesions is increased by
coughing, sneezing, and deep breathing. The respirations, because
of the pain, are generally short and rapid. Tenderness over the
abscess area is, as a rule, present.
Tropical abscess is generally free from pain; because, in the
first place, it is of slow development and is in the interior of the
liver; and, secondly, because it is free from inflammatory re-
action. Should it progress toward the surface and the peritoneum
become involved, pain is produced. If it is on the convex surface
and involves the diaphragm pain over the right shoulder is also a
prominent symptom.
In cirrhosis of the liver the pain, if present, is due chiefly to
an associated neuritis, which may be caused either by previous
alcoholism or by the toxemia which is associated with this disease.
This neuritis is confined principally to the arms and the legs.
In biliary cirrhosis there is generally a sense of weight in the
right hypochondrium ; and periodic attacks of pain with tender-
ness over the liver and spleen occur.
New Growths. — In new growths of the liver pain production
seems to depend upon two factors: (1) the location of the growth
in reference to the capsule of the liver, and (2) the rapidity of
the growth.
Growths which involve the capsule are generally more painful
than those which occur in the substance of the gland. When the
growth is superficial a certain amount of perihepatitis is to be ex-
pected, and this not only causes pain directly, but also indirectly,
by the adhesions which are produced. According to Rolleston the
pain due to malignant disease may be almost constant in the
right hypochondrium, but often is especially marked in the back,
in the shoulder, or in the loin. It often occurs in paroxysms,
frequently radiates to the right shoulder, and is worse at night
(characteristic). Early in the disease there is only a sense of
discomfort or dragging, pain being a later result of the process.
PAIN OF THE LIVER 555
Should the growths occur around the common duct symptoms re-
sembling gall-stone colic are produced. Tenderness is well
marked in growths of rapid development. This tenderness is fre-
quently a sign of the associated perihepatic inflammation.
Cysts, especially hydatid, in the liver and its appendages are
causes of pain. The pain in these conditions is not marked, unless
the growth is rapid or the peritoneum is involved. In the
first instance the pain is dull and aching and is due to distention
of the liver capsule. In the second it is the result of peritonitis,
is sharper and more acute, and is definitely localized to the upper
abdomen. In cystic formation the abdomen over the margin of
the liver is tender and often the irregular nodosities of the cystic
growths can be felt. Sometimes the passage of small cysts through
the cystic and common duct produces a typical gall-duct colic
(Schmidt). These attacks, like those of calculi colic, are most
conmion during the night, and the pain is worse in the left
lateral posture. The onset of hiccoughs indicates diaphragmatic
involvement. Syncope is common. The presence of booklets in
the fluid removed by exploratory puncture is confirmative of the
condition. Tenderness is generally a sign of suppuration. When
this occurs there are a rapid pulse and an elevation of temperature.
In some cases, owing to pressure on the stomach and intestines,
symptoms of obstruction of either one or of both of these two
organs may supervene. The rapidity of the growth influences to
a great extent the intensity of the resulting pain.
Growths of slow development generally are painless, because
with the slow increase in size the adjacent liver cells, having had
an opportunity to adjust themselves to changed surroundings, give
rise to no physical or economic disturbances. In growths of rapid
development, however, this does not occur, nor has the capsule
had an opportunity to adjust itself to excess of pressure, and
so pain is produced.
Secondary (metastatic) growths in the pleura and the perito-
neum also cause considerable disturbance. The pain and local ten-
derness, the results of these conditions, generally follow, by a
noticeable interval, the pains and tenderness due to the primary
656 THE LIVER, GALL BLADDER AND DUCTS
growth. Sometimes the common or cystic duct may be partially
occluded by the growth. Then biliary colic is added to the symp-
toms already present. In some cases gall stones are present as a
complication, and these add their own particular syndrome to the
symptom-complex.
Kapid progress of the disease is an indication that the growth
is probably of a primary nature. This belief is strengthened if
the pain first complained of was in the liver region. Should the
cancer be primary death generally occurs in three or four months.
Even in growths involving the liver secondarily, death generally
occurs within six months of the involvement.
Malignant disease of the liver, which, as a rule, is painful, is
frequently confused with cirrhosis, which is painless. Other
diagnostic points are: that in cirrhosis the spleen and liver
are both enlarged ; also in cirrhosis the liver enlargement is more
uniform than in malignant disease and cachexia is less marked.
If in malignant disease of the liver pain should be felt in the epi-
gastrium and vary with the ingestion of food, a secondary in-
volvement of the stomach is very likely present. Growths in the
liver, secondary to cancer of the stomach, or of the intestine, are
generally more painful than secondary growths in other locations,
because the accompanying inflammation is much greater.
In the secondary involvement of the liver the pain follows
that caused by the primary growth, wherever that may have been.
Should the primary growth have been in the stomach the primary
pain would indicate stomach involvement; and this, in case of
liver metastasis, would be followed in an appreciable interval by
pain in the region of the liver or gall-bladder.
Syphilis of the liver is indicated by attacks of pain, rapid in-
crease in size of the liver, and by fever. The enlarged liver is
tender, and has an uneven surface. The left lobe is more fre-
quently affected than the right, therefore the left-sided localiza-
tion of the pain under the left hypochondrium. There is also a
certain amount of inflammatory reaction accompanying all syphi-
litic growths, and this in turn causes inflammation of the cover-
ing of the liver (perihepatitis) and of the adjacent peritoneum.
PAIN OF THE LIVER 557
In view of these facts, it is hardly necessary to add that in all
cases of pain in the liver area, with enlargement of the liver,
syphilis should at least be considered and the Wassermann reac-
tion determined.
ExTRAPAKENCHYMATOUs Pain. — Perihepatitis. — Intimately
associated with the foregoing disorders, and generally following
as the result of one or the other of them, is inflammation of the
capsule of the liver, the so-called perihepatitis. Of these, there
are two varieties, the acute and the chronic. The acute variety
as a primary condition is never met with in the temperate zone.
It has been found as a primary disorder in the tropics, because
the congested state of the liver in inhabitants of these regions
easily lends itself to an inflammatory process. The inflammation
originates from local extension of a diseased process, either from
within the liver substance (acute hepatitis, abscess, new growths)
or from some adjacent viscera. In both the acute and chronic
form of perihepatitis a friction rub is generally heard over the
liver region on auscultation. It may also be felt on palpation
over the same area.
The extrahepatic disorders from which perihepatitis may re-
sult are: peritonitis in the lesser or greater peritoneal sac; rup-
ture of viscera adjacent to the liver, as the gall bladder, stomach,
or duodenum; and inflammation of adjacent viscera. Here the
inflammation is communicated to the peritoneum, or to the con-
necting ligaments, and thus is transferred to the liver capsule
(Roberts). In any of these conditions the character of the pain
present previous to the perihepatitis may give some idea of the
primary source of involvement.
In some intrahepatic lesions pain is not present, although, as
a rule, some discomfort is experienced.
Acute Hepatitis. — The pain in acute hepatitis is quite sudden
in its onset, while that of the chronic variety is of a more gradual
development. In either case the pain is directly over the liver
and is made worse by such motions as occur in respiration, in
changing the position of the body, or in contraction of the abdomi-
nal muscles. The liver is also tender to the touch. A method of
658 THE LIVER, GALL BLADDER AND DUCTS
palpation suitable to define this condition is to place one hand on
the hypochondrium over the liver and the other on the back under-
neath the liver. K"ow make a to-and-fro motion with the two
hands, when, if hepatitis is present, pain will result. Besides this
local pain there is also present a referred pain, felt in the right
shoulder, in the area between the clavicle and the acromion process
of the scapula on the front of the chest (Cantli).
Displacement of the Liver. — A further cause of hepatic pain
is traction on adjacent organs by an enlarged liver through its
ligaments. These ligaments are five in number: the falciform or
suspensory ligament, the round ligament, the two lateral liga-
ments, and the ligamentum venosum. Any or all of these may
be stretched or pulled upon in liver displacement.
In liver displacement (hepatoptosis) the liver may be rotated
in one of two directions: around the transverse axis, so that its
upper, convex surface becomes anterior; or around the vertical
axis, either to the left or to the right. The latter is the more
common. In this the right lobe becomes inferior, and the
inferior surface is turned to the left. In a left-sided rotation the
left lobe becomes the lower, and the inferior surface is turned
to the right. Rotation to the left will produce more traction on
the ligaments connected with the left lobe of the liver, while rota-
tion to the right will cause traction to be exerted on the ligaments
connected with the right lobe. In either case the pull is chiefly
upon the diaphragm and has about the same degree of force, irre-
spective of the direction of the turning. The traction due to rota-
tion will produce the same diaphragmatic symptoms as a down-
ward displacement of the liver (q. v.).
Downward displacement of the liver will produce: (1) a
pull on the diaphragm; (2) a pull on the left vena cava; (3) a
rotation and angulation of the portal vein, hepatic artery, and
common duct; (4) a slight rotation of the upper pole of the right
kidney; and (5) a compression of organs below the liver.
The pull on the diaphragm which is exerted through the falci-
form ligament, which is almost in the center of the diaphragm,
and through the coronary and triangular ligaments, which are to
PAIN OF THE LIVER 559
the right of the median line, will produce traction on the right half
of the diaphragm, and thence through the diaphragmatic attach-
ment, on the right ribs. This is felt as a dragging sensation, or
discomfort, in the right lower chest at the points of insertion of
the diaphragm on the six lower ribs.
Because of the pull on the vena cava, traction is propagated
up into the chest underneath the sternum, even as far as the base
of the heart. Here the inferior cava, because of its intimate asso-
ciation with other structure, is firmly fixed, and, as a consequence,
it is at this point that the greatest traction is made and the pain,
which is referred to the anterior chest wall, is produced. In other
cases the pain is propagated further, being transmitted through the
cervical fascia and is felt as high as the base of the neck.
Owing to the rotation of the liver, a twist or angulation of
the portal vein, hepatic artery, or the common or cystic bile duct
may occur. A twist and partial occlusion of the portal vein or
hepatic artery may not, of necessity, be provocative of pain,
though an occlusion of any of the bile ducts, provided it is acute,
is almost sure to be. When an occlusion of the ducts occurs, the
pain may be due directly to the occlusion, or the occlusion may
lead indirectly to pain production from the tendency, when stag-
nation of bile takes place, to the formation of gall stones.
The rotation of the kidney may cause the renal colic some-
times present in hepatic displacement The liver, when it is dis-
placed, causes, through its ligamentous attachments to the upper
pole of the right kidney, a downward and inward rotation of the
upper pole of the kidney, with a tendency to, and sometimes an
actual, kinking of the ureter. This is the cause of the pain.
All the pains due to hepatoptosis are relieved when the patient
assumes the reclining posture and are increased in the upright
position. When the pain is not relieved by lying down it can be
assumed that some permanent pathological change has taken place
in adjacent organs, such as cholecystitis in the gall bladder, colitis
in the colon, and chronic intestinal disturbance in the small
bowel, or that, in the reclining posture, either traction or pressure
is exerted on them by the enlarged liver.
560 THE LIVER, GALL BLADDER AND DUCTS
Brown (Osier's "System") describes the pain of hepatoptosis
either as spontaneous, or as being brought on by jumping, walk-
ing, raising the right arm, sneezing, coughing, and yawning, while
sometimes paroxysms of pain occur without apparent cause. The
pain is usually relieved by having the patient lie on the back or
on the right side, or by manual replacement of the organ. The
pain is commonest in the right hypochondriac and epigastric
regions, radiating thence toward the right shoulder or to the flank.
Pressure, though rarely painful, often produces peculiar sensa-
tions in various portions of the body, especially in the right arm
and shoulder.
Adhesions, — Following perihepatitis, and a result of it, adhe-
sions take place between the liver and the adjacent structures.
Adhesions between the liver and its associated structures, gall
bladder and bile ducts, may be present without the production of
pain, though pain is likely to occur when the patient changes his
position, or during some phase of digestion. Should the pain be-
come prominent on change of position, the area in which it is felt
is a good indication of the location of the adhesions, provided they
lie between the liver and the parietal peritoneum. Should ad-
hesions not be present in this location, but between the liver and
some intraabdominal organs, the pain, or rather discomfort, will
be referred to the area to which this organ refers its discomfort
and distress. Should adhesions, for instance, be present between
the liver and the stomach or intestine, the reference will be to the
somatic area associated with the stomach and intestine, and not
to the area associated with the liver. In cases in which dense ad-
hesions exist between the stomach and the gall bladder the pain
may be in the epigastrium or over the ensiform cartilage. It is
somewhat acute and is more or less severe, especially on movement.
Should the pain be especially prominent at the time of gastric
digestion it is reasonable to assume that the adhesions involve the
stomach. Should it occur at the time of the colonic passage of
food it is most probable that the colon is the adhering organ. In
all cases of adhesive formations there is a history of previous
acute pain, the result of infection of the liver, gall bladder, ducts,
PAIN OF THE LIVER 661
or adjacent viscera, with a gradually developing chronic (ad-
hesive) pain«
Universal chronic serositis, a disease in which all the serous
membranes are involved, is generally free from hepatic pain and
is slow in its development. Its principal symptom is ascites.
Essential Diseases of the Liveb. — Pain is absent in amv-
loid enlargement, fatty liver, leukemic enlargement, adenoma,
cysts (simple), angioma and fibroma. Pain is present in the
cirrhoses, hepatitis, acute yellow atrophy, syphilis and new
growths, hydatid, etc.
In chronic atrophic cirrhosis the pain is dull and heavy in
the first stage. There is also present tenderness due to intermit-
tent attacks of perihepatitis. In hepatitis the pain is over the
liver and is propagated to the area between the clavicle and the
acromion process of the scapula on the front of the chest. The
liver is very tender on pressure. In portal cirrhosis pain is absent
in the last stages. In the early stages there is a dull, heavy pain.
Tenderness in the right side (hypochondrium), intermittent in
character, is also present. In biliary cirrhosis there are periodic
attacks of pain with fever and jaundice. Tenderness is found over
the liver and spleen.
In acute yellow atrophy pain is nearly always present and is
often spontaneous. Tenderness is so marked that it can b^ elicited
when the patient is unconscious. In syphilis there is no pain,
unless the growth is tertiary and a perihepatitis has resulted with
inflammation of the capsule; in this condition pain is common. In
lymphadenoma pain is absent. In hydatid cystic disease the only
discomfort may be a feeling of weight or of dragging in the abdo-
men. If the peritoneal covering of the liver is inflamed pain is
present on respiration. Tenderness is also a marked symptom.
In fatty liver there is no pain. The enlargement is slow and the
liver surface is smooth. Lardaceous disease is generally secondary
to other conditions. The enlargement is constant, slow, and pain-
less. Simple cysts of liver are rarely large enough to cause any
special disturbance. In adenoma, angioma, myxoma, fibroma,
and lipoma there is no pain.
562 THE LIVER, GALL BLADDER AND DUCTS
GALL BLADDER
General Etiology. — The pain of gall-bladder disease is due to
over-distention of the walls, excessive contraction of its muscular
coat, or irritation of the mural nerves from either of the above, or
from inflammatory processes, which may be intra- or extramural.
Intramural inflammation affects only the mucosa and musculature,
while extramural inflammation affects the peritoneum. The drag-
ging by adhesions also produces pain.
Over-distention of the gall bladder is the cause of pain in
such disorders as hydrops of the gall bladder, but only when the
condition is acute. It is most likely that over-distention of the
gall bladder does not of itself cause pain, unless there is an
obstruction to the onward flow of bile, such as may be produced
by either a stone in or an inflammation of the cystic or common
duct. The obstruction hinders the flow of the bile and the muscu-
lature of the gall bladder, attempting to force it on, is thrown
into a series of painful spasms.
In gall-bladder colic the pain is generally sudden in its onset
and persists for some time, when it either gradually fades away,
or, owing to the passage of the stone or the removal of the duet
obstruction, it disappears, sometimes quite suddenly. In either
case it leaves a legacy of tenderness over the site of the lesion.
Over-distention of the gall bladder may occur from obstruc-
tion of the cystic or common duct by (a) inflammation, (b) stone,
(c) pancreatic lesions, (d) pressure from adjacent viscera, (e)
tumors, or (f) excessive contraction of the muscular coat. The
gall bladder is similar to many other abdominal viscera in the
method of its pain production. This pain is of a colicky character,
and, at the time of its production, palpation in the gall bladder
region will reveal a hard tumor mass, due to a spasmodic muscular
contraction of the gall bladder. Should this spasmodic muscular
contraction be relieved, either because of the opening of the gall
duct passages or of exhaustion of the musculature, the pain will be
eased and the hard tumor mass will disappear. If the bladder is
GALL BLADDER 663
not emptied the mass persists, but soon loses its hard con-
sistency.
One of the commonest lesions of the gall bladder is inflam-
mation. In addition to the local pains (the result of local perito-
nitis), inflammation of the gall bladder causes well-marked re-
ferred pains. The inflammation is generally of a very active
type and is very violent. It produces a well-marked tenderness.
If this tenderness suddenly becomes general and is associated with
signs of a spreading peritonitis, perforation of the gall bladder
should at least be thought of and searched for. Inflammation
of the gall bladder (cholecystitis) is invariably due to infec-
tion.
The common causes of gall-bladder infection, probably in the
order of their frequency, are colon bacillus, typhoid bacillus, and
influenza bacillus. The pneumococcus and tubercle bacilli are
only rarely found as causative agents. Pregnancy seems espe-
cially to be a predisposing factor for gall-bladder infection. Diar-
rhea is a prominent symptom of infection of the bile passages. It
occurs after eating or, in some cases, in the middle of a meal. At
the time of the diarrhea severe pain is felt in the epigastrium.
This pain is probably synchronous with, and due to, the contrac-
tion of and the emptying of the gall bladder.
Following the inflammation adhesions form, but these, unless
they are attached to the anterior abdominal wall, are not particu-
larly painful. Should they be so attached breathing becomes very
painful, and the pain is of a dragging character. Should adhe-
sions exist between the gall bladder and the stomach or duodenum,
the pains are associated with digestive activity. In these cases
there is some history of a previous acute attack, in which the pain
was confined to the gall-bladder region.
Diagnosis. — The means of eliciting gall-bladder pain are
palpation and percussion. Tenderness on palpation is generally
most pronounced beneath the costal margin at the level of the
ninth or tenth costal cartilage. There is here present a point of
most exquisite tenderness, and around this an area which is not
quite so tender. In some cases, where there is an associated ap-
604 THE LIVER, GALL BLAOnER AND DUCTS
pendix involvement, the hyperesthesia extends down to the neigh-
borhood of tlie appendix, over which there is another point of
maximum tenderness.
In lesions of the gall bladder, if pressure or percussion is ap-
plied over any portion of the abdomen, the pain is felt in the
J Ares of DtHt«n lender
I Generil in* of (nsiler
Fro. 126. — Area of Greatest Tenderness in Diseases or the Gall
Bladder and Appendix.
The upper X iadicatea the point of oiaximum tenderness in gall-bladder
inflammation; the lower X that of the appendix. In both, though the
entire area indicated may be tender, the points of maximum tender-
neae will differentiate the two disorders.
gall-bladder area or region. This is one method of differentiating
gall-bladder disease from appendicitis.
For the pnrjMjse of differentiating gall-bladder (dirert) tender-
ness from that due to li'sions of other organs, Murphy elaborated
a special technique. His method of eliciting the tender points in
gall-bladder disease is as follows; Having provioutily removed
all clothing from the part to l>c examined or from its neighbor-
hood, place the patient in a sitting position, bent well forward,
with his hands resting upon his knees. The e-taminer now stands
behind the patient and places his hand, with the palm flatly
OALL BLADDER 565
against the abdomen, immediately below the ribs on the right side.
Have the patient take deep breaths. After each expiration the
examiner's band follows the abdominal wall until it approaches
closely to the affected gall bladder and adjacent tissues, when sud-
denly the respiration ceases with a gasp and the patient complains
of severe pain. This indicates that the hand has come into contact
Fig. 127, — Method of Eucitinq Gall-Biadder Tendebnebs.
with the inflamed tissues. Xaunyn's sign as given by Da Costa
is very similar.
Tenderness at Mayo Robson's point is also supposed to indi-
cate inflammation of the gall bladder or ducts. This tenderness
lies along a line extending from the tip of the ninth costal carti-
lage to the umbilicus. The point of greatest tenderness is known
as Hobson's point, and is situated one inch to the right of the
umbilicus.
666 THE LIVEB, GALL BLADDER AND DUCTS
Percusaion as a means of elicitiug pain has been diecuesed
under the general consideration o£ liver painB.
Radiation of Pain,— In gall-bladder disease tbe patient fre-
quently complains of pain, which, according to Schmidt, may ex-
tend to the right nipple and backward into the shoulder blade,
and thence into the lumbar region. This radiation is more fre-
quent in the presence of an associated perihepatitis. Associated
pains in tbe lower extremities may be the result either of a neu-
ralgia or a septic thrombus (iliac or femoral). Fains in the left
arm may be symptomatic of a true angina pectoris, induced by
Fia. 128. — Radiation or Gall-Bladder Pain ab Given bt Schiodt
(p. 210).
the high blood pressure caused by the vesicular pain. Schmidt
also claims that radiation of pain into the genitals with retention
of urine may occur. Such a condition, however, is rare and, when
it does occur, is generally due to peritonitis. That such pain ever
occurs without some associated complication or some concomitant
disease is doubtful.
Eadiation into the right iliac fossa sometimes occurs, and it
is very apt to lead to a diagnosis of appendicitis. In fact, in
many of these cases, an appendix inflammation is associated with
the gall-bladder disease.
GALL BLADDER 587
r 4
Pain referred to a distance is seldom found in diseases of the
gall bladder except in neurasthenic patients. In the neuras-
thejiic all manner of pains are complained of, in addition to
the original pains of the gall-bladder inflammation. An example
of this was had in the case of a patient who complained of pain
over the spine, in tiie right leg, and the back of the head. At
the same time there were tenderness and pain in the epigastrium
and around the umbilicus.
The location, direction and radiation of pain produced by
pressure will frequently help to differentiate gall-bladder pains
from those due to disease of the kidney, duodenum, or stomach.
If the gall bladder is inflamed, pressure over it will cause pain to
appear in the right shoulder and in the epigastrium, to the right
of the median line, while, in the other diseases mentioned above,
the pain will appear in their respective associated areas.
It is sometimes difficult to distinguish the tenderness due to
disease of the gall bladder from that due to disease of the ap-
pendix. An aid to diagnosis is that in disease of the gall bladder
the segment of the rectus muscle over the gall bladder is in a state
of contraction, while the segment dver the appendix may be flac-
cid. Another point of differentiation is that in gall-bladder in-
volvement the maximum point of tenderness is at the junction of
the ninth or tenth costal cartilages with the costal arch, while in ^
appendicitis the area of greatest tenderness is at a point about
midway on the line joining the umbilicus to the anterior superior
spine of the ilium.
Reflex Tenderness. — It is claimed by Schmidt that in gall-
bladder disease there is a "point of sensitiveness along the upper
portion of the trapezius muscle about three fingers' breadth
distant from the acromion. Pressure at this point causes pain
which radiates to the gall bladder; and, vice versa, pressure over
the gall bladder causes pain that radiates to this area." He like-
wise claims that these conditions are found in liver abscess and
in subphrenic inflammations. They seem only to be associated
with diseased processes in which the diaphragm is involved. The
568 THE LIVER, GALL BLADDER AND DUCTS
vertebras between the fourth and twelfth thoracic may be tender
on pressure.
Diseases Causing Pain. — OallMadder colic is a term given to
the pain produced by an over-distention of the gall bladder from
any cause. But, as long as drainage from the gall bladder is free,
viz., as long as the cystic and common ducts are free, there will
be no pain. However, should the cystic or the common ducts be-
come occluded, pain immediately ensues. Since the causes of the
blocking of these ducts will at the same time be the causes of
gall-bladder pain, it behooves us to study them well. The com-
mon causes of blocking of the ducts may be arranged in three
groups, namely: (1) intramural, in which the obstruction is due
to a foreign body, such as a gall stone or an ascaris; (2) intra-
mural, such as inflammation and new growths, the inflammation
causing the stenosis may occur at any point along the course of
the bile pathways, may be local to the ducts, or may be an exten-
sion of any inflammation from the duodenum, ascending through
the papilla of Vater into the biliary system, or the inflammation
may be confined to the ducts, new growths arising de novo in the
walls of the bile passages are extremely rare; (3) extramural,
such as kinks, adhesions, pressure from adjacent organs or tumors.
Any of these, by temporarily shutting off the exit of bile, may be
the cause of temporary distention, and give rise to colic.
In some cases gall stones may be present without causing colic ;
but this happens only when the gall stones have been present for
some time and the gall bladder and ducts have accommodated
themselves to their presence. The presence of stones in the gall
bladder, in the absence of pain, is very common in enteroptosia,
in which case the patient may complain only of dyspeptic symp-
toms and some soreness in the epigastrium.
When gall-bladder colic occurs it resembles other colics in
that there is a period of distress followed by a period of freedom,
and this in turn is followed by pain which gradually increases to
the maximum, then gradually decreases until the patient is again
free from pain (intermission). Again, the pain commences, and
at first is of slight intensity and then gradually increases to the
GALL BLADDER 569
maximum and gradually decreases to the minimum. (See Varie-
ties of Pain, Colic.) In many cases gall stones cause small abra-
sions on the vesicular mucous membrane, and these permit the
entrance of bacteria, which give rise to inflammation, so that the
pain of colic is frequently associated with the pain of cholecystitis
(q. v.).
In some cases intestinal colic has been mistaken for biliary
colic. However, biliary colic can be diagnosed by the tendency of
the pain of intestinal colic to migrate and to localize itself in
different segments of the abdomen, depending upon the location
of the muscular spasm in the intestine.
Cholecystitis. — The pain of cholecystitis is of two types: (a)
paroxysmal and (b) constant.
The paroxysmal pain is most likely to be associated with the
occasional passage of a gall stone. When present it indicates that
the duct is intermittently blocked. This blocking may be due
either to a stone or to swelling of the mucous membrane. Should
the duct become permanently closed, the pain becomes constant,
owing to the continual effort of the gall bladder to empty itself.
Constant pain is also an indication that the inflammation
which is present has spread to the peritoneal coat and has in-
duced a peritonitis. When the inflammation has been active for
some time the accumulation of biliary secretion in the gall blad-
der may, if the duct becomes occluded, cause a distention of
that organ and thus produce pain. However, this obstruction
must be in the cystic duct, and must also be sudden in onset.
Otherwise, the gall bladder accommodates itself to the distention
without pain production.
In every case when the duct is occluded, in addition to pain
and tenderness, a tumor mass is formed. The size of this mass
varies and seems in some instances to depend upon the alternate
distention and emptying of the gall bladder. The common cause
of such a state is a gall stone having a ball-valve action, or a kink,
which can be straightened by the pressure of the bile posterior to
it. In both cases the passage of the bile is followed by the relief
of the pain, which reappears on the reformation of the tumor.
570 THE LIVER, GALL BLADDER AND DUCTS
This tumor, .which is formed by the distended gall bladder, is
freely movable from side to side, and follows the inspiratory
movements of the liver. Temperature elevation and increase of
pulse rate accompany this condition. Jaundice seldom oc-
curs. Clay-colored stools may be present, and nausea and vomit-
ing are frequent. A symptom group of this description indicates
a recurring cholelithiasis, from which a cholecystitis has arisen.
When the tenderness suddenly increases, becomes more acute, and
is associated with vomiting, it most commonly indicates the begin-
ning of a local peritonitis.
If the primary pain, which may have been either constant or
intermittent, suddenly becomes most severe, with increasing ten-
derness, or if the tenderness shows a tendency to spread, and if,
at the same time, there is an increasing rigidity of the upper
abdomen, a diagnosis of gall-bladder perforation is justifiable.
Deaver, in speaking of cholecystitis, says that the "pain is
situated in the epigastric region, is usually sharp, appears sud-
denly or gradually, and is increased by motion of the entire body
or of a regional organ, such as may be made by the stomach, in
peristalsis or in vomiting.^^ He further states that in the absence
of peritonitis "the accompanying tenderness indicates the situa-
tion of the gall bladder, and the presence and extent of peritoneal
irritation or of peritonitis are indicated by the extent of the asso-
ciated tenderness.^'
The pain and tenderness of cholecystitis are generally asso-
ciated with rigidity of the abdominal muscles. There is a rigidity
of the rectus abdominis on the right side, localized to the diseased
area; and, as the disease advances, this rigidity increases pari
passu with it. Finally, if a generalized peritonitis results, all
of the abdominal muscles become contracted.
In all inflammatory lesions of the gall bladder deep breath-
ing is painful. Pain also results if the inflamed and sensitive
peritoneum of the gall bladder is pressed against adjacent struc-
tures, as the sitomach, the colon, and the anterior abdominal walL
Movement of any kind (walking, running, or even bending over
so that the intraabdominal contents are on the stretch) causes
GALL BLADDER 571
pain. Should the inflammation have spread to the adjacent liver
tissue a friction rub can be heard on auscultation, and sometimes
can even be felt on palpation.
Cholecystitis may be mistaken for a movable kidney; but the
elevation of temperature, the increased leukocyte count, pain in
the prone position, and the location of the local tenderness and
its radiation, in cholecystitis should diflFerentiate this from the
movable kidney. However, in many cases of cholecystitis pain
may be entirely absent. That this is not by any means uncom-
mon can be deduced from the evidence furnished at autopsy,
where old and chronic inflammations of the gall bladder are
found, with an absolutely negative history of a gall-bladder infec-
tion. If the gall bladder is in close relation to the appendix, in-
flammation of it may induce an infection of the adjacent appendix,
and so cause appendicitis. This can happen only in very severe
cases of cholecystitis when the peritoneum is diseased, and only
so, if this, in continuity or contiguity, affects the serous coat of
the appendix. This secondary appendicitis may so divert the at-
tention as to cause us to overlook the serious gall-bladder involve-
ment.
New Growths. — The new growths of the gall bladder may be
classed as malignant and benign.
Malignant growths, of which carcinoma and sarcoma are the
chief, if not the only, representatives, are generally the cause of
at least some pain and discomfort. At first the sensation is more
like an unrest or a vague distress referred to the area of dis-
tribution of the seventh or eighth dorsal segments, which, accord-
ing to Head, are most commonly affected, though other segments,
as the fifth and sixth, are also very likely to be involved. By
means of this referred sensation, which later may increase to
actual pain, it is very difficult to differentiate gall-bladder from
liver disease, as the relationship between the two is so intimate
that diseases affecting the gall bladder generally at the same time
produce reflex disturbances in the liver ; hence it is next to impos-
sible for a lesion of the gall bladder to be present without pro-
ducing some associated disorder in the liver. Should well-marked
572 THE LIVER, GALL BLADDER AND DUCTS
pain be felt, localized to the region of the gall bladder (see fig-
ure), and a tumor mass, tender on pressure, be detected, together
with cachexia and emaciation, it is a fairly good indication that
malignant disease of the gall bladder is present. New growths,
however, do not always give rise to pain, for, in many cases, the
growths are latent and produce no complaints until the timior
cells begin to invade the adjoining structures. When this occurs
the symptoms of the gall-bladder involvement, which may have
been so vague and indefinite that they previously were unnoted,
become of diagnostic value.
Non-malignant growths of the gall bladder are generally pain-
less. Under non-malignant growths are included hydatid cyst,
papilloma, adenoma, fibroma, and fatty cysts.
New growths of the gall bladder are sometimes confused with
tumors of the hepatic flexure of the colon; but these latter can
generally be differentiated by the presence of signs of intestinal
obstruction. The range of motion and the arc of rotation iu
tumors of the colon is different than in tumors of the gall bladder ;
however, owing to adhesions, which may coexist with the two
growths, it is often very difficult to make a positive diagnosis.
Hysteria often produces a set of symptoms that resemble gall-
bladder colic. Here it is extremely hard to make a diagnosis,
but perhaps if we remember that in nearly all cases of hysteria
there is some basis for the pain phenomena, the diagnosis will be
far easier. In ninety-nine cases out of a hundred a diagnosis of
hysteria will be found to be incorrect.
GALL-DUOT PAIN
Etiology. — Gall-duct pain is due to two causes: (a) obstruc-
tion of the ducts, and (b) inflammation of the ducts, with exten-
sion of the inflammation to the adjacent peritoneum.
Obstruction of the ducts invariably leads to gall-duct colic,
and, if the obstruction persists, may end in gall-duct inflammation
(cholangitis). The latter inflammation may spread through the
wall and involve the peritoneum. The pain of peritonitis is now
added to that of the original complaint The causes of obstructicgx
GALL-DUCT PAIN 673
of the gall ducts are: intramural, by foreign bodies (such as gall
stones, ascarides, etc.) ; intermural, as inflammation (cholangitis)
and new growths; and extramural, by new growths, kinks, and
adhesions.
Pains that have their origin in the ducts may be classified as :
(a) gall-duct colics from gall stones, ascarides, and new growths ;
(b) inflammation pains (cholangitis), having their origin from
spread of inflammation from the duodenum; (c) inflammation
from infection with bacteria eliminated by the liver; (d) inflam-
mation due to infection following the lodgment of gall stones ; and
(e) malignancy.
Location of Pain. — The pain of gall-duct colic is sudden in its
onset and is located in the epigastric region. In some cases the
pain due to obstruction of the common duct may be referred to
the anterior surface of the chest at about the fourth to the sixth
left costal cartilages. Pain from obstruction of the cystic duct
may be referred to the right of the vertebral column, between the
eighth and eleventh dorsal vertebrae, while hepatic-duct pain may
be referred to the right hypochondrium, to the thigh, and even to
the head and neck. In some cases, owing to the location of the
pain in the cardiac region, gall-duct colic has been mistaken for
angina pectoris (Hall). In other cases it may begin in the epi-
gastrium and radiate over the abdomen to the right subscapular
region and has even been felt in the right lumbar region (May-
lard). It has also been known to radiate into the left shoulder.
When the pain in its onset is constantly located on the left side,
adhesions to the stomach are generally found.
Character of the Pain. — Gall-duct colic due to stone is gen-
erally very sudden in onset. Sometimes it follows the ingestion
of food, particularly acid drinks or alcoholic beverages, though
the attacks may occur independently of the taking of food. It
is very prone to occur at night, four to six hours after the in-
gestion of the last meal. The colic occurs in paroxysms, follow-
ing each other at variable intervals, at first of great severity and
then of gradually diminishing intensity. Between the paroxysms
there is, in the gall-bladder region, a constant dull aching which at
574 THE LIVER, GALL BLADDER AND DUCTS
times becomes magnified into pain of great severity. The cessa-
tion of the paroxysms generally indicates the passage of the stone,
either from the cystic to the common duct or from the common
duct into the duodenum; or it may be that, owing to the ball-
valve action which is present, the stone has been forced back to
the dilated part of the duct or to the gall bladder. The first at-
tack of biliary colic is the most severe, because at this time the
duct has not as yet been dilated. During successive attacks it
becomes of large caliber, the stone passes through more easily,
and the individual attacks, therefore, are of less severity. An
attack generally lasts one or two hours and ends with nausea and
vomiting. The nausea and vomiting seem to relax the duct and
permit the more easy passage of the stona^
After the painful paroxysms there is frequently present in tha
upper part of the abdomen a dull aching which persists until
the next attack occurs. In some cases the pain becomes more
severe, loses its spasmodic character, and gradually spreads over
the upper abdomen. At the same time, epigastric tenderness is
marked and abdominal distention occurs. Here we are dealing
with an associated peritonitis.
Biliary colics often come on without any apparent active ex-
citing cause, though, as stated above, they are often associated
with the ingestion of food or drink. They often conmience after
a severe spell of vomiting, the result of gastritis following an in-
discretion in diet. At first, on the entrance of the stone into the
duct, the pain is of a dull character; and then, owing to the
movement of the diaphragm and of the abdominal wall, the gall
stone or stones are forced deeper into the cystic or conmion duct
and a typical gall-stone colic results. The pain and vomiting of
the gastritis now merge into the pain and vomiting of the colic.
This seems to be the history of nearly all gall-stone cases. The
stones remaining quiescent in the gall bladder for a number of
years, until suddenly, owing to forcible movements and changed
^On the passage of the stone into the duodenum, there is, according to
Keay, a peculiar gliding sensation to the right of the tenth and twelfth dorsal
vertebrs (Bolleston, p. 725).
GALL-DUCT PAIN 575
relationship of the viscera in the abdominal cavity, they are dis-
placed into the cystic duct, where they may lodge and cause the
paroxysmal, cutting pain which is so distressing. Below is a cita-
tion of a case illustrating how this occurs :
In this patient the right ovary was removed, owing to its cystic
state. The history, as given by the patient, was that a month
after recovery from typhoid fever she was taken with a violent
colic, the pain, extremely severe, being present in the epigastrium.
It seemed to lie in the mid-line, a short distance above the umbili-
cus. Vomiting was severe at this time and was followed by diar-
rhea. These conditions quickly improved and the patient was in
fairly good health with the exception of a pain in the back, the
continuity of which (the pain) was interrupted by paroxysms of
increased intensity. Three weeks after this first attack she was
again indiscreet in her diet and another attack of acute indiges-
tion followed. Vomiting occurred, all of the stomach contents
were expelled, and, though the stomach was washed out, nausea
and retching still continued. The pain also was different. In-
stead of being in the median line and slightly above the umbilicus,
it was more to the right and immediately below the costal arch.
It seemed to run directly through to the back. It was extremely
severe, and was described by the patient as being sharp and break-
ing in character. It was at first almost continuous, but finally
became slightly intermittent. Localized tenderness was present
over the gall-bladder region. Operation revealed a stone occlud-
ing the cystic duct
It is evident that gall-stone colic may be caused by the lodg-
ment of calculi in either the cystic, hepatic, or common ducts.
The stone or stones deposited in the cystic duct are generally of
large size and the colic does not disappear until either the stone
is passed, which is rare, or until it is returned into the gall blad-
der, which is more common. Before this takes place gall-bladder
coUc occurs as a complication. The same holds true in the com-
576 THE LIVER, GALL BLADDER AND DUCTS
mon duct ; but in common-duct colic jaundice comes on as a com-
plication, while in cystic-duct colic it is absent. Hepatic-duct
stones are usually small and resemble gravel very closely, so
that the pain is not so acute as in the other colics. Examination
of the feces will often disclose the small calculi. X-ray examina-
tion may determine at once the presence and position of the
calculi. However, in the vast majority of cases the X-ray is of
little value.
More or less cholecystitis always accompanies all gall stones.
In fact, it is the inflammatory process which is responsible for
the passage of the calculus out of the gall bladder, so that fre-
quently the gall-duct colic follows a cholecystitis (Rolleston). In
some cases a gall stone becomes impacted in the cystic or common
duct and pain may be present, intermittently, for weeks. These
attacks are often associated with slight temperature, chills, and
an increase of pulse rate, the so-called Charcot's intermittent
fever. The patient is generally very restless and throws himself
into all sorts of positions. Tenderness in the region of the gall
bladder, according to Bishop, is invariably present, and not only
is found during an attack, but persists afterward, and can always
be elicited by properly applied pressure.
Associated Symptoms. — Symptoms associated with gall-duct
colic are (a) vomiting, which at times is most severe, the vomitus
containing no bile, which likewise is characteristic of the stools,
which are light in color and of a very disagreeable odor; (b) bili-
rubin is present in the urine and it leaves yellow marks upon the
linen ; (c) jaundice is also present, but this is not absolutely char-
acteristic of gall-duct colic, as it is also sometimes present in gas-
tritis and appendicitis, in duodenal ulcer, and in carcinoma of
the hepatic flexure; (d) temperature elevation is usual and per-
sists for some time after the cessation of the attacks. The rise
of temperature is generally an indication of the presence of a
localized peritonitis. Constipation most frequently accompanies
ijall-duct colic ; when diarrhea is present it is a probable sign that
intestinal complications have ensued. As a result of the pain of
GALL-DUCT PAIN 577
gall-stone colic, syncope and even death have been known to
occur. ^
Differential Diagnosis. — Gall-stone colic should be diagnosed
from (a) gastric ulcer, (b) floating kidney, (c) renal colic, (d)
appendicitis, (e) mucous colitis, (f ) hepatic crises of tabes, lead
colic, angina pectoris, gastric ulcer, malignant diseases of the
galj ducts, pancreatitis, and lumbago. For the most important
of these differential diagnostic signs see Differential Diagnosis
of Diseases of the Liver.
In catarrhal cholangitis, pain, as a rule, is absent; likewise
there is no tenderness. This difference between this form of
jaundice and infective and calculus jaundice should be noted.
Should biliary colic supervene during the course of a simple
catarrhal jaundice it is an indication that the gall bladder has
become infective and cholecystitis has supervened.
Suppurative Cholangitis. — In this disorder pain may be en-
tirely absent. When present it may be due to an extension of
the inflammation to the peritoneum, causing peritonitis. This
extension occurs directly through the wall of the ducts or extends
through the liver tissue from the inflammation located at the ter-
minal openings of the ducts in the liver. Obstruction of the bile
ducts may occur from some of the factors which were the original
causes of the inflammation, such as gall stones, worms (ascarides)
in the ducts, and rupture of hydatids into the ducts. Malignant
disease may also cause obstruction and produce inflammation and
jaundice. When the bile ducts are obstructed the same symptom-
complex is present as is found in duct obstruction from any other
cause. Should ascarides be the cause, either the worms or the
ova may be found in the stools.
Cancer of the biliary passages is generally first announced by
icterus ; then, as the lesion progressively increases in size, infiltra-
tion into the surrounding ligaments takes place, and a pull may
occur on the peritoneum, and so cause pain. This pain, though
generally secondary to the jaundice, may be primary and is of a
*Rolle8ton, ** Diseases of the Liver, Gall Bladder and GaU Ducts," p. 725,
quoted from AUbutt in * * System of Medicine, ' ' Vol. III., p. 47.
678
THE LIVER, GALL BLADDER AND DUCTS
dull, aching character. It is nearly always present and is found
in the right hypochondrium, in some cases in the left epigas-
trium. When it is located on the left side, the adjacent struc-
tures, as the pancreas (head) or the pyloric end of the stomach or
duodenum, are involved. Biliary colic is sometimes present and
may be due to the presence of vesical gall stones. In other cases
no gall stones are found and the colic is due to muscular spasms
in the walls of the duct from irritation by the malignant growth.
However, carcinoma of the gall ducts is at times entirely without
pain. This occurs when the obstruction is not of enough magni-
tude entirely to block the ducts. Symptoms indicative of malig-
nant growths of the gall ducts are distention of the gall bladder,
the presence of a tumor in the epigastrium, emaciation, and
DIFFERENTIAL DIAGNOSIS, GALL-BLADDER COUC
AND GALL-DUCT COLIC.
STMPTOlfS
Gall-Bladder Couc
Gall-Duct Couc
Pain.
More severe than in gall-
duct colic. Not so frequently
aflsociated with digestion as
is the pain of gail-ofuct colic.
Referred to right shoulder
or to the back between and
below the scapulse.
Less severe. Frequently
associated with the inges-
tion of food.
Referred to the left side
of the chest about the line
of the third or fourth cos-
tal cartilage.
Jaundice.
Generally absent. This is
especially true should the
cause of the gall-bladder
colic be an obstruction in
the cystic duct.
Generally present, always
so if the obstruction is m
the common or the he-
patic ducts.
Local Tenderaees
Higher in the epigastrium
and more toward the cos-
tal arch than is the tender-
ness associated with gall-
duct colic.
AtMayoRobson's point.
Vomiting.
Common and continued af-
ter the first paroxysm.
Generally no bile.
Generally present at first.
No bile.
Tumor.
Always present, is movable
if adhesions are not present.
No timior present.
Gall-bladder and gall-duct cohc are often so intimately associated that it is
very difficult to distinguish between the two. The gall-bladder colic is almost an
invariable accompaniment and sequcda of g^-duct colic.
GAUL-DUCT PAIN 579
cachexia. Jaundice, which gradually becomes more intense until
it is dark green or almost black in color, is also present
The stools are free from bile pigments, though bile is found
in the urine. Secondary metastatic growths may also occur, and
when found make certain the diagnosis of malignancy.
The pain due to cancer of the pancreas is different from that
due to cancer of the bile ducts, in that it is located in the epi-
gastrium, while the latter is in the hypogastrium. However, the
two conditions are very hard to diagnosticate from each other.
Oall-stone colic differs from obstruction colic due to cancer by
the onset of the colic before the appearance of the jaundice. Cour-
voisier's law should also help in the diagnosis; namely, that in
calculus obstruction of the common duct the gall bladder is not
enlarged, while in obstruction due to malignant disease of the com-
mon duct it forms a well-defined tumor.
CHAPTER XXVII
THE PANCEEAS
GENERAL CONSIDERATIONS
It is only recently that recognition of the diseases of the pan-
creas has emerged from the deep obscurity heretofore existent
In the last decade or two that organ has been studied, its diseases
and disorders defined, and their symptoms arranged and classi-
fied. Even to-day, however, the pathological processes are still a
matter of considerable conjecture and autopsy often discloses
disease which the clinician has been unable to define. But as the
years go on the patholog;^^ and the symptomatology are gradually
being more and more correlated, until to-day we have much more
definite knowledge and exact means for diagnosing pancreatic
lesions.
Symptoms which may be present in any disease are only of
as much value as we are able to interpret them in the terms of
that disease, and this is especially true of pancreatic pain, for it
is probably more difficult in many cases of pancreatic disorder
to determine the full value and significance of pain than it is to
interpret any other of the pancreatic symptoms. So much reliance
has to be placed upon the word of the patient, and so much de-
pendence upon the accuracy of his interpretation, that it is very
difficult to measure the full extent of the disorder from which he
suffers. To understand thoroughly the pains due to disease of
the pancreas and the method of their production and radiation it
is necessary to consider: (1) the nerve supply of the pancreas;
(2) its structure; (3) its peritoneal relations; and (4) its rela-
tionship to other parts.
580
GENERAL CONSIDERATIONS
581
Nerve Supply. — The nerve stimuli to and from the pancreas
travel through both cerebrospinal and sympathetic fibers. The
cerebrospinal filaments are the vagi ; the left vagus being brought
into contact with the pancreas through the hepatic and splenic
plexi, while the right communicates with the hepatic plexus,
which, through the pancreatico-duodenal plexus, supplies the right
half of the pancreas. These fibers probably convey vasomotor
and secretory impulses, though it is very probable that both
vagal and sympathetic fibers carry painful stimuli, although it has
been held that it is mainly through the splanchnics that painful
Branch to left
vaguB
Coronary plextui
Greater splanch-
nics
Celiac plexus
Splenic plexus sup-
plies tail of pan-
creas
Branch to right
vaguB
Hepatic plexus
Semilunar ganglia
Lesser splanchnics
Pancreatico-
duodenal plexus
supplies head of
pancreas
^Sup. mesenteric
""plexus
Pancreas
Branch supplying the
right half of pancreas
Branch supplying the
left half of pancreas
Fig. 129. — Nerve Supply to Pancreas.
stimuli are carried, and it is in the distribution area of the nerves,
whose centers have a common relationship with the centers for
the splanchnics, that pain is felt. The splanchnics arise from
the sixth or possibly fifth thoracic sympathetic ganglia to the
twelfth thoracic ganglia. These ganglia, in turn, are connected
with the corresponding segments of the cord to which the stimulus
is carried, and from thence reflex sensation^ are referred back to
the abdominal wall. The distribution area of these nerves extends
from about the level of the nipple to the crest of the ilium. That
the pain is, in most cases, referred to this entire area cannot be
admitted, because nearly aU the cases of well-defined pancreatic
lesions which have been carefully studied do not show such wide
682 THE PANCREAS
distribution. From the clinical findings, it seems that possibly
the greater splanchnic, alone, conveys the pain-producing stimuli,
for it is in the distribution areas of the nerves arising from the
same segment of the cord, to which the greater splanchnic is
connected, that pain is felt. According to Robeon and Cammidge,
the nerves accompany the arteries to the gland, in the substance
-iV"
IMitribution aru of i
FlO. 130. — DlBTSIBDTION AsXAfi FOB PaIN Dm TO PANCBBATIC LbSIONS.
of which they travel alongside the ductB, and terminate around
the acini in a rich plexus of nervee which send fibers to the
secreting cells.
Thus far a study of the hyperesthetic or hyperalgeeic areas, by
Head's methods, in pancreatic affections has not been made. The
presence or absence of these zones might be of considerable diag-
nostic merit should they be studied carefully enough to make
them of value. Figure 130 only indicates in a general way the
distribution areas for pain due to pancreatic lesions.
Stnictiir« of the Pancrew. — The structure of the pancreu
GENERAL CONSIDERATIONS 583
does not offer any special facilities for pain production besides
those which are found in ordinary secreting glands. All glands
have one or more ducts, and it is the ducts which generally are
the cause of the pain phenomena. Inflammation occurs in the
ducts, producing a stenosis, with blocking of the secretion, and
this leads to inflammation in the gland and muscular spasm in
the duct. The duct may also be obstructed by a calculus, or by a
foreign body, such as an ascaris.
Peritoneal Cov^ing. — Stretching of the peritoneal envelope
of the gland cannot be blamed for pain production, for the very
{Area of tenderaeas
in pmnereatic diseAse
Pig. 131. — Relation op Pancreas to Posterior Abdominal Wall.
It is only immediately over the vertebrse that the pancreas comes into
close relationship with the wall, the other portions being separated
from it partly by the duodenum and partly by the kidneys. Therefore
pressure made between the second and third lumbar vertebrse will
cause pain when the pancreas is inflamed.
good reason that an envelope in the form of a capsule is missing.
Posterior to the gland there is no peritoneum ^ and the gland
'This is disputed by the Viennese schools. It is quite true, as stated
by them, that in the embryonic development the gland is covered by perito-
neum, but English and American anatomists claim that during development
this covering is absorbed and that the gland finaUy lies in direct contact with
the posterior abdominal wall.
584 THE PANCREAS
parenchyma comes into direct contact with the connective tissue
on the posterior abdominal wall, so that inflammation of the
gland itself quickly spreads to the posterior wall and causes a
local pain in that region. This pain is most prominent, though
it is more of an aching than a pain, and, as is usual where the
deeper structures of any part are affected, tenderness on deep
pressure over the area of the gland is present.
Belationship to the Other Parts. — The pancreas lies in inti-
mate relationship with many important structures. It is almost
entirely surrounded by the duodenum; on either side, it is in
contact with a kidney, while above it lies the stomacL The
common bile duct passes through its parenchyma, and beneath
its lower margin pass the superior mesenteric vessels and nerves.
Consequently any lesion, even the simplest, will cause a reaction
out of all proportion to its extent, so that in the diagnosis of dis-
eases of the pancreas our surveys must never be warped by the
signs due to associated lesions in other organs.
One of the most confusing, while perhaps the most important,
of these symptoms is pain. Pain is almost always present in all
diseases of the pancreas, though it may not be found until late
in the process; and while it is almost invariably present, it like-
wise is almost constantly modified by the lesions produced in
adjacent organs. The most commonly associated pain is that due
to stenosis, or obstruction of either the pylorus, the duodenum,
or the common bile duct. If gall-duct obstruction is present, colic
occurs, so that in every case of gall-duct colic it must ever be re-
membered that since this colic is often due to the obstruction of
the common duct from the pressure of the enlarged head of the
pancreas, pancreatic lesions should always be suspected. Pyloric
and duodenal spasm are likewise caused by obstruction due
to the same cause. In all cases the obstructive symptoms are a
late manifestation of the pancreatic disease.
Closely related to the pancreas are the large ganglia of the
sympathetic. Pressure upon these ganglia causes ai disturbance
which is reflected as pain through the medullated nerves supply-
ing the body wall. Pressure upon the superior mesenteric vessels
GENERAL CONSIDERATIONS 585
and nerves will produce lesions referable to the small intestine.
Should inflammation be communicated to other organs we have
the signs and symptoms of inflammatory trouble in these organs
in addition to the symptoms due to the pancreatic lesion. Not
only at the time of its activity, but for long years afterward, in-
flammation manifests its presence by the pain and distress due
to the drag and pull from adhesive formations which it has left
as its heritage. Should the bowel be at fault the pain is very
often relieved when belching of gas occurs.
Character of Pain. — Sudden acute pain in the epigastrium,
accompanied by shock, should, in the absence of lesions indicative
of disease in other abdominal organs, focus our attention on the
pancreas. All of its acute diseases, such as inflammation and
hemorrhage, cause pain of a most agonizing type accompanied by
tenderness on pressure. Should the pain be due to hemorrhage
it is of an intermittent character, commencing with great severity
and gradually disappearing, to reappear on the renewal of the
hemorrhage. In chronic pancreatitis, even though an abscess has
formed, there is usually an absence of pain. However, this is not
always the case, for the pain may be severe and paroxysmal, and
the tenderness in the epigastrium may be excessive. Cysts are
generally without pain. Calculus, when it lodges in the diverticu-
lum of Vater, is, as a rule, most painful, but it may exist for
years in the body of the pancreas without causing pain.
In this connection Schmidt says: '^It is well to think of the
possibility of pancreatic lesions in all cases of apparent perito-
nitis, 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 conditions no indication is found in
the urine, but glycosuria appears spasmodically or constantly after
the attack of pain, the suspicion of a pancreatic lesion becomes
strong. The opinion is much strengthened if, in addition to these
signs, the stools show an insufficient digestion of albumins and
fats, and physical examination justifies the consideration of pan-
creatic disease."
Location of the Pain. — Pancreatic pain, when present, is gen-
586 THE PANCREAS
erally in the left epigastrium, and radiates to the left inguinal
region, or to the back under the left scapula. This is a distin-
guishing feature from gall-bladder disease, which generally causes
a pain under the right scapula. Should the pain be present in
the epigastrium and radiate around to both sides of the thorax,
it generally indicates a calculus disorder. If the celiac
plexus be involved (malignant growths, inflammatory swelling,
etc.), the pain radiates to the cardiac region and resembles angina
pectoris.
Chauffard claims that the initial pain in the left epigastric
region, which is common in pancreatic disease, is most probably
due to a neuralgia along the splanchnic nerves and their anasto-
moses. As the solar region becomes involved the pain takes on
its typical localization and its deep agonizing character. The
head of the pancreas is closely associated with the biliary ap-
paratus and if diseased may involve the common duct and so cause
pain referred to the biliary areas, while disease of the body is
referred principally through the distribution areas of the nerves
associated with the splanchnics.
Tenderness. — Tenderness in pancreatic lesions is present in
the epigastrium, and is most pronounced on deep pressure. This
pain on pres^re may represent either the peripheral local tender-
ness, as found in the zones of Head, or, if present only on deep
pressure, may be indicative of the irritation which has occurred in
the retropancreatic tissues. These structures are supplied by
spinal nerves, so that at least a portion of the pain found on deep
pressure is due directly to the pressure exerted by the examining
hand upon the hypersensitive sensory terminations of the spinal
nerves. The other part of the pain is due to reflex tenderness
in the skin and subjacent tissues, the nerve distribution of which
is derived from the same cord zone as is the nerve distribution of
the pancreas.
Because of the absence of peritoneum on the posterior surface
of the pancreas, and of the intimate relationship which it has to
the postabdominal wall, pressure made to either side of the second
or third lumbar vertebrce is also provocative of considerable pain.
DISEASES OF PANCREAS CAUSING PAIN 587
In diabetes, which has as one of its chief pathological phe
nomena a change in the islands of Langerhans, there is often
present, as pointed out by Beal, tenderness on deep percussion or
on pressure over the head of the pancreas or the descending colon.
Position of the Patient. — The pain in diseases of the pancreas
is most severe in the continued dorsal position; therefore it is
worse at night. In cysts and neoplasms, the dorsal position, in
particular, is very painful ; but on turning to either side the pain
is relieved.
DISEASES OF PANCREAS CAUSINO PAlN
The diseases of the pancreas producing pain are: (1) pan-
creatitis, acute and chronic; (2) calculus disease of the pancreas;
(3) cystic disease; and (4) malignant disease.
PancreatitiB. — Acute pancreatitis is of two types: hemor-
rhagic and inflammatory. The acute variety, especially when it
is hemorrhagic, is one of the disasters of medicine. Coming on
with great suddenness and with no appreciable warning; with its
most severe and agonizing pain and the associated symptoms of
collapse, it seems to be a prognosticator of the nearness of death.
In its onset the pain may be so violent that even morphin injec-
tions will not relieve it. However, it gradually becomes less
severe, but does not entirely pass away and has a tendency to
become paroxysmal and to be increased by movement. This first
pain, caused by the violence done to the peritoneal tissue, is
accentuated later, probably, by beginning sepsis, fat necrosis, or
other effects of the pancreatic disorder. The pain may be re-
ferred to the epigastrium or, in some cases, to the entire anterior
abdominal wall. In other instances it may be referred to the
lower abdomen to such an extent that a low abdominal incision
has been made under the mistaken impression that the lesion was
in the pelvis (Deaver).
Tenderness is present above the umbilicus, generally to the
right of the median line. In many cases it is very slight, though
generally on a careful examination it is elicited. "It becomes
688 THE PANCREAS
more marked if the case progresses to suppuration, especially with
the formation of a mass which is practically always tender''
(M. F. Richardson).
Fitz's Rule. — In relation to acute pancreatitis Fitz has
formulated the following rule, namely, that acute pancreatitis is
to be suspected when a previously healthy person, or sufferer from
occasional attacks of indigestion, is suddenly seized with violent
pain in the epigastrium, followed by vomiting and collapse, and
in the course of twenty-four hours by a circumscribed epigastric
swelling, tympanitic or resistant, with slight rise of temperature.
Fat necrosis, likewise, is generally present.
Symptoms of acute pancreatitis associated with the pain are:
(a) vomiting, which is almost an invariable accompaniment, the
vomitus at first consisting of food and then of blood ; (b) belch-
ing of gas; and (c) hiccoughs, persistent and uncontrollable.
Acute pancreatitis is frequently confused with intestinal obstruc-
tion, but the shock, slow pulse, and cyanosis present in acute pan-
creatitis are rather characteristic. In intestinal obstruction the
pain may be localized in any part of the abdomen, while in acute
pancreatitis it is localized in the epigastrium. Jaundice, the rapid
production of free fluid in the peritoneal cavity, absence of fecal
vomit, and the development of a tumor in the epigastrium are
confirmative of pancreatitis and negatory for intestinal obstruc-
tion.
Subacute Pancreatitis. — The course of a pancreatitis of a
mild type is variable. It generally begins with a slight pain in
the epigastrium, coming on a few hours after meals. The pain
gradually becomes worse until it resembles biliary colic. After an
acute attack of pain there is a period of freedom ; then, suddenly,
the patient again has a most severe paroxysm. Gradually, the
pain becomes less intermittent and more continuous. All these
pains are most pronounced in the epigastrium, but may radiate
to the back, between the shoulders, to the region of the appendix,
to the legs, or to the lumbar region. In some cases the epigastric
pain may be lacking, while the referred pain is present.
Tenderness is variable. It is found in the epigastrium, either
DISEASES OF PANCREAS CAUSING PAIN 589
to the right or to the left of the median line, depending upon the
part of the pancreas which is involved in the inflammatory proc-
ess. Pus when it forms generally gravitates toward the back.
Then the most severe pain is felt in the groin.
Associated symptoms of subacute pancreatitis are: (1) col-
lapse; (2) frequent and small pulse; (3) temperature but little
raised; (4) face of grayish pallor, with signs of anxiety; (5)
mind clear, with little delirium; (6) tongue dry; (7) retching
and vomiting, the vomitus frequently containing bile, seldom fecal
matter or blood; (8) tumor mass present in the upper abdomen;
(9) peritonitis beginning and spreading downward, but with no
decided resistance to the abdominal wall; (10) emaciation and as-
thenia developing and progressing till death ensues.
Chronic Pancreatitis, — Either acute or subacute pancreatitis
may persist and become chronic. Here the epigastric pain may
be severe or very mild. It may be continuous or paroxysmal. In
some cases it resembles a gall-bladder colic, except that the pain
is not over the gall-bladder region. It is more to the center of
the epigastrium and has a tendency to radiate to the left side,
while the pain in gall-bladder colics has a tendency to radiate to
the right side. Chronic pancreatitis is also associated with jaun-
dice, which gradually becomes more severe; it also causes weak-
ness, debility, emaciation, the presence of a tumor mass in the
epigastrium, and frequent diarrhea. Cases of chronic pancreati-
tis have been reported in which pain was felt in the left iliac
region or under the ninth or tenth costal cartilage on the left
side.
Pancreatic Calculi. — Pancreatic calculi cause a colic some-
what similar to the colic due to gall stones, with the exception
that in gall-stone colic, pain is referred to the right shoulder and
is present in the right side of the epigastrium, while the colic of
pancreatic calculi is generally in the left side of the epigastrium
and radiates to the left shoulder. It is also noticeably different
from gall-stone colic in the infrequency with which jaundice is
associated with it. Reasoning from the probability of chance.
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DISEASES OF PANCREAS CAUSING PAIN 591
pain of a typical duct-colic type is more likely to be due to ob-
struction of the gall ducts than to obstruction of the pan-
creatic ducts, for gall stones are four or five times as
common as pancreatic stones. In some cases of pancreatic
calculi pain may be absent, with only a soreness in the
epigastrium, or an aching in the upper lumbar region. When at
its height the pain may be associated with hiccoughs, vomiting,
rigors, cold sweats, and collapse. In one case in which pain was
present in the left iliac fossa considerable free fluid was found in
this fossa. In another case pain was present after the first six or
eight hours only in the region of the ninth and tenth costal carti-
lages on the left side.
Oystic Disease of fhe Pancreas. — The distress in cystic disease
of the pancreas may vary from a feeling of uneasiness and dis-
comfort in the epigastric region to one of the most severe pain.
It also may be broken by acute exacerbations, probably due to
the sudden increase of tension in the cyst walls, which, in turn,
is caused by a sudden increase (frequently due to hemorrhage)
in the volume of the cyst contents. Like other varieties of pan-
creatic pain it is generally confined to the upper abdomen, but
may radiate to the back and has been known to strike down into
the testicles.
Cancer of the Pancreas. — The pain of cancer of the pancreas
is the result of pressure on the neighboring structures or on the
pancreatic tissues. It may be very mild or very severe, continu-
ous or intermittent. It frequently starts under the costal cartilage
of the left side and gradually extends toward the midline, low in
the epigastrium, radiating around one or both sides to the shoul-
der or to the back (generally to the left side). It is worse at
night; paroxysms are frequent and give a corset-like constriction.
Because of its pressure on the gall duct, over-distention of the
gall bladder occurs, producing a most severe gall-bladder colic.
Pressure on the pylorus may be the incitor of a pyloric or gastric
spasm. Curtin speaks of a case of cancer of the pancreas in
which the pain radiated to the inguinal canal, back of the testicles
592 THE PANCREAS
and perineum, and down the thighs as far as the knees. In his
case the most prominent symptom was a girdle sensation about
the level of the tenth costal interspace. In cancer of the pancreas
the patients generally assume a posture in which the body is
bent forward and the knees drawn up.
CHAPTEK XXVIII
THE SPLEEN
GENERAL CONSIDERATIONS
Anatomy. — The spleen is the largest ductless gland in the
body. It is situated in the left hypochondrium and is in
■
intimate anatomical relation to the digestive apparatus. There-
fore, it is particularly prone to enlargement in diseases
of the liver, stomach and intestines. Any acute enlargement is
painful.
A small part of the superior surface of the spleen is in inti-
mate contact with the diaphragm in the vicinity of the esophageal
opening. The contact is very firm and so close that any disturb-
ance in the spleen would cause some related change in this part
of the diaphragm, so that disorders of the spleen may exert trac-
tion on this section of the diaphragm and so cause irritation to
the peripheral branches of some of the intercostal nerves distrib-
uted on its lower surface, with consequent pain, which is referred
to the body wall.
Nerve Supply. — The spleen receives its nerve supply from
the sympathetic. The fibers accompany the blood vessels to the
ultimate divisions and supply the parenchyma of the gland. They
are derived from the splenic plexus, a division of the celiac
plexus. From the celiac plexus collateral branches connect with
the right vagus, which, in turn, is in communication with the right
spinal accessory and the cervical plexus. Thus we may account
for the shoulder pain on the right side.
Embleton believes that "the splenic nerves are derived from
each side of the semi-lunar ganglion and from each of the mem-
bers of the par vagum, and thus, by receiving nerve twigs from
593
594: THE SPLEEN
each pneumogastricy the shoulder pain of the right side may be
accounted for." This is probably not true. (See Bechterew,
"Funktionen der Nervencentra/' I, p. 376.)
According to Lyon, "The spleen is supplied by nerve fibers
from the left splanchnic nerve, through which a control of the
size of the organ is obtained. Stimulation of the splanchnics
causes contraction of the organ, whereas cutting them causes
splenic enlargement."
The splanchnics carry both sensory and motor stimuli. Pain
in splenic disorder may therefore also be due largely to irritation
of their terminal branches from increase in tension of the splenic
capsule.
Character of the Pain. — Many of the lesions of the spleen
progress entirely without pain, though in nearly all cases, even
when pain is absent, there is present a feeling of dragging or of
pulling in the left hypochondrium. Sometimes there is also a
feeling as of weight in the epigastrium, or a sense of tension in
the splenic area. These pains and discomforts generally extend
from the left side around into the epigastrium. They may be
spontaneous, but most frequently are felt only on mechanical irri-
tation, such as comes from running, jumping, or from trauma on
the left side.
In splenitis and perisplenitis the pain is generally worse about
four hours after eating, because at this period digestion is
at its height, and the blood supply to the spleen is at its maximimi.
Consequently it is at this time that the spleen has reached its
greatest size, the tension on the capsule is greatest, and the pain is
most severe. From then on the pain gradually decreases until
about the twelfth hour, when it ceases, for the spleen has returned
to its normal size. The reason for this splenic enlargement is
that the spleen is supposed to act as a reservoir for portal blood,
which, during the active stage of digestion, is greatly increased
in quantity, with a consequent increase in the quantity present in
the spleen. This increase in size is the result of a vasomotor dila-
tation of the blood vessels of the spleen, with a general relaxation
of the musculature of the organ.
GENERAL C0N8IDERATI0KS 59S
A very significant feature in splenitis ie tendemesa of the left
. pneumogastric.
Of ten cases of splenitie (Embleton), in six caaea the left
pneumogastric was found tender on pressure, while in two cases
tfaiB condition was found in the right pneumogastric.
— SiimirBUi'* ipte«D point
Fio. 133. — Points ot Pain and Tenderness in Diseases of the Spleen.
Pain present Id epigastrium, upper part along the costal margin.
LoCBliied point of ten-
Fio. 134. — Points of Pain and Tenderness in Diseases of the Spleen.
Pain in interspaces, especially those lying directly over the spleen.
596 THE SPLEEN
PoBltion of Patient. — A patient suffering from splenitis gen-
erally finda the dorsal position and the left-sided position
painful.
Tenderaess. — Localized points of tenderness are found in the
shoulder over the acromion i>rocess, and at the "junction of the
upper and middle third of the upper edge of the trapezius
muscle." Signorelli's spleen point is near the intersection of the
Fig. 135. — Method of Palpating for Splenic Tenderness.
The patient is plared in a reclining posture with the knws flexed on the
thi);hs, and the thiglis on the abdomen; the abdominal muscles are
also relaxed. The examiner stands to the right of the patient and
introduces his right hand deep under the left costal border and the
left hand makes pressure over the left hypochondrium. The patient
now takes a deep breath and if the spleen is tender, pain is complained
of when it comes in contact with the examiner's hand. In case of
enhirgement the deep inapiration may not be necessary.
left fifth interc(i:sta] s|)aee and the raid-clavicular line. Tender-
ness is also felt, both on palpation and percussion over the splenic
area.
Factors Influencing Pain. — Factors influencing- the onset of
pain are motion, pressure, and circulation. Motion is a cause of
pain, especially should the movement be in the form of quiet,
sharp jerks or jars, such as occur in running, jumping, and horse-
back riding. Change of position of the organ, such as happens
in turning the body from the dorsal to the left-lateral position,
GENERAL CONSIDERATIONS 597
cauBes a sense of tension or of pain in the left side. This is most
prominent when the stomach is full.
Diaphragmatic movements, such as occur in sneezing, cough-
ing and hiccoughing, also cause pain. Pressure on the organ alao
very frequently produces pain. Such pres3ur« is exerted by the
patient himself when he bends forward or backward. In either
case the spleen is caught in the recess of the diaphragm and ia
squeezed considerably. If it is not enlarged the force of the
pressure may not be great enough to cause pain; but should it be
enlarged the least amount of pressure ia very painful. For the
same reason, straining efforts, such as take place in defecation
and in lifting, are very painful. Pressure may also be exerted by
Fig. 136. — Location of the Kidnet. (Campbell.)
the descent of the diaphragm ; thus, deep breathing is productive
of pain. This is markedly so should perisplenitis be present.
Palpation, especially when bimanual, causes, in a tender spleen,
considerable pain. The method of palpation is shown in Fig, IS.'i.
Percussion is alao painful, particularly if the percussing blow is
rather heavy. "Both palpation and percussion are made in the
splenic area, which is marked out upon the back, by drawing two
horizontal lines from the spinous processes of the ninth dorsal
and the first lumbar vertebrffi; these are joined by a vertical line
one and one-half inches to the left of the midline of the body,
and another corresponding with the left, midaxillary line"
(Monyhan). Within this quadrilateral space the spleen lies
obliquely between the ninth, tenth, and eleventh ribs.
Circulaiortf changes during digestion also produce and modify
spleen pains ; at this time there ia present a secondary hyperemia
598 THE SPLEEN
in the spleen. If pain is already present, it is increased; or, if
it is not present, it is initiated. Should the spleen be inflamed,
or adhesions be present, the pain is all the more pronounced.
Adhesions between the stomach and the spleen, or the spleen and
the colon, are the most painful because, in these cases, during cer-
tain stages of digestion, enlargement of both organs occurs and
the pull is doubly severe. Drugs, such as quinin and arsenic,
lessen splenic pain, because of the decrease in the size of the
spleen which they cause.
Symptoms associated with a painful or tender spleen are:
Enlargement,^ which is almost invariably present. Very often
the pain and tenderness seem to vary directly with the size of the
spleen. In nearly all cases of diseased spleen there is present an
inflammation or some congestion of the capsule. This causes a
deposit of fibrin on the peritoneal surface, or at least a roughening,
which gives rise to friction when, during respiration or deep
breathing, a to-and-fro motion occurs between the spleen and the
diaphragm. This friction rub can be heard on auscultation, and
be felt on palpation. Sometimes, in severe, active congestion, a
systolic murmur can be defined on listening over the splenic area.
DISORDERS OF THE SPLEEN PRODUGINO PAIN
Displaced or Movable Spleen. — Glenard states that a mov-
able spleen may be present without any special symptoms, though
generally a dragging or a sense of pulling in the back or sides,
referred along the line of attachment of the diaphragm to the
ribs, is present. Other organs may be affected by the displaced
spleen; their circulation becomes disturbed, congestion results,
and pain is produced. When the displacement is excessive the
splenic pedicle may be twisted and the splenic circulation inter-
rupted. Pain now becomes a prominent symptom, the character
and severity depending upon the completeness of the circulatory
* The spleen is increased in size, should its anterior border lie below the
line extending from the middle of the sternal notch to the tip of the eleventh
lib on the left side.
DISORDERS PRODUCING PAIN 699
obstruction. Should the veins alone be obstructed, congestion
results. The pain is very severe and the spleen is increased in
size. Should the obstruction be complete, both arteries and veins
being blocked, the spleen at first is not increased in size, and con-
sequently pain is not prominent. In gradual venous obstruction
the pain is not as severe as it is in venous obstruction of sudden
onset. In either case, whether the obstruction is complete or
incomplete, complicating perisplenitis, with secondary pain, re-
sults. The diagnosis of movable spleen can be made from the
shape of the tumor mass, which is oblong, with an indented
border and pulsating artery on its inner surface. The absence
of the spleen from its normal position, and the ability to replace
the tumor mass in the cavity the spleen should normally occupy
also assist in the diagnosis.
Displacement of the spleen is very rare, Glenard having found
only two in one hundred and sixty cases of enteroptosis, a condi-
tion with which, naturally, one would suppose it would be asso-
ciated.
Congestion. — Congestion of the spleen causes pain in nearly
every case. This is well illustrated in the infectious diseases,
which are almost invariably accompanied by a congested spleen
and have pain in the left hypochondrium. The presence of a
tumor below the left costal arch, moving with respiration, and
tender to the touch, is a sine qua non of splenic involvement. In
some cases of acute splenic congestion, accompanied by cardiac
disease, pulsation may be felt. In these cases the pain may be
localized to the splenic area, or may radiate in different directions.
An acute congestion of the spleen, originating in the presence of
a gastric ulcer, may be due to a thrombus of the splenic vein, the
thrombus, in turn, being caused by necrotic tissue or blood clot
arising from the ulcer.
The spleen, which in infectious diseases is enlarged and con-
gested, may also show signs of acute inflammation. In this it
does not differ from the lymphatic glands, which in the presence
of infection become enlarged, and, in some cases, acutely inflamed.
However, the spleen especially, because of idiosyncrasy and
000 THE SPLEEN
special peculiarity of function, seems particularly liable to in-
volvement in all acute infectious processes. Several factors may
account for this tendency, namely: (1) because of the great
amount of lymphatic tissue in its substance it acts as a producer
of leukocytes, and at the same time, (2) because of its relation-
ship to the circulation, it performs the function of a filter for a
portion of the blood. Thus, infections and septic conditions, by
casting detritus and bacteria into the circulation, are particularly
prone to cause splenic disease. The infectious diseases causing
the most marked enlargement are typhoid fever and malaria. In
both diseases the spleen is enlarged and tender, and pain is com-
plained of beneath the left costal arch. The enlarged spleen fre-
quently compresses that portion of the lung between the dia-
phragm and the thoracic wall so that, on deep breathing, a fine
crepitation may be heard. This, at times, has led to a confusion
of the splenic lesion with pneumonia. Such a mistake is most
likely to happen if the onset of the disease causing the spleen in-
volvement occurs with a chill. Deep breathing in the presence
of an enlarged and tender spleen is very painful. Because of the
associated splenic congestion, paroxysmal hemoglobinuria also
causes splenic pain.
In brief, it may be said that the causes of active congestion
and inflammation of the spleen are due: (1) to acute factors,
as microorganisms and their toxins (typhoid fever, malaria,
syphilis), drugs (acetanilid and other coal-tar derivatives),
trauma, and local and morbid processes in the spleen (hemor-
rhage, embolism) ; (2) to chronic factors, such as anemic states
(pernicious anemia, chlorosis, infantile anemia, splenic anemia,
chronic cyanotic polycythemia, rickets) ; or (3) to passive con-
gestions, which may be due (a) to disease of the heart and lungs
(produciiig obstruction to the general circulation), (b) to diseases
of the portal area (causing obstruction to the portal circulation),
such as cirrhosis of the liver and pyelophlebitis, or (c) pressure
on the portal or splenic veins by tumors, adhesions, and sometimes
by an enlarged and inflamed gall bladder (Lyon).
Perisplenitis. — In perisplenitis pain is almost invariably pres-
DISORDERS PRODUCING PAIN 601
ent, especially if the inflammatory process is acute. The pain
varies from a feeling of discomfort to one of the greatest distress.
All movements of the spleen initiate and aggravate it, particu-
larly those movements associated with breathing, turning or twist-
ing of the body, and bending forward or backward.
Of diagnostic importance, if the lesion is acute, are the fric-
tion sounds, which may be heard over the splenic area on auscul-
tation. Great tenderness, also, is present on pressure over the
same area. In cirrhosis of the liver perisplenitis frequently
occurs. It is found in syphilitic, Banti's and Hanot's cirrhoses,
while Laennec's cirrhosis rarely causes pain.
The causes of perisplenitis, according to Lyon, are: (1) local-
ized splenic involvement, as infarct, gumma, hemorrhage, abscess,
cysts; (2) generalized involvement of the splenic parenchyma in
the acute or chronic splenitis of the infectious diseases; and (3)
extension of inflammation from disease outside of the spleen, as
pleurisy, pneumonia, local or general peritonitis, tumors or cysts.
Abscess of the Spleen. — Abscess is most frequently caused by
lodgment of a septic embolus ; but so long as the abscess is con-
fined to the parenchyma it gives no indication of its presence.
It is only when the capsule is involved, and perisplenitis occurs,
that pain is felt. The pain of central abscess and other crypto-
genic forms of splenic involvement might be of great diagnostic
value ; but, unfortunately, as yet the pain equivalent has not been
defined and correlated to the different varieties of splenic disease.
Infarct. — In infarct of the spleen sudden, severe pain is felt
in the splenic area. Tenderness due to perisplenitis is also pres-
ent and is localized over the area of the infarct. After the first
acute pain, following the lodgment of the embolus, the pain
syndrome is that of a perisplenitis. The emboli causing these
infarcts are most commonly due to vegetative endocarditis, in
which a portion of these vegetations has been carried away in the
blood current and has lodged in the splenic artery or its branches.
Such a lodgment is very common, because in the spleen the ar-
teries are end-arteries and have no anastomoses; therefore, lodg-
602 THE SPliEEN
ment always cuts off the circulation to a limited area and causes
an infarct Should the embolus be septic an abscess of the spleen
results.
Bnpture of the Spleen. — Pain in the splenic area, following a
blow or a sudden trauma in the region of the spleen, particularly
if it be associated with collapse and signs of internal hemor-
rhage, is an indication of splenic rupture. The patient, in addi-
tion to the pain, has, at the time of the accident, a sensation
as of something being torn or of giving way in the abdomen.
However, pain does not at once, in all cases, occur, for immedi-
ately after the injury the patient may seem but little hurt. He
may be able to walk for some distance or to engage in some work
before the pain comes on. A rupture may also occur sponta-
neously, as has been observed in a few cases of very large and
congested spleens.
Tumors of the Spleen. — Tumors of the spleen, according to
Monyhan, are, as a rule, painful, the pain in some cases being so
severe as to prevent the slightest movement. On the other hand,
the enlarged, amyloid spleen, found in septic diseases, is apt to
be overlooked, because it rarely produces a pain-complex.
Cysts of the Spleen. • — Likewise, cysts of the spleen, unless of
very great size, are generally free from pain, though from their
size they may cause a sensation of weight or of fulness in the epi-
gastrium. Pain, when present, is in the area occupied by the
enlarged spleen. Hydatids, as a rule, are painless. They usually
grow from the upper surface of the gland and give a character-
istic thrill on palpation.
Kala-azar, a rare disease of the spleen found in certain
tropical countries, produces a splenic enlargement, which, as a
rule, is painless.
Of the blood diseases causing splenic enlargement, myeloge-
nous leukemia always causes pain. This pain, due to distention
of the capsule, is frequently the first symptom of the disease.
Pseudoleukemia and polycythemia also cause splenic pain, but
this is rare in chlorosis and pernicious anemia. The reason for
DIFFERENTIAL DIAGNOSIS
603
this may be that the spleen is enlarged in only about sixteen per
cent, of cases of pernicious anemia and chlorosis (Schmidt). It
is only in the cases of enlarged spleen that pain is present.
SPLEEN. DIFFERENTIAL DLA.GNOSIS.»
Symptoms
Spleen
Pleurisy
Pnbumonla.
Pain.
Felt in right side or
is referred to the ab-
domen. Worse on
respiration.
Localized to
diseased area;
not such a great
tendency to be
referred.
Localized over
area when pleura
is involved. Re-
ferred pain over
the chest wall is
also pre^tent.
Tenderness.
Splenic points of ten-
derness are present.
Prefisnre on t he lower
border of the spleen
(bimanual) ispamful.
No splenic
points of tender-
ness. Tender-
ness may be pres-
ent in 1 he inter-
costal spaces
over the affected
area.
No splenic points
of tenderness.
Tenderness a s a
rule ispresent over
the affected area.
R&les.
May be present, due
to pressure atelecta-
sis of the adjacent
lung.
May te present,
due to the asso-
ciated .involve-
ment of the sub-
pleural p n e u -
monic tissue.
Present.
Enlargement of
the spleen.
Present and spleen is
tender on pressure.
No enlargement.
Enlargement, sep-
tic in origin, may
occur late in the
disease.
Friction rub.
May be present ; gen-
erally absent.
Present. Dis-
appears when
effusion occurs.
Frequently pres-
ent.
Cough.
Generally not pres-
ent.
Present.
Present.
Sputum.
None.
Frothy or dry.
Rusty.
Temperature.
•
Generally that of
the causative lesion.
Generally none,
or very slight.
Generally p'-esent
and very high.
* Splenic disorders have been confused with acute rheumatism, especially
so when the splenic pain is referred to the left shoulder; but in rheumatism
some of the joints are almost invariably affected, while in splenic disorders there
is no joint involvement.
CHAPTER XXIX
THE KIDNEY
GENERAL G0NSIDEBATI0N8
It is said by Howard Kelly, in what is probably a fair esti-
mate, that over 60 per cent, of the patients with ill-defined, right-
sided pain have disease of the kidney. In view of this, it is easy
to understand the importance of being thoroughly conversant with
kidney pains, the rationale of their production, and the method
and manner of their perception.
The kidneys, unlike other abdominal viscera, are entirely
retroperitoneal and do not come in intimate relationship with the
other intraabdominal viscera. Their position, however, brings
them into more intimate contact with the parietes and conse-
quently with the nervous supply of the abdominal walls, which
is cerebrospinal. It is extremely doubtful if any cerebrospinal
fibers convey nerve impulses from the parenchyma of the kidney.^
Yet the capsule and some of the pericapsular tissue contain cere-
brospinal sensory fibers. In this way the localization of the
aching pain felt in all capsular or pericapsular affections can be
explained. Sympathetic nerve fibers supply the parenchyma.
They are collected into the renal plexus, which in turn communi-
cates, through the solar plexus, the lower and outer part of the
semilunar ganglion, and the aortic plexus, with the lesser and the
smallest splanchnic.
Nerve Supply. — The nerves supplying the kidney are derived
1 According to the latest researches the cortex of the kidney is derived
from the meaoblastic tissue of the posterior abdominal wall; consequently
there must have been, at least in the early stages of development, some slight
<Ii8tribution of the terminal branches of the spinal nerves to the kidney sub-
stance. Whether these persist in later life is problematical.
604
GENERAL CONSIDERATION'S 605
from the tenth, eleventh and twelfth dorsal, and the first lumbar
segments of the cord (Head).
How important these areas are to kidney pain production,
and how necessary the knowledge of their location is for a cor-
rect and satisfactory diagnosis, will be shown.
Etiology of Kidney Pain. — The direct cause of kidney pain is,
as in all painful lesions, an irritation arising somewhere in the
course of the nerve supply. Since the nerve fibers supplying the
kidney are related directly and indirectly with other organs, irri-
tation arising in their course may be referred to any or all of these
related organs. Therefore, since a lesion of the kidney will cause
pain and disturbance in other organs, and a lesion of other organs
will cause pain and disturbance in the kidney, it requires more
than the pain syndrome to make a diagnosis of a kidney lesion.
An exception to this probably could be made in favor of the local
tenderness which occurs upon pressure in the costal-vertebral
angle, when the kidney or the surrounding areolar tissue is in-
flamed.
The causes and the locations of nerve irritations causing kid-
ney pain are varied; yet it is most probable that nearly all of
the kidney pains owe their origin to stretching and pressure ex-
erted upon the nerve filaments terminating in the capsule.
In this connection, Watson reports a case of apparent renal
colic, in which the kidney was opened and no stone was found,
but the capsule was thickened. Complete relief followed the oper-
ation. Keyes also reports relief from the splitting of the capsule
in a case of chronic granular kidney. Even in a simple congestion
the pain is eased by capsulotomy. However, it is probable, in
all cases, that the pain is the result of an acute process, for in
chronic and slowly progressing disorders, like granular nephritis
or new growths of the kidney, pain is absent unless the tension
of the capsule, from any cause, is suddenly increased. The pain
of a severe and a colicky type instantly results. Indeed, it is
claimed by Bevan and others that the pain of renal calculus is the
result of a sudden increase in intracapsular tension. Bevan re-
ports a case in which, previous to a nephrotomy, severe pain had
606 THE KIDNEY
been present, but was entirely absent after operation, although a
stone, which was present in the ureter, had not been removed.
After the operation its progress down the ureter could be watched
with the X-ray. At no time in its descent was the slightest pain
present. This is only one of the many instances which seem to
show that kidney pain, that is, direct pain, is due to tension on
the renal capsule. Should the capsule be thickened and non-elas-
tic any increase in the mass of the kidney would be painful, be-
cause of the resistance to stretching offered by the thickened cap-
sule. For this reason, it may be, that old people and rheumatics
can, by the aching which they have in their backs (in the kidney
areas), foretell changes of weather. The lowering of the baro-
metric pressure may induce a kidney hyperemia, which produces
tension of the capsule and thus causes pain.
In cases of intracapsular tension, in which the renal pelvis
is distended with exudate, splitting of the capsule and opening
of the pelvis will let out the exudate and relieve the primary pain;
but a secondary congestion in the pelvis may result and produce
a secondary pain.
An example of the insensibility of the kidney parenchyma to
pain production is given by Cartwright (Lancet, 1888, Vol. II,
p. 403). He says that, when in China^ he was shown a speci-
men of a kidney removed from a Chinese cooley by an American
physician. Before its removal it had extended through an open-
ing in the loins and had suppurated from the treatment of bird
dung, saliva, etc., with which it had been daily dressed ; and yet,
during all this time, no pain had been present.
The kidneys are in close relation with the upper parts of the
lumbar plexus on either side and enlargements of their substance,
new growths, or perinephritic abscesses will sometimes press upon
certain of these nerves and cause pain. This pain is referred to
the distribution area of the nerves upon which pressure has been
made. A more complete discussion of these pains will be entered
into under the heading of referred pains of the kidney.
The ureters and their nerve supply will be considered in their
respective sections.
GENERAL CO>tSIDERATIONS 607
Character of Benal Pain. — In some cases, especially early in
the renal involvement, a well-defined pain is not present ; rather,
there is experienced a sense of discomfort and distress in the cor-
responding iliac fossa or lumbar region. This distress may gradu-
ally increase, so that in time it becomes a well-defined pain. If
the pain, when present, is of a dull, aching character, it indicates
that the tension on the capsule is not of any considerable moment,
but rather that the lesion involves the surrounding renal struc-
tures or is of some slowly progressing, intranephritic nature, such
as that which occurs in the large white kidney of nephritis. If
there is also considerable tenderness on palpation an extrarenal
complication may be suspected. An aid of value in the diagnosis
of intra- or extrarenal lesions is that intrarenal lesions generally
give rise to areas of referred hyperalgesia, while extrarenal lesions
do not.
In some cases of wandering kidney, from kinking of the
ureter, there is a sudden elevation of the intracapsular pressure,
with a very severe, colicky pain. These attacks go under the name
of Dietl's crises (see Wandering Kidney). They are accompa-
nied, at the time of the attack, by a considerable decrease in the
quantity of urine. This is followed, on the reestablishment of
the urinary channel, by the voiding of a considerable quantity
of clear urine which may be slightly tinged with blood. During
the attack palpation will disclose a swollen and tender kidney.
A calculus blocking the ureter will produce similar symptoms.
Both a kinking of the ureter and the blocking of the same by a
calculus are accompanied by von^iting and chills, and, in some
cases, by a mild fever.
A kidney in a state of hypertension from arterial hyperemia
has a peculiar rhythmical, pulsating pain, most pronounced in
the lumbar region. The pain is synchronous with the cardiac
systole and is the result of the increase in the intranephritic ten-
sion, which occurs during each systole.
Localization of Kidney Pain.« — In kidney disorders, as well
as in disorders of all other organs, there are two classes of pain
manifestations, namely: the subjective, in which the pain is pro-
608 THE KIDNEY
duced without any apparent external means of causation, and the
objective, in which pain is produced by manipulation, pressure,
etc. Tenderness comes under the class of objective pain. The
subjective pains may be divided into the following divisions:
(1) local, (2) referred, and (3) reflected.
Local Pains. — Local pains, as the name would imply, are
those which are produced directly in the kidney area. This area
is bounded by (Gray) :
(1) A line parallel with, and one inch from, the spine be-
tween the lower edge of the tip of the spinous process of the
eleventh dorsal vertebra and the lower edge of the spinous proc-
ess of the third lumbar vertebra.
{2) A line from the top of the first line outward at right
angles to it for 2f inches.
(3) A line from the lower end of the first transversely out-
ward for 2f inches.
(4) A line parallel to the first and connecting the outer ex-
tremities of the first and third lines just described.
The kidneys are therefore opposite the last thoracic and the
upper two lumbar vertebrae and reach to within 2..') to 3.5 cm.
(1 to IV2 ii^O <^f ^^^ highest part of the iliac crest (Piersol).
(See Fig. 136.)
Thus, any pain felt in this region should lead at once to the
suspicion of disease of the kidney, especially so when the pain is
associated with local tenderness. If the pain is sharply delimited,
and if referred or reflected pains are absent, a perinephritic in-
flammatory lesion should be sought.
'*This is most important to a correct diagnosis in infants and
children, because in them, cm account of lack of development, the
ability to localize pain is defective. In any case, either in them
or in adults, a severe abdominal pain, of unknown etiology, espe-
cially when associated with the drawing up of the limb, etc.,
should always direct attention to the kidney."
Referred Pain. — By referred pains are meant those pains
which are felt at a distance from the place where the irritation
producing them is located. The irritation may occur at any point in
GENERAL CONSIDERATIONS 609
the course of the affected nerve, but the pain is perceived as com-
ing from its peripheral distribution area. In kidney lesions this
is well exemplified, for pain due to the kidney may be felt in the
lower iliac region, the suprapubic, the outer, middle or the inner
Fio. 137. — Areas of Referred and Reflected Pains in Disease of the
Urinary Apparatls. {Modified from Fenwick.)
Unilateral pain of one limb is often a premonitory sign of brain hemorrhage.
part of the thigh. Pain, when felt in any other part of the thij^h,
if it is produced by k-wions of the genitourinary tract, is generally
due to those lesions which arc located in the ureter above the
bladder; while pain felt in the penis, scrotum, or in the lateral
margin of the perineum and the inner aspect of the thigh, or over
the lower part of the sartoriiis nnisclc (involvement of the obtnra-
610 THE KIDNEY
tor nerve), generally indicate involvement of the ureter adjacent
to the bladder.
A differential point of value in the diagnosis of the location
of lesions of the kidney or ureter is that in high ureteral in-
volvement the skin of the scrotum is not painful to pressure, but
the deeper tissues are; while the reverse is true in low ureteral
involvement. When the involvement is adjacent to the bladder
the pain may be referred through the inferior hemorrhoidal nerve
to the skin around the anus or through the perineal branch of the
pudic to the skin of the scrotum. It may also be referred through
the dorsal branch of the pudic to the glans penis. When, in cases
of renal calculus, pain is felt in these areas it is a good indication
that the stone is in, or almost in, the bladder. This is especially
true should referred pains in the lower areas follow those in the
upper areas, particularly those supplied by the eleventh and
twelfth dorsal, the ilioinguinal, iliohypogastric, and the genito-
crural nerves. The anterior crural nerve, because of its position
behind the psoas muscle, is fairly well protected from pressure
from any kidney or ureteral disorder, and therefore referred pain
is seldom, if ever, found in the region which it supplies. Another
diagnostic point of great value is that involvement of the lower
third of the ureter produces increased frequency of urination, but
no pain during urination. In this it differs from lesions of the
bladder, which cause both increased urination and pain. The
zones of Head are also of particular value in determining the
exact location of the lesion.
In some, but not in all cases the progress of the descent of
a calculus, and the distention of the ureter above it, can be noted
by the referred and reflected pains which are present. These pains
commence above in the area of the tenth dorsal and pass down
through the areas of the iliac, suprapubic and the ilioinguinal
to the scrotum and the penis, at which time, as a rule, the stone
is in the bladder.
Referred pains are also felt in the thigh. These Schmidt
regards as being due to pressure upon the twelfth dorsal nerve
and upon branches of the lumbar plexus by thickening of the
M ^
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H
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s
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611
612 THE KIDNEY
capsule. Such a causative agent is a far-fetched possibility, for
though the amount of capsular thickening may be excessive it
would not by any means interfere with the surrounding nerve
structures, unless there was, at the same time, an extensive peri-
nephritic inflammation.
For emphasis, even though it involves a slight repetition, it
may be permitted to recall that the nerves involved in referred
pain from the kidneys, and the areas which they supply, are:
(1) the twelfth dorsal, which supplies the skin of the lower ab-
dominal and lumbar region; (2) the iliohypogastric, (a) iliac
branch, supplying the integument of the anterior gluteal region,
(b) hypogastric branch, which is distributed to the integument
of the suprapubic region; (3) ilioinguinal, supplying the integu-
ment of the upper inner portion of the thigh; (4) genitofemoral,
which is divided into (a) genital branch, which gives branches to
the skin of the scrotum, the thigh adjacent to the scrotum, and the
labia majora in the female, and (b) the crural branch, which
supplies the upper anterior part of the thigh, between the regions
supplied by the external cutaneous and the ilioinguinal, and ex-
tends down as far as the middle third of the thigh; (5) the ex-
ternal cutaneous, dividing into (a) an anterior branch, supplying
the integument over the anterolateral aspect of the thigh as far
as the knee, (b) posterior branch, supplying the skin over the
tensor fasciae femoris and lower portion of tlie gluteal r^on;
(()) the obturator, which subdivides into (a) the anterior branch,
supplying the integument of lower inner third of the thigh, and
(b) the posterior branch, which by a branch supplies the knee
joint; (7) the anterior crural, dividing into (a) the middle
cutaneous, which, through its (I) external branch, supplies the
integument over the rectus femoris as far as the knee, and (2) the
internal branch also, which supplies the integument over the
rectus femoris as far as the knee; (b) the internal cutaneous,
supplying the integument over the anteromedian aspect as far as
the knee; and (c) the internal saphenous, which gives sensation
to the integument over the anterior internal portion of the leg,
and the posterior half of the dorsum, and mesial side of the foot ;
GENERAL CONSIDERATIONS 613
(8) the small sciatic, dividing into (a) the gluteal cutaneous,
supplying the skin of the inferior gluteal region, as far externally
as the great trochanter, and internally as far as the coccyx; (b)
inferior pudendal, supplying the skin of the upper mesial por-
tion of the thigh and also the perineal body and anus; (c) the
FiQ. 139. — Distribution of Cord ZoNEti (according to Head) and or
Nerves.
femoral branches, supplying the skin of the posterior aspect of
the thigh; (d) tlie popliteal branches, which are distributed to
the popliteal space, and at times extend as far as the ankle;
(9) the puJic, which, through its superficial branch, supplies the
lateral margin of the perineum and inner aspect of the tbigb, and
the integiunent of tlie serotuiti or labia majoru; and through the
inferior hemorrhoidal branches supplies the external sphincter
614
THE KIDNEY
and the integument of the anal region (Piersol, "Anatomj," Ist
ed., pp. 1320 to 1352).
Reflected Pains. — In the lesions o£ any viacns Head's zones
should be investigated. Their presence is of very great positive,
though their absence is of little negative, value.
It seems to be a ruie in kidney disease, as in disease located
Fio. 140 — Areas of Reflected Hyperalgesia, in IOih, 1 1th, 12th Dos-
sal, AND 1st Lumbar Visceral Seoments According to Head.
These arc the areas afTect«d in kidney lesions.
elsewhere, that the first acute attack of inflammation almost in-
variably produces reflected pain, but that later attacks are not so
prone to do so, because, during tlie first attack, the nerve termina-
tions are so mneh injured that their ability subsequently to react
to pain stimuli is very much impaired. This is the reason why
hyijeralgesic zones are not found in all cases of acute or chronic,
recurring inflammation. According to Head, "The kidney is par-
ticularly associated with the area of distributioD of the tenth
GENERAL CONSIDERATIONS 615
dorsal segment, and to a lesser degree with that of the eleventh
and twelfth dorsal and the first lumbar segments. Disease of
the kidney, of the renal pelvis, and of the ureter seems to be par-
ticularly associated with the eleventh and twelfth dorsal and the
tirat lumbar segmental areas."
The testicle receives its nerve supply from the same segment
of the cord as does the kidney, and therefore rc"] lesions fre-
quently give rise to pain in the testicle. It sometimes happens
that the pain may be felt entirely in the distribution area of the
lower cord segments, commonly associated with kidney disease,
Fia. 141, — Method of Palpation in Elicitino Tekdbrnbs8 in the
KlDNBYS.
and not at all in the upper, so that a lesion of the kidney may
sometimes be mistaken for one of the bladder,
Kenal pain also is frequently transfcrn-d across the cord and
is felt in the distribution area associated with the opposite kidney,
the so-called renorenal reflex of iforria, tboufib Front was prob-
ably the first to draw attent'On to tl'is plienoinciion.
Tenderness. — Tcndemosa is present to a greater or less extent
in nearly every case of kidney disease. The oidy exceptions are
new growths, which may be entirely free of tenderness. The
technique for examination for kidney fendernea.'i i.'* as follows:
Have the (jatient's bowels tt'0'-o'ig'''y c'e^'ised by a purgative
previous to the examination; cause the patient to recline on the
back; and have the limbs drawn up, and raise the shoulders
(preferably on a pillow), so that the abdominal walls may be re-
lazed (Fig. 141). Place one hand, palmar surface, over the lum-
GIG THE KIDNEY
bar region. Place the tips of fingers of the other hand in the
subcostal space anteriorly; then, have the patient take a deep
breath, and at the same time make simultaneous pressure with
both hands. If the kidney is displaced it can be felt slipping
between the fingers. If it is not displaced it cannot be felt.
When pressure is applied in this way to a healthy kidney no
pain, though sometimes a sense of discomfort, is produced;
while, on the other hand, if the kidney is diseased the patient
immediately complains of severe pain. Ransohoff palpates
simultaneously on both sides, with the thumbs along the last
rib from within outward, and thus finds the tender foci. E. H.
Thompson gives a somewhat similar method for eliciting
tenderness in kidney lesions, especially in renal calculus. ^^He
stands behind the patient and places the thumbs of both hands
under the last ribs and then so spreads the fingers over the abdo-
men that when the patient relaxes the abdominal walls, by bend-
ing forward, the kidneys are pushed up toward the spine; then,
as the patient straightens up, the thumbs are strongly pressed in.
If a renal calculus is present the patient will quickly bend over
to the affected side."
In some cases it occasionally happens, in kidney lesions, that
contraction of the psoas muscle may cause pain. This may be
demonstrated by having the patient, after having flexed the thigh
upon the abdomen, suddenly straighten the limb. The pain, so
produced by this maneuver, is deep down in the iliac region of
the side involved.
The points where tenderness are most marked are (1) in the
subcostal angle, between the margin of the erector spinae and the
last rib; (2) on the outer surface of the thigh, about the iliac
crest; and (3) on the abdomen, below the free margin of the
tenth rib. The tenderness may be divided into the superficial
and the deep.
Superficial tenderness and hyperalgesia are useful in outlin-
ing the zones of Head, while deep tenderness is a means of prac-
tical value in the diagnosis of deeply situated lesions. Should
tenderness be associated with edema it is almost pathognomonic of
GENERAL CONSIDERATIONS
617
a deep-seated inflammation. Poreiission is very useful in exactly
localizing the boundaries of renal tenderness.
Tenderness of the lower segment of tlie ureter can be deter-
mined bj palpation through the vagina or rectum. In case of
inflammation, pressure e.\ert-
ed upon it produces pain,
which is referred to the same
areas as is the pain due to in-
volvement of the lower seg-
ment of the bladder. Tender-
ness ia very marked in tiiber-
cnlosis of the ureter, or in
nreteropyelitic inflammations.
In some cases a stone, if
lodged in the lower segment
of the ureter, can be felt from
the vagina or rectum by the
palpating finger. The upper
segment of the ureter cannot
Ik^ satisfactorily palpated.
Factors Influencing Pro-
duction of Pain Factors in-
fluencing the production of
pain in kidney and ureteral
lesions are:
(1) The Position of the
Patient. — The patient always
assumes the posture of great-
est ease. In inflammatory
lesions he may lie on the side
in which the lesion is lo-
cated, although a.s a rule he
lies upon the opposite one.
However, in nephroptosis the patient is most comforlaljle when
lying upon the healtliy side. During an acute renal attack he
reclines in a semi-proue position, with the back slightly arched,
Via. 142.— Position Assumed in
Kidney Disorders, Ureteral and
Kidney Colic, Lumbago, Uterine
AND Tubal Adhesions and Drag
ON Back, Entero ptosis, Espb-
CIALLV AFTER REMOVAL OfCoRSET.
618 THE KIDNEY
and the limbs flexed upon the abdomen, so that the abdominal
muscles are relaxed. When standing the patient generally bends
forward and grasps the side of the body, pressing in on the lumbar
region with the thumbs, and on the iliac region with the flat
of the hand.
(2) Motion of the Patient in Relation to Pain Production, —
In all diseases of the kidney or ureter due to obstruction of the
ureter, or to an inflammatory process, motion of any kind is more
or less painful. This is especially true of those movements asso-
ciated with shock (vibration), as horseback riding, or movements
in which the kidney is subjected to pressure ; for instance, cough-
ing, sneezing, deep breathing, rowing, bending, stooping, or the
lifting of heavy weights. All of these movements throw great
pressure upon the sensitized kidney and so produce pain. In some
eases forcible flexion of the thigh causes pain. This is due to
the contraction of the psoas muscle, causing either a dragging or
a pressure upon the affected kidney.
(3) Duration of Kidney Pain. — Pain that is sharp, sudden
and spasmodic, coming quickly and passing away just as quickly,
generally indicates a lesion of transitory activity, probably a
calculus. Pains of greater severity and more constant duration
indicate a lesion of more permanence and greater gravity. The
persistence of tenderness for some time after the pain has ceased
is characteristic of infarct.
Absence of Pain in Kidney Lesions. — Pain is generally absent
in the following lesions of the kidney: new growths, acute and
chronic nephritis, and fatty and amyloid degeneration of the
kidney.
Sjrmptoms Associated with Pain Phenomena. — Symptoms as-
sociated with pain phenomena in kidney lesions are: (1) muscu-
lar rigidity, which is frequent on the affected side; (2) frequency
of urination; (3) urinary tenesmus; (4) the presence of patho-
logical products in the urine; (5) the presence of a tumor in the
kidney region; (6) the presence of edema, both localized and
general
Edema localized to the kidney area is present in cases of peri-
GENERAL CONSIDERATIONS 619
nephritis, inflammation, and abscess formation. Should edema
be present under the eyes of those who complain of pain in the
lumbar region it is a fair indication of nephritic trouble. Gener-
alized edema only occurs late in nephritic processes.
Pain in Diagnosis of Kidney Lesions. — After a review of the
anatomy, relationship, and pain-producing factors in kidney
disease, it is well again to recall to mind, in a brief summary,
the value of pain in the diagnosis of kidney lesions. Besides
pain the principal means that are of use in diagnosing lesions of
the kidney are the presence of a tumor and the character of the
urine.
(1) Should pain be present in the kidney areas without
tumor, and at the same time pus should be found in the urine,
and this be accompanied by a cystitis, with or without hematuria,
it indicates a renal tuberculosis. If pus is present in the urine,
without cystitis, and with or witliout hematuria, renal calculus is
probably present. The X-ray, as a rule, will disclose the stone.
In calculus the pain is made worse by movement and may be
referred to the neck of the bladder. Should no pus, but, instead,
blood, be found in the urine, the following should be considered
a& causative factors: cancer, hematuric nephritis, papillomata or
angiomata of the renal pelvis, and renal congestion.
(2) If pain is present in the kidney areas and is associated
with tumor, the following should be inquired into: (a) the
presence of pus in the urine, accompanied by a cystitis, with or
without hematuria, indicates a hydronephrosis; (b) the absence
of pus in the urine and freedom from cystitis and hematuria are
almost pathognomonic of aseptic hydronephrosis or of floating kid-
ney, with or without moderate retention of urine; (c) the pres-
ence of a hematuria with neither pus in the urine nor a cystitis,
most frequently points to cancer, especially if the hematuria
usually occurs at night or on awakening. In all cases of kidney
involvement the cystoscope should be used to tell which is the
affected kidney.
Pain in the lumbar region may be due to lesions of other
organs, as well as to those of the kidney, and these should be diag-
620 THE KIDNEY
nosed from kidney lesions. The lesions sometimes so mistaken are
iliosacralgia and iliomyalgia, and are distinguished from kidney
lesions by the following: (1) they produce no enlargement in the
lumbar region and no tumor can be felt by transabdominal palpa-
tion; (2) stooping and bending of the body are painful and, as
Cathelin has pointed out, those afflicted by the above-named condi-
tions are unable, upon arising in the morning, to button their
boots or to pick up anything from the ground; (3) gross urinary
changes are absent.
DIFFERENTIAL DIAGNOSIS OF KIDNEY DISEASES
CAUSma PAIN
After a general consideration of kidney pains, it is necessary
to particularize and to review separately the different lesions.
The order in which they will be considered is as follows: (1)
movable kidney; (2) renal infarct; (3) congestion; (4) inflam-
mation, acute and chronic; (5) peri- and paranephritis; (6)
rupture of the kidney; (7) tuberculosis of the kidney; (8) new
growths of the kidney; (9) pyelitis; (10) hydronephrosis; (11)
renal calculus.
Movable Kidney. — This is a very common lesion. Out of two
hundred patients it was present eleven times, but in only one case
were there any symptoms referable to it (Johnston). It is thir-
teen times more frequent on the right side tlian on the left. Even
allowing for its rarity in the usual class of patients, it cannot be
denied that it is the cause of a large proportion of the abdominal
discomforts usually encountered. However, frequency of this con-
dition is probably slightly exaggerated by Kelly, who says that
sixty per cent, of the cases of ill-defined, right-sided pain are due
to trouble in the kidney, which trouble is usually a displacement,
with a kinking of the ureter and retention of the urine in the
renal pelvis.
Anatomical Considerations, — Normally, the kidney is a mod-
erately movable organ, slight elevation and depression being asso-
ciated with the up-and-down movement of the diaphragm in
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622 THE KIDKET
breathing. This freedom of motion is permitted by the rather
loose connection of the kidney with the surrounding structures.
It ifi retroperitoneal and is in close relationship with the dia-
phragm. Both kidneys are inclosed in perirenal fascia which
divides into two layers. The anterior layer passes across the
great vessels and nen'es (such as those from the renal plexus, the
solar, eleventh and twelfth dorsal, ilioinguinal and iliohypogas-
tric), and joins the homologous layer of the opposite side. The
posterior layer passes behind the kidney and is attached to the
spine. Above, both fuse into the diaphragm, while below they
merge into the fatty subperitoneal tissue of the iliac fossa. This
structural formation permits considerable up-and-down move-
ment, while anterior or posterior displacement is limited. The
kidneys are joined on the right side to the liver, colon, and duo-
denum, while on the left the colon and the spleen are in intimate
relationship. It is because of these connections that displace-
ment frequently produces symptoms of discomfort and even of
pain in these associated organs.
Pathology. — In displacement of the kidney most of the pull
is made upon the diaphragm and the lumbar fascia. These are
supplied by the tenth, eleventh, and twelfth intercostal and the
first lumbar nerves. Therefore it follows that the pain and discom-
fort in displacement will be radiated over the lower abdominal wall
and the back. Such is the case. Yet every person having a mova-
ble kidney does not complain of pain. Indeed, in many people a
considerable amplitude of movement and of displacement are pres-
ent without any symptoms; it is only when the displacement be-
gins to cause disturbances in other organs that the patient be-
comes aware of the pathology. From this time on the unfortunate
individual has entered the realm of the nephroptotic, and is
subject to constant distress and discomfort. The first distress
from which he suffers is that of a pulling and a dragging in the
lower lumbar region. The discomfort may become so great that
the patient walks in a stooping posture, though this posture is
more characteristic of the enteroptosis, with which, as a rule,
nephroptosis is associated, the nephroptosis being but one symp-
DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 623
torn of the generalized condition. In renal displacement other
causes for later pain production are due to kinking or twisting of
the renal pedicle, which causes: (1) distention of the renal pel-
vis, because of complete or partial obstruction of the ureter, and
(2) distention of the renal parenchyma, because of renal conges-
tion, which is the result of partial obstruction of the venous flow.
In both these cases the pain is due to the sudden increase of intra-
capsular pressure. Both simulate, in severity and suddenness of
onset, the pain of renal calculus. In some cases a movable kidney
may also be the seat of calculus, pyelitis, tuberculosis, or inflam-
mation, and these give rise to their own typical symptoms, in addi-
tion to those of the displacement. A differential point of value
in the diagnosis is that a diseased kidney is tender on pressure,
while one which is only displaced is not tender.
Location of the Pain, — Local pain is generally absent in mov-
able kidney, though there is present a constant sensation of pull-
ing or of dragging in the lumbar region. In contradistinction to
local pain is the frequency with which referred pains (the so
called radiating pains) are found. They are due to the drag and
pull upon the nerves, which lie in close relationship to the kidney,
such as the eleventh and twelfth dorsal, the ilioinguinal, iliohypo-
gastric, and, at times, even the crural or the sciatic. Pulling and
dragging on these cause pain and discomfort in the lower abdomi-
nal wall, the outer and inner side of the thigh, or, in some cases,
in the genitalia. The pain in the shoulder, which Kelly states is
sometimes present, probably is due to traction on the diaphragm,
the irritation being carried through the phrenic to the supra-
acromial nerves, and thence to their distribution over the shoulder.
True reflected pain is seldom found in displaced kidney, except
when a state of very acute congestion, from venous stasis or
inflammation, occurs in the affected organ. Then pain is felt in
the kidney zones; in some cases it is felt in the kidney zone on
the side opposite to the one affected. This pain is probably trans-
mitted through the sympathetic nervous system to the cord, and
thence to the body wall on the opposite side.
Kelly, quoting from Moullin, reports a case where the pain
G24 THE KIDNEY
was in the epigastrium, shooting around to the back and shoul-
ders. It invariably came on one-quarter to one-half an hour
after eating; solid food made it worse, vomiting was frequent,
and seemed to relieve the pain. The reclining position eased the
symptoms. Kelly quotes this as a case of referred pain from the
kidney, but it is difficult to see why it is not one of gastric ulcer.
The vomitus at times contained blood and all the symptoms, man-
ner of pain production, its reference, and character would indi-
cate the lesion to be ulcer of the stomach. The relief coming
after the kidney suspension was due, it would seem, more to the
rest in bed than to the operation on the kidney. In addition to
the symptoms detailed above as resulting from displaced kidney,
there also result gall-duct colic, jaundice, and other symptoms
which are referable to the liver and its appendages, and are due
to the pressure of the right kidney against the common bile duct.
Character of the Pain in Displaced Kidney. — The pain may
be of a constant, dragging, or aching character, and may be either
mild or very severe. In certain cases it is so slight that the patient is
not aware of its presence unless his attention is directed to the
displacement. In other cases he is always in great distress. In
all cases, when present, the pain is made worse by standing or by
exercising, and is generally relieved by lying down. In some
women the pain, as a rule, is worse during the menstrual period.
In others it is worse at night time, after the removal of the corset,
while in still others it may be present when the patient is lying
in bed, but promptly disappears when, on arising in the morning,
the corset is put on. Generally, though, reclining in bed relieves
the pain.
Paroxysmal pains are also frequent in kidney displacement.
They were first described by Dietl in 1864, and are due to
torsion or kinking of the ureter, with the consequent acute hydro-
nephrosis. That such a twist or kinking is the causative agent in
the production of the pain of this condition would seem to be
verified from the fact that similar pains may be produced by arti-
ficial distention of the pelvis of the kidney by sterile water. In
addition to the hydronephrosis, it is likely that torsion of the renal
DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 625
vessels (especially the vein), by causing a sudden increase of the
intracapsular tension, may also be a partial factor in the pain of
the so-called crises. The attack is generally accompanied by nau-
sea and vomiting. It frequently takes place as a sudden increase
of existing symptoms and, as a rule, foUows excessive or violent
motion, either in the form of exercise or in the jolting incident
to riding horseback, or journeying in springless wagons over
rough roads. In some cases indiscretion in diet may induce the
pains. Generally, the attack subsides as quickly as it began,
though soreness in the loin may persist for some time. The at-
tack, as a rule, is associated with a weak and rapid pulse, cold,
clammy perspiration, and signs of collapse. It generally passes
off in a few hours, but may last for days. Should the pain be due
to torsion of all the renal vessels, with consequent renal conges-
tion and increased intracapsular pressure, it does not at once pass
off on relief of the condition, but persists as a soreness in the
kidney region for some time (Johnston). A transient polyuria
follows each paroxysmal attack.
Associated Symptoms. — The symptoms associated with mov-
able kidney are:
(1) The Urinary Changes. — The urine varies greatly in the
daily quantity. During the time of the acute torsion the quantity
of the urine is decreased and blood, albumin, and casts may be
present. Immediately after the attack the quantity of the urine is
greatly increased and it becomes clearer, though blood is occa-
sionally present, as well as albumin and casts. Painful urination
also is present at times.
(2) A tumor due to hydronephrosis may be noted during the
attack. It disappears after the hydronephrosis is relieved. In
some cases the tumor may represent only the kidney. If such
is the case, the kidney can be replaced by manipulation and the
tumor then disappears.
(3) Digestive disturbances, such as (a) flatulence, which is
the result both of pressure by the kidney on the intestine and of
the transmission of nervous stress from the kidney to the intes-
tines, the latter being due to the intimate association of the two
626 THE KIDNEY
organs through the nervous system, (b) nausea and vomiting,
which are very frequent.
(4) Constipation may be due to pressure on and obstruction
of the bowel by the kidney.
Tenderness. — When a movable kidney is pressed between the
fingers the patient feels a peculiar, sickening sensation, similar
to that felt when pressure is made on the testicle. If, instead
of the sickening sensation, pain results, some inflammatory lesion
of the kidney or some condition producing increased intranephritic
tension is present. Factors influencing the production of pain in
movable kidney are: (1) the position of the patient; standing,
especially if corsets or kidney pads are not worn, is provocative
of very severe distress. Lying down immediately relieves the
pain.
(2) Motion; all violent motions cause painful or distressing
symptoms. Such motions as are present in jumping, running,
and swimming are the most active.
Lesions with movable kidney are: (1) eiiteroptosis, which is
a commonly associated condition, and often is the primary cause
of the kidney lesion; the tympany, which may be present in
nephroptosis, is more a sign of the general enteroptosis than of the
movable kidney; (2) neurasthenia frequently accompanies mov-
able kidney, and is probably due to the pressure and pull upon
the abdominal sympathetic by the displaced organ.
Renal Infarction. — In renal infarct pain is of great value in
forming a diagnosis. The infarction may be either septic or
aseptic. In the septic variety the embolus is infected and is pro-
ductive of much more pain than is the non-infected type. Should
the embolus be infected, after the infarction has occurred there is
a slow increase in the pain. Pain and chills of gradually increas-
ing severity, arising in a case in which they previously have been
absent, are signs that infection has occurred.
Causes. — The causes of pain in infarction are, according to
Halperin: (1) insult to the renal plexus, (2) perirenal inflamma-
tion or inflammatory reaction, and (3) tension on the kidney
capsule (Halperin).
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628 THE KIDNEY
Type of Pain, — The pain is sudden, burning, or stabbing in
character, and is entirely free from any tendency to paroxysms.
It may be felt in the central part of the abdomen (Johnston) or
may be without any definite localization. A point of value in the
diagnosis of renal infarct is that in no case does the pain radiate
into the inguinal region or to the genitalia. Violent motion of
all kinds, such as running, jumping, coughing, and sneezing, in-
creases it greatly. The position of greatest ease is one in which
the patient reclines on the side of the lesion. Tenderness is
present over the affected kidney, particularly toward the back in
the costo-vertebral angle. Anteriorly, the abdominal muscles are
contracted and render difficult deep palpation, so that deep ten-
derness is hard to elicit, although the diffuse tenderness which, is
present is easily defined. Percussion is a valuable means of
diagnosis in this disorder and more definitely localizes the tender-
ness than does palpation.
Differential Diagnosis. — Conditions causing pain from which
renal infarction must be diagnosed are: (1) appendicitis, (2)
gastralgia, (3) perforative peritonitis, (4) acute ileus, (5) gall
f^lones, (6) lead colic, (7) embolism of either of the mesenteric
arteries, (8) gastric crises, (9) lesions of the kidney or of the
ureter, such as (a) torsion of the ureter, which may occur in wan-
dering kidney, (b) paroxysmal exacerbations of chronic nephritis,
(c) calculus colic, (d) pseudocalculus colic, from plugging of the
ureter with debris, of either tuberculous or neoplastic origin,
blood clots, or hydatids, or from obstruction from catarrhal swell-
ing of the mucous membrane, or from functional spasm of the
ureter.
Associated Symptoms. — Symptoms associated with renal in-
farct are : changes and variations in the quantity of the urine. In
the early stage of the attack the secretion of urine may be greatly
diminished or may entirely cease. The urine also always contains
blood, which, in the non-infected cases, may be present alone, but,
if the infarct is infected, pus and bacteria* are also to be found.
Considerable albumin and epithelial casts are present in the urine
during the early stages of the infarction. Vomiting and hiccou^-
DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 629
ing are also common. Frequently there is a history of an asso-
ciated or of a previous infectious disease.
Hematnric Nephralgia. — Hematuric nephralgia (Sabattier) is
a term used to designate a pain of the kidney that is without
a definite causative lesion. In many cases it seems to be an
essential neuralgia. That there is most probably some definite
organic basis for this variety of kidney pain can be judged from
the association of the pain with a hematuria. The productive
agency seems to be a congestion of the active type. The absence
of albumin in the urine in this disorder does not argue against
the presence of a congestion, for the kidney may be extensively
diseased without the presence of albumin in the urine, as has been
proven time after time by examination of kidneys removed for
nephralgia. In hematuric nephralgia one or both kidneys may be
affected.
In some cases, however, hematuria may be present without
any accompanying pain. This usually occurs when coagulation
of the blood has not taken place in the renal pelvis. When it has
occurred, spasmodic pain, typical of ureteral obstruction, is felt.
This variety of hemorrhage and pain production is frequent in
renal tuberculosis, renal tumors, and the like. A part of the pain
present in renal hemorrhage owes its origin to distention of the
renal pelvis with blood.
The presence of pain and tenderness in association with well-
defined Head's zones may be of inestimable benefit in helping to
decide whether one or both kidneys are affected by the inflam-
matory process. The definite localization is of very great prac-
tical value in the operation of capsulotomy or suspension. Should
only one kidney be displaced it is necessary to sling up only one,
and it is most important to know which one.
Inflammation of the Kidney. — Inflammation of the kidney may
be considered under two divisions: (1) congestion, and (2)
inflammation, which, in turn, may be divided into the acute and
the chronic.
CoNGESTiox. — Preliminary to inflammation of any kind is
congestion, which is very common and is frequently encountered
630 THE KIDNEY
during ordinary colds and in various infectious disorders. It is
of two types, (a) passive and (b) active. Passive congestion, as
a rule, is not painful, only the active variety being so. The cause
of pain in active renal congestion is the hyperemia (induced by
local irritants) and the resulting tension on the capsule. It is of
a dull, aching character, and is made worse on movement. Deep
breathing seems to cause more distress than does simple motion.
A characteristic point, differentiating congestion pain from lum-
bago, is that in lumbago the pain is worse in the morning and im-
proves as the day advances ; while in congestion the pain is better
in the morning and is worse in the evening. Also, the pain of lum-
bago is increased on pressure and is eased by fixation, while the
kidney-congestion pain is not eased by fixation with adhesive
straps and is very severe on deep pressure. In acute congestion
disturbances of sensation in Head's zones are present; the urine
also shows the effect of the circulatory disturbances and contains
albumin and casts (blood) to a variable degree. The quantity
daily eliminated is also diminished. The use of digitalis eases a
passive, while it increases an active congestion. There are all
degrees of congestion. Some may be so slight that they cause but
the slightest of transitory disturbances, while others may be of
such severity that they produce symptoms as severe as those found
in inflammation.
A case illustrating the pain phenomena in congestion of the
kidney is that of a young man who, at the time of the taking of
the history, had a congestive inflammatory lesion of the kidney,
with an associated pleural effusion which extended as high as the
fifth dorsal vertebra. He had a well-marked hyperalgesic zone
extending from the spine around the body to the right iliac region.
This hyperalgesic area was thought to be due to the kidney. If it
were due to a nephritis, the hyperalgesia would probably be bi-
lateral; consequently the areas of hyperalgesia would be present
on both sides and would be somewhat symmetrical in outline.
The areas of hyperalgesia in this patient were present only on one
side and strapping did not ease the pain. (If the pain was due
entirely to pleurisy, strapping the chest would probably have
DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 631
eased it.) Consequently, it would seem that the condition was
one of unilateral congestion. The figure below is an outline in
which the cutaneous hyperalgesic area is defined.
Inflammation (Nephritis). — Acute inflammation of the
kidney invariably causes pain, the intensity of which depends
upon the degree of the kidney congestion and the time which the
kidney has had to adjust itself to the circulatory changes. The
Arc» of hyper-
aigesia
Area oi maxi-
iruiii tender-
Deas
12tlirib
Area of maxi-
mum tender-
neiw
Area of hypei^
algesia
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Fig. 143. — Area of Hyperalgesia in Congestion of Kidney.
pain IS a much aggravated form of tBe aching present in the
kidney areas when the kidney is acutely congested. Inflammation
is one of the disorders of the kidney in which sensory disturbances
in Head's zones are very plainly marked. Their presence should
lead, with almost ji certainty, to the correct diagnosis. In renal
inflammation the urine contains casts and is loaded with albumin.
An interesting and valuable point in the diagnosis of this condi-
tion is the co-relation between the extent of the Head zones and
the intensity of the pain and tenderness for, as the hyperalgesia
(in Head's zones) becomes less extensive, the pain and tenderness
also gradually diminish. A peculiarity of inflammatory kidney
pains is that they never become paroxysmal, but are always char-
acterized by dull, constant aching. Stooping is not painful, but
local tenderness is marked. A good way to elicit tenderness is by
percussion, and the best way to percuss is with the whole hand,
the blow being delivered by the ulnar edge of the open hand. The
632 THE KIDNEY
referred pain is not constant. In a bilateral lesion it may be pres-
ent only on one side, and in a unilateral disorder it may be on
the side opposite to the one involved. The zones of Head are of
particular value in deciding which of the two kidneys is involved,
because they are present almost invariably only on the involved
side. If the subjective pain should be on one side and Head's
zones should be present on the opposite side, the latter would be
the side involved. Tenderness may be present on both sides, even
when only one kidney is diseased, or it may be found in the side
opposite to the one in which the diseased kidney is located.
Referred pain due to inflammation of the kidney parenchyma
is uncommon. When present it shows that the inflammation has
extended outside of the capsule into the adjacent perirenal tissues,
and that a perinephritic abscess has formed.
In some cases of nephritis pain is felt in the epigastrium.
Sometimes, also, a dull aching is present across the loins. Raver
has observed that in acute nephritis there is never any retraction
of the ttjsticle or radiation of the pain into the groin, such as are
so frequent in renal calculus.
In kidney disease should the pains become generalized it is
very often a sign of an early fatal termination, because general-
ized pains are the result of a generalized toxemia rather than of
the local process, and a generalized toxemia occurs only in the
most severe and usuallv fatal cases.
Chronic Inflammation, — In contradistinction to acute inflam-
mation, chronic inflammation, as a rule, produces no pain that
might be of value in forming a diagnosis.
Character of Pain in Nephritis. — In many cases nephritis
may be present for years, and not produce the slightest discom-
fort, while in other cases, very shortly after its origin, pains of
great severity, generally paroxysmal in type, may ensue. These
paroxysmal pains are due to an intermittent congestion of the
kidney. At the time of these congestions blood, as a rule, is pres-
ent in the urine.
Other pains associated with nephritis are the neuralgias and
the pains due to neuritis. Headache is the most frequently asso-
DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 633
ciated pain. It comes on periodically (at fairly regular inter-
vals) and, like migraine, may be limited to one side (hemi-
crania). It is located in various regions of the head. It may be
frontal, occipital, temporal, or occipito-frontal, the occipital form
being the most common. Frequently it is of a throbbing char-
acter.
Associated Symptoms. — The symptoms accompanying neph-
ritis are: (1) the presence of albumin, casts, and blood in the
urine, (2) nausea and vomiting, (3) edema, (4) dry skin, and
(5) slight fever and (6) a rapid pulse.
Illustrative Cases. — The following cases are intended to
illustrate the sensory disturbances in Head's zones and their bear-
ing upon the diagnosis and prognosis of nephritis.
Case 1. — The first case is that of Miss A. M. K., a school
girl 15 years of age, suffering from subacute parenchymatous
nephritis. The illness of which the pati^it complained began
about six weeks previous, with shortness of breath, vague pains,
headache, palpitation, coldness of the extremities, digestive dis-
turbances, eructations of foul gases, fetor of the breath, consti-
pated bowels, pains immediately after eating, nausea, and
occasionally vomiting. The patient says she has been voiding
urine, as a rule, only once a day for the past six months and
sometimes not at all for more than twenty-four hours. She says
that her eyes puff up in the morning and that the feet and ankles
are edematous. There is also some disturbance of vision. She
has had measles, chicken-pox, whooping-cough, and had scarlet
fever when seven years of age. Tonsillitis is frequent. The
family history has no bearing on the case. On physical examina-
tion the patient was found fairly well nourished, eyes bright, pu-
pillary reaction normal; pufliness of the lower lids, lips normal,
tongue coated; tonsils appear normal, pharynx bulges slightly;
adenoids are present, respiratory disturbances are absent. The
pulse rhythm changes; otherwise it is full and rapid. The
heart beats are normal in tone ; no valve lesions are present ; the
abdomen is tender and slightly tympanitic; the liver and spleen
are normal in size, but somewhat tender; great tenderness is
ill
V ■
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DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 635
present over both kidney regions ; the glandular system is normal,
with the exception that the postcervieal glands are enlarged; the
urine discloses hyalin and granular casts, albumin, a few cells,
a;nd has a specific gravity of 1.018. The patient complains of
sjabjeetive pain sometimes in the back and in the side; at other
times in the epigastrium. The blood pressure has remained at
140 mm. Hg. (Stanton). The general symptoms are probably
due to the high vascular tension in the abdominal organs.
A B
Fig. 146. — ^Abeas op Hyperalgesia in Kidney and Liver Congestion.
Case 2. — In the case of A. B., seen in consultation with
Dr. P., the kidney areas of nephritis are well defined and are
almost typical. The liver area is also present, because,
at the time of examination, the liver was in a state of passive con-
gestion.
The disease began with a tonsillitis about three weeks before
the examination was made. For the past two weeks the patient
has had no chills nor fever, though the tonsillar ulceration per-
sists. Vomiting was absent at the time of the tonsillitis, but dur-
ing the past week has been severe, especially in the morning.
Headache is present over the right eye. It is a steady, dull pain.
Nose-bleed occurred about six or seven days ago, and a slight
discharge of blood from the nose has since been constantly pres-
636 THE KIDNEY
ent. Dizziness is preeent at times. Buzzing or ringing in the
eara also is constant. The bowels are freely movable. The urine,
at first, WEB very slight in quantity, though at the present time
about two quarts are voided daily. The patient cannot rest lying
down and is compelled to assume the sitting posture. The entire
body is very much swollen and the swelling is worse in the morn-
ing.
Figure 146> A, shows the area of hyperalgesia, A being that
of the liver, which is greatly enlarged and tender; B and C the
Ana* of hyptraeuilivenei*
Fio. 147. — AsEAB OF Hyperalgesia in Nephritis. Tbe letters do not
correspond to the letters in Pig. 146.
areas of the right and left kidneys respectively. In Figure 146
B, the areas A, B, and 0 correspond to those for which A, B, and
C stand respectively in Fig. 146, A. Notice that the areas do
not meet in the median line; also notice the notch on the lower
border of tlie kidney area, and how the lower border extends
over the crest of the ilium. In the back the hyperalgesic areas
meet over the median line.
Examination of the eyes shows them to be normal, with llii-
eKception of au internal squint of the left (^ye. The tongue is
coated. Examination of the chest exhibits a normal heart
Fluid in the pleural cavity is absent.
DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 637
Fig. 147 s^ows the areas of hyperalgesia about one week after
the previous drawings had been made.
The area A in Fig. 147 A is becoming smaller, the diminu-
tion in size being more marked in the upper boundaries than in
the lower, because these boundaries mark the upper limits of the
liver hyperalgesia and, at this time, the. liver was much smaller
and its congestion much less; therefore, its areas of hyperalgesia
would be less. The other areas are not as well defined as thev
were in the last drawings, but they show a concentric, though ir-
regular diminution in size.
In Fig. 147, area B indicates the Byperalgesic zone of the
liver. This area lies above area C, which was more byperalgesic.
This, in turn, was bordered below by an area D of much dimin-
ished sensitiveness, though still byperalgesic; circles in the fig-
ures indicate the points of greatest sensitiveness. In a general
way the patient is much improved; the edema is becoming less
and the urine is increasing in quantity. The throat is also better.
The presence of the referred liver zones would indicate that con-
gestion of itself can produce a Head zone. The gradual disap-
pearance as the edema became less would also be another indica-
tion of potency of congestion as a causative factor in the produc-
tion of a Head zone. Why the area D, which was not present a
week ago, should be developed is rather hard to explain, unless
the adjacent cord cells became irritated, because of their proxim-
ity to those which were originally involved. This argument would
seem to be strengthened from the fact that the hyperalgesia in
this area was not as acute as in the mid-area C.
Perinephritis. — Perinephritis is the name given to the con-
dition in which inflammation is present in the perirenal con-
nective tissue. This inflammation generally progresses to the
point of abscess formation. It is in this lesion that the most pro-
nounced symptoms of any renal disorder appear. The most con-
stant and important of these symptoms is pain with its associated
tenderness.
Character and Location of Pain, — The pain is always severe
and is found in the lumbar region. Owing to the location of the
638 THE KIDNEY
inflammation the lumbar plexus of nerves and the psoas musde
are frequently involved in the inflammatory process. When the
lumbar plexus is involved, the pain is referred to the distribution
area of the nerves connected with it, viz., in the cutaneous distri-
bution area of the iliohypogastric, the ilioinguinal, the anterior
crural, the obturator, and the other branches of the lumbar plexus.
The distribution area of these pains is illustrated on page 677
(q.v.).
The pain in some cases of perinephritis is referred to the
knee. This is apt to cause the perinephritic abscess to be mis-
taken for a diseased hip. A reference of this kind is very fre-
quent when the abscess originates at the lower pole of the kidney,
for abscess formation in this region is more likely to make
pressure upon the anterior crural or the obturator nerves; these
nerves are distributed to the skin of the lower part of thigh
(ant.) and the knee, and when irritated anywhere in their course
refer the irritation (pain) thus produced to these areas.
When the abscess is at the upper pole of the kidney, the in-
tercostal nerves may be involved and pain may be referred to
their area of distribution. When the sheath of the psoas is in-
volved the abscess progresses downward and consequently aflfects
the external cutaneous, the anterior crural, and the genitocrural ;
and the pain is referred to their area of distribution. At the
same time, owing to the functional relation of the psoas to the
thigh, pain on flexion and extension of the hip results. In fact,
motion of all kinds is very painful, especially those movements
in which pressure is exerted upon the kidney and the inflamed,
sensitive tissues adjacent to it Thus, bending forward or back-
ward is almost impossible.
Tenderness. — Palpation and percussion are disagreeable to the
patient. The tenderness elicited by these procedures is most
marked over the renal area, the point of greatest tenderness in
perinephritic abscess being over the fascial triangle of Qrynfelt
and Lesshaf t, or, as it is called by Miller, the kidney triangle. 1 1
is bounded by the erector spin®, the twelfth rib, and the internal
oblique. Here the kidney is nearest the surface, and consequently
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640 THE KIDNEY
pressure at this point is made more directly upon the diseased
tissue. Pain is also felt in other inflammatory diseases of the
kidney upon making pressure at this point, but not to the same
degree as in perinephritic abscess. Tenderness on palpation and
percussion is also present between the crest of the ilium and the
last rib, in the midaxillary line, or somewhat posterior to it
Should a localized peritonitis occur over the inflamed kidney a
marked tenderness to transabdominal pressure will be found. Ac-
cording to RansohoflF, a perinephritic abscess may be diagnosed
from a kidney lesion proper by its exquisite tenderness on super-
ficial pressure, because, on the contrary, in affections of the kid-
ney proper, it requires deep pressure to cause discomfort. A
further point of diagnostic importance is that, in suppuration of
the kidney parenchyma, pressure made from in front through the
abdominal wall causes considerable pain, while in perinephritic
abscesses the greatest tenderness to pressure is in the loin just
below the last rib.
Posture. — As a rule the patient stands with ^^thighs flexed
on the pelvis. In order to relax the psoas he walks with body
bent forward and with the hand of the affected side resting upon
the upper part of the hip. To relax the part the tnmk is some-
times bent laterally, so that the ribs approach the iliac crest"
(Roberts, 127, p. 392). Roberts believes that flexion of the thigh
is an accompaniment of perinephritic abscess, especially if the
abscess is located at the lower third of the kidnev. The flexion
may be so slight as to be hardly noticeable; in other cases it may
be so severe that it resists all efforts at extension. All other
motions of tlie thigh may be painless.
Associated Symptoms, — Other symptoms of value in the diag-
nosis of a perinephritic abscess are :
(1) The presence of a localized, fluctuating swelling in the
lumbar region. The three cardinal features of this swelling,
which render its identification as a kidney lesion easy, are as
follows: (a) it lies entirely on the posterior wall of the abdomen
and, even when very large, does not approach the anterior ab-
dominal wall ; (b) it is diffuse and is not confined to the region
DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 641
of the kidney proper; its limits, also, cannot easily be defined;
(c) it is not influenced by respiration (a kidney enlargement due
to disturbance in the parenchyma of the kidney will move with
respiration).
(2) Aspiration of the tumor mass generally reveals pus.
(3) Gastrointestinal symptoms, such as vomiting, tympany,
and constipation, are present
(4) Jaundice sometimes occurs in perinephritic abscess on
the right side.
(5) There is frequently a history of an injury or of a renal
infarction. In the first, trauma is followed at first by renal ten-
derness, then by chills, and fever, and lastly by the tumor.
(6) In some cases there is a fixation of the lumbar spine with
scoliosis, the concavity being on the side of the diseased kidney.
(7) When the sheath of the psoas is involved extension of the
limb on the affected side is painful, while at the same time all
other movements can be made without pain. This differentiates
it from hip-joint disease.
(8) A characteristic of perinephritic disease is the high white
blood count (Morris, Booth, Miller).
(1)) Painful breathing, coughing, sneezing, etc., are some-
times present and may be due to involvement of the pleura.
Retraction of the testicle toward the affected side has been
given as an important sign; but according to Nieden it does not
occur unless a calculus nephritis is present in addition to the peri-
nephritic abscess. This statement is doubted by Roberts (127,
p. 392). When it occurs the retraction is due to involvement of
the genitocrural nerve (Roberts, p. 405).
Differential Diagnosis. — Perinephritic inflammation may be
confused with pleurisy. Hepatitis should be differentiated from
perinephritis on the right side; splenitis from perinephritis on
the left. Pneumonia also is sometimes mistaken for perinephritis.
It should also be diagnosed from osteomyelitis of the vertebra
and appendicitis with abscess formation.
Bnptnre of the Kidney. — While rui)ture of the kidney with-
out pain has been reported, it is almost inconceivable how this
642 THE KIDNEY
severe lesion could occur without producing at least some pain.
The rupture may tear into the perinephritic tissue ; when it does
so there is felt a sudden, sharp pain, not restricted to any area,
but generalized and diffuse. If the rupture is such that hemor-
rhage takes place into the pelvis of the kidney severe pain,
paroxysmal in type, ensues, and is due to the passage of blood
clots down the ureter. At the same time there is a transitory
hydronephrosis. One of the surest of the confirmative signs of
rupture is hematuria; however, there is an exception in slight
rupture of the cortex, in which, unless there is a concomitant
injury to the pelvis, blood may not be present in the urine.
Following the rupture, if it has not proved fatal, a perineph-
ritic abscess generally develops.
Tuberculosis of the Kidney. — Tuberculosis of the kidney may
or may not be painful. In some cases pain is present only in the
terminal stages of the disease, while in others it may be one of
the earliest symptoms. According to Maylard pain is absent as
long as the lesion is confined to the parenchyma, and, when pain
is present in the early stages, it is more vesical than renal in
origin. When present it occurs before and after urination and
is associated with increased frequency of the urinary act. In
these cases the symptoms are such that even in a normal bladder
cystitis might be diagnosed. In all advanced cases, however,
it is foimd, and should it be present in the absence of gonorrhea,
trauma, instrumentation, or stone, it must be looked upon as pre-
sumptive evidence, especially in the young, of renal tuberculosis
(Ransohoff).
Character of the Pain. — When the disease is fairly well ad-
vanced pain is a most important symptom. It is localized to the
side of the kidney and may radiate to the inguinal or to the iliac
regions. It may be produced spontaneously or be felt only on
pressure. According to Brazy, the three points on the anterior
abdominal wall where, in renal tuberculosis, pain is most likely
to be produced on pressure are the paraumbilical, the subcostal,
and the lumbar (Figs. 148 and 149). If the tuberculous process
advances beyond the capsule and invades the paranephritic tis-
DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 643
sues, the pain and tendemesB in the costovertebral angle become
excessive. In tuberculosis of the kidney Head's zones of reflected
hyperalgesia are sometimes present. When present they are, as a
rule, synchronous with the so-called ureteral colic, due to the pas-
sage of detritua, blood clots, pieces of necrotic tissue, etc., through
the ureter. The tissue and clots block the ureter and distend the
pelvis of the kidney either with urine or with blood. The intra-
nephritic pressure now becomes excessive and it is to this, and not
to spasm of the ureter, that the pain, paroxysmal in type, is due.
Fios. 148 AND 149. — ^Abbas of Tendbrness Present in Rehai. Tdber-
GULOSIB.
There are two types of pain in renal tuberculosis. The first is
the constant, steady, aching pain, which may be interrupted by
the paroxysmal paina, the second type. In some instances, sud-
den, acute, paroxysmal pain may be present without obstruction
of the ureter by clots or by pieces of necrotic tissue or other ele-
ments. It is, then, probably due to an acute congestion of the
kidney, with a great increase in the intracapsular tension. For-
tunately for the comfort of the patient, these paroxysmal attacks
are rare.
In kidney tuberculosis tubercle bacilli often can be discovered
in a eentrifugalized specimen of urine obtained by ureteral cathe-
terization.
644 THE KIDNEY
In many cases the tuberculous disease of the kidney may not
produce any well-marked pain, but rather a diffuse aching, discom-
fort, or a dragging sensation in the lumbar region. As sometimes
happens in other varieties of kidney disease, the pain and distress
may be referred to the kidney area on the side opposite to the one
affected.
Diagnosis. — Pain in the kidney region, in those cases in which
tuberculosis is present in other parts of the body, should always
lead to the suspicion of a probable tuberculosis of the kidney.
The diagnostic signs of tuberculosis of the kidney are :
(1) The presence of the characteristic pain.
(2) The discovery of blood, pus, cells and tubercle bacilli in
the urine. In some cases the presence of blood in the urine may
precede other symptoms of the disease for many years. Precipi-
tancy of urination is frequently present.
(3) Elevation of temperature is present in a fair proportion
of cases.
(4) Increased rapidity of the pulse is common. It generally
varies with the fever and is of a hypotension type.
(5) Lung symptoms, or signs of tuberculosis in other regions
of the body, are often found.
(6) Enlargement of the kidney is generally an early symp-
tom. The kidney is tender to pressure, and since the enlarge-
ment is commonly due to pyonephrosis it varies with the painful
crises.
(7) V. Pirquet, subcutaneous, and Calmette reactions for tu-
berculosis are, as a rule, present.
New Orowths. — New growths of the kidney are of two types,
the benign and the malignant. In either case, pain is not a symp-
tom of much value. The benign growths causing pain are cystic
in character, and may consist of simple cysts, polycysts, or hyda-
tids. The malignant growths are sarcoma, carcinoma, and hyper-
nephroma (Grawitz' tumor).
Etiology. — The pain in all of these conditions is due:
(1) To the dragging upon the surrounding tissues by the kid-
ney, because of its increased size and weight.
DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 645
(2) To an increase of intracapsular pressure, from (a) a
hydronephrosis, the result of a kinking of the ureter from a ptosis
of the kidney, or a blocking of it by a blood clot or a par-
ticle of the malignant tissue; (b) increase in the size of the
growth (a slow and gradual increase in size is not painful, it is
only when the increase is sudden that the pain is pronounced) ;
(c) a hemorrhage into the substances of the growth or into the
parenchyma of the kidney. This occurs more frequently in sar-
coma and carcinoma (Johnston) than in other growths. Indeed,
it is claimed that in these growths pain is not produced unless an
intracapsular hemorrhage has occurred. Sometimes, when the
new growth penetrates the pelvis, hemorrhages ensue and hema-
nephrosis, with its consequent pain, results.
(3) Contracting abdominal muscles, also, may, by pressing
upon tender kidneys, cause pain.
Character of the Pain in New Growths of the Kidney.
— The sensation present in these disorders is rather an aching
and discomfort than actual pain, though at times, when the
intracapsular tension is greatly increased, the pain becomes
most acute and assumes a paroxysmal character. Because as a
rule only one kidney is involved the pain is unilateral. It may be
caused, and in most cases is aggravated, by violent movements,
such as jarring, the lifting of heavy objects, or the carrying of a
heavy weight. The pain may radiate to the thigh. This radia-
tion is due to the pressure exerted upon the lumbar plexus by the
enlarged and heavy kidney.
Varieties of New Growths. — Cystic Disease. — (1) Simple
Cysts, — In these conditions the pain has been known to precede
the formation of the cyst. When the cyst has formed the pain is
of a dull aching type, and is varied with sharp paroxysms, which
are associated with enlargement of the kidney. These exacerba-
tions are probably due to a hemorrhage into the substance of the
cyst.
(2) Polycystic Disease, — In this disorder, if only one kidney
is diseased, the pain is on the diseas(Ml side. Should both kidneys
be affected the pain is bilateral. It may be constant or intermit-
646 THE KIDNEY
tent, is less when the patient rests in bed and is quiet, and is very
much increased upon movement. As in simple cysts, hemorrhage
may occur into the substance of the growth and produce great pain.
Considerable tenderness on pressure is present in the costoverte-
bral angle. The diagnostic symptoms associated with a polycystic
growth of the kidney are (a) the presence of a tumor (kidney),
which is mobile and contains knobs on the surface, and (b) the
character of the urine, which is increased in quantity, is of low
specific gravity, and contains a slight amount of albumin, casts,
and blood. It also contains bodies resembling those found in the
prostate.
(3) Hydatid Disease. — ^In this, as a rule, pain due to struc-
tural kidney change is absent; but in its stead is colic, due to
blocking of the ureter by the booklets. These booklets can some-
times be detected in the urine.
(4) Sarcoma of the Kidney, — This gives rise to pain of a
dull, dragging character, referred to the lumbar region or to the
thigh. Paroxysms of colic occur when the ureter is temporarily
blocked by blood clots or by pieces of -sarcomatous tissue.
(5) A hypernephroma may be without pain. Its onset may
be so insidious that its presence is not discovered imtil the size
of the tumor draws attention to the condition. Then pain may
ensue and aggravate further the discomfort and distress of the
patient. The pain may be constant, dull, and aching, or it may
be paroxysmal, the paroxysms occurring when the kidney capsule
is subject to considerable intranephritic tension, either from back-
ward stasis of the urine (a clot in the ureter) or from hemorrhage
either into the parenchyma of the kidney or of the tumor. The
pains may radiate into the pelvis or down into the thighs. Both
the kidney and the related tumor as a rule are very tender to
pressure. Ileraaturia is the most frequent associated symptom.
Diagnostic Symptoms. — Tumors of the kidney have the
following diagnostic symptoms (Piersol and Morris) :
(1) The large intestine is in front of the tumor. This does
not happen with liver or splenic tumors. If the colon is distended
with gas it produces a tympanic mass anterior to the tumor, while
DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 647
if collapsed it can often be felt as a roll of tissue beneath the
fingers.
(2) Renal tumor causes an anterior bulging into the abdo-
men. A posterior bulging generally indicates a perinephritic
abscess.
(3) 1^0 area of resonance, such as is found in tumors of the
spleen, is present between the dulness of the tumor mass and the
vertebrae.
(4) A kidney tumor retains somewhat the shape of the kidney.
(5) It generally does not reach the midline.
(6) There is an area of resonance on the right side between
the dulness of the liver and that of the kidney.
(7) Varicocele is often present on the side of the tumor.
(8) The tumor generally does not extend into the pelvis, and
generally does not move, to any considerable degree, with respira-
tion.
Associated symptoms may also be produced from obstruction
of the colon and also from traction on the spleen, the liver, or the
diaphragm.
Pyelitis. — Character, Causation, and Localization op
Pain. — In pyelitis pain may or may not be present, although in
about seventy-five per cent, of the cases it is manifested at some
time during the course of the disease. The pain is more severe
in the acute varieties, or in exacerbations of the chronic forms.
These exacerbations are sometimes the result of cooling of the
surface, such as occurs in getting drenched, or even in having
the feet wet or damp, and in being exposed to drafts or to chill-
ing. The chilling of the surface drives the blood inward and pro-
duces a congestion of the already inflamed kidney, with an exacer-
bation of the pain. The pain usually is felt in the back (in the
kidney area), and has a tendency to radiate to the thigh, the peri-
neum, the genitalia, or upward to the epigastrium or shoulder.
It is generally increased by pressure.
It is possible that pyelitis of itself does not produce pain un-
less there is a concomitant involvement of the kidney paren-
chyma. When such involvement occurs a slight tension of the
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DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 649
capsule may result, and both subjective and objective pain be
felt. The pain may appear in the form of an aching in the back,
or of tenderness over the diseased kidney.
These renal pains may be followed or accompanied by ureteral
colic, due to the blocking of the ureter by debris. This variety
of ureteral colic is hard to diflFerentiate from calculus colic. A
means of distinguishing it is by the X-ray, which defines a shadow
if a stone is present; or by the wax-tipped catheter, which shows
a scratch should stone be encountered. If the pain changes to a
dull, constant, or possibly throbbing type and chills and fever
appear, it is an indication that a pyelonephrosis or a renal abscess
is forming or has formed.
Pyelonephbosis and Pabenchymatous Infection. — In-
flammation of the kidney pelvis of itself may not produce pain
symptoms until some secondary complication such as (1) pye-
lonephrosis or (2) parenchymatous infection takes place. The
former, pyelonephrosis, produces symptoms that resemble in their
complex the paroxysms of ureteral colic. Both have the same etio-
logical relationship to pain production, which is due to ureteral
obstruction. This obstruction may be caused by blood clots, fibrin,
pus, necrotic tissue, inflammatory swelling, or organized exudates.
A peculiarity worth remembering is that pyelonephritic pains
generally precede the parenchymatous ones. Parenchymatous in-
volvement also causes pain symptoms which we have learned to
associate especially with kidney involvement. It is likely that
the irritation of the parenchyma gives rise to sensory signs in
the Head zones, while the capsule tension, also due to the paren-
chyma involvement, causes the achings so constantly found in the
lumbar region.
Therefore, in pyelonephrosis or in hydronephrosis, the pain is
due both to ureteral spasm and to capsule stretching, and Head's
zones will be absent, while in parenchymatous involvement Head's
zones and the capsule tension pains will be present, while the col-
icky pains are almost invariably absent.
DiFFEBENTiAL DiAOxosis. — One is likely to err in the diag-
hobIs of lesions of the kidney or of the upper part of the ureter.
660 THE KIDNEY
because involvement of the upper part of the ureter causes the
pain areas to be so distributed that they correspond to the kidney
zones. Yet if it is borne in mind that a ureteral colic cannot be
due to a lesion of the kidney without ureteral obstruction, the con-
clusion may be reached that the lesion is of such a nature that it
involves both the kidney and the ureter. Should pain be present
in the kidney area prior to its presence in the ureteral area, and
should the latter become manifest only during a severe colic, or
should pain in the ureteral area disappear after the colic, with the
persistence of a kidney zone, a lesion of the kidney, which causes
intermittently a renal colic, may be diagnosed. Among such
lesions are the following:
(1) Pyelitis or Pyonephrosis. — In these conditions colic, due
to the passage through the ureter of masses of exudate, such as
collections of fibrin, or pieces of kidney substance which have be-
come disorganized and cast off, is sometimes present. Kidney
aiid ureteral zones are both present. The kidney zone persists
after the obstruction has been removed, while the ureteral zone
disappears.
(2) Renal Calculus. — Here the pain comes on quite sud-
denly, and the ureteral zone and the kidney zone from the asso-
ciated hydronephrosis are both present. When the obstruction is
removed, and the dammed-up fluid escapes, the kidney and ureteral
zones disappear simultaneously.
In pyelitis, pyonephrosis, and ureteral calculus an intermit-
tent hydronephrosis occurs, and on bimanual examination the
physical signs associated with it are found. Such signs are: (1)
tumor, which is in the kidney region, and which increases in
size during the period of colic, to rapidly decrease in size on the
subsidence of the colic; (2) subjective pain in the back over the
location of the kidney; (3) tenderness to deep pressure over the
kidney region, the tenderness being especially well marked at the
time of the hydronephrosis.
It is easy to understand how difficult it is definitely to decide
from the pain complex the character of the kidney involvement,
and the stage at which it rests. But with constant endeavor and
DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 651
close application in nearly all cases it is possible to do so. For a
proper realization of the non-importance of their absence it must
be recalled that disturbances in Head's zones are not constantly
present, especially so should the attack under observation be only
one of a series which has preceded it. During the preceding
attacks the nerve filaments may have been destroyed to such an
extent that subsequently they are not able to carry stimuli. Thus
they are not able to respond to irritation. This is the reason why
the Head zones are so often absent in parenchymatous involve-
ment.
Pyelitis in Pregnancy. — Pyelitis is frequent in pregnant
women, and is due to the pressure of the pregnant uterus upon
the ureter, with a consequent stasis and infection of the urine.
As a rule the infection comes from the adjacent colon^
In these cases pyonephrosis accompanies the pyelitis, and all
the signs and symptoms usually associated with the former are
present. However, inflammation of the renal pelvis itself does
not cause pain unless there is a concomitant obstruction of the
ureter by the pregnant uterus (Pilcher). To produce pain it is
not necessary that the pyonephrosis be severe; in some cases a
very slight distention will cause the most severe pain. A pelvis
containing only one ounce of pus has been known to produce con-
siderable pain. The reason for this is that the existing inflamma-
tion of the pelvis has penetrated to the parenchyma, and has
caused it and the capsule to be more sensitive to stretching, and to
react with pain production to a lesser threshold pressure than
they would in their normal condition. The hydronephritic symp-
toms may be intermittent. They may disappear for a time only
again to reappear with increased intensity.
Symptoms Associated with Pyelitis. — In pyelitis a careful
examination of the urine is most essential to the making of a
proper diagnosis. The presence of pus cells in the bladder urine
is not of such special diagnostic import as are pus cells found
in a specimen of urine catheterized from the ureter. Ureteral
catheterization also gives a clear indication of the kidney which is
involved. The temperature in pyelitis, as a rule, has a typical
662 THE KIDNEY
septic curve. In some cases the temperature curve is present for
some days before the attack of pain. Chills are generally coin-
cident with the paroxysmal pains. They are due to the absorp-
tion of septic material from the dammed-up urine.
Owing to the sympathetic relationship of the bladder and
the kidney, secondary bladder symptoms, or rather preliminary
bladder symptoms, since in nearly all cases they precede the other
symptoms, are frequent. The symptoms especially associated with
the bladder are frequency and difficulty of urination.
Pyonephrosis is an advanced type of pelvic inflammation in
which a retention of urine from ureteral obstruction has taken
place. In the very early stages of this condition the pain is not
different from that 1)resent in the lesion from which the pyone-
phrosis originated. Later, pain typical of a hydronephrosis occurs.
The inflammatory process now travels through the tubules into
the parenchyma of the kidney and a general inflammation of the
kidney structures ensues, the so-called pyelonephritis. However,
a hydronephrosis does not always precede the formation of a
pyonephrosis; the preceding condition may have been a pyelitis,
without any accumulation of fluid in the renal pelvis. When
pyelitis is present without pelvic distention, pain is absent, and
only comes on when the pelvis of the kidney begins to dilate, and
tension is made upon the kidney capsule, when a diffused, dull
aching in the back is felt. At the same time disturbances in the
kidney (Head) zones may become prominent, so that in many cases
they are a sign of value. Should the disease still further progress
and become extracapsular, tenderness to pressure is excessive;
breathing becomes difficult, and motion of all kinds is greatly
limited. At this time a perinephritis may develop. Urination
becomes painful and frequent, and pain is referred to the glans
penis and down the thigh (p. 609). The patient walks or re-
clines with the body bent toward the affected side, and in many
cases the thighs slightly flexed on the abdomen. Pain may also be
present on pressure anteriorly over the abdomen, and posteriorly
over the flank ; in some cases the anterior pressure may cause pain
lind the posterior pressure may give relief.
DIAGNOSIS OF KIDNEF DISEASES CAUSING PAIN 663
Symptoms associated with a pyonephrosis are:
(1) The presence of pus in the urine. It may be present only
occasionally in intermittent pyonephrosis, being absent at the
time the ureter from the diseased kidney is blocked, but appearing
again as soon as the obstruction is removed. Its reappearance is
concomitant with a greatly increased urinary flow. Pyelonephritis
can often be diagnosed by the presence in the urine of casts com-
posed of pus cells. It may be distinguished from pyonephrosis
in that in the latter condition cellular casts are absent and large
quantities of urine and pus are passed at intervals, at which time
the symptoms referable to obstruction are relieved.
(2) Chills and fever, usually associated with a septic infec-
tion, are present
Hydronephrosis. — Causes. — ^Hydronephrosis is due to an ob-
struction of the ureter. It is of two types, constant and intermit-
tent. Constant hydronephrosis is the result of forces acting con-
stantly. Intermittent hydronephrosis is the result of some cause
acting intermittently, and is due to the blocking of the ureter by a
stone, blood clot, or piece of necrotic tissue.
Character of the Pain, — Pain in hydronephrosis is not marked,
except when the intranephritic tension is suddenly raised. Should
the obstruction be complete pain at first is very severe, then gradu-
ally ceases, because, as a rule, under such circumstances the secre-
tion of urine soon ceases and pelvic distention does not persist.
The pain in the majority of cases of hydronephrosis is of a drag-
ging or dull aching type, and may be continuous or intermittent.
The intermittency indicates that the ureteral obstruction is not
complete, and that at times there occurs a partial relief of the
pressure from some of the urine being forced through the semi-
patulent canal.
Sudden and severe pain may occur if the hydronephritic sac
should rupture into the abdominal cavity. Peritonitis then results
and the pain assumes the character of the pain associated with
that condition. It may radiate to the back above the pelvic brim,
or around the side to the external genitals.
Sudden subsidence of the pain in hydronephrosis indicates
654 THE KIDNEY
that the obstruction to the onward flow of urine has been removed,
either because it has been forced into the bladder, or because the
material (calculus) which was acting as a valve at the entrance
of the ureter has been forced back into the pelvis of the kidney,
thus allowing the passage to be free (ball-valve action).
Associated Symptoms, — Associated signs of hydronephrosis
are: (1) the presence of a tumor, located below the costal margin.
It is round, smooth, or lobulated. The colon is anterior to it or
is on its inner side ; in this particular a tumor or enlargement of
the kidney differs from that of the gall bladder, intestine, omen-
tum, or appendix, which are generally anterior to the colon.
(2) Nausea and vomiting are very common in the cases of
acute hydronephrosis.
Points that lead to an almost positive diagnosis of hydro-
nephrosis are: (a) the presence of a dragging pain in the back,
(b) a tumor mass in the kidney region, and (c) a decrease or
increase in size of this tumor mass, occurring simultaneously
with an increase or decrease in the amount of the urine, (d) ure-
teral catheterization and distention of the renal pelvis by meas-
ured quantities of salt solution, (e) injection of coUargol into the
renal pelvis, and then a Roentgen picture (these will clearly indi-
cate the lesion).
Hydronephrosis in Pregnancy. — ^During pregnancy the uterus,
because of unilaterai enlargement, or because of its peculiar posi-
tion in the pelvis, may make more pressure upon one than upon
the other ureter. The consequence is that, if the pressure is great
enough, a unilateral hydronephrosis results. This causes consid-
erable annoyance to the patient and much anxiety to the attending
physician, for, when the stasis occurs, violent pain, due to the in-
creased tension in the pelvis of the affected kidney, is produced.
Because of slight temperature, the presence of pus in the urine,
the appearance of a mass which is tender in the lumboiliac re-
gion, and the constant complaint of the patient, a condition of
this kind sometimes is mistaken for a lumbar or perinephritic ab-
scess; yet the normal leukocyte count, the marked remission fol-
lowing a copious discharge of urine, the low position of the uterus,
DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 655
the relief which sometimes follows the assumption of the abdom-
inal prone position, and the late stage of pregnancy, aU point to
a pressure hydronephrosis with a slight infection. After deliv-
ery the condition passes off without any permanent ill results.
A case illustrative of this condition is that of Mrs. M ,
eight months pregnant, who at times would have severe pain on
the right side in the kidney region. The pain would be accom-
panied by a lumbar enlargement on the same side. The pain and
enlargement would both disappear synchronously with the ap-
pearance in the urine of a considerable number of pus cells. At
the same time the quantity of urine would be greatly increased.
After delivery all the symptoms disappeared.
Benal Calculus. — Renal calculi may lie in the pelvis of the
kidney for many years without producing symptoms. Several
cases have been reported where stones weighing as much as one
ounce have remained quiescent in the kidney for long periods of
time. In one case the presence of the stone was entirely unknown
to the patient until an abscess formed and ruptured posteriorly.
If these stones do not at times produce symptoms it is necessary
to know what must occur before their presence becomes so intoler-
able as to draw attention to them.
Etiology of Calculus Pain, — From a long series of observa-
tions it has been concluded that renal calculi do not produce pain
•symptoms unless a blocking of the ureter occurs.
For a long time and by many observers it has been held that
a spasm of the ureter is the cause of pain in calculus colic, and it
has only recently been determined that the pain of renal calculus
is not due to spasm of the ureter, but is caused by tension on the
renal capsule from back pressure of the urine. Many cases con-
firmative of this could be cited, but Sevan's case, which is de-
scribed on page 605, will illustrate the point exactly. Fenwick,
in 1893, was one of the first to suggest this explanation of a
calculus colic.
That the distention of the ureter is not the only cause of renal
calculus pain, and that the ureter itself has some place in the
pain production, is seen in the changing position of the pain as the
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DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 667
stone gradually progresses downward toward the bladder. The
cause of this changing pain is the progressive distention of the
ureter proximal to the stone, for, as the stone advances, the dila-
tation progresses downward and the pain likewise becomes lower
until it merges into that due to bladder involvement. The reason
that the passage of some calculi is painful and that of others is
not is that those which are not painful as a rule are small, and
do not block the ureter to as great a degree as do the larger ones.
A stone that is sharp also may cause considerable irritation and
consequent inflammation of the mucous membrane, and thus
block the ureter, and give rise to greater pain than a smooth stone
of much larger diameter. Oxalate of lime calculi are rough, hard,
spiculated, and nodulated, and are more painful than the uric
acid stones, which are smooth.
The blocking of the ureter may be due to the calculus itself
or may be the result of the lodgment in the ureter of clots or of
fragments of debris, the consequence either of hemorrhage or of
infection secondary to the calculus formation. If the obstruc-
tion of the ureter is acute and complete, pain, which at first was
a prominent symptom, gradually becomes less marked and finally
disappears. This disappearance is accounted for by the slowly
progressive decrease in the urinary secretion, so that the pressure
in the renal pelvis, which at first was excessive, becomes less and
less, and finally is entirely absent. If in any stage of this process
the back pressure urine should be infected, or should infection
occur later, when the fluid in the renal pelvis has been absorbed,
a new factor in the pain production makes its appearance. For
this infection causes irritation to the kidney cells, pus again
accumulates in the renal pelvis, pressure is again exerted, and
pain once more appears.
This secondary pain is of a serious prognostic import. It tells
the tale of progressive kidney disaster, for as soon as pus invades
the parenchyma of the kidney, and a kidney abscess with marked
sensory disturbances in Head zones appears, it indicates further
spread of the infection, on its evil march of progress. It now soon
extends to the perirenal tissues, and forms a perirenal abscess.
668 THE KIDNEY
From this arises the last set of symptoms of this grave disorder.
For a description of these symptoms see Perinephritis.
Character of Calculus Pain. — In nearly every ease of renal
calculus pain is present at some time in its course. This pain may
be either constant or paroxysmal. The more or less constant pain
is present when the stone is in the renal pelvis and is too large
to enter the ureter. Because of its position it may have a ball-
valve action, and unless the inflammation is more or less severe,
the pain is not constant, so that when the pain does become con-
stant it indicates that inflammation of the renal pelvis has oc-
curred.
The paroxysmal pain complained of, as a rule, is very sudden
in onset and is unilateral. It is mostly on the side of the affected
kidney, but has been known to be present on the opposite side
(reno-renal reflex). It is present in half the cases of renal cal-
culi, and is of the greatest severity. In fact, it may be so severe
that the patient, under its influence, becomes irrational and de-
moniacal.
At first it is more of an intermittent or constant aching or
dragging in the small of the back. This at times is interrupted
and aggravated by twitches of pain, until suddenly some day an
attack of the greatest intensity occurs. The pain now switches
from the back, and may run around the crest of the ilium to the
anterior abdominal wall, and be located beneath the ribs or in the
iliac region. It may also be felt in the groin or in the tes-
ticle of the affected side, following the course of the genito-
crural, the ilioinguinal and the iliohypogastric nerves. It may
even be felt in the leg in the course of the lumbar nerves, and,
though it may go as far as the toe (anterior-crural), it rarely
runs farther than the knees. TJie testicle during an attack is pain-
ful and sore. It is said by Head that retraction of the testicle
takes place as soon as the stone reaches a point above the pelvis.
The scrotum is not affected. The reason of this is that originally
the testicle was an intraabdominal organ, arising at about the same
visceral level as the kidney. It gradually became more and more
displaced downward, until it reached its present position. As it
DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 659
descended it carried with it some of its coverings and its own
nerve supply; this nerve supply arises from the same cord seg-
ment as do the nerves supplying the kidney and upper part of
the ureter. Consequently any lesion in the kidney may reflexly
cause pain to be experienced in the testicle. The scrotum is not
aflFected because it derives its nervous supply from a different set
of nerves which are not in any way intimately related to those
supplying the kidney or ureter.
Duration of the Attach— The duration of the attack is vari-
able. It may last only for a few minutes or for as many hours.
Generally it lasts until the stone has either been forced back into
the kidney pelvis, has entered the bladder, or until dilatation of
the ureter has taken place, so that the urine can pass around the
stone. As the stone approaches the bladder, frequent and painful
urination occurs. When the condition has persisted for some
days exacerbations of pain are frequent at night, and are probably
due to pressure on the kidney by gas passing down the bowel
(Jackson). Attacks of pain may at times be caused by an over-
loaded colon. They may also occur spontaneously or be due to
mechanical means, such as jarring or vibratory movements. Ma-
nipulation of the kidney also incites an attack. Sudden cessation
of the pain generally indicates that the stone has passed through
the ureter into the bladder.
Location of the Pain. — In renal calculus there are three va-
rieties of pain: (1) local pain, (2) referred pain, and (3) re-
flected pain.
In the renal calculus disorders, the local pain, as a factor in
diagnosis, can practically be disregarded. It is not present,
except in the form of tenderness, which will be considered later.
Referred pain is the name given to the pain which is trans-
mitted along the course of the spinal nerves from an irritation
on one of their branches. Here is, indeed, a hornet's nest, for it
is almost impossible, in this connection, to differentiate the re-
ferred from the reflected pains, inasmuch as both are transmitted
along the same nerve fibers, though each has a slightly different
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DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 661
distribution area. Yet it is not of absolute importance, as far aa
diagnosis is concerned, to differentiate between the two.
Below will be shown the distribution area of the spinal
nerves, and at the same time the distribution area of the zones
of Head, which represent the reflected pain. The reno-renal re-
flex also represents a reflected pain.
Fio, 152, — Head Zones of Hyfer-
ALGK6U USUALLr AsBOCUTED
WITH Kidney Lesions: In-
terior View.
Fio. 153. — Head Zones op Hypeb-
ALOBSiA Usually Associated
WITH Kidney Lbsions: Pos-
tbhioeVibw.
Figures 150 and 151 show tht reaa of distribution of the cere-
brospinal nerves, figures 153 and i:3 show the area of distribution
of the cord zones.
From the accompanying figures it may be seen how closely the
distribution of the spinal zones corresponds with the distribution
area of the spinal nerves. As the calculus progresses down the
ureter, these areas of hyperalgesia extend lower ano ::"-'er (from
the tenth dorsal to the first lumbar), so that in some cases the
progress of the stone may be defined by the progressively lower
location of the hyperalgesic areas. The circles which are shaded
indicate the maximal points of tenderness of the respective zones.
When the colic comes on and ureteral dilatation occurs, these
662 THE KIDNEY
areas of maximal pain are most exquisitely tender, and by the
uninitiated are often mistaken for tenderness in an underlying
organ.
The following drawing is from Head, and the accompanying
legend will sufficiently explain it.
Reno-renal Reflex. — In some cases of renal calculus the pain
may be reflected entirely to the opposite side. Although there has
underDaiol lOtb
mud nth donal
Very tender ipoU Ana of digtcibution ol lOtb,
lIlhuDd laihdatuJ
Fig. 154. — Area of Cutaneous Hyperalqebia in Severe Renal Colic
IN WHICH THE Stone was in the Ureter. "The pain starts behind
at the tip of the twelfth rib and runs forward to a point in the left
iliac fossa, thence to a point above the internal ring, then to the
pubes, and thence to the inner aspect of thigh where it ends just above
the knee." (Head, Briun, Vol. XVI, p. 76.)
been much controversy in regard to this condition, there can l>e
no doubt that this so-called reno-renal reflex is occasionally present.
In it pain may apparently be associated with one kidney which is
entirely healthy, while the other kidney is diseased. Mr. Morris
does not believe in its presence, and in his work, '"Surgical Din-
eases of the Kidney and Ureter," says that "this theory is un-
sound and dangerous if acted upon"; but Mnylard quotes a case
of his own, confirmative of it, namely: A man, aged 28, com-
plained of a "nagging pain in the right iliac region, which
seemed to him to pass upward and lodpe in the right iliac lumbar
DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 663
region, where it produced a dull, sickening sensation. It would
linger there for twenty-four hours, during which time he would
vomit. Urine, after one of these attacks, contained albumin and
red blood cells, but not tube casta. Maylard explored the right
kidney and passed a catheter down the right ureter, but nothin»
could be detected. Suppression of urine developed immediately
after operation, and the patient died on the fourth day. On post
mortem the right kidney was perfectly healthy, but the left one con-
FiG. 155. — Pressure Made upon Ureter in Endeavor to Obtain Local
Tenderness. The pressure is made directly over the region where the
ureter passes over the pelvic brim and enters the cavity of the pelvis.
tained in one of the upper ealice^ a calculus about us large as a
pea," (ilaylard, ^'Abdominal Pain," p. 101.) Other cases, too
numerous to mention, confirmative of this condition could be
cited. Prout, in 1S40, was probably the first to draw attention
to this refiex.
Therefore, in all kidney cases it is most necessary, in-order
that mistakes may not be made, that this peculiar and unusual
transference of the symptoms be considered. JIany a tragedy of
surgery has occurred because the surgeon was ignorant of this
phenomenon. Its manner of occurrence is explained under the
description of the reflection of kidney pain. In all cases of sus-
pected kidney disorder the attending physician and, most of all,
the Burgeon,- should not rely too much upon the character of the
664
THE KIDNEY
symptoms to define the kidney affected. In every case one always
has the ureteral catheter with which to collect a little urine, and
thus possesses the means definitely to localize the lesion.
At times it is very difficult, from the pain phenomena alone,
to localize the stone to a certain definite part of the ureter, for
occasionally a stone in the lower end of the ureter will produce
pain in the kidney area, while one in the upper part of the ureter
or in the pelvis of the kidney will produce pain along the entire
distribution area of the zones associated with the ureter.
Toumier's points
Fig. 156. — Tournier's Points op Pressure in Kidney and Urbtbb
Lesions.
Tenderness, — Tenderness is always present in calculus disease.
It may be of the superficial type found in the maximal points of
tenderness of the Head zones, or it may be the local tenderness
found over the affected kidney (anterior or posterior) or along
the course of the ureter. •
The upper part of the ureter and the lower extremity of the
kidney approximately may be reached by pressure at the level of
a point described by Toumier as being ^'situated at the intersec-
tion of a transverse line drawn between the tips of the twelfth
ribs with that of a vertical line drawn upward from the junction
of the inner and middle thirds of Poupart's ligament."
Tenderness at this point indicates a painful lesion of the
DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 665
ureter, such as is produced by ureteritis, tuberculosis, or calculus.
The intersection of a line drawn between the two iliac spines with
one that is drawn vertically through the spines of the os pubis ap-
proximately indicates the point at which the ureter passes over
the pelvic brim. Because of the narrowed lumen of the ureter at
this point a calculus frequently lodges here and causes pain.
Palpation of the ureter is not very satisfactory. In men it
may be palpated for one or two inches above the bladder by a
rectal examination, while in women, by a vaginal examination, it
may be palpated for two or three inches above its vesical insertion.
In this lower accessible portion, therefore, local tenderness in
cases of stone or inflammation may be elicited by palpation. The
great diflSculty in drawing conclusions from tenderness located in
this region is that it is almost impossible to say with any degree
of positiveness whether the tenderness which is present is due to
ureteral involvement alone or is the result of some disease of the
adjacent structures.
Factors Influencing the Pain. — The factors influencing the
painful attacks are:
(1) The Position of the Patient. — Change of position some-
times causes pain, and certain positions are productive of more
pain than are others. These positions are generally the ones in
which the stone, if present in the kidney, would have a tendency
to gravitate to and block up the outlet of the renal pelvis. In
these cases the pain is the result of pelvic distention. Reversal
of the position which produced the pain generally eases it, and
may even cause it to disappear entirely, the disappearance being
followed by a considerable increase in the flow of urine. Should
the stone be in the ureter change of position would not produce
any special difference in the amount of pain produced unless the
changed position should cause pressure, pulling or dragging upon
the ureter by some of the adjacent organs.
On the other hand, should the kidney be movable, and dis-
placement occur, it is easy to conceive how, in the dropping or
in the turning of the kidney from the displacement, a kink or a
twist may occur in the ureter, and how this, by causing renal
666 THE KIDNEY
distention, may act as a pain-producing factor. Under these cir-
cumstances a replacement of the kidney into its normal location
will relieve the pain.
The patient^ during an attack of renal colic, generally lies all
bent up. At the same time he, as a rule, presses his hand into
the abdomen, and this seems to ease the pain. In this, renal
colic is not different from other colics, for all are to some extent
relieved by pressure. Patients affected with kidney calculus walk
with the hand so placed over the affected side that the thumb
presses on the loins behind and the fingers on the iliac fossa in
front. (See Figure 142, p. 617.)
(2) Motion. — In those who have kidney stones motion often
incites an attack, especially so when the motion is similar to that
which occurs in riding over rough roads in a badly constructed
carriage, or in vehicles in which there is considerable jolting, that
is, one may say, shakiug motion. Lifting, sudden, sharp turning,
as in tennis playing, throwing, running or jumping, all seem to
initiate an attack. Bending forward or backward is apt to cause
its appearance, or to increase it if it is already present.
(3) Digestion seems to be especially potent in causing pain
in renal calculus. This is probably due to two causes: (a) the
changing relationships of the bowel during. digestion cause it to
press upon the kidney and thus produce pain, and (b) the dis-
turbed digestive powers of the alimentary tract may cause some
substances to be absorbed, which, on being eliminated, increase
the irritability of the urine and give rise to pain as they pass
over the sensitive mucous membrane lining of the kidney and
ureter.
(4) Manipulation of the kidney frequently incites an attack
of renal colic.
Associaied Symptoms. — Symptoms associated with the passage
of a renal calculus are :
(1) Frequency of Micturition. — This becomes more annoying
the nearer the stone is to the bladder until, when it is just ex-
ternal to the bladder, the desire to urinate is almost constant.
According to Schmidt, the opposite holds true in tuberculosis of
DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 667
the kidney without a cystitis, and in kidney infarct, when the
desire to urinate almost entirely disappears.
(2) Increased Blood Pressure, — The blood pressure is greatly
increased at the time of the attack, but this is only a vasomotor
reflex incited by the pain sensation. It is nothing more than the
usual reflex associated with all severe pain. It but confirms the
patient's statements that pain is present.
(3) Swelling and sensitiveness of the urethra may precede
an attack.
(4) Digestive Symptoms. — Nausea may be present and vomit-
ing is very common. Both may be present without the pain. They
are due to the close association of the kidney, intestines, and
stomach, through the abdominal sympathetic. These digestive dis-
orders, when severe, may lead to error in diagnosis, especially so
when constipation is present.
(5) Changes in the Urine, — (a) Blood as a rule is present.
It follows an attack of colic. While appreciable microscopically,
as a rule it is not in any very great quantity, (b) Various uri-
nary salts, as phosphates, urates, oxalates, are present in abnormal
amounts, (c) Albumin may be found, (d) The sign of great
value is the absence of the normal urinary flow from the ureter
on the affected side. This can best be demonstrated by the use
of the cystoscope and ureteral catheter.
(6) Subjective sensations of cold in the thigh of the affected
side are sometimes present (Schmidt).
(7) Chills are very frequent, especially when Dietl's crisis
is present.
(8) Spasms in the muscles of the calf or thigh of the same
side may be present (see Innervation).
(9) Collapse may occur at the time of the greatest severity
of the renal pain.
(10) Elevation of temperature is frequent at the time of the
attack.
(11) Renal Stones, — The X-ray, as a rule, shows a renal
stone.
In many instances, while the colic may indirectly be due to
MB THE KIDNEY
calculuB formation, it is not directly so prodnoed ; for instead of a
calculus the obstruction to the ureter has in many instances been
foond to be pieces of blood clot, etc Generallv they are the
result of a secondarv infection.
Differential Diagnosis. — ^The diagnosis of a renal calculus
should be made from tuberculous kidney, new growth of the kid-
ney with hemorrhage into the substance, and kinks of the ureter.
In renal calculus the colic is sometimes mistaken for that of
intestinal obstruction, chiefly on account of the intestinal disten-
tion and the inability to move the bowels. These latter are fre-
quently the result of the large doses of morphin which have been
given to the patient Ureteral colic on the right side is often
confused with appendicitis.
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CHAPTER XXX
THE URETER, BLADDER AND URETHRA
THE UBETEB
Pain associated with ureteral involvement is due to :
(1) Obstruction of the ureter. This is caused by muscular
spasm, which produces (a) hydronephrosis, in which there is gen-
erally a certain amount of associated infection, and (b) dilata-
tion of the ureter. Obstruction may also be caused by calculus,
blood clots, detritus, kinks, external pressure from tumors (aortic
aneurysm) or growths in adjacent organs (as carcinoma of the
bladder at the point of ureteral insertion), displacement of adja-
cent organs (making pressure on the ureter), and stenosis of the
ureter, which may be intralumenary from stricture, or extralume-
nary from inflammation of the walls or of the surrounding tissues.
(2) Inflammation (ureteritis) may also cause pain in ureteral
disease.
Obstruction to the ureter produces at first a muscular spasm
and then a distention of the proximal ureter and renal pelvis.
This causes a sudden sharp pain. To what extent the ureters are
innervated by the cerebrospinal system is still a question for the
physiologists, but it has been shown that the mucous and muscular
coats are innervated by both medullated and non-medullated nerves,
so that the spasm, which is produced by an irritating stone, would
affect both cerebrospinal and sympathetic nerves, and thus cause
both local and reflected pain. The local pain is due to the irrita-
tion of the cerebrospinal nerves, and the reflected pain is the result
of irritation to the sympathetic nervous system. Later, should
inflammation ensue and the outer coat of the ureter be involved,
the local is more prominent than the reflected pain ; and if the
adjacent tissues are affected the local pain far outshadows the
670
THE URETER 671
reflected. Generally, however, such fine distinctions cannot be
made in practice, yet if it were possible to follow a case of
ureteral stone colic from its incipiency to its conclusion, such a
transgression from reflected to local pain might sometimes be
found, and the presence or absence of inflammation exactly de-
fined. This is easier if the obstruction is incomplete, but at the
same time sufficiently irritative to cause inflammatory reaction.
According to Ashton, "When the ureter is inflamed pain is
elicited at the brim of the pelvis, about one to one and one-quarter
inches on either side of the promontory of the sacrum, and over
the upper or renal portion by deep palpation." (See Fig. 155.)
A reference pain due to stone in the ureter which would seem
to be of value is given bv Bennett. In this case a stone lodged in
the vesical end of the right ureter, and caused more or less con-
#
stant pain in the right groin. The pain was never acute an 1
rarely was entirely absent. It was worse in the morning on leav-
ing the bed, and again in the evening. Possibly a little increase
of the pain was noted when the bladder was full. On removal of
the stone the pain ceased (Bennett). According to Howell (287,
p. 445) the pain in renal colic is felt at a point a little below the
ninth costal cartilage in the mid-clavicular line, from which it
runs downward to the testicle and along the inner side of the
thigh, following the cutaneous distribution of the eleventh and
twelfth dorsal and the first lumbar nerves.
Should obstruction be complete the pain of distention occurs
pari passu with that of the spasm. The distention of the renal
pelvis first occurs, and therefore the first organ to be affected by
the distention is the kidney. It reacts to it and causes a sense of
aching, tenderness, and pain in the lumbar region.
Tumors of the ureter as a rule are not painful unless they
cause a sudden obstruction to the ureter, either from pressure, or
from inflammatory swelling due to an acute infection. They may
also cause pain by the pressure of the ureteral mass upon the sur-
rounding structures. Depending upon the location of the mass,
either local or referred pain, or both, may be produced.
Piersol ("Anatomy," first ed., p. 1914) gives a good idea of
672 THE URETER, BLADDER AND URETHRA
the route of pain reference in kidney, ureter, and bladder diseases.
He says: "The skin of the scrotum and penis is supplied with
sensation from the same spinal segments as is the bladder, and
therefore the referred pain in vesical irritation or inflammation is
often felt in those regions in the distribution of the perineal
branches of the pudic and the inferior gluteal nerves. The tick-
ling or itching around the anus, or painful contraction of the
sphincter, which may be present, is the referred sensation through
the inferior hemorrhoidal nerve from the sacral plexus. Lumbo-
sacral pain is felt through the communications between the sec-
ond, third, and fourth sacral nerves and the hypogastric plexus.
Pains in the area usually associated with the kidney disease are
due to the junction in the spermatic plexus of filaments from
both the renal and the vesical plexuses. Pain over the kidney
region may also be due to the involvement of the spinal nerves.
Pains in the lower limbs, especially in the foot (pododynia), are
produced by the irritation carried through the sacral ner\'es into
the sacral plexus and the lumbosacral cord, which give off the
great sciatic nerve."
THE BLADDER
GENERAL CONSIDERATIONS
Anatomy. — The bladder is next to the last division of the
urinary apparatus, and acts as a reservoir for the urine. It is
very loosely attached to the surrounding structures, and can be
subjected to great distention before it causes inconvenience to,
or pressure on, adjacent organs ; but when it is so distended pain
and discomfort are most marked. The urinary bladder is unlike
most other abdominal viscera because of its great distensibility
(in this it resembles the stomach), and its peculiar position (being
almost extraperitoneal) and because its cavity is in almost direct
contact with the external air.
Because of this contact the bladder is much more susceptible
to inflammatory diseases than are the abdominal viscera, which
are entirely intraperitoneal.
Nerve Supply. — The nerve supply to the bladder, being both
THE BLADDER
673
Bympathetic and spinal, grants to it attributes possessed by both
these systems. The sympathetic system keeps it in harmony with
the abdominal viscera, while the spinal system supplies its muscu-
lar coats and acts as a finely sensitized apparatus which quickly
responds to all harmful irritations giving rise to the sense of pain.
The sympathetic nerves are distributed principally to the muscu-
CON TRACTION IMPULSE FROM BRAIN
INHIBITION IMPULSE FROM BRAIN
-I SENSATION IMPULSE TO BRAIN
URINARY
DLADPCR
WHEN THE LEGION 15 AQOVL
TME 3ACK.AL SEGMENTS.
5EN!>ATI0N WILL dl CONVCYtD
TO BRAIN. BUT THE POWER
OF RETAINING URlNE Vt\\X
BE DESTROYED.
Fig. 157. — Relationship Existing between Pain and other Sensa-
tions Arising in the Urinary Bladder.
lar coat. They follow the arteries and are derived from the vesi-
cal plexi, which, in turn, arise from the pelvic plexi (Pier-
sol). When the sympathetic fibers are irritated the stimulus is
carried to the cord, and thence is reflected to the body wall,
where it may be felt as pain. When the spinal nerve filaments
are irritated the pain is referred to the region of the bladder,
although its exact localization is rather indefinite. The sympor
thetic nerve supply differs from the spinal in that, although deep
pressure pain perception is carried through its fibers, it also car-
ries stimuli to the cord, from which they are referred as pain
to the cutaneous areas having their nerve supply derived from
the same segment
674 THE UBETEE, BLADDER AND URETHRA
The sympathetic Ebera are derived principally from the vesi-
cal plexus, which is in direct communication with the second,
third, and fourth lumbar segments of the cord, and it is through
these communications that motor impulses are carried to the
htadder wall. The vesical plexus communicates with the hypo-
gastric plexus, which, in turn, communicates with the second,
Fia. 158. — Pain Areas Associated with Diseases of Bladdbb. (Accord-
ing to Head.)
The 2d, 3d and 4th sacral areas are the ones in which the bladder pains
arc usually referred.
third, and fourth sacral nerves. This supply is sensory, as can
be seen from the diagram.
That the pain sensation is carried through the nerve fibers
which are derived from the sacral segments is apparent, because,
in a lesion of the twelfth dorsal segment, ordinary sensations
from the bladilcr are lost; but if the lesion is below the first and
second sacral segments sensation is not lost.
The cord zones, in relationship with the bladder, are given
THE BLADDER 675
above. These are not 80 useful in the defining of bladder lesions,
because the intensity of the pain from almost every painful lesion
of the bladder is so great that it overwhelms the localizing sense,
so that it is almost impossible to define the zonal areas. The
areas most commonly afftctpd in bladder lesions are the second
and third, and possibly the fourth sacral. It is possible also that
sensation may he referred through the second, third and fourth
lumbar nerves, though such a
reference is very unusual.
That it may occiir is certain, as
is maintained by Head, who
says that "in those cases where
there is distention of the blad-
der, and ineffectual attempts
are made by the patient to
evacuate, the pain is of a sharp,
shooting character, radiating
from the lower lumbar and
sacral regions behind, around
the ilium to the lower part of Fig. 159.-Relationship of Rectal
Tenesmus TO Vesical Tenesmus.
the abdomen just above the The transmission is through the
pubes, and also down the inner pudie nerve which also supplies
side of the thigh to the knee." w/"^'^^ fl™ ^rL^r^i
'^ When any of these regions are
The pain may also extend to affected it is common to have
the outer side of the thigh. Pf'" ^^f^ ^ "^y «"«■ <"■ *"
... three, of the three regions.
The accompanying drawing
(Fig, 159) illustrates tht- rchuionship of rectal teiiesmua to ves-
ical tenesmus and the method of reference of bladder pain into
the penis.
The reference areas of bladder pains have been nicely illus-
trated in Figure 160, which represents the pain of cystitis, fol-
lowing instrumental crushing for the removal of stone. These
drawings, which were taken from Head ('"Urain," Vol, 16, p. 82),
represent points of maximal tenderness, which were found, (1)
over the ischial tuberosity, (-2) over the lower part of the sacrum,
and (3) over the tip of the glans penis.
676
THE URETER, BLADDER AND URETHRA
Causes of Pain. — All direct bladder pains are, of course, due
to irritation of sensitive spinal nerve filaments in the bladder walls.
Some of the indirect pains are due to pressure, dragging or pulling
upon the adjacent peri vesicular structures. Generally lesions of
the bladder proper are not painful unless they encroach directly
upon the trigone, for this is the only part of the bladder which is
_ . Area of distributioD in
bladder
Sacral 4th / ~
Sacral 3d-
\-- Sacral 4th
-- Maximum tenderoMi aacral
4th
■- Area of maximum tender-
neas sacral 3d
--4--8acral 3d
Fig. 160. — Areas of Referred Pains Usually Assocla.ted wtfh Diskase
OF Urinary Bladder. (According to Head.)
extremely sensitive. Even in the absence of inflammation, touch-
ing of it by a sound or probe is provocative of the most intense dis-
tress. How much more this distress is increased when the mem-
brane is inflamed can easily be surmised. If it is inflamed, and
there is also increased irritation associated with a sharp and
jagged calculus, it is apparent that every time the bladder walls
contract a sharp and agonizing pain is bound to result. If adhe-
sions exist between the bladder and adjacent organs, pulling and
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678 THE UKETER, BLADDER AND URETHRA
dragging by these viscera at the time of the greatest activity
will produce pain. Should the bladder (in the male) be adherent
to the rectum or to the sigmoid, all evacuations of the bowel will
be attended with more or less urinary tenesmus and localized
bladder pain. Likewise, adhesions to the uterus and tubes in a
female will produce the most severe pain during the periods of
menstruation, during pregnancy, or during sexual intercourse.
In some cases the bowel and urinary bladder have become adher-
ent. In these the pain occurs at irregular intervals, and is fre-
quently accompanied by the gurgling noise which betokens bowel
contraction. If the adhesions are to the adjacent tissues, pres-
sure in the suprapubic region is painful, especially so if the
bladder is full. In woman the bladder can be palpated more
easily than in man, and surrounding adhesions and inflamma-
tion, because of the great tenderness they produce, are easier
to define. However, adhesions never cause such severe pain as
do intravesicular lesions.
Character of Pain. — Pain due to lesions of the bladder is of
two types: constant and paroxysmal. The constant pain is of a
dull, aching character, and is felt behind the symphysis pubis.
When present it indicates a rather severe inflammation of the
bladder walls, for an inflammation that has not progressed beyond
the mucous membrane will not produce this marked pain. The
constant distress, associated with this lesion, is interrupted by
paroxysmal attacks of pain occurring during micturition, slightly
before and at the termination of the act, at the time when the two
opposing internal surfaces of the bladder are brought into forcible
contact with each other by the contracting walls. Should a stone
also be present the most severe pain is felt at the end of the
urinary act ; in fact, the pain may be so severe that urination is
inhibited. This pain may be relieved by changing or reversing
the position of the patient ; for instance, if during the attack of
pain the patient lies down, the stone may gravitate away from
the urethral opening. The urinary flow is resumed and the
bladder pain ceases.
Location. — Tfearly all bladder diseases, even those of the least
THE BLADDER
679
magnitude, cause an aching in the suprapubic region. In some
cases this aching is the only discomfort produced by the disease,
while in others the aching progresses into acute, severe, and well-
marked pain, which may be local, referred, or reflected. If local
the pain is due to injury of the terminal filaments of the sensory
nerves of the bladder wall, which have become involved in the
A — Consestion of
peniB
B — Constant pain
in glans x>eni8 in-
dicates:
1, Fiflsure (mea^
tua)
2, Proatatitis
3, Inflammation
of the prostatic
urethra
4, Ulcer of the
urethra
C— Constant pain
in:
1, Chronic pros-
tatitis
2, Comme n c i n g
senile enlarge-
ment of the
prostate
3, Encysted cal-
culus at the
base of the
bladdtf
Pain relieved by
micturition in:
1, Acute prosta-
titis
C
Fig. 164. — Referred Pain in Dis-
ease OF THE Bladder Due to
Involvement op the Pudic
Nerve.
2, Tuberculous
prostatit is
(quiescent)
3, Tuberculous
bladder
Pain increased by
micturition in:
1, Encjrsted pros-
tatitis at base
of bladder be-
hind prostate
2, Ulceration
(a) Catarrhal
(b) Tuberculous
3, Local condi-
tions
(a) Sub-ure-
thral abscess
(b) Inflamnuu
tion of the
poet urethra
(c) Impacted
stone
(d) Carcinoma
of the bulb
process. These nerves are spinal in origin, and the pain is
perceived as coming from their distribution area. It sometimes
happens, though, that the pain is referred to the distribution
area of some other of the branches of the nerve involved, as
may happen, for instance, in the pudic; where, although the
only irritation which may be present is in the branch supplying
the lower part of the bladder, the pain may be felt in the glans
penis, or in the anal sphincter (see Fig. 159).
When the pain is reflected it is perceived as coming from the
680 THE URETER, BLADDER AND URETHRA
distribution areas of the third and fourth sacral segments. Thef^o
have been shown on page 677. In this connection it is well to
remember that the areas in which these pains are most often
found are: (1) in the kidney area (probably the result of the
backward stasis) ; (2) over the sacrum, and (3) in the foot, fre-
quently in the heel.
Time of Pain Attacks. — There is no special time at which blad-
der pain is at its maximum, although from experience with quite
a number of cases it seems that night, with its quiet and peace,
is the time when the poor unfortunate cystitic feels and suffers the
most distress. Often he fears the darkness more than the un-
godly fear the evil one, for never does it bring sleep, but always
anguish and pain.
Why he should suffer so much more at night is rather hard to
say; perhaps it may be that at this time the senses are more
acute. During the night they are relaxed from general care, and
perceive slighter irritations than otherwise would merit their atten-
tion. Another reason is that at night congestion of the retro-
prostatic plexus of veins occurs. This produces pressure upon
the prostatic nerves and possibly also upon the sensitive trigone,
and so gives rise to pain. It may also happen that the bladder is
fuller at night than during the day, and thus pain is more apt
to be produced.
The above description applies to all cases except those in
which a stone is present in the bladder. When such is the case
the pain is generally worse in the daytime because of the motion
which then occurs.
Position of Patient. — The position assumed by the patient
during urinary bladder pain when walking is one in which he
stoops slightly forward, in a posture similar to that assumed in
enteroptosis.
When a stone is in the bladder the patient frequently bends
forward, and, if a male, tugs at the foreskin of the penis. This,
in some cases, seems to give relief. Why, it is difficult to say.
Distention of the bladder also causes the patient to bend for-
ward.
THE BLADDER 681
The prone position is not so often sought by the person sub-
ject to bladder derangement. As a rule he likes best to sit on a
chair, bent forward, with his elbows on his knees. Sometimes he
makes pressure over the region of the bladder, though if the in-
flammation is severe he does so very carefully.
Factors Influencing Production of Pain. — E elation of Urinary
Bladder Pain to Motion, — One who is troubled with chronic blad-
der disease is not very active muscularly. Slow, calm, and de-
liberate in all his movements, he seems the perfect embodiment of
caution. He will not run, jump, ride in springless wagons, nor
in jolting cars; even walking may become distasteful to him. His
life is one living torment, for every motion hurts and injures him.
Even rest in bed may be denied him, for it may prove to be only
a snare with which to increase his pain. Yet he goes on hoping,
always hoping for a surcease from pain.
Relation of Food and Drink to Bladder Pain. — In food and
drink lie hidden dangers, for the first may produce bowel dis-
orders which are distressing, and the second may produce urine
which burns and scorches. Both bring added discomfort to an
already overburdened soul.
Drugs sometimes cause an attack of bladder pain. Witness
the frequency with which urotropin initiates one.
Cold air and drafts produce a congestion that may stir up
latent disease and cause old symptoms of pain and discomfort to
appear again; or, in the presence of an active involvement, they
may still further augment the di.^tress.
Tenderness in Disease of the Bladder. — Diseases of the blad-
der, when they cause pain, are always accompanied by inflamma-
tion, and inflammation as a rule produces tenderness. This ten-
derness of bladder lesions is marked in the three locations in
which it is possible to make direct pressure upon the bladder by
the examining finger.
The first and most prominent location is immediately above
the pubes in the suprapubic region. Here the fingers can be
pressed into the abdomen and then, by flexing, can be depressed
deep into the pelvis. Should the patient be a child this latter
682 THE URETER, BLADDER AND URETHRA
l>roce<lurc' is not necessary, as in children the bladder rides above
the pelvic brim. The second location is the base of the bladder.
In woman the base of the bladder may be palpated bimanuallv
between a finger placed in the vagina and the palmar surface of
the other hand laid over the abdomen. If the bladder is in-
flamed the patient will complain of pain on pressure between
the two. A stone in the bladder or lower ureter can often be
palpated by this method. A rectal examination frequently is
made in the male, but, as a rule, is not successful in eliciting
symptoms of any value because of the great sensitiveness of the
prostate.
The third location in which pain in inflammatory diseases of
the bladder is particularly marked is the trigone. The pain here
is elicited by the passing of a catheter, which when it enters the
bladder produces the most intense distress.
Associated Symptoms. — The symptom commonly associated
with disease of the urinary bladder is painful and frequent
urination. Frequency of iirination is one of the first signs of
bladder disorder.
Painful urination may also be associated with a new growth.
In the urethra the growth may be a caruncle, which is a small
raspberry mass lying to one or the other side of the meatus; or
a cancer (carcinoma or sarcoma). These are nearly always ulcer-
ated and have acrid discharges, which give rise to severe itching.
If the urination is painful and frequent, and pus, but no blood,
is present in the urine, it indicates a cystitis, in which the pain
is of a scalding nature and occurs during the entire time of
the passage of the urine. It is most pronounced at the beginning
of the urinary act, and difficulty is often experienced in starting
the stream.
Painful and frequent urination, with blood and pus absent
from the urine, indicates: (1) vesicourethral fissure, in which the
pain is constant and is increased during the urinary act, or (2)
pressure upon the bladder by an enlarged uterus, ovarian tumor,
or inflammatory mass. If painfid and frequent urination occurs,
with blood in the urine, the examiner should seek for: (1) tuber-
THE BLADDER 683
culoeis, in which the blood as a rule is found early in the disease
and ceases as the disease advances; tubercle bacilli also may
often, if persistently sought, be found in a centrifugalized speci-
men, while in (2) gonorrheal disease, the gonococcus may often
be found on a similar examination; and (3) vesical calculus, in
which condition other signs and symptoms of the calculus are
present.
Non-painful and frequent urination, with hematuria, generally
is the result of tumor, in which the pain becomes noticeable
only late in the course of the disease.
Differential Diagnosis. — ^Bladder diseases should be diagnosed
from involvement of the central nervous system. Here the "pain
occurs independent of micturition and radiates to the rectum or
to the genitals and thigh" (Schmidt). •
BLADDER AFFECTIONS CAUSING PAIN
The bladder lesions causing pains are: (1) cystalgia, (2)
vesicourethral fissure, (3) distention of the bladder, (4) rup-
ture of the bladder, (5) cystitis, (6) pericystitis, (7) tumors,
(8) tuberculosis, and (9) calculus.
Cystalgia.— -Montgomery speaks of a cystalgia. Reed is inclined
to think that this condition should be described as a hyperemia.
He says that while a neuralgia of the bladder may occur, gener-
ally it is only a term used for hyperemia. Under the circum-
stances a frequent desire to urinate is present, with a burning
during or after the act. Most of the women so complaining are
of a neurotic temperament, and are afflicted with displacement
of the uterus, movable kidneys, etc. Fenwick seems to believe
that neuralgia of the bladder may exist as a separate entity; and
that it is probably produced by the toxins of infectious diseases,
as those of influenza or of light septic infections. In some cases
pain apparently in the bladder is due to inflammation of the
pudic nerve. The pain in this case is also referred to the penis,
rectum, and perineum. The perineal pain may be so severe and
the perineal surface so sensitive that the sitting posture becomes
684 THE URETER, BLADDER AND URETHRA
almost impossible. Traveling on cars also causes the greatest
agony.
Pain with incontinence and frequency of urination should lead
to the suspicion of tabes, general paresis, etc.
Vesicourethral Fissure. — In this condition the pain as a rule
is constant, but is more marked during the urinary act. The con-
stancy of the pain is due to the irritation by the urine of the nerves
exposed in the bed of the fissure. It does not seem to make
much difference whether the urine is acid or alkaline, the pain
(in many cases) being equally severe in both, though the neutral
or slightly alkaline urine seems to produce the least pain. An-
other cause of the constant pain is the steady pressure made
upon the exposed nerves by the contraction of the sphincter. The
pain of this condition, differs from that of cystitis in that it is
sharply circumscribed, while the pain due to cystitis is diffuse.
Urination in cystitis gives relief from pain, while in vesico-
urethral fissure the pain during urination is increased. Tender-
ness, sharp and localized to the posterior urethra, is also present
in vesicourethral fissure, while in cystitis the tenderness is dif-
fused.
Distention of the Bladder. — Distention of the urinary bladder
is not very painful unless it is of sudden onset, when pain is a
prominent sjonptom. Distention may be due to an acute urethral
obstruction from a blocking of the urethra by a calculus or a
clot. If the distention of the bladder is the result of lack of
sensation or of muscular power in the bladder, it is likely due
to a lesion of the brain or of the cord, and may be entirely
painless.
In some cases the bladder may be so encompassed by adhe-
sions to adjacent viscera, the result of inflammatory exudates in
the pelvis, that only two or three ounces of urine produce a pulling
and dragging on the adhesions, and dull aching pain is felt in the
areas and regions of the viscera secondarily involved. In these
conditions pain is most severe during the urinary act because, by
the contraction of the bladder, traction is made upon the sur-
rounding adhesions and pain is produced. This pain is of a more
THE BLADDER 686
severe type than the dull, aching, continuous pain of distention,
and generally occurs as the acme of a pain of gradually increasing
intensity. This type of pain is found as a rule only in the
female, because a male is free from pelvic disease with its result-
ing adhesions. The pain is most frequently felt behind the blad-
der. The intervals between the periods of distention are free
from pain. The pain when present may radiate along the ure-
thra to the (testicles) anus and perineum. The two latter, in
common with the bladder, are innervated by the sacral plexus.
The pain may also be propagated reflexly to the hypochondrium,
to both thighs, or be referred to the regions innervated by the an-
terior crural and sciatic nerves. This radiation is very common
in prostate tumors.
Rupture of the Bladder. — Kupture of the bladder is indicated
by sudden severe pain in the lower part of the abdomen. It fol-
lows a trauma, and is associated with a constant desire to urinate.
On attempting to urinate no urine may pass, though the desire
does not abate. If any urine is passed it is mixed with blood. In
addition, tenderness over the lower abdomen in the prevesicular
region is most marked. All eases of rupture of the bladder are not
accompanied by pain. A case in point is related by Moullin
(226, p. 514) of a man who twenty-four hours after an accident
walked into the hospital and complained of his inability to pass
urine. Examination disclosed a ruptured bladder.
Cystitis. — Inflammation of the bladder is always accompanied
by pain. The cause of this pain production undoubtedly is the
irritation of the sensory receptors in the bladder mucosa and of
the sensory fibers in the bladder wall structure. This irritation
produces more pain when it occurs in the region of the trigone.
When it is present there, the entire urinary act may be painful,
though the pain is most marked at the end of the act.
Character of the Pain. — In mild forms of cystitis the only
annoyance may be a slight discomfort at the time of urination or
shortly before it, or if pain is present it is more of a burning
or scorching of the urethra after urination than a true pain.
This peculiar sensation disappears between the urinary acts, to
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THE BLADDER 687
recur when the urine is passed. The severity of the pain varies
with the intensity of the inflammation. In severe grades of in-
flammation the pain is most marked. In some eases urinary
tenesmus is so great that the unfortunate sufferer is compelled
to sit on the urinal for hours before he has relief from the in-
sistent desire to urinate. In the severest forms of cystitis the
patient's life is a living torment. Goaded by a constant and un-
satisfied desire to urinate, with the most severe pain and local
tenderness over the bladder, his existence may be said to be a
living hell. In chronic cystitis pain is not as severe as it is in
the acute. Should the pain occur only at the end of the urinary
act it indicates that the disturbance is in the trigone and the
posterior urethra. The lesion most likely to cause this pain is
inflammation, which in many cases is of gonorrheal origin. In
some cases, spasm of the urethra ensues, and the patient is unable
to urinate without the greatest pain. This pain may be so great
that he is loath to perform the act, and a partial retention of
urine results. However, in cystitis pain is not always present,
and may be absent for considerable periods ; and even when pres-
ent may at times be eased to such an extent that the patient is
fairly comfortable. Then suddenly, often without any apparent
cause, there ensues a very severe, painful and active paroxysm.
Location of the Pain, — The pain of cystitis may be either
local or referred. The local pain is felt both in the urethra and
in the suprapubic region. In the urethra it is most severe during
or before the urinary act, though, if the trigone is involved, it
may be most severe at the end of the act. In the suprapubic
region the pain is felt more as a dull, constant aching, increased
at time of urination. Both of these pains are due to the irrita-
tion of the terminal filaments of the cerebrospinal nerves supply-
ing the bladder. When the base of the bladder is involved the
inflammation may be communicated to the rectum, and severe
rectal tenesmus may then result.
The referred pain is present in the skin of the scrotum and the
penis. These (Piersol) are supplied by the perineal branches of
the pudic and inferior gluteal nerves, which are derived from the
688 THE URETER, BLADDER AND URETHRA
same segment of the cord as are the nerves supplying the bladder,
so that irritation from the bladder may be carried to the cord
and thence referred through these nerves to their distribution
area. The pain in the lower limbs and foot, especially the foot
pain (podalgia), is due to the transmission from the sacral
nerves, which form the pelvic plexus, to the lumbosacral cord,
which is formed into the great sciatic. Tickling or itching
around the anus and painful contraction of the anal sphincter
(rectal tenesmus) are present at times, and are most marked
when the trigone is affected. Lumbosacral pain is also present.
In some cases of cystitis pain has been felt in the region of the
umbilicus, with at the same time an entire absence of bladder
tenderness (Hilton). The pain may also be referred to the kid-
ney region. In some instances pain due to a lesion at the fundus
of the bladder may be referred to the head of the penis.
Tenderness. — In cystitis tenderness, as a rule, is present in
the suprapubic area; but Hilton reports a case in which the
tenderness to light pressure was a little to the left of the umbili-
cus, and pain to deep pressure was present toward the loin, no
tenderness being felt over the bladder region. The superficial
tenderness, it seems likely, was due to some other factor than the
cystitis. The tenderness in bladder lesions is most marked at
the time of the painful paroxysms. In examining for tender-
ness, pain is more frequently produced by sudden withdrawing
of the hand pressure than by deep palpation.
If the tenderness is marked, and the point of greatest ten-
derness is in the suprapubic region, cystitis is probably present.
This area, in inflammatory states of the bladder, is very sensitive
either to palpation or to percussion. In some it is so sensitive
that they cannot bear to have the clothing touch it.
Factors influencing attacks of pain in cystitis are:
(1) Anything which causes a congestion of the bladder mu-
cosa or musculature, such as exposure to cold, dampness, menstru-
ation, diarrhea, constipation, or exposure to drafts. These may
produce an attack or cause an exacerbation of one already present.
THE BLADDER 689
(2) Instrumentation, especially if it is at all rough, brings
on an acute and severe attack of pain.
(3) Digestion at times is also responsible for the production
of an attack.
The symptoms associated with a cystitis are: (1) frequency
of urination, (2) alkalinity of the urine, (3) the presence of pus
and bacteria in the urine (the bacteria found are those which
have been the chief factors in causing the cystitis), and (4) blood
in the urine. This last indicates a cystitis of considerable se-
verity, and is nearly always found in gonorrheal and tuberculous
cystitis, and in the later stages of the cystitis due to bladder
tumors.
Pericystitis. — Should pain and tenderness be present in the
bladder region,* and be associated with a mass either in the median
line or to one side, and should this follow instrumentation or
trauma to the bladder, it is a good sign that pericystic inflamma-
tion has occurred. This lesion produces a constant, severe throb-
bing or aching pain, made worse on urinating. If the process
continues an abscess may form.
Tumors of the Bladder.— Pain in tumors of the bladder is of
no practical moment, either as an aid in the making of a diag-
nosis or in deciding how far the process has advanced. It is
more prominent in carcinoma than in other tumors of the blad-
der, probably because, in this form of malignancy, the walls
quickly become infiltrated and pressure is made upon the sensory
terminal filaments. The infiltration also hinders the contraction
of the bladder muscles. When under these circumstances cystitis
develops it is very serious, and the pain incident to it is most
severe. Tenesmus, out of all proportion to the size of the tumor,
is nearly always present in malignant tumors of the bladder wall.
Tumors of the bladder, because they may block the ureters,
and thus cause a back pressure and distention of the renal pelvis,
also at times give rise to kidney pain. As a rule the malignant
tumors are the only ones which are very painful, the pain vary-
ing in direct proportion to the nearness of the growth to the
trigone. The reason why malignant tumors are so painful is
090 THE URETER, BLADDER AND URETHRA
that as a rule they are very friable, and pieces of the tumor
mass frequently slough off. These pieces, and in some cases
blood clots, are carried to the urethra. If they are not able to
pass, a blocking occurs, and bladder distention, which is painful,
results. In other cases the carcinomatous tissue invades the
wall of the bladder; when it does so, on each contraction of the
bladder, pain is produced by the pressure made by the contract-
ing muscles upon the terminal sensory nerve filaments in the
bladder wall. The tumor cells may also progress beyond the
bladder walls and involve neighboring structures. Then pain
due to interference with their functions may be produced, and be
referred to the distribution areas of the organs involved. The
tumor cells may also infiltrate adjacent sensory nerves. When
they do so, severe, continuous, dull, aching pain is referred to the
distribution area of the nerves involved.
Tuberctdosis of the Bladder. — Causes of Pain. — In tubercu-
losis of the bladder the greatest pain is felt in those cases in which
the trigone, the prostate, or the deep urethra are involved. It
may cause the most severe suffering. Infections of the upper
part of the bladder are not so painful as those of the lower part.
According to Fenwick, the pain of bladder tuberculosis de-
pends upon the depth of the ulceration, the state of the phos-
phatic deposit, the presence of exposed nerves, and the degree to
which the eroded edges are stretched by the accumulating urine.
*^Deep ulcerations may not produce any very severe pain, while
in other cases congestion or slight ulceration of the mouth of a
ureter, or a few miliary tubercles in the mucous membrane of the
trigone may increase the frequency of urination and tenesmus,
and pain may be excruciating." (Johnston, Surg. Diag., Vol.
II, p. 440.)
Character of Pain, — ^Pain occurs during urination. Gener-
ally it follows a period of increased frequency of urination,
which as a rule has been present for a long period before the
pain commences. Gradually the frequency of urination and the
pain increase, so that finally the patient is in a stage of perma-
THE BLADDER 091
nent discomfort, with constant urinary pain and tenesmus. The
pain is of a burning character.
Time. — The severest pain is felt during the urinary act, and
is most severe at the end of the act, when the sphincter closes
down upon the posterior urethra. Sometimes the intervals be-
tween the urinary acts are free from pain ; at other times pain is
constant, being aggravated only at the time of urination.
Location. — The pain may be local, referred, or reflected. Local
pain may not be present, except at the time of urination.. Even
then the pain may not be localized to the region where it is
produced, but may bo referred along the urethra to the glans
penis. It is especially severe at the end of the act, at the time
the sphincter muscles close down on the seiisitive urethra. The
other referred pains have been described imder the general con-
siderations of bladder pain. The reflected pain is present in the
(1) sacral region, (2) the kidney region, (3) the groin, and
(4) the thighs.
Factors Influencing Production of Pain. — Position does not
influence either the onset, course, or severity of the pain. Motion
also does not in the slightest degree modify or change the pain,
except in the presence of a cystitis, when the slightest movement
may cause the severest pain.
Associated Symptoms. — Associated symptoms of bladder tuber-
culosis are:
(1) Hematuria, which is present in about ten per cent, of the
cases (Johnson). It may precede the onset of pain by an appre-
ciable interval.
(2) Polyuria may be present. It also is frequent in renal
tuberculosis.
(3) Pus is commonly found in the urine, and, after a long
and careful search of the urine, tubercle bacilli are also, as a
nde, discovered.
A confirmative sign of value in the diagnosis of bladder tuber-
culosis is the presence of tuberculous foci elsewhere in the body.
Foreign Bodies in the Bladder. — ^Foreign bodies may be pres-
ent in the bladder without producing pain; however, this is
692 THE URETER, BLADDER AND URETHRA
true only in those cases in which the foreign body has no sharp
edges, or in those in which, by its position, it does not interfere
with the emptying of the bladder. The usual way in which a
sharp, pointed foreign body can cause pam is by penetration of
the bladder wall and the starting of an inflammation, either of
the perivesicular tissues or of the peritoneum. The peritoneal
inflammation will produce signs of a peritonitis, while the peri-
vascular inflammation will provoke the symptoms of a pericys-
titis. (See under the appropriate headings.)
A history of the introduction of a foreign body into the ure-
thra, and its lodgment in the bladder, followed by vesicular pain,
is presumptive evidence that the foreign body is the cause of the
pain. If the body should lodge in certain parts of the bladder,
such as the posterior prostatic space, especially if the space is
ample, as it is in those who are old and have large prostates, little
pain results. In these patients the bladder walls, on account of
the peculiar configuration of the parts, will not be able to contract
upon the object, and localized irritative pressure will be absent.
One of the commonest foreign bodies present in the bladder is a
calculus. Foreign bodies of the greatest variety may occasionally
be found in the female bladder. Over a hundred different objects
have been found in a single bladder. Such patients use such
bodies deliberately for urethral titillation. During use they fre-
quently slip into the bladder by accident or are placed there by
design.
Vesical Calculus. — Causes of Pain. — Stone in the urinary
bladder generally causes pain, the amount, variety, and constancy
of which depend on the position of the stone, its size and shape,
and the condition of the bladder wall.
If a stone is located at the opening of the urethra it always
produces more pain than it would if it were located in any other
part of the bladder. This pain is the result of interference with
the proper emptying of the viscus. In these cases, the bladder
walls, when they contract, are brought into contact with the stone,
which, if sharp and irregular, causes the most severe pain. Often
a small stone, if rough and irregular, will produce much greater
THE BLADDER 693
distress and pain than a larger one with a more regular outline.^
If the bladder wall is not irritable a stone may be present for
long periods of time without causing the least annoyance. This
also happens if the calculus, because of its fixation in a diverticu-
lum, be immovable, so that it cannot irritate the bladder wall.
Should the stone be rough and freely movable, and in constant
contact with the trigone, it causes very severe and constant pain.
This pain is very much increased during urination, especially
toward the end of the act, but may be entirely absent if, because
of incomplete contraction, the bladder does not make pressure
upon the stone. If the stone lies in a pouch or depression of
the bladder wall, or is lodged behind an enlarged prostate, pain
may also be absent. It is also much less in the aged, because
of the comparative insensibility of their bladder mucosa. Renal
hyperemia and congestion generally accompany vesical stone;
these cause parenchymatous enlargement of the kidney, and so
produce pains which are referred to the kidney area, so that in
some cases, even when the lesion is in the bladder. Head's kidney
zones may be present. In such cases, also, the ureteral areas may
be free of pain, while the vesicular and the kidney areas may be
hyperalgesic ; also the typical colic of ureteral stone may be
absent
Character of the Pain. — The pain of vesicular calculus, while
it lasts, is very severe. If a cystitis develops, the constant pain
may be interrupted by sharp, severe, spasmodic attacks, initiated
by urination. The pain is most pronounced at the end of the act,
and may persist for some time after. Some patients, while un-
able to urinate comfortably in any other position, can do so with-
out pain if they lie upon their backs. Sometimes the pain is of
such a character that the patients seem to gain ease by pulling up
the foreskin after urinating. The pain is always most severe in
those in whom the bladder presses down upon and comes into
direct contact with the stone.
1 Calculi of oxalate, of lime, or of phosphate are the roughest. Those of
cystin and uric acid are generally more round and smoother than the former,
and cause less pain.
694 THE URETER, BLADDER AND URETHRA
Location of the Pain of Vesical Calculus. — The pain may be
either local, referred, or reflected. The local pain is felt in the
suprapubic region and in the deep urethra. Referred pain is felt
in the glans penis, the perineum, or the anus, the reference taking
place through the respective branches of the pudic nerve. The
pain likewise may be reflected through the nerve fibers arising
from the third and fourth sacral and, in some instances, from the
second sacral visceral segments. Through these nerves reflection
occurs, so that the pain is felt as coming from the thighs, the
hips, the sacral region and, in some cases, from the shoulders and
the anus. A sensation is often felt as though a paper of pins
were in the rectum (Keen). These referred and reflected pains
are always worse when the bladder is full, or when the patient
assumes the erect posture. In some cases the pain is radiated into
the area of the distribution of the lumbar plexus. It is also said
(Head quoting from Erickson) that in some cases there is a
dragging sensation in the groins, and frequently a pain in the
soles of the feet.
Factors Influencing Pain, — Factors influencing the pain pro-
duction are:
(1) Motion. Rest is the choice of the patients. They are
very cautious about making the slightest movement, for from
experience they have learned that motion of all kinds results in
pain. Riding in springless wagons, jumping and running are
accompanied by pain; for the same reason, rapid walking, jar-
ring, and, in some cases, going up and down stairs are distasteful.
After such movements the urine is frequently tinged with blood.
Upon rest and quiet the pain ceases and the blood disappears.
Violent or sudden turnings or twistings of the body also cause
pain. If the stone is small and is freely movable, turning from
side to side, or rolling over in bed, generally causes severe pain.
This pain is sharp and burning, and is frequently referred to
the anus and rectum. Straining at stool will also cause pain.
In some cases coughing and deep breathing also produce pain.
(2) Position. The patient generally lies upon his back, since
he has found that this is the posture of greatest ease.
THE URETHRA 695
(3) Digestion. During the active stage of digestion pain is
always greater than at other times.
Absence of Pain, — Absence of pain symptoms, when a calcu-
lus is in the bladder, is due to :
(1) Anesthesia of the mucous membrane of the bladder, the
result of a cord lesion, such as tabes dorsalis.
(2) Mechanical causes preventing the stone from falling upon
the sensitive neck of the bladder, as (a) its adherence to the blad-
der walls; (b) sacculation of the bladder walls, or (c) pouching
of the bas-fond of the bladder, so that pressure cannot be made
upon the stone by the contracting bladder walls.
THE URETHRA
Pain in urethral disease follows the course of the twelfth dorsal
segment (Head). Urethritis will be considered in connection
with the male genitalia. Here will be considered only those con-
ditions connected with the urethra in its essential relation as a
urinary organ. These are caruncle and stone.
Urethral Canincles. — Urethral caruncles, found onlv in the
female, are very painful to the touch. They also give rise to
very considerable pain on the passage of the urine. This pain
<rradually lessens after the act until, in the course of a few min-
utes, only a slight burning or smarting remains. Intercourse may
become impossible because of the very severe pain, or because of
the vaginismus which is reflexly produced. In some patients
friction from the rubbing of the clothing or from the contact of
adjacent parts may become so distressing that moving or walking
is hardly possible.
However, in most cases, the pain is not so extremely severe.
In some it is most distressing, while in others it is of such a slight
degree that it may give rise only to a feeling of discomfort.
The pain is probably due to irritation of the delicate nerve
filaments exposed in the denuded surface of the caruncle. It may
also be due, in a certain degree, to the greatly increased sensi-
bility of the caruncle, owing to the increased nerve supply.
696 THE URETER, BLffDDER AND URETHRA
Calculus. — The passage of a calculus through the urethra causes
a burning pain, as though a hot iron were drawn along the pas-
sage. If the stone is rough the pain is much more severe. At
the same time urination is extremely difficult, and blood is gen-
erally present in the urine.
Rupture of the Urethra. — Kupture of the urethra in the mem-
branous portion causes an extravasation of blood and urine into
the tissue between the two layers of the triangular ligament At
the lateral aspect of this space are the dorsal nerves of the penis ;
so that, when extravasation occurs, pressure is made upon them
and the pain is referred to the glans penis, although the extrava-
sated fluid collects in the scrotum.
Transferred Pain in Urethral Disease. — Fenwick mentions a
case of pain in the foot due to stricture of the urethra. He also
records another case of pain in both forearms which occurred
during urination. In this patient a prostato-membranous catarrh
was found. Both patients were relieved of the pain by treat-
ment appropriate to the urethral condition.
Pain on Urinating. — Where pain is felt during urination
exact information should be obtained as to the exact time in the
urinary act at which it occurs. Pain at the beginning of urina-
tion, without a continuance during the act, generally means some
obstruction to the onward flow of the urine. This obstruction
may be due to a mild urethritis, owing to which the lumen of the
urethra is blocked by shreds of mucopus or mucus; or it may be
due to a very soft stricture, or to an enlarged prostate that at
first offers some obstruction to the onward passage of the urine.
A clot or small stone may lodge in the opening of the urethra,
and very severe pain and retention of the urine may thus occur.
This pain continues until the obstruction has been overcome,
when it ceases and urination again becomes free.
If pain be present during the entire time of the urinary act
the following should be inquired into:
The presence of irritating constituents in the urine itself,
such as phosphates, eliminated drugs (cantharides), urates, glu-
cose, and various ingested acids. The burning may also be due
THE URETHRA 607
to a too great concentration of a normal nrine, so that, owing to
that concentration, substances which ordinarily do not irritate
do so most severely.
This burning may also be caused by inflammatory states (in-
filtration, granular patches, etc.) along the urinary tract, either
in the prostate or in the urethra. The burning sensation in those
conditions is most severe, and at times does not end with urina-
tion, but persists some little period beyond. A narrowed meatus
also causes pain during urination.
Pain during urination also may be due to inflammatory
changes in the bladder walls, or to diseases of or changes in the
adjacent organs, such as anteflexion of the uterus, which in a
pregnant woman often, owing to traction on the bladder, causes
severe pain during the urinary act. Abscess in the prevesicular
space of Douglas and pregnancy itself, by its pressure on the
bladder, causes pain. Adhesions to different organs by the blad-
der are also a cause of painful urination, likewise are tumors of
the uterine adnexa. The pain in these various lesions is probably
due to the hindrance which they offer to the contraction of the
bladder musculature, or to the free exit of urine.
Pain at the end of urination is due to prostatitis, urethritis,
or to some disease in the bladder. At this time the bladder walls
close down, pressure is made upon the trigone, and, if pain is
present, it generally indicates an inflammation of the bladder
wall or the presence of a calculus, which drops or is pushed into
the triangular opening at the beginning of the ureter terminals,
and thus, by pressing upon the irritated surfaces, causes pain.
This pain is most excruciating. It frequently causes the
patient again to attempt to urinate, even though the act has just
been performed. Should the pain be present all through the act,
and be continued beyond, as a dull, aching sensation in the rec-
tum, it indicates that the prostate is probably at fault
Pain continuing beyond the urinary act may, in some cases, be
due to urethral changes, as a blocking from a calculus, or a growth
at the vesicular orifice, closing the urethra.
CHAPTER XXXI
THE MALE ORGANS OF GENERATION
The male organs of generation are the testicles, epididymis,
vas deferens, seminal vesicles, prostate, and penis.
THE TESTICLES
The testicles, when inflamed, become very tender, especially
to deep pressure. In testicular affections the skin of the scrotum
is not necessarily tender, the testicles and scrotum being supplied
by entirely different nerves. The stroma of the testicle receives
its nerve supply principally from the sympathetic segments, while
the skin of the scrotum is supplied by the genital branch of the
genitocrural. Irritative lesions . of the testicle cause referred
aching or discomfort in the reference areas (deep pres-
sure sensibility) of the eleventh and twelfth dorsal segments.
Pain sensibility in the testicle is also conveyed through the
genital branch of the genitocrural nerves. The testicle and its
coverings being supplied by different nerves, irritation of the
different structures will produce pain in different areas, but al-
ways in the area with which they have nerve connections. After
the testicle has descended into the scrotum, the communication
between the testicular sac and the peritoneum becomes abolished,
and the testicle lies in a closed sac.
The deep pressure pain produced in testicle disease is due to
distention of the capsule. It is a type of sensibility quite similar
to that found in other viscera. Should the distention be gradual
pain may be entirely absent. In some cases the testicle grows to
a great size, and does not produce any inconvenience other than,
the dragging due to its overweight.
The testicle is capable, however, of giving rise to severe pain
698
EPIDIDYMIS, VAS DEFERENS, AND SEMINAL VESICLES 699
when inflammation causes it to become greatly enlarged. At such
a time it is very painful and is extremely tender. Pressure on
it causes pain referred to the inguinal region and the inner side
of the thigh. In some cases it may be reflected to the back or to
the iliolumbar region.
Trauma of the testicle may or may not be very painful. In
a case of Mitchell's a wound of the testicle caused pain in the
back alone. The deep pressure sensibility of the testicle has a
peculiar quality, in that it is often associated with nausea and
vomiting.
EPmiDTBaS, VAS DEFERENS, AND SEMINAL VESICLES
The genital ducts are the epididymis, the vas deferens, with
the seminal vesicle as a reservoir.
In a complicated urethritis all of these may become involved,
and great inconvenience may result Yet pain is not a promi-
FiG. 165. — ^Areas of Cutaneous Tenderness in Disease op the Epi-
DmTMIS.
A and B correspond to the points of maximum tenderness of the Uth dorsal
segment. B and C correspond to the points of maximum tenderness
of the 12th dorsal segment.
nent symptom until the inflammation extends far enough to
involve the epididymis. Then it is most severe, and is of a
throbbing, aching character and, because of the increased blood
stasis, is most intense in a standing position. The epididymis, at
the same time, is exquisitely tender to the touch, and pressure
700 THE MALE ORGANS OF GENERATION
upon it produces the peculiar sickening sensation that is as-
sociated with deep pressure on the testicle. Pain when pres-
ent radiates anteriorly into the distribution area of the crural
branch of the genitocrural nerve, and posteriorly over the lower
lumbar and the upper sacral vertebrae, which, according to Head,
are the areas of the eleventh and twelfth dorsal segments. The
pain may also be felt in the 1^, as far down as the
knee, and in the perineum. Figure 165 illustrates the places where
cutaneous tenderness is generally found in inflammation of the
epididymis.
THE PB08TATE
The prostate is the principal seat of pain in all acute infec-
tions of the male genital tract Ordinarily the passage of the
urinary stream over it is without pain, but when the urethral
surface is inflamed, the subepithelial tissue, becoming congested,
swells and blocks the urethra. The urinary stream now cajses a
sudden separation of the urethral surfaces and compression of
the tender tissues, with consequent pain production. This pain
is most marked in the beginning, and persists during the entire
urinary act, and continues for some short time thereafter. If
the portion of the gland under the bladder wall is affected, and
the inflammation is communicated to the mucous membrane of
the trigone, frequency of urination, with severe pain at the end
of the urinary act, comes on. Likewise, if that part of the pros-
tate adjacent to the rectum is involved, defecation becomes very
painful. Abscess of the gland in any of these regions acts about
the same as does an inflammation, but has symptoms of much
greater intensity. In prostatic involvement referred pain may
also be present in the perineum (through the perineal nerves)
and in the back and down the legs (because of the intimate as-
sociation between the roots of the pudic nerve with the sacral
and lumbar plexi) (Bryant, 895).
Congestion and Inflammation. — Congestion of the prostate
occurs at times without inflammation, and is found especially
in those indulging in $e:^ual excesses. The sensation com]
m^mm
THE PROSTATE 701
of 18 more of an aching or drag^ng acrose the back in the lumbar
region than an actual pain.
However, both congestion and inflammation cause in the glan&
penis a pain not relieved by micturition. This glans pain is of
the referred variety, the stimuli being transmitted through the
dorsal nerve of the penis, a
branch of the pudic supplying
the prostate. The pudic also
sends a branch to supply the
perineum and the anus, and in
both these regions referred
pain may be felt.
Lesions. — Lesions of the
prostate may also cause re-
flected pain and hyperalgesia
in the tenth and eleventh dor-
sal, the flrst, second, and third
sacral, and sometimes also in
the first lumbar visceral seg-
ments. The areas of distribu-
tion of these segments are illua-
t rated in the accompanying
figure.
In some cases also the
jiroetate may make pressure
ou the sciatic nerve and thus
cause pain which is referred
to its distribution area.
The most common diseases
of the prostate causing pain are: (1) congestion, (3) inflam-
mation, (3) hypertrophy, (4) new growths.
Hypertropl^. — Congestion and inflammation have been con-
sidered. Next and closely related to these two is hypertrophy.
Generally it is without pain, or, in fact, symptoms of any kind,
unless, owing to increase in size, the prostate encroaches upon
the neighboring structures and causes some functional disturb-
FiQ. 166. — Areas of Dibtribution
OF THE lOm AND llTH DORSAI.
Seomento, and the IfiT, 2d, and
3d Sacbal Seomentb on thb
Riaar Sme.
These areas are most frequently
involved in prostatic disease.
(Head, Brain, Vol. XVI, p. 85.)
702 THE HALE GROANS OF GENERATION
ance. For instance, no pain i^ felt in median lobe enlargement
until the enlarged lobe causes retention of urine, with infection
and consequent cystitis. Then the paii* becomes most severe, but
it is not the pain of the hypertrophy, but of the cystitis. Hyper-
trophy of the prostate may cause pain in almost any r^on, de-
pending upon the changed relationships, pressure, etc, which
are produced in the neighboring structures. Some of the places
where pain is felt are the glans penis, the back, the hips, the
buttock, down the thigh and l^s, the foot, and the suprapubic
and perineal r^ons.
Tumors of the Proftate. — The most common is cancer. In
it prostatic pain may be complained of only when the bladder is
distended with urine. As a general rule, in the soft varieties
of cancer, pain is not a prominent symptom. It is usually only
when the cancer is hard and the surrounding tissues become infil-
trated that pain and discomfort ensue. In some cases, in which
the cancer involves the vesicoprostatic portion of the bladder, pain
of a spasmodic type occurs. It depends for its production upon
the compression of the nerve filaments in the muscular walls of
the bladder, particularly so if the lesion occurs in the vicinity of
or involves the vesical sphincter.
Tnberculosia. — Tuberculosis of the gland structure is not pain-
ful unless neighboring tissues are involved. Calculi, likewise, may
be present in the prostate without causing pain.
Associated Symptoms. — Associated symptoms of prostatic in-
volvement are:
(1) Frequency of urination. This is one of the most charac-
teristic symptoms. Commonly, when the prostate is not acutely
inflamed, urination is frequent, but is entirely free of pain.
(2) On passing a sound the most extreme agony is experi-
enced by the patient as it passes over the prostatic portion of his
urethra.
THE PENIS 703
THE PENIS
Pain felt in the penis may originate from conditions present
in its substance, involving principally the urethra, or it may
be referred from distant lesions.
Urethritis. — The lesion of the penis causing the most pain is, in
the vast majority of cases, an acute inflammation, generally gon-
orrheal, of the urethra. Inflammation of the urethra causes pain
in urination, which, however, is more of a burning sensation, or,
as some of the patients put it, "a feeling as though they were
passing hot oil," than an actual pain. The irritation is often
transmitted to the head of the penis, where it is felt as a severe
stabbing. When the urethra and adjacent tissues are inflamed
erection causes acute pain. Owing to the structure of the penis
inflammation, when the spongy body only is involved, causes it,
during erection, to be bent on itself. Many misguided individ-
uals, ignorant of the true nature of the pain production, have
attempted forcible straightening of the penis in such conditions,
with resulting rupture of the urethra.
Referred pains felt in the penis may originate in lesions of
the kidneys or ureters, in prostatic diseases, in some spinal cord
conditions, and occasionally from rectal disorder.
Inflammation of the prepuce (balanitis) causes a pain that is
especially marked on erection of the penis. In the state of erec-
tion the prepuce is stretched, normally, without any special sen-
sation, but should it be inflamed, pain results. Pain is also pro-
duced by the rubbing of the clothing against the inflamed and
eroded surfaces.
Inflammation of Cowper's Glands. — Sometimes the glands in
the bulbo-membranous urethra, known as Cowper's glands, become
inflamed. When they do, pain is felt in the perineum, where,
on palpation, a painful mass may be palpated. The pain is
greatly increased by motion, such as walking; defecation and the
sitting posture also increase the pain, which is of a throbbing
character. To cause this throbbing it is not necessary that the
congestion be severe, for the glands lie between the two layers of
704 THE MALE ORGANS OF GENERATION
the triangular ligament and are inclosed in perineal fascia, so
that the least engorgement is resisted, and gives rise to pain.
The glans penis itself, generally, is not painful. Examples
of an ulcer of the glans being present without the patient's
knowledge are common. Indeed, he may not be aware of any-
thing abnormal until the skin is involved, or until lymphangitis
or lymphadenitis occurs. However, the penis is not absolutely
without sensation, for it is capable, probably more so than ordi-
nary organs, of appreciating different degrees of pressure.
(Head and Rivers, 86, p. 39.)
CHAPTER XXXII
PAIN IN THE FEMALE GENITALIA
GENERAL C0N8IDEBATI0N8
Anatomy. — The female genitalia consist internally of the
uterus, Fallopian tubes, and the ovaries, and externally- of the
vagina. The internal organs lie deep in the pelvis, and are
protected against traumatism by the bony wall which surrounds
them. This wall, although it serves the purpose of a protection
to the sexual organs at the times when the organs, enlarging for
some reason, cannot accommodate themselves without making
pressure on the surrounding structures, also is a cause of pain and
distress. The free mobility of the uterus and adnexa helps to
overcome, in a measure, the structural disadvantages of its loca-
tion.
The peritoneum, which covers the uterus, tubes, and ovaries,
is reflected over the anterior and posterior surfaces of these or-
gans, and on either side forms the two layers of the broad liga-
ment. The uterus lies in front of the rectum and posterior to
the urinary bladder. Any enlargement or distention of the rec-
t\im causes a displacement of the uterus, raising it up and throw-
ing it forward. Normally this causes no discomfort, but when
inflammation, with its accompanying adhesive formations, arises,
this free mobility is curtailed, and change of position causes pain.
Owing to the close anatomical connection and relationship of the
uterus with adjacent organs, any inflammation or derangement
of the economy of these organs has an unfavorable influence upon
the uterus, either through the nervous system or the circulatory
supply, and may lead to pain production.
Nerve Supply. — The female genitalia receive their nerve sup-
705
706 PAIN IN THE FEMALE GENITALIA
ply from both the sympathetic and the cerebrospinftl Bjatems, the
sympathetic being distributed to the upper part of the uterus, the
tubes and the ovaries, and the upper part of the vagina, while the
cerebrospinal nerves are distributed to the lower uterine segment
and the vagina. The ovaries and tubes are supplied entirely
by the sympathetic, the nerves supplying the ovary and the distal
extremity of the
tubes being derived
from the ovarian
plexus, which, in
turn, receives its
fibers from the
fourth and fifth lum-
bar ganglia of the
sympathetic. The
proximal end of the
tube and the upper
part of the uterus re-
ceive their supply
from the uterine
plexus, and this also
derives most of its
Fig. 167.— Nerve Supply of Female GENrrALU. ^'*" from the
cu, spinal uterine center; plh, hypogastric fourth and fifth lum-
plexus; nhy, hypogastric nerve; npc, nerves bar ganglia of the
pudendres communis; nh, hemorrhoidal nerves; vmnatlipti
gu, peripheral ganglion"' m vaginal form; a, ^^ P *^
vagina; vu, bladder; vl, vulva; an, anus. At this point it is
(Bechterew'a "Functionen der Nervencen- well to recall that the
Inmbar ganglia <ln
not correspond with the lumbar visceral s^ments of the cord, as
described by Head. The nerves which pass through the ganglia
may arise from much higher segments of the cord than the ganglia
through which they pass would seem to indicate. The segmental
supply will be considered on p. 713.
To understand better the nerve 8iip])iv of the female genitalia
each organ will be considered separntely. The supply to the
GENERAL CONSIDERATIONS t07
ovaries and tubes will first be traced, and then the supply to the
uterus and vagina.
The ovaries are probably supplied entirely by sympathetic
fibers (Luschka, Van Hoerff), which are derived from a plexus
surrounding the ovarian artery. This plexus, in turn, is formed
by nerves from the renal and aortic plexi, and thus is in inti-
mate connection with the abdominal sympathetic; so that any de-
rangement of the ovaries may produce sympathetic disturbance
in the abdominal viscera. The plexus surrounding the ovarian
artery sends fibers into the ovary, to form plexi surrounding
the larger blood vessels. A plexus is also formed in the cortex
and sends nerves to the periphery, to end on the surface between
the germinal epithelial cells, or in the follicles, where they termi-
nate in the walls of the blood vessels. None of the fibers pene-
trate beyond the theca. In opposition to the view that the ovaries
are supplied entirely by sympathetic fibers is that of Head and
Rivers (86), who hold that the ovary receives a part of its nerve
supply from the abdominal wall, its innervation probably being
connected with the last dorsal and first lumbar nerves. However,
this is likely true only of the peritoneal covering which the ovary
has acquired during its developmental descent, for in early fetal
life it lies close to the abdominal wall, beneath the peritoneum.
The Fallopian tubes receive their nerve supply from the sym-
pathetic. The nerves follow the arteries and reach the tubes from
the ovarian and uterine plexi (cervical and corporal). After
reaching the tubes the nerve fibers penetrate into the peritoneum
and immediately beneath it form a plexus (the subserous), from
which some nerv^es are given off to supply the muscular tissues,
and others to form a subepithelial plexus, which lies in and
supplies the mucous membrane.
The uterus is supplied both by the sympathetic and the cere-
brospinal systems. The sympathetic is distributed chiefly to the
body of the uterus and is formed into two plexi, the smaller of
which lies upon the upper and lateral surface somewhat pos-
teriorly, and is distributed to the posterior and lateral surfaces
of the uterus. The larger is distributed to the cervix and the
708 PAIN IN THE FEMALE GENITALIA
vaginal vault One of these ganglia is especially large, and is
called the cervical ganglion. It lies behind and to the side of
the cervix. The uterus, in addition to the sympathetic fibers, re-
ceives meduUated fibers from the second, third, and fourth sacral
nerves * (third and fourth sacral, Novak), which also supply the
vagina, and, through the pudic, are distributed to the perineum
and the bladder. Therefore, when the lower uterine segment is
affected, pain may be felt in the bladder and the perineum.^
In the uterus the course of the sympathetic and spinal nerve
fibers is different, the sympathetic fibers being distributed to the
blood vessels, while the spinal fibers terminate between the muscle
bundles and in the mucosa (Piersol), but are probably not found
above the cervix. It is because of the intimate relationship of
the cerebrospinal fibers to the uterine musculature that uterine
spasm is so specifically localized to the uterus;* because, when
the uterus contracts, the nerve filaments are caught between the
individual muscle bundles and are tightly squeezed. This irri-
tation produces the sensation peculiar to the uterine contraction,
and is called uterine "colic."
The nerves of the uterus show great ability to adapt them-
selves to changes in size of the uterus. This is well seen during
pregnancy, when the uterus enlarges to many times its normal
1 Bechterew, quoting from Rein ami Pisemsky.
2 According to v. Basch and Hofman (379), there are two sets of nerves
in the uterus: the nervi uterini, reaching the uterus by way of the hypogastric
and sympathetic nerves, and the nervi uterini sacralis, passing from the main
sympathetic chain, and belonging to the pelvic splanchnics (Komer, BobUng,
378). The stimulation of the hypogastric nerve causes a contraction of the
circular muscles of the uterus. Stimulation of the cerebrospinal nerves eaoses
the longitudinal to contract.
s Since the stimuli carried to the brain over cerebrospinal tracts are
definitely localized to the area in which they are produced, any stimuli
occurring in the spinal nerves supplying the uterus would be referred
to the area in which they are produced, viz., in the lower uterine segment.
The localization of the pain is not as definite as it would be if some of the
somatic nerves were involved, for one of the chief functions of the somatic
nerves is to interpret pain, while those of the uterus are concerned more with
nutrition and muscular tone. So that pain stimuli present in the nerves
supplying the uterus are not interpreted definitely as coming from the utems,
but are referred to the area of distribution of the pudic, one of the functions
of which IS to transmit pain sensation.
GENERAL CONSIDERATIONS 709
size. The nerves increase in size but not in number. The gan-
glia also increase in size; naturally they wiU be somewhat
stretched, and this stretching produces irritation, which is trans-
mitted to the cord, and is reflexly felt as a pain or aching in
the back or down the thighs in the area of distribution of the cord
zones connected with the uterus.
The sensibility of the uterus, ovaries, and tubes to ordinary
stimuli is very slight, if it is present at all, so that, on exposure,
during operation (cocain anesthesia), a normal ovary can be
pinched with a clamp or a mouse-tooth forceps without the pa-
tient's knowledge. The same can be done, in the majority of
cases, with normal tubes (Sampson, Meyers, 152, p. 749). Deep
pressure upon an ovary produces that peculiar sickening sensa-
tion so familiar in the male when the testicles are squeezed.
Some women are more sensitive to ovarian pressure than are
others. Intrapelvic manipulation is usually less painful in
women past the menopause, and also less painful in those who
have borne children. Most observers agree that the uterine,
tubal, or ovarian peritoneum is not very sensitive to traction,
to pressure, or to gauze rubbing against it, but that the parietal
abdominal peritoneum is most sensitive to these same stimuli.
The cervix uteri is insensitive to touch, but is very sensitive to
crushing or dilatation. The endometrium is as a rule without
pain sensation (Novak), though when inflamed it may give rise
to a sensation of weight and heaviness. In this condition intra-
uterine points or areas of tenderness may develop (see imder
Uterus) .
Diagnosis of Pelvic and Hysterical Pain. — Pelvic Pain. — If
the patient complains of pain, and pelvic disease is suspected as a
cause, inquiry should be made as to the periodicity of the pain,
its exact location, its relationship to the menstrual period, and the
history of past diseases. If such inquiry is made, it will be
found that pain, if it is due to pelvic lesions, will have some or
all of the following characteristics:
(1) It is either constant, with periodic exacerbations corre-
sponding to the menstrual period, or is present only at the time
.710 PAIN IN THE FEMALE GENITALIA
of menstruation; (2) it is felt in the lower abdomen and radiates
to the back or lower limbs, or it is felt in the right or left iliac
region; (3) it is associated, in quite a fair proportion of cases,
with a tender point one to one and one-half inches below, and
three-quarters of an inch internal to, the umbilicus (Morris's
point).
In regard to the ananmese, careful questioning of these
patients will generally elicit the fact that at some time in the
past they have, suffered from parametritic inflanmiation. Yet
great care must be exercised in judging of the value of subjec-
tive symptoms, as given by the patient, for, at the present time,
because of the prevalence of pelvic diseases, and the diffusion of
knowledge concerning their symptoms, it frequently happens that
a hysterical patient will simulate a uterine or ovarian disorder
so closely that it is very difficult to make a diagnosis.
However, in nearly all cases a fairly positive diagnosis can
be made, for, as Eulenberg says (145, pp. 1274-1275) : "Spon-
taneous recurring pains in the inner or outer genitalia (in the
pelvis, coccyx, or abdominal wall), when they are the exclusive
or predominating symptom, if they occur without positive organic
findings, independently of the quality, intensity, persistency, and
former quality of the pain, speak first against the acceptance of
a genuine local disease, and eventually for a clear nervous cause,
in the sense of neurasthenia or typical pain of psychical hysteria.
"In any case spots, painful upon pressure, can only be re-
garded as affections of genuine genital suffering if they can be
referred back to a local change ; for instance, to enlargements of
the ovaries, or to parametritis. Should the pain, present on pres-
sure, remain in the same place, on the same side, and exist at
certain periods (menstruation) organic lesions are indicated,
while vacillation, irregularity, changes of the kind of pain occur-
ring periodically, and resistance, point on the contrary to the
neuropathic causes."
Hysterical Pain. — When pain is present in the ovarian re-
gion, hysteria should be considered as a cause; the hysterical
origin of the pain may be proven by finding pressure points on
GENERAL CONSIDERATIONS
711
other parts of the body (Windscheid, 148, p. 484). Another
point which aids in diagnosing hysterical pains is that they bear
no relation to sensory nerve distribution, nor to segmental cord
distribution (Dercum, 150, p. 849).
Another point aiding in the diagnosis is that pain due to
hysteria does not, as a rule, subside upon rest in bed, while pain
due to inflammatory disease of the pelvic organs usually does.
This is not invariably so, because many cases of hysteria and
neurasthenia are greatly benefited by rest in bed, owing to the
improvement in the general health which then ensues (Rothrock).
In hysteria, also, there is, as a rule, diminution or absence of
the conjunctival and pharyngeal reflexes (Windscheid). Hysteri-
cal (or neurasthenic) pain is confined to the left side. In hys-
DIAGNOSIS OF PELVIC FROM HYSTERICAL PAIN
Symptoms
Pelvic Disease
Hysterical Pain
Pain.
Has definite location and
remains constant in this
location. It makes no dif-
ference whether the pa-
tient's attention is attracted
elsewhere or not; pressure
over the site of the pain
will produce an exacerba-
tion of it. Menstruation
usually influences the pain,
generally increasing it.
Has no definite location,
but flits from one place to
another. Pain often is of
a burning character. Fre-
quently, when the patient's
attention is attracted else-
where, severe pressure can
be made over the indicated
site of the pain without
initiating it if it is not pres-
ent or without increasing it
if it is present. Menstrua-
tion usually has no influ-
ence on the pain.
Fever.
May be present in acute
disease.
None.
Leukocytes.
May be increased in acute
attacks.
No increase.
History.
Generally of gonorrheal,
tubercular, or puerperal in-
fections, pelvic tumors, or
of pelvic traumatism.
No history of gonorrhea,
etc., but one of neurosis.
Reflexes.
Conjunctival and pharyn-
geal present.
Conjunctival and pharyn-
geal absent.
Areas of hyperes-
thesia.
Absent.
Present.
712 PAIN IN THE FEMALE GENITALIA
teria (neurasthenia also) there seems to be a lessened resistance
to pain production in lesions of the female genitalia. This
causes them to react much more strongly than normal to the
slightest irritation (Dercum, 347; Herman, 316); so that when
the pelvic disease has produced a secondary neurasthenia or
hysteric weakness the pain may, after removal of the cause which
has originally produced it, persist and be renewed on the slightest
stimulus arising from causes which, in a normal state, would not
produce even a discomfort.^
As an aid in the diagnosis of these conditions a diagnostic
chart is given on page 711.
Varieties of Pain. — In some patients a long-continued lesion
has produced so much disturbance in the nervous system that a
permanent state of nerve weakness has occurred, and the patient
suffers from the condition termed neurasthenia. She is now
particularly unfortunate, for her years of suffering have so re-
duced the resistance of the nervous system, and the pathways for
pain have been so well defined, that irritations, even those of the
least magnitude, are interpreted as painful. It should not be for-
gotten, however, that the term ^'female complaint" is often used
as a subterfuge for weak, irresolute, or lazy souls to indulge their
innate propensities for idleness.
So far we have been speaking of pain and painful areas, not
specifying definitely their location, and therefore before we ad-
vance further it will be well to consider more exactly the limits
of these areas in which pelvic pain is felt.
In doing so, it is again necessary to draw attention to the
fact already stated that the pelvic viscera, unlike most of the
other abdominal viscera, have two sources of nerve supply: the
sympathetic and the cerebrospinal. The cerebrospinal system,
as is known, refers all its irritations to the peripheral distribu-
tion of the particular nerves concerned, while the sympathetic
carries the stimulus to its centers in the cord. Here the irrita-
tion is communicated to adjacent centers of the cerebrospinal
1 According; to Fritsch (348), pelvic pain persists in 33 per cent, of the
cases after corrective operations.
GENERAL CONSIDERATI
system, by which it is relayed to the brain,
as coming from the peripheral distributio:
connected with these centers. Thus the pain
irritation are more apt to have an exact o
due to irritation of the sympathetic system,
in uterine muscle-contraction pain, where th
what exact and the pain is of considerable
is due to cerebrospinal involvement; whik
pain, when present, is indefinitely placed i:
is referred to the back, to the hips, or to tl
of less intensity, being more of an aching
it is of sympathetic origin.
The sympathetic supply of the body of t
from the tenth, eleventh, and twelfth dorsal
and second lumbar (Donald and Lickley)], ^
segment is supplied by the third and fouri
times the first and second sacral segments
fourth sacral (Donald and Lickley)]. In
always well to remember that the sacral seg
means correspond to the sacral nerves. Th
concerned principally with the dilatation o
occurs in the first stages of labor, while tb
concerned principally with the contraction
Fig. 168 the distribution areas of the diffei
fined.
By an examination of this figure it is
corporeal pains are referred to the lower
while the cervical pains are referred to t
back of the hip and thigh, and the lower
foot. The pains due to the ovary are reflect
visceral areas, and those from the Fallopia
enth and twelfth dorsal and first lumbar v
In this respect a peculiar characteristi*
to be noted is that, irrespective of the local
pain is most common on the left side.
Novak (117, p. 480) states that Cham;
m PAIN IN THE FEMALE GENITALIA
cases of uterine cancer, found the proportion between left-eided
pain and right-sided pain to be as six is to one, and in these
eases no greater tendency to involvement was present on the left
than on the right. Herman, likewise, found that, in cases of
retrodisplacements of the uterus, pain was three times as fre-
quent on the left as on the right side, without regard to the fre-
quency of the displacement on the same side. Herman ascribed
Fig. 168. — Area or Dibthibution of Cosd Segments Involved in Uter-
ine, Ovarian, and Tubal Diseases.
The body of the uterus is supplied by the 10th, 11th and 12th dorsal seg-
ment*; the cervix by the 3d and 4th lumbar and sometimes by the lat
and 2d sacral segments; the ovary by the 10th, and the Fallopian tube
by the 11th and 12th dorsal and the let lumbar segments.
the greater frequency of pain on the left side to the fact that
the left side is weaker and less resistant than the right. Accord-
ing to Herman (144, p. 1,05G), the greater frequency of pain
on the left side has been fancifully explained as being due to a
shortening of either the left tube or of the left ovarian ligament.
It is also explained by Clark (350) as being due to tension of
the tightly drawn mesentery over the brim of the pelvis. It may
also in many cases be partially explained from the fact that on
GENERAL CONSIDERATIONS 716
the left side (in hysterically inclined subjects) there is usually a
hysterical zone in the region of the ovary (Charcot).
Sympathetic pains, occurring in the occiput and breast, are
very frequent in disease of the female genitalia. The presence
of the breast pains cannot entirely be explained on the hypothesis
that the stimuli are carried through the nervous system, although
it is probable that the nerve supply of the breast has a more
special connection with the genitalia than with other organs.
The pain in the head, and particularly that in the breast, seem to
be due to an active congestion of the meninges and of the breast
respectively, so that, in pelvic disease, at the time when the pain
appears in the breast, the mammary gland swells, becomes tender,
and the pain is (frequently) of the dull, aching variety that indi-
cates capsule tension. When the pain is felt in the head the
meninges are probably likewise congested, and the headache is
likely due to increased intraventricular tension.
The cause of both these congestions may be a toxin or ferment
either of uterine or of ovarian origin circulating in the blood.
This substance has a selective action on the meninges and on the
breast; the breast, because of the related sexual functions of the
two ; and the meninges, because they seem to be particularly sensi-
tive and reactive to deleterious circulating substances of any kind.
As yet a substance of this nature has not been separated from
the blood, nor has one been produced from the uterine or ovarian
tissue, though the actuality of its existence seems to be strength-
ened by the fact that during gestation, with all nerves divided,
the mammary gland develops. The only way a stimulus could
be carried to it is by the blood (Mott).
A peculiarity of breast pains, that might seem to show that
the uterus and the breasts are correlated through the nervous sys-
tem, is that breast pain is most frequent on the side in which
the diseased organ is located. If the causative factors were car-
ried through the circulation, why should the breast on the dis-
eased side be more frequently involved? As yet no clear expla-
nation has been offered.
As a conclusion it may be stated that the female genitalia are
716 PAIN IN THE FEMALE GENITALIA
capable of producing local, referred, reflected, transferred and
sympathetic pains. The transferred pains are found in some
cases of salpingitis, in which the pain is felt on the side opposite
to the one in which the lesion is located. Nearly aU surgeons
have had experience of such cases.
Character of Uterine Pains. — ^While a description of uterine
pains may entail some slight repetition, yet, for the sake of clear-
ness, we shall again very briefly consider them. As has been
said, they may be classified as constant and intermittent The
constant pains are those due to a continuously acting cause, such
as is found in inflammations (endometritis, metritis, salpingitis,
and oophoritis). Exacerbations frequently occur, producing in-
termittent pain, and usually indicate uterine contractions. Con-
stant pains, varying in intensity on change of position, are found
where inflammation has been followed by the formation of adhe-
sions. These adhesive formations are a potent cause of pain pro-
duction during the functional acts of the parts involved. For
instance, where the uterus is attached by adhesions to the bladder
wall, urination, owing to a lessened capacity of the bladder, the
result of traction, etc., by the adhesions, becomes frequent and
generally is painful; likewise adhesions to the rectum are the
cause of pain during defecation, and in some cases pain is felt
as soon as the fecal matter begins to accumulate in and distend
the sigmoid.
Position Assumed by the Patient Suffering from Pelvic Vis-
ceral Pain. — Some women who are afflicted with uterine or ad-
nexal disease have no rest in any position; standing or walking,
in motion or at rest, they are always subject to distress. Their
pains, like an unwelcome heritage, are ever with them. On the
other hand, there are others who have pain only when they as-
sume certain positions or perform certain acts. Very familiar
is the woman who is always complaining of her back. She has a
constant, steady aching, that is made worse on bending and on
flexion of the body. She will prove to be one who has a displaced
or retroflexed uterus. Women who not only have pain on standing
but on lying on one side will freiqiiently be found to bave an ^ute
GENERAL CONSIDERATIONS 717
inflammatory state of the adnexa on that side. Some women,
though, seem to have ease by lying on the affected side. Bending
forward or backward is particularly painful in all pelvic disease.
Especially in inflammatory states of the pelvic peritoneum are
frequent repetitions of the same act very painful.
On ascending stairs pain in the inguinal and lower abdom-
inal region, coming on as the foot is being removed from the
ground, generally indicates an involvement of the psoas muscle
or its sheath in the inflammatory adnexal disease. Pain on ele-
vating the arm indicates an increase of intraabdominal pressure
and disturbed peritoneal relations. This is common in adhesive
formations and in pelvic peritonitis.
If the adhesions are to the small bowels intestinal peristalsis
is painful. Pain of this sort comes on at irregular intervals and
is of varying intensity. It is frequently accompanied by a gur-
gling which indicates the reduction of a stenosis and the onward
passage of the bowel contents, with an almost immediate relief
from the pain.
Relation of Pelvic Visceral Pain to Functional Acts. — In all
acute and some chronic inflanmiations of the pelvic viscera, and
in those cases of adhesive union between different viscera, pain
is present on coitus. This pain may be severe during the entire
act or may be present only at the end, and, in either case, may
persist for some time after the act When it is present during
the entire act it is generally due to an acute inflammation, which
has progressed beyond the uterus and has involved the adnexa.
This pain persists, as a rule, for some time after the act. In
chronic pelvic inflammartion the pain may often persist through-
out the next day. The site of the inflammation modifies the
pain to a great extent. Inflammation high in the body of the
uterus generally does not cause as much pain as if the inflamma-
tion were low down in the cervix. Of course, vaginitis or cys-
titis will also cause pain, and should be considered. This pain
is present on the entrance of the male part, while the pain of
the inflammatory and adhesive states is present only during the
act, and, in many cases of mild inflammatory states persists only
718 PAIN IN THE FEMALE GENITALIA
during the time of the active movements. When it persists after
the cessation of these movements it is a sign that some damage
has been done to the female parts. If the patient has pus tubes,
a pain persisting in the tubal area after the completion of the
sexual act may, in some cases, indicate a leakage from the tube,
with a peritoneal irritation. Pain on entrance of the male organ
into the vagina may indicate a bartholinitis, fissures, sometimes
growths, or a tight introitus, either of spasmodic (vaginismus)
or organic origin.
A pain, or rather an aching and discomfort, only present at
the time of and at the completion of the sexual act (orgasm) in-
dicates an endometritis.
Menstruation acts as an exciting cause to pain production in
many cases of pelvic disease. When the pain comes on prior to
menstruation it indicates an existing inflammation, very fre-
quently of the tubes. Frequently, also, it is the best sign of a
cirrhotic ovary. Pain during the early stages of the menstrua-
tion indicates (generally) a stenosis of the cervix, while if pres-
ent during the entire time it indicates an inflammation of the
uterus or adnexa. Pain existing prior to and relieved by men-
struation indicates a uterine congestion, a very probable cause
of which is fibroid tumor.
Relation of Pelvic Visceral Pain to Motion and Change of
Position of the Patient. — In diseases of the genitalia all vibra-
tory motion produces pain, which is especially well marked dur-
ing violent movements, such as occur during horseback riding,
jumping and running. A form of motion particularly productive
of pain is that which occurs in sweeping, and in the lifting or
moving of heavy objects.
This pain probably depends for its production upon the in-
crease of the intraabdominal pressure, due to contraction of the
muscles of the abdominal walls. Certain functional acts, such as
vomiting, also incite pain. The vomiting causes extremely
marked variation in the intraabdominal pressure and visceral re-
lationships, and this probably leads to the pain production.
Certain ordinary acts of every-day life may also be produo-
GENERAL CONSIDERAT]
tive of pain, for instance, a patient who 1
inflammation finds it difficult to sit down
the affected side over the other limb in a
called '*lacing-the-8hoe position" (q. v.). I
due both to the direct pressure of the lii
abdomen, and to the stretching of the psos
the intraabdominal pressure.
In all cases where inflammation is begi
the pelvic viscera to the adjacent tissue i
seeks quiet, and, because of the resultan
aroused from her lethargy.
Tenderness due to pelvic lesions can be
dominal or vaginal examination. The abd
divided into the superficial and the deep.
The superficial examination is limited
of hyperalgesia. The limits of these areas
the heading, Reflected Pain (q. v.). The
nostic phenomena in pelvic disease is that
a "leader" as to where to search for the les
abdominal pain and discomfort. As no phyi
absolutely upon one symptom in forming a
nomenon of hyperalgesia should not be take
any one disease, but rather should be used a
or contradicting the conclusions arrived at
Tenderness produced on deep palpatio!
helpful than that produced by superficial j
demess is being sought for, the relationshi
to the anterior abdominal wall should be
uterus lies deep in the abdominal cavity, ;
are deeply placed. They are in intimate c
neum. Any inflammation of these viscera
surrounding tissue, and, because of the abi
ply, the area of involvement is much gre
This is the reason that the tenderness is m
these inflammatory conditions than one \^
type of lesion.
720
PAIN IN THE FEMALE GENITALIA
A method of eliciting abdominal tenderness in tubal disease
is to make pressure with the hand, with a slowly progressive,
downward motion, in the iliac fossa, so as to pinch the tube and
ovary between the hand and the pelvic wall. As soon as the ovary
and the tube are caught the patient makes an outcry, and the
lower segment of the rectus muscle
becomes rigid. This sign cannot
always be elicited, for in some cases
rigidity of the rectus is so great
that it is impossible to press the
hand into the pelvic fossa. A
method of making use of the ob-
servations of Mackenzie, that "the
muscular tissues" and of Lennan-
der that "the subperitoneal tissues'*
are tender in visceral disease, is to
place the hand palm downward on
the upper part of the thigh, and
then, with the fingers slightly
flexed and depressed into the flesh,
to draw the hand upward over the
abdomen. As soon as the fingers
pass above Poupart's ligament, and
a drag is made upon the abdominal
muscles and peritoneal tissues, the
patient complains of pain. These
signs are only confirmative of other
symptoms and are not to be con-
sidered of pathognomonic value.
In this connection, the areas of tenderness, as found by Donald
and Lickley (138, p. 434) in pelvic visceral disease, are of
interest. They found that, by pinching the skin between the
fingers, or by making slight pressure upon it, certain areas op
points were more sensitive than others. Each of these areas
seems to have a certain definite relationship to a visceral organ.
The area connected with the ovary is slightly below the umbilicus.
Fig. 169. — Points of Tender-
ness AS EUCITED BT DoNALD
AND Lickley (138) in Ova-
rian, Tubal, and Uterine
Diseases.
ov, ovarian tenderness; ov', ac-
cessory ovarian tenderness; T,
tubal tenderness; u, uterine
tenderness; u', accessory uter-
ine tenderness.
GENERAL CONSIDERATIONS 721
and about two inches to one side of the median line. It lies on
the intersection of a line joining the umbilicus to the anterior
superior spine, with a line lying on the outer border of the rectus.
At this point the cleveiith dorsal nerve pierces the sheath of the
rectus and becomes superficial, so that, because of its exposed
position, pressure may easily be exerted upon it There is also
found an associated area of tenderness on the lateral wall, at the
point where the lateral, cutaneous branch of the eleventh nerve
becomes subcutaneous. The area associated with tubal disease is
found at the intersection of the horizontal line joining the two
anterior spines with the outer margin of the rectus sheath. It
corresponds to the point of emergence of the twelfth dorsal nerve.
The uterine area is located over the inguinal ring.^ At the
internal ring the ilioinguinal nerve enters the canal and becomes
superficial. Other areas of tenderness associated with the uterus
are: (1) imme<liately below Poupart's ligament, where pressure
on the anterior crural is painful; (2) an area extending from
the outer margin of the erector spinae muscle to the gluteal re-
gion, following the posterior divisions of the first three lumbar
nerves (this area generally is associated with disease of the
body of the uterus) ; (3) in some cases also there is a tender
area over the sacrum from the second sacral vertebra to the coc-
cyx. This area extends laterally, and in extent corresponds to
the posterior primary divisions of the mid-sacral nen^es, and may
be present in diseases of the cervix uteri.
The most responsive of all these areas to disease of their asso-
1 Regarding the cause of tenderness at the interna! inguinal ring, two
theories are given: (1) the mechanical, and (2) the reflex neurological. In
regard to the former, the points apparently in its favor are the dragging nature
of the pain, and its location at a point where the broad ligaments are inserted.
This would be of considerable value if, in all cases in which the pain is present,
a dragging on this section of the abdominal wall were made by the broad liga-
ments, or if, in all cases in which dragging is found, pain were present. Many
examples of each of these states without pain production at this point can be
found, and their profusion rather negatives the value of this deduction. On
the other hand, it has been found that electrolysis of the uterus will produce
pain in this same area, without any general disturbance of relationship of the
other organs. This would indicate that if, in all cases, the pain is not pro-
duced reflexly, at least in every case it is capable of being so produced.
722 PAIN IN THE FEMALE GENITALIA
ciated organs is the ovarian, while the uterine area is the least
responsive.
A bimanual vaginal examination should be made on every
patient who complains of pelvic pain. Often the tube can be felt
through the abdominal wall to be enlarged and tender ; even tender-
ness of the ovary can sometimes be elicited. When pressure
is made upon either of these, reflected or referred pain will
be felt in the cutaneous areas associated with them. During the
vaginal examination the fingers in the vagina should ptish the
cervix from side to side. If the adnexa of one side are diseased,
pain is complained of in that side. In case of adhesions pain is
produced when the position of the uterus is such that the adhe-
sions are put on the stretch. Acute inflammatory conditions are
painful either on pressure or on traction. The pain is felt on
the side manipulated, and is produced either by pushing or
by rotating the uterus toward the opposite side or by pressing it
against the diseased tissues. Rotation of the uterus may be ac-
complished by using the cervix as a fulcrum to make pressure in
the direction opposite to that in which it is desired to have the
uterus turn. Pain on drawing tbe cervix forward and downward
may be due to a short, sensitive, uterosacral ligament (Novak),
inflammation of the parametrium, or recent uterine adhesions.
According to Garrigues (163) pain is produced at the side of
the second sacral vertebra by pressure on the corresponding utero-
sacral ligament.
Diagnosis of Pelvic Diseases. — Of value in the diagnosis of
pelvic diseases are:
(1) The history of the. case, which should always be carefully
reviewed. The manner of the onset of the present symptoms
and their duration should be defined. It should also be deter-
mined if they came on after a suspicious intercourse. Yet the
absence of such a history should not be of too great influence in
the forming of a diagnosis. For in many cases of pelvic disease,
gonorrheal in origin, the patient has innocently acquired the
coccus from an impure husband, and does not know of her affec-
tion, so that a negative history is but of slight value in forming
QENEEAL CONSIDEBATIONS 723
an opinion. In others puerperal sepsis is the cause of the trouble.
What proportion of pelvic lesions come from other causes than
the above is rather hard to decide, but the common opinion is
that it is very small. The non-specific lesions causing pain are
tumor, tuberculosis, etc.
(2) After a history of the onset a good description should be
obtained of (a) the character of the discharge, and (b) the type
and character of the menstrual flow. In specific infection the
vaginal discharge generally is thick and creamy, and if the disease
has to any extent invaded the uterus is usually of a foul odor.
A mixture of blood may indicate (unless it occurs at the men-
strual time) an endometritis or extrauterine pregnancy. A slight
whitish discharge before or after the menstrual period is of no
diagnostic value, as it is a common occurrence in many normal
women. The vaginal discharge should always be examined mi-
croscopically in order, definitely, if possible, to identify the caus-
ative germ.
Because it is so common, and occurs in so many ways, it is
very difficult to derive any useful information from menstrual
disturbance ; but change in its character is of great significance in
extrauterine pregnancy, cancer, fibroid, and pelvic inflammation.
As predisposing factors to the production of pain in tubo-
ovario-uterine disorders may be mentioned anemia, severe or pro-
longed illness, depressing mental influences causing a lessened
psychic resistance, and starvation. Before passing on to a more
special consideration of the pain-phenomena in the special or-
gans composing the pelvic viscera, it is well to consider in a
nervous, high-strung woman the possibility of the presence of
hysteria. In this condition many other criteria and indications
of involvement are present — for instance, the eye phenomena and
the areas of anesthesia and hyperesthesia present in other parts
of the body — and even though a severe pain may be complained
of over the region of the ovary (the so-called ovarian neuralgia),
it is not associated with such severe local abdominal rigidity as
are organic lesions of the ovaries, tubes, or uterus.
After this brief survey of the principal causes for pelvic pain
.724 PAIN. IN THE F EM ALR. GENITALIA
«
and the areas in which it is found, it is well^ before a more de-
tailed description is undertaken, to offer as a caution to those
who consider only the symptoms and not the patient, Novak's
warning. He says: "The gynecologist must learn to look on
pain as the resultant of two factors, the lesion and the patient;
and in order to arrive at an intelligent appreciation of the true
significance of pelvic pain he must study both, these factors with
equal fidelity.''
UTERINE PAIN
As a slight review of what has proceeded, let it be recalled that
the uterus is supplied by two sets of nerves, the cerebrospinal and
the sympathetic. The cerebrospinal nerves are derived principally
from the second, third, and fourth sacral nerves, and supply the
lower segment of the uterus. It is owing to the stretching of
these nerves in labor, and pressure upon them by cicatrices and
the like, that pain is felt. Above the cervix the muscular tissue
is supplied by sympathetic nerves from the hypogastric plexus.
The nerves forming this plexus are derived principally from the
tenth, eleventh, twelfth dorsal, and first lumbar, the third and
fourth sacral, and, at times, the first and second visceral sacral
segments.
There seems to be some relationship between the uterine and
the nasal mucosa, for, according to Chrobak, there is "apparently
a connection between the two organs, and pains of a genital type
can be relieved or stopped by the application of cocain (5 to 10
per cent., a few drops on cotton) to the septum or the lower tur-
binate bone." He found that "labor was made less painful, and
in one instance even painless." However, this might have been
the result of suggestion. Yet it is a fact that smell and the
genesic sensibility are connected in a variety of ways.
Character of Uterine Pains. — Uterine pain has certain charac-
teristics, namely, it is of irregular intensity; at times it may be
constant and remain so for some time; or the constancy may be
interrupted by a violent paroxysm, and the pain may then as-
sume the type of a colic. In fact, it is this colicky, cramp-like
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725
726 PAIN IN THE FEMALE GENITALIA
manifestation which makes uterine pain so characteristic. An-
other characteristic is its intensity, for the uterine pain is one
of the most intense that the human organism endures. Espe-
cially is this true of labor pains. In most cases uterine disorder
causes a pain in the back; in fact, a dragging pain in the back
is said to be characteristic of uterine disorder. The pains due
to disease of the uterus will not at this time be minutely con-
sidered. Later the different pains and the factors producing
each will be discussed.
The disorders of the uterus causing pain are: (1) neuralgia,
(2) displacement, (3) functional acts (as menstruation, preg-
nancy, and childbirth), (4) inflammation (as endometritis, me-
tritis, peri- and parametritis), and (5) new growths.
Neuralgia. — Neuralgia of the uterus is often (as was said when
the term was used in speaking of pains in other organs) but a
cloak for ignorance. That neuralgia may occur in the uterus, the
same as in other organs, cannot be doubted ; but, even so, the term
is generally used by the attending physician to hide his lack of
diagnostic skill. A diagnosis of neuralgia should be made only
after a negative search for lesions of sufficient gravity to cause
the pain. Neuralgia is frequently a term wrongly used in speak-
ing of the pain due to endometritis, etc.
Displacement of the Uterus. — Displacement of the uterus, of
itself, does not produce any severe pain, though it is frequently
the cause of the aching in the back, so common in this disorder.
This aching is due to two factors: (a) the drag upon the liga-
ments attaching the uterus to the pelvis, and (b) the congestion
of the uterus from partial obstruction to the return blood flow
in the broad ligaments. The displacement, of itself, produces a
direct pain, localized in the tissues deep in the back. Unless con-
gestion is excessive the pain, the result of displacement, disappears
on replacing the uterus in the normal position. However, if the
congestion is excessive the pain does not disappear so readily on
the correction of the mechanical defect, because it takes time to
eradicate the changes which have taken place in the structure of
the uterus following a long-continued congestion, and which have
UTERINE PAIN 727
been acting as causative factors of pain production. When con-
gestion and structural changes occur, sensory disturbances in
Head's zone also appear, and persist until recovery has taken
place. In some cases, where the uterosacral ligaments are par-
ticularly sensitive, a slight drag or pull upon them by an en-
larged uterus, or by the examiner, through traction made on the
cervix, will produce a very severe pain.
Character of the Displacement Pain. — Displacement produces
more of an aching in the back than an actual pain. In some
cases, where the displacement is excessive, as in complete pro-
lapsus, traction may be made upon some of the nerves arising
from the sacrar plexus. When this happens pain occurs in the
distribution area of these nerves (sacral plexus). In fact, under
such circumstances, any of the nerves passing through the pelvis
may be interfered with and pain be produced. The pain of disr
placement is made worse on walking, especially should the dis-
placement have been transformed into a prolapsus. The pain in
retrodisplacement is eased only by lying on the abdomen and is
increased by lying on the back, while in prolapsus, ease comes on
lying down in any position. On the other hand, all changes of
position are painful if adhesions bind the uterus to adjacent struc-
tures. Then the pain, instead of being entirely of uterine origin,
is modified by that due to disturbances in other closely related
organs. Antero-displaceraent is not as painful as retrodisplace-
ment, possibly because the anterior displacement occurs in
younger people in whom the pelvic structures have not been in-
jured by childbirth, and in whom other associated changes are
not so likely to be present In retrodisplacement defecation is
sometimes painful, while in displacements of the anterior type
there are often both complaint of pain during defecation and a
frequency of urination. In anterior displacements there may
also be a sense of pressure or of aching behind the symphysis
pubis.
Displacements are among the common causes of dysmenor-
rhea (Herman, Kelly). In displacement there often is an angu-
lation of the cervix, so that, during the menstrual period, the
728 PAIN IN THE FEMALE GENITALIA
blood and membranes are not so easily discharged, because of the
narrowing of the canal, due to the angulation. As a conse-
quence, the menstrual discharge from the uterus is hindered, and
uterine colic results.
Functional Disorders of the Uterus. — The principal functions
of the uterus are menstruation, pregnancy, and childbirth. The
first two should be painless; but unfortunately, as a price of our
higher civilization, the woman finds that frequently, instead of
these being periods of well being and content, they are, because
of the frightful pain and distress which she suffers, periods of
dread and dismay.
Menstkuation. — Among savages, menstruation is generally
without pain, and even among those of higher civilization it is fre-
quent to find the menses coming on without distress. Yet, as civ-
ilization advances, and our women mount the ladder of indolence
and ease, pain and distress gradually become more and more
pronounced, until, at the summit, in our latter-day civilization,
woman is incapacitated for a greater part of her time by condi-
tions which ordinarily should cause but slight^ if any, incon-
venience.
Painful menstruation is termed dysmenorrhea^ Holden ana-
lyzed the histories of one thousand consecutive cases of abnormal
pelvic conditions with reference to the occurrence of this symp-
tom. As the result of his observations he presents the following
conclusions ;
^^Dysmenorrhea is present in 47 per cent, of all gynecologic
hospital patients. In about 23 per cent of the entire number it
seems to be definitely caused by certain abnormal conditions of the
pelvic organs. In 22 per cent, of the entire number it is present
in conjunction with such conditions, but is apparently not caused
by them. The pathologic conditions which are most frequently
seen as the causes of dysmenorrhea are: (1) retrodisplacements of
the uterus, (2) pelvic inflammatory disease, and (3) myomata.
These three conditions account for nearly 90 per cent, of all the
dysmenorrhea which is caused by pathologic conditions of the
pelvic organs. Retrodisplacement accounts for 41 per cent., pel-
UTERINE PAIN 729
vie iDflammatory disease for 37 per cent., and myomata for 11
per cent. Of nulliparous patients with retrodisplacements causing
symptoms, 86 per cent, have dysmenorrhea. The frequency of this
association leads to the conclusion that the abnormal position causes
the dysmenorrhea. In retrodisplacements occurring after child-
birth it is much less common; 25 per cent, of mult i parse with
retrodisplacements have dysmenorrhea, which is apparently caused
by the malposition. Of all the patients with pelvic inflammatory
disease, 31 per cent, have dysmenorrhea, which is apparently
caused by the condition. Of all the cases of myoma, 20 per cent,
have dysmenorrhea apparently caused by the tumor."
During the normal menstruation the uterine muscles undergo
a slight contraction, but not of sufficient strength to be felt as such
(Winter, Menge). The factors that would cause the normal con-
traction to become abnormal, either in regard to the time or the
strength of the contractions, are : some hindrance to the expulsion
of the menstrual blood (as a contracted os uteri), an inflammatory
thickening of the endometrium,^ or a faulty position of the
uterus in which it is flexed and the cervical canal is angulated.
Stenosis of the external os is not as frequent a cause of pain pro-
duction as is stenosis of the internal os. Winter savs that he has
occasionally seen collections of blood behind the external os suffi-
cient to cause ballooning of the cervix without causing the least
pain.
Dysmenorrhea, when due to cervical stenosis or angulation
from whatever cause, is generally relieved by pregnancy. If the
dysmenorrhea be entirely mechanical, or be due to some struc-
tural defect (either a narrowing or contraction of the cervix, or
an angulation of the same from a faulty position of the uterus),
it is found that the menstrual pain dates from the period of the
first menstruation or from the time of some operative interfer-
ence. It is very characteristic, in that it begins only a very short
time, a few hours, before the blood commences to flow, and con-
1 Theilhaber claims that 25 per cent, of all cases of dysmenorrhea are
caused by a stenosis of the cervix, either congenital or acquired. Theilhaber
also claims that in hysteria a contraction of the circular muscular fibers of
the cervix may occur, causing a stenosis and consequent pain.
730 PAIN IN THE FEMALE GENITALIA
tinues as long as the blood flow is active, and then ceases as
abruptly as it came on. All other forms of dysmenorrhea gener-
ally start a day or two previous to the flow, and are the result
of the pelvic congestion incident to the flow. If anteflexion is
suspected as the cause of the dysmenorrhea, to make the diag-
nosis certain it is necessary that there should be present a freely
movable, normally developed uterus, in permanent, rigid ante-
flexion, in a person who is neither nervous nor hysterical
(Winter).
In some cases congestion of the endometrium, incidental to the
menstrual flow, may block up the cervical passage, and the expul-
sion of the uterine contents is difficult.
Spasmodic contraction of the cervix is a frequent cause of
uterine pain. This spasmodic contraction, according to Herman,
is due to the fact that the uterine center in the cord, or in the
sympathetic system which regulates the movements of the genital
canal, is imperfectly developed. The vagina, uterus, and Fallopian
tubes are muscular organs like the intestine. During the sexual
orgasm there is coordinated muscular action of these organs, the
object being to help the ovum from the tube and the spermatozoa
from the vagina into the uterus. In a normal, painless men-
struation there is also a coordinated action, the body of the uterus
contracting and the cervix dilating, so that the menstrual flow is
expelled without pain or difficulty. In this neurotic variety of
dysmenorrhea the natural dilatation, because of changes in the
cord or sympathetic ganglia located in the cervix, is absent; and
as a consequence the contractions of the uterine body are mor-
bidly violent and painful. The only physical sign observed in
these cases of dysmenorrhea is difficulty in dilating the cervix.
Another cause of dysmenorrhea is hindrance to the separation
of the decidual membrane. Owing to degeneration or disease the
endometrium may be difficult to separate entirely. Parts of it,
not being entirely free, lie loose in the uterine cavity, and may
cause repeated and violent contractions of the uterus. Endome-
tritis is one of the most common causes of this condition. Mem-
branous dysmenorrhea gives rise to large, free masses of mem-
UTERINE PAIN 733.
branous tissue in the uterine cavity, and it is the effort of the
uterus to expel them which probably causes pain,^
Endometritis dolorosa is the name given to an endometritis in
which severe pain is present ; but here again the pain is due to a
compression of the uterine nerves, for as soon as a dilatation of the
cervix is performed the pain vanishes (Sneguereff).
Maldevelopment of the tUeriis acts as a cause of pain during
menstruation. In these cases the uterine cavity is so small that
during menstrual congestion the two walls become so swollen
that they completely block up the opening and the blood and men-
strual debris cannot be discharged. Winter accounts for this
form of dysmenorrhea as the result of reflex contractions of the
uterine musculature, the reflex in turn being the result of in-
creased pressure in the uterine vessels; the increased pressure
being due to the facts, that the vessels are too small to allow for
the accumulation of the blood, and that the cavity of the uterus is
too narrow to permit the necessary degree of swelling of the
mucous membrane.
Hyperesthesia of the muscles (uterine) and of the uterine
mucous membrane may also be present. These may cause con-
traction of the uterus during menstruation, when otherwise the
menses would have been normal. Such is the case in those indi-
viduals of a neurasthenic nature, in whom we so often find a
marked dysmenorrhea. Very frequently this variety of dys-
menorrhea is also found in those of reduced vitality.
It may be that in some of these patients the receptive state
of the nervous system is also in a peculiar irritative condition in
which it responds to lighter stimuli than ordinarily would af-
fect it.
In cases of this character the pain is not relieved on lying
down, as it is when the dysmenorrhea is of congestive origin. It
generally begins with the flow and is of very short duration. The
1 Painful areas, present in one case, were (Sneguereff) the tuberosity pubis
on each side, the inner surface of the thighs, the renal plexus on both sides, the
solar plexus, the rectum (?) and the anterior superior spine. Perineal areas
were the emerging point (1) of the ilioinguinal, (2) of the sup. int. cutan.,
and (3) of the pudic.
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733
734 PAIN IN THE FEMALE GENITALIA
individual spasm lasts about one minute and recurs with about
the frequency of labor pains. This type often arises after years
of painless menstruation.
Polypoid growths inside the uterus may, by hanging down,
obstruct the cervix, and thus, by a ball-valve action, be a cause
of pain.
Ovarian dysmenorrhea is a term used to define the pain pro-
duced in the ovary from the congestion incidental to menstrua-
tion. It occurs before the flow commences and ceases as soon as
it becomes profuse.
Possibly a fissured state of endometrium at the internal os
may also excite such a spasm of the uterine musculature as is
produced in the sphincter in anal, fissure. A spasm of this type
is increased by congestion of the tissues. It is given as a cause
of pain by Keating and Coe.
Winter, after a careful review of the subject, gives the fol-
lowing very clear conclusions in regard to menstrual pain, namely,
that it is necessary, in order that the natural process may run a
painless course, that "nothing interfere with maturation and rup-
ture of the follicles; that the congestion in the uterine wall does
not meet with resistance from infiltration of the tissues ; that the
mucosa be capable of swelling and of taking up the extravasated
blood ; that the size of the uterine cavity be sufficient to accommo-
date the swollen mucous membrane; that the menstrual blood
escape readily from the cervix, and that the congestion of the
tubes and of the peritoneum take place in normal tissues. In addi-
tion the nervous system must possess a normal degree of irritabil-
ity an(l the psychic function must be normal ; otherwise the slight
alterations which take place in the nervous system during normal
menstruation may be abnormally exaggerated" (Winter, Clark's
translation).
Referred hyperalgesia in the uterine segments is very com-
mon in all these conditions which produce uterine pain. Pain in
the breasts is also a frequent accompaniment of menstruation.
It generally precedes the menstrual discharge by a few days. Be-
cause of this breast pain, breathing may be painful.
UTERINE PAIN 736
In rfisume, it may be stated that menstrual pain may occur
before, during, or after menstruation. When it occurs (1) be-
fore menstruation, it is due to hindrance to the discharge of
blood from the uterus because of (a) narrowing of the lumen of
the cervix, the result of a stenosis which has taken place from a
chronic inflammation of the endometrium, or from an angulation
of the cervix from a flexion of the uterine body on the neck;
(b) blocking of the lumen of the cervix by a blood clot or by a
piece of endometrium ; (c) obstruction to the menstrual discharge
by a foreign body (as tumor) ; and (d) chronic inflammation of
the ovary, which has caused a thickening of the tunica albuginea,
so that the Graafian follicle, because of the thickness and tough-
ness of this layer, has great difficulty in penetrating to the sur-
face ; congestion results, and this stretches the peritoneal coat and
causes pain; (2) during menstruation, it is generally due to
chronic endometritis; and (3) after menstruation, it is due, as
a rule, to inflammation of the adnexa.
Intermenstrual pain is the name given to a pain which
generally comes on about the middle of the mid-menstrual period.
It usually lasts for two to four days, though it may persist till
the next menstruation. Several theories have been advanced as
to its causation. Among the most reasonable are :
(1) That it is due to the retardation of the outward passage
of the Graafian follicle toward the periphery, by some change in
the ovarian stroma; the resultant congestion and tension pro-
ducing pain.
(2) That in cases of ovarian adhesions the pain is due to the
traction made on these adhesions by recession of the ovary after
each menstrual period. This recession necessarily reaches its
climax about the middle of the intermenstrual period (Reed).
(3) Circulatory changes in the ovary, causing ovarian conges-
tion, may also produce intermenstrual pain (Sheill).
The pain resulting from these factors may vary from a dull
ache to one of great intensity. It is generally reflected to the
ovarian region, on one or both sides, or it may be felt alternately
on either side. "It comes on about the twelfth to the fourteenth
736 PAIN IN THE FEMALE GENITALIA
daj after cessation of the menses. It lasts for a day or two, is
often accompanied by a dischai^ of clear fluid, and is followed
by a period of rest or complete cessation of pain up to the onset
of the next period" (Addison). Change of position does not
influence the intensity or character of the pain. On examination,
in many cases, no lesion can bo founJ.
FiQ, 170. — Areas of Hyperaloesia in a Woman Two Months Pbeonant,
They represent the 10th and tlth dorsal zones of Head. The mmrimiiTn
point of tendemeus is in the 10th dorsal. The zones did not extend
uninterruptedly around to back. Tenderness and hyperalgesia were
present over the corresponding spines. These areas of hyperalgesia
very likely are due to traction exerted on the ovary and tube of the
left side by adhesions.
Pheomancy. — In a normal woman pregnancy ia entirely free
of pain ; yet, it is common for the physician to be troubled by the
complaints of his patients who are with child. The causes of
pain during the gravid state are :
(1) Pressure upon adjacent and associated organs, as the
tubes, or ovaries; (2) traction on adjoining structures by adhe-
sions; (3) the weight of the organ itself, which, even though nor-
mal, may drag upon neighboring structures and produce discom-
fort and distress; (4) in some cases, the projection of a fetal part
UTERINE PAIN 737
into the uterine wall; (5) intestinal coils may drop beneath the
uterus, causing a partial strangulation; (6) should the ovary be
cirrhotic, the corpus luteum, when it begins to enlarge, is com-
pressed by the nondistensible connective tissue, and dull, aching
pain in the ovarian zone results; (7) partial obstruction to the
bowels may occur during pregnancy, owing to some of the intes-
tinal coils being caught between the uterus and the surrounding
parts; (8) obstruction to one or both ureters may occur from
pressure by the uterus, and thus hydronephrosis, with its conse-
quent pain, may result
The case given below illustrates the production of pain due
to a partial obstruction of the bowels. It might, also, be taken
as an example of pains produced by ovarian and uterine conges-
tion, the pains early in pregnancy being due to' the congestion, the
colicky attacks, later in the pregnancy, being the result of intes-
tinal colic. The early pains of which the patient complained
began about the second week of pregnancy and continued inter-
mittently. They were colicky in type and were located in the lower
abdomen. The individual attack was produced by the patient's
moving, especially by her turning on the right side. During the
attack she was doubled up, with the knees flexed, and the abdo-
men was tense and rigid. The hands were clinched and were
pressed tightly into the suprapubic region. The face was drawn
and the eyes closed. The individual attacks lasted about three
minutes.
These colics appeared at irregular intervals, ranging from a
few days to one week ; sometimes they appeared more frequently,
several in a day. After being present for six weeks, they disap-
peared and the patient then had neither pain nor colic. A vaginal
examination disclosed a retroflected, enlarged uterus, about two
months pregnant. The attacks ceased when the uterus rose above
the pelvic brim.
It is just possible that in this patient a part of the intestine
had been caught under the displaced uterus, and that its lumen
was constricted, the severe colic of which, at times, the patient
738
PAIN IN THE FEMALE GENITALIA
complained being due to the effort of the intestine to force its
contents beyond the constricted portion.
Childbieth. — Like menstruation, childbirth naturally
should be a painless process. It is only as culture advances
c
D
A
R
Fig. 17L — ^Phenomena Accompanying Tubal Disorders.
The uterus was at this time above the pelvic brim and the ovary was free
of its compression, yet the tube in the meantime evidently has become
injured and caused the above phenomena. Hyperalgesia was absent.
A few weeks after the above phenomena was defined, all pain and dis-
comfort ceased, and the patient had a normal dehvery.
A — ^Area of local tenderness, also area of pain to deep pressure. Superficial
pressure is not painful, neither is muscular pressure.
B — ^Area of maximum tenderness to deep pressure.
C — ^Area of pain to deep pressure.
D — ^Area'of maximum tenderness.
that the labor becomes painful, for in women of primitive races
pain is absent Savages of a low degree of civilization are gen-
erally but little troubled by parturiency. The reason is that,
although among primitive people the contractions of the uterus
are as severe during childbirth as they are among civilized races,
yet, because of the easy dilatation of the cervix,^ they do not
1 Why this should be is as yet unejcplained.
UTERINE PAIN 739
suffer pain. Among observers it is generally agreed that pain
of uterine contraction is not due to the contraction of the muscle
itself, but is the result of the restraint of this functional activity
by cervical obstruction. This cervical obstruction is not so promi-
nent among primitive people; therefore they have less pain.
When dilatation of the cervical segment occurs easily, pain is
absent.
At the present time, though rare, pain may be entirely absent
during labor. Allen explains this absence of pain as being due
to the relaxation of the parts by nature, while Young claims
that sometimes at the acme of labor there is a physiological anes-
thesia. A peculiarity that has been noted of the pains occurring
during labor is that, instead of being in the normal locations, they
may, as in a case sewi by the author, be radiated from the thigh
to the knee. In this case the pains were excruciating and occurred
synchronously with the uterine contraction, as was verified by ab-
dominal palpation. In this respect the words of Granville, whose
remarks hold true to-day, may be quoted. He says :
"Sensations of pain experienced by the parturient woman are
not invariably synchronous with what, for want of a better name,
we term the pains of labor; and from this and other premises,
for example, the circumstance that they are commonly referred
to regions more or less remote from the contracting uterus, or the
dilating external passages, in which the real seat of pain might
have been supposed to be located, I deducted that the pain attend-
ant on labor is neuralgic in character."
Labor pains, when present, are as a rule first felt as a drag-
ging or aching in the back, low down in the lower lumbar region.
In some there is present a sensation as though the back were
breaking. At this time (the first stage of labor) the pain corre-
sponds to the early stages of cervical dilatation. Later, when the
uterus commences to contract and the cervix begins actively to
dilate, pain is felt over the sacrum and coccyx in the second,
third, and fourth sacral areas, and sometimes in the first and
second sacral areas (Head). When the cervix has dilated, and
the contractions are forcing the head through the pelvis, the re-
740
PAIN IN THE FEMALE GENITALIA
feried pains are felt in the tentli, eleventh, and twelfth dorsal
and first lumbar areas. These are the areas in which pain is felt
post partum, when the uterus is forcing out of its cavity the
residual clots.
After labor and during the pnerperium, if subinvolution
Fia. 172,— Areas of Refekred Pain is a. Case of Labor. (Head.)
A— IMIatatioQ in the second stage of labor. The pain is in the Utb dorsal
segment and is due to contraction of the uterus.
B — Hyperalgesia is present in the 10th, 11th, 12th dorsal, 1st lumbar and
3d sacral, posteriorly present after the effort of the uterus to expel
poet-partum clots.
should occur, a feeling of weight and of dragging is felt in the
pelvis.
Inflammation of the Uterus. — Inflammation may occur in the
lining structure (endometrium, eudometritis), the contracting por-
tion (metrium, metritis), and the inclosing structures (perito-
neum, broad ligaments, peri- and parametritis).
UTERINE PAIN 741
Endometbitis. — ^A pronounced inflammation of the endo-
metrium can hardly take place without involving the next adjacent
structure (metrium), so that the pain due to a severe endometritis
partakes more or less of the character of the pain due to a metritis,
and if the inflammation is severe and involves the peritoneum,
the pain has also the characteristics of that due to peritonitis.
Ordinarily, the endometrium has no pain nor touch sensation, but
when inflamed it becomes very sensitive. This is of great diag-
nostic value, and tenderness (endometrial) should be searched for
in endometric inflammatory states. This tenderness may be dem-
onstrated by means of a sound (Winter).
The sound must not be too large, and should be carefully in-
troduced through a previously dilated cervix, and search should
be made for the sensitive spots. When the sound touches such a
spot the pain may be so severe that the woman "cries out, shrinks
from the sound, or faints." Should pain be severe only. on the
introduction of the sound, and on moving it with sufficient force
to disturb the relations of the uterus to the surrounding tissues,
and not present on gentle manipulation, peri- or parametritic
inflammation should be diagnosed. That the endometrium has
pain sensation in a normal case can hardly be admitted (Roth-
rock), though in the presence of inflammation, the adjacent layer
may be so involved by the inflammatory process that it becomes
irritable and responds to any irritation with a sensation of pain.
It is noticeable that the pain sensation in endometritis of ordi-
nary severity is never localized to the area of its production, but
is always referred; but should the inflammation be severe, and
perimetritis result, and the peritoneum become involved, espe-
cially if the inflammation occurs near the cervix in the area sup-
plied by the spinal nerves the pain is localized to the area of its
production.
Endometritis also causes pain, having somewhat the charac-
teristics of labor pain; this pain is caused by the same factors
that produce labor pains, namely, the contraction of the uterine
muscle, excessive in the endeavor to force foreign material from
the cavity of the uterus. The pain is most severe at the time of
742 PAIN IN THE FEMALE GENITALIA
the menses, though it does not necessarily appear at this time,
but may come on at any time that the secretions collect to such
an extent that, in the presence of a stenosed cervix, their expul-
sion requires forcible uterine contractions which are very painf uL
The pain of endometritis is worse on standing than on lying
down. Tenderness on palpation is not present unless the metrium
and the surrounding tissues are involved. When this occurs,
abdominal and bimanual palpation are very painful. If peritoni-
tis has set in, pressure in the pouch of Douglas produces severe
pain. Likewise, rectal palpation is very painful.
Later, as a result of these inflammatory states, adhesions form
and pain results from their drag and pull. The areas of reference
of these pains have been described.
Cervicitis. — Erosions of the cervix cause pain either through
the sympathetic or the cerebrospinal systems. .When the sympa-
thetic is involved, the pain is referred to the area of distribution
of the second or third sacral segments, but when the cerebrospinal
is involved the pain is referred generally through the branches
of the pudic to the perineum, or to the bladder. When the lat-
ter reference occurs, there is painful and frequent urination.
The involvement of adjacent nerves is probably the result of a
lymphangitis which has spread from the erosions into the peri-
uterine fascia.
Diagnosis of Endometritis. — The following, which are gen-
erally present, may aid in the diagnosis of endometritis :
(1) Hemorrhage; eliminate carcinoma, myomata, and tubal
inflammations, all internal disorders producing it, or local circu-
latory derangements, such as extrauterine pregnancy, obstruction
to the return flow by tumors, etc., and it is safe to say, in the ab-
sence of menstruation, that it is due to endometritis.
(2) The pain of endometritis is somewhat characteristic in
that it is much worse at the time of menstruation.
(3) Discharge of inflammatory products and endometrial
shreds from the uterus. The variety of endometritis is decided by
the history, the onset, the discharge, and the course.
Ulceration of the cervix, unless it is deep and has produced a
UTERINE PAIN 743
pelvic lymphangitis, causes no local pain, but a reflected pain is
felt in the region over the sacrum and the coccyx and is fre
quently localized to a spot immediately dorsal to the anus. This
spot is also very tender to the touch.
Metritis. — In inflammation of the muscular layer of the
uterus pain may be due to the contraction of the uterine muscles,
or to the irritation of the nerve terminals by the toxic products
of the inflammatory process. It may also be due to the pressure
exerted upon the terminal nerve filaments by the inflammatory
products. These pains are referred to the zone areas associated
with the uterus (see Fig. 168). Another cause of pain production
is the spread of the inflammation to the peritoneum with involve-
ment of the parietal layer. These causes are active only in the
acute cases, for as a rule chronic metritis is without pain (Theil-
haber).
New Orowths of the Uterus. — New growths are either benign
or malignant. Benign growths are not painful unless they block
the cervical canal; when, during contraction of the musculature,
pain of the type of a labor pain is felt. This pain persists in rhyth-
mical periods until the mass has been expelled or until the canal
has become free. The pain, naturally, would be greater at the
time of the menstrual periods. Growths may also press upon ad-
jacent structures and interfere with their function and so cause
pain. They may also press upon the lumbar and sacral nerves
and cause pain which is referred to the peripheral distribution
of these nerves in the back and legs (Donald and Lickley). Pain
due to pressure from growths, as a rule, is constant.
Malignant growths toward the end are always, painful, but
early in their course are usually free from pain. Pain occurs
only when the growth makes pressure upon the surrounding struc-
tures, or interferes with the emptying of the uterus, or when the
tumor cells invade the nerve trunks. Kundrat has shown, in the
case of carcinoma, that the nerve trunks become infiltrated with
cancer cells. In other cases pain may be due to the absorption
of toxins or to the extension of the inflammatory growths (Roth-
rock). In all these conditions, when the growth is in the fundus
744 PAIN IN THE FEMALE GENITALIA
t
or deep in the cervix, referred pain in the skin area, associated
with the particular part of the genitalia involved, is present.
Should the cervical canal become obstructed, typical uterine colic
pain appears. Pain seems, when present, to be more often felt
on the left side (Champney).
Fibroids of the uterus are fairly common. They announce
their presence by two varieties of pain: (1) a periodic pain which
appears before each menstrual period and is relieved by menstrua-
tion, and (2) an intermittent pain, which, in the case of intra-
uterine fibroids, accompanies the menstrual flow. It may also ap-
pear at other times. Some fibroids have also been known to extend
into the pelvis, and, by pressing on the lumbar and sacral plexis,
to give rise to pain in the distribution areas of the involved nerves.
The great sciatic is most frequently affected, and pain in its dis-
tribution area is common (Wilson, 361).
In cancer of the uterus, out of sixty-seven cases pain was the
first symptom to appear in twelve (Craig) ; leucorrhea, in forty-
five, and hemorrhage, in twenty-two.
FALLOPIAN TUBES
Pain due to disease of the Fallopian tubes may result from
(a) distention of the tubes; (b) inflammation of the tubes; (c)
adhesion of the tubes to neighboring structures.
Tubal Conditions Causing Pain. — All who practise medicine,
and particularly surgeons, are familiar with hydrosalpinx, a con-
dition in which the Fallopian tubes contain a considerable amount
of clear serum. In these cases the uterine and the fimbriated
extremities of the tubes are blocked, so that it is impossible for
the fluid to be discharged. Pain may follow this stagnation,
though the swelling in many cases reaches a considerable size
before its presence becomes intolerable; in fact, it may never
cause pain. Yet, because of the pressure exerted upon adjacent
structures, or because of the active inflammation which is pres-
ent, pain is frequently a prominent symptom. If the pain be
due to dragging or to pressure on adjacent structures, it may be
FALLOPIAN TUBES 746
eased by the patient's assuming a counter-posture. If it be due
to inflammation, the increase in pulse rate and elevation of tem-
perature will help to define the lesion. When the tube is inflamed,
the resulting pain is either reflected (Head zone, see figure) or
is localized to the area in which it is produced. In the latter in-
stance the pain is felt in the lower iliac region, and is due to the
inflammation, communicated to the parietal peritoneum from the
diseased tube. It is of a burning, stabbing character, and may
be very severe.
If the pain is the result of an acute hyperemia, it is of a throb-
bing character, while that due to chronic inflammation is of a dull,
aching type. All inflamed sensitive tissues are tender to pressure ;
therefore, pressure on the tubes will also be painful. This pres-
sure on the tubes may be exerted by two methods. The first is the
bimanual, by which pressure is made between one hand placed
over the abdomen and the index or the first two fingers of the
second hand inserted into the vagina. With the fingers in the
vagina, the uterus can be rocked to either side. If on this mo-
tion pain is produced it may be surmised that inflammation is
present. When the uterus is thrown to the side away from the
inflamed tube, pain is the result of the traction and stretching
which ensue, while if it is thrown against the inflamed tube,
pain results from the pressure. The pressure of the uterus
against the inflamed tube is much more painful than is the trac-
tion away from it
Should chronic salpingitis be present, pain may be produced
by grasping the tube between the examining fingers, thus making
pressure directly upon it. Sometimes, in pyosalpinx, if the ex-
amination has been rough, some of the pus may be pressed out
of the end of the tube, and a localized peritonitis results. This
is indicated at the time by a severe pain, persisting after the
examination. It may be accompanied by an elevation of tem-
perature and a rise in the pulse rate. Spontaneous rapture of a
tube through its fimbriated extremity is very rare.
In tubal inflammation all functional acts which in any way
cause a changed relationship between the tubes and the surround-
746 PAIN IN THE FEMALE GENITALIA
ing functioning structures are very painful. In many, micturi-
tion and defecation are productive of much pain; indeed, they
may become so painful that the patients voluntarily inhibit them-
selves from performing the acts. Constipation and retention of
urine necessarily result. Micturition is not so painful when the
inflammation is confined to the tube, but becomes extremely so
when the bladder itself is involved in the inflammatory process.
These disturbances produce, in addition to those already present,
their own particular form of pain.
Sometimes tubal inflammation causes uterine colic (Winter
and Clark). In such eases exacerbations of pain, occurring gen-
erally prior to the periods, are frequent. Should pain be present
in the ovarian, tubal, and uterine areas at the same time, it in-
dicates an involvement of all these associated structures. In a
case of gonorrheal salpingitis, Saenger (362) thought the pain
was due to the excitation of peristalsis by the inflammation
present.
As a result of tubal inflammation, adhesions are formed and
resist subsequent distentions of the tube, and are accountable for
a large share of the resulting pain, particularly so if the disten-
tion is accompanied by certain functional acts that in the ordinary
course of events would be painless. However, tubal swelling,
alone, without the presence of adhesions, may be painful. How
large it may become before it is painful depends particularly upon
the local conditions. A tube in a free and clear pelvis may reach
a much greater size without discomfort than if it were in a pelvis
filled with pelvic exudate and bound with adhesions. In some
the tube may reach the size of an orange without causing great
discomfort, while in others a very small swelling will produce the
utmost distress.
Extrauterine Pregnancy. — Extrauterine pregnancy (tubal or
tuboovarian) may cause no pain unless a rupture or a partial rup-
ture occurs, and bleeding into the peritoneal cavity takes place.
This complication may follow a vaginal examination, or it may be
the result of sudden motion or of forcible bending or flexion of the
body. It is indicated by severe and agonizing pain, generally in
i
OVARY 747
the iliac region of the side involved^ though it may be spread
over the entire lower abdomen. In some cases the pain is re-
ferred to the shoulder. In these cases it is possible that the
blood may extend as high as the diaphragm and so irritate it;
this irritation, in turn, is transmitted through the phrenic to the
supraacromial nerve, and so causes pain to be referred to the
shoulder.
It is rather surprising to note the small quantity of blood which
produces such a severe sensory reaction. In many cases the pres-
ence of an ounce or two of free blood in the peritoneal cavity will
cause the most severe distress.
The pain probably represents the prostration of the perito-
neum to the traumatism of the hemorrhage. In hemorrhage pro-
duced by the slipping of a ligature from the stump, following an
ovariotomy, no pain is present, probably for the reason that the
peritoneum, having already been subject to the shock and trauma-
tism of an abdominal operation, is not capable of again responding
when the hemorrhage occurs (Richardson).
Ruptured tubal pregnancy may be confused with (Crossen) :
(1) hemorrhage from the ovary, (2) tuboovarian hemorrhage, (3)
fulminating pelvic edema, (4) gonorrheal salpingitis, (5) miscar-
riage, occurring in a patient who has an ovartan tumor, (6) preg-
nancy with hydatidiform mole, (7) rupture of a pus tube, (8) ap-
pendicitis, (9) strangulation of internal hernia, and (10) perfora-
tive peritonitis.
In extrauterine pregnancy intense, lancinating pain in the
lower part of the rectum is at times complained of. The cause
of this pain may be adhesion between the gestation sac and the
rectum (Boldt).
OVAEY
No pain is caused during pelvic examination by taking a nor-
mal ovary between the fingers and thus making pressure upon it,
but a peculiar sickening sensation is experienced, somewhat of
the same character as is felt by the male when his testicle is
squeezed.
748 PAIN IN THE FJMALE GENITALIA
Local Point of Pain. — Head gives the area of cutaneous hyper-
algesia for ovarian disorders as that of the tenth dorsal segment
(see Fig. 173) and he mentions two points of maximum tender-
ness, one in the small of the back over one or more lumbar verte-
brse, and the other at a point a little below and external to the um-
bilicus on the same side as the ovary which is at fault It seems
very odd that Morris should have called attention to this point
during the past few years, as a sign of oophoritis or of disease of
the appendages. He claims that in disease of the ovaries or ap-
pendages there is a spot tender to pressure, about one and one-
half inches down from the umbilicus and one inch external to
the midline of the abdomen. In appendicitis there is pain on
pressure at this point, but it is present only on the right side,
while in ovarian or tubal disease the pain is present on both sides.
Pain from the ovary has also been known to be reflected to distant
points. In one case it was present in the shoulder, and ran down
the left arm.
Causes of Pain. — The causes of ovarian pain are: (1) pressure
from an increased cell production, (2) structural changes in the
nerves supplying the ovary, (3) functional changes in the nerves
by which their sensibility is greatly increased (McEvitt).*
Characteristics <Tf Ovarian Pain, — Cuthbert Lockyear (307,
p. 1061) gives the following characteristics of ovarian pain:
(1) It is referred.
(2) It is associated with superficial or surface tenderness.
1 Herman (144) says that the point that is commonly pressed upon in
eliciting ovarian tenderness is about two inches internal to the anterior su-
perior spine. That pressure over this area makes pressure on the ovary is very
doubtful, for the relationship between the abdominal wall and the ovary is con-
stantly changing by every variation of intraabdominal pressure, and by every
change of position of the intraabdominal organs, so that, because of this
mobility, it would be impossible to compress the ovary even by pressure on the
abdominal wall, applied directly over the ovary. The only effect would be
to cause a slight change in its position. Such an area of tenderness is also
found in hysterical men. From such data we may conclude that the pain is
not due directly to the ovary, but to related conditions such as irritation of the
peritoneum from inflammation spreading from other organs, or from stretching
due to traction made upon the peritoneum by ligaments and adhesions joining
it to abdominal organs.
OVARY 749
(3) It tends to become generalized or diffused.
(4) It follows the lines of spinal segmentation and not of
peripheral nerves.
(6) It is associated with exaggerated superficial reflexes.
(6) It is closely connected with the neurasthenic state.
Ovarian disorders may cause pain in distant regions, such as
headache, which is frequent. It is most common in the frontal
region and is worse at the menstrual period.
The diseases of the ovary causing pain are: neuralgia, dis-
placement, inflammation, abscess, and new growths.
Neuralgia of the ovary is possible, but generally, when ovarian
pain is present, it is due to structural changes in the ovary, such
as occur in congestion and inflammation.
Displacement of the ovary, or prolapsus, generally produces
pain which is felt in the ovarian reference areas. When displace-
ment occurs, vaginal examination will show the ovary to be in a
false position. If adhesions between the ovary and adjacent or-
gans have formed, the traction upon the adhering organ will
cause pain, which, as a rule, is referred to the pain area of the
organ adhering.
Hernia of the ovary is generally associated with hernia of
other organs, and is not especially painful. The presence of an
ovary in a hernial sac may be surmised from the peculiar sickening
sensation which is produced when pressure is made upon the sac.
Hyperemia of the Ovary. — Immediately preceding menstrua-
tion, all of the female genital organs are engorged with blood ; if
they are normal, this engorgement produces no disturbance, ex-
cept a slight physical discomfort ; but, should a hypertrophy or a
hyperplasia of the connective tissue have taken place, pain results.
This pain is present for one or two days preceding menstruation.
It is due to the constriction and pressure upon the terminal nerve
filaments of the ovarian stroma exerted by the congested tissues.
After the blood flow is well established, the pain quickly disap-
pears. The congestion may be so intense that hemorrhage into
the ovarian stroma occurs. This is productive of very intense
and throbbing pain in the region of the ovary or in the area to
760 PAIN IN THE FEMALE GENITALIA
which ovarian pain is referred. It is characteristic of this dis-
order that it progressively becomes worse, and removal of the
ovary is the only hope of relief.
In addition to the passive form of hyperemia, pain also may
be due to the active variety. One of these forms of hyperemia is
due to bacterial invasion. Here an active inflammation has taken
place, and the pain which, in passive congestion, was present only
preceding menstruation is now more or less continuous, and is
markedly increased during the menses. As may happen during
any intraperitoneal visceral disease, the inflammation may spread
beyond the organ of its origin and infect the adjacent organs,
especially the peritoneum. Such a spreading may also occur in
the ovarian inflammation. The referred ovarian pain, as well
as the mild local tenderness, is now much increased by the symp-
toms of the peritonitis arising around the ovary. The most
prominent of these symptoms is excessive tenderness in the lower
iliac region. The patient, who previously may not have been
compelled to take to her bed, now gradually avails herself of such
an opportunity. She is inclined to lie flat on her back and to
draw up the limb on the iaffected side; or, if both sides are
affected, to draw up both limbs. At the same time the lower
segment of the rectus muscle on the diseased side becomes quite
rigid. Should the inflammation spread further, all her symp-
toms are aggravated. She now lies slightly inclined to the side
involved, with the limbs drawn up. Breathing is restricted and
becomes entirely costal. All motion is abolished and the patient
is content to stay in bed, quiet and inactive. Such states are the
forerunners of an invalidism that may become chronic, and per-
sist, even after the original cause has been removed. When the
acute attack subsides, and the lesion assumes a chronic form, the
woman, although she can go about and do her work to a moderate
degree, is subject to sudden recurring attacks of inflammation;
perhaps in the midst of festivities, or at the time of greatest
need, she is compelled to take to her bed until the acute attack
again subsides. In any case, she is a poor unfortunate creature,
whose life, unless she is relieved by surgical measures, becomes
OVARY 761
an endless series of periods of ease^ alternating with those of the
most intense distress.
The pathology clearly shows why this lesion is so painful.
An ovary^ the seat of chronic inflammation^ generally is either
sclerotic or cystic^ and has a thickened tunica. An examination
will disclose that nearly all of the normal stroma has been re-
placed by connective tissue^ so that at the time of menstrual or
other engorgement there is no room for expansion^ and the sensi-
tive terminal nerve filaments are caught between the swollen
masses of tissues and are subjected to a severe pressure. This
causes pain. The greater the engorgement the more severe the
pain. Should the inflammatory engorgement continue, and con-
nective tissue form, the contraction of this tissue on the sensitive
terminal nerve filaments produces the pain. As this pressure is
continuous, the pain and distress become constant. Jessett (300,
p. 1059) thinks that, in cases in which "the capsule of the ovary
is foimd to be thickened and corrugated with fibrous tissue dip-
ping down into the ovarian stroma, and in which a single cyst
or multiple cysts are found incorporated, it is the binding down
of these by the dense capsule, which is the cause of pain." Her-
man, however, thinks that sclerocystic disease of the ovary is
generally free from pain unless it is associated with peritonitis.
Following inflammation, adhesions to other organs may form.
These adhesions are a common cause of pain production.*
Abscess of the Ovary. — If the pain of an acute inflammation
of the ovary does not subside within a reasonable time, an ab-
scess formation should always be considered. When this occurs,
the pain becomes greater instead of less, and a gradual but sure
increase in the local tenderness is noticed. At the same time, a
mass connected with the uterus and slightly movable makes its
1 Hejwood Smith (305, pp. 1060-1061) says that ovarian disease is painful
in three stages:
(1) "In stage of congestion through tension of the blood vessels.
(2) "Thickening of the stroma.
(3) "Indrawing or contraction of the fibrous stroma.
"In all these conditions, the tension of the blood pressure at the men-
itrual molimen is the cause of pain."
752 PAIN IN THE FEMALE GENITALIA
appearance in the lower iliac region. At once the question is pre-
sented : Is this mass the ovary or is it an inflammation of the tube
with a local collection of pus ? To answer rightly, it is necessary
to call into requisition the most acute diagnostic skiU. A diag-
nosis, it is true, may be easy if one is able to connect the inflam-
matory mass with the uterus, such as is possible if the abscess is
tubal, or to the ovary, if the abscess is ovarian.
Some slight aid in diagnosis of the exact location of the ab-
scess is furnished by the different areas of referred pain; but
generally it may be stated that only the diagnostic skill of the
examiner, combined with a clear and almost instinctive method
of deductive reasoning, will enable him to arrive at a correct
conclusion. After all, practically it makes very little material
difference whetlier the abscess is of the ovary or of the tube.
Inflanmiation of the ovary, with abscess formation, demands iden-
tical treatment with inflammation and abscess formation of the
tube. Both produce localized pelvic peritonitis and pus forma-
tion, the symptoms of which have been described.
Adhesions of the ovary frequently follow inflanmiation. When
they form, the resulting pain is related to the functional acts of
the adhering organ; for instance, micturition causes pain when
the bladder is adherent (this is rare) and defecation is painful
when the rectum is affected. In all cases, an ovary which is sur-
rounded by adhesions, as a rule, has been so badly diseased that
functional acts of its own, such as ovulation or the congestion
incidental to sexual connection, will cause pain.
Tuberculosis. — A tuberculous ovary is, as a rule, not very sensi-
tive. A characteristic of it is that it is closely approximated to
the uterus and seems glued to it (Reed, Martin).
Enlarged Uterus. — Pressure on the ovary by an enlarged
uterus may, in some rare instances, cause pain. In some cases the
pressure hinders the return blood flow from the ovary, and the
pain is the result of the consequent congestion.
Relationship of Ovaries and Parotids. — Swelling of the ovary,
and pain in the ovarian region, are common in parotitis. Like-
wise, in cases of swelling and inflammation of the ovary, pain
OVARY 753
and swelling may, in some cases, be present in the parotids. It
hardly seems possible that the association of these two organs
can be through nerve paths, for they are so widely separated from
each other and each derives its nerve supply from unrelated
nerves. It seems more than likely that the exciting cause is a
ferment, elaborated either by the ovary, or the parotid, the fer-
ment of the one producing activity in the other.
Tumors of the ovary include cysts and new growths, carci-
noma, and sarcoma.
Cysts of the Ovary. — Cystic disease of the ovary, unless peri-
toneal or pressure symptoms have developed, is without pain
(Herman, Gallaban). In a study of eight large ovarian cysts
Sampson found that the walls of all were insensitive to touch and
pain, the insensibility to pain being tested by cutting, pinching
and clamping.
However, traction on the pedicles of cysts causes pain, which
becomes greater as the traction is increased. The pain is usually
felt at or about the pelvic brim, but if the traction is increased
it becomes more diffuse, and is then generally felt over the entire
side of the abdomen or in the back. In some instances it may be
so diffuse that the patient is unable to localize it. Also, if the
pain be severe, nausea may occur. Immediate relief of both pain
and nausea follows removal of the traction.
Clamping or pinching of the pedicle gives contradictory re-
sults. In some cases it seems to cause pain, even when great care
is exercised to avoid all traction on the cyst or on any part of
the parietal peritoneum. In other cases the pedicle is relatively
insensitive to clamping, cutting, and ligating, if these are ac-
complished without traction. The pain from pulling or twisting
of the pedicle seems to originate from the traction on the parietal
peritoneum and the retroperitoneal tissues of the side and back.
The pain varies according to the force of the traction, and is felt
in the back or side. If it is very severe, the patient may be unable
to locate it. When the traction is slight, headache, accompanied by
indefinite abdominal and pelvic pains, may result.
As stated above, twisting of the pedicle almost invariably
754 PAIN IN THE FEMALE GENITALIA
causes severe pain. This is in accord with clinical experience.
The pain may be localized in the side or in the back, or may be
very diffuse, and is frequently accompanied by nausea. There
may be many mild attacks of pain, due to slight twisting of
the pedicle, which is quickly relieved by a shifting of the posi-
tion of the cyst with a consequent relief of pain. A sign very
characteristic of twist of the pedicle is that the pain is very much
increased when the patient turns from one side to the other. This
is due to the rolling over and dragging on the twisted pedicle, by
the tumor (Donald and Hickley). Should the twist persist, stran-
gulation may result, and another source of pain may arise in the
escape of the fluid from the engorged cyst. However, pain will
not immediately be felt unless the contents of the cyst are such
that they irritate the parietal peritoneum, though they may be
such that a non-infectious irritative peritonitis may ensue, and
pain may arise from this source.
Pain may also be associated with acute swelling and sudden
enlargement of the cyst, such as occur at the time of great pelvic
engorgement, as, for instance, during menstruation or at the time
of sexual connection. In some cases the sac ruptures, and blood
is thrown into the peritoneal cavity. Symptomatically, it now
closely resembles ruptured extrauterine pregnancy, from which it
is hard to diagnose (Winter, Sampson).
Adhesions between the cyst and other structures will not cause
pain unless the adhesions unite the cyst to sensitive structures
(parietal peritoneum), and conditions arise which cause traction
on the same.
The presence of abdominal or pelvic pain in patients with
ovarian cysts usually indicates either secondary changes in the
cysts, involving some sensitive nearby structure, or the presence of
some other condition, independent of the cyst, which may cause
pain. Previous symptoms may aid in the diagnosis.
Therefore, the principal causes of pain arising from ovarian
cysts are traction or twisting of the pedicles and the traction on
the parietal peritoneum by adhesions (Sampson).
New growths of the ovary as a rule are not painful. Out of
THE VAGINA 755
an enormous experience Mr. Doran could only find sixteen which
were painful and of those two were due to adhesions. New
growths are divided into two classes: (1) benign and (2) malig-
nant. The benign growths are painful when they interfere with
the ovarian functions or when they reach such a size that they
stretch the anterior abdominal wall (Donald and Lickley, p.
430). Likewise, in the earlier stages, from the same cause, the
malignant growths are painful ; while in the later stages pain is
also caused by infiltration of the nerve fibers by the tumor cells,
or by the action of the toxins of the malignant process upon the
incorporated terminal sensory filaments. In some cases torsion
of the pedicle of the ovarian tumor occurs and pain is severe. It
is due both to congestion and enlargement of the ovary from the
obstruction to the blood flow, and to the injury to the nerves in
the pedicle. In every case it must not be forgotten that malig-
nant growths may be present and not cause the least pain
(Brothers).
THE VAGINA
Nerve Supply. — Pain is a common indication of vaginal dis-
orders ; yet, because of the easily accessible location of the vagina,
other and better methods of diagnosis than pain syndromes are
available. The vagina is supplied by sympathetic and cerebro-
spinal nerves. The sympathetic fibers are derived from the in-
ferior hypogastric, while the cerebrospinal are derived from the
third and fourth sacral nerves. The reference pain seems to be in
the fourth sacral area. The sympathetic fibers are supplied to the
upper end of the vagina, which is comparatively insensitive, while
the lower portion, which is quite sensitive to irritation of every
description, is supplied by the cerebrospinal, through the pudic,
which is derived from the third and fourth sacral.
Affections Causing Pain. — Pain produced by palpation of the
vagina should always lead to inspection, as it may be due to col-
poritis. This is indicated by the reddened and inflamed appear-
ance of the mucous membrane. A profuse discharge is also pres-
756 PAIN IN THE FEMALE GENITALIA
ent. In inflammation the pain is of a burning type. Tenderness
of the vaginal wall and the pelvic floor is marked.
Hemorrhage into the soft parts surrounding the vagina is, as
a rule, painful. Even during the pains of labor, as Keed says,
the patient's attention is immediately attracted, when this compli-
cation occurs, by the increased pains which are then produced.
On the contrary, chronic edema or hemorrhagic infiltration of
the vagina or vulva is entirely free of pain.
A small nodule on the vagina may be a neuroma or a poly-
poid growth of the urinary meatus. Both are very painful. Tu-
berculous disease of the vulva is at first not painful, but later it
may cause considerable pain. Cancer of the vulva is nearly al-
ways very painful. Fortunately, the disease is very rare. Cysts
of the vulva, unless inflamed, cause no pain. Cancer of the vagina
is generally free from pain until late in the disease.
Pain on urination and on coitus generally means an inflamma-
tion of the lower genital tract or a cystitis. This inflammation is
frequently gonorrheal, but may be the result of trauma. Every
case of pain in the lower genital tract, associated with a copious
discharge, should be examined for gonorrhea. If the affection is
gonorrheal, as a rule, the vulvovaginal gland (Bartholin's) is in-
volved. The on«^et of this complication is indicated by sudden
acute pain localized to the region of the gland. Examination dis-
closes the enlarged and inflamed gland.
A marked pain on urination may indicate a vaginal (anterior
wall) tuberculosis. A slight fissure at the urethrovaginal juncture
is also a cause of severe pain.
Sexual Connection. — When pain is present during sexual con-
nection, the female is the one who most frequently complains,
except possibly in some cases of disproportion of the parts, when
both the male and the female are pained, though the female suf-
fers much more than does the male. Especially is this so in the
period following the first intercourse. To the female, the first
intercourse is almost invariably painful, and at this time the male
should exercise the greatest moderation. After a short time, this
pain during intercourse wears away, unless the partners are ill-
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758 PAIN IN THE FEMALE GENITALIA
mated; then the aversion of the female to the male may hinder
the development of the normal libido so that the vagina instead of
being moist and well lubricated during intercourse will be dry and
rough. Under these circumstances the friction which ordinarily
is productive of so much pleasure, inversely is productive of as
much distress. This is only a temporary impediment, however,
and, under propitious circumstances, entirely disappears. It is
only when it persists longer than a reasonable length of time, for
instance, a few months after the first intercourse, that it should
become a subject of medical inquiry.
How much the future happiness of the husband and wife may
depend on the cure of this abnormality can be judged when it is
borne in mind that no true conjugal bliss can be experienced so
long as natural and pleasurable intercourse is denied. Many men
spoil their entire married life by reason of stupidity and lack of
ordinary common sense in the act of coitus. No two women are
entirely alike and each should be treated differently and be made
the subject of careful medical study if difficulties due to painful
intercourse arise during married life. In the majority of cases
the female patient generally is the first to complain and to seek
medical advice, because, as a rule, she is the one who suffers most
She should be closely questioned as to the time of the pain, as to
whether it occurs before, during, or after intercourse, and she
should also be asked to define the positions in which intercourse is
most painful.
Pain at the beginning of intercourse generally indicates a lack
of lubrication of the vaginal canal, and this, since it is functional,
is generally due to an absence of sexual desire on the part of the
female, or a fear of the results of a coitus even though the desire
be present. These women are the ones who are unable to experi-
ence more than a single coitus a night without suffering greatly
for it. They generally complain of a burning pain during the
early stages of the act, which disappears under the excitement of
the libido to reappear in many cases after the conclusion of the act.
Generally, the pain disappears almost entirely in a very short
time, but often may persist to such a degree that the female will
THE VAGINA 759
not again, for some time, permit the approach of the male. Should
pain occur during the act, it indicates some abnormality or patho-
logical condition of the female parts ; inflammation or ulceration of
vaginal mucosa. Inspection will reveal this. It also may indi-
cate pus tubes, oophoritis, or appendicitis. In these cases pain is
present during the whole of the act and remains for some time
after. It is also present on particularly forcible and violent
movements, which the woman is very averse to making. When
pain occurs at the end of the act, after the orgasm has taken place,
it indicates some trouble with the uterine glands. Such a period
of pain is very unusual. Perimetric adhesions also cause pain,
which is more marked toward the end of the act.
In some women, by whom pain is complained of in the vagina
during the sexual act, digital examination reveals only a painful
spot at some point in the vagina. Xo pathological lesion can be
found.
The pain of the male arising during sexual intercourse is
slightly diiferent in its manner of production from that of the
female. The periods of pain likewise may be divided into: (1)
the pain prior to connection; (2) the pain during connection, and
(3) the pain following connection.
Pain before connection is due to some pathological lesion in-
hibiting erection of the penis, the most common being inflanmia-
tion of the urethra (frequently gonorrheal).
Pain during connection is due to herpes of the glands, ulcera-
tion of the glans penis, fissure at the meatus, inflammation of the
glans or foreskin, adherent j)repuce, or an inflamed frenum.
Pain at the time of the orgasm and persisting for some time
afterward is due to prostatitis or posterior urethritis. In any
case, when pain during intercourse is complained of, all possible
lesions in both the male and the female should be thoroughly in-
vestigated before forming a decision.
CHAPTER XXXIII
PAIN IN THE CHEST
When a patient has a pain in the chest, the idea first sug-
gested to himself, as well as to most physicians, is that he is suf-
fering from some lesion of the heart or of the lungs — of the heart,
if the pain is in the left half of the thorax ; of the lungs, should
the pain be in any other part of the chest. While in many cases
this is true, in many others it is not; and, unfortunately for the
careless physician, the exceptions far outnumber the rule. Pains
in the chest are the result of many causes.
In the first place, they may be due to injuries or disease located
in any one of the structures composing the chest walls; or they
may be felt in the walls and be produced elsewhere, as is seen in
referred, reflected, and transferred pains.
THE THOBACIC WALLS
The structures composing the thoracic wall are: (1) the skin,
(2) muscle, fascia, and nerves, (3) bone, and (4) pleura and sub-
pleural tissues.
THE SKIN
The skin of the thorax is painful in all those lesions which
cause epidermic pain, such as neuralgia, hysteria, inflammation,
hyperesthesia and hyperalgesia from reflex causes.
Neuralgia. — Neuralgia produces a very tender skin, so that the
slightest touch is painful. It is a frequent accompaniment of
influenza or some of the acute infectious diseases. When found,
inquiries should be made in regard to the presence of any recent
illness. A characteristic of neuralgic pain is that it moves around
freely from place to place, and does not stay very long in any
one location. It is also present in other parts of the body, and
760
THE THORACIC WALLS 761
the Bubjacent muscular tissues are, as a rule, veiy sensitive to
piuching or squeezing.
Hysteria. — In hysteria the skin is tender only in certain
areas.
These areas in the same person are constant in location, and
generally are produced only by certain types of irritants. In some
these areas may be sensitive to pinching and entirely insensitive to
Fig. 173. — Areas of Cutaneous Distribution of thb Thoracic Seg-
ments. (Head, Brain, Vol. XVI, p. 130.)
The iBt, 2d and 3d thoracic areas are the ones mostly affected in cardiac
disease. The 4th thoracic is the one especially involved in lung disease.
pin-point pressure; while in others these sense perceptions may
be reversed.
Infiammstion. — Inflammation of the skin of the thorax is un-
common, except when local irritation, particularly in the form of
a mustard plaster, etc., has been applied.
HTperesthesia and Hyperalgesia. — Hyperesthesia and hyper-
algesia are the result of nerve irritation, either in adjacent or in
distant areas. The adjacent causes may be inflammation of any
of the suhlying organs, such as osteomyelitis of the ribs, myositis
o£ the chest muscles, or a communicated inflammation from the
pleura. In all cases where pain is complained of in the chest
these conditions should be carefully sought. Symptoms leading
to the diagnosis of inflammation are swelling, local edema and
762 PAIN IN THE CHEST •
restriction of the respiratory movement on the affected side. In
addition to local causes, hyperalgesia may also be produced reflexly
by lesions of the heart and lungs. The segmental areas of these
hyperalgesic zones are given, according to Head, in Fig. 173.
MUSCLE^ FASCIA AND NEBVES
Muscle Pain — If there are no definite zone areas of hyper-
algesia and hyperesthesia and the areas of sensitiveness corre-
spond fairly well to the limitations of the different chest muscles,
myositis is very likely present. When it is, pain is produced by
grasping the muscle between the fingers and pinching it, or else
by trying to raise it from Its bed. If the muscle is hypersensi-
tive, pain results. Also, pain is produced on breathing by move-
ment of the affected muscle, while rest giv^s relief. If the inter-
costal muscles are affected, sudden pressure in the intercostal
spaces causes pain, and breathing is inhibited on the affected side.
If myositis be present ligK^ pressure applied to the muscle^ is
grateful, and severe pressure is painful. ' Also the pain does not
radiate. In neuralgia, on the contrary, pressure of all kinds is
most painful and radiation is usual.
Fascial Pain. — Musser speaks of a chronic inflammation of
the fibrous attachments of the muscles as being one of the causes
of chest pain. This pain is increased by motioti, and persists for
long periods. . .
NERVE AND MUSCLE PAIN
Nerve Pain. — ^If pain is present in the intercostal, ppaces,
either the nerve or the muscle is involved. The nerve may be
affected either with neuritis or neuralgia.
Neuritis. — When the pain is due to neuritis, it is referred
along the interspaces and the breathing is very much restricted.
The pain is also produced by pressure made in the interspace
about two inches from the vertebra, and when so produced runs
out anteriorly over the distribution area of the intercostal nerves.
A good way to determine vhe presence of nerve inflammation is
to run the finger round from the back to the front, in the inter-
THE THORACIC WALLS
70S
If
costal space, makiog, at the same time, coDsiderable pressure,
neuritis is present, the pain ia severe.
A somewhat similar condition is the nerve pain due to herpes
zoster. In this pain is very severe over an intercostal ner\-e.
Tenderness, also, is excessive. In a day or two small vesicles
A. XII rib
B
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D
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B
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a
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'brsnob inter-
ssr' ""•
■1. iliobypo-
H. Ilio-incui-
luliaiurva
Fig. 174. — Points At Which The Inter-
costal Nerves Become Superficial.
Especially the 11th and ]2tii over the
iliac region, which is the location of the
referred pain in pneumonia and dia-
phragmatic pleurisy of the right side.
(Splaleholz, Leipzig, 1909, vol. 3, 740.)
make their appearance over the site of the pain. Herpes then be-
comes apparent.
Neuralgia. — True intercostal neuralgia, like all neuralgias,
may arise without any obvious cause. The fifth to the ninth
thoracic nerves are the ones generally involved. The pain, owing
to the anatomical relation of the parts, is worse on breathing, or
on any movement o£ the chest wherein stretching of the nerve
(pressure irritation) may occur. This pain must not be mistaken
for pleurisy. The absence of the pleural friction rub is evidence
of value against its pleural origin. The reason for this confusion
is clear when it is stated that eho thoracic nerves divide into two
branches, the external and the internal. The internal supply the
764 PAIN IN THE CHEST
pleura, and the external supply the auterior body wall, so thjat,
should the pleural branches be affected, the stinuilus may be trans-
ferred to the external branch and neuralgic-pleural pain may re-
sult. On the other hand, when the first two dorsal nerves are
affected, the pain may run down the inner side of the arm
through the intercostal-himieral nerve. Intercostal neuralgia may
arise from thickening of the spinal meninges, specific or tubercu-
lous meningitis, or from new. growths, osseous or otherwise. It
may also arise from intra vertebral pressure, diabetes, or other
general conditions causing neuralgia. An intercostal neuralgia
may be the early sign of a tabes or of a spinal cord tumor.
BONE PAIN
Bone Disease. — Bone diseases (osteomyelitis) produce pain,
soreness, and redness over the area under which lies the necrosing
bone tissue. In these cases the location of the swelling and the
signs of inflammation render a diagnosis easy. Elevation of tem-
perature and an increase in the pulse rate also aid in the diag-
nosis.
Fractures. — Where a rib is fractured, the pain, on breathing,
is very severe. Generally, the inspiratory act commences all right,
but, because of pain, is brought to a sudden stop. On palpation,
crepitus and abnormal mobility of the rib can be felt. A diagnos-
tic sign of value is pain over the location of the fracture when
pressure is made between two hands, one placed on the anterior
chest wall and the other on the back.
Pleural Pain
See p. 769.
BEFEBBED AND BEFLECTED PAINS OF THE THOBACIC
WALLS
Referred and reflected hyperalgesia have been mentioned as
causes of chest pain. These are generally accompanied by subjec-
tive pain. There may also be a subjective pain without hyper-
algesia. This pain is refoiTed from distant k»sions, such, for in-
stance, as pain in the shoulder, in diseases of the gall bladder.
REFERRED AND REFLECTED PAINS
765
or pOBterior thoracic pain in lesions of the stomach. Both of these
are transferred pains, the same as the pain which is present in
the chest wall over the cardiac area in some eases of heart disease.
All these pains depend for their prodnction upon the transference
of stimuli from the sympathetic, through the cells in the cord, to
the nen-es supplying the body wall. In some cases, this reflection
:j
Eitra-ulBrino
D. Tendenu
; Hypcrablor-
jK.Ciutrii^ulcvr
I iM, Diwue of
1. 175, — Location of TF.NnERNEsa in
\'arious Diseases of the Chest
AND Abdouen.
passes entirely across the cord, and the pain is felt on the side
opposite to that of the lesion. It also may be transferred to a
higher or lower level of the cord and be felt at a higher or lower
level of the body.
These transferred pains, when present in the cheat, often
cause mistakes in diagnosis, since they are likely to cause confu-
sion as to which is the side of the lesion. They may also attract
attention from a distant causative pathology, as is sometimes seen
766 PAIN IN THE CHEST
in appendicitis, when pneumonia or pleurisy is diagnosed with an
entire disregard of the appendiceal condition. However, the
diagnosis is not always wrong, for in some cases there may be
local conditions (congestion, etc.) in the lungs to account for the
chest pain associated with appendicitis, as is emphasized by J. B.
Roberts (576). In other cases the pain may be felt in the ap-
pendix area when the. lesion is in the limg. This pain may be
due to irritation from a diaphragmatic pleurisy associated with
the pneumonia, the stimulus being carried through the eleventh
and twelftli intercostal nerves. The pain, as is usual, would then
be felt at the point where the eleventh and twelfth nerves become
superficial, that is, in the right lower quadrant of the abdomen.
Transfinred and reflected pains, in distention of the stomach
and colon, are found on the lateral surface of the chest, follow-
ing the points of attachment of the diaphragm. These pains occur
in tlie two conditions in which the greatest traction on the dia-
phragm is present, namely:
(1) In states of great cardiac and respiratory activity. The
heart and lungs, which in a normal person, under abnormal eon-
ditiona of exertion, would be incited to great effort, would, in a
patient who is emphysematous, be incited to much greater effort,
owing to the difficult circulation of blood through the lungs. This
relatively greater increase of cardiac and respiratory activity
would produce much greater than normal traction on the dia-
phragm, and this, in turn, would be communicated to the chest
wall at the points of diaphragmatic attachment. Thus it is that
after violent exercise pain is so frequently produced at these
points of attachment.
(2) In enlargement and dilatation of the stomach it is also
common to find pain or a sense of traction along the line of attach-
ment of ihe diaphragm to the chest wall. This pain is the result
of the diaphragmatic pull.
Distention of the stomach and intestine frequently causes such
a sudden and severe pain in the cardiac region that it is confused^
with angina pectoris; but a hurried examination of the epigas-^
trium will disclose the enlarged and tympanic stomach and quickly
REFERRED AND REFLECTED PAINS 767
clarify the diagnosis. The distended large intestine, also, at times
produces the same symptoms. Symptomatic of the latter condi-
tion is a painful spot on the left side of the chest at the margin of
the ribs (in men at a point opposite the suspender button). In
woinen the presence of this pain frequently causes them to loosen
the corsets (Reynier, 231).
According to Brown (Osier's "System"), pain over the front
of the chest is, as a rule, a referred pain from a diseased lung,
though it may also be due to an acute pleurisy or to the traction
of pleural adhesions. According to the same author, pain over
the lower part of the thorax may be due to pleurisy, while, if it is
over the interscapular region it is, as a rule, referred, and is the
result either of a pleurisy or of pressure on the intercostal nerves
from enlarged mediastinal glands.
Pain radiating around the chest wall is also present in herpes
zoster and tabes dorsalis, as well as in vertebral caries, if the
intercostal nerves are involved. Mediastinal glandular involve-
ment at times produces a pain in front of the chest, beneath the
sternum, and at other times in the back, underneath the vertebrae.
Should pain be present in the back between the scapulse, the fol-
lowing should be sought: vertebral disease, lung disease, particu-
larly tuberculosis (here the pain is more of an aching), aortic dis-
ease (aneurysm), pleural disease (pleuritic adhesions), splenic
and gastric lesions (inflammation and over-distention). Should
pain be present at the angle of the scapula on the right side, it
indicates liver involvement; if at the angle of the scapula on the
left side, it indicates splenic involvement.
Localization of Pain on the Chest Wall. — Pain on the lateral
wall of the thorax may be due to pleurisy, intercostal neuralgia,
or pleurodynia. Upon the upper surface of the thorax, in the
region of the shoulder, pain may be due to pericarditis (left
shoulder) (McKenzie), peritonitis, pleurisy, hepatic abscess
(right shoulder), or colic. According to Monro (32), Schmidt,
and others, the pain referred to this area is propagated through
the phrenic nerve to the fourth cervical (sometimes, also, to the
fourth and fifth), and thence through the external supraclavicular
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PAINS WITHIN THE THORAX 769
nerve (derived from the third and fourth cervical nerves) to the
integument over the shoulder tip.
Pains above the shoulder are due to involvement of the supra-
acromial nerves, branches of the fourth cervical. Deep-seated
pains, referred to the parts over the shoulder joint, and in the
deltoid, lie in the distribution area of the circumflex nerve, which
originates from the fourth, fifth, and sixth cervical nerves. When
the pains are behind the shoulder and over the deltoid, they are
also due to involvement of the circumflex, and at the point where
the nerve becomes superficial a painful spot is present (Dana,
123b). Tenderness is present over the eleventh and twelfth
dorsal and the first and second lumbar vertebral spines in gastric
lesions. (For other points of tenderness in gastric lesions, see
under Stomach.)
PAINS WITHIN THE THORAX
Inside the thorax are the following, all of which have the
power, directly or indirectly, of causing pain: (1) the pleura, (2)
the heart, (3) the hmgs, (4) the mediastinal glands, (5) the esoph-
agus, and (6) the nerves and vessels passing through the thorax.
In diseases of the heart and lungs hyperalgesia may be present
in the area of the first six dorsal visceral segments. Sometimes
it is felt as high as the seventh or eighth cervical or as low as the
seventh or eighth dorsal (Head). Generally, though, in the case
of the heart, the hyperalgesia is limited to the upper four dorsal,
while that of the lungs is comprised within the upper six dorsal.
The areas of distribution of these segments are illustrated in
Fig. 173.
THE PLEURA
Innervation. — The parietal pleura is innervated by the inter-
costal, sympathetic, and vagus nerves. The visceral pleura is
innervated by the vagus and sympathetic. The pericardial pleura
sends its sensory stimuli through the vagus and possibly through
the phrenic. The diaphragmatic pleura sends impulses over
770 PAIN IN THE CHEST
the phrenic and also in part through the last six intercostal
nerves.
In pleurisy pain is a symptom of great diagnostic value, be-
cause it is almost invariably present.^ The method of its pro-
duction and its areas of distribution have been discussed in the
preceding pages. In some cases the cutaneous hyperalgesia may
'be on the opposite side of the body to the one affected; but the
deep tenderness is always on the affected side, and this is a point
to be remembered, for it may be most useful in a differential diag-
nosis. Percussion is a good method of defining this deep tender-
ness. On palpating or percussing those cases of pleurisy in which
pain is complained of over the abdomen as far as the umbilicus,
it is noticed that tenderness is not present on percussion and pal-
pation beyond the costal margins, and this is a sign of the utmost
value in the making of a diagnosis. When tenderness to deep
pressure or percussion is present, it is a fair indication that the
diseased process lies in the percussed area.
The mere fact that an. area painful to palpation or percussion
is present does not necessarily prove a pleural involvement, for
these pain areas may be due to other causes than a pleurisy ; like-
wise their absence is of no negative value, for a pleurisy may be
present and jun a painless course. A method of arriving at a
diagnostic conclusion as to whether the pain felt in the chest wall
is or is not due to pleural involvement is to inhibit the respira-
tions on the affected side, as by strapping. This will at once stop
the pain, if it be due to a pleurisy. On the right side, if the pain
is the result of perihepatitis, strapping will a^ravate it In dia-
phragmatic pleurisy respiration is painful, but not nearly so
much so as it is in pleurisy of the lateral wall. In many cases
of diaphragmatic pleurisy the pain is referred to the chest and
abdominal wall, in the distribution area of the tenth, eleventh,
and twelfth thoracic nerves.
The pleura also is probably connected with the seventh, eighth,
1 According to Dr. Lord, 89.70 per cent. . of all cases of serofibiinoos
pleuhs7 give rise to pain at least sometime in their coune.
PAINS WITHIN THE THORAX 771
and nintli visceral dorsal segments, so that the pain, when reflected,
is felt in these segmental zones, most commonly on the right side
(Head. See Fig. 173). This corresponds closely with the state-
ments of Huss (102), who says that, in pleuritis, irrespective of
the area in which the disease is present, the pain occurs princi-
pally in the region of the mammillary line, between the fifth
and eighth ribs. When the inflammation lies in the outer and
lower half of the pleura, the pain may be felt in the region of
the hypochondrium, in the region of the quadratus lumborum,
and in the epigastrium (though infrequent).
In all cases in which the parietal pleura is involved (and it
is involved in nearly all pleuritic processes of whatever origin)
pain due to irritation of the intercostal nerves is also felt, and is
localized to the diseased area. If the pleurisy should extend and
involve the mediastinum there is then produced a mediastino-
pericardio-pleuritis. This causes severe pain on breathing. Per-
cussion over the sternum is painful, and pressure in the intercostal
spaces on either side of the sternum causes pain. Reflected and
referred pains are absent; only the direct pain is present.
Character of the Pain in Pleurisy. — The pain of pleurisy may
be slight or severe, depending upon the type and the location of the
pleuritic involvement. If the visceral pleura is involved, it is
not as severe as though the parietal pleura were affected. Like-
wise involvement of the diaphragmatic pleura, in the absence of
deep inspiration, may produce no very severe pain. In all cases
pleural pain of whatever origin is generally provoked on deep in-
spiration, cougMiig, yawning, singing, and laughing. As a rule
it is localized in the areas of maximum tenderness of the seventh
and eighth dorsal segments (q. v.). If the intercostal nerves be-
come affected and intercostal neuritis results, the pain is referred
to the anterior area of distribution of these nerves. Should the
pain suddenly cease, it is frequently an indication of a beginning
hydrothorax.
In those casSs in which the subjective pain is on the opposite
side to the one involved Gerhart thought that the transference
i72
PAIN IN THE CHEST
might be due to a communication in the anterior mediastinum, be-
tween the two sets of intercostal nerves. In this regard, Huss
speaks (102, p. 245) of a case in which such a connection was
found between the fourth and the middle part of the third nerve
on the right side and the corresponding nerve on the left side.
CHAPTER XXXIV
HEART DISEASE
GENEBAL OONBIDEBATIONB
It has frequently been said that cardiac disease does not cause
pain. Even well-known clinicians have claimed that the heart (of
itself) does not give rise to painful sensations. They attribute
all the pains which may be present in the chest, over the area of
the heart, as not being due to disease of the heart itself, but as
the result of other changes, such as rheumatism of the pectoral
or intercostal muscles, or intercostal neuralgia. Yet it is not
always wise for the clinician summarily to dismiss a pain in the
chest and rate it as being due to any one of these conditions,
especially so in those who are weak and debilitated from over-
work or disease. In the former class of patients the pain, though
slight, may be the first indication of a cardiac exhaustion. Early
and efficient remedies directed against this exhaustion may pro-
long the patient's life for years, while neglect of the warning
signs may pave the way for his early death. Every case of pain
or discomfort, in the areas usually associated with cardiac disease,
should lead the physician to question closely his patient as to age,
habits, manner of work, and past diseases, and then to make a
thorough examination of the entire body, with special attention to
the chest. The physician should also bear in mind that the heart
may be greatly diseased and yet give no apparent sign of its dis-
tress, excepting in cases of referred visceral hyperalgesias. Should
these hyperalgesias be present, they of themselves, even though no
other signs of heart disease are apparent, are of sufficient value
to merit a diagnosis of cardiac involvement. The absence of hy-
peralgesic zones does not carry weight against, as their presence
carries w^eight for, the existence of cardiac disease.
773
774 HEART DISEASE
It was in 1873 that Loomis first called attention to the asso-
ciation of heart lesions with referred pains. For instance, in an
article published in that year, he says that "disturbances of the
cardiac plexus, by reflex irritation, produce pain in the arm, in
the top of the shoulder, and the base of the neck." However, it
was not until Head and McKenzie published their articles on
referred and reflected pain that a clear conception of this rela-
tionship of the pain to the cardiac disease was reached.
Nerve Supply of tbe Heart. — The cutaneous hyperalgesia, in
a case of heart disease, lies in the cutaneous tissues which extend
from the eighth cervical to the fourth dorsal segments, as illus-
trated in Fig. 176. In this illustration, it should be noticed that
the eighth ceryical and the first and second dorsal zones are shown
as extending down the arm. This downward . extension explains
why, in some cases, the pain of cardiac disease ,runs down the
inner side of the arm, frequently as far as th^ little finger. The
reason for this downward extension is that, in early embryonic life,
the spinal nerves are distributed around the entire body ; but as the
body develops, and the arms and limbs are projected from its
surface, the nerves are dragged out with them, and are carried by
developing tissues farther and farther away from their point of
origin, until we find them in irregular though always concentri-
cally arranged zones, as in man. Ross explains how, in some
cases, the areas supplied by the dorsal segments are not continu-
ous from the chest to the arms, but are broken by intervening
areas ; for instance, the third dorsal is broken, the ^gap between the
two portions being made by the ingrowing second dorsal. The
different segments of skin grow with various degrees of rapidity,
so that in some cases the different skin segments become sepa-
rated from each other.
DiagnosiB by Means of Location of Referred Pain. — ^The man-
ner of distribution of the cord zones explains how the pain of
cardiac diseases may be distributed down the inner side of the
arm, and at the same time over the left upper half of the chest.
It also explains why, in some cases of cardiac lesions, the breasts
are very sensitive. Hyperalgesia due to cardiac disease may first
GENERAL CONSIDERAT
appear only aft^r some severe and debilit
pneumonia, which, so sensitizes the alread;
the slightest stimulus will give rise to pain
At the same time the hyperalgesic areas of 1
will be present. For example, if the hear
pain) and the patient catches pneumonia
non-painful heart becomes very painful,
of hyperalgesia appear. These heart are
long time after the pneumonic areas have
t).— Location of Hypehalgkbic Zoneb
. IN Cahdiac and Aortic Lbs
i cases there is a crossed reference and t
analogous area on the opposite (r
versa. In cardiac disease certain muscles,
the intercostals, the trapezius, and the steni
sensitive to pindhihg and squeezing.
That the pain felt iii heart disease is
pain is set forth in the following argumei
(1) The heart is in contact with the ch(
part of its anterior surf ace, and the pain an
with the cardiac disease cover an area sev
(2) If the pain were present in the hea
the heart, such as expansion or contraction,
tion in the pain and tenderness. Such is n
arguments apply to the origin of pain in '.
776
HEART DISEASE
Another point of interest, as well as of value, in diagnosis of
heart lesions is that in the first attack of an inflammatory affec-
tion of the heart, say, in endocarditis, the hyperalgesic zones are
very prominent, increasing and receding with each exacerbation
or recession of the disease. After the first attack, when the
process becomes chronic, as in chr<Hiic valvular disease, the re-
ferred zones of hyperalgesia are, as a rule, absent However, if
A Areaof hypenUgctta
^ The ai\A of hsrper-
alceaia down the
arm was not
wider than H
inch, and becan
abnrotly below
the uioulder, and
ended abruptly
before it reached
the elbow
Fig. 177. — ^An Area of Hypebalgesia Corresponding to Portions op
THE 2d, 3d and 4th Dorsal Zones.
The 2d dorsal is almost absent. The area corresponding to a portion of the
4th dorsal is more than ordinarily prominent. In this case also there
was no tenderness to blunt pressure, even in the area which was hyper-
algesic to pin-point pressure. The case was a mitral regurgitation re-
covering from an acute attack.
at this time an acute attack of endocarditis should ensue, the
hyperalgesic areas may or may not appear. The reason that they
do not reappear is not clear, but it probably is the result of the
destruction, in the first attack, of the sensory terminal nerve fila-
ments in the endocardium, so that, during the second and subse-
quent attacks, they cannot respond to the irritating stimuli. This
is well illustrated in the case of Lillian H., a school girl affected
with chorea. While under observation a mitral regurgitation de-
veloped, and at its height gave rise to the hyperalgesic areas
shown in Fig. 177.
As improvement occurred the zones gradually became less ex-
GENERAL CONSIDERATIONS 777
tenaive, first disappearing in the arm, then over the chest, until
only a small area over the heart remained (See Fig. 177). This
was the area of the third dorsal segment (the segment most fre-
quently associated with lesions of the left auriculo-ventricular
opening). In cases of mitral disease I have found it present even
when the other segmental areas were absent Another fact worthy
of attention is that disease of the aorta seems to be associated espe-
cially with the first dorsal segment. In all cases it will be ob-
served that the segmental areas are not as clearly defined as they
Fio. i78. — Areas of Cutaneous and Despbb Hyperalgesia in a Case
OF Acute Dilatation of the Hbart, Accompanied by Acute Dis-
tention of the Livbb.
are in the figures in which the distribution areas of the visceral
segments are shown. (See Figs. 24 to 26.) This is probably
due to the fact that hyperalgesia in cardiac disease is felt best in
the center of the area which is most frequently associated with
the heart ; and that the intensity of the sensation gradually fades
into the adjacent areas. In many eases the cardiac hyperalgesia
does not exactly coincide with the area of the cord zones, but may
overlap them or be confined only to certain portions of the zones,
which are most likely the zones of maximum tenderness of Ilead.
77S HEABT DISEASE
In some cues of beart disease there out alao be present an area
of hyperalgesia on the arm in the Bectnd dorsal s^ment and
another over the heart in the fourth dorsal segment, as in Fig.
177, wherein the hyperalgesia was present on the chest, and also
in a long narrow atrip on the anterior surface of the arm. In
this case the area of hyperalgesia most likely represented a dis-
appearing zone of hyperalgesia. It is in cases of this kind that
fayperalgesic zones are overlooked.
The hyperalgesia may sometimes extend into the right side or
Fio. 179.— livPERALGEsic Area in a Cask in Which .thk Mtocaroiuh is
PaoBABLr IN A Stati or Intoxication.
The beart rhythm is slightly irregular; at times the first sound is redupli-
cated, or, rather, instead of the normal first sound, there is a double
first, with an absence of the second. The right ade of the heart is
also involved, a tricuspid regurgitant murmur bung present.
up into the neck, as in the case of a negress (Fig, 179), who, after
recovering from pneumonia, developed a delirium cordis with
variable pulse and a slight tricuspid regurgitation. Since the
right side of the heart and the great veins bear the greatest part
of the stress of a tricuspid regurgitation in lesions of this char-
acter, the higher cardiac areas (the first and second dorsal) are
most frequently affected, and can be taken as indicators of this
condition. In this connection it is well to remember that the
right ventricle of the heart, when diseased, is not so apt to pro-
duce pain as is the left ventricle ; so that pain is not as prominent
a diagnostic symptom of right heart involvement as it is of in-
GENERAL CONSIDERATIONS
779
volvement of the left. In fact, the only symptoms complained of
in disease of the right side of the heart may be a feeling of
weight or pressure over the cardia, and a tendency to take strong,
deep inspirations. In some cases the anatomical structure of the
Area of Bsrmpathetio
pain (from cheat)
f Areas painful to the
touch. On making pree-
sure at times over these
spots a very severe pain
was produced on the
forehead in the left
frontal region
v
Fig. 180. — ^Arbas of Pain in a Case of Mitral and Aortic Regurgfta-
TION.
During the last few days previous to the time at which the outline was
made, the heart had been acting very badly, and only the night pre-
vious to the outlining of the pain areas the patient had an attack re-
sembling angina pectoris. At these times she also had pains referred
to the labia on both sides with painful urination and retention of the
urine. Examination of the urine and the urinary organs showed
nothing abnormal.
heart may be greatly deranged without causing any marked symp-
toms, as in one case, in which a column of fat one inch in diam-
eter extended through the wall of the ventricle, and the only
symptoms complained of were a slight shortness of breath and a
feeling of weight in the pericardium. But, as a general rule, it
780
HEART DISEASE
DIFFERENTIATION BETWEEN ACUTE ENDOCARDITIS AND
CHRONIC AND RECURRING ENDOCARDITIS
Acute
Chronic
Fever.
Present.
Absent.
Hypertrophy
(Heart).
Absent.
Present.
Murmurs.
Changeable in character —
gradual increase in intensity,
as the diseased process ad-
vances new murmurs may
make their appearance.
Constant in character —
presystolic murmur at
apex and aortic murmurs
are in favor of chronic
endocarditis.
Secondary
phenomena.
Blood.
Emboli are carried to several
organs and give rise to hem-
orrhagic infarcts in the
1. Brain.
Hemiplegia.
Aphasia.
2. Kidney.
Bloody urine.
Pain in the renal region.
3. Spleen.
Pain.
Swelling.
4. Limgs
Hemoptysis.
Circumscribed dulness,
generally at the base of the
lung.
Dyspnea.
These are generally uohered
in by a chill; also sympa-
thetic vomiting sometimes
occurs.
Culture generally shows bac-
terial growth.
Secondary phenomena are
due to changes in the
valve segments, etc., and
manifest themselves as
passive congestions
(lungs, liver, etc.)
No bacterial growth on
culture.
may be stated that acute inflammatory lesions of any part of the
heart will produce reflex hyperalgesia in one or all of the cardiac
zones of hyperalgesia.
This hyperalgesia is of considerable value as a prognostic sign
in acute endocarditis. Its disappearance indicates the recession
of the lesion and the return of the parts to the normal. However,
it must be borne in mind that the absence of hyperalgesia does
GENERAL CONSIDERATIONS
781
not positively indicate an absence of pathology in the heart, for
the pathology may be of such a character that it may not produce
any cutaneous hyperalgesia.
Cardiac pain may also in some cases be referred to distant
areas, as in one case where it was referred to the head in the
distribution area of the fifth nerve, being especially severe in the
area of distribution of the supraorbital branch (See Fig. 180).
Dilatation of the heart is always painful, and causes hyperal-
gesia in the second, third, and fourth dorsal, and in the cervical
regions, especially on the left side. The zones over the liver, the
seventh, eighth, and ninth dorsal, are also painful (see Liver).
This is due to the congestion of the liver which is always asso-
ciated with a failing heart Fig. 178 illustrates the point exactly.
The diagnosis between heart disease and intercostal neuralgia
is sometimes difficult, but is made easier if the physician remem-
bers that in intercostal neuralgia the pain is along the course of
the intercostal nerves, while in cardiac disease it has no such
distribution.
The differential diagnosis is as follows :
?
Cardiac Disease.
Pain is in the cardiac zone
areas.
Movement of thorax is not espe-
cially painful.
Pain does not radiate around
the chest, and the inter-
costal spaces are not ten-
der.
Pain, when present, is more or
less constant.
Pressure on area of tenderness
will not produce a pain
radiating around the chest.
Intercostal Neuralgia,
No pain in the cardiac areas.
Movement (respiratory, etc.)
of thorax is painful.
Pain may radiate round the
chest and is present on
pressure in intercostal
spaces.
Pain is intermittent.
Areas of tenderness are pres-
ent, pressure on which will
produce a pain radiating
around the chest.
•82 HEART DISEASE
Intracardiac Lesions as Causes of Pain. — The raising of the
intraventricular tension often causes cardiac pains. They gener-
ally occur after pronounced exertion, and are rather common in
patients with arteriosclerosis who have a leaking aortic valve. A
peculiarity worth noting is that, as soon as a mitral regurgitant
murmur develops, and an outlet is provided for the increased intra-
ventricular tension consequent to extra muscular effort, the pain
disappears. Mitral regurgitation often causes a pain referred
to the left shoulder and down the arm. Palpitation is a frequent
accompaniment. The cause of this pain may be that early in,
and, in fact, during the entire course, of the disease, the intra-
ventricular pressure in the right ventricle is increased, the ten-
sion is raised, and as a result pain arises from the greater work
thrown upon the heart (This may occur only in stages of acute
loss of compensation.)
Degeneration of the cardiac ganglia is given as cause of cardiac
pain by W. H. Thompson, who speaks of eases wherein severe pain
was felt in the cardiac region, with all the signs of angina; and
yet, when death supervened during an attack, no apparent patho-
logical abnormalities could be found. He suggested that a degen-
eration of the cardiac ganglia would probably account for the
condition. (Degeneration of these ganglion could have been
proved by careful microscopic examination.)
In some cases it is difficult to differentiate the pains of gastric
origin from those due to cardiac disease.
The following differential diagnosis after Smith may be useful :
Pains of Gastric Origin. Pains of Cardiac Origin.
Appear after food, and appar- Appear quite irrespective of
ently are the direct result whether food is taken or
of its ingestion. not.
Accompanied by feeling of f ul- No such feeling of fulness ; not
ness in stomach; often re- relieved by eructation of
lieved momentarily by wind.
belching.
ANGINA PECTORIS
783
Pains of Gastbic Origin.
Xot increased by active move-
ments, such as walking.
Heart sounds normal in rhythm
and character.
Pains of Cabdiac Obigin.
Increased by active movements,
which, owing to the sever-
ity of the pain, may even
be impossible.
As a rule, some cardiac bruit is
present, or at least some
alteration in rhythm and
volume of pulse.
Because it is the most characteristic of the painful diseases
of the heart, angina pectoris will next be separately considered.
ANGINA PEOTOBIB
Etiology. — ^Angina pectoris, which is the most painful as well
as the most distressing lesion of the heart, is said to be due to the
following :
(1) Anemia of the heart muscle, which in turn is the result
of the narrowing of the coronary arteries. This narrowing may
occur at their place of origin at the aortic valves; for instance,
aortitis, with consequent sclerosis of the aortic valve, may occur,
and lead to a partial closing of the coronary opening. The result-
ing pain is due to factors acting similarly to those which cause
the pain in intermittent claudication. Any condition causing
anemia of the cardiac muscle, such as exhaustion, bad health,
non-assimilation, etc., in a person previously disposed, will fre-
quently bring on this pain.
(2) Irritation of nerves in the heart wall. These nerves are
of the sympathetic variety, and consequently do not carry direct
pain stimuli, but only irritating ones, which are carried to the
cord and 'from thence are referred to the periphery as pain.
(3) Exhaustion of the heart muscle from overwork causes
pain. This pain is due to the same causes as the pain produced
in the affected muscles after excessive muscular fatigue (Mac-
kenzie).
784 HEART DISEASE
(4) In addition to the above causes of cardiac pain, Mac-
kenzie also claims that angina pectoris is due to a loss of con-
tractability of the cardiac muscle fibers.
(5) However, the direct exciting cause in angina pectoris
seems to be (a) psychic, the result of emotion, such as anger or
extreme joy; or (b) physical overstrain, such as accompanies the
lifting of excessive weights, running long distances, or the per-
forming of long-continued exercises.
Bramwell (890) and Osier (892) seem to be somewhat in-
clined to the view that it is the physical strain which is the cause
of the pain in angina pectoris, because it necessitates extra work
by the ventricle, and, as a consequence, irritation of the cardiac
nerves.
(6) Angina pectoris may also be due to a raising of the intra-
ventricular tension in a weakened heart. The most frequent or-
ganic lesion of the heart producing angina pectoris is aortic re-
gurgitation and stenosis, without an accompanying mitral lesion.
When the intraventricular pressure is relieved by a mitral regur-
gitation the blood is thrown back on the lungs, and the pain
ceases.
Pseudoanginal pain also occurs, and is frequently due to
stomach disorders.. The cord centers for the stomach are near the
same level as the cord centers for the heart, consequently the re-
flected pain and cutaneous hyperalgesia for both occur in the
same area, and one is apt to be mistaken for the other (Curtin,
891).
It seems that cardiac angina is often brought on by overeating,
or by the eating of unsuitable or indigestible food, or food that is
very apt to ferment, and thus cause dilatation of the stomach,
which would press up against and inhibit the work of the heart.
Character of the Pain in Angina Pectoris. — In some the sen-
sation may not reach the dignity of a pain, but is felt as a creep-
ing or a formication under the skin, or, in other cases, as a
tingling, or coldness of the skin surface. When it does approach
the magnitude of a pain it becomes very severe ; so much so that
the suffering individual thinks his life is about to terminate. A
ANGINA PECTORIS 785
definite characteristic of the pain of angina pectoris is that it
almost always follows exertions, mental or physical.
Location of the Pain. — The pain may be felt directly over the
heart; in the arms; in the chest as a girdle sensation; in the
neck; in the gums and throat, or in the right side. Monro (32)
FlQ. 181. — ArEAOPSbNSDRtDiBTURBANCBBIN ACASBOPANaiNAPxCTORIB.
A, analgesia with anesthesia; B, analgesia without anesthesia; C, hyper-
eethesia. (From G, A. Gibson. 250.)
mentions a case in which there was pain in the left eyebrow and
in the right upper limb. This pain was accompanied by an in-
tense desire to urinate. Osier mentions a case in which the pain
was in the testicle.
In some cases a pain equal in intensity to that usually felt
over the heart is present in the arm and is entirely absent over
786 HEART DISEASE
the heart It may start in the little finger or in the forearm, and
gradually progrese up the arm until it paaaes over the chest to
the cardiac area, where it may remain. In other cases the pain
may be felt in the chest in the cardiac area (third dorsal zone),
and in the forearm in the first dorsal area, the remainder of the
arm being entirely free of pain. In other cases the reverse is
MCeSMRy PORTtON
a— UPPER QltN&UON OF VAOUS
- PILAMCNT UNITIMG SPtNAL
ACCCMORYTO QAN6LIOM
OF VA6Uft-
'"-■. JUGUIAR FOR A MAN
TMC CORD T^-^CERVICALPLEXUS
Fig. 182. — Communication between Spinal AcLKShOKV and Vaqus.
The tender spot at the point of emergence of the spinal accessory from the
stemomaatoid (in cardiac disease) is probably due to the close asao-
ciatioD between the accessory and the upper ganglion of the vagus.
true, the pain being present in the cardiac area on the chest and
absent elsewhere. In nearly all these cases there is a peculiar
constricting sensation nronnd the chest, jis Ihough the body were
wound with a rope drawn so tightly that breathing wag inhibited.
The cause of this sensation is the spasmodic contraction of the in-
tercostflls, such contraction being explained by the hypothesis of
a visceromotor reflex. In cardiac disease pain may also be felt in
the trapezius and the sternomastoid, and in the skin overlyins
these muscles. This pain can be accounted for by the close rcla-
ANGINA PECTORIS 787
tionship of the ragal centers in the medulla to the centers of the
sensory nerves supplying the trapezius and sternomastoid muscles,
so that an irritation of the vagal centers will produce an irritation
of the sensory centers supplying the trapezius and sternomastoid
and overlying skin, and, as a consequence, pain will be perceived
in this area (Mackenzie). In still other cases pain has been
felt in the gums and throat. It may e\en be located on the right
side of the body, and may appear on the left side only late in the
disease, or not at all. According to Hoover, the pain in the neck
is in the distribution area of the third cervical segment.
Siidnil mcct-tretj narvi
FlO. 183. — EtdEROBNCE OF THE SfINAL ACCESSORY FROM UNDER THE StBRNO-
UASTOID.
This is the point where local tenderness is frequently preeeat in cardiac
Local Tendflinois. — In angina pectoris local tenderness is pres-
ent at a point on the border of the sternomastoid, where the spinal
accessory becomes superficial, and is also present over the second
and third ribs, about one inch external to the left sternal line
(Hoover).
Associated Symptoms. — The symptoms associated with angina
pectoris are: increase in the flow of the urine and saliva, an
increased arterial pressure, shock (indicated by pallor, etc.), dila-
tation of the pupils, and absolute inability to undergo any physical
or mental work during the time of the attack. The feeling of
approaching death is frequent. The termination of the attack
may be announced by the expulsion of the air which has been
788
HEART DISEASE
drawn unconsciously into the stomach during the attack (Mac-
kenzie).
Myocarditis is generally free of pain, though exertion is fre-
quently followed by pain and dyspnea.
Fig. 184. — Conducting Paths for Impulses from the Heart.
The figure shows the relationship existing between the heart, the pupillary
reactions, and the radiation into the arm. DP, the pupil dilating cen-
ter in the base of the brain; DP, radiating fibers of the iris; MM, muscle
of Muller; LP, nonnstriped portion of the levator palpebrse; S, indicates
the method of radiation into the arm. (Copied)
DISEASE OF THE PEBICARDIXTM
In disease of the pericardium pain may be entirely absent.
When present it is located in one of the areas of reflected cardiac
pain. A characteristic of pericardial disease, not so frequently
present in heart muscle or endocardial involvement, is that tender-
ness is marked over the cardiac area, especially so should a medi-
astino-pericarditis be present. In this condition, where the in-
DISEASE OF THE PERICARDIUM
789
flammation lies so close to the chest wall, pain and tenderness
are present over the third rib on the left side, and extend about
one to two inches from the left sternal border. This is also the
area which Hoover gives for tenderness in angina pectoris, and
which Head gives for the maximal tenderness in the third dorsal
zone (anterior). This accord is wonderful when it is considered
that the location of these areas has been worked out from different
premises, Head's area being considered as the result of a stimulus
acting reflexly through the cord, while Hoover's areas are re-
garded as the places where the local tenderness is most marked.
The tenderness of the skin and subjacent tissues in pericarditis
extends for a considerable distance lateral to the right sternal
margin. The pericardium of itself is insensitive to all ordinary
stimuli, as Richeraud has claimed and as many others have found
(during operations).
' .;!'•« ' ■
CHAPTER XXXV
THE BESPIRATOKY ORGANS
THE LUNOS
GENEBAL
Etiology of Lnng Pain. — Pain in the segmental areas asso-
ciated with the lungs may be the earliest indication of a pul-
monary involvement, though in many eases there may be no actual
pain manifestation, but only a feeling of discomfort in the chest
wall. It seems that pain is not as common in lung disease, with
the exception of pneumonia, as it is in disease of the heart When
it is present many causes are assigned, the principal one being an
inflammation of the pleura. That this is a very important factor
in the production of lung pain can hardly be doubted, in view of
the almost universal association of a pleurisy in those lung dis-
eases in which pain is a prominent symptom. Yet the visceral
pleura of itself has very little sensation, as can be demonstrated
during the removal of a pleural exudate, when, should the pleura
come in contact with the tip of the cannula, no pain results. Mac-
kenzie says that in several cases he has made careful dissections
of the intercostal nerves, following them to their terminaticms,
and that in no case could he find '^a single filament going to the
pleura." He suggests that the referred pain of basal pleurisy
may be due to the invasion of the diaphragm by the inflammation.
Distribution of Referred Pain. — If such is the cause, the pain
of pleural disease must be produced in the parietal subjacent
pleural tissue, and be carried through some of the branches of the
intercostal nerves, which, though not directly connected with the
pleura, are found ramifying in the subpleural connective tissue
(Johnston, 538). If this were so we should expect to find pleural
790
THE LUNGS 791
pain referred to the points of maximum tenderness of the inter-
costal nerves ; that is, to the points where the nerves become super-
ficial. Now, if we examine a case of pleurisy, with pain produc-
tion, we find that this is true, the pain due to pleural lesions be-
ing most often felt in the anterior axillary line, which corre-
sponds fairly well with the line of the points of emergence (areas
\^.^'
B. N. InMT-
C. N.thanc>]»
D. Huniural.
a(tliecu<.lst.
P, LatlBiimiu
dona
Ut. (pwt. ) n!
IX
I. N. iDterco,..
..N. !„..„«.
K, L, N. ilio-
hypofulric.
P, M. aerr
FiQ. 185. — Points of Emeroence op the Dobbal Nerves (Antehiob).
These points are, as a rule, the places where pain is complained of when
the thoracic nerves are irritated. Generally, tenderness is also present
in the skin immediately over these areas. (Spalteholz, Leipzig, 1909,
vol. 3.)
of greatest tenderness) of the intercostal nerves. However, be-
cause of the close relationship of the parietal and visceral pleura
it is almost impossible for one to be diseased without the other
being affected, so that we always find both taking part in the
inflammatory process.
When the parietal pleura is inflamed it is very easy for the
inflammatory process to spread and involve the intercostal nerves,
and thus cause an intercostal neuritis. Should this occur, tender-
ness is present in the intercosta. spaces, is moet marked at the
792 THE RESPIRATORY ORGANS
anterior axillary line, and extends out onto the anterior wall of
the chest. Pain is also felt in this area, but lies more toward the
sternal margin. When the lower part of the pleura is involved
respiration becomes very painful. This is due to the constant
friction of the parts, and the slight pressure and traction made
upon the supersensitive intercostal nerves during each respiratory
act.
Pain due to inflammation of the visceral pleura is not direct,
but is referred, through the sympathetic nervous system, to the
cord, and thence back to the chest wall through the spinal nerves.
This reference pain is located in one or more sharply defined
areas, the so-called Head zones.
The zones in relation with the lungs or pleura are those of the
first seven dorsal segments of the cord. The maximum points
of tenderness of these zones are the places where the patient fre-
quently feels the most severe subjective pain. That all these
zones are involved to an equal degree in disease of the lung or
pleura cannot be held. Indeed, it seems more than likely that
the only zone almost constantly involved, either in visceral pleural
disease or in disease of the lung itself, is the fourth dorsal,
which has its area of maximum tenderness slightly above and
external to the nipple, the point where the patient complains of
the greatest pain. How true it is that the physician often sees
cases which begin with a chill, followed shortly by a rise of tem-
perature and an increase of pulse rate, and which, with the excep-
tion of a cough, have no sign of lung involvement, except the
pain in the chest above and external to the nipple ! And yet after
two or three days typical signs of pneumonia appear. To those
who are not aware of the relationship of pain and pulmonary
disease it is surprising to find that the area of greatest pain does
not always correspond with the location of the lesion; yet, from
our previous knowledge, it is easy to explain this apparently
erratic reference.
If, on careful examination, no pleural friction rub or other
sign of pleurisy at the place where the pain is felt can be found,
how, otherwise, in the absence of other symptoms, can this chief
J
THE LUNGS
793
pain be accounted for, except under the hypothesis that through
the sympathetic stimuli are carried to the cord, and are thence
referred back to the body walls through the somatic nerves and
are there perceived as pain ?
A serous pleurisy of considerable magnitude may exist with-
out giving rise to the slightest pain. This has been exemplified
in many cases. They were all the result of chronic disorders,
VJ
*
Fig. 186; — Areas of Hyperalgesia in a Case of Diaphragmatic Pleurisy.
and were associated with a backward stasis from a failing heart.
In acute pleurisy pain is always a prominent symptom.
In inflammation of the pleura, over the diaphragm and adja-
cent to the mediastinum, the phrenic nerve may become irritated.
When this occurs the irritation is conveyed to its center ; and since,
according to Van Gehuchten, the phrenic conveys sensory fibers,
the stimulation may be felt as coming from its peripheral distri-
bution in the diaphragmatic, pericardiac, and costal pleura.
If the diaphragm alone is involved in the pleurisy the pain is
conveyed through the tenth, eleventh, and twelfth thoracic nerves,
and is referred to their area of distribution in the lower abdom-
inal wall.
11
ii
DISEASES OF THORACIC ORGANf CAUSING PAIN 795
Of these the tenth is the nerve most frequently involved. The
pain is of a characteristic dull, aching type. It may be stated as
an aphorism that as a rule only acute diseases of the limg and
pleura produce pain, and that chronic diseases are painless.
DISEASES OF THORACIC OBQANS CAUSmO PAIN
The acute diseases most commonly producing thoracic pain are :
lesions of the pleura, as acute inflammation, empyema, adhesions
(diaphragmatic, costal), and diseases of the lungs, which are:
acute bronchitis, pneumonia, and tuberculosis. Pain, as a rule,
is not a prominent symptom in the following chronic diseases:
chronic bronchitis, bronchiectasis, asthma, emphysema, chronic
tuberculosis, chronic pleurisy, hydrothorax, and new growths,
either of the lung or of the pleura.
Acute bronchitis, localized exactly in the bronchi, causes pain,
which is referred to the same somatic areas as is the pain of
parenchymatous pulmonary disease.^ But since all cases of bron-
chitis involve the trachea to a greater or less degree, the pain
is felt also in the area of distribution of the nerves supplying this
organ. These nerves are the pneumogastric with its recurrent
branches and the sympathetic. It is evidently the referred sensa-
tion from the trachea through the sympathetic to the skin of the
neck and the upper part of the chest that is the cause of the ach-
ing and soreness in these regions, complained of so much in
tracheitis and bronchitis. A pain in the lower part of the thorax,
or in the upper part of the epigastrium, is also present at times
in bronchitis. This pain is the result of the traction and pull on
the ribs and costal cartilages made by the abdominal muscles and
the diaphragm in the act of coughing. It is present only in
severer forms of bronchitis, which are accompanied by consider-
able coughing. As bronchitis is often but a localization of a gen-
eralized infection, pains due to this infection may at the same
time be present in other parts of the body. These pains are due
to the general toxemia, and are not caused by the bronchitis,
' Head gives the Becond dorsal visceral segment as related to bronchial
disease.
11. 1
5S •gS-.E
esa-S S =
" I ;s -S .=
H's. I
t-hH i -SE ■-
t.sl^l
"11]
DISEASES OF THORACIC ORGANS CAUSING PAIN 797
which, in the general involvement, is but a factor. Chronic
bronchitis is without pain-phenomena. When pain is present it
is due either to a myalgia or an intercostal neuralgia.
Pneumonia. — Pneumonia practically always is productive of
pain. Even the so-called central pneumonia causes pain. The
pain of pneumonia varies. In some cases it is an aching and a
dragging felt in the fourth dorsal visceral zone, while, in others
it extends up into the first, second, and thir4 dorsal zones. It
may also, according to Head, be found in the fifth, sixth, and
seventh dorsal zones. Owing to the co-association of these lower
cord zones with the lungs, the liver, and the stomach, lesions of
the lungs frequently give rise to hepatic and gastric symptoms,
and cause some confusion as to which of these organs is involved.
In involvement of these zones the pain is frequently felt in the epi-
gastrium or low down on the same side of the chest as the lesion.
There are also present in these zones maximal points of tender-
ness, in which pain is felt subjectively by the patient, and in
which the skin is exquisitely tender to the touch. It is in these
areas of maximum tenderness that pain is often referred in pneu-
monia. In central pneumonia these areas of pain may be the only
indications (in the early stages) of the pneumonic involvement.
Other forms of pneumonia are generally associated with a pleu-
risy, and the pleurisy generally monopolizes the pain syndrome to
such an extent that the pain of the pneumonia proper is over-
looked. When pleurisy is present tenderness may be marked over
the diseased area, so that, therefore, the associated pleurisy in
pneumonia may give rise to pain felt either locally or referred
to the abdomen (iliac region). This latter has been mistaken for
appendicitis pain. This probably occurs only when the diaphragm
is involved in the inflammatory process, in which case the twelfth
intercostal ner\^e is irritated, and the stimulus is perceived as
coming from its terminal filaments, which are distributed over
the area usually associated with appendix disease. A reference
of this kind frequently takes place in children, and when associ-
ated with abdominal rigidity, chills, elevation of temperature, and
a rapid pulse is apt to lead to the diagnosis of appendicitis. This
798 THE RESPIRATORY ORGANS
is all the more likely when, as in many cases, the signs of the
pneumonia do not appear until twenty-four to forty-eight hours
after the onset of the disease.
Janeway, Osier, Frantzel, Cozolina (492), Barnard, Hampe-
lin, Brewer, Richardson (491), Massalong (490), Lovett (494),
Ginnon (493), Comby and Zielenski (495), all report cases of this
character. Yet a mistake of this kind is almost inexcusable, for in
nearly all of these, cases, upon a thorough examination, signs of dis-
ease may be found in the thorax. In pneumonia, also, the rusty
sputum, expiratory grunt, cough, rapid respiration which is out of
all proportion to the pulse (respiration may be forty to sixty and
the pulse only a hundred to a hundred and ten), and sudden, high
elevation of temperature clearly point to the correct diagnosis.
Another diagnostic sign of value is, that, in those cases in which
the lung is diseased, there is noticed a slight reduction in the rigid-
ity of the abdominal wall at the beginning of inspiration. This is
not present in cases of abdominal inflammatory disease. The
abdominal wall in pneumonia also is sensitive to superficial pres-
sure and insensitive to deep pressure. Rings are absent from
around the eyes, and a flushing of the cheek on the affected sida
is generally seen.
In reference to the confusion of these two diseases, Rodman,
in a discussion on referred pain before the Pennsylvania State
Society, said that everyone, perhaps, has made mistakes in diag-
nosing pneumonia as appendicitis. He spoke of one case, a man
with an acute pneumonia, in whom pain in the abdomen was the
most prominent symptom. He was asked to see the case as one
of appendicitis, and concurred in the diagnosis. He was also
impressed with the fact that the man had a beginning pneumonia,
and declined to operate, believing that the patient's chances would
be best subserved by carrying him through the pneumonia and
operating for the appendicitis afterward. Another physician who
was called in did not concur in this opinion, especially as the
abdominal symptoms increased in severity, and as the pain was
very severe and did not yield to a large hypodermic injection of
DISEASES OF THORACIC ORGANS CAUSING PAIN 799
morphin. An operation was performed, and the appendix was
found to be practically normal.
A case of referred pain in pneumonia was reported to me by
McFarland. It was of a child, four years of age, in whom the
pain was over McBumey-s point. Signs of consolidation were
present at the base of the posterior part of the right lung.
In another patient, suffering from bronchopneumonia, the
pain complained of was half way between the xiphoid cartilage
and the umbilicus.
In these cases of referred pains the diagnosis is all the more
difficult should the pneumonic lesion be centric, though from the
absence of local abdominal tenderness and the freedom from
vomiting, etc., with the presence of rapid respiration, increased
pulse rate, and coughing, the lungs should be considered as at
fault, and a most searching examination made.
One differentiating characteristic between abdominal disease
and pneumonia with referred abdominal pain is that, in the pneu-
monia, the skin over the painful area is very hypersensitive, but
deep pressure can be made over it without causing much pain;
while in appendicitis both superficial and deep pressure are very
painful. Another characteristic of pneumonia is that the ab-
dominal pain disappears as the pulmonary signs become more
pronounced (Hood, Lancet, 1905).
The pain of pneumonia may also be felt in the neck and shoul-
ders. In some cases it may be transferred entirely and be felt on
the side of the chest opposite to that of the lesion. Such a trans-
ference is very common in infants. In infancy, pain is of doubt-
ful value in making a diagnosis, because of its irregular location
and frequently late appearance, for in many cases it does not
appear until from three to five days after the onset of the
disease.
In some patients the pain present during pneumonia persists
for long periods, after all the physical signs of the disease have
disappeared. This continuance in the majority of cases is due to
fibrous changes in the lung, or to adhesions. In a case of Anders,
pain in the cardiac region, persisting for four months after the
800 THE RESPIRATORY ORGANS
crisis, was shown, by the Rontgen rays, to be due to a fibrous band
stretching between the diaphragmatic pleura and the pericardiac
sac.
Tuberculosis.— In the early stages of tuberculosis, during ul-
cer formation, pain is not so likely to be present as during the
later stages, after an abscess has formed. At this later date, also,
a pleuritis is more likely to be present, especially so if the tuber-
cular lesion is in the apex. It is for this reason that pain in the
supra- and infraclavicular regions is so often an early sign of
pulmonary tuberculosis. During the second stage of tuberculosis
the whole half of the chest on the affected side has a tired, aching
feeling, not increased on deep breathing. It is during this stage,
also, that pain is often a prodrome of hemoptysis. The reason
for this may be that, prior to the hemorrhage, the lung, as the re-
sult of increased arterial tension, is in a state of congestion, and
this gives rise to pain. After the hemorrhage the congestion is
relieved and the pain disappears. Coughing, likewise, possibly
for the same reason, frequently increases the pain. The pain
most commonly associated with coughing is localized to the area
of insertion of the recti muscles into the costal borders. In some
cases of pleurisy the inflammation spreads to the intercostal
nerves and a neuritis develops; the pain is now felt over the
lateral and anterior parts of the chest. The branches joining
the nerves of the arm to the second and third intercostal ne^^^es
may also become involved, and then the pain runs do\\Ti the inner
side of the arm, in the area of distribution of the nervi intercosto-
brachiales (intercostohumeral nerves).
Character of the Pain in Pulmonary Tuberculosis. — In some
cases there may b(^ only a sense of discomfort or a feeling of dis-
tress in the chest, while in others actual pain may be present.
In many there is a sensation as though the pain extended all the
way through to the back. It may be constant or fleeting.
Tenderness is a marked feature of early pulmonary tubercu-
losis; and, according to Franeke, appears before many of the
other symptoms. Tenderness is elicited by percussion, and is mo^t
marked in the apex. It is probably due to involvement of the sub-
DISEASES OF THORACIC ORGANS CAUSING PAIN 801
jaceut pleura. This percussion pain Fraiicke found present iu
about 77.9 per cent, of all cases of pulmonary tuberculosis. When
search for this percussion is to be made high up over the back,
the anterior fibers of tlie trapezius are displaced to one side, by
i'lO. 191.— SOMB OF THE ArEAS OF PaIN AND TENDERNESS IN C'ABDIAC
AND Pulmonary Disease.
having the patient bfnil fonvard and fold his arms, so that the
[crcussion blows may be made as directly as possible over the
chest.
According to Klebs, in pulmonary tuberculosis tenderness is
very common above the clavicles, anteriorly and posteriorly, and
between the scapula posteriorly. A pain above the shoulder is
802 THE RESPIRATORY ORGANS
felt with each cough, and pain on every movement of the arm may
be present and is often mistaken for rheumatism.
Other causes of thoracic pain in pulmonary tuberculosis may
be myositis, nervous erethism, pulmonary congestion, pressure
from enlarged glands, localized fatigue of the muscles used in
respiration or in coughing, contraction of old cavities, traction by
adhesions to pleura or to the heart, pneumothorax, tuberculosis of
the ribs, and referred pain.
The intercostal muscles may also become involved in the in-
flammatory process, and intercostal myositis may develop. The
muscles are now extremely painful to touch or to movement, and,
owing to the pain, respiration is restricted.
If a pleurisy has ensued during the lung involvement, and ad-
hesions have formed between the pleura and the pericardia, pain
results. This may be felt both during respiratory movements and
cardiac contractions; in fact, it is pathognomonic of this variety
of pain that it has an alternating character, due to the variation
of pressure from the changed relationship of the heart to the sur-
rounding tissues. Pressure over the places where traction is made
upon the chest wall by the adherent pericardium and pleura is
painful.
When during tuberculosis a pneumothorax results, a sudden,
agonizing pain is felt. This may be so severe that it resists all
medication, even morphin. It is said by Clement that pronounced
neuralgia, marking the onset of tuberculosis, is a very grave
prognostic symptom. L. Brown claims that a stubborn pain, when
coincident with a poor general condition, chills, and fever, is fre-
quently an indication of a deep focus which is extending toward
the periphery of the lung.
THE MEDIA8TINXTH
The mediastinal diseases causing pain are aneurysm, medias-
tinal inflanmiation, abscess, and enlargement of the mediastinal
glands. The pain complained of is both local and referred. The
local pain is due to the pressure of the growths on the surrounding
THE MEDIASTINUM
803
structures, which, in turn, causes pressure on the anterior chest
wall and pain production. The referred pain is due to involve-
ment of the nerves in the diseased process. Pain is common in
the epigastrium, and may be present in the early stages. Pain
may also be present in the back. In one case of mediastinal sar-
coma it was present on each side of the chest over the scapulse.
In some cases of mediastinal tumors, especially in those of a ma-
lignant nature, the pain is due to an intercostal neuralgia, the
result of infiltration of the intercostal nerves by the tumor cells.
Aneurysm of the arch of the aorta, or of the thoracic aorta, causes
but few painful symptoms except those due to pressure. When
the aneurysm extends and lies just beneath the sternum, and
begins to push its way through, causing necrosis of the bone, a
boring, gnawing pain is felt. At this time marked tenderness
over the diseased area is present. The esophageal pains have
been described under the esophagus (q. v.).
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INDEX
Abdomen, divisions of, for localiza-
tion purposes, 395, 396
lesions of, causing epigastric
pain, 396, 397, 398
localizing center for pain, 307
muscular inflammation of wall of,
361
shoulder pains in lesions of, 392
use of, in estimating susceptibil-
ity of patient, 124
zones of, 395, 396
Abdominal adhesions, causes of,
368, 369
groups of, 369
Abdominal incisions, 415
Abdominal inflammation, thoracic
breathing in, 127
Abdominal pain, absence of, in
lesions of abdomen, 416
areas of tenderness with, 394
associated with arteriosclerotic
condition of arteries, 121
causes of, 307
characteristics of intestinal lesions
causing, 469
classification of, 360
concentric palpation in, 394
conditions associated with, 413
diagnosis of, 390
differential diagnosis of, 414
table of, 376, 412
distinguished from hysterical
pain, 414
due to biliary disease, 401
due to contraction and dilatation,
390
due to diaphragmatic traction,
307
Abdominal pain, due to extrav-
asations of septic material,
400
due to functional processes, 400
due to incisions, 415
due to intestines, 401
due to irritation of the sympa-
thetic fibers, 399
due to new growths, 362
due to pancreatic disease, 401
due to passive dilatation, 390
due to perforation in typhoid, 402
due to shock, 400
due to the stomach, 401
due to traction on the mesentery,
390
effect of, on diaphragm, 394
epigastric, 396
examination for, 394
forms of, 408
functional, 409
gastralgia, 409
hysterical, 360
in bowels, 372
in cysts, 399
in hernia, 371
indicanuria with, 414
intestinal lesions suggested by,
470
lesions causing, 408, 409
localization of, 394
organ producing, 395
muscular layer of wall as seat of
(McKenzie), 360
myalgia, 362
nature of, 390
neuralgia, 361, 409
neuritis of intercostal nerves, 362
869
870
INDEX
Abdominal pain, objective, 360
of the peritoneum, 362
of pneumoniay 392
organs causing, 408
points of reference of, 391
polyuria with, 414
post-operative, 415
posture in diagnosis of, 406
presence of, in neurasthenics, 409,
416
pressure in, 406, 407
referred, 307, 391, 392
to extra-abdominal regions, 416
reflected, 391, 392
regional, 393
relationship of, to defecation,
401
to ingestion of food, 400, 401
to menstruation, 401
rigidity of muscles with, 413
skin as seat of, 360
spasm of muscles with, 413
subjective, 360
sympathetic, 393
tenderness, maximmn points of,
393
toxemia with, 414
transferred, 392
transmission of, in the peri-
toneum (Lennander), 363
visceromuscular reflex with (Mac-
kenzie), 413
Abdominal protective position, 126
Abdominal tenderness, 403
causes of, 404
indications of, 404
in tubal disease, 720
means of determining : percussion,
404
palpation, 405
Abdominal visceral disease, pain
perception in, 377
Abscess, "closed" extradural, 338
extradural. See Extradural ab-
scess.
gas, 338
Abscess, hepatic, 553
in areola, from fissured nipple,
258
ischiorectal, 509
of the brain. See Brain abscess,
of the hip joint, intraarticular,
244
of mastoid process, 336
of the ovary, 751
of the spleen, 601
"open" extradural, 338
perianal, 512
perisinus, 338
peritonsillar, 340, 351
retropharyngeal, 352
Adenoid vegetation of nose, 343
Adenolipomatosis, symmetrical, 224
Adhesions, abdominal, causes of,
368, 369
groups of, 369
after intussusception, 498
appendicial, 519
epigastric pains from, 3d8
from tubal inflammation, 746
gastric, 369
hepatic, 553
intestinal, 370
distention due to, 492
of the bladder, 684
of the gall bladder, 563
of the omentum, 368
of the ovary, 752, 754
pelvic, 370
point of tenderness in, 405
perigastric, 459
perihepatitis causing, 560
peritoneal, 371
increased pain by tension, 368
nature of pain from, 367, 368
visceral, absence of pain in, 368
Adiposa dolorosa, associated condi-
tions of, 225
differentiated, from other forms
of adiposity, 224
from sciatica, 168, 169
fatty areas of, 224
INDEX
871
A d i p o s a dolorosa, hypophyseal
symptoms, 225
pain as a feature of, 224
Adiposis cerebralis (of Frohlich),
224
Adiposity, forms of, 224
tuberosa (of Anders), 224
Aditus larjmgis, tuberculous affec-
tions of, 354
Adrenals, hemorrhage as cause of
pain in, 259
Akinesia algera, 219
Alcohol, neuralgia due to, 142
Algometers, 68
in measuring pain, 130, 131
Alimentary tract, pains of, 418
referred pains in, 425
Alkalies, uses of, 119
Amblyopia, concentric contraction
of visual field from, 135
Amputated limb, imagined sensa-
tions in, 104
projection pain in, 103
visualization of, 103
Anal fissure, 510
acute pains of, 511
description of pain in, 511
reflex pains of, 512
Anemia, back pains due to, 304
chronic, of the brain, 181
pernicious. See Pernicious
anemia.
Analgesia, 61, 62, 63
area of distribution in a hysteri-
cal subject, 78
central, 61
endogenous, 61
exogenous, 61, 63
extrinsic, 63
peripheral, 61
toxic, 62
tabes producing, 66
voluntary, 62, 63
Anemic headaches, 272
Anesthesia, 61, 63
by freezing, 66
Anesthesia, by interference with
pain perception areas, 64
by ischemia, 66
by pressure, 64
cord tumor accompanied by, 65
dissociation of pain and touch
under incomplete, 34
electric current causing, 65
lesions within nerves producing,
66
of hysteria, 76, 77
of leg, by skull fracture, 64
paresis causing, 65
peripheral causes of, 65
pressure in nerve sheath produc-
ing, 66
on a nerve trunk producing, 66
reflex protective action in, 122
severance of nerve pathways pro-
ducing, 65
severance of posterior roots pro-
ducing, 66
syringomyelia causing, 66
transverse myelitis causing, 66
Anesthesia dolorosa, 66
in neuralgia, 144
Aneurysm, importance of pain as
a symptom in, 255
neuralgia from, 142
of arch of aorta, 803
of the arteries, 254
of the brain arteries, 187
pressure indicating, 127
Angina pectoris, associated symp-
toms of, 787
character of pain in, 784
distinguished from gastric ulcer,
451
etiology of, 783
local tenderness in, 787
location of pain in, 785
similarity of, to aortitis, 250
sympathetic pain due to, 103
Animals, sensation in the lower
forms of, 1, 2, 3, 4
Anus, pain in, 509
872
INDEX
Anus, pain in disease of, from def- ^
ecation, 117
Aorta, arteriosclerosis of, 251
inflammation of, 250
Aortitis, description of pain of, 250
time of onset of, 251
Aphasia, from tumors of the fron-
tal lobe, 184
Appearance of patient as means of
measuring intensity of pain,
120, 125
Appendicial disease, ingestion of
food in, 116
pain from defecation in, 118
transferred pain in, 107
Appendicial inflammation, aberrant
pains with, 527
Appendicial pain, distant, 519
due to adhesions, 519
due to inflammation, 517
due to obstruction, 517
left-sided, 527
local, 516, 517
referred, 516, 519
reflex, 517, 521
transferred, 516, 520
varieties of, 516
Appendicitis, colon involvement
with, 527
constipation with, 535
differential diagnosis of, 537, 538, .
539
increase in sensibility to pressure
in, 536
induction of pain by peristalsis,
537
interference with motion in, 535
jarring pain from, 536
nocturnal pains of. 111
pain from motion in, 117
pain induced by peristalsis in,
537
pain production in, symptoms as-
sociated with, 535
posture assumed in, 536
pressure on the abdomen in, 536
Appendicitis, rigidity of the rigbt
rectus with, 535
sympathetic pains with, 527
symptoms associated with pain
production in, 535
tenderness in, absence of, as a
symptom, 531
as a symptom, 529, 530
locations of, 533
points of, 534
varieties of, 532
Appendix, adhesions of, 519
description of, 514
diffuse pain in, 515
epigastric pain from lesions of,
397
hyperalgesia in, area of, 527
indications of, 525
hyperesthesia in, pointing to in-
flammation of, 524
inflammation of, 517
without symptoms, 516
obstruction in, causes of, 517
pain in, 514
vermiform, diseases of, 529
Apraxia, 185
Areas, cutaneous, relating to spinal
cord segments, 56
indefinite, of pain, 48
of distribution, of hysterical pain,
78, 79
of lumbar segments, diagram
of, 57
of nerves from lumbar plexus,
52
of nerves from sacral plexus, 53
of sacral and lumbar segments,
diagram of, 57
of SMisory fibers, 51
of sensory fibers in posterior
root, 51, 54
of hyperalgesia, 69, 70
of maximum tendeme^ and eord
zones, 59
of pain perception, interfereoee
with, 64
INDEX
873
Areas of peripheral sensory fibers,
50, 51
of sensory nerves, 47, 48
of tenderness, 72
surface, relating to visceral dis-
ease, 4, 5
Arsenic, neuralgia due to, 142
terminal anesthesia by, 67
Arterial congestion, 273
Arterial pressure, increase of, caus-
ing headache, 272
Arterial system, functional activity
of, causing pain, 249
Arteries, aneurysm of the, 254
diseases of, causing pain, 249
Arteries, inflammation of, 250
mesenteric, embolism of, 253, 254
thrombosis of, 253, 254
thrombosis or obliteration of, 248
Arthralgia. See Joint pains.
Arthritis, gonorrheal, 238
symptoms of, 235
Arthrotomy, in intra-articular hip
joint abscess, 245
Ascending path of sensory fibers, 45
Aspect theory of pleasure and pain,
18
Associated pains, 90
crossing of fibers in, 92
diffusion of stimuli in, 92
examples of, 92
hypochondriasis not manifested
by, 93
hysteria not manifested by, 93
in neuralgia, 146
physiological relationship between
areas of, 94
relation between irritated and
sympathetic points, 93, 94
Asthenopic disorders, 330
Astigmatism, 330
Atrophy, of liver, acute yellow, 561
of muscles, in neuralgia, 146
resulting from pain, 135
Auditory canal, external, pain in,
333
Autonomic sympathetic nervous
system, 12
Autosuggestion, 116
Autosuggestive sensations, 75
Autotoxic substances causing neu-
ralgia, 141
B
Bacillus pyocyaneus, 333
Back, localizing center for pain in,
296
Back pains, due to heart and aorta
affections, 301
due to hysteria, 304
due to intestines, 302
due to kidneys, 302
due to liver and gall bladder,
302
due to lung affections, 300
due to menstruation, 303
due to pregnancy, 303
due to spinal cord lesions, 207
due to static foot errors, 304
due to stomach affections, 301
due to uterine disorders, 726
due to visceral lesions, 208
in anemia, 304
indications from, in different re-
gions, 312, 313, 314, 315
muscular, 296
in myalgia, 297
of chlorosis, 304
over the coccyx, 300
referred, 300
from genito-urinary organs, 304
from ovary, 303
from pancreas, 303
from spleen, 303
from uterus, 303, 304
rheumatic, 296
vertebral, 299
Bacteria, productive of muscular
pain, 218
Belladonna, terminal anesthesia by,
67
874
INDEX
Bile duct, twist of, from liver dis-
placement, 559
Biliary cirrhosis, 554
Biliary colic, ingestion of food and
drink, effect of, case cited,
574, 575
Biliary passages, cancer of, 577
Bladder, adhesions encompassing,
684
anatomy of, 672
cord zones in relation with, 674
diseases of, causing pain, 676
distention of, 684
foreign bodies in, 691
general considerations of, 672
inflammation of. See Cystitis.
nerve supply to, 672
rupture of, 685
tuberculosis of, 690
tumors of, 689
Bladder disease, associated symp-
toms of, 682
differential diagnosis of, 683
tenderness in, 681
Bladder lesions, differential diag-
nosis of, 686
Bladder pains, causes of, 676
character of, 678
cold air, effect of, on, 681
diseases causing, 683
drugs, effect of, on, 681
food and drink, in relation to, 681
location of, 678
position of patient in, 680
production of factors influencing,
681
reference areas of, 675
reflected, 679
time of attacks of, 680
urinary, relation to motion of,
681
Bladder tuberculosis, associated
symptoms of, 691
causes of pain in, 690
character of pain in, 690
location of pain in, 691
Bladder tuberculosis, prodoetioD of
pain in, factors influencing,
691
time of pain in, 691
Blood, changes in, causing pain, 247
decreased alkalinity of, causative
factor of pain, 28
diminution of supply of, causing
pain, 248
diseases of, 248, 249
increased supply oi^ causing pain,
247
Raynaud's disease of, 248
Blood pressure, elevation of, in
labor, 121
in measuring intensity of pain,
120
hyperemia consequent upon varia-
tions in, 62
increase of, 251
sudden alterations of, eaosing
pain, 26
Blood supply, determining suaeepti-
bility of an organ to pain,
113
Blushing, 124
Bones, cause of pain fnun motion
of, 117
changes in structure of, 231
freedom from pain in, 113
lesions of, differentiated from in-
durative headache, 267
from those of the oveiiying
structure, 226
Bone pains, character of, 228
continuous, 227
diagnostic value of diurnal varia-
tion in, 228
differential diagnosis of, from
bursitis, 233
from hysteria, 234
from neurotic ostalgias, 233
general considerations of, 226
generalized, 232
in carcinoma, 233
in chloronui, 233
INDEX
876
Bone pains, in hematopoietic system
lesions, 233
in leontiasis ossea^ 233
in lymphadenoma ossium, 233
in myeloma, 233
in osteitis deformans, 233
in sarcoma, 233
in spurs, 233
localized, 228
in contusions, 230
in fracture, 229, 230
in new growths, 230
in periosteal lesions, 229
in traumatism, 229
pressure, intermittent, 227
septic involvement in, 231
spontaneous, intermittent, 227
syphilitic, dull aching character
of, 228
nocturnal aggravation of, 228
tuberculous nocturnal aggravation
of, 228
types of, 227
Bony processes, neuralgia from,
142
Bowel, colic of, gas with, 486
distention of, 491
inflammation of, 484
involvement of adjacent struc-
tures in, 486
peristalsis with, 486
symptoms of, 486
tenderness with, 486
obstruction of, absence of pain
in, 495
causes of, 492, 495
pain of, areas of tenderness in,
372
distinguished from hernia, 372
due to distention by gas, 373
Brachial neuralgia, 147, 150
associated symptoms, 161
bilateral pain in, 155
brachial plexus as seat of, 150,
151
character of pain of, 159
Brachial neuralgia, differential diag-
nosis of, 155, 158
table of, 162, 163
distribution areas of, 151, 152,
153
localization of, 158
location of pain in, 159, 160
tenderness in, 161
unilateral pain in, 155
Brachial plexus, area of distribution
of, nerves derived from, 152
description of, 150, 151
distribution areas of cords com-
posing, 155
of cutaneous nerves of upper
limbs, 154
neuralgia from lesions in, 150,
151
Brachialgia, brachial neuralgia, 159
Brain, abscess of, as caase of head-
ache, 271
differential diagnosis of, 195,
196
headache and other symptoms
of, 181, 182, 190, 191
origin of, 181
aneurysm of arteries of, 187
hemorrhages, differential diag-
nosis of, 196
pain in legs as forerunner of,
305
hyperemia of, 181
metabolism, disturbance of, in
hysteria, 77
pain in diseases of, 140
parasites of, 187
syphilis of, 188
substance, diseases of, imaccom-
panied by headaches, 178
headaches originating in, 176,
177, 178, 179
syphilis of, differential diagnosis
of, 196
tumor of, causing headache by in-
tracranial pressure, 270
diagnostic symptoms of, 270
876
INDEX
Brain, differential diagnosis of, 195,
197
headache and other symptoms
of, 182, 190, 191
tumors of the base of, 186
Break-bone fever, backache with,
298
Breast, carcinoma of, 259
diseases of, table of, 260
pains, correlation through nervous
system with uterus of, 715
pains in, 258
Bright's disease, ulceration accom-
panying, 509
Bronchitis, acute, 795
Bums, ulcers following, 489
Bursitis, distinguished from bone
pains, 233
Calculus, progress of descent of,
610
Calculus pain, character of, 658
etiology of, 655
location of, 659
Cancer, of the biliary passages, 577
of the pancreas, 491
of tl>e stomach, 452, 453, 454, 455
of the uterus, 744
of the vulva, 756
Carbolic acid, terminal anesthesia
by, 67
Carcinoma, effect of ingestion of
food in, 116
of the bones, 233
of the breast, 259
of the gall bladder, 57
of the larynx, 358
of the rectum, 507
of the stomach, 455
Cardiac disease, differential diag-
nosis between intercostal neu-
ralgia and, 781
Cardiac pain, degeneration of car-
diac ganglia as cause of, 782 i
Cardiac pain, mitral regui^tatioD
as cause of, 782
raising of intraventricolar ten-
sion as cause of, 782
origin of, cardiac, 782
gastric, 782
Cardiospasm, 436
cause of pain in, 437, 438
character of pain in, 438
contraction in, 437, 438
tension pains of, 437
Caries of the vertebral canal, 210,
211
differential diagnosis of, from
neurasthenia and hysteria,
210
Catarrh, of middle ear, 339
Catarrhal ulceration of the intes-
tines, 489
Cartilage, lack of pain in, 113
Caudal lesions, 209
Cell areas, superim position of, for
motion and sensation, 10
Centers of memory, for pain, 24,
25
Centers of motion, 173
of perception, for pleasure and
pain, 21, 22, 23
of sensation, 173
of the senses, 173
Central ganglion, tumors of, 185
Central nervous system, 172
anatomy of, 173
back pains connected with, 208
courses of fibers of, 174
diseases of, 179
origin of headache, 175
thalamic pains of, 198
tumors of, 183
Ceptors, noci-, 29
nocuous. See Noci.
Cerebellar abscess, 339
Cerebellar ataxia, symptoms of, 185
Cerebellum, as a sensory organ, 11,
12
tumors of, 185
DTOEX
877
Cerebral arteriosclerosis, headache
as symptom of, 274
Cerebral congestion, as canse of
headache, 272
brain fluid increased by, 272
due to increased arterial pres-
sure, 272
predisposing factors to, 273
Cerebral hemorrhage, differential
diagnosis of, 198
Cerebral tumor, as a cause of head-
ache, 269
Cerebrospinal fibers, of the abdom-
inal viscera, 378
Cerebrospinal fluid, increase of,
causing headache, 276
Cerebrospinal system, development
of, 32
Cervical lesions, 209
Cervical stenosis, dysmenorrhea
from, 729
Cervicitis, 742
Cervix, spasmodic contraction of,
730
ulceration of, 743
Cervix uteri, sensibility of, 709
Cheeks, pain in, 418
Chemical action, as stimulus of sen-
sation, 5, 6
Chemical changes, pain due to, 27
Chemical irritations, parenchyma-
tous pains from, 88
Chemotropism, 1
Chest, localizing center for pain,
310
pain in. See Chest pain,
thoracic walls of, 760
Chest pam, causes of, 310, 760, 767
diagnostic points on, 768
from diseased lung, 767
from stomach distention, 766
Chest wall, localization of pain in,
767
Childbirth, normal, 738
Chloral, effect on blood pressure ele-
vation, 120
Chloroma, 233
Chlorosis, back pains of, 304
symptoms of, 181
Choked disc. See Papilledema.
Cholangitis, 572
catarrhal, 577
suppurative, 577
Cholecystitis, 569
accompanying gallstone, 576
distingfuished from gastric ulcer,
450
Choroid, pain in, 328
Cicatrices, neuralgia from, 142
Ciliary body, pain in, 325, 326
Ciona intestinalis, 2
Circulation, affection of, by pain,
134
Circulatory system: arteries, 249
blood supply, 247
veins, 255
Circumflex neuralgia, 147, 164
causes of, 164
distinguished from rheumatism of
shoulder joint, 164
Cirrhosis, biliary, 554
of the liver, 552, 554, 556
chronic atrophic, 561
Claudication, intermittent, 251
Clavicular pains, 310
in extrauterine pregnancy, 392
Cocain, effects of, 119
terminal anesthesia by, 67
use of, 106
Coitus, pain in, 717, 756
Cold, causing pain, 28
neuralgic pain from exposure to,
142
physical factor of pain, 118
"Colds," productive of muscular
pain, 218
CoHc, 436
associated with uremia, 484
causes of, 223, 481
constant pain in, 483
: due to contraction, 223
I due to overdistention, 223
878
INDEX
Colic^ due to pressure, 223
due to tension, 223
due to traction, 223
hypotheses of cause of, 482
intensity of, 483
intermittent pain in, 483
intestinal, differential diagnosis
of, 484, 485
due to plumbism, 484
without bowel lesion, 484
location of pain in, 482
morphin in, 125
muscular movement in, 125, 126
nocturnal pains of, 111
onset of, 482
pain of, 388
posture in, 126
pressure in, 126
type of pain in, 483
variations of, 222
Colitis, chronic, 502
mucous, 503
ulcerative, 501
Colon, displacement of, 503
distention of, 504
infective states of, 501
inflammation of, 501
spasm of, 502
tumor formation due to displace-
ment of, 505
Colon spasm, description of, 479
Colonic disease, effect of ingestion
of food in, 116
Colonic involvement, in intestinal
pain, 500
Concentric palpation, 394
Conducting apparatus for pain, 29
Conducting fibers, pressure on, 29
Congestion, arterial, 273
causing affections of nerve trunks,
140
cerebral, as cause of headache, 272
Conjunctiva, discomfort from tear
secretions in irritations of,
324
foreign bodies in, 324
Conjunctiva, pain in, 322
Conjunctivitis, severity of pain in,
323
stretching of the lid in, 324
Consciousness, 4
classes of, 5
loss of, in anesthesia, 63
from emotion, 133
from pain, 132
modifying pain production, 115
objective, 5
obtunded, 63
senses in relation to, 5
subjective, 5
Constipation, colicky pains due to,
509
neuralgic pain due to, 509
Contact, dependence of sensation
on, 6
Contraction, of a hollow organ,
25
Contrary innervation, law of (Melt-
zer), 388
Contusions of bones, 230
Conveying channels for sensations,
35
deep, 37, 38
epicritic, 37, 38
protopathic, 37, 38
superficial, 37
Convolutions, of sensory area, 10
Copper, as cause of neuralgia, 142
Cord, pain in diseases of, 140
Cord twnors, 95
causing anesthesia, 65
Cord zones, areas of mazimnm ten-
derness of, diagram of^ 59
diagram of, 55
Cornea, erosions of, 324
foreign bodies in, 324
pain in, 322
perforation of, 325
sensibility to light in lesions of,
323
tear secretions from irritation of,
324
INDEX
879
Corneal herpes, 325
Corneal toxemia, 325
Corneal ulcers, 325
Corpora quadrigemina, tumors of,
185
Corpus callosum, tumors of, 184
Cortex, absence of central objective
pain in, 82
differential dia^osis between dis-
eases of the thalamus and,
203, 204, 205, 206
interrelations between the thala-
mus and, 200
Cortical lesions, unproductive of
pain, 82
Cortical tissues, pain receptors lack-
ing in, 82
Cowper's glands, inflammation of,
703
Cutaneous areas, relating to spinal
cord segments, diagram of,
56
Cutaneous distribution of nerves,
diagram of, 56
Cutaneous hyperalgesia, relating
to areas of visceral disease,
54
Cutaneous sensory nerve supply,
diagram of, 49
Cystalgia, 683
Cystic disease, of the kidney, 645
of the pancreas, 491
Cysticercus cerebri, 187
Cystitis, 685
associated symptoms of, 689
attacks of pain in, factors in-
fluencing, 688
character of pain of, 685
location of pain of, 687
referred pain of, 687
tenderness in, 688
Cysts, abdominal, 399
of the breast, 259
of the liver, 555
of the spleen, 602
ovarian, 399, 753
Defecation, physical factor of pain
in, 117
Deflected pain. See Reflected, 104.
Delayed pains, 34, 111
Delirium tremens, differential diag-
. nosis of, 197
Deranged metabolism, causing neu-
ralgia, 141
in influenza, 141
in senility, 141
Deterioration, physical, causes of,
134
Diagnosis, care in, 410
errors in, 410, 411, 413
intensity of pain a factor in, 114,
120
manual reproduction of pain in
an organ in forming a, 132
sensory examination in forming
a, 132
Diaphragm, crippling of, from ab-
dominal pains, 394
pull on, from liver displacement,
558
Diarrhea, with intestinal pain, 475
Digestion, physical factor of pain
in, 116
Dilatation of pupils, by pain, 73
causes of, 125
drugs causing, 125
means of measuring pain inten-
sity, 120, 125
Dilatation of the stomach, acute, 439
from pyloric spasm, 438
Diphtheria, pains of, 352
Displaced kidney. See Movable
kidney.
Displacement, of the ovary, 749
of uterus, 726
Dissociation of pain and touch, 32,
33,34
Distention, in intussusception, 498
of the bladder, 684
of the bowel, 491
INDEX
Emotions, modifying pain produc-
EInterospt
tion, 115
wit
phenomena accompanying, 132,
Eosinophj
133
aci
physical results of, 30
Epicritic
Empyema, acute, diagnosis of, 348
Epicritic
diseases in body related to, 344
of Hea
headaches arising in, 343
Epididym
treatment of, 348, 349
Epigastric
Encephalitis, from electric current,
distingi
65
45(
Encephalitis hsBmorrhagica, differ-
Epigastric
ential diagnosis of, 196
lesions
Endarteritis obliterans. See Inter-
organs
mittent claudication, 248.
suspect'
Endocarditis, differentiation between
39J
acute and chronic and re-
Epigastri
curring, 780
in.
Endogenous analgesia, 61
organs
Endometritis, 730
Epiphyse
character of pain in, 741
liff
diagnosis of, 742
Equilibrii
dolorosa, 731
Erythrom
involvement of adjacent structures
Esophagu
in, 741
foe
tenderness, demonstrated by a
hyperes
sound, 741
localiza
Endometrium, fissured state of, 734
obstruc
sensibility of, 709
pain in
Endonasal operation for neuralgia.
paresth
350
Esthesion
Endonasal therapy, uses of, 342
Ether, eff
Endurance, complaints of patients
Evolution
compared with, 120, 123, 124
to
Enlarged uterus, neuralgia from.
Exogenou
142
Exposure
Enteralgia, 476
frc
mistaken diagnoses of, 476
External
Enteroptosis, effect of constipation
External
in, 118
Extracrar
Enterospasm, 478
Extradurj
causes of, 480
difl
mistaken diagnosis of, for peri-
Extrahep;
tonitis, 480
Extraneu:
primary pain of, 478
141
secondary pain of, 479
Extrapar«
882
INDEX
Extrauterine pregnancy, differential
diagnosis of, 747
pain in, 746
Extrinsic analgesia, 63
Extrinsic factors modifying pain
production, 116, 118
Extroceptor sense organs, 12
Eye, action of stimuli on retina of,
316
asthenopic disorders of, 330
astigmatism of, 330
consciousness of normal retinal
stimuli of, 316
diurnal pain of, 110
fifth nerve the seat of sensation
in, 317
intensity of pain in, 316
lacrimation, 317
normal retinal stimuli to, 316
painful stimuli to, 316
pain in, diagnosis based on locali-
zation of, 318
duration of, 317
etiology of, 317
in the choroid, 328
in the ciliary body, 325
in the conjunctiva and cornea,
322
in the iris, 325
in the lids, 318
in the optic nerve, 328
in the retina, 328
in sclerotic coat, 327
in surroundings, 322
localization of, 318
quality of, 316, 317
phthisis of, 328
reflex phenomena connected with,
318
sensations of, disagreeable and
painful, 316
significance of pain in diseases
of, 316, 318
tender pressure points of, 322
topography of, 317
trigeminus irritation of, 317
Eye, various painful disturbances
of (Bielschowsky), 331
Eyelids, as source of pain, 318
diagnostic value of pain localiza-
tion in, 319
herpes zoster of, 319, 320
inflammation of, 318
neuralgia of, 320
Eye muscle, rheumatism of, 328
"Eye-strain," 331
F
Facial expression indicating pain,
127
Facies, Hippocratic, 127
of peritonitis, 127
simulation of, 128
Factors modifying pain production,
115
Fallopian tubes, acute hyperemia
of, 745
inflammation of. See Tubal in-
flammation,
nerve supply to, 707
pain due to disease of, 744
tubal conditions causing pain in,
744
Fatty tissues, adiposa dolorosa, 224
pain in, 224
Fear, vasomotor collapse from,
133
Febrile herpes, of the cornea, 320
of the pharynx, 352
"Female complaint," 712
Femoral hernia, 375
Fetus, external senses in, 12
Fibers, motor, 174
sensory conducting, 174
Fibroids, of the uterus, 744
Fissure, of the lips, 418
of the nipple, 259
of the tongue, 421
Fitz's rule in pancreatitis, 488
Flat-foot, radiated pain of, to knee,
305
INDEX
883
Flat-foot disease, neuralgia (Mor-
ton's) in, 169
Focal symptoms of the motor re-
gion, 183
Folliculitis, pain caused by, 342
Foreign bodies, in the ear, 334
neuralgia from, 142
sensation of, in pharynx with
carcinoma of base of tongue,
365
Fracture, 229
elicitation of pain in, 230
of the thorax, 764
Freezing, anesthesia by, 66
Frontal lobe, tumors of, 184
Functional pains, abdominal, 409
Furunculosis, causes of, 333
manifestations of, 334
O
Gall-bladder, adhesions of, 563
back pains referred from, 302
colic of, 562, 568
carcinoma of, 571
defecation in disease of, 118
infection of, 563
inflammation of, 563
ingestion of food in disease of,
116
location of pain and tenderness
in disease of, 72
new growths of, 571
non-malignant growths of, 572
overdistention of, 562
sarcoma of, 571
Gall-bladder colic, causes of, 548
distinguished from gall-duct, 578
hysteria distinguished from, 572
Gall - bladder disease, associated
pains of, 566
etiology of, 562
Gall-bladder pain, diagnosis of, 563
differential diagnosis of, 564, 567
diseases oausingi 568
Gall-bladder pain, ingestion of food
causing, 546
radiation of, 566
referred, 567
reflex tenderness with, 567
tenderness in, 563
Gall-bladder and ducts, epigastric
pains from lesions of, 397
Gall-duct colic, associated symptoms
of, 576
Gall-duct pain, character of, 573
classification of, 573
etiology of, 572
location of, 573
paroxysms of, 573
Gall-ducts, obstruction in, 572
Gall-stone colic, 575
differential diagnosis of, 577, 579
Gall-stone pain, 549
Gall-stones, 568
cholecystitis accompanying, 576
nocturnal pains of. 111
persistence of pain after removal
of, 142
Galvanic current, effect of, in neu-
ralgia, 145
Gkmgrene of the viscera, 417
Gas abscess, 338
Gasserian ganglion, neuralgia from
lesions in, 148, 149
Gastralgia, 431
abdominal pains of, 409
description of, 432
nervous, distinguished from ulcer
and cancer, 452, 453, 454,
455
Gastric adhesions, diagnosis of, by
pressure, 369
Gastric area, reflexes felt as pain in,
433
Gastric carcinoma, causes of pain
in, 457
infection in, effect of, 456
local disease with, 458
location of, 456
lymphangitis with, 458
OflBtric cardiioma, posture of pa-
tient in production of pain
in, 456
symptoms of, 455
Oastric erosions, 442
Qastrio mucosa, excess of acids on,
effect of, 435
Gastric pains, appearance of, 430
associated symptoms of, 431
character of, 429
confused diagnoses of, due to re-
fleses, 434
distinction between gastric and
nervous origin of, 433
duration of, 430
ingestion of food in, 430
Oaslric uteer, relative position of
pain to site of, 442
tenderness elicited on palpaticai
in, 445
tenderness of, 445
time of onset of, 444
Oaatritis, acute, 440
character of, 441
subjective pain of, 440
chronic, 442
Qastro-intestioal tract, pains of.
diurnal, 110
Qastromyalgia, 431, 432
predisposing causes <
acting as, 433
symptoms of, 432
INDEX
885
Glaucoma, acute, 329
primary and secondary, 327
source of pain in, 318
system of secondary, 325, 326
Globes, sunken, 329
Glossitis, 422
Glossodynia, classification of, 422
Gonococcus infection of shoulder
joint, 304
Gonorrheal arthritis, 238
Gout, nocturnal pain of, 110
Gouty hip joint, distinguished from
sciatica, 245
Gray matter cells, nerve fibers aris-
ing in^ 42
Groin, incidents of pain in, from
above and below, 96
Growing joints, symptoms of, 241
Growing-out pains of children, 229
Gummata of the rectum, 507
Gummatous masses, similarity of,
to tumors, 212
Habit headache, 289
"Habit pains," 80, 142
Hair, effect on, of neuralgia, 146
excessive weight of, as cause of
headache, 265
lack of pain in, 113
Happiness, phenomena resulting
from, 133
Head, hyperalgesic zones of, 290
localizing center for pain, 262
overwork on, effect of, 265
pain areas in, table of, 263
referred pains in, 264
sense of pain in, 264
sense of pressure in, 264
Headache, absence of, in diseases of
the brain substance, 178
associated with, aneurysm of the
brain arteries, 187
brain abscess, 181, 190, 191
brain tumor, 182, 190, 191
Headache, associated with, chlorosis,
181
chronic anemia of the brain,
181
diseases in general, 177
hydrocephalus intemus, 187
hyperemia of the brain, 181
hysteria, 188, 190
leptomeningitis purulenta, 180,
190, 191
leukemia, 181
neurasthenia, 189, 190
pachymeningitis interna hiemor-
rhagica, 179, 180
parasites of the brain, 187
pernicious anemia, 181
syphilis of the brain, 188, 190
tuberculous meningitis, 180
tumors, 183, 184, 185, 186
diagnosis of, 265
constancy of intermittent (peri-
odic), 286
in brain and meningeal disease,
190
of recent origin: infectious
disease, 281
intracranial lesions, 282
toxemia, 282
traumatism, 282
of remote origin: alimentarv
tract, 284
anemia, 285
brain tumors and abscesses,
284
cerebral arteritis, 285
ears, 284
eyes, 282
kidney lesions, 284
nose, 283
psychical strain, 285
sinus disease (accessory
nasal), 284
diagnostic value of, as a symp-
tom, 177, 178
differential diagnosis of, in brain
and meningeal disease, 195
886
INDEX
Headache, due to brain substance
affections, 176
due to diseases of the brain and
meninges, 192
due to empyema of the sinuses,
343, 344
due to hypertrophy of piiddle tur-
binate of nose, 349
due to irritation of organs of spe-
cial sense, 277
due to nasal stenosis, 342
due to nasal tumors^ 347
due to obstructed sinuses, 345
due to sphenopalatine diseases,
345
due to visceral disease, 176
external influences of, in diseases
of the brain and meninges,
193, 194
frontal, 192
hemicranic, 189, 190, 191
indurative, 265
intensity of pain of, in diseases
of the brain and meninges, 190
localization of pain of, in dis-
eases of the brain and men-
inges, 192
lymphatic, 290
origin of, 175, 176
postures assumed by patients suf-
fering from, 290
tension of pain of, in diseases of
brain and meninges, 192
therapy for, 194
toxemic, 271
unilateral, 192
Head pain, causes of, 265
due to the alimentary tract, 284
due to anemia, 272, 285
due to brain tumors and abscesses,
270, 271, 284
due to cerebral arteritis, 285
due to cerebral congestion, 272
due to cerebrospinal fluid in-
crease, 276
due to the ears, 284
I
Head pain, due to the eyes, 283
due to hyper blood-tension, 273,
274
due to increased venous pressure,
274
due to induration of muscles,
265
due to kidney lesions, 284
due to meningitis, acute, 271
due to metabolism, 268
due to muscle lesions, 265
due to nasal conditions, 283
due to nerve involvement, 268
due to neuralgia, 268, 278
due to neuritis, 268
due to pachymeningitis, 271
due to psychical strain, 285
due to sinus (accessory nasal)
disease, 284
due to skin lesions, 265
due to toxic irritation of the
cerebral cortex, 279
headache, 265
meningeal changes as a cause of,
functional, 269
organic, 271
origin of, extracranial, 265
intracranial, 269
projected, 268
referred, 269
referred from the viscera, 290,
291, 292, 293, 294, 295
reflex, 269, 277
rheumatic, 279, 280
toxemic, 271
Hearing, protective reflex action of.
123
Heart, back pains due to affections
of, 301
dilatation of, 781
nerve supply to, 774
Heartburn, 435
Heart disease, diagnosis of, bj
means of location of referred
pain, 774
general considerationfi of, 773
INDEX
Heart disease, hyperalgesia, impor-
tance of, as a symptom, 780
hyperalgesic zones in, location of,
777, 778
prominence of, 776
pain in, 775
referred pain in, 775
Heart pain, intracardiac lesions as
causes of, 782
Heat, physical factor of pain, 28,
118
Heel pains, 306
Hematoma of the dura mater. See
Pachymeningitis interna
hsBmorrhagica, 179
Hematomyelia, 210
Hematuric nephralgia, 629
Hemianesthesia, 184, 185
impairment of senses accompany-
ing, 135
transference of, in hysteria from
one side of body to other, 77
Hemianopsia, 184
Hemichorea, 185
Hemicrania, eye pain from, 321
Hemicranic headache, 189, 190,
191
Hemiplegia, 184, 185
Hemopoitic system, lesions of, 233
Hemorrhage, in the adrenals, 259
of the brain. See Brain hemor-
rhage,
cerebral. See Cerebral hemor-
rhage,
easing of pain by, 26.
into the meninges, differential
diagnosis of, 196
pain from, in body cavities, 26
in body tissues, 25, 26
of the peritoneum, 367
of spinal cord, 209, 210
Hepatic artery, twist of, from liver
displacement, 559
Hepatic congestion, 551
associated symptoms of, 552
Hepatitis, acute, 557
Hepatoptoi
deseripti
posture :
hereditai
Hernias, b
causes o:
chronic <
diagnosti
distingui
372
epigastri
femoral,
increased
inguinal,
mesenter
prod
nature oi
neuralgis
obstructi'
of the o\
omental,
pain as i
peritonea
pressure
372
stranguls
umbilical
Herpes, ac
ralg]
corneal,
febrile, o
of the
neuralgic
of ear di
of the lij
of the p
of the t<
Herpes cor
Herpes lar
Herpes zos
character
distinguii
neur
of the th
pharyngc
Heterosugg
Heterotoxic substances, catuiag nen-
ralgia, 141
Hilton's law, 220
Hip joint, ankylosis of, 244
gouty deposits in, 245
Hip joint abscess (intra-articnlar),
tension pains of, 244
Hip joint affections, rbeumatism,
305
tuberculous, 305
Hip joint disease, distinguished
from sciatica, 168
Hip joint pains, 240
functional, 241
in inflammation, 241
in movement, 242
radiatiuK, 241
Hyperalgesia, areas of, 69, 70
cutaneous, relating to areas of
visceral disease, 54
dilatation of pupils in, 69
following anesthesia in hysteria.
77
from intercnrrent infection of vis-
cera, 70
in reflected pains from the. via-
eera, 106
of the tongue, 421
referred, in uterine segments, 734
temperature and touch in, 35
tenderness differentiated from.
70, 71
testing of, in a part, 68
thoracic 761
INDEX
Hypertension headaches, associated
symptoms of, 275, 276
distention of veins of brow or
scalp in, 276
general consideration of, 274, 276
pressure points in, 275 .
Hypertrophy of the prostate, 701
Hypnosis, pain perception' under,
31
subjective pain by, 75, 80
Hypoalgesia of the viscera, 385
HypKKshondriac zones of the abdo-
men, 396
Hypophyseal symptoms in adiposa
dolorosa, 225
Hypophysis, tumors of, 186
Hypotonia of globe, 327
Hysteria, back pains due to, 304
basis of pains in, 76
causes of, 76, 77
differential diagnosis of, 196, 197,
199
differentiated from caries of the
vertebral canal, 210
differentiated from bone pains,
234
distinguished from gall-bladder
colic, 572
importance of diagnosis in, 76, 79
pains of, 216
pressure points in, 79
subjective pain caused by, 74,
75, 76
symptoms of, 188
thoracic, 761
Hysterical headache, 289
Hysterical pains, abdominal pains
considered with, 414
areas of, most frequent, 79
diagnosis of, 79
differentiated from real pains, 79
distinguished from pelvic pain,
710
distribution of, 78, 79
emotional shock causing, 79
in children, 79
Hysterica
in
positiv
7S
relief <
Hysterics
76
Hysterici
Idiocy, p
Imaginat
Incisions
Indican,
Indicanu
41
Indiffere]
Indurati(
of
Indurati^
sy
descrip
develo]
26
diagno
26
diagno
diagno
symptc
Infancy,
negligi
in
Infarct <
Infarctio
Infection
InfectioL
sy
Inflamm]
causini
to
nerv
menini
2'/
nasal,
of abd
Inflammation of arteries, 250
of the bladder, 685
of bones, 229, 231
of the bovel, 484
of the breaet, 258
of the cheeks, 418
of the colon, 501
of the esophagus, 424
of the ga]I-bladder, 563
of Ihe hip joint, 241
of the joints, 235
of the kidney, 629
of the kidney, acute. See Ne-
phritis,
chronic, 632
of the lips, 418
of the peritoneum, 304
of the rectum, 506
of the tongue, 421
of the ureter, 670
of the uterus, 740
of the veins, 255
of viscera, absence of pain in,
86, 87
thoracic, 761
Inflammatory pain, 84
beginning of, in blood vessels, 84
cause of throbbing in, 85, 86
characteristics of, 87
dull ache in later stages of, 86
increai^ed size of lumina of ves-
sels in, 84
means of conveyance of, 84
reaction of, 86
systolic pressure iucreaaed in, 85
Inflammatory states, effect of mo-
tion in, 116
Influenza, deranged metabolism in,
141
hyperesthesia from, 70
neuralgia in, 141
severe neck pain of, 352
slight pressure causing painful
reaction in, 71
Ingestion of food, associated with
pain, 111
Ingestion of food, effect of, on pain,
116
intestinal pain after, 472, 473
Inguinal hernia, case of, cited, 374
colicky pain in, referred to lower
quadrant of abdomen, 375
pain in, 374
pressure on, effect of, 374
Inherited predisposition to nea-
ralgia, 143
Inhibition, of pain sensation, 62
of perception, 63
Intellect, mental activity of, 13
power of, to reproduce pain by
memory, 13
Intensity of pain, 114
ammeters in measuring, 130,
131
amount of morpb in necessary as
indication of, 120, 125
appearance of patient indicating:,
120, 125
as a stimulus, 114
blood pressure elevation indicat-
ing, 120
circulation indicating, 134
complaints of patient indicating,
120, 123
depending factors of, 114
dilatation of pnpil indicating,
120, 125
facial expression indicating. 127
gestures indicating, 12S
in spinal cord lesitms, 216
irritability of nerves a factor in,
115
loss of equilibrium indicating.
mechanical factors in measuring,
120, 129
minima of, table representing.
130
motion indicating, 128
motor reflexes indicating. 120, 122
nerve fibers involved a factor of.
INDEX
891
Intensity of pain, patient's descrip-
tion indicating, 120, 128
respiratory system indicating, 134
sensitiveness of patient a factor
of, 115
trophic changes indicating, 134,
135
vasomotor signs of, 120, 124
Von Prey's hairs in measuring,
130, 131
Intercostal neuralgia, 147, 164
differentiation between cardiac
disease and, 781
distinguished from herpes zoster,
165
distinguished from pleurisy, 165
epidemic of, 143
location of pain and tenderness
in, 72
posture in, 127
respiration in, 127
Intercostal neuritis, 791
Interference with areas of pain per-
ception, 64
Intermenstrual pain, 735
Intermittent claudication, descrip-
tion of, 251, 252
Intestinal adhesions, case of, cited,
370
Intestinal atony, effect of constipa-
tion in, 118
Intestinal diseases^ pains due to, 401
Intestinal obstruction, acute, 492,
493
associated symptoms witl\, 494
cause of, 493
chronic, 493, 494
Intestinal pain, associated symp-
toms with, 474
colonic, 500
diagnostic points in, location of,
469
diarrhea with, 475
due to colonic involvement, 500
due to pressure on adjacent
nerves, 468
Intestinal pain, due to purpura,
402
due to traction of the mesentery,
465
due to tuberculous intestinal le-
sions and leukemia, 469
duration of, 473
etiology of, 463
general considerations of, 463
glandular enlargement with, 476
history of, 473
ingestion of food followed by,
472, 473
lesions causing, 476
localization of, 467
location of, 469
muscular activity causing, 468
of the anus, 509
of the rectum, 505
onset of, indications from manner
of, 471
peristalsis stimulation of, by food
in, 472
position of patient in, 472
rectal, 505
referred, 468
reflected, 467
result of, 473
shock and collapse with, 475
tenderness with, deep, 474
superficial, 474
tension as stimulus for, 465
tumor formation with peristalsis
in, 472
types of, 470
vomiting with, 474
Intestinal secretion, disorders of,
480
Intestinal ulcer, action of food in,
488
intervals of freedom from pain
in, 487
location of, 487
relief of pain of, 488
severity of pain in, 488
tuberculous, 488
892
INDEX
Intestinal ulceration, catarrhal, 489
syphilitic, 489
typhoidal, 488
Intestines, back pains due to, 302
degree of sensitiveness of, to pain
stimuli, 388
epigastric pain from lesions of,
397
functional disturbances of, 477
law of contrary innervation in
(Meltzer), 387, 388
lesions of, causing pain, 476
mesentery of, 463
motor disturbances of, 478
new growths of, 499
normal stimuli reactions of, 387
pain in, due to acute indigestion,
402
due to gall-stones, 402
due to hernia, 402
due to obstruction, 401
due to poisoning, 402
due to renal calculus, 402
due to uremia, 402
production of pain in, 464
secretory disturbances of, 477
spasm of, 479, 480
stimulus for pain production in,
463, 464, 465
ulcers of, 487
Intra-articular hip joint abscess,
description of, 244
diagnosis of, 244
nocturnal pains of, 244
treatment of, 244, 245
Intracranial head pains, causes of,
269
Intradural suppuration, 338
Intraneural causes of neuralgia, 142
Intraparenchymatous pain, disten-
tion of liver causing, 551
Intrinsic factors modifying pain
production, 116
Introitus narium, pain caused by,
342
Intussusception, 496, 497, 498
lodids, uses of, 119
Iridectomy, 329
Iridocyclitis, 326
Iris, pain in the, 325, 326
Iritis, forms of, 326
light as a cause of pain in, 323
myopic, 327
source of pain in, 318
sudden exacerbation of pain in.
326
treatment of, 326
Ischemia, anesthesia by, 66
Ischiorectal abscess, 509
Jacksonian epilepsy, 184
Jacksonian fits, 183
Jacksonian spasms, 184
Joint pains, classification of, 234
infections causes of, 238
inflammatory, diagnosis of, 239
intensity of, 236
nonseptic, diagnosis of, 239
of the hip, 241, 242
organic, 234
radiation of, 236
redness as a symptom of, 238
rheumatic inflammation in, diag-
nosis of, 239
septic, diagnosis of, 239
swelling as a symptom of, 238
symptoms of, 236, 237, 238
tenderness as a symptom of, 237.
238
traumatic causes of, 238
verification of a patient's descrip-
tion of, by manipulation.
237, 238
by palpation, 237
by therapeutic test, 238
Joints, as cause of pain from mo-
tion, 117
growing, 241
hypersensitive, cessation of func-
tion of, causes of, 237
INDEX
893
Joints, order of frequency of in-
volvement of (Elisendrath),
239
Kala-azar, 602
Keratitis, punctate superficial den-
dritic, 325
stellate, 325
superficial, severity of pain in,
323
ulcerating, 325
Kidney, anatomical position of,
604, 608
back pains referred from, 302
congestion in. inflammation of,
630
cystic disease of, 645
displaced, 620
epigastric pains from lesions of,
397
general considerations of, 604
hydatid disease of, 646
hypernephroma of, 646
hypertension of, 607
insensibility of parenchyma of,
606
location of, 608
lumbar plexus, relation with, 606
movable, 620
nerve supply of, 604
new growths of, 644
character of pain in, 645
etiology of, 644
varieties of, 645
parenchymatous infection of, 649
polycystic disease of, 645
rotation of, from liver displace-
ment, 559
sarcoma of, 646
tenderness in, 615
most marked points of, 616
tuberculosis of, 642
wandering, pain of, 607
Kidney area, edema in, presence of,
618
Kidney disease, absence of pain in,
618
differential diagnosis of, 610, 619,
620, 621, 649, 669
of hydronephrosis in, 656
of movable kidney, 627
of perinephritic abscess, 639,
640, 641
of pyelitis or pyonephrosis,
650
of renal calculus, 668
of renal infarction, 628
of renal tuberculosis, 644
of tumor, 646
hydronephrosis in, 650
pain in diagnosis of, 619
Kidney inflammation, acute. See
Nephritis,
chronic, 632
congestion in, 629
Kidney pain, absence of, in kidney
lesions, 618
character of, 607
differential diagnosis of, 620,
621
of renal calculus, 650
differential points, 610
duration of, 618
etiology of, 605
from bladder tumors, 689
local, 607
localization of, 607
motion of patient in relation to
production of, 618
position of patient in, 617
production of, factors influencing,
617
psoas muscle contraction causing,
616
referred, 608
nerves involved in, 612
reflected, 614
subjective, 607
symptoms associated with, 618
894
INDEX
Kidney pain, tension, intracapsular,
606
on renal capsule causing, 605,
606
Kidney rupture, 641
Kidney stones. See Renal calculus.
Kidney tumor, 646
Edllian operation, resection of su-
praorbital nerve in, 350
Knee, radiated to, pain from flat-
foot, 305
Knee pains propagated through ob-
turator nerve, 241
Labor, absence of pain in, 739
first stage of pains in, 739
pain in, 738
referred pains of, 740
Labyrinth, diseases of, 340
Lacrimation, 317
Lactation mastitis, 258
Laryngeal crises of tabes dorsalis,
359
Larynx, acute affections of, 357
anesthesia of entrance to, for
dysphagia, 358
carcinoma of, 358
chronic processes of, 358
inflammation of, 357
neuralgia of, 359
pain in acute affections of, 357
diseases of, 356
pus formations in, 357
referred pain of, 357
sensory nerves of, 356
tuberculous ulcers of, 358
Laws, Hilton's, 220
law of contrary innervation, 223
Lead as cause of neuralgia, 142
Lead colic, 402, 484
Leontiasis ossea, 233
Leptomeningitis, differential diag-
nosis of, 196
Leptomeningitis purulenta, differen-
tial diagnosis of, 195, 196
headache and other symptoms of,
180, 190, 191
Leptomeningitis serosa, differential
diagnosis of, 195, 196
Leukemia, back pain of, 299
bone pains of, 231, 232, 233
myelogenous, 602
symptoms of, 181
Limbs, localizing center for pain,
304
lower, flat-foot, 305
generalized pain in, 305
heel pains, 306
hip joint affections, 305
pain from circulatory changes,
305
upper, pain in, 304
shoulder pains, 304
Lingual nerve, 351
Lipomatosis, multiple, 224
Lips, pain in, 418
Liver, abscesses of, 553
adhesions, 553
atrophy of, acute yellow, 561
back pains referred from, 302
cirrhosis of, 552, 554, 556
acute chronic, 561
congestion of, 551
due to acute inflammatory le-
sions, 553
cysts of, 555
displacement of, 558
distention of, 551
epigastric pain from, lesions of,
397
essential diseases of, 561
examination for pain in, 543
growths of slow development in,
555
inflammation of the capsule of,
557
malignant disease of, 556
nerve supply to, 540, 543
new growths of, 554
INDEX
895
Liver, painful disorders of, 540
pain in, 545
secondary growths of, 555
secondary involvement of, 556
sensitive area in, 541
sensitiveness to pain of, produc-
ing stimuli, 542
syphilis of, 556
tropical abscess of, 554
vagus in innervation of, 541
Liver disease, in relation to other
disorders, 548
pain in right shoulder in, 542
palpation in, 544
percussion in, 544
sensibility examination in, 545
symptoms in diagnosis of, 543
tenderness as a symptom of, 543
elicitation of, 544
Liver pain, character of, 545
disturbance of liver substance
proper, 550
extraparenchymatous, causes of,
550
ingestion of food and drink in
relation to, 545
intraparenchymatous, causes of,
551
movement of the body producing,
547
neuralgia, 550
position of the body in relation
to, 547
time of appearance of, 549
with pregnancy, 548
Localization of pain, accuracy of,
decreased by hyperalgesia, 70
decreased by hyperesthesia, 70
indefinite area of, 48
motion in, 48
muscles in, 48
nervi nervorum in, 48
peripheral sensory nerves in,
51
touch sense in, 48
Localized anemia, 62
Locomotor apparatus, pain of, diur-
nal, 110
Locomotor ataxia, epigastric pains
from, 397
projection pain in, 103
Lorenz plaster hose for hip joint
abscess, 244
Lower animals, sensation in, 1, 3, 4
Luetic ulcers, pain of, 355
syphilitic process of, 355
Lumbago, 221, 222, 296
distinguished from neurasthenia,
297
Lumbar cord neuralgia. See sacral.
Lumbar plexus, distribution of
nerves from, 52
Lumbar segments, distribution of,
diagram of, 57
Lumbosacral lesions, 209
Lung pain, etiology of, 790
referred, distribution of, 790
Lungs, areas of pain of, in rela-
tion to location of lesion, 792
back pains due to affections of,
300
Lupus and lues, 333
Lymphadenoma ossium, 233
Lymphangitis, 442
with gastric ulcer, 458
Lymphatic headache, 290
M
Malaria, spleen, enlargement of,
from, 600
Mammary gland, 257
pain produced by changes in, 259
Marking code for recording pain,
136
Massage, effect of, for neuralgia,
161
Mastitis, 259
lactation, 258
pyogenic, 258
stagnation, 258
Mastoid, aigniflcanee of snppora-
tion of, 337
Mastoid process, abscess in, 336
Maximum tenderness areas, cord
zonee, and diagram of, 59
Meatus, external lesions of, 335
Mechanical changes, causative fac-
tors of pain, 25
Mechanical factors for measuring
pain, 129, 130, 131
Mechanical irritation, due to pres-
sure or contraction, 25
Mediastinum, pain of, SOS
Medulla, tumors of, 186
Memory, 13
Memory centera, for pain, 24, 25
subjective pains drawn from,
75
Meniogeal apoplexy, symptoms of,
209
Meningeal changes, as cause of
headache, functional, 269
oi^oic, 271
Meninges, syphilis of, 213
Meningitis, acute, as a cause of
headache, 271
spinal, 212
cerebrospinal, 212
diagnosed froui indurative head-
ache, 267
rigidity in, 127
tuberculous. See Tuberculous
meningitis.
Menstrual pain, conclusions in re-
gard to, 734
intermenstrual, 735
time of iJcciirrence of, 735
Menstruation, back pains due to,
303
contraction of uterine muscles in
Mental resultants, 14
Mental states, 14
influence of, on mmtal processes
of the body, 124
pain and, 30, 31
relation of pain and pleasure to,
15, 30, 31
Mercury, as cause of neuralgia, 142
uses of, 119
Mesenteric arieries, embolism of,
253, 254
thrombosis of, 253, 254
Mesenteric glands, enlar^ment of,
in tuberculosis, 261
pain in, 261
Mesentery, factor of pain produc-
tion in hernia, 372
traction on, cause of pain in vis-
cera, 390
Metabolism as cause of head pains,
268
Metaphysical consideration of pain,
20, 21, 22
Metastases, gastric ulcer due to, 458
Metastatic growths, 555
Metatarsa^a, 306
Middle-ear, catanb of, 339
complications of disease of, 337
disease of, 335
pus in, 337, 338
Migraine, 189
associated symptoms of, 287
diagnosed from indurative head-
ache, 267
differential diagnosis of, 196, 197,
198
due to contraction of peripheral
arteries, 288
due to diminished secretion o£
thyroidin, 289
INDEX
Migraine, due to syphilis, 289 Movable
eye pain from, 320 e
hereditary, 286 associ
hysterical, 289 chara«
localization of headache in, 192 const!
ophthalmoplegic, 321 differ<
premonitory symptoms of, 287 digest
reflex, 286 lesion
scintillating scotoma as symptom locati<
of, 287 parox
throbbing pain of, 287 patho
Minima of sensation, table repre- tende]
sen ting, 130 tumoi
Misplaced viscera, neuralgia from, urina]
142 Multiple
Misref erence of pain phenomena, 94 n
Molecular disturbance as cause of sympi
neuralgia, 142 Mumps,
Monomania pains, 80 Muscle :
Morphin, effects of, 119 Muscles
on blood pressure elevation, 121 causa
in colic, 125 causes
measuring intensity of pain by, inflan
120, 125 in loc
Morton's neuralgia, 169 involi
Motion, bone cause of pain from, motoi
117 nerve
cell areas of, 10 pain
intensity of pain indicated by, pain
128 2
joints as cause of pain from, 117 prote
localization of pain by, 48 sensai
muscles as cause of pain from, senso:
117 under
physical factor of pain, 116 t
reflex, 2, 3 volun
Motor fibers, course of, 174 ind
Motor manifestation of pain in my
lower animals, 3 my
Motor reflexes, in measuring inten- my
sity of pain, 120, 122, 123 my
protective tendency of, 122, 123 my
Motor region, effect of removal of, pol
7, 8 Musculi
focal symptoms of, 183 !1
location of, 173 Muscuh
898
INDEX
Muscular rigidity, with abdominal
pain, 413
Muscular spasm^ with abdominal
pains, 413
Muscular tissues, pain in, 218
Myalgia, 221
abdominal, 362
character of pains of, 222
of back, due to fatigue, 298
due to sprain, 298
due to toxemia, 297
MyeUtis, 212
Myelogenous leukemia, 602
Myeloma, bones, 233
Myocarditis, 788
Myositis, description of pain of,
218
forms of, 220
Myositis fibrosa, 221
Myositis hasmorrhagica, 221
Myositis ossificans, 221
Myringitis bulbosa, 335
N
Nails, absence of pain in, 113
Nasal septum abscesses, pain caused
by, 342
Nasal stenosis, headaches caused by,
342
Nasal tumors, headaches as symp-
tom of, 347
Naunyn's sign, 565
Nausea, protective tendency of, 123
Neck, localizing center for pain, 312
Neck pains, causes of, 312
Nephralgia, hematuric, 629
Nephritis, associated symptoms of,
633, 636
character of pain in, 632
Head's zones in, 631
sensory disturbances in, illus-
trative cases, 633, 635
hyperalgesia, area of, 636, 637
pain in, 631
referred pain in, 632
Nervo apparatus, 5
for receiving and conducting pain,
28
Nerve fibers, conveying deep sensi-
' biUty, 37, 38
conveying superficial sensibility,
37
extent and number involved as
factor of pain intensity, 115
gray matter cells, arising in, 42
of muscles and skin, 48, 50
posterior comua entering, 41, 42
Nerve force, 5
' regenerated by adrenalin, 102
Nerve supply, of the kidneys, 604
of the pancreas, 481
of the rectum, 506
of the spleen, 593
to the bladder, 672
to Fallopian tubes, 707
to female genitalia, 705, 706, 712
to the heart, 774
to Uver, 540, 543
to the ovaries, 707, 713
to the pleura, 769
to the stomach, 428
to the testicles, 698
to the ureter, 670
to the uterus, 707, 713, 724
to the vagina, 755
Nerve terminals, affections of, 140
Nerve trunks, affections of, 140
Nerves, as seat of head pains, 268
destruction of endings of, 364
involved in referred kidney pain,
612
irritability of, 115
of nose, 341
of pain, 36
pain in diseases of, 140
sensory, of the larynx, 356
of the pharynx, 351
Nervi nervorum, in localization of
pain, 48
Nervous system, autonomic sympa-
theticy 12
INDEX
899
Nerv'ous system, central, 172
evolution of, 31, 32
importance of, 79
in lower animals, 2, 3, 4
localization of pains due to dis-
eases of, 175
of the ureter, 670
Nervus nasalis anterior, course of,
341
Nervus nasopalatinum, scarpi, 341
Neuralgia, anesthesia dolorosa in,
144
area of pain of, 144
as cause of head pains, 268
brachial, 147, 150
causes of, 140, 141, 142, 143, 144
character of pains of, 144
circumflex, .147, 164
consideration of, as a separate
entity, 141
consideration of term, 158
diagnosis of, 147
differential diagnosis of, general,
106, 147
differentiated from muscular le-
sions, 147
neuritlB, 140, 159
tabes, 149
distant points in, 145
duration of, 146
effects of, 146
on heart, 146
epidemic of, intercostal, 143
etiology of, 142
exciting causes of, 142
extraneural causes of, 142
galvanic current for, 145
general discussion of, 141
infection, as cause of, 143
inherited predisposition to, 143
in influenza, 141
in senility, 141
intercostal, 147, 164
intraneural causes of, 142
laryngeal, 359
local points in, 144, 145
Neuralgia, massage for, 161
Morton's, 169
muscular changes from, 146
nose as cause of, 149
of abdominal organs, 409
of abdominal wall, symptoms of,
361, 362
of cheeks, 418, 419
of cortex, causing headaches, 278
of eyelid, fifth nerve, 320
diagnosis of, 321
of Ups, 418
of liver, 550
of lumbar cord, 169
of ovary, 749
of pharynx, 356
of stomach nerves, 461, 462
of the uterus, 726
pathology of, 141
peroneal, 147
piercing pain of, differentiated
from bone pains, 228
plantar, 169
predisposing factors to, 143
predisposition to, by alcohol, 143
by drugs, 143
by excessive sexual indulgence,
143
by tobacco, 143
from senility, 143
projected pain causing, 144
referred pain causing, 144, 149,
158
differentiated from, 102
reflex irritations causing, 143
relieved by endonasal operation,
350
sacral, 169
sinus suppuration producing, 345
skin as the seat of, 265
supraorbital, 143
sympathetic pain causing, 144
symptoms, 143
syphilitic, 147
teeth affected by, 148
thoracic, 760, 763
900
INDEX
Neuralgia, toxic materials causing,
141, 142
traumatism as cause of^ 143
trigeminal, 146, 147, 148, 149
trophic changes in, 146
types of, according to localiza-
tion, 147
sciatic, 147, 166
Valleix's points, 144, 146
vasomotor changes in, 145
visceral, 147
Neuralgic pains from spinal cord
tumors, 211
Neurasthenia, abdominal pain in,
409, 410
differential diagnosis of, 196
differentiated from caries of the
vertebral canal, 210
lumbago, 297
due to long continued lesion of
female genitalia, 712
headache and other symptoms,
189, 190
pains of, 215
predisposing to neuralgia, 143
sense of pressure in head with,
264
symptoms of, 216
Neurasthenics, diurnal pain of, 110
Neuritis, abdominal, of intercostal
nerves, 362
as cause of head pains, 268
brachial neuralgia in, 150
causes of, 140, 141
differential diagnosis of, 147
distinguished from neuralgia, 140,
141, 142, 159
localization of, 153
of the esophagus, 424
symptoms of, 143
thoracic, 762
Neuropathic conditions, effect of
constipation in, 118
Neurosis, effect of ingestion of food
in, 116
occupation, cause of, 30
Neurotic ostalgias, distingruished
from bone pains, 233
Neutral sensations, 14
New growths, abdominal, 362
causing bone pains, 230
intestinal, 499
of the gall-bladder, 571
of the liver, 554
of the rectum, 507
of the stomach, 455
of the uterus, 743
Nicotin as cause of neuralgia, 142
Nociceptors, 29
Nocturnal ostalgia, 228
Nocturnal pains, 110, 244
Nocuous ceptors, 29
Nose, adenoid vegetation of, 343
diseases producing pain in, 342
empyema of the sinuses, 343
headaches from obstructed
sinuses, 345
from tumors of, 347
from sphenopalatine diseases
of, 345
hypertrophy of middle turbinate
causing headaches, 349
in neuralgia, 149
local pains in cavities of the
sinuses of, 344
neuralgia of, from suppuration
of the sinuses, 345
obstructed sinuses in, 345
pain in diseases of, 341
reflex neuroses of, 344
sensory nerves of, 341
tumors of, 347
Numbness. See Paresthesia.
0
Objective pain, 82
abdominal, 360
central, 82
origin for, 82
thalamic, 83
peripheral, 83, 80
INDEX
90JL
Obstruction, appendicial, 517
due to hernia, 499
in the gall-ducts, 572
of intestines, 492
Occupation neuroses, 80, 81
Ocular headaches, 282
Omental hernias, 373
Oophoritis, remission of constant
pain in, 109
Ophthalmoplegic migraine, 320
Optic nerve, pain in, 328
Optic thalamus, origin for central
objective pains, 82
Organ, structures of an, 84
Organic disturbances causing head-
aches, 277
Organs of sense, 5, 11
of sense perception, 11
Ostalgia, nocturnal, 228
Ostalgias. See Bone pains.
Osteitis deformans, 233
Osteomalacia, 232
back pains of, 300
description of, 232
distinguished from spondylitis,
232
symptoms of, 227
Osteomyelitis, 231
acute, 231
chronic, 231
of the thorax, 764
symptoms of, 227, 228, 231, 236
Otalgia excarie dentium, 340
Othematoma, 332
Otitis externa diffusa, 334
Otitis media, acute, 335
differential diagnosis of, 195,
196
forms of, 336
Otosclerosis, 339
Ovarian diseases, transferred pain
in, 107
Ovarian dysmenorrhea, 734
Ovarian pain, causes of, 748
characteristics of, 748
local point of, 748
Ovaries, abscess of, 751
adhesions of; 752, 754
back pains, referred from, 303
cysts of, 753
displacement of, 749
hemi£^ of, 749
hyperemia of, 749
nerve supply to, 707, 713
neuralgia of, 749
pain in, 747
relation of, to parotids, 752
tuberculosis of, 752
Pachymeningitis externa, 337
Pachymeningitis haemorrhajofica in*
tema, differential diagnosis
of, 198
etiology of, 179
headache and other synjptoms of,
179, 180, 190, 191
Pachymeningitis interna as a cause
of headache, 271
Pachymeningitis spinalis hyper-
trophica, 212
Pain, character of, 108, 109
classification of, 74, 89
conditions associated with, 132
constant, 109
definitions of, 13, 18, 19, 20
description of, by patient, 108,
109
orientation of cause of, 262
Pain filaments, unequal distribution
of, 48
Pallor, indicating shock, 124, 125
indicating intensity of pain, 124
Pancreas, back pains, referred
from, 303
cancer of, 579, 591
character of pain in, 485
cystic diseases of, 491
diagnostic importance of pain in,
484
diseases of, causing pain, 587
902 IN]
Pancreas, epigastric pains from le-
sions of, 397
general consider^ions of, 480
location of pain in, 485
nerve supply of, 481
pain in, 580, 587
peritoneal covering of, stretching
of, 483
position of patient in diseases of,
487
reaction to pain stimuli in, 484
relationship of, to other parts,
484
stmcture of, 482
tenderness in lesions of, 486
Pancreatic calculi, 489
Pancreatic lesions, possibility of, in
apparent peritonitis or intes-
tinal obstruction, 485
Pancreatitis, acute, distinguished
from gastric ulcer, 451
hemorrhagic, 487
symptoms of, 488
chronic, 489
Fitz's rule for, 488
subacute, 4SS
associated Bymploms of, 489
tenderness in, 488
tenderness in, 487
Panophthalmitis, pain of, 330
Papilledema, associated with tu-
mors, 183
Papillilis of the tongue, 422
Paracentosis, 336
Paralysis, areas of, 59
from tumors, 183, 184, 185
Paraparesis, 184
Paraphasia from tumors of frontal
lobe, 184
Parasites of the brain, 187
Parenchymatous infection of the
kidney, 649
Parenchymatous pains, 83, 84, 140
causes of, 84
chemical irritations producing,
Parenchymatous pains, due to in-
flammation of the viscera, 86
iuflanunatory, 84
in glandular organs, 87
radiation of, 86
thermic irritations producing, 88
torsion producing, 88
traction producing, 88
Paresis, causing anesthesia, 65
differential diagnosis of, 197
Paresthesia, simulated pain in, 61, 73
Paresthesias, 183
Parietal lobe, tnmors of, 184
Parotid gland as canse of pain, 42-1
Parotids, relation of ovaries to, 752
Paroxysmal pains, 109
crises in, 109
Pedicle, torsion of, 399
Pedunculi cerebri, tumors of, 1R5
Pelvic adhesions, cases dted, 370
pain of, when present, 370
Pelvic diseases, diagnosis of, 722
importance of considering the
patient in, 724
discharge in, ?23
epigastric pains from, 398
history of case of, 722
menstrual flow in, character of.
723
pain production in, predisposing
factors to, 723
Pelvic pain, diagnosis of, from
hysterical, 709, 710, 711
examination, bimanual vaginal,
importance of, in, 722
functional acts, relation to, 717
motion causing, 718
on coitus, 717
on menstruation, 718
position assumed by patient Buf-
fering from, 716
position, change of, causing, 718
symptoms of, 709
tenderness areas of, 720
tenderness due to, 719
varieties of, 712, 715
INDEX
903
Pemphigi of the mucosa, 356
Penis, pain in, 703
referred pain in, 703
Perception, inhibition of, 63
. centers for, 30
degrees of, 61
drugs, effect of, on, 63
* idiocy, effect of, on, 62
inhibition of, 62, 63
in thalamic lesions, 199, 200, 201,
202
loss of, by interference with
areas of, 64
in anesthesia, 63
of pain, analgesia of, 61
perversion of, 61
psychosis, effect of, on, 62 '
single impression of, at one time,
71
toxemia, effects of, on, 62
Perceptive apparatus for pain,
30
Perceptive centers of pleasure and
pain, 21, 22, 23
Perforating ulcers, 449
Perforation, in typhoid, 402, 403
of a viscus, effect of, 416
Perianal abscess, 512
Pericardium, disease of, 788
Perichondritis, 332, 333
Pericystitis, 689
Perigastric adhesions, 459
localization of, in the abdominal
wall by palpation, 460
symptoms of, 461
Perihepatitis, 557
adhesions following, 560
Perimysium, sensitiveness to pain
of, 113
Perinephritic abscess, differential
diagnosis of, 639, 640, 641
Perinephritis, associated symptoms
in, 640
character of pain in, 637
location of pain in, 638
posture in, 640
Perinephritis, referred pain in, 638
. tenderness in, 638
Periosteal lesions, 229
Periosteum, condition of, in pain
from motion, 117
dull aching character of pain of,
• 228
sensitiveness to pain of, 113
Peripheral causes of anesthesia, 65
Peripheral distribution, of nerve
fibers, interpretation of pain
as coming from, 393
of sensory fibers, 50, 51
Peripheral nerves, section of, in
neuralgia, 65
Peripheral pains, associated, 90
causes of, 83
character of, 108, 109
extrinsic causes of, 83
functional causes of, 84
intrinsic causes of, 83
objective, 83, 89
organic causes of, 83
persistency of, 109
projected, 103
propagation of, 89
referred, 95
reflected, 104
sympathetic, 102, 103
tim^ of, 110
transferred, 106
Periphlebitis of lateral sinus, 337
Perisinus abscess, 338
Perisplenitis, 600
causes of, 601
degrees of pain in, 594, 600
friction sounds in, 601
Peristalsis, relation between gastric
and intestinal, 486
relation to pain production, 499
Peritoneal adhesions, general pain
of, when present, 371
Peritoneal irritation with hernia,
373
Peritoneum, absence of pain per-
ception in, 363
Peritoneum, adhesions of, 367, 368
diseases of, produdng pain in,
364
hemorrhage of, 367
inflammationB of, 364
layers of, 363
painful impulses of, seated in
subperitoneal layer, 362, 363
senaitiveness to pain of, 113
tumors of, 367
Peritonitis, absence of mnaeular
movement in, 126
acute, absence of pain in, 364
pain in, 364
chronic, causes of pain in, 366
location of pain in, 367
diagnostic criteria for, 365
facies of. 127
onset of. 365
posture in, 126
production of pain in, 366
tenderness in, 365
luberculous, pain in, 365
Peritonsillar abscess, 340
incision of, 351
Pernicious anemia, symptoms of,
181
Peroneal neuralgia, 147
Persistency of pains, 109
Pharyn^al tuberculosis, pain of
swallowing in, 355
Pharyngitis, types of, 423, 424
Pharyngodynia, pain of, 352
Pbaiyni, acute diseases of, 351
carcinoma of, at base of tongue,
355
chronic diseases of, causing pain,
354
febrile herpes of, 3.')2
herpes zosler of, 3-^3. 354
infectious diseases of, causing
pain, 352
cases cited, 353
inflammatory processes of, 351
luetic ulcers of, 355
neuralgias of, 356
Pharynx, pains in diseases of, 351,
423
sensory nene of, 351
tuberculous ulcers of, 354
Phlebitis, deep pressure causing
painful reaction in, 71
pain from, 255
Phlegmonous angina, pain of, 351
Phlegmonous pharyngitis, 423
Photochemical changes causing
pain, 28
Photophobia, explanation of, 323
Phthisis of the eye, 328
Physical consideration of pain, 20
Physical deterioration from pain,
133, 134
Physical factors of pain : change of
position, 117
defecation, 117
digestion, 116
drugs, 119
electricity, 118
extrinsic, 116, 118
intrinsic, 116
menstruation, 116
modifying production of, 116
motion, 116
pressure, 118
reepiration, 116
temperature, extremes of, 118
urination, 116
weather, 119
Pinching, measuring pain by, 129
Pinna, herpes of, 333
Plantar neuralgia, 169
Pleasure, differentiation between
pain and, 16, 17, 18
pain related to, 132
relation of, to mental state, 15
sensations causing, 13
transition to pain from, 15, 16
Pleura, inflammation of. 793
innervation of, 769
painful area of, not necessarily
indicative of pleural involve-
ment, 770
INDEX
905
Pleura, parietal inflammation of, 791
reflected pain in, 771
sensitiveness to pain of, 113
visceral, inflammation of, 792
Pleural pain, 764
Pleurisy, character of pain in, 770
diagnostic value of pain as a
symptom of, 770
distinguished from intercostal
neuralgia, 165
posture in, 127
respiration in, 127
serous, absence of pain in, 793
transferred pain in, 107
Plumbism, 484
Pneumococci causing neuralgia, 143
Pneumonia, abdominal pain of, 392
association of, with pleurisy, 797
differential diagnosis of, 196
epigastric pains of, 398
mistaken for appendicitis, 797
pain of; 797
referred pain in, 799
slight pain in, 113
transferred pain in, 107
Pneumothorax, 802
Podalgia, 688
Points, distant, in neuralgia, 145
douloureux apophysaires, 145
in neuralgia, local, 144, 145
of pressure, 144, 145
of tenderness, 161
Valleix^s, 144, 145
in trigeminal neuralgia, 150
Signorelli's spleen, 596
Poliomyelitis of children, 212
Polycystic disease of the kidney,
645
Polvcvthemia, 602
Polymyositis, acute, differentiated
from eosinophil ia, 221
symptoms of, 220
Polyneuritis, differentiated from
poliomyelitis, 213
Polypoid growths inside of uterus,
734
Polyuria, with abdominal pains, 414
Pons, tiunors of, 185
Portal vein, twist of, from liver dis-
placement, 559
Position assumed in lesions of the
middle-ear, 334
Posterior comua, nerve fibers en-
tering, 41, 42
Posterior cranial fossa, tumors of,
186
Post-hoc neuralgia, 142
Postures, indicating pain, in colic,
126
in disease of joint, 127
in distention of vesical bladder,
127
in intercostal neuralgia, 127
in peritonitis, 126
in pleurisy, 127
Pregnancy, back pains caused by,
303
hydronephrosis in, 654
liver pain during, or after, 548
normal, 736
osteomalacia, associated with, 232
pain in, causes of, 736, 737
pyelitis in, 651
Preprotective functions associated
with pain, 135
Prepuce, inflammation of, 703
Pressure, anesthesia by, on a nerve
trunk, 66
-within nerve sheath, 66
aneurysm indicated by, 127
blood, pain by sudden alterations
of, 26
by new growths, 25
causing affections of nerve recep-
tors, 140
of nerve trunks, 140
causing neuralgia, 142
constant pain caused by, 109
deep, causing painful reactions,
71
effect of, in neuralgia, 144, 145
in neurasthenia, 216
906
INDEX
t'ressure, effect of, on pain centers,
64
from inflammatory exudate, 25
in colic, 126
in distention of vesical bladder,
127
measuring pain by, 129
physical factor of pain, 118
projected bead pains due to, 269
reaction to, in influenza, 71
in phlebitis, 71
sense of, in head, 264
slight, causing painful reactions,
71
superficial, painful reaction to, 72
tenderness produced by, 70
three painful reactions to, 71, 72
tumor indicated by, 127
venous, headache due to increase
of, 274
Pressure points, in hysteria, 79
in neuralgia, 144, 145
Pressure sense, 46
Pricking, 73. See Paresthesia.
Primary paths in spinal cord, 42
Proctitis, dysenteric, 507
Production of pain, causative fac-
tors in, 25
change of position in, 117
diversion of attention in, 116
drugs in, 119
electricity in, 118
emotions in, 115
factors modifying, 115
in consciousness, 115
in defecation, 117
in digestion, 116
in menstruation, 116
in motion, 116
in respiration, 116
in urination, 116
l)liysical factors modifying, 116
pressure in, 118
psychical factors modifying, 115
serous membranes not the seat
of, 363
Production of pain, suggestion in,
116
temperature in, extremes of, 118
weather in, 119
Projected pains, in head, 268
in neuralgia, 144
Projection pain, 103
relief of, in stump of amputated
limb, 103
Propagation of pain, 89
Prophyseal disease (Marburg, Jel-
liffe), 224
Proprioceptive system of Sherring-
ton, 12
Prostate, congestion and inflamma-
tion of, 700
congestion of, without inflamma-
tion, 700
hypertrophy of, 701
lesions of, 701
pain in, 700
referred pain from, 701
tuberculosis of, 702
tumors of, 702
Prostatic involvement, associated
symptoms of, 702
Protective reflexes, reason for,
123
Protopathic fibers, 37, 38
Protopathic system of Head, 11, 12,
37, 39, 46, 47
Pseudo-anginal pain, 784
Pseudoleukemia, 602
bone pains of, 231, 232, 233
Psoas abscess, causing pain in groin
and thigh, 97, 98
Psychical factors of pain: con-
sciousness, 115
diversion of attention, 116
emotions, 115
modifying pain production, 115
suggestion, 116
Psychosis, pain perception in, 62
Pulse rate, indicating pain, 134
Purpura hemorrhagica, pain from,
249
pyelitis, c&usation of pain in, 647
character of pain in, 647
in pregnaney, 651
1 oca liza lion of paiD in, 647
pyonephrosis with, 651
symptoms associated with, 651
Pyelonephrosis, 649
Pyemia, difEerential diagnosis of,
196
Pyloric spasm, 436
character of pain in, 438
contraction in, 437, 438
tension pains of, 437
Pyloric ulcer, distinguished from
duodenal ulcer, 450
severity of pdin in, 445
Py<^nic mastitis, 258
Pyonephrosis, 652
symptoms a,>":ociated with, 653
Fyosalpinx, pain production in, 745
RanulUB, 423
Raynaud's disease, 248
Rc:ictiun, of animals to pain, 3
to stimuli without pain, 4
Kecnlled sonsalions in subjective
pains of hysteria, 75
I!(>ceptive apparatus of pain, 28
lieeeptors, abrogation of action of,
29
lowering of threshold value
of,
Rectum
Eeferre
intes
sense receinive organs, 28, 29
local
temperature, :ii)
terminal filaments, 28, 29
local
Recording pain, 135
moq
Rectal pain, local, 505
nerv.
referred, 506
neiir
Rectal tenesmus, 6SS
Rectum, careinoma of, 507
of c;
Referred pain; of renal calculus,
659
of thoracic walls, 764
posterior root lesions causing, 93
principal causes of, 95
proximal to orijrinotinjf area, 95
psoas abscess caiisiu^r, in thigh
and proin, 97, 98
rectal, 506
reference of, downward, 97, 9S,
100
upward, 97
upward and downward, 95, 96
reflected pains differentiated
from, 104
section of nerves causing, 101
to eittraabdominal r^ons, 416
Reflected pains, 104
abdominal, 391, 392
anatomical basis of, 105
hypogastric, 500
in pleura, 770
intestinal, 467
localization of viscuB causing, 106
producing, 388
lowered vitality causing, 106
neuralgia differentiated from, 106
of bladder, 679
of kidney, 614
of thoracic walls, 764
referred pains differentialed from,
104
'visceral irritation causing, 103
Reflected stimuli in viscera (Head's
law), 384, 3S5
Reflex headaches, diseases firoduc-
ing, 281
Reflex irritations in neuralgia, 144
Reflex migraine, 286
Reflex neuroses of iiokc, 344
Reflex oi^ans, of muscles, 123
of sense, 123
Reflex pains, 104
appendiceal, 517, 521
in gastric area, 433
in bead, 269, 277
1 Reflex pains, of anal fissure, 512
' of tbe viscera, 388
Reflexes, motor, protective tendenrj'
of, 122, 123
Regional pains, 262
abdominal, 393, 394
clavicular, 310
abdomen, 307
in back, 296, 312, 313, 314, 315
chest, 310
head, 262
limbs, 304
n neck, 312
Remittent pains, 109
Removal of calcareous teetb, psin
after, 142
gall-atones, pain after, 143
Renal calculus, 635
blocking of ureter in, 657
blood pressure, increase of, in,
667
character of pain in, 658
chills in, 667
collapse in, 667
differential diagnosis of, 668
digestion, causing pain in, 666
digestive symptoms of, 667
duration of the atUck of, 659
etiology of pain of, 655
factors influencing pain of, 665
byperalgesio zones in, 661
intermittent pain of, 658
localization of stone in, 664
location of pain in, 659
manipulalion of kidney inating
attack of, 666
micturition, frequency of, 666
motion inciting to attack of, 666
pain of, associated with healthy
instead of diseased kidney,
662,663
paroxysmal pain of, 658
position of patient in, 665
referred pain of, 659
renorenal leflex in, 662
secondat; pain in, 657
INDEX
909
Renal calculus, sensations of cold
in, 667 .
spasms in^ 667
symptoms associated with pas-
sage of, 666
previous to attack of, 667
temperature, elevation of, in,
667
tenderness in, 664
urine changes in, 667
Kenal colic, hyperalgesic condition
of testicle in, 106
Renal infarction, associated symp-
toms of, 628
causes of pain in, 626
differential diagnosis of, 628
type of pain in, 628
Renal pain. See Kidney pain.
Renal tuberculosis, character of
pain in, 642
diagnosis of, 644
types of pain in, 643
Renorenal reflex in renal calculus,
662
Reproduction of pain, manual, 132
Respiration, indicative of pain, 127
physical factor of pain, 116
Respiratory organs, pain in, 790
Respiratory system, how affected by
pain, 134
Retina, pain in, 328
Retropharyngeal abscess, pain of,
352
Rheumatic headaches, 279, 280
Rheumatism, confused with myositis
ossificans, 221
neuralgia associated with, 143
of abdominal wall, 362
of back muscles, 296
of eye muscles, 328
of hip joint, 305
of shoulder joint, circumflex neu-
ralgia mistaken for, 164
Rhinological examination, impor-
tance of, as a diagnostic
measure, 350
Rhinostenoma, symptoms of
(Piorry), 342
Rigidity of underlying muscles, ten-
derness associated with, 72
Robson's point, 565
Rules, Fitz's, in pancreatitis, 488
Rupture, of bladder, 685
of kidney, 641
of spleen, 602
of urethra, 696
Sacral neuralgia, 169
differential diagnosis of, 171
general discussion of, 170
herpes accompanying, 171
symptoms of, 169, 170
Sacral plexus, distribution of nerves
from, 53
Sacroiliac dislocation, back pains
of, 299
Sacrovertebral joints, diseases of,
299
Salivary glands, pain in, 422
Salpingitis, chronic, pain produc-
tion in, 745
remission of, 109
Saponin, terminal anesthesia by, 67
Sarcoma, 233
distinguished from sciatica, 168
of gall-bladder, 571
of kidney, 646
Sciatic neuralgia, 147, 166
Sciatic pains from spinal cord tu-
mors, 211
Sciatica, 166
character of pain of, 166
diagnosis of, 168
differential diagnosis, 168, 169
distinguished from goutj' hip
joint, 245
pains of intennittent claudica-
tion, 252
location of pain of, 166
and tenderness in, 72
910
INDEX
Sciatica, method of eliciting pain
in, 169
Valleix^s points in, 167, 168
Scleritis, pain of, 327, 328
Sclerosis, multiple, 213
See Multiple sclerosis.
Sclerotic coat of eye, 327
Secondary paths in spinal cord,
42
Seminal vesicles, pain in, 699
Senility, deranged metabolism in,
141
neuralgia in, 141
predisposing to neuralgia, 143
Sensation, absence of, 61
acute, 61
allied to pain, 132
autosuggestive, 75
causing pain, 13
cell areas of, 10
complexity of constituents of, 11
conveying channels for, 35
definition of, 4
duration of, 7
general consideration of, 1, 4
heterosuggestive, 75
in lower animals, 1, 3, 4
in muscles and skin, 48
intensity of, 7
interpretation of, 12
minima of, table representing,
130
neutral, 14
objective, 4
pain and tactile, 8
pain, considered as an attribute
of, 23
distribution of, 46
in relation to other sensations,
31
inhibition of, 62
perception of, 61
superficial, 46
perversion of, 61, 62
properties of, 6, 7
quality of, 6, 7
Sensation recalled, in subjectiTe
pains of hysteria, 75
subjective, 4
Sense-conveying oi^ans, 5
Sense organs, centers for, 7
classes of, 11, 12
Sense-perceptive centers, 30
hypersensitivehess of, 30
Sense-perceptive organs, 5, 11
Sense-receptive organs, 5
Senses, external, 5
internal, 5
Sensibility, abnormal. See Hyper-
algesia.
Sensibility, loss of, in lesions of the
thalamus, 200
mental activity of, 13
Sensitiveness of patient, factor of
intensity of pain, 115
Sensiti\eness to pain, development
of, 112
individual, 112, 113, 115
in infancy, 111
Sensorimotor area, 10
Sensory area, 10
convolutions of, 10
effect of destruction of, 10
location of, 10
Sensory examination, method of
making a, 131, 132
Sensory fibers, 10
arising in gray matter cells. 42
ascending path of, 45
association with vasomotor fibers,
aSO, 381
conducting, course of, 174
course of, 40, 41, 42, 43, 44. 45
entering posteiior comua, 41. 42
peripheral distribution areas of,
50, 51
Sensory mental activities, states of,
13
Sensory nerve receptors in mnscles,
218
Sensory nerves, areas of distribu-
tion, 47, 48
rves, of the larynx,
Sensory neurology, importaDce of,
201
Sensory orpons, 5, 11
Sensory iien-eplion, active agents
of, 10, 11
centers for, 7
Septic iiivolveiiient of osseous sys-
tem, 231
SerositiK, universal chronic, 561
Severance of posleiior roots, anes-
thesia produced hy, 66
Sexual act iiiduciug loss of con-
Sexual connection, importance of
cure of abnomialtiv in. 758
Sofi
SoU
Spinal cord, injury to pain conduc- | Spleen, nerve supply of, 593
tion paths in, 3R, 39
irr^ular distribution of pain i
39, 40
meningeal apoplexy, 209
meningitis of, 212 •
multiple sclerosis, 213
myelitis, 212
neurastbenia, 215
pain ill, 594
factors influencing, 596
nipture of, 602
SigTiorelli's point, 596
stimuli of, 594
symptoms associated with pain or
tendemesa of, 598
tumors of, 602
pachymeningitis spinalis hyper' I Spleen pains, circulatory changes,
stimuli, pain from excess of, 24 Sup
without presence ut', 141 Sup'
Stomach, acute dilatation of, 439
areas of maximum tenderness in,
428
of referred pain, caused by dis-
orders of, 427
back pains due to affections of,
301
causes of pain in, 427
dilatation of, from pyloric spasm,
438
displacement of, 431 Syin
epigastric pain from lesions of, Syni
914
INDEX
System, protopathic, 11, 12
vestibular, 12
Tabes, analgesia produced by, 66
differentiated from multiple
sclerosis, 213
distinguished from neuralgia, 149
sciatica, 168
Tabes dorsalis, 95
. associated symptoms of, 215
delayed pain sensation in, 111
laryngeal crises of, 359
location of pain and tenderness
in, 72
pains of, 214
tabetic crises of, 214, 215
Tabetics, dissociation between pain
and touch in, 34
Taste, protective reflex action of,
123
Teeth, destruction of, 420
pain in, 419
destruction of, 420
from neuralgia, 148
reference areas of, 420
sensitive part of, 419
Temperature, sensibility to changes
of, 35, 46
effect on pain of changes in, 119
elevation of, from pain, 135
extremes of, physical factor of
pain, 118
Temperature receptors, 35
Temperature senses, pain related lo,
32, 33, 34, 46
Temi)oral lobe abscess, 339
Tenderness, 70, 71, 72
abdominal, 403. See Abdominal
tenderness,
in tubal disease, 720
area of, 72
associated with enterospasm, 483
chronic, 405
deep, 405
Tenderness, hyperalgesia differen-
tiated from, 70, 71
in appendicitis, 529
in kidney disease, 615
in occupation neuroses, 81
in peh-ic pain, 719
of the gall-bladder, 563
point of, in pehdc adhesions, 405
points of (Cumston), 405
(Hubbard), 406
(McBumey's), 405, 406
(Morns'), 405, 406
reflected, 405
rigidity of underlying muscles as-
sociated with, 72
superficial, 405
temporary, 405
types of, 405
with intestinal pain, dia^ostie
value of, 474
Tendon spindles, 46
Tension, as cause of hollow visceral
pain (Hertz), 223
as cause of visceral pain, 38S
Tension pains of viscera, 388
Terminal anesthesia by toxic agents,
67
Terms, careless use of, 409
Testicles, deep pressure pain in,
698
enlargement of, 699
inflammation of, 698
ner\e supply to, 698
pain in, 698
reflected kidney pain in, 615
trauma of, 699
Tests, for diseased sinus (Glas' tun-
ing fork), 349
for eliciting pain in sacroiliac
region (Goldthwaite), 300
Thalamic center, 202
Thalamic functions, 198, 201
Thalamic pains, 198
severity of, 83
Thalamic syndrome, 199
loss of sensibility in, 199, 200
INDEX
915
Thalamic syndrome, overresponse to
stimuU in, 200, 201, 202
symptoms of, 199
Thalamus, differential diagnosis be-
tween lesions of the cortex
and, 203, 204, 205, 206
essential organ of, 201, 202
functions of, 201
interrelations between the cortex
and, 202
lesions of, 199
loss of sensibility in lesions of,
199, 200
overresponse to stimuli in lesions
of, 200, 201, 202
pains of, 198
paths of, 201
Theories of pleasure and pain, IS,
19, 20
Therapeutic measures applied to
empyema, 348
Thermal sensibility, 47
Thermic irritations, parenchymatous
paiuH from, 88
Thigh pains, referred from kidney
lesions, 610
Third ner\^e palsy, 321
Thoracic organs, diseases of, caus-
ing pain, 795
Thoracic pains, transferred from
distention of the stomach, 766
Thoracic walls, referred pains of,
764
reflected pains of, 764
structures composing, 760
transferred pain in, 765 .
Thorax, bone pain in, 764
facial pain of, 762
fractures of, 764
herpes zoster of, 763
hyperalgesia of skin of, 761
hyperesthesia of skin of, 761
hysteria, tenderness of skin in,
761
inflammation of skin of, 761
muscle pain of, 762
Thorax, nerve pain of, 762
neuralgia of, 760, 763
neuritis of, 762
osteomyelitis of, 764
pains within, 769
pleural pain of, 764
skin affections of, 760
Threshold values of pain, lowering
of, 30
Throat, pain in diseases of, laryn-
geal, 356
pharyngeal, 351
Thrombo-endarteritis obliterans, 249
Thrombosis of arteries, 248
differential diagnosis of, 196,
198
of mesenteric arteries, 253, 254
of veins, 256
Thymus gland, pain in, 261
ThjToid gland, pain in, 261
Tic douloureux, 420
of herpes zoster, 354
douloureux. See Trigeminal neu-
ralgia.
Tickling, 73. See Paresthesia.
"Time of life" pains, 410
Time of pain, 11 0
Tingling, 73. See Paresthesia.
Tissue susceptibility to pain, 113
Tissues, fatty, pain in, 224
glandular, 257
muscular, pain in, 218
Tobacco, i)redisposing to neuralgia,
143
Tongue, carcinoma of base of, 355
lesions of, an indication of a noc-
turnal epileptic attack, 422
causing i)ain, 421, 422
pain in, 421
reference areas in diseases of, 422
ulcer of, 419
Tongue pains. See Glossodynia.
Tonsils, pain in, 423
Toothache, causes of, 419
trigeminal neuralgia mistaken
for, 420
916
INDEX
Torsion, parenchymatous pains
from, 88
Torticollis, 221, 222, 296
Touch, dissociation of, from pain,
32, 33, 34
perception of, in anesthesia, 63
Touch sense, in localizing pain, 48
Toxemia, causing affections of nerve
receptors, 140
causing affections of nerve trunks,
140
pain, cause of, 26, 27
pain perception in, 62
with abdominal pains, 414
Toxemic headaches, due to en-
dogenous poisons, 271
due to exogenous poisons, 271
due to starvation products, 272
Toxic agents, anesthesia by, 67
Toxic analgesia, 62
Toxic materials, pain from, 142
Toxic products, pain from accumu-
lation of, 27
Traction, cause of pain in viscera,
390
parenchymatous pains from, 88
Transferred pains, 95, 106
abdominal, 392
appendiceal, 516, 520
cause for persistency of, 108
in breast, 258
in homologous segments, 107
in thoracic walls, 765
in urethral disease, 696
neuralgia differentiated from,
106
occurring in cord, 107
reference higher and lower, 107
sympathetic pain, differentiated
from, 102
Transverse myelitis, 95
anesthesia produced by, 66
Trauma, habit pains resulting from,
80
Traumatic neuroses, 216
differential diagnosis of, 196
Traumatism, causing affections of
nerve trunks, 140
neuralgia, 143
of bones, 229
Trigeminal neuralgia, 146, 147, 148,
149
area of, 262
associated with tumors, 183
characteristics of, 149
mistaken for toothache, 420
Valleix's points in, 150
Trigeminus, pains in head due to
action on receptors of, 82
Trophic changes, from neuralgia,
146
in skin, causing pain, 28
resulting from pain, 134, 135
Tropical abscess of liver, 554
Tubal inflammation, adhesions from,
746
functional acts, pain in, 745
uterine colic from, 746
Tuberculin, use of, 119
Tuberculosis, effect of tuberculin
in, 119
of hip joint, 305
of kidney, 642
of ovary, 752
of prostate, 702
of tongue, 421
of vertebrae, 211
of vulva, 756
pain from enlargement o£ mesen-
teric glands in, 261
pharyngeal, 355
pulmonary, 800
causes of thoracic pain in, 802
character of pain in, 800
pleurisy during, 802
pneumothorax during, 802
tenderness in, 800
Tuberculous caries, back pain of,
299
Tuberculous hip diseases, symptoms
of, 241
treatment, 243
INDEX
917
Tuberculous meningitis, differential
diagnosis of, 197
headache in, 180
symptoms of, 180
Tuberculous peritonitis, 365
Tuberculous ulcers, intestinal, 488
of larynx, 358
pharyngeal, 354
Tumor, brain, 270. See Brain
tumor.
cerebral, 269
distinguished from sciatica, 168,
169
gummatous masses similar to, 211
nasal, 347
neuralgia due to, 142
of base of brain, 186
of bladder, 689
of brain, 182
of breast, 259
of central ganglion, 185
of cerebellopontine angle, 183
of cerebellum, 185
of chiasm a, 183
of corpora quadrigemina, 185
of corpus callosum, 184
of frontal lobe, 184
of hypophysis, 186
of kidney, 646
of medulla, 186
of parietal lobe, 184
of pedunculi cerebri, 185
of peritoneum, 367
of pons, 183, 185
of posterior cranial fossa, 186
of prostate, 702
of spinal cord and vertebra, 211
of spleen, 602
pressure indicating, 127
visceromotor reflex mistaken for,
445
Twisted pedicle, cysts from, 399
diagnosis of, 399
Tympanum, pain in, 335
Typhoid fever, differential diagnosis
of, 196
Typhoid fever, neuralgia associated
with, 143
neuritis of toes in, 169
nocturnal ostalgia with, 228
perforations in, 402, 403
spleen, enlargement of, from, 600
Typhoidal ulceration of intestines,
488
U
Ulceration, of intestines, catarrhal,
489
syphilitic, 489
typhoidal, 488
rectal, 508
Ulcerative colitis, 501
Ulcer of stomach, chronic, distin-
guished from gastric ulcer,
451
distinguished from cancer and
nervous gastralgia, 452, 453,
454, 455
Ulcers, duodenal, 489
following bums, 489
of intestines, 487
of tongue, 419, 421
perforating, 449
tuberculous, of intestines, 488
of pharynx, 358
Umbilical hernia, local and referred
pain of, 374
Umbilical pain in intestinal lesions,
469
Universality of pain, 20
Uremia, colic with, 484
differential diagnosis of, 197
nocturnal pain of, 110
Ureter, inflammation of, 670
location of pain in inflammation
of, 671
muscular spasm in, 670
nerve supply to, 670
obstruction of, 670
complete, 671
pain associated with, 670
tumor of, 671
918
INDEX
Ureteral colic, cause of pain in tes-
ticle in, 105
Ureteral disease, route of pain ref-
erence in, 671
Ureteral stone, reference pains in
groin from, 671
Ureteritis, 670
Urethra, pain in, 695
Urethral calculus, 696
Urethral caruncles, 695
Urethral disease, transferred pain
in, 696
Urethral rupture, 696
Urethritis, 695, 703
epididymis involved in, 699
Urine, irritating constituents in, 696
Urination, burning sensation dur-
ing, 697
pain after, causes of, 697
pain during, due to inflammatory
changes, 697
pain on, 696
painful in bladder diseases, 682
physical factor of pain in, 116
Uterine colic from tubal inflamma-
tion, 746
T'terine muscle, hyperesthesia of,
731
rterine pain, character of, 716, 724
constant, 716
disorders causing, 726
due to cervical stenosis, 729
due to hindrance to the separa-
tion of the decidual mem-
brane, 730
due to spasmodic contraction of
cervix, 730
in childbirth, 738
in i)regnaney, 736
intensity of, 726
intermittent, 716
in-egular intensity of, 724
tenderness with, area of, 721
llerus, back pains referred from,
303, 304
benign growths of, 743
Uterus, cancer of, 744
correlation of, through nervous
system with breast, 715
displacement of, 726
character of, 727
enlarged, pain in ovary from,
752
fibroids of, 744
functional disorders of^ 728
inflammation of, 740
maldevelopment of, 731
malignant growths of, 743
menstruation, painful, to, 728
nerve supply to, 707, 713, 724
neuralgia of, 726
new growths of, 743
polypoid growths inside of, 734
Vagina, affections of, causing pain,
755
cancer of, 756
hemorrhage into the soft parts
surrounding, 756
nerve supply to, 755
nodule on, 756
pain in, 755
Vagus and greater splanchnics.
pain conductivity of, 383
Valleix's points, 71
in neuralgia, 144, 145
in sciatica, 167, 168
in trigeminal neuralgia, 150
Varicose veins, 256
Varieties of pain, origin and trans-
mission, diagrams of, 89, 90,
91
Vas deferens, pain in, 699
Vasomotor changes in neuralgia*
145
Vasomotor fibers associated with
sensory fibers, 380, 381
Vasomotor paresis, 133
Vasomotor signs of intensity of
pain, 120, 124
Vasoneurosis, 72
Veins, diseases of, causing pain,
255
iiifliinimation of, 255
tlii'ombosis of, 256
Vena vava, pull on. from liver dis-
plaeemeiil, 559
Venuiforai appendix, diseases of,
529
Vertebra, caries of the canal of,
210, 211
luxation and fracture of, pains
produced by, 208
symptoms of, 209
tumors of, 211
Vertebral diseases, dislocations, 299
leukemia, 299
of sacro vertebral joints, 299
liiberculons caries, 290
Vertebral painti, indications fi-om,
312
Vesical calculus, absence of pain
in, 695
causes of pain in, 602
character of pain in, 693
di^^iion in, 603
location of pain in, 604
motion,' cjinsin;; )>ain in, 694
position of patient in, 604
production of pain in, factors in-
fltieiicinjr, 604
920
INDEX
Viscera, abdominal, transference of
pain, manner of (Head), 384
zones of hyperalgesia in
(Head's), 384, 385
Viscera, absence of pain in inflam-
mation of, 8G, 87
back pains due to lesions of, 208
causing referred pain in head,
290, 291, 292, 293, 294, 295
inaccuracy of localization of ten-
sion pains in, 388
irritation of, causing reflected
pain in, 105, 106
pain in involuntary muscles of,
222
referred pains to back from, 300
Visceral diseases, surface zones re-
lated to, 54
Visceral nerves, 41
Visceral neuralgia, 147
Visceral pain, mobility of organ in
localization of, 470
produced by traction of mesen-
tery, 381
Visceral pain, tension only true
cause of (Hertz), 388
Visceromotor reflex, mistaken for a
tumor (Mackenzie), 445
Visceromuscular reflex, 413
Volition, njental activity of, 13
Voluntary analgesia, 62, 63
Voluntary lameness, symptoms of,
241
Volvulus, 496
Vomiting, protective reflex action
of, 123
with intestinal pain, 474
Von Frey hairs, measuring pain by,
130, 131
Vulva, cancer of, 756
cysts of, 756
tuberculosis of, 75C
W
Weather, effect of, on pain pro-
duction, 119
(1)
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