With the

Compliments of

the Publishers

W. B. Saunders Company

West Washington Square

Philadelphia

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tt'.

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In Wv, -

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UNIVERSITY OF CAMPnRNIA

CALIFORNIA COLLEGE Or MEDICINE

LIBRARY

IRVINE, CALIFORNIA 92664

Differential Diagnosis

PRESENTED THROUGH
AN ANALYSIS OF 385 CASES

RICHARD C. CABOT, M.D.

ASSISTANT PROFESSOR OF CLINICAL MEDICINE, HARVARD UNIVERSITY MEDICAL SCHOOL, BOSTON

SECOND EDITION, REVISED
PROEUSEL Y ILL USTRA TED

f HII.ADKI.IMMA AND LONDON

W. B. SAUNDERS COMPANY

1912

Copyright, 1911 by \V. K. Saunders Company. Reprinted March, 1911, June, 1911, and October, 1911.
Revised, reprinted, and recopyrighted, February, 1912.

Reprinted October, 1912

PRINTED IN AMERICA

PRESS OF

V. B. SAUNDERS COMPANY

PHILADELPHIA

PREFACE TO THE SECOND EDITION

I have corrected some typographical errors kindly pointed out by
correspondents, reorganized the index and table of contents, and
made a few more material changes. Two new cases are introduced:
one by the kind permission of Dr. Frederick J. Bowen of Mount
Morris, N. Y., whom I take this opportunity of thanking.

Some of the symptoms not treated in this volume (e. g., hema-
turia, edema, diarrhea, dyspepsia, glandular enlargement, etc.) will
be dealt with in a second volume along the same lines.

PREFACE

The attempt to make and defend a differential diagnosis brings
all one's failings into sharp relief. Though I have done my best to
avoid obvious errors in this book, I am confident that it contains
much that deserves and I hope will receive challenge from other
physicians.

My best thanks are due to Dr. James H. Young for help in the
diagrams, and to my secretary, Miss Edith K. Richie, who has made
the index and rendered many invaluable services throughout the
preparation of the book.

190 Marlborouc.h St., Boston, Mass.

TABLE OF CONTENTS

INTRODUCTION Page

The Presenting Symptom 17

The Grouping of Reasonable Possibilities 17

Advantages of the Plan Here Adopted 18

Limits 19

Vulnerability of All Differential Diagnosis 19

Omissions 21

Explanation of Diagrams and Charts 22

CHAPTER I

PAIN

General Considerations 24

Degree of Pain 25

Types of Pain 26

Relation of Pain to Other Facts 27

Habit Pains 29

Theories Regarding the Production of Pain 29

CHAPTER II

HEADACHE

General Considerations 32

Position and Nature of the Headache 37

Two Traditional Fallacies About Headache 38

Important Tests 39

Cask No.

1. Methemoglobinemia 39

2. Syphilitic Periostitis 41

3. Syphilis 43

4. Syphilis 45

5. I leadache of Psychic Origin 47

6. Uremic Headache; Chronic Glomerulonephritis; Graves' Disease 40

7. Typhoid Fever 52

8. Fracture of the Base of Skull 54

9. Sinusitis 55

10. Miliary Tuberculosis 50

1 1. Stone in the Kidney with Abscess and Nephritis 58

1 j. Malaria (10

13. Paroxysmal Tachycardia Complic ating a Chronic Myocardial Insufficient y . (>i

14. Postpneumonic Empyema "3

6 TABLE OF CONTENTS

Case No. Page

15. Staphylococcus Infection (Osteomyelitis) 65

16. Dementia Paralytica 67

17. Headache of Unknown Origin 68

18. Meningitis 69

19. Sinusitis 7 1

20. Typhoid Fever 73

21. Miliary Tuberculosis 74

22. Cerebral Hemorrhage 76

CHAPTER III

LUMBAR PAIN

Examination of Patients with Lumbar Pain 87

Case No.

23. Tuberculous Pneumothorax 87

24. Hypertrophic Spinal Arthritis 89

25. Typhoid Fever 91

26. Appendicitis; Herpes Zoster 93

27. Unknown Infection 95

28. Sacro-iliac Strain 96

29. Sacro-iliac Strain 97

30. Renal Infection, Hematogenous or Ascending 98

3 1 . Pneumonia 100

32. Debility 101

33- Typhoid and Colon Bacillus Infection 103

34. Neuritis 105

35. Infectious Spondylitis 107

36. Vertebral Tuberculosis 108

37. Aortic Aneurysm 109

38. Lumbago (?); Infectious Spondylitis (?) no

39. Renal Stone; Multiple Renal Abscess in

40. Gall-stones 113

41 . Retroperitoneal Sarcoma 114

42. Typhoidal Spondylitis 115

43. Spinal Tuberculosis 117

44. Old Syphilis; Acute Spondylitis 118

45. Renal Stone 119

46. Debility 120

47. Streptococcus Meningitis 121

48. Prolapsed, Retroverted, Incarcerated. Pregnant Uterus 122

49. Parturition 1 23

49a. Tetanus 1 24

CHAPTER IV

GENERAL ABDOMINAL PAIN

Cask No.

50. Neurosis; Mucous Colitis 128

51. Bad Hygiene 132

52. Constipation 133

53. Peritoneal Tuberculosis 134

54. Postoperative Neurosis 136

TABLE OF CONTENTS 7

Case No. Page

55. Typhoid Fever 137

56. Neurosis 139

57. Lead Poisoning 140

58. Dynamic Aorta 141

50. Acute Gastro-enteritis 143

60. Cancer of the Stomach 144

61. Recurrent Intestinal Cancer 146

62. Tertian Malaria 148

63. Perforative Colitis and General Peritonitis .' 149

64. Cancer of the Rectum 150

65. Obstruction of the Intestine; Volvulus 151

CHAPTER V

EPIGASTRIC PAIN
Case No.

66. Hepatic Gumma; Syphilis 154

67. Plumbism 157

68. Constipation 159

69. Chlorosis 160

70. Tabes Uorsalis 161

71. Gastric Neurosis 162

72. Duodenal Ulcer 163

73. Gall-stones 165

74. Hvperchlorhydria (Alcoholism ?) 167

75. Angina Pectoris (Low) 168

76. Plumbism 169

77. Sarcoma Testis with Metastases 171

78. Tuberculous Peritonitis 172

79. Constipation 173

80. Pyloric Adhesions 174

81. Cholelithiasis and Gangrenous Gall-bladder 176

82. Cholelithiasis with Perforations 178

83. Acute Pericarditis 1 70

84. Arteriosclerosis; Vascular Crises 1S1

85. Pericarditis 183

86. Gastric Cancer 184

87. Pancreatic Cancer (Chronic Pancreatitis ?) 186

88. ( lastric Ulcer 1 87

89. Gastric Neurosis i8q

(jo. ( Jastric Neurosis 1 00

91. Alcoholism 102

92. Melancholia 103

93. Hepatic Congestion (Uncompensated Valvular Heart Disease) 105

04. Gall-stones 107

95. Gall-stones 10S

CHAPTER VI
RIGHT HYPOCHONDRIAC PAIN

Cask N'o.

06. Pericardial F.ffusion 205

07. Renal Stone 208

TABLE OF CONTENTS

Case No. Page

98. Catarrhal Jaundice 210

gg. Hepatic Cancer 211

100. Alcoholic Gastritis 214

101. Fibrous Endocarditis of the Mitral and Aortic Valves, with Insufficiency

of Both 215

102. Phthisis 217

103. Acute Cholecystitis 219

104. Hepatic Syphilis 220

105. Hiingebauch 222

106. Stone in Ductus Choledochus 224

107. Debility; Floating Kidney 225

108. Debility 227

109. Subdiaphragmatic Abscess 229

1 10. Pancreatic Cancer 230

in. Pericecal Tuberculosis 233

112. Duodenal Ulcer (Local Peritonitis) 234

113. Hysteria Minor 236

114. Cholecystitis Complicating Typhoid Fever 238

CHAPTER VII

PAIN IN THE LEFT HYPOCHONDRIUM

Case Xo.

115. Pyonephrosis with Stone 242

116. Functional Angina Pectoris 243

117. Congenital Cystic Kidneys 246

1 18. Myeloid Leukemia 247

1 19. Renal Infection 250

1 20. Hyperchlorhydria 251

121. Renal Stone 253

122. Hypernephroma 255

123. Tuberculous Enteritis 256

CHAPTER VIII

RIGHT ILIAC PAIN

Case Xo.

1 24. Pericecal Tuberculosis 258

125. Pericecal Tuberculosis 261

120. Tuberculosis of the Cecal Region 2O1

127. Normal Pregnancy 262

128. Ovarian Cyst with Twisted Pedicle 263

12Q. Tabes Mesenterica 264

130. ( )varian Cyst with Twisted Pedicle 265

131. Ruptured Ovarian Cyst 266

132. Ovarian Cyst 2(17

133. Stone in the Right Ureter 268

134. Tuberculosis of Right Tube 268

135. Mucous Colitis 269

136. Appendicular Colic (Chronic Appendicitis) 270

137. Stone in Both Kidneys 27:

TABLE OF CONTENTS 9

CHAPTER IX

LEFT ILIAC PAIN

Case No. Page

138. Perforated Gastric Ulcer 277

130. Bladder Cancer 278

140. Constipation 280

141. Syphilitic Adenitis 281

142. Multilocular Ovarian Cyst (Twisted Pedicle) 282

142a. Diverticulitis 284

General Consideration of the Diagnosis of Abdominal Pain 286

CHAPTER X

AXILLARY PAIN

Case No.

143. Pneumonia 288

144. Broken Rib 292

145. Unknown Infection 293

146. Angina Pectoris 295

147. Syphilitic Heart and Aorta 296

148. Pneumothorax (Pulmonary Tuberculosis) 298

149. Pleural Effusion 300

150. Artificial Menopause 302

151 . Typhoid Fever 303

152. Weak Heart; Acute Pulmonary Edema 305

153. Gall-stones 307

1 54. Sepsis with Thrombi 308

153. Pus Kidney (Tuberculosis ?) 310

1 5(1. Neurosis 312

157. Pericarditis 313

1 58. Thoracic Aneurysm 315

159. Old Pleurisy 317

160. Intercostal Neuralgia 310

161. Costal Tuberculosis 320

162. Starvation 1.20

CHAPTER XI

PAIN IN THE ARMS
Case No.

163. Traumatic Neurosis 324

164. Aneurysm (Called Rheumatism)

165. Mediastinal Neoplasm (Metastatic) 320

1 60. Neuralgia 330

i(>7. Infectious Cellulitis with Arthritis

108. Tuberculosis of the Humerus

i(>o. Septic Osteomyelitis ^34

170. Cellulitis 330

171. Cervical Rib

1 7 j. Sarcoma I lumen

1 73. Sarcoma I lumeri

IO TABLE OF CONTENTS

Case No. Page

i 74. Septic Osteomyelitis 340

1 75. Thoracic Aneurysm 341

176. Angina Pectoris (Syphilitic Aortitis ?) 343

177. Metastatic Hypernephroma 344

178. Malignant Lymphoma 346

CHAPTER XII

PAIN IN THE LEGS AND FEET
Case Xo.

1 79. Gonorrheal Arthritis 350

180. Arteriosclerosis; Chronic Nephritis; Pleural Effusion; Terminal Infection. . 353

181. Psoas Spasm Due to Nephrolithiasis 355

182. Psoas Tear 357

183. Pott's Disease with Psoas Abscess; General Tuberculosis 358

184. Sciatica 359

185. Neuritis with Herpes Zoster 360

186. General Pyogenic Infection 363

187. Gout 365

188. Fractured Pelvis and Sepsis 366

189. Acute Infection of the Hip 368

190. Tabes Mesenterica; General Tuberculosis 369

191. Flat-foot; Psychoneurosis 371

192. Acute Foot-strain 372

193. Alcoholic Neuritis 373

194. Pneumococcus Arthritis, Endocarditis (?), and Pneumonia 375

195. Gout 376

196. Pelvic Neoplasm 380

197. Carcinoma Uteri '. . 381

198. Sarcoma of the Femur 383

199. Septic Knee 385

200. Hysteria 3&5

201. Syphilis 386

202. Gout and Gonorrhea 3^7

203. Syphilis 389

204. Cerebrospinal Syphilis (Vascular Crisis ?) 3 C > X

205. Gonorrheal Arthritis 3Q 2

206. Sepsis 394

207. Flat-foot 305

208. Sacro-iliac Strain 395

209. Syphilitic Periostitis 397

210. Syphilitic Periostitis 39&

211. Pneumonia 399

212. Ischiorectal Abscess 4

CHAPTER XIII

FEVERS

Short Fevers 405

Xox-iNFECTiors Fevers 405

TABLE OF CONTENTS II

Case Xo. Page

213. Renal Infection (Bacillus Coli) 406

214. Syphilis 407

215. Pulmonary Tuberculosis '. . . . 409

216. Septic Thrombosis of the Lateral Sinus and Jugular Vein 410

217. Perirectal Abscess; Perinephric Abscess 411

218. Syphilis 413

219. Interlobar Postpneumonic Empyema 415

220. Poliomyelitis; Renal Infection 416

221. Typhoid Fever with Relapse 418

222. Typhoid Fever (Brief) 420

223. Typhoid Fever (Afebrile when First Seen) 422

224. Typhoid Fever; Impaction; Dysuria 423

225. Pleurisy (Tuberculous) 424

226. Pericecal Tuberculosis 426

227. Phthisis 428

228. Malignant Endocarditis 430

22Q. Vascular Crisis 432

230. Pneumonia and General Pncumococcus Infection 435

23 1 . Sepsis 437

232. Pleural Effusion 439

233. Epidemic Meningitis 441

234. Unknown Infection 443

235. Pneumonia 444

236. Pneumococcus Infection 446

237. Urticarial Fever 447

238. Pharyngeal (and Transpharyngeal) Infection 449

239. Streptococcus Sepsis 44q

240. Otitis Media 451

241. Glandular Fever 452

242. Catarrhal Jaundice 434

243. Miliary Tuberculosis 454

244. Estivo-autumnal Malaria 450

CHAPTER XIV

CHILLS
Case No.

245. Hepatic and Pulmonary Abscess 462

246. Hysteria (with Arteriosclerosis ?) 404

247. Influenza 405

24S. Chronic Glomerulonephritis 4(17

240. Otitis Media 4<>q

250. Phthisis 470

251. Phthisis 471

252. Double Pleurisy (Septic ?) 473

253. Pneumonia 475

234. Visceral Syphilis 477

233. Typhoid Fever . 478

25O. Ischiorectal Abscess . . . 4S1

237. Gall-stones 483

258. Deep Axillary Abscess 484

12 TABLE OF CONTENTS

CHAPTER XV

COMA

Page

Examination of Comatose or Convulsive Patients 486

Certain Hoary Errors to be Avoided 486

Causes of Coma and Convulsions 486

Valuable Clues 490

Case No.

259. Stokes-Adams' Disease 492

260. Mitral Disease (and Hysteria ?) 493

261. Chronic Valvular Disease; Sudden Heart Failure from Unknown Cause. . 495

262. Cerebral Tumor (?) 496

CHAPTER XVI

CONVULSIONS

Case No.

263. Alcoholism 501

264. Hysteria 502

265. Hysteria 503

266. Epidemic Meningitis 508

267. Chronic Interstitial Nephritis; Vascular Crisis 511

268. Chronic Interstitial Nephritis; Uremia 513

269. Otitis Media 514

270. General Paralysis 516

271. Stokes- Adams' Disease 518

272. Stokes-Adams' Disease 520

273. Tonsillitis and Congenital Heart Disease 522

274. Cerebral Tumor 523

275. Dementia Paralytica 525

276. Lead-poisoning 527

277. Syphilis 529

CHAPTER XVII

WEAKNESS

Case No.

278. Addison's Disease 535

279. Alcoholism 53$

280. Secondary Anemia; Piles 539

281. Pernicious Anemia 54

282. Apprehension 54 2

283. Chlorosis 544

284. Empyema (Tuberculous ?) 545

285. Empyema 547

286. Gastric Cancer 548

287. Cancer of the Liver 550

288. Diabetes Mellitus 551

289. Diabetes Mellitus 553

290. Lead-poisoning 554

291. Myeloid Leukemia 555

TABLE OF CONTENTS 1 3

Case No. Page

292. Alcoholic Neuritis 557

293. Chronic Plastic Pleurisy 559

294. Convalescence from Pneumonia 560

295. Psychoneurosis 562

296. Pus-tube 563

297. Staphylococcus Sepsis 565

298. Phthisis 567

299. Vertebral Tuberculosis 568

300. Pernicious Anemia 570

301. Graves' Disease 572

302. Myxedema 573

CHAPTER XVIII

COUGH

Varieties of Couch 576

Case No.

303. Pulmonary Abscess 579

304. Aneurysm 582

305. Bronchitis and Appendicitis 584

306. Bronchitis and Asthma 585

307. Streptococcus Bronchopneumonia 587

308. Bronchiectasis 588

309. Bronchitis; Bronchopneumonia; Bronchiectasis; Emphysema 590

310. Pneumonia 501

311. Pneumonic Phthisis 503

312. Traumatic Pneumonia 596

313. Phthisis 599

314. Miliary Tuberculosis and Diabetes doo

315. Syphilitic Disease of the Lung 002

316. Tuberculosis of the Lungs, Chronic Interstitial Nephritis, Hypertrophy

and Dilatation of the Heart. Tubercular Ulcers of the Intestine.

Hypernephroma 604

317. Internal Urticaria 605

CHAPTER XIX

VOMITING
Important Factors in the Production of Vomiting 611

Cask No.

3 1 8. Alcoholism 611

310. Appendicitis 613

320. Gastric Cancer ''14

)id
uX

12 I

321. Gastric Cancer

322. Cancer of the Sigmoid.

323. Chlorosis

324. Constipation (Neurosis
3-'v Constipation (Neurosis
32(1. Catarrhal Jaundice. . . .
327. Exhaustion

14 TABLE OF CONTENTS

Case No. Page

328. Tabes with Gastric Crisis 630

329. Traumatic Neurosis 631

330. Gastric Neurosis 633

331. Neurosis; Gastroptosis 635

332. Gastric Ulcer; Pyloric Stenosis 637

333. Tertian Malaria 639

334. Malaria (Tertian) 642

335. Tuberculous Meningitis 643

336. Incomplete Miscarriage 645

337. Chronic Interstitial Nephritis, Enteritis and Gastritis with Chronic

Colitis and Terminal Streptococcus Septicemia 646

338. Nervous Exhaustion 649

339. Phthisis 650

340. Pneumonia 652

341. Vomiting of Pregnancy; Pleural Effusion 654

342. Mitral Stenosis 656

343. Cancer of the Ascending Colon 657

344. Hysteria; Alcoholism; Drug Habits 659

345. Chronic Intestinal Obstruction, Probably Due to Malignant Disease 661

346. Neurosis; Morphin 662

CHAPTER XX

HEMATURIA

Causes and Types of Hematuria 667

Case No.

347. Tuberculosis of the Kidney and Bladder 669

348. Tuberculosis of the Bladder; Renal Tuberculosis (?) 670

349. Renal Neoplasm 671

350. Chronic Nephritis 673

351. Cancer of the Bladder 674

352. Cystitis of Unknown Origin 675

353. Papillary Cystadenoma of the Kidney 677

354. Hematuria, Cause Unknown 678

355. Renal Irritation from Oxaluria 680

356. Hypernephroma 681

357. Gastric Ulcer; Hematuria, Cause Unknown 682

358. Cystitis; Enuresis 683

CHAPTER XXI

DYSPNEA

Causes of Dyspnea 689

The Effect of Position and of the Time of Day 690

Cheyne-Stokes' Breathing 690

Case No.

359. Hysteria; Polypnea 6qo

360. Aortic Stenosis and Regurgitation 694

361. Infectious Endocarditis, Myocarditis, and Pericarditis; Mitral Stenosis

and Regurgitation 695

362. Hyperplastic Endometritis; Debility 698

TABLE OF CONTENTS 1 5

Case No. Page

363. Bronchitis and Emphysema; Epilepsy 700

364. Tuberculous Empyema and (Presumably) Phthisis 701

365. Acute Cardiac Dilatation, Cause Unknown 704

366. Acute Laryngitis 706

367. Croup 708

368. Chronic Glomerulonephritis 709

369. Myocardial Insufficiency 710

370. Mitral Stenosis and Regurgitation 711

CHAPTER XXII

JAUNDICE

Types and Causes of Jaundice 715

Associated Symptoms 716

Intensity of Jaundice 719

Case No.

371. Catarrhal Jaundice 719

372. Catarrhal Jaundice 721

373. Tertian Malaria 722

374. Gall-stones 723

375. Gall-stones 724

376. Pancreatic Cancer 726

377. Acute Yellow Atrophy of the Liver 727

CHAPTER XXIII

NERVOUSNESS
Case Xo.

378. Diabetes Mellitus 731

379. Phthisis 733

380. Suppurative Nephritis 735

381. Endothelioma of the Pleura; Acute Serofibrinous Pericarditis and General

Arteriosclerosis 738

382. Pernicious Anemia 739

383. Chronic Interstitial Nephritis 741

Appendices 743

Index 747

DIFFERENTIAL DIAGNOSIS

INTRODUCTION

J. THE PRESENTING SYMPTOM

Cases of disease present, as we say, certain leading symptoms.
They thrust forward, like a soldier who presents arms, a complaint such
as pain, cough, or "nervousness," so that it occupies the foreground
of the clinical picture. Such a "presenting symptom" comparable to
the "presenting part" in obstetrics, may turn out to be of minor im-
portance when we have studied the whole case. But at the outset it
has the power to lead us toward right or wrong conclusions in diagnosis,
prognosis, and treatment, according as we have or have not learned
the art of following it up.

This book is an attempt to study medicine from the point of view
of the presenting symptom. I hope to show how the complaints of the
patient fragmentary expressions of the underlying disease should be
used as leads, and how their lead can be followed to the actual seat of
the disease.

The plan thus outlined has three parts:

(a) To present a list of the common causes of the symptoms
most often complained of by patients, e. g., the causes of pain
in the back, of vomiting, or of hematuria.

(b) To classify these causes in the order of their frequency,
so far as this is possible.

(c) To illustrate them by case-histories in which the present-
ing symptom is followed home until a diagnostic problem
and its solution are presented.

2. THE GROUPING OF REASONABLE POSSIBILITIES

Diagnoses are missed (a) L^sually because physical signs are not
recognized; (b) occasionally because we do not think correctly.

This book will not help any one to recognize the signs of disease,
but it ought to aid physicians to solve those clinical puzzles wherein
the diagnosis is missed because the patient's disease is not among those
2 17

l8 DIFFERENTIAL DIAGNOSIS

considered and looked for. In other words, correct diagnosis depends
upon what enters the doctor's head as possible, and on what his head
does to sift the possibilities after they have entered it, as well as on the
direct recognition of signs by physical examination.

To throw open the mind's door and allow all disease to enter into
consideration each time that we are called to a bedside is foolish in the
attempt, and impossible in the performance. Each case should lead
us to arrange before the mind's eye a selected group of reasonably prob-
able causes for the symptoms complained of and for the signs discovered.
What we select should depend upon the clues furnished us by the
patient himself, or by the results of our own examination.

When, for example, a patient pronounces the word "headache" a
group of causes should shoot into the field of attention like the figures on
a cash register. Blue lips and finger-nails call up quite another group
of ideas. Each clue or combination of clues should come to possess
its own set of radiations or "leadings," determined partly by what we
know of anatomy and physiology, partly by the hard knocks of clinical
experience.

3. ADVANTAGES OF THE PLAN HERE ADOPTED

This way of working into a knowledge of medicine has the advantage
of following the course of procedure by which we often question and
examine patients in the office or in the clinic. We begin with the chief
complaint and work inward and backward to the causes, the organic
lesions, the evolution, probable outcome, and rational treatment of the
case. Cases do not often come to us systematically arranged like the
account of typhoid in a text-book of practice of medicine. They are
generally presented to us from an angle, and with one symptom, often a
misleading one, in the foreground. From this point of view we must
reason and inquire our way back into the deeper processes and more
obscure causes which guide our therapeutic endeavors.

Why do so many practitioners treat symptoms only? Why are their
diagnoses and the resulting treatment so full of vagueness, groping,
hedging, and ''shot-gun'' prescriptions?

Because they do not know how to get beyond symptoms. They
have not been taught from the point of view of practice i. e., of the
presenting symptom. What are the possible causes and linkages of
any symptom? Which of them are most probable? Bv what methods
of questioning or of examination can the actual cause be found? This
book aims to put into the physician's hand the means of answering these
questions.

INTRODUCTION 1 9

I quite realize that the art of forming reasonable hypotheses about a
case of disease and then of testing these hypotheses by such experiments
as shall establish the correct and nullify the incorrect, is useless unless
the methods of physical and chemical diagnosis have been mastered and
unless the natural history of all common diseases has been learned by
observation and reading. But experience shows that a man may pos-
sess a considerable acquaintance with physical diagnosis and with the
course of disease, and yet be quite helpless in the presence of a suffering
person, simply because he cannot apply his knowledge to this case.
He can observe, he can remember, but he cannot constructively think
and experiment. Every item of physical or chemical examination is an
experiment made to test the soundness of an idea about the case in hand.
Skill in thinking and in putting our thoughts to such a test of experiment
are not learned either by drill in physical diagnosis or by reading upon
the history of disease.

To give such practice in thinking and working one's way into the
mastery of a case of disease, through the intelligent verification of our
thoughts by physical examination, is my object in the following chap-
ters. They follow the method of case-teaching which I have used for
eight years at the Harvard Medical School, applying there a method long
employed at the Harvard Law School, and first described by Dr. W.
B. Cannon.

4. LIMITS

To keep the book within reasonable limits I have selected 12 symp-
toms (see Table of Contents) which are most often complained of by
patients. I am well aware that others, such as diarrhea, constipation,
loss of weight, paralysis, pallor, edema, purpura, or palpable tumors,
might well have been discussed did space permit.

5. VULNERABILITY OF ALL DIFFERENTIAL DIAGNOSIS

The discussions which here follow each printed case are concerned
with differential diagnosis, a very dangerous topic dangerous to the
reputation of physicians for wisdom. It is. I suppose, owing to this
danger that so little has been written on differential diagnosis and so
much on diagnosis (non-differential). To state the symptoms of typhoid
perforation is not difficult. To give a set of rules whereby the condi-
tions which simulate typhoid perforation may be excluded is exceedingly
difficult. Physicians are very naturally reticent on such matters, slow-
to commit their thoughts to paper, and very suspicious of any attempt
to tabulate their methods of reasoning.

20 DIFFERENTIAL DIAGNOSIS

Yet all diagnosis must become differential before it can be of any use.
All recognition of a lesion or a disease involves distinguishing possible
sources of error and excluding them by a reasoning process more or
less definite and conscious. To be of any value, then, diagnosis must
descend into the arena where it is questioned and assailed, where all
sorts of errors and uncertainties arise to unsettle our wisdom. Those
differential tables which we all distrust so much are really no more
untrustworthy than the diagnoses we make in practice for every diag-
nosis expresses the results obtained by using such a table more or less
unconsciously, as we exclude possible errors and alternative diagnoses.

I am very well aware, therefore, that the differential diagnostic state-
ments which fill this book are one and all subject to such limiting phrases
as "in most cases," "as a rule," etc. This must always be so as long as
the list of possible causes or diagnoses which we call to mind when we
attack any diagnostic problem is an incomplete list (or possibly an over-
inclusive one) . To decide which of the known causes of jaundice is the
cause of the yellowness of Miss Smith we investigate, by the experiments
known as "history," "physical examination," and "therapeutic test,"
a list of these known causes. But some day we may meet a case in which
none of these well-known causes is present. Some new cause, so far
unlisted, may, in fact, be at work. There are probably as many fish in
the sea as ever came out of it; the unrecognized infections, poisons,
and maladjustments are probably as many as those already described in
text-books.

All this unconquered territory lies about us, full of hidden dangers to
our differential diagnosis i. e., to all practical diagnosis.

One other limitation must be mentioned. Whenever one says:
"The symptoms produced by typhoid (or by peritonitis or by renal
stone) are such and such," one should tacitly add "provided that it
produces any characteristic symptoms at all." It is certain that the
three diseases just mentioned may exist without producing any symp-
toms of which the patient is aware. It is probable that this is true of
all other diseases. But as we can have no direct dealing with these
silent types of disease, we can give them place in the theater of our
reasonings only in that outer circle reserved for "possible sources of
error," a great and distinguished company whose presence serves to keep
us within the bounds of humility and of scientific caution.

Meantime we must go on with our work of finding the most prob-
able among the known causes and discoverable types of disease.

INTRODUCTION 21

6. OMISSIONS

Some diseases are omitted by choice, others by necessity. The 385
cases which I have selected for study were all seen in private or hospital
practice. To prevent the possibility of their recognition by the individ-
uals concerned I have changed or omitted certain personal details.
In essentials the cases are reproduced as they were observed.

I have chosen no cases in which diagnosis was obvious and none in
which it was impossible or dependent chiefly on good luck. To avoid
the obvious, I have omitted discussion of such clinical pictures as the
following:

Patient of twenty-five, who has had two attacks of rheumatic fever, complains of
dyspnea, dropsy, and cough. Examination shows a rapid, irregular, transversely enlarged
heart, with a presystolic murmur and thrill at the apex and an accentuated pulmonic
second sound. There is evidence of passive congestion of the lungs, liver, legs, and gas-
trointestinal tract, with dropsy of the serous cavities.

There may be many difficulties in physical examination here, but
none in the reasoning processes which lead us to the examination and
thence to our conclusions. Obvious maladies, such as pharyngitis,
peripheral gangrene, or talipes, have been omitted for the same reason;
likewise all those in which diagnosis is made only by incision; e, g., acute
pancreatitis, certain breast tumors.

While selecting cases in which diagnosis was difficult, but not impos-
sible, I have tried to choose those in which in the end we could attain a
reasonable certainty. Absolute certainty is attainable only as the result
of operation or autopsy, and not always then. Hence it is possible that
certain of my readers may disagree with the diagnosis finally reached in
some cases. This is inevitable in a book of this kind, as it is in actual
practice. Book and practice alike can only reflect the existing state of
medical knowledge, medical uncertainty, and ignorance. But I sin-
cerely hope that my errors may be pointed out by correspondents.

After restricting the field in the way just mentioned, I have tried
to exemplify in each chapter all the diseases which often lead a patient
to consult his phvsician, complaining of the symptom which forms the
subject of that chapter. Now and then, however, I have altogether
omitted some important disease because T could not find any suitable
example of it within my own cases or among those which I had myself
studied.

In a few cases certain items have been omitted here because they
were likewise omitted in the version of the ease given me by the attending
physician. My task was to notice their conspicuous or inconspicuous

22 DIFFERENTIAL DIAGNOSIS

absence, and to act accordingly. It seems justifiable, therefore, to impose
a similar task upon my readers.

7. EXPLANATION OF DIAGRAMS AND CHARTS

The book contains figures, tables, diagrams, and charts. The two
last need some explanation.

The diagrams, which are introduced in each chapter just before the
illustrative cases, represent an attempt (the first that I know of) to esti-
mate the relative frequency of the commoner causes for each symptom
discussed. This estimate, which can be but approximate, rests upon the
following data:

(a) An enumeration of the total number of cases of every disease
treated at the Massachusetts General Hospital during the last six years.
About 180,000 cases are thus classified according to diagnosis, and the
relative frequency of each disease in this material is thus roughly com-
puted. But these figures do not give us the relative frequency of any of
the symptoms (such as jaundice or headache) studied in this book.
Many cases of gall-stones are not jaundiced; hence we cannot directly
compare the number of gall-stone cases with the number of cirrhoses
(for example), but must estimate the percentage of jaundiced cirrhoses
and jaundiced gall-stone disease in each group. This is done by con-
sulting

(b) Statistical articles from the literature in which the percentage
occurrence of each symptom in a large series of cases is worked out.
Such statistical articles, however, are not common. In Rolleston's
magnificent monograph on the liver almost every statement has a
statistical basis, and the wearisome recurrence of phrases like "as a
rule," "not infrequently," "sometimes," etc., is replaced by concrete
quantitative estimates. But there are not many such books. Hence
I have been forced in some instances to compute the percentage occur-
rence of a symptom by

(c) The study of the symptom and of the frequency of its occur-
rence in 250 cases of the disease in question; these cases were taken
from the more recent records of the Massachusetts General Hospital.

By the methods described under (a), (b), and (c) the length of every
line in every diagram has been calculated. I am well aware that there are
numerous sources of error in these calculations. The diagnoses in the
Massachusetts General Hospital records ma}' be faulty in some instances,
though the large number of cases used tends to minimize such errors.
The statistical articles referred to under (b) may be incorrect, and do not
often include a very large bulk of cases. Finally, the number of cases

INTRODUCTION

referred to in the calculations under (c) is smaller than I should wish.
More important than any of these errors are the absolute omissions which
are sure to be discovered among my tables of causes. I hope for much
aid from my critics in supplying such missing links. Indeed, I am con-
fident that some one will be so indignant at my mistakes that he will at
once begin to write a better book on similar lines a result which I most
earnestly desire.

The sources of my information regarding the figures used in the dia-
grams are given in Appendix A, p. 743.

The list of causes represented in these gridiron-shaped diagrams is
not wholly the same as that exemplified in the illustrative cases. Only
the commonest, clearest, and most important causes are drawn in upon
the "gridirons." Still a third group of causes, which do not lend them-
selves either to diagrammatic or to detailed illustrative treatment, are
mentioned briefly in the introductory section of each chapter. Hence
the complete list of causes discussed is to be found (a) In part in the
gridirons; (b) in part in the illustrative cases; (V) in part in the intro-
ductory section of each chapter.

The Charts. Beside the three lines, which represent in the ordinary
way the course of temperature, pulse, and respiration, there is a fourth
line interwoven with the respiratory curve, and distinguished by the
presence of cross stria?, like the railroads on a map. This line stands for
the twenty-four-hour amount of urine measured in ounces.

In the charts the line of this type - t m mmem nimmmrn i Himnn
indicates the amount of urine in ounces, while the line cut by suirs, as
follows, * * * represents the blood-pressure.

CHAPTER I

PAIN
GENERAL CONSIDERATIONS

Before we begin to study the cause or the cure of any pain, we need
to convince ourselves that it really exists. Not only in the cases of
deliberate deception or malingering, but in dealing with perfectly honest
people, we are liable to error. Many persons, especially of the less
educated classes, do not distinguish between pain and the other varieties
of discomfort, such as itching or a sense of pressure. Many patients who
say at first that they have a headache or a stomachache may be brought,
by a little questioning, to recognize that they are referring to a sense of
weight, constriction, or vague discomfort, rather than to pain in the
narrower sense.

As evidences of pain we are accustomed to scrutinize:

(a) The facial expression and bodily movements.

(b) The account of some onlooker, such as a nurse or relative.

id) The blood-pressure.

When a patient's face is contorted and his body writhes, stiffens, or
doubles up, we can have no doubt that he is suffering, unless we believe
him an impostor, but obviously these evidences of pain may be easily
simulated or exaggerated.

It is in such cases that we need the testimony of some third person
who can watch the patient at a time when he supposes himself to be alone.
Many patients who do not intend to deceive us show far greater evidences
of suffering when a doctor, a nurse, or a friend is near at hand than when
they believe they are unobserved. This is partly due to the fact that a
perfectly genuine though distinctly mild lesion is very much more pain-
ful to the patient when his self-pity is aroused by the presence of a sym-
pathetic onlooker.

When a patient who bears the ordinary marks of blooming health
states that he has been suffering excruciating pain for many months,
the lack of any of the ordinary evidences of suffering naturally and

PAIN 25

properly make us take his statement with a grain of salt. Chronic
suffering is pretty sure to leave its mark on the face and body.

In cases of suspected malingering, when an individual states that a
certain motion or a certain pressure upon a supposedly tender point
causes great suffering, we may control his statement to a certain extent
by measuring the peripheral blood-pressure at the time. Severe pain
almost always causes a notable rise in blood-pressure, and if we find noth-
ing of the kind, we may rightly conclude that if pain is present, it is
probably not intense.

DEGREE OF PAIN

I have long been accustomed to compare, as a matter of routine and
in every case, the extent and quickness of the knee-jerks with the patient's
statement regarding his own suffering. I have found that those who
describe all their troubles as "terrible," "awful," "fearful," and the
like, are very apt to have lively knee-jerks, and that those who are more
moderate in their expressions have usually less active reflexes. It
seems quite probable that there is a parallelism here between reflex
sensibility and sensitiveness to pain. Those who respond to a given
stimulus by an exaggerated knee-jerk might well be expected to respond
to a given cause of pain by an exaggerated complaint. So it has seemed
to me as a result of many observations, and I have come to believe that
people are more likely to be oversensitive and to exaggerate their suffer-
ings when the knee-jerks are unusually lively.

This is, of course, a very rough and uncertain method of measuring
pain, and would perhaps be more truly described as an attempt to meas-
ure the severity of the cause of pain, rather than of the pain itself. We
are greatly in need of some more accurate method of estimating how
much people suffer. For the present, we have to judge largely by such
uncertain evidences as were mentioned in the last section facial expres-
sion, bodily movement, the accounts of onlookers, and the evidences of
such physical changes as pain might produce. In addition to these
we get a certain amount of information by asking:

''Does the pain prevent you from working?''

"Does it prevent sleep?"

"Does it take away appetite, the capacity for movement and en-
joyment in the ordinary functions of life?"

We know that certain races for example, the Chinese are much
less sensitive than others to pain in that they exhibit far less evidence of
"shock" after a bullet wound or a disembowelment. We can only guess
at the sensory side of this phenomenon, but the absence of the ordinary
organic effects produced by the same injury in a Caucasian gives us some

26 DIFFERENTIAL DIAGNOSIS

ground for believing that the suffering is proportionately small. In all
probability there are similar differences between individuals of the
same race.

Though women are generally believed to be more highly organized
and more sensitive than men, it is a well-known fact that they bear pain,
especially prolonged pain, better than men. I have never heard any
plausible explanation of this fact.

TYPES OF PAIN

Most of the adjectives which are attached to the complaints of pa-
tients, either by themselves or in the text-book description, give us no in-
formation of value because they are not regularly associated with any
one disease. Boring pains, tearing pains, and knife-like pains do not
characterize any particular disease. Nevertheless, there are a few dis-
tinctions of importance.

Pains that recur rhythmically, or at regular intervals, working up
gradually to a climax each time, and then disappearing suddenly or
gradually, are often associated with hyperperistalsis within some hollow
tube, such as the intestine, the ureter, the bile-ducts, or the uterus. To
such pains the name of "colic" is traditionally attached, though it is
often used much more vaguely to denote any type of severe and sudden
pain in the abdomen.

Throbbing pains, increased momentarily with each beat of the heart,
are characteristic of vascular hyperemia, such as occurs about the roots
of an inflamed tooth. In connection with vasomotor headaches and in
dysmenorrhea we occasionally see the same phenomenon.

Pain with a sense of constriction is of great diagnostic value when it
occurs in the precordial region, pointing, as it does, in the great majority
of cases, to angina pectoris as its cause. Other diseases producing pain
in this region are rarely, if ever, accompanied by this sense of constriction,
which the patients often express in very vivid phrases, e. g., "as if I were
squeezed in a vise," or "as if some one gripped my heart in his hand."

Thoracic or abdominal pain increased or produced by exertion and
promptly relieved by rest is almost always due to the cause just men-
tioned angina. Many pains supposed by the patient to be due to in-
digestion, to rheumatism, or to neuralgia may thus be recognized as
anginoid.

Pain that shoots and darts, especially if it follows the course of some
nerve-trunk, usually turns out to be neuralgic. In many cases such a
[tain is associated with prickling, burning, numbness, or other pares-
thesias.

PAIN 27

RELATION OF PAIN TO OTHER FACTS

A careful history of the bearing of various factors in the patient's
habits and environments upon the occurrence or the severity of pain is of
prime importance in diagnosis. Among the elements to be taken account
of are the relation of pain to:

(a) The time of day.

(b) The position of the body.

(d) The effect of motion involving the painful part, or of jolt-
ing of the entire body.

(e) The effect of emotional excitement.
(/) The effect of occupation.

(g) The effect of season and the weather.
(h) The mode of relief e. g., by heat, cold, food, vomiting,
medicine, rest, occupation.

Neurasthenic headaches and the pains of chronic joint troubles arc
apt to be worse in the morning and to improve as the day goes on. Any
pain associated with fever and infection is likely to be worse in the even-
ing, when the temperature is at its highest.

Pains affected by position are especially those due to diseases of the
joints and muscles, such as lumbago, sacro-iliac strain, all the types of
arthritis, stiff neck, and the like. Almost all varieties of pelvic disease
are worse when the patient is on her feet, as the position is likely to
involve some pressure or dragging upon painful points. For the same
reason the surgical affections of the kidney and all diseases which in-
volve splenic enlargement are usually more painful when the upright
position is assumed. Occasionally a headache is distinctly improved or
aggravated when the patient lies down. The distress accompanying
uncompensated cardiac disease is always aggravated by recumbency.

Most muscular pains are aggravated by the use of the muscle; hence
the presence of such an aggravation may help us to distinguish muscular
pains from those of different origin. It must be remembered, however,
that in some cases the pains of neuritis are increased by use of the part,
even when no muscular lesion is discoverable. The motion of coughing
brings great distress in pleurisy, pneumonia, and all diseases involving
the intercostal muscles. Anginoid pains are increased not only by
motion, but by any other cause which raises blood-pressure (.gastric
digestion, mental exertion, or excitement).

On the other hand, some pains are made worse by rest; for example.
all types of habit pains, to which 1 shall refer more in detail in the next
section. The pains of chronic joint troubles are worse immediately after
rest, when the patient attempts to move his stiffened joints.

28 DIFFERENTIAL DIAGNOSIS

The effect of jolting, as in riding on a rough road or a rough-gaited
horse, is traditionally associated with an increase of the distress pro-
duced by stone in any part of the urinary tract. Doubtless this is a true
observation, but there are many exceptions to the rule.

Aggravation of any pain by the taking of food properly inclines us
to believe that the pain is produced in the stomach (gastritis, gastric
ulcer, gastric cancer, gastric neurosis). Many intestinal pains, however,
are likewise produced or increased when food enters the stomach.
Thus the sufferings due to enteritis and to chronic intestinal obstruc-
tion are often much worse immediately after a meal. It appears to
be true, moreover, that pain due to gall-stones, and even to chronic
appendicitis, may be set agoing by the presence of food in the
stomach. I have already referred to the excitement of anginoid pain
through the rise of blood-pressure produced by the act of digestion.
Possibly an accompanying gaseous distention may help to call out the
attack.

Relief of pain by food is characteristic of peptic ulcer and of hyper-
chlorhydria, as well as of the vaguer gnawings due to hunger.

Many types of muscular, articular, and neural pains are subject
to aggravation as the result of various meteoric conditions, of which we
understand all too little. It cannot be questioned, I think, that the
muscular pains involved in lumbago and stiff neck are more apt to be
present in damp, rainy weather, such as occurs in the spring and fall,
than in dry heat or dry cold. The persons who can foretell a storm by
the disagreeable sensations in the neighborhood of diseased joints are
very numerous, but I have never been able to associate this form of
prophecy with any one type of disease. I am also convinced that the
approach of a thunder-storm may precipitate a headache not only in
those predisposed to migraine, but in other sensitive persons. Whether
this is due to barometric, to electric, or to quite unknown conditions
I am unable to say. Many of my patients have noticed that their
headaches are more apt to occur on especially bright, bracing days,
when the air is unusually clear.

Relief by vomiting does not prove that the disease is of gastric origin.
Intestinal pain, biliary colic, renal colic, and the sufferings of duo'denal
ulcer may also be relieved by emesis.

Relief by heat or by cold cannot be predicted for any variety of
pains. The same disease in different individuals may be assuaged now
by the one now by the other agencies. It is wholly a matter of experi-
mentation. But in my experience most of the pains which cold relieves
are more completely and more permanently abated by heat.

PAIN

HABIT PAINS
The term is a misleading one, and needs more explanation than the
fact. The genesis of the latter may be described as follows:

(a) Some exciting, terrifying, or mortifying event draws the patient's
attention to a certain part of his body the cardiac region or the pharynx,
for example. Then

(b) As the microscope discovers bodies invisible to the unaided eye,
so the patient's focused and concentrated attention discovers sensa-
tions due probably to some of the physiologic changes occurring normally
in the part to which attention has, unfortunately, been directed. These
changes go on normally without producing any sensation noted by the
brain. But when the brain is sensitized, especially in relation to the part
attended to, even the heart-beat may be felt as painful, or the normal
blood, lymph, and nerve-currents of the pharynx may be magnified
into painful events.

(c) The "set" of attention produced by habit keeps the brain "on
edge," keyed up to perceive the slightest glimmer of sensation, such as
we ordinarily disregard.

(d) Finally, some actual disturbance of the function of the part
may follow this abnormal interference of consciousness in activities
which should be subconscious. The heart-beat becomes irregular;
the pharynx secretes abnormally. This redoubles, of course, the
patient's alarmed concentration upon the part, and so a vicious circle
is established.

Such a circle is broken, and the diagnosis of habit pain confirmed
when we succeed in switching off the patient's attention upon other
subjects and thus making him forget, at any rate for a time, his habitual
sufferings.

THEORIES REGARDING THE PRODUCTION OF PAIN
I wish to refer briefly to the beliefs of McKenzie and Head, also to
those of J. Pal, regarding the means whereby pain is produced under
certain conditions.

To James McKenzie 1 and to Henry Head 2 we owe the elaboration
of a theory whereby pain and cutaneous hyperesthesia are viewed as
associated manifestations of morbid irritability in one or another group
of spinal ganglion-cells. According to their theory, this irritability
is due to impulses transmitted from a diseased organ, which, though
not itself the seat of pain, yet causes in the corresponding spinal segment

1 James McKenzie, Symptoms and their Interpretation, Shaw and Sons, London, 1009.

2 Henry Head, On Disturbances of Sensation, Brain, 1S93, vol. xvi, p. 1; also in
6ui>sc<[Uent numbers, 1S94, 1896, 1900, etc.

3<D DIFFERENTIAL DIAGNOSIS

a disturbance which is transferred thence to the periphery of the body,
and there recognized by the individual as pain in a place often far distant
from the organ diseased.

Thus these writers account for the umbilical pain experienced in
intestinal obstruction, no matter where the stoppage occurs, by supposing
that all parts of the intestine are represented in the cord by the same
spinal segment, and that the umbilical region is the seat of centrifugal
impulses from that center, resulting in cutaneous hyperesthesia, as well
as pain.

The best confirmation and exemplification of this theory are seen in
the so-called radiations of the pain known as angina pectoris, and in the
similar radiations from the site of biliary colic. It is difficult to account
for the arm pains of angina and the shoulder pains of gall-stone disease
on any other hypothesis, and if all other types of pain could be traced
with similar accuracy to a spinal segment, rather than to an organ
directly underlying the painful spot, the theory of McKenzie and Head
would deserve our unqualified assent. In point of fact, however, the
two examples given above are almost the only ones in which the theory
is clearly verifiable. The pain of appendicitis, of pleurisy, most kid-
ney pains and splenic pains do not well accord with the tneory, and
the zones of cutaneous hyperesthesia which are essential to the con-
firmation of their theory have seldom been found by other observers.
In spite of my profound respect for the originators of this theory, I have
been unable to apply it successfully in clinical work, except in the two
diseases just referred to, and in the localization of spinal lesions.

More useful, on the whole, is the book on Gefasskrisen, 1 in which
Pal elaborates, upon the basis of careful observation, both at the bed-
side and at the dead-house, a theory of the origin, not of all pains, but of
certain paroxysmal types of suffering associated especially with the vessels
of the brain, the heart, and the kidney, but to a lesser extent with those
of the intestine and of the extremities. He supposes that arterial spasm
(favored and prepared for by arteriosclerosis, by uremia, by lead-poison-
ing, and by the nerve lesions of tabes) is the cause of a large group of
pains, paralyses, and other functional disturbances which had never before
been brought together under any single explanation. Taking lead-poison-
ing as an impressive example of the theory, he points out that we have
here a notable rise of blood-pressure, associated sometimes with cerebral
crises (headache, convulsions, coma), often with abdominal crises
(lead colic), and occasionally with anginoid seizures. In arteriosclerosis
we have likewise cerebral, abdominal, and cardiac crises, and, in addi-

1 J. Pal, Ge/asskrisen, Leipzig, 1905.

PAIN

tion to these, well-marked peripheral crises (intermittent claudication).
In uremic and eclamptic poisoning we have likewise cerebral and ab-
dominal crises. In tabes dorsalis the abdominal crises are the most
familiar.

In all these affections postmortem examination may demonstrate
that there is no gross lesion, such as cerebral hemorrhage or throm-
bosis, coronary occlusion, or blocking of a peripheral artery. Indeed,
the arteries and the surrounding tissues may appear almost or quite
normal postmortem. It is natural, therefore, to assume some functional
change, such as spasm, to account for the pain, paralysis, and other
functional changes recognized at the bedside. In favor of the hypothe-
sis of vascular spasm, or Gefasskrise, are two considerations:

(a) A rise of blood-pressure has many times been demonstrated by
Pal bejore, as well as during, the crisis. This hypertension cannot
be accounted for as a result of pain, since in many of Pal's cases it pre-
ceded the pain. He has found it in the gastric crises of tabes, as well as
in the uremic, saturnine, and arteriosclerotic cases.

(b) During an attack of transient blindness occurring in a patient
who had been subject to various other ''crises," ophthalmoscopic ex-
aminations showed a high-grade spasm or contraction of the retinal
arteries.

So much for the theory and the evidence on which it is based. It
seems to me a good working hypothesis as an explanation of many
of the transient amauroses, aphasias, monoplegias, hemiplegias, and
headaches associated with chronic nephritis. Like other theories,
it is to be tested partly by what it enables us to discover. Like the
atomic theory, it may lead us to perceive and so to fill in certain gaps,
such as appear in the following table:

CRISES

1. Arteriosclerosis

2. Nephritic hyperten-
sion ("uremia")

3. Tabes dorsalis

4. Plumbism

Cerebral.

irdiac.

Abdominal.

ripheral.

+ ?

I may here acknowledge my deep indebtedness to Rudolf Schmidt's
book on Pain, 1 which has guided and confirmed my own observa-
tions on many points.

1 Pain its Causation and Diagnostic Significance, by Rudolf Schmidt; translated
by Karl M. Vogcl and Hans Zinsser, J. B. Lippincott Company, 190S.

CHAPTER II
HEADACHE

J. GENERAL CONSIDERATIONS

In discussing this, probably the commonest of all symptoms, I shall
exemplify by cases only such causes as are likely (a) to be complained
of by the patient as his leading symptom, and (b) to occasion diagnostic
difficulties. Others will be briefly mentioned here.

i. Anemia of any type pernicious, chlorotic, posthemorrhagic
is now and then accompanied by headache, usually as a minor symptom.
It is noteworthy, however, that intense anemia often persists for months
without producing any headache whatever. It may well be doubted
whether anemia is ever in itself the cause of headache. 1

2. Fatigue, hunger, and bad air often produce a headache (perhaps
due to the circulation of " fatigue poisons") whose cause is made obvious
by its disappearance after rest, food, and fresh air.

3. Poisons, such as alcohol, morphin, and lead. Except after a
drinking bout, I have never known a patient whose chief complaint, as a
result of any of these poisons, was headache. Other symptoms usually
occupy the foreground.

4. Arteriosclerosis. It has long been stated in medical lectures and
text-books that the headaches of elderly persons are frequently caused by
arteriosclerosis. My own experience, however, coincides entirely with
that of Thomas, of Walton, and of Paul, 2 who deny any such asso-
ciation. In my experience, it is only when the kidney is extensively
involved and blood-pressure thereby raised that headache results from
arteriosclerosis.

5. Indigestion and Constipation. Gastric stasis, arrested digestion,
and the resulting abnormal fermentation of food often lead to a head-
ache which needs no further mention here. The patient can usually
make the diagnosis for himself. The same is often true of the headaches

1 Of 697 cases of pernicious anemia studied by me, 300 had no headache at any time.
See Osier's Modern Medicine, vol. iv, p. 622.

2 Walton and Paul, Jour. Amer. Med. Assoc, 190S; Thomas, Osier's Modern Medicine,
vol. vii, p. 336.

Causes of Headache

1. FATIGUE, BAD AIR, AND HUNGER

2. CONSTIPATION AND INDIGESTION ("BILIOUS-

NESS"'

3. ALCOHOL (THE "DAY AFTER" HEADACHE)

CASES TOO MANY AND TOO
VAGUELY ENUMERABLE FOR

4. EYE-STRAIN AND INTRINSIC DISEASES OF graphic representation.

THE EYE

5. INFECTIOUS DISEASES (ONSET)

6. MENSTRUATION

7. PSYCHONEUROSES

8. NEPHRITIS

9. MENINGITIS

10. SINUSITIS

11. TRIGEMINAL \

NEURALGIA I

12. " INDURATIVE"

13. MIGRAINE

14. BRAIN TUMOR

15. SYPHILITIC \

PERIOSTITIS 1 I

16. UNKNOWN CAUSE

1039
602
172
157

117

89
46

619

1 The diagnosis of intracranial syphilis seems to me still so uncertain that I have
not included it hire.

HEADACHE

resulting from constipation, miscalled "lithemia," "biliousness," or
"torpid liver."

A remarkable feature of this type of headache is its swift disappear-
ance, in certain cases, after defecation. From several very intelligent
patients I have heard repeatedly the story of a headache that disap-
peared, wholly or mostly, within a few minutes of the time of defeca-
tion. This is hard to reconcile with any chemical theory regarding the
origin of such a pain.

6. Many common infections rhinitis, tonsillitis, the exanthemata,
etc. are often accompanied by headache, which, however, is rarely
the patient's chief complaint. There are other infections examples of
which will be given below which cause so severe and persistent a head-
ache that it becomes the "presenting symptom."

7. The headache sometimes accompanying otitis media and other
forms of aural disease gets its recognition, in the vast majority of cases,
from the concurrent aural symptoms.

8. Menstruation is often preceded or followed, less often accompanied,
by headache the exact origin of which is very obscure.

9. Trigeminal neuralgia, with or without the paroxysms and spasms
of tic douloureux, presents, as a rule, no serious difficulties in diagnosis,
and will, therefore, not be further mentioned here. Mild types may
originate in dental caries or other peripheral irritations. The severer
forms appear to be due to changes in the Gasserian ganglion.

10. Insolation, with or without actual sunstroke, has often been
listed among the causes of headache. In my experience, however, there
is usually a large neurasthenic element in these cases, and the history
of insolation is often vague and forced.

11. Adolescence is frequently associated with a headache for which no
local cause can be found. We connect such headaches vaguely with
adolescence, because they pass off with the end of that period.

12. Cerebral concussion as in a foot-ball game is a common cause
of headache, which usually presents no diagnostic difficulties.

13. Indurative Headache. "This probably the most frequent
form of headache seems to be unknown to the majority of physicians,
although it has been described in text -books for decades" (Edingcr, in
Die Deutsche Klinik 1 ).

The term "indurative"' expresses an attempt to characterize the
malady without committing ourselves to any theorv regarding its cause
or morbid anatomy. In some of the older books it is referred to as

1 Translated under title of Modern Cliniral Medicine, in the volume >>n Piseasesof
the .Nervous System, p. 863, Appleton, 190S.

DIFFERENTIAL DIAGNOSIS

"rheumatic headache." Its distinguishing feature is the presence
of painful "indurations" near the insertions of the muscles at the
occiput. Bits of the trapezii, sternocleidomastoids, scaleni, or splenii
become sensitive, uneven, and nodular, "as if something were deposited
in the substance of the muscle." (See Fig. i.)

Pain which is chiefly, but not exclusively, occipital is associated with
these "indurations," and disappears when they are removed by mas-
sage. It is on this account that the disease is so much better known to

Fig. I. The points upon which indurations are most frequently found (Edinger).

the masseurs and to the physicians who have studied and practised
massage than to the medical profession at large. Writers on massage
do not hesitate to speak of the "indurations" as foci of "chronic myo-
sitis," but there are, so far as I know, no histologic examinations on
which we can base such a term. Edinger ' apparently considers the con-
dition a neuralgia. Swelling of the neighboring lymph-glands and of
the cervical sympathetic ganglia is mentioned by some writers.

The sensitiveness to touch extends to the aponeuroses over the skull,

1 P. 86^ in the volume above cited.

HEADACHE

to the vertex and even to the frontal region; also down along the outline
of the trapezius on the shoulder. In this as in many other respects it
resembles "lumbago" and "stiff neck."

The disease is often referred to as "rheumatic," because it seems in
some cases to follow exposure to cold and wet, e. g.: "A few days before
the appearance of the symptoms he had been overtaken by a hailstorm
while riding a bicycle." To some these statements still carry convic-
tion, c. g., to Edinger, who says: "It is certain that refrigeration may
produce the disease."

I have, I regret to say, no cases in my own experience which exem-
plify this disease. I have referred to it here because it seems to me to
deserve more careful study by clinicians and because of Edinger's
statement, based on his extensive experience at the Neurological Institute
in Frankfurt-am-Main, that it is probably the most frequent form of
headache, and that: "The examination of the insertions of the muscles
should never be neglected in any case of headache."

14. Vasomotor Headaches. Though vasomotor disturbances may
occur in various types of headache, especially in migraine, there remains
a group of cases in which only the vasomotor trouble (vasoparalysis
and vasodilatation) is discoverable as cause. These patients have very
red faces in the attack, and usually show reddish blotches or striae over
the rest of the body. The diagnosis is made by the presence of the above
signs and by exclusion of all other known causes.

2. POSITION AND NATURE OF THE HEADACHE

(1) Many text-books map out the surface of the skull with special
"headache areas," reminding one of a phrenologic map, but in my
experience there is not often much to be learned from the position of a
Jieadaclic. Ocular headaches often begin or center near the eyes; pains
due to otitis media often spread from an initial focus near the ear.
Inflammations of the antrum or frontal sinus cause pain over the affected
cavity. The pain of syphilitic periostitis corresponds with the position
of the lesion. Migraine, with its unilateral distribution, and trigeminal
neuralgia have also a typical distribution.

( >n the other hand, ocular and aural headache is often not thus
localized, and the pain due to any of the other familiar causes 1 uremia.
infection, brain tumor, constipation, menstruation, neurasthenia' may
be in any part of the head, and is often unilateral, so as to be mistake!'.
for migraine.

(2) The kind of pain is likewise of very little siimiiicance: throbbing.
dull, burning, boring headaches are encountered in all sorts of diseases.

38 DIFFERENTIAL DIAGNOSIS

A sense of constriction and pressure is mentioned by many patients of
the psychoneurotic group, especially if they have been to France and
have been told that they have a "tete en casque."

(3) The severity of headache is probably greatest in organic diseases
of the brain or periosteum (cerebral tumor, meningitis, syphilitic perios-
titis), in the paroxysms of tic douloureux, and in those of migraine.

(4) Chronic headaches, sometimes lifelong, are associated with all
the psychoneuroses (neurasthenia, hysteria, psychasthenia), and are
sometimes present without any discoverable cause. They are often
referred to the ''base of the brain" (meaning the nape of the neck).
Blows on the head, sunstroke, arsenical poisoning, and all sorts of
"reflex" disturbances (pelvic, ocular, gastro-intestinal) are often vainly
invoked as causes, and the term "constitutional" is often attached to
such pains, but a frank confession of our ignorance seems to me
better.

(5) The time of day markedly influences some headaches; those
associated with frontal sinus disease often begin at the same hour each
morning, last a certain time, and pass off. This is also true of the psy-
choneurotic group, but the time of seizure and of relief is much less
accurately recurrent.

Headaches due to syphilis, to brain tumor, and to uremia are often
worse at night, but syphilis has no monopoly of this characteristic.

3. TWO TRADITIONAL FALLACIES ABOUT HEADACHE

(a) The belief that physiologic and pathologic states of the
female generative organs often produce headache is widespread. Text-
books, such as Butler's, list dysmenorrhea, " uterine disease," disease
of the ovaries, and even of the bladder (!) as causes of headache. No
proper justification for these ideas has yet been attempted, so far as I
am aware. Headache is, of course, exceedingly common in menstru-
ation, but so it is in eclampsia; yet no one to-day connects the eclamptic
headache in any direct way with the condition of the uterus. Toxemia
of the puerperium, toxemia of the menstrual period, is a much more
plausible, though not a demonstrable, hypothesis. (For further evidence
on this point see p. 83.)

(b) " Lithemia " and " rheumatism " are also frequently invoked to
explain headache. Neither word is defined by those who use them in
this connection. " Lithemia " means constipation and the indigestion
of lazy, gluttonous people, conditions which certainly do produce head-
ache. (See p. 35.)

HEADACHE

" Rheumatic headaches " refer usually to the type associated with
"stiff neck " and indurations in the bellies of muscles attached to the
occiput or the temporal region. (See above, p. 36.)

There seems, however, no sufficient reason for continuing the tradi-
tion which applies the word "rheumatism" to such lesions.

4. IMPORTANT TESTS

The following tests should be made in all puzzling cases:

1. Thorough examination of the eyes (including retinoscopy) ,
the pupil, and the testing of intra-ocular tension (glaucoma).

2. Temperature record (infections).

3. Blood-pressure measurement (nephritis, tumor).

4. Urinalysis (albumin, sugar, acetone).

5. Palpation of the insertion of the nape muscles at the occiput.

6. Examination of the nose and its accessory sinuses.

In the history, the following clues should be attended to:

(a) Is the headache of paroxysmal occurrence and fixed duration
(usually, twelve to twenty-four hours), accompanied by disturbances of
vision and great prostration (migraine)?

(b) Is the history that of a psychoneurosis?

Case 1

A married woman of forty-two consulted me March 17, 1904, for long-
standing headaches which had been present, off and on, during the last
five years, since an attack of what was called ''grip." followed by deaf-
ness and ringing in the left ear. The patient lives in a very malarious
part of a specially malarious suburb of Boston, but has never had the
disease, so far as she knows.

For the past year the headaches have been much more severe, and
have come with especial frequency at night, together with a burning
sensation over the left side of the head, and to some extent over the entire
body, and accompanying this burning sensation she feels chilly, but the
temperature has never been taken. The menopause occurred a year ago,
and since that time she has noticed that she is getting stouter, that her
skin is very dry, harsh, and sallow, with scarcelv any perspiration, and
that her lips look bluish. Pain and the sense of coldness are often kit
in the lower left axilla. Each winter she feels the cold more and
more.

Some months ago she noticed edema of the feet and face: ;it the

40 DIFFERENTIAL DIAGNOSIS

present time there is none, but she gets out of breath upon the slightest
exertion, and her heart then beats violently, rapidly, and irregularly.
Her urine is thick, dark, offensive, and at times its passage is followed
by vesical tenesmus. The headache often wakes her in the night, and as
soon as she wakes she has to pass water, which gives relief to the head-
ache. She thinks she passes more urine at night than in the daytime.
She is very irritable, and has much twitching and quivering of the lips.
Her only child was born ten years ago, and died within the first year.

On examination the hands and lips were of a dark, slaty-blue color,
yet quite warm. The face showed a yellow pallor, the total effect being
that often seen under the Cooper Hewitt mercury light, such as is used
in automobile garages. The heart was negative, save for a slight sys-
tolic murmur at the base. The lungs showed nothing abnormal. The
edge of the spleen was easily felt on full inspiration. Its consistency
seemed increased. The abdomen was otherwise negative. The tem-
perature was 99.2 F. at 5 p. m. The urine, save for high color and
other evidences of concentration, showed no abnormality.

Discussion. -The possibilities which were first considered in this
case included cardiac disease, myxedema, malaria, and another presently
to be mentioned. The diagnosis of the attending physician was "some
queer kind of heart disease," but on examination I could find no heart
disease, queer or otherwise, although the breathlessness and cyanosis
made it natural to search for a cardiac lesion.

Myxedema was suggested by the cutaneous changes and the sensi-
tiveness to cold, but on cross-questioning neither of these two character-
istics was at all well marked, and there were no mental changes, no sub-
normal temperature and no special alteration in the physiognomy
except as regards the extraordinary coloration before mentioned. It
was easily made clear that this cyanosis did not depend upon any disease
of the heart or lungs. The enumeration of the red cells showed but
4,icSc,ooo, proving that the color of the lips was not due to polycythemia.
There was nothing in the symptomatology nor in the gross character-
istics of the feces to suggest a cyanosis of intestinal origin, nor did the
coloration appear to be of the vasomotor type, so often seen in neurotic
and hysteric patients. There was no ebb and flow about it, no varia-
tion in the tint from hour to hour, nor from day to day. By rough tests
there was no notable deafness and no mastoid tenderness.

After excluding the causes above referred to, it was natural to think
of methemoglobinemia, such as is often produced by overdose of head-
ache powders containing acetanilid. Her attending physician had given
her no such powders nor any diug belonging to the group prone to pro-

HEADACHE

duce methemoglobinemia, but on questioning the patient I learned
the following facts : For the last five years she had been taking headache
powders in increasing numbers. Her husband obtained a box of them
from the local druggist once or twice a week, and by calculation it
appeared that she had averaged 100 grains a week for some months,
great relief being thus obtained for the headache.

A drop of her blood soaked into the bibulous paper of the Talqvist
hemoglobin scale produced a chocolate-brown stain, quite incomparable
with any of the hemoglobin tints of the scale. Spectroscopic examina-
tion showed the familiar spectrum of methemoglobin.

Outcome. The patient was ordered at once to stop the headache
powders and to take no medicine containing acetanilid or any member
of that group. May 3d she reported that her headaches were much less,
her sleep and breathing much better, and her sensitiveness to cold much
less troublesome. She was still weak and pale, but her appetite was
much improved, and she had gained eight pounds since March 17th.

January 26, 1907, the attending physician writes me: "A year after
you saw her the general condition was much better, although she occa-
sionally had severe headaches. The color of the blood was improving,
but at the time of the last examination which I made, a year after you
saw her, blood still showed a tinge of brown."

Diagnosis. Methemoglobinemia.

Case 2

A longshoreman of thirty-six was first seen March 8, 1904. The
patient has been in the habit of taking three glasses of whisky a day.
He had gonorrhea at twenty-six, and chancre twelve years ago. followed
by sore throat, a mucous patch, and an eruption.

He had typhoid and pneumonia at thirty. Family history good.

For a good part of the past live years lie lias had frontal headache.
Last October he began to take potassium iodid, but in November
the headache became worse, and a swelling appeared on the forehead
over the left eve. The pain lasted a week and then disappeared. A
week ago, after being exposed to a violent draft on a sleeping-car, he had
a similar attack. This time his eyes were closed by a swelling n
lids. His forehead was tender and swollen, especially on the left. Now
he complains of severe pain in the forehead, with sw elling and tendi

Two vears ago he had what seemed like a similar process i ' 1
metacarpal bones of the right hand, the bom- becoming enlarged
verv lender. His general condition is now better than six m< 1
He has taken potassium iodid, but finds that it makes ti e : worse.

42 DIFFERENTIAL DIAGNOSIS

He has taken as much as 225 grains a day, but not regularly. His
appetite is good, his bowels regular. He has had no symptoms of
iodism, and feels perfectly well but for his headache.

On physical examination the points mentioned in the history were
verified, and nothing else was discovered. The second left metacarpal
bone was much enlarged and irregular in outline. There were also
enlargements at the base of the first phalanx of the left index-finger,
and a slight rounded prominence over an area the size of an egg above
the left eyebrow. The temperature ranged between 98 and 99.5 F.
The leukocytes were 17,200 at entrance, 78 per cent, of them being poly-
nuclear. The hemoglobin was 70 per cent., and the red cells showed
a slight achromia.

1. What further inquiries and examinations are likely to throw light
on this case?

2. What inferences can be drawn (a) From the effect of a draft on
the pain; (b) from the effect of potassium iodid?

3. Why is eye-strain an unlikely cause for this headache?

4. What points against frontal sinus disease?

5. What three common chronic ulcerative processes involve the skin
and deeper tissues most frequently.

Further inquiry into the past history revealed the fact that he had
had a chancre at twenty-eight, followed by a rash and a sore throat,
with white patches in his mouth. A Wassermann test (not known in
1904) would have helped toward diagnosis.

Probably the "effect" of the draft was coincidence, at most, an
exciting or favoring cause. Many headaches miscalled "rheumatic"
are really syphilitic. There is no reason to believe that "rheumatism"
ever causes headache except in acute infectious cases. The failure of
potassium iodid is discussed below.

Eye-strain does not often begin at thirty-six in a man who uses his
eyes for such work as a longshoreman's.

The long duration of the headache is against disease of the frontal
sinus. Physical examination, however, must determine the point.

Three common causes for chronic ulcerative processes (excluding
varicose ulcer) are: Syphilis, tuberculosis, malignant disease.

[The man was seen in consultation by Drs. Bowen, Shattuck, Fitz,
Gannett, A. T. Cabot, and j. P. Clark. All concurred in the diagnosis
of syphilitic periostitis.]

Outcome. The day after entrance two distinct craters about the
size of a half-dollar were felt on the forehead. The headache was given
some immediate relief by 10 grains of phenacetin with 2 of caffein, but

HEADACHE

sulphonal and trional, 10 grains each, were also needed for sleep. He
was given inunctions of mercury and potassium iodid grains 10, increas-
ing to ioo. Black-wash was also applied to the forehead, and on the
twelfth the iodid was omitted on account of marked swelling of the left
eyelid. By that time the swelling of the forehead was much less, and
after omitting the iodid, the swelling of the eyelid also became normal.
By the fifteenth of March his symptoms had almost disappeared. Ob-
viously, the mercury, rather than the iodid, was what helped him. He
showed at no time any signs of salivation.

In view of the above facts the diagnosis of syphilis is not in doubt,
and needs no further discussion in this case. The relation of syphilis
to headache seems to warrant us in dividing syphilitic headaches into
three groups:

(a) An acute infectious headache, occurring at or near the time of the
roseola, adenitis, and other "secondary" lesions.

(b) A chronic periosteal headache, with or without obvious external
lesions on the forehead.

(c) A headache with symptoms of brain tumor, due to localized syphil-
itic processes within the skull, forming syphilomatous tumors or causing
internal hydrocephalus.

The latter group is of especial importance, since they are often
mistaken for genuine brain tumor, whence follow a hopeless prognosis,
a neglect of vigorous antisyphilitic treatment, and much unnecessary
suffering. I have three times seen recovery after antisyphilitic treatment
in cases given up to die of brain tumor. The only safe rule is: Give
mercury (in moderate doses) and potassium iodid (in doses gradually
becoming enormous) in every case presenting the signs and symptoms of
cerebral tumor.

The prognosis is for immediate relief and subsequent recurrence
in one or another form. The expectation of life is much less than for
non-syphilitics.

Treatment mercury especially should be given at intervals tor
life. Potassium iodid is needed only when definite lesions are recog-
nized.

Diagnosis. Syphilitic periostitis.

Case 3

A married Russian housewife of thirty-seven entered the hospital
May 17, 1004. In 1001 she had been in the surgical wards for .1 >tric-
ture of the rectum of inflammatorv origin, for which an inguinal colos-
tomy was done. After this operation she had no trouble ' it her I ~

DIFFERENTIAL DIAGNOSIS

(which had been seriously constipated) , the inguinal wound was closed,
and she remained well until May i, 1904, when she began to have pain
in the back of her head, at first mild, and relieved by "bromo-seltzer,'
but for the past week very severe and extending over the whole head.
It now lasts through the entire twenty-four hours, and has prevented
sleep for the past two nights. Day before yesterday she had an attack
of nausea and vomiting. The headache is so severe that she wants to
jump through the window and kill herself. She feels first hot, then
cold, sweats a great deal, especially at night, and easily becomes tired.
Physical examination, including the fundus of the eye, shows nothing
abnormal except an inequality of the pupils. Their reactions, however,
are normal, likewise the blood and urine.

K.,r

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tor

r
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Fig. 2. Chart of case 3.

For the first two days her headache was continuous and severe,
despite lactophenin, 10 grains, caffein, 5 grains, sodium bromid, ^o
grains, potassium iodid, 10 grains, three times a day. Compound jalap
powder, 1 dram, and high enemas of oil and suds were given in the hope
that the headache might be relieved by purgation. In spite of all these
remedies the headache was undiminished at the end of the first week
in the hospital.

Discussion. No certain diagnosis can be made in this case. The
relief following potassium iodid may well be a coincidence, for many
headaches of unknown origin subside without any treatment after a
period similar to the course of this case.

HEADACHE

The rectal stricture was of the type ordinarily regarded as always or
usually syphilitic, but on insufficient evidence. There is no good
histologic evidence for syphilis in such strictures, whereas it is well
known that gonorrhea is prone to produce stricture in any tube. The
presence of syphilitic lesions elsewhere in the body often gives color to
the diagnosis of syphilis in a rectal stricture, but in this case there were
no such lesions.

The study of the previous history is of prime importance in the diag-
nosis of such cases. It revealed in this case that the woman had been
sterile, but had had no miscarriages and no lesions suggesting syphilis,
so far as she knows.

If the case is syphilitic, it is probably due to an intracranial lesion of
the type simulating brain tumor. (See Case i, p. 39.)

The prognosis is for immediate recovery, but probable recurrence, if
the diagnosis of syphilis is correct, though the recurrence may involve
any other organ (liver, aorta, bones, subcutaneous tissues).

Antisyphilitic treatment should be continued at intervals for life.
The interval depends on the character, circumstances, and physical
condition of the patient.

Outcome. The potassium iodid was increased after the first week
to 15 grains and then to 30 three times a day. The headaches had
rapidly diminished in severity and frequency. Slight signs of iodism
had in the mean time appeared. By the eighth of June she was feeling
well and ready to go home. Three months later there had been no
recurrence.

Diagnosis. Syphilis ?

Case 4

A married cloakmaker, forty years old, was seen June 21, 1894.
Eight years previously she had begun to have womb trouble, charac-
terized by bearing-down pain in the upper abdomen and back. Five
years ago she had an accident to her head, and 17 stitches had to be
taken. Since then she has had unilateral ''sick headaches" about
four times a year, lasting usually one day. She has been pregnant six
times, and has three times produced an abortion.

Four weeks ago she began to have pain in the back ot her neck, some-
times darting, sometimes constant, worse in the day-time, not preventing
sleep. With the pain there seemed to be a swelling, which impressed
her as being both inside the throat and in the nape. She had no dilli-
culty in swallowing, though her throat was somewhat sore at the same
time. Three weeks ago this pain extended to the whole head, altecting

46 DIFFERENTIAL DIAGNOSIS

especially the temporal regions, which feel swollen and tender. She
has had no other symptoms.

Physical examination showed the patient sallow and covered with
a reddish, papular eruption, with a shot-like feel under the skin. It is
most marked upon the face and trunk. Visceral examination is other-
wise negative, as is the blood. The urine is alkaline, high in color, 1023
in gravity, with the slightest possible trace of albumin- The sediment
shows large squamous epithelial cells in clumps, also polynuclear cells,
triple phosphate crystals, and some octahedral crystals which resist the
action of acetic acid. The fundus oculi is normal.

Discussion. Three types of headache are immediately suggested
as we read the story of this patient:

1. Due to trauma.

2. Due to migraine.

3. Due to syphilis.

Traumatic headaches, following violent cerebral concussion, as in
foot-ball or coasting, are apt to follow an initial period of coma, and
usually persist steadily for weeks or months. Periodic pain, such as is
here described, is not often associated with trauma.

Migraine is apt to appear before the thirty-fifth year, and to occur
more frequently than in this case.

It is important to realize that unilateral periodic headache accom-
panied by nausea and vomiting deserves the term "migraine" only when
all known causes of headache can be excluded. The headaches asso-
ciated with nephritis or cerebral tumor are often migrainoid in type,
especially in the earlier stages of the malady. The study of the urine
and of the fundus oculi is thus often omitted because the attacks are so
described by the patient that "typical migraine" is assumed and treated
from the start.

A migrainoid headache which later became constant, aroused, there-
fore, the suspicion of nephritis and of cerebral tumor. Nephritis, how-
ever, could be excluded in this case by the absence of urinary changes
and of vascular hypertension. The fundus oculi was negative; there
were no focal symptoms (such as aphasia, paralysis, Jacksonian or general
epilepsy, paresthesia, or astcreognosis), and the absence of vertigo,
vomiting, and vascular hypertension also militated against the
diagnosis of cerebral tumor, which, however, could not be absolutely
excluded.

Syphilis is suggested by the rash. Further examination showed a
postcervical adenitis. The absence of any knowledge of infection is of
no importance. Only positive evidence is of value in relation to syphilis,

HEADACHE

and it cannot be too positively stated that in any person, young or old,
rich or poor, whatever his character or circumstances, syphilis is always
a possible diagnosis. The opportunities for the non-venereal acquisition
of syphilis are very many.

In this case the rash was not typical, but might have been an ordinary
skin infection. Its generalized distribution, the associated adenitis, and
the persistent headache made it, however, more suspicious.

The absence of miscarriages is less significant, since the abortions
may have anticipated the course of nature. On the whole, syphilis seems
the most probable diagnosis.

The prognosis and treatment of syphilis have been sketched on pp.
43 and 45.

Outcome. The headache was relieved temporarily by 5 grains of
phenacetin with I grain of codein. Later, some morphin was required on
one or two occasions. Mercury and iodid of potash were given by
mouth, in small doses, and in a week she was very much better. In
two weeks the headache was very slight, the rash nearly gone, the glands
barely palpable. July 12th she was discharged well, with the advice
to continue the iodid of potash in 5-grain doses three times a day for a
number of months.

Diagnosis. Syphilis.

Case 5

A Jewish shoemaker of thirty-seven was seen July 8, 1908. He has
had some trouble with his stomach since he first came to this country,
five years ago. Five days ago he began to have "pain over his heart,"
followed by shortness of breath and fainting. This attack lasted only
a few hours, but since that time he hae had severe headache, loss of appe-
tite, and gastric distress without vomiting. His bowels have become
constipated, and his sleep is disturbed by bad dreams.

On examination a few fine transient rales were found at the base
of each lung. Respiration at the left base and axilla was somewhat
louder than on the right. There was slight epigastric tenderness, and
the edge of the spleen was easily felt i^> inches below the costal margin.
There was anterior and internal bowing of the right tibia, with promi-
nence, but no roughening. The temperature at entrance was ioo 1.;
pulse, 75; leukocytes were 4S00; the Widal reaction negative. Blood-
culture was negative; urine normal.

Discussion. What are the causes of prominence or enlargement oi
the tibiae?

Significance of the rales in this case?

48 DIFFERENTIAL DIAGNOSIS

The pulmonary signs are not characteristic of tuberculosis nor of
any other disease of the lung.

The prominence and bowing of one tibia might be due to old
rickets, to osteitis deformans (Paget's disease), or to syphilitic changes,
but the latter are usually accompanied by roughness, unevenness, and
cutaneous changes, while Paget's disease should affect the femora and
the clavicles more extensively than the tibiae. Rickets seems the more
likely explanation.

An acute headache (five days' duration) with fever suggested,
naturally enough, an infectious disease. The acute infectious diseases
most often causing headache in a temperate climate are the milder
respiratory infections ("common colds"), tonsillitis, sepsis, and typhoid
malaria less often.

The negative blood examination, the normal temperature, and the
paucity of visceral lesions rule out these infections.

There are many items pointing to a psychic origin for this headache.
It began immediately after an attack of thoracic pain, which was evi-
dently believed by the patient to be due to heart disease that terrifying
affliction. The subsequent bad dreams and gastro-intestinal disturb-
ances are very common results of a scare about one's heart, especially
in high-strung people like the Jews.

The therapeutic test also bears on the diagnosis here. As soon as
the patient was assured (after a searching and thorough examination)
that his vital organs were sound, his headache and other trouble began
to improve. The application of suggestion (in the form of menthol)
completed the cure. It is, of course, impossible to exclude some obscure
infectious or toxic disease, but the weight of evidence is against it.

Outcome. A diagnosis of typhoid had previously been made, but
the next morning the temperature was normal and the man complained
of nothing but headache. This continued for several days, but was
relieved by a 25 per cent, alcoholic solution of menthol applied to the
painful part. Reassurance played a considerable part in his recovery.

Diagnosis. Headache of psychic origin.

This is a fit piace to consider the so-called "neurasthenic," "essen-
tial," or "constitutional" headaches. There are some persons so ab-
normally sensitive to sensory stimuli that the weight of the body gives
pain, even when they are seated on soft chairs; the pressure of the clothing,
the ordinary changes in atmospheric temperature, hurt them as a decay-
ing tooth is hurt by simple pressure, heat or cold. Tn such persons the
circulatorv or neural processes in the head may be sufficient to cross the
pain threshold and to present themselves as pain. Not all such persons

HEADACHE 49

have any of the mental or physical characteristics of the neurasthenic,
and it seems to me to darken counsel if we class such headaches as
"neurasthenic" merely because we discover no organic basis for them.

In another group of persons the headache is clearly dependent upon
psychic states, which can be used both to produce and to allay the pain.
The suffering is forgotten when the person is active and interested,
returning when the sufferer's attention relapses upon himself.

In a third group there are no general hyperesthesia and no variation
of the pain with psychic states. I have followed several such cases
through the period of adolescence and up to their disappearance with
the end of this state.

Others occur in later life, and may be steady or vaguely periodic.
Of this large group we know practically nothing, and this should, I
think, be plainly indicated in our terms. I believe then that we should
distinguish within the so-called "neurasthenic" group:

(a) Headaches due to constitutional or chronic hyperesthesia.

(b) Headaches due to psychic causes.

As an example of the type last mentioned, I recently studied the case
of a hearty, vigorous Italian laborer who began to suffer from constant
headache in July, 1908. In August I saw him in consultation, but
could discover no cause for his steady suffering, which now disabled
him from work. I sent him to the Massachusetts General Hospital,
where the most careful study of his internal viscera, body fluids, eyes,
ears, nose, throat, and bony sinuses revealed absolutely nothing. Just
as we reached the end of this fruitless search the headache after nine
weeks' duration suddenly ceased altogether without treatment, though
quinin, mercury, and potassium iodid had been proved ineffectual by
thorough trial previous to his entering the hospital. Up to the present
time (September, 1910) there has been no recurrence of pain.

Case 6

A housewife of forty-seven entered the hospital December 23, 1907.
Since the beginning of her menstruation at the eleventh year she had
noticed a fullness in the front of her throat, which became more promi-
nent at the time of her first pregnancy in her twenty-sixth year. It
became smaller after delivery, but increased with the next and with each
of the succeeding eight pregnancies. Each time the swelling increased
more during the pregnancy than it diminished after delivery, so that the
total effect has been an increase of the tumor. It has never caused any

discomfort or inconvenience.
1

50 DIFFERENTIAL DIAGNOSIS

For the past two years she has had " sick headaches," beginning earl)
in the morning or long after eating, lasting twenty-four hours, coming
about once in two weeks, until lately, when they have begun to come
twice a week and have been accompanied by nervousness. She feels
hot most of the time, and prefers cold weather. For six months she has
noticed a weakness of her hands. Two weeks ago she had the "grip,"
and has since then noticed considerable shortness of breath, amounting
of late to orthopnea. She has lost 30 pounds in the last two years.
The bowels have been slightly loose; the appetite excellent.

Physical examination showed emaciation, cyanosis, a slight exoph-
thalmos (not previously noticed by the patient) , a fine tremor of the hands,
and marked asymmetric enlargement of the thyroid, its greatest circum-
ference being 162- inches. The heart's impulse was in the sixth inter-
space, I inch outside the nipple-line, 4 inches to the left of mid-
sternum. The action was rapid, ranging between 100 and 120, accom-
panied by some irregularity. The first sound was very sharp at the
apex, and was preceded by a presystolic roll. The pulmonic second
sound was much greater than the aortic second sound. Systolic blood-
pressure, 175 mm. Hg. Shadows and movements of the intestinal
coils were visible over the abdomen. There was considerable tender-
ness in the epigastrium and about the navel. The edge of the liver was
felt 3 inches below the costal margin. There was no ascites, but both
iegs showed soft edema throughout. The leukocytes were 15,400.
The blood was otherwise normal. The urine was pale, 1010 to 1012 in
specific gravity, with a trace of albumin. There were many leukocytes;
no casts. The twenty-four-hour amount ranged between 15 and 30
ounces.

Discussion. 1. What was the nature of the thyroid tumor?

2. What caused the headache?

3. Can any reason be given for her preferring cold weather?

4. How are the characteristics of the urine explained?

5. Is there more than one possible explanation of the presystolic
roll heard in this case?

6. Under what conditions are intestinal movements visible through
the abdominal wall?

7. What diseases produce loss of weight despite good appetite and
digestion?

The discussion of these questions will involve a statement of the diag-
nosis, prognosis, and treatment.

Regarding the thyroid tumor, it is clear that its duration (thirty-six
years) excludes malignant disease. We have left the so-called "simple

HEADACHE 5 1

goiter" and "exophthalmic goiter." The case illustrates well the
transition from the first to the second condition; also the relation of the
thyroid to pregnancy. From her eleventh to her forty-fifth year the
patient had no symptoms from her goiter. It was increasingly unsightly,
nothing more. After the forty-fifth year came the familiar symptoms
of hyperthyroidism loss of weight despite good appetite, a sense of
increased bodily heat corresponding with the abnormally rapid metabol-
ism; finally tachycardia, tremor, and exophthalmos.

The only important diseases causing loss' of weight despite good
appetite are diabetes (either form), Graves's disease, and some cases
of arteriosclerosis. In one of my cases of Graves's disease loss of
weight was the symptom which brought the patient to me. He wanted
to know why he was losing weight despite an excellent appetite. He
mentioned no other complaints.

In the present case the emaciation explains the visibility of intes-
tinal peristalsis, for emaciation is all that is necessary to produce this
symptom. In patients not emaciated such a sign usually means in-
testinal obstruction.

The condition of the urine in this case can hardly be explained
(as one might at first think) as a result of renal stasis due to a dilated
heart, for the low specific gravity and pale color are the opposite of what
we expect in renal stasis. When taken in connection with the abnor-
mally high blood-pressure, these features of the urine suggest nephritis.
Such vascular hypertension is unusual in' Graves's disease. The head-
aches are also much more comprehensible if we suppose that the patient
had both nephritis and Graves's. I have already referred to the fre-
quency of so-called "sick headache" in nephritis, as well as in brain
tumor and syphilis. In simple hyperthyroidism headache is not common.

The cardiac signs suggest, first of all, a mitral stenosis with dilata-
tion of the heart, but another possibility is to be remembered, namely,
that the dilatation itself may be the cause of the murmur. It has been
repeatedly noted of late that not only in connection with aortic regurgi-
tation (the so-called Flint's murmur), but in any form of cardiac hyper-
trophy and dilatation affecting the left ventricle, a presystolic roll may
be heard at the apex. Thus in adhesive pericarditis and in simple
nephritic hypertrophy we often hear such murmurs. There is no way
of deciding in this case whether or not mitral stenosis is present, but it is a
good rule, often borne out by postmortem experience, to assume as few
lesions as can be made to explain the facts. On this principle, the diag-
nosis of this case should be Graves's disease; chronic nephritis with
resulting cardiac hypertrophy and dilatation.

52 DIFFERENTIAL DIAGNOSIS

The prognosis is for a few months of life at best. In treatment
rest is the essential. Morphin, followed by bleeding, purgation, and
diuretics, may give some relief. Digitalis is not likely to be effectual.

Outcome. The pulse-rate steadily declined during her first week
in the hospital, and the swelling became less; but on January ist the
patient became noisy and mentally confused, the respiration slow and
deep, the breath having an ammoniacal odor. There were frequent
attacks of severe dyspnea. In the next thirty-six hours she was, for
the most part, semiconscious, but never unconscious, and was com-
fortable except during the attacks of dyspnea. Pilocarpin produced no
sweating, and attempts to give a hot-air bath were unsuccessful. It was
impossible to purge, as she refused to swallow anything. Her heart
continued strong and not rapid.

She died on the third of January.

Autopsy showed chronic glomerulonephritis with hypertrophy and
dilatation of the heart and general dropsy; simple adenoma of the
thyroid; obsolete tuberculosis of the spleen.

One of the interesting points in this case is the existence of nephritis
without albuminuria during the period under observation. The blood-
pressure gave more correct indication for diagnosis, as is often the case.

Diagnosis. Uremic headache; chronic glomerulonephritis; hyper-
thyroidism.

Case 7

A young woman of twenty-live, a student, entered the hospital
November 7, 1907. One of her aunts died of consumption. She was
treated by Dr. R. W. Lovett for three years for some spinal trouble,
beginning with her fifteenth year. When she was eighteen her menstrua-
tion stopped and her spleen became enlarged. She was then treated for
some time by Dr. Franz Pfaff. Two years ago menstruation again
ceased during the winter. The intervals between her periods are still
five or six weeks long, and she always has headache during the cata-
menia. She has been overworked for the past three years, and has
been nervous, but has had no actual breakdown and no hysteric symp-
toms; she has been especially tired most of the time since the first of
October. She takes two cups of tea and one of coffee a day.

Eight days ago she found it very hard to concentrate her mind upon
her work. The next day she had severe headache, and that night was
sleepless. Six days ago the headache became still worse, and she
coughed up a little blood and phlegm. Ever since then she has coughed
a little, but without sputa. Five days ago she had photophobia and felt

HEADACHE

tender lumps upon the back of her head. That evening she had chill,
followed by sweating. Three days ago she had another chill, and her
teeth and her left ear ached. This time she began taking aspirin in
5-grain doses for the relief of her headache, and found it very effectual.
The last two days her headache has been less severe, but it is still present
in the back of her head. She has been slightly constipated and has felt
somewhat weak.

Temperature, 101.3 F.; pulse, 83; respiration, 18.

Physical examination was negative, save for a short, sharp, whistling
systolic murmur in the pulmonary area, transmitted only along the left

Fig. 3. Chart of case 7.

side of the sternum. The abdomen was held slightly rigid throughout,
but was tympanitic and free from tenderness. The spleen was not felt.

Discussion. Certain features in this case suggest that the head-
ache mav be due to tuberculous meningitis. The history of consump-
tion in the family and of a prolonged treatment addressed to the spine,
together with the cessation of menstruation at her eighteenth year, are
all factors which make us think of tuberculosis. The photophobia, too,
is a common meningeal symptom.

Against meningitis, however, is the absence of any tuben ulous ! 1 -
now discoverable on phvsical examination, the absence of any Icsa ns
referable to the cranial nerves, and the recent subsidence of the headache
without anv oncominir coma.

DIFFERENTIAL DIAGNOSIS

Could this be a neurasthenic headache, so called? She is at the age
when such things are commonest, and there is a history of nervousness
and overwork. But the continued fever seems to me to make this im-
possible. I do not think there is any good evidence that a fever such
as is shown in the accompanying chart ever results from neurasthenia,
hysteria, or any psychoneurosis.

Malaria is suggested by the chills and the headache, but is excluded
by the absence of parasites in the blood. The lumps complained of in
the occipital region were not discoverable on physical examination.
Had they turned out to be glandular, syphilis might have been suspected.

With the exclusion of the above possibilities we have to consider
what diseases are the most frequent in patients who have fever with a
negative physical examination and a low leukocyte count. The answer
must, I think, be as follows : If the fever is a short one, it is generally
labeled "grip" under these conditions, though I prefer to call it an un-
known infection. If the fever persists for two weeks or more without
the development of physical signs, typhoid usually turns out to be present,
as was the case here.

Outcome. On the right side of the abdomen there developed later
two red macules which decolorized on pressure. The course of the
temperature is seen in the accompanying chart. The Widal reaction
was positive at entrance. Blood otherwise negative. The course of
her illness was uneventful, and she was discharged well on the seventeenth
of December.

It is worth emphasizing the fact that constipation, cough, and chills
are common symptoms at the onset of typhoid, also that the headache
is usually earlier and more prominent than in other infections. (For
the treatment of this case see Appendix, p. 743.)

Diagnosis. Typhoid.

Case 8

A Russian clerk, eighteen years of age, entered the hospital February
27, 1908. The only history which could be obtained from him was
that two days ago he fell downstairs and since then he has had a good
deal of headache.

Physical examination showed that he was drowsy, his right pupil
slightly larger than his left, both reacting normally. His throat was red
and slightly swollen. There was considerable rigidity of his neck, but
no actual retraction. Rotation and backward flexion were normal,
but the head could not be bent forward. Visceral examination was
entirely negative, with the exception of Kernig's sign, which was present

HEADACHE 55

on both sides. The temperature was 100.3 F.; the pulse, 60; respira-
tion, 25. Fundus oculi normal. Blood and urine normal. Blood-
pressure, 145. During the night he became unconscious, and the next
morning had marked retraction of the head, unequal and unresponsive
pupils, a strabismus, absence of superficial reflexes, Babinski's reaction
on the right, and a rectal temperature of 102.8 F.

Discussion. Concussion of the brain and meningitis were the diag-
noses at first suggested in this case. Any headache following a fall on
the head is rightly suspected as being due to concussion, but there are
certain symptoms in this case not thus to be explained, i. e., the
inequality of the pupils, the rigidity of the neck, and the presence of
Kernig's sign.

These three signs, together with the presence of fever and slow pulse,
the rapidly developing coma, strabismus, and Babinski's reaction, all
point to meningitis, which was the diagnosis made at the outset.
Acting upon this a lumbar puncture was done, and 35 c.c. of bloody,
turbid fluid were removed. The examination of this fluid, however,
showed nothing but macerated red corpuscles, no micro-organisms
either in cover-glass or culture. This speaks strongly against epidemic
meningitis, while the great rapidity of onset and the absence of any
lymphocytosis in the spinal fluid make tuberculous meningitis unlikely.
The presence of blood in the spinal fluid suggests cerebral hemorrhage
or fracture of the base of the skull.

Normal urine and normal blood-pressure rule out uremia, and nor-
mal blood excludes malaria. Brain tumor may manifest itself suddenly
after a long latent period by symptoms like those in this case, but the
absence of paralysis, of changes in the fundus oculi, and the presence of
the rigid neck and the bloody spinal fluid militate against this diag-
nosis. No absolute decision was arrived at before death, which oc-
curred on the first of March.

Outcome. Autopsy, March 1st, showed fracture of the base of the
skull, multiple contusions of the cerebellum and frontal lobes, with
hemorrhage.

Diagnosis. Fracture of the base of the skull.

Case 9

A domestic of twenty-three was seen March 14, 1908. She was
perfectly well until noon of the day before, when she was seized with
sharp, cutting pain in the forehead and a slight sore throat, with fever.
She went to bed and slept well, but .awoke with the same headache, and
vomited when she cot out of bed. The headache lias continued since.

56 DIFFERENTIAL DIAGNOSIS

When seen at the hospital the patient's temperature was 102.5 F.;
her pulse, 125, the skin hot and dry. The pupils were equal, regular,
and reacted normally; the fundus negative; the throat slightly reddened
and swollen; face flushed. The viscera, negative. Leukocytes, 9000.
Blood and urine were otherwise normal. Blood-pressure, 125. During
the first thirty-six hours of her stay in the hospital she suffered a good
deal with headache, relieved more or less by phenacetin and an ice-bag
in the frontal region.

Discussion. I have known tuberculous meningitis to manifest
itself first by intense pain at the root of the nose, as in this case. All
the ordinary symptoms of that disease, however, except headache and
fever, are absent in this case. Typhoid, malaria, and most other infec-
tions are ruled out by the negative physical examination and the short
course of the disease, which was practically gone in four days. On the
third day careful questioning showed that the pain was limited to the
region of the frontal sinuses. On the eighteenth she was able to go back
to work.

In view of these facts an infection of the frontal sinus seems the most
likely cause of her headache. In some cases of this disease the head-
ache appears in a characteristic way at the same hour each morning,
perhaps owing to the accumulation of secretions during the night.
Sometimes the diagnosis is assisted by the sudden appearance of a nasal
discharge coincident with the cessation of pain; in other cases the close
limitation of the pain to the region of the frontal sinuses is our best clew
to diagnosis.

Outcome. On the eighteenth of March she went back to work.

Diagnosis. Sinusitis.

Case 10

A cook of twenty-three entered the hospital April 9, 1908. Her
family history and past history were excellent. Two months ago she
stopped work for a fortnight because of fatigue and persistent headache.
Ten days ago the headache returned and has persisted since. It is
severe in the frontal and occipital regions. Four days ago she began
to vomit, and since then has vomited about six times every twenty-four
hours. Even water is rejected. There has been no abdominal pain,
but persistent nausea. She has had no cough and no other symptoms.
The course of the temperature is seen in the chart on page 57.
The white cells were 4400 at entrance, 4900 on April 20th; the Widal
reaction always negative; the blood otherwise negative. The urine
ranged between 20 and 30 ounces in twenty-four hours, with a specific

HEADACHE

gravity between 1026 and 1036; a trace of albumin; a few hyaline and
fine granular casts. The pupils were equal and reacted to light and
distance; the fundus oculi, normal; the chest and abdomen negative,
save for slight tenderness and rigidity in the epigastrium. During the
first week she seemed rather hysteric at times, complained continually
of headache, and was hungry, but no diagnosis could be made.

Discussion. Typhoid is suggested by the course of the tempera-
ture, the subnormal leukocyte count, and the headache. Indeed, there
is nothing in the case, as here stated, positively to exclude typhoid.
Against it, however, are the long duration of the headache, which is
usually gone after the first ten days in typhoid. The persistent nausea
is also very unusual in typhoid. Per-
haps the strangest symptom, however,
is the excellent appetite, which is al-
most unknown in a patient seriously
sick with typhoid.

The question of hysteria must be
considered. All the symptoms in the
case are consistent with this diagnosis,
with one exception the continued
fever. There is, in my opinion, no
such thing as a hysteric fever of this
type. An elevation of less than one
degree over a considerable period or a
sharp sudden, short-lived rise occurs in
hysteria, but not a persistent fever of
this type.

The two diseases seriously to be
considered are cerebral syphilis and
tuberculous meningitis. As a matter

of fact, the diagnosis of syphilis was made in this case by a skilled
neurologist. The entire absence of any history and of any visible lesions
of this disease is not in itself at all conclusive against it, neither is the
age of the patient, although the great majority of cases of cerebral
syphilis occur in older persons. More important evidence against
syphilis is the subnormal leukocyte count, which is distinctly rare in
syphilitic cases.

Epidemic meningitis comes on more suddenlv, almost always pro
duces a leukocytosis, and usuallv runs a shorter course. Nevertheless,
it cannot be excluded without an examination of the spinal fluid.

Outcome. April 22(1 lumbar puncture was dune, and ic c.c. of

Fig. 4. Chart of case 10.

58 DIFFERENTIAL DIAGNOSIS

clear pale fluid was obtained, the sediment showing 72 per cent, of
lymphocytes, 28 per cent, of epithelial cells. In the Thoma-Zeiss coun-
ter, this fluid showed 42 lymphocytes per c.mm. On the twenty-third
the patient seemed to be restless, the left pupil slightly larger than the
right. During the forenoon the left hand became flexed. At noon, the
left leg and the left side of the face became paralyzed, and the reflexes
absent. Syphilis, producing softening from thrombosis in the region
of the right internal capsule, was suspected. The patient soon after
became semicomatose. The head was drawn sharply to the right. At
times the patient would recognize and talk with her relatives, and is even
able to move the left arm and leg.

On the twenty-fourth knee-jerk of the right leg disappeared, and a
pin could be passed through the skin of either leg without pain.

On the twenty-fifth there was left lateral conjugate deviation with
lateral nystagmus, more constant in the right eye. Respiration became
labored. Edema appeared in the hands, and the patient died at noon
on the twenty-fifth.

Autopsy showed miliary tuberculosis of the lungs and spleen; tuber-
culous meningitis; tubercular ulcers of the ileum; tuberculosis of the
retroperitoneal glands.

It should be distinctly stated that cases of proved tuberculous menin-
gitis have recovered. Probably this outcome takes place in less than 1
per cent, of the cases, but it is important to know that it is possible.

Diagnosis. Miliary tuberculosis.

Case 11

A house-painter of forty-two entered the hospital December 4, 1907.
He is in the habit of taking three drinks of whisky a day, but has had
no previous illness. A year and a half ago he began to have headaches,
vertigo, cramps, and vomiting; was sick for three or four days. He
was treated in the Somerville Hospital for five weeks, but did net im-
prove much, and has been unable to work since. He is now troubled
much with occipital headache, worse in the morning and after he has
been drinking. He now rarely vomits. Last night he had a nosebleed.
He has had no abdominal pain of late. He has had occasional night-
sweats, but none for two weeks. Headache is his chief complaint.

Physical examination of the chest is negative except for a short
systolic murmur at the apex of the heart and accentuation of the aortic
second sound. The pulse tension seemed to be high. The blood-pres-
sure was 160 mm. Hg. On the right side of the abdomen, at the level
of the navel, a smooth, rounded, slightly tender mass is felt. The

HEADACHE

patient subsequently said that he had had blood in his stools for fifteen
or sixteen weeks, averaging a gill a day. An expert proctoscopic ex-
amination showed no sufficient cause for this blood. On examination
in a warm bath the tumor previously described was much easier to feel.
It appeared to be about the size of a grape-fruit, and connected with
the kidney. The urine was about 30 ounces in twenty-four hours,
milky, 1013 in specific gravity, the sediment containing a large amount of
pus, and an occasional granular cast. The hemoglobin was 70 per
cent.

Profuse bleeding from the rectum continued, and vomiting of large
amounts of green material with a little fresh blood happened several
times. The right lung was full of coarse moist and dry rales. X-ray
showed a shadow, probably of stone in the right kidney. The profuse
intestinal hemorrhage suggested malignant disease, but no other evi-
dence of it could be found. The amount of urine passed became
smaller and smaller. On the seventeenth of December the sputum
became bloody and the patient continued to vomit blood and to pass it
by rectum. Numerous purpuric spots appeared on the skin. He
sweated profusely in the hot-air baths and seemed better after them.

Discussion. Although the patient is somewhat alcoholic, there
certainly is not enough evidence to make us believe that whisky is the
cause of his sufferings.

Lead-poisoning is naturally suggested by the patient's occupation,
by the history of abdominal cramps, and headaches. If lead-poisoning
were present, it might also account for the renal symptoms and for the
rather high blood-pressure. As a matter of fact, the patient was treated
for five weeks for lead-poisoning, and the fact that he did not improve
during that time is, in itself, against the diagnosis. More important,
however, is the tumor above described, which cannot possibly be ex-
plained by lead. The presence of this tumor, together with the pus in
the urine and the results of v-ray examination, point strongly to stone
or tuberculosis of the kidney. The headaches, pains, and sweats are
quite explicable if there is suppuration of tuberculous or calculous
origin in the renal pelvis.

We have still to explain in some way the mysterious hemorrhages
from the rectum, stomach, and respiratory tract. The accentuation of
the aortic second sound, the blood-pressure, the low specific gravity of
the urine, and its constantly diminishing amount suggest a concomitant
nephritis.

Outcome. Operation was considered, but postponed, owing to the
man's poor condition. During the last two days of life he passed practi-

DIFFERENTIAL DIAGNOSIS

cally no urine. He was irritable and unreasonable, his mind wandering.
He died on the twenty-second of December.

At autopsy the right kidney was found to contain a very large stone,
and several smaller ones. Three-quarters of the .organ was converted
into a bag of pus, and the remaining portion showed as cystic degenera-
tion. The left kidney showed the lesions of chronic glomerulonephritis.

Diagnosis. Stone in the kidney with abscess and nephritis.

Case 12

An electrician of thirty- three entered the hospital September 10, 1907.
He was perfectly well until two weeks ago, when he began to have

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severe, shooting pain in the forehead, spreading to the rest of the head.
His face was puffy and red every forenoon and his hands became swollen.
Yesterday he became very dizzy and could hardly see to walk, but did not
fall. He lost three pounds in two weeks and is thirsty and nervous.

The patient was semicomatose and answered no questions. He
moved restlessly upon the bed with his eyes shut and his hand to his
head. He was not asleep or drunk, and there was no evidence that he had
been drugged.

On examination, the face was distinctly puffy. The muscles about the
eyes twitched involuntarily from time to time. Fundus oculi negative.
The incisor teeth were worn down the patient says because he grinds

HEADACHE 6 1

them at night. The spleen was not palpable. Physical examination
was otherwise negative. Blood-pressure, ioo mm. Hg. Temperature,
102.6 F. White cells, 3400. Urine negative. The blood showed
no malarial organisms. The symptoms seemed to point strongly toward
uremia at the time of entrance, but the urine was absolutely negative.

At entrance the patient was put into a hot bath, but collapsed twenty
minutes later, his blood-pressure being very low.

Discussion. Nephritis is suggested by the drowsy condition, the
edema of the face and hands, and the headache. The negative urine
does not necessarily exclude chronic nephritis, but the low blood-pressure
and the normal size of the heart are strongly against this diagnosis.

Brain tumor is suggested by the headache, the vertigo, and the
drowsiness. Against it are the negative fundus examination, the low
blood-pressure, the absence of focal symptoms.

Migraine may produce symptoms similar to those in this case, but
one almost never sees a patient of thirty-three in his first attack of
migraine, and this patient had had no previous attacks like this.

There is no evidence of reflex causes. In fact, the diagnosis was not
suspected until the fall of temperature to normal next morning, and its
subsequent rise on the succeeding day suggested malaria.

Outcome. On the fourteenth he had a chill. The blood showed
a number of fully grown malarial parasites. Under quinin the patient
was well within a few days.

Diagnosis. Malaria.

Case 13

A Russian housewife of fifty-eight entered the hospital November 30,
1906. She entered the hospital first in April, 1906, suffering from
"interstitial myocarditis" with paroxysmal tachycardia. She was next
seen on the thirtieth of November; her physician states that since leaving
the hospital she has had attacks of tachycardia every few weeks, the
attack usually lasting two days and often accompanied by headache.
Between attacks she felt well; her appetite was good, her bowels regular,
there was no loss of strength.

Nine days ago she began to have constant headache, precordial dis-
tress, insomnia, and anorexia. There is now no cough and no dyspnea,
but she feels weak and tired.

Physical examination showed slight pallor and marked pulsation
in the neck. The left border of cardiac dulness was six inches to the
left of the midsternum in the fifth space, the right border one inch to the

DIFFERENTIAL DIAGNOSIS

right of midsternum; sounds rapid, but regular; the first apex sound
sharp; the second, barely audible; a rhythm like that of the fetal heart,
the rate something over 190. All the heart-beats were transmitted to
the wrist, though the tension was low.

Physical examination was otherwise entirely negative. During the
first part of her stay in the hospital the tachycardia showed only slight
remissions, sometimes for a minute, sometimes for several hours. The
rate did not seem to be affected by sleep, talking, or food. Digitalis
had no effect. Tincture of aconite had no effect. Except for weak-
ness and some mental anxiety, the patient seemed well.

Discussion. Although the headache was much complained of in
this case, it was at once thrown into the background by the general

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physical examination, which made tachycardia prominent. Our chief
problem is to interpret the tachycardia existing in this case, more espe-
cially as regards prognosis, which is always the essential point in tachy-
cardia.

Cases of paroxysmal tachycardia may be divided into three groups:

(a) Those having an obvious exciting cause.

(b) Those occurring in the course of a chronic cardiac disease.

The first and the last of these groups carry a good prognosis. For
practical purposes this is the most important point. I was once sum-

HEADACHE 63

moned in hot haste to the bedside of a woman of forty, where I found
the family assembled awaiting her death. The attending physician
thought she had but a few hours to live. Her pulse was 210, her heart
action absolutely regular and of the fetal type, her heart not enlarged,
her breathing slow and easy in a recumbent position. The tachycardia
had come on six hours previously, during a family quarrel, the patient
being partly drunk.

Vigorous reassurances were given to the family in the patient's
hearing, but without addressing her. Within an hour the tachy-
cardia ceased.

I have seen a similar attack in a high-strung young girl who was in
the dentist's chair during menstruation. The dentist was excessively
alarmed, as the pulse was over 200 and barely perceptible, but the
patient was as well as usual next day.

Attacks may follow a gastric upset or come after a surgical operation.

Tachycardia of this type occurring in patients who have definite
signs or history of cardiac insufficiency, whether from valvular or myo-
cardial lesions, are more serious, but I have never known a patient to die
during or soon after such an attack. The prognosis is that of the under-
lying lesion, and is not appreciably modified by the occurrence of tachy-
cardia.

Treatment. Some cases are immediately relieved if the patient is
placed head downward for a few seconds; others have been known to
recover immediately after by drinking ice-water after emptying the
stomach or after moderate exercise. Drugs have no obvious effect.

Outcome. On the twelfth of December the tachycardia ceased
during the night, and on the sixteenth she had two days without any.
From this point on the attacks grew shorter and occurred at longer inter-
vals. There was no evidence that they were influenced in any way
by any drug or other treatment given her, and she left the hospital much
relieved, on the third of January, though the myocardium still showed
evidence of weakness.

Diagnosis. Paroxysmal tachycardia complicating a chronic myo-
cardial insufficiency.

Case 14

A school-boy eight years old entered the hospital May 16, 1907.
Since early childhood he and his brother and his sister have had
vomiting spells about once a month. Tn such a spell he goes to bed
feverish, vomits in the night, is feverish and sleepy the next day; after
that he is perfectly well. It is surmised that these effects are due to
eatintr too much candv.

DIFFERENTIAL DIAGNOSIS

Five days ago he had headache and fever and vomited once. The
headache and fever have continued since, and he has been unable to go to
school. He has had a slight loose cough, but no expectoration. Last
night he slept poorly and complained of epigastric pain. The course of
the temperature is seen in the accompanying chart (Fig. 7).

Physical examination of the head, neck, and heart was negative.
The abdomen was slightly distended, tympanitic, firmly held, and very
tender throughout. The child breathed rapidly, with short, groaning
expiration. He was admitted to the hospital with a diagnosis of acute
appendicitis. The right lung showed dulness
from the apex to the fourth rib in front and
over the entire back, associated with bronchial
breathing, increased voice, and fremitus.

Discussion. I have known several cases
like this operated upon for appendicitis owing
to the lack of a thorough physical examination.
Especially in children it is essential to make a
thorough examination of the chest whenever the
presenting symptom is abdominal pain. The
backs of the lungs are often not thoroughly
examined, because we shrink, very naturally,
from having a patient sit up or even turn upon
his side; but in a case of this kind this is a short-
sighted kindness.

Outcome. On the twenty-second the tem-
perature reached normal and the patient felt
finely. On the twenty-fifth the temperature
again rose, and the white cells, which had been 35,000 at entrance, were
found to be still at approximately the same figure, with 92 per cent, of
polynuclear neutrophiles.

When fever persists in a case of this kind and the percussion dulness
does not clear up, one of three possibilities is generally entertained:
One thinks of an unresolved pneumonia, of a pleural thickening, or of
postpneumonic empyema. In nine cases out of ten the latter turns out
to be the true diagnosis. Unresolved pneumonia is mostly a myth. In
the vast majority of cases it spells empyema. Pleural thickening causes
no such elevation of the leukocyte count.

A needle introduced at the right base drew pus containing poly-
nuclear leukocytes and pneumococci.

Diagnosis. Infection (post-pneumonic empyema).

1 mTtyt;

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HEADACHE

Case 15

A little girl of fifteen, a chocolate dipper by trade, entered the hospi-
tal December 27, 1900, complaining chiefly of headache, which she has
had for three days. It has been accompanied by some aching of the
feet, general fatigue, and weakness. Her appetite has been good, but
her food has been frequently vomited. She has had to stay in bed for
the past three days. The course of her temperature is seen in the accom-
panying chart (Fig. 8).

Physical examination showed good nutrition, flushed face, heavy
eyes, pupils equal and reacting, tonsils enlarged and red, a soft, sharply
localized systolic murmur at the apex of the heart; the spleen palpable
on inspiration. The internal viscera were otherwise negative; the first
phalanx of the right ring-finger was a
little red and swollen. On the ulnar side
there were a patch of granulation tissue
and a large bleb, from which pus could be
expressed. From the history and spleen
typhoid seemed to be the most probable
diagnosis.

The Widal reaction was absolutely
negative. White cells, 11,000. There
was a diazo-reaction in the otherwise
negative urine. The headache continued
very troublesome.

On the night following entrance the
patient complained of a little pain in her
right knee, the inner side of which was
found to be very slightly swollen and
tender, not red or hot. The next three
or four days there was the same com- g * 8, chart of case I $-

plaint at the same time every night. The knee gradually became more
swollen, and there was a suggestion of floating of the patella.

Discussion. In the early days of this case, with headache, high
fever, and nothing to show for it, it was probably impossible to make a
definite diagnosis. The presence of the heart murmur suggests an endo-
carditis, with or without general sepsis. Such infections are very com-
mon in girls of this age. The white count of 11,000 is somewhat against
this; the condition of the ring-finger favors it.

Typhoid seems more probable in many respects. The history and the
enlargement of the spleen especially favor that diagnosis, and the diazo-
reaction would be generally considered confirmatory evidence, while the

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66 DIFFERENTIAL DIAGNOSIS

absence of the Widal reaction by no means excludes typhoid. In fact,
the only decided evidence against typhoid during the early days of her
illness was the leukocyte count.

The headache and splenic enlargement are quite consistent with
malaria, but the time of year makes this unlikely and the blood examina-
tion excludes it.

With the appearance of pain in and about the right knee thirty-six
hours after entrance a new crop of possibilities springs up. Rheumatic
arthritis or gonorrheal arthritis comes first to mind. The fact that only
one joint is involved is against ordinary "rheumatism," and in any type
of arthritis we should expect more pain when the fever and constitutional
manifestations are as marked as in this case.

I have recently seen a case of trichiniasis with symptoms a good deal
like those in this case, and absolutely without eosinophilia during the
first week under observation. In this case the diagnosis was made by
finding the trichinella embryo in the peripheral blood.

Osteomyelitis should always be considered in a case presenting the
symptoms here described. It is not at all unusual to have the fever and
constitutional manifestations precede, by a considerable interval, any
localization of the process. We get strongly the impression that the
infection is first general and later local.

Occasionally we see a case beginning exactly like this one, but going
on to rapid recovery without ever presenting symptoms any more definite
than those here described. We have then to be content with surmising
that some low-grade infection has been overcome.

Outcome. On January 2d the temperature was still high, and the
knee intermittently painful. At times the patient awoke from sound
sleep complaining bitterly of knife-like pain in her knee. The swelling
increased over the inner condyle of the femur, where there was also the
greatest tenderness. There was no cording of the veins, no glandular
enlargement or tenderness, no edema of the leg.

January 6th: "The swelling of the knee has been increasing. The
whole leg is now somewhat swollen. At the knee it measures 1 \ inches
more in circumference than the left. The patella now floats. Leuko-
cyte count is now 16,000. At entrance it was only 11,000. The tem-
perature is also lower, and in the past two days there has been some de-
crease in the swelling. There was a diazo-reaction in the urine at the
time of entrance, and this has persisted since.

"January 9th: Pain in and around the knee has been very severe in
the last three days. The leukocyte count is now 19,300."

January 10th: Incision over the outer condyle of the femur liberated

HEADACHE 67

two ounces of greenish staphylococcus pus. Three perforations were found
in the periosteum at the lower end of the femur, with pus all around the
bone. The bone was opened and pus found in the lower epiphysis and
the lower end of the shaft. Convalescence normal.

Diagnosis. Staphylococcus infection (osteomyelitis).

Case 16

A laborer of thirty-six entered the hospital September 25, 1906.
For three years he has complained of indefinite stomach symptoms.
For sixteen months these symptoms have been more marked, but have
not amounted to actual pain, though they have been severe enough to
prevent his working ; there has been no vomiting. During these sixteen
months he has had fairly constant headache, not localized, not very
severe, but often accompanied by vertigo. A year ago he was so sick
that he was in bed four months, after which he was much improved, and
has not been in bed since.

His bowels move from one to three times a week, and only with
purgatives or enemata. He has no appetite and has lost about thirty
pounds. He has had many doctors, many diagnoses, and much treat-
ment. He denies alcoholic excess and venereal disease.

Physical examination shows slight irregularity and sluggish reactions
in the pupils; the left is larger than the right, and there is right external
strabismus. There is a well-marked tremor of the tongue when pro-
truded, and at times his lips are tremulous, as are his hands. The edge
of the liver is palpable on deep inspiration. The knee-jerks are lively,
Achilles jerk normal. White cells, 12,000; urine normal. Gastric
examination with the stomach-tube showed the lower border of the
organ reached two inches below the umbilicus; its functions and secre-
tions appeared to be normal. Visceral examination otherwise negative.

Under daily lavage and Zander treatment with vibrations he showed
some improvement. He took a good deal of exercise and gradually
acquired a good appetite.

Discussion. The questions which we naturally ask ourselves in
this case are as follows:

1. Can this be a "neurasthenic" headache?

2. Can it be due to eye-strain?

3. Has it any connection (a) With the gastrectasis or (b) with the
pupillary changes?

A "neurasthenic " headache i. c, one of unknown cause and benign
outcome is suggested by the long course of the symptoms, by the ab-
sence of fever and visceral lesions, and by the apparent nervousness

68 DIFFERENTIAL DIAGNOSIS

manifest in trembling of the lips and hands. But against this hypothesis
is, in the first place, the fact that he is a day-laborer and has, therefore,
no right to such troubles unless under the influence of alcoholism or some
severe and obvious mental strain. Further, this hypothesis does not
explain the irregularity and sluggishness of the pupils nor the tremor of
the tongue.

Eye-strain causes chronic headache, and the strabismus here present
might well be a favoring cause. How long that strabismus has existed the
patient has no idea, but it is certainly a very old affair as compared with
the headache. Again, it is inherently unlikely that a day-laborer should
begin to suffer from eye-strain at thirty-three. The point could only be
definitely settled by a more accurate examination of his eyes.

Dementia paralytica is distinctly suggested by the association of
pupillary defects with the tremor of the tongue and lips and the chronic
headache. The absence of a syphilitic history does not exclude the
existence of that disease. We might expect more change in the reflexes
and more obvious mental symptoms, but these are by no means neces-
sary. The diagnosis could be made much more certain in case the
spinal fluid obtained by lumbar puncture contained an excess of cells
with a lymphocytosis.

Outcome. By the eleventh of October his stomach ceased to trouble
him, but he showed a marked lack of initiative; he was perfectly content
to sit and gaze absent-mindedly at nothing in particular. He expressed
himself as greatly improved, and had gained a couple of pounds. It
was subsequently ascertained that he had been in an insane asylum in
November and December, 1905. There they obtained a history of con-
vulsive attacks, said to be brought on by eating, and characterized by
twitching of both arms, with numbness of hands, occurring daily for
about a week and lasting something less than an hour. During these
attacks he was sometimes unconscious, and after coming out of them,
failed to recognize people for a considerable time.

While at the asylum his eyes showed typical Argyll -Robertson
pupils. The knee-jerks were exaggerated, and there was a Babinski
reaction on the left, with marked incoordination of the upper extremities
and in the gait. Examination of the eyes was entirely negative. Men-
tally, he seemed more cheerful than the situation justified.

Diagnosis. Dementia paralytica.

Case 17

A widow of seventy-three was seen March 8, 1907. She had a fall
at twenty-one, was hurt inwardly and doctored for ten years. She had

HEADACHE 69

"brain fever" at twenty-four, and was four months in bed. Ten years
ago she had an attack similar to the present one, but less severe. She
has become very nervous in the last few years. Six weeks ago she was
taken with sharp pain in the eyes, spreading later to the top of the head
and the left side of the face, sometimes shooting along the jaws or behind
the ears. The pain has been steady during these weeks at times sharp
enough to make her cry out. Light hurts her eyes. Cold increases
the pain, and her jaw is so painful that she cannot chew.

Physical examination showed obesity, but was otherwise negative.
When the patient's attention was turned from herself, she seemed to
be perfectly happy. One night she kept the whole ward awake because
of an indefinite fear that something was going to happen to her.

Discussion. In this case, as in the la*st one, dementia paralytica
is suggested, but there is really very little to support that supposition.
The tremors and pupillary signs present in the last case are quite absent
here.

Although the pain here started in the eyes, there is nothing else in the
case to suggest eye-strain, and as the suffering has not been closely lim-
ited to the region of the frontal sinuses, we have no good reason to sup-
pose any inflammation there.

In genuine neuralgia we cannot ease the pain by diverting the pa-
tient's attention.

On the whole, the headache seems to be one of that large class of
mysteries from which we divert our attention because we are unable to
give them a name and because they pass off fairly quickly. No doubt
in this case the psychic condition was in some way an important cause.

Outcome. On examination by an eminent alienist she showed no
proof of insanity, but was believed to be a nervous, hypochondriac,
weak-minded old lady. Magnesium sulphate, 1] ounces daily, seemed
to do her good. She was easily controlled by reason and by appealing
to her better nature. Since the first night when she raised the roof for a
time she had no bursts of temper or loss of self-control. The pain
did not seem to mean much, and she was discharged on the nine-
teenth.

Diagnosis. Headache of unknown origin.

Case 18

An Irish housewife of twenty-three entered the hospital April 30,
1007. She was confined eighteen days ago, the labor being accompanied
by a large loss of blood. At the end of a week she complained of a
severe pain in the side of her face; later in the other side as well, but was

DIFFERENTIAL DIAGNOSIS

able to get up and take care of the baby. Last night the doctor found
her in a slight stupor, which has increased during to-day. The course
of the temperature is seen in the accompanying chart (Fig. 9).

The patient was semicomatose, had considerable pigmentation of
the face and neck, normal pupils, twitching right eye-brow, pulse of
high tension, viscera otherwise negative; reflexes normal; urine normal;
red cells, 3,832,000; white cells, 10,000, with 76 per cent, pblynuclears.
By May 2d Kernig's sign, photophobia, and marked stiffness of the neck
had developed. The patient moaned continuously, and had headache
unless she was kept under morphin.

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Discussion. Any headache near the time of parturition naturally
suggests uremia or some related autointoxication, but in this case nothing
was found in the examination of the urine or of the heart to support these
ideas.

Cerebral hemorrhage or embolism is not uncommon near parturition,
but would probably have a more sudden onset and produce paralysis
or aphasia.

Cerebral tumor should be considered and cannot be excluded with-
out an examination of the fundus. The absence of focal symptoms
and the presence of Kernig's sign, photophobia, and retracted head
militate against it.

Meningitis is left as the most plausible diagnosis, though the tem-
perature-chart and the leukocyte count are against it.

HEADACHE 7 I

Outcome. On lumbar puncture a clear fluid spurted eight inches
through the cannula; immediate and great relief followed. The patient
ceased moaning and went to sleep. A sediment of the fluid thus ob-
tained showed very rare leukocytes or degenerate mononuclear cells
and a few Gram-decolorizing bacteria not characteristic. Cultures
remained sterile; urine, normal. After the lumbar puncture the
pupils, which were previously inactive, became normal, the Kernig
sign less marked, and the head, though still stiff, was not retracted. By
the thirteenth of May there was marked improvement. The tempera-
ture, as seen by the chart on p. 70, was entirely normal. Less mor-
phin was required to control the headache. Consciousness returned
on the ninth of May. May 13th she fed herself.

May 19th : Marked improvement. Sits up daily. No stiffness of neck.

May 28th: Red cells, 4,380,000; leukocytes, 4000; hemoglobin, 65
per cent.

May 29th: The patient anxious to go home and is discharged.

Just what type of meningitis was present could not be determined.
At the present day an injection of Flexner's antimeningeal serum would
probably be indicated, despite the dubious results of this lumbar puncture.

Diagnosis. Meningitis.

Case 19

A married woman of thirty-five entered the hospital December 9,
1897. She had septicemia after the birth of her baby, six years ago.
She has never been quite as well since. For three weeks she has had a
little cold in her head and a little headache, gradually getting worse,
until four days ago, when she went to bed. Three days ago she began
to have severe "neuralgic" headache, localized just above the left eye.
She has had a hard, dry cough, which is now somewhat better; and for
three days there has been some pain in the left chest on full inspiration.

Physical examination showed the evidences of intense suffering from
headache, marked tenderness at the exit of the left supra-orbital nerve,
and less marked tenderness over its distribution. There is considerable
voluntary spasm of the right rectus abdominis. The temperature
is T00.5 F.; pulse, 90; respiration, 25; white cells, 14,000; urine, nor-
mal. Freezing the supra-orbital nerve with ethyl chlorid gave no relief.
Morphin in |-grain dose eased the pain, but soon after she became
hysteric, noisy, apprehensive, and almost delirious. She sat up in bed,
trembling, breathing rapidly, with widely dilated pupils, said she could
not get her breath, and wanted something to counteract the eflect ol the
morphin.

-j 2 DIFFERENTIAL DIAGNOSIS

Discussion. The problems presented by this case are:
i. Is the headache due to neuralgia, to frontal sinusitis, or to some
other cause?

2. What is the significance of the thoracic pain and of the abdominal
spasm?

3. What was the nature of the acute attack following the administra-
tion of morphin?

The fact that no relief was afforded by freezing the supra-orbital
nerve argues against neuralgia. Sinusitis is made more likely by the
direct sequence of the symptoms upon a cold in the head. There is
nothing in the history to suggest any other diagnosis.

Regarding .the cause of the thoracic pain and the abdominal spasm,
we must say, in the light of the outcome, "ignoramus." It should be
said with emphasis that in almost every carefully studied case there are
one or two facts like these which stray across the clinical field quite wild
and untamed, and never submit to any rational explanation. If a case
does not manifest some such symptom, but reels itself off like a text-
book account, I always suspect that it is carelessly reported.

At the time of the acute attack above described meningitis was sus-
pected on account of the association of the mental symptoms and head-
ache, but there was at no time any fever, and the results of treatment
(see below) made it obvious that it was one of those semihysteric attacks
of excitement which not infrequently follow the administration of mor-
phin in idiosyncratic individuals.

Outcome. She was reassured in regard to her breathing, and
given common salt in water to counteract the morphin, after which she
was quiet for the rest of the night. The next morning the pain had al-
most disappeared. The temperature was normal, and on the third day
she was allowed to go home.

Diagnosis. Sinusitis.

Case 20

A farmer of thirty-five was seen October 8, 1906. About August 1st
he began to have eruptions described as resembling giant urticaria in
various parts of his body. He had previously been treated for an attack
of angioneurotic edema. In the middle of August he had smothering
sensations in his chest, which lasted from one to three hours. The
coagulation time of his blood was then two minutes.

Four and a half days ago he began to have headache, which has
grown rapidly worse. Two days ago he had a chill at 3 p. m., and
yesterday one at 7 p. m. Fever has been continuous since the onset.

HEADACHE

The bowels have moved but once in three days. He has lost much
money of late, but says he does not worry about it.

Physical examination showed palpable glands in the neck, axillae,
and groins. Examination of the chest and abdomen was negative.
The blood showed no Widal reaction.

Discussion. The questions which naturally present themselves in
this case are:

i. Can the headache and fever be due to some of the urticarial group
of lesions, which, as we know, are sometimes associated with fever and
sometimes manifest themselves in the internal organs (respiratory
and gastro-intestinal tracts)? The smothering sensations complained

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of in August may have indicated the involvement of the respiratory tract
by lesions of the urticarial group.

2. Can financial worry, owing to his money losses, account for his
symptoms?

3. What is the significance of the general glandular enlargement?
leukemia? syphilis?

In relation to the first question it must be said, first of all, that
urticarial or erythematous lesions almost never occur on mucous surfaces
and serous membranes alone. If the fever and headache were of this
type, there ought to be some external lesion.

Neither worry nor any other psychic event produces a fever like
that here shown.

74 DIFFERENTIAL DIAGNOSIS

The text states that glands are palpable in the neck, axillae, and
groins, but this is far from indicating that the glands are now in a dis-
eased condition. Glands are palpable in health in a large majority
of adults in one or more of the above-mentioned situations. Neverthe-
less, the possibility of leukemia cannot thus be dismissed. I recently
saw a leukemic case with signs much like those here described, and
with a total leukocyte count nearly the same, the differential count, how-
ever, showing 95 per cent, of lymphocytes. As a matter of fact, this
examination was made in the case here under discussion, but the blood
was wholly normal.

General glandular enlargement certainly suggests syphilis, but such
enlargement was not present in this case, the glands being no bigger
than normal. There is nothing else in the case to suggest syphilis,
though a fever of this type is quite compatible with syphilis.

The suggestion of malaria (chills) was promptly negatived by the
blood examination.

The clinical picture then is that of a fever with nothing to show for
it. This makes us suspect typhoid, especially in October. The absence
of Widal reaction at this stage of the fever is, of course, not evidence
against typhoid. Still the diagnosis is not certain. Is there any way of
making it more certain? Blood culture should certainly be undertaken.

Outcome. A blood culture showed a bacillus giving all the reactions
of the typhoid organism. White cells, 6000. The Widal reaction did
not appear until the seventeenth. The course of the fever was unevent-
ful. He was discharged well on the eighth of November.

This case well illustrates the value of blood-cultures, which are most
likely to be positive at the very time when the Widal reaction oftenest
fails us, viz., at the beginning of the disease.

For the treatment of this case see Appendix B.

Diagnosis. Typhoid.

Case 21

A sailor of twenty-seven entered the hospital November 26, 1906.
He has lost one sister of " meningitis." Six months ago he had malaria,
with chills every second day for three weeks. He has not felt perfectly
well since. He denies venereal disease. Two weeks ago he began to
have slight, throbbing headache, with blurring of eyes and general
fatigue. Three days later he felt feverish. Eight days ago the head-
ache became severe enough to confine him to bed, where he has been
since. His appetite has been poor. Vomiting has been frequent. He

HEADACHE

has lost much weight and strength. The course of the fever is seen in
the accompanying chart (Fig. n).

On physical examination the right pupil was found to be slightly
larger than the left; both reacted normally; heart and lungs normal,
except that respiration at the left apex was rather harsh, with slight
dulness. A rare sibilant rale was heard over this area. White cells,
8300; polynuclear cells, 80 per cent.; there were no malarial parasites.
Widal reaction negative, November 26th, 29th, and December 1st.
The urine was normal; fundus oculi perfectly nor-
mal; sputa negative; stools normal.

Discussion. Naturally, our first thought is of
typhoid, but after ten days of fever the temperature
should be higher in typhoid, unless, indeed, we are
dealing with one of the rare abortive cases which
finish themselves up within ten days, so that we are
here seeing only the tail end of the disease. Against
this, however, militates very strongly the total
leukocyte count (almost always subnormal at this
stage of typhoid), and especially the high percentage
of polynuclear cells, which is practically unknown
under these conditions.

The history of a previous malaria makes that
disease worth a moment's consideration, but as this
individual has not been out of a temperate climate
for many months, it is practically impossible that he
should have acquired an estivo- autumnal malaria,
which is the only type compatible with a fever-curve
like that shown below. The patient's occupation brings syphilis to
our minds as a possibility, but there is nothing else about the case to
support this supposition.

Brain tumor often produces a remarkably slow pulse, such as is seen
in this case, but there is nothing else about the patient to verify this
hypothesis. The fact that the patient is obviously sick and yet has a
very slow pulse directs our attention still further to the possibility of a
brain lesion. Can he be suffering from tuberculous meningitis? There
are no disturbances of the cranial nerves nor retraction of the head, and
no leukocytosis, but the lung signs suggest a possible tuberculosis there.
Lumbar puncture should certainly be done unless further evidence soon
appears to clear up the diagnosis.

Outcome. On the twenty-eighth slight stillness of the neck on
forward bending was noticed; otherwise there was no change.

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case 21.

DIFFERENTIAL DIAGNOSIS

On the twenty-ninth he became slightly delirious, and in the evening
required restraint and refused to swallow.

On the first of December he became comatose, and the stiffness of
his neck disappeared. On the third of December he died. Autopsy
showed general miliary tuberculosis and tuberculosis of the mesenteric
and retroperitoneal glands.

Diagnosis. Miliary tuberculosis.

Case 22

A bricklayer of sixty-four entered the hospital May 15, 1908.

Three

uncles upon his father's side died of consumption; his family history
is otherwise good. He takes from a pint to a quart of whisky a day;
has had gonorrhea many times; had chancre fourteen years ago, for which
he was treated three years. He was down South at the time the present
illness began, two weeks ago; he does not seem to
know exactly how he got there. He has been in
bed for a week and a half, complaining of nothing
but headache and poor appetite.

On examination, his pupils are equal, regular,
and react normally. His temperature is as seen
in the accompanying chart. His tongue is covered
with a thick, dry coat. The heart-sounds are faint.
A faint, systolic murmur is heard all over the pre-
cordia, transmitted into the axilla. The aortic
second sound is slightly accentuated; heart not en-
larged; the arteries palpable. In the lower half of
the right lung, behind, slight dulness, diminished
breathing, many medium and coarse crackling rales;
abdomen and reflexes normal; white cells, 13,600;
urine normal; Widal reaction negative.

The patient was sent in with a diagnosis of
typhoid fever, but showed at entrance only head-
ache and bronchitis in an alcoholic subject.
May 19th: The hospital record states that he does not need hospital
treatment, and will be sent home in a day or two.

May 21st: On the morning visit he seemed "dopey"; for the past
two nights he has complained of severe headache. At 11 p. m. May 21st,
he was found unconscious.

Discussion. The family history, the presence of lesions suggestive
of a pleurisy at the base of the right lung, suggest the possibility of a
tuberculosis with involvement of the meninges. This could only be

Fig. 12. Chart of
case 22.

HEADACHE

partially excluded by lumbar puncture, and must remain a possibility
in the diagnosis of this case.

Headaches with nocturnal exacerbations suggest syphilis, especially
in a patient who has certainly had that infection in previous years. It
is impossible, however, to go beyond suspicion unless we can get further
evidence, such as disturbances of the cranial nerves, of the reflexes, a
positive Wassermann reaction, or other syphilitic lesions.

The history naturally suggests alcoholism ("wet brain"), but in the
absence of any sign of delirium tremens this seems unlikely, since the
amount of alcohol consumed in the last ten days has been almost nil.

Typhoid and other infections disappeared from consideration when
the temperature fell to normal and stayed there.

Can the diagnosis be malaria? The patient has recently come from
a malarial country, where he may have acquired a type of the infection
not characterized by the familiar tertian or quotidian chills seen in tem-
perate climates. In a case very similar to this, occurring in a drummer
who had recently returned from a southern trip complaining of fever,
headache, and prostration without chills, I found large numbers of
estivo-autumnal "rings" in the red cells. The present case, however,
showed no such evidences in the blood.

It is much to be regretted that we made no measurement of blood-
pressure in this case. An elevated pressure would support the sup-
position that some brain lesion (tumor, hemorrhage, softening, or
meningitis) existed. As it was, no diagnosis was made during life.

Outcome. In the evening the pupils ceased to react; the left arm
and leg were cooler than the right; Babinski on both sides; abdominal
reflexes absent; no paralysis made out. He died on the twenty-second.

Autopsy showed subdural cerebral hemorrhage; hemorrhage into
tegmentum of epencephalon ; arteriosclerosis; atheromatous endocarditis
of the aortic valve; fibrous endocarditis of the mitral valve; hypertrophy
of the heart; syphilitic cirrhosis of liver; bronchopneumonia; acute
fibrinous pleuritis; congenital cyst of kidney; round ulcer of stomach;
fibrocalcareous tuberculosis of the lungs; chronic pleuritis; subcapsular
hemorrhage of kidney.

Diagnosis. Cerebral hemorrhage.

DIFFERENTIAL DIAGNOSIS

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CHAPTER III
LUMBAR PAIN

Some years ago, when I was doing a good deal of work on the blood,
I was asked to substitute as visiting physician to a convalescent home
intended primarily for tired domestics and shop-girls. The matron
met me with that patient and respectful expression which long service
under many enthusiastic young physicians produces in some nurses.
"I hear," she said, "that you are specially interested in the blood.
Dr. R., the gynecologist, who was visiting last autumn, found that all the
patients were gynecologic. When Dr. C. visits us in summer, he finds
them all nose and throat cases that's his specialty. Now that you are
to visit us, I suppose they will all turn out to be blood cases."

It must be explained that there was no election on the patients' part.
They did not seek the institution because they heard that Dr. X. (a
specialist in their particular trouble) was on duty. They were sent
there by a variety of other physicians who had no knowledge of the
interests of the different attending specialists.

Now, in a similar way, we may explain, I think, the various interpre-
tations of backache given by different physicians, each according to his
point of view. To the gynecologist backaches are usually gynecologic
symptoms; to the orthopedist, they result from sacro-iliac disease or
postural strain; to the neurologist, they represent one phase of habit-
pain due to a psychoneurotic make-up. There are stomach specialists
who explain backache as a result of malnutrition, gastroptosis, or consti-
pation (loaded colon).

So it goes! The one thing which remains unchanged is the backache.
When we find 15 or 20 drugs recommended for one disease, we are in-
clined to believe that none of them has much value. Similarly, when
we find many and various explanations for one condition, it is natural
to doubt whether any of them are true.

The one thing clear about the obscure backaches called "functional."
"postural," "uterine," "sacro-iliac," etc., is relief by mechanical com-
pression exerted about the pelvis and lower lumbar region by means of
corsets, plaster strapping, belts, or plaster-of- Paris.

In many cases a strong neurotic element can be traced the mental
or nervous weakness acting on the back through a reduction of muscular
tone. Flabby mind, flabby muscles, unsupported joints, pain. Doubt-

80 DIFFERENTIAL DIAGNOSIS

less any of these factors (and probably various others) may so "activate"
the rest that in various ways the back may be made to ache. I do not
think that any one knows much about it.

On the gynecologic side the most careful study of backache (and
other pains) in relation to pelvic disease is that reported by Dr. C. T.
Dercum, 1 of Philadelphia, in which she shows statistically what I have
long believed from unrecorded but fairly extensive observations in the
Women's Medical Clinic of the Massachusetts General Hospital, viz.,
that there is no type of backache or other "reflex" pain which can
reasonably be referred to pelvic disease. All types of pain in the back,
head, and extremities occur with equal frequency with and without
pelvic disease. All types of pelvic disease exist with and without back-
ache. Even deep-seated cancerous growths may be latent and symptom-
less for many months.

The tables on page 83 from Dr. Dercum's article show to my satis-
faction the mutual independence of backache and pelvic disease.

Aside from this huge group of backaches cured by mechanical sup-
port and lateral compression of the pelvis, but explained in many ways,
as gynecologic, neurasthenic, or functional, as sacro-iliac strain or as
loss of balance, 2 etc., we have two other affections which I have found
it convenient to bracket with it under the clumsy title of the orthopedic
group of backaches. These diseases are:

1. Lumbago.

2. Hypertrophic spondylitis.

These may be for a time indistinguishable from each other and from
the larger and vaguer group above referred to.

The "kidney group" of causes for backache is a term which I shall
use throughout this chapter to denote the "surgical" diseases in or near
the kidney: tuberculosis, stone, neoplasm, abscess, cystic degeneration.

The "pressure group" refers to diseases which involve a progressive
compression of the lumbar cord or its nerves: aneurysm, neoplasm,
vertebral tuberculosis.

Some of the commonest causes of lumbar pain will not be discussed
in any detail here. Probably more persons experience such discomfort
as a result of

(a) Fatigue and simple weariness than from any other single cause.
The patient usually finds this out when the pain goes off after a rest.

1 The Nervous Disorders in Women Simulating Pelvic Disease; An Analvsis of 591
Cases, Jour. Amer. Med. Assoc., March 13, 1909, p. 848.

2 Reynolds and Lovett, An Experimental Study of Certain Phases of Chronic Back-
ache, Jour. Amer. Med. Assoc, March 26. 1910, p. 1033.

Causes of Lumbar Pain

1. FATIGUE AND DEFECTIVE BALANCE ("FUNCTIONAL ]

BACK")

2. CHILDBIRTH

3. INFECTIOUS DISEASES

4. POSTOPERATIVE

CASES TOO MANY
AND TOO VAGUELY
ENUMERABLE FOR
GRAPHIC REPRE-
SENTATION.

5. SACRO-ILIAC DISEASE

(NON-INFECTIOUS)

6. LUMBAGO

7. HYPERTROPHIC I

ARTHRITIS I

8. HERPES ZOSTER |

("SHINGLES") (

9. INFECTIOUS ARTHRITIS\
OF SPINE I

10. ACUTE SPRAIN OF THEl

BACK I

11. RENAL STONE

12. SPINAL TUBERCULOSIS

13. RENAL SUPPURATION

14. PERINEPHRIC ABSCESS

15. RENAL TUMOR

16. CANCER OF THE SPINE

17. RETROPERITONEAL I

TUMOR /

711

549
351

214

178

149

109
72
65
26
16
6

LUMBAR PAIN 83

TABLE I.

Location of Pain or Tenderness. Pelvis Pelvis

Normal. Diseased.

Both groins (so-called ovarian tenderness) 70 14

Left groin (so-called ovarian tenderness) 40 14

Right groin (so-called ovarian tenderness) 20 3

Under both breasts (inframammary tenderness) 2 o

Under left breast (inframammary tenderness) 26 2

Under right breast (inframammary tenderness) 1 o

On either side of the spine in the cervical region 3 1

On either side of the spine in the dorsal region 14 2

On either side of the spine in the lumbar region 9 4

Over the sacrum 14 3

At the end of the coccyx 10 2

Above the spines of the scapula; 4 o

Clavus hystericus 5 3

Deep intra pelvic pain (hysteric) 10 o

Painful areas on mucous surfaces, vagina, vulva, rectum, and

tongue 4 o

Limbache (legs, thighs, arms, and shoulders) 40 3

Sacral backache 60 10

Lumbar backache 2 7

Headaches, vertical 3 o

Headaches, diffuse 6 2

Headaches, frontal and occipital 35 3

Headaches, occipital 26 5

Headaches, frontal 16 3

Hysteric vomiting 3 o

Hysteric pain in one eye during menstruation 1 o

Hysteric globus 9 " o

Disturbed sleep 18 5

Insomnia 3 o

Gastro-intestinal disturbances of nervous origin, such as constipa-
tion, flatus, gastric distress, diminished secretions, and ano-
rexia 96 12

TABLE II.

Backache, headache, and other
Pathologic Condition. hysteric or neurasthenic

symptoms.

Absent. Present.

Cvstii degeneration of the cervix 3 o

Tubo-ovarian inflammations and exudates 53 34

Fibroid growths, including one weighing 17 pounds 11 4

Cervical and perineal lacerations 39 :i

I )ysmenorrhea 7 23

Anteflexions 24 28

Retropositions 44 3')

Splanchnoptosis (relaxation of uterine supports) 10 ,}

Lacerations that were repaired 2 o

Where lx>th ovaries had been removed c) o

Where one ovarv had been removed 2 o

Where the appendix had been removed 4 o

Carcinoma (no nervous svmptoms found in any cast' of car-

1 inc una ) u o

Pelvic organs normal o 181

84 DIFFERENTIAL DIAGNOSIS

Sometimes, however, the fatigue has become cumulative, and is so
chronic that it has developed, as it were, into a member of the household.
Its source and origin may have been forgotten, and come to light only after
close questioning or as a result of a therapeutic test, viz., a thorough rest.
In persons of high-strung, hypersensitive, and neurotic temperament,
these simple fatigue pains merge into what may be called

(b) The psychoneurotic backaches, which have certain character-
istics worth noting here. Pains of this type are often confined to the
region of the coccyx, and, unfortunately, they are apt to lead the patient
into the hands of some fervid and eager surgeon, who speedily does an
operation on the coccyx. If the operation is followed by prolonged rest
with hypernutrition and a considerable amount of reeducation given
consciously or unconsciously by the surgeon or his assistant, the patient
may recover, but the credit is falsely given to the operation, which would
have been quite useless as, indeed, it often proves without the nutri-
tive and educational influences linked to it.

Another type of psychoneurotic backache makes the patient ab-
normally conscious of the whole length of his vertebral column, which is
affected, not only by pain, but by a variety of paresthesias, tingling, sen-
sations of heat or cold, sensations of pressure or crawling. This type of
trouble may arise without any obvious reason, but it is also often met
with following some accident, whence the term, "railway spine." In the
vast majority of these cases, however, the accident has served merely
to direct the patient's attention to a certain part of the body, in this case
the spine, and also to perturb his moral consciousness through the ex-
pectation of damages and court-room scenes.

A third type of psychoneurotic backache, to which further reference
will be made below, is recognizable by its obvious connection with
psychic and especially emotional states. A depressing emotion will
produce it, a joyful event will cure it; but one must beware of doing the
patient injustice by dubbing the pain imaginary or unreal, either in this
or any other type of psychoneurotic trouble. What the facts show is
that a certain direction and morbid concentration of attention is fol-
lowed by pain, and that a new habit of life, physical and mental, leading
to a more profitable direction of attention, is followed by relief. The
most plausible hypothesis, and also the most useful one, because the
most helpfully comprehensible to the patient, is that which assumes
the following: Xumberless physiologic changes are occurring every
moment in even' part of our anatomy the circulation of blood, the
distention and contraction of blood-vessels, the movements of lymph-
currents, the varying tension and pressure of muscular masses, ligament-

LUMBAR PAIN 85

ous strands and fasciae all these and presumably many other phenom-
ena go on very busily but quite unconsciously when our minds are normal ;
but when attention gets caught and concentrated upon the spine or the
coccyx or the back of the neck, and when the patient has made a mental
picture of the organ which he supposes to be diseased ("the base of the
brain," "the whole spinal cord," "the outlet of the stomach," "the
left ovary"), then this unfortunate begins to be aware of physiologic
processes normally unfelt. This very awareness, through the forma-
tion of brain habits and possibly also through vasomotor influences
acting upon the points supposed to be diseased, reinforces and increases
the sensations referred to this point until they finally attain the dignity
of pain, which ultimately becomes a habit ("habit pain").

I shall not try to exemplify in any detail this type of pain, though it
is one of the most common in the practice of all busy physicians.

(c) Lumbar pain due to parturition is only rarely mistaken for any
other variety, and offers, as a rule, very little diagnostic difficulty.
Obviously, it is one of the commonest of all such causes.

(d) BackacJic from infectious disease of any type, from a simple
cold to the severest septicemias and pneumonias, is, I suppose, the next
commonest variety. Occasionally this type offers some difficulties in
diagnosis, examples of which will be considered later. In the great
majority of cases, however, the presence of fever, headache, and widely
distributed pain in other parts of the body enables us to identify infec-
tious backache without much difficulty.

(e) Postoperative backache appears usually about twenty-four hours
after the operation, and is troublesome for the next two or three days.
Though often associated with gaseous distention of the lower bowel,
there seems to me to be no good reason to believe that the distention
causes the pain, since similar distention is so commonly present in
typhoid, pneumonia, and other infectious diseases without any back-
ache. The postoperative lumbar pain seems to be more common after
prolonged operations in which the patient's back rests upon a flat table,
so that the normal spinal curvature is no longer maintained by muscular
tone, which the anesthetic relaxes. Pressure by the surgeon or his
assistant upon the patient during operation may contribute to the
result. If this explanation be correct, the backache should be prevented
by padding or curving the surface of the table to correspond with the
normal lumbar curve of the spine.

The types of lumbar pain next to be discussed all differ from those
above mentioned in two important respects: those listed so far have
been far commoner than those still to be mentioned, and far less depend-

86 DIFFERENTIAL DIAGNOSIS

ent upon direct physical examination for their recognition. It is for
this latter reason that diagnostic difficulties are far commoner in the
still remaining groups already mentioned on p. 80.

(/) The Orthopedic Group. What was almost universally called lum-
bago ten years ago has now been split up into three main subtypes of
disease: spinal osteo-arthritis, sacro-iliac disease (non-tuberculous),
and a residue still known under the name of lumbago. Despite the
important differences which have now been demonstrated and have
given rise to this separation, these three diseases are still loosely bound
together by the fact that their treatment is very similar. It is, however,
altogether for reasons of convenience in the discussion of differential
diagnosis that I have linked them together under the title of the orthopedic
group. They differ sharply, both in prognosis and treatment, from all
the types of disease above referred to, as well as from those next to be
described.

(g) The pressure group of diseases causing lumbar pain includes
vertebral tuberculosis (Pott's disease), aortic aneurysm, and neoplasm
in or near the spinal column. I am quite aware that this term has no
other merit than that of convenience for discussion, since in two members
of the lumbago group pressure is also the cause of the pain.

(h) The kidney group of causes for lumbar pain includes renal stone,
tuberculosis, neoplasms, hematogenous infection of the kidney, and para-
nephritic abscess as its chief members. Among the rarer causes for
lumbar pain may also be mentioned renal infarct, hydronephrosis,
pyonephrosis, and cystic kidney.

(i) Lumbar neuralgia or neuritis, clearly recognizable only in the
presence of the vesicular eruption (herpes zoster or shingles), is a com-
paratively rare cause for lumbar pain. Of about equal rarity as a cause
of such pain is

(j) Cholelithiasis. -Perhaps one case of gall-stones in a hundred shows
itself by pain starting in the back and working toward the gall-bladder
instead of in the opposite direction, as is usual.

With lumbar pain or tenderness due to ulcer or cancer of the stomach
or bowel I have had no experience, though I have asked and examined
for such pain many times. Schmidt 1 mentions very specifically that in
lead-poisoning sharp lumbar pain is occasionally associated with the
ordinary abdominal colic.

To investigate the cause of lumbar pain it is well to ask the follow-
ing questions:

1 Pain, Tts Causation and Diagnostic Significance, by Rudolph Schmidt, translation
published by Lippincott.

LUMBAR PAIN 87

(1) Is it unilateral (diseases of the renal group especially) or bilateral?

(2) Is it of long duration? Chronic lumbar pain points especially
to the psychoneuroses and to the pressure group of causes.

(3) Is it made much worse by stooping or sidewise bending? This is
the characteristic of the lumbago group and of many psychoneurotic
cases, while diseases of the pressure group and the kidney group are not
thus characterized.

(4) Is the lumbar region sensitive to pressure or percussion? Such
sensitiveness is especially common in diseases of the renal group, but if
localized over the sacro-iliac joint, it often points to disease there.

(5) Does pain radiate along the course of the intercostal nerve?
This occurs especially in the lumbago group and the pressure group.

(6) Does the urine contain blood or pus?

EXAMINATION OF PATIENTS WITH LUMBAR PAIN

Incredible though it seems, there are physicians in practice to-day
who do not hesitate to treat lumbar pain without stripping the patient
so that the naked back can be examined. I have known a case of
herpes zoster to be treated for " rheumatism " (salicylates, alkalis,
vegetable diet, etc.) simply because the vesicular eruption was unknown
to the patient and had never been looked for by the physician.

Osier mentions a case of aneurysm of the descending thoracic aorta,
which presented as a pulsating tumor near the angle of the left scapula,
quite undiagnosed through many weeks of treatment for lumbago and
neuralgia. The attending physician had never examined the exposed
back, presumably because the patient, being a male, wore clothes which
opened in front and did not offer to remove them.

Once we have formed the habit of examining the naked back, we
should note especially:

(a) Is the spine rigid locally or throughout ? (Allowance must be
made for the moderate rigidity of normal old age.)

(b) Is there any tenderness over the spinous processes?

(r) Is there any dulness on percussion of the bases of the lungs?
(Renal abscess or neoplasm may push up the diaphragm and encroach
upon the thoracic space.)

(<!) Does the patient stand or walk with a list to one side?

Case 23

A Swedisli tinsmith, twenty years of age, of excellent family history,
past history, and habits, entered the hospital on the twenty-fifth of June,

88 DIFFERENTIAL DIAGNOSIS

1908. On June 7th, while sitting in a chair upon his piazza, he had a
sudden attack of sharp pain in the right lower back. This pain con-
tinued severe for the next six days, and on the day after its onset he began
to be short of breath on slight exertion. A dry cough began at the same
time, and has persisted since. His appetite has been poor, but he has
not been in bed. He has had no constipation or other symptoms.

When first seen, his temperature, pulse, and respiration were normal.
His heart's apex was i-j? inches to the left of the nipple-line in the fifth
space, the right border of cardiac dulness two inches to the left of the
midsternum line in the fourth space. The heart-sounds were of good
quality, and there were no murmurs. The upper part of the right chest
was slightly dull as low as the third rib. Below this there w r as tympany
extending two inches to the left of the midsternal line, below the costal
margin, and to the middle of the right axilla. Tactile fremitus was
diminished over this area, and breath-sounds distant or altogether
absent, except at the right apex, where the voice sounds were increased
and the breathing was bronchovesicular.

In the back, with the patient sitting up, there was relative dulness
down to a point iV inches below the angle of the scapula, the line of
resonance rising from that point obliquely across the axilla to the level
of the third rib in front. Below this there was tympany.

Over the dull area in the back fremitus is diminished, and at the
extreme base absent. Otherwise the signs are the same as in the corre-
sponding area in the front. There are no rales, no friction or other ab-
normal sounds.

Physical examination is in other respects negative. The blood and
urine are normal.

Discussion. As we read the signs set down in this case, pneumo-
thorax is naturally our first thought. But can pneumothorax occur so
suddenly in a person of excellent health and without any of the known
causes of pneumothorax (phthisis, trauma)? Let us consider the other
possibilities before answering this question.

Pain, dyspnea, and cough suggest pneumonia, but the absence of
fever and of any evidence that the patient has had and passed a crisis
exclude this.

A sharp thoracic pain, followed by dyspnea and cough, constitutes
the ordinary onset of pleurisy, but the physical signs of this case, especially
the tympany at the base of the chest, together with the absence of the
friction sounds, exclude this.

Passing to other possible explanations of the tympanitic resonance
just referred to, we think of emphysema; but this cannot be so localized.

LUMBAR PAIN 89

and is never of sudden onset. The presence of gas below the diaphragm,
either in the bowel or in an abscess cavity, would explain many of the
signs in this case; but there is no history of any previous abdominal
symptoms, such as usually lead to the so-called subphrenic pyopneumo-
thorax. There has been nothing to suggest appendicitis, perforating
gastric ulcer, or hepatic abscess. There are not enough fever and con-
stitutional disturbance.

We, therefore, return to the first supposition, viz., pneumothorax.
Investigation of any large number of cases of this disease shows that
its symptoms may be either stormy and virulent, or so mild as to be prac-
tically negligible. Twice I have seen pneumothorax (proved to be such
by the liberation of air through puncture) in patients who felt practically
well and were examined almost by chance. This means that the cause
present and leading to the vast majority of all cases of pneumothorax
namely, tuberculosis may be absolutely latent and symptomless.
This is, of course, a well-known fact, but the sudden appearance of a
tuberculous pneumothorax brings the truth home to us in a startling
way.

Outcome. The patient was given 3 milligrams of tuberculin after
five days of normal temperature, and the temperature thereafter rose to
101 F. and was accompanied by headache and malaise.

The patient was accordingly transferred to a sanatorium for tuber-
culosis.

The prognosis in a case of this kind and the treatment are those of
the underlying process phthisis. The advent of pneumothorax does
not render the outlook much graver. In the great majority of cases the
air is readily absorbed, and no special treatment need be directed to it.
If the air persists in the chest unchanged for a number of weeks, or if
its amount is so large as seriously to embarrass the action of the heart
and lungs, it may be removed by puncture, after which it may, or may
not, reaccumulate.

Diagnosis. Tubercular pneumothorax.

Case 24

A stationary fireman of fifty entered the hospital November 0. 1001.
Seven years ago, following an injury to his left elbow, the joint gradual!}'
grew stiffer, and he was told that there was a growth of bone there,
lie came to the out-patient department for treatment, and the elbow-
was baked daily for five weeks, with considerable benefit, but he has
never been able full} - to extend the arm since that time.

Three weeks ago he began to have shooting pains across the small

90 DIFFERENTIAL DIAGNOSIS

of his back, brought on by any motion. Three days ago these pains
became so severe that he could scarcely move. The pain now starts
in the small of the back and extends down the left leg as far as the ankle.
Three days in bed has given him no relief.

Physical examination showed well-marked Heberden's nodes on the
fingers. The physical examination was otherwise negative, except that
the left elbow could not be flexed beyond 80 degrees or extended beyond
45 degrees. There was tenderness along the back of the left thigh from
the popliteal space to the sacrum, also over the Achilles tendon, pressure
on which causes pain to shoot up the thigh.

So long as the patient remained absolutely quiet he was comfortable,
but coughing, sneezing, any movement of the leg or body caused pain to
shoot from the sacrum to the foot. Fixation with a ham splint afforded
no relief, nor did the application of cold along the nerve. Drugs were
without effect. Heat, on the other hand, relieved him somewhat.
Tight criss-cross strapping of the lower back and, later, a supporting
belt, gave still more relief, although numbness of the thigh and calf
developed as the pain diminished.

Discussion. The great majority of cases of pain in the back fall
into three groups:

1. The infectious group.

2. The orthopedic group.

3. The renal group.

The first and the last of these may be excluded by the absence of
fever and of urinary signs. Within the group which I have called ortho-
pedic fall chiefly lumbago, sacro-iliac strains and displacements, spinal
osteo-arthritis.

Lumbago is pretty definitely excluded by the long duration of the
disease. After three weeks of pain we must find some other cause,
especially as the pain is no longer confined to the lumbar muscles, but
extends down the left leg.

Sacro-iliac disease (strain, sprain, displacement, or pinching of joint
fringes) should cause the patient to stand with a list to one side, and
should produce tenderness over the sacroiliac joint, together with pain
increased when the leg is raised without bending the knee. Direct
physical examination of the sacro-iliac joint usually reveals nothing in
these cases except localized tenderness. In this case the above tests were
all negative.

Spinal osteo-arthritis is favored by the age of the patient, and by
the presence of similar joint outgrowths elsewhere (elbow and fingers).
Pain on cou"hin; and sneezing is also rather characteristic of osteo-

LUMBAR PAIN

arthritic processes, because they so often involve the costovertebral
joints, which have to move sharply and suddenly when we cough or
sneeze. This symptom, however, also occurs in all the orthopedic
group of diseases above referred to.

Malignant growths in or near the spinal column might account for
all the symptoms here present, and can only be excluded by #-ray
examination or by the outcome of the case.

Outcome. X-ray showed osteo-arthritic outgrowths in the lower
lumbar region. By December 5th he was able to walk about with
crutches, and by the eleventh he was able to go home very much relieved.

Diagnosis. Hypertrophic spinal arthritis.

Case 25

A motorman of twenty-four entered the hospital August 19, 1907.
His habits and previous history were good, but for the past two weeks
he has had pain across the small of his back. For the past four days
the pain across the small of his back has become more severe and he has
been nauseated when he tried to eat, although he has felt hungry.

Six days ago he felt chill}- in the evening and shivered a little; but he
did not give up his work until two days before his entrance to the hospi-
tal. This morning he had a brief spell of tingling in the left arm. He
continues to feel hungry, but cannot eat. He does not feel at all weak.
His bowels move once daily.

At entrance the patient's temperature was 103.8 F.; pulse, 88;
respiration, 24. He was mentally alert, and did not look very sick.
There was a harsh, systolic murmur heard all over the precordia. loudest
in the pulmonary area, where there is a suggestion of a systolic thrill.
The pulmonary second sound was slightly greater than in the aortic.
The heart shows no evidence of enlargement. A slightly tender mass
was felt to descend below the left costal margin on full inspiration.

Physical examination was otherwise negative. The urine was normal.
The Widal reaction was negative; the white cells were 5400.

Discussion. The presence of continued fever excludes most of the
so-called orthopedic group discussed in the last case. We have left
the infections, local and general. Local infections producing pain in the
back are chiefly spinal tuberculosis, hematogenous renal infection, and
perinephric abscess. These are excluded in the present case, because
the spine, the region of the kidney, anteriorlv and posteriori}', and the
urine, are all negative. We are left with the question, What general
infections are most apt to cause backache? The answer is: "grip."
tonsillitis, typhoid, and sepsis. Of tonsillitis and sepsis we have no

DIFFERENTIAL DIAGNOSIS

positive evidence, though the harsh systolic murmur mentioned in the
text might suggest a sepsis of the type known as ulcerative endocarditis.
There is, however, nothing conclusive about this murmur as described,
and nothing else in the case to support the diagnosis of sepsis. The
murmurs most suggestive of a septic endocarditis are those that rap-
idly change their characteristics under observation, especially diastolic
murmurs.

The good appetite and the mental alertness are not characteristic
of typhoid, but there is nothing in the case absolutely inconsistent with
that diagnosis. The tender mass felt below the left ribs might be the

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spleen. The absence of a Widal reaction is not unusual at the onset of a
typhoid.

In the absence of a well-marked infection of the upper air-passages
with the influenza bacillus predominating in the discharges there is
never any good reason for the diagnosis "grip." Such a diagnosis is
usually a rather equivocal way of saying "I don't know." The word is
used largely to satisfy the patient.

On the evidence thus far presented, then, one can only guess at the
diagnosis of this case. Only as the chart develops do we begin to feel
any more confidence that our original guess, typhoid, is correct.

For treatment see Appendix.

Outcome. The subsequent course of the temperature is shown

LUMBAR PAIN 93

in the accompanying chart. The Widal did not appear until August
25th. The mind was clear and alert throughout, and after the twenty-
eighth the mass was no longer felt in the left hypochondrium. The
patient sat up on the twenty-second of September, and went home well
on the first of October.
Diagnosis. Typhoid.

Case 26

A widow of fifty entered the hospital March 17, 1908. Her history
was always negative up to a month previously, when she began to have
pain in her lower back and in her right hip, making it difficult to lie down.
The pain was sharp, constant, and increased by motion. It was usually
relieved by heat, but last night she had to take morphin to get to sleep.
She has worked until four days ago, though her appetite has been poor,
and she has some nausea and loss of weight.

On the right back, on a line with the spine of the ilium, is a group of
broken vesicles covering an area of 2I inches by one inch, and extending
at right angles to the spinal column. Temperature, pulse, and respira-
tion normal.

Dr. R. B. Osgood found nothing wrong in the bones and joints.
Vaginal examination was negative, as were the blood and the urine.
Dr. James J. Putnam considered the pain due to herpes. She slept well
on the night of the twenty-first after 10 grains of veronal, and aspirin in
doses of 10 grains also relieved her. Acctanilid 5 grains with 2 grains of
caffein was later given to insure sleep. Aconitin in -o-i-g- to y^- grain
doses had no effect, although it was pushed up to the point of toxic
symptoms, when she remarked that it made her feel cold and clammy,
like a chicken just taken off the ice. Later her pain became more severe,
and was not relieved either by aspirin, by quinin, or by strychnin. Phe-
nacetin and salol relieved her more, and by the sixteenth of April she
was able to sleep without any drugs at night. Veronal and codein, the
former 10 grains, the latter half a grain, were repeatedly needed before
April 10th for sleep.

After she had been in the ward live weeks with normal temperature
and pulse throughout, her temperature suddenly rose to 10^.5 F., and
her leukocytes, which had previously been normal, rose to 10.200.

The lungs were negative, but there was marked tenderness in the
right lower abdomen, without spasm. The patient was so hypersensitive
when she was touched at any point that it was difficult to know how
much weight to lav upon her abdominal pain.

Bv the twentv-fifth the temperature had airain readied normal; the

94 DIFFERENTIAL DIAGNOSIS

white cells were still above 15,000, and there was indefinite sensitive-
ness in the right lower quadrant.

On the twenty-ninth, after she had been sitting up, she appeared
to be very sensitive in the right iliac fossa.

Discussion. Lumbar pain without fever and without evidence of
any disease of the orthopedic group or of the kidney group should
always suggest the possibility of a neuritis. The group of vesicles,
though covering so limited an area, gives strong support to the hypothesis.
Neuritis of the thoracic region, involving, presumably, in every case a
lesion of the spinal ganglion corresponding, is especially apt to be
accompanied by that vesicular eruption which we call herpes zoster or
"shingles." In the majority of cases the painful area is much larger
that the vesiculated area. It need not surprise us, then, that in this case
the vesicles cover such a small spot, and we have no good reason to
hesitate regarding the diagnosis herpes zoster. Presumably this is
due to a local infection of the spinal ganglion similar to that which has
been demonstrated in the ganglia corresponding to the facial herpes in
pneumonia.

Regarding the treatment of this painful affection, it is worth noting
that the application of an ethyl chlorid spray over the corresponding
spinal ganglion sometimes gives very striking relief to the pain.

Can the abdominal pain, occurring in the sixth week of this case, be
attributed to a second attack of the same trouble? Experience has
taught us never to multiply causes or diagnoses if the facts can be ex-
plained otherwise. But in this case the occurrence of fever and leuko-
cytosis, with the new pain, should make us look for some local in-
flammatory cause. We should search for evidence of a local abscess,
of tonsillitis, of phlebitis, arthritis, or pneumonia. By the twenty-ninth,
when tenderness in the right iliac fossa was marked, there seemed to be
every reason to suspect the appendix.

Outcome. On the second of May the white cells had risen to 31,000,
and a distinct mass could be felt in the right iliac region.

On May 3d the abdomen was opened and an ounce of pus evacuated
from the region of the appendix.

The patient's recovery was complete.

This case constitutes one of those exceptions which prove the rule
the rule, namely, that we do not often deal with two diseases as the
explanation for a group of symptoms. In the light of the findings at
operations we naturally ask ourselves whether the whole thing, from start
to. finish, might not have been due to appendicitis. I should answer
decidedly, "No." The location of the original pain, the absence of

LUMBAR PAIN 95

fever, and the presence of the vesicular eruption seem to me to make
this supposition impossible, though it is conceivable that there may have
been a common cause both for the zoster and the subsequent appendi-
citis.

Diagnosis. Appendicitis; herpes zoster.

Case 27

A married woman of twenty-one had "grip" three times last winter,
but has otherwise been well until two weeks ago, when, after her last
attack of "grip," she began to have pain in her back, and to a less extent
in her arms, chest, and knees, without any limitation to the movement
of the joints. For the past week she has been in bed, but for the past
two nights she has slept little on account of pain in the back.

When the patient was first seen, March 26, 1908, her temperature was
101 F., pulse, no, and respiration, 25.

The temperature remained elevated for four days; after that it was,
for the most part, normal. The action of the heart was regular and rapid,
with a gallop rhythm. The pulmonic second sound was accentuated,
and the first sound at the apex was accompanied by a rough systolic
murmur heard all over the precordia and in the axilla. There was no
obvious enlargement of the organ. Physical examination was otherwise
negative, except that the white cells numbered 16,300.

Rest in bed, 10 grains of salicylate of strontium every four hours, with
an ice-bag over the precordia, an occasional A. S. and B. pill, and an
occasional \ grain of morphin, gave her relief within a few days. Later,
she complained of piercing pains in the precordia, which made her very
nervous. Nothing was found there on physical examination.

Discussion. I have included this case because it seems best that
my book should mirror some of the most annoying defects of our present
knowledge, as well as its strong points. This is the sort of case which
is ordinarily called "grip" at the start, while we watch for developments.
If none come, the diagnosis is formally confirmed.

For what other possibilities should we be on the watch in a case of
this kind? Fndocarditis, first of all, on account of the cardiac murmur,
the leukocytosis, and the early joint pains. Only the disappearance of
these symptoms with the lapse of a few days excludes endocarditis.

Typhoid is made practically impossible by the presence ol well-
marked leukocytosis.

As T have already said in the discussion of previous cases. 1 think
"unknown infection" should be our verdict. It is time to drop the
equivocal use of the word "grip" as a cloak for our ignorance.

96 differential diagnosis

It is worth noting that the use of an ice-bag over the precordia very
probably accounted for a good deal of the patient's later suffering. It
drew her attention to the possibility of heart trouble. In a nervous
person this is enough to produce heart pains.

Outcome. Nervousness was throughout a prominent feature, but
by the sixteenth of April she was nearly well, and was discharged to
finish her convalescence at home.

Diagnosis. Unknown infection.

Case 28

A night watchman of sixty-nine entered the hospital January 31,
1907, complaining that when he got up two days before he "felt his hip
catch." Within three hours he was unable to bear any weight on the
left foot and went back to bed. The pain has continued since, and he
has been helpless.

On physical examination it was found that any motion of the left
hip or back caused exquisite pain. There was some tenderness at the
upper point of exit of the nerve. Physical examination otherwise nega-
tive. Temperature oscillated between 98 and 101.4 F. for four days,
then normal. Whites, 8000.

Flexion of the thigh, with the knee kept straight, caused pain referred
to the left sacro-iliac joint.

Discussion. Can the symptoms be due to strain of the back?
What tests should be employed to confirm or exclude the diagnosis of
lumbago, of sacro-iliac disease, of hip disease, of spinal osteo-arthritis?
What further data are necessary?

In answer to these questions I should say that it is wholly unlikely
that strain entered into the causation of these symptoms, since the pain
was first felt after the blameless action of getting out of bed.

For lumbago the main tests are for the production of pain by any use
of the lumbar muscles, together with the absence of any disease of the
bone or kidney.

In relation to sacro-iliac disease we should endeavor to ascertain
whether the patient stands with a list to the other side, whether the
pain and tenderness are referred especially to the sacro-iliac joint when
the thigh is flexed with the knee straight, whether there is any sacro-iliac
pain on compressing the wings of the ilium.

The therapeutic test, the effect of attempting to immobilize the
ioint by strapping or otherwise, is also of importance. Hip-joint
disease is to be excluded in case the motions at that joint are really
free,

LUMBAR PAIN

Osteo-arthritis is difficult to exclude or to identify positively. We
suspect it in the presence of long-standing lumbar pain associated with
radiations along the thoracic, lumbar, and sciatic nerves, aggravated
if when the muscular protection is relaxed in sleep, the patient at-
tempts to turn over. It is aggravated also by coughing and sneezing.
An #-ray picture and the exclusion of sacro-iliac disease complete our
task.

The present case offers a fairly characteristic picture of what is
ordinarily known as sacro-iliac sprain or strain. The pathology of this
affection is still very obscure. It may be that one of the joint fringes
gets pinched owing to slight relaxation or subluxation of the joint when
the muscular or ligamentous protection is imperfect. A person becomes
debilitated or tired, muscularly or nervously. His muscles are no
longer as alert and well toned for protection as they should be. A slight
slip occurs, and a joint fringe or some other sensitive joint structure is
impinged upon. If this were true, it would explain the frequent asso-
ciation of the trouble with neurasthenic and debilitated states.

Outcome. The patient was considerably relieved by 10 grains of
aspirin every four hours and tight cross-strapping of the back and hip.
He was able to leave the hospital by the twenty-fifth of February.

Diagnosis. Sacro-iliac strain.

Case 29

A nurse of thirty-six who had previously suffered from dysentery
when nursing in the Philippines, entered the hospital March 21, 1908,
complaining that for the past four months she had had pain in the lower
part of her back, extending down the right leg. She has also had swelling
of the right foot and stiffness of the neck off and on during these four
months. The pain is somewhat relieved by heat, but she has had to
have morphin pretty continuously in order to keep her comfortable.

She has been unable to work since the previous December, and has
lost 20 pounds in the past five weeks.

On physical examination the thyroid gland was found to be slightly
enlarged. Temperature, pulse, and respiration were normal, the chest
and abdomen negative. Urine normal.

The pulsations of the aorta were violent in the epigastrium. The
knee-jerks were extremely lively, but there was no clonus and no Babin-
ski. Cross-strapping gave her a great deal of relief.

Discussion. Here is a long-standing pain which, in a woman of
thirty-six, should make us consider Pott's disease and cancer; but ex-
amination shows no evidence of cither of these troubles, and a closer

9 8

DIFFERENTIAL DIAGNOSIS

study of the case shows two causes whereby the duration of the pain may
well have been inordinately prolonged. I refer to the use of morphin
and to the evidence of a hypersensitive temperament, shown in the
exaggerated knee- jerks and the violent pulsation of the abdominal aorta.
Coming then to the milder possibilities, we should naturally think of
lumbago, because the patient has also suffered from stiff neck (so often
associated with lumbago). The duration, however, is somewhat too
great. She should have been relieved by rest within a week or two.

The pain extends down the right leg, and is accompanied by swelling
of the right foot. Can it be due to neuritis? There were no nerve
tenderness and no disturbance of sensation. The ordinary tests for
sacro-iliac disease (see above) were positive.

Outcome. Dr. Goldthwait saw the case in consultation and made
a diagnosis of chronic strain in the right sacro-iliac joint.

Diagnosis. Sacro-iliac strain.

Case 30

A school-girl, eight years of age, entered the hospital May 26, 1908,
complaining of dull, constant pain in the right side of the lower back,

worse at night, accompanied by

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fever, vomiting, and constipation.
Her bowels have not moved for four
days. There has been no injury to
the back, no cough, and no chill.
Family history and previous history
are negative.

Physical examination showed a
herpes on the lips. Nothing ab-
normal was found in the chest or
abdomen except for a general ten-
derness, especially marked in the
costovertebral angles and in the
flanks.

The urine showed a large amount
of pus, and the culture revealed a
characteristic growth of colon bacilli.

The temperature remained above
101 F. for a week. (See accom-
panying chart.) The patient was at first very sick, with a white count
of 24,000, 82 per cent, of the cells being polynuclear.

Any lumbar pain with fever in a small girl suggests Pott's disease.

LUMBAR PAIN

This being excluded by the absence of any kyphos or muscular spasm
about the spine, we have next to note that the patient is rather young
for any of the orthopedic group of diseases.

If it is an infection, as the fever suggests, is it local that is, renal or
perirenal or is it general? The condition of the urine and the leuko-
cytosis point strongly to a local urinary infection.

Outcome. The leukocyte count fell to normal along with the tem-
perature. The treatment consisted of alcohol sponges at 80 F. every
four hours; urotropin, 4 grains, three times a day, an abundance of
water to drink, and a liquid diet.

By the eleventh of June the urine was nearly normal and the child
practically well.

In view of the rapidly favorable outcome in this case there was no
need for any attempt further to verify the diagnosis by cystoscopy or
ureteral catheterization.

The renal infections, among which the hematogenous are not always
to be distinguished from the ascending affections, may be subdivided into
the following four groups:

1. Those presenting in girl babies or young girls an apparently
unaccountable fever, without anything to suggest its source. It is not
always easy in these cases to collect and examine the urine, hence this
most important clue is often neglected. The presence of a moderate
or considerable number of leukocytes in the sediment of such a urine,
when vaginal contamination is excluded, strongly suggests a urinary
infection. A pure culture of colon bacilli can usually be obtained from
the urine, as it was in this case, and the therapeutic test (rapid improve-
ment under forced water-drinking and urotropin) puts the diagnosis
upon a fairly firm foundation.

2. In other persons the disease often sets in in an acute and threat-
ening way, like appendicitis or acute cholecystitis. Fever, leukocytosis,
pus in the urine, and tenderness in the costovertebral angle are a very
suggestive group of symptoms and demand cystoscopy as confirmation.
Nephrotomy or nephrectomy may be necessary to save life if the symp-
toms do not rapidly abate after the ingestion of urotropin and large
amounts of water.

3. Relatively mild and chronic cases, characterized by pyuria, with
waves of irregular fever and possibly some bladder symptoms, often
occur in women before or after parturition. In some of these chronic
cases the urotropin and water treatment may be assisted by the use of
a vaccine prepared from the organism isolated from the urine almost
always the colon bacillus.

IOO

DIFFERENTIAL DIAGNOSIS

4. There seems to me to be good reason to believe that most, if not
all, cases of perinephric abscess represent neglected forms of the hema-
togenous infections just classified. It is a notable fact that in the past
two years, since our attention was called to the frequency of hematogen-
ous renal infections by the papers of Brewer and Cobb, the number of
cases of perinephric abscess has greatly diminished.

In my opinion there is no longer any ground for supposing that a
primary pyelitis, distinct from ascending infections, exists at all. It has
neither a pathologic nor a clinical basis.

Diagnosis. Renal infection, hematogenous or ascending.

Case 31

A waitress of twenty-six, of good family history and previous history,
entered the hospital January 30, 1908. Up to yesterday morning she
had been well. She then was seized with pain in the right lumbar

region and lower back. This pain
has persisted and become worse ever
since. She has vomited a clear liquid
several times, and has had some
cough, with thick white sputum. She
has no abdominal pain, but consider-
able headache.

Physical examination showed
many papules scattered over the en-
tire body. The conjunctivae were
injected and watery; the breath offen-
sive. At the angle of the right scapula
the respiration was slightly dimin-
ished, and the whisper slightly in-
creased. The right kidney was
doubtfully felt, and there was some
tenderness there, but more marked
tenderness under the risjht costal
border and in the right iliac fossa.
The general abdominal tenderness was so marked that the patient
was seen by a surgical consultant who, however, found no evidence of
peritonitis. The urine was negative.

The temperature ranged for seven days above 101 F. (see accom-
panying chart), and the white count between 13,000 and 15,000. The
chest was strapped, with very slight relief.

Discussion. An acute lumbar pain, accompanied by fever, head-

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LUMBAR PAIN 1 01

ache, leukocytosis, cough and some tenderness about the right kidney,
suggests several possibilities.

i. Since the pain began upon the right and is accompanied by some
tenderness in the region of the right kidney, a renal infection must be
considered, especially as the right kidney is far more often affected than
the left by such infections. But in the presence of a negative urine all
the other possibilities must first be carefully canvassed before proceeding
to cystoscopy or any such bothersome tests.

2. The orthopedic group of troubles seems unlikely in view of the
acute febrile onset and the absence of confirmatory tests.

3. Against the diagnosis of local peritonitis (gall-bladder, appendix,
perforating gastric ulcer) is the entire absence of muscular spasm and
the very wide area of tenderness.

4. Despite the exclusion of all these possibilities, the diagnosis re-
mained uncertain. The rather doubtful signs at the base of the right
lung were sufficient, however, to make us examine this part very fre-
quently in anticipation of the possible development of pneumonia. So
many cases beginning with abdominal symptoms have ultimately turned
out to be pneumonia, escaping laparotomy narrowly, if at all, that we are
always on the watch for such an event.

Outcome. On February 2d the signs of solidification finally ap-
peared at the right base. Abdominal distention and tenderness were
marked. The patient had a crisis on the evening of the sixth of Feb-
ruary, and by the fourteenth was out of bed and convalescent, though
loud pleural friction, entirely unaccompanied by pain, persisted from
the eleventh of February until her discharge from the hospital on the
sixteenth.

It is a familiar and a puzzling experience that many infections,
especially pneumonia, cholecystitis, and appendicitis, begin with vague
general symptoms (fever, wide-spread pains, chills, vomiting) before
settling down to business in any discoverable locality. Looking back
over the course of such a chain of events, after the pneumonia or the
appendicitis has been found, we are apt to suppose that the local trouble
was really there all the time. The weight of evidence, however, seems
to me to point the other way. The local manifestation of an infection is
often, I believe, a late event in fact, as well as in our diagnoses.

Diagnosis. Pneumonia.

Case 32

A married woman of thirty entered the hospital October 27, tSqo.
Four and a half vears ago she had had a miscarriage, induced by the

102

DIFFERENTIAL DIAGNOSIS

introduction of a sound into the uterus, and a second miscarriage, with-
out known cause, four years ago. Otherwise than this she had been
always well until seven weeks ago, when she was taken with severe pain
in the small of the back, which has lasted ever since, and which extends
at times to the front of the abdomen. Her bowels are very costive,
moving about once in five days. The pain in her back is not affected
by motion, but has been severe enough to confine her to bed for the first
two weeks of her sickness. Since that time she has been up part of
each day, but has gained very little in strength, and has lost 20 pounds
in weight. The range of temperature and pulse are seen in the accom-
panying chart. The right lobe of the
thyroid gland is palpable, and seems
about the size of a plum. The patient
has noticed this lump for several months,
and says that it varies greatly in size, at
times being scarcely palpable.

The chest shows nothing abnormal.
The abdomen shows slight general
resistance and considerable general
tenderness, the latter most marked in
the left iliac fossa. Motions of the back
are limited in all directions by muscular
spasm, and seem to cause pain, es-
pecially when she bends to the right.
Pelvic organs normal.

Examination of the stomach through

a tube shows a capacity of only 16

ounces. The position of the organ

after distention with air was apparently

normal. After a test-meal the stomach-contents showed 0.1 per cent.

of free HC1, no lactic acid, and no blood.

In the course of two weeks all the pains disappeared. Dr. Gold-
thwait found no lesion of the spine, hip, or pelvic joints. A firm binder
about the hips gave no relief. Tonics, sodium bromid, enemata, and
hypnotics were given for the control of symptoms as they appeared from
time tc time.

By the eleventh of November the patient seemed nearly well.
Discussion. The case is afebrile, and apparently not of the renal
or orthopedic groups. The pain is not affected by motion and, there-
fore, is not due to lumbago. There is no evidence of sacro-iliac or spinal
disease. The most definite and important feature in the case is the fact

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LUMBAR PAIN

J 03

that the woman is debilitated, has lost 20 pounds in weight, is badly
constipated, and probably has a wide-spread depression of other func-
tions. There is no reason to suppose that the thyroid enlargement has
any bearing on the symptoms.

Nothing certain can be said regarding the diagnosis of such a case
until the lapse of some time has made it clear that nothing else is going
to develop. After this we may settle down more or less discontentedly,
with the diagnosis of what some orthopedic specialists call a " functional
back." This is a very familiar clinical entity, whatever its real cause
and best nomenclature may be.

Two things seem to me clear about this trouble: first, that psychic
causes enter into it, and, second, that they are not the whole of it. For
example, I have seen a young woman drag herself painfully down the
street to the post-office with lumbar pain at every step, while each foot
seems to weigh a ton and every muscular contraction is an effort. She
calls at the post-office, gets a certain kind of letter, and walks home
erect and free from pain. We are apt to say that such symptoms
are imaginary, but this seems to me wholly unscientific. Certainly
psychic causes enter powerfully into their production and destruction.
May we not plausibly suppose that discouragement has slackened the
muscles as it does those of a tired army on the march? A psychic cause
renders them taut a band of music, a long-expected letter; they there-
upon begin to support the sagging joints, and the pain disappears as
sensitive parts are relieved of pressure. It is in cases of this type that
practitioners are apt to seek a cause for the symptoms in the pelvis,
with what scanty justification I have endeavored to show in the intro-
duction to this chapter.

Diagnosis. Debility.

Case 33

A metal polisher of thirty-six entered the hospital June 24, 1008,
because of pain in the back, beneath the twelfth rib, on both sides.
This pain had been present for one week before entrance, accompanied
by fever for the past four days, and vomiting for the past three days.
Ten days ago micturition was frequent and painful for one day and the
urine bloody.

The urine at entrance showed much pus, a little blood, a slight trace
of albumin. The specific gravity varied between ioo:; and 1010.
The twenty-four-hour amount was from 80 to 100 ounces a day. An
occasional granular cast was found in the sediment. The leukocytes
ranged from 16,000 to 19,000 per cubic millimeter. Widal's reaction

io4

DIFFERENTIAL DIAGNOSIS

was negative; the range of the temperature and pulse was as seen in the
accompanying chart.

On physical examination the man was emaciated, pale, with sunken
eyes. The edge of the spleen was easily felt. Physical examination
was otherwise negative, except for considerable tenderness in both
costovertebral angles. On the second of July a macular erythema
appeared upon the back of the trunk and hands, and was seen by Dr.
Charles J. White, who stated that he could not definitely recognize the
nature of these macules. His bowels were moved by calomel and
enemata, and he was given liquid diet. A culture specimen of urine
showed a pure growth of colon bacilli. By the thirteenth of July pus

had disappeared from the urine. The
white cells were 8700. The Widal re-
action was negative, as it was throughout
the illness.

Discussion. The symptoms point
obviously to the kidney, but the enlarge-
ment of the spleen suggests the possibility
of some other cause for the fever. With
such a urine, with costovertebral tender-
ness and leukocytosis, a urinary infection
must form at least a partial explanation
of the symptoms. Owing to the persis-
tence of fever and the splenic enlargement,
a routine blood-culture was taken, which,
to everyone's surprise, showed typical
typhoid bacilli. In view of this fact it may
well be questioned whether the macular
erythema was not, in fact, due to some
form of typhoid rose spot in other words,
whether it was not due, like the ordinary crop of rose spots, to the
lodgement of typhoid bacilli beneath the skin.

Evidently we were dealing, in this case, with a double infection, both
typhoid bacilli and colon bacilli being active pathogenic agents. The
colon bacilli, in process of elimination from the body, presumably caused
the renal infection. The lumbar pain was probably of the general
infectious type, and not due to kidney lesion.

Outcome. The patient was given urotropin, 7^ grains three times
a day, and left the hospital well on the twenty-sixth of July.
Diagnosis. Typhoid and colon bacillus infection.

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LUMBAR PAIN

I05

Case 34

A laborer of thirty-nine entered the hospital June 11, 1907.

In 1899 he wrenched his back in lifting a heavy jack, and was lame
for three or four weeks afterward. In February, 1906, he had sciatica.
For the past two months he has noticed an ache in his back when he
gets up in the morning. Ten days ago he noticed tingling and numbness
in his toes and the pain in his back increased. Since then he has slept
very little, and six days ago he had to have morphin, which has been
frequently used since then, but lately with only slight relief.

Both legs, from the knees to the heels, are now sensitive and prickling.
His feet feel freezing cold. He denies alcohol and venereal disease.

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Present Condition. The range of temperature and pulse are as
seen in the accompanying chart. The patient is well developed and
nourished, but looks worn out and in much pain. Indeed, he can scarcely
lie still a moment. The chest and abdomen show nothing abnormal.
From the third to the eighth dorsal vertebra the backbone is bowed
posteriorly. There is much tenderness on pressure over the seventh
cervical spine. There is no disturbance of sensation in the feet or legs.
and motion is everywhere normal.

The urine is normal in amount, 1028 specific gravity, with the slight-
est possible trace of albumin and a few finely granular casts. Xo blood
or pus. The white cells number 14,800. The red blood-cells show

io 6 DIFFERENTIAL DIAGNOSIS

no stippling; #-ray is negative. The lines of expression in both sides
of the face are flattened out. The right side moves less than the
left. The patient cannot whistle, and protrudes his tongue slightly to
the right.

The grasp in both hands is equal, but markedly diminished.

The knee-jerks are absent, the superficial reflexes normal, the mind
clear.

Discussion. Clearly, we cannot blame the old wrench for the present
trouble. The sciatica also seems to be ancient history, though both of
these events may be of some importance as indicating a locus minoris
resistencicp,.

In contrast with all the types of lumbar pain previously discussed
this case stands out, marked by the presence of sensory symptoms (numb-
ness and prickling) in the legs. It is also notable that the face and arms
are affected, though not at the beginning of the case.

Though the backward bowing of the spine brings the possibility
of Pott's disease to mind, there is nothing else in this region to support
any such hypothesis, and neither here nor in the cervical region, where
some tenderness was present, did .v-ray show any lesions. The entire
absence of muscular spasm helps to exclude spinal tuberculosis. No
other disease of bone or joint is definitely suggested, and there is nothing
to point to the urinary system or to any general infection as the source of
these troubles. The urine cannot be called normal, but its abnormalities
are of a very vague and general nature, consistent with the presence of
almost any disease and with the absence of all known disease, so that in
this differential diagnosis they may be disregarded.

In view of the general sensory symptoms, the loss of muscular power
and tone and the diminished reflexes, multiple neuritis is the natural
diagnosis. Were the spinal cord involved, one would expect pupillary
changes, increased reflexes, relaxed sphincters, and the absence of such
wide-spread sensory symptoms.

As to the cause of the neuritis, we are here, as in so many other cases,
quite in the dark. Alcohol and lead can be definitely excluded. There
is no reason to suspect arsenic. The presence of moderate waves
of fever and a continued leukocytosis makes it reasonable to suppose
that an infectious process is at the bottom of the symptoms.

Outcome. The leukocytes continued to range high, and the pain
and the tenderness continued to be very troublesome. Sterile water was
given at times instead of morphin, and the patient was gradually weaned
from his fondness for the drug.

By the thirtieth of June the pains were less severe and could be con-

LUMBAR PAIN 107

trolled by aspirin, 10 grains, once or twice a day, or by placebos. There
was moderate muscular wasting, and tenderness along the nerve- trunks
was present.

By July 8th the grip was much improved. The patient was up and
about the ward, and soon went home to finish his convalescence.

Diagnosis. Neuritis.

Case 35

A negro of fifty, with a negative previous history, entered the hospital
August 2, 1906, complaining that for three weeks he had been suffering
from loss of appetite, nausea, fever, and weakness, and had been in bed
a good deal of the time.

Ten days ago he was beginning to recover his strength, but four days
ago he suddenly began to have shooting pain in the lower back and but-
tocks, the pains running down the backs of both legs, especially the left,
and intensified by motion. He is fairly comfortable when quiet in bed.
At the onset of his disease he took large doses of quinin with relief.
His bowels now move every two or three days.

On physical examination, temperature, pulse, and respiration
were found to be normal, the chest and abdomen likewise normal, the
blood and urine negative. Extension of the left leg with the knee
straight caused marked pain in the left sacro-iliac joint. Movements of
the leg with knee flexed were not painful. There was tenderness over the
left sacro-iliac joint and over the lower dorsal spines. X-ray was nega-
tive. The motions of the spine were markedly limited in all directions.

Discussion. Apparently the symptoms in this case followed a
three weeks' febrile illness, the nature of which we do not know. The
possibility of typhoid and a post-typhoidal spondylitis is naturally sug-
gested, but if typhoid is often complicated by a late spondylitis, presum-
ably other infections may have a similar sequel.

The marked limitation of spinal motion and the tenderness in the
lower dorsal region make it necessary to consider spinal tuberculosis.
The negative rv-ray, however, goes far to exclude this possibility. Only
the course of time and the effects of treatment can make us more certain
on this point. The same remarks apply to the possibility of malignant
disease.

Outcome. Dr. Robert B. Osgood, who saw the case in consulta-
tion, considered it one of infectious arthritis of the spine and the left
sacro-iliac joint; strapping of the back, with enemata and tonics, was
the treatment. The patient was able to leave the hospital almost well
in twelve days.

Diagnosis. Infectious spondylitis.

io 8 DIFFERENTIAL DIAGNOSIS

Case 36

A Swedish housemaid of twenty-five, with an excellent family history,
entered the hospital March 27, 1907. She states that eight or nine years
ago she was in bed for six weeks with "catarrh of the lungs," and that
since she was ten years of age she has had frequent attacks of tonsillitis.
Otherwise she has been well. At Christmas, 1906, she caught cold and
was weak and feverish. At this time her back became very sore and
painful on motion, and she had to give up work the first of January.
Since then she has not improved at all, and has been in bed a consider-
able part of the time. At entrance, the temperature, pulse, and respira-
tion were normal, the chest and abdomen negative, the spine held rigidly
and all motion painful. There was no kyphos and no sacro-iliac ten-
derness.

Discussion. The long duration of the symptoms holds our attention
at once. Chronic backaches may be due to functional causes, to osteo-
arthritis and the pressure group (Pott's disease, new-growths, and aneur-
ysm) . It is notable that in this case a rest in bed has not produced any
marked improvement, neither has there been any alarming advance in
the severity of the symptoms, such as would probably occur with malig-
nant disease. The physical signs are confined to the evidence of a rigid
and painful spine. Renal lesions and general infections are easily ruled
out. Any ordinary lumbago would have been cured long before this.
The spinal rigidity and tenderness make it very improbable that sacro-
iliac disease is the only lesion present.

The so-called functional, neurasthenic, or hysteric affections of the
spine are naturally suggested by the long duration of the symptoms, by
the age and sex, and by the absence of fever, kyphos, and other obvious
lesions. The outcome of the case shows the great importance of not
jumping at such conclusions until every method of physical examination,
including the x-ray, has been used. This is especially true of all dubious
and chronic cases.

Outcome. At entrance, the diagnosis was "acute osteo-arthritis
with a neurasthenic background." An x-ray taken the first of April
showed that the body of the second lumbar vertebra was extensively
diseased, and a knuckle was later developed in the lumbar region.
The patient was put at once into a plaster jacket, and by April 6th was
able to sit up with comfort. On April 9th she left the hospital.

Dr. Osgood's diagnosis was early Pott's disease.

Di agnosis. Vertebral tuberculosis.

Fig. 19. Area of pulsation at a point often overlooked in physical examination.

plaint, pain in the back.

Com-

LUMBAR PAIN 109

Case 37

A carriage painter of thirty-four entered the hospital March 20,
1907. His father died of a paralytic shock; his family history was other-
wise excellent. He remembers no sickness in his life. Had a soft sore
eleven years ago, and a bubo about the same time; had no rash, sore
throat, falling of hair, or pains following it, but was treated for a year
after it, with what medicine he does not know.

In his work he lifts from 100 to 200 pounds every day. He was per-
fectly well until five months ago, when he began to feel weak. Since
that time he has been losing weight and has done no work. Three
months ago he strained his back, and since then he has had a burning
pain in the small of his back and below the region of the heart on the
left. This pain has increased considerably in the last three weeks,
and is now so severe that he has to bend forward and to the left to ease it.
It is made worse by walking, and interferes with sleep. He has no
dyspnea and no other symptoms.

Physical examination showed normal temperature and respiration;
pulse somewhat accelerated, keeping most of the time between 100 and
120. His pupils are equal and react normally; his heart and lungs
negative, except as shown in the diagram (Fig. 19), his right radial pulse
slightly larger than the left.

There is resistance and dulness in the epigastrium, but no definite
mass made out. The glands are considerably enlarged in the groins and
axilla?.

Discussion. As in the previous case, the element of duration is a
most important one in the diagnosis. A steady pain lasting three months
is not likely to be due to functional causes when it occurs in a carriage
painter of thirty-four. Lead-poisoning, suggested by the occupation,
never produces such a pain as this without other symptoms. The general
infections and the renal group of lesions are easily excluded by the physical
examination. This leaves us with the diseases which I have called the
pressure group (Pott's disease, aneurysm, and neoplasm) especially
deserving of consideration. Only one diagnosis is possible in this case,
provided it occurs to our minds at all. The clanger is that it will not be
thought of, and, therefore, will not be found in physical examination.
Nothing but aneurysm produces an impulse and thrill with dulness and
absent breathing between the spinal column and the left scapula. Pul-
sating pleurisy and pulsating sarcoma do not present themselves at this
point.

Outcome. A'-ray showed a distinct shadow in the area of pulsation,

IIO DIFFERENTIAL DIAGNOSIS

as figured in the diagram. The pain felt over the lower ribs in front
seemed to be explained by pressure of aneurysm on the intercostal nerve.

There is now no pain in the region of the tumor. The patient was
given iodid of potash. 15 to 30 grains, four times a day; nitroglycerin,
tttt grain, every three hours; when needed for pain an occasional
dose of morphin, | grain.

The patient left the hospital slightly relieved on June 4th.

Diagnosis. Aortic aneurysm.

Case 38

A laborer of twenty-two entered the hospital July 4, 1906, with a
negative family history. All last winter, he says, he suffered from
"rheumatism around the heart"; otherwise his past history and habits
are good.

For the past two weeks he has been ailing, especially on account of
pain in the abdomen, the back, the neck, or the head, every day. The
pain in the back has prevented any continuous sleep for the last five
nights, but he also aches all over, although he was able to work until
two days ago. For the past week he has had a bad taste in his mouth
in the morning. He says a number of his friends have the same trouble,
and call it the "grip." His appetite is poor, and he has nausea after
eating. The bowels are regular; there are no other symptoms. A soft,
systolic murmur is heard all over the precordia, loudest in the pulmonary
area. The pulses are of low tension and dicrotic. The chest and abdo-
men are negative. On the forearms are a number of sharply defined
macules and papules, which decolorize on pressure (mosquito bites?).
In the left hypochondrium is a group of rose-colored macules, five in
number.

During the first three days of his stay in the hospital he had fever,
ranging from ioo to 103 F., accompanied by considerable pain in his
back.

Leukocytes were 5900; Widal reaction persistently negative. Xo
malarial organisms were found in the blood. The urine was negative.
His abdomen was always rigid, and his bowels difficult to move. On
the twenty-first of July, after four days of normal temperature, his back
still showed limitation of motions in all directions, with considerable
tenderness on his shins. A diagnosis of lumbago was made this day
by Dr. Joel E. Goldthwait. Under criss-cross strapping his pain was
almost gone by the twenty-fifth. His lips were cyanotic throughout
his stay in the hospital; his appetite, enormous.

His treatment consisted of salicylates and aspirin for the pain; also

LUMBAR PAIN m

the acetate and the iodid of potash, an occasional dose of morphin, and
laxatives. At entrance he was treated as for typhoid.

Discussion. The diagnosis of lumbago is very plausible in this
case, owing to the fact that the patient has general limitation of the
lumbar motions, and has previously suffered from stiff neck and other
apparently muscular pains. But there are other features about the case
which make it seem more like a post-febrile spondylitis of the type most
often seen after typhoid. Lumbago does not produce a fever like that
here described, and there are many other facts pointing to the existence
of a general infection. The rapid recovery under a simple strapping
treatment does not necessarily prove that the diagnosis is lumbago, but
does tend to exclude all other possibilities, except the two above men-
tioned. The cyanosis and the enormous appetite are not explained.

Diagnosis. Lumbago (?) Infectious spondylitis (?)

Case 39

An ice-man of twenty-five entered the hospital April 10, 1906. His
family history was negative, his past history good. He had urethritis
six months before. He has taken five or six glasses of beer a day, and
one or two glasses of whisky a week, as a rule, but has seldom been drunk.

Except for the urethritis, he was well until two weeks ago, when he
began to have a dull, aching pain in the right side of his back and flank,
not severe enough to make him give up work nor to keep him awake.
After a couple of days this pain disappeared, but returned five days ago.
This time it extended into the right leg, but not into the groin or testes.
The painful area is tender, and the pain is constant. He has noticed
no change in his urine; he thinks, however, that he passes more urine in
the night than in the day. He has some shortness of breath and pal-
pitation on exertion.

He had no temperature above 99. 5 F. during his stay of ten days in
the hospital. The abdomen was held firmly above the navel, was every-
where tympanitic, and in the right upper quadrant was tender. At this
point a mass the size of the fist was felt, moving with respiration,
apparently lobulated, and coming down a hand's breadth below the ribs
on full inspiration. It was easily felt bimanually, and could be partially
replaced behind the ribs.

The urine was between 60 and 80 ounces in twenty- four hours, and
contained a very slight trace of albumin. In the sediment were many
intracellular diplococci, decolorizing by Gram's stain. Twenty minims
of the sediment of urine was inoculated into a guinea-pig. The animal
was killed two months later, and showed no evidence of tuberculosis.

112 DIFFERENTIAL DIAGNOSIS

On the twentieth of April x-ray showed a definite shadow in the region
of the right kidney. Dr. Davis catheterized the right ureter and ob-
tained pus containing gonococci.

Discussion. Everything points to the kidney as the source of this
patient's troubles. Our suspicions in that direction are promptly con-
firmed as the result of cystoscopy, x-ray examination, and animal
inoculation, a group of procedures demanded in almost every case of
chronic renal pyuria.

Since "surgical kidney" is excluded by the cystoscopic examination,
and tuberculosis by the results of animal inoculation, the only important
possibility left is renal stone, a supposition strongly supported by the
x-ray evidence.

Outcome. The patient was transferred to the surgical ward and
operated upon on May 2d. A stone was removed. The patient's
convalescence took place without any incident and he was discharged
May 26th.

He was readmitted December 5, 1907. After leaving the hospital
he was well and strong, and worked hard until three weeks ago, when he
began to pass blood and pus in his urine and suffered pain in the right
lumbar region, similar to that which he had previously had. He now
suffers from two sorts of pain : (a) A dull ache in the right side, present
most of the time; and (b) a stinging pain occurring only after micturition,
starting from the urinary meatus and running up into the right side.
The urine continued bloody for the first week of this attack, the last
two or three spoonfuls of each discharge being bright blood with threads
of yellow pus. Of late, no blood has been visible. He has lost appetite
and has been very thirsty, although he has not been conscious of any
fever. He has lost about 10 pounds in weight. The patient entered
the hospital with a temperature of 102 F., pulse 120. After two days
the temperature subsided to normal. His leukocytes were 10,000 at
entrance. The abdomen was altogether normal, but in the right flank
there was a visible prominence and a palpable, tender, dull, rounded,
lobulated mass, apparently retreating under the ribs on pressure.

The urine, as at the previous entry, was persistently of low gravity,
ranging from ion to 1014, and rather large in amount from 50 to 70
ounces a day. The sediment was composed almost entirely of pus in
moderate amounts. The pus persisted in his urine, and the patient con-
tinued to have considerable pain in the right flank. X-ray showed only
doubtful shadows of a possible stone.

Operation, December 24th, showed no stone, but many pockets of
pus scattered throughout the kidney, with smaller foci of round-cell

LUMBAR PAIN

113

infiltration between them. The kidney was enlarged, and at one end
was fibrous. Its pelvis was normal. The patient did well after nephrec-
tomy.

Diagnosis. Renal stone; multiple abscesses.

Case 40

A housewife of fifty-one entered the hospital August 11, 1906, for
the third time. At her first entry, in June, 1899, a diagnosis of gall-
stones had been made; at the next entry, June, 1901, neurasthenia was
the diagnosis. Her attacks of illness between February, 1899, and
December, 1901, were very frequent and of a similar character. There
was a sudden occurrence of pain, severe and cramp-like, doubling her up.
It always started in the right side of the back, thence radiating to the
right hypochondrium, but never to the right shoulder. It would last
from two hours to two days, and was relieved occasionally by household
remedies, but always by morphin. After relief there would be no
recurrence for weeks or months. The pain was associated with vomit-
ing, but showed no special tendency to occur at night. The urine and
feces were normal, and there was no fever with the attacks. Twice
she entered the hospital for these attacks, but has always been free from
pain while here. For the past two and a half weeks she has had an attack
every day, sometimes in the afternoon, sometimes at night. Morphin
has been injected several times, and she has had morphin pills on hand.
Her bowels are moved daily, but she has had no appetite.

Her physical examination, including blood and urine, temperature,
pulse, and respiration, was wholly negative. On the thirteenth, at 3 a. m.,
she began to have severe pain. A rounded tumor was easily felt below
the ribs, in the region of the gall-bladder, moving with respiration, and
easily mapped out by percussion.

Discussion. Colicky pain in the right lumbar region naturally
suggests renal stone. In the absence of any urinary changes, however,
an rc-ray would be necessary to confirm the diagnosis. The account of
the pain does not sound like that of lumbago, which is not promptly
driven away by morphin, and is rarely so severe as to call for its use.

Another cause for the pain is suggested by the rounded tumor in the
right hypochondrium. This tumor might be connected with the stom-
ach or intestine, but the absence of gastric or intestinal symptoms be-
tween the attacks of colic makes this unlikely. It seems more probable
that the tumor is due to distention of the gall-bladder, the absence of
jaundice being due to the fact that the common duct is patent.

It is well to say a word in condemnation of the previous diagnosis

H4 DIFFERENTIAL DIAGNOSIS

of neurasthenia, based, apparently, on the fact that the patient happened
to be in the hospital during an interval between her severe attacks.
Such a diagnosis, based wholly on negative findings, is always unjustified;
for the patient it is often adding insult to injury. It is far better to make
no diagnosis at all and watch for a recurrence of the previous symptoms.

Outcome. Jf-ray of the renal region was negative. On the fifteenth
the abdomen was opened, and a number of gall-stones were found in the
gall-bladder.

Diagnosis. Gall-stones.

Case 41

A longshoreman of forty-four with a good family history entered the
hospital March 7, 1907.

He had used a quart of ale daily until five weeks ago. In 1883 he
had malaria in India. In 1890 he had blood-poisoning of the arm, and
was in the Royal Infirmary, Liverpool, twenty-five days.

Two years ago he had "pleurisy," and half a gallon of fluid was
taken from his left chest.

March 28, 1906, he had some operation done on his right testis, just
for what cause he does not know. Since then he has been w r ell until
five weeks ago. He entered the hospital March 7, 1907, complaining of
constant pain across the small of his back. It has been severe for the
past two weeks, so as to prevent work or sleep. For a week he has had
frequent cramps in his calves, and lately has been short of breath. He
has lost 14 pounds in the five weeks.

Physical examination of the abdomen showed in the right hypochon-
drium and epigastrium two smooth, rounded masses, palpable biman-
ually, descending with respiration. (See Figs. 20 and 21.) On inflation of
the stomach the masses appeared to be behind it. Physical examination
was otherwise negative, except that the urine was of low gravity 1007
ranged in amount from 70 to 120 ounces during the week of his stay
in the hospital, and contained in its sediment a few hyaline and fine
granular casts. X-ray of the spine was negative.

The gastric contents contained no hydrochloric acid after a test-
meal. The size of the stomach was normal, and there were no organic
acids or fasting contents.

Discussion. The occupation is one of those often associated with
lumbago or spinal osteo-arthritis, but for simple lumbago the pain
has been rather too steady and prolonged. The question of osteo-
arthritis will be referred to later.

The history of pleurisy, together with a severe and long-standing

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LUMBAR PAIN

spinal pain, often points to a spinal tuberculosis. It is quite possible,
also, that the previous operation may have been for tuberculous epi-
didymitis. Against this diagnosis, however, is the absence of fever and
muscular spasm, as well as the negative #-ray examination.

The two latter facts are also against the diagnosis of osteo-arthritis,
though this cannot possibly be excluded.

We naturally desire to connect all the symptoms and signs in the case
into a mutually explaining group, and this brings us to the consideration
of the abdominal tumors. Cystic kidney (congenital) would produce
such a tumor and such a urine, but as it is invariably bilateral, we should
expect to get some evidence of a tumor in the left hypochondrium.
Further, cystic kidneys never cause pain in the back of anything like the
severity here complained of.

Hydronephrosis would explain the tumor, and possibly the urine, but
would not account for the pain.

Can the tumor be in the stomach, possibly with spinal or glandular
metastases to account for the pain? This is suggested by the absence of
hydrochloric acid in the gastric contents, but it must be remembered that
a similar lack of hydrochloric acid has been frequently demonstrated in
association with malignant tumors of any organ, e. g., cancer of the
breast, as well as in a variety of debilitated conditions. Since no gastric
symptoms are complained of, and there are no changes in the size or
motility of the stomach, a gastric tumor seems unlikely.

Retroperitoneal growths certainly deserve consideration. The
previous tumor of the testis may well have been sarcoma, and if so, a
metastasis in the retroperitoneal lymph-glands would be very likely.
Further than this one cannot go without exploratory operation.

Outcome.- The abdomen was opened on March 15th, and a retro-
peritoneal mass the size of a grape-fruit was found behind the pylorus.
It was afterward learned that the tumor of the testis was sarcoma.

Diagnosis. Retroperitoneal sarcoma.

Case 42

A medical student of twenty-three entered the hospital July 18, 1907.

He had typhoid fever in the Massachusetts Hospital in August and
September, 1906. After that he went back to college for the second
half-year in February, 1907, taking his work easily, but finding it hard
to concentrate his attention, having a good deal of pain in the fort-head
after studying, and needing to lie down every afternoon. On March
1st he had an attack of severe pain in the small of his back; this lasted
five days, with much stiffness. Four weeks ago he had another attack,

DIFFERENTIAL DIAGNOSIS

following exposure to cold and wet, lasting four days. For the past
three weeks he has been in bed with the same trouble. Ten days ago
he woke up in the night, doubled up with pain, and had to have morphin
to relieve it.

On physical examination the knee-jerks were found to be exaggerated.
Kernig's sign was marked, and ankle clonus present.

Temperature at entrance was 102 F., pulse, 120, but after forty-
eight hours both pulse and temperature were normal.

The white count was 3200; urine was negative.

The spine was held rigidly in extreme lordosis, with well-marked
spasm of .the erector spinae group. The patient was unable to stand or

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to sit erect. The hip motions were free and normal, except that hyper-
extension of the right hip is painful. There is slight tenderness on pres-
sure over the right sacro-iliac joint.

Discussion. A rigid, tender spine following typhoid fever and
associated with some neurotic symptoms is almost the typical picture of
post-typhoidal spinal arthritis. The chief objection to. such a diag-
nosis in this case is the long duration of the interval between the typhoid
fever and the present symptoms. Almost all cases of "typhoid spine"
come on within three months, while in this case the interval is almost
six months. This, however, is by no means convincing evidence against
the diagnosis.

LUMBAR PAIN

117

In the earlier editions of Osier's text-book this disease was described
as a neurosis without anatomic basis. The reason for this belief is sug-
gested in the present case, as in the majority of all cases. Mental symp-
toms, of the type usually referred to as neurotic or neurasthenic, consti-
tute one of the varieties of post-typhoidal psychosis, and may be obstinate
and long continued. Various types of insanity are also met with as
sequelae of typhoid, though nearly all of them recover. It is easy to see
how mental depression, associated with muscular relaxation, might
accent and aggravate the symptoms of an otherwise latent spondylitis.
That spondylitis may be latent is proved by the occasional finding of
rigid spines in patients who have never experienced any previous pain,
and in whom x-ray demonstrates osteo-arthritic lesions.

Outcome. Dr. R. B. Osgood saw the case in consultation, and con-
sidered it a typhoidal arthritis of the lower spine and sacro-iliac joints.

On the twenty-third a plaster jacket was applied, with complete
relief to the pain in the back. The patient had a good deal of vomiting,
and for some days took nothing but cracked ice by mouth. At this time
the urine showed a trace of albumin, with hyaline, granular, and epithelial
casts in small numbers.

The Widal reaction was positive.

The second week of his stay in the hospital he had a rise in tem-
perature (see accompanying chart) lasting five days. The patient was
very hysterical, and a false chart hung at the head of his bed had a
salutary effect. After the application of his plaster jacket he had no
pain. On the eighth of August he was able to sit up in a chair. On the
fourteenth he was discharged, much relieved. On the twenty-sixth of
August he reported that he had been walking as much as twice a day
without pain. He was still hypochondriacal and introspective, but was
otherwise well.

Diagnosis. Typhoidal spondylitis.

Case 43

A Jewish housemaid of twenty, with a good family history and past
history, entered the hospital September 2, 1907. She said that for two
years sJic had had a steady and rather severe pain in the small of the back.
At the beginning of this period she was in bed for three months, after
which she was able to work, although her back was stiff and her trunk
bent toward the right. Last winter she had for several weeks a 'painful
cough, without expectoration; she had no fever at any time. Although
in constant pain, she has worked until three days ago.

There was no fever. Examination of the chest and abdomen,

Il8 DIFFERENTIAL DIAGNOSIS

blood, and urine was negative. The left knee-jerk was considerably
livelier than the right. The spinal muscles were rigid.

Discussion. The most important fact about this particular case of
lumbar pain is that it has lasted far longer than any other hitherto
described. Such prolonged suffering suggests either some member of
the "pressure group" (aneurysm, tuberculosis, or neoplasm), or a func-
tional neurosis; no general infection, no form of renal disease, and none
of the orthopedic group of diseases would last so steadily and so long.

A functional neurosis is not likely in a girl who keeps steadily at
work, although in constant pain. The difference in the knee-jerks is
also decidedly against this diagnosis. The patient is rather young either
for neoplasm or for aneurysm. The muscular rigidity, the long duration
of the pain, and the history of a previous cough support the suspicion
of tuberculosis.

Outcome. Just below the level of the twelfth rib a knuckle the size
of a small apple was later made out; it was very tender and hard, not
red or hot. The patient was then in exquisite pain, but on the applica-
tion of a plaster jacket was greatly relieved.

Diagnosis. Spinal tuberculosis.

Case 44

A married woman of fifty entered the hospital October 10, 1907.
Her family history was good. She passed the menopause one year ago.
Her menstruation has always been irregular, profuse, and painful. She
has had no children and no miscarriages. In childhood she had rheuma-
tism, typhoid fever, and abscesses on the forearm. For the past fifteen
years she has had stomach trouble, symptoms consisting of lack of ap-
petite, distress after eating, and constipation. For the past two months
she has had frequent severe pains in the back, chest, neck, and legs; also
occipital headache, "pins and needles" in the legs, noises in the head,
buzzing in the ears, palpitation of the heart, insomnia, and great ner-
vousness. Examination of the throat showed a linear aperture three-
quarter inch long in the soft palate in the median line.

There was anterior bowing of both shin bones, with roughening of
their front surfaces, and three large white scars; also two or three deep
scars on the extensor surface of the left forearm. Spinal motions were
limited in all directions, but the pain was greatly relieved by strapping
and rest. Dr. E. G. Brackett examined the spine and considered the
trouble an acute infectious osteo-arthritis.

Discussion. In any patient who has such a multitude and variety
of symptoms as this we naturally suspect a psychoneurosis, especially

LUMBAR PAIN

119

as the menopause has recently occurred. There are a number of data,
however, brought out by the physical examination, which point in
another direction. The hole in the soft palate is almost pathognomonic
of old syphilis, especially when taken in connection with the scars on
the extremities and the roughening and the prominence of the shin
bone.

There is no reasonable doubt, then, that this patient has suffered
from syphilitic infection. The question remains whether this can ex-
plain her present complaints. That syphilis may attack the spinal
column has been satisfactorily demonstrated by #-ray evidence. At the
same time, it is quite possible that her present troubles may be due to an
acute infectious process of some other origin, or to purely functional
derangements. Only by further observation and by noting the effects
of treatment can the diagnosis be definitely established.

Outcome. -The patient was also given sodium salicylate, 10 grains
every hour, until toxic. Citrate of potash, 45 grains four times a day,
until the urine became alkaline. Later, iodid of potash, 15 grains
three times a day, increasing 10 grains daily, when the other drugs
were omitted.

Diagnosis. Old syphilis; acute spondylitis.

Case 45

An Italian fruit-dealer of twenty-three is in the habit of carrying
heavy loads, and thinks he has strained his back. He has never been
sick otherwise, and has good habits and a good family history. He was
first seen August 16, 1907. For five years he has had attacks of pain in
the right side of his back almost every day. The pain is sharp, and he
says it feels as if something was "rolling over" in his back. Six days
ago the pain lasted all day. It never radiates to any other point, and
has not often kept him awake. It does not hurt him to stoop.

Physical examination was entirely negative, except for the presence of
numerous musical rales, with slightly prolonged expiration throughout
both chests.

Discussion. Muscular strain or lumbago is our first thought in this
case; it was the patient's own explanation of his troubles. The long
duration and paroxysmal occurrence of the symptom, however, and its
independence of stooping, make this idea impossible. Any lumbar pain
that lasts so long suggests one of the pressure group of causes, but
physical examination does not bear this out. The pain should be steadier
and less intermittent were it due to pressure. The same considerations,
together with the absence of radiation or night attacks, tend to exclude

120 DIFFERENTIAL DIAGNOSIS

osteoarthritis and sacro-iliac disease. The absence of local tenderness
and urinary changes militates against the idea of renal disease.

Vertebral tuberculosis was suggested by the prominence of certain
vertebral spines, and by the doubtful phenomena in the lungs. The
absence of any muscular spasm or tenderness makes this more unlikely,
but x-ray should be taken in confirmation. On the whole, from the
paroxysmal nature of the attack, some renal lesion seems the most
likely.

Outcome. Aug. 19th there was no muscular spasm or tenderness
about the spine or sacro-iliac joints, but he could not bend to the left as
well as to the right. The vertebral spines from the eighth to the twelfth
dorsal were slightly more prominent than their neighbors. There were
slight prolongation of expiration and a shade of dulness at the right apex.
Numerous musical rales were scattered through both chests. There was
no fever. Blood and urine were still normal.

Physical examination was otherwise negative. The patient was
free from pain and said he felt perfectly well. X-ray showed a stone
in the right kidney. Operation on the twenty-fourth verified this
diagnosis.

Diagnosis. Renal stone.

Case 46

A housewife of twenty-three was first seen December 29, 1907.
For three months she has been having pain in the left side of her back,
worse at the menstrual period, and accompanied by constipation and
general weakness. She has kept at work until two days ago. Family
history, past history, and habits are good. The physical examination
is negative in all respects.

Discussion. The chronicity and steadiness of the pain are like
those often seen in spinal tuberculosis, and this disease can only be
positively excluded by x-ray examination and by the course of the case,
though it is made unlikely by the absence of muscular spasm of fever
and of local tenderness or prominence.

Kidney lesions cause unilateral pain like that here described, but
there is no further evidence to support any such hypothesis.

The orthopedic group of lesions is excluded by the mobility of the
spine and the absence of local tenderness.

Since there is no fever, we have no good reason to suspect any infec-
tious disease.

If the x-ray proves negative, the case must be treated as one of func-
tional pain, while we await further developments.

LUMBAR PAIN 121

Outcome. After a week's rest in bed with German powder as a
laxative the patient's symptoms were entirely relieved, and as the rc-ray
was wholly negative, she was allowed to resume work.

Diagnosis. Debility.

Case 47

A blacksmith of thirty-one was seen July 21, 1906. Seven days ago
he began suddenly to have sharp stabbing pains in the lower part of both
chests and on both sides of his back, and was unable to take a deep
breath on account of the pain. Three days ago he gave up his work.
Two days ago he went to bed. He has felt feverish, especially at night;
for the last two days has had general headache and has slept poorly.
Just before the onset of the present illness a horse had thrown him heavily
against a building. He had a negative past history and family history
and good habits.

On physical examination the pupils were found to be equal and to
react normally. The chest showed nothing abnormal. The abdomen
was full and rather rigid, but showed nothing else of interest. The
spleen was not palpable. Flexing the neck caused pain in the back, but
there was no rigidity of the neck muscles and no Kernig sign.

The white cells were 5200. Stained specimen negative. Widal
reaction and blood culture negative. The urine was normal.

The temperature ranged between 102.5 an d io 5-5 F* f r ten days,
the pulse gradually rising from 100 to 120, the respiration most of the
time ranging between 40 and 50 to the minute. The abdomen became
more distended, and on the twenty-fourth the patient developed delirium
and tremor. On the twenty-sixth his neck was found to be entirely
rigid, though rotation was possible without pain.

Discussion. The onset of the present symptoms immediately
after an accident makes it natural that we should attempt to connect
them with some injury then sustained, but the negative visceral exam-
ination and the presence of continued fever make it probable that
the accident had nothing to do with the case.

I have known tertian malaria to begin exactly in this way, with sharp
stabbing pain in the lower part of both chests, but in that case the char-
acteristic course of the fever, with remissions on alternate days, quickly
led me to examine the blood and to demonstrate malarial parasites. In
the present case the temperature curves and the results of blood examina-
tion enable us to exclude malaria.

With the rapid onset of thoracic pain, fever, headache, and acceler-
ated respiration we should consider pneumonia, which may be present

122 DIFFERENTIAL DIAGNOSIS

even without demonstrable signs in the chest and without leukocytosis.
Within a few days, however, repeated and painstaking examinations of
the lungs usually demonstrate some evidence of solidification, even
when cough and sputum are absent. No such signs developed in this
case.

Typhoid fever was the diagnosis made during the first five days of
the patient's illness, and in the absence of all physical signs, with con-
tinued fever and low white count, this was probably as good a guess as
we could expect to make. With the appearance of stiffening of the neck
on the twenty-sixth of July the diagnosis was promptly changed to
meningitis, though the condition known as meningismus complicating
typhoid was also a possibility; indeed, between meningitis and menin-
gismus i. e., between cerebral congestion and actual exudation of the
pus-formation we have no certain way of distinguishing.

Outcome. Kernig's sign and leukocytosis appeared next day, and
the delirium ceased, though a low muttering and twitching of the arms
continued. Lumbar puncture was tried on the twenty-seventh, but
no fluid was obtained.

Throughout, the patient's behavior was strikingly like that seen in
typhoid. Death occurred on the second of August.

Autopsy showed acute purulent leptomeningitis ; septicemia (strep-
tococcus pyogenes) ; hypertrophy and dilatation of heart; septic hyper-
plasia of the spleen; obliterated extra ureter on the left side; fatty meta-
morphosis of the liver; fibrous cord from umbilicus to the mesentery.

Case 48

An unmarried seamstress of nineteen entered the hospital January
25, 1908. The girl had never been sick until a few days ago, when she
began to have pain in the small of the back, relieved by lying down, a good
many headaches, and an occasional vomiting spell. There was no
costovertebral tenderness ; the urine was negative. The spine was nor-
mally flexible without pain, and no tenderness in the sacro-iliac joints
could be elicitated by any maneuver. Fever was absent. The cata-
menia had been absent for three months.

Vaginal examination showed a mass the size of a horse chestnut,
reddened and eroded, protruding slightly from the vulva, but reducible.
In the posterior culdesac was a mass the size of a large apple, not at all
movable, apparently in the back of the uterus. There was milk in the
breasts, and the areolae were darkly pigmented. Under light ether
anesthesia it was easily possible to free the fundus from the sacrum
and to put the whole organ into normal position. Examination then

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Fig. 23. Signs as recorded in Case 49. Lumbar pain is the chief symptom. (See also

Fig. 24.)

Fig. 24. Results of physical examination of the chest in a ease of lumbar pain. (See

also Fig. 23.)

LUMBAR PAIN

123

showed a normal uterus enlarged about the size of a three and a half
months' pregnancy with a very soft, patulous cervix.

Discussion. In the absence of all the causes of lumbar pain hereto-
fore discussed, and in view of the amenorrhea, a pelvic examination was
obviously indicated. The only remaining question is whether the
symptoms are likely to have been due to the condition of the uterus.
The anatomic position of the displaced and enlarged organ as here
described seems to me to put it in a different category from any of the
minor pelvic disorders to which I have previously referred as unlikely
of themselves to cause lumbar pain. The question seems to me solved
in all reasonable probability by the

Outcome. The patient was entirely relieved by these procedures.

Diagnosis. Prolapsed, retroverted, incarcerated, pregnant uterus.

Case 49

A Russian housewife, twenty-eight years old, entered the hospital
December 10, 1908, complaining of sharp pain in the back and on both
sides of the chest below the ribs, which has lasted a week. She has
also had a cough for the past three weeks. She is eight months' preg-
nant. At entrance her temperature is 101 F.; pulse, 125; respiration,
32. She is slightly cyanotic. The heart's apex is in the fifth interspace,
anterior axillary line, 14 cm. to the left of midsternum. A harsh systolic
murmur is heard at the apex and in the axilla. The pulmonic second
sound is accentuated. The superficial veins over the chest are very
prominent. Near the junction of the second rib with the sternum on
each side are seen tortuous arteries which pulsate visibly. In the lower
left axilla there is flatness, absence of breath-sounds, and fine crackling
sounds. (See Fig. 24.) The abdomen is distended as by a pregnant
uterus. A fetal heart is heard in the left lower quadrant; rate, 148.
The pain in the back is intermittent.

Discussion. Only one question need be seriously considered in
this case. Is the pain due to an infectious disease or to the contractions
of a pregnant uterus?

Infection is suggested by the fever, the three weeks' cough, and the
signs in the left lower axilla, which are quite consistent with a pleurisy.

On the other hand, the intermittence of the pain is what we should
expect if it coincided with uterine contractions. The next thing to do,
then, is to watch the patient continuously with the hand over the uterus,
and sec whether the pains coincide with the uterine movements. In a
somewhat similar case, occurring in a young, neurotic Jewess six and a
half months pregnant, and suffering also from a moderately advanced

124

DIFFERENTIAL DIAGNOSIS

tuberculous process in the lung, I stood by the patient, with my hand
upon the abdomen, until I convinced myself that the lumbar pain was
dependent upon her restless movements and not upon uterine contrac-
tions. In this latter case the patient went on to full term, though the
tuberculous process developed ominously.

Outcome. On observation the pain was soon determined to coincide
with uterine contractions. On December 12th she gave birth to a
seven-and-a-half-pound boy.

Diagnosis. Parturition.

Case 49a

Called May 9th, 191 1, to a girl eight years of age, who complained
of severe pain in back and thighs, with difficulty in walking. The
father is addicted to the too liberal use of intoxicants, but is otherwise
in good health. Mother in good health. The patient is the third
child in a family of seven children, all living and well. On questioning,
it appeared that two days before, while playing at school, she was
thrown down a bank ; she thinks that the vertebrae in the dorsal region
struck a stone. No history of any previous illness or injury could be
obtained. She had pain in the back during the forenoon of the injury,
and while walking home at noon she lay down beside the road for
some time because of the pain in back and legs, and the consequent
difficulty in walking. She felt unable to return to school in the after-
noon, but went as usual the next day.

On the third day she was seen by a physician. The brows were
then contracted, the eyebrows raised at their inner ends, and the
muscles of the face rigid. There was stiffness of the back and legs.
When she was turned on her side the legs would remain separated,
with no support for the upper one except the tonic spasm of the
muscles. The hands were rigidly flexed at the metacarpophalangeal
joint. There was no anesthesia. No signs of injury along the spine
or elsewhere on the body were found on casual examination. At
this time a consultant saw the case and was unable to decide be-
tween myelitis and meningeal hemorrhage.

Next morning there was a general muscular tonic spasm, lasting
one or two minutes, with involuntary micturition and defecation.
The mind was perfectly clear. This condition continued for about
twelve days, the temperature varying from ioo to 102 F., with several
tonic convulsions daily. The jaws were not tightly closed, but would
not open over a third of an inch. The respirations were "grunting"
in character, and during the spasms there was marked cyanosis. No

LUMBAR PAIN

cough. The patellar reflexes were present at the time of the first
examination, but were not tried for after that. Physical examina-
tion (including the urine) was otherwise negative.

Discussion. In view of the history of trauma to the spine,
one thinks first of some abnormal pressure upon the cord, perhaps a
hemorrhage. But with hemorrhage into the cord one would expect
a more definite localization of the symptoms below the level of trau-
matism. The muscles of the face would not be affected as they are
here. Paroxysmal and general tonic spasm is also uncharacteristic
of hemorrhage into the cord. Fracture of the spine seems to be
excluded by the physical examination and by the free power of
locomotion.

In view of the presence of fever, pain, and muscular weakness,
with relaxation of the sphincters, acute myelitis or poliomyelitis might
be considered. The latter is easily excluded by the absence of definite
paralysis and the very widespread tonic spasm. In transverse mye-
litis or diffuse inflammation of the cord, anesthesia or other sensory
symptoms are almost always present, and convulsions with involve-
ment of the face are, so far as I know, unknown.

The muscular spasms present in this case have something in com-
mon with those seen in poisoning by strychnin, which may have been
taken accidentally or with suicidal intent. Continued fever, however,
is not usually present in strychnin-poisoning. The face is not often
involved and the sphincters are rarely relaxed. No strychnin was
found in the house, and none had been given therapeutically.

Uremia may be ruled out by the absence of changes in the heart
and blood-pressure, and the negative urinary examination.

Epileptic convulsions may occur, as in this case, without loss of
consciousness, but so far as I know they almost always include clonic
as well as tonic spasms, whereas in this case clonic motions were alto-
gether absent. Continuous fever without loss of consciousness is also
rare in epilepsy.

Hysteria may produce tonic spasm not unlike that here described,
but is practically never associated with continued fever nor with
involuntary micturition and defecation.

A rigidly resistant condition of all the muscles is sometimes seen
as a feature of the negativism in dementia praecox, but this disease can
here be ruled out by the great suddenness of this patient's attack
without any accompanying or preceding mental abnormalities, and
by the presence of continuous fever and relaxed sphincters.

With the exclusion of all these possibilities one naturally comes

126 DIFFERENTIAL DIAGNOSIS

to ask one's self what infectious disease can produce fever like that
here present, associated with widespread muscular tonic spasm.
Obviously tetanus is such a disease, but we have no history of any
wound or injury whereby the bacillus of tetanus could have been
introduced. There has been no subcutaneous injection of any sub-
stance which could contain the tetanus bacillus as an impurity (e. g.,
diphtheria antitoxin, gelatin). Nevertheless cases are on record in
which it was not possible to discover the portal of entry for the bacil-
lus, though such a portal had to be assumed, since the bacillus was later
isolated from the tissues. It is not generally believed that infection
can enter through the gastro-intestinal tract. On the whole, tetanus
is the best choice among available alternatives.

Outcome. After the diagnosis of tetanus had been decided
upon and tetanus antitoxin administered, repeated and prolonged
inquiries were again instituted regarding any previous injury, and it
was learned that two weeks before the onset of symptoms there had
been an abrasion of the knee from the edge of a rough board; a sliver
had been removed and the wound had healed. A closer examina-
tion of the knee was accordingly made; it revealed a small bluish
area on the inner side of the right knee, posterior to the hamstring
and superficially healed except for one small spot from which a drop
of pus could be expressed. This area was incised and curetted and
a further sliver of wood about one-third of an inch in length was
thus found and removed. The wound was swabbed out with iodin
and a second injection of antitoxin administered. No cultures were
made. On the fifteenth day of the illness the patient was convales-
cent, and twenty-four days from the onset was well. There had been
marked loss of flesh and a decidedly round-shouldered condition of
the upper spine persisted; also occasional muscular pains.

Diagnosis. Tetanus.

LUMBAR PAIN

12'

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CHAPTER IV
GENERAL ABDOMINAL PAIN

The diagnosis of the causes of abdominal pain is one of the most
unsatisfactory, as well as one of the most important, in medicine;
unsatisfactory, because our methods of examination are so inadequate.
The chest, the cranium, and the extremities present far less difficulty,
partly because their diseases are more accessible to direct inspection,
partly because (in relation to thoracic disease) we have developed the
technic of auscultation, percussion, and #-ray examination to a point
quite out of the question in dealing with the belly. Our methods of
investigating the abdomen are rough and primitive compared to those
for the study of the chest.

Aside from the information obtained by study of the urine, blood,
gastric and intestinal contents, practically all our knowledge depends
upon palpation and a good history of the case. The latter is of crucial
importance in this diagnosis of gall-stones, peptic ulcer, gastric cancer,
colica mucosa, and many other common diseases. Palpation is mate-
rially assisted by immersing the patient in a bath as hot as he can bear.
In some cases the procedure gives us almost as complete a relaxation
of the belly walls as can be obtained under anesthesia. It should be
employed in all dubious abdominal cases (questionable tumors, unex-
plained pains, etc.), especially if spasm of the muscles makes ordinary
palpation difficult. 1

Further reference will be made at the end of this chapter to another
obstacle to correct abdominal diagnosis; namely, the tendency of local
lesions to produce generalized pain, and of generalized lesions to pro-
duce localized pain. These obscure radiations often deceive even the
expert.

Case 50

A clerk of thirty-nine, of good family history and habits, entered the
hospital January 31, 1907. He had rheumatic fever eight years ago.
Three and one-half years ago he was doubled up by an attack of
pain and aching all over his bowels. He was seen in the Brockton
Hospital by Dr. Daniel F. Jones, who said it was not appendicitis.
Since this attack he has been well up to three weeks ago, when, after
lifting, he had a stitch in his back, could not straighten up, and had to

1 Women can be protected by making the water opaque with soapsuds.
128

Causes of General Abdominal Pain

1. CONSTIPATION

DIARRHEA AND
ENTERITIS

3. APPENDICITIS

4. TYPHOID

5. GENERAL PERI-

TONITIS

6. LEAD-POISON-

ING

7. I NTESTI NAL1

OBSTRUC-
TION, in-
cluding!

STRANGU-
LATED HER-
NIA

8. TUBERCULOUS]

PERITONITIS
AND TABES
M E S E N-
TERICA

9. TABES GAS--)

TRIC CRISIS) J

2761

661

451
379

237
169

167

10.

11.

EXTRA-

UTERINE
PREGNANCY

NEUROSES^
(GASTRIC) i

108

Among the rarer causes are many varieties of abdominal tumor (which usually pro-
duce local rather than generalized pain), malaria (especially in children), and spinal tuber-
culosis.

GENERAL ABDOMINAL PAIN

J 3I

stop work. The pain in his back was eased by lying down, and has not
recurred. His bowels have since been very costive; hence after taking
laxatives without result he took two injections, which caused cramps in
the abdomen so severe that he "almost went crazy." The doctor came,
gave him some " dope," and explained that he had appendicitis or gall-
stones. He is very nervous and sleeps poorly. He has sometimes a
voracious appetite.

Physical examination showed good nutrition and slight pallor. Tem-
perature, pulse, urine, and blood normal. The patient was a cribber.
Physical examination was entirely negative, except for slight tenderness
in both iliac fossae. There was considerable mucus in the feces, bind-
ing the whole stool together into a single tenacious mass, like sputum.
The patient was very much afraid of appendicitis, and complained fre-
quently of terrible pain relieved by cooking soda. Guaiac test persist-
ently negative.

Discussion. Appendicitis is and should be our first thought in any
case beginning with such symptoms, but the suspicion is shown to be
groundless by the absence of elevation of the pulse, temperature, or
leukocyte count, and by the fact that there is no tenderness or spasm
in the appendix region.

Inflammation of the gall-bladder is ruled out for similar reasons.

Lead colic is consistent with all the symptoms here mentioned, but
no such diagnosis can be made in the absence of all other evidence that
lead is in the system (lead-line, stippled red corpuscles, occupation in-
volving lead).

Pain relieved by cooking soda is often the result of duodenal ulcer,
a disease always to be thought of in patients with acute abdominal
symptoms. The history and the physical examination, however, offer
no confirmatory evidence. No blood has apparently been discharged,
either by the mouth or by the bowels, and we have not the usual history
of long-standing digestive disturbance. Mucous colitis or colica mu-
cosa is a diagnosis consistent with all the symptoms here described.
The chronic constipation, the suggestion of a neurotic constitution,
the occasional attacks of severe abdominal pain, and the presence of a
large amount of mucus in the stools passed soon after such pain com-
plete a typical picture of this disease.

Three groups of cases are often met in practice:

(r) Those with much nervousness, some pain, and some mucus.
^2) Those of much pain, some nervousness, and some mucus. v
Those of much mucus, some nervousness, and some pain.

In all three groups constipation is the underlying factor. Treat-

I32 DIFFERENTIAL DIAGNOSIS

ment must be directed to the relief of this and of the accompanying
neurosis.

Outcome. His points of tenderness varied from day to day, but at
no time did he have tenderness in the right iliac fossa. After his bowels
got to moving regularly, the pains disappeared and he gained 4 pounds
inside of a week. Simultaneously his urinary excretion increased from
30 to 60 ounces. He left the hospital well on the eleventh of February.

Diagnosis. Neurosis; mucous colitis.

Case 51

A stenographer of twenty-four entered the hospital March 26, 1908.
Six years ago she had six attacks of cramp-like pain in the abdomen,
each lasting six or eight hours, and relieved by morphin. The pain was
not localized in any one place, but after an attack she had soreness in the
left lower quadrant. Since that time she has had a more or less con-
tinuous "hard ache" in the left lower quadrant, never moving to any
other place. She also has stiffness in both legs down as far as the knees.
Her pain is not aggravated by motion. She has had no vomiting at any
time. Working at the typewriter seems to cause cramp-like pains in the
stomach. On account of these she was operated on in August, 1907,
for appendicitis, and was told that " chronic appendicitis" was found
and cured. The pains have continued as before. . Her appetite and
sleep are good, but she is markedly constipated. Last August she
weighed 126 pounds; now she weighs 118. She often has pain on mic-
turition, and occasionally difficulty in passing her urine.

On physical examination her pupils are widely dilated, equal, and
react normally. The gums are normal. There is a short, rough,
systolic murmur heard all over the precordia and in the left axilla.
There is no enlargement of the heart nor accentuation of the pulmonic
second sound. The abdomen is negative; likewise the blood, urine,
temperature, pulse, and respiration.

Discussion. The gist of this case seems to be: non-localized ab-
dominal pain, with a negative physical examination in all essentials.
Lead-poisoning is easily ruled out by the absence of changes in the blood
or in the gums. Since the pupils react normally, tabes dorsalis seems
very unlikely, though there is nothing said about the reflexes in the
description as given above.

Dilatation of the pupils is common in a great variety of psycho-
neurotic states; nevertheless, it should always suggest the possibility of
a cocain habit, especially if any heart trouble is complained of or comes

GENERAL ABDOMINAL PAIN 1 33

to light on physical examination. In the present case there was no such
evidence, and the habit was firmly denied.

In a considerable number of cases of pulmonary tuberculosis there
is dilatation of one or both pupils, and the presence of this sign always
leads me to examine the pulmonary apices with particular care. In
this case such an examination was negative.

The controverted question of chronic appendicitis is raised afresh in
this case, but I suppose no one will maintain that an appendix can
produce symptoms seven months after it has been removed. When
the patient's symptoms persist unchanged after the removal of a so-
called chronic appendix, it is generally agreed upon that in this case
the appendix was not the cause of the symptoms. Indeed, this is one of
the few points regarding chronic appendicitis on which physicians do
very generally agree. Personally, I believe that in a considerable pro-
portion of the cases operated upon as chronic appendicitis the ap-
pendix has nothing to do with the symptoms. The disappearance of
symptoms following operation is not always a proof that the appendix
was the offending member. The operation itself, with the postoperative
rest, diet, physical and mental training, may well have been the cause
of the relief.

In the present case, if we take account of the age and sex, the marked
constipation, and the variety of "wild symptoms," such as painful
micturition and stiffness of the legs, it seems more than likely that a
general neurosis based on faulty habits and unfortunate environment
is at the root of all the troubles. The domestic and industrial back-
ground should be looked into.

Outcome. On further investigation it appeared that insufficient
food, hurry, worry, and sedentary occupation in a close office had much
to do with her condition. All the reflexes were lively.

Diagnosis. Bad hygiene.

Case 52

A Russian Jew, apparently without occupation, forty-eight years old,
entered the hospital December 26, 1907. For seven weeks he has been
having pain and "burning" in the center of the abdomen, not very severe,
but constant and worse at night, though he sleeps well. It is worse, also,
immediately after eating. His appetite is poor; he has taken nothing
but a little milk of late. His bowels are very irregular, usually con-
stipated. He does not vomit or cough.

On physical examination a regularly distributed, rose-colored macular
eruption is found in various parts of his body, and there aie marks of

134

DIFFERENTIAL DIAGNOSIS

scratching on the upper arms. The chest shows nothing abnormal.
Beneath the umbilicus, and extending out toward the right flank, is a
smooth, rounded, cylindric mass, about three inches long, one and a
half inches wide, freely movable, not hard or tender, feeling not unlike
a kidney. Physical examination, including the blood, urine, tempera-
ture, pulse, and respiration, is otherwise entirely negative.

Discussion. The important objective findings are the macular
eruption and the cylindric mass in the abdomen; the former suggests
syphilis, the latter, an abdominal tumor. Against syphilis, however, is
the itching of the eruption, as evidenced by scratch-marks. There is
also no evidence of a primary lesion, and the patient denies all knowledge
of the disease.

Russian Jews in general, and unoccupied Russian Jews in particu-
lar, are very prone to neuroses and vague unexplained pains. It is
striking how often they refer to these pains as "burning." "Es brennt
mir das Herz," or "Es brennt mir uberall," are very common com-
plaints among them.

It is noteworthy also that this pain, though worse at night, does not
prevent him from sleeping well.

Turning now to the abdominal mass, we note that it occupies the
position in which a displaced kidney is often to be felt, especially in
women. It seems, however, rather too short and too little sensitive.
In view of his chronic constipation a mass of retained feces may well be
the explanation. It seems reasonable, then, to explain his indigestion,
eruption, and anorexia as the result of constipation, the latter in turn
being the commonest of all manifestations of a general neurosis.

Outcome. The patient was given an A. S. and B. pill, and the next
morning the tumor had entirely disappeared. The following day it
was again felt just at the level of the umbilicus, and considerably smaller
than at entrance. Similar masses were then felt in the left iliac fossa.
These also disappeared with free movements of the bowels. On Decem-
ber 31st his abdomen was wholly negative, his eruption gone, and he
had a wonderful appetite.

Diagnosis. Constipation.

Case 53

A storekeeper of twenty-six, of good family history and habits,
entered the hospital October 17, 1907, stating that he had always had a
weak stomach and had been troubled by pains in the chest and limbs
off and on for the past ten years. Nevertheless he kept about and did
his work in this condition until January, 1907, when he was confined to

GENERAL ABDOMINAL PAIN

135

bed for fifteen days by an attack of pain "in the lungs and back." In
March he was again confined to bed for two days with pain across the
upper abdomen. In April and May he felt poorly, but kept at work.
In June he first noticed .general abdominal tenderness and considerable
enlargement, with painful micturition. He was then in bed for three
weeks. After that he worked until August, when he was suddenly
taken with violent headache, chills, sharp pain under the left breast, in
the back and in the loins, with enlargement of the abdomen. He
remained in bed thirty-five days, his temperature rising every afternoon
to 102 F. or 102.5 F. He sweated profusely every night. Since then
he has been poorly and his night-sweats have continued, but the size of
his belly has diminished. During the past nine months he has lost
1 1 pounds in weight. He had at times a slight cough, with sputa rarely
blood-specked. During the past few days there has been slight swell-
ing of his legs.

Examination of the lungs and heart showed nothing abnormal.
The abdomen was symmetrically distended; there was slight tympany
in the flanks; the belly elsewhere was dull, tense, firm, slightly tender
throughout. There was vague resistance at and about the umbilical
region.

The blood and urine showed nothing abnormal, and the temperature,
pulse, and respiration were not elevated during the seven weeks of his
stay in the hospital. After the injection of 5 milligrams of tuberculin
there was no rise of temperature, but he felt sick and weak, and his belly
became much more tender.

Discussion. Chronic abdominal pain and tenderness, with fever
and sweating, form a clinical picture characteristic of very few diseases
occurring in the male sex. Subphrenic abscess may produce such symp-
toms, but not without further physical signs, either in the abdomen,
near the costal margin, or in the chest through displacement of the dia-
phragm. Perforative peritonitis could not be so chronic without either
healing or killing.

Typhoid fever might produce such a pyrexia, and would account for
most, if not all, of the abdominal symptoms, but during his stay in the
hospital his abdominal symptoms continued despite the absence of all
fever. Typhoid would not explain this.

Can he be suffering from chronic intestinal obstruction? The
abdominal pain and distention suggest it, but his bowels have moved
regularly throughout. There has been no vomiting, visible peristalsis,
or other evidence of local lesion.

In my own experience there are only two diseases which present a

136 DIFFERENTIAL DIAGNOSIS

clinical picture at all like this: (a) The psycho-neurotic state, and (b)
abdominal tuberculosis. Since the former can be ruled out by the five
weeks of daily fever, only one diagnosis seems reasonable.

Outcome. On the second of November the spine of the fifth dorsal
vertebrae was found to be very tender on pressure. This, in connection
with the fact that sitting erect caused sharp pains in the chest and
abdomen, suggested spinal tuberculosis, but an orthopedic consultant
thought it more likely to be glandular tuberculosis in the abdomen.

Two other consultants thought the symptoms probably due to
chronic appendicitis.

On the sixth of December the abdomen was opened, and the in-
testines found to be everywhere adherent to each other, to the omen-
tum and to the abdominal wall. A large chain of glands was matted
together in the appendix region, and many others were scattered about.
There was no fluid. Microscopic examination of a piece excised showed
tuberculosis.

Diagnosis. Peritoneal tuberculosis.

Case 54

A housewife of forty-four who had been in the hospital in May, 1905,
and been operated on for inflamed tubes and ovaries (which were
removed), chronic appendicitis, and sigmoid adhesions, entered the
hospital February 20, 1908. Ever since May, 1905, the symptoms
which then led to operation have persisted. She has been treated in
the medical, surgical and orthopedic departments for out-patients, and
has worn flat-foot plates and abdominal supporters without relief.
She has been unable to do any work on account of soreness in the lower
abdomen, together with sharp attacks of pain starting in the back and
passing around the sides to the center of the abdomen. These attacks
come on when she steps or moves quickly, even when she turns over in
bed at night. The pain is somewhat less sharp when her bowels are
open, but she is exceedingly constipated. She complains of a " drawing,
scratching " feeling in her bowels, as if they were trying to move, but could
not. She has gained 20 pounds since the operation at which the tubes
and ovaries were removed.

Physical examination shows extreme obesity, slight tenderness in
the left lower quadrant of the abdomen, and nothing else, except slight
soft edema over the shins.

Discussion. In an analysis of "One Hundred Christian Science
Cures," printed in McClure's Magazine for August, 1908, I pointed out
that patients who have had many doctors and many diagnoses are very

GENERAL ABDOMINAL PAIN

137

apt to be successfully rounded up and cured by Christian Science, owing
to the fact that in such cases no organic disease is present.

The history of the present patient and of the vicissitudes through
which she passed suggest that she belongs in this group. Doubtless
many of her symptoms represent only the discomforts inseparable from
extreme obesity, especially when it is associated with constipation.

If this be true, the question may be asked how the edema of the
leg is to be accounted for, but I think it is generally recognized that obesity
is in itself sufficient to account for such a swelling, without supposing
any insufficiency of the heart or kidneys.

Doubtless this patient's symptoms are due in part to the nervous
instability often following the removal of the ovaries, but the constipa-
tion, the obesity, and the firmly acquired "doctor habit" are also im-
portant factors.

Such a diagnosis, though satisfactory enough from our point of view,
may be of very little use to the patient, whose sufferings often go on
unabated unless we can succeed in the almost superhuman task of
changing most of her habits, mental and physical.

Outcome. When the patient is alone in the ward, she does not seem
to suffer, but her complaints are very numerous whenever a doctor or a
nurse approaches. She complains that she is restless at night, but
snores loudly. A tight abdominal binder and vibratory massage
had relieved her considerably by the eleventh of March.

Diagnosis. Postoperative neurosis.

Case 55

A school-boy of nine was first seen September 23, 1907, with the state-
ment that he had never been sick before, except that six months ago he
had an attack similar to the present. Seven days ago he began to have
general abdominal pain. Five days ago the pain was much aggravated,
and seemed to be more troublesome on the right side of the abdomen.
Four days ago he had a sore throat. His appetite has been good; his
bowels regular. He has had no headache or nausea.

Examination September 23d was negative, except for a temperature
of 103. 6 F., and the leukocyte count of 22,000. with a negative Widal
reaction. There was at that time slight tenderness at and above
McBurncy's point.

September 26th the fever still continued; physical examination was
negative in all respects. The Widal reaction was negative; white cells,
8400; the course of the temperature was as shown in the accompanying
chart.

138

DIFFERENTIAL DIAGNOSIS

Discussion. During the early days of my attendance on this case
I could make no diagnosis. The fever, the leukocytosis, and the ab-
dominal signs favored appendicitis, though the absence of all spasm
and of all but very slight tenderness in the appendix region made this
doubtful. The sore throat was practically gone before I saw him, and
could not be held responsible for the symptoms then present.

On the twenty-sixth, however, the clinical picture had quite changed.
Continued fever with a low white count and a negative tuberculin reac-
tion were now the essential features. This means, in all probability,
either typhoid fever or some of the unknown infections unwisely called
"febricula" or "grip." The latter possibilities were soon ruled out

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Fig. 25. Chart of case 55.

by the long duration of the fever. Under the hypothesis of typhoid fever
it was left for us to explain the initial leukocytosis and the absence of the
Widal reaction. No such explanation, however, was then forthcoming.
The phenomena just referred to remained as examples of the wild,
untamed, residual items so characteristic of any accurately described
case of illness.

Outcome. On the third of October the "Widal reaction appeared.
On the eighth he was given a drop of tuberculin in the left eye, without
any subsequent reaction.

On November gth he was discharged well.

Diagnosis. Typhoid.

GENERAL ABDOMINAL PALN

139

Case 56

A Portuguese housewife of thirty-two entered the hospital October
25, 1907, with a negative family history and good habits. She had a
miscarriage two years ago, and two other miscarriages since her marriage
three years ago. She has one healthy child. For seven years she has
been subject to general abdominal pain, not severe.

Three weeks ago she began to have dull, steady pain, starting in the
left lower quadrant, whence paroxysms of more severe pain extended
across the abdomen and up both sides of the chest to the neck. The
appetite is poor; there is occasional nausea, but no vomiting. The
bowels are constipated. For the past three weeks micturition has been
somewhat painful.

Physical examination shows obesity. The chest is normal, the
abdomen tympanitic in the upper part, dull in the lower part, where
tenderness is so great that palpation is impossible. The blood-pressure
is 100 millimeters of mercury; the white count, 14,900. Urine, tem-
perature, pulse, and respiration are normal. During the week of her
stay in the hospital she complained of pain in every part of her body.

Discussion. Syphilis is the first possibility that occurs to us in this
case, in view of the frequent miscarriages. It is impossible, however,
to incriminate any particular organ or to obtain any more definite history
of the disease, which must remain in the background as a possibility
incapable, at present, of further verification.

We naturally ask ourselves next whether the abdominal tenderness
and painful micturition are not due to gonorrheal infection of the tubes
and bladder. This possibility cannot be absolutely excluded, but in the
absence of fever, leukocytosis, and urinary changes, it seems decidedly
unlikely.

The very wide distribution and radiation of the pain, and its asso-
ciation with vomiting, constipation, and anorexia, lead us to conclude
that if any inflammatory lesion has existed in the pelvis it is now burnt
out and exerting its effect chiefly through the nervous system.

Outcome. A few nights before her discharge she was rolling and
groaning with pain, but a subcutaneous injection of sterile water gave
immediate relief. Vaginal tampons also improved her mental condition.

Obviously, the therapeutic test was here of considerable diag-
nostic value. I believe, however, that the same important information
can be obtained through the investigation of the psychic state, and
without any of the charlatanry which seems to me inherent in the methods
here employed.

Diagnosis. Neurosis.

140

DIFFERENTIAL DIAGNOSIS

Case 57

A factory girl of twenty-six, a Canadian by birth, was first seen
May 28, 1907. In April, 1906, she had a sickness similar to the present
one. At that time medication gave no relief, but a six weeks' vacation
in Roxbury entirely relieved her. Her home is in Blackstone, Mass.

In March, 1907, she began to have dull, colicky pain and tenderness
in the lower part of her abdomen, constant, showing no relation to meals
nor to the kind of food eaten, often keeping her awake at night, usually
relieved by pressure. Frequently she has to sleep upon her belly all

night. With the pain she has constipation,
and has noticed that she is getting pale.

On physical examination the abdomen
was full, soft, tympanitic throughout, and
showed no tenderness at any point. The
chest was likewise normal. A blood-smear
showed 60 per cent, hemoglobin, some
achromia and many stippled cells.

The urine averaged about 25 ounces in
twenty-four hours, and contained a trace
of albumin, many hyaline and granular
casts with an occasional cell adherent.

Discussion. Although this case puz-
zled a number of physicians, there would
have been no puzzle about it but for the
neglect of a routine blood examination,
for there is only one disease which often
produces basophilic stippling of the red
cells in the absence of marked anemia.
That disease is chronic lead-poisoning. Other diseases (e. g., diabetes)
have been known to produce a similar blood-picture, but this is rare.

Lead-poisoning is a very common disease, but the failure to recognize
it is, in my experience, still commoner. This is not because it is difficult
of diagnosis, for the very reverse is the case, but because physicians so
often fail to suspect its possibility and to examine patients for definite
evidence of its presence. When once our attention is turned toward this
diagnosis, we shall note, as in the present case, a very striking group of
confirmatory signs. A chronic abdominal pain relieved by pressure
would be likely to have more relation to meals if it were due to duodenal
ulcer or to any cause other than lead. Association with constipation,
pallor, and albuminuria should certainly make us search for a lead line

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-Chart of case 57.

GENERAL ABDOMINAL PAIN 141

on the gums one of the signs which is most often forgotten in routine
physical examination.

Outcome. The gums showed a typical lead line. Her mother and
sister have a similar but less severe trouble. The patient was given
magnesium sulphate, an ounce every morning; iodid of potash, 5 grains
three times a day, and an occasional dose of morphin and atropin was
also needed. Turpentine stupes relieved her pain more or less.

By June 6th her appetite had improved, her cramps were gone, and
her color had begun to return.

By the ninth of June she was ready to go home. It appeared that
the whole family got their water from a well through a lead pipe 75 feet
long.

The reader will note the striking rise in pulse-rate and its continued
rapidity after the first week of treatment. The bradycardia of plumb-
ism has often been recorded, but never, I think, satisfactorily explained.

Diagnosis. Lead-poisoning.

Case 58

An Italian meat-cutter of thirty-five was seen June 20, 1907. He
stated that he had never been sick before until a year and a half ago
(six months after his arrival in this country), when he began to notice that
his abdomen was slightly larger than normal. He also noticed a beating
in the pit of the stomach with vague abdominal pains, much loss of
strength, occasional chills, and slight fever. At times his abdomen has
seemed to be swollen, but of late it has been smaller. The pain is steady,
dull, worse on dark, cold days. He is easily fatigued and has done no
work for six months, but his weight has remained steady. He has had
dizziness and buzzing in his head for three months, and for one month
night-sweats. He eats and sleeps well, but his bowels move only with
laxatives.

Physical examination of the chest was negative. The abdomen
showed dulness in the left flank, which, however, did not shift with
change of position. There was slight tenderness in the region of the
umbilicus. Near this tender point a violent pulsation was felt, synchro-
nous with the heart-beat. It was expansile in character, and during pal-
pation a systolic thrill could be appreciated over it. A systolic murmur
was audible at the same site. The tuberculin reaction (subcutaneous)
was entirely negative. The urine averaged about 22 ounces in twenty-
four hours, was free from albumin, but contained rare hyaline and gran-
ular casts. Blood examination was negative; white cells, 7000. Tem-
perature, pulse, and respiration were normal.

142

DIFFERENTIAL DIAGNOSIS

Discussion. In the presence of chronic abdominal pain with swell-
ing of the abdomen, weakness, night-sweats, and constipation, the pos-
sibility of tuberculous peritonitis should always be entertained, espe-
cially when the patient is an Italian recently settled in America. In the
present case, however, the absence of fever at the present time, the
negative tuberculin reaction, and the fact that no characteristic lesions
either of "dry" or of "wet" tuberculosis can be detected in the abdo-
men make this diagnosis unlikely.

More plausible is the idea of aortic aneurysm, and this was, in fact,
the diagnosis of the attending physician. Against it, however, were
two very important facts: the pain was in the wrong place and there
was no tumor. The pain of abdominal aneurysm is almost entirely in
the' back and legs. Further, the diagnosis of aneurysm is never well
grounded unless we can feel a definite tumor with a beginning, middle,
and end. However violent the pulsation we may find in the abdomen,
and I have seen it sufficient to shake the bed in which the patient lay,
we have no right to make the diagnosis of aneurysm unless we have, in
addition to the pulsation, a definite tumor or severe pain in the back.
Expansile pulsation, thrill, and systolic murmur can be appreciated over
any abdominal aorta which is superficial enough to be reached with the
fingers and with the stethoscope.

It seems almost incredible that an illness so prostrating as this
could be produced by the mere accident of having one's attention di-
rected to the normal, though lively, pulsation of one of one's own blood-
vessels; but such was really the case here. Dynamic aorta that is,
a somewhat unusual liveliness in the pulsation of a perfectly normal
blood-vessel in a person of neurotic constitution is very frequently
mistaken for abdominal aneurysm. Indeed, I should say that five out
of every six cases in which I have known the diagnosis of abdominal
aneurysm to be made have turned out to be nothing but dynamic aorta.
Nothing but the experience of following such a case to complete and
lasting recovery, as the result of the policy of disregarding all the symp-
toms and turning the attention in other directions, can convince the
patient and his physician of the facts just quoted.

In true abdominal aneurysm the tumor is seldom in the median line.
It is much larger and more globular, and pulsates less violently than the
dynamic aorta. One of the most astonishing things about the latter
is that it often appears just beneath the skin of the abdominal wall,
seemingly separated from our finger-tips only by the thickness of a piece
of blotting-paper. As we recall our dissecting-room experiences, it
does not seem possible that the aorta can lie so close to the abdominal

GENERAL ABDOMINAL PAIN

wall. Doubtless this is due to a somewhat atypical curve of the spinal
column.

There can be no doubt, I think, that three factors enter into the pro-
duction of the neurosis known as dynamic aorta:

(i) An unusually superficial position of the abdominal aorta.

(2) A sensitive and impressionable temperament, such as shows
itself in rapid bodily motion, quick excitable speech, lively knee-jerks
and easily excited heart action.

(3) The abnormal concentration of attention upon the pulsation.
This latter condition is favored by the physician's obvious interest and
concern, as expressed in his careful and repeated examinations of
the part, his overclouded countenance, and sometimes his unguarded
utterances. If by any mischance the patient begins to suspect that he has
an aneurysm, he is pretty sure to learn from a dictionary or otherwise
what the disease really means. Thereafter he passes his days and nights
feeling very much as though he had inside of him a dynamite bomb
which might explode at any minute. This, of course, reacts upon his
mental condition, and makes him watch himself all the more care-
fully, thereby increasing the pulsation and soon leading to the develop-
ment of pain; but it should be reiterated that the pain is in the spot to
which his attention has been directed, and not in the place where it
would be were aneurysm really present.

I have dwelt at considerable length upon the nature of this trouble
and the means of its recognition, because it is by no means uncommon,
is prone to lead to a great deal of unnecessary misery when mistaken for
aneurysm, and because it is not treated at any length in most text-books.

Outcome. Gas in the abdomen and the perception of the pulsating
artery were apparently the cause of his symptoms. This was explained
to him, and by June 27th he was free from complaint. He returned to
work after ten days more and has since (1910) remained well.

Diagnosis. Dynamic aorta.

Case 59

A printer of twenty-seven entered the hospital August 19, 1907.
His family history and habits are good. He states that he had "renal
colic" last May for two days, and has since then been well. Two weeks
ago his bowels began to be rather loose. His appetite has remained good
and he has slept well. Beginning tin's morning he lias had severe ab-
dominal cramps, his bowels have moved six times, and he lias vomited
six times. The pain is felt throughout the abdomen.

Physical examination shows two irlands the si/.e of marbles in the

144 DIFFERENTIAL DIAGNOSIS

right axilla. No other glands seem to be enlarged. There is a soft
systolic murmur at the heart's apex. The chest is otherwise negative.
The abdomen is slightly retracted. There is general muscular rigidity,
especially in the epigastrium, and in the right side near the navel. On
percussion the belly is tympanitic, except in the left flank no definite
mass or tenderness found. Temperature at entrance 99.8 F.; white
count, 16,600, with 96 per cent, of polynuclear cells. The next day
the temperature and the white count were normal. The diarrhea had
ceased.

Discussion. What further evidence should be searched for in this
case? In any printer who complains of abdominal pain we should at
once look for a lead line on the gums and search for basophilic granula-
tions in the stained blood-smear. Both these lesions were absent in this
case. The presence of diarrhea is also very uncommon in lead-poison-
ing.

An #-ray examination is indicated in view of the patient's statement
that he had renal colic a few months before. There is nothing, how-
ever, pointing to any such disease in a physical examination.

Perforative peritonitis would account for the pain, vomiting, fever,
leukocytosis, spasm, and tenderness, but the presence of a diarrhea with
good appetite and sleep makes this very unlikely, especially as there is
no local point of maximum pain and tenderness.

But for the definite evidence afforded by the blood examination, it
would be necessary to consider an acute lymphoid leukemia. I have
seen leukemia presenting the symptoms here described with no more
striking glandular enlargement. The blood examination, however,
was distinctive.

Why should it not be a simple gastro-enteritis, especially in view of
the time of year at which the symptoms occurred? Severe abdominal
cramps, a general muscular rigidity in the abdomen, transitory fever
and leukocytosis are all quite consistent with that diagnosis; there
seems to be nothing of importance against it.

Outcome. X-ray showed no evidence of renal calculus, after rest
in bed and regulated diet, ten half-grain doses of calomel, and an ounce
of magnesium sulphate, the patient was discharged well on the twenty-
second.

Diagnosis. Acute gastro-enteritis.

Case 60

A teamster of forty-four, with a negative family history, was first
seen August 24, 1907.

GENERAL ABDOMINAL PAIN

145

For many years he has been in the habit of taking from twelve to
twenty glasses of beer and three to five glasses of whisky daily. He
chews a five-cent plug of tobacco a day, and smokes three or four pipefuls
besides. He has always been very well and strong until five months
ago, when he began to have dull pain in the abdomen, not definitely
localized, but more marked in the lower half. This was accompanied
by distress and flatulence after meals, and frequent vomiting imme-
diately after the taking of food. The vomitus is bitter, yellow-green,
never bloody. His appetite is poor, his bowels constipated, and he has
been short of breath for the past four weeks. For the past two weeks
he has had to pass his urine twice each night. Two years ago he weighed
155 pounds; to-day he weighs 121.

On physical examination the skin is dry and satiny. There is a
marked alcoholic odor on the breath. The arteries are all palpable,
and there is a lateral pulsation in the brachials. The chest and ab-
domen showed nothing abnormal.

Examination of the blood showed red cells, 2,030,000; white cells,
7200; hemoglobin, 25 per cent. The stained specimen showed achromia,
slight poikilocytosis, many off-colored cells, no nucleated red cells.

The urine was negative. After a test-meal the stomach-contents
showed no free hydrochloric acid. The gastric capacity was 23 ounces.
His stools were brownish-black, with a well-marked reaction to guaiac.
Rectal examination was negative. The prostate was not enlarged.

Discussion. -The excesses in alcohol and tobacco above described
would naturally lead one to suspect cirrhosis of the liver. The long-
continued gastric symptoms, as well as all the minor complaints, could
be thus explained. The guaiac reaction in the feces might be the result
of blood poured out from dilated veins in the esophagus or stomach.
Against this supposition, however, is the extreme degree of anemia, with-
out any history of severe hemorrhage. Even if the blood were dis-
charged by rectum, the patient would probably be made aware by faint-
ness, weakness, and thirst, of the loss of an amount of blood sufficient
to explain the present anemia. It is unusual, furthermore, that a cir-
rhosis disables the patient and produces such marked symptoms as are
here present, without manifesting itself by any change in the size of the
liver or by the accumulation of ascites.

Whenever a patient past forty years of age, and previously free
from stomach trouble, begins to have any sort of gastric discomfort,
severe or mild, gastric carcinoma should be considered. This diagno-
sis would explain all the symptoms in this case, including the anemia.
It is remarkable, however, that there should be no more definite evidence

j 46 DIFFERENTIAL DIAGNOSIS

of gastric stasis, no food in the vomitus or in the stomach-washings.
If cancer is present, it is probably not at the pylorus its usual seat.

So extreme a degree of anemia, associated with gastric symptoms
and achylia gastrica, brings the thought of pernicious anemia to mind.
The blood, however, is very uncharacteristic, and is, indeed, typical
of secondary anemia.

On the whole, gastric cancer is the most probable diagnosis.

Outcome. On the morning of the twenty-seventh of August the
right middle finger was blanched and cold up to the knuckle-joint.
Examination of the patient in the warm bath showed a sharp edge in the
region of the liver, descending with respiration. (See Fig. 27.)

On the third of September the abdomen was opened, and an inoper-
able cancer of the anterior stomach-wall found. The mass thought to
be liver before operation proved to be part of the gastric tumor.

Diagnosis. Cancer of the stomach.

Case 61

An Italian shoemaker of thirty-two has complained for a year of
general bellyache with diarrhea, at times bloody. Much intestinal
noise. Has lost 28 pounds in two months. For the past week he has
been costive.

Examination was negative, excepting for a palpable spleen and a
hemoglobin of 65 per cent. During his fortnight under observation
(September 1-14, 1904) he had no fever, no diarrhea, and gained eight
pounds. He had slight abdominal pain, especially at night. There was
slight tenderness in both iliac fossa?. Colitis, possibly tuberculous, was
the diagnosis in the out-patient department and in the wards.

Next spring (May 22, 1905) he was again at the hospital. His
pain, he said, had never ceased. Constipation has been obstinate
and is getting worse. The rumbling noises are still loud. He has
lost 14 pounds since his previous entry.

Slightly above the region of the cecum is a firm, regular mass, about
the size and shape of the kidney, freely movable in all directions, dis-
tinctly tender on pressure. No reaction to tuberculin (two large doses) .
Stools foul, watery, no blood, no tubercle bacilli, some mucus.

Discussion. In view of the information which came to light when
this patient entered the hospital for the second time, there are only two
diseases to be considered as at all likely to produce these symptoms,
viz., cancer of the cecum and pericecal tuberculosis. The latter is made
unlikely by the negative reaction to tuberculin.

The interesting question remains: could the cancer which now

Fig. 27. Diagram of the findings in Case 60. Chief complaints, dull abdominal pain,

vomiting, and flatulence.

GENERAL ABDOMINAL PAIN

147

shows itself at the cecum have been suspected in 1904? Certainly no
positive diagnosis of this disease could have been made, but it seems to
me that whenever we have the history of very loud and marked intestinal
noise, accompanied by pain experienced at short intervals throughout a
year's time, we ought to suspect that some sort of disease has caused
intestinal stricture with muscular hypertrophy of the gut behind it. It
is true that in many cases of diarrhea from colitis intestinal noise is
heard, but it is especially in the acute varieties that we meet with this
symptom. In cases lasting a year it is much more uncommon. Again,
a good many women are troubled by intestinal noise at the time of the
menstrual period, or whenever they are especially nervous, but the process
is never so continuous as in the present case.

Except for this symptom, the diagnosis of chronic colitis was certainly
justifiable in 1904. The case, however, reenforces in a striking way the
well-known rule that in all long-standing diarrheas intestinal obstruction
should be suspected, especially, but not exclusively, in elderly people.
It is, of course, a very familiar fact that many cases of cancer of the sig-
moid begin with diarrhea.

Despite such warnings as are given us by a case like this, the diag-
nosis of intestinal cancer is often entirely impossible with our present
methods of investigation. There is good reason to believe that it is
often present and quite latent for years. The symptoms we see are
merely terminal. For example, a patient whom I saw in 1906 for pain
high up in the rectum, accompanied by discharges of blood and mucus,
had been troubled by severe periodic pains with considerable constipa-
tion, referred to appendicitis, for at least fifteen years. At the autopsy
in June, 1907, cancer of the sigmoid was found, but no appendicitis.
In another group of cases the patient is aware of the presence of
tumor in the abdomen for three or four years, without any pain or dis-
turbance of the bowels, yet the tumor turns out on exploration to be
cancerous. Not infrequently pain may be referred to the pit of the
stomach, and so closely associated with ordinary gastric symptoms
that all our attention is drawn in that direction.

Outcome. Dr. Conant diagnosed tuberculous colitis and advised
operation.

A growth the size of an orange was found in the cecum (adeno
carcinoma by microscopic examination) and excised. Discharged well
June 23d.

A year later (June 5, kjoO) he returned. The operation had L r iwn
relief for months, and hi' had gained 20 pounds, but of late pain and
bloody stools have returned, this time in the left lower quadrant, where

148 DIFFERENTIAL DIAGNOSIS

there is a mass i by 2] inches, and tenderness. Operation showed
inoperable cancer of the sigmoid. Cecal region normal. Inguinal
colostomy. Discharged July 7, 1906, to out-patient department.
Diagnosis. Recurrent intestinal cancer.

Case 62

A boy of eleven was seen September 28, 1903. Since his third year,
when he had malaria, he has had fleeting pains in his arms and legs,
especially at night. The feet often show toe-drop.

For three months he has been troubled with attacks of bellyache,
accompanied often by chill and vomiting and by an increase in the
troubles in his arms and legs.

Twice he has had tonic-clonic convulsions.

Discussion. When a child has a stomachache in summer, it would
be folly to conclude that malaria is the cause; but it is equal folly not to
suspect that malaria may be the cause. For some unknown reason the
malarial attacks of children and of young adults are much more likely
to be atypical than those of older persons.

(a) Malaria often exists in children without producing any symptoms
at all, and is demonstrated only by blood examination.

(b) In many cases it produces only a recurrent headache and list-
lessness, due, in fact, to a rise in temperature every twenty-four or forty-
eight hours, without any chill ("dumb ague").

(c) Vomiting recurring at regular intervals, daily or every other day,
has been the only suggestion of malaria in some of my cases until the
blood was examined.

(d) An intractable diarrhea is sometimes associated with a malarial
infection of the blood, and promptly cured by the administration of
quinin.

(e) Abdominal pain of the type exemplified in this case is perhaps
the most common of the atypical manifestations of malaria. In some
cases it is localized in the right iliac fossa. In one week's service at the
Massachusetts General Hospital three patients were sent in to be operated
upon for supposed appendicitis. All of them had malaria, and were
promptly cured by quinin. These have been referred to by Dr. James
M. Jackson, in his article published in the Boston Medical and Surgical
Journal, June 26, 1902. I have already referred, in the discussion of a
previous case (see p. 121), to a case of malaria beginning like pneu-
monia with violent thoracic pain.

(/) In adults we not infrequently see cases of malaria with predom-
inating cerebral symptoms, such as acute mania or coma.

GENERAL ABDOMINAL PAIN

149

Now if malaria can assume such a bewildering variety of clinical
aspects, what is to guide us toward correct diagnosis. I should answer
that in practically all these atypical forms a thorough blood examination
should be suggested by the presence of an irregular fever and the low
leukocyte count. Enlargement of the spleen and the firm, painless edge
which the organ presents to the palpating finger are generally to be recog-
nized in these cases, and should also put us upon our guard against
malaria. The therapeutic test is valuable, but should not be abused by
continuing to pour quinin into the patient at the rate of 20 to 40 grains
a day for a week or more. This is not a therapeutic test: it is a stupid
blunder. Two or three days is enough to settle the matter in 999 cases
out of 1000, and in the remaining case no further information is obtained
by prolonging the administration of quinin.

Outcome. The blood was found to be swarming with tertian para-
sites. Wrist-drop and toe-drop. Knee-jerks absent.

Diagnosis. Tertian malaria.

*:,.-

Case 63

A woman of fifty, a lawyer's clerk, entered the hospital January 2,
1906, stating that she had had many attacks similar to the present one,
but had always been able to work. Two days ago she
felt some abdominal discomfort in the afternoon. Early
yesterday morning she awoke with a sharp, steady pain,
especially in the right side of the abdomen, but not
definitely localized. This was accompanied by disten-
tion and obstinate constipation. Last night the pain
was felt in the left side. She has vomited several times,
and has slept poorly on account of pain. (For tem-
perature, see chart.)

The abdomen is distended, tympanitic, and generally
tender; white cells, 4600; urine, 1029; a very slight
trace of albumin; many fine, granular casts. Physical
examination was otherwise negative. A glycerin enema
and hot-water bottle to the abdomen gave her some relief,
but on the morning of the fourth, the temperature
continuing to rise, though the white cells were still only
4000, she was operated upon.

Discussion. -A definite diagnosis was impossible
here, but the general appearance of the patient made it
clear that she was very ill, while the course of the symptoms went on
progressively from bad to worse. It was for these reasons that the

'hart

DIFFERENTIAL DIAGNOSIS

abdomen was opened, although without any clear notion of what would
be found.

Outcome. Chronic ulcerative enteritis and colitis, with numerous
strictures and diverticula, were found. One of these diverticula, which
contained an orange-seed, had perforated and gave rise to general
peritonitis, from which she died. At autopsy the enteritis seemed to be
due to tuberculosis or syphilis.

This case is introduced chiefly to show how short and how slight may
be the symptoms associated with a fatal general peritonitis. The pain
was never sharp during the time when she was under observation, and
there was no muscular spasm. The subnormal leukocyte count was
doubtless due to the virulence of the process, but previous to the opera-
tion it was impossible to be sure of this.

It is probable that this patient had previously had many slow and
partial perforations of the gut, which were protected by adhesions so that
no general peritonitis resulted. In a normal intestine an orange-seed
does no harm; only in the presence of severe ulceration and thinning of
the intestinal wall, such as was present here, could such a foreign body
be dangerous.

Diagnosis. Perforative colitis and general peritonitis.

Case 64

A woman of fifty-four has had for a year cramps after meals in various
parts of the abdomen. The pain has not been severe, but has led her
to cut out from her diet one food after another in search of relief, until
now she eats very little, and has lost 45 pounds during the year.

Eight months ago the bowels began to move more and more often,
and now act eight to ten times a day, with blood and pain on defecation.

On examination the internal viscera, the urine, the temperature,
pulse, and respiration are normal. Digital examination of the rectum
shows a relaxed external sphincter, with ballooning above it. The red
cells are 1,792,000; hemoglobin, 25 per cent.; leukocytes, 12,400, 86
per cent, of which are polynuclear.

Discussion. Chronic colitis is so common in elderly persons that
it is naturally our first thought in this case. It is especially frequent
when there is a slight degree of interstitial change in the kidneys, as
evidenced by high blood-pressure, with or without characteristic urinary
changes. This possibility certainly cannot be excluded by any of the
facts so far given.

Pernicious anemia produces a reduction in red corpuscles such as is
here present, and is often associated with a chronic diarrhea, but in

GENERAL ABDOMINAL PAIN 151

the finer points revealed by blood examination the picture is one of
secondary anemia.

Any case presenting these symptoms demands a very careful examina-
tion of the rectum and lower sigmoid by means of a speculum, since
cancer of this part of the gut is a frequent cause of all the symptoms
here presented.

Outcome. Through a rectal speculum with an adequate light a
large cauliflower mass could be seen nearly occluding the upper part of
the rectum. From it there was a foul serosanguineous discharge. An
excised bit proved to be cancer.

Diagnosis. Cancer of the rectum.

Case 65

An active, muscular young man of twenty-six, a machinist by trade,
had always been perfectly well until three years ago, when he had an
attack of acute appendicitis for which an operation was performed.
A five-inch incision was necessary; the wound was drained for a long
time, and later a large ventral hernia developed. Thereafter he seemed
perfectly well until five days ago, when he had an attack of acute general-
ized abdominal pain lasting for about eighteen hours, and accompanied
by constipation. He was then perfectly well for the two succeeding
days, when a second attack of pain came on, accompanied by nausea
and vomiting. This had persisted nearly twenty-four hours when he
was seen in consultation.

When examined, the head, chest, and extremities showed nothing
remarkable. The abdomen was slightly tender throughout, and there
was a moderate amount of spasm not localized. Attacks of colicky
pain, now here, now there, but for the most part in the umbilical region,
recurred every few minutes. There was no bulging at the seat of the
scar, and no palpable mass anywhere. There was slight dulness in the
flanks, which shifted with change of position. The temperature was
normal; the pulse no and of low tension. The face was drawn and
showed evidences of severe pain; indeed, the patient looked exceedingly
ill. The blood and urine showed nothing abnormal. There was no
lead-line on the gums. An enema brought away a small movement,
normal in character.

Discussion. Intestinal obstruction and general peritonitis are the
most likelv hypotheses. There is nothing in his occupation nor in the
examination of the blood and the gums to make lead-poisoning at all
probable. Tf perforative peritonitis were present, there would be
apt to be more tenderness and some fever. Vet I have several times seen

152 DIFFERENTIAL DIAGNOSIS

acute virulent peritonitis demonstrated without any fever or tenderness.
We have no evidence pointing to any source for peritonitis, and nothing
to connect the symptoms with the stomach or the gall-bladder, while
the appendix has already been excluded surgically. What can we argue
from the presence of shifting dulness in the flanks? In the absence of
diarrhea there is every reason to believe that this sign indicates fluid free
in the peritoneal cavity, but this is fully as common in cases of intestinal
obstruction as in general perforative peritonitis.

Many of the symptoms here present could be explained by simple
constipation. Indeed, on paper this seems quite a reasonable diagnosis.
In the living patient, however, this could be quite readily excluded by
the obvious severity of the patient's sufferings and of the prostration
accompanying them. By the same tokens it was easily possible to rule
out those multiform neuroses which are, on the whole, the commonest
cause of general abdominal pain.

By exclusion, intestinal obstruction seems the most probable diag-
nosis.

Outcome. The abdomen was opened at once, and the mesentery
of the lower ilium was found to be tightly twisted on itself, the twist
leading to a group of intestinal coils which were distended and dark
purple in color. There were many adhesions near the site of the appen-
dix, but apparently these were not responsible in any direct way for the
strangulation. There was about a quart of bloody serum free in the
abdomen.

The intestines were untwisted and returned to their proper position,
the wound sewed up, and the patient made an uneventful recovery,

This case illustrates the truth of the rule that in young people most
cases of intestinal obstruction are connected in some way with the
results of a previous peritonitis or operation, while in old people the great
majority of cases are due to cancer. For some unknown reason twists
occur much more frequently in those whose peritoneums have been
damaged by a previous operation or inflammation, even when no con-
stricting band of adhesions can be found.

Diagnosis. Obstruction of the intestine; volvulus.

GENERAL ABDOMINAL PAIN

153

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CHAPTER V

EPIGASTRIC PAIN
Case 66

An Italian laborer of forty entered the hospital November 22, 1906.
For sixteen days he had been having pain at the "pit of the stomach."
The pain came on rather suddenly, and had since been dull and steady,
at times interfering with sleep. He has not been able to work since the
onset of the pain. It has no relation to food or posture. There are no
gastric or urinary symptoms, no jaundice, no constipation, and no loss
of weight. The patient denies venereal disease, and has never, to his
knowledge, been sick before.

Physical examination, except in so far as relates to the abdomen,
was negative. There a hard, apparently nodular mass was felt just
below the ensiform cartilage and a little to the left of the median line.
It was not tender, and descended readily with inspiration. The liver
dulness extended as high as the fourth interspace, but the edge was not
felt. The blood and urine showed nothing abnormal. The capacity
of the stomach was enlarged to 72 ounces, and the lower border reached
4} inches below the navel; the upper border, 1 inch above it. Free HC1
was absent. The total acidity was 0.12 per cent. There were no
organic acids, no blood, no fasting contents. There was no reaction to
guaiac in the stools. The patient's temperature ranged, for the most
part, about 99 F., often reaching ioo F. and occasionally 101 F. His
pulse and respiration were within normal limits. At times there was
considerable tenderness over the epigastric mass.

Discussion. Tuberculous peritonitis is remarkably common in the
newly arrived Italian immigrant. The presence of fever and of ab-
dominal pain without fulminating or alarming symptoms is quite sug-
gestive of tuberculous peritonitis, but we have no evidence either of free
fluid in the abdomen or of the tenderness, spasticity, and localized
masses which are necessary for the diagnosis of this disease when fluid
is absent.

Some of the gastric signs in this case are quite consistent with gastric
cancer, but against this are the sudden onset, the absence of emaciation,
stasis, or blood.

1.-.4

Causes of Epigastric Pa

CONSTIPATION

DIARRHEA AND ENTERITIS

ACUTE INDIGESTION

APPENDICITIS

NEUROSES

LEAD- POISONING

INTESTINAL OBSTRUCTION

TABES

TABES PERITONITIS AND TABES MESENTERICA J

NO ACCURATE STATISTICS
AVAILABLE.
- ONLY THE FIRST THREE ARE
COMMON AS CAUSES OF EPI-
GASTRIC PAIN.

1. GASTROHEPATIC

CONGESTION
DUE TO C I R- (
RHOSIS OR CAR
DIAC DISEASE

2. APPENDICITIS

3. PEPTIC ULCER

4. GALL-STONES

5. HYPERCHLOR- |

HYDRIA 1 I

6. GASTRIC CANCER

7. PERICARDITIS I

8. GASTRIC NEUROSIS

9. PANCREATITIS I

10. PYLORIC I

ADHESIONS

1 1. ANGINA ABDOMI- )
NALIS I

1 Many of these cases may actually be case- of peptic ulcer. < >ni\
autopsy can decide.

898

350
347
329

326

133
88
72

EPIGASTRIC PAIN

157

The induration about a partially perforated gastric ulcer sometimes
produces a mass in the left hypochondrium similar to that here described.
But as the symptoms seem to have no relation to food, and as there is
no tenderness or spasm about the indurated point, there seems to be
no good reason to consider this possibility seriously.

The tumor is on the wrong side for gall-bladder disease, and the
absence of colic and jaundice makes it unnecessary to look further in this
direction.

Malignant disease of the liver might cause such a fever as is here
described, and occasionally arises without any previous or coincident
growth in the stomach. This possibility cannot be excluded, especially
as the liver seems to be enlarged upward; but the left hypochondrium
is a very unusual place for a hepatic neoplasm.

On the other hand, the position of the mass here described corre-
sponds with the point at which hepatic syphilis most often shows itself.
This diagnosis would explain the fever, and is more consistent with the
history and with the good nutrition of the patient. In the absence of
any further evidence, however, one could not do more than suspect
syphilis. Treatment by mercury and potassium iodid and the use of the
Wassermann test are indicated as a means to a more certain diagnosis.

Outcome. On December 6th the abdomen was opened, and the
liver was found to be adherent to the abdominal wall by fine, soft ad-
hesions. The mass felt through the abdominal wall was found to consist
of an irregular, boggy, yellowish-white elevation, from which a con-
siderable amount of pus-like material was removed by cautery.

Microscopic examination showed it to be a gumma. The patient
left the hospital on December 29th feeling perfectly well.

Diagnosis. Hepatic gumma; syphilis.

Case 67

A Lithuanian of twenty-nine, working in a rubber factory, and
never consciously sick in his life before, entered the hospital April 10,
1907. Sometimes he takes as much as eight beers and four whiskies
daily. At other times he goes without alcohol for at least a week.
For two weeks he had been having severe epigastric pain, with loss of
appetite and obstinate constipation.

The patient was very nervous, trembling, and pale. The red cells
were 2,750,000; hemoglobin, 65 per cent.; white cells. 7200. The
stained smear showed 78 per cent, of polvnuclear cells and very
marked stippling of the reds. The abdomen was flat, moderately stiff,
and slightly tender. The reflexes were very lively, and there was hyper-

158 DIFFERENTIAL DIAGNOSIS

esthesia of the feet. The aortic second sound was accentuated. The
urine showed a very slight trace of albumin; otherwise it was negative,
as was the rest of the physical examination.

Three days after entrance the patient became maniacal in the night
and had to be restrained. This continued for six days, after which he
became sane. His temperature was frequently above 99 F., and once
reached 101.4 F. This was at the height of his maniacal attack.

Discussion. The history, the maniacal attack, and the gastric
symptoms point toward alcoholism. The anemia, however, is not
thus to be explained.

Tuberculous peritonitis and meningitis are suggested by the com-
bination of a spastic, tender abdominal wall, and the maniacal attack
accompanied by fever. This form of tuberculosis, however, rarely
produces anemia, and mania is very unlikely in it, unless other cerebral
symptoms (lethargy, coma, squints, headache, or vomiting) are also
present.

Work in a rubber factory often produces a stubborn type of general
debility, but it does not lead, so far as I know, to fever, to mania, or to
anything like this grave anemia.

Nephritis must be considered. It would explain the albuminuria,
the accentuated aortic second sound, and the mania; but a nephritis
which had lasted long enough to produce such an anemia would almost
certainly produce a demonstrable enlargement of the heart and some
other uremic manifestations, such as headache, vomiting, or hemor-
rhages.

Lead-poisoning should always be considered in a case presenting
the combination of anemia and cerebral symptoms, especially if the red
cells contain a basophilic granulation, as in this case. Looked at from
this point of view, all the symptoms seem to fall very naturally into line
lead colic, lead anemia, lead nephritis, lead encephalopathy.

Outcome. The treatment consisted at the beginning of glycerin
enemata and magnesium sulphate, with morphin for the pain. lodid
of potash, 10 grains, was given three times a day, while hot applica-
tions and turpentine stupes were also used for the pain. Chloroform
anesthesia was once needed during his attack of mania. Fifteen grains
of trional were given several times for sleep.

April 19th the red cells were 3.600.000, and no stippling was found.

By the twenty-third of April he had nearly recovered and was ready
to go home. It was subsequently found that he drank water which came
through a lead pipe, and that he seldom let the water run before drinking
in the morning.

EPIGASTRIC PAIN

159

In connection with this case I will mention briefly a patient to whom
I was called because of anemia and convulsive attacks. She was a young
married woman with a baby three months old. She lived in a rural
district, and did no work outside her own house. Epilepsy and uremia
were the diagnoses previously considered, but examination showed
that she and every other member of the household except the baby had
a well-marked lead-line on the gum and all the other evidences of lead-
poisoning. After giving up a water-supply heavily impregnated with
lead, this patient rapidly recovered.

Diagnosis. Plumbism.

Case 68

A blacksmith of twenty-three entered the hospital November 24,
1906, with a negative family history and past history and good habits.
He had been complaining for three weeks of epigastric pain, usually
coming on about eleven o'clock in the morning, seeming to bear no rela-
tion to food described as "pulling" in character, and relieved by lying
down. There had been slight 'tenderness in the epigastrium, especially
under the right ribs. The bowels had been very constipated, moving
only once in three days. Three days ago he began to vomit, and had
done so once or twice a day since. The vomitus contained no blood
or food, but was yellow in color. His pain was never present when he
waked in the morning; it was sometimes brought on by drinking water.
He appeared to be 15 pounds lighter than in the previous June.

Physical examination was entirely negative, except that lumps were
felt in the sigmoid region.

Discussion. ]t does not seem likely that a blacksmith of twenty-
three is suffering from a pure neurosis, and he is at an age when cancer of
the stomach is very rare. The pain comes at a time when the stomach
is likely to be empty, and, therefore, suggests hyperchlorhydria or duo-
denal ulcer. The fact that his vomitus contains no food goes to strengthen
this hypothesis, and the negative physical examination is entirely con-
sistent with it.

Is it possible that the lumps felt in the sigmoid region may be due to
a fecal accumulation behind a stricture, cancerous or of other origin.-"
f have known cancer of the intestine in a boy of twenty-one, so that the
youth of this patient does not exclude that possibility, and the vomiting
and constipation are quite consistent with it. In the absence of more
definite symptoms, however (such as visible peristalsis, blood in the
stools, and abdominal distention), there seems to be nothing further to
verify this idea.

J60 DIFFERENTIAL DIAGNOSIS

May not the symptoms be due to simple constipation, so called?
Why then should he have symptoms just now and not previously?

On the whole, the youth of the patient and the short duration of the
symptoms make cancer and constipation less likely than the other al-
ternative above mentioned, but no certainty can be attained on the basis
of the facts here presented. Only by the therapeutic test the results of
treating the patient for duodenal ulcer (a treatment identical, in its
early stages, with that of hyperchlorhydria) can greater certainty be
obtained.

Outcome. After castor oil by mouth and enemata of oil, large
movements followed. Guaiac test negative. Olive oil by mouth also
relieved him very much, likewise a gastric ulcer diet. In five days he
seemed to be entirely well.

Diagnosis. Constipation.

Case 69

A chambermaid of twenty-two, with a negative previous history
and family history, entered the hospital March 2, 1907. In February,
1906, she had what was called "grip," followed by abdominal pain,
weakness, and the loss of 10 pounds in weight. The pain was sudden
and nagging, coming sometimes immediately after meals, sometimes
later, never lasting long, and never severe. She has had recurrences
of this pain at intervals ever since. Four weeks ago the pain became
more troublesome, and was accompanied by belching and constipation.
It did not always remain in the epigastrium, but might shift to the lower
abdomen, to the left chest, and to the back. It seemed to be produced
especially by toast, potatoes, and meat; it was sometimes relieved by
drinking hot water, but not by cooking-soda. It had kept her awake
during the past two nights. She also complained of "palpitation in her
stomach." She had very rarely vomited. At the present time her
bowels are regular, and she feels fairly well except for weakness.

On physical examination it was noted that her cheeks were red, but
her lips pale. The chest, abdomen, and urine showed nothing remark-
able. Blood examination showed: Red cells, 4,976,000; white cells,
5600; hemoglobin, 60 per cent. The stained specimen was normal
except for moderate achromia. The patient was treated by a careful
diet.

Discussion. Lead-poisoning is always one of the possibilities
when a patient demonstrably anemic complains of abdominal pain.
Lead may be excluded, however, in my opinion, by the absence of baso-
philic stippling in the red cells. I have never known a clear case of

EPIGASTRIC PAIN x 6i

plumbism without stippling. There was nothing else, moreover, to
favor the suspicion of lead-poisoning in this patient.

If the patient were somewhat older, the history would be quite con-
sistent with gastric cancer, which would also explain the anemia; but as
these symptoms have lasted a year, we should almost certainly find more
evidence of cancer if that were the cause of the patient's sufferings.

Chlorosis is generally accompanied by constipation and hyper-
chlorhydria, which appear to be present in this case. The age and the
occupation favor this diagnosis, which may be provisionally accepted,
subject to confirmation by the results of treatment. The pain in this
case is very typical of that most often associated with constipation,
whether or not the latter is its cause.

Outcome. The bowels were regulated by cascara and enemata.
She was given 10 grains of Blaud's pill after each meal. Recovery
was uneventful.

Diagnosis. Chlorosis.

Case 70

A married woman of thirty-five entered the hospital December 5,
1906. She has always been well, but subject to what she calls bilious
attacks. She was operated on four years ago for strangulated hernia.
Since then she has had a great deal of severe, cramp-like epigastric
pain, sometimes relieved by a movement of the bowels. On December
10, 1905, the catamenia failed to appear, and she had vomiting and
headache. In January, 1906, she was operated on for extra-uterine
pregnancy. In convalescence she was troubled by diarrhea and gaseous
distention of the bowels. Later on she was obstinately constipated.
She felt as if her intestines would fall out, but found relief by holding
them up with her hands. Two months ago she woke up with a violent
pain in her right hand. The next morning the hand was swollen up so
that she could not close it. This trouble soon passed away, but ever
since that time, she says, she never knew when a sharp, shooting pain
would strike her. The pains were felt in all parts of the body, and lasted
from a minute to four hours. She has had to take morphin for them at
times. She says that she had never been nervous or hysteric before.
She now enters the hospital expecting an operation for intestinal obstruc-
tion, having been sent in by one of the visiting surgeons with a diagnosis
of intestinal obstruction of mechanical origin.

Physical examination showed that the pupils were irregular and did
not react to light. Knee-jerks were present, but diminished. The
ankle-jerk was absent; otherwise examination of the reflexes was negative.

1 62 DIFFERENTIAL DIAGNOSIS

Sensation and coordination appeared to be perfect. In the right loin a
mass was felt descending below the ribs on deep inspiration, slightly
tender.

Physical examination, including the blood and urine, was otherwise
negative.

Discussion. Certainly a very complicated case. No doubt con-
stipation accounts for a part of the symptoms, but the pains are very
wide-spread and unusually intense for constipation. Moreover, there
are certain facts in the physical examination which cannot possibly be
thus explained.

Intestinal obstruction by bands or adhesions is always a menace in
those who have had a strangulated hernia and an operation for extra-
uterine pregnancy; but for the same reason as mentioned in the last para-
graph, intestinal obstruction cannot account for all the facts in this case.

Much in the patient's behavior and appearance, and something in
her symptoms, point toward a neurosis, but this would not account for
the absence of ankle-jerks and pupillary reactions.

The signs just mentioned practically assure us that this patient has
tabes dorsalis. The only important question remaining is whether the
tabes explains all the symptoms. Certainly the pains are very character-
istic of tabes, and the gastro-intestinal symptoms may well be inter-
preted as "crises." The mass in the loin is certainly not due to tabes,
but in all probability does not represent evidence of any disease what-
ever, but is merely a sagging kidney.

On the whole, it seems reasonable to believe that all the symptoms
are now due to tabes. At any rate, the patient should be treated on that
basis for the present. The chief lesson of the case is the necessity for
self-restraint on the part of earnest surgeons when the patient's pupils
and Achilles tendons fail to react.

Outcome. The patient remained only two days in the hospital,
whither she had come reluctantly and under the impression that a
second operation would be necessary. When it was decided that no
operation was advisable, she declared that she felt well and went home at
once.

Diagnosis. Tabes dorsalis.

Case 71

A married woman of forty-two, of negative family history and past
history, entered the hospital December i, 1906. On January 28, 1906,
she broke her leg and was confined to bed for eight weeks, during which
time she lost her appetite, had palpitation of the heart, a grinding pain

EPIGASTRIC PAIN

163

in the epigastrium, and a feeling as if there were strings inside her
hitched to the navel and to the backbone. She had occasional vomiting
of whitish material. She was given various medicaments without relief.
In July she began to walk on crutches, but her symptoms were unrelieved.
Her appetite was poor, and she lost 30 pounds in weight between Janu-
ary and December.

Her physical examination was entirely negative, except for a leuko-
cytosis of 20,000. The gastric capacity was 27 ounces; the stomach
considerably prolapsed. There were no fasting contents, and after a
test-meal free hydrochloric acid was found to the amount of 0.23 per
cent. There was no blood. Three days later the white cells had fallen
to 10,000, and ranged between that and 16,000 during the three weeks of
her stay in the hospital. At no time was there anything abnormal about
her temperature, pulse, or respiration.

Discussion. It is natural to fear cancer in this case, for gastric
symptoms of recent origin always threaten cancer when the patient is
over forty. The presence of abundant free hydrochloric acid in the
stomach-contents by no means excludes cancer. The most hopeful
feature in this regard is the absence of tumor or stasis, one of which
would, in all probability, be manifest after a year of suffering.

To those who are always on the look-out for psychic causes in gastro-
intestinal disease, the fact that this patient had no stomach trouble until
she broke her leg and was confined to bed, offers an important clue. It
should lead us to investigate very carefully the patient's mental condition.

Outcome. It turned out on careful questioning that she feared she
was suffering from cancer. She was greatly encouraged by the negative
results of the gastric tests, and in eighteen days gained 7] pounds, mostly
as a result of forced feeding, with laxatives and myrrh pill, one or two at
night, aromatic chalk mixture, sodium bicarbonate when in distress,
and a quassia cup before meals. She was also relieved by 10 grains
of sodium bromid after meals, and on two or three occasions had trional
at night. The main point, however, in her recovery, was forced feeding.

The leukocytosis is not explained, but must be listed as one of those
wild and untamed facts which I have grown to expect as a normal
element in every well-studied case.

Diagnosis. Gastric neurosis.

Case 72

A factory hand of thirty-eight entered the hospital December jo,
1007. Seven years ago lie began to suffer from tape-worm, of which
large segments were passed until three years ago, when the whole worm

164

DIFFERENTIAL DIAGNOSIS

was removed. During this time he had attacks of epigastric pain and
vomiting, often associated with jaundice. His family history and habits
are good. Eight days ago he was again seized with pain in the epi-
gastrium, relieved by vomiting. An hour later the pain returned and he
vomited again. This happened five times that day. The next day he
kept quiet and had no pain or vomiting. On the third day he went to
work, and the pain and vomiting recurred. On the fourth day he was
quiet and felt well. On the fifth day he again worked, and again had
pain and vomiting. For the past three days he has not worked and has
felt well. This association of pain with work has been present in all his
past attacks. He has never had pain at night, on Sundays, or on holi-
days; and during the time that he has had these attacks he has changed
his work three times. His pain bears no special relation to the time or
kind of food. The vomitus consists of small amounts of greenish mater-
ial and saliva. He has never seen food or blood either in the vomitus
or in his stools. During the attacks his appetite is poor and his bowels
constipated. He states that he has been considerably jaundiced during
this last attack. He has lost five pounds in the course of the last year.

On physical examination no jaundice is found. Many teeth are
missing; the rest are in fair condition. There is a systolic murmur
at the apex, not transmitted. The heart-apex is in the fifth interspace,
inside the nipple-line. The aortic second sound is louder than the
pulmonic second sound. The tension of the pulse is apparently high,
the lungs normal. The abdomen is level, slightly rigid, tympanitic
throughout, and very slightly tender on pressure in the epigastrium.
There are slight dulness and resistance in the region of the gall-bladder,
but no jaundice. The liver is not felt. Physical examination, includ-
ing the blood and urine, is otherwise normal.

Discussion. The tape- worm is obviously "a blind." It is very
unlikely that the epigastric pain and vomiting from which the patient
suffered from 1900 to 1904 had any real connection with the tape- worm.
It is perhaps worth mentioning here that practically all the symptoms
traditionally associated with tape- worm arc mythical. In the vast
majority of cases tape-worm produces no symptoms whatever.

Since the death and burial of "gastralgia," that ancient foe of clear
diagnosis and helpful treatment, such pain as this patient suffered has
been shown to be generally due to one of two causes duodenal ulcer or
gall-stones. Since the attacks have apparently been associated with
jaundice, our first thought is gall-stones, but on a closer study of the
case we find that he lias now no jaundice, although he now considers
himself as yellow as in the previous attacks. This makes us doubt

EPIGASTRIC PAIN

l6 5

whether he really was ever jaundiced. I have many times found reason
to discount patient's own statements in this matter. Patients and their
friends often use the word "jaundice" to denote nothing more definite
than a sallow complexion. To the consideration of duodenal ulcer I
shall return later.

Aneurysm or angina abdominalis is suggested by the fact that the
pain is increased by exertion and the pulse tension high. On the other
hand, a pain which produces and is relieved by vomiting is rarely due to
either of the causes just mentioned. The physical examination shows
no evidence of aneurysm.

Is it likely that the lack of a good set of teeth explains some or all of
this patient's symptoms? It does not seem to me so. Despite the many
positive statements regarding the close association of digestive troubles
and poor or deficient teeth, I have never seen any clinical evidence
which would enable us to say more than "perhaps," so extraordinarily
common is it to examine people who have lived their lives quite free from
digestive troubles, though only one or two blackened fangs remain in each
jaw. I by no means deny the possibility that malnutrition or poor diges-
tion may in certain cases be due to defective teeth, but I think we need
a great deal more definite study and evidence before we shall have
justification for the positive statements and the expensive municipal
crusades that are now so rife.

A definite diagnosis in this case would be easier if we knew (a)
Whether there is blood in the stools and (b) whether hyperchlorhydria
is present. Even in the absence, however, of these data I think the
diagnosis of duodenal ulcer is justifiable. Between this disease and the
hyperchlorhydria which leads to it diagnosis is not always possible, as
will be exemplified in a subsequent case. Hie absence of any tem-
peramental or occupational cause for the worry and irritability so often
associated with hyperchlorhydria makes me incline, on the whole,
toward ulcer.

Outcome. On January t, 1908, the abdomen was opened. The
gall-bladder and ducts were found to be normal, but a small duodenal
ulcer was present. No aneurysm. The patient made a good recovery.

Diagnosis. Duodenal ulcer.

Case 73

A married woman of forty-seven, with negative family history and

good habits, entered the hospital December 2T. 1007. She stated that

for eighteen years she lias had abdominal cramps every three or four

months, but that for the last two weeks these have come much more

!66 DIFFERENTIAL DIAGNOSIS

often seven times in two weeks. The pain starts in the epigastrium
very suddenly and without known cause, without relation to food,
to menstruation, or to the time of day. It radiates to the right flank,
lasts about three hours, and often wakes her from sleep. It is usually
accompanied by vomiting of food or brownish liquid. There is no his-
tory of jaundice, and between attacks she feels perfectly well, although
the pain is so severe as to require morphin. Her bowels are regular,
her urination normal, although for the last three days she has passed less
urine than usual. She thinks she has lost a great deal of weight.

Physical examination is negative, except for considerable epigastric
tenderness. The white cells number 15,800; the stained smear negative.
The urine contains a slight trace of albumin; gravity, 1030; a few hyaline
and granular casts.

Discussion. Such symptoms might be due to constipation, but her
negative statement upon this point was confirmed by our observation in
the hospital. The history is also suggestive of lead-poisoning, except
for its extreme duration, but the condition of the blood and of the gums
enables us to rule this out.

The negative physical examination, which included tests of the
pupillary and other important reflexes, makes tabes with gastric crisis
out of the question. The regularity of the bowels and the long dura-
tion of symptoms render chronic intestinal obstruction (cancer) very
unlikely.

Gastric cancer is always to be feared at the age of forty-seven when
the patient has vomited a brownish liquid at frequent intervals, has had a
great deal of epigastric pain, and is believed to have lost a great deal of
weight. By the use of the stomach-tube we were able to establish the
fact that there were no gastric stasis and no blood in the stomach-con-
tents or in the vomitus. The size of the stomach was normal, and no
tumor palpable.

Duodenal ulcer often gives a history of very prolonged suffering,
similar to that in this case, and there is nothing in the history to exclude
it. Even the fact that blood was absent from the vomitus, the artificially
abstracted gastric contents, and the feces by no means excludes ulcer.
The radiation of the pain, however, its sudden onset and its sudden
relief by morphin, are less characteristic of duodenal ulcer than of the
disease next to be considered. We note also the absence of any relation
between the pain and the digestive activities.

Gall-stones might explain all the symptoms in the case, although the
diagnosis is not forced upon our notice, as it would be were jaundice
present. We are no longer surprised, however, to find gall-stones in the

EPIGASTRIC PAIN

167

absence of jaundice, and, on the whole, no other diagnosis seems as
likely. The negative physical examination does not militate at all
against this idea, nor does the condition of the urine incline us to change
our minds, though it is not at all obvious why the albumin and casts are
present.

Outcome. On December 26, 1907, the abdomen was opened and
15 large stones were found in the gall-bladder. The patient made a
good recovery.

Diagnosis. Gall-stones.

Case 74

A tailor of forty-nine with a good family history and good habits
entered the hospital on June 15, 1907. For the last eighteen years he
has had occasional spells of dull epigastric pain coming on in the after-
noon for a month or so. These attacks had never troubled him much,
and were often absent for a month at a time; but for the last ten years
they have become more frequent, and the pain has appeared in the
morning, as well as in the afternoon, accompanied by a feeling of weight
in the abdomen, but rarely by vomiting. About a year ago the pain
began to come regularly between 10 and 12 in the morning, and between
4 and 6 in the afternoon, except during the periods when he was under
treatment. The pain is now sharp, and radiates sometimes from the
epigastrium to the back, rarely to the left hypochondrium. It is partly
relieved by eating, and wholly by cooking-soda, but never by pressure.
He frequently belches gas.

Two months ago, after a day during which he had been constantly
regurgitating sour fluid, he vomited at one time almost three quarts of
sour, foaming yellow fluid, with great relief. Two weeks ago he vomited
a similar quantity, and at the end of it was a little chocolate-colored
stuff. He thinks he has lost 20 pounds in the last six months, yet he
worked until May 29th and until very recently felt as strong as ever,
and has eaten and slept well.

Physical examination was negative, except that the stomach capacity
was 74 ounces, the organ extending three inches below the navel and
showing visible peristalsis.

Discussion. Here is a history nearly typical of duodenal ulcer.
I have given it here to prove that in some such cases no ulcer is demon-
strable at operation. One of the wisest clinicians of my acquaintance
recently said in a personal letter: "In my experience ' hypcrchlorhydria '
generally spells duodenal ulcer." T agree with this statement if it is
taken literallv that is, if we distinguish "generallv" from "always."

1 68 DIFFERENTIAL DIAGNOSIS

My object at the present time is to exemplify one of the weak points in
clinical diagnosis our inability, namely, clearly to distinguish the two
diseases above referred to. Had we known at the outset that this patient
was an alcoholic, the balance might have inclined a little more toward
hyperchlorhydria, as this trouble is not infrequently associated with
alcoholism. But still we should have been wandering in the region of
probabilities.

Outcome. Operation on the ninth of July showed no dilatation,
ulceration, or scar formation anywhere in the stomach or duodenum.
The pyloric ring was of good size. The patient made a good recovery,
and on July 28, 1908, reports that he had had similar attacks of pain,
but less severe. He now admits that at times he drinks liquor freely,
but thinks that these sprees have no relation to his gastric attacks.

Diagnosis. Hyperchlorhydria (alcoholism?) .

Case 75

A farmer of forty-six, with a negative family history and good habits,
entered the hospital February 19, 1907. For the past two years he has
had many severe attacks of epigastric pain, coming without apparent
cause, and relieved about once a month by vomiting. For the past two
weeks the pain has increased in severity. He localizes it accurately
just below the ensiform cartilage, and describes it as sharp, increased
by coughing, by exertion, or by a meal containing pork, eggs, or veal.
It is usually worse at night, especially just after he goes to bed. It is
somewhat relieved by hot- water bottles, but it generally keeps him awake
most of the night.

Physical examination shows the heart's impulse two inches outside
the nipple-line in the fifth space. There is a presystolic thrill and
murmur at the apex, ending in a sharp first sound. A short systolic
murmur is also heard at the apex. Both murmurs are transmitted to
the axilla. The pulmonic second sound is very difficult to hear. At
the base of the heart a soft systolic thrill can be felt in the aortic area,
and a high-pitched diastolic murmur heard under the sternum at the
level of the third rib and above this point, together with a soft systolic
murmur, which is audible throughout the precordia. No second sound
can be heard in the aortic region. The pulse is of the plateau type;
the arteries are tortuous and thickened. There is a lateral excursion
of the brachials. Blood-pressure, 195. The edge of the liver is felt on
inspiration, and there is moderate tenderness, sharply localized below
the ensiform cartilage, and accompanied by muscular spasm.

Discussion. In this case, as in most of those preceding and follow-

EPIGASTRIC PAIN

169

ing it, the pain is worse at night. This symptom has often been referred
to as characteristic of gall-stone pain or duodenal ulcer, and there are
other features in the case consistent with one of those two diagnoses,
but it is of crucial importance in the study of this case to note that the
pain is increased by exertion and by coughing. This is not usually
the case with duodenal ulcer or gall-stones, although inflammatory
adhesions may be so situated that muscular action stretches them pain-
fully.

The presence of the well-marked heart lesions (aortic stenosis and
regurgitation), and especially of the high blood-pressure, makes us
suspect any pain of being connected with the circulatory system. The
relation to exertion is very characteristic of angina pectoris. Does pain
of this type ever occur as low as the epigastrium? It certainlv does,
although the term "angina abdominalis" is perhaps more appropriate.
I have seen a great many cases of this type treated quite unsuccessfully
by stomach specialists without regard to the circulatory condition.
To get further clearness on the diagnosis, one would need to observe
carefully the effect of rest and of nitroglycerin. Certainly no type of
stomach or gall-bladder trouble is relieved by nitroglycerin.

Outcome. A few days' observation in the hospital ward demon-
strated the truth of our suspicions: rest rendered the attacks less fre-
quent, and those which occurred were promptly relieved by nitroglycerin.

Diagnosis. Angina pectoris (low).

Case 76

A salesman of forty-nine came to the hospital on December 10, 1907,
complaining of pain, constipation, and vomiting. He is in the habit of
taking several drinks of whisky a day, but has never been sick until the
present illness, and his family history is good. For five weeks he has
suffered from abdominal pain. The pain began at a time when he was
"not feeling well," and had stopped work for a few days. It is in the
epigastrium, worse at night, relieved by eating, and accompanied by
much wind and belching. It usually begins about 4 P. m., and reaches
its maximum severity between 11 p. m. and 4 a. m., after which it sub-
sides. Of late it has come every night. He often vomits with the pain,
and last night did so three times. He has small movements of the
bowels every second or third day. Two months ago he weighed 160
pounds. Now lie weighs 136 pounds.

Physical examination, including the urine, is negative. Xo lead-
line is to be seen. The leukocytes number 10,400; hemoglobin, go
per cent. In the differential count the polynuclear cells are So per cent.;

170 DIFFERENTIAL DIAGNOSIS

lymphocytes, 18 per cent. ; eosinophiles, 2 per cent. There is very marked
stippling and abnormal staining of many red cells.

Three days later the urine was found to contain a trace of albumin,
with numerous hyaline, finely and coarsely granular casts, many with
cells adherent.

Discussion. Our first impression is naturally that "rum done it,"
but on second thought there seems no special reason why he should
suddenly begin to suffer at this time as the result of so long continued
a habit.

The fact that his bowels are so constipated raises the question
whether this trouble may not account for all his symptoms, whether it
be of the ordinary functional type or dependent upon a stricture (malig-
nant?). But, as before, the question arises, why should he suddenly
begin to suffer from constipation at the age of forty-nine? The func-
tional types of the affection usually make their appearance long before
that age. Only some special aberration in diet or some great nervous
strain would account for the sudden appearance of functional constipa-
tion in a man of this age.

It is possible, of course, as I have previously stated, that cancer of
the bowel may exist for months or even years without manifesting its
presence by any symptoms, but when we look over the history and ex-
amine the patient with this possibility in mind, there seems to be nothing
to support it, although the loss of weight is suggestive.

A pain relieved by eating often occurs in connection with hyperchlor-
hydria or peptic ulcer, and there is nothing in the case absolutely to
exclude these affections, which, like cholelithiasis, must always remain
in the background of our minds when paroxysmal epigastric pain is the
presenting symptom.

Before making any further investigation or following up any other
clue, we should test the possibilities suggested by the presence of marked
stippling in the stained red corpuscles despite the absence of anemia.
Although no lead line is seen and nothing in the patient's occupation
suggests plumbism, this blood lesion is so characteristic that every
effort should be made to follow it as a clue.

Outcome. During the first three days the diagnosis was not made;
and later it was discovered that he has for three years used drinking-
water coming through 30 feet of lead pipe. His blood-pressure was found
to be 185 mm.

On December 17th his attacks of colic were less marked, but sudden
muscular weakness in both arms appeared for the first time. On Decem-
ber 24th he was free from colic and the urine had cleared up, but the arms

EPIGASTRIC PAIN 171

and back showed very marked muscular weakness. On this day
(the 24th) a well-marked lead line was found on the gums, visible only on
the inner side of the teeth of tlie lower jaw.
Diagnosis. Plumbism.

Case 77

A negro of sixty-four entered the hospital August 7, 1907. He
stated that his mother died at eighty-five "of worry." His family his-
tory is otherwise not remarkable. He now complains of severe epigastric
pain which had been present for three months. During the Civil War
he drank a quart of whisky daily. Fifteen years ago he had a venereal
sore which was treated at the Boston Dispensary with calomel locally
and iodid of potassium internally. He was treated for six months and
noticed no secondary symptoms. He says it was his habit to take three or
four glasses of whisky a day and three or four beers, but for the past
four months he has abstained. He smokes and chews five cents' worth
of tobacco a day.

At the onset of the pain, three months before, he fell in the street,
although he was not unconscious. Since that time the pain is apt to
radiate from the epigastrium across his chest or up his left side and
through his back. Occasionally it shoots from the lower part of his back
up to his left shoulder, or from his right hip down his leg, but it is worst in
the epigastrium.

Four weeks ago he was examined at the Boston Dispensary and
thinks that he was ruptured at that time. He has had no vomiting, head-
ache, or palpitation. In January, 1907, he weighed 180 pounds; in June,
145 pounds; now, 140. His digestion is good.

Physical examination shows a pallor of the mucous membranes. The
heart is negative except for accentuation of the aortic second sound.
The carotid arteries are prominent and easily palpable. The blood-
pressure is 130 mm. of mercury. The right lung shows a consider-
able number of coarse rales below the scapula, with modera e dulness
extending to the base of the lung. One and a half inches below the right
costal margin is a rounded nodule an inch and a half in diameter, con-
siderably elevated, apparently not connected with the skin. It is some-
what movable, not tender, and does not descend with respiration. There
is dulness in both flanks, shifting with change of position. The penis is
six inches in circumference, markedly edematous, as is the perineum.
The motions of the back arc limited and painful. A rectal examination
shows that the prostate is the size of a small grape-fruit, very firm, im-

172 DIFFERENTIAL DIAGNOSIS

movable in the pelvis, and encroaching markedly upon the rectum.
The right testis is enlarged and tender.

Red cells, 2,696,000; differential count normal; white cells, 14,200;
hemoglobin, 45 per cent.

Discussion. Abdominal aneurysm must certainly be considered as
a cause of pain like that described in this case, especially when there
is so well authenticated a history of syphilitic infection. The enlarged
testicle would then naturally be explained as syphilitic orchitis. The
sudden onset of the pain and its prostrating effects might be accounted
for by a partial rupture of the aneurysmal sac.

Against this diagnosis, however, is the evidence furnished by rectal
examination. I know of no syphilitic lesion which will produce such
changes in the prostate. Another fact of importance, which came to
light later, was the inefficiency of a prolonged course of antisyphilitic
treatment which he had recently undergone. Malignant disease is
certainly the commonest cause for an extensive, hard, immovable tumor
connected with the prostate gland. This would easily account for the
anemia and for the nodule in the abdominal wall, though both of these
might possibly be accounted for also by syphilis.

If malignant disease is the correct diagnosis, why was the patient so
suddenly stricken that he fell in the street three months before? I can
give no confident answer to this question. Possibly his habits have some-
thing to do with explaining it.

Outcome. The patient died on the tenth of August. Autopsy showed
sarcoma of the right testis, with metastasis in the prostate, adrenal glands,
small intestine, bronchial lymphatic glands, pleura, pericardium, and
abdominal wall.

Diagnosis. Sarcoma testis with metastases.

Case 78

A colored woman of twenty-four entered the hospital August r, 1907.
Seven months ago she began to complain of a severe steady pain about
the center of the abdomen, a little more on the left than on the right.
At this time a large, hard tumor was discovered near the navel. For
three months following this she had many attacks of pain in the same
region, and her temperature ranged from ioo to 105 F. The lump in
the mean time decreased in size. For the last four months she has had
occasional spells of pain lasting two or three days. She does not feel
feverish. For the past four months she has had severe epigastric pains,
coming on every fifteen minutes, lasting two or three minutes, and often
leading to vomiting, but for the past twenty-four hours she has been free

EPIGASTRIC PAIN

173

from pain. She has lost twelve pounds in the past seven months, but
until the last four days has not felt very much weakness. Nose-bleed
has been frequent all her life, and has been more apt to come at the
menstrual period. Her bowels have been constipated for years, but with
medicine have usually moved once a day. Temperature, never above
99 F. Hemoglobin, 80 per cent.; leukocytes, 8800; urine, normal.

Physical examination shows nothing abnormal in the chest. The
abdomen is held very stiffly, especially in the lower portion, where there
is slight dulness. Much tenderness is complained of throughout. Noth-
ing else could be made out on account of this tenderness. By vagina a
band could be felt to the right of the uterus, but the fundus could not be
palpated on account of abdominal spasm. Immersion in a warm bath
failed to relax the abdominal muscles, and even under ether the spasm did
not entirely relax.

Discussion. Clinical experience teaches that whenever a negress is
sick and the symptoms are below the waist, fibroid tumor of the uterus
usually turns out to be the diagnosis. The abdominal examination was
so unsatisfactory in this case that nothing definite could be said regard-
ing the uterus. The lump which was so readily felt some months
before would play in very well with the idea of a fibroid tumor, but its
apparent decrease in size, the prolonged fever (three months' duration) ,
and the generalized abdominal spasm do not fit well with this diagnosis.

Pelvic peritonitis originating in a pus-tube would explain the band
felt by the vagina and the tenderness of the lower abdomen, but would
not account for the long fever, the wide extent of the abdominal spasm,
and the tumor near the umbilicus. Tuberculous peritonitis, however,
will explain all these facts, and is, moreover, exceedingly common in
young colored folks.

Outcome. On August 7th the abdomen was opened and showed
tuberculous peritonitis, the viscera irregularly matted together; no fluid.

Diagnosis. Tuberculous peritonitis.

Case 79

A married woman of thirty-eight, a French Canadian, entered the
hospital December 10, 1907, for chronic abdominal pain which has lasted
for several weeks and apparently has incapacitated her for any work.
This pain has troubled her on and off for three years and a half.
At times it is very severe and interferes much with her sleep. Now
it is present every da} - ; formerly she would have respite from it for
many weeks at a time. It is not affected bv eating nor by the time of
day. Her appetite is fair, and she has newer been jaundiced. She

174 DIFFERENTIAL DIAGNOSIS

vomits occasionally, the vomitus not being in any way characteristic.
Her bowels move about once in three days. She has no cough and no
headache, but thinks she has lost 20 pounds in the past eight months,
and has been unable to work during that time on account of pain.

Physical examination showed considerable loss of weight and pallor
of the mucous membranes. Temperature, pulse, and respiration normal.
The chest was normal, the abdomen somewhat retracted, rigid, tym-
panitic throughout, and tender in the epigastrium; no masses felt. The
blood and urine showed nothing abnormal.

Discussion. The symptoms are strikingly like those of the last case
(tuberculous peritonitis), but in the present case there are weeks of
freedom from symptoms and no fever has been recorded. All the ordi-
nary clues suggested by the cases last studied were followed up quite
fruitlessly. We could obtain no positive evidence of an intestinal stric-
ture, of lead-poisoning, of peptic ulcer, cholelithiasis, or of any form of
peritonitis. There seemed no reason to suspect the kidney or any part
of the urinary tract.

Under these conditions it is proper to ask ourselves whether the
symptoms may not be due to pure constipation?-' It seems extraordinary
that a loss of 20 pounds in weight should be brought about by this cause.
Only the therapeutic test, however, can decide the question. If the
symptoms all disappear when the bowels are properly regulated, and if so
long as they continue regular there is no recurrence of pain, the diag-
nosis will be justified.

Outcome. Under careful diet, with sodium bicarbonate | dram
after meals and mild laxatives, the patient ceased to have pain and left
the hospital in six days. Her subsequent history has been uneventful
(1910).

Diagnosis. Constipation.

Case 80

A Russian Jew of thirty-two entered the hospital February n, 1908.
He has complained for live months of epigastric cramps beginning about
4 p. m., lasting all night and until noon the next day. In previous
years he has had similar attacks occasionally. The pain has no relation
to eating, but on the days in which his stomach has been washed out in
the out-patient department he has been relieved. He has a good ap-
petite and eats well, but vomits daily, sometimes spontaneously, some-
times purposely for relief of distress. The amount of vomitus is large
often as much or more than he has eaten since he last vomited. His
bowels often go five and six days without moving. About a week ago

EPIGASTRIC PAIN

175

he woke at 2 o'clock in the morning feeling very faint. He soon began
to be "choked up," and for twenty-four hours had great difficulty in
breathing. About a year ago he weighed 145 pounds. His present
weight is 114 pounds. He was formerly a painter, but has had nothing
to do with lead for thirteen years.

Physical examination is negative, except that there are tenderness
and some spasm under the right costal border. The blood and urine
are normal. His stomach holds 108 ounces of fluid. The contents, ob-
tained by washing, smell strongly of organic acids, and it is difficult to get
the wash-water clear. On inflation, the lower border of the stomach
reaches to a point midway between the navel and the pubic bone.
Sahli's test was administered, with the following result: 300 c.c. of the test
fluid were given. After one hour the total residue was 315 c.c, of which
109 c.c. are test fluid and 206 c.c. secretion; therefore the percentage of
test fluid passed from the intestine in one hour is 63 per cent, as compared
with the normal of 75 to 90 per cent.; the hydrochloric acid of the pure
gastric juice, 3.4 per cent.; average normal, 3.5 per cent. Diagnosis:
deficient motility with hypersecretion. His chief complaints during his
stay in the hospital were a burning epigastric pain, flatulence, and con-
stipation. He received no relief from diet, medication, or gastric lavage.

Discussion. We repeated in this case the therapeutic test used so
successfully in the last, but even when the bowels were in a perfectly
satisfactory condition, the suffering continued without respite. Con-
stipation, therefore, was not the trouble; it was the result, not the cause.

Lead-poisoning was excluded by the study of the blood and the
gums.

Tenderness and spasm under the right costal border occurring in a
patient who suffers from paroxysmal epigastric pain compel us to con-
sider gall-stones. This possibility cannot be ruled out, and was one of the
alternatives in the mind of the surgeon who later opened the abdomen.

Obviously, however, there must be something wrong outside the
gall-bladder, for the patient's stomach is markedly dilated and does not
empty itself properly. Gastric stasis, however, may be one of the disas-
ters following in the train of repeated gall-stone attack and as a result of
the adhesions thus produced.

For gastric cancer that commonest of all causes of pyloric stenosis
the history seems to be too long in this case. Yet can we explain the
loss of weight on any other hypothesis? In answering this last question
it is worth while to state emphatically that patients may lose a fifth or
a quarter of their weight within a few months as a result either of gall-
stones or of peptic ulcer.

176 DIFFERENTIAL DIAGNOSIS

In the present case all that was certain before operation was the
existence of an obstruction to the outflow of gastric contents. As a
cause for this, the scar of a duodenal ulcer and the adhesions resulting
from repeated gall-stone attacks were the alternatives most seriously con-
sidered.

Outcome. Accordingly, on February 19th the abdomen was opened.
No disease was found in the stomach, duodenum, or gall-bladder, but
the pylorus was considerably obstructed by adhesions. Gastro-enter-
otomy was done. After the operation the patient improved, and by
March 13th seemed to be in excellent condition except for weakness. On
May 20th he was discharged, wholly free from gastric symptoms.

Diagnosis. Pyloric adhesions.

Case 81

A married woman of thirty-two has been complaining for some
months of acute epigastric pain coming immediately after meals, lasting
about fifteen minutes, and relieved by the belching of gas. She entered
the hospital on July 29, 1907. She had suffered from typhoid fever
at the age of fifteen, from diphtheria at twenty, scarlet fever at twenty-
two, "peritonitis" five years ago. She has been married fifteen years,
but has had no children and no miscarriages. Five years ago she weighed
250 pounds, and she thinks she has gained in weight lately. She is in
the habit of taking two or three drinks of whisky a week for the " blues."
Four days ago she ate very heartily at supper-time. At 1 o'clock
the following morning she was taken with severe epigastric pain, which
has persisted ever since.

After palpation of the epigastrium the pain becomes spasmodic
and seems to go straight through to the back. It is worse with every
deep breath, and is increased by emotion.

The bowels were moved last night for the first time during this
illness, as a result of laxative pills. The pain has prevented sleep, and
last night she thinks she was delirious. The patient's temperature is
102 F.; pulse, 100; respiration, 30. There is tenderness on percussion
over the lower part of both lungs behind, but nothing else abnormal is
made out. The abdomen is somewhat hollow above the umbilicus,
rather full below; the abdominal wall very thick and flabby. There is
slight rigidity in the lower part, less in the epigastrium, where the pain
is worst. Deep pressure elicits expressions of pain in both the lower
quadrants and in the right hypochondrium. The edge of the liver
cannot be made out.

EPIGASTRIC PAIN

177

Next morning the pain was more definitely localized in the epi-
gastrium, and the temperature and pulse remained elevated, while the
white corpuscles had risen from 13,400 to 17,000.

Discussion. Out of this very checkered past history, with its
suggestions of dyspepsia, peritonitis, and alcoholism, no clear indica-
tions for diagnosis emerge. The constipation and the very wide-spread
character of the pains, both in the back and the front of the body,
are common features of some types of neurosis, but the presence of
fever and leukocytosis make neurosis very unlikely. In the foreground
of the clinical picture are the epigastric pain and tenderness of acute
onset. Many possibilities may emerge, but at present no clear diagnosis
is possible.

The problem here presented is a very familiar one. We have
good reason to believe that in the course of twenty-four or forty-eight
hours the diagnosis will be much clearer, but is it not dangerous to
wait so long? Should not an operation be done at once before more
dangerous symptoms appear? No definite rules can be given by
following which we can solve this difficulty in every case. The decision
rests mainly upon two points of observation:

1. How sick is the patient?

2. Is she getting worse from hour to hour?

An answer to the first question depends on long and mature clinical
experience. A general impression is gained, of which no very clear
account can be given. The look of the patient's face and the quality
of the pulse are perhaps the most important items in the judgment.

More important is the demonstrable change under observation of
some of the measurable data, such as temperature, pulse, respiration,
leukocytosis, the degree and area of spasm, tenderness, and pain.
While we are watching the course of these variables, it is quite likely
that the pain and tenderness will have time to "settle." Careful
observation of most cases of this kind brings out three stages:

1. The initial pain, its location being of great diagnostic value if
the history is clear and definite.

2. The subsequent radiations of this pain, often most confusing.

3. Its final "settling" in a single spot, most important in diagnosis.
but often dangerous to wait for.

The symptoms do not seem to be violent enough for perforated
peptic ulcer or for acute pancreatitis, though neither of these can be
ruled out. Gall-stones is the next most frequent cause for pain of
this type, provided lead, tabes, constipation, pericarditis, and angina
pectoris are excluded, as is easily possible in the present case. Since

178 DIFFERENTIAL DIAGNOSIS

there are fever and leukocytosis, it is reasonable to believe that some
cholecystitis has also occurred here.

Outcome. On the afternoon of the thirtieth of July operation
showed an enlarged, edematous, partially gangrenous gall-bladder,
with one faceted stone within.

The patient made a good recovery.

Diagnosis. Cholelithiasis and gangrenous gall-bladder.

Case 82

A woman of forty-eight entered the hospital February 14, 1908.
She has had four children, all of whom are now dead. The first was a
congenital idiot; the second had water on the brain; the third was
still-born, and the fourth died at three years of pneumonia. She had
repeated convulsions during the latter months of her third pregnancy.
During the others she had no such trouble. She has had no miscarriage.
Her habits are good, but she has usually passed her water eight or ten
times each night during the past ten years.

For the past seventeen years she has had many attacks of epigastric
pain, with distention and belching. The pain has never been colicky
or accompanied by jaundice, but has radiated to the back, and has
sometimes been severe enough to require morphin. The attacks of
pain have no relation to mental conditions nor to the character or time
of meals. Her weight is unchanged.

Two and a half weeks ago she had a sudden attack of pain, worse
than at any previous time, and vomited several times in the first twenty-
four hours. She had fever for five days, and has been in bed ever
since. She has had daily chills, lasting from fifteen to twenty minutes
each, and recurring about the same hour. Her bowels have been con-
stipated, and she has taken only liquid food for two weeks.

Temperature, pulse, and respiration are normal. The patient is
very obese. The sclera shows a very slight yellowish tinge. The chest
is negative, and the abdomen shows nothing but general tenderness.
At a point 2} inches below the costal margin a rounded edge (presum-
ably the liver) is felt to descend on inspiration, and there is considera-
ble tenderness at this point and just above it. The surface of the liver
seems irregular. The right sacro-iliac joint is tender to pressure, and
she feels better with a pillow under the lumbar snine. Her pain and
vomiting continued after the patient entered the hospital, and despite
laxatives, counterirritants, and starvation. The leukocyte count at
entrance was 8000, but rose on the third day to 17,000, with 90 per

EPIGASTRIC PAIN

179

cent, of polynuclear cells. The temperature at the same time rose to
102 F.

Discussion. When a woman's pregnancies have resulted as in
this case, syphilis must always be thought of as a possible cause for any
subsequent symptoms. The presence of chills and the suggestion of an
irregular liver point toward that organ as possibly the seat of a syphilitic
process. On account of such chills I have twice known patients to be
drenched with quinin for weeks at a time, when syphilis of the liver was
the true diagnosis.

In this case, however, the normal temperature makes us wonder
whether the chills may not be of nervous origin. Trembling and
shivering are very common nervous symptoms, with or without the sen-
sation of cold, and under these conditions often get mistaken for a chill,
which usually carries with it the presence of fever. We are by no means
certain, however, that the temperature has always been normal previous
to February 14th; indeed, the patient's statement directly contradicts
such an idea. At any rate, we cannot be content with the diagnosis of
psychoneurosis in view of the quite definite physical signs described above.

Can her troubles all be due to sacro-iliac arthritis? Attention is
drawn to this point by the tenderness over the sacro-iliac joint and the
relief following support of the lumbar spine, but the jaundice, enlarged
liver, and the persistent vomiting cannot be thus explained. Pain and
tenderness in various parts of the abdomen may be produced through the
nerve radiations originating in sacro-iliac disease. Both gall-stones and
appendicitis may thus be simulated. But in this case we have other
objective signs.

By far the commonest lesion associated with a picture like that here
given is cholelithiasis, and although the case is atypical in various respects,
this seems to be the most reasonable diagnosis.

Outcome. Operation showed an enlarged, thickened, and perfor-
ated gall-bladder, surrounded by a considerable amount of pus, and con-
taining numerous gall-stones.

Diagnosis. Cholelithiasis with perforations.

Case 83
A school-boy of thirteen entered the hospital February 14, 190S.
Tn November and December, 1906, lie had an acute urethritis, and
gonococci were demonstrated in the discharge. He has had "rheu-
matism" for about one year in the past three years, in periods lasting
from six weeks to three months. His family history is not remarkable,
and he has been well for the past two vears.

!8o DIFFERENTIAL DIAGNOSIS

Seven days ago he began to have epigastric pain. Five days ago his
knees became swollen and painful on motion, and he took to his bed,
where he has since remained. In the past two days his knees have im-
proved and no other joints have been involved. Yesterday morning he
began to breathe very rapidly, but has had no cough and no vomiting.

Physical examination shows slightly labored breathing, with pallor
of the mucous membranes. Temperature, 100.2 F.; pulse, 112; res-
piration, 28. The heart's dulness extends into the sixth interspace,
two inches to the left of the nipple-line. The right border extends if
inches to the right of midsternum. The cardiohepatic angle is ob-
tuse. All over the precordia, but loudest at the apex, a systolic mur-
mur and a rough diastolic murmur are heard. The latter is also heard
over the lower end of the sternum. In the left back there is dulness ex-
tending up to a point one inch above the lower angle of the scapula,
thence sloping down through the axilla to meet the cardiac dulness.
Over most of the dull area bronchial breathing, increased voice-sounds,
with increased tactile fremitus, and fine moist rales, are heard. At the
extreme base, where dulness is most marked, the intensity of voice-
sounds and breath-sounds is very slight. Later a capillary pulse was
demonstrated, and the diastolic murmur was shown to be loudest along
the left edge of the sternum, but also fairly loud in the second right
interspace.

At no time was there any cough. The leukocytes ranged between
12,000 and 13,000; the urine was between 30 and 40 ounces in twenty-
four hours, and free from albumin.

Discussion. Obviously, this boy has an arthritis, and gonorrhea
is its probable cause. The problem of present importance is to deter-
mine what complications have occurred. Evidently some infectious
disease is still going on, and the physical signs call our attention especi-
ally to the heart and the lungs.

Pneumonia, with or without empyema, would explain the signs in the
right back, and it is a very familiar fact that pneumonia and pleurisy often
begin in children with abdominal pain. The absence of cough by no
means excludes pneumonia.

But the cardiac signs have also to be explained. The increased area
of dulness and the double apical murmur are the ordinary evidences of
endocarditis with disease of the aortic and mitral valve. But the per-
cussion lines on the right side of the heart (see diagram) are more
indicative of pericarditis, though no typical friction is described. If
a pericardial effusion were present, it might account not only for the per-
cussion outlines and the auscultatory abnormalities, but also for the

Fig. 29. Percussion outlines in a patient complaining chiefly of epigastric pain. (See

also Fig. 30.)

Fig. 30. Signs demonstrable in a case of endopericarditis. (See also Jig. 29.

EPIGASTRIC PAIN

signs in the back of the left lung, since this is just the area of lung on
which a pericardial effusion exerts pressure in bed-ridden patients.
By such pressure sufficient condensation of the lung is produced to sim-
ulate the signs of pneumonia. It is impossible to exclude a patch of
pneumonia complicating the other troubles present, but experience shows
that we are more apt to be right when we explain a clinical picture by
one diagnosis rather than by two. Pericarditis, therefore, seems the
most reasonable working hypothesis.

Outcome. The temperature gradually subsided in ten days. The
murmurs disappeared, and the boy seemed entirely well by February
28th.

Diagnosis. Acute pericarditis.

Case 84

A sexton of sixty-five was first seen December 16, 1907, complaining
of paroxysmal abdominal pain relieved only by morphin. About three
years ago he began to suffer from dyspnea and swelling of the legs.
This trouble has been present, off and on, ever since, but he notices that
it is better if he is working hard than if he sits around the house.

In July, 1907, he had an attack of sudden, cramp-like pain in the upper
abdomen, accompanied by dyspnea and persistent vomiting of foul
green fluid. After twenty-four hours the pain was relieved by a sub-
cutaneous injection of morphin. Since that time he has had similar
attacks, gradually increasing in frequency and diminishing in severity.
He now has them every second or third day, but does not vomit with
them. In the last three months he has noted that during the day and
night before an attack he passes large amounts of pale urine, and on the
day following an attack small amounts of dark urine. His abdomen is
often bloated, but this subsides without treatment.

Physical examination shows that the pupils are equal and react well.
The tongue is large and smooth, especially in the posterior portion.
The apex of the heart extends one inch outside the nipple-line in the
fifth space. The first sound at the apex is weak, the second sound every-
where accentuated; no murmurs are heard. Blood-pressure ranges
between 140 and 160 mm. The artery walls are stiff and tortuous.
The abdomen shows general voluntary spasm, and the edge of the liver
is felt one inch below the costal margin. The knee-jerks cannot be ob-
tained even on rcenforcement. The urine averages about .jo ounces in
twenty-four hours, with a gravity of about 1020. There is no albumin,
but a few hyaline granular casts are seen in the sediment. The white
corpuscles are 6100.

1 82 DIFFERENTIAL DIAGNOSIS

During his month in the hospital the patient had many attacks of
abdominal pain, always coming on at night, relieved by morphin so
completely that next morning he felt well and wanted to get up. Nitro-
glycerin and amyl nitrite were repeatedly tried without any relief.
Most of the attacks of pain were preceded by slight shortness of breath.
The patient sometimes vomited during an attack.

Dr. James J. Putnam examined the patient and said that the loss of
knee-jerk might be due either to spinal arteriosclerosis or, more prob-
ably, to the diphtheria of his youth.

Discussion. In a patient who has no knee-jerks and complains of
paroxysmal abdominal pain, the thought of tabes should automatically
rise in our minds. In this case tabes must remain a possibility unex-
cluded to the last, though it is very unusual to find the pupils normal and
the other signs of tabes (lightning pains, sphincteric disturbances, sen-
sory abnormalities, ataxia, syphilitic history) all absent.

Angina pectoris (or angina abdominalis) is the natural inference
when we come to take account of the evidences of failing heart power
and of arterial degeneration. But angina is almost never accompanied
by vomiting, and it is rare to find a case absolutely unrelieved by the
nitrites.

Though the pain is not in the typical place and has not the typical
radiations of cholelithiasis, there are a number of points suggesting that
diagnosis. It would be very unusual, however, to find no fever or chill
in the history of a patient who has had gall-stone pains for six months.
Further, the association of the pain with dyspnea and with changes in
the amount of urine would be very unexpected in cholelithiasis.

Peptic ulcer might produce such a pain, but the brief paroxysms
completely relieved by morphin are not at all characteristic of that
disease. Further, it is very rare to find an active peptic ulcer coincident
with evidences of failing heart.

Plumbism, simple constipation, and intestinal obstruction by cancer
can easily be ruled out.

It seems to me of importance to notice the background of this case.
For nearly three years previous to the onset of the symptoms now
complained of the patient had suffered from dyspnea and edema of the
legs. Physical examination at the present time seems to indicate that
this is not due to primary valvular trouble, but rather to vascular degener-
ation. It is possible that all the symptoms may be due to this same cause
acting upon different organs.

It is a well-known fact that in arteriosclerotic subjects there appear
from time to time a great variety of paroxysmal attacks which in former

EPIGASTRIC PAIN

l8 3

years were attributed solely to the obliteration, embolic closure, or rup-
ture of one or another blood-vessel. In the light of more careful post-
mortem study we have come to speak of these paroxysmal attacks as
vascular crises} The idea of vascular spasm takes the place of the older
idea of gross vascular lesion, in view of the fact that postmortem there
is often no gross vascular lesion to be found. Under this general head-
ing of vascular crises belong in all probability many of the transient hemi-
plegias, monoplegias, aphasias, comas, local or general spasms formerly
explained as due to permanent anatomic lesions. Cardiac vascular crises
may be supposed to account for the cases of fatal angina pectoris without
marked narrowing of the coronary arteries. The gastric and other crises
occurring in tabes are very possibly to be accounted for in the same way.

In the present case there are three sets of data supporting the hypothe-
sis of vascular crisis: (a) The curious urinary changes which strongly
suggest the "urina spastica" seen in vasomotor affections and hysteric
states; (b) the swelling of the abdomen during attacks; and (c) the associ-
ation with dyspnea.

I have already stated that it is impossible to exclude tabes in this
case. Were that the correct diagnosis, the mechanism by which the
attack was produced would be the same as under the hypothesis of vas-
cular crisis without the other lesions of tabes.

Outcome. He died of pneumonia at the end of a month; the
autopsy showed arteriosclerosis with hypertrophy and dilatation of the
heart. The celiac axis and the coronary arteries were only slightly
involved in the arteriosclerotic process. Xo tabes.

Diagnosis. Arteriosclerosis; vascular crises.

Case 85

A school-boy of ten entered the hospital January 28, 1908, on ac-
count of epigastric pain which came on night before last after a supper
of pork and beans with cheese. It has prevented him from sleeping
since then.

He says that it feels as if some one had punched him in the stomach.
Breathing or gaping gave pain at this point and in the left axilla. He
has almost constant nausea, and has been feverish since yesterday morn-
ing. He has a brother who has been treated at the Children's Hospital
for tuberculosis of the knee.

At entrance his temperature was 102.4 F.; pulse. oS; respira-
tion, 30, and accompanied by a grunt. He now complains of pain
both in the epigastrium and at the top of the sternum. The car-

1 For Pal's account of these crises see p. ; >.

jg^ DIFFERENTIAL DIAGNOSIS

diohepatic angle is obtuse, and over the area shown in the diagram
(Fig. 31) there is a to-and-fro friction sound, loudest in the second
right interspace. Physical examination is otherwise normal. The
white cells number 9600; the urine is negative. The day after entry the
friction-rub disappeared and the temperature fell to normal on the
second day. On February 5th he was playing about the ward, and a
fairly loud systolic murmur was heard at the apex and in the axilla?.
The cardiohepatic angle was now acute.

Discussion. Some digestive disturbance is naturally the first ex-
planation which occurs to us, since the symptoms followed so imme-
diately upon the taking of a heavy meal; but a simple digestive upset of
this kind would not account for a temperature of 102.4 F. forty-eight
hours after. In all probability the digestive upset was a result, not a
cause, of the present trouble.

Tuberculosis of the spine is said to be associated with epigastric
pain, such as is here present, and the presence of tuberculosis in the
patient's brother makes it proper for us to consider this disease seriously.
There is nothing, however, in the physical examination to support any
such idea no spasm of the erector spinas group and no prominence or
tenderness of any vertebra; nor are there any indications of tuberculosis
elsewhere.

With these two alternatives excluded and with due regard for the results
of the physical examination the only reasonable diagnosis is pericarditis.
Indeed, the diagnosis could hardly have been missed except by reason of
the all too common error the failure to look for it.

Outcome. It was learned subsequently that when the patient was
three years old he had considerable pain and weakness in his legs, ac-
companied by fever. Recovery was uneventful.

Diagnosis. Pericarditis.

Case 86

A brass-finisher of fifty-six entered the hospital on January 30, 1908,
with a negative history up to eight weeks ago, although he had been
in the habit of taking about five drinks of whisky a day for a good
many years. Eight weeks ago he began to have abdominal pain,
worst in the pit of the stomach. This pain is sharp and piercing,
almost constant of late, keeping him awake at night. For the past
week or two it has run up under the left costal margin at times. There
have been no vomiting and no belching, but he has gradually lost his
appetite entirely. Food does not affect the pain in any way. His
weight has fallen 42 pounds in three months. His bowels are regular.

Fig. 31. Friction-area and percussion outlines in Case 85. Chief complaint is epigastric

pain.

EPIGASTRIC PAIN

185

On physical examination temperature, pulse, and respiration are
normal, likewise the lungs. The heart shows no evidence of enlarge-
ment, and its sounds are regular and of good quality. At the apex
there is a faint systolic murmur transmitted to the axilla, heard also
in the pulmonary area and more faintly in the aortic area. All over
the precordia and over the left pectoral is heard, during inspiration
alone, a faint, grating, systolic sound, loudest in the third space and
anterior axillary line. In the fourth space, near the left edge of the
sternum, is heard a crackling systolic sound not affected by respiration.
The aortic second sound is considerably accentuated; the artery walls
are somewhat thickened. Examination of stools shows nothing re-
markable, the guaiac test being negative. The stomach was found to
hold 76 ounces of water. The lower border descended if inches below
the navel. After a test-meal the gastric contents showed no free hydro-
chloric acid and no lactic acid; the guaiac test was negative.

Discussion. Whisky is so old a friend of this patient that it is not
likely to begin to disagree with him in his fifty-sixth year. Probably
it has nothing to do with the symptoms in this case.

Peptic ulcer might produce such pain, and is perfectly consistent
with the loss of 42 pounds' weight in two months. But the lack of
appetite, the entire absence of vomiting and belching, and the short
duration of the symptoms make this unlikely.

What are we to make of the curious signs in the chest? Have they
anything to do with the symptoms complained of? Inspiratory systolic
sounds, absent during expiration, and best heard along the margins
of cardiac dulness, constitute the commonest type of so-called cardio-
respiratory murmur. The phenomenon has no clinical significance
except that in a considerable proportion of cases it is found to be asso-
ciated with pleural or pleuropericardial adhesions, which may be due
to tuberculosis. The same may be said of systolic crackling sounds,
which occasionally mystify the practitioner.

It is well to make it a rule always to hunt for evidence of gastric
cancer when a patient past forty comes to us with a recent and unex-
plained history of gastric symptoms, mild or severe. Errors in diet,
worries, and such causes are not apt to take effect for the first time
after a person has lived fifty-six years. If gastric symptoms arc due
to any cause other than cancer, careful questioning of the patient will
usually prove that they have existed at intervals for years. In the
Present case the evidence of enlargement of the stomach and the absence
of hydrochloric acid from the gastric contents arc chiefly of confirma-
tory value as evidence, the history being the important thing.

1 86 DIFFERENTIAL DIAGNOSIS

Very characteristic of gastric cancer is the gradual but complete
loss of appetite in this case. On the other hand, the absence of vomit-
ing and of any relation between the pain and the taking of food is rather
unusual.

Outcome. His symptoms were somewhat relieved by 10 grains
of orthoform, given four times a day, and 15 minims of dilute hydro-
chloric acid, given twenty minutes after each meal.

The patient died on March 15th. Autopsy showed cancer of the
stomach.

Diagnosis. Gastric cancer.

Case 87

A bricklayer of fifty-two entered the hospital April 7, 1908, with a
diagnosis of gall-stones. His family history and past history were
negative; his habits good. For three months he has complained of
pain in the epigastrium, not severe, but worse after eating, and usually
radiating to the right back. For six weeks he has noticed white stools,
dark urine, and jaundice. Throughout this time, however, his appetite
has been good, and he has had no vomiting.

On physical examination he was found to be deeply jaundiced,
his lungs hyperresonant in front, with slightly prolonged expiration.
Over the sacrum was a soft, flattened, subcutaneous prominence the
size of a dollar. Nothing else was detected on physical examination,
abdominal palpation being unsatisfactory, owing to constant rigidity.
On April nth the abdomen became less resistant, and an indefinite
mass was felt in the region of the gall-bladder. A stomach-tube was
passed, and the capacity of the organ was found to be 42 ounces of
water, the lower border extending to a point one inch below the navel.
No contents were found in the fasting stomach. After a test-meal,
however, hydrochloric acid was found to be 0.09. Lactic acid test
and guaiac test were negative.

Discussion. Excluding congenital cases, an afebrile, persistent
jaundice usually presents to us the problem of deciding between three
causes:

1. Gall-stones and their effects.

2. Cancer, either of the pancreas or bile-ducts, occasionally of the
liver itself.

3. Cirrhosis.

Hepatic syphilis is considerably less frequent as the cause of long-
standing jaundice, and the duration is here assumed to be sufficient
to exclude the acute infectious and the catarrhal type of jaundice.

EPIGASTRIC PAIN

l8 7

Against gall-stones in the present case is the intensity of the jaundice
without variation in six weeks, the absence of colic, and the presence of
a mass in the region of the gall-bladder. Long-standing jaundice due
to gall-stones is usually associated with a normal sized or contracted
gall-bladder (Courvoisier's law). It is quite possible, however, that
the mass in the region of the gall-bladder is not due to distention of that
viscus.

Cirrhosis almost never produces an intense degree of jaundice. The
coloration is slight or moderate. It is rarely associated with pain, and
usually produces either enlargement of the liver or some evidence of
portal stasis.

Cancer then seems the more likely diagnosis; whether it is of the
pancreas or the bile-ducts we have no means of determining. That it
is probably not in the liver itself is to be argued from the absence of gastric
symptoms and of objective manifestations of gastric disease.

Outcome. Operation, April 23d, showed moderate enlargement
of the liver, distention of the gall-bladder, and a mass of hard, apparently
cancerous, tissue in the region of the pancreas. The patient made a good
recovery from the operation.

Diagnosis. Pancreatic cancer; [chronic pancreatitis].

Case 88

A chef of thirty-two entered the hospital on April 8th with the state-
ment that his mother had died of a "complication of diseases"; his
father had had a persistent cough for four years; one brother had died
of consumption at the age of twenty-four, and a sister died of ''rectal
abscess" at the same age. The patient had been exposed to tubercu-
losis.

Ever since he was nineteen years of age he has had attacks called epi-
lepsy. These have always come during sleep, and do not awaken him. In
the morning he wakes with a headache and general pains, usually finding
that he has bitten his tongue. At first these attacks came about once a
month; now they come only about once in six months. Nevertheless, he
was well and strong until four years ago, when he vomited about four
quarts of fluid. Following this he was sent to a hospital for tuberculosis
and remained there six months, although, so far as he knows, he has never
had a cough and nothing abnormal has been found in his lungs. Two
and a half years ago lie weighed t6o pounds; now lie weighs 137 pounds.
I lis habits are good.

For the past six weeks he has been treated for abdominal pain not
closely localized. Four davs airo he vomited a few times, and this vomit-

1 88 DIFFERENTIAL DIAGNOSIS

ing has persisted and rather increased since then. In the last two days
he has vomited up about two quarts of dark-brown material, together
with some food which he thinks was eaten at least twenty-four hours
before. His pain is now tnost severe in the epigastrium and under both
costal margins. It is sometimes relieved by vomiting, and is never
worse after eating. Yesterday he noticed palpitation for the first time.
He has a good appetite, but has had some constipation for three weeks.

Physical examination was negative except for slight tenderness in the
left epigastrium and under both costal margins. His vomitus was found
to contain free hydrochloric acid, and the guaiac test was positive, both
in the stomach-contents and in the stool. Despite careful diet, he con-
tinued to vomit and have pain.

Discussion. Abdominal symptoms of any kind, when occurring in
a patient with so strong a tuberculous history, compel us to make a
most searching examination for evidences of tuberculous peritonitis.
This is true even when the onset is much more acute than in this case. 1
But in the absence of fever and of all the local manifestations of tubercu-
lous peritonitis (free fluid, generalized tenderness, spasm, and tumor-
like masses) this disease may be excluded.

Is it possible to connect in any way the history of epileptiform
attacks with the present symptoms? Such attacks might be due to
cerebral syphilis, and the same disease attacking the liver and spleen
might now produce acute abdominal pain. But in the absence of
any enlargement of the liver or spleen, and without fever, anemia, or
other lesions pointing to syphilis, we have no good reason for consider-
ing this disease seriously.

In the treatment of cases characterized by pain and vomiting I have
often been misled so as to forget the possibility of chronic intestinal ob-
struction misled, I mean, by the prominence of symptoms apparently
referable to the stomach. Especially when there is constipation, as in
the present case, this possibility should never be lost sight of; but it must
remain a mere possibility unless there is other evidence to support it.
In the present case the positive guaiac test in the stool is all that we
have in the way of physical signs favoring obstruction. In the absence
of tumor, visible peristalsis or intestinal noise, chronic obstruction de-
serves no further consideration.

If, then, the symptoms are of gastric origin, as seems, on the whole,
most probable, there are but two diseases deserving serious considera-
tion cancer and ulcer. In the absence of alcoholism and of any other
cause for chronic congestion of the stomach (heart disease, cirrhosis),

1 As an illustration of the acute onset of symptoms in tuberculous peritonitis see p. 427.

EPIGASTRIC PAIN 1 89

cancer and ulcer are the only diseases likely to produce hemorrhage both
from the stomach and the bowel, associated with persistent vomiting
and epigastric pain. This likelihood is increased when the patient fails
to improve after careful dieting.

Against cancer is the fact that the patient is relatively young, has no
steady gastric stasis, and especially the persistence of a good appetite.
The presence of free hydrochloric acid is also somewhat against the diag-
nosis of cancer. On the whole, peptic ulcer, gastric or duodenal, is the
best working diagnosis.

Outcome. On the fifteenth of May his stomach was opened and a
puckered scar found on the posterior wall of the stomach. Posterior
gastro-enterotomy was done. The patient did well.

Diagnosis. Gastric ulcer.

Case 89

A waitress of twenty-eight entered the hospital on May 5, 1898.
She said that she had "malaria of the stomach" seven years ago, and
was sick for three days with fever and chills. At that time she had no
vomiting and no pain, and has otherwise been well except for occasional
"chills," until three years ago, when she began to have a gnawing in the
stomach, coming immediately after eating and followed by gastric
distention and belching, which continues until about two hours after
eating. This belching has been worse for the past year. At times
enormous quantities of gas are expelled with much noise. For relief
from the gnawing sensation she sometimes makes herself vomit, the
vomitus usually consisting of about half a pint of white phlegm in which
she has several times seen specks of blood. Her appetite has been good
and her bowels regular.

Physical examination shows a very marked pulsation near the navel;
over it a thrill is felt and a systolic murmur heard. There is slight ten-
derness in the center of the epigastrium. The examination revealed
nothing abnormal.

The guaiac test in the stool was negative. She was put on a diet of
carbohydrate and fats, with a diagnosis of gastric neurosis, and was at
once relieved of her symptoms.

Discussion. Any one who had the opportunity to hear the thunder-
ous noise with which this patient expelled gas from the stomach would be
strongly biased, I think, toward a diagnosis of gastric neurosis, for
these explosions are almost always preceded and brought about by the
habit of "cribbing," or swallowing air, which in turn is usually the result
of gastric neurosis. The most important question is. can we exclude pep-

190

DIFFERENTIAL DIAGNOSIS

tic ulcer? Many of the symptoms suggest this disease, and the patient's
neurotic constitution by no means excludes it. On the other hand, it
is unusual for the patient to be relieved of pain and other gastric symptoms
at a time when the stomach is empty. Though many gastric ulcers exist
without producing hemorrhages, it would be impossible, I think, to make
a diagnosis of ulcer in this case unless hemorrhage occurred. The
specks of blood in the vomitus are, of course, of no special importance,
and the epigastric tenderness has no diagnostic value.

The thought of aneurysm is apt to disturb both doctor and patient,
when, as in the present case, abdominal pain is associated with a marked
pulsation, palpable thrill, and systolic murmur near the navel. The
evidences by means of which aneurysm may be excluded in this and
similar cases have already been fully discussed on p. 142. Malaria was
considered in the diagnosis of this case, but a careful temperature
record enabled us to exclude it. The diagnosis remained in doubt,
gastric ulcer and gastric neurosis being the main alternatives.

Outcome. On June 6th she was once more on house diet, up and
about the ward, and seemingly quite well. With care about diet and an
improved environment, the patient has continued well up to the present
time (1910).

The continued good health, after so short a period of treatment, seems
to me to argue strongly against ulcer.

Diagnosis. Gastric neurosis.

Case 90

A Jewess of thirty had been operated on, July 30, 1900, for cholecys-
titis. The gall-bladder was drained. After this operation she re-
mained well, and has had three children. She entered the hospital
March 13, 1907, complaining of epigastric pain of two years' duration,
coming at irregular intervals, and worse after eating. For the past
month the pain has increased in severity and has radiated to the back,
but not to either side; it often awakens her at night. Her bowels are
constipated, and she has eaten little for the past four weeks, though her
appetite was previously good. She has lost much strength, and for the
past four days has remained in bed.

At entrance and thereafter her pulse ranged most of the time above
90, and not infrequently reached 120. Her evening temperature was
usually above 99 F., but below ioo F.

Physical examination showed nothing abnormal in the chest. There
was general abdominal rigidity, especially above the navel, where there

EPIGASTRIC PAIN

191

was marked diffuse tenderness. The white cells were 27,000 at entrance,
and 88 per cent, of these cells were polynuclear. Three days later the
tenderness was gone, and the leukocytes were found to be normal ; they
remained so thereafter. The urine was at all times negative.

Examination of vomitus showed free hydrochloric acid in abundance,
and a positive guaiac test for blood was obtained. Tube examination
was negative. In the stool the guaiac test was twice negative. The
patient complained of marked abdominal pain, but obtained great
relief from the subcutaneous injection of sterile water.

The patient was treated by careful feeding, the administration of
|-grain doses of cocain, and dram-doses of Hoffmann's anodyne for
gastric distress. On one or two occasions | grain of morphin was
administered. Nutrient enemata were tried, but were always expelled
within a short time. The patient took liquids well after the first few
days and was, for the most part, free from pain and vomiting.

Discussion. The symptoms seem to be very much the same as
those previously proved to be due to cholecystitis. Since the gall-
bladder was drained, and probably, for the most part, obliterated, it is
unlikely that there is any return of inflammation at that point, especially
as she seems to have had five years of freedom from symptoms. The
same considerations, however, lead us to wonder whether adhesions
may not have formed in the vicinity of the gall-bladder, resulting in
gastric stasis and precipitating the attacks of pain. The absence of
any gastric stasis, however, as evidenced by the stomach-tube examina-
tion, makes this supposition less likely.

The local signs at the time of entrance and the leukocytosis point
rather toward a local peritonitis, possibly from a gastric ulcer. Were this
the case, however, we should not expect the disappearance of all these
signs within three days. One cannot help being influenced by the fact
that this patient's pain was greatly improved by the " lie cure"' (injec-
tions of sterile water, mistaken by the patient for morphin).

Chronic appendicitis has not been yet extensively discussed in this
book, for the reason that I find it hard to arrive at any very definite
conclusion upon the subject, but certainly this case is very similar to
those which surgeons are accustomed to operate on with that diagnosis.
The childhood attacks often seen in chronic appendicitis are not here
mentioned. There was at no time any local tenderness or spasm in the
right iliac region, nor any radiation of pain to that region. Nevertheless,
it is certainly true that cases no more typical than this have been relieved
of all symptoms after the removal of an adherent, kinked appendix.
In this connection I wish to call attention to the following table, which

192

DIFFERENTIAL DIAGNOSIS

embodies the conclusions of Drs. Graham and Guthrie, 1 arrived at after
the study of a large series of cases from the Mayos clinic:

DIFFERENTIAL DIAGNOSIS OF THE MILDER TYPES OF CHRONIC
APPENDICITIS, PEPTIC ULCER, AND GALL-STONES. {After Graham
and Guthrie, Jour. Amer. Med. Assoc, March 19, 1910.)

Disease.

Chronic appendicitis 34 j +

(dyspeptic type)

Gall-stones 40

Peptic ulcer 45

Severity of
digestive
disturb-
ance.

Mode of
relief.

Radiations
of pain.

Tempera-
ment.

Consider- By pass- To right Neurotic,
able, age of gas iliac re-
! or feces, gion.
Sudden To back, 1 o

often by right ax-;
morphin. ilia, and
right
shoulder.
Moderate ; By food, o

in early! soda,

stages.

vomiting,
or irriga-
tion.

The conclusions of these observers are borne out by most of my
observations, and seem to me about as near to wisdom as any yet offered
upon the subject.

After very careful study of the case we were unable to arrive at any
definite diagnosis. We could not definitely incriminate the stomach,
the gall-bladder, or any other viscus, yet we were by no means certain
of the absence of severe disease calling for surgical interference. Ac-
cordingly, on March 24th the abdomen was opened, but careful search
revealed no disease of any kind. The patient made an uneventful
recovery.

Diagnosis. Gastric neurosis.

Case 91

A dressmaker of twenty-three, whose mother died of cancer of the
stomach, was seen January 28, 1907. She admitted that for a year
she had taken a great deal of beer, wine, and whisky, and for the past
two weeks she had taken from a pint to five pints of whisky a day.
During this last period she had eaten practically nothing, and has
been in bed most of the time. A few days ago, whenever she closed
her eyes, she saw big animals and other apparitions. For the past three
days she has vomited almost constantly, and had some epigastric pain,
which has become more severe during the past two days, especially

1 Jour. Amer. Med. Assoc, March 19, 1910.

EPIGASTRIC PAIN

[ 93

when she breathes deeply. Last night her respiration was very difficult
and shallow in consequence. There has never been any blood in the
vomitus.

Temperature, pulse, and respiration were normal, the left pupil
considerably larger than the right, but both reacted normally; a heavy
brownish coat was found on the tongue, and a marked tremor in the
ringers. The chest showed nothing abnormal. The abdomen was
rigid and tender throughout; exquisitely so in the epigastrium. Liver
dulness was not increased, and there was no shifting dulness in the
flanks.

Discussion. The chief problem in this case is to decide whether the
alcoholism from which she is suffering will account for all the symptoms.
We are not accustomed to associate extreme abdominal tenderness and
rigidity with delirium tremens or with simple alcoholism. On the
other hand, if perforative peritonitis (stomach, gall-bladder, appendix)
were present, there should be some rise of temperature, pulse, respira-
tion, or leukocyte count, none of which occurred. There is nothing in
the case to justify the suspicion of lead-poisoning, tabes, chronic intestinal
obstruction, passive congestion of the liver, pericarditis, pneumonia, or
any of the other causes of epigastric pain which have been discussed on
previous pages.

Is it possible that the symptoms may be due merely to the excessive
vomiting, with the wrenching strain thereby brought upon the abdominal
muscles? We decided to take our chance of this diagnosis, and planned
our treatment accordingly.

Outcome. The next day the pain was much less, likewise the ten-
derness and tremor, and there has been no vomiting. By February 3d
she was entirely free from complaints, and on the sixteenth she left the
hospital well.

Her treatment consisted of milk diluted one-third with lime-water,
4 ounces every two hours when awake; orthoform, 10 grains, every four
hours; hot stupes to the abdomen every hour when awake; whisky, V
ounce every four hours; triple bromids, 30 grains, and tincture of cap-
sicum, 15 minims before meals. After the first two days the whisky was
omitted. The other medicines were not needed after the thirteenth.

Diagnosis. Alcoholism.

Case 92

A teamster of forty-eight entered the hospital August 12th. Gas-
tric ulcer and abdominal aneurysm were the diagnoses suggested by
the out-patient physician. The family history was not remarkable,

194 DIFFERENTIAL DIAGNOSIS

except that one sister has been in the Worcester Insane Asylum. The
patient's habits and past history are good. Ten weeks ago he began to
have steady epigastric pain, usually dull, sometimes sharp. After two
or three days he had to give up work on account of pain and weakness,
but he has not been in bed for the whole of any day. Previous to this
illness he has never had pain of this sort. It is worst about one hour
after eating, but it is not relieved by food, and does not radiate to any
other point. During the same period he has also had aches and darting
pains in his neck, legs, and the right side of his chest. For the past
two or three weeks he has felt sleepy and nervous in the daytime, while
at night pain and nervousness have often kept him awake. He has
headache during most of every morning. The last four or five weeks he
has been short of breath, but has noticed no swelling of his feet. His
bowels move only once in four days. His appetite is poor, but he has
not vomited.

On examination he seems to be emaciated. The chest shows noth-
ing abnormal. The abdomen is decidedly concave and somewhat tender
in the epigastrium, where there is marked pulsation visible and palpable
from a point two inches below the sternum to a point one inch below the
navel. Otherwise physical examination is negative, and the blood, urine,
and temperature-chart indicate nothing abnormal. The patient was
depressed, seemed very apathetic, and at times refused nourishment.
The stomach-tube proved that the stomach held 30 ounces of water and
showed no evidence of enlargement. After a test-meal the extracted con-
tents showed free HC1, 0.12 per cent., no lactic acid, no blood.

Discussion. Although abdominal aneurysm was considered in
this case, the physical signs are clearly those of dynamic aorta, the differ-
ential diagnosis of which has been already discussed. (See p. 142.)

Gastric cancer is always a threatening possibility when a man of
forty-eight begins to have digestive symptoms for the first time in his
life. The emaciation present in this case lends support to this hypothesis,
and the negative results of examination by the stomach-tube do not en-
able us positively to exclude cancer. We will return to the discussion of
it below.

Peptic ulcer does not cause pains so wide-spread as those here de-
scribed. If this were the diagnosis, we should expect also some relief
after food, and very possibly some blood in the stomach-contents. Yet
while ulcer would not account for all the facts here present, we must hold
judgment in reserve regarding it, as we have already done regarding
cancer.

Could the symptoms be explained as the result of simple constipa-

EPIGASTRIC PAIN 195

tion combined with starvation which his emaciation suggests? Very
possibly they may, but we still require some reason for the sudden appear-
ance of constipation in a healthy teamster of forty-eight.

We cannot afford to leave out of consideration the psychic symptoms
in this case. A middle-aged laboring-man does not begin to be sleep-
less and nervous without obvious cause. The ordinary cause for such
symptoms is alcoholism, which could be definitely excluded here. Tn
view of the patient's depression, his persistent headaches, his nervous-
ness, insomnia, and apathy, a mild type of insanity (depressive maniac
psychosis) seems probable, especially since no cause for his depression
can be found in any of the recent events of his life. Assuming this to
be true, the question remains: Can the abdominal symptoms, the ano-
rexia, and emaciation be thus explained? To this it is to be answered
that in sanatoria and asylums for the insane it is a very common ex-
perience to find the foreground of the clinical picture occupied mainly by
gastro-intestinal symptoms almost as severe as those seen in organic
disease. The further course of these cases, however, demonstrates the
absence of any such disease, and leads us to the conclusion that the
gastro-intestinal symptoms are simply one item in the symptom-complex
called insanity.

Assuming then that this patient is mildly insane, we are justified in
supposing that his stomach symptoms are dependent upon this psychosis,
even though, were he normal mentally, we should be strongly inclined to
believe that he had gastric ulcer or cancer.

Outcome. -The patient became more and more depressed. Two
special consultants pronounced the case simple melancholia, and he was
removed to an asylum.

Diagnosis. Melancholia.

Case 93

An Italian laborer forty years old had "rheumatism" five years ago
and one year ago. Many joints were swollen, painful, and tender for
a few weeks in each attack, but lie has regained perfect function in all
the joints.

lie takes two whiskies before breakfast and four beers (hiring tin-
day. Denies venereal disease.

For six weeks he has had gnawing pain in the epigastrium and right
hypochondrium, gradually getting worse, sometimes disturbing >le
but never influenced by food. Nocturia, 1 to 3 times.

Physical Examination. The cardiac' impulse extends 1 cm. oui-ide
the nipple in the fifth space. No enlargement to the right is detected.

196 DIFFERENTIAL DIAGNOSIS

Cardiac action regular 80 per minute; the apex first sound is replaced
by a long, blowing murmur, which is also audible in the left axilla. At
the third left costal cartilage is the maximum intensity of a diastolic
murmur, which is also faintly heard in the second right interspace. The
pulmonic second sound is accentuated.

All the superficial arteries pulsate strongly, and there is a "Corrigan"
and capillary pulse.

Nails slightly incurved. Lungs negative.

In the upper right abdominal quadrant is a mass easily felt bimanu-
ally, descending over an inch on full inspiration, with a rounded edge
and a semifluctuant consistence. The liver dulness extends 8.5 cm.
below the ribs (nipple-line) and 12.5 cm. below the ensiform. Whether
or not the liver is continuous with the mass described above cannot be
certainly determined. The liver edge is sharp on the left of the median
line, but cannot be felt distinctly on the right.

The spleen is palpable 2 cm. below the ribs. Abdomen otherwise
negative; likewise the rest of the body. Urine, 40 ounces; specific grav-
ity, 1021. No albumin, pus, blood, or casts. Blood normal.

Cystoscopy showed evidence of normal functioning in each kidney.

Discussion. Clearly enough this patient has incompetence of the
aortic and mitral valves, presumably of rheumatic origin. The inter-
esting problem remaining concerns the mass in the right hypochondrium.
Is it liver, kidney, or retroperitoneal tumor?

The alcoholic history may have produced a cirrhosis, but cirrhosis
rarely causes pain, and the cirrhotic liver is hard, not semifluctuant.
Moreover, we do not expect to feel the liver bimanually, though that is
by no means impossible. There seems reason to believe that the liver
is enlarged in this case, but apparently there is something else wrong.

A mass palpable bimanually in the right flank usually turns out to be
connected with the kidney, and it was with this in mind that cystoscopy
was done. The results of this examination go far toward excluding
renal disease, and were interpreted in this sense.

Tumors of the retroperitoneal glands produce not infrequently a
mass like that here described. Diagnosis of such tumors, however, is
impossible unless there are more definite pressure symptoms (pain in the
back and legs), or unless there has been malignant disease elsewhere in
the body, with possible metastasis in the region now under considera-
tion.

Syphilis of the liver and cancer of the liver or colon would not account
for so soft a mass as is here described. Is it possible that simple passive
congestion due to the cardiac lesion might produce so soft an enlarge-

EPIGASTRIC PAIN

197

ment of the liver? Against this is the absence of much stasis in the lungs,
legs, or abdominal cavities, and the fact that the questionable mass can-
not with certainty be connected with the liver edge palpable to the left of
the median line. A surgical consultant considered the symptoms due
to a tumor of the gall-bladder or of the kidney. On the whole, there
seems to be enough doubt upon this point to justify exploratory lapa-
rotomy.

Outcome. Laparotomy showed the kidneys and gall-bladder to be
normal. A large, dark, congested liver was tiie only finding.

This case seems to me to be of unusual interest, since it shows that
passive congestion of the liver is one of the items which must be seriously
considered in a diagnosis of diseases involving the right upper quadrant.
So far as I am aware, this is one of the few cases on record in which
laparotomy has been done for passive congestion of the liver.

Diagnosis. Hepatic congestion.

Case 94

A private secretary, sixty years old, entered the hospital March 2,
1907. Her father died of consumption. She had diphtheria at twelve.
Twenty-five years ago she had inflammatory rheumatism and ophthalmia,
was in bed a week, and has had a slight similar attack since. In the past
thirty years she has had about twelve attacks of colic, characterized by
sudden painful cramps in the abdomen. The last attack was in July,
1906. Ten years ago an appendix abscess was opened and drained. She
has never been jaundiced, but always has had a strong tendency to con-
stipation. Her best weight was 182 pounds six months ago. Six weeks
ago she had several attacks of indigestion within a week; after this she
was well until four weeks ago, when she had a sudden severe attack of
epigastric pain lasting an hour. She lias had live or six similar attacks
since, most of them coming after breakfast and lasting several hours until
relieved by morphin.

The pain does not seem to radiate in any direction. For three days
she has been jaundiced.

Physical examination showed an obesity and a marked jaundice,
but was otherwise negative. Bv the sixth of March the jaundice had
cleared up and the patient was comfortable except for slight sore throat.

Discussion. Since tuberculous peritonitis may manifest itsell lor
the first time with symptoms as acute as those here present, it deserves
a moment's consideration, especially in view of the tuberculous family
history. But there are no phvsical signs corresponding to this disease,
and in the absence of fever it need not be further discussed.

198

DIFFERENTIAL DIAGNOSIS

Attacks of abdominal pain in a patient who has no knee-jerks should
always remind us of tabes, yet there are no other confirmatory facts,
and it is quite possible that the diphtheria which the patient passed
through at the age of twelve may have produced a neuritis which
accounts for the loss of knee-jerks.

In elderly persons with a strong tendency to constipation we need
no further explanation for many uncomfortable abdominal symptoms;
but constipation practically never produces pain so sharp as to require
morphin unless, indeed, it be due to organic obstruction. Her age and
the character of the pain are quite consistent with this diagnosis, and
experience has shown that intestinal obstruction is always a serious
danger for those who have been operated upon for appendicitis, especi-
ally if the formation of adhesions has been favored by drainage of the
wound. But if the intestine were obstructed, we should expect disten-
tion and vomiting, while the attacks of pain would probably not occur
so frequently and at such short intervals.

Peptic ulcer is, as in so many cases, a possibility impossible to exclude,
but the presence of jaundice, the sudden relief by morphin, and the
absence of any definite relation between the pain and the taking of food
turn our attention rather to gall-stones. Since the appearance of the
jaundice this diagnosis has been tolerably obvious. It is favored by
the age and sex, the obesity, and the character of the pain.

Outcome. The abdomen was opened on the ninth of March, and
showed a small gall-bladder completely filled with stones.

Diagnosis. Gall-stones.

Case 95

Mrs. H., a widow of seventy, was seen in consultation November
8, 1901. Her mother died of old age at eighty-one; her father of dia-
betes at sixty. Three sisters died of pulmonary tuberculosis; one from
an accident; one of unknown cause; one is still living.

Mrs. H. has had ten children: By first husband, eight; two of these
died of pulmonary tuberculosis, one of "dropsy"; one daughter died
from "effects of a surgical operation"; three died in infancy, cause
unknown; one living. The two children by her second husband are
living and well.

She had the usual children's diseases, but otherwise was always
well until 1890, when she had strangulated hernia and was operated
upon. During the following year she did not feel well, had fever,
chills, vomiting, and pain, and in 1891 was operated for right empyema.
This discharged for six months, but finally healed. Since that time

EPIGASTRIC PAIN

199

she has complained of dyspepsia, sour, bitter eructations, dull pain
in epigastrium, headache, malaise, and gradual loss of flesh about
20 pounds in all.

In May, 1901, she had an attack of severe pain in the epigastrium,
midway between umbilicus and ensiform; the pain was relieved by hot
drinks. A month later had a similar attack; a physician was called,
who said it was acute neuralgia of the stomach. He gave her something
to make her vomit, and she vomited for twenty-four hours almost con-
tinuously, the vomitus consisting mostly of "green, bitter stuff." She
had a similar attack September 1, 1901, relieved by hot drinks. There
was some vomiting in this attack. Next attack, September 8th; then,
September 14th; the last two relieved by morphin, \ grain. The final
attack about October 19th. This last attack was the most severe. Be-
tween attacks patient was fed on liquids and semisolids, and complained
of no pain or indigestion. The pain seemed to start at a spot in the
right back on the level of the sixth or seventh rib, radiating straight
forward to "pit of stomach," thence down the left side of the belly.
There was nothing to be seen at this dorsal spot, but it was painful to
touch. After receiving a subcutaneous injection of morphin, she began
to vomit and continued to vomit about every half-hour for thirty-six
hours. She became very weak, but had a normal temperature and a
pulse of 60. She passed but little urine during this thirty-six hours,
but at the end of it she voided nearly two quarts. Examination of this
urine showed specific gravity 1022, color high, about 0.1 per cent, of albu-
min. Sediment contained few hyaline and fine granular casts, with fat-
drops adherent. A specimen of urine sixteen hours later was smoky, con-
tained 0.1 albumin, and in addition to sediment in previous urine was
full of blood and calcium oxalate crystals. The patient now complained
of pain in both flanks and soreness all over abdomen, especially on right
side. The temperature now is ioc F. and pulse 88. There is headache.
Blood-pressure, 145. No jaundice now or in any of these attacks, but
the patient says she always looked a little yellow.

She is a well-preserved lady, rather fat. Liver normal in size. A
point of extreme tenderness is situated half-way between ensiform and
umbilicus. Heart and lungs negative. Colon distended with gas. The
sclera near the iris is clear blue. On drawing back the eyelid a slight
tinge of yellow is visible at the periphery.

Discussion. Intestinal obstruction is naturally our first thought
when a patient complains of acute abdominal symptoms with persistent
vomiting, and has previously had an operation for strangulated hernia.
But in this case there is no abdominal distention, no constipation or

200 DIFFERENTIAL DIAGNOSIS

diarrhea, no visible peristalsis, and an unusual degree of comfort between
attacks.

When a patient is relieved as markedly as in this case by the
taking of hot drinks, gastric flatulence with pyloric spasm seems a
natural explanation. But this symptom in practically all cases is
dependent upon some deeper cause, such as peptic ulcer or gall-stones.
The long history of dyspepsia leading up to sharp attacks of pain is
consistent with either of the above diagnoses, which will be further
discussed below. One of the confusing elements here is the condition
of the urine. Can the symptoms be due to uremia, which is traditionally
supposed to lead to attacks of abdominal pain in certain cases? The
urine does not suggest acute nephritis, and if any type of chronic nephri-
tis were present, there should be hypertrophy of the heart and a higher
blood-pressure. In all probability, therefore, the urinary findings
are to be explained as the result of some toxic irritation of the kidney,
and are not of any serious significance. In one of the later examinations
the presence of macroscopic blood in the urine is noteworthy as sug-
gesting a possible stone or tumor of the kidney, but one remarks that
this specimen of urine was passed not long after the bladder had been
emptied of two quarts of urine following an acute retention. This
chain of events is notoriously prone to produce hematuria. On the
whole, then, in the absence of any palpable mass in the kidney region,
there seems no good reason to suspect that organ.

We are left with the two diseases so often suspected and discussed
heretofore gall-stones and peptic ulcer. The tender spot in the
back corresponds rather to the pain of gall-stones than to that of ulcer,
and it is especially significant that in one of the attacks the pain started
at this point and radiated thence forward. The immediate relief of
pain by morphin and the absence of indigestion between attacks incline
us to the diagnosis of gall-stones, especially since the less accessible
portions of the sclera have begun to show a yellowish tinge. 1

The prolonged vomiting after the administration of morphin is
presumably to be ascribed to one of the not uncommon idiosyncrasies
in relation to this drug.

Outcome. Next day slight jaundice was evident in the sclera.
This gradually deepened until her skin was almost a coffee color.

1 It is perhaps worth noting here that when we are expecting or suspecting a slight
degree of jaundice, we should examine especially the peripheral portions of the sclera,
which show a yellowish tinge long before there is am- coloration around the iris. Tt is
only in the more pronounced grades of jaundice that the yellow color actually meets the
iris. Attention to this point sometimes renders the more delicate tests of the serum un-
necessary.

EPIGASTRIC PAIN 2 OI

The stools were carefully sifted, but no stone found. Liver tender.
In two days the gall-bladder could be felt. Urine heavy with bile;
stool clay colored. Temperature, ioo to ioi F.; pulse, 80 to 100.
Pain in both flanks. The spot on her back has developed into a mark
that looks as if some local application had been made. It is shaped
like this: 0> has sharply defined edges, is not tender, not swollen, and
not hot.

Operation showed stones in the common duct.

Diagnosis. Gall-stones.

202

DIFFERENTIAL DIAGNOSIS

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Causes of Pain in the Right Hypochondrium

1. PASSIVE CONGESTION OF THE UVER

2. GALL-STONES]
AND ACUTE 1
CHOLECYS-
TITIS

3. HIGH APPENDIX

(INFLAMED)

4. CANCER OF THE

LIVER

646

5. URETERAL STONE 15

6. RENAL STONE I 10

7. PEPTIC STONE | 9

8. SUBDIAPHRAGM-
ATIC ABSCESS

Rarer causes are : Hydro- and pyonephrosis, renal and perirenal
infections, sacro-iliac lesions, and retroperitoneal neoplasms.

204

CHAPTER VI

RIGHT HYPOCHONDRIAC PAIN

Case 96

A boy of twelve entered the hospital April 6, 1908, complaining
of tenderness and pain in the right hypochondrium. He had a tempera-
ture of 100 F. Gall-bladder inflammation was the diagnosis suggested
by his physician. His previous and family history suggested nothing,
but he had been suffering almost constantly for two months with the
pain above described. This pain has been gradually growing worse,
and is now aggravated by deep inspiration. Occasionally he has a
sharp pain in the right shoulder; otherwise than this he has had no
symptoms, and has been able to go to school until five days before his
entrance to the hospital. He has
been decidedly constipated.

Physical examination showed that
the heart's impulse was best seen
and felt in the fourth interspace,
just outside the nipple-line. The
sounds were regular and of good
quality. A soft systolic murmur was
heard at the apex, not transmitted
widely; the pulmonic second sound
was slightly accentuated; the pulse
not remarkable. The lungs were
normal, likewise the abdomen, with
the exception of tenderness and con-
siderable voluntary spasm in the right
hypochondrium and right iliac fossa.
The temperature record is shown
in the accompanying chart. The
leukocytes numbered 0200 April 7th.

April 8th, two days after entrance, the temperature rose to 102. 4
F. and the pain increased. A surgical consultant saw the boy. and
said that the ease was one for exploration of the bile duets, but it was

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?. Chan of cut

206 DIFFERENTIAL DIAGNOSIS

decided to wait until the boy's parents could be communicated with.
In the meantime, dulness and diminished breathing were found in
the lower right back, and on April ioth the abdominal rigidity had
almost disappeared. On this day a hypodermic needle was intro-
duced in the back over the dull area, but no fluid obtained. An .v-ray
taken April 13th showed no lesion of the lung or pleura and no enlarge-
ment of the cardiac area to the right. So far the diagnosis was wholly
in doubt.

April 15th, nine days after entrance, a double pericardial friction
sound was heard for the first time, and the right border of cardiac
dulness on the level of the fifth rib was found to be two inches from the
midsternal line.

Discussion. Gall-stones are so rare in boys of twelve that one
should be very slow to make the diagnosis, no matter how much the
symptoms resemble that disease. Pain and spasm constitute the
whole of our positive evidence pointing toward gall-stones, though the
fever shown on the accompanying chart would be quite consistent with
gall-bladder inflammation. Without more characteristic colic, with-
out jaundice or palpable gall-bladder, we should not make the diagnosis
of gall-stones until every other possibility has been disproved.

Abdominal pain in children always points toward disease of the
chest (pneumonia or pleurisy) as well as of the abdomen. In the well-
meant desire to solve the problem through some diagnosis of this kind
an area of dulness and diminished breathing was worked out in the
lower right back, a most dubious region, owing to the varying height
of the liver dulness. Such signs as were found were not substantiated
in any way by the results of exploratory puncture and v-ray examina-
tion. In view of this they maybe set down as hallucinations of hearing,
due to what the psychologists call "expectant attention."'

From the lips of the majority of physicians we should surely hear
of ''rheumatism'' or "neuralgia'' as explanations of an obscure pain
like this, but in the present case these antiquated blanket-diagnoses
may be excluded without qualification. Boys of twelve do not have
neuralgia or rheumatism at the sites where pain is complained of here.
We must demand that the pain shall be localized at or near a joint
before the word "rheumatism" can find any place, while all pain called
"neuralgic" should follow the known anatomic course of some nerve.

Inflammation of an undescended (subhepatic) appendix is suggested
by the position of the pain and spasm. The onset has not been as
sudden nor the leukocyte count as high as in most cases of appendicitis
associated with so much fever and pain. Nevertheless, until the spasm

RIGHT HYPOCHONDRIAC PAIN

207

disappeared and the pericardial friction made itself apparent, a "high
appendix" could not be ruled out.

We may ask ourselves whether the position of the cardiac impulse
(fourth interspace, just outside the nipple) indicates any pathologic
condition or has any bearing upon the diagnosis. The answer should
be in both cases, no. At this boy's age the heart's apex is not infre-
quently thus situated.

Until the appearance of the pericardial friction-rub I do not believe
that a diagnosis could have been made in this case, nor do I believe
that the pericarditis, which ran its course in so typical a way after that
date, was itself the cause of all the previous symptoms. There seems
to me good reason to believe that many infections, especially in young
people, are in their early stages as wide-spread and unlocalized as their
symptoms. It is probably by a further step in the progress of the infec-
tious process that inflammation appears in a well-marked circum-
scribed area with an exudate and the resulting pathologic changes.
It was with the idea of producing such a localization of a previously
general process that French physicians have employed subcutaneous
injections of turpentine to bring about what they call a "fixation ab-
scess."

Possibly blood cultures would have helped us in this case. They
must be, for the present, our only means of recognizing many infections
in their early, unlocalized stage.

Outcome. On the nineteenth the area of cardiac dulness had con-
siderably increased in size, and now extended well out into the left axilla.
The leukocyte count had meantime risen from 9200 at entrance to
iq,qco on the eighteenth. The friction sound had meantime disap-
peared, while dulness and diminished breath-sounds were detected in
the left lower back.

On the twentieth dulness in the left axilla was found to extend
nearly to the posterior axillary line. The leukocytes numbered 22.000,
with 80 per cent, of polynuclear cells. The diagnosis of pericardial
effusion was then made, and a trocar was inserted in the fifth space, (me
inch outside the left nipple, and just beyond the palpable cardiac impulse.
Seven ounces of turbid, blood-tinged fluid were obtained, with a specific
gravity of 1022; 2.1 per cent, albumin. The sediment of this fluid
showed 87.5 per cent, of polynuclear cells. Xo tubercle bacilli were
found. Immediately after the tapping a double friction-sound eouid
again be heard all over the precordia, and great pain was complained
of in this region. Pain and audible friction continued, with some inter-
vals of relief, durinir the next three davs.

208 DIFFERENTIAL DIAGNOSIS

April 23d the case was again seen by a surgical consultant, and on
the twenty-fourth the pericardium was opened and drained by resecting
a costal cartilage. The boy afterward developed a left pleural effusion,
which finally became purulent, but after rather a tedious illness he
completely recovered.

Notes of Treatment. The bowels were moved by calomel, \ grain
every fifteen minutes until ten doses were given; afterward by cascara
and by an enema. For the pain, hot fomentations and turpentine
stupes were given. A mustard poultice to the abdomen also gave some
relief, and later an ice-bag was placed over the heart and about | grain
of morphin was given daily by subcutaneous injection.

Diagnosis. Pericardial effusion.

Case 97

A highly neurotic Jewish boy of eighteen was seen June 19, 1907.
His illness began in November, 1906, when for two weeks he was troubled
by pain in the right loin and right back, together with "dizzy headaches"
and weakness in his legs. He believes that he strained himself in lifting
a heavy packing-case in October, 1906. In the latter part of December
he had a similar but milder attack. He states that since January 20th
he has suffered from constant pain in the right loin, frequently catching
him with a severe stitch on inspiration. Occasionally the pain has
shot down from his side toward the groin or up toward the epigastrium.
His urine is usually clear, but sometimes stained red, and full of floating
particles. He has gained in weight, but lost in strength since February.

In January he was carefully examined, but no disease found. On
June 12th his urine showed a slight trace of albumin, with many
leukocytes and blood-cells in the sediment. On June 19th a physical
examination was negative except that the right rectus abdominalis was
spastic, and there was tenderness over the right side, most marked at
the edge of the ribs, in the right nipple-line, and in the right iliac
fossa.

At the time of this examination the lower edge of the right kidney
was palpable on deep inspiration, and there was a slight tenderness
along the lower dorsal and lumbar spine. The movements of the spine
were free. He had no fever and no increase in the leukocytes. The
urine varied greatly in gravity, being twice below 1008 and three times
above 1020 within twenty-four hours. It always contained a very slight
trace of albumin, and in the sediment a very small number of blood-
cells and leukocytes. One specimen showed a blood-clot the size of a
bean.

RIGHT HYPOCHONDRIAC PAIN 2O0

Cystoscopy was done on the twenty-sixth, and showed on the floor
of the bladder "a brownish, cylindric, putty-like plug." The orifice
of the right ureter was greatly dilated, and a little pus was seen to issue
from it. A strong, clear stream of urine issued from the left ureter.

Discussion. In the actual presence of this patient it was far more
difficult than in reading the printed case to avoid being unduly impressed
by his neurotic temperament. Any one so manifestly and annoyingly
self-centered, especially if he be of the Jewish race, runs a considerable
risk of being falsely accused or falsely suspected of being "merely a
neurotic." Our better judgment, however, should make it clear that
there is something else in the background.

The patient himself was inclined to attribute all his symptoms to
the strain suffered in the previous October, but on careful questioning
it was clear that the symptoms did not make their appearance until
some weeks after the date of the supposed strain.

We may note that in the physical examination there are no data
regarding the condition of the sacro-iliac joints. Many of the symptoms
here described could be accounted for by some of the acute lesions of
those joints. In fact, however, the joints were normal, although this is
not stated in the text.

The chief moral of this case is the impossibility of a satisfactory
diagnosis through the ordinary methods of physical examination in
many cases involving the right upper abdominal quadrant. Without
cystoscopy a " high appendix" (see case 96) could not have been excluded,
and the diagnosis must have remained long in doubt; indeed, the case
is introduced largely to illustrate the importance of cystoscopy in cases
involving neither bladder symptoms nor ordinary "renal colic."

It remains merely to discuss what lesion we should expect to find
in the kidney on the basis of the facts here given. Malignant disease
of the kidney is rare at eighteen, and cannot be recognized in the absence
of tumor and hematuria. Tuberculosis of the kidney should produce
fever, pyuria, and vesical discomfort. In the majority of cases also a
tumor would be palpable after eight months of suffering. Renal stone
seems the most reasonable diagnosis.

Outcome. An x-ray plate taken on the twenty-eighth showed a
shadow apparently in the pelvis of the right kidney. ( )n the same day
operation confirmed the findings of the .v-ray, though the stone crumbled
up into fine sand when touched. The patient made a good recovery.

Diagnosis. Renal stone.
11

2IO DIFFERENTIAL DIAGNOSIS

Case 98

A factory-hand of twenty-six, whose family history was unimportant,
had typhoid fever when he was eight years of age, and has suffered from
constipation for the past ten years. With the exception of 20 cigarettes
a day, his habits are good.

For the past four months he has been more constipated than usual,
his bowels moving only once in four or five days. For the past two weeks
he has been troubled by headache, which, however, has disappeared
to-day. During this time his appetite has been poor.

Eight days ago he began to have a steady, moderately severe pain
at the right costal margin. Five days ago he noticed that his eyes
were yellow, and that his urine was of a deep-red color.

On physical examination his sclera was found to be moderately
yellow, and his skin considerably discolored. Both tonsils were slightly
enlarged, and there were a few white spots upon the right tonsil. The
heart's impulse was not seen or felt. The sounds were best heard in
the fourth interspace, three inches from the median line. There were
no murmurs nor other modifications of the sounds. There was rigidity
in the right upper quadrant, with tenderness and dulness extending
an inch and a half below the ribs. A sharp edge could be felt to descend
on full inspiration at this point. The upper border of liver dulness was
at the sixth rib. The abdomen was otherwise negative, as were the
other organs. The urine contained bile and a very slight trace of
albumin, but was otherwise normal. There was no anemia and no
leukocytosis.

The patient was first seen on the twenty-second of February. Under
sodium phosphate, 20 grains after meals, and a hot-water bag to the
hypochondrium, he became comfortable, and by March 4th his yellow
color had considerably faded. His constipation was later treated by
cascara and by enemata.

Discussion. Any case involving jaundice and a past history of
typhoid fever suggests a typhoid cholecystitis with the resulting gall-
stones, and this possibility cannot be excluded here. Without colic,
fever, chills, or vomiting, and without a palpable gall-bladder, we
cannot get beyond suspicions in this direction.

Cases of relatively short jaundice, with or without slight enlargement
of the liver, such as is here present, are traditionally labeled as "catarrhal
jaundice" if nothing more definite appears in sight; but it is always
quite possible that we may be dealing in these cases either with a transient
obstruction due to stone or to an infectious cholangitis travelino; down

RIGHT HYPOCHONDRIAC PAIN 211

the ducts rather than up. There is little if any proof that so-called
catarrhal jaundice spreads upward from an inflamed duodenum. For
the present, however, and until our knowledge of the subject is con-
siderably increased, we must be content with the old term.

Outcome. On the fifteenth of March his color was practically
normal and the bile was gone from his urine. He felt perfectly well
and was discharged. There has been no recurrence in three years.

Diagnosis. Catarrhal jaundice.

Case 99

A widower of seventy-seven entered the hospital February 25, 1908.
He has always followed the trade of carpenter and has been strong
and well except for two attacks of malaria, one during the Civil War
(when he served for three years), and the other eight years ago.

Seventeen years ago he was kept out of work for fourteen months
on account of symptoms supposed by one doctor to be due to cancer
of the stomach, by other doctors to be caused by liver trouble. At that
time he suffered pain under the right costal margin; this pain shot
through into his back and was associated with vomiting and frequent
black stools. He never vomited blood, was never jaundiced, and had
no chills, fever, or colic. The pain was always worse at night, but had
no relation to the character of food nor to the time of taking it.

He completely recovered from this attack, and has been at work
ever since except for a period of two months, seven years ago, when
he was in the Massachusetts General Hospital for an attack diagnosed
as duodenal ulcer. At that time he frequently passed blood in his
stools and his weight fell to 200 pounds, where it has since remained.

One year later he had an attack of vomiting with tarry stools, similar
to those passed the year before, but was well again in a few days. Three
years ago he had an attack of vomiting lasting nine hours; there was
no blood in his stools at that time, but lie had to remain in the house for
two weeks. Between the attacks, /. c, for most of the last fifteen years.
he has called himself well. Twenty months ago he had a severe attack
of pain under the right costal margin, accompanied this time by the
appearance of a red spot on the skin just below the ribs, lie was told
by his doctor that he probably had an abscess of the liver. After a
day or two of tills pain his urine suddenly became pink and remained
so for ten days; the pain and the red spot then gradually subsided,
and the urine became normal in appearance.

.1 year ago lie had an attack of indigestion, with pain under the right

212 DIFFERENTIAL DIAGNOSIS

costal margin and fainted, so that he fell out of his chair while the
doctor was talking to him. His habits have always been excellent.

For tlie past six months he has had a continuous, dull pain under the
right rib-margin. This pain gets worse on moving about, is not affected
by food, and occasionally becomes severe, radiating to other points of
the abdomen and to the back. He had such an attack three nights
ago, but was relieved by drinking three glasses of cold water.

Six weeks ago he noticed under the right costal margin a swelling,
which has steadily increased in size and become exceedingly tender
to the touch. He has had no fever, no jaundice, no vomiting, and no
change in the amount or color of his urine. He has noticed nothing
remarkable about his stools.

Physical examination reveals no emaciation and nothing abnormal
in the chest. The right costal margin is markedly prominent, and in
the center of this prominence is a rounded protrusion which is very
tender. (See Fig. 33 .) The tender mass is firm and somewhat movable,
sometimes reaching the median line in the epigastrium. The edge of the
liver is felt just below the mass, and is apparently somewhat irregular.

Physical examination is otherwise negative, likewise the blood and
urine. His stools contain no occult blood. After further observation
it was found that the tumor would move with a change in the patient's
position until it reached the left costal margin; with this motion the
upper border of liver dulness also moved downward. Examined by
means of a stomach-tube, the stomach was found to reach one inch
below the navel when inflated. The upper border was at the tip of
the ensiform cartilage. The stomach-contents after a test-meal showed
hydrochloric acid, 0.11 per cent., and total acidity, 0.17; no occult
blood.

Discussion. The early history of this case points straight to the
diagnosis of duodenal ulcer. Between these initial symptoms, how-
ever, and the sufferings of the last six months, there are two curious
episodes which may be first briefly discussed.

How are we to explain the appearance of the red spot in the right
hypochondrium and the close sequence of pink-colored urine? Since
these symptoms began together and ceased together, it is reasonable
to look for a common cause. We may conjecture that the spot on
the hypochondrium was due to a "purpuric" extravasation of blood,
and that the urinary oloration was due to a similar ecchymosis in the
kidney. Such occurrences would be easily explicable were jaundice
present, for we are well accustomed to see all sorts of oozing and hemor-
rhages in jaundiced patients. It has been pointed out, however, by Dr.

Fig- 33- diagram of signs recorded in a patient who complains of pain and swelling

under the right ribs.

RIGHT HYPOCHONDRIAC PAIN

213

Maurice H. Richardson and others, that the hemorrhagic tendency in
diseases of the liver is not confined to those which produce jaundice.
If, therefore, we assume, as seems warranted by the outcome of the
case, that this patient may have had liver disease at the time of the
phenomena we are now attempting to explain, the idea of multiple
hemorrhage would be plausible.

What shall we say of the fainting attack which occurred a year ago?
Since this patient has had repeated and profuse intestinal hemorrhages,
presumably from duodenal ulcer, it seems not unlikely that the faintness
was due to the repetition of such a hemorrhage.

Coming now to the events of the last six months, we find them
characterized by continuous pain in the region of the liver, apparently
unconnected with the taking of food, but complicated later by enlarge-
ment and irregularity of the liver.

In patients who have never lived under conditions favorable to
hydatid infection (association with sheep and sheep-dogs, especially
in Greece, Australia, and Iceland), we need consider only two diseases
to explain a nodular enlargement of the liver, viz., cancer and syphilis.
The nodules due to cirrhosis are rarely if ever palpable through the
abdominal walls. The hepatic enlargements due to passive congestion,
fatty infiltration, leukemia, pseudoleukemia, amyloid disease, obstruc-
tive jaundice, and abscess do not produce a nodular surface. Our
problem, then, is reduced to narrow limits cancer or syphilis. I
have never known syphilis to produce so much pain as was suffered
in this case. The absence of fever is also against this diagnosis. The
same is true in a lesser degree of the absence of syphilitic history and
syphilitic lesions in other parts of the body.

Cancer of the liver which seems the most probable explanation
of this man's present sufferings is rarely primary. We may suppose
it to be secondary to a growth implanted in the site of the peptic ulcer
which we have good reason to believe existed some years ago. Yet
we have no definite evidence of any such growth in the stomach or
duodenum, and the starting-point of the disease must be left in uncer-
tainty.

Outcome. On the seventh of March the abdomen was opened
and showed a firm, nodular mass of malignant disease in the liver about
the size of a cocoanut. The abdomen was closed and the patient lett
the hospital oh the nineteenth of March. lie died three months later.

Diagnosis. I lepatic cancer.

214 DIFFERENTIAL DIAGNOSIS

Case 100

The patient is a stable-man of thirty-six who was first seen March
7, 1908. He had a good deal of trouble with his stomach three years
ago, but since then has been well until four weeks ago, when he began
to vomit and to have severe pain in the right upper quadrant. His
vomitus sometimes contains large quantities of food. The pain is very
severe, and for the last two weeks has forced him to walk the floor every
night and to take morphin tablets.

At present his pain is at its worst about two hours after meals; it is
also very troublesome at night; sometimes it shoots across to the left
costal margin and up to the right nipple. For three weeks he has eaten
only bread, milk, and tea.

On physical examination his right pupil was found to be slightly larger
than his left. Both react normally. The skin was everywhere notably
smooth and satin-like to the touch. His radial arteries were considerably
thickened, and his aortic second sound was greater than his pulmonic;
otherwise nothing wrong was found in the chest. There was moderate
tenderness in the right upper quadrant. Physical examination, includ-
ing the blood and urine, was otherwise normal. A stomach-tube passed
before breakfast showed no fasting contents. The capacity of the
stomach was 24 ounces, and the percussion outlines after distention
with air indicated no dilatation of the organ. Microscopic and chemical
tests of the gastric contents after a test-meal revealed nothing abnormal.

It was later ascertained that this attack followed a debauch in which
he took whisky, beer, and ale to excess for a week, "which," he says,
"scalded his insides." Before that he had taken no liquor for years.

Discussion. By force of ancient tradition we are accustomed
to think of syphilis as a cause for all pains which are worse at night.
We have seen, however, from the cases already studied in this book,
that pain due to hyperchlorhydria, to peptic ulcer, gall-stones, and
lead-poisoning, is also aggravated at night in many cases. In the pres-
ent case the suspicion of syphilis is somewhat increased by the finding
of thickened radial arteries, accentuated aortic second sound, and
unequal pupils; yet there is nothing sufficiently definite in the physical
examination to justify a diagnosis of visceral syphilis.

Of the other causes of pain above mentioned there is not sufficient
evidence, though only lead can be positively excluded. The most
significant point of the physical examination is the satin-like surface of
the skin. This quality, when well marked in workingmen, is strong
evidence of recent alcoholism, and when, as in this case, the history

RIGHT HYPOCHONDRIAC PAIN

215

does not at once suggest any such habit, the evidence obtained through
a routine physical examination, which includes a note on the condition
of the skin, may be most important. This is especially true when no
other cause can be found for the sudden appearance of marked gastric
disturbances in an adult.

Outcome. The patient was put on Lenhartz's diet, and in a couple
of weeks seemed perfectly well.

Diagnosis. Alcoholic gastritis.

Case 101

A young Jewish house painter eighteen years old, who was first seen
March 16, 1908, has had several attacks of rheumatism, but neverthe-
less has considered himself well until five weeks ago, when he began
to suffer from pain in the right upper quadrant, together with dyspnea
on exertion, weakness, and cough, with frothy white sputa. For the past
ten days he has been in bed, and found it impossible to lie down at night
on account of cardiac distress.

On physical examination he was found to be pale and slightly cyanotic.
The veins of his neck were markedly distended and showed a systolic
pulsation. The carotids also pulsated vigorously. The heart showed
a diffuse pulsation in the second, third, fourth, and fifth left interspaces,
but the maximum impulse was seen and felt in the sixth spac2 i inches
outside of the nipple-line. The area of cardiac dulness extended 2\
inches to the right of midsternum, and the cardiac impulse could be
felt for nearly an inch beyond the right of midsternum. The heart
was regular; rate, no. At the apex a systolic and a presystolic murmur
were heard. In the left axilla and along the left sternal border the sys-
tolic murmur was much more intense, and a musical diastolic murmur
was heard. The pulmonic second sound was much accentuated; the
aortic second sound was absent. The pulse was of low tension and
of the Corrigan type, but no capillary pulse was demonstrated. The
lungs were normal except for the presence of a few moist rales at the
base of the left axilla. There was dulness in the flanks, shifting with
change of position. The edge of the liver was felt three inches below the
ribs. The organ was tender, and moved with each systole. The urine
averaged 30 ounces in twenty-four hours, with a specific gravity ol icj;.
There was a slight trace of albumin and a few granular casts. The
blood showed nothing abnormal. There was no fever.

Discussion. In relation to the prognosis and treatment oi this
case it is important to form some estimate of its duration. Kven a
cursory studv of the cardiac lesion must convince us that the heart

2l6 DIFFERENTIAL DIAGNOSIS

was diseased for some time previous to the last five weeks, during which
he has called himself sick. In view of the size of the heart and the
character of the murmurs (which suggest stenoses and therefore chronic-
ity) we may assume that the disease has existed for months, if not for
years.

Cardiac lesions involving marked hypertrophy are most often due to:

(a) Valvular disease.

(b) Chronic nephritis.

(c) Adherent pericardium, with or without interstitial myocarditis.
Renal disease may be ruled out by the low tension of the pulse and

by the characteristics of the urine. Adherent pericardium by itself
cannot produce so marked a diastolic murmur and would not account
for the arterial changes (Corrigan pulse). We cannot exclude the
possibility of adherent pericardium complicating other lesions, but
alone it would not account for the facts.

The signs certainly point to the existence of disease at the aortic
valve, and probably to a similar condition at the mitral. Is the aortic
lesion single or double? The physical signs give us assurance only of
aortic incompetence, but postmortem experience has led me to believe
that whenever aortic regurgitation is recognized in a cardiac case of
considerable duration occurring in a young person, aortic stenosis is
almost always present as well, whether the physical signs indicate it or
not. In other words, aortic disease due to endocarditis almost always
produces stenosis as well as regurgitation if it has lasted longer than a
few weeks.

As this case occurred previous to the discovery of the Wassermann
reaction, we had no means of ascertaining whether the aortic lesions
were possible or probably due to syphilis.

As regards the mitral valve, we have no way of being sure whether
or not an endocarditis has been at work there. The systolic murmur
might be due to relative insufficiency without lesion of the valve itself,
while the presystolic murmur might be of the type described by Austin
Flint. But the strong accentuation of the pulmonic second sound
gives us reason slightly to favor a definite mitral lesion.

Obviously, there is passive congestion of the liver, explaining the
pain and tenderness in the right hypochondrium, and these facts,
together with the gathering ascites (shifting dulness in the flank), make
it clear that the tricuspid valve is leaking badly. This still further
inclines us to assume an organic mitral disease. The urine is typical
of passive renal congestion.

Why should the heart have begun to fail just at this time? We are

RIGHT HYPOCHONDRIAC PAIN

217

apt to explain such events through a so-called break of compensation
supposedly of mechanical origin. The individual is supposed to have
reached and overpassed the limits of his cardiac reserve power. It
has been pointed out, however, especially by Dr. Charles Hunter Dunn, 1
that many of the so-called breaks of compensation, occurring as they
usually do without any known strain or overexertion, are, in fact, due to
a fresh outbreak of the endocarditis which has previously been smoulder-
ing upon the diseased valve. This possibility is especially to be thought
of when the supposed break of compensation comes, as it were, out
of a clear sky, and is accompanied by a polynuclear leukocytosis, with
or without a slight elevation of temperature.

Outcome. The boy lived in the hospital from March 6th to April
8th. At no time did he show any improvement; and despite digitalis,
strychnin, morphin, magnesium sulphate, diuretin, calomel, squills,
and other drugs, he died on April 8th.

Autopsy showed fibrous endocarditis of the mitral and aortic
valves, with stenosis and insufficiency of both. There was also a fresher
verrucose process on both valves, and some acute degeneration of the
myocardium.

Diagnosis. See last paragraph.

Case 102

An Irish laborer fifty-eight years old entered the hospital February
18, 1908. His family history was unimportant, but he stated that for
the past two years he had had ''bronchitis," and that he had used each
week 70 cents' worth of tobacco all his life, until eighteen months ago;
very little since. Since the middle of October his "bronchitis" has been
very severe, and he has felt weak and tired, but as the rest of the family
were out on a strike, he had to keep at work. Three days ago he got
wet through, and since then he has been in bed. He complains of
pain in the right hypochondrium, with dyspnea and cough, especially
when he is working. He raises yellow sputum in considerable amounts,
but has never raised blood. Last November he was troubled for some
weeks with pain in the left side of his chest. Two years ago he weighed
185 pounds; now he weighs 135. Whenever he coughs he has an
aggravation of the pain in the right side of the abdomen beneath the
ribs.

Physical examination showed small, irregular pupils, which reacted
normallv. The throat was reddened and slightly swollen; the heart's
action irregular in force and rhythm, but showing no other abnormality.

1 1 >unn, Jour. Amcr. Med. Assoc, February g, 11)07.

2i8 DIFFERENTIAL DIAGNOSIS

His pulses were apparently of increased tension, and his arteries easily
palpable, but on measurement his blood-pressure showed only 120
mm. Hg. There was no dyspnea in the recumbent position and no
edema anywhere. The lower two-thirds of the right lung behind
showed dulness. At the base there was intense bronchial breathing,
with marked increase of voice-sounds and fremitus and many fine,
moist rales. These sounds became less marked in the upper portion
of the dull area.

During a ten days' stay in the hospital there was no notable change
in the physical signs. The patient had an irregular pyrexia, reaching
as high as 102 F. at frequent intervals, but always falling below normal
at some time in the twenty-four hours.

Discussion. Chronic bronchitis (usually with disseminated bron-
chiectatic cavities) is the commonest cause of a long-standing winter
cough in elderly people. The fact that this patient's cough appears
to last all the year round does not exclude this type of bronchiectasis,
but the fact that it is accompanied by loss of weight, by pain in the
right hypochondrium, and by intense bronchial respiration at the base
does not fit in well with bronchitis and bronchiectasis. The sputum
examination is very important in solving this problem.

The irregularity of the heart and the evidence of degeneration in
the peripheral arteries make us wonder whether the signs at the base
of the right lung may not represent a hydrothorax due to cardiac weak-
ness. The signs, to be sure, are by no means typical of hydrothorax,
but might possibly be consistent with that condition, were it not that
the absence of dyspnea and edema points strongly against the existence
of any cardiac weakness sufficient to account for hydrothorax.

If we fix our attention upon the physical signs alone, there is much
to suggest a pulmonary abscess, dependent either upon a postpneumonic
empyema rupturing into a bronchus or upon some unknown cause
(" primary pulmonary abscess ") . But the long duration of the symptoms
and the lack of any suggestion of acute onset make this rather unlikely.

But for the unusual position of the signs, it would be natural to
consider pulmonary tuberculosis first of all in this case. Even as it is
this disease is by no means to be excluded. Repeated and thorough
examinations of the sputa are called for.

Outcome. The sputum showed many tubercle bacilli and also
many pneumococci, both within and outside of the leukocytes. The
patient remained in the hospital until the second of March without show-
ing any considerable change in any respect, except that he gained 4
pounds in weight. He is troubled greatly with insomnia, for which

RIGHT HYPOCHONDRIAC PAIN 219

he was given chloral hydrate, 15 grains, on two occasions, and veronal,
10 grains, once. His coughing was relieved by \ grain of codein, and
his bowels were kept regular by A. S. and B. pills. After the first few
days he was able to be up and out-of-doors, and gained considerably in
strength.

Diagnosis. Phthisis.

Case 103

An English tailor thirty-eight years of age, who entered the hos-
pital March n, 1908, had been complaining of pains throughout his
body, especially in his lower legs, for the past seven weeks. The
pains were so severe as to compel him to give up work, but were
relieved by treatment. Three days ago he began to have pain in
the right upper quadrant, radiating to other parts of the abdomen and
downward. His appetite has been poor, but he has not vomited. His
bowels have been moved by cathartics. Three days ago he had two
severe chills, and since then he has sweat a good deal at times.
Nothing abnormal was noticed about his water.

Physical examination revealed nothing wrong in the chest. The
abdomen was full, tympanitic throughout, and held rather rigidly.
The patient appeared to suffer a good deal of pain, but when his atten-
tion was distracted, one could palpate deeply without discovering any
tenderness. Attempts to move the bowels were not satisfactory. The
leukocyte count at entrance was 14,000; next day it had risen to 21,000,
and on the third day to 25,200. His temperature ranged between 101
and 102 F.; his pulse, between 90 and 100. His urine showed nothing
abnormal.

Discussion. The patient's account of himself leaves us still in the
dark as to the nature of his trouble. Discovering that his abdominal
tenderness apparently disappears when his attention is distracted, we
are in danger of discounting his other and more serious symptoms.
But with pain, chills, and an increasing leukocytosis there is almost
certainly a focus of infection somewhere. Our best guide in all proba-
bility is the initial pain, since he has not yet arrived at that third stage
in the development of an infection at which, after scattering itself in
confusing radiations, the pain and tenderness finally "settle" over
the site of the disease. (See further discussion of tins point' on p. 207.)

There is nothing in the data here presented to incriminate the
kidney or the stomach. On the whole, therefore, the most likely place
for investigation is the gall-bladder. Nevertheless, there are many
other possibilities. 1 have seen a case much like this in which throm-

220 DIFFERENTIAL DIAGNOSIS

bosis of a mesenteric artery was found at operation, but I have never
known that diagnosis correctly made before operation. Appendicitis
and portal phlebitis are also possible.

Outcome. Laparotomy on the thirty-first revealed an acute chole-
cystitis.

Diagnosis. Acute cholecystitis.

Case 104

A Hungarian woman of sixty entered the hospital August 22, 1907,
complaining of two months' pain in the right upper quadrant of the
abdomen, but asserting that her sickness was wholly due to the behavior
of her step-daughter. As a result of this the patient has lost her appetite,
become constipated and rather sleepless, but has not given up work.
She has had five children and no miscarriages, and has always con-
sidered herself well. She passed the menopause twenty years ago;
her past history and family history have been wholly good.

On examination she was found to be decidedly pale. There was
no glandular enlargement. There was ptosis of the left upper eyelid,
but the eyes were otherwise normal except for marked irregularity of
the pupils and a failure to react to light. The chest revealed nothing
abnormal. The abdomen was large and flabby. The whole of the
right half of it was occupied by a hard, smooth, irregular mass, immova-
ble, not tender, and very sharp at the edge. The dulness over this
area was continuous with the liver dulness, which began at the sixth
rib. The lower border of the tumor was six inches below the costal
margin (Fig. 34). There were slight edema along the shins and marked
varicosity of the veins in both legs.

The hemoglobin was 20 per cent.; leukocytes, 2000; the urine
normal. Vaginal and rectal examinations were negative. The gastric
contents extracted after a test-meal showed no free hydrochloric acid
and no occult blood. The capacity of the stomach was 50 ounces.
There was no residue before breakfast.

Discussion. The problem here is of a tumor in the right hypo-
chondrium with anemia a tumor which gives every evidence of being
coarsely irregular in shape. Under these conditions the possibilities for
diagnosis are as follows:

(a) Liver cancer, syphilis; much less probably hydatid, enlarged
gall-bladder, downward displacement of the normal organ.

(b) Kidney tuberculosis, hydronephrosis or pyonephrosis, cystic
degeneration, neoplasm.

I-'ig. 34. Outlines of a mass felt in Case 104. Chief complaint is pain in the right hypo-

chondrium.

RIGHT HYPOCHONDRIAC PAIN 2 21

Tumors of the stomach or intestine are practically out of the ques-
tion. Masses of exudate and matted intestines, such as occur with
tuberculous peritonitis, are smaller and have no sharp edge.

Returning, then, to the three main groups listed above, we may
exclude displacements of the liver and enlargements of the gall-bladder,
since the shape of the tumor here present does not correspond at all
with any of these.

Hydatid cysts of the liver do not produce so grave an anemia and
are usually large enough to be perceptible by the individual and com-
plained of by him before the physician discovers them. This patient
was wholly unaware of her tumor.

Cancer and syphilis of the liver remain as possibilities, to the dis-
cussion of which we shall return presently.

Of the tumors connected with the kidney, those due to tuberculosis
are perhaps the commonest. They almost invariably produce pyuria
and bladder symptoms, which are not present here. Further, the shape
of this mass and its position in the abdomen are not at all characteristic
of tumors originating in the kidney. Fever and pain would also be
expected in a patient suffering from renal tuberculosis, though these
symptoms are less constant than those above mentioned.

Hydronephrosis and pyonephrosis produce smooth, rounded tumors,
usually elastic in feel, and more deeply situated in the loin than the
mass here in question. They often appear intermittently, their dis-
appearance being accompanied by an increased flow of urine.

Cystic kidneys are practically always congenital and bilateral.
They are not associated with anemia; indeed, none of the renal lesions
hitherto mentioned produces any considerable anemia in the great
majority of cases.

New-growths of the kidney may produce grave anemia, but when
this is the case, they arc practically always associated with hematuria,
which has been absent here.

Retroperitoneal tumors originating in the prevertebral glands occa-
sionally present a picture much like that here seen. The fact that the
tumor is immovable tends to identity it with a retroperitoneal structure,
rather than with the liver. Not infrequently these retroperitoneal
tumors displace the liver downward and forward, so that what our
hands feel is, in fact, not the new-growth itself, but the normal liver.
I have taken part in long and fruitless discussions as to what disease
of the liver is present in a case of this kind, only to discover at operation
or autopsy that we have been suspecting the wrong organ. The nodular

22 2 DIFFERENTIAL DIAGNOSIS

surface of the growth from which this woman is suffering excludes the
latter possibility.

The tumor is certainly not the normal liver: it is either a diseased
Hver or a new-growth arising elsewhere.

With these possibilities in mind we return to the general study of
the case, and are struck by the fact that the patient has a ptosis and
pupils unresponsive to light, both of which symptoms are characteristic
results of old syphilis. This naturally makes us inclined to follow up
the clue and try the therapeutic test. A course of iodid and mercury
will do no harm to any malignant new-growth, and will probably produce
marked improvement, local and general, if the liver be syphilitic.

Outcome. Under mercurial inunctions and potassium iodid, 5 to 50
grains, the patient improved very markedly in ten days, and the size of
the tumor rapidly decreased. Except for occasional doses of veronal, 5
grains, and the painting of a 25 per cent, alcoholic solution of menthol
over the epigastrium for the relief of pain, no other medication was given.

Diagnosis. Hepatic syphilis.

Case 105

A Russian Jewess of forty-two has been complaining for eighteen
months of a burning pain in the right upper quadrant, almost constant,
often keeping her awake, sometimes shifting into the back, but never
colicky or paroxysmal. She has vomited occasionally, but has never
been jaundiced. For the same period she has had distress across the
upper half of the abdomen after meals, with belching and constipation,
her bowels moving only every four or five days. For three months all
these symptoms have been aggravated, and she has vomited green
materia] nearly every day. She has never vomited any blood or any
food. She thinks she has lost much weight. She has no appetite
and has been in bed much of the time of late.

The patient was obese, the chest negative, the abdominal wall loose,
flabby, and soft. The right kidney could be felt at three fingers' breadth
below the ribs, and the edge of the liver was also palpable. Physi-
cal examination, including the blood, pulse, temperature, respiration,
and blood-pressure, was normal. The urine ranged between 25 and 35
ounces in twenty-four hours, with a specific gravity from 1012 to 1019;
there were very slight traces of albumin and a few hyaline, granular,
and brown granular casts. Examination of the stomach-contents and
of the stools revealed nothing abnormal.

Discussion. When a Russian Jew complains of a "burning pain,"
it usually turns out, on closer questioning, that he has a burning and

RIGHT HYPOCHONDRIAC PAIN 223

not a pain. The word "burning" (brennend) is used by the Jews far
more often in describing their symptoms than by any other race, and, as
a rule, patients who use this term turn out to be free from organic disease.
Whether it is a cutaneous paresthesia connected with nervous debility,
or whether it is connected with gastric stasis and fermentation, is often
very difficult to determine.

Gastric symptoms appearing for the first time in a person over forty
always make us think of cancer of the stomach, but if that disease had
existed for eighteen months, we should be almost certain to find stasis,
emaciation, or anemia. Peptic ulcer cannot be positively excluded,
but the symptoms are not definite enough to warrant our beginning
treatment for that affection until more probable alternatives have been
tried out.

The palpable kidney and the presence of albumin and casts in the
urine make it our duty to consider whether the symptoms may be due
to some form of renal disease. These symptoms could be produced by the
kidney if the latter exerted direct pressure upon the pylorus or intestine,
so as to retard their movements in the course of digestion. But this
seems very unlikely in view of the moderate size and free mobility of
the organ. The kidney might also be responsible for suffering like
that here described if it were the seat of a chronic nephritis with uremia,
but the normal condition of the heart and blood-pressure makes this
unlikely, and the urine is not at all typical of acute nephritis.

Evidently the patient has a general visceroptosis, and this, with
her obesity, her incompetent abdominal muscles, and her constipation,
might well be sufficient to account for her complaints.

It ma}' be well to say a word here about the psychic significance
of green vomiting. Of course, every physician is aware that, from
the physical point of view, any long-continued or violent vomiting
produces green-colored vomitus through the compression exerted upon
tlie gall-bladder by the abdominal walls. But in the patient's mind
green vomiting has often a dark and terrifying significance, so that
it is well explicitly to reassure any patient who complains of this symptom,
remembering that he does not share our understanding of its harm-
lessness.

Outcome. A snugly fitting abdominal bandage gave the patient
verv marked relief, and when her bowels had been regulated by the
use of calomel, I grain every fifteen minutes until ten doses, followed
in half an hour bv a seidlitx powder and thereafter by caseara, she was
able to leave the hospital, much relieved, at the end of two wirks.

Diagnosis. Hiingebauch.

224 DIFFERENTIAL DIAGNOSIS

Case 106

A carpenter of fifty-four entered the hospital June 19, 1908, with
the statement that six weeks ago, while at work, he had a sudden attack
of pain in the right upper quadrant, radiating to the right shoulder. This
pain was relieved by a hot drink, and disappeared in about three hours.
He vomited once that night. He went to work the next morning. A
week later the pain returned, and it has since been nearly continuous,
though for the past two days it has been less severe. At the onset it was
accompanied by a swelling of the abdomen and by jaundice. He
has had dark urine, light stools, and much itching for the past five
weeks. Fever and vomiting have been absent. His appetite has been
poor, and he has had moderate constipation.

On examination, moderate jaundice and marks of scratching were
everywhere evident. The chest was normal. The abdomen showed
tenderness in the epigastrium and for several inches to the right of this
point. The upper right rectus was more resistant than the left. The
edge of the liver could be felt an inch and a half below the rib margin.
The patient has lost 42 pounds in the past eight weeks.

Discussion. The diagnostic problem confronting us concerns the
cause of emaciation, jaundice, steady pain, and enlargement of the liver
in a man of fifty-four. Cancer of the pancreas or of some portion of the
bile-ducts would produce all these symptoms, and is their commonest
cause in men of this age, but it is hard to understand why any of these
lesions should produce so sudden an attack of pain and of jaundice.
The supposed cause cancer being an affair of gradual growth, one
would expect the symptoms to develop gradually, not suddenly. Never-
theless, clinical experience has shown that cancer may manifest itself
suddenly, and with the symptoms here described. We must face the
fact, whether we understand it or not. Against cancer is the ab-
sence of an enlarged gall-bladder, which is the rule when cancer
obstructs the bile-ducts. But this objection is not sufficient to make
us certain that cancer is not present. The possibility must still be
entertained.

Stone in the common duct might produce all the symptoms under
discussion, and would account, better than cancer does, for the sudden
onset and the biliary colic. The loss of 42 pounds in eight weeks as
a result of cholelithiasis alone is at first sight astounding, but experience
shows that it is not at all unusual. More unexpected is the absence
of fever, chills, vomiting, and of variations in the intensity of the jaundice,
all of which are the rule when a stone blocks the common duct. The

RIGHT HYPOCHONDRIAC PAIN 225

moderate degree of jaundice, on the other hand, favors stone rather than
cancer.

Obliteration of the bile-ducts by the scar of an inflammatory process,
due to syphilis or some other cause, is a very rare lesion. It is usually
gradual in onset and does not produce sharp pain.

Nothing is said in the history about the patient's habits. If we
choose to assume that he was a confirmed alcoholic, his jaundice might
be due to cirrhosis of the liver, especially as the edge of that organ is
easily palpable. The sudden pain, however, could hardly be due to
cirrhosis, and, as the case stands, we have nothing to support such a
hypothesis. The habits should be further investigated.

On the whole, the diagnosis must remain in doubt as between stone
and cancer, the odds slightly favoring stone.

Outcome. On the twenty-second of June the abdomen was opened
and two large stones were removed from the common bile-duct. The
patient made an uneventful recovery.

His itching was relieved by a powder consisting of sodium salicylate,
talc, and starch in equal parts, dusted on the skin, and also by an alkaline
bath.

Diagnosis. Stone in ductus choledochus.

Case 107

An unmarried woman of twenty-nine entered the hospital March
11, 1908. Since the age of sixteen she has had at times "stoppage of
the bowels," worse when she is on her feet. When questioned as to
the nature of this stoppage, she stated that it consisted of pain in the
right upper quadrant, so severe that she cannot stand the pressure of
her clothes, accompanied by the presence of a lump which is more
prominent when she exercises. This trouble has been especially bad
for the past five months. Her bowels rarely move without medicine,
and her stools are small, hard, and often black. She has a poor appetite,
but never vomits. She had considerable cough and sputa off and on for
years, but has never raised blood. For four months she has had much
dyspnea and palpitation. Her urine is at times scanty, never bloody,
and never passed in large amounts. She has lost five pounds in the
last two years.

The patient is pale (hemoglobin, 75 per cent.). Scattered on the
right half of the trunk and the inner aspect of the right upper arm are
numerous light-brown, irregularly shaped spots. The glands are
palpable in the axillae and groins. The tongue is bat shaped widest
at the tip. It is protruded very far, and during this act the anterior

226 DIFFERENTIAL DIAGNOSIS

pillars of the fauces are drawn forward. A low-pitched systolic murmur
is heard over all the precordia, but not transmitted beyond that area.
The heart shows no enlargement. The pulmonic second sound is
greater than the aortic second. In the epigastrium a violent pulsation,
vertical and lateral, is felt, raising the hand three-quarters of an inch
at each beat of the heart. Beneath the margin of the right ribs a
smooth, rounded mass, about four inches long and two inches wide,
can be grasped between the hands and moved about in all directions.
It is very tender.

Discussion. The points deserving discussion in this case are the
nature of the "stoppage of the bowels," the interpretation of the heart
murmur in connection with the patient's dyspnea and palpitation, the
significance of the way in which the tongue is protruded, the nature
of the rash upon the chest, and the importance of the mass in the right
hypochondrium.

It is clear that she has no stoppage of the bowels. We have to
explain, however, why the lump complained of in the upper right quad-
rant and the pain which accompanies it are more prominent on exer-
tion. This is the case not infrequently with a tender, passively congested
liver, the result of cardiac insufficiency. But have we any such insuf-
ficiency in this case?

Since the heart is not enlarged and the pulmonic second sound no
louder than we should expect it to be in a woman of twenty-nine, we
have only the murmur to suggest heart disease. But from a systolic
murmur alone it is never wise to infer the presence of any disease of
the heart, especially when the patient is anemic. It seems reasonable
to consider this murmur as hemic or functional. We have no reason,
then, to believe that the heart is failing or that the lump in the right
upper quadrant has any relation to it.

A patient who protrudes his tongue in the way described above,
so that the whole of it can be seen, has usually been in the habit of
looking at his tongue in a mirror. The pillars of the fauces are then
drawn forward by the effort to get the tongue completely into the outer
world. These facts give us a certain inkling of the patient's mental
condition and of its possible bearing on the interpretation of his symp-
toms.

The eruption here described seems to correspond with that produced
by tinea versicolor. Though other possibilities are open, this seems
the most reasonable one, provided the lesions are of long standing.
This is the most common position for an eruption of that origin.

The mass in the right hypochondrium corresponds accurately to

RIGHT HYPOCHONDRIAC PAIN 227

the description of a floating kidney, though not all such kidneys are
tender. It is probably the lump which the patient felt at the times when
she supposed herself to have stoppage of the bowels. This would
account for its greater prominence when she is on her feet.

The association of floating kidney with a great variety of so-called
neurasthenic symptoms is a very familiar fact clinically. That this
patient is of a neurotic temperament is suggested by the violent beating
of the abdominal aorta (dynamic aorta), by the way she puts out her
tongue, and by her chronic constipation. In the absence of any other
lesions discoverable on physical examination the diagnosis of floating
kidney associated with slight anemia in a neurotic person seems the best
explanation of the symptoms. The dyspnea may well be due to the
anemia.

Outcome. The patient was given a close-fitting abdominal binder,
which apparently gave much relief. Reassurance and general tonic
treatment (Blaud's pill, 10 grains thrice daily, tincture of nux vomica,
10 to 50 drops before each meal) played a large part in her recovery.

Diagnosis. Debility; floating kidney.

Case 108

An American woman of forty-six has been doctoring for stomach
trouble for five months. A month ago she was taken suddenly with a
profuse black, watery diarrhea. This was followed by vomiting, chills,
and pain in the epigastrium and back. For a week she was kept more
or less under opium, after which the gastric and intestinal symptoms
abated, but she has remained in bed most of the time since then, in a
very exhausted condition, and suffering most of the time from pain in
the right upper quadrant and in the small of the back. This pain is
constant, with occasional exacerbations. Opium has frequently been
given. For several weeks she has taken only liquids. Although the
pain appears only in relation to eating, she vomits nearly every day at
irrregular intervals. She has never vomited blood, and has never been
jaundiced. She has had a slight cough for five years, and dyspnea
on exertion for one year. She has lost 13 pounds in the past two years.
The pain is often severe enough to keep her awake at night.

On physical examination the mucous membranes are found pale.
The chest is negative, except for slightly diminished respiration in the
right back, below midscapula. The abdomen is entirely negative, except
that the edge of the liver is palpable on deep inspiration.

The blood shows red cells, 4,032,000; white cells, 6S00; hemoglobin,
55 per cent.

228 DIFFERENTIAL DIAGNOSIS

The stained smear shows some achromia and poikilocytosis. The
differential count and the other features of the blood are normal. Care-
ful examination in a warm bath, with complete and satisfactory relaxa-
tion of the abdominal muscles, shows absolutely nothing abnormal.
Examination of the stomach shows no fasting contents. The gastric
capacity is 36 ounces the lower border of the organ one inch below
the navel after inflation. After a test-meal no free hydrochloric acid
and no organic acids are found. The guaiac test is negative in the
gastric and intestinal contents.

After three weeks' stay in the hospital the patient gained three pounds,
but continued to complain of pain and seemed very miserable.

Discussion. The black color of the stools, associated with a long-
continued gastric disturbance, forms an important portion of the picture
of peptic ulcer. We must remember, however, that as she has been
doctoring for stomach trouble for five months and has taken a great
deal of opium, it is quite possible that her symptoms may be due wholly
or in part to the treatment. Black stools may well be due in this case
to that commonest of gastric medicaments, subnitrate of bismuth. In
patients who have been through five months of this kind of treatment
it is not at all surprising to find hydrochloric acid absent from the gastric
contents. Her stomach empties itself normally, shows no enlargement
and no blood. One more point serves to increase our confidence that
no visceral disease is present, namely, the complaint of a year's dyspnea
by a patient whose heart and lungs are normal. This dyspnea ante-
dates the occurrence of stomach symptoms by at least seven months.
This would be quite natural if we supposed that the dyspnea and the
stomach symptoms were alike due to the anemia shown by the present
blood examination. If, on the other hand, the anemia resulted through
hemorrhage from an ulcer, the dyspnea should not have antedated the
stomach symptoms.

Yet, after the use of treatment based upon the idea that anemia was
the cause of her symptoms, there was no clear proof that we were right
and it seemed best to explore the abdomen.

Outcome. Operation by Dr. F. B. Harrington revealed absolutely
nothing, but the patient seemed greatly improved after it, and when
last heard from had continued in good health. Cases of this type
should be borne in mind when discussion arises regarding those opera-
tions for "chronic appendicitis" in which the appendix shows signs of
appendicitis only to the eye of the surgeon, while the pathologist remains
unconvinced.

"But the patient's symptoms abated after the operation," says the

Fig. 35. Diagram of bulging and resistance as recorded in Case 109. Symptoms, pain
over the above area, weakness, dyspnea, and cough. (See also Fig. 36.)

Fig. 36. Signs discovered in the hack of patient described on page .229. (See also Fig. 35.)

RIGHT HYPOCHONDRIAC PAIN 229

surgeon. True, but so they did in the case just described, though
nothing was removed. There is abundant experience to prove that
operations and postoperative hygiene (mental and physical) are in
themselves enough to produce a marked improvement in the symptoms
of many a patient.

Diagnosis. Debility.

Case 109

March 18, 1907, I examined a Russian tailor thirty-nine years old,
with the history of pain in the right upper quadrant lasting fifteen
weeks, accompanied by frequent dry cough, shortness of breath, and
increasing weakness, but no fever, so far as he knows. For the past
two weeks he has had night-sweats, tenderness in the left shoulder,
and inability to sleep on the left side. He has lost weight and strength,
but has worked irregularly until two weeks before entrance. His
previous history, family history, and habits are otherwise excellent.

Examination showed a sallow, emaciated, worn-looking man.
Nothing abnormal was detected in the examination of the heart. In
the right back there was dulness below the angle of the scapula, with
diminished breath and voice-sounds. The condition of the abdomen
is best explained by Fig. 35.

The patient's temperature ranged for eight days between 99 and
ioiF. His red cells were 4,000,000; white cells, 11,000; hemoglobin,
60 per cent. The stained smear showed nothing abnormal. The urine
was equally blameless. In the stools numerous eggs of the Trichuris
trichiuria were found. Rather large, palpable glands were found above
both clavicles; the chest, head, and extremities negative, except as
above noted. Free purgation produced no change in the physical signs.

Discussion. There is a good deal to suggest phthisis in the first
impression of this case cough, dyspnea, weakness, night-sweats.
But though there are some abnormal signs in the right back, they are
not sufficient to account for the symptoms. Empyema is, perhaps,
more likely, but I have never heard of an empyema which worked to
the surface so near the ensiform cartilage. It is unfortunate that an
.v-ray was not taken, owing to the patient's great prostration. By this
means one might have obtained some evidence as to whether the trouble
was above or below the diaphragm. Our attention naturally centers
on the region of the prominence shown in Fig. 35; at first sight the
mass certainly appears to be below the diaphragm.

Tumors of the liver should first engage attention. Cancer of the
liver almost never presents itself in this situation only. We find almost

23O DIFFERENTIAL DIAGNOSIS

invariably a general enlargement of the liver downward, and multiple
nodular masses below the ribs. I have never known a hepatic cancer
to produce a localized bulging of the chest-wall such as was present in
this case. This latter observation applies also to tumors of the colon,
gall-bladder, retroperitoneal glands, and kidney. The hypothesis of
cancer somewhere receives some support from the presence of enlarged
glands over the clavicle, which might represent metastases; but it is
very hard to see where the cancer could be situated.

Hydatid cyst of the liver was much discussed in the numerous bed-
side consultations over this case, but it was pointed out that hydatid
does not produce so much prostration and pain, not, at any rate, until
it has produced a tumor much larger than that in this present case.
The striking thing about most hydatid cysts of the liver is the slight
impression that they seem to make either upon the patient's conscious-
ness or upon his general health and nutrition. The feel of the tumor
in this case is not at all characteristic of hydatids.

Can local disease of the chest- wall explain these symptoms? Tuber-
culosis, syphilis, actinomycosis, or neoplasm might appear at this point,
but they should involve the ribs or intercostal tissues themselves, whereas
in this case the ribs seem to be quite unaffected merely pushed forward
by something behind them.

Hepatic abscess or subdiaphragmatic abscess often causes a promi-
nence at exactly this point, and some of the symptoms of the case the
pain, cough, dyspnea, weakness, and night-sweats could be thus ex-
plained. On the other hand, we have no history of the ordinary causes
for either of these varieties of abscess no dysentery, no appendicitis,
no peptic ulcer or gall-stones. It seems remarkable, moreover, that
the leukocytes should not be more increased if there is an abscess large
enough to produce such a tumor. Despite these objections, however,
the picture corresponds more nearly with that of subdiaphragmatic
abscess than with any other disease.

Outcome. A week later the patient's abdomen was opened and a
subdiaphragmatic abscess found. Its source remained doubtful.

Diagnosis. Subdiaphragmatic abscess.

Case 110

A fireman of fifty-eight worked on the Panama canal in 1904 and
1905, but had to return in December, 1905, on account of a long
attack of dysentery. Though always a heavy drinker, he was other-
wise well until May, 1906, and then weighed 212 pounds. In May
irregular colicky pains began in the right upper quadrant, which were

RIGHT HYPOCHONDRIAC PAIN

23 1

much worse at night and which did not, as a rule, bother him in the
day-time. At times he suffered enough to require morphin. There
was no radiation and no vomiting, but there was nausea, and consider-
able relief was obtained by belching gas. The bowels were rather
loose, and a movement caused relief of pain. At times the movements
were clay colored; at other times they were brown. About June ist
the stools became persistently clay colored, the skin was noticed to be
yellow and the urine dark colored.

From June ist until the present time (August 8th) he has had no
pain, but to-day about noon he suddenly began to have a series of very
severe cramps, vomited for the first time, and had a
chill. His present weight is 161, a loss of 50 pounds,
but he had been able to work until six weeks pre-
viously.

Inspection of the patient's body revealed nothing
abnormal except intense jaundice, with brownish mu-
cous membranes and an increase of liver dulness, such
that the organ extended from the fifth rib in the
nipple-line to a point one inch below the costal margin.
Below this edge a soft, rounded mass could be made
out, about the size of a lemon. The spleen was not
palpable. The white cells were 16,600; hemoglobin,
90 per cent. The Cammidge test was positive. In the
afternoon after entrance the patient suddenly sat up in
bed and yelled with pain; it was referred to the epi-
gastrium, and was, he said, unlike any that he had had
before. The abdomen was now rigid throughout, with
marked tenderness, especially in the epigastrium. The
patient vomited several times this afternoon.

Discussion. A history of dysentery and a residence in the tropics,
when followed by symptoms which appear to involve the liver, should
always remind us that hepatic abscess is a common complication of
tropical dysentery. This idea seems all the more plausible in the
present case, because there have been chills, fever, leukocytosis, and an
increase of liver dulness. Yet the pain of hepatic abscess could rarely
be described as "cramps." The disease is often painless; if there is
any pain at all it is usually a steady, dull, but increasing type. The
soft tumor below the ribs, moreover, cannot be due to hepatic abscess,
and we do not expect such intense and persistent jaundice as the
result of that disease.

The colicky pains and the jaundice might well have been due to a

Fig- 37- ( 'hart
case 1 10.

232 DIFFERENTIAL DIAGNOSIS

stone in the common duct. Had this stone been near the entrance of the
cystic duct, infection might well have extended to the gall-bladder.
Suppurative cholecystitis and final perforation of the gall-bladder would
then account for the chill and intense pain on the day of entrance.

Against this we have the fact that a gall-bladder which has previously
nourished stones is not often so distensible as to form a tumor, such as
projected below this patient's liver. The intensity and steady persistence
of the jaundice are also somewhat unusual for choledochus stone.

Cirrhosis does not seem probable, though the usual cause of that
disease appears to have been operative. A pain like that here described
is rarely if ever due to cirrhosis, and the jaundice which occurs in a
certain proportion of cirrhotic cases is almost never intense. Cancer
of the pancreas or of the bile-ducts is the commonest cause of intense
and persistent jaundice in a man of this age. The tumor below the
ribs might be the enlarged gall-bladder which generally results from
this disease. On the other hand, the pain is severer and more sudden in
its onset than is to be expected in cancerous obstruction of the bile-
ducts. The colic and the variation in the color of the stools seem more
like cholelithiasis. No one of these facts, however, excludes cancer,
which seems, on the whole, the most reasonable diagnosis.

How are we to explain the chill and attack of pain described in the
last few lines, which are intended to convey an idea of the greatest
possible severity of suffering? In my experience an abdominal pain
of this description, such that the patient suddenly yells out in agony, is
almost always due to one cause perforative peritonitis. This might
be accounted for under either of the diagnoses last discussed; either
stone or cancer may have caused ulceration of the ducts and set up at
first a localized peritonitis, which later perforated and set free a virulent
fluid into an unguarded peritoneum.

Outcome. He died three days later. The variations of his tem-
perature are shown in the accompanying chart. He was able to take
very little food, and during the last twenty-four hours was delirious.
Autopsy showed cancer of the head of the pancreas, almost occluding
the common bile-duct. The pancreas was practically destroyed. The
gall-bladder was enlarged, much distended, not inflamed, and con-
tained a single gall-stone. There was an extensive cancerous infiltra-
tion of the posterior wall of the stomach. There was also an acute
general peritonitis, for which no cause could be joundl

Diagnosis. Pancreatic cancer.

RIGHT HYPOCHONDRIAC PAIN

233

Case 111

A negro of thirty-five has complained of steady pain in the right
hypochondrium for two months. This pain came immediately after
eating and lasted about two hours. His appetite is good. His bowels
are constipated, moving only once in from two to seven days with
medicine. He has also suffered from numbness and tingling in his legs,
with weakness, and has had a cough for the past two weeks, with slight
white sputum.

Physical examination shows an irregular fever (see chart), the skin
very dry and scaling, the heart not remarkable, the lungs negative.
There is a nodular mass indistinctly felt in the
right iliac fossa, tender, but at times difficult
to outline. The abdomen is retracted, and
peristalsis can be seen near the navel. On
the left hand and the dorsum of the right
foot are elevated areas of reddened skin, with
a pink, smooth center, about one inch in diam-
eter. The chest is negative; likewise the
blood and urine.

Examination of the stomach by means of
a stomach-tube showed that the organ would
hold about only 23 ounces of water without dis-
tress. Its lower border after inflation reached
just below the navel. The contents extracted
after a test-meal showed free HC1, 0.1 per
cent.; no occult blood; no lactic acid. No
contents could be obtained from the stomach

, r . i c , Fig. 38. Chart of case in.

before breakfast.

Discussion. There is no need of extended discussion here. A
nodular mass in the right iliac fossa, accompanied by visible peristalsis,
marked constipation, and fever, means chronic intestinal obstruction
in the region of the cecum. Obstruction at this point is practically
never due to fecal impaction alone; there is almost always some stricture
of the gut behind which feces accumulate. Such a stricture might be
syphilitic, cancerous, or tubercular. Occasionally a chronic appendicitis
with adhesions produces obstruction.

Imagine that an abscess has occurred earlier in the history of the
case; this may later have become walled off and massed into a tumor
something like that here felt. The adhesions associated with it might
then lead to the symptoms of obstruction here described.

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234 DIFFERENTIAL DIAGNOSIS

A retracted abdomen and an irregular fever without leukocytosis is
distinctly more suggestive, however, of tuberculosis.

If the stricture is tuberculous, the tumor mass is probably made up of
caseating glands adherent to the cecum, itself infiltrated by tuberculosis.
The fact that the patient is a negro and the presence of fever especially
fever of the type shown in this chart make tuberculosis more probable
than cancer. Syphilis rarely produces so large a mass in this region.
Extensive syphilitic infiltrations are generally found near the rectum.
The diagnosis of pericecal tuberculosis is further supported by the
character of the cutaneous lesions, which are distinctly suggestive of
tuberculosis.

No good reason can be given why the pain is referred in this case to
the right hypochondrium, rather than to the region of the tumor, as is
the rule in such cases.

Outcome. The patient remained ten days in the ward, complain-
ing continually that he did not receive enough medicine, but showing
no improvement in any respect. At the end of that time the abdomen
was opened and showed a nodular mass of tuberculosis in the cecal
region, with general adhesions but without fluid. At death, a month
later, tuberculosis was found also in the lungs, adrenal glands, lymph-
glands, skin, and in almost every other organ.

Diagnosis .Pericecal tuberculosis.

Case 112

A young farmer of twenty-five, whose father had died of tuberculosis
but whose family history was otherwise good, came to the hospital
January 25, 1906, with the following story: For the past fifteen years
he has had from time to time pain in the right upper quadrant, in attacks
lasting from three to five days, then gradually subsiding but leaving
him much used up. For the past three years the pain has been so sharply
localized that it could be covered with one finger.

Up to one year ago he averaged about two attacks a year, but within
the past year the attacks have been from one to four weeks apart, appar-
ently depending upon the performance of heavy work or the eating of
hearty food. During these attacks the pain is not constant, but comes
in spasms and is relieved by taking a "pain-killer" and using a hot-
water bag, or by leaning over the back of a chair so as to bring strong
pressure to bear upon the painful spot. In the last attack the pain
radiated to the back, but never to any other point. Three years ago
he thought he noticed in the region of the pain a bunch, which was
tender, but gradually disappeared. The painful spasms last from

RIGHT HYPOCHONDRIAC PAIN 235

fifteen to twenty minutes each. He was very sallow three years ago,
and thinks he has been so since then. His severest attacks are accom-
panied by chills and fever. During the past year he has been able to do
only very light work. He occasionally vomits during an attack, the
material being usually greenish. During an attack he has nightly
emissions. Walking on hard pavements or hard floors, especially dur-
ing the time of an attack, causes pain in the right upper quadrant, and
sometimes shortness of breath. His appetite between attacks is always
good and his bowels are usually constipated. In the fall of 1905 he
weighed 185 pounds. Now he weighs 165 pounds. Work that requires
stooping or heavy lifting will often bring on an attack within two or.
three hours.

Physical examination showed no jaundice. There was nothing
abnormal in the chest or abdomen, and nothing wrong with the blood
or urine. After staying four days in the hospital entirely free from
symptoms he was discharged.

May 24, 1907, he entered the hospital for the second time, and
stated that, since leaving the wards fifteen months previously, he had
had many attacks of pain similar to those previously described. His worst
attack was ten months ago, when the pain failed to yield to morphin
or chloroform, and lasted four hours. For a week after this he was
unable to leave his.bed. This spring he had nearly steady pain for five
or six weeks following the ingestion of a large quantity of maple syrup.
After an attack his urine is always high colored, almost black; the color
of his stools is not abnormal.

As on a previous occasion, physical examination was entirely nega-
tive, but this time the use of a stomach-tube revealed that the percentage
of free hydrochloric acid after a test-meal was 0.29, and that in the
fasting contents the percentage of hydrochloric acid was 0.23. There
was no reaction to guaiac in stools or gastric contents.

Discussion. There is much to make us think of gall-stones in
this case, though the age and sex are against this diagnosis. The
association of such a pain as is here described with chills and fever,
with deep discoloration of the urine, which may well have been due to
bile, and with a bunch which may have been the gall-bladder, goes far
to complete the clinical picture of cholelithiasis. Tin's picture becomes
still clearer as we note the freedom from digestive symptoms between
the attacks of pain. Moreover, it may be that on stooping he shifts
the position of a stone in the gall-bladder in such a way that it becomes
impacted and produces colic.

But this trouble has been going on for fifteen years, and ^ull-stones

236 DIFFERENTIAL DIAGNOSIS

are practically unknown in a boy of ten, which was the age of our patient
at the beginning of his attacks. Again, it is difficult to see why a gall-
stone colic should not be relieved by morphin or by chloroform, and
why it should not produce tenderness in the region of the gall-bladder.
Patients who have had many attacks of gall-stones almost always ex-
perience some of the typical radiations of the pain, which, with one
exception, have been wholly lacking here. The absence of jaundice
and enlarged gall-bladder adds a certain weight to the arguments already
adduced against gall-stones.

Next to gall-stones, by far the commonest cause of symptoms like
these is peptic ulcer, gastric or duodenal. The long history of his
attacks and the gradually shortening intervals between them, the excess
of hydrochloric acid in the gastric contents, and the relief of pain by
pressure are facts tending to convince us that peptic ulcer is present.
On the other hand, it is curious that we were unable to obtain any
reaction to guaiac in the gastric contents or in the stools. Why the pain
should be increased by walking on hard pavements or hard floors, and
w r hy the attacks should be associated with nocturnal emissions, are
problems not explained by any knowledge that I possess.

A "high" (undescended) appendix comes to our minds as a possi-
bility, but who ever saw a case of appendicitis high or low in which
the pain was relieved by strong pressure, as in this case?

Outcome. On May 29th the abdomen w T as opened; a duodenal
ulcer was found. It had perforated and become adherent to the gall-
bladder. In connection with the relief of pain by pressure in this case
I recall a case of duodenal ulcer which I saw with Professor Osier at
Oxford in the summer of 1908. The man told us, without a ghost of
a smile, that the pain was so bad that his wife often had to kneel on
his stomach for half the night.

Diagnosis. Duodenal ulcer (local peritonitis).

Case 113

A single woman of thirty-seven entered the hospital on July 20, 1906.
Up to the age of five years she was subject to convulsions with loss
of consciousness, but these have not recurred since. She had diph-
theria with paralysis of the palate at the age of twelve. In 1892 she
fell in a gymnasium and hurt her back, since which time she has done
no work, and has suffered from severe pain in the middle of the back
and on the top of her head. At times she has a sense of constriction in
her throat. She consulted an orthopedic specialist in 1902, and has
since then worn a brace for her back off and on, with very little relief. A

RIGHT HYPOCHONDRIAC PAIN

P37

spur was removed from her nose one year ago. Three weeks ago she
began to have very severe pain over the right side of the face, and was
operated on for disease of the antrum, but none was found. Her pain
was immediately relieved, and sleep induced by the subcutaneous injec-
tion of sterile water.

Since that time she has suffered especially from pain in the right
hypochondrium worse in the early morning, somewhat relieved after
the morning urination or by vomiting.

Physical examination shows rigidity of the abdomen with marked
sensitiveness of the right half of the head and of the back, especially
in the dorsal region. The internal viscera, the blood and urine are
normal, likewise the temperature and pulse. Respiration ranges
between 30 and 45. She is often awakened by spasmodic pain in the
neck, much increased by attempts to walk. She looks well, but still
complains "of soreness in the bowels, which prevents her from eating
and causes her to vomit and her head to ache."

Discussion. We get a strong impression, on reading this case,
that we are dealing with nervous invalidism reinforced and made more
obstinate by a variety of meddlesome treatments. But in any case which
gives us this first impression we should do our best to combat it by
endeavoring to establish the existence of some form of organic disease.
Only in this way can we avoid doing serious injustice to many patients
who have both organic disease and a nervous make-up, with the latter
in the foreground. One of the problems which first engaged our
attention was this: Why should her pain be relieved after the morning
urination? This combination of symptoms is not at all unusual, and
in my experience it signifies that the pain has resulted from gaseous
distention of the colon, which is relieved when the emptying of the bladder
shifts the pelvic tensions enough to allow the escape of intestinal gas.

The unilateral distribution of sensitiveness over the head and trunk,
the relief of pain by the subcutaneous injection of sterile water, the
rapid respiration, and the history of her medical fortunes justify us, I
think, in believing that our negative physical examination represents
the truth, and that we are justified in making that dangerous diagnosis:
hysteria. But it is only by experimental therapeutics, that is. by trying
out the results of treatment based on the hypothesis that we are dealing
with habit-pain and nervous invalidism, that we can get any further
certainty upon the diagnosis. To such experiments, accordingly, we
addressed ourselves.

Outcome. Under a combination of scolding, encouragement, and
reeducation she was able, at the end of a month, to walk fifteen vards

238 DIFFERENTIAL DIAGNOSIS

without support. Two weeks later she could walk an eighth of a mile,
and the pain in her head was much relieved. She still complained,
however, of soreness in the bowels, and this she has had at intervals ever
since that time, especially when she gets run down.

This case seems to me to illustrate well that fallacy about the impor-
tance of " reflex causes " for general nervous disturbances which had so
strong a hold on the last generation of medical men. The wonder is
that this patient escaped without appendectomy and hysterectomy. In
many clinics she would also have undergone a gastroenterostomy. I
think the opinion is coming to prevail that when the history and the
physical signs point strongly toward a general neurosis, attention to so-
called reflex or local sources of irritation not only does no good, but
makes the patient distinctly worse by concentrating his attention upon
the part, by increasing the period of invalidism, and by withdrawing
him from the normal supports and stimuli of the working life.

Diagnosis. Hysteria minor.

Case 114

A Portuguese tailoress, forty years old, entered the hospital December
21, 1908. When a little girl in Portugal she had typhoid fever. In
the preceding June she was in bed for a week with "malaria," and has
not been well since. She has now had fever for five weeks. She has
been at work for the first two weeks of this time, but has had headache,
anorexia, vomiting, diarrhea, and cough for most of the time in the last
five weeks. She has been in bed for ten days.

Physical examination shows no emaciation. Many fine rales are
scattered over both chests, and a few squeaks distributed among them.
Whichever side she lies on appears to contain the greatest number of
rales. There is a slight cyanosis, with movements of the nostrils as she
breathes. Voice-sounds are slightly increased at the right base. The
white cells are 6800, 56 per cent, of them being polynuclear. Widal
reaction positive. The spleen was palpable on full inspiration.

On the fourth of January she was suddenly seized in the night with
sharp pain in the right upper abdominal quadrant, accompanied by
vomiting, sweating, and a weak, rapid pulse. Despite -J grain of mor-
phin and -fa grain of strychnin, the pain and vomiting persisted. Xext
morning there was distinct tenderness over the seat of pain, and a tender,
rounded mass was vaguely felt in the region of the gall-bladder.

The white cells, January 5th, were 12,800 at 10 A. m., 23,600 at 9
p. m. ; 22,800, January 6th at 9 A. m. There was still no abdominal
spasm.

RIGHT HYPOCHONDRIAC PAIN

239

Discussion. This patient has a fever of long duration. In tem-
perate climates, as I have elsewhere shown/ there are but three common
fevers which last more than two weeks, viz., typhoid, tuberculosis, and
sepsis. This woman has cough, cyanosis, rales in both lungs, and,
since the nostrils move visibly, she probably has dyspnea. May it not
be that she has miliary tuberculosis with tuberculous peritonitis, the
latter showing itself in one of those acute paroxysms which are so often
mistaken for appendicitis, cholecystitis, intestinal obstruction, and other
abdominal emergencies ? But if this is so, why is the patient not more
emaciated after five weeks of illness? Unless we can get evidence of
tuberculosis either in the family history, in the sputa, or in some other
part of the body, there is no way of verifying this hypothesis any further.

As we read that the Widal reaction was positive, it seems at first
unnecessary to discuss the diagnosis further. There is nothing in the
case to exclude typhoid, since lung signs like those here described may
represent simply the ordinary bronchitis of typhoid. But as she has
previously passed through an attack of typhoid fever, it may be that
her Widal reaction is one of the residual results of that illness. We know
that the Widal reaction may persist for thirty years or more after an
attack of typhoid. The splenic enlargement is quite consistent either
with typhoid or with tuberculosis. As there seems no good evidence of a
generalized septic infection, and as the leukocyte count is at the outset so
low, there seems no good reason to consider any disease other than typhoid
and tuberculosis. The rarer causes of prolonged pyrexia (meningitis,
rheumatism, syphilis, leukemia, malignant disease) do not deserve
serious consideration.

But there seem to be two acts to this drama, and the second
which began January 4th throws considerable light upon the first, for
the new pain gives every evidence of being due to cholecystitis, and
cholecystitis is a common complication of typhoid, not of tuberculosis.

Outcome. Operation was done on the sixth and showed an injected,
distended gall-bladder filled with pus, with a spot of gangrene on the wall
and several stones within.

The disease showed thereafter the ordinary course of typhoid.
Eberth's bacilli were recovered from the gall-bladder.

Diagnosis. Cholecystitis complicating typhoid.

l R. C. C;ilx>t, The Three Long-continued Fevers of New England, Bosun Med.
and Surg. Jour., August 29, 1907.

240

DIFFERENTIAL DIAGNOSIS

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CHAPTER VII

PAIN IN THE LEFT HYPOCHONDRIUM

The left hypochondrium is not a common place for puzzling pains.
I have known very few diagnostic problems which centered there.
Many discomforts arising from the stomach are felt in the left hypo-
chondrium, but, as a rule, their origin and nature are tolerably clear.

1. Flatulence, the commonest of all causes of pain in the lower left
axilla, is also responsible for many complaints below the left ribs. The
relief by escape of gas distinguishes many such pains, but we must
remember that in many cases the flatulence itself requires explanation.
Gas-formation may be the result, and its discharge the relief, of pain
due to:

(a) Angina pectoris.

(b) Peptic ulcer and hyperchlorhydria.

(d) Gall-stones (rarely).

Even toothache may cause recurrent flatulence and be temporarily
relieved each time the gas (air ?) is discharged.

2. Surgical disease of the kidney (stone, tuberculosis, neoplasm,
local infection, hydronephrosis) occasionally causes pains in the left
hypochondrium. More often, however, the pain is in the loin, in the
lumbar region, or along the course of the ureter. The presence of a
tumor and of urinary disturbances usually makes it clear that the kidney
is the source of the pain.

3. Adhesions about a spleen enlarged by leukemia, splenic anemia,
malaria, syphilis, or polycythemia often produce pain in the left hypo-
chondrium and above that point, but the obvious enlargement of the
organ puts us on the right track unless we neglect physical examination
altogether.

4. Cancer of the splenic flexure of the colon rarely gives pain over
its own site. Usually such pains are in the umbilical region or diffused
over the whole belly.

Some of the other diseases mentioned in Table V may cause pain
in the left hypochondrium as well as in the right (c. ., pneumonia and
pleurisy, especially in children), but no separate discussion of them i.-
needed here.

ic, 211

242 DIFFERENTIAL DIAGNOSIS

On the whole, then, it appears to me that most pains in the left
hypochondrium have either an obvious origin from one of the easily
recognized sources mentioned above under i, 2, 3, and 4, or are to be
explained by reasoning identical with that already applied to the
right hypochondrium. Some of the possible occasions for doubt are
exemplified in the following cases:

Case 115

A white-lead worker of twenty-one entered the hospital July 16,
1906, with negative family history, past history, and habits, except that
he had syphilis four years ago. Five years ago he passed some bloody
urine, with clots, and at times nearly pure blood; this lasted for about ten
days. He was well after that until two years ago, when he began to have
dull, dragging pain under the left ribs, fairly constant day and night for
two weeks, preventing work, but not preventing sleep. At this time
he passed some "white stuff" looking like pus in his urine, mostly at
the end of micturition. After two weeks he was well enough to be about
and work, but he still notices the white stuff and occasional little strings
in his urine. At times the urine is entirely clear, but for the past five
months he says it has been clear for only five consecutive days. There
has been no blood since four or five years ago. At times the urine smells
very badly. Eight months ago and a year ago he had similar attacks of
pain, relieved, as formerly, by the passage of pus.

The present attack came on five months ago; he began to have dragging
pain under the left ribs, severe enough to prevent work, but not sleep.
At times it doubles him up. At the beginning of this period he thinks
he had high fever. He now passes urine every hour. He has lost nearly
20 pounds.

Physical examination of the chest is not remarkable. In the left
hypochondrium is an irregular mass, palpable bimanually, hard, and
slightly tender. Its position is fixed.

White cells, 11,700; the temperature ranges most of the time about
99.5 F. There is no elevation of pulse or respiration.

The urine shows pus, at times in large amounts, at times in very
small amounts. It is not otherwise remarkable. Five milligrams of
tuberculin were injected subcutaneously and caused fever, constitutional
symptoms, and increased pain in the tumor.

Discussion. If we fixed our attention chiefly upon the history of this
case, our first impression as to diagnosis would naturally be lead-poison-
ing. Any abdominal pain in a lead-worker may be lead colic. We know
also that lead affects the kidney. On the other hand, the physical ex-

PAIN IN THE LEFT HYPOCHONDRIUM

243

amination includes data not thus to be explained, and assures us that
lead cannot play more than a subordinate part in the case. The mass,
palpable bimanually, and the pus in the urine have nothing to do with
lead.

Abdominal pain in patients who give a history of syphilis should
lead us to consider tabes with gastric crises. As we look over the case
with this idea in mind, we note that there is no record concerning the
pupillary reactions, the knee-jerks, or the ankle-jerks. We know that
tabes often leads to bladder troubles, and sometimes to a retention of
urine. In this way a cystitis and pyuria might have been produced,
and thence, by ascending infection, a pyelonephritis. In this way all the
facts might be accounted for. Actually, however, the pupillary and
other reactions were normal, and there was nothing to support the
hypothesis of tabes.

Local renal disease giving rise to pyuria and tumor, with slight leuko-
cytosis and fever, turns out most often to be due to renal tuberculosis.
The positive reaction to tuberculin is not especially significant in an
adult, since many adults react to tuberculin whether they are sick or well.
More significant, however, is the increase of pain and sensitiveness over
the tumor immediately following the injection. There seems to be no
way of obtaining further insight into the nature of the trouble here pres-
ent until we have further information in regard to the following points:
(a) Can tubercle bacilli be demonstrated in the sediment of the centrifu-
galized urine? (b) If not, what is the result of injecting this sediment
into a rabbit or a guinea-pig? (c) What does x-ray show in the region
of the kidney? Even without these data, however, renal tuberculosis
seems the most probable diagnosis.

Outcome. On July 21st the kidney was opened and a considerable
amount of pus evacuated from a trabeculated cavity in which were frag-
ments of stone. There was no positive evidence of tuberculosis.

Diagnosis. Pyonephrosis with stone.

Case 116

A carpenter of thirty-seven, whose mother died of consumption, had
an attack of "brain fever" eighteen years ago, and was in bed ten days.
Ten years ago he fell while carrying some heavy lumber and broke four
ribs. He was laid up for twelve weeks, and his left side "has never been
strong since." He has had bleeding piles for seven years. His habits
are good.

Four years ago he began to have needle -like pains under /lie left costal
margin, coming on about every fifteen minutes, usually not severe. < )c-

244 DIFFERENTIAL DIAGNOSIS

casionally the pains have been decidedly severe, radiating to the region
of the heart and into the back. During these attacks he usually sweats,
and at times, but not during the attacks of pain, his heart seems to
pound. He has worked irregularly, and although at times he felt faint,
he has never actually fainted.

Twelve days ago he awoke in the night with great difficulty in breath-
ing, severe knife-like pain about the heart, radiating to the left arm, cold
sweat upon the forehead, and great weakness. The attack lasted five
minutes. After that he staid in bed for a week with slight, needle-like
pains as before, and an annoying general soreness about the heart, in the
left arm and in the back. Four days ago he awoke with a severe grasp-
ing pain in the region, of the left nipple, extending through to the back,
but not increased by deep breathing. He staid in bed for the next three
days. To-day he got up and felt much better, but still feels heaviness
and soreness in the left side.

On physical examination the heart's apex is seen and felt in the fourth
interspace, four inches to the left of midsternum. There is no enlarge-
ment at the right. The sounds are regular and of good quality. A soft
systolic murmur is heard at the apex, transmitted a short distance into
the axilla. The artery wall is somewhat thickened above the elbow, but
not beaded.

Blood-pressure, 150 mm. of mercury at entrance; a week later,
130. Blood and urine normal.

In the left lower back, below and around the lower angle of the
scapula, over an area the size of the palm, breath- and voice-sounds are
diminished and fremitus is lessened. An area about two inches in diam-
eter in the left midaxillary line, over the sixth and seventh ribs, is tender
on pressure. There are scattered areas of tenderness over the ribs below
this point.

Discussion. Flatulence is the commonest cause of pain like that
here described, but the pain of flatulence is rarely so severe, and since
there are no gastric symptoms to speak of, we cannot account for the
patient's complaints in this way.

The signs in the back of the left chest are consistent with a chronic
pleural thickening, such as might result from tuberculosis, and the
family history of that disease strengthens this possibility. But although
it is quite possible that the patient has had tuberculous pleurisy, we can-
not account for the paroxysmal painful attacks in this way, especially
as they seem to be independent of respiration.

The callouses due to broken ribs sometimes include nerve termina-
tions and produce pain similar to that in the stump of an amputated

PAIN IN THE LEFT HYPOCHONDRIUM 245

limb. Presumably, we should interpret in some such way the patient's
statement that his left side "has never been strong" since he broke his
ribs twelve years ago. But it seems very unlikely that the recent parox-
ysmal attacks are due to his broken ribs. How large a part his old
pleurisy may have played in his consciousness of weakness in the left
side and in the heaviness and soreness which he still complains of it is
difficult to say. The tenderness still complained of certainly cannot be
due to pleurisy.

Functional angina pectoris is the natural explanation for severe
precordial pain extending to the left arm in a patient whose age and rela-
tively low blood-pressure do not suggest organic disease of the cardio-
vascular apparatus. This idea is favored by the long duration of his
sufferings and by the fact that there is no demonstrable relation to
exertion.

In connection with paroxysmal attacks of this character, and more
especially with precordial and left axillary pain of moderate severity
and long duration, the physician must never forget the mental aspect
of the case. Pain supposed by the patient to be in the region of the heart
is always made up of two elements (a) The pain itself; and (b) what he
thinks of it. The latter element is all the more important when it is largely
unconscious. Dr. H. F. Vickery taught me years ago that, in dealing
with patients who complain of pain in the precordial or left axillary
region it is always well, after excluding organic disease by physical
examination, to ask the following question:

" Suppose you had that same pain in your shin, would you have come
here to see me to-day?"

This clever little psychologic device of Dr. Vickery's enables the
patient to separate the pain itself from what he thinks of it, and to
decide whether or not his fear of heart disease and its consequences
has added to his sufferings. To think of the pain in his shin is to think
of it freed from the additions and vague dreads sure to be associated with
pain "around the heart." The very vagueness of these fears magnifies
their organic effects, their tendency to aggravate pain. It is really as-
tounding how rapidly such a pain will abate when the patient under-
stands that his heart is entirely sound.

Outcome. On further questioning it appeared that the patient
smokes and chews tobacco constantly while at work. After ten days in
the hospital, during most of which time the patient felt perfectly well,
he said that lie wanted to go gunning; accordingly he was advised to
stop the use of tobacco and discharged.

Diagnosis. Functional angina pectoris.

246 DIFFERENTIAL DIAGNOSIS

Case 117

A laundress of forty-five, with negative family history and past history,
entered the hospital March 2, 1904. She passed the menopause six
years ago. She has been markedly alcoholic for years. One month ago
she began to have pain in the left hypochondrium, relieved by painting
with tincture of iodin. Three weeks ago she had a similar attack, re-
lieved in the same way. Nine days ago she had some pain in the lower
abdomen, relieved by a vaginal suppository. Since then she has been
in bed for about half the time, owing to nausea and pain in the left hypo-
chondrium. She says she has vomited blood, but her daughter has seen
only greenish and dark-brown material. For a week the urine has been
reddish. The patient has been pale for about five months.

At entrance the patient was apparently in a uremic condition. The
chest showed nothing abnormal. All the superficial lymph-glands
were considerably enlarged. Only a few ounces of urine could be
drawn from the bladder, and this nearly clear blood, some pus, no
casts. Blood-pressure, 215. The patient was semicomatose, with
coarse tremor of the hands. She died on the fourth of March.

Discussion. Peptic ulcer is naturally our first thought, but on
further study of the case there seems to be little to support it. The
condition of the abdomen and the high blood-pressure cannot possibly
be thus explained.

Cirrhosis of the liver, with associated splenic enlargement, might
explain the abdominal symptoms. The vomiting of blood would then
be the result of passive congestion of the stomach. The alcoholic his-
tory makes this explanation plausible, but on careful palpation we do
not get the impression that the abdominal masses shown in the diagram
represent enlargement of the liver and spleen. There is no sharp edge
on either side, and the respiratory mobility is slight.

The general enlargement of the superficial lymph-glands might be
due to syphilis. Enlargement of the spleen and liver is also frequently
the result of this disease, and the pain of which the patient complains
might be due to local peritonitis (perihepatitis and perisplenitis). The
gastric hemorrhage might be explained under this hypothesis as a result
of splenic fibrosis, the circulatory mechanism being the same as in
splenic anemia. Against this, however, may be urged the same con-
siderations which incline us to rule out cirrhosis: the abdominal masses
do not suggest spleen and liver.

By the same reasoning and by the negative results of blood examina-

Fig. 38a. Abdominal findings in Case 117.

PAIN LN THE LEFT HYPOCHONDRIUM 247

tion we may exclude leukemia, although this disease would account for
the glandular enlargement, and (through a cerebral hemorrhage) might
explain the high blood-pressure and the semicomatose condition.

Tuberculous peritonitis as part of a general tuberculosis might produce
nearly all the symptoms of the case. This disease produces masses more
or less vaguely felt in the abdomen, is often associated with abdominal
pain, and, if we suppose an accompanying tuberculous meningitis with
internal hydrocephalus, would explain the high blood-pressure and the
psychic strte. We should expect, however, some cranial nerve paralysis.
some fever, and some signs in the lungs, even if only those of diffuse
bronchitis; also some indication of a focus whence the disease, previously
local, may have spread. Free fluid would probably be demonstrable
in the abdomen.

It is not definitely stated in the text that the abdominal masses
were palpable bimanually, or that a connection with the kidney was thus
suggested. Whenever we have reason to believe that some renal lesion
exists, and whenever this lesion although apparently of a gross, "sur-
gical" nature is associated with high blood-pressure, we should re-
member the possibility of cystic kidney. It is rare to find any other non-
nephritic lesion of the kidney associated with hypertension. Cystic
kidney is generally a bilateral, congenital condition. Why, then, should
these symptoms have appeared only within a month? Why should the
disease have remained so strikingly latent? In answer, I can only say
that this is the usual course of the disease, which encroaches upon the
renal substance so slowly and so gradually that the system becomes
accustomed to it, as to any other form of chronic interstitial nephritis,
which is practically equivalent to the condition here described. Just
what determines the final breakdown we usually cannot discover.

Outcome. Autopsy showed congenital cystic kidneys; there was
almost no kidney substance remaining. There was hemorrhage into
several of the cysts and pus in the pelvis of the left kidney.

Diagnosis. Congenital cystic kidneys.

Case 118

A housewife of thirty-nine lost one sister of phthisis thirteen years ago.
Family history otherwise good. In her seventeenth and in her twenty-
fifth year she was in poor condition and was told that she had anemia.
Five years ago she had her first attack of fever, with pain in the left lower
abdomen. Since then she has had more or less pelvic trouble, especially
after standing or after working hard. About Christmas-time. 1006. she
had frequent attacks of pain in the left upper abdomen; the pain doubled

248 DIFFERENTIAL DIAGNOSIS

her up, and was ascribed to gas in the stomach. During the winter
the pain grew less, but the abdomen seemed to be enlarged. In March,
1907, she noticed in the left upper abdomen a visible prominence, which
has steadily increased up to the present time. By May she had to let
out her clothes three inches, and thought she could feel a lump in the left
side.

Now (June, 1907) there is a dragging pain after standing, and a feeling
of pressure when she lies on her left side. Since early spring she has had
frequent attacks of palpitation, associated with pulsation in the neck,
roaring in the ears, and slight dyspnea. Once during the summer she
saw red spots in front of her eyes, but she has noticed no bleeding from
any point. Her gums have several times been swollen. Three weeks
ago, while urinating, she heard a sound in the chamber-pot, and looking
in saw that the urine was very red and contained several hard, dark-
brown masses about the size of a large pin's head. She felt no pain and
noticed no stoppage of water.

When examined at the hospital, her urine showed nothing worthy of
note.

Physical examination was negative except as regards the left hypo-
chondriac region, where she felt an enlargement (as figured in the dia-
gram, Fig. 39). The mass is only slightly tender, and moves freely with
respiration; it is very firm.

Discussion. When a patient tells us that his stomach is so sore
that he can't bear the weight of his clothes on it and that it is "all puffed
up," examination generally shows nothing in particular, no actual disten-
tion or prominence. Such symptoms usually occur in the neurotic, and
represent the referred pain described so admirably by Henry Head.
In the present case, however, physical examination shows that the patient
is perfectly correct in supposing that the abdomen has enlarged. In-
deed, the results of abdominal palpation make it unnecessary to consider
any organs except the spleen and the kidney.

The present tumor seems to be spleen rather than kidney, for the
following reasons:

(a) It has a sharp, hard edge, superficial and easily felt. Tumors
of the kidney usually have no distinct edge, but shelve off into the depths
of the abdomen. They are rarely as hard and superficial as those con-
nected with the spleen.

(/;) In the present case the tumor descends at least an inch with full
inspiration. Kidney tumors sometimes move half an inch, often not
at all.

Fig. 31). -Percussion outlines in a case of left-sided abdominal pain.

PAIN IN THE LEFT HYPOCHONDRIUM 249

(d) We are not told whether or not the air-distended colon overlies
the tumor, but in view of its superficiality this seems very unlikely.
Tumors overlain by the air-distended colon usually originate in the
kidney or retroperitoneal glands.

All the signs, therefore, in this case lead us to believe that the tumor
is due to the spleen. Assuming, then, that this is the case, we have to
consider the following possibilities:

(a) Leukemia (proved or disproved by blood examination).

(b) Malaria (proved or disproved by blood examination).

The spleen may remain enlarged long after the malaria has died
out, a fact very frequently illustrated in Armenian patients. In such
cases, however, the patient presents no symptoms.

(c) Syphilis (anemia, hepatic enlargement, and ascites often accom-
pany the splenic enlargement) ; the history, the evidence of syphilis
elsewhere, the result of treatment and of Wassermann's test, must
decide.

(d) Splenic anemia (diagnosis based upon the presence of a chronic
anemia, secondary in type, often associated with gastric hemorrhages.
All other causes for splenic enlargement must be excluded).

(e) Cirrhosis of the liver and Banli J s disease. In cirrhosis we have
a hepatogenous splenic enlargement; in Banti's disease, a splenogenous
hepatic cirrhosis. The end-result is the same. Without evidence of
cirrhosis, which is absent here, neither diagnosis can be made.

(/) Splenic enlargement of unknown cause is a rare but well-recog-
nized clinical entity. It produces no symptoms other than those de-
pendent upon the weight and dragging of the enlarged organ. The
diagnosis rests, of course, upon the exclusion of all known causes,
such as have been listed above. Abscess, neoplasm, and echinococcus
of the spleen are so rare that, for practical purposes, they may be dis-
regarded. The splenic enlargements accompanying acute infectious
disease never reach any degree comparable to that shown in the accom-
panying diagram (Fig. 39).

The next step in differential diagnosis evidently depends upon blood
examination.

Blood examination showed 277,000 white cells; 4,800,000 red cells;
75 per cent, hemoglobin. Among the white cells were 35 per cent, of
myelocytes; 4 per cent, of eosinophiles; 2 per cent, of mast cells; 52 per
cent, of polynuclcar cells.

Diagnosis. Myeloid leukemia.

2 5

DIFFERENTIAL DIAGNOSIS

Case 119

A girl of six years, whose mother" died of quick consumption, entered
the hospital September 2, 1907. She drinks three cups of tea a day
and eats considerable candy. She was recently operated on for con-
genital cataract at the Eye and Ear Infirmary. For nine days she
has been suffering from weakness, with tenderness and pain in the
left upper quadrant of the abdomen. September 1st the white cells were
19,000. The temperature was 103 F. The Widal reaction was nega-
tive. There were no parasites in the blood. The urine showed a
moderate amount of pus, but nothing else remarkable.

Fig. 40. Chart of case 119.

Examined on September 2d, the child is found to have moderate
photophobia and seems apathetic.

Examination of the abdomen is negative except that in the left
upper quadrant there are considerable tenderness and slight spasm
extending through the left flank into the back. There is also dulness
from the seventh rib (anterior axillary line) to the costal margin. The
patient is tender in the costovertebral angle. Culture from the urine
shows a strain of colon bacillus, and a heavy pus sediment which lasted
throughout her stay in the hospital. A^-ray of both kidneys was normal.
The temperature was as shown in the accompanying chart (Fig. 40).

PAIN IN THE LEFT HYPOCHONDRIUM 251

Discussion. Surgical disease of the kidney is rare at this age.
Renal tuberculosis and renal stone, which might account for such
pain, are especially rare in small children.

The dulness in the axilla, the pain, fever, and tenderness, might
be accounted for by pleurisy. The text does not state whether or not
these signs were supported by auscultatory evidences of disease. We
should seek for diminution in the respiratory murmur, with decreased
transmission of voice-sounds and of tactile fremitus. Friction-sounds
might also be heard. As a matter of fact, however, neither of these
confirmatory signs was present, nor was there any evidence of pneu-
monia. I mention pneumonia and pleurisy especially because in children
they are frequently ushered in by abdominal pain without any reference
to the chest.

The most notable feature in the physical examination is the presence
of pus in the urine. Not many years ago this might have been passed
over with very little attention, but since so much has been said and
written of acute infection of the kidney, either hematogenous or ascend-
ing, the urinary sediments are more carefully scrutinized. We are
especially on the alert in young girls who, from babyhood up, are par-
ticularly apt to acquire renal infection, presumably of the ascending type.
The presence of the colon bacillus in pure culture in urine obtained
under aseptic precautions, such as were observed in this case, lends
support to the hypothesis of renal infection. In view of the negative
results of .v-ray, renal infection may be accepted as a working diagnosis.
(For a discussion of clinical types of renal infection see Lumbar Pain,
p. 99.)

Outcome. By the thirteenth of October the patient was well.
The treatment consisted of counterirritants, laxatives, urotropin, 3
grains, three times a day, and abundant water.

Diagnosis.- Renal infection.

Case 120

A wool-spinner of fortv entered the hospital March 3, 1908. He had
been in the hospital four years before for ''gastric indigestion." One
sister died of cancer of the stomach at thirty-five. He takes four to six
cups of tea a day. His habits are otherwise good.

Since the fall of tqoo he has had intermittent pain in the left hyf.o-
chondrium, worse on dee]) breathing, associated with belching, con-
siderable nausea and vomiting, loss of appetite, and constipation. 1 lie
vomitus consisted at first of sour liquid, later of yellow or greenish, bitter
liquid containing no pus, blood, or mucus. Taking food sometimes

252

DIFFERENTIAL DIAGNOSIS

makes the pain better, sometimes worse. He has often taken morphin
to relieve the pain. For the past two weeks he has had the pain almost
constantly. He has done no work. His best weight is 125 pounds.
Now he weighs 117.

The patient is pale and sallow, with pigmentation about the eyes.
His pupils are small, equal, and react very slowly, either to light or
distance. The tonsils are somewhat enlarged. The chest shows
nothing abnormal, nor does the abdomen. The knee-jerks are very
lively. Water-distention of the stomach with a tube showed that the
organ held 28 ounces. On inflation, the lower border reached about
one inch below the navel. After a test-meal free hydrochloric acid was
0.32 per cent. Lactic-acid and the guaiac tests were negative. No
fasting contents were obtained.

Discussion. -We have here a long period of suffering from chronic
dyspepsia, which has led, as it so frequently does, to the taking of
morphin. It is well to remember this fact, since abdominal pain that
leads to a call for morphin is often associated in our minds with the
diagnosis of gall-stones.

Further analysis shows us that the motor power of the stomach
is good and its outlet free. There has been no vomiting of food, but only
of liquid which may be interpreted as gastric secretion. Tube exam-
ination shows no stasis. Since most gastric cancer produces pyloric
stenosis and stasis, the absence of stasis in this case, especially in view of
the long duration of the symptoms (1900-1908), makes cancer unlikely.

Of leukemia, pleurisy, and the other extragastric causes for left
hypochondriac pain, physical examination shows no evidence. Cancer
of the splenic flexure might produce most of the symptoms here present,
but there is no palpable tumor nor visible peristalsis, no diarrhea, and no
blood in the feces. The constipation here described might be due to
many causes.

The high percentage of hydrochloric acid in the gastric contents is in
itself a partial diagnosis, and might account for many of the symptoms.
Our chief remaining problem is to determine whether anything more
serious than hyperchlorhydria is present. Many probably most cases
in which hyperchlorhydria is associated with symptoms so long continued
and so severe turn out sooner or later to be peptic ulcer. No further
exactness of diagnosis is possible without operation. The absence of
the reaction to guaiac, both in the stomach-contents and in the feces, by
no means excludes ulcer.

What treatment should be advised here? The proper rule in such
cases seems to me to be this: give a fair trial to treatment by hvgiene,

PAIN IN THE LEFT HYPOCHONDRIUM

253

diet, and drugs; if these fail to make the patient reasonably com-
fortable, advise operation. It does not seem evident, from the data here
presented, that any persistent attempt has been made to control the
symptoms by non-operative measures. Such measures should, there-
fore, be tried first. I have had excellent success with a modification of
Lenhartz's diet, suggested by Dr. H. F. Hewes, which consists essentially
of the following regimen:

For the first two or three days: For the next two or ihreeweeks:

2 ounces of milk.
1 powdered soda-cracker.
1 ounce of sugar.
To be given every two hours
while the patient is awake.

6-8 ounces of milk.
4 powdered crackers.
1-2 ounces of sugar.
Eight such feedings in
twenty-four hours.

For the final two months:
Milk and crackers.
Indian-meal mush with cream

or salt.
Potato puree; jelly.
Milk and whites of two eggs.
Soft custard.
Chocolate.
Pea puree.
Eight feedings in twenty-four

hours.

If the patient is uncomfortable despite this diet, he should take
cooking-soda in doses sufficient to relieve him. What this dose is can be
ascertained only by experiment. It may be anywhere between 10 grains
and 2 drams.

Outcome. On a subsequent examination free hydrochloric acid
after a test-meal was 0.11 per cent. The patient complained of "cold
sweats" at night, but under careful diet, small doses of calomel and
seidlitz, olive oil, two teaspoonfuls after meals, and an occasional lavage,
he seemed practically well by the eleventh of March. Rest and freedom
from worry seemed to have much to do with his recovery, which by the
nineteenth was complete.

Diagnosis. Hyperchlorhydria.

Case 121

A teamster of forty-four entered the hospital April 4, 1908. He
has always been well until four years ago, when he was working on the
great Clinton dam; a blow in the left side by a heavy pile laid him up for
six weeks, during which he suffered from pain in the left side and had
bloody urine. Since that time lie has never been entirely free from pain
in this region, and after any unusual exertion he has passed Mood}- urine.
Last fall he had to give up work because of the severity of the pain.
Three weeks ago he had a specially sharp pain in the left hypoehomlrium
just below the ribs, the pain traveling down the left leg. occasionally
to the left testis, and un toward the heart. Since then he has had three

254 DIFFERENTIAL DIAGNOSIS

or four attacks, lasting from five to twenty-four hours, all of the same
character. When the pain is severe he vomits, and is relieved to a certain
extent thereby. There is tenderness under the ribs in the left hypochon-
drium during and after his attacks. He has been in bed most of the last
three weeks, but has passed no bloody urine. His weight, eighteen months
ago, was 197 pounds; now it is 167.

Physical examination shows nothing wrong in the chest. The arteries
are easily palpable. The aortic second sound is louder than the pulmonic.
Blood-pressure, 140. In the left lumbar region there is slight volun-
tary spasm and tenderness, increased by inspiration.

The temperature, .pulse, respiration, and blood are normal.

The urine amounts to 40 ounces in twenty-four hours; 1022 in
specific gravity ; it shows a trace of albumin and many fresh red blood-
cells. No casts.

Discussion. Can we connect the symptoms with the injury sus-
tained four years previously? The patient had hematuria immediately
after this, and he has had it more or less ever since. Can we conceive
any type of trauma which would produce an effect so lasting? I do
not see that we can. The trauma, I think, must be regarded as having
no important connection with his present disease.

In the absence of all bladder symptoms, causes of hematuria arising
there deserve no further consideration. The clinical picture is one of
renal colic associated with hematuria and a loss of 30 pounds in weight.
Malignant disease of the kidney would produce these three symptoms,
but would hardly have lasted so long. Either it would have killed the
patient or it would have produced a palpable tumor. The hemor-
rhages from renal tumor are apt to be longer continued and of larger
amount, leading to decided anemia.

Tuberculosis of the kidney of anything like this duration would have
produced tumor and pyuria. It may be easily excluded.

Chronic nephritis, either of the glomerular or the interstitial type,
may be complicated by sudden attacks of hemorrhage unassociated with
any special increase in the other urinary manifestations of disease
(casts, cells, deficient solids). Such hemorrhages may be painless, or
may lead to colic, owing to the formation of clots and the difficulty of
their expulsion into the bladder. The present case, however, shows no
signs of nephritis.

We have left the two commonest and most puzzling occasions for
hematuria: (a) stone and (b) unknown cause. The latter is. I believe,
one of the most frequent of all the types of hematuria. Between this
and stone our chief means of distinction is the .v-ray examination.

Fig. 41. Outlines of mass referred to on p. 255.

Palpable bimanually.

PAIN IN THE LEFT HYPOCHONDRIUM

255

Outcome. i^-ray taken April 8th showed a small round shadow in
the region of the left kidney. Cystoscopy helped to confirm the diag-
nosis of stone. The stone was subsequently found at operation.

Diagnosis. Renal stone.

Case 122

A clerk of thirty-five entered the hospital October 21, 1907. He
was operated on for appendicitis four years ago. He had left-sided
pleurisy at the same time. He says he has always been pale. Eight
weeks ago he began to have a sore, uneasy feeling, first in the left lower
quadrant, later in the left hypochondrium, left hip, and over the left
kidney in the back. He has also had numbness in the leg, extending
from groin to knee. Three and a half weeks ago he first noticed a
lump in the left upper quadrant, and began at the same time to have a
very obstinate constipation the bowels moving scantily by enema
only. No blood seen in the stools.

Examination showed pallor of the mucous membranes and negative
chest, while in the left upper quadrant there were marked resistance
and tenderness. There is also considerable tenderness over the anterior
muscles of the left thigh. Four days later palpation of the left flank
had become easier, and a mass filling the whole flank from back to
front, immobile and slightly tender, was easily felt. Blood-pressure
normal. The inflated colon lay in front of the mass. Urine: 40 ounces
in twenty-four hours; normal color; 1020; no albumin; sediment
negative. (See Fig. 41.) Physical examination otherwise negative.

Discussion. Is it possible that this patient's pleurisy of four years
ago is in any way connected with his present symptoms? It is a familiar
fact that after any pleurisy most patients have a certain amount of
pain in one or another part of the affected side of the chest, a pain that
lasts on, oftentimes, for months and even years. But in such cases we
expect to find some residual signs of the old pleurisy, and there seems
to be nothing of the kind here. It is obvious, moreover, that pleurisy
could not explain more than a small fraction of the facts in this case.

Leukemia would explain the lump and the pallor. Even in advance
of blood examination, however, leukemia is practically excluded by
the fact that the colon passes in front of the tumor. The blood examina-
tion was also negative.

Cancer of the splenic flexure of the colon would produce a mass in
just this situation, and might account for all the pains here described.
We should expect, however, if such a cancer existed, to get some of
the ordinarv evidences of intestinal obstruction, such as visible peri

256 DIFFERENTIAL DIAGNOSIS

stalsis, intestinal noise, gross or occult blood in the stools, diarrhea, or
constipation. None of these symptoms was present except the con-
stipation, which may well have been due to other causes.

The tumor is in the position usually occupied by growths arising
from the kidney. Tuberculosis, cyst, and neoplasm may be considered.
Against tuberculosis is the fact that we have no fever and no pyuria.
The amount of pain and the extent of its radiations exceed what we
usually find in renal tuberculosis. The latter remark applies also to
renal cysts, which often attain a much larger size than the mass here
present without producing any pain at all. Most chronic renal cysts
also produce an elevation of blood-pressure, which did not exist here.
New-growths of the kidney might explain all the symptoms that are
here present, but in most cases would also cause hematuria. The
nodular surface of the growth, if the observation be correct, would
identify it almost certainly with a neoplasm. In some cases, how-
ever, the irregularities of a cystic kidney or of a tuberculous kidney
feel very much like the nodules of malignant disease.

Outcome. The patient was operated on March 25th, and hyper-
nephroma found.

Diagnosis. Hypernephroma.

Case 123

A single woman, thirty-three years old, was first seen June 28,
1 901. Family history, personal history, and habits excellent. Eight
years ago she weighed 122 pounds; now, 104.

For two years she has had almost daily attacks of severe general
bellyache with rumblings; the pain is worse in the left hypochondrium,
lasting one to twelve hours, doubling her up, making her cry aloud,
and radiating to the left shoulder. The pain has no clear relation to
food. When the pain occurs, she usually vomits, and is promptly re-
lieved thereby, but in the last seven months she has vomited only twice.
Vomitus consists, as a rule, of food eaten recently, but on several occa-
sions it has contained food eaten two days before and exceeding the
amount of the last meal.

She has distress and acid eructations one-half to one hour after
meals. Diarrhea often comes with the attacks of pain (3 or 4 move-
ments). Mucus, but no blood, has been seen in the feces.

She has worked except during paroxysms of pain.

Examination. Well nourished. Visible peristalsis below the navel,
with slight general fulness of the abdomen. Much gurgling. No

PAIN IN THE LEFT HYPOCHONDRIUM 257

tenderness. Leukocytes, 8800; hemoglobin, 95 per cent. Borborygmi
can be heard all over the house.

Stomach and its contents negative. Temperature (three weeks)
normal.

Discussion. The complaint of long-standing gastric pain and
the evidences of gastric stasis make it reasonable to consider briefly
the possibility of hyperchlorhydria or of a constricting ulcer near the
pylorus. Most of the patient's complaints might be thus accounted
for. Two facts, however, militate against this diagnosis: (a) Peristalsis
is visible below the navel. In a well-nourished patient this has con-
siderable diagnostic value, and points to the intestines rather than to
the stomach as the source of trouble, (b) Very loud intestinal noise
is a feature of the case. This, like the peristalsis, directs our attention
away from the stomach.

The record of the physical examination is printed here as it was
given me by the attending physician. In it we lack the data necessary
to exclude lead-poisoning and tabes, either of which might account for
part, if not for the whole, of the symptoms. My own examination dis-
closed no lead dotting of the gums, no basophilic stippling of the red
cells, no abnormalities of the ocular or tendon reflexes. The age and
symptoms are consistent with gastric neurosis were it not that visible
peristalsis is revealed by examination.

With the exclusion of the possibilities mentioned above, chronic
intestinal obstruction is left as the most plausible diagnosis. But what
is its cause? In any patient who has had no known cause for the forma-
tion of adhesions within the peritoneal cavity (appendicitis, pyosalpinx,
or gall-bladder disease, with or without operation), cancer is the com-
monest cause for chronic intestinal obstruction. The age of this patient
does not enable us to exclude this disease. More important evidence
against cancer is the duration of the symptoms. Cancer of the gut
often lasts two years or more, but in such cases it usually produces
a palpable tumor. In the absence of any such tumor our best diagnosis
is: chronic intestinal obstruction of unknown origin; the most significant
symptoms being the visible peristalsis and the loud intestinal noise.

Outcome. Operation, July 17th, showed strictures 1 to () inches
long in the small gut. The gut was thickened and, in the contracted
portions of it, tubercles could be seen.

Diagnosis. Tuberculous enteritis.

CHAPTER VIII

RIGHT ILIAC PAIN

Case 124

A girl, fifteen years old, was first seen July 21, 1898; six months
ago she began to get run down. Pallor, dyspnea, anemia, and weak-
ness brought her to the out-patient department, where, March 26th, the
hemoglobin was found to be 55 per cent. Patient had moderate general
abdominal pain throughout her illness, but did not complain loudly of
it until June 21st, when it began to be localized chiefly in the right iliac
region. It is more soreness than pain, she says, jolting in a wagon
or rising from a chair aggravates it. She limps in walking lately.
Otherwise feels well. No fever (two weeks' observation). Bowels reg-
ular. Last menstrual period ten days ago.

Examination. Negative save for a large hard "cake" filling most
of the right iliac region nearly to Poupart's ligament. On the lower
side of the mass is a tender prominence diagonally placed. Leukocytes,
7400; hemoglobin, 95 per cent. Urine negative. Vaginal examination
negative.

Discussion. The essential point in this case is the presence in
the right iliac region of a large mass, associated with anemia and pre-
ceded in its development by a considerable period of general constitu-
tional symptoms, such as weakness and dyspnea. All this in a girl of
fifteen can hardly be due to the cause which ordinarily produces such
symptoms in the latter half of life namely, malignant disease.

For appendicitis or pyosalpinx the onset seems rather too gradual,
the preceding constitutional symptoms too marked, the fever and
leukocyte count too low. What was known as to the girl's circum-
stances seemed to render gonorrheal infection very unlikely.

Ovarian tumors, especially those of the dermoid type, may occur in
girls of this age, but rarely produce so much constitutional disturb-
ance, and are not apt to be described as a "cake," being, as a rule,
elastic and globular. The catamenia have been regular, the last period
occurring so recently that extrauterine pregnancy seems impossible.

Many points in the case suggest pericecal tuberculosis. These
points are especially the early general weakness and anemia, the slow

25S

Causes of Right Iliac Pain

1. APPENDICITIS

2. P U S-T U B E

(AND PELVIC
ADHESIONS)

3. DYSMENORRHEA

4. EXTRA-UTER-]

INE PREG-
NANCY J

5.0VARIAN]
CYST WITH
TWISTED
PEDICLE

6. PSYCHONEU-
ROSIS AND
THE FEAR
OF APPEN-
DICITIS

7. COLICA MUCOSA |

8. URETERAL i

STONE i

1169

427

31
23

Obstruction in the ileocecal region {neoplasm, tuberculosis, adhesions)
occasionally produces right iliac pain. As a rule, however, the pain
is not thus localized.

Inguinal hernia produces usually an inguinal pain with radiations
which may involve the iliac and other neighboring regions.

Any of the causes of generalized abdominal pain {e.g., tuberculous
peritonitis) may produce right iliac pain. Conversely, the local causes
above mentioned may in exceptional cases lead to generalized pains.

Many of the dragging " bearing down " inguinal pains of debilitated
women (see page 8o) extend now and then to one or the other iliac
reinon.

RIGHT ILIAC PAIN 2 6l

onset and moderate degree of abdominal soreness, the large size of the
mass. Against this diagnosis is the absence of fever and of any con-
siderable disturbance of the bowels. One expects constipation, with
or without intervals of diarrhea. The diagnosis then lies between
ovarian cyst and pericecal tuberculosis, inclining rather toward the latter.

Outcome. Operation, August 4th, showed a tumor the size of a
lemon, studded with tubercles pericecal abscess with the tube also
involved.

Diagnosis. Pericecal tuberculosis.

The two following cases do not seem to me to admit of any accurate
differential diagnosis previous to operation. They are introduced here
to suggest the variety of clinical pictures which pericecal tuberculosis
may present.

Case 125

A little girl of six was first seen September 19, 1905. She had
whooping-cough January, 1905. Since then she has made frequent
complaints of pain in the right iliac fossa, worse after meals, and has
vomited almost every day. For five months she has had tenderness
in the painful region. No other complaint.

Appetite good; bowels regular; urine normal.

Examination. Poorly nourished. Chest negative. Belly nega-
tive, save for slight tenderness in the region of the appendix. Leuko-
cytes, 8000. No fever.

Operation as for appendicitis. Tuberculosis was found in a loop
of small gut about four inches long. This was excised and the diag-
nosis confirmed by microscope.

A year later (November 28, 1906) was in "splendid general condition.
Appetite, bowels, and sleep satisfactory. Some thickening in cecal
region." "'Several abscesses have broken through," and in October
she entered the Children's Hospital and was very sick for twelve days.

Pain occasionally wakes her at night (spasmodic pain with rumb-
ling), but she soon drops asleep. She sometimes vomits with pain-
once daily on an average. Wets bed once or twice a week. Is listless
and disinclined to exertion. No dyspnea. Weight, 31 pounds. Slight
resistance in appendix region. No spasm; no tenderness.

Diagnosis. Pericecal tuberculosis.

Case 126

A young Assyrian was admitted March iq, 1906, for chronic appen-
dicitis. Several attacks of right iliac pain in the past year. Diarrhea

262 DIFFERENTIAL DIAGNOSIS

with one attack. Nd vomiting. Most of the attacks last a few hours
only. Bowels regular.

Examination. Chest negative. Belly negative except for a large
mass indefinitely outlined in the right iliac region, with slight tenderness
and spasm.

Mass was not affected by free catharsis. Comfortable. No fever.
Pulse, 90.

Operation March 21st: Some free fluid. A nodular mass in the ileo-
cecal region. Similar smaller masses could be felt in the mesentery and
along the cecum. Cecum adherent.

April 14th discharged well.

Microscopic examination of excised piece showed tuberculosis.

Diagnosis. Tuberculosis of the cecal region.

Case 127

Consulted October 23, 1902, by a married woman of thirty-one
who has had left tube and ovary removed at Boston City Hospital in
1897. For eighteen months she has been more or less constantly in
pain, referred to the right lower quadrant. For the past six weeks it
has been severe. No fever or chills. Last menses in July, and again
three weeks before entrance, when she flowed for five days, using five
napkins a day. Many clots came away, one the size of a hen's egg.

The diagnosis of the attending physician is extrauterine pregnancy.

Examination. Tenderness over the uterus and in appendix region.
Movable pelvic mass on the right, thought to be closely attached to the
uterus, which does not seem enlarged.

The patient ran a slightly elevated temperature with a normal pulse.
Her general condition was excellent. Twelve days' observation.

Discussion. The essentials in this case are right iliac pain of
eighteen months' duration and amenorrhea of three months. The
latter fact strongly inclines us to believe that the genital tract is in-
volved, and tends to exclude a simple appendicitis. Amenorrhea is
consistent with any of the following possibilities: Normal pregnancy,
extrauterine pregnancy, pyosalpinx, ovarian cyst, 1 fibroid tumor, peri-
tubal tuberculosis. It is, however, less frequent in ovarian cysts and
in pyosalpinx, and very much less frequent when fibroid tumors are
present than in either form of pregnancy. The flow which is said

1 1 shall make no attempt in this or in subsequent cases to distinguish between ovarian
and parovarian cysts, nor between either of these and a cyst of the broad ligament or a
hydrosalpinx. I do not believe that these can often be distinguished by physical ex-
amination alone.

RIGHT ILIAC PAIN

263

to have occurred three weeks before entrance, came at a time not cor-
responding to the menstrual period. In many ways it sounds like a
miscarriage, but one must be on one's guard when patients give a
history such as this, for not infrequently stories of pure fabrication are
designed to induce the physician to curet the uterus and thereby to
bring about a miscarriage.

Very possibly the diagnosis might have been made clearer had a
uterine sound been introduced, but in view of the possibility of pregnancy
this was obviously improper. On the whole, the diagnosis seems to me
to be impossible, and the case is introduced merely as an example of
the present limitations of our diagnostic skill.

Outcome. Operation for ovarian cyst revealed normal pregnant
uterus (three months) strongly right latero-vertcd. Subsequently
tried to miscarry at six months but failed, and child was born at
term (Boston Lying-in Hospital).

Diagnosis. Normal pregnancy.

Case 128

A married woman of forty-two; has one child two years old, and
suffered a miscarriage three years ago.

For three months has had periodic attacks of pain in the right
lower abdomen which make her feel '"sick all over." These came at
first every four weeks, now every two weeks. Vomiting, constipation,
distention, relieved by enemata. Catamenia normal.

Last attack began ten days ago, and pain has persisted since. It
shoots into right hip and flank. When she reaches out for anything
she has a sense of tension in the right lower belly.

Examination. Hard, smooth tumor in right iliac region, fairly
tender, about size of a large orange. No fluctuation. Vaginal examina-
tion cannot determine whether or not tumor is connected with uterus.
No fever. Leukocytes normal.

Discussion. We rightly consider appendicitis in every patient
who complains of right iliac pain, but in the present case this possibility
may be promptly dismissed. An appendix abscess rarely if ever lasts
so long or attains such a size as this without producing more con-
stitutional and local disturbance.

Tubal abscess would probably produce more tenderness, and rarely
attains this size. The woman's age is not typical for tubal disease, though
this, in itself, is not a point of great importance.

The tumor suggests especially uterine fibroid and ovarian cyst.
Fibroids are more apt to be situated in the median line and to be obvi-

264 DIFFERENTIAL DIAGNOSIS

ously connected with the uterus. They are rarely smooth. Unless they
lead to profuse flowing, they usually cause no symptoms of any impor-
tance until a considerably greater size has been reached.

Except for its extreme hardness and the absence of mobility, the
tumor is fairly typical of ovarian cyst. Cysts of this size rarely produce
marked symptoms unless the pedicle becomes twisted, with resulting
necrosis, hemorrhage, or local peritonitis. Any of these conditions may
be here present.

Outcome. Operation showed a cyst the size of a child's head.
Its pedicle was twisted. The patient was discharged in three weeks.
A year later she was heard from and had remained entirely well since
her operation.

Diagnosis. Ovarian cyst with twisted pedicle.

Case 129

An Italian laborer of twenty-four entered the hospital August 22,
1908, complaining of right iliac pain which has been severe only for
ten days, but had troubled him off and on since March. He has had
no constipation, vomiting, jaundice, or headache.

The pain is worse at night, is somewhat relieved by applications
of iodin, and somewhat increased by the taking of food.

Worked until four days ago. Family and previous history good.

Examination. Scars in the neck near the angle of the jaw. Tender-
ness throughout the belly on deep pressure, most marked in the right
iliac region. Physical examination, including the blood and urine, tem-
perature, pulse, and respiration, showed nothing else that was abnormal.

Discussion. This case was operated upon as one of acute appendi-
citis. Against this diagnosis, however, were urged the following con-
siderations, to which, as I think, insufficient attention was paid. The
patient's pain was never sharp and never well localized. The same was
true of his tenderness. He never suffered from constipation, vomiting,
or fever; his blood showed no leukocytosis. In view of these facts it
seems to me that all the other possibilities should have been considered.

His symptoms have been of long standing and have increased little
in severity. The long history of the case, the scars in the neck, and the
fact that the patient is a recently arrived Italian immigrant, make ab-
dominal tuberculosis a genuine possibility. Many cases of abdominal
tuberculosis produce no more symptoms than are here described, al-
though the absence of fever is somewhat surprising.

The pain has none of the radiations characteristic of stone in the
ureter, and there has been nothing in the urine to suggest this disease.

RIGHT ILIAC PAIN 265

Gall-stone pain is sometimes referred to the right iliac region, but no
diagnosis of gall-stone disease is possible upon the evidence here pre-
sented. There seems no good reason to suspect any part of the gastro-
intestinal tract.

Young Italian laborers rarely suffer from functional neuroses. I have
once known a case somewhat similar to this in which the patient turned
out to be a malingerer, but he had obvious reasons for his lies, while this
patient has none. On the whole, I think that, had tuberculosis been
seriously considered by the surgeon who performed the operation, the
diagnosis of appendicitis would never have been made.

Outcome. Operation revealed a normal appendix. Many glands
of the size of marbles were felt in the mesentery and along the spinal
column. Two of them seemed a little soft on one side. The patient
made a rapid and permanent recovery.

The outcome of this case seems to me to prove that the glands were
tuberculous. The patient's recovery proves that they were not malig-
nant, and there is nothing to make us suspect typhoid. What should
have been the treatment had the diagnosis been known before operation?
Clearly, I think, it should have been purely a hygienic and dietetic
one, similar to that applied in pulmonary tuberculosis.

Diagnosis. Tabes mesenterica.

Case 130

A young married woman complains that since her second child was
born, four months ago, she has had intermittent right iliac pain in spells
of one to two weeks. It is worse on standing or exertion.

Examination. Slight enlargement of the thyroid. Flat, globular,
smooth mass, the size of a grape-fruit, is felt in right iliac region. It
can be moved to the other side of pelvis. Distinct fluctuation wave over
it. No connection with uterus can be made out.

Next day (September 15th), at 4 p. m., sudden right iliac agony with
vomiting. It lasted until 12 P. M. Then she slept (no drug). Free fluid
was demonstrated in the peritoneal cavity.

September 16th, comfortable in day similar attack in evening.

September 17th: Operation: Ovarian cyst with twisted pedicle (free
bloody fluid as usual).

Discussion. This is a typical case, quite easy of diagnosis. The
smooth, globular, painful mass in the right iliac region, the free mobility
of the tumor, the sudden advent of agonizing pain, and the evidences
of free fluid in the peritoneal cavity make up the typical picture of ovarian
cyst with twisted pedicle. In many, perhaps most, cases, however, we

2 66 DIFFERENTIAL DIAGNOSIS

cannot be so sure either of the cyst or of the twist because we have had
no opportunity to question and examine the patient previous to the advent
of any acute symptoms. Very large, centrally placed cysts are recog-
nizable in case they project sharply forward, leaving the flanks compara-
tively free from bulging and still resonant on percussion. The diag-
nosis is much aided if the patient has been able to notice that the tumor
originated at one side of the abdomen and only assumed its central
position at a later date. But the majority of patients remember nothing
of the kind and pay no special attention to their condition until it gradu-
ally dawns upon them that the enlargement cannot be due either to
fat or to the so-called "high stomach." Under these conditions it may
be difficult or impossible to distinguish the disease from tuberculous
peritonitis. The other and commoner causes of ascites (cirrhosis, cardiac
or renal disease, cancerous peritonitis) are more easily recognized.

In another group of cases the cyst is smaller and bears no great re-
semblance to an ascitic accumulation, but is of such a board-like
hardness that we can scarcely imagine its contents to be fluid. A careful
examination under ether and the introduction of a uterine sound will
usually determine the point.

As a rule, it is useless to attempt any distinction of the different
varieties of ovarian tumor. Occasionally the smaller and more solid
tumors (ovarian fibroid, cancer, or sarcoma) may be recognized by their
consistency, and especially by their association with ascites, which is
much commoner with solid than with cystic tumors.

The occurrence of a twist in the pedicle of an ovarian tumor is often
recognized without difficulty, provided we have seen and studied the case
before the twist occurred. If we know that an ovarian tumor is present,
the occurrence of any kind of acute abdominal symptom is strongly sug-
gestive of a twist. But if we see the patient for the first time after the acute
symptoms have appeared, it may be quite impossible to make out any-
thing which enables us to distinguish the condition from perforative
peritonitis or intestinal obstruction. The abdomen may be so tender and
its muscles so spastic that nothing definite is distinguished on physical
examination, while the pain, vomiting, constipation, and general pros-
tration are quite equivocal.

Diagnosis. Ovarian cyst with twisted pedicle.

Case 131

A seventeen-year-old school-girl has had three attacks like the present
one, the last eight months ago. Catamenia regular and normal.

RIGHT ILIAC PAIN 267

Yesterday general abdominal pain, with vomiting and diarrhea,
brought her to her physician.

Examination. Temperature, 102 F.; pulse, 105; respiration, 25.
Slight rigidity and considerable tenderness in right iliac region. Leuko-
cytes, 14,000. Operation: Normal appendix. Considerable bloodv
fluid in pelvis. Ruptured ovarian cyst one inch in diameter, whence
oozed gelatinous material.

Discussion. Much that was said in the discussion of the last case
applies equally to this one. With no accurate knowledge of her condi-
tion previous to the present attack, appendicitis was the most natural
and reasonable diagnosis. Such mistakes cannot be avoided. It is on
this account that I have not discussed ruptured ovarian cyst in detail
among the possibilities to be considered in differential diagnosis, as I
have intended to deal chiefly with the recognizable and verifiable possi-
bilities.

Diagnosis. Ruptured ovarian cyst.

Case 132

A married woman of forty-seven was seen January 25, 1908. Eight
months ago, on getting out of bed, she felt sudden sharp right iliac
pain, which ceased in one hour on lying down. Many attacks since -
lately, three or more every week.

Two months ago noticed a lump in right side of belly. Thought
she was getting fatter there; lump seemed larger during the attacks of
pain. Thinks she has lost weight in the rest of her body.

Examination. Thin, worn face. Belly prominent, especially to the
right of the median line below the navel. Dull here, tympany elsewhere.
A large, slightly compressible mass, extending from the pelvis to a hand's
breadth above the navel. Not tender; freely movable. Vaginal ex-
amination adds nothing.

Operation revealed a multilocular ovarian cyst about 24 cm. in diam-
eter. There were no adhesions except a few about the appendix.
Well in two weeks.

Discussion. This case is introduced to exemplify the occurrence
of attacks of pain in connection with an ovarian cyst easily recognizable
as such. These attacks, however, were demonstrably not due to a
twisting of the pedicle. Their cause is not explained.

Diagnosis. Ovarian cyst.

268 DIFFERENTIAL DIAGNOSIS

Case 133

A man of forty-eight has had for two days pain in right side of belly,
extending to the back, tending to shoot upward, and increased by motion.
Dull ache with exacerbations. No other symptoms.

Temperature, ioo F.; pulse, 62. Leukocytes, 12,000.

Tenderness in right loin and along the ureter down to McBurney's
point. No muscular spasm. Urine normal.

The tenderest areas are: (a) Midway between the ribs and the ante-
rior superior iliac spine; (b) over the right kidney.

Discussion. Although this case was diagnosed and operated upon
as appendicitis, there are several points distinctly against that diagnosis.
In the first place, it is important that the pain and especially the tender-
ness centered rather in the loin and over the ureter than at McBurney's
point. The absence of muscular spasm is also distinctly against appen-
dicitis. Dull aching pain with exacerbations occurs in appendicular
colic, but also in colic of other origin (intestinal, biliary, renal, uterine).

So much in this case suggests kidney that, even though the urine is
normal, cystoscopy and the introduction of a catheter into the ureters
seems indicated.

Outcome. Operation showed in the ureter a stone the size of a
large bean. Recovery was uneventful.

Diagnosis. Stone in the right ureter.

Case 134

A factory girl of twenty-four entered the hospital June 21, 1906.
She had pleurisy eighteen months ago. One month ago, without known
cause, her abdomen began to be sore and tender on pressure, especially
in the lower portion and on the right side. There has been no actual
pain, but she has been too weak to work, and has been part of the time in
bed. The menses have been regular and normal.

Physical examination showed normal temperature, pulse, and res-
piration, nothing abnormal in the chest, general rigidity of the abdomen,
especially in the right lower quadrant, where there are marked tender-
ness and an oval mass, the size of half a lemon, raised above the surface.

Discussion. -The presence of a raised mass in the region of the
appendix narrows the field of possibilities considerably. The most
important differential point in the case seems to me to be the gradual
onset of the symptoms and signs, without anything that the girl will call
pain. Appendicitis and pyosalpinx may have a gradual onset, but almost
never does this occur without marked pain. If these two possibilities

RIGHT ILIAC PAIN 269

are for the moment put on one side, we have left ovarian cyst, cancer,
and tuberculosis of the cecal region and extrauterine pregnancy. If
we believe the girl's story, the latter is excluded by the regularity of men-
struation and the absence of pain. Cancer is very rare at her age, and
should produce symptoms more distinctly referable to the intestine.
Ovarian cyst cannot be excluded, but there are two points which in-
cline us to the only remaining alternative, tuberculosis. These points
are: (a) the occurrence of a pleurisy (/. e., of a tuberculosis) eighteen
months previously; and (b) the wide distribution of tenderness and
rigidity over the abdomen. Ovarian cysts generally cause very little
either of tenderness or of muscular spasm, except in the presence of other
acute symptoms, such as are absent here.

Outcome. The patient was operated on June 23d. A large tuber-
cular abscess originating in the right tube was drained.

Diagnosis. Tuberculosis of right tube.

Case 135

A married woman of thirty-nine entered the hospital July 29, 1908.
Her father died of consumption; one of her sisters is partially paralyzed.
The patient was a seven-months' baby, and was said to have weighed
only a pound at birth (? ;. She has had measles four times, and many at-
tacks of grip. A year ago she had an attack similar to the present one.
She formerly took alcohol in considerable quantities "to give her
strength," and for six months she has not felt well and has had darting
pains in various parts of the abdomen, especially in the right iliac region,
also in the back, knees, and other joints. Three days ago she began
to have frequent loose, slimy movements, with much pain in the right
iliac region. The pains in the joints and back have also been increased.

Physical examination shows a slight systolic thrill at the apex of the
heart, with a systolic murmur, which, however, is loudei in the pulmonary
area, and not heard in the axilla. There is no enlargement; slight general
abdominal tenderness, more marked in the right iliac region; blood,
urine, pulse, temperature, and respiration are normal. The stools show
a few food elements and large amounts of mucus. The patient lies in
bed with her eves closed most of the time, paying no attention to what
is going on about her, but complaining of pains in different parts of her
bodv.

Discussion. The suspicion of tuberculosis which is naturally ex-
cited when we learn that the patient's father died of consumption
receives verv slight support from any of the other facts in the case. It
is true that the patient has slight general abdominal tenderness, but at

270 DIFFERENTIAL DIAGNOSIS

no time has there been any fever or any evidence of free fluid or tuber-
culous masses in the abdomen. Nor do we get any very distinct help in
diagnosis from the knowledge that she has been alcoholic at times, and
that she apparently had a very poor start in the world. Possibly her
alcoholism may have something to do with her mental state or with the
various pains of which she complains.

The darting character of these pains and their distribution correspond
quite accurately with the "lightning pains" of tabes. The physical ex-
amination as it is here reproduced gives us no evidence wherewith to
support or to attack this idea, but from my own examination of the case I
know that all the reflexes were normal.

The essential symptoms in the case seem to me at the present time
as follows: Right iliac pain, accompanied by frequent bowel movements
containing much mucus. Occurring in a patient of the temperament and
physique which may be inferred from the above description, these symp-
toms suggest especially the condition known as " colica mucosa''' 1 or
mucous colitis. Three types of this disease are familiar to most prac-
titioners: (a) Those characterized mostly by pain, with a moderate
amount of constipation and neurasthenia; (b) those characterized mostly
by constipation, with a moderate amount of pain and neurasthenia;
and (c) those characterized mostly by neurasthenia, with a moderate
amount of constipation and pain.

In all these cases the stools contain varying amounts of mucus,
sometimes mixed with fecal matter, sometimes making up practically
the whole of the dejection. In my opinion, however, the fundamental
and underlying factor in all cases is the neurasthenic state which is the
cause of the constipation, and thereby of the pain and mucus. The most
successful treatment must address itself to the cure of the constipation,
but this cannot be permanently relieved unless the patient's mental
habits and point of view can be reconstructed.

Outcome. Under treatment for constipation, with 5 grains of
Blaud's pills three times a day, the patient was discharged relieved on
the nineteenth of August.

Diagnosis. Mucous colitis.

Case 136

A school-girl seventeen years old was first seen December 4, 1908.
Six days before she had a stomachache, which lasted about twenty-four
hours and then got better. Three weeks before she had had a similar,
but less severe, pain. Since then she has had similar attacks three or
four times a dav.

RIGHT ILIAC PAIN

27I

On examination the temperature, pulse, and respiration are normal;
the chest negative, the abdomen level, generally tender, with slight mus-
cular spasm over the whole right side.

The last menses came two weeks ago. The diet has been blameless.
The present attack followed immediately after some high jumping in the
gymnasium. The pain was almost as great in the back as in front.
The bowels moved normally during three days of observation. The
temperature was steadily normal, likewise the pulse. Pain, however,
persisted and kept her awake most of three nights. At times it was
rhythmic, coming every fifteen minutes and lasting about two minutes.
The girl and her family were all well acquainted with the symptoms of
appendicitis, and much afraid of it. The leukocytes ranged close to
io,cco. Pressure on the left side of the belly caused pain in the appen-
dix region. Physical examination was otherwise wholly negative.

Discussion. The extension of pain and tenderness to the back,
the absence of temperature, elevated pulse, and increased leukocyte
count, and the apparent relation to a strain at the time of the onset,
inclined me at first to believe that this case was due to a wrench either
of the back muscles or of the sacro-iliac joint. I could not rule out the
possibility of a pure neurosis, since the patient was an exceptionally
high-strung and nervous girl, who had known and feared appendicitis
all her life. Indeed, this diagnosis was furnished to me, ready made, as I
entered the sick-room.

But against both these possibilities there was the fact that the pain
was not relieved either by a complete rest in bed with cross-strapping of
the back and elevation of the lumbar region on a pillow, nor by repeated
assurances that she was not suffering from appendicitis. On the con-
trary, the pain continued with very little abatement. Heat gave it only
very slight relief; aspirin was equally inefficacious. Judgment was
still more affected, however, by the pain's rhythmic character, which
usually indicates spasm produced in some hollow, tubular structure.
This could not lit in with either of my previous diagnoses, and the verdict
had to be shifted to appendicular colic. At no time was there any in-
dication of an involvement of any part of the urinary tract. The pain
never followed the course of the ureter, nor showed an}" of the typical
radiations of nephrolithiasis. The urine remained wholly negative.

Outcome. Operation, December 8th, showed an appendix bent
upon itself, and covered with old adhesions, but not inflamed.

Diagnosis. Appendicular colic (chronic appendicitis).

2 72 DIFFERENTIAL DIAGNOSIS

Case 137

A Scottish housewife of thirty-five was first seen February 7, 190S.
Her family history is good, though her mother died of cancer. She
had polyarthritis, with fever and prostration, seven years ago (soon after
marriage) .

For one year she has had nearly constant pain in the right lower
quadrant of the belly. There is no colic, but the steady pain often needs
morphin. Pain is relieved by lying down and always disappears at
night. She sleeps well and has worked until three weeks ago. She is
not in bed.

Sometimes the pain extends down the right leg, but it has no other
radiations. No jaundice. No urinary, circulatory, respiratory, or in-
fectious symptoms.

Examination. -No emaciation or anemia. Visceral examination
was negative except that in the right upper quadrant there was a mass
palpable bimanually, irregular of surface, descending to the navel with
inspiration. Tenderness of right lower lumbar muscles. (See Fig. 42. )
Cutaneous tuberculin reaction negative.

A catheter specimen of urine showed microscopic blood and pus.
Cystoscopy showed a normal bladder. Turbid urine was obtained from
the right ureter; injected into a guinea-pig; five weeks later negative
autopsy.

Discussion. It is noticeable in this case that, although the pain is
in the right iliac fossa, the tenderness is in the lumbar region, where a
mass is felt bimanually. The fact that the pain disappears when the
patient lies down tends still further to connect it with the kidney, rather
than with any structure in the neighborhood of the cecum.

Tumors of the kidney produce pain, enlargement of the organ, and
often a urine such as that here described, but it would be unlikely that
the amount of pus would be so large in proportion to the amount of
blood. There has been, indeed, no true hematuria, and after a year's
duration kidney tumors usually produce a hematuria so profuse as to
result in anemia. Emaciation would probably be present also by this
time.

Renal tuberculosis would explain all the symptoms, though it usually
does not give rise to such severe and long-standing pain, and almost
always produces bladder symptoms, which are not complained of here.
Nevertheless, it is only the results of animal inoculation that enable us to
exclude tuberculosis in this case.

Is it possible that a simple looseness and displacement of the kidney

Hg. 42. Position of the mass described in Case 137.

RIGHT ILIAC PAIN

273

could produce such symptoms? This idea is favored by the disappear-
ance of pain in the recumbent position, but we do not expect a kidney,
not in itself diseased, to secrete a urine turbid with blood and pus, al-
though when the kidney gets in such a position as to twist its blood-vessels,
we may have hematuria from congestion. The enlargement here present
seems sufficient to exclude a simple floating kidney.

The important evidence which we still lack is that obtainable through
the #-ray examination of the kidneys with special reference to stone. The
only point distinctly against stone here is the absence of any colic. The
good preservation of nutrition is more in harmony with the diagnosis of
nephrolithiasis than with any other condition producing enlargement of the
kidney. It is not easy to see just why the kidney should be enlarged as
the result of stones in the pelvis, unless there were obstruction to the flow
of urine, a complication of which we have no evidence here. Yet it is
a very familiar fact that kidneys which turn out to be the seat of no
disease other than nephrolithiasis uncomplicated, seem considerably
enlarged when palpated before operation.

Outcome. X-ray shows stones in both kidneys.

Operation : in right kidney a stone with a body the size of a plum
and three branches one inch long was found; in left kidney three stones,
the largest as large as a marble, the smallest the size of a marrow-fat
pea. November 12th: Discharged well.

Diagnosis. Stone in both kidneys.

274

DIFFERENTIAL DIAGNOSIS

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Causes of Left Iliac Pain

PUS-TUBE AND
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OVARIAN CYST)
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MOID

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Inguinal hernia, the debility of neurotic women, and the temporary
and atypical localization of some of the causes of diffuse abdominal
pain are also to be mentioned.

270

CHAPTER IX

LEFT ILIAC PAIN

Case 138

A housewife of forty-six was seen in consultation May 10, 1907.
The attending physician's diagnosis was cancer of the intestine, probably
in the sigmoid. The patient has had for three or four years a " stomach
trouble" characterized by pain near the left costal margin, with vomiting
of greenish fluid and "coffee-grounds," the vomitus being sometimes
sour, sometimes bitter. Vomiting relieved the pain. For the past year
she has had no vomiting and only moderate soreness in the left side.
Six weeks ago she felt a sudden knife-like
pain in the left lower quadrant, which lasted
twenty-four hours, following which she was
in bed for five weeks. The bowels moved
every second day. She has lost five or six
pounds.

Physical examination showed fair nutri-
tion; marked pallor. Red cells, 3,332,000;
hemoglobin, 50 per cent.; polynuclear cells,
52 per cent.; considerable achromia; urine
negative; chest negative. Above and to the
left of the umbilicus a hard, movable, sausage-
shaped mass, extending from the median line
obliquely outward and downward for three
inches.

A stomach-tube showed no fasting con-
tents and no enlargement of the organ. After
a test-meal, free T1C1 was 0.2S per cent.; total
acidity, 0.35 percent. The guaiac test was negative, both in the gastric
and intestinal contents.

The diagnosis of cancer of the sigmoid was generally agreed to.

Discussion. At least three years of a stomach trouble which lias
produced anemia and hyperchlorhydria, but which lias not led to any
gastric stasis such is the background against which the recent symptoms

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278 DIFFERENTIAL DIAGNOSIS

of this case stand out. A sudden acute attack of left iliac pain and in
the same region a tumor, regarding the age of which we have no knowl-
edge, are the facts which must in some way be woven into a satisfactory
diagnosis.

With such a tumor and such a pain, a diagnosis of sigmoid cancer
seems at first inevitable. But a cancer which has existed long enough
to be palpable as a tumor of this size should also manifest itself by visible
peristalsis, intestinal noise, gross or occult blood in the stools, diarrhea,
or marked constipation. That none of these symptoms is present should
certainly give us pause.

Were the tumor situated higher up in the abdomen, we should cer-
tainly be inclined to consider a perigastric exudate resulting from the
attempt of a gastric ulcer to perforate. The long previous history, the
present hyperchlorhydria, the anemia, and the recent acute attack of pain
are all quite consistent with this diagnosis. It seems somewhat remark-
able, however, that the symptoms should have come to so complete a
standstill as has apparently occurred since the attack six weeks ago.

Though nothing is said in the text regarding the results of pelvic
examination, I may add here that nothing could be found in the pelvis
to connect any of its organs with the disease under consideration.

Outcome. On the twenty-first of May the abdomen was opened.
The mass proved to be composed of a perigastric exudate adherent to
the abdominal wall. Behind this was the narrow neck of an hour-glass
stomach, which barely admitted the little finger and was evidently due
to the scar of an old gastric ulcer. Gastro-enterostomy was done. Six
days after operation the patient was doing well.

Diagnosis. Perforated gastric ulcer.

Case 139

A housewife of twenty-six entered the hospital December 27, 1906.
For two months she has been having pain in the left iliac region, at
first darting in character and extending through to the back; later, dull
and constant, sometimes more severe at night. Pain has been accom-
panied by weakness and frequent micturition. Her appetite has been
good, her bowels regular, her urine dark and cloudy for a month.

The course of the temperature is seen in the accompanying chart.
The urine was alkaline and contained always a large amount of pus, and
sometimes a great deal of blood in clots. The specific gravity was always
low, averaging about 1012, and the amount of albumin large; no casts
were ever found. Examination of the chest and abdomen was negative;
likewise ar-rav examination of the renal regions. After entrance to the

LEFT ILIAC PAIN

279

hospital the urine was sometimes quite normal, at other times composed
almost wholly of blood. Several small concretions were passed in the
early days of January, 1907. On the sixth, one obstructed the urethra
and had to be removed. It was shown to be composed of calcium phos-
phate upon a nucleus of mucin. Its pas-
sage was not attended with pain. Re-
peated examinations of the urinary sedi-
ment showed no tubercle bacilli.

Discussion. The essential features
of this case are left iliac pain of two
months' duration, associated, during the
past month, with the frequent passage
of an alkaline, cloudy urine containing
large amounts of pus and blood. The
continued fever is also of importance.

All these symptoms may be produced
by renal tuberculosis, and this diagnosis
cannot be possibly excluded upon the evi-
dence here presented. Animal inoculation
is necessary. Nevertheless, the absence
of any evident enlargement of the kidney,
demonstrable by palpation or jc-ray ex-
amination, the presence of an alkaline
urine, and the constant abundance of blood, are facts which tend to
support the negative results of the search for tubercle bacilli.

In the hands of a competent operator we may say that #-ray examina-
tion, declared by him to be negative, is very strong evidence against the
existence of renal stone. The predominance of bladder symptoms here,
the absence of anything suggesting colic, and the apparently steady dis-
charge of blood and pus tend to rule out nephrolithiasis.

Malignant disease of the kidney rarely produces such a predomin-
ance of bladder symptoms or so large an amount of pus in the urine.
Unless we suppose the neoplasm to be complicated by bladder disease,
we could not account for the alkalinity of the urine.

Stone in the bladder is rare in women if we leave out of account the
secondary calculi incrusted about a hair-pin or some other foreign body.
There is no history of the introduction of any such body in this case, and
if we take the history on its face value, this is evidence against 1 ladder
stone. In one sense, of course, we are quite sure that stones have been
in the bladder, since several small ones have been passed; but from the
rarity of primary bladder calculi in women and the absence of any of the

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280 DIFFERENTIAL DIAGNOSIS

exacerbations due to jolting or moving, we may suppose that the small
stones which have emerged were formed as a secondary result of some
other disease. The question remains as to what that disease is likely to
be.

Chronic cystitis is now universally recognized to be, in practically
all cases, a symptom of some deeper cause. The days of primary or
idiopathic cystitis are passed. Gonorrheal cystitis is distinctly rare
unless as a part of a much more obvious acute and general infection of
the genito-urinary tract.

Tuberculosis of the bladder is a frequent cause of cystitis, and is
practically always secondary to renal tuberculosis, reasons for excluding
which have been already given.

Tumor of the bladder is the only remaining cause of cystitis fre-
quently occurring in women, and against that diagnosis there seem to be
no important data. The occurrence of small concretions in and about
tumor of the bladder is a familiar fact.

Outcome. On the twenty-third cystoscopy showed an exceedingly
foul bladder and a ragged tumor mass on the left side. Operation on
the twenty-sixth confirmed this diagnosis. A cutting from the mass
was examined histologically and pronounced undoubtedly malignant.
The walls of the bladder were much thickened and contracted.

Diagnosis. Bladder cancer.

Case 140

A laundress of forty-four entered the hospital December 24, 1907.
She had lost one sister of consumption ; her family history was otherwise
good. She has been subject all her life to occasional sick headaches.
At half-past nine this morning, while washing, she suddenly began to
have steady, severe pain half-way between the navel and the left flank.
Soon after she vomited her breakfast. The pain was so severe that
she could not lie down until night. Her suffering has been constant,
though varying in intensity, and she has continued to vomit a thin, yel-
lowish fluid. There is some soreness in the region of the pain, but no
headache at the present time. The bowels moved two days ago with
medicine, not since. She has been very constipated for years, sometimes
going a week without a movement.

Physical examination of the chest was negative save for accentuation
of the aortic second sound. The urine and blood were normal. The
right kidney descended two fingers' breadth below the costal margin
on full inspiration. During the first two days in the hospital the patient
vomited everything that was taken by mouth. Finally, the bowels were

LEFT ILIAC PAIN 2 8l

started by calomel and enemata, and by the twenty-seventh the patient
was taking milk and feeling happy. The first urinary examination
showed sugar, acetone, and diacetic acid. After that there was no sugar,
but acetone and diacetic acid persisted until the twenty-eighth.

Discussion. The chronic constipation leading to acute pain and
obstinate vomiting cannot but incline us very strongly toward the diag-
nosis of sigmoid cancer, especially since the woman is forty-four years
old. But what are we to say when, after we have made such a diagnosis,
we succeed in getting the patient's bowels to move naturally and all
the symptoms disappear? I have introduced this case in order that I
might emphasize the point that such a recovery by no means excludes
cancer. In the early stages of that disease, when the growth is little
bigger than a signet ring, temporary obstruction with fecal impaction
behind the stricture often leads to symptoms quite like those here de-
scribed, which, nevertheless, disappear under treatment and may not re-
cur for weeks or months. It is only by a careful following of the case
that we can be justified in excluding cancer.

Outcome. On the first of January sugar was again present in the
urine. On the second it was gone and did not return, although the pa-
tient was allowed a full mixed diet. Thereafter the patient's bowels
were kept regular by the use of an A. S. and B. pill four times a day.
There has been, so far as known, no return of symptoms.

Diagnosis. Constipation.

Case 141

A hostler of thirty-two entered the hospital June 3, 1902. His
family history and past history were negative. Until the previous
fall he had always taken five or six beers and three or four whiskies a day.
He denied venereal disease. Yesterday morning he awoke with a chill,
chattering teeth, fever, vomiting, headache, and pain in the left groin.
He slept poorly last night. The course of the temperature was as seen
in the accompanying chart. On the sixth the glands were discovered
to be tender and considerably enlarged in the left groin. There was
an operation scar over the upper part of the left tibia; the bone under-
neath it very rough. Below this the skin was bluish red. and several
ulcerated areas from the size of a silver dollar to that of the palm were
present. An .v-ray showed that the tibia was considerably thickened
in its upper third, and the fibula throughout its entire length. Physical
examination, including the blood and urine, was otherwise negative.

Discussion.- -This story seems to narrow itself down to a case of
fever with painful glands in the groin. Our chief task is to consider the

282

DIFFERENTIAL DIAGNOSIS

probable cause of the glandular enlargement. The ulceration on the
lower leg may well produce sufficient irritation to stimulate the glands
into a work-hypertrophy, ordinarily known as a bubo. Leukemia
being ruled out by the negative result of the blood examination, and
pseudoleukemia by the absence of glandular enlargement elsewhere,
it remains only to consider the probable nature of the ulcerations which

have led to the adenitis and so to the pain
and fever.

Ulcerations in this situation are most
frequently due to the malnutrition following
varicose veins, hence the term varicose ulcer.
Next to this, syphilis is the most common
cause, though it is more apt to produce ulcera-
tions in the calf or above the knee than upon
the shin. In view of the x-ray evidence,
which shows a bony change very commonly
associated with syphilis, this seems the most
reasonable diagnosis.

Regarding the cause of the acute infec-
tion, with its attendant pyrexia and chill,
nothing very definite can be said. Possibly
there was some secondary invasion of the
tissues induced by a sudden lowering of their
vitality, for which there are many occasions
in the life of such an individual.
Outcome. Under iodid of potash the glands became smaller, the
fever went down, the leg ulcers began to heal; on the fourteenth the
patient was discharged.

Diagnosis. Syphilitic adenitis.

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Case 142

A housewife of twenty-seven entered the hospital June 21, 1908, for
pain in the left iliac fossa, her second severe attack within three weeks.
The first attack (twenty days ago) was very severe, but lasted only about
one minute. Yesterday at 2 a. m. sudden severe pain began again at the
same point, lasted until 10 a. m., then suddenly ceased until this morn-
ing about five, when it returned as she was getting up. At times she has
seen and felt a swelling in the region of the pain.

She has had three children, the youngest three months old. Menses
normal. Xo other illnesses.

Examination. Abdomen prominent in lower left quadrant, where

LEFT ILIAC PAIN

283

there are circumscribed dulness and a large, hard, irregular mass, mov-
able and very tender. It was apparently not connected with the uterus,
but could be felt per vaginam. Physical examination, pulse, tempera-
ture, blood, and urine negative.

Discussion. The association of left iliac pain with a hard, irregular
mass in the same region naturally suggests malignant disease. The
sigmoid flexure of the intestine is the commonest site for such a growth
in this part of the body, and the age of the patient by no means excludes
this possibility. I have seen a cancer of the sigmoid demonstrated at
autopsy in the body of a boy who died before his twenty-first year.
In the present case, however, we have no intestinal symptoms sufficient
to incriminate the sigmoid, and a growth of the size above described
would certainly have produced such symptoms if the gut were involved.

Ovarian tumor seems more probable. We do not expect the com-
moner varieties of ovarian tumor to be as firm of surface as the descrip-
tion of this tumor suggests, but I have often been deceived in this
respect and seen at operations a cystic tumor which felt as hard as a piece
of wood when examined through the abdominal wall, so that I am no
longer willing to trust my tactile sensations. Solid tumors of the ovary
are considerably less common, especially in women of this age, and rarely
reach so large a size without previously attracting any attention. Fibro-
myoma of the uterus would probably show an obvious connection with
that organ and would be less likely to be situated so much at one side.

Uncomplicated ovarian tumors do not produce acute symptoms like
those above described, but there are many accidents to which such
tumors are exposed and by which severe pain may be produced. As
we have no way, in the great majority of cases, of distinguishing these
accidents clinically, it is safest to assume that the commonest of them
twisting of the pedicle has occurred.

Outcome. Operation showed a gangrenous, strangulated, multi-
locular ovarian cyst with a double twist in its pedicle and a quart of blood-
serum in the peritoneal cavity.

It may be well to mention here some of the varieties in the sympto-
matology of strangulated ovarian cyst, so as to bring out features not
exemplified in the case just discussed.

(a) In many cases there are repeated attacks which are clinically
similar in type, but lesser in intensity than that above described. Many
of these attacks are due, doubtless, to patches of local peritonitis such as
result in the adhesions which often confront the operator years later.

(b) General abdominal tenderness and spasm, associated with vomit-
ing and great prostration, often make the clinical picture much like that

284 DIFFERENTIAL DIAGNOSIS

of acute peritonitis, which can be excluded only when the patient or her
physician has previously known of the tumor's existence.

(c) Tumors occupying the right side of the abdomen are fully as
common as left-sided growths. In a considerable proportion of cases the
cyst is to be found in the median line, and the diagnosis is thereby con-
siderably obscured.

(d) Moderate fever and leukocytosis are the rule, the former ranging
between ioo and 102 in most cases, while the leukocytes are usually
between 14,000 and 20,000.

(e) If menstruation occurs during such an attack of pain, the latter
is often relieved.

Diagnosis. Multilocular ovarian cyst (twisted pedicle).

Case 142a

A widow of sixty-seven called her physician in September. 1908,
on account of pain in the left iliac fossa. For five or six years she has
noted a bloody discharge w r ith some odor. This discharge has been
supposedly due to hemorrhoids and has been treated as such, but
examination now shows it to come from the vagina. For the past
week this discharge has been active and the blood has been bright.
Four weeks previously to this time she had a week's flowing, and
similar periods have occurred from time to time during the last five
years.

The present illness began three weeks ago with pain, tenderness,
and enlargement of the left lower quadrant of the abdomen, accom-
panied by fever which averaged 101 F. for the first week of her
illness. This gradually fell to normal, so that ten days ago the
local physicain was able to discontinue his visits for three days.
With the subsidence of temperature the weakness, tenderness, and
pain of which she had previously complained gradually disappeared,
but a week ago all the symptoms returned, and during the last six
days fever has averaged 100 F. The pain is now referred not only
to the left iliac fossa, but to the left thigh and hamstring muscles.
The bowels are moved by enema.

The appetite has been very poor and there has been marked
prostration, so that she has been in bed most of the time during the
last four weeks. Her weight has fallen considerabley. There has
been no vomiting, no cough, and no pain other than that described
above. The menopause occurred thirteen years ago.

When seen in consultation October 19, 19 10, the patient's tern-

LEFT ILIAC PAIN 285

perature was 101.2; there was moderate emaciation; at the apex of
the right lung the physiologic peculiarities of that space on auscul-
tation and percussion seemed somewhat exaggerated. Otherwise
the chest showed nothing abnormal. The left lower quadrant of the
abdomen was filled by a smooth, resistant, apparently elastic mass,
protected by a considerable amount of muscular spasm and rather
tender. The same mass was felt by vagina, but seemed to be un-
connected with the uterus, which was normal.

The leukocytes numbered 25,600, 90 per cent, of which were
polynuclears. There was no anemia. The urine was normal.

Three weeks later the attending physician reported that the
patient was about the same, the temperature still reaching about
10 1 F. each night, being normal or subnormal in the morning. There
was then very little pain and the vaginal discharge had ceased.

Discussion. Cancer of the uterus was first suspected on ac-
count of the ill-smelling vaginal discharge. That this was not of
the ordinary type, involving the cervix uteri, was readily shown by
the vaginal examination. Cancer of the body of the uterus was not
excluded, as no intra-uterine examination was made. It is very
unlikely, however, that so much fever and left iliac tenderness would
be produced by a neoplasm of the body of the uterus.

Cancer of the sigmoid was next considered. The position of the
tumor mass, the age of the patient, and the presence of a bloody dis-
charge, which the patient believed to have come from the rectum,
favored this diagnosis. On the other hand, nothing definite could be
felt by rectum. There was no evidence of intestinal obstruction and
no diarrhea, while the presence of continued fever for more than a
month made uncomplicated neoplasm very unlikely. The same
holds true of ovarian neoplasm. Pyosalpinx was considered, but
seemed exceedingly unlikely in view of the patient's age and char-
acter.

Diverticulitis is strongly suggested by all the facts of the case.
The age of the patient, the position and consistency of the tumor,
and the continued fever with leukocytosis are typical.

Outcome. On operation. November 13th, a large inflammatory
mass was found tying together the bladder, the lower sigmoid, and the
adjoining parts. In the tenter of the mass, close to the sigmoid, a
pus-cavitv containing about a tablespoonful of pus was found. Lead-
ing out of this cavity was a sinus connecting with the interior of the
lower sigmoid, which was greatly thickened and infiltrated lor a
considerable distance above and below the >inu>. Microscopic

286 DIFFERENTIAL DIAGNOSIS

examination later showed that the sinus originated in a diverticulum.
The pus was evacuated and drained, a portion of the sigmoid resected,
and an end-to-end suture done. The patient made a somewhat slow,
but uninterrupted recovery.

Diagnosis. Diverticulitis of the sigmoid.

GENERAL CONSIDERATIONS ON THE DIAGNOSIS OF ABDOMINAL

PAIN

Though I have followed current practice in separating the causes of
localized from those of generalized abdominal pain, it must be admitted
that the separation is not always true to fact. Diseases like appendi-
citis, whose pain belongs in the right iliac fossa, are very apt to set their
pain loose all over the belly. On the other hand, lead-poisoning, which
usually causes wide-spread "dry" bellyaches, may anchor its colic to
a single spot in a most misleading way.

Hence one who looks under one chapter for some familiar type of
pain may wonder at its absence and be surprised to find it in another.
Some causes of suffering, on the other hand, are listed under two different
headings (e. g., ectopic gestation, strangulated ovarian cyst), because
they are about equally common on the right and on the left.

When searching out and thinking out the probable cause of an ab-
dominal pain we are all guided, I take it, by the following obvious rules:

i. Suspect, first of all, the gastro-intestinal tract, and if its simpler
troubles (such as constipation and colitis) can be excluded, consider
especially appendicitis, peptic ulcer, neoplasms cf the stomach or large gut,
and the remoter consequences of these lesions (peritonitis, intestinal
obstruction).

2. Suspect next (in women) the genital tract (pus-tube, ovarian cyst,
uterine fibroid, ectopic gestation) .

3. The gall-bladder and its ducts are especially to be considered if
the patient is past middle life.

4. The urinary tract, especially in elderly men or young girls, comes
next in the order of causes for abdominal pain.

In investigating any of these causes the history, palpation, the blood,
the urine, .\--ray, and cystoscopy are the most valuable aids.

LEFT ILIAC PAIN

287

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CHAPTER X

AXILLARY PAIN

Case 143

A stableman of thirty-nine entered the hospital January 24, 1908,
with negative family history and good habits. Past history uneventful
except for an attack of malaria in September, 1907. Three days ago,
while at work, he had a severe chill. He went home, but did not go to
bed. The next morning he went to work as usual, but had to give up

about noon and take to bed, where
he has remained since, with head-
ache, high fever, pain in the left
chest, sore throat, nausea, thirst,
and frequent vomiting. His
bowels were moved by laxatives
this morning. When he swallows,
he sometimes feels a sharp pain
which shoots from his throat to-
ward his left ear.

The patient's temperature is
seen in the accompanying chart.
At entrance he was breathing
easily, and there was no motion
of the nostrils. He complained
of deafness and buzzing in his
ears, especially the left. There
was internal strabismus on the
right, which he says is of long
standing. There was a mild spasmodic cough, but no sputa. Visceral
examination was negative, save that in the lower left back there was a
little dulness, and the voice-sounds were a trifle nasal in character.
Just below the scapula the breath-sounds were somewhat diminished,
whispered voice slightly increased, and an occasional clicking rale was
audible. No bronchial breathing.

The white cells were 20,000; urine, 32 ounces; specific gravity, 1023.
There were a few hyaline, many line granular casts, and a slight trace of
albumin.

Fig. 46. Chart of case 143.

2s6

Causes of Axillary Pain

1. FLATULENCE LEFT AXILLA AND PRECORDIA>

PLEURISY i^MHHHHHH^HHHHHHM^HBi 1013

3. PNEUMONIA nHmHiBIBBB 803

4. FRACTURED RIB ^^H 234

5. INTERCOSTAL) __ AQ

> 48

NEURALGIA J

6. RADIATIONS1

FROM HYPER-

TROPHIC} 45

SPINAL A R- j

THRITIS J

Among other lesions not graphically represented here, because of
their rarity as causes of axillary pain, are :

I lerpes zoster.

Costal tuberculosis.

Costal neoplasm.

Costal actinomycosis.

Angina pectoris.

Deep axillary abscess.
Fractures and dislocations of the shoulder and humerus often pro-
duce axillary pain, but usually present no diagnostic difficulties so far
as the source of the pain is concerned.

Finally, there is a large group of axillary pains, apparently of mus-
cular origin, akin to lumbago and "stiff neck." The bombastic term
" pleurodynia" is often attached to these pains, but since their actual
nature is unknown and their diagnosis never certain, I have attempted
no estimate of their relative frequency.

I!)

AXILLARY PAIN 291

Discussion. Obviously, we are dealing with an infectious disease,
though gastric symptoms occupy the foreground of the clinical picture.
For simple tonsillitis the patient is apparently too sick, and there was
nothing in the tonsillar region sufficient to justify the diagnosis.

The deafness, the buzzing sounds, and the shooting of pain toward
the ear might indicate otitis media, but unless pain is more definitely
localized and continuous in or about the ear, one could not make such a
diagnosis in the absence of any discharge or any knowledge of the con-
dition of the drum membrane.

Acute meningitis may begin in this way, and there is nothing said
in the text regarding the condition of the neck muscles or of the ham-
strings (Kernig's sign). The strabismus would be of great diagnostic
importance if we disregarded the patient's statement that it has existed
for many years. As a matter of fact, however, investigation showed that
there was no stiffness of the neck or of the ham-string muscles. Without
lumbar puncture no further certainty can be obtained on this point,
and meningitis must remain a possibility unless we can find some more
plausible explanation for the symptoms.

It was subsequently learned that the patient had been given large
doses of quinin before he entered the hospital, the chill and the previous
attack of malaria having led to the exhibition of this drug.

Although the pulmonary signs are very slight and not distinctive,
they seem to me sufficient to warrant a diagnosis of pneumonia when
we link them with the continued fever, the leukocytosis, the chest pain,
the chill, and the gastro-intestinal symptoms. Cases of pneumonia
which do not show early and well-marked signs of pulmonary solidifi-
cation are very apt to begin with several days of gastro-intestinal symp-
toms, the significance of which would be very obscure but for their
association with fever and leukocytosis.

Outcome. Rusty, tenacious sputum was later raised, and in it
the pneumococcus was the predominating organism.

At no time were the signs in the chest any more definite than at en-
trance. On the twenty-sixth there were moist rales in various parts
of the lungs, and the patient was somewhat delirious. On the thirty-
first, the day after the crisis, there was a friction-rub in the sixth left
space, anterior axillary line.

On the twelfth of February the patient left the hospital perfectly
well.

The treatment consisted of laxatives, a tight swathe, ice bag. and
hot-water bottle for pain, and an occasional dose of morphin.

Diagnosis. -Pneumonia.

292 DIFFERENTIAL DIAGNOSIS

Case 144

An Italian farm-laborer, sixty-six years old, was first seen January
30, 1908. His family history and past history were negative, his habits
good. Seventy-two hours ago, while standing on a chair to put a cloth
over his canary's cage, he lost his balance and fell to the floor, striking
his left side on the back of the chair. He was unconscious for some
minutes, and later experienced a sharp pain in the left side of the chest,
worse on coughing or deep breathing. This pain has troubled him
ever since, and has been accompanied by a slight dry cough. For two
days he has been feverish.

At entrance, the patient's temperature was 99.4 F.; pulse, 79; res-
piration, 20. There was a marked posterior convexity of the lower
dorsal and upper lumbar spine. The breath was foul. There was a
slight, diffuse, systolic pulsation under each clavicle, especially on the
left. The heart was negative. Scattered throughout both lungs were
squeaks and crackles. There was marked tenderness over the eighth
and ninth left rib in the midaxillary line. Pressure over the vertebral
end of the ninth rib caused pain over the same rib in the midaxilla. No
definite crepitus was obtained. A rough grating was heard with inspira-
tion in the painful area. At the top of the left axilla was a suggestion
of bronchial breathing. On the left forefinger and the back of the last
phalanx was a raised, reddened, tender area, half an inch in diameter,
crusted in the center. From this a little seropurulent fluid could be
expressed. He has had this trouble for a month. The next day the
fluid in this lesion was distinctly purulent.

Discussion. Fever, cough, rales, and axillary pain in a man of
sixty-six lead straight to the diagnosis of pneumonia if we are in the habit
of judging by symptoms alone, and so far as the pulmonary signs are
concerned, they are perfectly consistent with the existence of a central
pneumonia or of pneumococcus infection which has not yet become
localized anywhere. More important evidence against pneumonia is
furnished by the temperature chart, the low respiration rate, and the
absence of gastro-intestinal symptoms. Up to the time when I saw the
patient no leukocyte count had been made, and as this seemed to me
one of the most important diagnostic data, I made the count at once.
There were 6500 leukocytes per c.mm. So low a count rarely occurs in
pneumonia unless the patient is more ill than this man seemed to be.

The pulsations beneath the clavicles had given rise to considerable
anxiety in the mind of the attending physician, who thought they might
be connected with an aneurysm, which he suspected of producing pain

AXILLARY PAIN

? 93

in the side. But there was really no evidence of aneurysm, and the
pulsation was not greater than is often seen in thin persons whose sub-
clavian arteries happen to lie near the surface.

Of pleurisy there were no certain physical signs, and although this
diagnosis is often made on the basis of the patient's account of his pain,
and often definitely at his suggestion, experience does not justify anv such
diagnosis. Many patients and not a few physicians allow themselves
to speak of "pleurisy pains" when they would not seriously maintain
that they had evidence of any form of pleurisy. The rough grating
sound referred to was probably due to another cause, soon to be men-
tioned.

Pain of muscular origin the so-called pleurodynia akin to stiff
neck and lumbago must be shown to vary directly with the amount of
muscular motion; apparently there was no such variation. Pleurodynia
produces general widespread tenderness, much less local than was
present in this case.

The protuberance of dorsal and lumbar vertebrae makes us ask whether
any form of spondylitis may be responsible, through radiations along
nerve-roots, for this patient's pain. Pain of this type is often made worse
by coughing or deep breathing. It does not, however, lead to tenderness
in midaxilla, and would be very unlikely to appear suddenly after a fall.

The fact that pressure on the ninth rib near the spine produces pain
localized in the axillary portion of that rib is strong evidence that that
rib is cracked, and the local tenderness and the rough grating sound
following such a fall point strongly in the same direction. In the ab-
sence of crepitus no further evidence can be obtained, unless a callus
forms. This diagnosis would doubtless have been made at the start had
not the patient chanced to be feverish. Presumably the fever was due to
the slight infection on the forefinger.

Outcome. The chest was strapped with plaster and in two days
the patient was well enough to go back to work of a light character.

Diagnosis. Broken rib.

Case 145

A housemaid of twenty-five entered the hospital July 20. 1006.
Nine days ago she suddenly experienced sharp, shooting pain in the lower

ribs and in the right axilla, not worse on cough nor on deep breathing.
This pain lasted one day; she then began to have pains in her head and
knees, with fever, chill, and general weakness. Four days ago she had
to give up and go to bed. Her bowels have moved regularlv. but she
has vomited once.

294

DIFFERENTIAL DIAGNOSIS

Physical examination was entirely negative.

The white cells were 2500; no Widal reaction; urine normal, except
for the presence of a diazo-reaction.

The course of the fever is show r n in the accompanying chart.
Discussion. At the outset it was impossible to exclude pneumonia,
although the association of so low a white count with a good general
condition seemed very much unlike pneumonia. Had the leukocyte
count been high, I should have suspected pneu-
monia, present or to come, even in the absence of
definite signs in the chest.

I have known a case altogether similar to this to
be counted among the successes of a physician who
thought he could abort typhoid fever. It is true
that typhoid fever not infrequently shows under
observation no longer a period of pyrexia than was
here recorded, but the presence of a diazo-reaction
is by no means sufficient evidence on which to base
a diagnosis of typhoid under these conditions.
Only by the demonstration of typhoid bacillus or
at least of a well-marked Widal reaction can the
diagnosis be justified when the fever is so brief.

Pleurisy is excluded by the short duration of the
pain and by the absence of physical signs.

I have known tertian malaria to produce symp-
toms strikingly like those with which this case be-
gan, but the pain and fever were then much more
definitely intermittent and did not cease permanently until quinin was
given. In the case here under consideration no quinin was exhibited.

It is the fashion to call such cases as this "grip" or "influenza."
but although these words are not taken very seriously by the physician
who makes the diagnosis, they seem to me sufficient to mislead the patient,
and incidentally the physician himself. They hide from us the fact that
we are facing something which we do not understand. A well-known
name easily transforms itself into the impression that we know some-
thing of the disease to which we are applying it. This tends to make
progress impossible. It seems more sensible to recognize that the un-
named infections are probably as numerous as those already listed and
named in our text-books, and that in a case like this we are confronted
with one of this unnamed and unknown multitude.

Outcome. In six days the patient seemed perfectly well; the treat-
ment consisted mainly of an occasional laxative and hypnotic.
Diagnosis. Unknown infection.

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case 145.

AXILLARY PAIN 295

Case 146

A master painter of sixty entered the hospital November 18, 1907.
His family history was good. From the age of sixteen up to the age
of thirty-two he suffered from neuralgia in the right side of his forehead,
but was finally cured in 1879. He had typhoid at eighteen, just after the
Civil War. Twenty years ago he was laid up for six weeks with lum-
bago, and has had several less severe attacks of this pain since. He has
never had lead colic, nor any pain in his joints. His habits are good.

For six years he has been troubled with pain in the left upper chest,
the attacks gradually growing worse and more frequent. Now the pain
is nearly constant unless he takes medicine. The pain is of three sorts:
(1) A dull, burning pain, present in the chest most of the time; (2) a
terrilily severe pain, with a feeling as if he were gripped in a vise. This
comes from once a week to once a month, and has several times waked
him in the night. (3) A sharp, shooting, knife-like pain, beginning in
his left chest, running up to his shoulder and neck, and sometimes felt
also in his arms. This comes at irregular intervals more often within
the last two or three years. There are no gastric symptoms. The pain
does not seem to have any relation to food. There is no dyspnea, cough,
j/alpitation, or edema. Years ago exertion seemed to make him worse,
but now, he says, it seems to make him better, and lately he has dreaded
bed-time. He has been treated in the out-patient department since
May, 1902. He still directs his business and works irregularly.

Physical examination shows an obese man, with normal tempera-
ture, pulse, and respiration; the blood-pressure, 150 mm. The urine
averages 40 ounces in twenty-four hours; specific gravity, 1027; no al-
bumin and no casts. The white corpuscles range between 12.000 and
14,000 per c.mm. No stippling of red cells. No lead-line.

The first sound at the heart's apex is followed by a soft murmur,
best heard in the aortic area, not transmitted to the axilla. The aortic
second sound is greatly accentuated. There is no demonstrable cardiac
enlargement. The pulses are equal and regular, the artery wall not
remarkable.

Physical examination is otherwise negative, except that there is some
dulness in the Hanks, which, however, shows no shift attendant upon
change of position.

Discussion.- When a house-painter complains of a pain of any kind,
our knowledge of the pathology of lead-poisoning naturally leads us
to do what we can to connect the pain with the patient's occupation.
In this case, however, there is no definite evidence oi lead-poisoning

296 DIFFERENTIAL DIAGNOSIS

(stippling is often present in lead-workers who show no evidence of ill-
ness), and the pain is not such as we are accustomed to see produced by
that disease.

The previous history of lumbago makes us seek to find evidence of
that disease in the patient's present symptoms, but there seems to be no
such close relationship between the pain and movement of the affected
muscles as would be expected in lumbago.

The situation and continuity of the pain are such as we are accustomed
to associate with aortic aneurysm, and only by #-ray examination (which
was not made, owing to the patient's poor condition when he first entered
the hospital) can aneurysm be positively excluded.

Angina pectoris produces pains the character and location of which
correspond accurately with those here described. The patient's state-
ment that exertion now seems to make him better is practically the only
consideration that seems to contradict this diagnosis, and this is not
sufficient to exclude it. As to the nature and prognosis of the affection,
our judgment would be much assisted if we knew whether the patient
was an excessive consumer of tobacco. No further certainty can be
obtained without the therapeutic test (nitroglycerin or amyl nitrite) and
an x-ray examination.

Outcome. He has used nitroglycerin in doses of T ^ grain from the
first, and for years a single tablet gave prompt relief. Gradually the
necessary dose has increased, until of late he takes as much as -^5% in
twenty-four hours.

X-ray showed no evidence of aneurysm. During the patient's stay
in the hospital he usually had an attack each night, best relieved by
amyl nitrite. Sitting up or walking about the ward seemed to bring on
attacks, relieved in the same way.

On the second of December he was discharged not relieved.

Diagnosis. Angina pectoris.

Case 147

A French-Canadian cabinet-maker of thirty-six entered the hospital
November 3, 1906. His family history and past history were not remark-
able, but he has used a great deal of tobacco and taken three or four
drinks of hard liquor every day for fifteen years.

Five years ago he began to have pain in the left side of the chest and in
the pit of the stomach, brought on by exertion or excitement, gradually
increasing in frequency and in severity. The pain stabs like a knife,
lasts about half a minute, makes him stop whatever he is doing and stand

AXILLARY PAIN 297

bracing himself back. Occasionally it comes on at night, and then
he has to sit up in bed "holding onto himself."

Last winter he began to have palpitation and dyspnea on exertion.
Four months ago he stopped work by his physician's advice and went
into the country, following which he promptly became worse and for a
time could not sleep on less than four pillows. His abdomen also swelled,
and the upper part of it was tender. These symptoms have now so
far subsided that he can sleep on one pillow. Two or three years ago
his wife noticed that one pupil was larger than the other. He has lost
twelve pounds in the last three years.

On physical examination the above observation regarding the pupils
was confirmed. Both were slightly irregular in outline, but reacted
normally. The heart's impulse was in the sixth interspace, if inches
outside the nipple. A systolic murmur was heard, loudest at the apex,
transmitted also over the whole precordia and into the axilla. In the
axilla and back, a harsh diastolic murmur was also heard replacing the
second sound. No second sound at all was heard in the aortic area. The
pulse was of the Corrigan type. The systolic blood-pressure was 165 mm.
The daily amount of urine averaged 30 ounces, with a trace of albumin
and no casts. At times a presystolic rumble was heard at the apex.
During the first ten days' stay in the hospital he was given magnesium
sulphate, an ounce every morning, tincture digitalis, 10 minims every
six hours, iodid of potash 10 grains four times a day, -j-fo grain of nitro-
glycerin when needed. His progress during this period was uneventful.
On the night of the fourteenth he was rather uncomfortable. On the
fifteenth he vomited several times. His pulse was more rapid and
weaker.

Discussion. The pain is strongly suggestive of angina pectoris, but
the patient seems rather young for the organic type, dependent on arterio-
sclerosis, and too ill for the functional type. As in the previous case,
we are unable to exclude aneurysm, as the patient is too ill to be moved
to the .v-ray room. The pain and the inequality of the pupils remind
us distinctly of that disease.

As regards the type of cardiac lesion, there seems to be distinct evi-
dence of aortic insufficiency with hypertrophy and dilatation oi the
heart. In a patient of this age the occurrence of aortic disease with no
preceding rheumatic attacks justifies us in treating the cast- as one of
syphilis, especially when the cardiac lesions are associated with irregular
and unequal pupils. This assumption rests upon the fact that syphilis
of the cardiovascular system usually begins in the arch of the aorta and
extends thence to the aortic valves.

298 DIFFERENTIAL DIAGNOSIS

Outcome. About 7 p. m. he remarked that he had had rather an
uncomfortable day, and felt that it was his duty to stay in bed, but that he
hoped to be allowed to get up the next day. About 8 o'clock be became
unconscious and died within a few minutes.

At the autopsy (No. 181 6) no cause for the suddenness of death was
discovered. The heart was greatly dilated and hypertrophied. There
was a chronic fibrous myocarditis, and the heart-wall was much thinned
near the apex of the left ventricle. There was stenosis of the coronary
orifices and a fibrous deformity of the aortic valve. Just above the aortic
valve, and in the arch of the aorta, were very many fibrous plaques. A
chronic pleuritis and chronic perihepatitis with adhesions was also
found.

Microscopic examination of the aortic wall showed a number of the
organisms of syphilis (treponema pallidum).

Diagnosis. Syphilitic heart and aorta.

Case 148

A Jewish laborer of nineteen entered the hospital November 4, 1907.
His family history and past history were good, also his habits. In Feb-
ruary, 1907, he began to have a loud, ringing, brassy cough, and to raise
considerable sputa. At the same time he had hoarseness and pain in
the left upper chest, both front and back. He improved at first, later
losing all he gained. Yet he has felt less thoracic pain of late, although
he has coughed considerably. Three days ago, following a severe par-
oxysm of coughing, he was seized with intense pain in the left lower chest,
both front and back. The pain has gradually improved since, but is still
severe on coughing. During the same period he has been somewhat
short of breath a new symptom for him and has felt feverish.

The movement of his temperature, pulse, and respiration is seen in the
accompanying chart (Fig. 48). The iris of his left eye is bluish; of the
right, brownish. The right pupil is smaller, markedly irregular, and situ-
ated more toward the inner side of the eye. The vision of this eye is much
diminished. The right border of the cardiac dulness extends 3} inches
beyond the midsternal line, and reaches a point just inside of the right
nipple. The left border of dulness extends about an inch beyond the
midsternum. The cardiac sounds are best heard in the second and
third right interspaces. Here the rhythm is fetal; the sounds sharp and
clear. To the left of che sternum they are difficult to hear. The left
chest is hyperresonant throughout, while the right is somewhat dull.
Breath-sounds are markedly diminished on the left, increased on the

Fig. 49. Physical signs in Case 148. Cough, fever, and a sudden attack of pain in the
lower left axilla are the chief complaints.

Fig. 50. Physical signs found posteriorly in Case 148. (See also Fig. 48.)

AXILLARY PAIN

299

right. Tactile and vocal fremitus are almost absent on the left. Physi-
cal examination of the abdomen and the rest of the body is normal.

By the seventeenth of November the patient was much more com-
fortable, though the physical signs had not changed. At the apex of the
left lung a few fine moist rales were heard, with distant bronchial breath-
ing and slight dulness (Fig. 49).

X-ray revealed a shadow in the left chest about the level of the angle
of the scapula. There were evidences of fluid below this point.

Discussion. Although fever, chest pain, and cough are so often the
precursors of pneumonia, these symptoms have lasted far too long, in
the present case, to be at all typical, and as soon as we scrutinize the de-

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tails revealed by physical examination, it is obvious that tho picture is
quite unlike that of pneumonia.

The extension of dulness, continuous with that of the heart's area
to the right of the sternum, the hoarseness and brassy cough, and the
pain in the chest suggest aneurysm. But the pain is on the left, and the
extension of cardiac dulness on the right. There are no pressure signs,
pulsations, or .v-rav shadows to support the suspicion oi aneurysm;
only the patient's complaints are favorable to that diagnosis.

When the heart is displaced to the right, as seems to be the case lure.
we naturallv investigate the causes of this displacement, beginning with
the commonest -left pleural effusion. Tn favor of this condition we have
the diminution of respiratory murmur and the absence oi vocal and tactile

300 DIFFERENTIAL DIAGNOSIS

fremitus in the left chest. But in spite of these signs, pleural effusion,
serous or purulent, may be unconditionally excluded on the evidence of
a single sign, viz., the hyperresonance of the whole left chest. Hyper-
resonance of a portion of one chest for example, the lower axillary
region or the upper quarter is quite consistent with pleural effusion,
but total hyperresonance has never been recorded, so far as I know,
with pleural effusion. Over a pneumonic consolidation situated deeply
in the lung substance the percussion-note is not infrequently hyperres-
onant or tympanitic, but this never occurs, I believe, throughout a chest
containing a pleural effusion. Hyperresonance of one chest then, with
displacement of the heart toward the opposite side, is practically distinc-
tive of pneumothorax, which seems the reasonable diagnosis of this
case.

Emphysema produces general hyperresonance, but it is never uni-
lateral, never dislocates the heart, and never causes pain.

The prolonged cough, with the rales and dulness at the apex of the
left lung, are presumably due to that disease which almost invariably
underlies pneumothorax phthisis. The v-ray shadow and the evi-
dences of fluid which gradually developed at the base of the left chest are
doubtless due to the accumulation of an exudate, converting the pneu-
mothorax into hydropneumothorax according to the ordinary rule.

Some account of the two main clinical types of pneumothorax has
already been given. Hence nothing further is added here.

Outcome. The sputum contained many tubercle bacilli. A suc-
cussion splash was once made out.

On the nineteenth of December there was still no change in the pa-
tient's condition so far as the signs in the chest were concerned; the
patient was feeling much better, had gained considerably in weight, and
had almost no cough. On the twenty-first of December he was allowed
to go home.

Diagnosis. Pneumothorax (pulmonary tuberculosis).

Case 149

A teamster of fifty-two entered the hospital April 3, iqo8. His
family history and habits were good. He had right-sided pleurisy in
1872, and was in bed ten weeks with fever and pain in the chest. He
was not tapped. Since then he has been well. In October, 1907. he
was struck on the right chest by a roll of cotton duck weighing 400 pounds.
He had some pain there, which went off after a few days. He thinks
no ribs were broken. Three weeks ago he began to have dull, constant
pain in the right chest, worse on deep breathing. This pain lasted a week.

AXILLARY PAIN

301

March 30th he went to work, but the pain soon returned and compelled
him to stop work. Now that he is in bed he has practically no pain, no
cough, no fever, an excellent appetite, and feels in most respects very
well.

His temperature, pulse, and respiration are normal, likewise his
blood and urine. He lies comfortably in bed without dyspnea. His
heart is negative. The artery walls are tortuous, with visible pulsation
in the radials, brachials, and axillaries. The right chest is flat below the
fourth rib in front and midscapula behind. Over this area respiration
js absent, likewise voice and fremitus.

Discussion. As this patient has previously had pleurisy on the right
side, we need to consider whether the organized results of that attack
pleural adhesions might account for the symptoms which are now
present. I should say decidedly not. An inflammation which has en-
tirely died out thirty-six years earlier does not lead to acute pain. The
pain of a pleural effusion may linger on for months, or even for a year or
two, but never for thirty-six years. Pleural adhesions may cause dul-
ness and diminished breathing, but not flatness and absent breathing.

Can the trauma of October, 1907, be the cause of the present trouble?
The interval of five months between the time of the blow and the onset
of the present pain makes this rather unlikely. Hemothorax never
results, so far as I know, from an injury of this kind without fracture of a
rib or puncture of the pleura. Serous pleurisy has also, in my opinion,
no connection with such an accident.

Dropsical effusions due to disease of the heart or kidney have a
predilection for the right chest, but we have no evidence of any such
disease in the present case, although there appears to be some arterio-
sclerosis in the peripheral vessels. Further, dropsical effusions do not
produce pain.

These alternatives can be easily excluded, and the diagnosis of pleural
effusion is then so automatic that it may be questioned whether J am
justified in introducing this case in a book supposed to deal with diag-
nostic difficulties. On this point 1 can only say that I have repeatedly
seen in consultation cases of serous pleurisy which had not previously
been recognized because the patient had complained so little of the chest
that no thorough physical examination had been made. Under these con-
ditions the diagnosis is usually ''typhoid," "slow fever," "autointoxica-
tion," or " ptomain-poisoning."

It is worth while to note in passing that this patient was in lied
ten weeks with his untapped pleurisy of 1872, whereas in kjoS hi> illness
lasted less than two weeks.

302 DIFFERENTIAL DIAGNOSIS

Outcome. A paravertebral triangle was demonstrated, its dulness
3 inches wide at the base. The right chest was tapped, and 32 ounces of
fluid obtained. Specific gravity, 1017; albumin, 2.7 per cent.; lympho-
cytes, 87 per cent.

The fluid did not reaccumulate. On April 9th he was discharged
well, with the caution that he must always be rather more careful than
other men as regards fresh air (day and night), regular meals, and the
avoidance of all excesses.

Diagnosis. Pleural effusion.

Case 150

An Italian housewife of thirty-five entered the hospital April 25,
1907. Three years ago she had an operation, following which she has
had no menstruation, but frequent "hot flushes" rising from the ab-
domen to the head, accompanied by sweating and headaches which
sometimes "made her crazy." During the past five months she has had
frequent attacks of pain in the epigastrium and left chest. The pain is
never severe enough to make her lie down. It lasts sometimes most of the
day. It sometimes runs down the inner side of the left arm to the finger-
tips. The pain comes on suddenly, feels like needles pricking the skin,
and is often accompanied by a sensation of heat all over her abdomen.
Her urine scalds her during micturition.

She has worked up to the time of entrance, although she eats and
sleeps poorly and her bowels are costive.

Temperature, pulse, and respiration are normal. Physical exam-
ination of the chest and abdomen is wholly negative. There is a thin,
yellowish, vaginal discharge. The urine shows considerable pus.

Discussion. Everything inclines us to explain many of the symp-
toms in this case as the result of an artificial menopause. We must make
sure, however, that the familiar and typical phraseology used by such a
patient does not sometimes mislead us into overlooking some deeper
organic disease, such as pulmonary tuberculosis. If this occurs to us
as a possibility, the use of a thermometer will soon make clear in the
vast majority of cases that there is no fever, the sweating and sense of
heat being due to vasomotor changes.

The presence of pus in the urine makes it reasonable to inquire
whether some local infection of the genito-urinary tract may not be con-
nected with the cardiac symptoms, since gonorrheal endocarditis is not
nearly so rare as is often supposed. The first point, however, is to make
sure that we are dealing with a genuine pyuria, not with an admixture
of urine and vaginal discharge. In the present case a specimen of urine

AXILLARY PAIN

drawn by catheter showed no pus. A smear from the vaginal discharge
showed a variety of saprophytic organisms, but no gonococci.

Returning now to the main complaint the thoracic and epigastric
pain we notice first that it is accompanied by paresthesia', that it has
no special relation to exertion, and is often prolonged over many hours.
These facts, together with the negative results of physical examination,
tend to show that it is not due to the organic type of angina pectoris, but
belongs in the loose group of pains to which the name of "functional"
or "false" angina has been given. As in so many other cases of this
group, the patient's own interpretation of the pain have led to forebod-
ings and apprehensions, and so to a concentration of attention which
greatly increases the suffering. The clinical importance of this fact is
that it should lead us to a much greater vehemence, directness, and cir-
cumstantiality in our reassurances than would seem to be warranted
by the patient's own statement. The organic effects of a fear are often
in proportion to the patient's reticence upon the subject.

Outcome. After eloquent reassurance and a few days' rest with full
diet the patient seemed so much better that she was allowed to go home.

Diagnosis. Artificial menopause.

Case 151

A Portuguese lumberman of forty entered the hospital May 30, 1908.
His family history, past history, and habits have been good. Three
years ago he began to have pain in the left side of the chest, with cough
and thick yellow sputa; also a headache, backache, lack of appetite,
occasional vomiting. For the past week he has been worse. Three
days ago he took to bed. His throat is now rather sore. The course of
the temperature, pulse, and respiration is seen in the accompanying
chart (Fig. 51).

The patient was found to be slightly delirious, with rapid res-
piration and slight dry cough. The leukocytes were 5000 per c.mm.
the urine, negative. Widal reaction negative. The heart was negative.
There were coarse rales scattered throughout both chests. In the left
back, just outside the lower end of the scapula, the voice-sounds were
slightly nasal. The right clavicle was somewhat more prominent than
the left, and expiration just below it was somewhat prolonged. The
abdomen was held rather rigidly, and there was slight general tender-
ness there. The spleen was not felt, and there were- no rose spots.

Discussion. A low leukoevte count in a patient who i> not ap-
parently very ill may be taken as important evidence against the diag-

DIFFERENTIAL DIAGNOSIS

nosis of pneumonia, especially if the patient's lungs give little evidence
of disease.

Pulmonary tuberculosis seems more probable in view of the long
duration of cough with sputa, but unless we suppose that we are dealing
with a miliary tuberculosis, there is not enough in the lungs to account
for so sudden and severe an illness. Miliary tuberculosis cannot be ex-
cluded. The evidence is suggestive, but not compelling. This possibil-
ity should, therefore, be held in reserve until other alternatives are ex-
hausted.

Acute influenzal bronchitis, or bronchitis of some other type, might
account for most of the facts in this case. This diagnosis also it is im-

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possible to exclude, although my impression as I saw the patient was that
he was too sick for simple bronchitis. The grounds of this impression,
however, are hard to convey. Bronchitis and miliary tuberculosis, there-
fore, remained as possibilities to be accepted or rejected as the further
course of the case might determine.

Influenzal infection of numerous small bronchiectases (such as occur
very frequently with the clinical picture of chronic winter cough) is
strongly suggested by the history and is compatible with the physical
sign here described. It rarely causes so high a temperature, however,
usually produces leukocytosis with profuse nummular sputa, and often
has an emnhvsema associated with it.

AXILLARY PAIN

305

Meantime it is important not to forget the possibility of typhoid
fever, although the time of the year is not the usual one, and although
no definite evidence of typhoid has yet been presented. It seems to me
essential, however, that we should consider typhoid in every febrile
patient with vague and colorless symptoms which do not compel us to
incriminate any one organ or group of organs. Typhoid is, beyond all
other infections, the disease which produces fever with nothing particular
to show for it in the way of local lesions. Hence in all such cases we
should remember it and test for it by all the available methods.

Outcome. Blood-culture taken into bile was positive for typhoid
bacilli.

The course of the disease was uneventful. The patient went home
well on the thirteenth of July. There was but little cough or sputa.
The treatment consisted of \ grain of calomel given every fifteen minutes
for ten doses, at the time of entrance, followed by a suds enema; there-
after he had alcohol and water sponges at 80 F. every four hours when
the temperature was above 102.5 F.; urotropin, 7 grains, three times a
day twice a week, and turpentine stupes from time to time. In conva-
lescence he had a good many boils, from one of which the staphylococcus
was isolated. For this, staphylococcus vaccine was given.

Diagnosis. Typhoid.

Case 152

A Turkish rug-repairer of forty-seven entered the hospital May 2,
1908, stating that when he was twenty-six he was sick for three weeks,
and had shortness of breath on exertion. He has since been well until
three weeks ago, when he began to have pain in the back of his neck and
the left side of his chest, with dyspnea, orthopnea, and nocturia. For
ten days he has had cough and yellowish sputa.

The patient's temperature during the nine weeks of his stay in the
hospital was generally subnormal; his pulse averaged about 100, his
respiration 27. The daily amount of urine was generally diminished,
averaging 25 ounces; specific gravity, 1023; no albumin or casts were
found.

The heart's impulse was best seen and felt in the third space, four

inches to the left of the midsternal line; the right border one inch to the

right of the median line. In the fourth space the impulse was barely

felt. The sounds were loudest and the palpable impulse strongest

just below the ensiform. The sounds were regular and of good quality,

the pulmonic second accentuated. The pulse was of good volume and

tension. In front the percussion-note was dull below the left fourth rib,
20

36 DIFFERENTIAL DIAGNOSIS

below the fifth rib on the right, below the angle of the left scapula, while
in the right back the dulness extended one inch higher. Over these dull
areas breathing, vocal and tactile fremitus were diminished. There were
many fine, crackling rales at the left base, and a few coarse crackles after
cough at the left top, behind. The systolic blood-pressure was 145.

The spleen was easily palpable. The abdomen and extremities
otherwise negative.

On the night of the fourth of May the patient's respiration became
rapid and difficult respiration, 42, with pulse, 130; tracheal rales could
be heard half-way across the ward. The first heart-sound was almost
inaudible, the second loudly accentuated. The pulse was very weak.
The outline of the heart was normal on percussion. The patient was
livid, cyanotic, and covered with perspiration.

Discussion. But for the persistently subnormal temperature coming
on, as it has, with acute axillary pain and dyspnea, one might think of
pneumonia in this case, although the duration is somewhat too great.
The signs in the lungs point to fluid accumulation in both chests.
Is this an exudate or a transudate, due to. inflammation or to dropsy?
Double pleural effusion is very rare. The absence of fever and of pain
connected with respiration makes pleural effusion still more unlikely.
Indeed, this possibility would scarcely have been considered but for the
fact that there seems hardly enough in the condition of the heart or kidney
adequately to account for so much effusion as a dropsy.

In the urine there is really no evidence of renal disease, the slight
variations from normal being more characteristic of passive congestion.
In the heart, accentuation of the pulmonic second sound is the chief
abnormality, and this is indicative less of any cardiac lesion than of a
blocked condition of the lungs, however produced. The displacement
of the apex impulse is also to be regarded rather as the result of the
pleural effusion than of any disease of the heart itself. On the whole,
therefore, there is no direct evidence of heart disease obtainable by ex-
amination of the organ itself, and if we are to predicate any weakness of
the heart's action, we must do so upon the evidence of passive con-
gestion in the pulmonary circuit. This is not satisfactory, but it is
a very familiar dilemma, and one in which experience has shown that it
is usually safe to assume a myocardial lesion provided that there is no
evidence of nephritis, goiter, or adherent pericardium. Such diagnoses
as "myocarditis" used to be much more frequent than they are at the
present day, since the habit of routine blood-pressure measurements has
led us to recognize so many latent cases of chronic nephritis not evident
by urinary examination. In the present case it seems inevitable that we

AXILLARY PAIN

should blame the heart-wall for the circulatory disturbance, though it
may be wiser to speak of "myocardial weakness" (adopting the vaguer
functional term), rather than of "myocarditis."

The acute attack of May 4th tends to confirm our opinion that the
heart is organically weak. This attack will be easily recognized as one
of acute pulmonary edema one of the most interesting and mysterious
of clinical pictures. The vast majority of such attacks occur in persons
whose cardiovascular system has shown a distinct but not extreme grade
of degeneration and weakness. In many cases the kidney has also shown
evidence of chronic disease, but this is about the sum of our knowledge
on the subject. As to the nature and determining cause of the attacks,
we know almost nothing, and in a few cases we are not even warned or
guided by any definite evidence of cardiac or renal disease; the edema
appears, as it were, out of a clear sky. It will be understood, of course,
that the types of edema here briefly referred to are distinguished from
the ordinary, long-standing, gradually increasing edema of uncompen-
sated heart disease.

Outcome. He was bled a pint from a vein of the left arm and given
strychnin, -^ grain, and digitalone, 20 minims, subcutaneously. Fol-
lowing this the pulse- rate fell at once to ico, and the perspiration and
dyspnea diminished. The left chest was then tapped, and three pints
of fluid removed. After this the pulse fell to 90. After I grain morphin
subcutaneously the patient went at once to sleep and slept five hours,
waking vastly improved, with good color, strong and regular heart
action.

The fluid removed from the chest had a gravity of ion, with 2.7 per
cent, albumin. In the sediment lymphocytes made up 76 per cent.,
polynuclears, 14 per cent., endothelial cells, 10 per cent.

Two nights after this he again became uncomfortable; the other
chest was aspirated and four pints of fluid withdrawn. The specific
gravity was again ion; the albumin only 1.2 per cent.; lymphocytes,
77 per cent. The patient was then given magnesium sulphate ] ounce
every morning, a dram of French Vermouth in a small amount of water
just before dinner and supper, diuretin, 15 grains four times a day.
Following the tapping of the chest the amount of urine increased markedly.
On the sixth of July he left the hospital much relieved.

Diagnosis. Weak heart; acute pulmonary edema.

Case 153

A single woman of twenty-five, a nurse, entered the ward on January
2, 1906. The night before she had had some pain in the left side. She

3 o8

DIFFERENTIAL DIAGNOSIS

was awakened by it several times in the night. She finds it uncomfortable
to lie on the right side or on the back, but pressure on the left side, or
lying on that side, relieves the pain. She has an extremely tender spot
under the right border of the ribs in front.

Examination showed spasm in the right hypochondrium, with tender-
ness. The pain, however, was consistently referred across the abdomen to
a point in the left axilla on a level with the left nipple. Physical examina-
tion, including blood and urine, was otherwise negative. The temperature
ranged between 99 and 101 F. The pain did not
seem to be affected by morphin, and came on two or
three times a day in spasms lasting one-quarter to
one-half hour. The tender point in the right upper
quadrant grew steadily more rigid and more sensitive.
Pressure there caused pain to shoot to the left axilla.
She was seen daily by a surgical consultant, who did
not advise operation. On the fourth day the white
cells rose to 14,000.

Discussion. This case is introduced to exemplify
an unusual reference of pain to a point far removed
from the lesion producing it. The tenderness and
spasm turn out here, as in so many other cases, to
guide us better than the pain, when the two diverge.
A rhythmic or spasmodic character in any painful
seizure usually turns out to mean frustrated peristalsis
within a hollow muscular organ. But there is no such
organ in the left axilla; the nearest hollow muscular
organ is the heart, and there is nothing else in the
clinical picture to connect the pain with that organ.
The rising leukocyte count and the fever are data not ordinarily
associated with angina of any type.

Outcome. Three days later the abdomen was opened and a much
distended and twisted gall-bladder found; the cystic duct was dilated,
twisted, and occluded by a large stone. Three other stones were also
found in the gall-bladder, which was acutely inflamed.
Diagnosis. Gall-stones.

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Case 154

A Swedish machinist aged twenty-five entered the ward February 8,
1907. Five weeks previously he had suffered from tonsillitis. In two
weeks he was back at work, but began to have pains in his legs and feet;
at one time both knees were red and swollen. Ten days ago he gave

AXILLARY PAIN

309

up work and went to bed, with fever, headache, loss of appetite, and
weakness. His chief complaint for the past week has been pain in both
chests, worse in the right front. His legs have shown only indefinite
stiffness and soreness in the past few days.

Physical examination of the chest showed in the right axilla very
slight dulness, with diminished breath-sounds and a suggestion of friction.
The heart was negative. There was no redness or swelling of any joint,
but some pain on motion of the right knee, and a slight rigidity of the
neck. Belly negative. Temperature, 101.8 F.; pulse, 120; respiration,
30; hemoglobin, 70 per cent.; white cells, 24,000; urine normal.

On the twelfth of February there was still no evidence of any localiza-
tion of the infection except that the signs in the lower right axilla had
slightly increased. The patient looked decidedly sick, and the white
count had risen to 25,400. On the fourteenth, pain and edema of the
whole right leg appeared without tenderness; the next day swelling ap-
peared in the left foot and the veins below the left knee were distended ;
there were still no tenderness and no change in the signs in the right chest.
By the sixteenth the swelling of the left leg had considerably increased,
and there was tenderness over the red, cord-like veins of the left calf.
The white count remained the same, 88 per cent, of the cells being poly-
nuclear.

The patient remained in the hospital until August 12th six months.
There was some sloughing of the superficial tissues of the right foot.
A well-marked nephritis appeared on the twenty-fourth of February, and
lasted until July, but finally disappeared altogether. Pleurisy appeared
in the left side on the tenth of May, but disappeared in the course of a
week. Thrombosis appeared in both arms in the early part of March,
and in the middle of the month there was bloody expectoration for a couple
of days, without any special pulmonary signs to account for it. By
April 1 st the arms were normal and the left leg nearly so.

A marked anemia gradually developed, so that on the thirteenth of
April the red cells were 2,725,000, with 65 per cent, of hemoglobin.
Late in June there were purpuric spots on the dorsum of the left foot,
but they disappeared within a few days.

Discussion. As the history of this case opens with a tonsillitis.
it may be well to consider some of the lesions which the clinical experience
of the last fifteen years tends to associate with tonsillar inflammation.
Although the majority of cases of tonsillitis progress beyond their origin
no further than the lymphatic glands at the angle of the jaw, the very
striking prostration which accompanies and follows the acute infection
probably indicates that the disease rarely remains local. It seems to be

DIFFERENTIAL DIAGNOSIS

shown beyond reasonable doubt that in many cases an infection first de-
monstrable in the tonsil appears soon after in one or another synovial
membrane or joint surface, in the endocardium, in the kidney, or on
some serous surfaces. This may be taken to indicate that bacteria are
circulating in the blood-stream in a considerable proportion of cases,
though they have not often been isolated by blood culture.

The case above described is remarkable chiefly because it narrates the
fortunes of a patient who suffered, one after another, most of the common
complications of tonsillitis above referred to. Beginning with multiple
arthritis and right-sided pleurisy, he next suffered a series of infections
of the peripheral veino, leading to multiple thrombi. Then came the
nephritis, which I have often seen occurring in tonsillitis as the only mani-
festation of the body's effort to expel invaders. The pulmonary bleeding
is probably to be explained as analogous to the purpuric spots which
appeared for a few days in the latter part of his illness. Only histologic
examination could decide whether these pulmonary and cutaneous hem-
orrhages were due to embolism or to some other cause. The develop-
ment of a marked anemia in a six months' illness of this severity is not to
be wondered at, since chronic sepsis always tends to produce anemia.
But it is quite remarkable that the heart escaped, apparently without
injury. Possibly the transient rigidity of the neO* might be interpreted
as a larval infection of the meninges ("meningi^mus"), since we know
that all the serous membranes pleura, pericardium, peritoneum, men-
inges may be attacked in cases of generalized sepsis.

Another very remarkable feature about thL : :a se was that the patient's
final recovery was complete. The treatment :onsisted essentially of
good nursing.

Diagnosis. Sepsis with thrombi.

Case 155

An Italian laborer of twenty-nine entered the hospital on March 18,
1908. The family history was negative; his past history likewise so; his
habits good.

Four weeks ago he began to have pain in his left chest, chiefly low
down in the axilla, accompanied and aggravated by cough or deep
breathing. There was slight dyspnea on exertion. For three days he has
felt chilly and feverish, especially at night. He has noticed nothing
remarkable about his urine, and no pain except as above described.

On physical examination the heart showed nothing abnormal. The
right side of the chest moved better than the left, and there was slight dul-
ness at the right pulmonary apex as low as the second rib, with broncho-

AXILLARY PAIN

3 1 *

vesicular respiration and increased voice. At the base of the left axilla
the percussion-note was flat below the sixth rib. Tactile fremitus was
absent, voice- and breath-sounds diminished. Over the area of flat-
ness were scattered a few fine rales, and some were audible as high as the
second rib. In the back the area of flatness reached up to the lower angle
of the scapula. Tactile fremitus was diminished over the whole left
back, and absent, together with voice- and breath-sounds, below the angle
of the scapula. A paravertebral triangle was percussed out on the op-
posite side. The abdomen showed considerable general rigidity and
in the extreme flanks some dulness, which did not, however, exhibit any
change with change of position. During the next ten days his tempera-
ture ranged between 99 and 101 F., his pulse between 70 and 80, his
respiration between 20 and 25, his urine between 40 and 50 ounces in
twenty-four hours, with a slight trace of albumin, a moderate amount of
pus, many hyaline and granular casts, some of which have blood or fat
adherent. The leukocytes were 6700; hemoglobin, 75 per cent.

By March 22d the dulness in the chest had somewhat diminished,
and the paravertebral triangle was not evident. The dulness on the
left side seemed to rise higher in the axilla than near the spinal
column. A large mass was now felt in the left flank, but could not be
definitely outlined on account of the rigidity of the whole abdomen, which
did not relax even in a warm bath.

On the twenty-fourth of March the x-ray showed apparently a large
stone in the left kidney.

On March 27th the area of dulness in the left chest had not changed,
but there were coarse, moist rales in the right lower back and axilla.
The urine still showed a slight amount of pus. Cystoscopy showed this
pus to issue from the left ureter, while normal urine came from the right.

Discussion. The signs at the base of the left axilla and in the back
seem to indicate a localized pleurisy, with or without a small effusion. In
view of the later developments of the case, however, I believe that the para-
vertebral triangle was percussed out largely as the result of "expectant
attention" i. e., of the interne's conscientious determination to find it.
Even at the beginning of the case every one who saw the patient felt that
the pleural effusion was not sufficient to account for the marked fever
and constitutional symptoms. We all thought there must be "something
back of it."

Our first clue to that "something" in the background was the I Hid-
ing of pus in the urine. This led us to search more carefully the region
of the kidneys, whence the mass in the left flank came to light. As I
read the record now it is amusing to note how promptly the chest signs

312 DIFFERENTIAL DIAGNOSIS

retire into the background of the clinical picture as the kidney begins to
loom up in the foreground. How far this represents the actual course of
events in the patient and how far it is a matter of the historian's psy-
chology it is now difficult to say.

Outcome. On March 28th operation showed a large kidney filled
with thick pus and adherent to the diaphragm and other structures.
No stone was found, but there was a calcareous plate near the surface of
the kidney; no histologic report is preserved.

The patient made a good recovery.

Diagnosis. Pus kidney (tuberculous ?).

Case 156

A widow of forty entered the hospital February 13, 1908. She had
typhoid fever three years before, and was operated on for extra-uterine
pregnancy seven years before. Otherwise she has never been sick, but
has had many colds this winter. Six weeks ago she began to suffer
from pain in the left side of the chest. Four weeks ago she had to give
up her work on account of vomiting immediately after eating. The
vomitus rarely contained food. It usually was greenish. There was
constant soreness in the epigastrium, and a good deal of pain in the left
arm and left side of the chest. She has taken almost no solid food for sev-
eral weeks. She has considerable dyspnea and palpitation, and has lost
twenty-six pounds. Twice she has had shivering spells lasting several
hours at night. She admitted the occasional use of alcohol, and it was
apparent on her breath at the time of entrance. Some nights she passes
urine at frequent intervals.

Physical examination was negative except for considerable tenderness
in the epigastrium and moderate enlargement of the axillary glands on
both sides. Blood-pressure, 135.

Discussion. On p. 738 of this book I have referred to a case
diagnosed and treated as neurasthenia, but dying shortly afterward of
cancer of the pleura. The symptoms in that case were not unlike those
described above, and my remembrance of the former mistake leads me
to be especially cautious in the diagnosis of supposedly neurasthenic
pains in the side of the chest. The presence of enlarged glands would
be quite consistent with malignant disease of the chest, and is often one
of the most important clues to the discovery of that trouble. The import-
ance of this enlargement, however, is weakened by the fact that it is bi-
lateral. Adenitis secondary to malignant disease is usually unilateral.
In the present case I did my best to find signs of malignant disease
by physical examination of the chest, but could find nothing.

AXILLARY PAIN

3*3

By the negative results of physical examination, which included a
temperature record, we were able also to exclude pleurisy.

The extension of the pain to the left arm, the presence of dvspnea
and palpitation, and the age of the patient are data quite consistent with
the diagnosis of angina pectoris. Against this, however, is the absence
of any relation to exertion as a cause of pain, the long-standing and
moderate character of the suffering, and the low blood-pressure.

After the exclusion of these and all the other possibilities which we
could call to mind, it seemed best to make a diagnosis of neurosis and use
that as a working basis for a therapeutic test.

I interpret the left axillary pain as due to that commonest of all
causes for such a complaint, viz., flatulence. When the stomach is over-
distended, whether by atmospheric air which has been swallowed and
"cribbed" or by the products of gastric fermentation, the l( Ma gen-
blase, " or bubble, which is usually to be seen near the cardia by fluoros-
copy, swells to huge dimensions, invades the axillary region, and often
causes much discomfort. The patient usually thinks she has heart dis-
ease; the thought increases her nervousness and thus her flatulence.
The vicious circle is then in complete working order.

Outcome. The patient was put to bed and given a diet of liquids
and soft solids, with paraldehyd, half to one teaspoonful, on two success-
ive nights. Within two days the vomiting had ceased and she felt much
better. She had apparently been working hard, and was of a neurotic
type, easily frightened by the slightest unexpected noise or occurrence.
She was well enough to go to work again on the twentieth of February.

Diagnosis. -Neurosis.

Case 157

A Greek waiter of twenty-one, with a negative family history, entered
the hospital November 13, 1907, with the statement that he has been
feeling rather poorly for the past four months, but had no definite symp-
toms until three weeks ago, when he began to have frequent severe pains
in the front and left side of his chest and a distressing cough without ex-
pectoration. The pain and cough were both worse at night, but he - has
been very comfortable lying flat, and lias complained of no shortness of
breath. He has been chilly and feverish and had much vertigo and
frontal headache. During the past three weeks he has lost 20 pounds.

At entrance the patient was unable to lie down on account of dyspnea.
The cardiac apex was neither visible nor palpable. The area oi cardiac
dulness, as shown in the diagram, had a total width of 1 1 \ inches, the
left border of dulness being 7! inches to the left of the midsternum in the

314

DIFFERENTIAL DIAGNOSIS

fifth interspace. In the upper front of the right chest there was tubular
breathing over the dull area, and in the left back, near the angle of the
scapula, all the signs of solidification were present. The abdomen was
everywhere dull except in the umbilical region and in the left flank. The
patient's temperature was irregularly elevated for the whole of his three
months' stay in the hospital. (See Fig. 53.)

The blood showed 9900 white cells and 90 per cent, hemoglobin.
The urine was not remarkable. A paradoxic pulse was demonstrated
on the fifteenth.

Discussion. If we accept as accurate the record of a to-and-fro
friction-sound at the point shown in the diagram, there seems no reason
for doubt that pericarditis is present. It remains to discover, if we can,
whether a pericardial effusion is present and by what other lesions the
pericarditis is complicated.

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Fig. 53. Chart of case 157.

The diagnosis between a pericardial effusion and a dilated heart is
notoriously difficult, often impossible. In the present case we have no
good cause for such a dilatation of the heart no valvular or arterial lesion,
no goiter or chronic nephritis, no history of beer-drinking. The area
of solidification in the left back is, in all probability, due to pressure ex-
erted upon the lung either by a pericardial effusion, a pleural dropsy,
or a greatly dilated heart. The latter possibility is very rarely mentioned
in text-books, but I have been convinced by postmortem evidence that
a heavy, distended heart in a patient who lies persistently on the back may
compress the left lung so as to produce an atelectasis or pseudopneumonic
condensation of the lung similar to that often caused by pericardial
effusion. A common mistake in these cases is to suppose that a lobar
pneumonia is present. Experience has shown that when we hear the signs

Fig- 54- Lateral limits of an area of percussion dulness found in Case 157.

AXILLARY PAIN

315

of solidification near the angle of the left scapula in the course of a case
showing a greatly dilated heart, with or without pericardial effusion,
these signs turn out in the great majority of cases to be due to pressure
exerted on the lung by the heart, or by a pericardial or pleural effusion,
and not to an exudate in the lung.

The presence of a high continued fever and the absence of any cause
for cardiac dilatation in the present case incline me to believe that
there is a pericardial effusion. The long duration of the case with-
out any notable improvement suggests that the pericarditis may be
tuberculous.

The extensive dulness in the abdomen is in all probability due to fluid
which may be the result either of tuberculous peritonitis or of stasis.
Ascites is especially apt to accumulate as the result of a chronic pericardi-
tis which has gone on to complete obliteration of the pericardial sac, but
it does not seem probable that the inflammation has lasted long enough in
this case to bring about that result. Further evidence as to the nature of
the fluid in the peritoneum might be obtained by tapping, for a dropsical
fluid would probably be of lower gravity than one due to tuberculous
peritonitis.

Outcome. He was admitted to Tewksbury Almshouse January 22,
1908.

The left lung continued to show the flatness and loss of voice-sounds
below the fourth rib in the axillary line. Sputum was examined twelve
times and found negative for the tubercle bacillus. Slight dulness and
bronchial breathing spread to both lungs.

In February his temperature rose daily, going as high as 103 and
104 F., but usually reaching 102 F.

He died June 4, 1908. No autopsy.

Diagnosis. Pericarditis.

Case 153

A night watchman of forty-six entered the hospital August 24. 1906.
He has been a hard drinker up to eleven months ago. He had syphilis
twenty years ago. For over two years he has been troubled by a hack-
ing cough without sputa, accompanied by night-sweats and a slight pain
in the left side of the chest. He has gradually increasing dyspnea on
exertion, but can still lie flat and with the greatest comfort on the right
side. For the past ten months he has been having pain in the left upper
chest and paroxysms of distressing cough. At times lie loses his voice
for a few hours, but is never constantly hoarse. Nitroglycerin has given
him considerable relief, but he has rattled and wheezed all summer,

316 DIFFERENTIAL DIAGNOSIS

especially during the last four days. He sleeps poorly, has lost much
weight, and has no appetite.

The heart's apex is in the fifth space, one-half inch outside the nipple,
the right border of dulness two inches to the right sternal margin in the
fourth space. There is marked bulging of the left chest over the area
show r n in the accompanying diagram, and considerable pulsation in the
third and fourth left spaces. The veins of the neck and arms are dis-
tended. Loud groaning, whistling sounds are audible throughout both
lungs. Physical examination of the heart, blood, and urine is otherwise
negative (Fig. 55).

Discussion. If a careful physical examination were made and duly
meditated on in this case, the only hesitation in diagnosis would be on
the question whether aneurysm or malignant disease of the chest is the
cause of the patient's sufferings. In the absence of such an examina-
tion, however, I have known a case very similar to this to be treated
as consumption for a number of months, the cough, night-sweats, emacia-
tion, and pain in the chest being accepted as sufficient evidence of
phthisis.

In another case the wheezing and rattling led straight to a diagnosis
of bronchial asthma and to all sorts cf therapeutic attempts based on
that diagnosis.

Returning to the only diagnostic problem which ought to exist in this
case (aneurysm or malignant disease cf the chest), I may say in the first
place that in a considerable number of cases in which I have known this
discussion to arise, the outcome has always shown aneurysm. In this
man the history of syphilis, the absence of any glandular enlargement, and
the slow march of the symptoms, which apparently have lasted two years,
all favor aneurysm. The loss of weight is perfectly characteristic of
aneurysm, and occurs, as I have previously shown, 1 in the vast majority
of all cases. I emphasize this point because in the discussion of this
differential diagnosis I have several times heard emaciation adduced as
evidence against aneurysm and in favor of malignant disease.

Outcome. X-ray showed a large shadow corresponding to the area
of dulness. The mass seemed to grow and then to decrease in size in the
next few days, the pulsation varying much from time to time in amount
and in extent. There were two main projecting points one over the pre-
cordia, and one above it, under the clavicle. Sarcoma of the chest-wall
was considered seriously. The patient died on the sixteenth. Autopsy
showed aneurysm of the first portion of the aorta; rupture into the

1 Two Possible Causes of Emaciation Not Generally Recognized, R. C. Cabot. M. D.,

Jour. Amer. Med. Assoc, March 17, 1906.

lig. 55. Physical signs found in a patient who complained of dyspnea, cough, emacia-
tion, night-sweats, and pain in the chest.

AXILLARY PAIN 317

pericardium; compression atrophy and bronchopneumonia of the left
lung. The aneurysm was filled by a very thick clot lying in front of and
above the heart.

Diagnosis. Thoracic aneurysm.

Case 159

In March, 1898, a housewife of thirty-three came to the hospital for
hemoptysis, supposedly due to phthisis. No sign was found in the lungs.
In October, 1898, she was again treated for pleurisy with effusion and
fistula in ano. She had had a nervous breakdown in 1896, and had been
very irritable and self-centered since that time.

In April, 1899, she began to suffer from pain in the right side of the
chest, much aggravated by coughing and laughing.

The urine contained a trace of bile and a good many leukocytes; other-
wise it was negative, as were the blood, temperature, pulse, and respiration.

Physical examination, April 23d, was negative save for a patch at the
right base near the scapular angle, where there were slight dulness, dim-
inished voice, respiration, and fremitus.

Discussion. Pulmonary hemorrhage of any amount an ounce or
more means pulmonary tuberculosis in 999 cases out of ioco, if disease
of the heart and aorta be excluded, as they easily can be in most cases.
The other traditional causes of hemoptysis disease of the throat,
vicarious menstruation, hemorrhagic conditions amount practically
to nothing; that is, they are usually quite obvious, like purpura hemor-
rhagica, or quite mythical, like vicarious menstiuation. Pulmonary
hemorrhage due to distomiasis never occurs in North America except
among Japanese immigrants.

The fact that signs are absent on examination of the lungs after
a hemoptysis due to tuberculosis is entirely according to rule when
hemoptysis is the first evidence of disease. We almost never find an}'
signs of disease until some months later; in many cases we never find
them at all, and only the postmortem examination proves tuberculosis.

All this, however, refers to an event over a year old. Is it not possible
that her suffering, at the present time, is connected with her nervous
condition and due to habit pain? Against this hypothesis we have the
fact that she has previously had pleurisy with effusion and fistula in ano.
both of them tuberculous affections in practically every case. Bearing
these troubles in mind, we naturally assume that her present pain is in
some way produced by her old pleurisy, of which there seems to be still
some evidence at the right base. There are, however, two other possibil-
ities which must first be considered briefly:

318 DIFFERENTIAL DIAGNOSIS

The urine contains bile. This directs our attention to the liver; but
enlargement of the liver upward may produce in the right back all the
signs here described signs which, if interpreted as pleurisy, might be
due either to a small effusion or to marked pleural thickening. I have
known abscess of the liver to produce exactly these signs, so that it was
mistaken for empyema. Against the possibility of liver disease there is
not a great deal to be said, as our methods for detecting liver disease are
so few and unsatisfactory. We may note, however, that there seems to
be no enlargement of the liver downward, no bile staining of the skin
or conjunctiva, none of the ordinary causes for cirrhosis, hepatic abscess,
passive congestion, amyloid or fatty metamorphosis, no change in the
spleen, glands, or blood to suggest leukemia or Hodgkin's disease.
This is the best that we can do to exclude liver disease. Had these same
signs appeared in the back following an appendicitis, amebic dysentery,
or cholelithiasis, the situation would suggest hepatic abscess.

I once made a diagnosis of purulent pleural effusion in a case bearing
a good deal of resemblance to this one. I put in a needle an inch and a
half below the angle of the scapula, drew pus, and promptly handed over
the case to a surgeon for drainage. He opened the pleura, found it
smooth and clean, and indulged in disparaging remarks on medical diag-
nosis. Further exploration, however, showed that the diaphragm was
pushed up nearly to the angle of the scapula, and that through its domed
surface fluctuation could be detected. A second puncture, ten days later,
after the pleura had healed without infection, liberated a quart of pus
from the region of the kidney. Since that time I have always remem-
bered the possibility of perinephritic or subdiaphragmatic abscess when
dealing with what appears at first sight to be an effusion (serous or puru-
lent) at the right base. The presence of leukocytes in the urine makes
it all the more necessary to consider the kidney in this case, but we must
first make sure that those leukocytes come from the urinary tract by
obtaining a catheter specimen of urine. When this was done, the urinary
sediment no longer showed leukocytes, and as there were no other facts
pointing distinctly to the kidney, I returned to my original idea
pleurisy at the right base.

This case is one of many which exemplify the long duration of pain
and of physical signs after the healing of a pleural effusion. Perhaps
in the majority of cases there is more or less suffering for a year.

Outcome. The pain remained mostly in the back, and not in the
side, during the five days of her stay in the hospital, but soon disappeared
with rest, full diet, and counterirritation.

Diagnosis. Old pleurisy.

AXILLARY PAIN

Case 160

3i9

A typewriter of twenty-three lost her mother and one brother of
phthisis. Two and a half years ago she was in bed several weeks on
account of pain in the left axilla. The whole attack lasted three months.

Lately she has noticed pain in the left side when she is nervous
sharp for a few minutes, and leaving an ache for two or three days after-
ward. Sometimes exertion relieves it. Coughing or sneezing does not
increase it.

Five months ago the pain increased. For six weeks she slept almost
none and walked the floor much. Her weight fell from 132 to 108.
The pain is chiefly in the left side, but there is also a constant sense
of pressure in the right breast and back, with occasional sharp pains.
Suffering is worse at night. She has a good deal of indigestion and con-
stipation.

Examination. Cardiac apex in fifth space, nipple-line. Accom-
panying the first sound is a systolic murmur, loudest at the apex, but
audible also over the whole precordia and in the left axilla. The pul-
monic second sound is slightly louder than the aortic.

Tender spots near the left lower scapular edge, in post-axillary line,
in the axillary line in fifth, sixth, seventh spaces, and along sternal border
[fourth to eighth ribs] were found. Sensation normal.

Discussion. In view of the site of the pain and the family history
of tuberculosis, it would be wrong not to consider pleurisy in this case;
but there was no definite evidence of it on physical examination, and
without such evidence the diagnosis can never be made.

Pain due to dyspepsia and flatulence would hardly be so constant,
and this same characteristic excludes both types of angina pectoris.
Muscular pains (pleurodynia) would show exacerbation rather than
relief by exertion. Of local diseases of the chest-wall we have also no
evidence.

Intercostal neuralgia is characterized by pain like that here described,
and especially by tender points corresponding approximately with those
which physical examination has revealed. I believe intercostal neuralgia
to be a rare disease, although the diagnosis of it is so common. By
intercostal neuralgia one means ordinarily the so-called " primary " type,
unrelated to any cause of pressure, such as aneurysm or spondylitis.
Pressure pains of this type are, of course, by no means uncommon,
but primary intercostal neuralgia unaccompanied by herpes and without
any known cause is, I believe, distinctly rare. The diagnosis, like
all diagnoses of a "primary " or obscure lesion, is one with which we are

320 DIFFERENTIAL DIAGNOSIS

never quite content, and which we can tolerate only when we have done
our best, by rigid scrutiny and thorough sifting of all other recognized
possibilities, to find a cause. In the present case, for example, I should
not be satisfied unless disease of the spinal column had been, so far as
possible, excluded.

Outcome. The pain gradually disappeared in six weeks. Many
forms of treatment were tried, but none of them had any effect that I
could discover.

Diagnosis. Intercostal neuralgia.

Case 161

An alcoholic Irish teamster of twenty-eight has noticed for a week a
pain in his right lower axilla. The pain has several times been associated
with vomiting and a slight cough. No injury is remembered.

Family and past history good.

Physical examination is negative, save for a rounded swelling about
15 cm. in diameter near the right costal margin in the axilla. The
swelling is brawny, with a slightly fluctuant crater in the center.

Discussion. There seems every reason to believe that the pain and
the tumor are connected in this case. It remains to ask, What is the nature
of the tumor?

The commonest causes are: septic osteomyelitis or tuberculous osteo-
myelitis of a rib. The patient might have broken one or more ribs with-
out knowing it during one of his drinking bouts, but the resulting cal-
luses would not produce a mass like that here described.

A fatty tumor or an empyema necessitatis would not have a brawny
surface. Either of these lesions, if fluctuant, would be fluctuant through-
out. Malignant disease of the chest- wall does not often show itself
at this point. Actinomycosis cannot be excluded ; it is, however, a rare
lesion, and the commoner causes of a swelling at this point should be con-
sidered first.

Further diagnosis is impossible without incision.

Outcome. Two ounces of pus were removed by incision and a sinus
found leading to a rib. Rough bare bone was found at the bottom of
the sinus. There was no evidence of actinomyces. The patient seemed
greatly debilitated.

Diagnosis. Costal tuberculosis.

Case 162

An unoccupied girl of twenty-eight entered the hospital January 15,
1908. Nine months before she caught cold at a dance, and a week after

AXILLARY PAIN

321

began to have pain in the left chest. Ever since it has been a constant .
ache, at times becoming severe, worse after eating; it is not affected
by respiration or motion. Her appetite is good, but she has complained
of a great deal of " gas upon her stomach," and for some months has lived
upon a diet excluding meat and eggs, sweets, salt, and fried stuff. She
never vomits. Her bowels are constipated, and she has considerable
dyspnea on exertion. One year ago she weighed 150 pounds; she thinks
she has lost weight since.

Physical examination shows a rather obese girl weighing 149^ pounds.
There is a harsh systolic murmur audible all over the precordia, but
not transmitted elsewhere. The apex is neither visible nor palpable.
The left border of dulness is in the nipple-line and fifth space. The
aortic second sound is louder than the pulmonic second sound. Physical
examination, including blood and urine, is otherwise normal.

Discussion. The only objective abnormality in the physical exam-
ination is the cardiac murmur and the accentuation of the aortic second
sound. ' These items are not sufficient, separately or in combination,
to warrant any inference of disease. The history shows that she has been
starving herself, yet on physical examination she is obese. Possibly
she is trying to reduce her weight, which may have been greater six
months ago.

In the absence of any local cause for the pain one naturally thinks
of neuralgia, especially since the diet is so insufficient. But there are no
tender points corresponding to the nerve exits, while the fact that pain
is worse after eating is very uncharacteristic of neuralgia. While this
diagnosis cannot be positively excluded, it seems rather unlikely.

Muscular pain (pleurodynia) should be more distinctly related to ex-
ertion and less to food.

In view of these facts and of the absence of any apparent connection
between the cardiac murmur and the pain, it seems reasonable to believe
that it is due to a digestive disturbance favored by insufficient food
and associated with gaseous distention. On p. 288 I have already men-
tioned the great frequency of axillary pain due to this cause. Such pain
is very common as an element in the clinical picture of the gastric neuroses,
with or without starvation.

Xo cause of stomach trouble in women is commoner than starvation.
The vicious circle is established in the following manner: Some tempo-
rary fatigue or depression of vitalitv results in digestive disturbance.
The food eaten last or most abundantly is blamed by the patient and
excluded from the subsequent meals. Digestive disturbance continues.
Other foods are excluded. The nutrition of the whole body, including

L'l

3 22

DIFFERENTIAL DIAGNOSIS

that of the stomach itself, begins to suffer, and digestion is still further
delayed by gastric stasis or insufficient secretion. The suffering thus
produced makes the patient aspirate air into the stomach ["cribbing"],
which in time increases the discomfort and renders her still more timid
about eating. The circle is then complete. To break it one must force
the patient to eat, despite considerable pain, until some gain can be made
in the general and so in the local nutrition. A weakened stomach, like
a weakened muscle, cannot be strengthened without exercise, and this
entails, for a time, increase of suffering.

Outcome. The patient was given a full diet, a tight swathe, \
dram bicarbonate of soda after meals, and half a dram of the elixir of the
valerianate of ammonia before meals.

By January 21st she seemed perfectly well and able to go home.

Diagnosis. Starvation.

AXILLARY PAIN

3 2 3

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CHAPTER XI
PAIN IN THE ARMS

Case 163

A theatrical advance agent of thirty-five entered the hospital January
10, 1907. Ten days ago he strained his arm while swinging on a trapeze.
A week ago he was suddenly taken with aching and soreness in the
muscles of the right arm, with a slighter amount of pain in the other arm
and in the legs. The joints were not affected, and there was no fever or
chill, but the right arm was somewhat swollen above the elbow, where it
was more tender than in any other part. He had severe, constant, frontal
headache and a harassing, dry cough. He stayed in bed for the first
day, but, feeling no better, got up again and has been up most of the time
ever since. Four days ago he began to be short of breath, especially on
exertion, and for three days he has had chilly sensations. To-day he
complains chiefly of dyspnea, cough, soreness all over his body, head-
ache, weakness, and a sharp pain in his right wrist on motion. He
gets up three or four times at night to pass his water.

On physical examination, temperature, pulse, respiration, blood, and
urine were found to be normal. The patient looked sick and breathed
with some difficulty. The lungs were slightly dull in both backs, and
showed many line and coarse rales with a few squeaks on both sides.
The heart was negative, likewise the abdomen. The rales in the chest
disappeared the next day. The principal complaint thereafter was of
pain in the whole right arm, and in it there were slight general swelling and
apparently great tenderness. The arm was held rigid most of the time.
Dr. Goldthwait found nothing abnormal about the bursse or joints.

The pain did not prevent sleep at all, and the temperature remained
normal.

On the eighteenth of January the patient dropped and broke a cup.
Immediately after this he had a convulsion, in which his body became
rigid and his eyes rolled up, while the lids, flickered.

Discussion. All that physical examination reveals in this case is the
evidence of a slight bronchitis and a tender arm, very possibly due to a
strain. There is no evidence of inflammation or of any lesion of bone or
3 24

Causes of Brachial Pain

VARIOUS TYPES OF ARTHRITIS (INFECTIOUS, ATROPHIC, HYPERTROPHIC)

SUBACROMIAL AND
SU BCORACOI D }
BURSITIS

FATIGUE AND OC-
CUPATION NEU- \
ROSIS

OSTEOMYELITIS
HUMERI

ANEURYSM HB 14

NEURALGIA (CAUSE?) 10

MEDIASTINALTUMOR 7

NEOPLASM OF]

THE ARM AND | 4

SHOULDER i

CERVICAL RIB I 3

ANGINA PECTORIS | 1

Among the other causes not here represented are:

(a) Wounds, with or without lymphangitis or thrombosis :

(/>) Bruises, fractures, sprains, and strains ;

(o Poliomyelitis and cortical irritation (tumor, gumma).

PAIN IN THE ARMS 327

joint. The pain does not follow the course of any nerve, is independent
of exertion, and associated with no evidence of cardiac or vascular disease.
Cervical rib, aneurysm, and tumor were excluded by careful examination.

In view of all this negative evidence, and in consideration of certain
neurotic mannerisms which were obvious, but not easily described, we
were strongly inclined from the outset of the case toward the diagnosis of
traumatic neurosis. After the fit, which was clearly hysteric in nature,
we felt much surer of our previous diagnosis, and instituted treatment
based upon it.

Outcome. From the fit above described he could not at once be
aroused. He was, therefore, ignored, and after about twenty minutes he
sat up and acted as if nothing had happened. Up to this time the arm
had been held rigidly, and all attempts to move it had been resisted
as he said, because of severe pain. After the convulsion he was given a
severe scolding, and the arm was raised and the fingers were bent and
straightened again by force for about five minutes, in spite of his shrieks
and protestations. Motions not anticipated by the patient were found
to be free. The next day the patient was up and about the ward, the
use of his arm as good as ever, and there was no sign of his previous
incapacity. He is now anxious to go out and get to work. The chest is
clear, and he was discharged well.

It is worth noting in this case that there was no suit for damages in
contemplation. Some writers on traumatic neurosis and many lawyers
engaged in defending suits for damages try to persuade us that the ex-
pectation of a money payment as the result of litigation produces most
of the symptoms of the traumatic neuroses. Cases like that here de-
scribed upset such assertions.

Diagnosis. Traumatic neurosis.

Case 164

A Turkish jeweler forty-five years old entered the hospital December
26, 1907. His family history and past history were not remarkable.
He denied venereal disease. Three years ago he had his first attack of
"rheumatism " in the right hand and forearm, later in the other hand and
other arm. There was no involvement of the joints and no increase of
pain by motion. Six months later the pain extended up to the shoulders
and to the neck. For this rheumatism he has been treated by many doc
tors, but without relief. Three years ago he gave up work and has never
resumed it. Fifteen months ago he began to have a distressing cough
with foamy sputum and this has continued ever since. For about the
same period he has noticed hoarseness and dyspnea on exertion. For

328 DIFFERENTIAL DIAGNOSIS

the past live months he has been unable to lie down at night. His appe-
tite remains excellent, but he sleeps poorly.

A loud ringing cough is the patient's most striking symptom, and no
cause for this could be found on examination of the lungs. Over the
base of the heart a loud, harsh systolic murmur is heard. There is an
area of percussion dulness as shown in the diagram (Fig. 56). Physical
examination is otherwise negative.

Discussion. In view of the symptoms which have recently developed
in this case it no longer presents any diagnostic problems of special
difficulty. Any patient who has a long-standing violent cough, with
dyspnea, hoarseness, pain in the arm, and a dull area over the manu-
brium, with negative heart and lungs, has either aortic aneurysm or medi-
astinal tumor in all human probability. To this residual problem I will
return later.

The great interest of the case centers in the three years which have
led up to the appearance of the present distinctive symptoms of medi-
astinal pressure. Until very recently this case was regarded, as most
such cases are, as one of "rheumatism." I have taken occasion in vari-
ous parts of this book to illustrate the dangers and fallacies inherent in
most diagnoses of rheumatism. Xo other word in the doctor's vocabu-
lary stands so frequently for a dangerous mistake, one for which the
physician bitterly reproaches himself when he discovers it. How are
these dangers to be avoided?

1. Let us never use the word rheumatism unless there is evidence of
acute infection, with distinct and predominant involvement of joints.
Muscular pains will then be ruled out, their distinguishing characteristic
being an increase of pain, especially when the muscle is used. The
recognition of nerve pains, distinguished by the close relation of the
suffering to the anatomic distribution of one or more nerves, will still
further to restrict the unchartered freedom with which we pronounce the
word "rheumatism." Pain due to inflammation involving the subcu-
taneous tissues or deeper parts may ordinarily be recognized by the other
familiar evidences of exudation (tenderness, redness, swelling, heat).

2. When muscular pains, neuralgias, and subcutaneous exudations
are excluded, we have left a very large group of lesions in or near the
joints bony outgrowths, periosteal inflammations, septic and tubercu-
lous osteomyelitis, malignant disease of the bone, cartilage, or perios-
teum, joint fringes and foreign bodies, joint atrophies, traumatic syno-
vitis, gout, hemophilic arthritis, joint suppurations, and other less com-
mon affections. From all these true rheumatism (/. c., acute injections
polyarthritis of unknown origin) may be distinguished, in the vast major-

Fig. 56. Physical signs in a case characterized for nearly three years l>y pain in the arms.

PAIN IX THE ARMS 329

ity of cases, by the fact that it produces no permanent changes in any of
the joint structures and gives a negative a*- ray picture. Joint fringes,
traumatic synovitis, and suppurative arthritis may show nothing charac-
teristic in the x-ray picture, but the history and the accompanying symp-
toms usually make the diagnosis clear. The point which must be in-
sisted upon, however, is that if we are to be even approximately secure in
a diagnosis of rheumatism we must have a satisfactory x-ray picture of
the joint in any case persisting over two weeks.

3. It is, I trust, worth while to mention here some of the diseases
which I have known frequently diagnosed as rheumatism. The list
includes many cases of tabes dorsalis, aortic aneurysm, and osteomyelitis
(septic or tuberculous), a smaller number of cases of malignant disease
involving the mediastinal, prevertebral, or abdominal glands and the long
bones; also a good many cases of pressure neuritis (due to spondylitis,
subacromial bursitis, or cervical rib).

Returning now to the case under discussion, we must attempt a
diagnosis between aneurysm and mediastinal tumor. The strongest
evidence against tumor is the long duration of the symptoms without
any involvement of the external lymphatic glands and without more ob-
vious depression and exhaustion of the patient's physical condition.
As has been already said, diagnostic problems involving the differentia-
tion between aneurysm and mediastinal tumor are usually settled sooner
or later by the discovery of aneurysm.

Outcome. The .r-ray confirmed the diagnosis of aneurysm. On
the eighth of January a diastolic murmur was noted, best heard at the
apex. The pulse showed no change. At times the murmur was loudest
in the anterior axillary line in the fifth space, and could be heard indis-
tinctly as far back as the posterior axillary line. The murmur was long
and wholly replaced the second sound at the apex. Gelatin injections
produced great pain, but no relief.

The patient left the hospital on February 24th.

Diagnosis. Aneurysm (called rheumatism).

Case 165

A washwoman of fifty-nine entered the hospital February to. igcS.
Three years ago she had what she was told was a benign tumor in the
left breast, which was removed in September, 1005. ( Hherwise. she ha*
been well until three months ago, when she began to notice pain on motion
of the right upper arm and shoulder. Since Christmas, too - , - :
been able, to do little or no work. Until verv recently there has been no
pain when the arm is kept still. Coughing produces pain; bre;

33o

DIFFERENTIAL DIAGNOSIS

does not. For two weeks she has had a somewhat similar soreness in
the right groin and hip.

Physical examination showed no emaciation, normal temperature,
pulse, respiration, blood, and urine. The chest and abdomen were
also normal, but it was found that the patient could not raise the right
arm without marked pain. The greatest tenderness was in the front of
the upper arm. There was no atrophy.

Counterirritation and small doses of morphin did not relieve the pain
at all. On the nineteenth it was found that the right arm and the right
side of the chest were almost completely anesthetic. An orthopedic
consultant considered the case one of subacromial or subcoracoid bursitis.
A neurologic consultant agreed. The pain in the right groin disappeared
after a short stay in the hospital.

Discussion. Against the diagnosis of subacromial bursitis the most
important datum is the area of anesthesia, which involves not only the
right arm, but the right side of the chest, and was apparently overlooked
by the other consultants. I have never heard of a bursitis producingjso .
wide-spread an anesthesia. Less important considerations antagonistic
\ to the diagnosis of bursitis are the absence of any trauma or of any evi- '.
dence that abduction or rotation is especially painful, and the fact that ,
the pain is not especially worse at night. In the great majority of cases
of bursitis the opposite is true.

Three months' suffering with shoulder pain and disability, associated
with so wide-spread an anesthesia, should always lead at once to the in-
vestigation of the mediastinum by radioscopy, especially since we have
no positive evidence that the mammary tumor removed in 1905 was as
benign as the patient had been led to suppose.

Outcome. X-ray taken on the twenty-sixth showed a wide shadow
in the mediastinum. On March 4th the patient began to complain of
a smothering sensation in the chest, and some edema appeared in the
right hand. The veins in the neck, especially on the right, now began
to be engorged, though the pain was diminished. The patient left the
hospital March 21st, not relieved.

Diagnosis. Mediastinal neoplasm (metastatic).

Case 166

A clerk of forty-nine entered the hospital June 25, 1908. He had
previously been in the hospital twenty-two years before, suffering from
what was considered facial neuralgia, but since that time he had been
perfectly well until five months ago, when he began to have sharp pain
under the ripht shoulder and finallv down the whole of the ritrht arm.

PAIN IN THE ARMS

33*

After the first two or three days the pain never bothered him at night, but
seven weeks ago it compelled him to give up work. He has had to have
morphin for it once. The pain is most severe near the elbow. The joints
do not seem to be involved. There is no limitation of motion. His
appetite and sleep are poor. For a month he has had five or six loose
movements of the bowels a day.

Physical examination was entirely negative. There was no tender-
ness along the course of the nerve-trunks. X-ray showed nothing ab-
normal in the chest, the neck, or in the joints. On the second day of
his stay in the hospital he had a return of the facial neuralgia, which he
had not previously had for twenty-two years.

Discussion. Neuralgia, i. e., nerve pain of unknown origin, is
always an unsatisfactory diagnosis, and one that we should make with
the greatest hesitation and as a consequence of a long process of exclusion,
whereby all known causes for such a pain are sought for without result.
In the present case we can make a diagnosis of neuralgia only by satis-
fying ourselves that there is:

(a) No relation to exertion (angina pectoris).

(b) No injury of the part (unrecognized fracture, traumatic neuritis,
contusion or traumatic traction of nerve-trunks, tearing of muscular,
capsular, or ligamentous fibers).

( c) No e vidence of bursitis (limitation of motion, tenderness at the
point of the shoulder or in the region of the bicipital groove).

(d) No signs of inflammation involving the veins, lymphatics, or sub-
cutaneous tissues.

(e) No local lesion of the bone or periosteum (septic or tuberculous
osteomvelitis, periostitis, benign or malignant neoplasm).

(f) No evidences of pressure, such as cervical rib, aneurysm, mediasti-
nal, supraclavicular, or axillary glands, or pulmonary tumor.

(g) No atrophic or hypertrophic arthritis (x-ray evidence).
(h) No occupation neurosis.

(7) No systemic, infectious, or vertebral disease.

In the present case it seems possible, by rigid cross-questioning and
examination, to exclude all these possibilities. We had reason to believe
that the patient was already subject to nerve pain of unknown source.
The diagnosis of brachial neuralgia was, therefore, finally made.

Outcome.- Under aspirin, to grains every hour for eighteen hours,
hot and cold douching, rest, and generous diet, the pain was very much
relieved by the second of July. On the seventh he left the hospital prac-
tically well.

Diagnosis. Neuralgia.

3$2 DIFFERENTIAL DIAGNOSIS

Case 167

A colored housewife of twenty-eight entered the hospital July 23,
1907. She has never menstruated, but has otherwise been well until
seven days ago, when she woke up with a sore throat and stiffness through-
out the whole left side, such that she could not raise her arm or leg.
Since then she has had much pain in both arms and has taken a great
deal of morphin. At entrance the arms, knees, and lower legs were
tender and swollen, the tenderness being as great in the muscles as at the
joints. Physical examination was otherwise negative, though the tem-
perature ranged between ioo and 101 F. for a week, gradually falling
to normal in the course of another week. The blood showed a moderate
polynuclear leukocytosis. The urine contained bile for the first five days,
and she had severe nose-bleed several times in the first four days of her
stay. The conjunctivae were distinctly bile-stained.

Discussion. It seems obvious that we are dealing with an infection
of some kind. The well-marked pyrexia, the jaundice (hemolytic pre-
sumably), the polynuclear leukocytosis, and the evidences of local in-
flammation all point to a bacterial origin.

Swelling of the extremities is not a common symptom when the heart
and kidneys are sound, as they appear to be in this case. This is especi-
ally true of the arm. Occlusion of the vein by infectious thrombosis
should produce a well-localized cord-like induration along the course
of one or more veins. We have nothing of the kind here.

Lymphangitis is usually the result of some infection involving a break
in the skin. It generally produces a red blush, extending from the point
of injur}- or its neighborhood up the extremity toward the nearest lymph-
glands. But of such an inflammation there is no evidence.

Of septic myositis we know so little that it is hard to make any definite
statements about it in a diagnostic discussion. I have never heard of so
diffuse a myositis except that resulting from the disease next to be men-
tioned.

Trichiniasis might produce almost all the svmptoms in this case,
though it is not often limited to the extremities and rarelv associated with
so much edema. 1 The patient's color, the polynuclear leukocytosis, and
the absence of the eosinophilia strengthens the case against trichiniasis.

With the exclusion of all these possibilities, there is nothing left but
an inflammation of the subcutaneous tissue and joint structure, not in-
volving the veins or lymphatics, not due to an infected wound or to any

1 A case of trichiniasis involving still more wide-spread edema was reported by Dr,
Donald Gregg in the Boston Med. and Surg. Jour., December 3, 1909.

PAIN IN THE ARMS

333

known parasite. In the great majority of such cases the tenderness and
swelling soon "settle" in the joints, leaving the other tissues free. Be-
cause of this fact and because the joints ultimately recover entirelv, such
cases are usually labeled "rheumatism." For the reasons previously
discussed on p. 328, I believe this term should be restricted to articular
disease involving no permanent joint changes nor lesions of the subcu-
taneous tissues around the joints. The present case, therefore, should
be labeled provisionally as a cellulitis and arthritis of unknown origin.

Outcome. The patient was given hot fomentations surrounding the
extremities, and 10 grains of sodium salicylate every hour. Bv the
third of August she was greatly improved. By the thirteenth she was up
and walking about, all pain and swelling having gone except from the
left hand. This also gradually got well in the course of six weeks.

Diagnosis. Infectious cellulitis with arthritis.

Case 168

An unmarried girl of eighteen has always been well save for a bunch
over the left collar-bone which formed five years ago, broke and dis-
charged for several months.

For six months she has had slight pain and considerable disability
in right shoulder. Rotation is painful and creaky, but abduction is
not especially limited. The deltoid is very weak and markedly atro-
phied.

Physical examination, including temperature, pulse, respiration,
blood, and urine, is otherwise negative.

Discussion. Weakness, soreness, and stiffness of the shoulder
lasting six months make a clinical picture raising many diagnostic
possibilities before our minds. Since the general physical examination
reveals nothing abnormal in the internal viscera or in any other part of
the body, we are justified in fixing our attention upon the local lesion.

Subacromial bursitis might produce all the symptoms here described,
but the history does not suggest any of the ordinary causes of this disease,
such as trauma, prolonged fixation, or sepsis. If subsequent examination
(.v-rav) reveals no other disease of the bone or joint, bursitis will present
strong claims upon our notice.

Tuberculous osteomyelitis involving the head of the humerus might
also account for all the symptoms of which this patient complains. 'I he
fact that she has previously had a chronic suppuration originating in
a bunch on the left side of the neck (presumably a tuberculous gland)
inclines us toward the belief that the bone also is tuberculous. Although
there is no apparent involvement of the soft parts overhang the joint,

334 DIFFERENTIAL DIAGNOSIS

the tuberculous process may be confined to the destruction of bone
(caries sicca). Further evidence must be sought by x-ray examination.

Only by this means can we exclude an unrecognized fracture of the
upper end of the humerus. It would be strange, however, if, in a
young girl apparently free from disease of any other part of the body,
we should find a fracture of the humerus without any known trauma.
In the early stages of such a lesion the history should have mentioned
the presence of ecchymosis and swelling, especially on the inner side
of the arm. Six months after the time of fracture we should expect
the symptoms either to be gone altogether or to be associated with some
bony deformity.

Circumflex paralysis rarely occurs without some much more obvious
cause than is stated here. In case of such a paralysis there would be
no visible or palpable contraction of the deltoid fibers if the patient
were to make an effort to raise the arm (abduction). In the present
case there were distinct wrinkling and hardening of the deltoid under
the palpating hand during the patient's effort, although no considerable
motion resulted.

Atrophic or hypertrophic arthritis would be almost certain to involve
some other joint to a greater or lesser extent. The age and sex are
typical for atrophic arthritis, not at all so for hypertrophic lesions.
Further evidence regarding such disease could only be obtained by x-ray
examination.

A deep axillary abscess, small and high up under the pectoral,
sometimes produces a fixation of the shoulder-joint and pain on any
motion involving it; but careful examination of the upper axilla behind
the pectoral should disclose a deep tenderness and induration, and there
should be some fever. In the present case such an abscess is unlikely
on account of the long duration of the symptoms.

Outcome. X-ray showed considerable necrosis of the head of the
humerus, which was therefore excised. Examination of the portion
resected showed tuberculosis. The girl ultimately made a good re-
covery, with very fair use of the arm.

Diagnosis. Tuberculosis of the humerus.

Case 169

An Armenian factory hand of thirty-one received a blow on the
right shoulder six weeks ago. Afterward the shoulder swelled and
stiffened. The patient is not able to give any more detailed history
of his illness.

Examination. There is almost complete loss of active motion in

PAIN IN THE ARMS

335

the right shoulder. Passive motions are also somewhat restricted in all
directions; there is marked tenderness over the upper third of the
humerus. No swelling, no hollowing of the deltoid, but marked atrophv
of the whole upper arm. The axilla is full of tender glands.

Temperature, ioo to 103 F.; leukocytes, 8000.

Discussion. The signs seem to point toward some type of osteo-
myelitis, but why does not the man get well? Why are there atrophy
of the whole arm and such marked loss of power in the shoulder? Six
weeks of disuse might alone cause atrophy and limitation of motion.
Is there some malignant disease behind it all, some lesion of the central
nervous system, or tuberculosis? The presence of temperature and
tender axillary glands tends to show that there is still infection going
on, although the leukocyte count is so low. The fact last mentioned
inclines us slightly toward tuberculosis as the cause of the osteomyelitis.

Obviously, however, the chief need of the case is for an .r-ray examina-
tion, to be followed in all probability by a more thorough investigation
of the conditions below the deltoid.

Cases of this type offer an extensive field of possible alternatives for
differential diagnosis. The_ history of trauma makes it necessary to
consider fracture or dislocation of the humerus and subacromial bursitis.
Contusion or hematoma would presumably have been well before the
end of six weeks, but there may always be an element of traumatic
neurosis in the case.

On the other hand, it is essential to remember that the history of
trauma is often evolved quite out of whole cloth by the patient, whose
mind imperatively demands some such explanation for a painful and
tender swelling, due, in fact, to neoplasm, to tuberculosis, to septic
osteomyelitis, or other disease in which trauma plays a very subordinate
role.

Further, we must realize that a subacromial bursitis is sometimes
brought about by the prolonged immobilization of the shoulder resulting
from a shoulder contusion which is coddled by a neurotic patient or an
overanxious mother.

Taking up now these alternatives, we may eliminate fracture and
dislocation by the negative results of .v-ray examination; .bursitis, by
the absence of characteristic limitations of mobilitv; neoplasms, by the
results of .v ray. The tenderness is distinctly suggestive of osteomyelitis,
especially if neoplasm can be ruled out. The results of exploratory
incision will be important here. Tuberculosis, whether in the form
of caries sicca or whether including subcutaneous tissues, should be
shown up by the results of .v-ray examination.

33 6

DIFFERENTIAL DIAGNOSIS

Outcome. A'-ray showed a large cavity in the head of the humerus
and a smaller one in the shaft; shoulder-joint obliterated. After opera-
tion, the patient recovered. The excised bone showed no tuberculosis.

Diagnosis. Septic osteomyelitis.

Case 170

Two months ago a teamster's left arm suddenly became stiff and

pained at night near the neck of the humerus. Two days later the

fingers and palm began to swell and to get shiny. Three days after this

the whole arm swelled. The pain then extended into the upper back.

He was then treated in the South Framingham

hospital for neuritis, and was two weeks in bed,

but without fever. Now he is much better.

Edema gone.

Examination. All motions of the left shoulder
were made voluntarily. The muscles were still
very weak, and there was tenderness over the
scapula, which later improved with counterirrita-
tion and sodium salicylate. X-ray negative.

Discussion. The earlier symptoms remind
us of tuberculosis of the humerus or of sub-
acromial bursitis. But neither of these diseases
produces so much swelling of the lower arm.
Tuberculosis may be, with reasonable probability,
excluded by the negative results of v-ray ex-
amination, bursitis by the absence of spasm or
characteristic limitation of motion and the pres-
ence of diffuse extensive edema.

This edema might be explained by the pres-
sure of an intrathoracic tumor or a cervical rib
upon the veins of the arm, but the fact that the edema so promptly
disappeared and that physical examination shows no evidence of these
causes of pressure, suffices to exclude them.

Swelling of the arm without obvious cause is occasionally due to a
thrombophlebitis, but such a diagnosis cannot be made unless we find
induration and tenderness along the course of some vein or veins.

Brachial neuralgia is a possible diagnosis, although the presence of
edema and the absence of tenderness following sharply the course of any
known nerve make it rather unlikely.

Diffuse inflammation of the subcutaneous tissues (so-called cellulitis)
is not, in my opinion, a very rare condition, even in the absence of any

. Si*

*.::,?

J, j

,.' ,

/ /

i ' ,,

, ,

101'

> i

! i i

*sl *""*

E
--

BS'

M'
K*

HO
130

120

100
00

J-.

(i\ 1(31 If

r i

Fig. 57. Chart of
case 1 70.

PAIN IX THE ARMS

337

known cause. We hear but little of such affections, because they are
apt to be called muscular rheumatism, as the present case was. In view
of the outcome of the case cellulitis seems to me to be the best diagnosis.

Outcome. The patient made an uneventful recovery in the course
of three weeks.

Diagnosis. Cellulitis.

Case 171

A housewife of thirty-five has suffered for many years from " rheuma-
tism " in her right shoulder.

For three years the pain has been worse and has been referred especi-
ally to the region of the right clavicle and to the whole right arm. Some-
times it is localized at the lower end of the ulna.

Within a month she seems to be losing strength in the arm, and the
pain often keeps her awake at night.

Examination shows a pulsating mass above the left clavicle, with a
sense of firm resistance below and around it. Backward motions of the
arm cause sharp pain. The outer side of the pulsating mass is very
tender. There is no considerable atrophy or limitation of abduction.
Temperature range, 98 to 99.5 F. Pulse, 90 to 120. Urine pale.
acid, 1016; albumin, slightest possible trace. Sediment. Numerous
blood-globules; small round mononuclear cells, some of which are fatty.
Man}' calcium oxalate crystals. Internal viscera negative.

Discussion. The diagnosis was not suspected in this case until the
conditions were actually seen at operation. This seems to me wrong,
for there are very few causes which produce a pulsating mass above the
clavicle. Aneurysm is naturally our first thought, but this is a very un-
usual place for an aneurysm, although diffuse dilatations of the sub-
clavian or carotid arteries often occur as a result of aortic regurgitation
and in connection with a diffuse dilatation of the arch. This condition
is not aneurysm, and should not be confounded with it. since there is no
breaking of the arterial coats and no tendency to end in rupture of the
artery. Further, an aneurysm of two years' standing is very rare in this
situation, and the source of the marked resistance around the pulsating
mass would not be explained by the diagnosis of aneurysm.

("an the pulsation be transmitted through some tumor or glandular
mass by a normal artery beneath? It would seem very unlikely that a
tumor which would produce pressure pains in t he arm for three years
should not have attained greater size and pulled the patient down more,
and metastasis would probably have occurred.

The presence of a slight fever ,r i\vs some color to the idea ol gland-

33& DIFFERENTIAL DIAGNOSIS

ular tuberculosis, but such a process rarely if ever causes much pain, and
would scarcely have existed so long without abscess formation.

Brachial neuralgia is a diagnosis which one never has a right to make
in the presence of anything which can possibly be interpreted as a
mechanical cause of the pain under investigation. With a mass like
that here described the diagnosis of neuralgia has no justification.

A pulsating mass above the clavicle means cervical rib in nine cases
out of ten, the pulsation being due to the subclavian artery which over-
lies the rib, while brachial pain results from pressure on the brachial
plexus.

The firm resistance below and around the pulsating mass was the
rib underlying the artery. Had an rr-ray been taken, the diagnosis should
easily have been clinched before operation, but even without an jc-ray
one might make a reasonably certain diagnosis on the history and physical
signs, provided one had ever seen a similar case.

Outcome. The brachial plexus and subclavian artery were found at
operation to be elevated on the blunt head of a cervical rib which joined
the first dorsal rib about two inches from the sternum.

After excision of the cervical rib the pain disappeared within ten
days and did not return.

Diagnosis. Cervical rib.

Case 172

A very alcoholic clerk of thirty-three was sent into the hospital for
"osteomyelitis humeri." He has had three months' pain in right upper
arm, at times sharp; occasionally it shifts to the elbow or forearm. Day
and night make no difference.

One month ago it began to swell and the soreness and tenderness
increased. Otherwise he feels well.

Examination. Whole upper right arm 2} inches larger in circum-
ference than the left. Hard (bony?) enlargement is felt beneath the
muscles. The whole mass is hot and tender.

A plexus of veins is prominent over upper inner side of the arm.

Discussion. The fact of enlargement of the upper arm below
the shoulder and at the point of pain excludes many of the conditions
discussed in previous cases. Subacromial bursitis, arthritis of the
shoulder-joint, circumtlex paralysis, brachial neuritis, tuberculous
disease without abscess formation (caries sicca), all produce atrophy.
not enlargement.

The heat and tenderness dispose us to consider a septic osteomye-
litis, a periostitis, or a tuberculosis with abscess and infiltration of the

PAIN IN THE ARMS

339

overlying tissues, but in such diseases one would expect fluctuation
rather than such extreme induration. Rarely, moreover, does an osteo-
myelitis or periostitis result in enlargement of the superficial veins.

Syphilitic disease of the bone, or gumma involving the skin, would
probably produce far less pain and little or no enlargement. After
three months' duration there would almost certainly be some involve-
ment of the skin, some discoloration or ulceration.

The enlargement of the veins associated with an increase in the size
of the whole arm, with marked induration, is very characteristic of
malignant disease involving the bone.

Outcome. X-ray examination showed only a slight increase in the
area of bone-shadow apparently a periostitis. The Wassermann
reaction was negative. Operation showed osteosarcoma.

Diagnosis. Sarcoma humeri.

Case 173

A school-boy of twelve was struck on the right arm just below the
shoulder eight weeks ago. The arm became at once swollen, and in the
past few weeks has been so painful as to require morphin, especially at
night.

Examination. A swelling one-half the size of an orange occupies the
deltoid region, and extends one-third of the way down the arm, about
half encircling it. The shoulder motions are free and painless. The
veins over the lower portion of it are enlarged. The mass is rather
soft, very tender, and apparently adherent to the bone. < )ne enlarged,
non-tender gland is felt in the right axilla (normal microscopically").

Discussion. -The acute swelling and pain near the head of the
humerus are rather characteristic of septic osteomyelitis, espeeiallv in
a boy of this age. Hut in the course of eight weeks one would rather
expect that the pus would have burrowed to the surface or brought
about a general septicemia.

Kxperts in legerdemain accomplish their tricks by selling a trap
for our attention and attracting our gaze to the wrong plate at the wrong
time. By a similar psvchologic mechanism a historv of injmw like
this becomes one of the commonest and most dangerous ot traps sei to
catch unwarv diagnosticians. Our attention gets concentrated
a group ot lesions, such as dislocation, fracture, hematoma, or l>ui>iti-.
which might result dircetlv from trauma. While we are puz/lim; tc
decide between these alternatives, or perhaps carrvin" out treatment
designed to relieve one of them, the actual but unsu^oected neooiasm

34-0 DIFFERENTIAL DIAGNOSIS

or tuberculosis progresses without hindrance. We forget for the moment
that osteosarcoma is common in this situation and at this age.

The plexus of swollen veins over the swelling is rather suggestive of
tumor, but against it, apparently, is the normal microscopic structure
of the enlarged axillary glands, which one would expect to find trans-
formed as a result of metastasis from the bone tumor. It must always
be remembered, however, that the examination of a gland under condi-
tions like these sometimes proves very misleading. Twice I have
known malignant disease of the mediastinum associated with a large
axillary gland, which, when removed, showed nothing abnormal in its
structure. Diagnostic conclusions from the examination of glands in the
neighborhood of doubtful lesions are of value only when the results of
examination are positive. Negative results are valueless, as was, indeed,
exemplified in this case by the outcome.

Outcome. Incision allowed the escape of some soft material
resembling grains of sago. On microscopic examination these grains
showed the structure of round-cell sarcoma.

Diagnosis. Sarcoma humeri.

Case 174

A boy of ten was sent to the hospital for a tumor of the humerus.

One month's pain in the right upper arm, with subsequent gradual
swelling but no tenderness, was the gist of his history.

Two weeks ago the pain became severe. No known cause.

Examination. Looks worn out. Right forearm and upper arm
swollen (radial pulse good). Motions free. The lower half of the
humerus is tender.

Discussion. The boy is at the age when septic osteomyelitis or
malignant tumors are apt to attack the end of the long bones. The worn-
out appearance of the boy and the absence of tenderness rather favor
tumor, but it is to be noted that tenderness is absent only in the upper
part of the arm, while the lower part is notably sensitive.

Why is the whole arm swollen? We have no evidence of pressure from
tumor, aneurysm, or cervical rib, no sign of phlebitis or cellulitis. Such
a swelling would be very unusual were we dealing with tuberculous
osteomyelitis.

It does not appear that the diagnosis can be made any clearer with-
out x-ray evidence or operation. To these procedures, accordingly,
we must turn.

Outcome. X-ray shows thickened periosteum over a swollen
humerus with a dark area in the middle of the lower one-third of the

PAIN IN THE ARMS

341

bone. Three ounces of pus were evacuated from a cavity in the medul-
lary portion overlain by thickened bone and periosteum. Staphylococci
in pure culture from the pus. Temperature, 99 to 100 F.

Well in a week.

Diagnosis. Septic osteomyelitis.

Case 175

A hardwood finisher of forty-seven fell down stairs in 1901, striking
the right shoulder and the back of the neck. For three months after
this the shoulder continued sore.

In 1903 he began to have attacks of sharp pain between his shoulders,
disabling him from work for several weeks at a time, not relieved by
any medicine.

In September, 1904, pain in the nape troubled him and continued
until January, 1905. In December, 1904, the pain between the shoulders
and in the right shoulder became severe again, and has lasted until the
present time (January 17, 1905). This pain is not affected by motion
or position, but often keeps him awake at night.

Cough with profuse white sputa, two months. The cough produces
an increase of pain in the right shoulder and at the root of the neck in
front.

Has lost 20 pounds in two years.

Examination. Left pupil larger than the right. The patient stands
with a well-marked stoop. An impulse lifts the manubrium with each
heart-beat. A diastolic murmur, loudest in the second right space, is
audible over the whole heart, which shows no obvious enlargement.
The pulse collapses markedly. The larynx and trachea are normal.
There are dulness, tenderness, bronchial breathing, and increased voice-
sounds at the right apex. The right clavicle and shoulder are tender to
touch, but all motions are free. There is no muscular atrophy. Physi-
cal examination is otherwise negative.

Discussion. The history of the case naturally suggests that the
present symptoms are due to trauma, especially as the shoulder is still
tender. But a more careful reading shows that the interval between
iqot and 1903 is too long for any such explanation.

Apparently there is no lesion of the joint, muscle, or nerve. All
articular motions are free; muscular action does not increase the pain,
and the suffering is not definitely localized along any nerve-trunk.

The long-continued cough (two months"), the emaciation, the ab-
normal physical signs at the right apex, and the chest pain had led to
a diagnosis of pulmonary tuberculosis by the attending physician.

342

DIFFERENTIAL DIAGNOSIS

But there seems to be no fever, no evidence of breaking down within
the lung (rales, purulent sputa), and a great deal more pain in the
shoulder than one expects to see in phthisis. Especially notable in this
respect is the long duration of pain before the cough began. There
seem to have been nearly two years of suffering before there was any
cough.

By some orthopedic specialists many pains in the back, shoulders,
and arms are explained by the so-called "round-shoulder deformity"
the ordinary stooping habit. Up to date I have not been convinced of
the validity of these explanations. The difficulty with all such explana-
tions is that they fail to show why the stoop has persisted so many years
longer than the pain supposed to be due to it. In any case it is not at
all probable that a stoop will be advanced to explain such severe and
definitely localized pain as is here complained of.

This patient's pain is in a very queer place. One very seldom
hears patients complain of pain high up between the shoulders^, and when-
ever one hears such complaints, some cause of intrathoracic pressure
should be suspected. Such causes are, for practical purposes, three and
only three, viz., aneurysm, vertebral tuberculosis, and malignant disease.
Turning now to the circulatory system with the thought of aneurysm in
mind, we note that there is evidence of aortic regurgitation, such as
often accompanies aneurysm. We notice also the inequality ol^Jhe.
pupils, and we are led thus to suspect that the pulmonary lesions may be
the result of pressure upon the lung itself or upon one of the larger
bronchi. Obviously, this possibility -aneurysm has much in its favor,
especially when we consider the long duration of the symptoms. Intra-
thoracic neoplasm would probably have produced more obvious and
alarming symptoms if it had existed so long. Tuberculous or
other disease of the cervical or upper dorsal vertebrae should pro-
duce some stiffness or tenderness of the spine, and after so long a course
some evidences of caseation, telescoping, kyphos, or fever would be
expected.

Outcome. A'-ray shows an extensive shadow to the left of the ster-
num. Had in the ward several attacks of severe precordial pain, with
great anxiety, relieved by nitroglycerin. Pain then ceased for live
weeks.

In March, 1905, he began to have pain in the top of the right shoulder,
with a scalding feeling in the arm above the elbow.

The heart apex was then found to be in the sixth space, six inches
to the left of the median line. The right pulse is smaller than the left,
and of "Corrigan" type. Tracheal tug. The patient remained in the

PAIN IN THE ARMS

343

hospital until April 6th, suffering very little pain. His treatment con-
sisted of potassium iodid, aspirin, and laxatives.
Diagnosis. Thoracic aneurysm.

Case 176

A cook, fifty-nine years old, colored, born in Martinique, entered the
hospital March 28, 1908. He has always been well except for "rheu-
matism" many years ago, which attacked many joints but did not keep
him in bed. He denies venereal disease.

For two years he has had attacks of pain in the left shoulder, radiat-
ing thence to the breast-bone and to the pit of the stomach. These
attacks of pain have come at considerable intervals until within the past
two weeks, when they have come every other day, and have forced him
to stop work. The pain is not severe, and is always relieved by rest or
drinking hot water. He says that his left arm is weak, especially after an
attack of pain. His ankles have been painful and swollen for two weeks,
and he has had a hacking cough for five months. At one time he noticed
that he passed more urine at night than in the day-time, but this is not
now the case.

His appetite is good; he has no indigestion and no headache.

On physical examination the painful shoulder showed no objective
abnormalities. The cardiac apex seemed to extend one inch outside the
nipple-line in the fifth space. A systolic murmur was heard at the base
and down to the fourth left space. The aortic second sound was faint,
the pulmonic second sound somewhat louder, but not accentuated.
The pulses seemed to be of high tension, but the blood-pressure read
only T38 mm. of mercury. The radials and brachials were markedly
thickened and tortuous. The edge of the liver was felt two inches below
the ensiform. In the fourth left interspace, near the sternum, a faint
diastolic murmur was later made out. At no time was there any capillary
pulse or Corrigan pulse. A'-ray was negative.

Discussion. We may exclude all varieties of arthritis (rheumatic
and other), because the joints are at present normal. Muscular.
periosteal, and nerve lesions can be ruled out by the absence of swelling,
tenderness, and heat, the absence of any relation of the pain to muscular
movements or to the anatomic position of the nerve. There is no
important evidence pointing to any source of pressure within the chest.

When these possibilities are excluded, we note that the pain comes
in paroxysms which are relieved by rest, and that it has wry wide
radiations. Any pain of this type occurring in a man ot lift}' nine

344

DIFFERENTIAL DIAGNOSIS

suggests aneurysm or angina pectoris, especially if the patient is a
negro. Of aneurysm we have no definite evidence, though it cannot
be ruled out without x-ray examination. Most cases of angina pec-
toris are associated with a greater elevation of the blood-pressure, but
the disease cannot be ruled out on that account. Angina is, there-
fore, the most reasonable diagnosis. Greater certainty can be attained
through the therapeutic test, but only time can exclude aneurysm.

Outcome. The patient was given 5 grains of potassium iodid
three times a day, with y^g- grain nitroglycerin and cascara as needed;
later, 15 minims of tincture of digitalis three times a day were added.

By April 4th he had made marked improvement, and was sleeping
soundly every night. On April 5th he was out of bed, and thereafter
was almost free from symptoms until his discharge on the eleventh.

This case is introduced as an example of a somewhat unusual dis-
tribution of pain in angina pectoris. In other cases the pain may be
wholly epigastric, wholly or largely in the arms or in the back. We
are justified in grouping all these widely separated pains under the
single heading of "angina," because all of them are associated with
arteriosclerosis and with cardiac disease which is fairly well compen-
sated. It is important that all of them are produced and relieved in
the same way. The four specially characteristic occasions for anginal
pain are all of them occasions of suddenly raised blood-pressure. These
are:

(a) Muscular exertion.

(b) Strong emotion.

(d) Getting up in the morning.

The vast majority of anginal attacks are produced by one of these
four causes, which I have arranged in the order of their frequency.
Much less common is angina that wakes the patient from sleep. The
relief of pain when one of these causes has been removed usually enables
the patient and his physician to be quite clear as to its cause. The
relief by some one of the nitrite preparations, which tend to lower
blood-pressure, is also of great diagnostic value.

Diagnosis. Angina pectoris [syphilitic aortitis?].

Case 177

A tailor of sixty entered the hospital July 21, 1906. He stated
that for eight or nine weeks he had had rheumatism in his right shoulder,
which is now much better and troubles him very little. A little later
he noticed a lump just above and to the right of his breast-bone. This

PAIN IN THE ARMS

345

has gradually increased in size until the last week, when it has grown
very rapidly. It is hard, not tender, and seems to "beat." He now
notices pain on lifting his right arm or turning on his right side. There
is no history of injury. For the past two months he has been hoarse.

Physical examination shows that the pupils are equal and react
normally, though they are slightly irregular. The heart shows nothing
abnormal. To the right of the sternum, above the second rib, is found
an expansile, pulsating tumor, the size and shape of an egg. The
right clavicle is pushed forward, and the sternal end seems to be buried
in the tumor. The manubrium is eroded and the first rib completely
cut off from the sternum. There is no dulness beneath the manubrium,
and no other abnormal pulsation. There is a faint systolic murmur
over the tumor.

Physical examination of the lungs, abdomen, extremities, blood,
and urine is otherwise normal.

Discussion. Hoarseness, shoulder pain, irregular pupils, and a
pulsating lump near the breast-bone seem at first almost indisputable
evidence of aneurysm, and so, in fact, they did seem to most of those
who saw this case in the hospital wards. Certain points, however,
were, at any rate, atypical, to wit:

(a) The pain: why should it decrease? It rarely does decrease
in cases of aneurysm unless the patient takes to bed and adopts other
measures for slowing the circulation.

(b) The percussion area: why should there be no substernal dul-
ness? The aneurysm must be supposed to arise from the arch of the
aorta, and ought, therefore, to produce dulness under the manubrium.

(c) Aneurysms rarely begin above the level of the sternum in the
neck or behind the clavicle. Unusual pulsations at this point rarely
turn out to be aneurysm.

(d) The patient is rather old for aneurysm, though this by no means
excludes it.

(e) An aneurysm situated in this position would probably involve
the subclavian artery or the innominate sufficiently to produce inequality
of the pulses.

Decisive evidence might probably have been obtained by .v ray
examination.

If not aneurysm, what else could this lump be? Gummatous tumors
a^e common in this situation. They are not usually painful and destroy
much less bone than appears to have disappeared in this case. They
pulsate only in case they have perforated the sternum, which is a rare
occurrence.

346 DIFFERENTIAL DIAGNOSIS

Tuberculosis of the bones composing the thoracic wall usually shows
more evidence of caseation, produces but little pain and that confined
to the diseased focus itself, and never pushes the clavicle forward.

Malignant disease originating in the ribs, in the sternum, or in some
of the mediastinal structures would produce most of the signs here
described. The marked pulsation seems less inconsistent with a vascular
neoplasm than with syphilis or tuberculosis. The patient's age is sug-
gestive of neoplasm rather than of aneurysm.

Outcome. Despite the considerations just adduced, a diagnosis
of aneurysm was made. The patient left the hospital on the twenty-
fifth of July, and not long after consulted Dr. Maurice H. Richardson,
who removed an incapsulated vascular tumor which suggested, on
histologic examination, a metastasis from hypernephroma. There
was no aneurysm. Some months later the patient entered the Cam-
bridge Hospital for profuse renal hemorrhage, probably due to the
primary tumor.

Diagnosis. Metastatic hypernephroma.

Case 178

A milliner of twenty-seven entered the hospital March 9, 1907.
Her family history was negative, and she remembered no illness until
within the past year, when she has had dysentery with eructations of gas
after eating, especially after taking fried food. She has had to get up
to pass water once or twice at night for the past year. For two months
she has been conscious of her heart-beat. Eighteen months ago she
weighed 112 pounds, which was about her average weight. Now she
weighs 97 pounds.

Three months ago she began to have cough, which sometimes is so
intense as to make her vomit. She spits almost nothing. For the same
period she has noticed shortness of breath on slight exertion. January
30, 1907, she was admitted to the Rutland Sanatorium for tuberculosis,
and five examinations of her sputa were made, with negative results.
Her temperature while there was normal the greater part of the time, but
at irregular intervals it would rise to ioo or 100.5 F. She comes to
the hospital directly from Rutland. On more careful questioning she
admits that for a year she has been having dull pains in the left side
of her neck, and pain and numbness in the left arm. This pain is apt
to increase gradually for two or three minutes and then suddenly stop.
Eggnog or anything containing alcohol makes the pain distinctly worse.
It has quite frequently kept her awake at night. Eying on the left side
makes it worse.

PAIN IN THE ARMS 34-

Physical examination shows slight brownish pigmentation of the skin.
The left chest is somewhat fuller in front than the right, and the veins
over it are prominent. Over the left clavicle is a small mass the size
of an English walnut, hard and movable, not tender. The heart is
negative. The left lung shows dulness just above and below the clavicle.
Throughout the left front, breathing is distant, and the same is true of
the left back below the scapula, where there is dulness and diminished
fremitus as well. The abdomen is negative. The left upper arm
measures 21 centimeters; the right, 9 centimeters.

Discussion. The mistaken diagnosis of tuberculosis was quite-
excusable in this case. Cough, dyspnea, pain, with dulness at one pul-
monary apex, loss of weight, and a slight pyrexia are certainly very
strong evidence in favor of tuberculous infiltration. It was only after
repeated negative examinations of the sputa that it seemed necessary to
reconsider the diagnosis. The fact that no rales had appeared during
a considerable period of observation, and especially the early appearance
and long persistence of pain, began to make it seem likely that some
deeper and more serious disease was at work.

The most significant fact in this case is, 1 think, the long interval
(nine months) between the beginning of pain sufficient to keep her
awake and the onset of cough. This, I think, should have made us
suspicious and doubtful of our diagnosis from the first.

High Pott's disease must be reckoned with. There need be no
kyphos in such cases, and the pain is often referred to points distant
from the spinal lesion. The pain, however, is the only symptom which
points toward vertebral tuberculosis. We have no muscular spasm, no
stiffness or torticollis, none of the evidences of caseation or abscess
formation such as might well be expected after a year's duration of the
disease.

When the arm began to swell and the lump appeared above the left
clavicle, there was no longer any considerable doubt that a mediastinal
tumor of some type was pressing upon the brachial plexus. Such
tumors, whether they arise from mediastinal glands, from the root ol
the lung, or from the pleura, usually begin with symptoms oj ordinary
pleural effusion, for which they are frequently mistaken. In their early
stages there are often no pain, no external tumor, and no swelling of the
arm. The pleural effusion, however, reaccumulates with astonishing
swiftness after aspiration. It mav or mav not be bloody, and its cellular
constituents may or mav not lie identical with those of ordinary (tuber
culous) pleurisy. But it is especially the rapid refilling of the chest alter
tapping that finally awakens our suspicions of malignant disease.

348 DIFFERENTIAL DIAGNOSIS

Outcome. X-ray of the chest showed a diffuse shadow, chiefly on
the left side, but extending also a short distance to the right of the spinal
column. The nodule at the base of the neck was removed and examined
by Dr. Wright, who pronounced it malignant lymphoma. The evidences
of fluid at the base of the lung steadily increased. The patient did not
react to 3.5 mgm. tuberculin. On the twenty-fourth of March she
was discharged not relieved.

Diagnosis. Malignant lymphoma.

PAIN IN THE ARMS

349

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CHAPTER XII
PAIN IN THE LEGS AND FEET

Case 179

A HACKMANof twenty-five entered the hospital March 6, 1907. His
family history was negative. A year ago he had urethritis and was sick
for a month. For a week his left ankle was swollen and red and he was
unable to use it for a month. Six days ago he noticed a cutting pain in
his right hip, relieved by sitting down. Four days ago he was unable to
get out of bed. Yesterday his left ankle was swollen and sore.

Physical examination showed normal temperature, pulse, and res-
piration. The chest and abdomen were normal. There were slight
tenderness, redness, swelling, and pain across the instep of the left foot.
Motions of the right hip caused marked pain in the sacro-iliac joint.
There was also tenderness there.

Discussion. We are dealing with lesions of the right hip and left
ankle in all probability some type of arthritis. The diagnosis of
rheumatism must be avoided like a blasphemy unless we are forced to it
by the exclusion 'of all other possibilities. To those possibilities we will
accordingly turn our attention.

Hypertrophic arthritis (osteoarthritis) does not attack these joints
in a man of twenty-five. It will be remembered that in the hip -joint
this lesion constitutes the malum coxa senilis and leaves youngsters
unscathed.

Atrophic arthritis might involve these joints in a young man, but
always involves other joints as well (particularly those of the hand), and
it is very prone to a symmetric distribution, c. g., both wrists, both
ring lingers, both hips, both feet.

Were the sacro-iliac joint alone affected, it might not be necessary
to assume the presence of any inflammatory lesion. Some strain or
displacement of the joint might suffice to produce the pain. But since
the opposite ankle-joint is also involved, we have no reason to connect
the two lesions mechanical]}'. Infection is the only other familiar link.
especially as we have no definite evidence of any metabolic defect, such
as gout.

Causes of Pain in Legs and Feet

1. INFECTIOUS DISEASES (AT ONSET ESPECIALLY;

2. FLAT-FOOT

3. INFECTIOUS |

ARTHRITIS J

4. VARICOSE VEINS

5. TABES

6. HYPERTROPHIC!

ARTHRITIS i

7. PHLEBITIS

8. SCIATICA

9. OSTEOMYELITIS

10. TUBERCULOSIS

11. SPRAINED ANKLE

12. SPRAINED KNEE

13. SYPHILITIC |

PERIOSTITIS I

14. ATROPHIC 1

ARTHRITIS I

15. TENOSYNOVITIS

16. ALCOHOLIC )

NEURITIS '

SARCOMA OF LEG 1
BONES I

17,

18. GOUT

19. MORTON'S META- )

TARSALGIA I

20. INTERMITTENT )

CLAUDICATION *

2204
789

513

313

265

205
157
136

134

130

3 I

PAIN IN THE LEGS AND FEET

353

If the joint troubles are of infectious origin, the first question to
be answered is: Could a urethritis last so long? Can the joint trouble
be due to a gonorrheal infection? To answer this question we must
investigate the urethra.

Outcome. A urethral smear showed gonococci. Vaccines were
given beginning March 8th, and within two days were followed by
considerable improvement.

On the seventeenth there was much pain in the sacro-iliac region,
and this lasted until the twenty-second, after which he improved rapidly.
The opsonic index was low most of the time until the twenty-eighth,

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next is the leukocyte count; the third stands for the opsonic index, and the fourth for the
dose of vaccine.

after which it rose and stayed high. Its variations are shown in the
accompanying chart. On April 7th he was walking about without
any difficulty, and on the ninth he was discharged much relieved.
Diagnosis. Gonorrheal arthritis.

Case 180

A colored man of sixty-four entered the hospital July n, 1007.
His family history is negative. He stated that he almost died of a
"bad cold" at fifteen, that he had had spinal curvature since he was
thrown from a horse at fourteen. In the eighties he was at the Boston
Insane Asylum for a time.

354

DIFFERENTIAL DIAGNOSIS

aia

Since spring his right hip has pained him, and for the last three
weeks the pain has been so severe as to interfere with sleep, and when
he wakes there is much pain and stiffness in both legs, though it wears
off considerably with exercise. Three weeks ago his feet were swollen
for some time. This has now gone. He drinks much water and usually
passes urine three or four times at night. His bowels move every day
or two, and only with medicine.

The movements of the patient's pulse, temperature, and respiration
are seen in the accompanying chart. At entrance his white cells were
7700, but a differential count showed that 90 per cent, of these were

polynuclear. There was no anemia. The
spine showed scoliosis, resulting in a marked
prominence of the ribs of the left back.
There was an old bony deformity of the
right elbow-joint, which was stiff. He was
poorly nourished. There was marked arcus
senilis. The heart showed nothing of in-
terest. The radial arteries were tortuous
and stiff. The front of the chest was nega-
jj^l^liolf 3 tive except for a few fine rales over the right
clavicle. Behind, the right chest was dull
below the spine of the scapula, with dimin-
ished or absent breathing; the left back was
full of moist rales. The abdomen showed
slight tenderness in the region of the gall-
bladder. There were glands the size of
walnuts or almonds in the groins, axillae,
and neck. There was practically no motion
in the spine. The urine averaged about 35 ounces during his stay in
the hospital, with a specific gravity of 1015, a slight trace of albumin,
and very many hyaline and fine granular casts, with cells adherent,
some of which were fatty.

On the fourteenth the chest was tapped and 27 ounces of fluid
removed, with a specific gravity of 1015, albumin, 2 per cent., lym-
phocytes, 81 per cent. The sputa showed nothing remarkable.

From the seventeenth of July until the twentieth he was delirious.
Discussion. There appear to be many widely diverging clues in
this case. The history gives us hints of psychic stigmata, of tuberculosis,
of renal or cardiorenal disease, of multiple arthritis and multiple adeni-
tis. Certainly it is a difficult case to untangle. We seem to have
reasonably good evidence of a chronic interstitial nephritis. The

Fig. 59. Chart of case i

PAIN IN THE LEGS AND FEET 355

nocturia, the swollen feet, and the character of the urine point in this
direction, but it is practically certain that he has something else the
matter with him.

On the other hand, that "bad cold" which he had at fifteen, follow-
ing immediately upon the spinal trouble, which appears to have resulted
in a rigid spine, makes us very suspicious of tuberculosis, especially
as the symptoms occur in a colored man. The effusion in the right
chest (evidenced by dulness and absent respiration) may be due either
to tuberculosis or to mechanical causes (dropsy). The low specific
gravity inclines me to believe that the fluid is not a pure exudate. The
multiple adenitis is not inconsistent with tuberculosis, though it might
also indicate syphilis. All types of leukemia are excluded by the blood
examination.

That some infection has invaded the patient's body seems indicated
by the continued fever and the delirium. We might suppose that this is
a terminal sepsis due to the streptococcus or some other of the common
terminal invaders, the rest of the symptoms being then explained under
cardiorenal disease. But this would not account for the stiff spine,
the stiff elbow-joint, the general glandular enlargement, and the early
history.

A positive diagnosis seems impossible, but more facts can be ac-
counted for by assuming a tuberculous infection than by any other
hypothesis. As a matter of fact, however, this diagnosis was not made.

Outcome. He became comatose on July 20th and on the twenty-
third he died.

Clinical diagnosis: Arteriosclerosis; chronic nephritis; pleural effu-
sion; terminal infection. Autopsy showed old tuberculosis of the spine;
tuberculosis of the kidneys; tubercular ulcer of the ileum; miliary
tuberculosis of the bronchial lymph-glands, with suppuration; tuber-
culosis of the lungs, liver, spleen, kidneys, and epicardium. The
guinea-pig which was inoculated with 25 minims of the sediment of the
pleural elTusion was killed August 23d and showed no evidence of
tuberculosis.

Diagnosis. See last paragraph.

Case 181

A housekeeper of thirty-one entered the hospital November 4, 1007.
Her family history was negative. She had been operated upon at the
Massachusetts General Hospital for stone in the right kidney in 1003,
but no stone was found. All the summer of igo; she had been run down,

356

DIFFERENTIAL DIAGNOSIS

had been easily nauseated, and had vomited frequently. The vomiting
had sometimes been brought on by worry.

For five weeks she has been tired, restless, and overemotional.
Appetite and sleep have been poor. Three weeks ago she first noticed
that she limped, favoring the right leg. This limp has steadily in-
creased, and for the past two weeks she has been constantly in bed.
Two weeks ago she began to have sharp pain in her right groin, in the
right hip and to some extent in the right lower back. The pain is worse
at night and often keeps her awake; it comes in paroxysms, leaving her
entirely for a few hours at a time. When tired, she passes urine every
two hours or so, but she has noticed no change in it. The course of the
temperature is seen in the accompanying chart.

Examination of the chest was negative.
The abdomen was tympanitic throughout and
held more rigidly on the left than on the right.
On deep palpation there seemed to be some ten-
derness on the right. The right leg was kept
continually flexed upon the body. Extension of
the hip-joint or outward rotation was painful;
other motions were good. The scar of the pre-
vious operation was seen in the right flank. On
deep inspiration a rounded, tender mass could be
indistinctly felt in the right flank.

Examination by an orthopedic consultant con-
vinced me that the psoas contraction was not due
to any hip lesion. The kidney and the mesen-
teric glands were suggested as possible causes.

On November 5th and 7th the urine showed
a large amount of pus in the sediment; a very
slight trace of albumin; specific gravity, 1013; the
amount, about 40 ounces in twenty-four hours.
Discussion. In this and the succeeding case we are dealing with
a hip pain associated with a psoas spasm. There seems no evidence that
the hip-joint or spine is involved. One looks accordingly for the other
and less common causes which lead to contraction of the psoas. Deep
tenderness on the right side of the abdomen, associated with fever and
psoas spasm, is a well-known feature of appendicitis. But appendicitis
rarely begins with a limp before there is any right iliac pain. It should
produce some muscular spasm of the abdominal wall, but there is none of
this here, nor is there any localized tenderness or "cake" over the
appendix region.

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case 181

Chart of

PAIN IN THE LEGS AND FEET 357

Tuberculosis of the mesenteric gland and occasionally other causes
of mesenteric adenitis may lead to psoas spasm. Such a diagnosis is
hard to make, harder still to deny. One inclines toward it if there is
nothing to suggest any other recognized cause of psoas contraction.
Probably adenitis accounts for some of the mysterious cases of ''idio-
pathic" or "hysteric" spasm of the psoas. Psychic causes are often
invoked when our diagnostic resources are exhausted.

Various kidney lesions (hematogenous infection, perinephritic abscess,
tuberculosis, stone) have been known to bring about a contraction of the
psoas. This patient has pus in the urine, and an investigation of the
kidney is, therefore, of the first importance.

Outcome. On November ioth the flexion of the leg had become
more marked. The patient ate and slept poorly. Three #-ray plates
were taken. They showed apparently two renal stones on the right.

Operation November 16th showed two stones and a little pus in the
kidney. Even under deep anesthesia the leg could not be extended,
but later, in convalescence, this spasm entirely disappeared and she
walked well.

Diagnosis. Psoas spasm due to nephrolithiasis.

Case 182

An Italian hod-carrier of thirty-two entered the hospital June 26,
1906. Three weeks ago, while carrying bricks on a ladder, he felt a
peculiar sensation in the left hip, described as "throbbing" (probably
clonic spasm). Since then there has been pain in the hip, with marked
stiffness, the pain being increased on motion.

Visceral examination (including blood and urine) was negative.
The left thigh was partly flexed, and could not be straightened without
pain. Flexion and rotation caused no pain. There was no other
obvious spasm and no tenderness. The left groin was slightly fuller
than the right. X-ray showed no sign of hip-joint disease, renal disease,
or of aneurysm, which had been suggested by Dr. Goldthwait in the
out-patient department; although there was greater pulsation in the
vessels of the affected side, the temperature in both legs was the same.
There was slight dulness in both flanks, not shifting on change of posi-
tion.

Tuberculin was given, but no rise of temperature followed.

On July 1st Dr. Goldthwait thought that some fibers of the ilio-
psoas were probably ruptured.

Discussion. Tn many respects this case resembles the last. In
studying it we interrogate, by means of physical examination a) The

358 DIFFERENTIAL DIAGNOSIS

hip-joint; (b) the spinal column; (c) the appendix region; (d) the renal
region and the urine. We consider enlargements of the mesenteric
glands, always so easy to include and so hard to exclude in cases of this
type. We look for evidence of abdominal tumors or aneurysm of the
aorta.

In the present case we are able, apparently, to exclude all these
possibilities except tabes mesenterica, and this, in view of the negative
tuberculin reaction, seems very unlikely. Since there is no reason for
accusing the stolid Italian laborer of the "vapors," we have to fall back
upon a hypothetic strain involving the psoas. There seems no reason,
a priori, why this muscle may not be subject to strain or sprain like any
other, but it is obvious that, until we have followed our patient far into
convalescence, we cannot place any reliance on such a diagnosis.

Outcome. By July 9th the patient was walking well, without limp
or pain. Uninterrupted recovery followed, apparently as the result of
the magnificent air which he breathed in the surgical wards of the
Massachusetts General Hospital.

He was given no other treatment.

Diagnosis. Psoas tear (?).

Case 183

A beef-carrier of fifty-three entered the hospital January 29, 1907.
His family history is negative. He has never been sick until the present
illness, but has been in the habit of getting drunk once to three times a
week. Two weeks ago he woke in the night with a pain in the right
hip. Since that time he has been confined to bed with pain and fever,
wandering in his mind, and constant twitching of the arms. His wife
says he has had no alcohol for two weeks. He has been treated for
lumbago and for diabetes. Later it was learned that five years ago he
had had some abscesses on his neck which discharged for a year. They
were finally cured by an extensive operation.

Physical examination showed good nutrition, but the patient's
mind was cloudy, though he would answer simple questions. All his
muscles were held rigidly, especially those in the neck and arms, but
there was no paralysis. The pupils were slightly irregular, but reacted
normally. The eye motions were normal, the chest and abdomen
negative. The white cells were 13,000; the Widal reaction suggestive,
but not positive; the blood otherwise normal, likewise the urine. Marked
subsultus was the most prominent feature. At entrance the case was
taken for an acute abdominal emergency and immediate operation was

PAIN EST THE LEGS AND FEET

359

Sia

urged. On the second day the patient became unconscious, with pro-
fuse sweating.

Discussion. Hip pain, fever, and delirium are the presenting
symptoms. The character of the delirium suggests alcoholism, but
two weeks' abstinence from alcohol should have steered him past the
danger of delirium tremens. The general muscular rigidity, moreover,
the hip pain, and the irregularity of the pupils could not be
thus accounted for.

The mental condition, the muscular twitchings, the fever,
and suggestive Widal reaction furnish us with some of the
material whence a diagnosis of typhoid might be built up.
But the leukocyte count is remarkably high for that dis-
ease, and we should still be left without an explanation of
the hip pain, the muscular rigidity, and the condition of
the pupils.

Rigidity of the neck in a febrile patient always makes
us fear meningitis, and all the other facts in this case go to
strengthen this hypothesis. If he had been treated for dia-
betes, as the history states, he has probably had sugar in
his urine. Transient glycosuria is not uncommon in
meningitis of any type.

But if he has meningitis, can we in any way explain
the hip pain ? Certainly not by the epidemic or aural type
of meningitis, but meningeal tuberculosis might well origi-
nate in a tubercular hip, the probability of which is in-
creased as we note that he has had chronic discharging
abscesses of the neck, presumably tuberculous.

Outcome. He died on the thirtieth of January. Autopsy showed
tuberculosis of the bodies of the fourth and fifth lumbar vertebra*, with
large psoas abscesses; tubercular meningitis; tuberculosis of the retro-
peritoneal glands; obsolete tuberculosis of the left apex.

Diagnosis. Pott's disease with psoas abscess. General tuberculosis.

Case 184

An architect of thirty entered the hospital May 3, 1907. His family
history, past history, and habits are good. Five weeks ago, while
jumping to catch a base-ball, he felt a sharp pain in the left hip. He
got home with difficulty, and has been in bed ever since, suffering
almost continual pain in the left hip and along the back ot the thigh.
Opiates have been necessary to produce sleep, and even then only a
few hours' sleep at a time has been obtained. The pain has never hcen

360 DIFFERENTIAL DIAGNOSIS

in the back and has gradually diminished in intensity, but the patient
is still unable to walk or to put the foot to the ground. The left thigh
is held slightly flexed, and there is a tender point two inches outward
and upward from the tuberosity of the left ischium. There is also
tenderness along the course of the sciatic nerve, but none over the sacro-
iliac joints. It was afterward learned that five years ago he had a
similar attack, following bicycling; he was then laid up for five weeks.
Later he brought on another attack by jumping while playing tennis.

Discussion. As in the previous case, the presenting symptom is
sciatic pain, but here its origin is not insidious and obscure, but abrupt
and apparently traumatic. In studying it we must go through the
same series of investigations intended to bring to light any cause for
pressure upon the nerve (pelvic tumors, bony outgrowths from the
femur, spinal osteoarthritis, sacro-iliac displacement) and any metabolic
disturbance, such as diabetes, whereby a toxic neuritis or neuralgia
might arise. [It should be noticed in passing that no one seems ade-
quately to have investigated the possibility that diabetic sciatica may
be due not to a chemical cause, but to muscular weakness, destroying
the support of the pelvic articulations. Certainly toneless, flabby muscles
play an important part in many cases of sacro-iliac trouble.]

Many cases of sciatic pain seem, like the present one, to begin after
an injury which is usually of the type here described, i. e., a wrench such
as might bring about violent extension of the hip-joint and possibly
some strain or stretching of the sciatic nerve. It has been more fre-
quently assumed, however, in recent discussions, that the trauma has
affected the sacro-iliac joint primarily, the nerve only secondarily.
This seems to me to be a matter rather of fashion than of reasonable
conviction.

Outcome. X-ray showed no evidence of spinal involvement or of
sacro-iliac disease, and an orthopedic consultant considered the case
one of "simple sciatica." From the time of entrance until the thirteenth
of May he was treated, chiefly with a view to relieving the pain, by
means of ice-bags, hypnotics, and an occasional dose of morphin. On
the thirteenth he was given hydrotherapy and Zander treatment, which
within a few days produced remarkable improvement. On the seven-
teenth he was discharged, much relieved.

Diagnosis. Sciatica.

Case 185

A farm hand, thirty years old, entered the hospital February 16, 1907.
Three years ago he had a compound fracture of the right thigh. He

PAIN IN THE LEGS AND FEET 361

was in bed seven months, and has had half an inch of shortening in that
leg ever since. After being out of bed about a month, he had an attack
of what was called "sciatic rheumatism," which, so far as he remem-
bers, was exactly like his present illness. He was then confined to bed
for two months and was treated by electricity and drugs. He denies
venereal disease, takes about 25 cents' worth of beer and whisky a week,
and chews 10 cents' worth of tobacco a day.

Three days ago, without any known cause, he felt a sharp pain in
the right hip-joint. This pain has continued ever since, is worse on
motion or pressure, radiates down the back of the leg to the ankle,
and is accompanied by a burning sensation, also described as like
electricity. He has never any pain in his back. He worked until
last night, but then the pain was so severe that he was unable to sleep,
even with morphin. This morning for the first time he noticed blisters
on the leg, due, he thinks, to a poultice.

Physical examination of the chest and abdomen was negative, except
for a sausage-shaped mass in the left iliac fossa, which disappeared in
the course of a couple of days.

The knee-jerk was very active on the left, less so on the right. On the
left buttock was a series of vesicles filled with straw-colored fluid. On the
right, opposite the upper part of the sacrum, and over the thigh, in the
region of the great trochanter, was a line of ruptured vesicles. Pressure
over the sciatic nerve, especially near its exit from the pelvis, in the pop-
liteal space and in the calf, was painful. Sensibility was normal. There
was no tenderness over the spine or pelvic bones. Rectal examination
was negative. The pain was excruciating in all positions, and was very
little affected by morphin. Ice at times gave slight transient relief.
After the twentv-second the pain became more bearable, following
the administration of three grains of quinin every two hours until the
ears rang. Static electricity seemed to increase the pain. Aspirin did
not help at all.

Discussion. The history of pain coming on for the first time soon
after a severe fracture of the femur naturally directs our minds to the
possibility that by the callus formed at the site of fracture, pressure
may be exerted upon the sciatic nerve or adhesions formed involving it.
The difficulty with this supposition is that the patient has been free from
pain for over two years, although nothing has been done which would
remove adhesions or alleviate pressure. Possibly there may be some less
direct connection between the fracture and the present pain, but it is
difficult to get beyond the region of conjecture. Only by .v-ray examina-
tion and rectal palpation can we get any further evidence in this direction.

362 DIFFERENTIAL DIAGNOSIS

Any sciatica which involves both legs is very suggestive of pelvic
new-growth. In this case we have apparently a bilateral herpetic erup-
tion, the usual manifestation of a lesion of the ganglion with its corre-
sponding nerve-root. The pain, however, is unilateral, and we have no
definite evidence to support the idea of pelvic new-growth.

In every case characterized by sciatic pain we should remember
that diabetes is one of the commonest causes for such pain. There is
no statement about the urine in the above record of this case, and evi-
dence should certainly be sought in that direction.

Largely through the influence of Dr. J. E. Goldthwait the medical
profession has now learnt to search for osteoarthritis of the lumbar spine
or for some lesion of the sacro-iliac joint in all cases of sciatic pain. The
nature of the connection between the pain and the bone lesions has not,
I think, been fully explained as yet. Most of the important evidence of
such a connection consists in the results of a therapeutic test fixation
of the spinal and sacro-iliac joints by strapping, belt, or plaster-of-Paris
and on the relief of symptoms following such fixation. This is of great
practical importance, but does not answer all the questions regarding the
mode of production of sciaticas thus relieved. In the present case we
find no evidence of spinal or sacro-iliac disease.

The term "sciatic rheumatism" is now happily falling into disuse,
and with it, I believe, will soon go out of existence the hoary and over-
worked theory that cold produces such troubles. Doubtless it was their
connection with joint lesions such as those just referred to that first
suggested the term "rheumatic," with the theory of cold as the cause.
In view of the negative result of all the examinations directed toward
finding a cause for the pain we shall be obliged to leave it as an unex-
plained symptom ("primary," "idiopathic," or "simple" sciatica).
Since it is associated with herpetic eruption, and since we know that
many cases of herpes are due to infectious disease, it is fair to surmise
that the neuritis with which we are now dealing may be of the infectious
type. All this, of course, presupposes that the results of urinalysis and
x-ray examination are negative.

Outcome. A"-ray of the femur showed a large callus with a project-
ing spicule, but as there had been no pain for two years, this seemed prob-
ably not responsible for the pain. Dr. J. J. Putnam considered the case
neuritis with herpes zoster. Dr. Goldthwait agreed.

On the twenty-fifth the patient was discharged much relieved.

Diagnosis. Neuritis with herpes zoster.

PAIN IN THE LEGS AND FEET

3>3

Case 186

An Italian pressman of forty-five entered the hospital March 26, 1906.
Three weeks ago he gave up work on account of pain in his hands and
feet, which has been severe ever since, and has recently kept him awake.
His appetite is poor and he has vomited several times. He attributes
his pain to the fact that he gets very wet with perspiration at his work and
then rides home upon a car. He got very cold in this way, just before
the present illness.

The course of the temperature is shown in the accompanying chart.
There was soft edema of the backs of both hands. The right wrist

bsV LUr it T5 !?^5 "TTTT~T"7 !?^T?"" """""" ^3

*-" J ~ " ' t\ii u a ill i, 1 1 H 1 1 1 II A' 1 I f 1 l;J_ J. "','','' ' ' ' L\

IM J

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- " * ^_^2i^v

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iZ A Tt^ \i . . H

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* n ..^+ rr2~-- s-ia^P-- - -5s- a s s-i^**.?

11.

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Z 3^ . 1* d *._. _,_, Zn-2

it ^4^X M^M^-S&IZ J Z"*'?.?.* 4 J

" - 1si/3ct"S- "is.***^* #* sl. ,**

/;%*;'/ "4 * L*. j* l ,*% **

n tT ^3 ' ^* \i-

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- \f ,*<^ , i % n.

r M |U^.*-js%l4* , ***' * \^m *'

J a a[J a ra a .. a ^ a a a _js . ...

Fig. 62. Chart of case 186.

and left elbow- joint were swollen, slightly stiff, and tender. There was
tenderness on moving the fingers, and convincing evidence of fluid in the
left knee-joint.

Both ankles were somewhat red, swollen, and tender. There was
tenderness on pressure in the calves of the legs and over the muscles of
the forearm, a bright red macular rash over his back, with small, shiny
papules scattered through it, and in the arm-pits numerous small, dis-
crete, transparent vesicles. He was seen by Dr. Goldthwait on the
twelfth of April. He found at this time an infectious process, chiefly
in the cellular tissue, with very little involvement of the joints.

The temperature fell to normal about the twenty-eighth of March,
but on the thirty-first the patient was delirious and chattered a great

364 DIFFERENTIAL DIAGNOSIS

deal in the night. After omitting the salicylates, which had been given
steadily up to that time, the delirium cleared up within twelve hours.
The knee-jerks were present, but the Achilles reflex absent. The eyes
reacted better to accommodation than to light. The urine averaged
60 ounces in twenty-four hours, the specific gravity varying very widely
between 1009 and 1020. Hyaline and granular casts were numerous, and
there was always pus in the sediment. The blood showed 12,800 leuko-
cytes, 81 per cent, of which were polynuclear.

On April 4th the swelling of the hands still continued. No obvious
change in his condition accompanied the fever of April 10th to 19th.

Purulent conjunctivitis was present throughout his stay in the
hospital. The smear showed no gonococci; a variety of other organisms
were present. May 1st he was discharged, not relieved.

Discussion. Judging from the condition of the pupils and of the
ankle-jerks, there seems reason to believe that this patient has tabes,
but evidently that is not his most important malady at the present time,
so that our interest centers in the question : What else is the matter with
him? We have obvious evidence that an infectious process has invaded
the subcutaneous tissues, the joints, and the conjunctivae. In all prob-
ability the pus in the kidney is to be attributed to a genito-urinary in-
fection due to the same organism which is attacking his other tissues.

At one period in the case it seemed as if the meninges, also, were in-
fected, but the immediate cessation of meningeal symptoms when the
salicylates were stopped makes it pretty clear that we were dealing with
a salicylate delirium, which should always be borne in mind when any
delirium occurs during the administration of salicylate in large doses.
This is a very frequent occurrence. Indeed, it is impossible to avoid it
if we are in the habit of pushing this drug rapidly to its physiologic limit,
as we should do in most cases of acute arthritis. No considerable harm
results, as the delirium always ceases promptly when the drug is with-
drawn.

We have evidence, then, of a very wide-spread infection of the body.
Presumably this is due to one of the pus-forming organisms, since we
have no definite evidence of tuberculosis, glanders, or syphilis. No
further certainty can be arrived at without blood culture.

Milder cases of this type are often called "inflammatory muscular
rheumatism" (see above, p. 333), J us ^ as tne m ilder septic infections
of the joints pass as articular "rheumatism." But in both cases there
is no reasonable doubt that we are dealing primarily with an infection
of the blood-stream, following which the micro-organisms take root and
multiply here or there, following laws of distribution which we do not

PAIN IN THE LEGS AND FEET 365

understand. Evidently the joints present especially favorable condi-
tions for the growth and multiplication of micro-organisms. But we
see many instances where an infection which seems to start in and to be
distributed by the blood-stream gets its only recognizable localization
in the heart, lung, kidney, or beneath the skin. I am inclined to think
that the gall-bladder, the meninges, the peritoneal cavity, and possibly
also the appendix, should be added to this list. I shall return to the fur-
ther discussion of the types of pyogenic infection in the section on
Fevers.

Diagnosis. General pyogenic infection.

Case 187

A clerk of forty-nine entered the hospital January 3, 1907. He
had previously been in the hospital in 1889, with a diagnosis of acute
rheumatism and mitral endocarditis. Since that time he has had many
similar attacks. The attacks seem to be brought on by cold, indiscre-
tions in diet, and alcoholic drink. He had syphilis in 1884, and later
on had trouble in controlling the movements of the bowels, following an
operation for piles and fever.

At times he has been a heavy drinker. Ten days ago he "got cold"
and passed bloody urine. Since then he has had several acute attacks
of diarrhea.

On examination his pupils are slightly irregular, but are equal and
react normally. Marked pronation of both feet, with flattening of the
arches, is noted. The second joint of the right big toe is immovable,
thickened, not red or tender. There is some enlargement of the joints
of the fingers and toes. A r -ray shows thin, eroded areas on the fingers
and toes, also some bony outgrowth. The urine shows nothing of note.

Discussion. What type of arthritis are we dealing with here?
The association of the previous attack, in 1889, with a mitral endo-
carditis gives us some ground for calling it a rheumatic arthritis, although
we cannot be quite sure of the endocarditis, since there are no signs of it
at present. It is impossible categorically to deny that a mitral endocardi-
tis can heal, leaving no sign of its presence, but we have no good reason
for believing so at the present time. Patients with true rheumatism
often attribute their attacks to cold, but rarely to alcoholism or indis-
cretions of diet. This feature of the history, as well as some others
presently to be mentioned, does not fit the ordinary picture of rheumatic
arthritis.

Syphilitic disease of the joints is not at the present time a very
sharply defined clinical entity, but the cases on record have not been

366 DIFFERENTIAL DIAGNOSIS

characterized by such a tendency to recurrence and speedy recovery as
have occurred in this patient.

Since the arches of the patient's feet are markedly flattened, we must
consider whether this deformity is a cause or result of his symptoms.
The periodic and paroxysmal character of the patient's sufferings is not
at all characteristic of mechanical weakening of the arch. Ordinary
flat-foot is apt to cause pain until it is relieved by treatment. It does not
appear and disappear so suddenly. Against flat-foot also is the presence
of eroded areas and bony outgrowths, as shown in the rv-ray plate.

But although flat-foot is very unlikely as a cause of this patient's
troubles, it may well be viewed as a result of them, since almost any form
of arthritis affecting the joints of the foot may be followed by flat-foot
which remains as a cause of weakness and pain after the inflammatory
trouble has passed. Thus it comes about that many cases of true ar-
thritis of rheumatic or other origin are best treated, when they reach the
doctor, by flat-foot plates and exercises designed to strengthen the ad-
ductors of the foot. The inflammation has passed, and its sequel is
mechanical weakening, not an infectious process.

The rc-ray evidence, the thickening and stiffening of the right big toe-
joint, and the apparent relation of the symptoms to indiscretions in diet
suggest gout. Nothing is said in the history of acute night-attacks of
pain in the great toe, nor of the presence or absence of tophi. But
further inquiry showed that both these gouty symptoms were present.
Still unexplained is the relation between the gouty diathesis and the bony
outgrowths seen in this and other cases of gout, as well as in the hyper-
trophic form of arthritis.

Outcome. On the fourth of February the patient was discharged
quite free from symptoms. Tophi were still present in his ears, and
crystals of sodium biurate were obtained both in this attack and four
years previously.

Diagnosis. Gout.

Case 188

A housewife of twenty-nine entered the hospital January 14, 1908.
She was delivered of her first child on December 2d, but previous to that
delivery she had much pain, owing, as she supposed, to a partially re-
tained placenta. She was douched and cureted twice a day until she
decided to get a new doctor. The second physician omitted the cureting.
She has since been better.

Two days after delivery both legs became swollen, and were still so
when she was seen January 14th. On entering the hospital she com-

PAIN IN THE LEGS AND FEET

367

plained bitterly of pain in the left buttock. Physical examination
showed nothing but moderate jaundice and a bed-sore over the left sacro-
iliac joint. The white count was 15,800; two days later, 38,200. On
the second day after entrance she began to be delirious, and this con-
tinued twenty-four hours, after which she was more rational, but had
occasional hallucinations at night. There was marked dulness through-
out the lower abdomen. The uterus was soft, flabby,
and somewhat tender, but there was no vaginal dis-
charge.

By the sixteenth the edema had practically dis-
appeared from the right leg, and was less in the left.
A blood culture was taken, which showed no growth.
Nevertheless, antistreptococcus serum was injected.
The urine as drawn by catheter was bright green, but
showed no other striking abnormalities. There was
some tenderness in the left groin, but no other evidence
of thrombosis. By the eighteenth this tenderness had
increased and there was considerable fulness in the
same region.

Discussion. Fever occurring after childbirth and
accompanied by jaundice, by marked leukocytosis, and
by pain in the left buttock and groin, points to the exis-
tence of some deep-seated septic process originating in
parturition. Though there is edema in both legs, we
find no good evidence of peripheral thrombosis. Pelvic
thrombosis possibly, or some other cause for pelvic obstruction to the
circulation, is our natural conjecture, since all the other symptoms
appear to originate in the pelvis. 1

The green color of the urine is presumably due to biliverdin, a result
like the yellowing of the conjunctiva of hemolysis. Nothing more
definite can be said as to diagnosis. Pelvic sepsis we doubtless have;
its form, extent, and origin can only be revealed by surgery or by the lapse
of time.

Outcome. Incision allowed the escape of 25 ounces of pus, the
source of which was extraperitoneal and apparently extended back to
the region of the left sacro-iliac joint. A culture showed streptococcus.
The patient died a week later.

E
*

IM'

Mf'

me
mf

if
m-
OT
'
"

1M
1*0
HO
1

100

to
ft

H
U
M

l '

_ft

Fig. 63. Chart
of case 188.

1 Any one who has seen postmortem the condition of the uterine and the periuterine
tissues in the days soon after a normal lal>or cannot but wonder how any woman escapes
sepsis and embolic infarctions of the lung.

3 68

DIFFERENTIAL DIAGNOSIS

Autopsy showed several fractures of the pelvic bones, deep burrow-
ing pus without obvious point of origin, and streptococcus septicemia.
The course of the temperature is seen in the accompanying chart.
Diagnosis. Fractured pelvis and sepsis.

Case 189

A medical student of thirty-three entered the hospital March 2, 1907.
On February 21st his left great toe- joint swelled up, but the swelling
was gone the next day. He then began to have pain and stiffness in
the left hip. This has gradually increased ever since. Yesterday
it took him twenty minutes to walk three blocks.
No other joint has been affected. Any hip motion
causes pain down the back of the leg. The great-
est tenderness is over the tuberosity of the
ischium.

At the onset of his symptoms, hives appeared
at night all over his body, some of the lesions
being as large as half a dollar. They always dis-
appeared in the day-time. For the past two
days he has not had them.

Physical examination was negative, except that
all motions involving the hip-joint caused intense
pain extending from the tuberosity of the ischium
down the back of the leg.

Rectal examination showed marked tender-
ness on the right, but no mass or fluctuation.
The case was considered an ischiorectal abscess by
the surgeons. To an orthopedic consultant it
appeared to be an infectious arthritis of the hip.
The white count at entrance was 27,400, with 89 per cent, of poly-
nuclear cells; on the fifth there were 15,000; on the twelfth, 9000.
The course of the temperature is shown in the accompanying chart.
By the tenth of March the pain and tenderness were much less and
the motions of the thigh freer. By the thirteenth he was almost free
from symptoms and was able to walk about. X-ray was negative. Hot
fomentations and sodium salicylate helped him very much in the early
days of his illness.

He was discharged on April 9th well.

Discussion. Pain and tenderness in the hip following a similar
pain in the toe a week earlier are the presenting symptoms here. The
hip pain has sciatic radiations, and is accompanied by fever and leuko-

Yi r

sr.i' .1

T'b

H~"~!

til

i
f

107'
1M*

104"

1M'

tar
m'

1H>
ISO

no
100

f]\

a
10
u

v>
tl

' ;

Fig. 64

case 1

Chart of

PAIN IN THE LEGS AND FEET

369

cytosis. No source of infection is obvious. There has been no injury
to account for the symptoms.

Our first business is to examine the hip, sacro-iliac joint and spine.
As a result of this search it seems that only the hip-joint is affected,
the sciatic pain being doubtless secondary to this. What, then, is
the infection of the hip? Tuberculosis, the commonest of hip infections,
has rarely so acute an onset, and usually occurs in younger persons.
The high white count, the hives, and the acute brief pyrexia seem more
like some pyogenic infection. We have no positive evidence of gonorrhea
or of any other infection from without.

The marked tenderness over the tuberosity of the ischium and on
rectal examination suggested a deep ischiorectal abscess, especially as
the leukocyte count was so high. There is no way by which this diag-
nosis can be excluded, though it is rare to see such an abscess clear up
without breaking or being evacuated externally. It is a well-known
fact that some cases of acute arthritis at the hip produce pain in the
situations complained of by this patient. In view of these facts and
of the favorable course of the disease without external manifestations
of abscess it seems most probable that the case was one of acute
arthritis of unknown origin, such as usually receives the name of
"rheumatism."

Diagnosis. Acute infection of the hip.

Case 190

A widow of forty-five, with a negative family history, passed the
menopause two years ago. She is a heavy drinker. Has been strong
and well, but in the past two years has lost 36 pounds. She now weighs
go pounds.

She has had a cough since last fall, with a grayish sputa. Has been
unable to work for a year. In bed most of the last five weeks, because
of pain in both legs and hips. Bowels move five or six times a day for
the past six months. She entered the hospital August 15, 1904.

Examination. Left pupil larger than the right, and reacts to light
but not to accommodation. Ptosis of right eyelid. At left base behind
and in the left axilla the breathing, vocal and tactile fremitus are dimin-
ished, with slight dulness and many tine, crackling rales. I hart negative.
Considerable tenderness in the whole belly. Dulness in the right
hypochondrium and flank, shifting slightly on change of position.

Mass felt bimanually in this region. It is movable antcropostcriorly
and with respiration, and is apparently continuous with the liver. Navel
flushed. Lower abdominal veins prominent. Slight edema of the belly-

DIFFERENTIAL DIAGNOSIS

wall and of feet. Liver dulness reaches from the fifth space to four
inches below the ribs. (See Fig. 66.)

Temperature, ioi to 103 F. (see Fig. 65). The white cells were
5300. Urine negative.

On the third day after entrance fluid was found in the belly. The
Widal reaction was negative. On the sixth day she had three hemor-
rhages \ pint each from the bowel.

Discussion. The past history is of special importance in the
interpretation of these symptoms. It is to be noted that a woman not
previously subject to cough has now coughed steadily for nearly a year,
and lost continually in weight, though she is at the menopause. As-
sociated with her cough the chief symptoms have been
diarrhea and leg pain.

Summing up the physical examination, we may say
that there are indications of very wide-spread lesions;
the ptosis and pupillary changes indicate something
wrong at the base of the brain. The lung signs must
be interpreted (in the absence of cardiac or renal ab-
normalities and in the presence of fever) as pleurisy
with effusion or thickening. Finally, below the dia-
phragm, there are evidences of pressure exerted ap-
parently upon the vena cava and its radicles (as well
as upon the spinal nerve-roots), by the mass figured in
the diagram. The liver also seems to be much enlarged.
Cancer, syphilis, or tuberculosis are the three diseases
most capable of producing symptoms distributed through
the body as widely as those in this case. Syphilis would
account for the ptosis and pupillary changes. If we inter-
preted the mass below the diaphragm as a syphilitic
liver, the edema, ascites and fever would be explicable
under the same hypothesis. The pleurisy and leg pains would remain
unaccounted for, likewise the prolonged cough. The diarrhea might
be due to amyloid disease of the intestine as a result of the syphilis.

Malignant disease of the liver is sometimes associated with fever,
and would explain the abdominal symptoms very well, but would not
help us to account for the ocular signs, the chronic cough, the pleurisy,
or the diarrhea. Tn the great majority of cases hepatic neoplasm is
preceded by marked and long-continued gastric suffering, due to a
preceding neoplasm of the stomach. We have no such suffering here.
Tuberculosis involving the base of the brain, the pleura, the intes-
tine, and peritoneum would account for all the facts in this case. Under

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Fig. 66. Condition of the abdomen in Case 190; bedridden by pain in both legs.

PAIN IN THE LEGS AND FEET 371

this hypothesis the intestinal hemorrhages result from ulcerations of
the gut, while the mass above the umbilicus represents a conglomera-
tion of caseous glands and adherent intestinal coils. Enlargement of the
liver might be due to fatty or amyloid metamorphosis. By strict reason-
ing this diagnosis seems the most probable.

Outcome. The patient died August 18th. Autopsy showed ex-
tensive tuberculosis of the mesenteric and retroperitoneal lymphatic
glands, also of the large and small intestine, with ulcerations evidently
the source of hemorrhage. There were long-standing tuberculosis of
both lungs and a general miliary infection.

Diagnosis. Tabes mesentcrica. General tuberculosis.

Case 191

A housewife of thirty-seven entered the hospital October 18, 1907.
Her family history, past history, and habits are good. For the past
four and one-half years she has had frequent attacks of severe pain
in the back of the left thigh, running down the leg, preceded often by
a mild chill, and relieved after five or six hours of sweating. She is
also troubled by nervousness and apprehension, and has worried a
good deal since last winter about a prune-stone that she swallowed.
She wonders where it is now. Her sleep and appetite are poor, and she
has frequent attacks of headache and nausea, with some flatulence
after eating and considerable constipation.

Physical examination showed great restlessness; no swelling, tender-
ness, or limitation of motion in any part of either leg. The arches of both
feet were found to be much flattened. The rest of the examination,
including the pelvis, the blood, and the urine, was negative.

Discussion. In view of the negative results of a searching physical
examination and of general observation under hospital conditions,
we seem driven to the diagnosis of a psychoneurosis with flat-foot and
sciatica. Only by the continued study and prolonged observation of
such cases can we realize the harm done by semiconscious fears based
on such an incident as the swallowing of a prune-stone. Especially in
persons who have no knowledge of anatomy and physiology, the imagina-
tion runs riot in speculation over the possible paths which such a stone
might travel. Very great benefit follows in such eases if the patient
can be assured, as a result of exhaustive physical examination, that no
organic lesion exists.

An element in tin's benefit is the result of the patient's opportunity
to bring to full consciousness, as the result of the physician's questions,
the vague and unformed dreads from which he has been sultering.

372 DIFFERENTIAL DIAGNOSIS

As soon as they are forced to take shape, many of these apprehensions
are alleviated, as the child's terror is gone when it has recounted its
nightmare to its mother. To this familiar psychologic rule the name
of the "cathartic method" has been given by Breuer and Freud. The
essential point is that ideas or emotions which do the most harm to
the body are often the most deeply hidden beneath the superficial
layers of consciousness. The patient himself may be altogether unaware
of their existence or may manifest his vague cognizance of them only
by a systematic refusal to face them squarely, either in his own mind
or in conversation with his physician. It is for this reason that the
physician must sometimes employ what Freud calls "psycho-analysis"
the effort to find, by a persistent process of drawing the patient out,
submerged ideas which resist more or less unconsciously the attempts
to drag them to the surface. The process is risky, but occasionally
valuable.

Outcome. After a week's rest and several long talks with her
physician, counterirritation to the thigh, laxative medicines and proper
shoes, she was discharged much relieved.

Diagnosis. Flat-foot; psychoneurosis.

Case 192

A cook of thirty-six entered the hospital March 14, 1907. At
irregular intervals for five or six years she has had sharp pains in her
arms and fingers, sometimes lasting as long as a week, usually worse
in summer. During the last five years she has grown very stout, her
average weight being 175 pounds. Otherwise her past history is good,
likewise her family history and her habits. She was perfectly well
until eight days ago, when she began to have pain in her heels, later
passing around to the front of the foot, but never to the toes nor to the
ankles. The pain kept her awake at night, and the foot has been
swollen, red, and tender to touch. She has been in bed for the last three
days, and seems to have been getting worse.

The patient is 5 feet 4 inches tall, very obese; chest and abdomen
are negative; reflexes normal; no tenderness over the joints of the feet.
After a few days in bed the patient's pain was gone. There was no
fever, and physical examination, including the blood and urine, was
otherwise negative.

Discussion. This seems to be a case of obesity with pain in the
feet; the nature of this pain it is our problem to discover. Is it of me-
chanical or infectious origin? The redness, tenderness and swelling look
like infection, but there is no fever or leukocytosis, no involvement of

PAIN IN THE LEGS AND FEET 373

any other joints, and experience has shown that even redness and
swelling may result from the mechanical causes leading to the acuter
forms of flat-foot. We are influenced especially toward the latter
hypothesis when we find that there was no tenderness in the foot-joints,
but only in the soft parts. The fact that she gets better as soon as she
is off her feat is evidence pointing in the same direction.

Very similar symptoms are often seen in gout, but I see no way of
coming to any closer terms with this possibility, since we have no tophi,
no night attacks of pain in the great toe, and no knowledge of a heredity
or habit of life predisposing to gout.

Outcome. Padding the feet gave temporary relief. Much more
permanent benefit followed the adjustment of flat-foot plates.

This case well illustrates one of the indirect evils resulting from
obesity. There are many cases of obesity which do not call for treat-
ment by reason of the inconvenience or unsightliness of the fat, but
which entail, nevertheless, a genuine risk to the patient. At any time
the heart may be slightly weakened or the feet slightly strained by some
temporary cause. In the obese the results of these otherwise trivial
injuries may be a serious and obstinate illness. During this illness it
is rarely wise to attack the obesity. Later, when the acute suffering is
past, the patient may be unwilling to submit to the privations entailed
by the attempt to reduce his fat. Thus many patients go on from bad
to worse. Their good resolutions cannot be summoned at the right time.

Diagnosis. Acute foot-strain.

Case 193

A bartender of twenty-nine, with negative family history and past
history, entered the hospital January 29, 1908; he has been in the
habit of taking 25 glasses of beer a day, and one whisky every morning.
For the past six months he has been growing short of breath, and lately
has needed two or three pillows at night. He has no digestive symptoms,
but rarely eats any breakfast. Five weeks ago he began to notice a
swelling of his legs below the knee, accompanied by soreness and stiffness.
The swelling disappeared after five days, but he continued to feel poorly
and three weeks ago gave up work. Throughout his illness he has had
slight cough and white, frothy sputum. Eight days ago he began to have
considerable pain in both ankles and the left knee, without any swelling,
redness, or fever.

His pains have never been of a darting character.

His eve-sight is good. He has had no headache. For the past
emht davs he has been in bed.

374

DIFFERENTIAL DIAGNOSIS

As seen by the accompanying chart, the patient had a slight fever
the first five days of his stay in the hospital. This was accompanied
by a leukocytosis, which on January 29th reached 17,800; January 30th,
18,800. The urine was sufficient in amount, averaging 1017 in specific
gravity, with a very slight trace of albumin, but no casts. His pupils
reacted well to light and distance. The aortic second sound was mark-
edly accentuated. The heart was otherwise normal, also the lungs.

The pulse tension was apparently increased.
The edge of the liver was felt one finger's
breadth below the edge of the ribs, like-
wise the spleen. There were considerable
tremor of the fingers and obstinate insomnia.
Within a few days he began to have pain
in both arms, accompanied, as in the legs,
by tenderness to pressure, although the
reflexes were everywhere normal.

Discussion. Chronic alcoholism, six
months' dyspnea and cough, and five weeks
of leg pain are the essential data of the his-
tory. Tabes is always to be thought of in
men of these habits, but there is nothing in
the physical examination to verify this con-
jecture. Doubtless the great majority of
such cases are destined to be labeled "rheu-
matism," chiefly because they do not pre-
sent a clear picture of any more definite
malady. But there seems no good reason to fall back upon this ancient
darkener of counsel when we have no fever and no special tenderness
over the joints.

Alcoholic neuritis is the natural explanation of diffuse leg pains
occurring in an alcoholic without fever or evidence of local inflamma-
tion. But in this as in most cases called alcoholic neuritis, we cannot
answer the question, Why is this man stricken at this particular time;
Why does the result appear so tardily when the cause has been busy
throughout so many years? Doubtless there is some other determining
factor of which we are, as yet, quite ignorant.

Outcome. The patient was given sodium bromid, 20 grains, after
breakfast and dinner, and 30 grains at night. Twice he needed | grain
morphin. For his cough he was given a prescription containing 3
grains of codein, 15 minims of spirits of chloroform, 3 ounces of syrup
of wild cherry. Of this mixture a dram was given every two hours

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PAIN IN THE LEGS AND FEET 375

when the cough was troublesome. On the first of February he was
given 15 grains of sodium salicylate four times a day. By the ninth
of February he was free from symptoms, but had slight toe-drop and
slight tenderness in the calves.

He was advised to avoid alcohol, and went home on the tenth of
February.

Diagnosis. Alcoholic neuritis.

Case 194

A plasterer of thirty-seven entered the hospital June 12, 1907.
He had his first attack of rheumatism at seventeen, when he was sick
for several months. He has since then had five or six other attacks,
and since his last attack, which lasted a month (five months ago), he
has had a weak heart and more or less pain in various parts of his body.
He has had urethral discharge off and on since he was seventeen, until
five years ago; not since then. He takes from two to six glasses of beer
and one or two whiskies a day. Two weeks ago he began to have pain
and swelling in his feet and knees, and got transient relief from a Turkish
bath. He has also had considerable severe pain in the region of his
heart and right lower ribs for the past two weeks. He has had very
little fever, but has sweated a great deal. For the past fortnight he
has been troubled with many attacks of "hives," which, however, have
not bothered him for the last two or three days. Throughout his illness
he has had a cough, with whitish, frothy sputa. His appetite is poor.
His bowels move twice a day. He has slept fairly well. The course
of the temperature is seen in the accompanying chart.

Examination.- The heart's apex was seen and felt in the fourth
space, four inches from the midsternum in the nipple-line. There was
no enlargement to the right. The sounds were regular and of good
quality; the pulmonic second sound accentuated. A blowing, systolic
murmur was heard best at the apex, very faintly over the rest of the
precordia and in the axilla. The pulses showed nothing remarkable.

The right lung was dull below the third rib in front and below the
angle of the scapula behind. Over this area distant bronchial breathing
with increased fremitus was detected. Just above the dull area, taint
crackling rales were heard. The abdomen was negative. The right
knee and shoulder, left shoulder and elbow, were slightly stiff and painful
on motion.

Xo sputum examined. The leukocyte count was 22.000 at entrance,
16,000 on the first of July, t 2,000 on the third of July, and ranged lower
after that time. The urine was essentially normal.

37^ DIFFERENTIAL DIAGNOSIS

Discussion. We can arrive at no clear conclusion, nor even at any
helpful clue, from reading the first paragraph of this record. The
patient has had many attacks of arthritis, some or all of which may
have been due to gonorrhea, but it is not probable that his present
joint pains are gonorrheal in origin, as he has had no local signs of
that disease for five years. His other symptoms cough, sweating,
chest pain, urticaria, and anorexia are very indefinite. Pleurisy is
perhaps the possibility most indicated.

On physical examination we find the evidence of multiple arthritis,
of solidified lung (right lower lobe), and possibly of mitral regurgitation.
All of these might be due to a single infectious agent, such as the pneu-
mococcus or tubercle bacillus. So far as I know there is no good evidence
that the gonococcus can produce pneumonia, although it might explain
the other lesions from which the patient is suffering. The temperature
chart (Fig. 68) is by no means characteristic of pneumococcus infec-
tion, nor, indeed, of any other acute infection. It is more suggestive
of tuberculosis.

If we are to clear up the diagnosis any further our chief need seems
to be a knowledge of the sputa, which should be repeatedly and care-
fully examined. I have known tuberculous pneumonia to begin with
just such a history and with very similar symptoms, including even
the joint pains. On the other hand, many of the irregular, low-grade
pneumonias, associated with a cardiac lesion and with some organism
other than the pneumococcus, present a picture much like this.

Outcome. The patient was treated by tight chest swathe; 15
grains sodium salicylate every four hours, chloroform liniment, an
occasional dose of trional or morphin, and hot applications to the joints.
On the seventh of July his only complaint was of weakness. At the
right base there was still dulness, but the breathing and fremitus were
diminished. These signs gradually disappeared, and he was discharged
well on the seventh of August.

Diagnosis. Pneumococcus arthritis, endocarditis (?), and pneu-
monia.

Case 195

A bartender of fifty entered the hospital March 24, 1908. Four
weeks ago he had an attack of rheumatism in his feet, ankles, and in
his shin, just above the ankles. The ankles were swollen, red and
tender. He took 5 grains of aspirin every four hours on the fourth
day of his trouble, and in a day or two his pain had gone, but ever since
then he has been feeling mean and cannot sleep. He still has difficulty

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PAIN IN THE LEGS AND FEET 379

in walking, but can hop round fairly well. His appetite and bowels
are normal. He gets up six or eight times at night to pass water, and
thinks he passes more at night than during the day. (This observation
was verified during his stay in the hospital.)

There were various rose-colored macules scattered over the trunk.
The pupils were found to be irregular, but reacted normally.

Along the margin in each ear there were some white, firm nodules,
the size of a pin's head, resembling sebaceous cysts, but surprisingly
hard. The radials were tortuous; pulse of high tension; blood-pressure
175; aortic second sound slightly accentuated. No cardiac enlargement
could be demonstrated, and the heart showed no other abnormality.
The breathing was slightly harsh in the left back, below the angle of
the scapula; otherwise the lungs showed nothing abnormal. The
abdomen was normal. There was flattening of the arches of both feet,
especially the left; blood and urine were normal, except that the urine
was persistently of low gravity, ion, with the slightest possible trace
of albumin, but no casts.

Discussion. Arthritis, hypertension, nocturia, irregular pupils
and flattened arches are the main points on which we may be clear
from the start in this case. There seems good reason to believe that
the patient's kidneys are somewhat atrophic, although no cardiac
enlargement can be made out as a support for this hypothesis. The
remaining question is: Does flat-foot account for all the rest of his
symptoms, or is the weakening of his arches secondary to some form
of arthritis? This brings us to the more careful consideration of the
nodules on the patient's ears, for any case of doubtful joint lesion,
especially in the feet, calls for a careful scrutiny of the aural cartilages.
If the nodules on the ear were sebaceous cysts, they would be soft,
never hard. Such multiple, firm white nodules along the ear margin
may represent the sodium biurate deposits of gout. They may also
occur when the ear has been frozen. The crucial test is to ascertain
whether we can dig out of one of these nodules a chalky, gritty powder,
showing fine, needle-like crystals under the microscope. In the present
case we obtained such crystals and our diagnosis was made.

Outcome. He was given wine of colchicum root, 20 minims every
four hours; veronal, 10 grains, for the first two nights; magnesium
sulphate, \ ounce every morning. By the twenty-ninth his digestive
disturbance was gone and he felt much better. The colchicum seemed
to produce diarrhea, and was promptly omitted. Thereafter lie was
given a liberal diet, and by April 2d was discharged, relieved.

Diagnosis. ~ Gout.

380 DIFFERENTIAL DIAGNOSIS

Case 196

A widow of fifty-five entered the hospital December 10, 1907. Her
family history is good. Fifteen years ago she had cataract in both
eyes, and was very successfully operated on, so that now she has very
fair vision. As long as she can remember she has passed urine five or
six times every night. She passed the menopause two years ago, without
event.

A year ago she began to have transitory numbness in the right hip
and along the back of the right thigh. Six months ago she began to
have a burning pain extending from the right knee to the right hip when-
ever she remained seated for any length of time. She took osteopathic
treatment during the summer, and was assured that her hip had been
out of joint, but was now properly set. Nevertheless she did not improve.
In July the pain was sharp, shooting, and often kept her awake. Since
August it has been very bad until the first of December, since when it
has been rather better. When the pain is severe, there is often involun-
tary twitching of the foot and leg. This was more frequent six weeks
ago than it is now.

At present the leg feels fairly comfortable during the night and in
the morning, but after she has been up for half an hour or so it begins
to feel numb, and in a short time there is a burning and shooting pain
which comes and goes through it. The back of the thigh and some-
times the lower leg are markedly tender to touch. There has been no
pain in the back, no eruption, no fever. She has been in bed or on a
sofa most of the time for the last four months, and has lost about 25
pounds in weight.

The aortic second sound is louder than the pulmonic, and is preceded
by a faint murmur transmitted up to the clavicle and down to the third
space. Another murmur is heard with the first sound at the apex,
but is not transmitted. In the lumbar and dorsal region there is con-
siderable curvature of the spine with convexity to the left. The ribs
to the left of the spine are prominent. The abdomen and all the deep
reflexes normal. In the right groin there are glands somewhat larger
than the average. There is tenderness along the right sciatic nerve
and in the right calf. The patient is apparently more relieved by
3 a ? gr. of codein taken from her own bottle, of which she is very fond,
than by larger doses of morphin and codein given her in the hospital.
There seems to be a large mental element in her suffering.

Discussion. In seeking the origin of this pain it is natural to
think first of the spinal curvature, which has forced the ribs apart on the

Fig. 69. Outline of the mass referred to on p. 381,

Fig. 70. Mass apparently the cause of sciatic pain.

PAIN IN THE LEGS AND FEET 38 1

left and jammed them together on the right. But it is hard, to see how
this could produce suffering confined to the leg. Some of the intercostal
nerves would probably be involved.

We next consider the different varieties of arthritis involving the
hip, spine or sacro-iliac joint. Infectious arthritis would hardly last
so long. Osteo-arthritis would probably cause some pain in the back,
and would be unlikely to be worse in the sitting posture. Further,
the pain produced by it is hardly ever confined to the leg. X-ray ex-
amination might help positively to exclude this disease. Sacro-iliac
disease seems more probable. Against it, however, is the gradual
onset, the age and sex, and the absence of any tenderness, pain or
palpable abnormality in that joint.

Some facts stated in the record incline us to believe that the pain
may be of the functional or neurotic type. But before one settles down
upon such a diagnosis or tries to content himself with calling the trouble
a " primary sciatica " the pelvis should be thoroughly investigated for
possible sources of pressure.' The slight enlargement of the inguinal
glands makes such an investigation all the more important.

Outcome. Vaginal examination showed in the right side of the pelvis
a firm mass, tender on pressure, seemingly attached to the pelvic wall
(Fig. 69). The right thigh and calf were found to be \ inch smaller
than the left, but there was only slight weakness of the leg; no paralysis.

Later, a large mass was found in the region of the right buttock
(see Fig. 70). X-ray showed no definite abnormalities. On the
second of January one of the glands was removed from the groin, and
histological examination showed it to be malignant disease.

On the fourteenth of January the patient was discharged somewhat
relieved.

Diagnosis. Pelvic neoplasm.

Case 197

A colored scrub-woman of forty-nine, whose husband had previously
been treated at the hospital for syphilis, but whose own family history.
past history, and habits were not in any way remarkable, entered t In-
wards December 26, 1907. Since February she has been gradually
running down, but worked until four days ago. During these months
she has grown very weak and thin. Her meals have been scanty and
irregular for some time, and once or twice a week she has vomiting
spells, apparently without relation to the nature of her food. Since
last winter she has been troubled by cold sensations in the left leg and
more or less constant aching there. For the last two or three months

DIFFERENTIAL DIAGNOSIS

she has limped, and occasionally she has been short of breath in going
upstairs.

The chest showed nothing abnormal. The edge of the liver was
easily felt. The left knee-jerk could hardly be obtained, although the
right one was easily brought out. The left Achilles jerk could not be
obtained at all. The leg was quite warm to touch, although the patient
complained of its being cold. Both legs could be extended more than
normal upon the flexed thigh, without pain. There was no tenderness
along the course of the sciatic nerve, but slight sensitiveness on firm

pressure over the left calf. An area
of anesthesia was found, as shown
in the accompanying diagram. Lift-
ing the left leg with the knee stiff
caused pain throughout the leg.
Lifting the right leg produced no
discomfort.

Discussion. Evidently we are
dealing here with a neuritis involving
the sciatic and probably other nerve-
trunks. But as usual in such cases
the diagnostician's chief task is to
search for a cause for the neuritis.
It seems probable that the patient
has had syphilis, but syphilitic
lesions so localized as to produce
a neuritis confined to one extremity
do not occur, so far as I am aware.
Tuberculosis is so common in the negro race that it is natural to
suspect it whenever a negro is seriously sick. But there seems to be
no limitation of motion in any joint and no other evidence of muscular
spasm, burrowing abscess, telescoping of joints, fever, or any other
result of tuberculosis. The area of anesthesia and the long, steady
duration of the pain make it more than ordinarily probable that we are
dealing with a pressure neuritis, the position of which must be investi-
gated by radioscopy and by pelvic examination.

Outcome. Inspection of the cervix uteri shows the cervical canal
to be open, inch in diameter and lined with small, projecting nodules.
The patient has a slight uterine flow each day, but no foulness. The
uterus extends half-way up to the navel. Lifting the straightened
left leg causes moderate pain; lifting the right, no pain.

January 7th a nodule was removed from the uterus, and shown by

Abea or

(rrno am piu)

Fig. 71. Shows anesthetic areas re-
ferred to on p. 382. Complaints: Ach-
ing and paresthesia (coldness) in left
leg.

PAIN IN THE LEGS AND FEET

383

microscopic examination to be cancer. Presumably there were metas-
tases in the broad ligament, causing pressure upon the pelvic nerves.
Diagnosis. Carcinoma uteri.

Case 198

A colored housewife of thirty-two entered the hospital June 7, 1908.
Her family history and past history were excellent, her habits good.
Since last fall she has had some pain and stiffness, without swelling, in
the left knee. On February 13th she fell and injured the knee. Her
physician said that she had sprained it. Since then there has been little
swelling, but considerable pain. After three days in bed she got up and
hobbled around with a crutch, the knee being somewhat stiff, but not
painful, until two weeks ago, when pain and swelling commenced
and have confined her altogether to bed for the last six days. During
the last two weeks she has had occasional night-sweats and nose-bleeds.
Her appetite is poor, and her bowels constipated.

The chest and abdomen showed nothing abnormal. The reflexes
were all present. The blood and urine were blameless; there was no fever.
The left knee was found to be swollen and flexed to an angle of 70
degrees. Its circumference was 1} inches greater than the right knee.
Most of the swelling was on the anterior surface, and there was a sug-
gestion of posterior subluxation of the lower leg. The skin over the
knee was brownish, shiny, and slightly warmer than the right. There
was some induration and some infiltration, with moderate tenderness on
pressure. All attempts at motion caused extreme pain.

Discussion. Although there is much in the history pointing to
a traumatic cause for this pain, the severity and long duration of the
symptoms argue something more serious.

Septic osteomyelitis has generally a more sudden onset, produces
severer pain, disability and fever. This patient lias had night-sweats,
but, so far as we are aware, no fever.

Tuberculous osteomyelitis might produce almost exactly this picture,
though it would probably be accompanied by more fever and less pain.
After so long a duration one would rather expect some sinus formation.
but this does not always occur. Without .v-ray evidence we cannot
either affirm or exclude tuberculosis.

Were there any evidence of spinal disease (tabes, syringomyelia ,
one might suspect a Charcot joint, though such joints are usually pain-
less. But in this case there is no evidence of the primary disease whence
Charcot's joint proceeds.

Malignant disease of the bone presumably sarcoma would account

3^4

DIFFERENTIAL DIAGNOSIS

for all the symptoms in the case. Between this and tuberculosis the diag*
nosis must remain in doubt on the basis of the data here presented.

Outcome. X-ray examination showed extensive destruction of the
lower end of the femur, with a fracture just above the condyles. June
13th the leg was amputated for sarcoma of the femur.

Diagnosis. Sarcoma of the femur.

Case 199

A Russian tailoress of seventeen entered the hospital July 13, 1907.
Six days ago her right knee and lower thigh became slightly swollen and
very tender. Since then she has felt a little chilly, and has had a poor
appetite, but no other symptoms of any kind.

The course of the patient's temperature is
shown in the accompanying chart.

Physical examination of the internal viscera
showed nothing abnormal. The right knee was
red, very tender, slightly swollen. The white
cells ranged between 8000 and 11,400. The
urine was about normal in amount and in weight.
There was no albumin, but a few hyaline and
finely granular casts were found. Widal's reaction
was negative. On the eighteenth the knee was
less tender, but larger and the thigh was also
swollen.

Bier's treatment was given, one hour off, two
hours on, night and day, without much relief.

Discussion. We are dealing with a mon-
articular inflammation which has involved also
the soft parts in the vicinity of the joint. Such a
condition is never rheumatic, and the atrophic
and hypertrophic varieties may also be excluded, because they are
practically never confined in febrile cases to a single joint.

Gonorrhea is perhaps the commonest cause of monarticular inflam-
mation, but such infections are very rare in the young, unmarried Russian
Jewesses of Boston. The patient had no vaginal discharge, and there
was nothing else about her to make us suspect gonorrhea. Neverthe-
less, this infection cannot be positively excluded. The course of the
disease is too acute and too painful for tuberculous osteitis.

To obtain any further light on the subject the joint should be as-
pirated under aseptic precautions, as may be very easily done with an
ordinary hypodermic needle. In my opinion joint puncture is far too

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case 199.

PAIN IN THE LEGS AND PEET 385

rarely performed. If done with rigid cleanliness, it has no dangers,
produces scarcely any pain, and often gives us information of the highest
value. Since I have been in the habit of using this procedure frequentlv
I have been astonished to see how commonly one finds turbid or purulent
exudates with demonstrable micrococci in joints which have been onlv
moderately painful, and would certainly have been classed under or-
dinary rheumatism but for the puncture. In some cases our treatment
is made far more effective when the joint puncture makes it possible to
prepare a vaccine from the invading organism.

Outcome. On the twentieth the right knee was aspirated and six
ounces of fluid pus withdrawn. From this as well as from the circulat-
ing blood a pure culture of the yellow staphylococcus was obtained.
On the twenty-third the knee was surgically drained. Recovery followed,
though there was limitation of motion in the knee.

Diagnosis. Septic knee.

Case 200

A waiter of twenty-four entered the hospital December 29, 1906.
He had been in the hospital twice previously for exophthalmic goiter.
The last time was in May, 1905. Since then he has worked steadily at
hard jobs and has felt well. Four nights ago he came home with a pain
in his left instep. The next day the pain extended up the leg, and in the
afternoon was in both knees. It confined him to bed and took away
his appetite. In October he weighed 150 pounds a week ago, 130.

Physical examination showed both eyes slightly prominent. The
pulse ranged between 90 and 100. Examination was otherwise negative
except for spasm of the leg muscles, both legs being held flexed. The
patient insisted at first that they could not be moved, but was finally
induced to straighten them out. Later, the right hand was held very
stiffly, with the thumb flexed into the palm. The patient persisted that
it too was paralyzed, but was finally persuaded that it was normal.

Discussion. The pain is probably due to muscular spasm, as in
the familiar cramps most of us have experienced if the foot or leg is bent
in an unusual position. We can hardly doubt that these cramps are of
the functional or hysteric type, in view of the results of moral suasion.
but it is important to remember that a latent tuberculosis, recognizable
only by ;v-ray, may produce contractures of the legs fully as severe as
those here described. If the contractures were not so wide-spread, one
might suspect flat-foot with leg pains due to compensatory effort. 1 he-
onset of the case reminds us distinctly of this lesion, but its later course
makes this verv unlikelv.

386 DIFFERENTIAL DIAGNOSIS

The case illustrates the importance of firmness and confidence in our
treatment a confidence such as can be based only on the conviction built
up in us by most painstaking physical examination and interrogation of
the patient. Any doubt, vacillation, or hesitation in the management of
such a case may lead to disastrous results. Decisive action, on the other
hand, may be of incalculable benefit to the patient by nipping hysteric
tendencies in the bud. Like so many other diseases, hysteria can be
checked most often and most effectually in the incipient stages.

Outcome. A liberal diet with 30 grains of bromid every four hours
for two days, preceded by an ounce of castor oil at the time of entrance,
was followed by marked improvement. By the third of January the
patient seemed practically well. He had still, however, a slight fine
tremor of the hands, a remnant, no doubt, of his hyperthyroidism.

Diagnosis. Hysteria.

Case 201

A housewife of forty-four, who has had two miscarriages, one child
of nine years and one of five, entered the hospital December 5, 1906.
She herself was born with crooked legs, which were straightened by
splints at her home in Sweden. She has had pneumonia four times.

Nine years ago she had bad pains in her shoulders and arms, so
that she could not raise her hands to her head. At that time lumps
came out upon her arms, and ever since then she has had fleeting pains,
now in one place, now in another. Thirteen days ago she was wakened
out of sleep by pain in her feet. Now the pain comes suddenly and
lasts from two to ten or more minutes, often shooting from the hips to the
knees. It is almost as sharp as labor pain at times, and is accompanied
by a dragging-down sensation. Her feet have been a little swollen.
There has been some dyspnea on exertion and a little cough without
sputa. She has attacks of rapid heart action almost every day. Five
days ago she fainted, and had to sit up in bed all that night. Her
appetite is poor, her bowels regular. There has been no nocturia.

The patient was a neurotic-looking individual, and constantly
demanded attention to trivial wants. The pupils were irregular, but
reacted normally. The uvula was missing, and replaced by a white
scar; the throat and lungs otherwise normal. The glands were palpable,
but not enlarged, in the neck, axilla?, and groins. Occasional squeaks
were heard scattered through both lungs. The chest was otherwise
negative; likewise the abdomen, blood, and urine. The shafts of both
tibiae were enlarged and bowed forward, their surface rough and nodular.
The deep reflexes were all present.

PAIN IN THE LEGS AND FEET 387

On both forearms, especially on the extensor surfaces, there were
a dozen nodules from the size of a pea to half a horse-chestnut. They
were oyster-shaped, discrete, of rubber}' consistency, not tender, freely
movable under the skin. Vaginal examination was negative.

Discussion. Fleeting pains in various parts of the body are often
the most distressing symptom, and the earliest, in tabes dorsalis. The
history of miscarriages and the tibial deformities increase the proba-
bility of syphilis, and, therefore, of tabes. But this disease may be
ruled out of consideration because of the fact that the pupils and the
deep reflexes are normal.

The patient's statement that her legs were crooked from birth
makes us hesitate to attribute the present condition of the shins to
syphilis, and as the patient has two healthy children, the miscarriages
may well have had a non-syphilitic origin. But the scar in the soft
palate and the absence of the uvula are decidedly more characteristic
of syphilis, and in any patient who presents such lesions we must do our
best to find any connection that may exist between the old infection
and the present symptoms. Very possibly the vascular lesion so com-
monly produced by syphilis may be connected with the pains here
complained of. " Vascular crises " are certainly more common in those
who have suffered a luetic infection, and through such crises, with or with-
out a syphilitic neuritis, the pains of this patient might be accounted for.

We must also consider, however, the nodules present upon the fore-
arms and mentioned in the history as having appeared nine years earlier.
The fact that these tumors have lasted so long makes it sure that they
are not of a malignant type, and their limited distribution assures us
that they are not connected with the much more widely distributed
pain of which the patient complains. Their physical characteristics
are those of lipomata, which are practically the only tumors which
could last so long without more disastrous effects.

Outcome. The patient was given mercury and potassium iodid.
Her leg pains were greatly relieved by injections of sterile water, especi-
ally in the first two days after entrance. The lumps on the arms were
taken to be fatty tumors.

She was discharged much relieved on the twelfth of December.

Diagnosis. Syphilis.

Case 202

An engineer of forty-five entered the hospital July 25, 1006. His
family history was negative. He had urethritis twenty years ago, also
five weeks ago, the latter attack followed bv "rheumatism." He had

388 DIFFERENTIAL DIAGNOSIS

"slow fever" twenty years ago, and was five weeks in bed. Ten years
ago he had inflammatory rheumatism, lasting three weeks, in both feet.
No other parts were affected. He takes an occasional glass of beer,
but denies any other use of alcohol. Eleven days ago his left foot
became red, swollen, and tender. This gradually improved, but yester-
day the right foot became similarly affected. He has been unable to
work since the onset of the symptoms. He has had a poor appetite,
constipation, slight headache and fever.

The patient was obese, slightly cyanotic. The first sound at the
apex of the heart was replaced by a short systolic murmur, not trans-
mitted. The aortic second sound was accentuated, the heart not en-
larged. The lungs were normal, likewise the abdomen, except for
dulness in the right flank, which does not, however, shift with change
of position. The second joint of the right toe was much swollen, hot,
and tender. The same joint in the other foot was similarly affected,
but the swelling also extended up the foot toward the ankle.

Discussion. In any patient who complains of subacute pain in
both feet, and is not flat-footed, suspect gout. Most of the ordinary
joint infections do not long remain confined to the feet, while gout is
very prone to do so.

Naturally, however, the first possibility to be investigated in this
patient is gonorrhea, as he had so recently suffered from that infection.

Next we must search the cartilages of the ears and nose, the great
tendons near the elbow and ankle, and the vicinity of the great toe-joints
for signs of uratic deposit. Thirdly, we must investigate the plantar
arches, since precisely these symptoms might be produced by flat-foot.
Other infectious and non-infectious lesions are far less probable.

Outcome. A smear from the urethra showed a biscuit-shaped
diplococcus both within and without the leukocytes. It did not stain
by Gram's method. The ears showed several small, yellowish-white,
soft lumps. A scraping from one of these showed crystals correspond-
ing to those of sodium biurate. X-ray showed areas of atrophy or
erosion of the second phalanx of one great toe, which were believed by
an x-ray expert to be due to gout.

By the sixth of August the patient was practically comfortable.
His treatment had consisted of sodium salicylate, 20 grains every hour
for the first two days, then 10 grains every hour. Hot fomentations
applied to the painful parts, an ounce of magnesium sulphate every
morning, 10 grains of urotropin four times a day. He was not in bed
after the twenty-ninth, and was discharged relieved on the sixth of
August.

Diagnosis. Gout and gonorrhea.

PAIN IN THE LEGS AND FEET

389

Case 203

A restaurant-keeper of forty-nine entered the hospital September
18, 1907. His mother died at seventy-two, after suffering from consump-
tion for fifteen years. The patient has had " rheumatism " in his joints
in two attacks of three weeks each three years ago and eighteen months
ago. He has had four attacks of urethritis, the last twenty-five years
ago, but denies syphilis.

He says that he was as strong as an ox until four years ago, when he
sold his business and had difficulty in getting a new start. He then
began to have almost constant pain near the right costal margin. These
symptoms he has had off and on ever since. He has rather frequent
attacks of vertigo and weakness, and his appetite is often poor. As
long as he can remember his fin-
gers have been clubbed, as they
are at present. He usually takes
two glasses of beer and two or
three of whisky a day, and his use
of tobacco is distinctly excessive.
Yesterday he noticed that the
corners of his mouth cracked. Off
and on for four years he has felt
feverish, and sometimes chilly and
shivery in the evenings. His knees
and ankles have burned, especially
after he gets to bed.

These joint symptoms have been
getting steadily worse, and two
days ago he had to give up and
go to bed on account of pain in
his legs and knees. Yesterday
the right knee became a little
better, the left worse. At the same time his left thumb began to be red,
swollen, tender and painful. This time he had true chill.

Physical examination showed that the left pupil was larger than the
right, though both reacted normally. The heart was normal. There
was slight dulness below the right scapula, with slight increase of vocal
and tactile fremitus, and a few rales. Expiration was everywhere rough
and prolonged. The abdomen was negative. The right knee was
swollen, hot and shiny; the leg was kept bent at a right angle, and
motion was painful. A similar condition was found in the right foot and

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39 DIFFERENTIAL DIAGNOSIS

ankle. Both feet were pronated. There was marked clubbing, cyanosis,
and curvature in both planes in the lingers and thumbs, and to a less
degree in the toes. Scattered over the chest and back was a reddish-
brown, macular eruption, the spots about the size of the little finger-nail.

Discussion. There seems to be no way by which we can connect
the mother's consumption or the patient's alcoholism with the present
symptoms. The joints are obviously not tuberculous, and alcohol does
not attack articular structures.

Though it would be natural to connect the former attacks of ure-
thritis with the present joint pains, the gap of twenty-five years between
the two renders this impossible if the history is taken on its face value.
In looking over the body for any other lesion which we can connect with
the joint symptoms, we notice the irregular pupils, the clubbed-fingers,
and the cutaneous eruption.

If the clubbing of the fingers be assumed to be such as is described,
it is not likely to have any connection with the arthritis. Bony out-
growths near the finger-ends (Heberden's nodes) bear some resemblance
to clubbed-fingers, but could hardly be mistaken for them. Such out-
growths, if present, might incline us to conjecture that the right knee
and ankle were the seat of a similar process.

The irregular pupils and the cutaneous eruption look like syphilis,
and since there is nothing very definite known about the differential
symptomatology of syphilitic arthritis, it seems reasonable to interpret
the joint manifestations in this case as syphilitic until this is disproved
by therapeutic test. If no improvement follows the vigorous use of
mercury and iodin, the joint should be tapped in search of some other
infective agent.

Outcome. Under daily inunctions of mercury and the administra-
tion of potassium iodid 10 grains after each meal the joints rapidly
improved, and within ten days were practically well.

The clubbing of the fingers remains in this, as in many other cases.
a mystery. If clubbing were more carefully searched for as a matter of
routine in cases presenting no pulmonary or cardiac lesions, it would
be found, I believe, to occur in a great variety of diseased conditions and
in a good many persons who have no demonstrable disease. Personally,
I have observed it chiefly in chronic diseases of the liver (cirrhosis, ab-
scess, gall-stone disease), in tuberculous peritonitis, and in ill-nourished
children.

Its occurrence in connection with long-standing cardiac disease (con-
genital or acquired), with chronic pleurisy or empyema, phthisis and
bronchiectasis, is, of course, familiar.

Diagnosis. Syphilis.

PAIN IN THE LEGS AND FEET

Case 204

39i

A plumber of thirty-seven entered the hospital April 11, 1908. He
drinks and smokes to excess. Last evening he came home complaining
of severe pain in both legs, especially in the left one. About one o'clock
this morning he awoke unable to speak or to move the right arm and
leg. Soon after the patient became unconscious, with stertorous breath-
ing.

The right forearm was in flexion, the fingers of the right hand flexed
and spastic, the mouth drawn to the left; he made only inarticulate
sounds. . The right leg was spastic. By April 13th he had regained con-
sciousness and he could move the toes slowly; otherwise he had no mus-
cular control. His tongue came out to the right when protruded. There
was no lead line. The chest and abdomen showed nothing abnormal.
The blood-pressure was 155, the blood and urine normal, the right knee-
jerk lively in comparison with the left knee-jerk. There were no other
changes in the reflexes at this time.

By April 15th Babinski's reflex had appeared in the right foot.
Lumbar puncture was done on the seventeenth, and the cells in the fluid
which was withdrawn were 50 to the cubic millimeter. Practically
all of them were lymphocytes.

Discussion. The patient's occupation naturally leads us to attempt
to explain the symptoms as a result of lead-poisoning, especially as
paralysis and cerebral symptoms are present. But we do not expect
pain or hemiplegia in plumbism, and we practically always find changes
in the staining properties of the red blood-corpuscles.

Against apoplexy, which, as the commonest cause of hemiplegia,
naturally occurs to us next, is the patient's age, the very moderate
blood-pressure, the absence of cardiac hypertrophy, and especially
the results of lumbar ] juncture.

The examination of the spinal fluid taken in connection with the
absence of fever and the well-marked cerebral symptoms lead us straight
to the diagnosis of cerebrospinal syphilis. A similar lymphocytosis
occurs in the chronic forms of meningitis, especially tuberculous menin-
gitis, but the clinical picture is quite different from that here under
consideration.

The most interesting point in this case is the occurrence' of a pain
which, though referred to the legs, seems to be cerebral or spinal in origin.
Such pains are seen not uncommonly in infantile paralysis, in sonic of
the types of acute myelitis and meningitis, and especially in cerebro-
spinal syphilis. I recently studied a case in which attacks oi Jack-

39 2

DIFFERENTIAL DIAGNOSIS

sonian epilepsy, involving the right hand and forearm, were preceded,
again and again, by severe pain referred to the parts about to be con-
vulsed. Many of these central pains are preceded or accompanied by
paresthesia.

Outcome. Under mercury and potassium iodid the patient was
able to walk by the twenty-second, though his mind was still very sluggish.
The next day he was sent to a State infirmary.

Diagnosis. Cerebrospinal syphilis (vascular crisis?).

Case 205

A machinist of thirty-nine entered the hospital May 29, 1908. His
father died of apoplexy, his mother of dropsy. Seven years ago he was
in bed five days, owing to swelling, redness and pain in the left knee.

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In the past five years he has had tonsillitis six or eight times, once
severely enough to keep him in bed. He had urethritis twenty-three
years ago.

He takes two or three glasses of whisky and two or three of beer each
week. Two weeks ago he had a sudden chill accompanied by pain
in the lower back, in the hands and the calves of his legs. He took to
bed and has been there since, with persistent fever. The next morn-
ing his right knee and the joints of the left hand were painful and stiff.

PAIN IN THE LEGS AND FEET 393

Six days ago the knee became red and swollen, while the left hand
greatly improved.

He has had no urinary symptoms; his appetite has been good;
his bowels regular; there has been no sore throat and no cough.
The course of the temperature may be seen in the accompanying chart.

The chest and abdomen were negative, the knee-jerks normal;
the plantar reflexes were not obtained. There was no glandular en-
largement. The right knee was flexed at an angle of 45 degrees, any
motion causing severe pain; all the evidences of fluid were found in the
joint.

Discussion. As in many of the cases discussed in this section,
we have here a general infection which shows, at first, no hint of its
ultimate localization.

Since the urethritis occurred too long ago for us to connect it with
the present symptoms, it seems at first likely that the joint trouble
may be due to the patient's repeated attacks of tonsillitis, and as gout
and traumatism can be excluded by the lack of any evidence of them,
tonsillitis would perhaps be the best guess we could make, were we
debarred from any further and more direct investigations. But, as
I have previously insisted, all monarticular infections of any serious-
ness or obstinacy should be tapped, since the information thus to be
derived may be of the greatest therapeutic value. (See p. 385.)

In all probability the infecting organism is one of the pyogenic
cocci, but it may be of great importance to know which, as a treatment
by autogenous vaccines has much to recommend it.

Outcome. On the first of June the joint was aspirated and 35 cm.
of fluid withdrawn. Specific gravity, 1008; albumin, 3.6 per cent.;
in the sediment, 94 per cent, of the cells were polynuclear. Among
them were numerous intracellular diplococci which did not stain by
Gram's method. After this information had been obtained, the patient
admitted a urethritis ten weeks ago, but insisted that there had been
no discharge for the past four weeks. From the fluid withdrawn from
the joint, gonococci were isolated in pure culture. From tins a vaccine
was prepared and injected. He improved quite rapidly after this, and
by the sixteenth was able to go to the Zander room daily.

On the twenty-fourth the knee was smaller and much more com-
fortable. Bier's treatment was given after that date, and he was soon
taught to apply it for himself. On the fourth of July he was discharged,
much relieved.

Diagnosis. Gonorrheal arthritis.

394 DIFFERENTIAL DIAGNOSIS

Case 206

A metal worker of fifty entered the hospital March 27, 1908, stating
that he had never been sick before, and giving a good account of his
habits. Seven weeks ago, while at work, he was taken with a sudden
chill and went home and to bed. In the night he awoke with a sharp
pain in the right shoulder and the left knee. He managed to get to
sleep, however, and was much surprised to find the next morning that
the pain had left the shoulder, but that the knee was hot and swollen,
painful, red and tender. The knee has increased in size since, and
he has been confined to bed, but has had no more fever or chills and
no pain except in his knee.

On physical examination the patient was very apprehensive and
emaciated; there was a moderate, coarse tremor of the hands and feet;
his face was dusky and dark under the eyes, his mucous membranes pale,
though his leukocyte count was 80 per cent. His heart's apex was in
the fifth space, an inch outside the nipple-line. The sounds were rapid
and weak, the aortic second louder than the pulmonic second. There
was no enlargement to the right and no murmur. The pulses were of
very low tension, and the artery wall barely palpable.

The lungs were negative; the abdomen showed considerable volun-
tary spasm and slight dulness in the extreme flanks, not shifting on
change of position. The left knee was markedly enlarged, tender, hot,
red and very painful on motion. The swelling was most marked on
the front of the knee, but extended up to the middle of the thigh
and two inches below the tubercle of the tibia. The front of the
thigh was fluctuant, tender, and covered by a tracery of prominent
veins. A fluid wave could be transmitted from the knee to the middle
of the thigh.

Discussion. This case, though very similar to the last, is given
as an awful example of what may result from the neglect of early joint
puncture in monarticular arthritis. It is a sin and a shame that this
patient should have gone seven weeks without any effective etiologic
or radical treatment. From the facts presented, no trained observer
could doubt that there is pus in and around the joint. The nature of
the infection is the only remaining diagnostic problem.

Outcome. On the twenty-seventh the knee was tapped and thick
pus obtained. A culture from this pus showed streptococci. On
March 28th the knee was opened and almost a quart of pus obtained,
which apparently came from outside the knee-joint. The patient ran
a jagged, septic temperature for a month, and developed a metastatic

PAIN IN THE LEGS AND FEET 395

abscess in the axilla, whence a colon bacillus was obtained. Despite
amputation, he finally died.
Diagnosis. Sepsis.

Case 207

A physician forty-six years of age entered the hospital June 5, 1906.
He had a primary lesion on his thumb one year ago; a secondary eruption
with adenitis and sore mouth followed. A thorough antisyphilitic
treatment has been given since. Two weeks ago a swelling appeared in
the left foot. Within a few days the soles of both feet became red,
swollen and tender. Ten days ago he was laid up in bed for three days.
In every other way he is perfectly well.

Physical examination showed considerable irregularity of the pupils,
but was otherwise negative except as relates to the left foot, which was
red, tender and slightly swollen over the dorsum and on the sole opposite
the head of the second metatarsal bone.

Discussion. It is difficult to decide whether the syphilitic infection
of a year ago has any connection with this patient's present suffering.
It seems rather improbable, in view of the absence of specific lesions at
the present time.

As the patient has now no fever, one naturally thinks of flat-foot
as a cause of such foot-pain, even though redness and tenderness would
otherwise incline us to assume an inflammation. The mutual relations of
arthritis and flat-foot have been previously discussed. (See p. 366.)
In any such case the first and best thing to do is to try two therapeutic
tests: (a) The effect of taking the patient off his feet, and (b) the effect
of padding the arches.

Outcome. Though no medicine was given, the pain was entirely
gone after a few days 1 rest, and as soon as foot-plates had been fitted, the
patient was able to walk without pain.

We have still on our hands, however, the question: Why did the
arches break down just at this time? Possibly some latent and un-
recognized phase of his old syphilis may provide the answer.

Diagnosis.- Flat foot.

Case 208

A laborer of forty-seven entered the hospital July 6, 1906, complain-
ing of sciatica. He had a similar trouble nine years ago, which lasted
three weeks. Otherwise he has been well until seven months ago. when
he gradually began to notice pain in the back and left hip, running
down the left thigh behind and extending into the calf. He has had tc
give up work, but has walked about with a marked limp.

396 DIFFERENTIAL DIAGNOSIS

For the last six weeks the pain has been much worse and has kept him
awake at night. He has had some tingling and other curious sensations
in his lower left leg. He has lost 15 pounds in weight, though his appe-
tite is good.

Physical examination shows that the patient cannot stand erect,
but supports himself with the spine curved to the left and forward. The
motions of the back are inhibited by a pain referred to the sacro-iliac
joint. Full extension or flexion of the left leg is impossible on account
of pain referred to the same point. There is tenderness over the
region of the left sciatic nerve and slight atrophy of the muscles of the
left leg, making about one inch difference in the circumference of the
thighs and calves.

Discussion. In the out-patient records of the Massachusetts
General Hospital previous to the year 1900 there are to be found notes of
a large number of cases with the diagnosis "lumbago and sciatica."
At the time when we were dealing with these cases it always seemed
remarkable to me, and I imagine also to many of my colleagues, that a
disease affecting a muscle (lumbago) should occur simultaneously with
a neuritis (sciatica) . The case reported above is typical of a great many
of those which we used to label "lumbago and sciatica."

Looking at it from the point of view of the present day, one would
say, first of all, that the lumbar pain has lasted too long for lumbago,
which, like other muscular pains, is a transient though perhaps recur-
rent affair, producing its symptoms for not more than a week or two at a
time.

The other half of the old diagnosis sciatica we should now be
unwilling to make without a far more searching investigation of the
possible causes for sciatic pain, especially diabetes, disease of the lumbar
spine or sacro-iliac joint, and pelvic tumors.

The present case is fairly typical of what is now called sacro-iliac
strain, a diagnosis based most firmly upon the therapeutic test the
means by which it is relieved. The etiology and pathology of the affec-
tion are still very obscure, and the theories usually advanced do not
seem satisfactory to me.

Outcome. The patient was seen by Dr. Goldthwait, who made a
diagnosis of "chronic strain" of the left sacro-iliac joint.

The pain was entirely relieved by a pillow under the knee and a folded
sheet under the lumbar spine, with rest in bed. A plaster jacket was
then applied, and by August 2d he was free from pain and could walk a
little. On that day he was discharged, much relieved.

Diagnosis. Sacro-iliac strain.

PAIN IN THE LEGS AND FEET

397

Case 209

A housemaid of twenty-five entered the hospital August 16, 1907,
stating that for three weeks she had had swelling, pain and tenderness
in the lower legs, especially at night.

Physical examination shows yellowish pallor and only 25 per cent.
of hemoglobin; the white cells varied between 28,000 and 43,000 in the
course of the next four days, the polynuclears making up 82 per cent.
of this increase. For temperature see the accompanying chart.

Physical examination was negative save for an indefinite resistance
in the right upper quadrant of the abdomen. The front of both legs
showed numerous sharply defined, punched-out ulcerations on a red-
dened base; the right lower leg showed soft nodules the size of a pea,
raised one-half inch above the surround-
ing skin, covered with unbroken skin.
They were of a doughy consistence and
tender.

The subcutaneous ulcerations were
drained by surgical incisions and con-
siderable pus liberated.

Discussion. Obviously, we are
dealing with some type of acute infec-
tion, the most probable source for
which seems, at first examination, to
be the gall-bladder. But on further
scrutiny it is equally obvious that we
need some source for the very marked
and apparently chronic anemia which
has reduced the hemoglobin to 25 per
cent. 1 In cases accompanied by
marked secondary anemia I have found
that in moving toward a diagnosis it
is a useful strategic maneuver to fix

attention, first of all, upon this anemia, and to investigate what causes
of such an anemia are possible in this patient. The patient may. ol
course, be chlorotic, but as she certainly has something else the matter
with her, we must make two diagnoses (which we are always loth to
do) in case we call it chlorosis.

bj /fcoliuLii/L

ror-pm

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1 I regret that no estimation of red cells was recorded in this case, ll was evident,
however, from the appearance of the stained smear, that they were no! greatly reduced
and that the anemia was of the sec ondary type.

398

DIFFERENTIAL DIAGNOSIS

Aside from chlorosis, what are the possible causes of a severe secon-
dary anemia in a woman of twenty-five who has had no hemorrhage,
no malaria, and no evidences of malignant disease? The lesions on
the shins, and especially those covered with unbroken skin, suggest
gummata, and although there is certainly a secondary infection, the
hypothesis of syphilis should be put to the therapeutic test.

Outcome. Microscopic examination of an excised nodule showed
gumma with secondary infection. The lesions quickly cleared up
under antisyphilitic treatment.

Diagnosis. Syphilitic periostitis.

Case 210

A hostler of thirty-two was first seen June 3, 1907. He takes five

or six beers and three or four whiskies daily, but denies venereal disease.

Yesterday morning he woke with a chill followed by headache, fever

and aching bones. To-day his chief com-
plaint is of pain in his legs.

Physical examination of the chest and ab-
domen is negative. The right tibia is rough
and nodular; the skin bluish red and con-
taining three ulcerated areas from the size of
a silver dollar to that of the palm. The course
of the temperature and pulse is seen in the
accompanying chart. The leukocytes are
12,500. The glands in the right groin are
enlarged; urine normal. X-ray shows evi-
dences of a syphilitic periostitis. Under large
doses of iodid of potash, the glands of the
groin became smaller and the pain disappeared
within ten days.

Discussion. This case is introduced
chiefly to show the importance of x-ray ex-
amination of the shin bones in all cases in-
volving an obscure pain referred to the lower

leg. Without the evidence thus obtained a diagnosis would here have

been impossible.

Doubtless there was also a certain degree of secondary infection

in the ulcerated area, whence the chill, high fever and other acute

symptoms may be explained.

Diagnosis. Syphilitic periostitis.

Fig. 76. Chart of case
210.

PAIN IN THE LEGS AND FEET

399

Case 211

A shoemaker of nineteen entered the hospital May 14, 1908, with
a good family history, past history and habits. Three days ago he
began to have pain in his legs and to a lesser extent in his left side. At
night he vomited twice and has since kept his bed. The pain has been
more severe in his chest, until to-day, when it has diminished. He
has slept and eaten poorly and has been constipated. He has had no
cough and no chill.

Physical examination showed dulness in the lower half of the left
back, with bronchial breathing; increased voice and fine, crackling rales.

The leukocytes were 22,000. The urine and the
rest of the physical examination were normal. The
course of the temperature is shown in the accom-
panying chart. A tight swathe prevented all pain.
On the nineteenth he was put in a chair, and by
the twenty-fifth was able to go to his home.
Throughout his illness he had practically no cough
or expectoration.

Discussion. This case is introduced in order
briefly to exemplify a pain due to general infection,
but confined to the legs. Some of these pains are
very mysterious, and give not the slightest indica-
tion, during the first two or three days of the pa-
tient's sufferings, where the trouble is finally to settle.
Obviously, in the present case the pain was ushering
in a pneumonia. I recently saw a woman who suffered
for two days from quite intense pain throughout all
the tissues of the thighs and legs. We could find
absolutely no cause for it, though the presence
of an accompanying fever and leukocytosis made us believe that some
infective agent was at work. The joints, the nerves, the muscles and
subcutaneous tissues, the arteries and veins were searched for evidence
of a cause for the pain, but none was found. On the third day an acute
dysenterv made its appearance, and the pain in the legs quickly dis-
appeared.

Tn view of these and similar cases we must always bear in mind, when
examining the legs for a cause of pain referred to them, that a general
unlocali/.ed infection bearing no special relation to the leg may have
invaded the body. Disease of the brain or spinal cord should also be
remembered as among the long- range causes for leg pains.

Diagnosis. Pneumonia.

l-'ig. 77. Chan of
case 211.

400 DIFFERENTIAL DIAGNOSIS

Case 212

A homeopathic confrere called me in consultation October 31st to
see a curious case of grip with pelvic neuralgia and perhaps malaria.

The patient was a young architect of twenty-seven, always pre-
viously well until he began, October 1st, to have what he called "grip"
i. e., a fever of 103. 6 F., accompanied by aching in his head, back,
and legs. After a couple of days the temperature fell to 101 F., and
the patient had what was called a right facial neuralgia. From October
5th to October 12th the temperature did not rise above 100 F., and
the patient seems to be convalescent, though complaining somewhat
of piles. He then went off for a week's vacation, but on his return,
October 19th, said that he had been poorly while he was away, suffering
a great deal from pain in the testes, which was especially severe every
night about 6 p.m., and was associated either with a rectal tenesmus,
a urinary frequency, or both. The pain radiated to both hips and groins.

On October 25th the temperature was again 101 F., and since that
time it has risen to that point or a degree higher every day. On the
twenty-seventh, quinin, the doctor said, seemed to stop the pelvic neu-
ralgia, but for the last two days he has been eating poorly, and at n p.m.
to-day his temperature was 103 F. and the pelvic pains so great as to
require morphin. The urine has been high colored, but not cloudy, and
shows no gross sediment. The blood has not been examined.

Physical examination of the chest was negative; the spleen was not
enlarged, and the blood showed no malarial organisms. There was
no evidence of an influenzal infection of the upper air-passages or else-
where. The urine was high colored, but showed no other important
abnormality. The leukocytes numbered 28,000, 83 per cent, of which
were polynuclear.

The local examination, which had been hitherto neglected, showed
a reddened, tender, and resistant area close to the rectum on the left.

Discussion. -The points of interest in this case are the slow "set-
tling" of the infection at the point where it was finally discovered,
and the unwisdom of treating symptoms without careful physical
examination. In view of the local conditions one could hardly doubt
that the patient was suffering from an abscess near the rectum, the
wide radiations of the pain being due, doubtless, to the burrowings of
pus which should have been liberated long before.

Incision allowed the escape of a pint and a half of pus. The abscess
cavity healed up in the course of three weeks, and by December 1st
the patient was back at work.

Diagnosis. Ischiorectal abscess.

CHAPTER XIII

FEVERS

The distinction between "long" and "short" fevers i. e., those
continued for two weeks or more, and those of briefer span allows
us to narrow the diagnostic possibilities of the "long" group practically
to three alternatives: tuberculosis, sepsis, typhoid.

In the following table l I have classified 784 cases in which a fever
lasted two weeks or more without touching normal:

Typhoid 586

Sepsis 70

Tuberculosis 54 710 (90 per cent.)

Meningitis 27

"Influenza" 10

Acute "rheumatism" 9

Leukemia 5

Cancer 4

Syphilis 2

Trichiniasis 2

Cirrhosis 2

Gonorrhea 2

"Scattering" n 74 (10 per cent.)

It will be noted that most of the 10 per cent, of long fevers not due to
typhoid, tuberculosis or sepsis are due to diseases easy of diagnosis
because of their local or distinctive signs. Thus meningitis, with its
evidences of cerebrospinal irritation, "rheumatism" with its joint
lesions, leukemia and trichiniasis with their blood changes, cancer
with the easily palpable tumors which febrile cases practically always
show, gonorrhea and cirrhosis with their characteristic local manifesta-
tions all these are, or should be, easily recognized. Obscure long-
continued fevers, then, will include only the dominant three, plus "in-
fluenza" and syphilis. In this group the dominant three make up
98 per cent.

Instead of " influenza" we should write ''unknown infection" against
most of the 1.2 per cent, of obscure fevers so diagnosed in my statis-

1 R. C. Calxit, The Three Long-continued Fevers of New England. Boston Medical
and Surgical Journal, August 2(>, 1907.

2(i lOi

402

DIFFERENTIAL DIAGNOSIS

tics, for bacteriologic proof of influenza was rarely obtained in this
series. I do not doubt that long as well as short fevers may be pro-
duced by true influenzal infection, but I believe that the diagnosis is
rarely well founded on cultural evidence.

The proportion of typhoid in the figures above quoted is far too
high, because in the Massachusetts General Hospital, whence these
figures were gathered, the typhoid cases of a large area are aggregated.
In fact, the number of long typhoid fevers is generally far less than
the number of long tuberculosis or septic fevers; but these are treated
at home and therefore missed in hospital statistics.

The manifold manifestations of tuberculosis in the spine, the hip.
sacro-iliac, and other joints, in the lymph-nodes, peritoneum, meninges,
and genito-urinary tract, as well as in the lungs and pleura may all pro-
duce long as well as short periods of fever.

Under "sepsis" I mean to include here an extensive variety of
clinical pictures, such as (a) vegetative endocarditis (also called
benign, malignant, ulcerative, or septic); (b) puerperal fevers; (c)
deep-seated abscesses originating in the appendix, the gall-bladder,
the genito-urinary tract, the stomach, and duodenum; (d) empyema;
(e) wound sepsis; (J) lymphangitis, erysipelas, and phlegmonous in-
flammation.

Yet only a small minority either of tuberculous or of septic fevers
are obscure in origin or lead us to any diagnostic puzzles. The osseous,
lymphatic, peritoneal, and meningeal forms of the disease are usually
easy of recognition. It is chiefly the pulmonary and renal forms of
tuberculosis that are latent and produce obscure fevers. Among the
fevers due to sepsis also the great majority are plain enough. It is
chiefly in the cases of vegetative endocarditis, and in some of the deep-
seated abscesses especially those in or about the liver and kidney
that local symptoms are absent.

Hence we may say that, when studying obscure fevers of long dura-
lion, we should search especially for:

(a) Pulmonary and renal tuberculosis.

(b) Typhoid.

(d) Vegetative endocarditis.

The lung, the liver, the kidney, and the blood are especially to be
suspected and examined. Auscultation, v-ray examination, blood-
counts, cultures, biologic tests, cystoscopy and a carefully taken history
will help us most in difficult cases.

Causes of Long Fevers

2. sepsis van uo

3 TUBERCULOSIS 108 1

4. MENINGITIS Hi 54

5. INFLUENZA 20

6. INFECTIOUS
ART!

DTIOUS1
HRITISJ

7. LEUKEMIA I 10

8. CANCER | 8

9. SYPHILIS | 4

10. CIRRHOSIS I 4

11. GONORRHEA I 4

12. "SCATTERING" 26

1 In statistics of hospitals for chronic diseases this figure is often much larger pro-
portionally.

io:i

Causes of Short Fevers

(Omitting those listed under " Long Fevers " and excluding the
exanthemata and diphtheria.)

1. "COMMON COLDS," ^^^H 4164
Including :

(a) ACUTE
BRONCHITIS

(b) ACUTE )

tonsillitis/

PHARYNGITIS

T620

1405

751

} =

(d) ACUTE "I

"INFLUENZA" f ^ 388

2. ACUTE APPENDICITIS HBBHBHHi 1504

3. ACUTE ARTHRITIS i 1 016

4. salpingitis mmmmmm 871

5. PNEUMONIA OHMHI 803

6. LYMPHANGITIS M 365

7. SINUSITIS Wm 259

8. ERYSIPELAS m 241

9. POLIOMYELITIS Mi 227

404

FEVERS 405

SHORT FEVERS

Excluding the exanthemata and the milder types of the infections
just mentioned, we may say, I think, that the majority of short fevers
are of unknown origin. The habit of attributing such fevers to " com-
mon colds," to "grip," "influenza," "febricula," "auto-intoxication,"
"rheumatism," constipation, etc., is a pernicious way of concealing
our ignorance not only from our patients, but from ourselves.

The temperature-pulse ratio has never seemed to me of much prac-
tical value in diagnosis. It may confirm a diagnosis established mainly
in other ways, but in my experience it is as apt to lead us wrong as
right. In typhoid the pulse may be relatively slower than in fever of
similar degree due to pneumonia, sepsis or tuberculosis, but there are
many exceptions to this rule.

The rapidity of respiration is also a very unreliable guide. Many
non-respiratory infections (e. g., typhoid, erysipelas, liver abscess)
may notably quicken the respiration, while the sudden fall of respira-
tion at the crisis in pneumonia, when the lung signs remain quite un-
changed, inclines us to believe that even in pneumonia the polypnea
is due to the general rather than to the local pulmonary condition.

NON-INFECTIOUS FEVERS

(a) Brain injuries and diseases of any kind may produce fever of
various types. Thus cerebral hemorrhage, tumor, and acute delirium
due to alcohol or other causes, often raise the temperature considerably.

Other important causes are:

(b) Malignant tumors (such as cancer of the liver, Hodgkin's disease),
especially when extensive and of rapid growth.

(d) Poisoning by belladonna and illuminating gas.

(e) Uremia, eclampsia, hepatic toxemia, gout, and hyperthyroidism
(Graves' disease).

(J) Sunstroke.

Whether pure "nervousness" or hysteric states of one or another
type can produce fever is a question which frequently arises.

Pyrexia not exceeding ioo F. and of short duration certainly accom-
panies many such psychoses. Temperatures taken when a patient
first enters a hospital often register 102 , 103 , or 104 F., but are
followed by normal records within twelve to twenty-four hours. Ex-
haustion and alarm doubtless contribute to produce these temporary
abnormalities. Aside from the two types of fever just mentioned, I
have no experience of pyrexias due to psychic causes.

406 DIFFERENTIAL DIAGNOSIS

Case 213

A fourteen-months-old girl baby was seen December 23, 1902. She
was born in Cuba, had malaria before she left the island, and since she
came to live in Cambridge, Mass., had, during the summer just past, a
large number of mosquito-bites. November 16th the baby began to
vomit, lost appetite and soon became weak and listless. She was fed
on Eskay's food and milk. From that time on she ran a continuous
fever, ranging from 100.6 to 104 F., with long excursions almost every
day. She was fretful and listless, dozing most of the time, rolling her
head back and forth upon the pillow, running her tongue repeatedly over
the region of the expected incisor teeth, but exhibiting no more definite
localizing symptoms.

The symptoms were ascribed to teething, but the child grew steadily
worse, and by December 2d voluntary motion of the extremities had
almost altogether ceased. Repeated physical examinations elicited
nothing either in the legs or elsewhere. December 3d the child seemed
to be markedly "anemic," and it was difficult to obtain blood from the
toe. Nevertheless, the hemoglobin was 80 per cent. The Widal reac-
tion was negative; the white cells, 6500. Iodophilia was very marked.
The child was seen by Dr. C. P. Putnam daily for a week, but no diag-
nosis was made.

December 6th a squint was noticed. This disappeared within
twenty-four hours and has not recurred since. December 23d, the fever
continuing unabated, while the child grew constantly thinner, I saw her
in consultation, but could make no diagnosis. The blood showed at
this time:

Red cells, 4,892,000; white cells, 39,000; hemoglobin, 80 per cent.;
iodophilia, very marked; among the leukocytes, 93.6 per cent, were poly-
nuclear.

A week later Dr. T. M. Rotch saw the baby, noticed a slight "rosary,"
made a diagnosis of rickets, and directed the treatment accordingly.
Nevertheless the child continued to go down-hill.

Discussion. As in the case previously mentioned, there was no
culture made from the urine, and the possibility of urinary infection
was not, so far as I know, considered. One heard nothing of such
infections in 1902. The ears were examined, with negative result.

As the child had been healthy at birth, had been properly fed during
most of its life, and showed no more signs of rickets than a large propor-
tion of healthy children, there seemed to me no good reason to attribute
its serious and progressive symptoms to that disease.

Fig. 78. Condition of the spleen and liver in Case 214.

FEVERS

407

Outcome. January 23d the child died. Autopsy by Dr. W. T.
Councilman showed in the kidneys numerous foci of hemorrhage
between the tubules; also here and there infiltrations of leukocytes, so
extensive as to constitute small abscesses with destruction of the tubules
and epithelium. Organisms of the colon group were found in these
lesions.

At the time when this baby's illness occurred the frequency and import-
ance of the urinary infections of girl babies was not recognized. Natur-
ally, therefore, no one thought of this diagnosis during the life of the child,
though in all probability this life might have been saved had the urinary
tract been investigated earlier.

Diagnosis. Renal infection (bacillus coli).

Case 214

A real-estate broker of thirty-nine was seen June 19, 1909. He had
" typhoid " when he was six, and again when he was twenty-one. For
the ten years succeeding this attack he had gall-stone colic in frequent
paroxysms, which were finally cured by an osteopath in 1900. He had
no fever at that time. His wife died in 1900. He married again in 1908.

February 24, 1909, he went to Alabama feeling perfectly well. About
six weeks ago he lost his appetite and began to have a headache, with
much pulsation in his head. Soon after he noticed that climbing a slight
hill exhausted him completely. For the past thirty-three days he had
been aware that he had fever, ranging between 99 and 103 F., and
usually reaching the lower figure once or more in every forty-eight hours.
With this fever he had repeated chills and lost fifteen pounds.

He returned from the south a month ago, and has been in bed for
ten days, troubled a good deal with gas in his bowels, with occasional belly
pain and much weakness. Some weeks ago a homeopathic pathologist
found a malarial parasite in his blood, and since then he has received at
least 20 grains of quinin a day. Nevertheless, he has continued to have
fever and has grown steadily paler, thinner and weaker.

On physical examination he shows a yellowish pallor, hemoglobin
being 55 per cent. The conjunctiva? are not discolored; the urine shows
no bile-pigment. The chest and extremities are negative, the abdomen
as per diagram (Fig. 78). The edge of the spleen and liver are both
very sharp and hard; the surface of the liver seems to be somewhat
irregular. There is no ascites.

Discussion. As will be at once surmised from the treatment referred
to above, malaria was the diagnosis up to June 19th. The chills, the
anemia, the large, hard spleen and the report of malarial parasites in the

408

DIFFERENTIAL DIAGNOSIS

blood had led very naturally to this diagnosis. Yet in my opinion malaria
could be absolutely excluded, owing to the fact that the fever, though
approaching the tertian type more nearly than any other, did not yield
appreciably to large doses of quinin, which were obviously absorbed,
as the patient's ears had been ringing steadily for weeks. My examina-
tion of the blood revealed no trace of malarial parasites. The red cells
numbered 3,120,000; the leukocytes, 4800, the different varieties being
present in approximately normal percentages.

By the blood examination just reported leukemia could be excluded.
I have seen a very similar clinical picture produced by myeloid leukemia,
but the blood was in that case very distinctive and the chills less num-
erous.

As the patient has a history of gall-stone colic and has now an irregu-
lar fever with chills and enlargement of liver and spleen, it is natural to
consider for a moment the possibility that he may now be suffering from
gall-stone fever. The condition of the abdomen and the course of the
temperature are consistent with that diagnosis, although the spleen is
unusually large; but gall-stone fever is almost always accompanied either
by attacks of pain or by more or less transient yellowing of the conjunctiva
during some part of the attack.

The irregular surface of the liver, if it be taken as an established
fact, is of great diagnostic importance, as there are but two common
diseases which produce hepatic enlargement with irregularities of surface
palpable through the abdominal wall, viz., cancer of the liver and syphilis
of the liver. Both of these diseases may be associated with fever, though
this is more common in syphilis. The age of the patient, the freedom
from marked gastric symptoms, and the size of the spleen point distinctly
toward syphilis rather than cancer.

As soon as I asked the patient the direct question, he admitted that he
had had syphilis seven years previously, and been treated for it by a well-
known specialist whose diagnosis I knew to be irreproachable. The
patient had concealed this portion of his history even from his attending
physician, who had not happened to ask him the direct question.

Outcome. The patient was at once put on intramuscular injections
of mercury with 15 grains of potassium iodid after each meal. By June
28th his fever was abating and general improvement quite noticeable.

He afterward made a complete recovery.

Diagnosis. Syphilis

Fig. 79. Physical signs in Case 215. No dulness; no bacilli in sputa; died of phthisis

in two weeks.

Fig. 80. Physical signs in a case of unexplained fever. Practically no cough.

FEVERS 4Q9

Case 215

I was called October 24, 1905, to see a young man of twenty-four a
steam-gage fitter. I reproduce the history as it was given to me.

He had complained of a week's increasing dyspnea and great lassi-
tude. The attending physician, who saw him at the beginning of this
illness, had kept a temperature chart which showed that there had
been fever each day, rising to 101 or 102 F. at night. The pulse
range was from 100 to 112. The respiration rate showed a steady
rise 28 for four days, 30 for the succeeding two days, and 36 for the
past twenty-four hours. There was much sweating with the fever,
but no pain and no other symptom except a slight, dry, hacking cough,
which was not complained of and produced nothing until the day
previous, when a single small mucopurulent mass was expectorated.
This was examined at the Board of Health laboratory and found to be
negative. The urine 1025 contained a trace of albumin, a few
fine and coarse granular casts, and a positive diazo-reaction.

The blood showed no Widal reaction. There was no wound or other
known source for sepsis; no history of syphilis; no recent gonorrhea.
The chest and abdomen had been examined with negative results.

What possibilities should be here investigated?

1. The past history should be scrutinized.

2. The physical examination should be repeated with special reference
to the presence of

(a) Central pneumonia; (b) endocarditis and pericarditis; (c)
typhoid; (d) miliary or generalized tuberculosis.

Further investigation of his past history showed that he had always
been well, although in the previous August he had had some swollen
glands in the side of his neck, which persisted for three weeks and
were accompanied by night-sweats. After that he felt very well and
went to work again.

Physical examination showed the signs indicated in Figs. 79
and 80. The heart and pericardium showed nothing abnormal.
The temperature chart [showing a normal or subnormal temperature each
morning] was practically sufficient, considering the previous course of
the illness, to exclude typhoid and central pneumonia. The leukocyte
count, which was normal, added to the evidence against pneumonia.

The boy did not cough at all during my visit, but the character of
the signs, when taken in connection with the fever and other symptoms,
seems to me to point strongly toward pulmonary tuberculosis, of which
disease he died two weeks later.

4io

DIFFERENTIAL DIAGNOSIS

The attending physician was much surprised and rather skeptical
at my diagnosis, "for," as he said, "the boy has practically no cough,
almost no sputa, and what he does raise has been examined and found
negative." It cannot be too strongly insisted, in view of this and many
other similar cases, that a negative sputum examination, unless it has
been many times repeated, should never be considered as evidence
against pulmonary tuberculosis. Even then it is by no means conclusive,
as bacilli may not appear for many weeks or even months after the onset
of the disease in the lung.

Diagnosis. Pulmonary tuberculosis.

Case 216

On January 18, 1897, soon after the discovery of Widal's reaction
in typhoid fever, I was asked to examine the blood of a febrile case in
which that diagnosis seemed fairly certain. Some confirmation, how-

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Fig. 81. Chart of case 216.

ever, was desired. Four weeks previously the patient had had a mastoid
operation following an attack of otitis media. All had gone well, and
the wound was now almost healed; only a small area of healthy granu-
lations remaining in the mastoid region. Nevertheless, soon after the
operation the patient had begun to have fever, the course of which is
shown in the accompanying chart (Fig. 80).

FEVERS

411

Throughout its course he had complained of nothing except such
discomforts as could be reasonably attributed to the fever itself. He
had had no headaches, no tenderness at or near his wound, no symptom
that would serve to localize any cause for the fever.

At the time of my examination a group of typical rose spots were
scattered over the abdomen. Each spot was about 2 mm. in diameter,
and disappeared wholly on pressure. The spleen was not palpable,
and visceral examination was otherwise negative, with the exception of a
few scattered rales at the base of each lung.

The blood examination showed leukocytes, 23,000, 88 per cent, of
which were polynuclear. The Widal reaction was entirely negative,
even in dilutions of 1:10.

Discussion. I reported to the surgeon in charge of the case that it
was not one of typhoid fever, and that I believed some type of wound
infection must be present. At that time I did not know of the common-
ness of infectious thrombosis of the lateral sinus and jugular vein, since
so thoroughly studied by Libman l in its relations to bacteriemia.
Doubtless micro-organisms might have been cultivated from the cir-
culating blood had I known at that time the importance of the test.

A great skepticism of my results was expressed at the time. The
chart was so typically that of typhoid, the rose-spots so diagrammatic,
the patient so completely free from any local symptoms or complaints,
that it seemed absurd to exclude typhoid on the evidence of so academic
a laboratory test as blood examination. This was before we had been
shown by thousands and tens of thousands of blood-counts that un-
complicated typhoid never produces such a leukocytosis as that here
recorded, and that the absence of a Widal reaction after four weeks of
fever is strong evidence against the existence of typhoid.

Outcome. The patient died January 21st; autopsy showed a septic
thrombosis of the lateral sinus and jugular vein.

Diagnosis. Septic thrombosis of the lateral sinus and jugular vein.

Case 217

A physician of thirty-nine was seen November 30, 1905. Six years
previously he had had the grip, followed by weakness, emaciation and
night-sweats. Pulmonary tuberculosis was suspected, but not proved.
He went south for two months and recovered entirely, and has since then
worked very hard, "mostly," he says, "on his nerve."

August 17, 1905, a hair-follicle on his finger got infected. It was

'The Importance of Blood Culture in the Study of Infections of Otitic Origin, by
E. Libman and II. I,. Celler, Trans. Assoc Amer. Physicians, iqoq. p. ,;i'i.

412 DIFFERENTIAL DIAGNOSIS

opened and cureted on the nineteenth under cocain. He felt much ex-
hilarated thereafter, and made his medical calls as usual throughout the
rest of the day. In the evening he collapsed, and had a very severe pain
in the right intercostal region, accompanied by high fever not relieved by
poulticing, and only modified by f grain morphin. Next day the signs
of pleurisy were found, and two days later an area the size of an orange
appeared near the angle of the right scapula. Over this the breathing
was bronchovesicular, with dulness and crackling rales. These signs
lasted without much change for four weeks, and were not wholly gone for
two weeks more. An irregular fever persisted throughout.

October 6th, though still weak, and despite the presence of high-
pitched respiration over the area described above, he felt well enough
to be moved to the White Mountains, where he rapidly improved, ate
well and slept well, took four-mile walks, and had no cough to speak of.
He had several bad headaches, but otherwise felt well and returned to
work October 26th. At this time his lungs were examined and found
normal; his sputa contained no bacilli and no elastic fibers. The day
after his return he got overtired and again collapsed, i. e., could not talk,
eat, or sit up, had a bad headache, and was awake all night.

Next day he felt better, and the day after felt "like a fighting cock."
During the next ten days he did his medical work as usual, although he
felt somewhat poorly every second day. November 3d he did a very
hard day's work, and at the end of it felt chilly and languid. His tem-
perature was found to be 102 F. From November 3d to November
30th the day on which I saw him he had an irregular fever, accom-
panied by headaches. All his symptoms tended to be worse every second
day.

Two of his colleagues saw him in consultation November 10th,
the diagnoses considered being grip, malaria, and simple nervousness.
The spleen was felt, and accordingly quinin, 24 grains daily, and Fowler's
solution, 5 minims three times a day, were administered. The quinin
hammered the temperature down, but it rose again as soon as the drug
was stopped. The blood was twice examined at this time, and found
to be normal ; no anemia, no leukocytosis, no Widal reaction. The urine
was also normal (November 13th).

By this time the doctor always of a very high-strung nervous tem-
perament had gotten so worked up about himself that he was again sent
to the country, but while there still had fever, ranging from ioo F. in
the morning to 101.4 F. in the evening, despite the administration of
quinin, 24 grains a day. During the last two weeks he has had ten days
of pain over the lower left back, in the region of the diaphragmatic

Fig. 82. Physical signs simulating pulmonary tuberculosis in a case ot sepsis with pros-
tatic and perinephric abscess. Complete and lasting recover}- followed.

FEVERS

413

attachment. Throughout the last ten days of his fever he has also had
pain in urination, and for the past few days some distress in the rectum
and perineum.

On the twenty-ninth of November he returned to his home feeling
pretty poorly and eating very little.

Examination November 30th showed temperature ioo F., no emacia-
tion, abdomen negative, spleen not felt, lungs as per diagram (Fig. 82).

Discussion. Typhoid and malaria, it seemed to me, could be easily
ruled out. I could find no evidence of any form or focus of sepsis.
Accordingly, I made the diagnosis of pulmonary tuberculosis. December
1st the prostatic symptoms became more marked; tenderness and fluc-
tuation appeared in the perineum and a large prostatic abscess was
evacuated.

December 10th, tenderness and swelling appeared in the region of the
left twelfth rib. Incision liberated a large amount of pus from the region
of the kidney, which was not felt or seen. The patient made an unevent-
ful recovery, and has been well ever since (October, 1910).

I made two chief mistakes in this case: first, in forcing myself to
make some diagnosis, even an improbable one, because everything else
seemed more improbable. The proper course would have been to wait
until something more distinctive appeared.

My second blunder was in paying so little attention to symptoms on
the part of the bladder and rectum, which, though very trifling at the time
when I saw the patient, were enough to suggest the presence of a septic
focus which became evident within twenty-four hours.

Diagnosis. Perirectal abscess; perinephric abscess.

Case 218

A married woman of thirty-two consulted me in October, 1908, ac-
companied by her physician, who was an intimate friend of the family.
The diagnosis was splenic anemia, and the problem presented to me for
consideration was whether splenectomy should be done.

The patient's complaints were of general weakness, languor, and a
dragging sensation in the left axillary region. A slight continued fever
was found to be present. The spleen reached almost to the navel, and
appeared to be unusually immobile, perhaps owing to the presence of
adhesions. Visceral examination was otherwise negative. The blood
showed 3,500,000 red cells, 8000 leukocytes, 45 per cent, of hemoglobin.
The differential count showed nothing worth}- of note. The red cells
showed in the stained smear a marked achromia with slight variations
in size. No nucleated red cells were seen.

4I4 DIFFERENTIAL DIAGNOSIS

The patient was advised to enter the hospital for more careful study,
and probably for an eventual splenectomy. She delayed, however,
nearly three months before accepting this suggestion. Meantime there
had been a considerable accumulation of fluid in the abdominal cavity,
and tapping had already been required about two weeks before her
entrance to the hospital.

A reexamination of the patient at this time showed, except for the
ascites, no especial change as compared with the conditions previously
found, although the anemia had slightly increased. The temperature
continued slightly elevated, the pulse, respiration, and urine normal.
Blood-pressure, 125. Although I was somewhat apprehensive that he-
patic changes might have progressed so far as to prevent the splenec-
tomv from relieving her symptoms, it seemed as if she were going on from
bad to worse in spite of all that good hygiene and the administration of
iron and arsenic could do; hence it seemed best to go on with the splen-
ectomy, perhaps preceding it by a direct transfusion of blood.

At this juncture Dr. Wilder Tileston saw the patient at my request,
and, in conversation with him, the patient mentioned that she had been
troubled for a long time with catarrh and cold in her head. "It had
been there so long," she said, "that I am getting quite used to it; but
a little while ago, as I was blowing my nose, something came away, and
I noticed that there was a passage from one nostril to the other, inside."

Discussion. Following up this hint, Dr. Tileston learned that she
had had "some sort of skin disease" in her scalp, as a result of which
there were still marked unevennesses over the cranial vault, though the
skin was wholly normal.

No other evidences of her previous syphilis were demonstrable either
in the history or in the physical examination, but the facts seemed to
me to warrant an immediate abandonment of the plan for splenectomy
and a thorough trial of antisyphilitic treatment, which she had never
had. As a result of this she gradually returned to perfect health, the
spleen diminished to one-quarter its former size, the anemia and ascites
disappeared, and the patient was enabled to take up her usual mode of
life.

This was a very narrow escape from a serious mistake. There was
nothing in the history, as given to me, to suggest syphilis. Doubtless
1 was misled partly by the obvious innocence of the woman, partly by
the fact that her physician, who was intimate both with her and with
her husband, had clearly no idea that the husband had been infected
previous to marriage. Nevertheless, 1 ought to have considered syphilis
merely from the association of the enlarged spleen and ascites with an

Pi g _ 83. Chest signs obtained on physical examination of Case 219.

Fig. S4. Pencil sketch from an x-ray plate of Case 219.

FEVERS

415

anemia of unknown cause, for in that text-book which we should all
know by heart I find the following, under Syphilis of the Liver:

"Ina second group of cases the patient is anemic, the liver is enlarged,
perhaps irregular, and the spleen also is enlarged. Dropsical symptoms
may supervene." (Osier's Practice of Medicine, seventh edition, p.
276.)

Diagnosis. Syphilis.

Case 219

A boarding-school boy of sixteen was seen December 12, 1907.
He had had a "regular cold" with a little fever which seemed to be
ended three days ago, but next day the temperature rose again to
102 F. Yesterday morning crackles were heard for the first time at the
right base. Last night at midnight he vomited and complained of pain
in the right axilla on coughing. When examined at 7 p. m. his tempera-
ture was 102 F., his pulse 90 and dicrotic. Except for slight disten-
tion of the belly, the abdomen and extremities showed nothing abnormal,
likewise the left lung. Examination of the base of the right lung behind
showed in some positions nothing but enfeebled vesicular respiration,
but when lying on the right side there were crackles, increased whisper,
and a small patch of feeble bronchial breathing near the angle of the
scapula.

Although these signs were not very distinctive, their association
with a typical rusty sputum and a high leukocyte count seemed to me
to justify a diagnosis of lobar pneumonia. On the nineteenth, as the
temperature suggested an empyema, a needle was put in near the angle
of the scapula, but only an ounce of bloody serum was obtained. On
the twenty-fourth he was tapped again, this time in the axillary line,
and an x-ray was taken of the chest, which showed nothing abnormal.

January 3d the temperature was normal, the boy hungry and sleep-
ing well, but the chest signs were still far from normal. On January
6th the temperature rose again, and though the boy was still eating,
sleeping, and feeling finely, the signs were as in the accompanying
diagram (Fig. 83). The front of the chest and the axilla showed
nothing of importance. The boy's temperature was 101.6 F. in the
morning, 99. 4 F. in the afternoon. January 7th it was 102.2 F. in
the morning, ioo F. in the afternoon. Between this date and the
twenty-second of January two other unsuccessful taps were made.
The boy continued in excellent condition despite his daily fever. The
sputum was repeatedly examined, with negative results.

At this time he was moved to New York city and put in charge of

4i6

DIFFERENTIAL DIAGNOSIS

Dr. Evan Evans. A second A--ray made at this time showed the appear-
ances sketched in Fig. 84. January 2 2d pus was finally found under
the scapula by a puncture made through the axilla. The boy made an
excellent recovery.

Diagnosis. Interlobar postpneumonic empyema.

Case 220

A girl of six entered the hospital November 18, 1907. She has
always been weak, and often complained of her ears. She has had
measles, chicken-pox, and whooping-cough. Three days before en-
trance she fell and hurt her head. That night she was feverish and
complained of headache. The next day, her mother said, she "never
opened her eyes." She has vomited watery material several times,
and continued to complain of pain in her head, also in the abdomen.
She has been somewhat constipated. She has been in bed two days.

Physical examination showed a red throat, but two cultures, taken
November 18th and November 22d, were negative for diphtheria. The
ears were also negative; no stiffness of the neck; no glandular enlarge-
ment. The mucous membrane of the mouth was normal. The chest
and abdomen normal. The edge of the spleen was felt. The urine
was free from albumin and sugar. There was no edema. The blood
was normal. The chart was as follows :

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FEVERS

41/

Discussion. The fevers of children give rise to far more diagnostic
difficulties than those of adults. Children's temperatures undergo
far wider and more numerous oscillations in perfect health than adults'
temperatures. Besides these supposedly normal variations, there are
a great many short periods of pyrexia occurring in children who are more
or less out of sorts without any reason at present assignable.

In addition to the variations just alluded to, children are subject to
many fevers lasting several days "with nothing to show for them"
i. e., without any obvious local physical signs and without an}- com-
plaint to direct our search to any organ or tissue. Among the commoner
causes ultimately discovered for such fevers are:

(a) The onset of the exanthemata.

(b) Infections of the heart and pericardium, with or without joint
pains (" rheumatic ").

(d) Urinary infections ("pyelitis," ascending or hematogenous).

(e) Empyema (without pain, cough, or dyspnea).
(/) Poliomyelitis.

(g) Tuberculous meningitis.

(h) Typhoid fever.

In all such cases the best that we can do is to make repeated and
comprehensive examinations of the child, who is meantime kept in bed,
given an easily digested diet and plenty of water to drink. Sooner or
later, if we are vigilant, something comes to light. The points neglected
in the present case will be obvious from the outcome.

Outcome. On the twenty-fourth repeated examinations from head
to foot still showed no cause for her illness. She slept and ate fairly
well, and took an interest in what went on.

November 29th: "Several nights ago she complained of pain in the
left leg. Next morning the left knee-jerk was absent, the right easily
obtained. It was found that the child's mother had been bringing her
chocolate candy and that the child had eaten about a quarter of a pound
of it, hiding the box at night under her bed-clothes."

That night her urine was reported to be full of non-motile bacilli
resembling colon bacilli.

December 8th: "The knee-jerk on the left is sometimes present,
sometimes absent, sometimes obtained after long trials. On walking the
child drags the left foot ever so little. There is no muscular atrophy.
A considerable amount of pus appeared in the urine on the fifth of Decem-

4 ii

DIFFERENTIAL DIAGNOSIS

ber, and this has increased since. Urotropin, 5 grains thrice daily, and
abundant water were given."

On the twenty-fourth of December a little drooping of the left shoul-
der was perceptible, and the left foot still dragged a little.

January 2d, the urine being free from abnormalities, the child was
discharged well.

Diagnosis. Poliomyelitis; renal infection.

Case 221

An Irish laborer of eighteen entered the hospital May 20, 1908. On
the recommendation slip from the out-patient is written: "Appendicitis?
Typhoid? Tuberculosis? " His father and one brother died of phthisis.
The past history is good. On the fourth of December he began to have

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pain in the stomach, which has kept him awake at night off and on ever
since. There is no vomiting; no appetite. He has also been coughing
for the same period, with a good deal of sputa.

Physical examination shows slight emaciation, enlarged tonsils, es-
pecially the right, but no exudate. The heart is normal. The lungs
show a few scattered crackles and squeaks. The right half of the ab-
domen is slightly more resistant than the left, and in the region of the
cecum there are marked local tenderness and a mass about the size of an
egg. The edge of the spleen is just felt on full inspiration, likewise the

FEVERS 4ig

edge of the liver. The knee-jerks are obtained with difficulty. There
are old, irregular scars on the backs of both hands and at the lower end of
the right ulna. Leukocytes, 2800.

At no time was there any considerable abdominal spasm. By Mav
2 2d the tenderness in the abdomen was gone.

Discussion. Remembering the great susceptibility of the Irish
to tuberculosis, the patient's family history, and the long persistent cough
of which he complains, we cannot but consider the possibility of a
tuberculosis, pulmonary or generalized. The signs in the lungs are con-
sistent with miliary tuberculosis, but not in any way characteristic of
that or of any other pulmonary affection. The sputa should, of course,
be repeatedly examined. (This was done, but with negative results.)
A tuberculin reaction might be tried, but would be significant only in
case it was negative, as the vast majority of adults react positively,
owing to the latent obsolete foci of tuberculosis. Had the disease been
of the ordinary pulmonary form, the signs in the lungs should have been
more extensive, in view of the long duration of the cough.

Tuberculous peritonitis with glandular masses and adherent coils of
intestine near the cecum might explain many of the symptoms, though
one would expect more abdominal spasm and tenderness.

Appendicitis must, of course, be considered, though the local signs are
few and slight, and the cough and splenic enlargement could not be thus
explained. The leukocyte count is also surprisingly low for appendi-
citis.

The scars upon the back of the hands and on the right forearm re-
semble those sometimes produced by syphilis. The splenic and hepatic
enlargement, the cough, and fever might thus be explained, and the
absence of any history of this infection is of no importance. Without
further evidence, however, one would not resort to the therapeutic test,
at any rate until other probabilities had been excluded.

The diagnosis of typhoid fever would explain the present symptoms
very well. Many cases of typhoid exhibit a certain amount of tenderness
in the appendix region, and this patient's lung signs are those usually
found in typhoid. We are puzzled, however, to explain the long duration
of symptoms. This man can hardly have had typhoid from December
4th to May 20th. and if we suppose the typhoid to have begun more
recently, we have no means of conjecturing what other disease lie may
have had previously. Evidently, what we most need at the present
juncture is a Widal reaction and blood culture.

Outcome.-- The Widal reaction was found to be positive May 20th,
and typhoid bacilli were isolated at the same time from the ear blood.

420

DIFFERENTIAL DIAGNOSIS

The course of the disease thereafter was uneventful,
home perfectly well on the fourteenth of July.
Diagnosis. Typhoid with relapse.

The patient went

Case 222

A salesman of nineteen entered the hospital June 22, 1908, with a

negative family history and good habits. Four months ago, in Georgia,

he had a fever which kept him in bed for six weeks and a half. The

blood was not examined. He had been given capsules with considerable

relief. Six days ago he had a chill, followed by headache, fever, and

nosebleed. Four months ago he weighed

154 pounds, now he weighs 124 pounds.

Physical examination showed a soft

systolic murmur, heard all over the pre-

cordia, while the first sound at the apex

was very faint. The pulmonic second

was greater than the aortic second sound.

There was no enlargement or irregularity.

The arteries were palpable between beats.

Liver dulness extended from the sixth rib

to a point two inches below the costal

margin in the parasternal line. The soft

edge of the spleen was felt on inspiration.

The course of the temperature is shown

in the accompanying chart. The white

cells were 4300. Widal reaction negative.

No malarial parasites were found in the
Fig. 87. Chart of case 222. 11 1

Discussion. Estivo-autumnal malaria is naturally our first guess
in the case of a febrile patient who has recently returned from Georgia,
but this is at once ruled out by the negative examination of the blood :
and the good condition of the patient. If he had had estivo-autumnal
malaria in his system for four months, his spleen would have been
harder and probably larger, his general condition worse.

Endocardial fever is suggested by the presence of a cardiac murmur
and long duration of symptoms, but the leukocytes are rarely so few in
this disease, and the murmur may well be explained as "functional."

What inference should be drawn from the extension of liver dulness

1 Very rarely malarial parasites are not to be found in the peripheral circulation at a
single examination during the febrile stage of estivo-autumnal malaria. I have known of
hut one such case.

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FEVERS

421

two inches below the costal margin? Should we consider some of the
hepatic diseases which are often associated with fever (hepatic syphilis,
abscess, cholangitis, leukemia)? I think not, for we have no good
reason to believe that the liver is enlarged. The extension of dulness
below the costal margin should never, in my opinion, be taken as evi-
dence of hepatic enlargement unless the edge of the organ is also palpa-
ble. Dulness below the right ribs, continuous with that of the liver,
is to be found in countless cases which never show any other evidence
of hepatic enlargement.

The loss of thirty pounds in four months makes us suspect tuber-
culosis hidden somewhere in the body, but there seems to be no good
evidence to support this suspicion, though tuberculosis cannot be
positively excluded.

We must ask ourselves the question, Can this be the "fag-end" of
a typhoid despite the absence of a Widal reaction? The time of year
is not at all the usual one for such an infection, and at first sight we
should suppose that after so long an illness the patient would either
be well or dead if he had had typhoid all that time. Experience shows,
however, that just such a history of long, indefinite illness is to be ob-
tained in many cases which turn out eventually to be unmistakable
typhoid. No one, so far as I know, has adequately accounted for this
fact, but no one who has seen much typhoid will dispute it. It is com-
monly explained by saying that the patient has probably had most of
his typhoid before he came under observation, and that what we are
seeing represents the end of a relapse perhaps the second or third
relapse that he has had. This is perhaps the most plausible explana-
tion, although we should expect the patient to be much more exhausted
as we recall the appearance of patients who have had two or three
relapses under treatment. We must reject the blasphemous thought that
the patient may be in good condition because he has had no treatment.

The present case, however, is hard to explain, even by this rather
far-fetched hypothesis, for he had his six weeks and a half of fever four
months ago, and has, since that time, been up and about Ins business
until he was suddenly seized with a chill on June 16th. It remains
to me a mystery, although a very familiar one, many examples of which
I see each autumn when patients in the typhoid ward relate very cir-
cumstantially the course of an illness which has lasted all summer.

Outcome. On the twenty-fourth of June the Widal reaction was
positive. The patient was out of bed July 10th and discharged well
on July 1 8th.

Diagnosis. Typhoid (brief).

422

DIFFERENTIAL DIAGNOSIS

Case 223

An Italian laborer of twenty-eight entered the hospital September
23, 1906. His family history, past history, and habits are good. Three
weeks ago he went to bed with a headache and has been there ever
since. His appetite is good, but he has not been allowed to eat much.
His bowels have been constipated. There has been no cough. He has
had three nosebleeds.

On physical examination the pupils were found to be slightly irregular,
the right larger than the left. Both reacted normally. The glands in
the neck, axillae and groins were palpable, but not enlarged. Physical

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Fig. 88. Chart of case 223.

examination was otherwise negative, also the urine. The eye-grounds
were normal. White cells, 7000.

Discussion. One's first impression would be that there is really
not much the matter with this man. His temperature is practically
normal, his organs negative to physical examination. But on second
thought we must recognize that a young Italian laborer does not stay
in bed three weeks for the fun of it. Something must be the matter with
him, and his doctor says that he lias had a fever.

A very considerable proportion of Italian laborers appear to have
had syphilis. The irregularity of the pupils and the palpable glands
seemed to support this idea; but it was not possible to get beyond the

FEVERS

423

region of conjecture as regards syphilis, for the Wassermann reaction
was not then in use.

The slow pulse and the rather persistent headache might be taken
as evidence pointing toward brain tumor or other cerebral lesions; but
this suggestion, like the others, had to be left hanging, as there were no
sufficient grounds for a more positive decision.

At this time of year and in a patient with this history it is always
advisable to try a Widal reaction. The result of it was, in this case,
extremely interesting, as is indicated by the outcome.

Outcome. The Widal reaction was strongly positive at entrance.
The later course of the temperature is shown in Fig. 88. The patient
went home, apparently well, on the twenty-second of October*

Diagnosis. Typhoid (afebrile when first seen).

Case 224

A housewife of thirty-seven was seen March 16, 1907. Her family
history was good. She has never been sick before. She has been nursing
her twelve-year-old girl, who has been sick for three weeks with fever,

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Fig. Sy. Chart of case 224.

diarrhea, thirst, and stupor. Yesterday her boy of fourteen was also
taken sick. She lias felt tired from nursing her children, but did not call
herself sick until the doctor took her temperature at 6 p. m. today, and

424

DIFFERENTIAL DIAGNOSIS

found it io2 F. She sleeps well, but is constipated and has a rather
poor appetite.

Examination showed an obese, apathetic woman, her scalp covered
with crusts. A soft, blowing systolic murmur was heard over the pre-
cordia, loudest in the pulmonary area. The pulmonic second sound was
accentuated, the heart not enlarged. The lungs and abdomen were
negative. White cells, 4600; Widal reaction negative. The bowels
moved daily. On the twenty-sixth she began to suffer from diarrhea
with distressing tenesmus, which lasted three days, and on the same day
she passed a small amount of blood, the pulse not being at all affected.

On the twenty-eighth, rectal examination revealed a large mass of
feces just inside the anus. Removal of this relieved all the symptoms.

On the third of April she complained of a burning micturition. The
urine showed nothing abnormal except extreme acidity. Citrate of
potassium and cream of tartar water promptly relieved this symptom.
She was discharged well on the twenty-seventh.

Discussion. When a woman has a fever and nothing to show for it;
when the leukocytes are subnormal and two others in the same family
have febrile illnesses, the chances are strongly in favor of the assump-
tion that she has typhoid fever, probably acquired by contact. In the
present case the Widal reaction appeared March 20th, but the diagnosis
was easily made before that.

The case is introduced here to exemplify the occurrence of diarrhea
and tenderness due to fecal impaction in typhoid fever, even though the
bowels had been moving daily. Such cases are not at all uncommon, and
if rectal examination is neglected, the trouble is rarely recognized, and
may cause much suffering. It usually occurs toward the end of the case,
at or near the period of defervescence, coming on quite suddenly and
without warning. The accumulation is often so great that it has to be
removed mechanically. The lesson forced upon me by my failure in one
such case was never to neglect rectal examination in a case of diarrhea.

Of some interest also is the dysuria, which the therapeutic tests ap-
parently prove to be due to hyperacidity of the urine.

Diagnosis. Typhoid; impaction; dysuria.

Case 225

A rubber worker of thirty-seven, a Swede by birth, entered the
hospital June 10, 1908. His family history and past history were good,
except that he had "typhoid" at the age of eighteen, and "malaria"
for a week a year ago.

Two weeks ago, while at work, he had a severe chill and abdominal

FEVERS

425

cramps, which doubled him up. After three hours he went to work
again and kept on for the next two days, when he had to give upon account
of weakness and pain in his stomach. He has been in bed for a week.
To-day he vomited twice; he has had no appetite, poor sleep, moderate
constipation. He has passed urine only twice in each twenty-four hours
during the last two weeks. What he passes is very red.

Physical examination showed obvious loss of weight. Cardiac dul-
ness extended one inch beyond the right border of the sternum. No
cardiac impulse was seen or felt. There was nothing abnormal about
the sounds. The left lung showed bronchial respiration above the
clavicle, bronchovesicular respiration and increased voice-sounds down

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Fig. 90. Chart of case 225.

to the second rib. Below that level voice-sounds, breath-sounds, and
tactile fremitus were diminished; percussion was dull to Hat. The abdo-
men was quite negative. The white cells were 7400; the urine negative.

The chest was tapped on the eleventh and 40 ounces of clear, pale
yellow fluid removed. Specific gravity, 1017; albumin, 2.8 per cent.;
lymphocytes, 97 per cent.

On the sixteenth 64 ounces more were removed from the chest,
the twentieth it was tapped a third time, but only 10 ounces [<.
On the twenty-eighth it was again tapped and 70 ounces were rem<
His weight a month before entering the hospital was 155 pounds.
the time of his discharge it was 124 pounds.

< >n

ml.

cd.

426 DIFFERENTIAL DIAGNOSIS

Discussion. In rubber workers we meet with all sorts of obstinate
and debilitating symptoms which oftentimes refuse to be grouped into
any recognizable disease, although lead colic sometimes emerges from
the obscurity, in case the workers deal with that part of the process of
manufacture in which lead is used. But, so far as I am aware, none of
the toxic effects of work in a rubber factory produces fever.

The patient's account of himself gives us no inkling of what may be
the cause of the fever. Physical examination and the results of aspira-
tion leave no doubt that the patient has been suffering from a pleural
effusion. It is unusual, however, to observe so rapid a reaccumulation
of the fluid. In the vast majority of cases of ordinary tuberculous pleur-
isy a single tapping suffices, or if recurrence takes place, it is far less
rapid than in the present case, which suggests another and more ominous
possibility.

Whenever rapid and frequent reaccumulation of pleural fluid occurs
in a case believed to be one of ordinary (tuberculous) pleurisy, we should
always suspect malignant disease of the lung, pleura, or mediastinal
glands, no matter how young the patient and despite the absence of all
pain. I have twice made the mistake of diagnosing as pleurisy a case
which turned out to be malignant disease with secondary effusion. Malig-
nant disease not infrequently produces a bloody effusion, but this is by
no means invariable.

The x-ray gives us usually but little assistance in doubtful cases of
this type, as the collapsed lung may simulate the shadow produced by
malignant disease. The cellular elements of the sediment may be iden-
tical in both diseases. The first clue obtained in most doubtful cases is
the appearance of a metastasis in one of the external lymph-glands or
elsewhere. Later the steady decline in the patient's strength makes
it obvious that something more serious than pleurisy underlies the
effusion.

Outcome. After July 28th there w T as no further reaccumulation
and the patient rapidly improved. On August 6th he went to Rutland
Sanatorium.

Diagnosis. Pleurisy (tuberculous) .

Case 226

A young married woman of twenty was first seen January 27, 1904.
Two months ago her second child was born. Hemorrhage and cureting
followed.

Fever and chills for three weeks. (See Fig. 91.) No pain what-
ever. No other complaints.

FEVERS

427

Physical examination negative. Widal, negative. Whites, 7000.
The case was considered by Dr. R. H. Fitz a mild septicemia. The
uterus was dextroretroverted. Cervix very soft. Uterine body very
hard. Culs-de-sac free. The uterus was dilated and cureted.

February 19th vaginal examination showed some edema in right iliac
region.

Discussion. This woman complained of nothing in the world but
fever. As she had rather recently emigrated from Italy, had had re-
peated chills and irregular fever, her blood was many times examined
for malarial parasites, but none were found.

After this, typhoid was considered, although the chart was very
unlike it, and the patient showed at no time any hebetude. The Widal

Fig. 91. Chart of case 226.

reaction was done a number of times, always with negative results.
Nevertheless, typhoid could not positively be excluded.

Since the symptoms came on soon after her confinement, there
seemed good reason to believe that the case might be one of mild sep-
ticemia, pelvic in origin. The dilating and curetage were done with
this idea in mind, but no improvement followed, and the diagnosis
remained altogether in doubt.

Mesenteric and peritoneal tuberculosis are especially common in
recent immigrants of the Italian race, and it is impossible to exclude
this diagnosis, though there were no signs of fluid in the peritoneal
cavity, no palpable glandular masses, and only a moderate general
abdominal spasm, rather more marked in the lower half.

Outcome. The patient was examined under ether on the twenty-
third of February, and a mass was felt in the region of the cecum. The
abdomen was then opened, and the mass found to consist of caseous

428

DIFFERENTIAL DIAGNOSIS

glands intimately adherent to the cecum. Microscopic examination
proved tuberculosis. After a long illness the patient finally made a
perfect recovery.

Diagnosis. Pericecal tuberculosis.

Case 227

A carpenter of twenty-seven entered the hospital February 17, 1907,
with an excellent family history and past history. He drinks one or
two pints of beer a day, rarely a glass of whisky. His habits are other-
wise good.

Two weeks ago he "got a cold," and felt sick enough to go to bed,
although free from pain. Since then he has had a slight cough and has

1 "!&? n /fTjCT!/ ill*, . Jin-, ilujji ? l|,.J

7 t

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Fig. 92. Chart of case 227.

raised a little sputa, which he describes as black and white. He says
he feels tired all over, and for the past three days has had some pain
in the right axilla and in the region of the right nipple, not increased by
deep breathing. To-day his only complaint is of weakness. His
appetite is good, his bowels regular, but he thinks he has lost much
weight. (For the temperature, see the accompanying chart.)

On physical examination the heart showed nothing abnormal.
The left lung was negative, save for a few scattered rales. Throughout
the right lung fine crackles were heard, with slightly diminished voice-

FEVERS

429

sounds, except at the apex, where they were slightly increased, with
a little dulness on percussion. The edge of the liver was felt one finger's
breadth below the ribs. Physical examination, including two examina-
tions of sputa, was otherwise negative. The Widal reaction was always
negative. The leukocytes numbered 12,400 on February 17th; 13,000
on February 18th; 16,500 on February 22d; 11,900 on February 26th.

Discussion. It seems natural to associate the fever and the rather
indefinite pulmonary signs as cause and effect, but it is hard to see
how these signs can be considered sufficient to represent a pneumonia,
an acute pulmonary tuberculosis, or an empyema, which are about the
only lung diseases one would think of in this connection. Tuberculosis
seems perhaps the more probable of the three, but we have no positive
evidence of this in the sputa or elsewhere.

Let us attack the problem from a different point of view. As I have
elsewhere shown, 1 there are but three obscure continued fevers in New
England which last over two weeks typhoid, tuberculosis, and pyo-
genic infections (sepsis). The other fevers, such as those due to menin-
gitis, to acute articular rheumatism, to leukemia, pernicious anemia,
syphilis, or malignant disease, are rarely " obscure" that is, they show,
as a rule, some obvious local lesions as their cause. Returning then to
our case with this clue, it seems that we may exclude typhoid because
of the continued leukocytosis, the continued absence of the Widal
reaction, the excellent appetite, the absence of splenic enlargement, and
the time of year.

Sepsis is not so easily excluded, but the great majority of cases show
either (a) a definite localized focus or source of infection, or (b), in
the absence of such focus, a much more serious clinical picture. This
patient does not seem much sick, especially when we compare his con-
dition with that of patients with generalized pyogenic infection without
demonstrable source.

Can pulmonary tuberculosis which shows its presence by signs as
slight and as few as in the present case be yet responsible for such
marked and continued pyrexia ? Experience shows that it can. Nothing
is more remarkable, as one studies a large series of cases of pulmonary
tuberculosis, than the discrepancies between the amount of lung involved
and the amount of constitutional disturbances, such as fever, prostra-
tion, emaciation, indigestion. Some patients in whose lungs two or
three lobes are obviously infiltrated feel scarcely sick at all, and keep
about their work for many months. Others, in whom we can scarcely
discover enough physical signs to assure the diagnosis, are utterly

1 Sec Reference <>n p. 4o,i-

DIFFERENTIAL DIAGNOSIS

prostrated, drenched with sweats, constantly febrile, unable to digest,
and rapidly emaciate. Presumably these differences are due in part
to the variations in individual resistance, in part to the nature of the
secondary infection ingrafted upon the original tuberculosis.

Outcome. After many examinations tubercle bacilli were finally
demonstrated February 25 th in a small speck of mucus which accom-
panied about 30 c.c. of fresh blood. No typical signs of solidification
appeared until March 6th. March 13th he was discharged worse.

Diagnosis. Phthisis.

Case 228

A teacher of thirty-four, of good family history, entered the hospital
December 17, 1906. He had been told about eight years ago that he

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Fig. 93. Chart of case 228.

had a weak heart. He had gonorrhea five years ago, syphilis eight
years ago.

Five weeks ago he "took cold," had a slight cough and fever, occa-
sionally a little pain in the right knee, later in various other parts of the
body, never constant or definite. He kept at work until five days ago,
when he took to bed on the advice of his physician. He now feels
some aching all over his body; he has no appetite, much constipation.

The palpable cardiac impulse extends as low as the sixth space
in the nipple line. There is harsh, systolic murmur, best heard at the

FEVERS

431

apex, but also audible all over the chest. The pulmonic second sound
is slightly accentuated. Dr. H. F. Yickery, who had previously seen
him, stated that this murmur has been here for at least fourteen years.
Physical examination is otherwise negative except for a leukocytosis
of 19,200, and a fever ranging between 101 and 103 F. (See Fig.

93-)

On December 23d, slight dulness and slight increase of voice were
made out at the left pulmonary apex. The patient says he has worked
very hard for more than a year and is tired out. He now sleeps most
of the time, but complains of no discomfort.

There was no change in his condition for the next month. He
remained cheerful, his sleepiness gradually wore off and his appetite
returned, but he continued to have fever.

Pneumovaccines were given, beginning March 17th, but produced
no improvement. After the 12th of March the temperature became
subnormal, and remained so for most of the following month, though
the leukocyte count was persistently high, varying between 10,000 and
34,000. On the twenty-fourth of March the red cells were 3,012,000,
the hemoglobin, 50 per cent. Of the white cells, 92 per cent, were poly-
nuclear and the rest lymphocytes.

Discussion. Another case exhibiting at the time of entrance a fever
and nothing else. The constant leukocytosis makes it possible to
exclude typhoid, and the other features of the examination rule out
practically everything else except tuberculosis and some form of pyo-
genic infection. The patient slept so large a portion of his time during
the first month of his stay in the hospital that meningitis was at times
suspected, but at no time were there any physical signs tending to
confirm this suspicion.

The pulmonary signs described under the date of December 23d are
such as are found in a great number of sick people if the examination is
conducted with the utmost care in a quiet room. At the right apex
they would have no significance whatever. At the left they call for
more consideration, but are not in themselves sufficient to make us
seriously fear pneumonia or tuberculosis.

Whenever a continued fever accompanies a cardiac murmur such
as that here described, there is reason to fear that a vegetative endo-
carditis is at work. But in the present case we have reason to believe
that the murmur lias existed for at least fourteen years, so that its
association with tins fever may not be significant. On the other hand,
the severe secondary anemia and the constant leukocytosis give us
reason to believe that the old process, which was recognized upon the

43 2

DIFFERENTIAL DIAGNOSIS

mitral valve fourteen years ago, has again become active, like some
hitherto quiescent volcano.

Outcome. Beginning with March 29th, he had a great deal of
vomiting, the vomitus containing considerable blood on one occasion.
At this time there was little or no pulse to be felt in the right arm, although
in the left it was fairly strong. Vomiting ceased within a few days,
but the patient was left exceedingly emaciated and weak. Two pur-
plish areas developed April 14th on the dorsum of the left foot; they
disappeared during the day. Another appeared oh the heel in the
same afternoon. The patient began to be delirious about this time
and he died on the twenty-first of April.

Autopsy showed polypous endocarditis of the mitral valve; multiple
infarcts of the spleen and kidneys; hypertrophy and dilatation of the
heart.

Diagnosis. Malignant endocarditis.

Case 229

A housewife of sixty-seven entered the hospital February 10, 1909.
She has seemed to be perfectly well until this morning, although she
has noticed that her feet swell from time to time, and has been aware
that she passed unusually large quantities of urine. She has had no
headache and no vomiting.

This morning she awoke at four o'clock, saying that she did not
feel well. Within a short time she had several convulsions and became
comatose.

Physical examination showed a red, parched tongue, the heart's
apex one inch outside the nipple line, the action regular and slow;
there were no murmurs and apparently no increase in pulse tension, but
the blood-pressure was 175 mm. Coarse and medium rales were
scattered throughout both lungs.

During the examination the patient had a general clonic convulsion,
with frothing at the mouth, biting of the tongue, dilatation of the pupils,
incontinence of urine and feces. The urine contained sugar, and had
a marked reaction for acetone and diacetic acid. Gravity, 102 1; albu-
min, a slight trace; sediment, negative. The blood showed 25.000
white cells per c.mm.

The course of the temperature is seen in the accompanying chart
(Fig. 94).

Cheyne-Stokes' breathing began soon after the patient entered the
hospital, and the aortic second sound was noted to be very loud. There

FEVERS

433

was no evidence of meningitis, and a blood culture was negative. Con-
vulsions followed each other in rapid succession.

Within an hour of the time of entrance the patient was bled, 14
ounces of blood being taken from the arm, and 2 pints of normal
salt solution containing 5 drams of sodium bicarbonate were put into
the vein. Convulsions, however, continued until the eleventh, when,
under copious sweating by means of hot-air baths, and subpectoral
infusions of salt solution, she began to improve steadily.

On the thirteenth she was conscious, though confused. Sugar,
acetone, and diacetic acid were gone from the urine, in the sediment
of which many hyaline, fine and coarse granular casts were found,

<|'|-s-k

n .--

''\ >

*.!.

10?"
'
10J
10i'
1M'
101

lor
100"

i~
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W

ISO
110
130
MO
110
100

so
:o

60
M
41

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30

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;

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W-

Fig. 94. Chart of case 229.

some with fat adherent. The left pupil was now larger than the right,
though both reacted normally.

On the fourteenth she was at times rational, at times in a muttering
delirium. She could swallow and took milk well, but had no control
over the sphincters, and was occasionally noisy and profane. The
white count had dropped to Sooo.

On the eighteenth she had hallucinations both of sight and hearing.
but when spoken to answered rationallv.

On the twenty-second she was up in a chair, free from any paralysis
or anesthesia, quite rational in the dav-time. although a little irrational
at night. She had now regained control of the rectal sphincter.

434 DIFFERENTIAL DIAGNOSIS

On the twenty-fifth the urine showed no casts; leukocytosis was
still absent. The Widal reaction was entirely negative.

On March 9th she was able to walk about very well, and was
to have gone home. At three o'clock she sank into a chair with a very
poor pulse, and had a short convulsion, lasting only fifteen seconds,
but followed by hallucinations of sight and hearing. She then sud-
denly came to, remarked that she was afraid she had made a fool of
herself, asked what had struck her, and remained quiet and rational.

On March 12th she was discharged.

Discussion. The features of this case may be summarized as con-
tinued fever with epileptiform attacks and glycosuria.

The last item may be dealt with first. A patient seen for the first time
with coma or convulsion should always be catheterized and the urine
examined for albumin and sugar, yet I have known a very large number
of mistakes arising from an inference made because either albumin,
sugar, or both were found to be present. It should always be remem-
bered that convulsions or coma, whatever their cause, frequently give
rise to glycosuria, to albuminuria, or to both conditions. One must
have other evidence before concluding that diabetes or nephritis is
present. Such evidence is to be sought in the condition of the heart,
in the previous history, and in the result of subsequent examinations
of the urine, which, in the present case, were negative, as indeed they
usually are in patients seen for the first time in convulsions or coma.
The acetone and diacetic acid are not easily to be accounted for, as
we have no evidence that the patient has been starving herself, and
her vomiting is very recent.

Subsequent examinations of the urine showed no sufficient evidence
of renal disease. A trace of albumin and a few casts were present
from time to time, but the amount and gravity of the urine were normal,
and in my opinion it has been amply demonstrated that albumin and
casts in a woman of this age are not in themselves evidence of renal
disease, 1 although they are perfectly consistent with such a diagnosis,
and do not in any way exclude it.

Attacks of convulsions and coma in an elderly person whose heart
shows some evidence of enlargement should always lead us to scrutinize
the veins of the neck and to listen very carefully over the precordia

1 F. C. Shattuck, Boston Med. and Surg. Jour., 1894, vol. exxx, p. 613: "On the
Urine of Persons over Fifty Years of Age." William Osier, New York Medical Jour.,
1901, lxxiv, p. 949: " On the Advantages of a Trace of Albumin and a few Tube-casts
in the brine of Certain Men Above Fifty Years of Age."

FEVERS

435

for evidences of heart block (Adams-Stokes disease). In the present
case no such evidence was forthcoming.

Meningitis may begin as suddenly as this, with fever and convul-
sions as the chief evidence of its presence. (See Case 266, p. =508.)
Although there were no positive evidences of meningitis in this case,
lumbar puncture was done, and a sterile fluid almost free from cells
spurted out under considerable pressure. No micro-organisms could
be demonstrated in the sediment. The very transient character of the
leukocytosis is also evidence against any type of meningitis except that
due to tuberculosis.

Typhoid fever was difficult absolutely to exclude. The patient's
age and the time of year, the initial leukocytosis and the convulsions
all were unusual and atypical, but none positively excluded the disease.

Looking over the case as a whole, and taking account of the high
blood-pressure, the absence of any focal symptoms and the intermit-
tence of the cerebral manifestations, it seems to me that this case may
best be classed as one of the group denominated by Pal as vascular
crises l of the cerebral form. Pal's monograph (which does not seem
to me to have received the attention which it deserves) describes in
detail a large number of cases in which the diagnosis of cerebral hemor-
rhage, embolism or thrombosis would ordinarily be made, yet in
which the autopsy showed no gross organic lesion in the brain, no
hemorrhage, softening or vascular occlusion. He shows that similar
crises would reasonably be supposed to occur in cases of lead-poisoning
(lead encephalopathy), in nephritis (transient uremic hemiplegia,
aphasia, or amaurosis), as well as in arteriosclerotic cases with dimin-
ished elasticity of the vessels and high blood-pressure. Presumably,
as he argues, the colic of lead-poisoning, the gastric crises of tabes
dorsalis, and many of the acute attacks of abdominal pain occurring
without any other explanation in arteriosclerotics may be likewise
explained as abdominal vascular crises, while the various forms of angina
pectoris and of intermittent claudication may reasonably be considered
as pectoral or peripheral crises of the same type. Vascular spasm is
in all eases assumed as the fundamental change.
Diagnosis. Vascular crisis.

Case 230

A girl three years old entered the hospital May 5, igo8. The
child was perfectly well until the day before, when vomiting, headache,
and abdominal pain were complained of. bast night the vomiting

1 ('irfusskriesen, J. Pal, Liqisic, 1005 (S. Hirzrl).

43 6

DIFFERENTIAL DIAGNOSIS

continued, although she took food well. The bowels were natural and
there were no convulsions.

Physical examination showed nothing wrong in the throat or ears,
a normal heart, a slight dulness at the right apex extending down to
the third rib in front and to the spine of the scapula behind. Over this
area there was bronchial breathing and increased fremitus.

The course of the temperature was as seen in the accompanying
chart (Fig. 95).

White count, 38,400 on May 5th; 50,000 on May 7th; 79,200 on
May 13th; 69.000 on May 16th; 39,000 on May 18th; 23,000 on May
20th; 17,000 on May 23d.

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On the ninth of May the lower left lobe became likewise involved.
On the eighteenth an aural consultant found double otitis media and
opened both drums. On the twenty-second, though both ears were
discharging freely, the temperature still remained high. Dulness and
diminished breathing were then discovered at the right base.

The child's general appearance was very poor.

On the twenty-fourth the dulness and diminished respiration at the
right base had increased, although there were no signs of anything
abnormal in the front of the chest. A needle introduced into the back
drew pus containing many extracellular pneumococci. A pure culture
of pneumococci was obtained from this fluid.

FEVERS

437

Discussion. Obviously, this child's illness began with a pneu-
monia, continued with a double otitis media, and ended with an
empyema. The case is introduced mainly in order to call attention to
the very typical chart, which exhibits, between the thirteenth and
twenty- fourth, the variations which used to be interpreted as an un-
resolved pneumonia, but which of late years have been shown to be
practically always associated with a development of a postpneumonic
empyema.

The diagnosis of unresolved pneumonia was made at the Massa-
chusetts General Hospital: n times from 1900 to 1905, 5 times from
1905 to Oct., 1909.

I feel quite convinced that the cases which I used to designate as
" unresolved pneumonia " were all, or practically all, mistakes, the
actual lesion being postpneumonic empyema.

Outcome. The chest was opened on the twenty-seventh and a
large amount of pus evacuated, after which the temperature promptly
fell to normal. The discharge ceased in three weeks. The week after
this the wound was healed and the child went home well.

Diagnosis. Pneumonia and general pneumococcus infection.

Case 231

A laborer of twenty-four entered the hospital April 25, 1908. In
June, 1907, he had had rheumatism for a week. Two weeks before
the present illness he had had a bad sore throat. Ten days ago he
began to have tenderness and pain in both knees and ankles, which
compelled him to go to bed. Later, his hands, lips and shoulders
became affected, the pain preventing sleep. During the past week he
has had four nosebleeds.

Physical examination showed that the tonsils were large and soft,
but not red. Cardiac impulse extended to the fifth space, but did not
pass the nipple. There was no enlargement to the right. The first
sound was replaced by a murmur. The pulmonic second sound was
reduplicated. The murmur was also heard in the axilla. Lungs and
abdomen showed nothing abnormal.

The joints of both hands, wrists, and the right knee and both ankles
were swollen, hot, slightly reddened, and tender.

White cells were t 6,600.

The course of the temperature is seen in the accompanying chart
(Fig. 96).

On the second of May, under strontium salicylate. 10 grains every
hour, the patient seemed almost well, and was about ready to go home

438

DIFFERENTIAL DIAGNOSIS

when a loud friction-rub, roughly synchronous with the heart's action,
was heard along the left edge of the sternum, on the level of the fourth
and fifth rib. There was no pain and no fever. The white cells were
11,000. The friction-rub persisted for two weeks, but was never accom-
panied by any pain.

On the eighth of May he began to have considerable dyspnea, and
crackling rales appeared at the right apex, in front, and throughout
the whole left lung. He became rather cyanotic. His white cells rose
to 29,000.

On the ninth pain appeared in the right upper quadrant of the
abdomen, together with rigidity and slight distention. Nothing could
be made out on palpation.

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On the eighteenth of May the leukocytes were still 29,000. The
patient was up in a chair a good deal of the time, and fairly comfortable,
but slept little and did not seem to gain strength. The abdominal
distention was very obstinate and difficult to overcome. His hands and
feet began about this time to show considerable edema. From the
twentieth of May he gained steadily, although his white cells remained
high, and on the twenty-ninth of May were still 24,000.

On the eighth of June his lungs were clear, the heart showed the
murmur previously described, but no pericarditis.

On the twelfth of June he had a second attack of sore throat. On
the nineteenth his tonsils were removed, following which a whitish mem-
brane formed over the stump. Nevertheless, he continued to improve,
and on the twentv-fourth was discharged well.

FEVERS

439

Discussion. The sequence of events here may be summarized as
follows: After a previous attack of acute arthritis the present illness
begins with tonsillitis, which leads immediately to a second attack of
arthritis associated with an equivocal cardiac murmur which may or
may not be due to endocarditis. In May he develops a friction-rub,
due, presumably, to pericardial exudate. Later we have edema of the
lungs and cyanosis, due in all probability to an invasion of the myo-
cardium by the same infectious agent which has already attacked the
pericardium, and perhaps the endocardium (pancarditis). The ab-
dominal symptoms lead us to conjecture that the gall-bladder may have
become infected, or that a mild degree of peritonitis such as often
occurs as part of a general sepsis may also be present. Finally, the
illness winds up with a second attack of sore throat.

We have here an excellent example of a septic infection due to some
unknown but presumably attenuated type of pyogenic organism. One
structure after another is attacked, yet the patient's resistance is such
that he overcomes the invasion again and again, and may be left in
the end nearly or quite as strong as he was in the beginning. In case he
overcomes altogether this present attack, the chief danger is that the
myocardium or the kidney will be permanently scarred, so that in
later life a "chronic" myocarditis or nephritis will appear apparently
out of a clear sky. In practice we often see this second chapter without
the first, as the infection has been passed through without being desig-
nated as anything more important than "the grip" or "a common cold."

Diagnosis. Sepsis.

Case 232

A stableman sixty-two years old entered the hospital February 10,
1908. He has always been well. He denies venereal disease. His
habits are good. For the past four or live days he has noticed fever
and severe cough, with yellow sputa. This morning he began to have
severe pain in the lower right chest, associated with shortness of breath,
but was able to walk to the hospital. The course of his temperature
is seen in the accompanying chart.

Physical examination showed slight cyanosis; rapid, labored breath-
ing; the right pupil larger than the left, and reacting sluggishly to light.
The tongue came out somewhat to the right. There was well-marked
Riggs' disease. The heart's apex extended 1 J inches outside the nipple
line in the fifth space; the right border of dulness not made out; the
heart was otherwise negative. The right lung was dull below the
nipple line in the front and axilla, and up to a corresponding point in

DIFFERENTIAL DIAGNOSIS

the back. Tactile and vocal fremitus were diminished. Breathing was
bronchial, especially near the upper border of dulness. Many fine
crackles were heard throughout both chests.

The liver and other abdominal viscera were normal, though the belly-
wall was held rather rigid.

The sputa was mucopurulent. It contained no tubercle bacilli
and very few pneumococci.

The patient did not seem very sick, but was slightly delirious at
night.

On February 16th the physical signs and temperature were un-
changed. The patient was alert, active, and did not seem to feel sick.

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X-ray showed no evidence of pleural effusion. The sputa, repeatedly
examined, showed nothing abnormal.

On March 8th he was sitting up, but there was no change in the
physical signs.

On March 30th the dulness is perhaps a little less. There are no
rales. He feels quite well, has no cough, and is discharged.

Leukocytes: February nth, 17,800; February 14th, 19,400; February
1 6th, 27,400; February 18th, 15,700; February 20th, 13,900; February
22d, 31,100; February 25th, 14,700; February 29th, 24.200; March
4th, 16,300; March 7th, 10,900; March nth, 11,400.

Discussion. This case is introduced chiefly on account of the re-
markable temperature chart and the equivocal signs in the chest. The

FEVERS

441

rapid, labored respiration, the cyanosis, the bronchial breathing, and
the high initial fever are strongly suggestive of pneumonia, but it is
very unusual to find the vocal and tactile fremitus diminished over
pneumonic solidification.

The long duration of the fever, the absence of any rusty sputa, the
moderate constitutional symptoms, and the signs at the base of the
lung are very characteristic of a pleural effusion, serous or purulent;
yet the v-ray, which usually shows a shadow corresponding to such
an exudate, was negative at the time when the physical signs were
exactly as above described. In view of the outcome of the case I do
not see how we can make any other diagnosis than pleurisy, and in
view of the negative v-ray examination it seems quite possible that we
are dealing with a plastic exudate resulting finally in thickening from
scar formation.

Diagnosis.- Pleural effusion.

Case 233

A child of five entered the hospital May 20, 1908. His father had
just had typhoid fever and his mother pneumonia. They are both at
the Massachusetts Hospital. One
sister is now having measles at
the City Hospital. The child
was perfectly well until last night,
when he became feverish, lost
his appetite, and at nine o'clock
vomited. Since then he has been
drowsy, with slight cough, and lias
vomited several times more. He
complains of no pain anywhere.

The course of the tempera-
ture as seen in the accompany-
ing chart ( Fig. 98).

Physical examination showed
head, chest, and abdomen nega-
tive. There was no rigidity of
the neck; no Kernig's sign.
There were many small red spots
scattered over the trunk and limbs,
not disappearing on pressure.

The white cells were 51,000, with 88 per cent, polynuclear.

Negative urine.

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442

DIFFERENTIAL DIAGNOSIS

After entrance the child was drowsy and continued to vomit fre-
quently and with great suddenness. On the twenty-first he became
slightly delirious.

Discussion. In view of the other cases of fever in the family, one
would naturally conjecture that this child has contracted either typhoid,
measles, or pneumonia. The eruption is apparently hemorrhagic,
not macular or papular, and this, with the absence of coryza, conjuncti-
vitis, and Koplik's spots, is sufficient to exclude measles even at the
outset, before the long course of the fever had shown us that some more
serious infection must be at work.

Typhoid may be unconditionally excluded by the presence of a high
and continued leukocytosis.

Of pneumonia there are no signs, though the herpes, the fever
and leukocytosis suggest it. In children pneumonia is almost never
"central," perhaps because it is easier to reach the depths of their lungs
by the ordinary methods of physical examination.

The vomiting and sluggishness, as well as the sudden onset, are
rather characteristic of meningitis, but against this is the normal flexi-
bility of the neck, the absence of any ham-string contractions and of
any complaint of headache all very constant symptoms. No further
certainty can be arrived at without lumbar puncture.

In all doubtful fevers occurring in young children one should in-
vestigate the ear-drums, and, especially in girl babies, the urine, with
reference to presence of pus and bacteria. In the present case the
latter examination was made, not the former. We were thrown off
our guard because the child did not complain of its ears, nor, indeed,
of any pain, and because there was no discharge.

Outcome. Not until May 2 2d was there any evidence of rigidity
in the neck. In the afternoon of the twenty-second lumbar puncture
was done and 20 c.c. of turbid fluid obtained. In the sediment of this
fluid 92 per cent, of polynuclear cells were found, and many Gram-
negative diplococci were seen within and without the cells. Flexner's
serum was injected, and the boy seemed brighter next day; but Kernig's
sign was present on both sides, and slight internal strabismus had
appeared.

Herpes appeared upon the lips on the twenty- fourth. On the
twenty-sixth he was taking nourishment freely, and wanted to sit up and
go home. The neck was less rigid and strabismus gone; the pulse
was of excellent quality, though rapid.

The white count, May 23d, was 42,000; on the twenty-sixth, 21,000;
on the twenty-eighth, 39,000.

FEVERS

443

Lumbar puncture was done seven times more in the course of the
next three weeks, and Flexner's serum repeatedly injected. The amount
of fluid obtained was usually large 35 to 40 ex.

The patient seemed to be doing well until the eighth of June, when
be became rapidly worse and died. Autopsy showed meningitis, double
otitis media, and a very large thymus.

Diagnosis. Epidemic meningitis.

Case 234

A child of six entered the hospital August 2, 1907. He has always
been well until nine days ago, when he woke near midnight, feverish
and vomiting. Five days ago his temperature was found to be 104 F.
Four days ago it was 103 F. In the middle of the day he had less fever
than at night. The last two nights he has slept fairly well. Before
that he was rather restless. All the time his appetite has been good,
but he has had only liquids. His bowels have been
moved by cathartics and since the first he has had
no vomiting, no nosebleed, no pain. He has lost
considerably in weight.

The course of the temperature as seen in the
accompanying chart (Fig. 98).

Physical examination was entirely negative;
urine, normal. White cells, 15,000. No Widal
reaction.

By the eighth of August his temperature was
normal and the child seemed perfectly well. The
treatment consisted of laxatives and alcohol sponges.

Discussion. All general practitioners see many
cases like the above. Ordinarily, they are spoken
of as "grip" if they occur in winter, and as
"indigestion" or "ptomain poisoning" if they
occur in summer. Both these usages seem to me
unfortunate, in that they tend to delay the prog-
ress of medical knowledge. In the vast majority
of cases there is not the slightest scientific warrant for either diagnosis.
The bacteriologic or chemical evidence on which alone such diagnoses
could be based is practically never secured, and the terms are used
mainly to satisfy the family.

It seems to me much wiser, as well as more truthful, to state that
in such a case we are dealing with an unknown infectious disease. (See
p. 405.) Ptomain poisoning is just now a very fashionable diagnosis,

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case 234.

444

DIFFERENTIAL DIAGNOSIS

and a phrase which the laity loves to brandish about. People are quite
proud to have suffered from such an illness. But all this does not
advance the progress of medicine, and tends in the long run to discredit
our profession.

I have seen similar fevers in which a Widal reaction was obtained,
and to which, therefore, the term "abortive typhoid" was quite justifia-
bly applied. If there is a pharyngitis, a tonsillitis, or a bronchitis, an
inflammation of the frontal sinus, a jaundice, or a diarrhea, an infec-
tion of the urinary passages or a subcutaneous abscess at any point,
the fever may properly be considered as a manifestation of one of these
local disturbances. In the absence of such it should, I think, be made
clear primarily to ourselves and also to our patients that the disease
has at present no name, and cannot be identified with any trouble
previously known.

Diagnosis. Unknown infection.

Case 235

A school-boy of fourteen entered the hospital December 15, 1907.
He has always previously been well. Four days ago he began to have
pain in the right lower quadrant; it was not very
severe, but has persisted to the present time. He
vomited once the first day and twice the second day;
he has been feverish throughout. He has had no cough,
no sore throat and no pain except as above described.
The bowels have moved every day. He was sent into
the hospital with a diagnosis of appendicitis. At en-
trance, there was slight tenderness in the right iliac
fossa, but without any spasm.

Rectal examination was negative; white count,
20,000; Widal reaction negative.

During the night the patient became slightly de-
lirious and the temperature rose to 106.2 F.

Physical examination showed at the right base slight

Bdulness, slightly diminished tactile, slightly increased
"L~ vocal, fremitus, and a few moist rales. Chest and

abdomen were otherwise negative. The right knee-
jerk could not be obtained; the left could be obtained
only with difficulty.
The patient was very delirious, quarreling with imaginary persons,
and reaching out for objects in the air. There was no stiffness of the

~'-i

Fig. 100. Chart
of case 235.

FEVERS 445

neck, no Kernig's sign. The pupils have been markedly dilated through-
out, but have been equal and reacted well to light.

Discussion. What infectious diseases are most common in boys
of this age?

(i) Pyogenic sepsis, with or without a focus in bone, joint, or heart
valve.

(2) Pneumococcous infections, with or without a demonstrable
pneumonia.

(3) Meningitis (otitic, epidemic, or tuberculous).

(4) Typhoid.

(5) Appendicitis.

(6) Unknown infections.

The latter are perhaps the commonest of all.

Though the pain is referred to the right iliac fossa, the presence
of a temperature of 106 F. and of an active delirium is distinctly
against appendicitis. We are on our guard also against the mistake,
so common in patients of this age, of overlooking a pneumonia or a
pleurisy because the abdominal pain often associated with these infec-
tions in children occupies so prominent a place in the clinical picture.

Meningitis might begin in this way, and the delirium and the absence
of knee-jerks, together with the very high fever and leukocytosis, are
quite consistent with that diagnosis. We are surprised, however,
whenever we find meningitis without stiffness of the neck or Kernig's
sign, especially if the patient is fourteen or younger, for these nervous
manifestations are much more apt to be early and well marked in the
fevers of children than in those of adults. Even meningeal irritation
without actual meningitis often makes a child assume the posture of
meningitis. The absence of headache, herpes, and eye changes is
also somewhat against meningitis. Nevertheless, this disease can be
ruled out only in case lumbar puncture shows no evidence of infection.

A general septicemia, associated either with a pneumococcus or one
of the varieties of streptococcus, is the next most reasonable hypothesis.
Without blood culture one cannot get any greater certainty in this
direction, but the signs in the lung, though in themselves slight, are
sufficient to incline us toward a belief that a pneumococcous infection
is present, ft seems now to be quite clear that the existence or tin-
degree of lung consolidation is quite a secondary and accidental matter
in infections due to the pneumococcus. We are dealing in all cases
probably with a general infection carried by the blood. Tn the lung it
may arouse no special reaction, may produce a slight bronchitis or
bronchopneumonia, or mav bring about the solidification of an entire

446

DIFFERENTIAL DIAGNOSIS

lobe. But if all the pneumococcous infections were recognized and
classified, we should probably find that those attended by a frank
pneumonia are in the majority.

Outcome. The blood showed a pure culture of pneumococci. By
the nineteenth signs of solidification were obvious at the right base.
Lumbar puncture showed nothing. The child died on the same day
on which solidification became obvious.

Diagnosis. Pneumonia.

Case 236

A carpenter of thirty-nine entered the hospital January 18, 1907.
His family history is good. For the last three or four years he has
had considerable cough in the morning, with greenish sputa. He
denies venereal disease. He takes a pint of whisky three times a week.
Three days ago he began to be chilly, stopped work and went to bed.
Two days ago he began to have pain in the region of the heart and in

the right axilla. To-day he has
been spitting up reddish, frothy ma-
terial. His cough has not kept him
awake at night. The course of his
temperature is seen in the accom-
panying chart.

Physical examination showed
cyanosis, a negative heart, thick-
ened arterial walls, many coarse
and medium bubbles and squeaks
throughout both lungs, diminished
resonance in the lower right back
and axilla. The upper part of the
right front was hyperresonant, the
lower part somewhat dull, with
much-diminished breath-sounds and
voice-sounds over the area between
the third and fifth ribs. Abdomen
negative.

Over both lower legs there were many patches of brownish pigment
from the size of a nickel to that of the palm of the hand; over the shins
there were three white scars, two inches long, .v-inch wide, surrounded by
brownish pigmentation. The sputum showed a great variety of bacteria,
but nothing of special importance. Leukocytes, 25,300, with 94 per
cent, of polynuclear cells.

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FEVERS 447

On the twenty-third, as noted, the temperature remained high, the
pulse irregular; the patient was cyanotic and very noisy. The physical
signs remained as before. The sputum was constantly blood-stained.

Discussion. There is no way in which we can make alcohol re-
sponsible for the present fever. Some cases of delirium tremens are
febrile, but we have neither tremor nor, at the start, any delirium, and
there has been no special accumulation nor increase of alcohol.

The syphilitic infection suggested by the scars on the leg has nothing
to support it in the rest of the clinical picture.

Though the signs in the lungs are by no means typical of pneumonia,
there seems sufficient reason to take as a working hypothesis the disease
which used to be called " central pneumonia." The postmortem evidence
seems to be insufficient to justify the belief that in any considerable
number of cases solidification actually begins in and remains for a time
confined to the central portion of the lung. The conception of "central
pneumonia" is derived, I think, mostly from "hind-sight" in cases
characterized first by the symptoms, and only later by the physical
signs of pneumonia.

It seems to me more reasonable to suppose that in most of the cases
usually designated as " central pneumonia " we are dealing, in fact, with a
general pneumococcous infection which produces in the lung no lesions
whatever or only a moderately severe bronchitis. When a crisis occurs
in such a case and the temperature falls suddenly to normal, we are
very apt to argue that this proves the case to have been one of lobar
pneumonia. I believe, however, that the familiar crisis is character-
istic of the pneumococcous infection itself, whether or not it is localized,
for it is a very familiar observation that the signs of solidification are
often unchanged for many hours after the occurrence of the crisis. It
has long been recognized that the dyspnea and cyanosis which cease
so suddenly with the crisis, even though the lung signs remain the same,
must be due not to the lack of lung space for aeration, but to general
toxemia. The same is true, I believe, both of the fever and of the crisis.

Outcome. On the twenty-seventh the patient was much better.
On the third of February he was up and about the ward, and on the
sixth he went home well.

Diagnosis. Pneumococcous infection.

Case 237

A school-boy six years old was seen December 14. iqo6; he had
never been ill previously. He has not been well for the days, complain-
ing of pain in his legs and abdomen. The doctor said it was appendi-

44 8

DIFFERENTIAL DIAGNOSIS

citis. His bowels have not moved for four days. To-day his parents
noticed red blotches on his face and body, which they say he does not
scratch.

Physical examination is entirely negative, except that the whole
bodv is covered with red, discrete patches from the size of a pea to that
of a silver dollar, apparently elevated and surrounded by evidences of
scratching.

The urine was negative.

The white cells were 25,200 on the fourteenth; 24,600 on the six-
teenth; 27,600 on the twenty-second; 17,000 on the twenty-sixth.

Widal's reaction was slightly suggestive, but not positive. The coagu-
lation time of the blood was three and three-quarters minutes with the
Brodie-Russell instrument. Throughout his stay in the hospital the

patient had no other symptoms or
signs.

He had numerous crops of spots
up to the twenty-second of Decem-
ber. After that they ceased, and
after a few days he seemed so well
that he was discharged on the
second of January.

Discussion. In the absence
of all physical signs of visceral dis-
ease it seems reasonable to associate
this fever with the profuse crop of
urticarial lesions. The most im-
portant lesson from such cases is the
recognition that the disease which
underlies urticaria can, and often
does, produce fever. The other

Fig. io2.-Chart of case 237. ^ ^ ohy[ous resuks of the urti _

carial group of lesions discussed so fully by Osier in a series of important
papers l must always be borne in mind when the history of the case
or the inspection of the skin gives us any knowledge of what we are
dealing with.

Symptoms resembling appendicitis, gall-stones, perforating peptic
ulcer, pneumonia and many milder affections of the respiratory and
gastro-intestinal tract may be produced, when wheals or edematous
patches appear in the internal organs as well as in the skin.

Diagnosis. Urticarial fever.

1 Amcr. four. Med. Sci., 1S95, vol. cxxxvii, p. 620; Brit. Jour. Dermatol., Lon-
don, moo, vol. xii ; Amer. Jour. Med. Sci., 1904, vol. cliv, p. 1.

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FEVERS

449

Case 238

A butcher of twenty-one entered the hospital May 24, 1908. He
has never been sick before. His habits are good. Since early yester-
day morning he has had fever, headache, sore throat, slight cough with
whitish sputa, and severe, deep-seated pains all over his body. He
has vomited several times. His bowels moved once this morning.
The course of his temperature is seen in the accom-
panying chart. His throat was red, showed no exudate
and no swelling. Physical examination was otherwise
entirely negative.

Discussion. Some time in the course of his medical
experience every physician, confronted with a case like
that here described, has occasion to ask himself the
question :

" Can a man be as sick as this and nothing wrong
with him but a red throat?" In such cases we rack
our brains to see what possible diagnosis we have for-
gotten. YVe examine the patient again and again in
search for some more extensive organic lesion. But
if all these efforts are vain, we are driven in time to
the conclusion that a "simple red throat" may be a
pretty serious affair. The case here quoted is one of
the milder type, but others which begin just as inno-
cently develop into the most virulent type of general-
ized sepsis. The conclusion is that so frequently
emphasized in these pages, viz., that few "local" in-
fections are really local even from the start, that they usually sow their
wild oats very widely be/ore settling down, and that this settling may
be only temporary.

Outcome. The patient was given half an ounce of castor oil,
followed by three 5-grain doses of phenacetin at hourly intervals, with
a grain of caffein to each dose. In two days he seemed to be entirely
well.

Diagnosis. Pharyngeal (and transpharyngeal) infection.

Fig. 103. Chart
of case j;S.

Case 239

A printer of eighteen entered the hospital June 1, iqoS; his family
history and past history were good. lie is a heavy smoker of cigarets,
and chews a good deal of tobacco besides. Nine days ago he began
to have a ticklish throat, then a cough and "cold in his head." which

450

DIFFERENTIAL DIAGNOSIS

soon became severe enough to make him give up work. He has been
" up and down " until two days ago, when he took to bed for good.
Seven days ago his right foot began to be painful. Yesterday he began
to complain of pain in the region of his heart, and his breathing was
accompanied by a groan. His cough, at the same time, became much
worse, and his fever higher. Last night and to-day he has been some-
what delirious. He has had no chill, no abdominal pain, no vomiting
or diarrhea. The course of his temperature is seen in the accompanying
chart (Fig. 104). The white cells were 55,700, with 90 per cent, of
poly nuclear cells. The urine showed a very slight trace of albumin, but
no casts. The tonsils were enlarged and the pharynx reddened. The

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heart-sounds were regular, rapid and distant. There were no murmurs.
Respiration was rapid and groaning, the nostrils moving with each
breath. There was slight dulness in the left back below the angle
of the scapula, a trifling increase of voice-sounds and of tactile fremitus.
The respiration was normal. Over the lower axilla and in the precordia
a very intense double friction sound was heard synchronous with respira-
tion.

The abdomen and extremities were negative, except that on the top
of the right foot was a swollen, reddened, painful area the size of a
dollar. Movements of the toes seemed to be painful.

On June 3d the pleural rub had disappeared. Respiration seemed

FEVERS

451

to be distant in the left back, and there were many coarse rales in the
lower right back. Cyanosis was very marked. On the fourth the right
border of cardiac dulness had moved to the right at least an inch, and a
pericardial friction was heard to the right of the sternum, while pleural
friction had returned in the left axilla. There was no definite evidence
of fluid or solid in the lungs. Many fine purpuric spots developed on
the trunk and limbs during the forenoon of July 4th.

Discussion. In cases like this we are prone to ask the muckraker's
familiar question: "Where did he get it?" The illness is so sudden,
so severe, yet there is so little to account for it.

It appears that an infection showing itself first as a sore throat was
scattered thence to the joints, the pericardium, the pleura and the
subcutaneous tissues. In any one of these and in many other places
a more definite localization might have occurred, as is shown by the
course of other similar cases. But here apparently there was a very
widespread attack, not wholly successful (7. e., not producing any very
obvious or extensive disease) in any one locality. For some unknown
reason infections which do not become " ''localized" ojten seem to be the
worst in case they are not oj the very mildest type. Those which "local-
ize" make up the great middle class of moderately severe but not fatal
infections.

In all such cases our diagnosis must remain vague unless the results
of blood culture are positive.

Outcome. On the fourth of July a blood culture showed a profuse
growth of the streptococcus pyogenes. The patient died next day.

Diagnosis. Streptococcus sepsis.

Case 240

A Russian girl baby, twenty-three months old, entered the hospital
December 13, 1907. She had never been sick before; three days ago
she became sleepy and feverish, with considerable dyspnea, but no
cough. She has had no appetite and has vomited twice. The body
has been very hot, the feet and hands cold. The bowels have been
moved by cathartics, the stools being blackish. Physical examination
of the chest, abdomen, and extremities was entirely negative.

White cells. iS.ooo; urine, not obtained.

Discussion. Although the history and the physical examination
appear to have been conscientiously made in this case, two all
essential points are omitted. It is because of these that I introduce
the case.

11) Sick babies do not complain of their cars even when they are

45 2

DIFFERENTIAL DIAGNOSIS

seriously diseased. The uninitiated are apt to expect that a baby with

otitis media will indicate in some way that its ears are painful, even

when it is too young to talk, but experience
shows that the baby rarely puts its hands to
its head or gives any other sign that it
knows what ails it.

(2) Especially in girl babies suffering from
obscure fevers we should always remember
the urinary tract and the possibility of in-
fection, hematogenous or ascending. The
difficulties of collecting and examining the
urine of young babies often lead to its being
disregarded, to the great detriment of the
child, since most of the milder urinary infec-
tions can be cured in their earlier stages by
the administration of urotropin and an abun-
dance of water.

Outcome. On the nineteenth a puru-
lent discharge was seen in each ear. Tem-
perature, pulse, and respiration promptly fell
to normal and remained so. The child

had been fretful up to this time, but after the discharge became quiet.

By the twenty-fourth the ears had ceased discharging and the child

went home well.

Diagnosis. Otitis media.

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240.

Case 241

A school-girl of fourteen with a negative family history entered
the hospital March 14, 1907. She has had measles, chicken-pox, and
whooping-cough. For the last six months she has complained of frontal
headache each day after school. The pain goes away by bed-time. On
January 24, 1906, the child had adenoids removed, without any improve-
ment either in her hearing or in her general health. Her appetite has
been poor since her measles seven vears previously. Two months ago
she had a discharge from one ear. For a week or two there has been
tenderness in the sides of her neck and under her jaws.

On February 8th she began to have constant headache, with fever
and drowsiness. These symptoms have continued ever since.

On physical examination the child looked sick and "toxic," the
sublingual gland large and tender, both submaxillaries also large. The
glands in the axilla; and groin were slightly enlarged. There was a soft

FEVERS 453

systolic murmur at the apex. The heart was otherwise normal, likewise
the lungs and abdomen. There was no tenderness over the mastoids;
the white cells were 12,400, 65 per cent, of which were polynuclear;
there was no anemia; the urine was normal, Widal reaction negative.
Her throat and ears were carefully examined, but nothing abnormal
was found there.

Discussion. No doubt this girl has had eye-strain and presumably
fehe has had adenoids and otitis media, but there seems no reason to
believe that the otitis, the adenoids, or any of her previous infections
are the cause of the present glandular enlargement.

The main question is whether we are to connect the headache, fever,
and other constitutional symptoms with the presence of these glands.
Glandular fever is a diagnosis to be made only when no other causes
can be found either for the adenitis or the fever.

Such an adenitis is common enough as part of an infection arising
from the mouth or throat, or as the residual result of such. But at the
present time there seems to be no source of infection in the mouth or
throat, no bad teeth, no alveolar abscess, no tonsillitis or otitis.

There is no enlargement of the parotid glands, no history of exposure
to mumps, and none of the periglandular infiltration usually seen in that
disease.

The glands may possibly be tuberculous, but we have no evidence
of tuberculosis elsewhere, no softening or sinus formation, no adherence
to the skin or surrounding tissues; the sublingual gland, moreover, is
not often involved in tuberculosis unless as a part of a very extensive
process.

Leukemia can be ruled out by the blood examination. Hodgkin\s
disease rarely occurs with just this distribution. It cannot, however,
be positively excluded save by the outcome of the case. The absence
of any history or lesions of syphilis makes it reasonable to exclude that
disease in a girl of this age.

As a result of this reasoning we are left with an unexplained fever
and glandular enlargement. To this combination of symptoms, when
running a rather short, self-limited, and usually favorable course, the
name of glandular fever may be given.

Outcome. By the twenty-third she was sitting up in her chair
and the glands were much smaller. By the twenty-fifth she was free 1
from all symptoms. The glands were still palpable, but now were
hard and free from tenderness.

Diagnosis. Glandular fever (?).

454

DIFFERENTIAL DIAGNOSIS

Case 242

A factory hand, twenty-six years old, entered the hospital February
22, 1908. His family history and past history are negative, his habits
good. He has been more constipated than usual for the past four
months, the bowels moving once in four or five days. Two weeks ago
he began to have headache and poor appetite. Eight days ago he began
to have steady, moderate pain at the costal margin, not referred else-
where. Five days ago he noticed that his eyes were yellow.

Physical examination is negative, except for moderate jaundice of the
skin and conjunctivae, accompanied by rigidity of the right rectus near
the ribs. There is tenderness and dulness on percussion, extending
1 1 inches below the rib margin in the nipple line. The edge of the spleen
is not felt at entrance, but on the twenty-third of February it was easily
felt and considered to be sharp. The urine contains bile, but is not
otherwise remarkable. The stools are not clay colored. By February
26th the tenderness and spasm had disappeared, but the jaundice was
still present at the time of his discharge, March 17th, although it had
become very much less intense.

The treatment consisted of 20 grains of sodium phosphate three
times a day, \ grain of calomel every fifteen minutes for ten doses, fol-
lowed by \ ounce of magnesium sulphate. A diet free from fat was also
given.

Discussion. When we have a case of jaundice of short duration,
not following upon or resulting in any other recognizable disease such
as gall-stones, obstructive cancer, syphilis or cirrhosis of the liver,
we are apt to call it catarrhal jaundice.

Just what this means we do not know. Many cases like the present
one have a considerable degree of fever, many more have jaundice for
some days preceding the onset of digestive symptoms, so that it seems
hardly reasonable to suppose that a gastroduodenitis has extended up
the bile-duct and occluded it, according to the classic conception of
the disease. It seems more reasonable to believe that the jaundice is
one feature of an infectious cholangitis or some other type of hemato-
genous infection.

Diagnosis. Catarrhal jaundice.

Case 243

A housemaid of twenty-one entered the hospital April 30, 1907,
complaining of abdominal pain. Physical examination indicated the
presence of fluid, and operation showed a diffuse tubercular peritonitis.

FEVERS

455

The patient had fever for two weeks, after which she became afebrile
and was transferred to the medical wards.

At both bases there was diminished breathing, fine rales and, on
the right side, dulness. The abdomen was of board-like rigidity, with
shifting dulness in each flank and general tenderness. The patient
when received was vomiting everything taken. She was starved for
twenty-four hours without relief. Washing her stomach was also of no
benefit, and many drugs were tried ineffectually. Soon after the first
of June the patient spontaneously ceased vomiting, began to be more
comfortable and to take food. The course of her temperature, mean-
time, is seen in the accompanying chart (Fig. 106). On the ninth of

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June slight dulness and prolonged expiration were noticed at the left
apex in front and behind. By the fifteenth she had developed a left-
sided otitis media, which was pronounced to be tubercular by the aural
consultant, Dr. H. L. Morse. On June 23d, a purulent vaginal discharge
and slight pericardial friction were made out.

Discussion. Tn the discussion of previous cases T have repeatedly
referred to the special points of election at which a general infection is
prone to settle or break out (joints, heart, pleura, gall-bladder, peri-
toneum, subcutaneous tissues, kidney).

In the present case we have indications of a similarly wide distribu-
tion of lesions. The patient has already been operated on for the relief

456

DIFFERENTIAL DIAGNOSIS

of a tubercular peritonitis. It seems reasonable, therefore, to suppose
that tuberculosis is also the infection at work at the present time in
various other tissues.

Outcome. The patient died on the twenty-fourth of June. Autopsy
showed general miliary tuberculosis and tubercular peritonitis, tuber-
culosis of the tubes, retroperitoneal and mesenteric lymph-glands,
tuberculous ulcers of the rectum. The infection of the middle ear was
not tuberculous, but was of streptococcous origin.

Diagnosis. Miliary tuberculosis.

Case 244

A longshoreman, twenty-one years old, entered the hospital August
24, 1910. He has been to sea a good deal, especially to the West Indies,

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but within the past year has not been further south than Georgia. Left
there eighteen days ago and landed at Boston eight days ago, where he
at once fell ill, with severe pain in the back and legs, which has lasted
ever since. Feverish and sleepless. One nosebleed. Xo chills. Diar-
rhea began two days ago, but ceased yesterday.

Three or four weeks ago he had a boil on his left hand, but it healed
promptly. A similar boil appeared three days ago on his right hand.

FEVERS

457

Family history, past history, and habits good. Denies venereal
disease.

Physical examination showed an abundant crop of rose spots on the
trunk. The axillary lymph-glands were slightly enlarged. The spleen
was not felt, but seemed distinctly enlarged on percussion.

Widal reaction positive (1-50). White cells, 10,000, among which
there were 59 per cent, of polynuclears, 33 per cent, of large lymphocytes,
7 per cent, of small lymphocytes, and 1 per cent, of eosinophiles. The
stained smear was otherwise negative.

The urine averaged 50 ounces in twenty-four hours. At entrance it
contained a large trace of albumin, and in the sediment very numerous
fine and coarse granular casts with cells, blood and fat adherent. A
week later the albumin and casts disappeared and did not return. The
stools were negative.

The temperature is seen in the accompanying chart.

By August 30th the boils on his hand were healed, but two more
appeared on the back. Culture from the pus obtained on opening them
showed Staphylococcus aureus.

Discussion. Typhoid seemed obviously the diagnosis, though the
patient (like many other typhoid patients) was never "typhoidal," /. c,
stupid, in the least; but September 21st, as the temperature looked un-
characteristic and showed no permanent trend either up or down, we
tried another Widal test and found it negative. This test was again
negative on the 2 2d and the leukocytes were found to number 10,000.
The absence of Widal's test and of leukopenia at this period of the
disease seemed very suspicious, also the repeatedly negative Diazo re-
action.

Paratyphoid (alpha and beta strains) was tested for twice, with nega-
tive results. There was a slightly suggestive agglutination test with a
strain of colon bacilli.

Tuberculosis was next searched for, but the lungs, the osseous,
lymphoid, and genital tissues were entirely negative.

October 3d we tried von Pirquet's cutaneous test, which proved
negative. Blood-cultures were also negative.

"Bed fever" (a temperature which disappears when the patient gets
up and moves about) was tested for by getting this patient out of bed.
but after several days his fever was as high as ever.

Typhoid remained the diagnosis, though a most unsatisfactory one.

Outcome. October 7th the blood was again examined for malaria.
and estivo-autumnal crescents were found in abundance. The original
blood-smear of August -?./th "was then hunted up and found to contain

458

DIFFERENTIAL DIAGNOSIS

estivo-autumnal {ring-form) parasites, which had been overlooked on the
first examination. The original Widal reaction remains unexplained.

The absence of chills, the presence of Widal's reaction, and the false
report on the blood-smear are responsible for my mistake in this case.

Diagnosis. Estivo-autumnal malaria.

Table XI. Long Fevers. Signs and Symptoms.

Causes

Favoring con- ! . .

(Ji t ; ns Onset. Local lesions.

Typhoid fever

Aug., Sept., Oct. j
Infected water or | Slow,
milk. Carrier.

Sepsis Lowered vitality. Rapid.

Tuberculosis

Meningitis

Infectious arthriti

yphilis

Poverty.
Congestion.
Contagion.

Focus of infec-
tions. Heart.

Suggestive
signs.

Blood.

Rose spots. Leukopenia.

Palpable Widal. Bacilli

spleen. by culture.

Steep curves in T ,

chart. Leukocyte

<. Lungs. Pleura. Steep curves in Not

blow. t s ,-., i l ,

Bones. Glands. chart. I characteristic.

Rapid.

Stupor.
Nervous Delirium,

system. ( Retracted head.

Spinal fluid.

Influenza ' Contagion. Rapid. Upper respira- j g ..

" tory tract.

Rapid.

Slow.

Joints.

Joint lesion
obvious.

Spleen. Glands. Spleen. Glands,
Blood. Blood.

Leukocytosis.

Rarely bacill
by culture.

Moderate
leukocytosis.

Characteristic.

ei, r\c u . lumor. usu-

Slow. Often hepatic. ,, , .

v ay obvious.

Contagion. Slow.

Often

enlarged liver

and spleen.

Wassermann
test.

Cirrhosis

Alcoholism

Slow. Ascites Large L&r g^^ a]]
or small liver. & ,.

Contagion. Rapid.

Lower urinary
tract.

Gonococci in

discharge or

blood.

Occasionally

gonococci by

culture.

Causes of Chills

1. NERVOUSNESS ) CASES TOO MANY and too vaguely enumerable for graphic

2. PYOGENIC SEPSIS

j REPRESENTATION.

3. PHTHISIS

4. PNEUMONIA

5. GALL-STONES

6. MALARIA (IN

NEW ENG-
LAND)

7. TYPHOID

(ONSET)

1171
465
395

276
26C

Many other infectious diseases at the onset.

400

CHAPTER XIV

CHILLS

The rapid clonic spasm of many muscles which may be the onlv
mark of a chill is not to be clearly distinguished from a tremor such
as many normal persons are subject to when excited. A subjective sense
of cold and an abnormal temperature may or may not accompany the
tremor. The chill accompanying gall-stone colic is often seen without
pyrexia. Even when the chill marks the onset of an infectious disease
the temperature is not always elevated. Hence the distinction between
"nervous chills" and those due to infection is sometimes to be made-
only by the accompanying signs and by the later developments. All
chills except those of nervous origin are soon followed by fever.

"Creeping" chills, or chilly sensations without any definite tremor
or any chattering of the teeth, are much commoner and less distinctive
than the true or "shaking" chill ("Schuttelfrost").

As a rule, when chills are the evidence of infection they accompany
an abrupt rather than a gradual rise of temperature. The sudden high
fevers of malaria, pneumonia, tonsillitis and pyogenic sepsis are more
often attended with a chill than the more gradual rise seen in typhoid
or pleurisy.

Among the causes of chills are:

(a) Pyogenic Infections. These are doubtless the commonest.
Under this heading comes, in all probability, most of those occurring
in tuberculosis fas a result of secondary infections) as well as those due
to appendicitis, septic wounds, renal and hepatic suppurations, tonsillitis
vegetative endocarditis, phlebitis, empyema, and erysipelas.

(b) Malaria probably ranks next, especially in the tropical and
subtropical regions.

(c) Severe pain (as in renal or biliary colic) may lead to a chill or
follow it, even when no infection or fever is demonstrable. In some
cases chill (or vomiting) seems to replace the colic as a sort of equivalent.

(d) "Urethral chills," such as often follow the passage of a catheter,
occur in persons who show nothing of a nervous or hysteric taint, yet
there may be no fever with or after them. Probably the pain and
irritation are enough to set the nervous system "on edge," even it" it be
ordinarily stolid.

4i.'l

462

DIFFERENTIAL DIAGNOSIS

Case 245

A baker of thirty-eight entered the hospital February 6, 1908. His
family history, past history and habits were good.

January 29th he had a sudden chill in the evening. The next
morning he vomited his breakfast. Since then he has been having
severe chills about twice a day and has vomited a great deal. He
has been lounging about the house, but has not been in bed during the
day-time; he has had no cough and no pain.

On examination he is found to be splendidly developed. His left
pupil is slightly irregular, both pupils reacting somewhat sluggishly to

Fig. 108. Chart of case 245.

light. The heart is altogether negative. The lungs show slight dul-
ness and many crackling rales at the left base behind, but no other signs.
White cells, 17,000. The rest of the physical examination and the urine
are normal.

The sputa shows many pneumococci, some streptococci; no tubercle
bacilli.

On the tenth there were no new physical signs. The leukocyte
count continued high 17.600.

On the twelfth there was distant but distinct bronchial breathing at
the left base.

The patient received 190 grains of quinin in twenty-four hours,

CHILLS

463

but continued to have chills. On the fourteenth, after a very severe
chill lasting half an hour, the rectal temperature was 107 F. The
white cells had now risen to 23,900, and the patient continued to have
daily chills lasting from forty to forty-five minutes, the temperature
reaching 106. 5 F. each time and remaining there several hours.

On the sixteenth exploratory puncture of the" chest was done twice,
the needle entering solid lung each time. From the blood withdrawn
by the second tapping a smear was made which showed many pneu-
mococci, both within and outside the leukocytes.

On the twenty-second of February #-ray showed a very high dia-
phragm on the right side, and a shadow behind the scapula between the

==i - *"- '' ~<r..f-_~r- * r~. * -/* v r3 iii-f" ii/ - r- * r/v * *. 4. *U v | , J . , , t

-R- -m-X - - ; , X A. jt

A 14 .. *I ^4 j4 fi *

. Z -iq tl "n z\ r^ i H M 7 1

-=i - ' V- l_Ka L H L_ ~ f 1

^ il 9 l_ 4I_J 4 1 H i H J it L J t ^

it A 4 t J E ] l 1 * ^ J X^ 1 a3 t ^

w V- >-t t* t 5 -,' V, r ^--S X-t* " 4

1 . ^y \ / t ^ * r x " ^zztz ^

r .

M - *#

*.*- A *

* ^4- A ^ -4-* A -

: ^ 23 ,- v- Q -1 *^

. a Z^I-V - L ,_ E I J t . 7X 3 h- * ^

1 . a rm . r 23 it __^:1f ^ r & ^ .^ s

*/ > -3 ^ > ^4 w^ \v l v ^ *v^

It *_I -* *-*: C v

^ ^ y ^ .

w 1 . , I

S M I A

i * * A P

= M '? / \ A ; A *s, f-v V / \. '^*

? i. ^ I . ^ V -^X -4 ^~,X -V JL^*^* .-=*^~

H 1. -V > *-*./ | A W V A > - ^ V -*"*- ji i

" T ^ t *

Fig. 109. Four-hourly chart of case 245.

fifth and seventh ribs. Erysipelas developed on the twentieth of
February and spread all over the face.

Discussion. When a patient has two chills a day and a leuko-
cytosis ranging from 17,000 to 23,000, the administration of large doses
of quinin is altogether unjustifiable. There is no reasonable possibility
of malaria.

Pulmonary tuberculosis often produces chills, which not infrequently
come as close together as in this case, and sometimes recur at exactly
the same hour each day, so that the unwary are led to diagnose malaria
and to waste time and strength in attempting to stop the chills with
quinin. The signs in the lungs of this patient are not at all character-

464 DIFFERENTIAL DIAGNOSIS

istic of phthisis, and the sudden onset of the symptoms would be quite
inexplicable if the chills were due to that disease. Chills occurring
in pulmonary tuberculosis come after the disease has made its presence
evident for many weeks or months previously.

By far the most significant point in this case is the evidence obtained
by x-ray examination, which appears to prove that the source of the
chill lies in or near the liver. That this is usually the source of chills
for which no obvious cause can be found is, I think, the general experi-
ence. When we have searched the blood, the sputa, the subcutaneous
tissues, the ears, and the heart for a septic focus and found none, it
usually turns out that the source of infection lies in septic thrombosis
of the portal vein, in hepatic abscess, single or multiple, or in a sub-
phrenic abscess.

We cannot be more definite than this in the present case.

Outcome. On the twenty-seventh a needle introduced through
the eighth right space below the angle of the scapula drew pus. A rib
Avas resected March 2d, and a pus-cavity the size of the fist was drained.

The patient continued to have chills, and died on the twenty-sixth.

Autopsy showed multiple abscesses of the lung and of the liver.

Diagnosis. Hepatic and pulmonary abscess.

Case 246

A Swedish housewife of fifty-six, who had passed the menopause six
years previously and had been otherwise well all her life, entered the
hospital December 31, 1907. She says that one night last spring while
in bed, but not asleep, she " began to feel queer." In a short time she
was seen to shake violently all over, complaining at the same time of
headache and vertigo. These chills recurred five times during that
month. After them she felt weak and had abdominal pain, extending
up through the chest to the throat. During the past summer she was
much better, but three months ago she went to bed on account of increas-
ing pain, weakness and chills; she has stayed there ever since.

Her most troublesome symptoms are headache, vertigo and constant
ringing in her ears. She has a poor appetite and often vomits, though
the vomiting seems to have no distinct relation to pain nor to the time
of eating. Of late she has a good deal of dyspnea, cough, and expecto-
ration, though the latter is never bloody. She sleeps poorly, and her
urine is scanty. She has lost about ten pounds in weight.

Nevertheless, when examined, she was found to be rather obese.
Her lips were pale and bluish; the heart's dulness extended one-half inch

CHILLS 465

outside the nipple line in the fifth space, five inches to the left of mid-
sternum. A blowing, systolic murmur was heard at the apex, but was
not transmitted more than an inch or two in any direction. The pul-
monic second was not accented. The pulse tension appeared normal.

In the right back, below midscapula, there was dulness without any
other signs. Throughout the left back there were a good many fine,
crackling rales. Hemoglobin, 80 per cent. The white cells were 16,200
at entrance; three days later they were 12,300. The urine and the
stained blood-smear were normal. Vaginal examination was also
negative. The temperature was below 99.5 F. throughout.

Discussion. In some respects this case reminds us of the previous
one. We have chills, associated with obscure, bilateral, pulmonary
signs. Just as we were getting ready to investigate these by means of
the #-ray they cleared up entirely; otherwise our diagnosis might have
remained long in doubt, although with chills lasting nearly nine months
we should feel pretty sure that more definite and extensive changes
would by this time be demonstrable in the lungs were they the source
of the trouble.

Endocardial infection should always be suspected when chills of
obscure origin are found to be associated with a cardiac murmur
and a slight enlargement of the organ, especially if, as in the present
case, there is a leukocytosis. Against this, however, is the long dura-
tion of the symptoms and the obesity of the patient. A person who has
had ulcerative endocarditis for nine months is not likely to be obese.
Further, the course of the temperature is altogether uncharacteristic
of a cardiac infection, especially one which would appear to be of
long duration.

In view of these facts and of the nature of the attacks it is fair to
suppose that they may have been due to some form of ' ; nerves." But
since the patient is well past middle life it is altogether probable that
there is some arteriosclerotic change underlying the nervous symptoms.

Outcome. By the fifth of January the lungs were entirely clear
and the patient was able to sit up. After that she complained only of
pain in the small of the back, which was greatly relieved by cross-
strapping with adhesive plaster. January 16th she went home well.

Diagnosis. Hysteria (with arteriosclerosis?)

Case 247

A housewife of thirty-nine, of good family history and past history
entered the hospital November 8, 1907. She got a cold in the head two
weeks ago and was hoarse for a da}' or two; she then began to cough

4 66

DIFFERENTIAL DIAGNOSIS

up considerable yellow sputa. During the whole illness (from two
weeks ago until yesterday) she had two chills every day at irregular
intervals, with shivering, chattering of the teeth and profuse sweating
thereafter. At present she feels sore throughout the whole chest,
especially beneath the lower half of the breast-bone. The course of
the temperature is seen in the accompanying chart.

Phvsical examination was entirely negative. The sputum showed
very large numbers of influenza bacilli both within and outside of the
cells. The blood and urine were normal.

By the thirteenth the patient was im-
proving slowly under laxatives, heroin for
cough and bitter tonics for appetite, but it
was not till the nineteenth that she was
able to go home practically well.

Discussion. One investigates in a case
like this the ordinary causes for multiple
chills: concealed sepsis with or without endo-
cardial localization, malaria, tuberculosis,
otitis media, liver disease (including gall-
stones), renal infection, and nervousness.
Since none of these is to be found, we must
fall back upon the evidence of an influenza
infection, which is the best clue we have to
the nature of the chills, although the amount
and gravity of the infection seem dispropor-
tionately slight when compared with the
violence of the constitutional reaction mani-
fested in the chills.
It is to be remembered that the make-up of the individual, what
is often called his "temperament," and especially his nervous system,
influence the degree and character of the reaction against any infection,
such as influenza. Any shock or painful experience, such as death,
flood or fire, will leave one person quite unmoved, will deprive a second
of the power of sleep and make a third irritable and nervous; in a
fourth it may provoke that curious motor spasm known as a "nervous
chill," and in a fifth may determine an actual convulsion of the type
ordinarily called "hysteric." All these reactions represent differences
in the degree of sensitiveness of the motor nervous system.

But there are similar differences in the way in which different tem-
peraments react to an attack from within namely, a bacterial invasion.
Those whose motor responses are excessive in the presence of the ordinary

a,,-

i T/t 1/1/ 1

1 1\ i

1M"
10ft*

!i!"'I>

...?....

IM*

101
100*

M'
M'

K-
0}

1W
IM

110

100
00
90
JO

1 1 !

AAA-'

, J

. *

Mill

; i

i '

~'~'*- : 7^

If^i

! I

7 / '/'' 'F

MyV-

Fig. no.

-Chart of case
247.

CHILLS 467

annoyances and discomforts of life are apt to show a similar exaggeration
of the normal response in their constitutional reaction against an infec-
tious disease. In the present case it was learned by subsequent ques-
tioning that this woman had been in the habit of having chills whenever
any kind of slight ailment affected her. This is perhaps a less common
idiosyncrasy than that by reason of which certain persons, whom every
physician meets in the course of his practice, show a very high tempera-
ture reaction when they catch cold or have a slight digestive upset.

In the discussion of some of the previous cases I have said that most
diagnoses of "grip" or influenza seem unjustified, because the bac-
teriologic evidence is quite insufficient. I do not feel quite sure that
we are right in making the diagnosis of influenza even upon such evi-
dence as is presented in the present case. Since the epidemic of 1889--
90 the influenza bacillus has been a regular inhabitant of the upper air-
passages of practically the whole population in Xew England. The
fact that we find it in the sputa in connection with one or another type
of disease is, therefore, in itself, of little significance. When the germ
occurs in large numbers, both within and outside the leukocytes,
and when the other varieties of organisms found are in very small
numbers, it is probably justifiable to consider the infection one of in-
fluenza.

Diagnosis. Influenza.

Case 248

A chambermaid of thirty-eight was first seen November 6, 1907.
Two years ago she was in the Massachusetts Eye and Ear Inlirmarv
for nine days with an acute inflammation of the left middle ear, which
was lanced several times. Her hearing remained good afterward.

Four days ago she had a severe chill, followed by sweating, vertigo,
ringing and buzzing in both ears. The next day there was severe pain
in the left ear. Since that time she has felt feverish, and during the
last two days has had eight chills and has vomited several times.

During the last two days she has had a dull ache in the left ear,
extending down her neck to the left side of the throat. This morning
and yesterday morning she went to the Eye and Ear Infirmary, but no
trouble was found with the ears. Throughout her illness she has had
insomnia, anorexia, and constipation.

Physical examination showed an obese woman with normal pupils.
The heart's impulse was felt with difficulty in the fourth space, just
outside the midclavicular line. There were no murmurs or accentua-
tions. The lungs were normal. There was some epigastric tenderness,

468 DIFFERENTIAL DIAGNOSIS

but nothing else of importance in the abdomen. The urine ranged
between 40 and 60 ounces in twenty-four hours, the specific gravity
varying between 1005 and 1023. Albumin was sometimes absent,
sometimes present in very slight traces. Casts were sometimes absent,
sometimes numerous and of the hyaline and granular type, some of
them having cells adherent. In the majority of the examinations it was
exceedingly difficult to find any casts at all.

The blood-pressure at entrance was 230. The fundus oculi was
normal on the right. On the left there was a large area of opaque
nerve-fibers at the lower edge of the disk.

Discussion. The foreground of this case consists of chills and ear
pains, the background of various signs pointing toward a chronic ne-
phritis. The high blood-pressure and the ocular changes are especially
important in this latter respect. The urine is equivocal and dubious.
The condition of the heart is not characteristic, though suggestive of
slight enlargement.

Taking for granted that there is an underlying chronic nephritis,
what is the cause of the chill? Otitis media is naturally our first and
very decided suspicion, but the high character of the work done at the
Massachusetts Eye and Ear Infirmary makes us confident that we may
rely upon their negative report regarding the ears.

Nothing is said in the text about an examination of the blood for
malaria or for leukocytosis, because these examinations had not been
undertaken at the time when I first saw the case. They both turned
out, however, to be negative.

Knowing the proneness of all cases of chronic nephritis to an inva-
sion by an infectious disease, it seems natural to assume that some such
infection was present in this case, although we do not find definite
evidence of its whereabouts. There remains, however, one further
possibility: the chills may be a direct result of nephritis without any
infection. Chills and convulsions are -first cousins. In fact, a chill
may be described as a generalized clonic spasm of very short excursion.
In view of this it seems more than possible that the excessively high
blood-pressure which existed for a short time in this case may have
determined the onset of chills, as we well know that a similar rise of
pressure often determines the onset of convulsions. In view of the out-
come of the case, without further evidence of infection, this hypothesis
deserves consideration.

Outcome. ( )n the thirteenth the blood-pressure was still markedly
elevated. 190, though she had been having daily hot-air baths and
was purged every second day with an ounce of magnesium sulphate.

CHILLS

469

On the twenty-seventh the blood-pressure had fallen to 155. The
patient had no symptoms except slight tenderness and weakness in her
legs. She was then allowed to go home.

Diagnosis. Chron ic glomerulonephritis.

Case 249

A school-boy of fifteen, whose father died of consumption, was first
seen April 15, 1908. He was always well until two weeks ago, when
he began to have headache, backache, and soreness all over his body.
Since then he has had several chills, with chatter-
ing teeth. Yesterday he vomited; throughout he
has slept well. There has been no nosebleed.
(See Fig. in.)

When examined, the face was flushed, the
throat reddened and covered with a mucopurulent
secretion, the glands in the axilke and the right
epitrochlear enlarged, the neck not stiffened. The
heart was negative except for a soft, systolic mur-
mur in the pulmonary area, the lungs entirely
negative, likewise the abdomen.

The white cells were 13,400; Widal reaction
negative, blood culture negative.

Discussion. Among the infections common
in boys of fifteen, which are most often obscure ?

(a) Endocarditis, with or without arthritis or
chorea.

(b) Tuberculosis, especially of the bone, glands,
or peritoneum.

(d) Brief febrile maladies to which no name can be given at present,
and in which no definite localization in any organ is found (febricula,
"gastric fever," "grip").

This latter group is the most numerous of all.

The present case seems to have been investigated sufficiently to ex-
clude with considerable confidence any tuberculous or endocardial
infection. No search, however, appears to have been directed toward
excluding otitis, a possibility which should never be forgotten in youth
and infancy, in the otitis of the adult our attention is usually called
at once to a source of the trouble by the occurrence of severe earache.

Outcome. On the eighteenth the left ear began to discharge
and the other followed suit soon after; by the twenty-fourth the ears

Fig. 1 1 1 . Chart of
case 249.

DIFFERENTIAL DIAGNOSIS

had stopped draining, and the hearing and the boy seemed practically
well. At no time was there any considerable amount of pain in or near
the ears.

Diagnosis. Otitis media.

Case 250

A Russian clothes-presser of twenty-three was first seen September
28, 1907. His family history and past history were excellent. He stated
that he has never been sick until sixteen days ago, when he was seized
while at work with a severe chill, followed by a profuse sweating. Since
then he has had a slight chill twice a week. Occasionally he has sharp

pain in the right side of the chest if
he happens to take a specially deep
inspiration.

When examined, the patient was
well nourished. (See Fig. 113.) The
glands in the axillae were as large as
lima-beans. There was marked acne
on the back and sides of the chest.
The heart showed nothing abnormal.
The lungs showed occasional scattered
rales throughout, somewhat more
numerous in the right front.

White cells 10,200; Widal reaction
and stained smear, negative.

Urine, negative. The next morn-
ing the lungs were as in the accom-
panying diagram (Fig. 114). The
pulse was rapid and dicrotic, the
patient alert and anxious. Each day
thereafter until October 15th, the signs in the lungs shifted and changed,
rales coming and going, patches of bronchial breathing appearing and
disappearing.

Discussion. The physical signs suggesting possible causes for this
patient's chills are those in the lymphatic glands and in the lungs.
These possibilities should first be investigated, though we must bear in
mind that some of the other and more obscure causes mentioned in
previous cases may be here at work.

Chills may be associated with glandular enlargement in lymphoid
leukemia, in Hodgkin's disease (with infection of the glands), and in
glandular tuberculosis; occasionally also in syphilis. Leukemia is

y-if J-jTalJu )[ ; ^ >> f!~

' 7] 6 9 icj // i- Trt IS

d~, \ L ? r

l/\ll/ 11 l\nl 11 l/\ ( II

100 1

106

\l !^"1

' Z- r* ,

i^, c

5 "i^Vt" ,

* .. jfZZIl

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''ff^l^i 21

I! ,0 ' ^77

ts^ if n

t t~. -I

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;" vii/ 1 '//v

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- m \J * * '

, *J J /

.. rt?t^A.

a, 100

+ilrM ; 1

T \t ^-P >

2 I i '/vv\ i i

J"Tklt*' fcS fSt *i

'? r- B-tS.

r 1 r lV vSzl

- " &****' '

,: srrm\ \ k \

1/31 ft /3

Fig. 112. Chart of case 250.

Fig. 113. Physical signs in Case 250. (See also Fig. 114.)

Fig. 114.- Physical signs in Case 250. Adenitis, chills, and chest pain; no cough.

CHILLS

471

here excluded by the blood examination. Hodgkin's disease never
manifests itself in the axillary glands alone, and the same is true of
syphilis. Glandular tuberculosis cannot here be excluded, though in
an adult it rarely causes such marked constitutional disturbance unless
other tissues are involved. Of course, the internal glands bronchial,
mesenteric, etc. would be assumed as affected in addition to those of
the axilla.

The pulmonary signs are most like those ordinarily seen in acute
bronchitis with bronchopneumonia, but the duration of the disease,
which is more than a month at least, is hardly consistent with this idea,
and makes us suspect a pulmonary tuberculosis. Further evidence
can be obtained only by the sputum examination. The cutaneous
tuberculin reaction seems to be of little value in patients of this age,
and the fever precludes our trying the subcutaneous reaction.

Outcome. When first questioned, the patient stated that he had
no cough whatever, so that when the physical examination was under-
taken we had practically no clue from his history regarding the source
of the chills. Later he acknowledged that he did cough occasionally,
and on the thirteenth of October a little glairy sputum, resembling
saliva, was obtained. It seemed hardly worth examination, but to
our surprise a few tubercle bacilli were found in it. The patient passed
out of observation October 16th, his condition having become steadily
worse meantime.

Diagnosis. Phthisis.

Case 251

A man of sixty-eight, a dealer in sponges, was seen February 1,
1908. Thirty years ago he had "Bright's disease'' and was sick for a
year. He has had "malaria" off and on for thirty-five years; other-
wise he has been well until seven years ago, when he began to have
"stomach trouble," which has become worse in the last three months.
This is characterized by pain and discomfort in the epigastrium, coming
after each meal and lasting two or three hours. His appetite has been
very poor, and for six weeks he has lived mostly on liquids. He never
vomits or is jaundiced.

He passes urine eight or ten times at night. He has considerable
frontal headache, no cough or dyspnea. A year ago he weigh. ed 17S
pounds; now he weighs 134; he thinks he has lost chiefly in the past
three months. Four weeks ago he began to have eh ills coming every day
about 4 P. m. For two weeks he has taken 20 grains of quinin e\ery day.

When examined, the patient was found to be emaciated, with a dry,

472

DIFFERENTIAL DIAGNOSIS

rough, pale skin. There was no dulness or bronchial breathing any-
where in the chest. There were crackling rales at the right apex in
front, scattered, dry whistling sounds below the right clavicle, and
harsh respiration at both bases.

The hemoglobin was 75 per cent. No malarial organisms were
found after repeated examinations. The urine was normal; Widal
reaction negative. At entrance the patient's temperature was normal.
(See Fig. 115.) It soon rose and remained elevated throughout his stay
in the hospital. By the stomach-tube examination no fasting contents
were recovered. The stomach held 44 ounces, its lower border reaching

just below the navel. After a
test-meal, free hydrochloric acid
was 0.05 per cent., total acidity,
0.19 per cent. The guaiac test was
negative. In the warm bath an
edge, distending with respiration,
was felt in the right hypochon-
drium.

The patient was given 10 grains
of quinin every four hours, but his
temperature was not much affected.
On the fourteenth of February
there was bronchovesicular breath-
ing in the second right intercostal
space near the sternum, with in-
tense whispering bronchophony and
coarse consonating rales after cough.
Otherwise the sounds were as at
entrance.
Discussion. Since the patient has apparently had malaria for a
good many years and is now moderately anemic, it is proper to assume
until proved to the contrary that the chills of which he now com-
plains are of malarial origin. This idea, however, was decisively dis-
proved by the blood examination, on which we can entirely rely in such
cases if it is made by any one who has had the proper training.

Can there be any connection between the stomach, of which he com-
plains so much, and these chills? Tn answer, we may say, I think, that
unless the disease has extended far beyond the stomach (e. g., sub-
phrenic abscess from perforated peptic ulcer) that organ is incapable
of producing such a clinical picture. Phlegmonous gastritis that very
rare disease produces a far more fulminating and virulent type of

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CHILLS

473

infection. The other stomach diseases may be disregarded in our
efforts to explain the chills.

Since the edge of the liver is felt, it is proper to inquire whether any
infection in or near that organ may be at the bottom of this patient's
troubles. Provided the patient has no leukocytosis (a point on which
we are still ignorant), liver infections, whether rising from the gall-
bladder, from the intestine, or otherwise are improbable. The upper
border of the organ, especially in the axilla and back, is almost always
raised, as percussion will demonstrate, if there is any infection in or
near the liver. In doubtful cases the #-ray examination may help us
to determine the outline and position of the organ.

The pulmonary signs do not seem at first examination to be of any
special significance. Many patients of sixty-eight present similar
abnormalities, off and on, without complaining of anything in particular.
In the present case, however, their persistence and the absence of any
other important lesions discoverable by physical examination lead us
to focus attention upon the lungs. Apparently the conditions, whatever
their nature, are steadily getting worse.

In patients of this age we are rather apt to forget the frequency
and importance of tuberculosis. Statistics show that, contrary to
the impression current, both among the laity and among medical men,
tuberculosis is just as prone to occur in the latter decades of life as in
the earlier. In this case we are tempted still further away from the
track of the truth because the patient says practically nothing about
cough indeed, denies that he has had any previous to the first of
February. In all probability this is a mistake, and in view of the steady
increase in the lung-signs during the three weeks' period of observation,
tuberculosis seems the most reasonable diagnosis.

Outcome. On the eighteenth a small accumulation of free fluid
appeared in the peritoneal cavity. There was no circulatory weakness
to account for it. The patient was very fussy and hard to please, de-
claring that lie had no saliva and no secretion from his stomach. On
the twenty-first he became much discouraged and insisted upon going
home. Tubercle bacilli were never found in his sputa during the three
weeks of his stay in the hospital.

Diagnosis. Phthisis (?).

Case 252

An Irish laborer fifty-four years old lost his father of consumption
and one sister of the same disease. His wife and one daughter are
now sick with "colds." He was first seen February 13, 1907.

474

DIFFERENTIAL DIAGNOSIS

Thirty-eight years ago he was seven weeks in bed with "rheuma-
tism," and had stiff and painful joints for three years thereafter. Thir-
teen years ago he had a right-sided " pleurisy," but was well in a few days.
He denies venereal disease, but for ten years has been unable to hold
his urine for any considerable length of time in the day, though he
passes it only twice at night. As a rule, he does not drink liquor
to excess, but a week ago he got drunk and stayed so for two days.

Two weeks ago he began to have chills, several occurring during
one night, accompanied by cough and a thick white sputum. He was
unable to lie down on account of the distress across the upper abdomen.

Two days later he had a sharp pain in the
lower part of both chests, increased by cough or
breathing. Pain ceased two days ago in the
left chest, but persisted in the right. He has
been in bed for the past three days, complain-
ing of pain, cough, and weakness.

The course of the temperature is seen in the
accompanying chart.

Physical examination showed no enlargement
of the heart and no murmurs, though the heart-
sounds were irregular in force and rhythm. The
brachials were very tortuous and showed a lateral
exertion, with apparently an increased tension.
There was slight dulness in the lower part of
both backs and at the right base in front, over
which area there are a few crackles, while below
the right nipple there was heard an indistinct
friction-rub, which on the seventeenth had become
rougher and more easily audible.
Discussion. The common causes of obscure chills, such as malaria,
deep-seated suppurations, acute endocarditis, tuberculosis, and nervous-
ness, must all be canvassed in a case of this kind, but there is very
little to substantiate our belief in any one of them. A number of points,
however, not fully stated in the printed account must be further in-
vestigated.

(a) Nothing is said about the urine. In men of this age an old
urethral stricture, with or without prostatic hypertrophy, urinary reten-
tion and chronic cystitis, often leads, through an ascending infection,
to pyelonephritis, and thus to chills like those here described. Investiga-
tion of the urine, however, showed no evidence of any such disease.
(b) Nothing is said about the size of the liver. Pain in the upper

116. Chart of

2^2.

chills 475

portion of the abdomen, associated with chills, should always make us
look for evidence of liver abscess, gall-stone disease, or subphrenic suppu-
ration. We should expect a leukocytosis in connection with any of these
types of infection. Nothing is said about the leukocyte count in the his-
tory printed above. As a matter of fact, however, both the blood and
the size of the liver appeared to be normal.

(c) It is well known that alcoholism is often associated with night-
sweats and sometimes with chills. So far as I know, however, both of
these phenomena are of nervous or vasomotor origin, and do not depend
upon any variations of temperature, such as are shown in the chart.

On the whole, the chest signs seem the most significant, now that
we have excluded some of the other possibilities. Evidently there has
been some pleurisy on the right side, possibly on both sides, though
double pleurisy is not a common condition. As to the nature of this
pleurisy, it is hard to get any definite information; perhaps only the
outcome will decide. The pleurisy might be of the type closely asso-
ciated with lobar pneumonia, although we have no signs of that disease.
Many cases of obscure septic infection by pyogenic organisms affect
all the serous membranes and joint surfaces to a greater or less extent,
passing rapidly from one to another. Some such infection may well
have been present here. Tuberculous pleurisy is also a possibility
regarding which we can obtain decisive information only by following
the case for a long time.

Outcome. On the fifteenth a fine friction-rub was also heard in the
left lower axilla, and this persisted until the twentieth.

The patient was given a tight swathe for four hours and a teaspoon-
ful of a mixture consisting of phosphate of codein, 8 grains, potassium
citrate, 3 drams, syrup of hydriodic acid, 4 ounces. This, with a bitter
tonic for his appetite, made him able to leave the hospital on the twenty-
fourth.

Diagnosis. Double pleurisy (septic?).

Case 253

A court officer seventy-six years old, of good family history and
past history, entered the hospital March 18, 1908. His habits are good.
He has had chills occasionally ever since the Civil War.

This morning, about eight o'clock, while on the train, he was seized
with a violent chill, not followed by sweating. Since then he has felt
very sick and is still chill}-, but has no pain anywhere. About noon he
vomited four times.

At no ti.ne has there been any cough.

476

DIFFERENTIAL DIAGNOSIS

Physical examination showed in the left back, below the angle of
the scapula, slight dulness, distant bronchovesicular respiration, in-
creased fremitus, and medium-sized crackling rales. There were a
few elevated red patches the size of almonds, covered with crusts, about
the left ankle and shin. The white cells were 18,900; urine was normal.
The temperature was as seen in the accompanying chart (Fig. 117).

There was a fine trembling all over
whenever the man moved. There
was no cough and no sputa.

Discussion. The point which
I wish to insist upon in this case
is that the history and the symp-
toms give no indication of the diag-
nosis.

With a careful physical ex-
amination it becomes tolerably
obvious that we are dealing with
a lobar pneumonia (although the
signs are not very marked), but the
diagnosis must rest wholly on signs,
as there is no cough, rusty sputa,
or pain in the side. The chill was
confidently attributed by the pa-
tient to the malaria which he ac-
quired in the Civil War.
Although I have referred to the disease here present as ''lobar
pneumonia," it is more than probable that the infection is not so
definitely localized and involves only local congestion with pleurisy and
perhaps some bronchopneumonia. The main bulk of the infection
works free in the blood-stream.

The old skin lesions about the left ankle have no relation to the
symptoms complained of in this case. They probably represent a chronic
eczema.

Outcome. On the twenty-first the white cells were 17,400, and on
the twenty-sixth, 27.000. That night the temperature fell by crisis
and he convalesced without incident.

The treatment consisted of strychnin, -fa grain, three times a day,
whisky, 1 ounce, even- four hours. The bowels were moved by glycerin
enemata.

Diagnosis. Pneumonia.

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CHILLS

477

Case 254

A cook, forty-six years old, was seen May i, 1907. She has one
child living and well ; one died in infancy. She has had two miscarriages.
Her family history is excellent.

Three years ago the patient had a severe sore throat which had to
be lanced fifteen or twenty times. Since that time her voice has been
thick.

Seven weeks ago she began to have chills and sweating every day or
two, accompanied by persistent nausea and vomiting. For the past
three weeks she has been troubled chiefly with cough, thoracic and
epigastric pain. Throughout her illness she has had moderate irregular
fever and epigastric tenderness. Her tempera-
ture is seen in the accompanying chart (Fig. 118).

The patient was obese, pale, incoherent, and
almost comatose. There was marked photo-
phobia, so that the pupillary reactions could not
be obtained. Through the soft palate there was
a median perforation the size of a quarter of a
dollar. Behind it broad white bands, probably
old adhesions, could be seen. The heart-sounds
were faint and valvular in quality. No murmurs
were heard and no enlargement found; the lungs
showed nothing abnormal. Blood-pressure, no.

In the abdomen there was general tenderness,
especially marked in the epigastrium, where vague
resistance was felt behind the spastic muscles.
The reflexes were normal. The white count was
16,000; polynuclears, 70 per cent. There were no
malarial parasites. The urine averaged 20 ounces
in twenty-four hours, 1013 in specific gravity;
albumin, 0.1 per cent., a few coarse granular and epithelial casts
Widal reaction was negative.

Discussion. This patient had been working very hard for a number
of years without vacation, and the diagnosis of her attending physician
was general exhaustion. But the condition of the urine made it at once
evident that something more serious was going on. Although the
patient is febrile, the condition of the urine cannot be explained thereby,
as its characteristics are not those ordinarily associated with fever. ( )n
the other hand, it does not seem like anv of the more familiar types ot
nephritis. It has not the concentration and bloodv sediment seen in

Fig. 1 18. Chart of
cast' 254.

The

47-

DIFFERENTIAL DIAGNOSIS

most cases of acute nephritis, while against chronic nephritis is the
absence of any cardiac enlargement or hypertension.

Leaving for the time undecided the problem of the renal condition,
we mav start from one of the most certain and reliable physical signs
present in the case, viz., the perforation of the soft palate and the adhe-
sions between it and the posterior pharyngeal wall. This condition
[practicallv pathognomonic of syphilis unless there is a history of the
patient's having swallowed some caustic], the long-standing hoarseness
of the voice, the chronic sore throat, and the miscarriages may well be
accounted for in the same way.

Experience shows it a fairly safe rule to assume that any acute
manifestations occurring in a patient with unmistakable lesions of a
past syphilis, are part and parcel of the same infection. There are, of
course, exceptions to this rule, but they are not numerous. If now we re-
turn to the attempt to explain the condition of the kidneys, we notice
that the urine shows the characteristics traditionally associated with a
syphilitic type of nephritis involving amyloid change. In this kind of
disease cardiac hypertrophy usually does not occur, though the urine
has the main features of chronic nephritis.

We get no hint as to the cause of the chills unless it be the epigastric
tenderness which might be associated with hepatic syphilis. I have
known this disease to produce chills as well as fever, and in the absence
of any more obvious cause we may conjecture that something of the kind
is going on here. It is quite possible, however, that some acute pyogenic
infection may have supervened.

Outcome. The white count steadily rose during the week of her
illness, reaching 25,000 on the fourth of May; 30,800 on the sixth;
37,500 on the eighth. The urine became smoky or bloody, the albumin
rising to 0.8 per cent, despite the sweating and purging.

In the last two days the pupils ceased to react and the lungs filled
with coarse crackles. The patient died on the ninth; no autopsy.

Diagnosis. Viscera) syphilis.

Case 255

An Irish housemaid of thirty-six, whose father died of cancer, was
seen August 30, 1907. She has had no previous illness. Thecatamenia
are usually painful in the first three days, but not otherwise abnormal.

She has called herself perfectly well until a week ago, when she
awoke with a stiff neck, fever, and pain in her neck, back and hips.
She worked that day, but the next day had to go to bed, and has been
growing worse since. She has been seen four times by her physician,

CHILLS

479

who thought at first that she had malaria, as she had frequent chills
during the first three days. More recently he thought it might be
pneumonia.

The bowels have moved only three times in the past week. Last
night she had a chill worse than any of her previous ones. She vomited
a great deal and slept very little.

(For the course of the temperature see the accompanying chart,
Fig. 119.)

The patient's hair is nearly all white. The left pupil is larger than
the right, both reacting normally. She has marked Riggs' disease.
The throat is red, the tonsils somewhat enlarged. The chest shows

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nothing abnormal. The abdomen is rather full below the umbilicus
and slightly tender throughout. The spleen is not palpable. The
most distressing symptom is headache. Her head can be bent only a
short distance forward or sidewise, and then with evident pain.

There is also considerable stiffness of the spine and Kernig's reac-
tion is present on both sides.

Lumbar puncture was done, and 32 cm. of clear thiid withdrawn.
No cells or organisms were found in the sediment. The white cells at
entrance were 16.200. On September 2d they were 9O00; on the sixth,
13,500; on the eighth, 12.600.

The fundus oculi was normal.

480 DIFFERENTIAL DIAGNOSIS

On the sixth of September she passed about 30 ounces of blood by
rectum. The temperature fell, and she became very thirsty and per-
spired profusely.

The next day her extremities were cold and her pulse of very poor
quality, but she had no further hemorrhage, and did very well after
the sixteenth. (See accompanying chart Fig. 119 of the tempera-
ture.)

Discussion. Meningitis is very strongly suggested, and cannot
be positively excluded, but the characteristics of the fluid obtained by
lumbar puncture are strongly against ever}' type of meningitis except
that due to tuberculosis, and not characteristic even of that.

The intestinal hemorrhage is like that occurring in typhoid fever,
and the meningeal symptoms might be explained as meningismus, i. e.,
irritation of the meninges from congestion, toxemia, or edema, without
actual inflammation. Uncomplicated typhoid practically never pro-
duces such a leukocytosis as is here present, and the Widal reaction
is absent, although this fact is not so significant in a case like this seen
early in the course of the disease, as it would be in the later weeks of
the fever. The description of the abdomen is quite consistent with the
signs usually present in tuberculous peritonitis, yet the clinical picture,
seen as a whole, is very different from that of peritoneal tuberculosis.
In the latter disease the symptoms and signs are confined almost wholly
to the abdomen itself, while in this case there is much to call our atten-
tion elsewhere.

A rigid search was, of course, made for any local infection which
might cause the chills. All the familiar situations in which deep-
seated suppuration conceals itself (the ears, the deeper portions of the
axilla, the perirectal tissues, the hepatic region, the urinary tract, the
pericardium) were examined, with negative results.

Finding no other satisfactory diagnosis, we naturally return to
typhoid with some complication producing chills. What can that
complication be? In the reports of the Johns Hopkins Hospital (vol.
v, p. 445) is a study of chills occurring in typhoid fever. The following
causes are discussed:

(a) Chills at the onset of the disease.

(b) Chills at the onset of a relapse.

{d) Chills as a result of treatment (antipyretics, antityphoid vaccina-
tion, and intravenous saline infusion).
(e) Chills due to concurrent malaria.

CHILLS

48l

(/) Chills due to unknown cause (sepsis?) in protracted cases.

In the present case we must classify the chills under the last heading

Outcome. On the sixteenth of September the Widal reaction be-
came positive. On the twenty-fifth of September it was noticed that
for a number of days she had been passing only from one-third to one-
fifth as much fluid by the urethra as she took in by mouth, although
there was no considerable amount of sweating and the bowels were
normal. This remarkable retention of fluid was, doubtless, necessary
in order to make up for the losses suffered both by hemorrhage and as
a result of the fever itself. She continued to improve steadily and went
home perfectly well on the third of November.

Diagnosis. Typhoid.

Case 256

A glazier of twenty-four, whose father died of consumption, was seen
November 13, 1906. He has been perfectly well all his life, but takes
two or three glasses of whisky and three or four of beer every day.

The temperature curve is seen in the following four-hourly chart:

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Ten days ago he had a chill, followed by sweating and weakness.
These chills have recurred ever since that time, usually between 7 and
8 P. M. The chills arc accompanied by pain in the left side of the

482

DIFFERENTIAL DIAGNOSIS

chest and in the back. They usually last an hour and are accompanied
by vomiting. He has been in bed two days.

Physical examination was entirely negative. White cells, 7000.
Hemoglobin, 75 per cent.

Malarial parasites were repeatedly sought for, but never found.
The polynuclear cells made up 88 per cent, of the leukocyte percentage.
Widal's reaction was always negative. The patient looked sick and
toxic. No diagnosis was made.

On the seventeenth of November, in the course of a routine examina-
tion of all parts of the body, an area of reddening and brawny induration
was found in the left buttock, extending along the perineum and up to
the groin. The patient had made no complaint of pain in this region.
The white cells were now 17,000.

Discussion. In cases characterized by chills and fever, when
malaria and neurasthenia can be excluded, the only proper course for
the physician is to keep on looking, day after day, by repeated and
searching physical examinations, for some local cause. Typhoid
fever is, of course, a possibility in a case of this kind, but the high per-
centage of polynuclear cells and the continued absence of a Widal
reaction, after a period of at least two weeks from the beginning of
the illness, makes this unlikely.

The left chest was repeatedly examined for evidence of pleurisy
or empyema, but at no time were there any physical signs of disease
discoverable there.

Tuberculosis and meningitis were considered, but could not be
verified.

The point at which the suppuration was finally found is, I think,
a rather frequent one in cases of this kind. Sometimes we fail to find
it because the patient's modesty and our own too limited physical
examination gives us no hint. In other cases I believe that the sup-
puration actually causes no pain or recognizable physical sign until
it reaches the surface of the body, or, at any rate, the subcutaneous
tissues. Another possibility, which the more frequent use of blood
cultures of late years has brought to our attention, is that the chills
were produced by a non-localized bacteremia which later manifests itself
as an abscess.

Outcome. Operation, November 18th, liberated nearly a pint of
pus. The temperature fell at once, and the patient went home well
three weeks later.

Diagnosis. Ischiorectal abscess.

Fig-. i2]

-Results of

ihvsical examination in Case 257. Complaints: chills and "old-
fashioned stomach trouble."

CHILLS

483

Case 257

An old lady of seventy-one was first seen September 28, 1909. Twentv
years ago, following the menopause, she had two or three chills at inter-
vals of fort} -eight hours. No other symptoms. Since that time she has
had one or more similar attacks ever}' year without known cause or
relation to seasons. Quinin has often been given her, but has no appre-
ciable effect.

No other symptoms occurred until live weeks ago, when she had
an attack of what she called "ordinary old-fashioned stomach trouble,"
i. c, an epigastric pain which "cut its way through the right side to
the back." There was vomiting with this. These
attacks have recurred every second day ever since.
The pain is usually controlled by drugs. Her
appetite has been failing for live weeks. Her stools
have never been light colored, and she has never
been jaundiced. Now she feels well and strong.
(See Figs. 121 and 122.)

Discussion. The patient was an exceedingly
intelligent and frisky old lady who said what she
meant and meant what she said, so that I believe
that she really had had chills off and on for
twenty years a remarkably interesting history.

In a woman of a different type one might
suspect that these chills were of the nervous
variety, but no one who conversed for any length
of time with this patient could entertain such a
supposition.

There was absolutely nothing in the physical
examination to suggest any source or cause for
the chills. She had never been in a tropical

country where she could have acquired relapsing fever. She had no
sign whatever of Hodgkin's disease. There is but one other common
cause for a relapsing or recurring type of fever, such as we may assume
to have accompanied this patient's chills, viz., gall-stones.

This latter possibility gall tone disease is borne out by the at
tack of so-called stomach trouble, for man}" gall-stone pains are referred.
as in this case, to the epigastrium. The most surprising feature, however,
of the case and the greatest difficulty with our diagnosis of gall stoiu^
is the entire absence of jaundice. It is true, of course, that many
perhaps most- cases of gall-stone run their course without jaundice,

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Chart nf case

DIFFERENTIAL DIAGNOSIS

but the particular type of trouble which is prone to produce recurrent
attacks of fever with chills common duct stone with infection almost
always causes jaundice.

Outcome. As the patient refused operation and soon left the hospital
with a rather low opinion of the modern medical profession, we have
no absolute proof that our diagnosis of gall-stones is correct, but I feel
no considerable doubt of it, for we learned later that in a previous attack
one of her physicians had found yellowing of the conjunctivas and bile
in the urine.

Diagnosis. Gall-stones.

Case 258

A married woman of thirty-one was seen October 7, 1909. She
has been working excessively hard for six weeks, caring for four children
at home and working to support them during the illness of her husband.

Has been very short of food and sleep.

One week ago she had a sudden severe
chill and vomiting. Three days ago began
to cough, raising considerable yellow or
brownish sputa. No pain, no headache, no
chill, or vomiting, after the first day. Now
suffers from great exhaustion, anorexia, con-
stipation, and racking cough which disturbs
sleep.

Examination. (See Fig. 123.)
Marked herpes labialis. Chest and belly
negative. Urine and sputa negative. Leuko-
cytes October 8, 11,500; October 13th, 19,000.
No localizing evidence.

Discussion. Since we were unable to
find any evidence of lobar pneumonia or
of bronchopneumonia, we began to think
that the case must be one of those uncharted,
unnamed infectious diseases ordinarily called
"grip." There was not a particle of evidence pointing to any part
of the body as the seat of an abscess or inflammation. I rather
think this was due, in part, to the fact that we had not in mind any
list of the "likely places" where experience has shown that obscure
suppurations are prone to occur. Among these we should have remem-
bered a deep axillary abscess.

Nevertheless, in view of the symptoms with which the disease began

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Fig. 123. Chart of case

2vS.

CHILLS

485

the cough, sputa, herpes, and vomiting I do not believe that the
inflammation was localized from the start in the axillary region. In
other words, when we were looking most fruitlessly for a local source
of infection, there was no such local source. That was a later chapter.
Perhaps in the earlier stages of the disease a blood culture would have
revealed the actual nature of the trouble.

Outcome. October 14th a swollen, tender mass was found in the
left axilla. On the surface of the indurated tissues a few small glands
could be felt; underneath, a deep fluctuation (?) was detected. Incision
released several ounces of very foul pus and revealed a cavity extending
far back under the scapula. The temperature fell after the establish-
ment of the drainage, and in ten days the patient was well.

Diagnosis. Deep axillary abscess.

TABLE XII. Chills. Signs and Symptoms.

Nervousness '

Blood.

Local signs

Negative.

Reassurance.
I >isi ipline.

Pyogenic sepsis

R. , At source of infec- Absorption or

eminent. Leukocytosis. , '

! tion, or 111 heart. drainage.

Phthisis

Remittent.

Usually

leukocytosis.

Lungs. Sputa. Hygienic measures.

Pneumonia

Continued.

Usually

leukocytosis.

Lungs. Sputa.

By progress of
disease.

Gall-stones

Remittent. Not characteristi

Colic.
Jaundice (?).
Enlarged gall-
bladder (t).

Morphin. Opera-
tion. Passage of
stone.

Malari;

lteriiuttent.

Parasites.
I .eukopenia

Enlarged spleen.

I eukopenia.
Typhoid fever (onset) . . Continued. Widal test.

Bacilli by culture

Rose spots.
Enlarged spleen.

By progress ot
disease.

CHAPTER XV

COMA

EXAMINATION OF COMATOSE OR CONVULSIVE PATIENTS

I. CERTAIN HOARY ERRORS TO BE AVOIDED

i. Make no diagnostic inferences from squints or inequalities of the
pupils, and be cautious in all conclusions drawn from pupillary con-
tractures or dilatations. In the majority of comatose cases the state of
the pupils gives us no valuable information. Lack of response to light
is proportional to the depth of the coma, and in hysteric states the
responses are usually normal.

2. Conjugate deviation of the head and eyes has at present no di-
agnostic value. I have seen it in sunstroke and in uremia when the
autopsy showed no local lesions whatever.

3. Stertorous breathing (often mere snoring) means simply deep
coma from any cause. It is not characteristic of apoplexy or of any
other disease.

4. Albumin or sugar in urine with or without casts have usually no
significance. They are far more often seen in non-uremic than in
uremic cases, for they may occur in deep coma from any of its numerous
causes. In uremic cases we have the history, the condition of the heart
and fundus oculi, and usually the evidences of dropsy to guide us.

5. Hemorrhage from the ear often accompanies a coma due to frac-
ture of the base, but it is by no means pathognomonic of this condition,
as injuries to the tympanum or external auditory meatus may also cause
bleeding.

6. Hemiplegia, aphasia, and Jacksonian epilepsy may occur in coma
due to uremia or other non-localized brain irritation. They are not
proof of focal disease.

II. CAUSES OF COMA AND CONVULSIONS

These two manifestations of cerebrospinal disturbance cannot well
be studied separately, since practically all causes of coma are also
causes of convulsions and vice versa.

48(>

Causes of Coma

1. ALCOHOLISM

2. "SYNCOPE"

3. "APOPLEXY" 1

4. POSTEPILEPTIC) ^^^^^^^^^^^^^^^^^^^^^^^^^

EXHAUSTION ^^^^^^^^^^^^^^^^^^^^^^^^^^

5. UREMIA BBHHBB 211

6. MENINGITIS HBHHH 172

7. DEMENTIA

PARALYTICA

8. BRAIN TUMOR 19

1 Although we have treated at the Massachusetts Hospital only 62 cases fur coma clue
to apoplexy during the six years covered bv this report, the statistics of mortality from
apoplexy convince me that this disease must be among the commonest causes for coma.
The patients arc Heated at home.

Id?

COMA

489

The following exceptions may be noted:

(a) Opium and sunstroke cause coma, but very rarely convulsions.

(b) Strychnin and tetanus cause convulsions, but rarely coma.
Otherwise the whole list of diseases shown in the table below are

causes of both symptoms.

CAUSES OF COMA AND CONVULSIONS

Diseases.

I. Brain injuries or dejects:

1. Concussion and traumatic edema 1

2. Compression and laceration (with or with-

out hemorrhage)

3. Congenital defects," with or without hydro-

cephalus, hemiplegia, or idiocy

II. Brain diseases:

' (a) Meningitis (all types) . . .

(b) Apoplexy 3

(d) Sclerosis (dementia
paralytica)

1. With gross
lesions:

(e) Syphilis

2. With microscopic lesions: Epilepsy

III. Infectious diseases (e. g., tetanus, typhoid, ty-

phus, pyogenic sepsis, pneumonia, trypano-
somiasis, malaria, etc.):

IV. Poisons:

1. Alcohol

2. Illuminating gas

3. Lead

4. Opium

5. Strychnin

6. Uremia

7. Eclampsia (puerperal)

8. Hepatic toxemia

9. Diabetic acidosis, cachexia of cancer, and

pernicious anemia

V. Syncope and cardiac weakness:

1. "Simple fainting"

2. Stokes-Adams' disease

3. Valvular or myocardial disease.

4. Pleural irritation (as during irrigation)
VI. Sunstroke

VII. Digestive and injections disorders oj infancy. . .
VIII. Hysteria and malingering

Coma .

Convulsions.

Often

Occasionally

Often

Occasionally

Often

Occasionally

Often

Occasionally

Often

Occasional !v

Occasionally

Often

Occasionallv

Post -convulsive,

Invariable

or in status epi-

lepticus

Late

Early (in children

and in tetanus)

Often

Occasionally

Often

Occasionally

Rare

Often

Very rare

Rare

Often

Occasionally

Often

Occasionalh

Often

Rare

Occasionally

Occasionalh

Often

45 per cent.

Often

Rare

1 Also called "serous meningitis.'' 2 Including birth palsies and accidents.

3 Including cerebral hemorrhage, thrombosis, embolism, and softening.

490 DIFFERENTIAL DIAGNOSIS

In the vast majority of adults the cause of any coma or convulsion
will be found to be:

(a) A brain disease, injury, or defect.

(b) An infection.

((/) A form of cardiac insufficiency.

The details included in these four headings, together with three other
and less common types, are shown in the table on p. 489.

III. VALUABLE CLUES

1. The History. It is always of the greatest importance to question
carefully any available relatives or friends; indeed, it is usually more
valuable than the physical examination. Most of the mistaken diagnoses
in comatose or convulsive states are due, in my experience, to the lack
of a good history.

(a) In comatose patients with head injuries it is essential, though
often impossible, to ascertain whether the injury caused the coma or
the coma the injury. A man falls from a scaffolding and strikes his head.
Did he fall because he was already unconscious perhaps from cerebral
hemorrhage? His comrades may be able to tell us. Another useful
datum in "head cases" is the order of symptoms, and their relation
to the time of the injury. In concussion and traumatic edema the
coma is immediate and any focal symptoms (paralysis, aphasia, etc.).
come later. In traumatic cerebral hemorrhage there is often an interval
of hours or days between the injury (e. g., a boxer's blow) and the focal
paralysis which next makes its appearance. Coma comes later still.

(b) A clear history of syphilis is obviously an important clue.

(t) The mental and motor changes of dementia paralytica should
always be carefully inquired into when an "epilepsy" or a "fainting
spell" appears for the first time after the fortieth year. Fainting and
epilepsy almost never begin after forty.

(d) Cases of poisoning by alcohol, opium, lead, or gas are usually
seen under conditions which make the history (and, therefore, the
diagnosis) clear. Hut in police stations, where the Saturday-night
"drunks" are gathered in, the question, "Drunk or dying?" not infre-
quently arises. Cases of alcoholic pneumonia more or less comatose
and delirious are treated and die as "common drunks" because the
temperature and the lung signs are not investigated. Cerebral hemor-
rhage may occur during a drinking bout, and the obvious odor of alcohol
may then prevent our making any distinction between the drunk and the
dving.

COMA 491

(e) Uremia, without any previous history of the ordinary symptoms
of nephritis, is, I believe, a very rare occurrence, when the physical
examination leads to the diagnosis of uremia and the history does not
support such a diagnosis.

2. The Physical Examination. (a) The temperature is most apt
to throw light upon the case if a normal reading is found, for thereby
we can usually exclude the acute infections as causes of coma or convul-
sions. Very high temperatures (107 , no, 115 F.) are strongly sug-
gestive of sunstroke if the weather gives any countenance to the idea.

(b) A slon pulse occurs especially with tumors, injuries, and infections
of the brain; less often in opium-poisoning.

(c) Evidence of cardiac hypertrophy and vascular hypertension are
of importance as suggesting that the brain or the kidney is the source
of the trouble.

(d) The presence of a lead line and of basophilic stippling in the
red corpuscles is occasionally of the greatest importance, and should
always be sought for in doubtful cases.

(e) Evidences of hemiplegia (unilateral increase of knee-jerk,
Babinski's reaction, increased or diminished muscular tonicity on one
side of the body, unilateral analgesia) point toward the brain, but not
necessarily toward any gross lesion therein, since hemiplegia may occur
without any such lesion in uremia and in epidemic meningitis.

(/) Lesions suggesting syphilis are sometimes discoverable in the
bones, glands, skin, or nasopharynx. The presence of such lesions
gives us ground for suspecting that similar disease of the brain may be
responsible for the coma or convulsions which we are studying.

(g) Spinal puncture may give us information of life-saving value,
as, for example, in epidemic meningitis. More often it may help us to
identify a syphilitic or metasyphilitic lesion.

3. The Recognition of Hysteric States. There is only one way
of being comatose, and, save for the peculiarities of individuals, there
are no distinguishing marks or qualities in any of the varieties of coma
above referred to. Their causes arc distinguished by the accompany-
ing physical signs or by the history, not by the characteristics of the
coma itself.

Hysteric states are rarely true coma, and the distinction, which may
be of considerable importance, rests mainly upon the following points:

(</) By appropriate stimulus the patient can be roused. This
>timulu> may be a pail of water or a well-chosen remark. The patient
may, however, be quite insensible to pain, and apparently so to noise
or litrht.

492 DIFFERENTIAL DIAGNOSIS

(b) The motions or attitudes during the apparently unconscious
period are usually semivoluntary or purposive. Grasping movements
and efforts at resistance, as when, for example, the nose and mouth are
covered, are especially characteristic. The clonic spasms which so
often occur in coma are not seen in hysteria. Hypertonicity and opis-
thotonos are frequently seen.

(r) Tremor or flickering of the eyelids and rolling up of the eye-
balls are very common.

(d) In falling, the patients almost never hurt themselves, and during
the convulsions there is rarely any biting of the tongue or relaxation of the
sphincters. Often there is confused talk or screaming.

I will now exemplify a few of the causes of coma; many others will
be found in the chapter on Convulsions, because the spasm was more
striking than the coma in these cases.

Case 259

A Russian housewife of forty-eight, whose father died of a "cold in
his foot," * had typhoid fever in childhood, but has otherwise been well
all her life. She passed the menopause three years ago.

For three or four months she has complained of "rheumatic" pains
in her limbs, with headache, constipation, and loss of appetite. For
two or three days she has had distress about the precordia. To-day
at i p. M. this distress increased until she was forced to lie down, follow-
ing which she became comatose. After two or three minutes she regained
consciousness and screamed violently for several minutes on account
of precordial pain, which apparently did not radiate at all.

These attacks recurred every ten to fifteen minutes until seven in
the evening. She vomited six or seven times during the afternoon, and
when seen at n P. M., complained of palpitation and a sense of weakness
about her heart.

A physician who saw her in one of her "fainting attacks" previous
to her entering the hospital said that she was practically pulseless during
the period of unconsciousness.

Subsequently it was learned that she had been subject to fainting at-
tacks for over thirty years, and had had a goiter for the same length of time.

Physical examination revealed the tumor above referred to, which
was about the size of a hen's egg, situated in the median line, smooth,
rounded, not tender, moving with the larynx on swallowing.

Upon inspection the heart's impulse was very diffuse, apparently
extending a half inch outside the nipple in the fifth space. There were

1 Gangrene presumably.

COMA

493

no murmurs, and physical examination was otherwise negative; blood
and urine normal.

The patient presented chiefly the picture of exhaustion. She com-
plained of various pains in her arms and legs. The pulse during most
of her stay in the hospital was very irregular, but there was no repetition
of the attacks of syncope.

On February 7th, when the pulse was no, there was noticed a pulsa-
tion in the jugular veins, filling from below at exactly twice the rate of
the arterial pulse. On the eighth there were three beats in the neck for
every one at the wrist.

Discussion. Fainting attacks often repeated usually turn out to
be due to some important underlying disease. One should always
look with great suspicion upon any attack so designated if it is known
to have occurred frequently. Hysteria is perhaps the disease which
turns out most frequently to be the cause of attacks of this nature,
but I have known also cases of nephritis, of cerebral tumor, and of
epilepsy which have been called "fainting attacks" for months or years
before the real cause was recognized.

In the present case, since physical examination is so nearly negative,
the most important diagnostic feature is the report by the physician
who watched her in one of these fainting attacks and noticed that she
was practically pulseless. In the absence of any obvious valvular
disease, this observation should lead us to suspect disease of the myo-
cardium and to study very carefully the condition of the neck veins
during attack.

Outcome. February 7th it was noticed that the jugular veins
filled from below and pulsated at exactly twice the rate of the arterial
pulse. After two weeks' rest in bed and the administration of iodid of
potash the patient seemed much benefited. She was seen two years later
and stated that she had had no recurrence of the "fainting fits," although
from once a month to once in three months she had had severe attack?
of precordial pain relieved by rest and applications of heat. She now
passes water two or three times each night, and has had various attacks
of infectious arthritis and one of erysipelas. The goiter remains un-
changed.

Diagnosis. Stokes- Adams' disease.

Case 260

An unmarried Russian seamstress of twenty, whose mother died of
diabetes, lost her father and one sister of tuberculosis. Three brothers
and one sister are well.

494

DIFFERENTIAL DIAGNOSIS

The patient herself became much run down five years ago and
was sent into the country, apparently for suspected tuberculosis, though
her cough was not very persistent, and her sputa was never examined.
She was first seen April 14, 1908.

Four days ago she became excited and fell unconscious. There
were no convulsion and no paralysis, but she was somewhat rigid during
the attack, and she has since then been in bed and has vomited every-
thing that she has taken by mouth. Constant vertigo and palpitation,
with epigastric pain, have been her complaints.

On examination, the heart's apex was
found one inch outside the midclavicular
line in the fifth space. There was a pre-
systolic thrill and murmur at the apex. The
sounds were very irregular, and at times
amounted to delirium cordis. The pul-
monic second sound was sharply accentu-
ated. At times a systolic murmur was
heard, following the very sharp first sound
at the apex. As is shown in the accom-
panying chart (Fig. 124) many heart-beats
failed to reach the wrist. 1 There were fine
crackling rales at the base of both lungs,
especially on the left side.

The abdomen was tender and rigid in
the right hypochondrium, and dulness ex-
tended two inches below the costal margin;
no edge was felt. Blood and urine nor-
mal.
Despite the extreme rapidity and irregularity of the heart, there was
no cyanosis or orthopnea.

Discussion. The essential features here are the tuberculous family
history, the "fainting fit," and the present condition of the heart.

The latter shows all the evidences of mitral stenosis rather poorly
compensated. Probably she has to thank this heart trouble for her
freedom from tuberculosis.

To what should we attribute the attack of coma? In many respects
it resembles an hysteric attack. Patients who faint very seldom do
so as the result of valvular heart disease, although there is no symptom
except "pain about the heart," which so often alarms a patient about

124. Chart of case 260.

1 In this chart the line immediately above that representing the pulse stands for the
number of heart-beats counted at the apex.

coma 495

his cardiac condition. Of the numerous patients who have consulted
me believing that they had heart trouble because of the occurrence of
"fainting fits," I have never found heart disease in a single case. The
sufferings of this patient are, therefore, all the more interesting. Care-
ful inquiry into her previous history showed that she had had similar
attacks in childhood, and had always had a decided tendency toward
hysteria. In view of this it is probably true to say that her heart disease
was only a contributing cause of her "fainting fits."

It must not be forgotten, however, that in cases of mitral stenosis a
thrombus often forms in one of the left auricular appendages, whence
a bit is detached and carried to the brain, producing embolic hemiplegia.
Possibly a minute embolus or a group of such emboli might produce a
"fainting fit" without paralysis, but this conjecture is so far wholly
unsupported.

Outcome. The patient was given I grain of morphin subcutane-
ously and fed on milk and lime-water in small amounts. The bowels
were moved by small doses of calomel, followed by a suds enema.

On the fourteenth of May the heart-beats all reached the wrist.
On the twenty-third she was able to walk about, and had no complaints.

Diagnosis. Mitral disease (and hysteria?).

Case 261

A club waiter forty years old has been at work as usual during the last
five days, as is learned from the manager of the club where he was
employed. He was first seen August 7, 1907. He has done no heavy
work, and nothing is known of his previous history. It has been noticed
that his color is poor, and he has expressed a fear that he might have a
breakdown. Night before last he had an attack of dyspnea, from
which he recovered, however, without medical attendance. The next
day he did his work as usual, but seemed irritable and rude, so that he
was warned by the manager. This morning at 5 o'clock he was found
lying on the grass outside the club. He said that he went out there to
get the air. He seemed very short of breath, but walked to the porch
and sat down. On his way thence to the hospital he became unconscious,
and at the time of his entrance was almost moribund.

His nutrition was excellent, his color dusky. The heart's apex was
in the anterior axillary line, in the sixth space. The sounds were very
irregular in force and rhythm; no murmurs were heard. Tracheal
rales were so loud as to make examination of the heart and lungs very
difficult. Respiration was very rapid and irregular. The liver seemed
to be slicrhtlv enlarged.

496 DIFFERENTIAL DIAGNOSIS

Outcome. The patient died within a few hours. Autopsy showed
chronic endocarditis of the mitral valve, with mitral stenosis; general
arteriosclerosis; hypertrophy and dilatation of the heart; hydrothorax;
hydropericardium ; cicatrices in the liver.

Discussion. Why was this patient's death so sudden? The vast
majority of cardiac cases die in their beds after prolonged periods of
dropsy and dyspnea. Now and then a case either of the valvular type
(chronic endocarditis), of the arteriosclerotic, or of the syphilitic types
dies suddenly.

In a number of such cases no coronary disease, no pulmonary em-
bolism, and no other sufficient cause for sudden death can be found post-
mortem. I have seen so many fruitless examinations of this sort that I
no longer count on the pathologist to explain by mechanical causes the
sudden death in cardiac cases.

Some ultramechanical, perhaps some chemical, explanation must be
sought.

Diagnosis. Chronic valvular disease. Sudden heart failure from
unknown cause.

Case 262

An Irish housemaid of twenty-five was seen November 30, 1909.
The previous morning she had seemed perfectly well and in good spirits.
At 9 p. m., November 29th, she suddenly became unconscious and fell
to the floor, though her brother caught her, so that her head did not
strike. After this she vomited several times without regaining con-
sciousness.

This morning she roused enough to moan and complain of severe
headache, but soon lapsed into coma again.

Examination. Temperature, 101.6 F.; pulse, no; respiration, 22.

Blood-pressure, 245 mm. Hg. Leukocytes, 28,000. Urine clear,
acid, 1020; very large trace of albumin; no sugar. Sediment negative.
Left pupil slightly larger than right. Both react sluggishly to light.
Left arm and leg moved but little on sensory stimulation. Babinski's
reaction on the left. Knee-jerks and Achilles jerks absent.

Physical examination was otherwise negative.

Lumbar puncture was done, and blood-tinged serous fluid spurted
nearly a foot through the needle. The sediment of this fluid showed
no excess of leukocytes and no organisms in cover-slip or culture. Vene-
section gave no relief.

Fundus examination showed double optic neuritis.

Discussion. Coma, leukocytosis, fever, and hypertension with

COMA

497

pupillary inequality and apparently a left hemiplegia are the essentials
of this case.

The negative character of the spinal fluid is sufficient to exclude
meningitis.

Diagnoses of uremia made under these conditions always turn out
wrong. The reasons for this I have discussed more fully on p. 509.

The content of the spinal fluid makes syphilis unlikely, especially
in a girl with no previous history or lesion suggesting that disease.

Apoplexy, using this old term to include cerebral hemorrhage,
thrombosis, or embolism, with or without softening, is practically un-
known in a girl of this age so long as the heart is negative.

The double optic neuritis with the very high blood-pressure and
the normal heart points strongly toward cerebral tumor.

Outcome. The patient died suddenly of respiratory failure De-
cember 2d. The temperature, pulse, respiration, and leukocyte count
remained practically as at entrance. After lumbar puncture she moved
all parts of her body freely, complained of headache, and answered a
few questions clearly and with comprehension.

It was learned later that she had had several attacks of vomiting
during the past summer, and that her eye-sight had not been good.

Diagnosis. Cerebral tumor (?).

49 8

DIFFER EX XI A L DI AGX OSIS

Paralysis or
spasm.

Usually

hemiplegia.

< )ccasionally
transient.

Rarely

paralysis.
Often spasm.

Often,
o

Flaccid, wide-
spread paraly-
sis, as a rule.

Stiff neck
and Ker-
lllg >. sign.

3 3 rt +

Fundus oculi.

May show

arteriosclerosis.

< >ften albumi-
nuric retinitis.

No constant
changes.

Choked disc.

Changed color

field.

Occasionally

retinitis or
optic atrophy.

Circulatory
anomalies.

Usually hyper-
trophy and
hypertension.

Often
hypertension.

Urine.

Occasionally
casts and
albumin.

Negative.

Usually casts
and albumin.

Sugar not charac-
teristic. Acetone
bodies more so.

Not
characteristic.

Spinal fluid.

Negative.

Sometimes
bloody.

: Negative.

Under high
pressure.

1 Bacteria and

cell count

characleristic.

Lympho-
cytosis.

Under high
pressure.

Causes of Convulsions

1. ECLAMPSIA (PUERPERAL)

2. INFANTILE SPASM

3. ALCOHOLISM

MHH^MaHIMHl^HB^HBMBMi^^ 544
uremia tmrnammmma^ammmm

6. HYSTERIA ^^^H 108

7. MENINGITIS Hi 28

5u0

CHAPTER XVI

CONVULSIONS

Case 263

An Irish longshoreman of fifty entered the hospital November 17,
1907. He has been a steady, hard drinker for many years, but denies
venereal disease, and has been otherwise well. Four years ago, he
says, he had a fit, which lasted twenty minutes; nothing of the sort
has occurred since. All last week he drank hard. He spent Saturday
night at the Salvation Army rooms. On Sunday,
November 17th, while attending a Salvation Army
meeting, he became unconscious.

When examined at 5:25 P. m., November 17th,
he was still unconscious and in convulsions, at times
confined to the right side, later general, and succeed-
ing each other without intermission.

There was a deep, bleeding cut on the chin, and a
shifting strabismus of the eyes. Marked hyperreson-
ance of the lungs made it impossible accurately to
estimate the size of the heart. Its sounds were also
obscured by snoring rales, but the arteries showed no
evidence of degeneration, and physical examination was
generally negative. For temperature, see the accom-
panying chart (Fig. 125). The blood showed nothing
abnormal.

The urine was pale, 102 t in specific gravity, with
the slightest possible trace of albumin. One finely
granular cast was found in the sediment.

Blood-pressure was 125 mm. Hg.

Discussion. Tn the absence of any obvious localizing brain symp-
toms or signs, epilepsy is naturally our first thought, especially as we
know that an attack of epilepsy is apt to be precipitated by acute
alcoholism. But if we are to take the history on its face value and
understand that there has been but one attack previously, it seems
unlikely that a man of this age would become epileptic so recently.

! :

: : :

Fig. 125. Chart of
case 263.

5<D2 DIFFERENTIAL DIAGNOSIS

In the urinary examination quoted nothing is said about sugar, but
even if it were known to be present, its quantity cannot be large in view
of the specific gravity of the urine, and it may be further stated that,
although diabetes may produce convulsions, it practically never does
so "out of a clear sky" that is, in patients who have not previously
known themselves to be ill or suffered any of the cardinal symptoms of
diabetes.

Meningitis might begin in this way, and the chart is consistent there-
with, but a knowledge of the results of lumbar puncture would be neces-
sary before any such diagnosis could be made, since we have none of
the ordinary manifestations of meningitis (cervical rigidity, Kernig's
sign, squints and pupillary changes, headache, vomiting, and delirium).

Of lead-poisoning, of dementia paralytica, brain tumor, or abscess
all of which might cause similar convulsions we have no evidence
either in the history or in the physical examination. Hysteria and
trauma need not be considered.

With the exclusion of these alternatives the most reasonable hypothesis
remaining is that the alcohol is the source of the trouble. From con-
versations with physicians who attend the Saturday-night drunks in city
prisons my own more limited experience of ''rum fits" is fortified in
making the following division into three groups:

(a) An alcoholic debauch may make a person hysteric and so pre-
cipitate hysteric convulsions.

(b) Alcohol may bring on one of the regular epileptic attacks in a
patient already suffering from that disease.

(c) A true "rum fit" may be produced by alcohol in a person not
epileptic or hysteric. These fits are presumably due to the cerebral
changes ("wet brain," vascular crises) produced by alcohol.

The present case seems to belong to the third group.

Outcome. The patient was bled about 20 ounces, and an equal
amount of saline solution was injected. About 10 p. m. he regained
consciousness and remained thereafter practically normal. Later he
admitted that his present trouble began on the second night of his last
spree. The bystanders say that there was no cry at the time he fell
and the sphincters were not relaxed. He was discharged well on the
twenty-second.

Diagnosis. Alcoholism.

Case 264

A housemaid of twenty, of good family history and past history,
entered the hospital February 12, 1908. She has been irregular in her

CONVULSIONS

503

menstruation for the past six years, and has been subject, during that
period, to frequent severe left-sided headaches and to attacks of uncon-
sciousness. These attacks are apt to occur on the first day of menstrua-
tion, but they may come in the middle of the intermenstrual period.
She has considerable pain in the lower abdomen during the first two
days of menstruation, otherwise the function is not abnormal. During
her attacks of unconsciousness she falls, but sometimes can get up and
steady herself by taking hold of something. She is then apt to become
violent, going out of her head, frothing at the mouth, often gripping
her throat with her hands, sometimes bleeding from the mouth and
nose. She has never injured herself nor passed urine during an attack.
The attacks last from a few minutes to a few hours.

Her last menstruation ceased five days ago. Two days ago, while
sweeping, she felt dizzy, fell down, and says she remembers no more
until she was seen at the hospital. From her friends it was learned
that after her fall she was put to bed, where she threw herself about
and talked incoherently all day. At 7 in the evening she apparently
came to, and was taken home from her place of work at 11 p. m. She
again became unconscious and lay still in bed with limbs rigid.

Yesterday she awoke and said she felt well. She went to work
at 8 o'clock in the morning, but an hour later again fell unconscious
and rigid and remained so until this morning at 6, when she was partial lv
aroused by an enema of soapsuds, but became again unconscious after
twenty minutes. She has taken no food for four days, according to
her own statement. She has been very constipated for years. During
these attacks she says her feet are apt to swell, but at other times they
are never swollen.

Physical examination showed a well-nourished girl, herpes on her
lips, dozing most of the time, apparently rational when aroused, but
apathetic and complaining of headache and abdominal pain.

SS//////sV//

-TO

1 ig. 126. Diagrammatic representation of upper median incisors in case 264. They
are set far apart and are malformed, curving toward ea< h other at the ends.

The upper and median incisor teeth are malformed. Hie other
teeth arc in fair condition. (Sec Fig. 126.) The pupils are dilated
and react sluggishly to light and distance. The vault of the palate
is very high and narrow. She is a mouth-breather. The heart's apex
is in the fourth interspace, one-half inch outside the midclavicular line.
The sounds are of good quality. At the apex there is a loud systolic

504 DIFFERENTIAL DIAGNOSIS

murmur, heard clearly in the axilla, faintly in the pulmonary area.
This murmur, or a similar one, is heard in the tricuspid area, and there
it seems to be of a higher pitch and different quality. In the tricuspid
area the first sound is much louder and sharper than in the mitral area.
The pulmonic second sound is slightly accentuated. There is a systolic
venous pulse in the neck. The radial pulses are not in any way remark-
able. The abdomen and reflexes are not abnormal. Sensation is
apparently normal.

During the first night after her arrival the patient complained of
headache and severe abdominal pain. Half an hour later she began
to grow rigid and clutched the blankets firmly. She then became
apparently unconscious. Her pulse was 76, respiration 44. When
the lighted lamp was held in front of her she closed her eyes more tightly.
When they were forcibly opened, the balls were found to be rolled up,
and she turned her head as if to avoid the light. The rigidity of the
arms could be overcome, though with difficulty. It seemed to be
partially voluntary. A pin could be passed through a fold of the skin
without causing any change of expression or any motion.

After half an hour of this rigidity the patient became again sensitive
to pain and would reply to questions.

On the twenty-first she complained of a severe headache, which
immediately disappeared under the ethyl chlorid spray. The attention
then became concentrated on the abdominal pain. After that the
headache did not return and she said the treatment cured her.

Discussion. The symptoms in this case and the description of the
attack remind us very strongly of hysteria. Two other possibilities,
however, must first be considered.

Can the malformation of the incisor teeth be interpreted as a lesion
of congenital syphilis and the convulsions be also due to that disease ?
This is very improbable, for aside from these attacks there is nothing
in the patient's condition or history to suggest syphilis, a disease which,
in its congenital form, almost always appears earlier than in the twentieth
year. The nature of the attack, moreover, is not at all characteristic
of cerebral syphilis, of which more anon. The malformed teeth are
not of the Hutchinsonian tvpe.

Can the tricuspid regurgitation, evidenced by systolic venous pulsa-
tion in the neck, the swollen feet, and the murmur in the tricuspid area,
account for the attack? In answering this question it must first be
noticed that the tricuspid regurgitation must be slight if, indeed, it
exists at all in any pathologic sense. Many observers believe that a
slight degree of tricuspid regurgitation is physiologic. As a result of

CONVULSIONS

3 U :>

various strains or accidents we may conceive that this physiologic
reflux is more or less exaggerated, but one can hardly believe that its
effects would be so disproportionately concentrated upon the brain
as to produce convulsions without bringing about any more obvious
stasis in the other internal organs.

With the exclusion of these two possibilities we may conclude that
the attack was due to hysteria. The present case exemplifies many of
the characteristic signs by which hysteric convulsions have traditionally
been differentiated from those due to the other causes discussed in this
chapter. Such characteristics are:-

(a) The absence of deep coma.

(b) The semivoluntary and semiconscious nature of the motions
(e. g., such as to prevent her hurting herself in falling, grasping motions,
talking, resistance of efforts to open the eyelids).

These characteristics hold good in probably the large majority of
hysteric cases, but it must be realized that these and all the other signs
by which we have sought to differentiate hysteric Jrom epileptic convul-
sions may jail us. Attacks which, on the whole, must be judged hysteric
may occur in the night during sleep, may be accompanied by biting of
the tongue and all the ordinary evidences of an epileptic fit. I have
recently known such a case in which the cause of the spasms was found
to reside in a partly subconscious knot of morbid ideas, acquired in
childhood, reenforced by the abnormal conditions of a girls' boarding-
school, and finally removed as a result of psycho-analysis and Freud's
cathartic method. Attacks which can be thus abolished must be
recognized, I suppose, as belonging to the hysteric group.

The reasonable conclusion is that, in doubtful cases, we cannot rely
upon the precise nature of the movements or on individual features of
attacks to differentiate hysteria and epilepsy. ( )nly by a study of the
possible causes in the patient's mental life and by the therapeutic test
(i. e., the attempt to remove these causes) can the nature of the malady
be determined. This is in line with Babinski's conception of hysteria.

Diagnosis. Hysteria.

Case 265

A married woman forty-eight years old entered the hospital January
t, iqo8. Her last menstrual period was in the preceding September,
and she has apparently readied the menopause. She has had nervous
prostration three times, the last time two years ago. Five days ago

506 DIFFERENTIAL DIAGNOSIS

she was taken with influenza and confined to bed. She was first seen
by her physician three days ago, when she suddenly collapsed from
''acute heart failure" and pain in the back.

The doctor found her much exhausted, pale, very dyspneic, and
partially stuporous. At frequent intervals, three times within an hour,
the pain in her back became very severe; the muscles of the trunk were
rigid and all the muscles of the body twitched convulsively. Nitro-
glycerin afforded much relief. The next day the paroxysms of pain
continued and she lost the use of her limbs. For twenty-four hours
she had retention of urine, and 40 ounces were finally drawn by catheter.
Within the last twenty-four hours the use of her limbs has in part re-
turned, but the pain in her back continues and is sharp when she tries
to move. The attacks of pain are still accompanied at times by muscular
twitching.

When first seen, her temperature was 102.2 F. During the first day
in the hospital it was ioo F.

Visceral examination was negative, as were reflexes, the urine, and
the blood. Blood-pressure, 135 to 140. The pharynx, larynx, and
trachea were markedly injected, and there was herpes on the lips.

By the fifth of January she was much better and able to be up, but
was very unwilling, even on the thirteenth, to leave the hospital. On
the thirtieth she was able to do so.

Discussion. There are some indications of an acute infection
here, especially the red throat and the herpes on the lips. It is a very
familiar fact that in children the onset of acute infectious diseases often
produces a typical epileptiform convulsion. It seems possible that the
present attack may be the equivalent of such a convulsion, modified
by the age of the patient, although the precise nature of the infection is
unknown ("influenza").

Some facts in the case, however, suggest a different type of convul-
sion. The intense pain in the back, the rigidity of the trunk muscles.
the temporary loss of power in the limbs, the retention of the urine, are
all of them symptoms consistent with some type of organic disease of the
spinal cord or its membranes. The difficulty with this idea is that
closer scrutiny of the symptoms fails to find any arrangement among
them corresponding to any known disease, while their outcome seems
to show that no permanent lesion has occurred in the central nervous
system.

By the results of physical examination it is possible to exclude
organic brain disease, such as meningitis, dementia paralytica, abscess
or tumor, and apoplexy. There is no evidence of poisoning by lead

CONVULSIONS

507

nor of any organic disease of the heart and kidney. There has appar-
ently been no previous attack resembling the present one, and an epilepsy
beginning at forty-eight is always an improbable diagnosis.

In view, therefore, of the negative result of physical examination
directed to reveal the ordinary organic causes of convulsions we may
conclude that this attack is of functional type, ordinarily, though some-
what loosely, designated as "hysteria." This diagnosis, however, does
not end our study of the actual nature of this attack.

Two points are of especial interest in relation to this particular
example of the vague type of spasms known as "hysteric" or "func-
tional." We have, in the first place, to consider the possible influence
of the psychic elements which may have been introduced quite uncon-
sciously by her physician and friends. It will be noted that she is said to
have suddenly "collapsed" as a result of "acute heart failure." Now
these phrases have a very great effect upon the mind of a patient and
thereby upon his symptoms. We often see what a great benefit may
be produced in a patient when we persuade him that his headache is
not in "the base of his brain," but merely in the nape of his neck, or
that the pain in the left side of his chest is not "around the heart,"
but merely in the stomach or in the ribs.

A corresponding aggravation of symptoms is pretty sure to follow
if, by chance, such phrases as "collapse" or "acute heart failure" are
let loose in the patient's vicinity, whether they are from the patient's
own lips and merely corroborated by the physician, or whether the
patient overhears them in the conversation of relatives or bystanders.
Particularly in their early stages, functional attacks may be greatly
relieved if we call a spade a spade, rather than an agricultural instru-
ment. To make light of symptoms which our physical examination
assures us are not of serious importance may shorten by man}' days the
patient's illness, while, on the other hand, suggestions conveyed by a
grave and serious expression reflected from the doctor's face to the
family, by the terminology used or permitted by the doctor, or by the
nature of the remedies employed, may greatly aggravate and prolong
the patient's sufferings. For example, 1 remember a case of post-
operative pleurisy in which the patient, who was high strung and pretty
well tired out previous to the operation, began to breathe very rapidly,
so that the nurse in charge brought in a can of oxygen and administered
it at regular intervals. The patient took for granted that this was
done by the doctor's orders. Hut his previous hospital experience, in
connection with an appendix operation, had led him to associate the
arrival of the oxvgen can with the most serious and even terminal >taucs

508 differential diagnosis

of disease. He had noticed that pretty soon after the oxygen can was
carried into a patient's room the patient himself was carried out dead.

As a result of putting two and two more or less unconsciously together
in this way, my patient became greatly alarmed about himself, was
hardly able to breathe, and totally unable to sleep. Soon after, his
physician came in, was greatly surprised at the sight of the oxygen can,
promptly ordered it out, and irritably asked the nurse, in the patient's
hearing, what on earth she ''had brought that thing in for when there
was not the slightest need for it." The patient soon afterward went
to sleep, and awoke next morning much improved. He afterward
confessed to the writer how the sight of the oxygen can had affected
him, and how profoundly its removal had relieved him.

The other point of interest in this case is the relief by nitroglycerin.
In Pal's book on Vascular Crises, to which I have already referred, he
shows that any type of vascular spasm, cerebral, cardiac, pulmonary,
abdominal, or peripheral, may be relieved by the administration of
nitroglycerin, and uses the fact of such relief as corroborative evidence
of the nature of the attack. Now this patient is apparently at the meno-
pause, a period in which disturbances of vasomotor balance are notori-
ously frequent, manifold, and annoying. Is it not possible that this
attack was of the nature of a vascular crisis induced by the onset of an
acute infection at an especially sensitive period of life? In the present
state of our knowledge no definite answer can be given to this question.

Diagnosis. Hysteria.

Case 266

An unmarried woman, thirty-eight years old, was seen in consulta-
tion at 8 a. m., September 26, 1909.

She had suffered all her life from periodic headaches occurring
every two to four weeks, more especially at the time of menstruation.
Aside from these attacks, she had never been sick, and seemed to be
vigorous in every respect. On the nineteenth of May she went to bed
with one of her regular headaches, so it seemed. During the day she
had seemed as well as usual. About 1 o'clock in the morning her sister,
who slept in the same room with her, was aroused by some curious
sound, and found the patient unconscious and in a convulsion. When
seen in consultation at 8 o'clock a. m., she was conscious, but very
drowsy and heavy. Between 1 a. m. and 8 A. m. she had had six general
tonic-clonic convulsions, five of them accompanied by complete loss
of consciousness, each lasting about a minute, and followed by profound
relaxation with deep relaxed breathing.

CONVULSIONS

509

Physical examination of the chest and abdomen was negative. The
reflexes were all somewhat exaggerated, especially on the left side, and
at times Babinski's reaction could be elicited on the left. The pupils
were moderately dilated, the left larger than the right, and responded
rather sluggishly to light stimulus. When conscious, she was aware
of no pain, and although she had been more or less nauseated, there
had been no vomiting. The urine drawn by catheter showed specific
gravity of 1014, 0.125 per cent, of albumin, a moderate number of
hyaline casts, some with granules or cells adherent. There was no
edema anywhere. The blood-pressure was 138 mm. Hg.

The convulsions were usually preceded by some shaking of the left
hand, extending thence to the foot and leg, and then becoming general.
The eye-grounds were not examined. The temperature was 101.3 F.;
pulse, 100 between convulsions, becoming rapid and feeble during and
after them.

The blood showed 16,000 white cells, 81 per cent: of which were
polynuclear.

The bowels were moved by enema, and showed nothing of impor-
tance in the intestinal evacuation.

Discussion. When I saw this patient, a diagnosis of uremia had
already been made by the attending physician. Against this I imme-
diately rebelled in my own mind, even in advance of accurate physical
examination. For this prejudice I had two reasons: First, I had
recently heard one of the wisest and most experienced clinicians in the
world say that he had never known a diagnosis of uremia, made when
the patient was seen for the first time in coma, to turn out correct. By
this he meant that the correct diagnoses of uremia are those made in
chronic cases, not those made in patients who, out of a clear sky, with-
out any previous complaints, have suddenly fallen in coma or convul-
sions.

My second reason was that in the study of 1500 postmortem examina-
tions made at the Massachusetts General Hospital within the last ten
\ears I have been unable to find a single case in which the diagnosis
of "acute uremia" had been confirmed at autopsy. I found many in
which this diagnosis was shown to be erroneous.

This mistake results, no doubt, because nearly all cases in which
coma or convulsions suddenly supervene, show albuminuria and casts,
sometimes in great abundance. This is true whatever the cause oj the
seizure.

Nocturnal epilepsy with status epileptic us seemed very improbable
because the patient's sister had been in the habit of sleeping in the si me

5 TO DIFFERENTIAL DIAGNOSIS

room with her for some years, and had never known of any similar
attack, nocturnal or diurnal.

The absence of any previous cardiovascular or renal disease, the
normal condition of the heart and blood-pressure, the absence of any
historv or present evidence of syphilis, made apoplexy and vascular
crises somewhat improbable.

Cerebral tumor and abscess have been known to begin or rather to
show themselves for the first time with symptoms like those here de-
scribed, and there is nothing by which we can positively exclude these
lesions. We should expect, however, a higher blood-pressure. Fundus
examination, which was not made in this case, might be of decided assist-
ance, since the vast majority of cases in which a cerebral tumor produces
convulsions also show optic neuritis (choked disk).

What is the significance of the leukocytosis here present? Experience
has shown me that the leukocyte count is practically valueless as a source
of information in cases involving coma or convulsions. Whatever the
cause of these symptoms, leukocytosis is practically always present.
In cerebral hemorrhage, for example, it is almost constant. In this
case, therefore, as in others, I disregarded it.

Utterly in the dark as to the diagnosis, it seemed to me possible
that some light might be shed upon it, or possibly some relief given to
the patient's symptoms, by lumbar puncture. As will be shown by the
outcome, this puncture turned out to be of critical, indeed, I think, of
life-saving, importance. Its value in this case was such that I shall
in future never be content unless it is done in every doubtful case involv-
ing coma and convulsions.

The fever here recorded has as little diagnostic value as the leuko-
cytosis. It is in nowise indicative of an infectious process, but occurs
with equal frequency in all types of coma and in all diseases producing
convulsions.

Outcome. A needle introduced into the spinal cord drew 37 c.c.
of clear, transparent, colorless fluid. Of the cells contained within the
sediment of this fluid seventy-eight per cent, were polynuclear, and
both within and without the leukocytes a diplococcus was seen which
corresponded with the diplococcus of epidemic meningitis.

Flexner's antimeningitic serum was injected several times. The
patient made a complete recovery, although for a few hours on the sixth
day she became suddenly and completely blind. The attack, however,
left no untoward effects behind it.

Diagnosis. Epidemic meningitis.

CONVULSIONS

Case 267

A plumber of sixty-two, one of whose children died of consumption,
had been an intermittent hard drinker for many years, taking rather
more of late sometimes a quart of whisky a day. He entered the
hospital January 29, 1908. Every night for two or three years he has
filled a chamber vessel with pale urine and has been seen to drink
much more water than formerly. He has had no headache, no cough,
no vomiting, but has belched a good deal of late. His eye-sight has been
good.

At 2 o'clock on January 29th he had a convulsion in a street car,
and was brought at once to the hospital, where he immediately had a
second convulsion, after which he was very restless,
struggling and throwing himself about on the table.
At first he said nothing and did not answer ques-
tions, but later he swore profusely. There was no
odor of alcohol or of acetone on the breath. The
right pupil was larger than the left; both reacted
well to light and accommodation. The tongue was
very dry and red. No enlargement of the heart was
made nut, and there seemed to be no accentuation of
either second sound. Blood-pressure was 1 70 mm. Hg.
The artery walls were palpable and tortuous. The
lungs were hyperresonant throughout. Breath-sounds
were accompanied by many medium, crackling rales
over both lungs. The abdomen was held somewhat
rigidly, but nothing abnormal was detected.

During this examination he had a third convul-
sion lasting about three minutes, quite epileptiform
in type, with coma. The course of the temperature Fi 6- >-; t:han <f
is seen in the accompanying chart (Fig. 127).

White cells were 16.500; hemoglobin. 80 per cent.

The urine was of high gravity, with a very slight trace of albumin,
but no casts at all.

Discussion. In such a hard drinker the question of "rum fits"
must be entertained. The patient has. however, no odor of alcohol
and no history of a recent increase in the amount of alcohol consumed.
This is not an acute debauch of the Saturday-night type, such as makes
"rum fits'' so common in our police stations. It is a longstanding
habit, which would probably not begin to produce these e>pccial eitect>
at the aire of sixtv-two.

5 1 2 DIFFERENTIAL DIAGNOSIS

The condition of the urine is not characteristic, but the history of
excessive nocturia and the high blood-pressure makes us suspect chronic
nephritis as the ultimate cause of this attack. When the lungs are
universally hyperresonant, it is very difficult to make out the size of
the heart. Hence there may well have been a cardiac hypertrophy
in this case, although none was discovered.

Of the organic diseases involving the brain and its membranes, we
have no definite evidence. This does not by any means exclude them,
but makes it impossible for us to move any nearer toward a diagnosis
of any one of them until further signs appear. An examination of the
fundus oculi might give great assistance, likewise lumbar puncture.

My reasons for ignoring the diagnosis ordinarily made under these
conditions i. e., acute uremia have already been given (see p. 509),
and may here be simply summarized by saying that I do not believe that
any such condition exists. Uremia is a chronic affair.

As a working diagnosis, therefore, sufficient to guide treatment in
the emergency, a vascular crisis favored by the underlying nephritis
seems reasonable.

Crackling rales were to be heard throughout both lungs in this case.
Their significance deserves some discussion. Any one who has seen
many cases of sudden coma, with or without convulsions, must have
noticed that we can almost always hear these scattered rales, whatever
the nature of the attack. Their number and the extent of their distri-
bution seem to depend upon the severity of the attack and the depth
of the coma, rather than upon its cause. I have seen them in sunstroke,
alcoholic and narcotic poisoning, apoplexy, brain tumor, plumbism,
meningitis, and various other conditions, with or without a fatal issue.
I am not now referring merely to the tracheal rales or snoring sounds
attributable merely to the coma which prevents the patient from clearing
the throat or closing his mouth, but rather to finer sounds audible
with a stethoscope over the backs alone in milder cases and over the
entire chest in severer ones.

No adequate explanation for these rales, so far as I am aware, has
ever been given, but the rapidity with which they appear and disappear
seems to point to some vascular condition which affects the lungs directly,
rather than through any change in the heart's action. Certainly they
are not always associated with cardiac lesions, but may be associated
with the most forcible and efficient action of that organ.

Outcome. The patient was lightly etherized, and a subpectoral
infusion of four pints of normal saline solution was given. The bowels
were moved by magnesium sulphate, and a hot-air bath was administered.

CONVULSIONS

5 J 3

He had to be partially restrained, owing to his desire to get up, but by
February 2d he was entirely rational, and the restraint was removed.

X-ray showed cardiac hypertrophy. Hypertension and an excess
of light-weight urine persisted.

On February 4th he was allowed to go home.

Diagnosis. Chronic interstitial nephritis; vascular crisis.

Case 268

A shoemaker of twenty-seven entered the hospital June 28, 1908.
He had been in the hospital in the previous December for an attack
similar to the present. Four weeks ago his knee became swollen and
painful, and with this he was in bed for two weeks. Since then he
has been walking with crutches. Yesterday the left elbow also became
swollen and painful. This afternoon he had a convulsion, for which
he was brought to the hospital. He had similar attacks in April and
in February. It has been noticed that he passed an increased amount
of urine, that he had to get up seven or eight times each night for this
purpose, and that he had had edema of the legs for three weeks and
almost constant headache. He has vomited four or five times a week
since January. He has no dyspnea.

At entrance the patient held the left arm across his body in a condition
of moderate spasm. He could move it but slightly. The left elbow was
swollen and tender, the whole arm and axilla also slightly tender, the
dorsum of the left hand swollen, the grip very weak. There was no
other evidence of paralysis or weakness.

The heart's apex extended \ inch outside the nipple-line in the fifth
space, the right border 1-' inches to the right of midsternal line. A
systolic murmur was audible at the base, faint at the apex. There was
no accentuation of either second sound. The right pulse was somewhat
larger than the left. Blood-pressure was 140 mm. Hg.

During the nine days of the patient's stay in the hospital the urine
varied from 1006 to 1017 in specific gravity, amounting to 50 or 60
ounces in twenty-four hours. Albumin, from 0.7 per cent, to 2.4 per
cent.; there were no casts. There were depressed scars on the right
tibia from the knee to the ankle, also one an inch above the inner condyle
of the left tibia. The blood was negative.

Discussion. The age of the patient and the condition of the heart
and urine apparently make it clear that we are dealing with a case
of chronic glomerular nephritis. (See Appendix C. on The Classifica-
tion of the Types of Nephritis.) If this be the case, the arthritic svmp-

5*4

DIFFERENTIAL DIAGNOSIS

toms are probably due to a low-grade infection, favored by the weaken-
ing of resistance which chronic nephritis usually entails.

In view of these conclusions it would seem reasonable to interpret
the attack as uremic, since the patient has had previous symptoms indi-
cating renal insufficiency, viz., headache, vomiting, nocturia and
edema. It seems altogether probable that some chemical retention will
account for the sudden appearance of cerebral symptoms in a case like
this. (For fuller discussion of this matter see p. 509.)

The scars upon the shins naturally direct our search toward other
evidences of syphilis, but as none such are forthcoming the possibility
must be left open.

Outcome. There was no repetition of the convulsions while in the
hospital from June 28th to July 7th.

The treatment consisted of hot-air baths, purgation, and diet.

Diagnosis. Chronic interstitial nephritis; uremia.

Case 269

A child of fourteen months, who had never been sick previously,
entered the hospital January 12, 1907. She fell down two days ago

in a convulsion and has since then
appeared to be very sick, crying much
of the time, and extremely thirsty.
Yesterday she had the "'shivers," but
no convulsion. The last twenty-four
hours she has not seemed to recognize
her mother, and has vomited occa-
sionally. Whenever she is touched
anywhere, she cries as if hurt. There
is no discharge from either ear.

On examination, numerous white
circular scars are scattered over the
body.

There is convergent strabismus,
and vision is apparently impaired.
Considerable mucopurulent secre-
tion can be seen in the pharynx.
There is no mastoid tenderness, no
retraction or rigidity of the neck:
there is a slight fulness under the angle of the left lower jaw; moderate
rickety rosary; coarse squeaks and bubbling sounds are heard through-

t g? m"X t n i'Wi Jfecn rogp?

< ii.i 1 1 a a /i I/in- /' 1 111

10.

. "*. T_

, uJ

' .or *Zi- A -4

;.r *T^ 4.^1

l- Z 41 t^f^^jitf*,

- _U _L

l ^ -41 la

\ ^-/--d-^? *

i t}&%. \j<,t\>. ^^71" \

*" - J _L JT t 4

Z 1 i i.

j 1

" ^r _L

- 3 1

10 * c

H \~

: f 4 3=

= It jt-L- 1Z

!! : W^/^s^i-=

n -n n n fiTi ^1 n^.r- Tinr- ^q

Hg. 128. Chart of case 269.

CONVULSIONS

515

out both lungs. Physical examination, including the reflexes, is other-
wise negative.

The white cells are 18,300; the temperature range is seen in the ac-
companying chart (Fig. 128).

Discussion. It used to be the fashion to attribute most of children's
convulsions to teething or colic, and it is still generally believed that
digestive upsets may be sufficient to produce convulsions which in older
individuals would have a much more serious significance. In the
present case there is no evidence that the teeth or any part of the diges-
tive tract are connected with the seizure.

Rickets has been made responsible for almost every symptom and
ill to which a baby's flesh is heir. On p. 406 I have already referred
to a case of fatal urinary infection in which, owing to the presence of a
rickety rosary and some slight errors in diet, the clinical diagnosis was
rickets. I have known similar mistakes made in various other cases
in which a slight epiphyseal enlargement was present. The moral seems
to me to be that one should not explain any severe illness as due to
rickets unless there is other evidence of that disease beside a rosary.

The child is thirsty, suggesting fever, has a leukocytosis, and a good
many rales in its lungs. Rales may sometimes be the only auscultatory
evidence of bronchopneumonia. Might not this case be one of infectious
bronchopneumonia with convulsions at the onset? I have previously
noted, however, that rales of this type generally distributed throughout
the lungs are present in practically all cases of coma. This child is
apparently semicomatose, and might easily, therefore, have many rales
of this type without the existence of any pneumonia. Moreover, the
rales of bronchopneumonia are only distinctive when grouped in discrete
patches and associated with a good deal more cyanosis and dyspnea
than are present in this case.

In an adult, meningitis would naturally be considered, and even in
a baby of this age it can be by no means excluded. Other and com-
moner causes for convulsions should, however, be first investigated.

The most important of these causes is otitis media. 1 have already
referred in a previous case to the fact that children suffering from otitis
do not usually indicate in any way what part of their body is affected.
It is, therefore, all the more important that we should write upon the
tablets of our memory, in such a form that it will never be for-
gotten when we are dealing with children, the motto: "Remember the
ears.'''

Outcome.-- Examination of the ears by a specialist showed otitis
media on the left. Paracentesis allowed the escape of a little bloodv

5i6

DIFFERENTIAL DIAGNOSIS

and purulent fluid, after which the child was much more comfortable,
though there was still some deafness in the left ear.

On the eighteenth a swelling, apparently a gland, appeared at the
angle of the left jaw. It did not extend up in front of the ear and was
not tender. Ten days later it was still persistent, although the baby
seemed otherwise entirely well.

Diagnosis. Otitis media.

Case 270

A freight-handler of forty-seven was first seen on June 2, 1905.

He has had a markedly alcoholic history five or six whiskies a day.

He denies venereal disease. He has been well up to six months ago,

when he began to complain of short-
ness of breath and cough, with a
"rush of blood" to the head. Two
months ago his eye-sight began to fail,
and glasses seemed to do him no good.
Within the past year he has had to
pass water twice each night.

Ten days ago he felt too sick to go
to work, vertigo, dyspnea, weakness,
and nausea being his chief symptoms.
This continued until three days ago,
when he felt better and went out for a
walk, but on returning he had a con-
vulsion lasting three minutes.

For the past week he has been for-
getful and incoherent at times. At
noon to-day, while sitting in his yard,
he went into a convulsion, with coma
and snoring breathing. This convul-
sion recurred before 4 o'clock, when he was brought to the hospital,

still unconscious.

Physical examination showed good nutrition, slight enlargement of

the glands of the neck, axillae, and groins, nothing abnormal in the chest

except a few coarse rales at the base of the lungs.

The abdomen and extremities were not remarkable; reflexes normal.

(See Fig. 129.)

The white cells were 27,000; urine, 20 ounces in twenty-four hours;

specific gravity, 1022; the slightest possible trace of albumin; a few

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CONVULSIONS 517

hyaline casts. Examination of the fundus oculi showed nothing remark-
able.

The patient was treated with milk diet, hot-air baths, and magnesium
sulphate.

By June 7th he was fairly clear in mind, and by the eleventh seemed
perfectly well. There was no special change in the urine, but the white
cells had come down to 13,000.

The patient was seen again on the eighteenth of August, 1906. He
had remained in good health and had no trouble with his eyes until
about two weeks ago, when he "began to feel queer " and had frequent
attacks of vomiting. Three days ago he had two convulsions, and
has had several of the same since. Between them he has been drowsy
and remembers nothing. His. pupils were at this time irregular, the
left larger than the right, the speech thick. He was unable to repeat
his alphabet or to repeat sentences said aloud to him. His blood-
pressure was 125 mm. Hg.

Physical examination otherwise was as when last seen, except that
the white cells were now 8000.

Discussion. In all cases where a convulsion is the presenting
symptom we must first determine the question of epilepsy, in case it
seems possible to exclude all gross organic changes or chemical poisons
as causes for the convulsion. In any man of this age, however, we
should always be very skeptical of a diagnosis of epilepsy. Why should
it begin at forty-seven, when it is well known that the vast majority
of cases of epilepsy begin in youth or young adult life. Only if no
other possible explanation can be found is such a diagnosis justifiable
in a patient of this age.

Although the patient is markedly alcoholic, there seems no evidence
of any unusual indulgence, such as might determine at this time a "rum
fit."

As there seems to be no residual paralysis or focal symptom, we have
no right to conclude that hemorrhage or tumor is present. The normal
condition of the fundus and the absence of any long-standing headache,
vomiting, or vertigo strengthen the evidence against cerebral tumor.

The study of the blood and urine reveals no evidence of plumbism,
diabetes, or nephritis. The latter disease is still further debarred from
consideration (in its chronic form) by the low blood-pressure. Acute
inflammatory changes (meningitis) do not deserve consideration, even
in view of the leukocytosis present at the time he was first seen, for
leukocytosis occurs in all acute cerebral seizures.

Attacks of unexplained convulsions associated with, marked forget-

518 DIFFERENTIAL DIAGNOSIS

fulness, incoherence, irregular pupils, and some disturbance of speech
should always lead us to investigate, by further tests, the possibility of
dementia paralytica. Such tests are, especially, the condition of the
hand-writing as compared with previous years, the presence or absence
of slight changes in manner or habits, the cellular constituents of the
spinal fluid, and the Wassermann reaction.

Outcome. August 24th he was extremely cordial and polite, even
effusive, but some of his words were slurred, as if he were drunk, and
his talk was decidedly muddled. He says he feels excellently well-
better than for ten years.

On the second of September he escaped from the hospital and went to
early mass, clad only in his red wrapper and carpet slippers. He
returned immediately after service and did not seem to realize that he
had done anything unusual. The later course of the case confirmed the
diagnosis of dementia paralytica.

Diagnosis. General paralysis.

Case 271

A manufacturer of sixty-two, with a good family history, entered
the hospital January 2, 1908. He says he has always been "tougher
than a boiled owl," though he had diphtheria when a child, followed
by a paralysis of both legs. His habits are excellent.

Three weeks ago he had the "grip," and when nearly over it eight
days ago caught a fresh cold, and began to have pain in both wrists,
knees and the left shoulder, the pain not severe, but catching him when
he moves. He has had no other symptoms.

On the morning of entrance, at 9.15, he had a series of short general
epileptiform convulsions, lasting from five to ten seconds. During
these the pulse fell to 22 and was very irregular. There were periods
of fifteen to twenty seconds when no pulse could be felt and no heart-
beat heard; following this came an epileptiform convulsion lasting from
three to five seconds, then from seven to ten slow, full beats of the heart;
the whole cycle would then be repeated. The convulsions were accom-
panied by momentary loss of consciousness, with flushing of the face;
there was no cyanosis, orthopnea, drooling, or incontinence. The
breathing throughout was deep and regular. The convulsions lasted
all day and until after midnight, when they became less frequent, occur-
ring at 1 a. m. and 5 A. M.

Physical examination showed a powerful, obese man, without
glandular enlargement, with pupils altogether normal, and dry, brown
tongue. The heart-sounds were almost inaudible. The heart's impulse

CONVULSIONS

519

was neither visible nor palpable; by percussion there was no evidence
of cardiac enlargement. The belly was negative.

The blood-pressure was only 95 mm. Hg. and the arteries were barelv
palpable. The lungs were hyperresonant everywhere, and contained
many scattered rales. The knee-jerks were not obtained, even with
reenforcement ; the Achilles jerk was likewise absent.

The joints of the left shoulder, knee, ankle, and the right wrist were
slightly red, swollen, tender, and very painful on motion.

The course of the temperature is seen in the accompanying chart
(Fig. 130).

The white cells were 15,000 at entrance; 18,500 two days later. The
joint symptoms rapidly improved under sodium salicylate, 10 grains
every hour, and a dram of potassium
citrate every four hours, with mild laxa-
tives.

Discussion. The striking point
about this convulsion is its associa-
tion with a very slow pulse and periods
of pulselessness. Almost any variety
of convulsion may be associated or fol-
lowed by slow pulse, that is, by a re-
duction in the number of beats to 60

or even 50 a minute, but a pulse of 22,
such as that here recorded, has a very
special significance, particularly when
the general condition of the patient,
both before and after the convulsion,
shows no evidence of heart failure.
Stokes-Adams' disease is always the
first working hypothesis to be con-
sidered.

Confirmation of this diagnosis can be obtained only by the study of
the venous pulse in the neck, which was not undertaken in this case, so
that no certainty can be arrived at. Nevertheless, it is altogether
probable that if such a study had been undertaken, evidence that the
auricle beat more frequently than the ventricle would have been found.

Two other points in the case are of interest: the joint symptoms
and the absence of dee]) reflexes. The latter is probably to be explained
as a result of the diphtheric neuritis of his childhood. The normal
condition of his pupils, the good control of the sphincters, the absence
of characteristic sensorv symptoms are sufficient to exclude tabes.

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5 2

DIFFERENTIAL DIAGNOSIS

The occurrence of multiple arthritis, accompanied by fever and
leukocytosis, and promptly disappearing during che administration of
salicylate, is cf interest to me because I have several times observed such
an attack simultaneously with a paroxysm of Stokes-Adams' disease.
The fact may be a mere coincidence, though one may also conjecture
that the blood changes accompanying infection may interfere with the
transmission of impulses through a previously diseased bundle of His.

Outcome. The patient slept a great deal during the first ten days
of his stay in the hospital. After that he gradually regained his appetite
and strength until, by the eighteenth, he seemed altogether normal and
was allowed to go home.

Diagnosis. Stokes-Adams' disease (?).

Case 272

A cook, sixty-eight years old, was first seen September 9, 1907.

Six brothers and three sisters died of unknown causes. Three sisters

and two brothers are well.

For eighteen years he has had fits without known cause. In them

he falls suddenly and usually without warning. Occasionally he bites

his tongue, sometimes he "shakes."

The attacks last from a few minutes
to an hour, and are usually accom-
panied by coma. They may come from
once a week to once in three months;
the last attack was two months ago.
He denies venereal disease. He drinks
two or three glasses of ale a day. Eight
weeks ago he began to have swelling of
his legs and abdomen, and this has
steadily increased ever since. He has
passed urine once or twice at night for
twenty years. He worked until yester-
day.

The patient was ill-nourished, pale,
with normal pupils and a heart extend-
ing I inch outside the left nipple and
5 j inches from the median line; sounds
regular, slow, and forcible. A moderate

systolic murmur was heard all over the precordia, loudest at the apex;

blood-pressure 162 mm. Hg. The arteries were palpable and tortuous

above the elbow. In the left back there was dulness up to the eighth

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CONVULSIONS

521

rib in midaxilla, and to the seventh rib on the right. Over the dull area
breath sounds and crackling rales were heard; fremitus was feeble.
There was dulness in the flanks, shifting with change of position, marked
soft edema of the legs and lower eyelids. By tapping, four quarts of
straw-colored serum with a specific gravity of 1009 were withdrawn
from the abdomen. In the sediment of this fluid lymphocytes made up
82 per cent.

About 2 a. m. on the 13th of September the patient became uncon-
scious, and had general epileptiform convulsions, lasting about ten
minutes. There was no incontinence or biting of the tongue. Within
the next two days he had six more such attacks. Each began with
groaning respiration, which in a short time altogether ceased, so that
the patient became almost black in the face, the pulses ceasing, the
heart-sounds inaudible, the tongue protruded. Soon he breathed
again; the heart-beat rose rapidly to 80 in a minute, then again fell to
about 25. A short time after the beginning of the attack the muscles
of the face moved convulsively, the whole body became rigid and then
shook. The urine and feces were passed involuntarily. The whole
attack lasted from half a minute to two minutes, and was followed by
unconsciousness lasting some hours. In one of these attacks the breath-
ing ceased for over two minutes by actual observation. The heart and
pulse began again before the respiration.

Discussion. This patient had been seen by several physicians on
account of the convulsions from which he had suffered so long, and it
had been so far assumed that the diagnosis was epilepsy. I have already
called attention to the rarity of epilepsy beginning after the attainment
of middle age. This patient's fits, it will be noticed, began when he
was fifty. Presumably, therefore, some cause for them can be found.

The evidences of arterial degeneration at the peripheral, the moderate
elevation of blood-pressure, and the age of the patient make it proj>er
to consider cerebral arteriosclerosis or general arteriosclerosis with
vascular crises as possible cause for these attacks. Their long duration,
however, is against this supposition, and the fact that there is stasis,
evidenced by the signs in the lungs, the abdomen, and the legs, points
also against vascular crisis, since such crises usually cease when stasis
begins.

Dementia paralytica rarely produces attacks extending through
anything like so long a period of years. It is true that the disease may
run a long course, but a duration of eighteen years after the appearance
of convulsions and without any more marked mental or motor symptoms
than are here recorded is contrary to all experience.

522 DIFFERENTIAL DIAGNOSIS

The most important fact for the differential diagnosis is the cessa-
tion of the pulse-beat observed during the attacks which occurred in the
hospital. This is very suggestive of Stokes-Adams' disease, but needs,
of course, the confirmation obtainable by the study of the venous pulse
in the neck.

Outcome. Between attacks it was noticed that the pulse in the
veins of the neck was to the radial pulse as 2 is to 1, or as 3 is to 2. Syn-
chronous tracings confirmed this.

The urine averaged 20 ounces in twenty-four hours, specific gravity
1020, the slightest possible trace of albumin, many hyaline, granular,
and epithelial casts; leukocytes, 8000. By fluoroscopic examination
the auricular beat was counted at 62, while the pulse was 25. The fluid
in the abdomen rapidly reaccumulated, and had to be tapped several
times before the patient's death, December 15. Autopsy showed cir-
rhosis of the liver and a calcareous ridge in the region of the bundle of His.

Diagnosis. Stokes- Adams' disease. 1

Case 273

A child of three years, of good family history, was first seen May
12, 1908. She has always been subject to colds, but was otherwise
well until yesterday afternoon, when she had a convulsion, more or less
relieved by a mustard bath. Later she vomited twice and was some-
what feverish. This morning she began to cough and to breathe
rapidly. The course of the temperature is seen in the accompanying
chart (Fig. 133).

The tonsils are large and covered with a whitish exudate. There
are small tender glands on each side of the neck. The neck muscles
are not at all rigid. The heart shows no enlargement in any direction.
In the pulmonary area a very loud systolic murmur is heard, completely
replacing the first sound, and transmitted to all parts of the chest.
There is no thrill. The pulmonic second sound appears to be much
accentuated and reduplicated.

Physical examination was otherwise negative; the white cells, 10,700.

Discussion. Besides the convulsion, the essential symptoms seem
to be cough and dyspnea, associated with all the evidences of an acute
tonsillitis and a cardiac murmur.

Before concluding that the convulsion merely expresses a reaction on
the part of the symptom against the onset of the infectious tonsillitis,

1 This case was reported by Dr. H. F. Vickery in the Boston Medical and Surgical
Journal, Oct. i, 1908, and is reproduced here by kind permission of the doctor and

the journal.

* '.' -

Fig. 1 32. Calcareous ridge involving the bundle of His in a case of Stokes-Adams'
disease. The arrow points to the ridge. A hit has been cut out for microscopic exami-
nation. 1 Photograph by Lewis A. Brown. I'sed by kind permission of i)r. II. F.
\"ickerv and the HosLoii Medical and Surgical Journal. 1

CONVULSIONS

523

we must exclude the other and more serious possibilities. Meningitis
h one of these, but there seems to be nothing definite except the con-
vulsion itself to support this idea. Children are very prone to show
cervical rigidity, with a retraction of the head, strabismus, and Kernig's
sign, even when meningitis is not present; but the absence of all these
symptoms is strongly against meningitis.

Can we connect the cardiac abnormalities, hinted at by the murmur,
with the convulsions? Such a connection might be made out in case
there were evidence of embolism of the brain or lung, of
marked cerebral anemia, or of a broken compensation
involving the accumulation of C0 2 in the cerebral cir-
culation. But we have no reason to believe that any
of these conditions exist, and I can think of no other
way to connect the cerebral and cardiac symptoms.

The ears were examined without showing anything
abnormal. The urine showed only the ordinary results
of fever. It seemed probable, therefore, that our original
supposition was correct, and that the onset of the ton-
sillitis was in itself sufficient to explain the convulsions.

What is to be said of the heart murmur ? Very loud
murmurs in the pulmonary area are usually the result
of congenital heart disease. This is probably the best
diagnosis to make in the present case, although one
would feel much surer of it if any cyanosis and thrill
were observable. It is usually unwise to attempt any
further or finer description of the anatomic conditions
in congenital heart disease. Autopsy seldom confirms
the details of our diagnosis. Those who have seen most
cases are generally least willing to commit themselves regarding a par-
ticular lesion or combination of lesions which is producing the trouble.

Outcome. There was no repetition of the convulsion, and within a
week the child seemed to be perfectly well, though the cardiac murmur
persisted unchanged.

Diagnosis. Tonsillitis and congenital heart disease.

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Case 274

A married woman of thirty-four with three healthy children was seen
September 8, iqoq.

She has had no miscarriage. Her husband denies syphilis. Five
years ago began to have convulsions typical "epilepsy.'' Considerable
headache in this time, and occasional diplopia.

5 2 4

DIFFERENTIAL DIAGNOSIS

Cureted for dysmenorrhea five years ago with relief to the dysmenor-
rhea, but none to the fits. Had tried many doctors without relief. For
past six months no general convulsions, but attacks of twitching of the
right hand and wrist, apparently provoked by excessive use.

Examination. Choked discs. Urine and blood-pressure normal.

Lumbar puncture gives clear, non-cellular fluid under pressure. Viscera

normal. Later she developed paralysis of external rectus and ptosis on

the left, with contracted pupil. Wassermann test

and blood negative.

Died September 9.

Discussion. This patient is at the age when
ordinary epilepsy is common. The most notable
feature in the case, however, and the most important
from the diagnostic point of view, is the change in
the nature of the spasm within the past six months.
The attacks from which she now suffers have been
diagnosed as "writer's cramp," for she is of a very
nervous type, and has done a great deal of writing
and sewing of late.

As soon as we had observed one of the attacks,
however, it became obvious that it had nothing to do
with "writer's cramp," that it was wholly involuntary,
and possessed all the characteristics of Jacksonian
epilepsy. Localized spasms of this type are often
seen immediately preceding an attack of ordinary gen-
eralized epilepsy; in fact, pretty much all epileptic
attacks begin in some single group of muscles. It is
only when the convulsion fails to spread beyond the original group
that we attribute localizing significance to it, and begin seriously to
consider a circumscribed lesion, such as tumor, cyst, meningeal adhe-
sions, abscess, or softening.

The presence of choked discs, with a normal urine and blood-
pressure and normal cerebral spinal fluid obtained by lumbar puncture,
points strongly toward brain tumor. Were cerebrospinal syphilis, tabes,
or paresis present, the spinal fluid would in all probability show an
excess of cells. The negative Wassermann reaction is also of some
significance, although in this, as in so many other fields, negative evidence
is far less valuable than positive.

Meningitis does not give rise, so far as I am aware, to Jacksonian
epilepsy, and the content of the spinal fluid suffices to exclude it.

There seems to be nothing left but cerebral tumor, and no important

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-Chart

274.

CONVULSIONS 525

evidence against it. At first sight the long duration of her illness
the five years of typical "epilepsy" seems confusing, but there are
now on record a considerable number of cases in which cerebral tumor
has been demonstrated at autopsy after a number of years of headache
and convulsive attacks, like those here described.
Diagnosis. Cerebral tumor.

Case 275

A physician of fifty was seen October 28, 1908. He has always been
well until eight years ago, when he had a good deal of pain in his lumbar
region and down the back of his right leg. For this he consulted Dr.
J. E. Goldthwait, who put him into a plaster jacket, with marked
relief.

After this he was well until three years ago, when he had "some
kind of a spasm," the nature of which cannot be more accurately learned.
In July, 1907, he was seized with some sort of an attack during the night
while in his bath-room. He found himself on the floor, and was unable
to get to his feet, but crawled back to bed. Ever since that time it
has been noticed that his gait is somewhat shuffling or shambling,
especially when he is much fatigued.

In September, 1907, he had an attack of catarrhal jaundice. A con-
sultant saw him at that time and considered it a case of "brain-fag."
Muscular power, sensation, and the pupils were then examined and
found to be normal. During the next six months, however, he had a
number of attacks of vomiting without obvious cause and without
relation to meals. They did not, however, prevent his carrying on a
very active practice, in which he has been engaged up to the present
time.

In September, 1908, he had a bad nose-bleed, and next day seemed
very weak, with profuse sweating and marked pallor. To these nose-
bleeds he says he has been subject all his life. Many other members
of his family have a similar tendency.

October 27, 1908, the day before the one on which I saw him, he
was seized about 6 p. m. with a general epileptiform convulsion, and
within the next twenty-four hours he had nine similar attacks. The
first convulsion followed immediately upon the eating of a very heavy
meal. After it he was comatose, and between the subsequent convul-
sions he did not fullv regain consciousness until about three hours before
the time at which I saw him.

On examination he was normally conscious, intelligent, and cheerful.
There was no paralysis anywhere, and the tendon reflexes were normal.

526 DIFFERENTIAL DIAGNOSIS

The pupils immobile. The heart, lungs, and abdominal viscera showed
nothing worthy of note except that the aortic second sound was sharp
and ringing, and the pulse of high tension. As he spoke to me in answer
to questions I noticed an occasional stumbling, and now and then the
elision of a syllable. He said he felt quite well, and wanted to make
some medical calls that afternoon.

On subsequent inquiry it was learned that his urine had been ex-
amined several times in the past eighteen months and always found
to contain a trace of albumin. He had sometimes had a little trouble
in urination, and once last summer involuntary' defecation took place.

Discussion. Every' physician sees many cases of this type, if one
omits the history of the convulsion. In the absence of such convul-
sions as were here described the diagnosis of neurasthenia is very fre-
quently made. Such a diagnosis, in my opinion, is never justified
when the patient's symptoms first appear at or after middle life. Nervous
weakness under these conditions means organic disease with nervous
manifestations. The underlying trouble is most often cardiovascular
disease, with or without a demonstrable arteriosclerosis. The per-
sistent elevation of the blood-pressure, which is almost always to be
found, should put us on our guard against the mistake of supposing the
patient to be "merely nervous."

In all such cases, however, and more especially when a convulsion
has occurred, we should make such inquiries as would serve to de-
termine whether any evidence of beginning dementia paralytica is
present. In a physician carrying on an active and successful practice
it may seem hardly justifiable to consider so serious a disease, but in
the present patient inquiry brought out the following points:

(a) His hand-writing, always indistinct, had now become so illegible
that apothecaries were frequently unable to decipher his prescriptions.
(I fear this happens to many not demonstrably the victims of dementia
paralytica.)

(b) His wife had noticed that he had recently become entirely in-
capable of making up his accounts or doing even simple sums in
arithmetic.

(c) Despite the vagueness and inaccuracy of his account books, he
was very cheerful, if not optimistic, upon money matters, though his
wife declared with tears that he had little ground for such optimism.

(d) He has fallen into the habit of dropping asleep while at work,
or even in the midst of a conversation, and his attention at all times is
short-lived and wandering. (This is true, also, of many other members
of his family, and, indeed, of the human family.)

CONVULSIONS 527

(e) His memory and decisiveness of action have been gradually
failing for many months.

(f) It has been noticed that he drops things very frequently, and
complains that he has no feeling in his fingers.

In view of these mental and psychomotor changes the diagnosis of
dementia paralytica seemed to me clear.

Outcome. The patient went away for a few weeks on a vacation
soon after I saw him. He then returned to Boston and tried to resume
practice, aided by a very old friend, a physician, who, for friendship's
sake, was willing to go everywhere with him and make good his mis-
takes.

On February 13, 1909, he had another convulsion, and March 10th
a general tonic clonic spasm, without loss of consciousness. After this
he gradually improved in strength, gait, and ability to write, but his
personal habits previously most correct became somewhat untidy.
May 25th he went to his old home on a Maine farm, where he passed
the summer in reasonable comfort. October 3, 1909, he seemed in
unusually good spirits, but at midnight he had a series of convulsions
and died within a few hours.

Diagnosis. Dementia paralytica.

Case 276

July 9, 1906, I was called to a small town in the southern part of
Massachusetts, on the outskirts of which lived a farmer whose wife I
was asked to see for the relief of convulsions of unknown origin. She
was a woman of twenty-eight, of excellent family history, and had
always up to this time been well and strong. Nine weeks previously
she had borne her first child, parturition and the convalescence from it
being normal.

Three weeks before I saw her she consulted her physician on account
of persistent headache, an entirely new symptom for her. A week
later she was noticed to be distinctly pale. Iron was prescribed, and she
seemed to be doing well until eight (lavs ago, when she had an attack
of vomiting without any known reason. Such attacks have recurred
every day or two since that time.

Five days ago she had her first epileptiform convulsion, which was
followed within twelve hours by a second convulsion involving only
the muscles of the right half of the body. Four (lavs ago a similar
unilateral convulsion occurred. Yesterday she had a generalized
convulsion without loss of consciousness. The urine has been several
times examined. It is alwavs rather scanty, but has never shown anv

528 DIFFERENTIAL DIAGNOSIS

albumin. The gravity has averaged 1024, the color rather darker than
normal. She has voided 27 ounces in the past twenty-four hours.

Between the convulsive attacks she seems pretty well, though
rather weak. There has been no pain at any time and no paralysis.

Physical examination of the chest and abdomen was entirely nega-
tive. The reflexes and pupils were normal; the hemoglobin, 50 per
cent; the urine free from albumin, and otherwise as above described.

Discussion. Naturally, our first attempt in such a case is to relate
the convulsions in some way to the recent childbirth, but this seems,
on reflection, rather far fetched, as the woman was in perfect health
for the six weeks following parturition.

Uremia seems to be excluded by the absence of any cardiac hyper-
trophy or urinary changes. Unfortunately, the blood-pressure was
not measured. To the palpating finger the arterial tension seemed
unusually low.

Without an examination of the fundus oculi one cannot speak with
confidence against the possibility of brain tumor; but there is really
little to suggest it, local symptoms being entirely absent, the headache
being very moderate and unaccompanied by vertigo.

In the physical examination and in the reasoning process above
reproduced one essential step has been omitted primarily, because
in the first fifteen minutes of my study of this case it was altogether
forgotten, also because it never occurred to the mind of the attending
physician. Both of us forgot to consider lead-poisoning. After my
first unsatisfactory and fruitless review of the case I began again and
went over the patient systematically from head to foot. On the gums
I found this time a typical lead-line, which I had previously omitted to
look for, because lead-poisoning is associated in my mind chiefly with
those who work in some trade involving the use of lead. A young
woman living in the depths of the country and doing no work outside
her own house does not necessarily suggest the possibility of lead-
poisoning.

After finding the evidence of lead in her gums I began to wonder
where she could have acquired the metal. Could it be from drinking
water? If so, other members of the family should be affected. I
turned at once to the husband, standing at the foot of his wife's bed,
and examined his gums. They also showed a typical lead-line, though
he had had no symptoms. There was no one else in the house but the
baby, who had taken no water and seemed to be quite healthy.

The family then recollected that the water had tasted queer since
the previous winter, but they had been using the same well-water for

CONVULSIONS 529

the past three years. About 100 feet of lead-pipe intervened between
the well and the house.

The patient was ordered to drink no more of this water, to take
5 grains of potassium iodid three times a day, and a purge of magnesium
sulphate every morning. The convulsions ceased at once, and the
patient made a rapid and lasting recover}'.

Diagnosis. Lead-poisoning.

Case 277

In July, 1893, a gentleman of forty-nine entered the hospital with
the diagnosis of astasia abasia, made by a neurologist three weeks
previously. He remained in the hospital for three months, during
most of which time he had partial paralysis of the leg, relaxed sphincters,
and a great number of complaints referred to different parts of his
body. The reflexes were never markedly abnormal, and visceral
examination was always negative. He gradually improved until he
was able to walk with a cane, left the hospital, and was not seen again
until 1903.

During most of the intervening decade he lived in India or in Egypt,
painted a good many pictures, and enjoyed himself thoroughly. In
1900 he had an indolent abscess on his forehead, which did not heal
after it had been opened, and showed no considerable improvement
for six weeks. After that he was given some medicine "with a salty
taste," and the abscess promptly healed.

Since 1897 he has been troubled with attacks diagnosed as "petit
mal." These occur every two to five days, and last about half a minute.
A typical attack begins with slight nausea and a bad taste in the mouth;
next he begins to notice a sudden change in the behavior of the people
around him. They seem to be walking so as not to disturb him, or
creeping toward him. After this, comes a tremor or thrill down the
left arm and an involuntary closing of the left thumb and index-linger,
with some shaking of the whole hand, so that he may almost drop
his newspaper if he is reading one at the time. All the colors of the
objects around him become intensified. He does not think that any
one about him notices what is going on. Between these attacks he
feels pretty well, but occasionally wets his bed at night, and always
passes water five or six times after he gets to bed. Occasionally he has
noticed that his linen is stained, owing to relaxation of the rectal sphinc-
ter.

In 1904 he went abroad and enjoyed himself very much. Various
English doctors told him that his troubles were all due to gout. Occa-

530 DIFFERENTIAL DIAGNOSIS

sionally his left ankle gives way under him, but, as a rule, he walks
very well. November 7, 1904, he fell unconscious in a water-closet,
and for half an hour afterward was drowsy and drooled saliva. January
21, 1905, after four days of excellent spirits and entire absence of the
attacks of "petit mal," he woke up in the night with severe pain across
his forehead, a very sore tongue, and much sensitiveness of his muscles,
especially across the loins. For the whole day following this he was
very sleepy and stupid.

February 20th he started to dine with a friend in Cambridge. The
next thing that he knew he found that the electric car in which he was
had come to the end of its route, in surroundings which he did not at
all recognize. How he got there he had no idea. About three-quarters
of an hour had elapsed since he took the car for Cambridge. Next day
he noticed that his left foot dragged a little in walking.

In 1906 he began to have trouble with his rectum, and a tumor was
felt high up upon the right. Operation showed an apparently inopera-
ble tumor mass involving a large portion of the rectum and lower sigmoid.
An artificial anus was made, after which he was greatly better. Four
years later there had been no increase of symptoms. The artificial
anus was working excellently well. Occasional attacks of uncon-
sciousness, with or without generalized convulsions, and very many of
the seizures called "petit mal," still troubled him.

Discussion. Twice this patient was given up to die the first time
in 1893, the second time in 1897; yet he is alive and healthy (1910). The
most important diagnostic and therapeutic indication in his case was
to my mind the so-called abscess on the forehead, which resisted all
ordinary treatment and then healed so promptly after the administra-
tion of a medicine which had the taste of potassium iodid. The patient
had no knowledge of any syphilitic infection, but had lived the type of
life in which such infections are acquired. I see no reason to doubt
that all his symptoms were due to syphilis in one form or another.
First the spinal cord, later the brain, and finally the perirectal tissues
were involved.

The question of operation for the relief of his attacks of "petit mal"
was often and seriously considered, but in view of his previous history
it seemed probable that the disease was so widely diffused that little
could be expected from operative interference.

Diagnosis. Syphilis.

CONVULSIONS

531

5"
g.

2.
P

i
i

J-

Causes.

evidence of

nephritis.

Habits.

Temperament.

attacks.

Sudden onset.
No previous

attack.

Previous
attacks.

Childbirth,
recent or
imminent.

Previous at-
tacks. Diges-
tive upsets.

Habits.

Aids from
history.

Occasionally.

C
p

Fever.

(

t
i

IK
P

Negative.

Leukocytosis.

Blood

^ d

3 v

CHAPTER XVII

WEAKNESS

So many patients consult a physician complaining primarily of
weakness that I have thought it best to discuss it and to illustrate it by
cases, although so little is known regarding the manner of its production
in the great majority of patients. We must make at the outset a dis-
tinction which is often not noticed by patients themselves, the distinction,
namely, between:

(a) Paralysis due to organic lesions of the brain, cord, or peripheral
nerve.

(b) Hysteric and psychasthenic " f orgetf ulness " (Janet), whereby
a patient loses control of his motor tract.

(c) Weakness in the narrower sense, excluding (a) and (b), and due
to a great variety of defects in nutrition, excretion, or blood-supply.

Of this latter type of functional insufficiency we really have very
little knowledge. It is often said that anemia is directly and in itself
the cause of many weakened states, yet I had under my care for three
years a patient with pernicious anemia who was in the habit of taking
a daily swim of about a mile in the Charles River, when his red cells
numbered less than 1,500,000 per c.mm. He also walked to and from
his work, a distance of about two miles each way, and was very
actively engaged as a salesman in the basement of a department store
for nearly twelve hours in every twenty-four. In view of this and
similar cases it is difficult to believe that anemia is in itself the all-
important cause of weakness such as we should often be led to suppose.

It is also well known that the size of muscles and their firmness have
only a rough and general relation to their strength. Some of the most
remarkable athletes have small and apparently soft muscles.

In a large group of cases weakness appears as the result of cardiac
insufficiency, but even here it is difficult to fix the blame, since dyspnea
is so intimately related to the disabilities of which the patient com-
plains.

Fever is likewise associated in our minds, and apparently, in fact,
with many cases of weakness, yet, on the other hand, we have all of
us dealt with patients who feel much brighter and better when their
temperature is elevated than when it is normal.

532

Causes of Paralysis

"APOPLEXY"
WITH HEMI-^I I 346

)PLEXY")
H HEMI-
5IA )

PLEGIA

TABES DORSALIS ^^^HMHMnBBHHHmBHi 323

POLIOMYELITIS IHBH^^HHBHIHHHHH 227

DEMENTIA
PARALYTICA

PARKINSON'S
DISEASE

ATAXIC "1

PARAPLEGIA i

121

NEURITIS 80

BIRTH PALSY 40

LATERAL )
SCLEROSIS-* 25

r:;:{

WEAKNESS 535

Despite all these limitations of our knowledge it is doubtless true
that anemia, lack of muscular development, cardiac insufficiency,
malnutrition, and fever are in some way connected with the weakness
of which our patients complain. Clinically, such complaints are most
often associated with the following conditions:

i. Neurasthenia and other psychoneuroses.

2. Tuberculosis.

3. Anemia.

4. Bad hygiene.

5. Nephritis.

6. Valvular heart disease.

7. Convalescence from acute respiratory infections ("influenza").

8. Diabetes.

9. Hyperthyroidism.

In the latter two diseases we have the striking phenomenon of loss
of weight and strength despite good appetite. Besides those above
listed, one sees now and then a patient complaining only of weakness,
yet proving, on examination, to have typhoid fever. The same is true
of myxedema and not infrequently of obesity.

Case 278

An expressman, thirty years old, of good family history and good
habits, had pneumonia seventeen years ago, and again seven years
ago. Six years ago he passed a life-insurance examination and was
told that his lungs were sound. He was first seen October 29, 1906.

He has been feeling entirely well until about two years ago, when
he began to get weak, lost his appetite, and felt some nausea and faint-
ness. He kept at work, however, until October, 1905, when he went
to his father's home in New York State, was out-of-doors hunting,
and felt much stronger and better, but still was not cured.

Some time after this he had jaundice. He was treated with calomel,
but did not improve. He went back to work in February, 1906, but
in May broke down again, and since then has never been able to work
more than three weeks at a time on account of weakness.

At no time has he had any pain, but his weakness gradually became
so troublesome that six weeks ago he gave up work for good.

His appetite has been poor throughout this illness, but for the past
three weeks he has eaten almost nothing because he cannot bear the
sight of food. He has had no vomiting, no pain anywhere, and his
bowels have moved regularly once a day.

For the past two weeks he has been very sleepy, and found it difficult

536

DIFFERENTIAL DIAGNOSIS

to keep awake in the day-time. For the past two weeks he has taken
beef-juice in teaspoonful doses, but no other food. He has had no
drugs except sodium phosphate. Of this, he says he has used half a
bushel-basket full of bottles.

A year ago he weighed 125 pounds, now he weighs 103.
On examination the patient is emaciated. His breath shows an
odor like acetone. His skin is of a dark yellow hue.

His heart is negative, except that the sounds are very faint. His
pulse is of very low tension; his blood-pressure, 50 mm. Hg.

The edge of the liver is just palpable below the ribs on full inspira-
tion. The knee-jerks are absent.

There is no edema. The urine is negative.

The temperature is as seen in the accompany-
ing chart.

Red cells are 5,040,000; white cells, 17,200;
hemoglobin, 85 per cent.; 69.5 per cent, of the
leukocytes polynuclear, the remainder lympho-
cytes, the majority of which are very large. The
blood is otherwise normal, repeated search for
malarial parasites being fruitless.

The stools showed nothing abnormal except
a slight reaction with the guaiac test. The vomitus
showed no hydrochloric acid; nothing else of
interest.

Extreme weakness was practically his only
symptom.

Discussion. The marked gastric symptoms
complained of by this patient direct our search
first toward some cause in the gastro-intestinal
tract.

(a) Anorexia nervosa often produces a condi-
tion even more serious than the one now under
discussion. Indeed, it is not infrequently fatal. But in a person of
this age, sex, and manner of life it is, so far as I know, unknown.

(b) Cancer of the stomach may occur at this age or even earlier,
though such an occurrence is very rare. One of its earliest symptoms
is often a complete loss of appetite, such as this patient suffered. The
absence of hydrochloric acid in the vomitus would seem to support this
hypothesis. On the other hand, in a patient so markedly emaciated
we should certainly expect to feel a tumor, especially as the symptoms
seem to have lasted two years. Other gastric symptoms such as

/Uy-

.'./

n~~.i

...

107'
I0'
1W"

103"

10!'

1W C

IB*
n*

M"
M
1M

HO
130

110

00
M
M
M
M
H
o
M
SO
*

1ft

-W

C-

Fig. 135. Chart of
case 278.

WEAKNESS

537

stasis and vomiting would certainly have appeared by this time in
the great majority of cases of gastric cancer.

(c) The enormous amount of sodium phosphate which this patient
had taken might cause us to conjecture that he has poisoned himself
with the drug were there any evidence that it is capable of producing
toxic symptoms; but so far as I know there is no such evidence.

The patient's yellow pallor reminded me strongly of some of the
cases of chronic malarial poisoning which I had seen in soldiers return-
ing from the Cuban war, but the results of blood examination absolutely
excluded malaria.

As there was no discoloration of the conjunctivas and no bile in the
urine, we did not consider a chronic hemolytic jaundice. The low
blood-pressure and the great emaciation were such as one often sees
in the latest stages of some form of tuberculosis. There were no lesions,
however, discoverable by physical examination, and no fever.

The absence of knee-jerks was not explainable by any of the diag-
noses which we considered. There was no sufficient reason to con-
sider tabes, as there were no sensory, pupillary, or sphincteric changes
and no pain. Very possibly he may have passed through an attack
of peripheral neuritis at some previous time, but there was no reason
to connect it with the present symptoms.

Addison's disease produces the lowest blood-pressure that has been
observed, so far as I know, in any disease previous to the moribund state.
It is often associated with gastric symptoms like those from which this
patient has suffered. The discoloration of the skin is usually more
marked than that here described, but as it is well known that Addison's
disease can occur without any pigmentation at all, it is well always
to remember the disease in any differential diagnosis of cases character-
ized by extreme weakness of obscure origin.

Outcome. The face and hands were a good deal darker colored
than the rest of the body; there was no increase at the body folds.

Tn the mouth was a small patch of dark-brown color on the inside
of the cheek, near the corner of the mouth, also some clusters of minute
brownish points on the inside of the cheeks near the junction of the
teeth, and a few on the hard palate. The patient looked like one in
the last stages of malignant disease or tuberculosis. At times he would
suddenly feel much better.

The patient was put on forced feeding by mouth and rectum-
whisky, i ounce every four hours, strychnin, -^ grain every four hours
and seemed better until the fourth of November, when he developed
fever and chill, became delirious, and soon died.

538

DIFFERENTIAL DIAGNOSIS

Autopsy showed tuberculosis of the adrenal glands; obsolete tuber-
culosis of the apices of the lungs.
Diagnosis. Addison's disease.

Case 279

A freight truckman, thirty-eight years old, entered the hospital July
i, 1906. He had formerly used alcohol in moderation, but had used
none for over a year until it was prescribed by a doctor during the
present illness. He denies venereal disease, and has been well until
twelve davs ago, when he began to feel weak, mean, and seedy. Three
days ago he had to give up work on account of weakness, night-sweats
accompanied by constant frontal headache, pain all over him (especially
in the back), anorexia, nausea, and vomiting.

Physical examination was negative, except that the knee-jerks and
abdominal reflexes were not obtained. The nutrition is fair.

Blood, urine, temperature, pulse, and respiration were normal.

Despite his weakness and prostration, there was noticeable during the
examination an unusual degree of nervous alacrity. Any direction
given him was executed with lightning speed and almost with violence.

Discussion. The symptoms of the onset seem like those of an acute
infectious disease, especially pneumonia or typhoid, and although
fever was absent, we made rigorous and repeated search for visceral
evidences of some such infection. Nothing came to light, however,
and we were obliged to look elsewhere for a cause of the symptoms.
In cases of this kind it is always well to consider:

(a) Neurasthenia or some other type of psychoneurosis.

(b) Poisoning by morphin or some other drug.

Though abstractly possible, the psychoneuroses were practically
easy to exclude when we were face to face with this burly, lethargic,
hard-working wage-earner.

Of morphinism there was no hint, either in the history or in his
present condition. He showed none of the vague longings, irritable
complaints of widely distributed pain, itching about the face, scars of
hypodermic punctures, pallor, emaciation, insomnia, or other evidences
of the morphin habit.

On the other hand, another poison alcohol was distinctly sug-
gested by the absence of knee-jerks, when considered in connection
with his mental state. The peculiar alertness and alacrity, shown by
alcoholics immediately previous to an attack of delirium tremens, is
difficult to convey by description, but easily recognized by any one
who has once or twice seen it. In the present case it was very marked, and

WEAKNESS

539

was associated also with a very noticeable smoothness and satiny tex-
ture of the skin, a sign often of great value in patients who deny al-
coholism, but present other evidences which make us suspect it.

Outcome. Although the patient indignantly denied any recent
alcoholic excess, he began to show the nervous symptoms of approach-
ing delirium tremens two days after his entrance to the hsopital, and in
spite of considerable doses of potassium bromid. These symptoms
abated, however, within two or three days, when he was able to go home
in much better condition.

Diagnosis. Alcoholism.

Case 280

A bridge-tender, fifty-eight years old, of good family history, has
had "chronic rheumatism," and especially "sciatic rheumatism," in
the right leg at irregular intervals for ten years or more. Otherwise
he has always been well and strong, and his habits have been good.

Ten months ago he began to notice a weakness so marked that at
times he came near fainting. This weakness was most noticeable in
the legs, but he has felt tired all over. For the last six weeks he has felt,
on exertion, a rather severe pain in his chest, near the lower part of the
breast-bone, accompanied by shortness of breath, which compels him
to stop whatever he is doing. The pain ceases after a few moments'
rest. Hearty food also brings on this pain, which comes on immediately
after eating and lasts for an hour or more.

He has no cough, no vomiting; is usually somewhat constipated;
the bowels move once in two or three days.

Two years ago he weighed 250 pounds; he still weighs 215. He
gets up three or four times at night to pass water.

The temperature, pulse, respiration, urine, and blood-pressure all
were normal. The heart showed no enlargement, and its sounds were
of fair quality. There was a faint systolic murmur at the apex, trans-
mitted a few inches to the left; no accentuation of either sound at the
base. The edge of the liver was felt two inches below the costal margin;
the abdomen is otherwise negative, likewise the lungs, reflexes, and
extremities.

Rectal examination showed prominent external hemorrhoids, but
no evidence of bleeding.

Examination of the stomach with a gastric tube showed nothing
abnormal, either physically or chemically.

The red cells were 2,520.000; white cells, 8000; hemoglobin, 30 per
cent.; differential count normal. The stained specimen showed marked

540 DIFFERENTIAL DIAGNOSIS

achromia, very slight variations in the size of the red cells, but nothing
else abnormal.

Discussion. The history of sciatica and the complaint of especial
weakness in the legs naturally lead us to consider peripheral neuritis.
No such diagnosis can be made, however, when the reflexes are normal
and all sensory symptoms are absent, as in this case.

Arteriosclerosis must occur to us whenever a patient of fifty-eight
complains of substernal pain and general weakness. Possibly there is
some arteriosclerosis in this patient, but I do not see that we can be
sure of it or that we can connect it with his present symptoms, since his
blood-pressure is low, his heart negative, and symptoms of stasis absent.

But for the blood-examination this patient would present almost
precisely the picture of pernicious anemia; even the substernal pain,
which he complains of, is sometimes seen in that disease, apart from
arteriosclerosis or nephritis. The blood-picture, however, is that of
secondary anemia, and compels us to make a most careful search for its
cause.

That search should be directed so as to ascertain whether syphilis,
malignant disease, hepatic cirrhosis, or any disease involving hemor-
rhage is present. All these except the last could easily be excluded,
but in view of past experience I always look with particular care for
evidence of hemorrhoids when the problem is to find the cause for the
anemia of a middle-aged patient. I recollect three persons suffering
from anemia of unknown cause and totally unaware of any trouble
from piles, which, nevertheless, turned out subsequently to be the
source of frequent long-standing hemorrhages. In all these cases
the anemia was cured by treating the piles and stopping the hemorrhage.
The same turned out to be true in the present case, the moral of which
is that careful examination of the rectum with a speculum should always
be made when we are searching for the cause of an obscure anemia.

Outcome. It was learned subsequently that the patient had had
bleeding piles off and on for at least four years. For some unknown
reason he omitted to mention this fact. Operation was advised, but
refused.

Diagnosis. Secondary anemia. Piles.

Case 281

A post-office clerk of sixty-three entered the hospital November
T4, 1907. He was in the hospital first in 1901 with genito-urinary
tuberculosis, and again in 1904 for stone in the bladder. He seems
to have recovered entirely from both his previous troubles. For the

WEAKNESS

541

yi*V~r*fJO*Js

past year he has been losing strength and weight. Twenty years ago
he weighed 196 pounds; five years ago, 170; one year ago, 167; and
now, 128. From July 1st to November 1st of this year he was unable
to work. For the past two weeks he has been at work again, but had
to give up to-day. He has no other symptoms of any kind, and has
noticed no pallor or pigmentation of the skin.

The patient is somewhat pale and much emaciated. A systolic
murmur is heard at the apex, but not transmitted. The heart is other-
wise negative, as are the lungs. The arteries are
rough and tortuous. The pulse appeared to be one
of high tension. Hemoglobin, 25 per cent.

The abdomen and extremities show nothing ab-
normal. The course of the temperature is seen in
the accompanying chart (Fig. 136). The urine
averaged 30 ounces in twenty-four hours, with a
specific gravity of 1012; a slight trace of albumin
was found, but no casts.

Discussion. In looking for a cause for the
anemia here present we notice that the kidneys do
not seem to be doing much work, and might be
rash enough to assume that some type of nephritis is
responsible for the symptoms. It is true that
nephritis may be in itself the cause of very intense
anemia, but is there any sufficient evidence that
this man has a nephritis at all? The total solids
excreted are certainly very deficient, but this may Flg- r 3 6 - Chart of
be the result merely of insufficient food. Although
we know very little about his diet, it is safe to assume that he does
not eat enough to give him the normal output of urinary solids.

Emaciation is at least as important a feature as the anemia in this
patient. He is at the age when very considerable emaciation often
occurs merely as the result of the aging process /. e., of arteriosclerosis.
Such, at any rate, seems to me the reasonable conclusion as we observe
the rapid loss of weight which takes place in a large proportion of
elderly persons without any corresponding change in the diet. It must
be confessed, however, that the evidence of arteriosclerosis in this patient
is not conclusive. Many patients whose arteries are rough and tortuous
turn out, postmortem, to have very little arteriosclerosis, and the high
pulse tension which would seem to verify, to a certain extent, the hypothe-
sis of arteriosclerosis, was based merely on digital examination a most
unreliable procedure.

542

DIFFERENTIAL DIAGNOSIS

Pernicious anemia is probably the commonest cause of an extreme
reduction in the hemoglobin percentage at the age of sixty-three. In
most cases of pernicious anemia, emaciation is comparatively slight;
sometimes it is absent altogether. But this fact does not by any means
suffice to exclude pernicious anemia in this case. The blood must be
much more carefully investigated.

Outcome. The red cells were found to number 863,000, so that
the hemoglobin, though very low ; was yet relatively high (color index,
1.4). The leukocytes numbered 4200, 58 per cent, of which were
polynuclear, with 41 per cent, of lymphocytes and 1 per cent, of mast
cells. During a differential count of 200 cells, four normoblasts and
two megaloblasts were found. The red cells were of huge size, deeply
stained, and much deformed. Many of them contained basophilic
granulations or showed diffuse abnormal staining reaction.

The blood-pressure was only 100 mm. Hg. The patient rapidly
failed and died on the twenty-first.

Diagnosis. Pernicious anemia.

Case 282

An Irish housewife of forty-two, of good family history, had malaria
fifteen years ago; a still-born child last May; no other children or mis-
carriages.

Her chief complaint at the present time is of weakness, affecting
especially her back. She entered the hospital on April 27, 1908. Six
months previously she had had a good many dizzy spells, with insomnia
and much nervousness. At that time she was five weeks in a hospital,
but no diagnosis was made. At the present time she has a good appetite
and sleeps well.

Her catamenia are regular, but she believes herself to have some
pelvic disease, and vomits occasionally without relation to food.

Physical examination shows an obese woman, with a dry skin and
numerous rose-colored papules scattered over the front of the chest and
abdomen. Th^ course of the temperature is seen in the accompanying
chart. The chest and abdomen showed nothing abnormal. The
reflexes, blood, and urine were negative. Vaginal examination showed
no pelvic disease.

Discussion. The papules here described had all the characteristics
of rose spots, and would have passed perfectly well for the exanthem
of typhoid fever had any pyrexia been present. In the absence of fever
no obvious explanation was found for them. It may be worth stating
here that, even in febrile conditions, the rose spot, although most valuable

WEAKNESS

543

as confirmatory evidence of typhoid, is by no means pathognomonic of
that disease. The typhoid bacillus is not the only germ which is prone
to settle beneath the skin and produce the hyperemic area known as
a rose spot. I have seen the same thing in pyogenic sepsis many times,
and in tuberculosis once.

The patient is stated to be obese. Is this enough to accouni for her
weakness? Occasionally one sees persons for whose exhaustion and
incapacity no other cause can be found. But I have never known a
patient to enter a general hospital on this account. Further, there has
been no special increase in the amount of fat
during the period occupied by her illness.

Myxedema is sometimes mistaken for obesity,
and often causes a very troublesome weakness.
In the present case, however, we have no good
reason to believe that myxedema is present.
There are no cutaneous or mental symptoms,
no subnormal temperatures, nor special sen-
sitiveness to cold. The facial expression is un-
changed.

If physical examination, repeatedly and con-
scientiously performed, is wholly negative in a
case of this kind, it is proper to investigate the
mental condition of the patient. Subconscious
fears and internal tensions may be enough to
account for all the troubles of which this
patient complains, though we should never
assume anything of the kind until every other
possibility has been exhausted. In the search
for a psychic cause it is never sufficient to ask a patient such a question
as, "Are you worrying about anything?" or "Have you anything on
your mind?" The worries which do the most harm physically are those
of which the patient is partially or quite unconscious. Of course, the
onlv proof that our diagnosis is right, when we believe we have succeeded
in drawing out of the depths of a patient's consciousness some sub-
merged cause of internal strife, is the physical results. If immediate
improvement follows, it is reasonable to suppose that we have hit upon
the source of the trouble.

Outcome. It developed later that after her child was born and
she had left the hospital, she was told that she was "in a bad way";
this idea fermented in her mind and apparently was the basi> ol her
present troubles.

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Fig. 137. Chart of case

282.

544 DIFFERENTIAL DIAGNOSIS

During two weeks' observation she seemed to be perfectly well,
and after being officially reassured, her sensations corresponded to
her good digestive condition.

Diagnosis. Apprehension.

Case 283

An Irish chambermaid of twenty-two, of good family and past history,
was seen December 18, 1906. She came to the United States four months
ago. Her menstruation began at the age of fifteen and has always
been regular, but her last period occurred on the steamer during her
passage to America.

A month ago she began to feel weak and unfit for work. This
weakness was accompained by a palpitation on any exertion and some-
times by faintness. She has been very constipated all through her sick-
ness, but has had no vomiting or other gastric symptoms, and no cough
or fever, so far as she is aware.

On examination the girl is well nourished, with bright red cheeks,
but somewhat pale and slightly bluish lips. The glands are palpable
in the neck, axillae and groins, but not enlarged. The heart seems to
be of normal size, its action regular, but there is a rough systolic murmur
heard best at the base and transmitted to the left axilla. The pulmonic
second sound is distinctly louder than the aortic.

The lungs show scattered coarse rales.

Visceral examination is otherwise negative. The patient weighed
165I pounds. Her pulse, temperature, respiration and urine were
normal throughout three weeks' observation.

Discussion. Could this girl be pregnant? The amenorrhea, weak-
ness, palpitation, and fainting are consistent with that diagnosis, which
could only be confirmed, however, in case the uterus was found to be
demonstrably enlarged. We should expect also some gastric disturb-
ances and changes in the breasts. Since none of these necessary con-
firmations appear to be present, we must look for some other cause for the
amenorrhea.

Vegetative endocarditis produces general weakness without localiz-
ing symptoms. It had been considered by the attending physician
on account of the rough murmur over the base of the heart. But such
a diagnosis needs a great deal more evidence before we can be content
with it. The pulmonic second sound, though louder than the aortic, did
not appear to be abnormal, and there was no fever, chills or cardiac
enlargement. Regarding the leukocytes, which should be increased
in number if endocarditis is present, we have as yet no information.

WEAKNESS

545

Cases of early tuberculosis often have a history very much like this,
and one should always examine the pulmonary apices with especial care
in such a case. But without fever, loss of weight, gastric disturbances
or cough we should not be warranted in entertaining any further the
hypothesis of tuberculosis, nor in suggesting it to the patient or her
family. Diffuse rales in both lungs are not what we expect to find in
early tuberculosis, except in the miliary form, and then with much
more virulent symptoms.

If the patient were pale, we should naturally suspect chlorosis.
Everything else in the case seems consistent with that idea. Can a
patient with bright red cheeks have chlorosis or any other form of
anemia? Most certainly, and it is for this reason that I have intro-
duced the case. Many like it are overlooked, I believe, because we
have not the habit of making routine hemoglobin estimations. The
color of the face is no guide. The majority of pale people are not
anemic, and many anemics are not pale.

Outcome. The red cells are 3,364,000; white cells, 3200; hemo-
globin, 35 per cent. The stained specimen shows marked achromia, no
nucleated cells, no abnormal staining or abnormal shapes. The dif-
ferential count is also normal.

It was subsequently learned that before coming to this country
she had always been used to out-of-door life, though during her work
here she had been closely confined.

Under Blaud's pill, 10 grains three times a day, the red cells had
risen by the fifth of January to 4,400,000, the hemoglobin to 60 per cent.,
and the girl felt entirely well.

Cascara was needed at the beginning of the treatment, but not after
the first week.

Diagnosis. Chlorosis.

Case 284

A Syrian thirty-seven years old entered the hospital June 27, 1906.

He has had many touches of malaria, and takes three whiskies a day.

Otherwise his history was not notable until seven months ago, when

he began to lose strength and got run down. For the past three months

he has been rapidly growing weaker. At no time has lie had any pain

or other localizing symptoms except at the very beginning of his illness,

when he had a rather indefinite pain in the right shoulder and right

axilla. This passed off within a few weeks, but has returned again of

late.

He has no cough and no dvspnea, but within the past week he has
35

546

DIFFERENTIAL DIAGNOSIS

taken \ grain of morphin every night to make him sleep. For four or
five davs he has been in bed. Two weeks ago he noticed for the first
time that his feet were swollen.

On examination the man was emaciated. The right chest was flat
in front below the third rib and below the spine of the scapula above.
Breath-sounds and voice-sounds were absent over the same area.

The heart's impulse was in the fifth space, and reached if inches
outside the nipple-line. The right border could not be determined.
The pulmonic second sound was accentuated.
There were no murmurs. Blood-pressure, 140.

The abdomen was held rigidly throughout. It
was tympanitic, not tender. There was soft edema
of the lower legs and feet, also some over the
sacrum. The white cells were 1 5,000; hemoglobin,
85 per cent. The course of the temperature is seen
in the accompanying chart.

Discussion. The essential features of the case
are: fever, weakness, displacement of the cardiac
apex, edema of the feet, and apparently fluid in
the right chest.

Pleurisy is naturally our first thought, but we
are puzzled by the absence of pain, cough, or
dyspnea, and by the presence of swelled feet. Can
the latter symptoms be the result of a pleurisy, or
must we suppose that both the swollen feet and
the thoracic fluid are the results of some common
cause, perhaps disease of the heart or kidney?
If the heart is diseased, we should expect either a murmur, a change
in blood-pressure, an arhythmia, or some other evidence besides dropsy.
Further, it is difficult to explain the fever as the result of heart disease
unless there is a vegetative endocarditis, in which case there should be
a murmur, though this is not invariable.

No more positive evidence can be obtained without tapping the
chest. The characteristics of the fluid thus presumably to be obtained
should decide the question. Meantime it may be suggested that in
children such a group of symptoms would be clearlv indicative of em-
pyema. What happens frequently in children may occur now and then
in adults.

Outcome. Exploratory puncture showed foul pus on the twenty-
eighth. Xext da}- a rib was resected, and several pints of the same
fluid removed. The pus showed no growth on ordinary culture-media.

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case 284.

WEAKNESS

547

The patient did well for the week following operation, and went home
with a small discharging sinus. His further progress could not be
traced.

Diagnosis. Empyema [tuberculous ?].

Case 285

A boy of four years, with good family history, entered the hospital
May 27, 1908. He had always been well until nineteen days ago, when
he complained of being tired, and seemed listless and disinclined to play.
Soon after this he began to be feverish, especially at night.

For the past fifteen days he has been in bed. At no time has he
complained of any pain. His appetite has been good, his bowels regular,
and he sleeps well. He has had a little dry cough for a week. (The
course of the temperature is seen in the accompanying chart, Fig. 139.)

Physical examination shows a well-nourished child, with ]>ink
cheeks and a freckled face. His left tonsil is enlarged, his throat some-
what reddened. The heart's impulse is in the fourth interspace, just
outside the nipple-line. The organ seems otherwise normal.

The right chest in front is flat below the fourth interspace, the line
of flatness rising in the axilla, so that it reaches to the top ot the chest
behind. Respiration is normal over the left chest, harsh in the front
of the right chest, above the line of flatness; below that it is nearly
absent.

Just below the midscapular level behind, there is a spot of bronchial
breathing and a few crackling rales. Voice-sounds are slightlv in-

548 DIFFERENTIAL DIAGNOSIS

creased at this point. Elsewhere they are absent. The edge of the
liver is felt one finger's-breadth below the ribs.

Discussion. One could hardly make a mistake regarding the
diagnosis in this case if he placed his reliance upon physical signs.
What I desire specially to point out is the misleading character of the
history. The child has no pain in the side, almost no cougb, no dyspnea,
nothing to call one's attention rather to one part of the body than to
another.

Relying on the physical signs, we cannot doubt that there is fluid
in the right chest. The small spot of bronchial breathing near mid-
scapula is not in the least in contradiction to this diagnosis. Indeed,
we generally hear bronchial breathing in some part of the chest of a
young child when fluid is present in large amounts. Pneumonia, the
only other disease which we could consider at all, never has so insidious
an onset or so prolonged a course in young children.

When we know that a child's chest contains fluid and have no reason
to suspect disease of the heart or kidney, we may feel practically certain
that empyema is the diagnosis. Insidious serous effuson, so common
in adults as a result of tuberculosis, is distinctly rare in infancy, while
the pneumococcus infections leading to empyema are common, and
present, as a rule, just such a clinical picture as I have here reproduced.

Outcome. On the twenty-eighth the chest was opened, with the
escape of 10 ounces of pus teeming with a growth of pneumococci. The
child's convalescence was prolonged and often interrupted by the reten-
tion of pus in subsidiary cavities, owing to unsatisfactory drainage.
Recovery was ultimately complete.

Diagnosis. Empyema .

Case 286

A Scottish salesman, seventy years old, of good family history and
past history, entered the hospital November 8, 1906. He gave up
work six months ago on account of progressive weakness. About a
month later he noticed that gas gathered in his stomach about twenty
minutes after eating, causing considerable noise and some nausea.
He has at no time any pain, but has gradually become weaker, paler,
and more short of breath. Within the past three weeks his legs have
swollen; his skin has turned yellow and itched. Ten months ago he
weighed 195 pounds, now he weighs 155.

Examination showed obvious loss of weight; skin pale, and of a
yellowish tinge; no demonstrable jaundice, the color being more like
that of pernicious anemia. The heart showed a systolic murmur,

WEAKNESS

549

audible all over the precordia and in the left axilla. The sounds were
faint and distant. There were no evidences of enlargement and no
irregularity. Visceral examination was otherwise negative, except for
a slight puffiness of the face and hands, and a moderate, rather brawny
edema of the lower legs.

The red cells were 2,328,000; white cells, 5000; hemoglobin, 25
per cent. There was a very marked serum ring around the blood-
stain as I took the hemoglobin test by the Tallqvist scale. The differen-
tial count showed polynuclears, 59 per cent.; lymphocytes, 41 per cent.
The red cells showed very marked achromia, moderate deformities in
shape, no abnormal staining reactions, no blasts. The urine was
altogether negative. A small amount of brownish material which gave
a positive guaiac reaction was found in the fasting stomach. The
organ held 52 ounces, and after a test-meal showed no free HC1.

Discussion. Here we have the symptoms of pernicious anemia
but the blood-picture does not correspond. It is a familiar puzzle and
an important one. As a result of a fairly extensive experience in dealing
with this particular problem I think it may be stated that it is the part
of wisdom to follow the indications of the blood-examination in such
cases. Primary anemia does not produce a blood-picture like that here
described in patients of this age. The most distinctive features are the
achromia and the low color index.

Assuming, then, that we are dealing with secondary anemia, what is
its cause? In men of this age severe secondary anemia is produced
usuallv by cancer, syphilis, or hemorrhage. The anemia of nephritis
or of cirrhosis usually occurs in younger persons. Since we have no
evidence whatever either of syphilis or hemorrhage, cancer is the most
probable diagnosis. But what is the seat of the tumor? Such slight
indications as we possess seem to point to the stomach. The recovery
of a material reacting positively to the guaiac test, the absence of hydro-
chloric acid, the slight enlargement of the stomach, the nausea and
flatulence tend to confirm this indication.

The case is of special interest because of the absence of pain and
vomiting. It tends to substantiate the old rule, which bids us suspect
gastric cancer whenever a patient, previously free from digestive dis-
turbances begins in later life to have any gastric symptoms, however
slight.

Outcome. The patient was given forced feeding and oxygen by
rectum in the hope of inhibiting the growth of anaerobic bacteria, but
on the fourteenth of November he was so weak that he could not walk
alone. The blood examination then showed: Red cells, 1,820.000;

DIFFERENTIAL DIAGNOSIS

white cells, 3200; hemoglobin, 12 per cent. The stained specimen
showed essentially the same as the previous examination.

The patient died on the seventeenth. Autopsy showed a large,
cauliflower growth at the pylorus, almost obstructing its lumen; car-
cinoma histologically.

Diagnosis. Gastric cancer.

Case 287

An Italian housewife, fifty years old, entered the hospital June 17,
1907. She began to complain four weeks ago of weakness and fatigue.
It was also noticed that she passed very little urine.

For three weeks she has been in bed, complaining mostly of weakness,
accompanied by anorexia, insomnia, and constipation. Her mouth is
dry and she is very thirsty. There is a dull, constant epigastric pain.
Last week she vomited twice small quantities of
green fluid. She has no headache; her eye-sight
is good. The urine continues scanty.

On examination the patient is found to be some-
what emaciated. Her chest shows nothing abnor-
mal except a few crackles and squeaks in the lower
part of each lung.

The abdomen is protuberant, the umbilicus
pushed out, and there is shifting dulness in the flanks.
The condition of the epigastrium is shown in the
accompanying diagram, and the temperature in the
accompanying chart (Fig. 140).

The blood and urine show nothing abnormal.
The circumference of the abdomen at the level of
the navel is 80 cm.

Discussion. Cirrhosis of the liver was the "snap
diagnosis" in this case, suggested, of course, by the
insidious onset of extensive ascites. Although this
disease cannot be excluded from consideration, there
are a number of points against it. The most important is the patient's
pain, a symptom of which we hear practically nothing in cirrhosis.
Further, Italian wine, which is all that this patient has taken, does not
often produce cirrhosis. Finally, the surface of the liver, which is
stated to be rough on palpation, is not characteristic of cirrhosis from
the clinical point of view. The hob-nails of the hob-nail liver are almost
never to be felt through the abdominal wall. I have known many
cases where they were felt, but not one of these cases turned out to be

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Fig.

140. Chart of
case 287.

Fig. 141. Hndings in a case characterized chiefly liv weakness and swollen belly (four

weeks' duration).

WEAKNESS 551

cirrhosis. The supposed hob-nails proved to be nodules of fat in the
abdominal wall or irregularities due to cancer or syphilis.

The course of the disease seems very short and rapid for syphilis.
The transition from perfect health to great prostration, with ascites,
anorexia, and vomiting is rarely brought about by syphilis within four
weeks. Of course, it may well be that the history is inaccurate, especially
as it was obtained through an interpreter. If we disregard the history,
the chief evidence against syphilis is the absence of any luetic lesions
in other parts of the body. Wilhout the therapeutic test, however, it
is impossible positively to exclude syphilis in this case.

Tuberculous peritonitis is not common at this age, rarely produces
so much prostration, and would not explain the enlargement of the
liver and spleen, or what we take to be such. Cancer of the liver would
explain most of the symptoms, and would account for the rapid march
of the malady. It is surprising, however, that no more marked gastric
symptoms are complained of. Hepatic cancer usually shows itself as
a later development in an illness characterized by months of severe
digestive disturbance. Possibly the cancer may have originated in
some "silent," deep-seated organ, whence it was extended by metastasis
to the liver.

Banti's disease is always to be suspected when an Italian is found
to be suffering from enlargement of the liver and spleen with ascites.
It must be admitted, however, that the clinical picture of Banti's disease
has seldom been clearly recognized except by Italian writers. It is
essential, at all events, that we should be able to demonstrate an enlarge-
ment of the spleen preceding by a considerable period the onset of
ascites and hepatic hypertrophy. Nothing of the kind can be shown
in the present case.

The most reasonable diagnosis, therefore, appears to be cancer of the
liver, origin unknown.

Outcome. June 18th it was learned that she had received large
doses of mercury and potassium iodid before entrance, hence this clue
was not followed up any further. The patient died on the twenty-
second. Autopsy showed primary cancer of the liver with metastases
in the mesenteric glands, spleen, pancreas, lungs and thyroid.

Diagnosis. Cancer of the liver.

Case 288

A Jewish married woman, thirty-four years old. was first seen
February 4, 1907. Her father died of kidney disease; her family

552 DIFFERENTIAL DIAGNOSIS

history is otherwise good. She had chlorosis when she was seventeen.
She has had three children, the youngest five years old.

For eighteen months she has felt weak, and in that time she has lost
about 30 pounds. Her appetite has been poor throughout this period.
At times she has been feverish. She often has a bitter taste in her mouth
after eating. Four weeks ago she had a severe left-sided headache;
since then she has heard roaring noises in her head, and has felt still
weaker than before.

Two weeks ago she had two similar attacks within a week, and
the headache has been continuous for the last five days. With each
of these attacks of headache she has vomited, but there has been no
other pain. When her eyes were examined recently at the Eye and Ear
Infirmary they were found to be normal. Throughout the eighteen
months of her illness she has had diarrhea alternating with constipation.

The patient was poorly nourished, the skin brightly colored. Visceral
examination was wholly negative, as was the blood examination. The
urine was free from albumin and casts; twenty-four-hour amount
normal.

Discussion. Weakness and loss of weight with headache and
digestive symptoms are complained of by innumerable Jewesses of this
age without our being able to discover any more definite cause than
their self -starvation and a psychoneurotic constitution. If 1 he physical
examination is wholly negative and no drug habits can be discovered,
the case will have to be treated on this basis.

We must first make sure, however, that nothing of any importance
has been omitted from our physical examination. Are we quite certain
that no hints of larval hyperthyroidism are to be found? No tremor,
tachycardia, profuse sweating without cause or slight thyroid enlarge-
ment? All these signs were searched for in the present case, with
negative results.

One all-essential point, however, is omitted in the account of the
case printed above, because it was absent from the record presented to
me when I saw the case in consultation. There is no record of the
test for sugar nor of the specific gravity of the urine, which turned out
to be 1040.

Outcome. Five and a half per cent, of glucose was found in the
urine. In the course of a month, however, this disappeared under a
diet of increased fats and diminished carbohydrates. The headache,
which had been throughout her chief complaint, disappeared as soon
as the urine became sugar-free. Jn the course of the month under my
observation she gained six pounds.

Diagnosis. Diabetes mellitus.

WEAKNESS 553

Case 289

A school-boy of fifteen was first seen on November 28, 1907. His
family history is good, and he has always been well until three weeks
ago, when he began to complain of weakness, headache, vertigo, and
slight nausea.

Six weeks ago he weighed 99 pounds; now he weighs 81. His
appetite is good, his bowels regular, and there is no vomiting.

Physical examination shows emaciation and mental dulness.

The edge of the liver is felt on inspiration. Physical examination,
including the blood, is otherwise negative. The urine is pale, its quantity
from 3500 to 5000 c.c. in twenty-four hours, the specific gravity never
far from 1030; amount of sugar, 5.5 per cent., gradually rising to 7.5
per cent, during the live weeks of his stay in the hospital.

Discussion. This case is introduced merely as a further exempli-
fication of the fact that diabetes may occur without any of the cardinal
symptoms on which we often rely for diagnosis. This boy complained
of no thirst, had no increase of appetite, and, so far as he knew, no
polyuria. The diagnosis was simple enough as the result of a routine
examination, including, as all such examinations should, a test for sugar.

Of some interest, I think, is the outcome of the treatment, which,
though it sufficed merely to prolong the boy's life for a month, un-
doubtedly did accomplish as much as this. Such a respite is sometimes
of very great importance when a relative wishes to come from a distance
or when a financial matter has to be finished up.

T may call attention also to the convulsions which occurred as a
part of the terminal acidosis. Diabetes is not often mentioned among
the possible causes of convulsions, because there is so rarely any diffi-
culty in recognizing spasms of this type, occurring as they do at the
end of a prostrating illness, the nature of which is not likely to have
been in doubt. When a convulsion occurs "out of a clear sky'' in a
patient not known previously to be ill, it practically never turns out to
be due to diabetes.

The purpura noted in the outcome was doubtless of the cachectic
type.

Outcome. As he showed every sign of impending coma at entrance.
he was saturated as rapidly as possible with sodium bicarbonate, given
both by mouth and intravenously. Sodium bicarbonate. 250 c.c. ol a
2.5 per cent, solution, was given, and next day 350 c.c. of a 5 per cent,
solution of glucose was administered intravenously. This was followed
by a very marked improvement.

554

DIFFERENTIAL DIAGNOSIS

On account of the very marked acidosis the patient was given an
unmodified diet, the bowels kept open by enemata, and his appetite
stimulated- by bitter tonics. He was kept out-of-doors daily, well
wrapped up, in bed.

December ioth the diet was slightly restricted, omitting starchy
soups, though cereals, bread, milk and potatoes were given without
restriction. Chewing-gum was allowed on his request, and gave much
relief to the dryness of the mouth.

Impending coma was again relieved on the fifteenth by a treatment
similar to that previously given, but it seemed wise not to attempt
further to restrict the diet.

He steadily lost weight and strength, and any exertion made him
drowsy.

On the thirtieth numerous purpuric spots appeared on the trunk,
arms and legs, and he began to have drowsiness, which rapidly in-
creased to complete coma, after which he had a series of general clonic
convulsions lasting from thirty to sixty seconds each. At midnight he
died.

Diagnosis. Diabetes mellitus.

Case 290

An Irish painter of thirty entered the hospital November 25, 1907.
His mother died of cancer, and he has lost one sister of consumption.
He is a hard drinker every Saturday, rarely drinking during the week.
He had gonorrhea three times, but denies syphilis.

For six weeks he has complained of weakness in his legs and back
he says his legs won't hold him up. His joints are lifeless and he cannot
go upstairs. There is no swelling of his joints, and he has no pain
except on stretching the muscles. He has lost no weight. His appetite
is good, and he feels well except for the above complaint. He quit
work two weeks ago, but has not been in bed.

Physical examination shows slight irregularity of both pupils, with-
out any other abnormality there. There is no lead line.

The heart is slow 60 to the minute, with a prolonged diastolic
pause. The artery walls are firm, but not nodular; lungs normal,
abdomen rather spastic, not otherwise remarkable. There is well-
marked left varicocele.

The knee-jerks are absent even on reenforcement. Kernig's sign
present on the right; well-marked Romberg sign; superficial reflexes
lively; no Babinski; temperature, pulse, respiration, and urine are
normal.

WEAKNESS 555

Discussion. Most patients who come to us complaining of weak-
ness in the legs have some disease of the nervous system. Occasionally
a case of diabetes or of cardiac trouble brings this symptom into the
foreground, but, as a rule, all general diseases outside the central nervous
system have some chief complaint or complaints other than weakness.

Among diseases of the nervous system some type of neuritis is
suggested because the pupils are normal, the reflexes diminished, and
the symptoms bilateral. The occupation of the patient naturally pre-
judices us in favor of lead-poisoning, but as there is no lead line, no
colic, no special involvement of the extensor muscles (toe-drop), we
are inclined to canvas the other possible causes of neuritis first.

As an alcoholic he has a perfect right to alcoholic neuritis, though
we see no special reason why it should come on now rather than sooner.
Most, if not all, cases of alcoholic neuritis, however, present some
sensory symptoms. This patient has none.

Tabes dorsalis is very unlikely on account of the normal reaction
of the pupils and the entire absence of sensory symptoms such as
usually occupy the foreground in tabes.

One possibly decisive test has been omitted blood examination.
Alcoholic neuritis rarely if ever produces any marked basophilic stip-
pling of the red cells; saturnine neuritis practically always does. To
this question, therefore, it is reasonable next to turn our attention.

Outcome. Blood examination showed hemoglobin, 70 per cent.;
leukocytes, 5500. In the stained smear the red cells exhibited marked
achromia and a great deal of stippling, but no other abnormalities.

Under potassium iodid 10 grains thrice daily the patient began to
improve at once, and by the thirteenth of December could walk fairly
well, though a slight exertion put him out of breath.

Diagnosis. Lead-poisoning (?).

Case 291

A married woman, forty-three years old, with an excellent family
history, past history, and good habits, entered the hospital October 13,
1906. She had always been well until a year ago, when she noticed
that she was gradually growing weak. She had no pain anywhere;
her appetite remained good and her bowels regular; but some months
later she noticed that the abdomen was increasing in size and that she
was short of breath on exertion. At this time she was much annoyed
by noises in her left ear and by attacks of vertigo. Throughout the
past year her weakness has steadily increased and is her only com-
plaint at the present time.

556 DIFFERENTIAL DIAGNOSIS

Four years ago she weighed 160 pounds, now she weighs 117.
On examination the patient is somewhat pale, but the hemoglobin
shows 70 per cent. She is well nourished.

The heart is negative, save for a soft systolic murmur, best heard
in the third left interspace, and not transmitted. The vessels of the
neck pulsate rather strongly. The lungs are entirely negative. The
abdomen shows a marked prominence on the left side, and dulness as
shown in the accompanying diagram (Fig. 142).

Discussion. One could hardly make a mistake in the diagnosis
of this case unless one were in the habit of relying on symptoms rather
than on the results of physical examination. No one could fail to
notice the abdominal tumor if he had palpated the abdomen with any
care. No one with any knowledge of physical examination could have
any doubt that that tumor was due to splenic enlargement.

Splenic enlargement associated with such evidences of anemia as
this patient presents is characteristic of three diseases seen in temperate
climates, and among those who have never visited the tropics. The
huge "ague-cake" of chronic estivo-autumnal malarial or kala-azar
need not be considered in any patient who has never been out of New
England. Leukemia, splenic anemia, and syphilis are the only diseases
which we need to consider. Leukemia can be instantly recognized by
the blood examination. Splenic anemia and visceral syphilis may be
almost indistinguishable unless other evidence of syphilis can be ob-
tained from the history or in the physical examination.

Outcome. Examination of the blood showed: red cells, 2,656,000;
white cells, 652,000. Differential count showed polynuclears, 54 per
cent.; myelocytes, 38 per cent.; eosinophiles, 3.5 per cent.; mast cells,
2.5 per cent.; lymphocytes, 2 per cent.

The red cells were well stained and showed no special abnormalities.
This blood-picture did not change appreciably during the month in
which the patient was under observation.

The patient was much more comfortable as the result of an ab-
dominal support which held up the enlarged spleen.

Under .x-ray treatment she seemed to be getting steadily better
until the ninth of November, when she had a slight pain in the left back,
which later in the evening became severe; morphin, | grain by mouth,
was vomited.

Respiration was slightly quickened. At 2 o'clock in the morning
of November 10th the patient had a chill and vomited. The pulse
rose to 130; respiration was very rapid; temperature, 99. 4 F. Morphin,
I grain subcutaneously, gave some relief; but at 4.50 the respiration

Fig. 14^.' Showing results of percussion and palpation in a patient complaining only of
weakness and abdominal enlargement.

WEAKNESS 55/

suddenly ceased. No cause for this sudden death was found either
before or after the autopsy, which showed the lesions of myelogenous
leukemia.

Diagnosis. Myeloid leukemia.

Case 292

A married woman of forty-four was first seen on July 10, 1907.
Her family history is entirely uneventful. She was said to have had
cerebrospinal meningitis when a child, and has ever since been subject
to headaches and nose-bleeds. The menopause occurred five years ago.
She has had no children and no miscarriages.

She takes two glasses of beer a day, but never takes whisky. She
drinks the Boston city water through a lead pipe.

Two weeks ago she became so weak that she fell to the floor, striking
the back of her head. She was unconscious for about an hour, and
woke up in bed, where she had been put by her husband. Since then
she has been unable to stand unless supported, although she can move
her legs readily in bed.

During the past four days her arms and fingers have become numb
and lifeless. She can hold a knife and fork, but she cannot lift a glass
of water. Her speech has not been affected, and sphincteric control
is perfect. She has no headache and sleeps well. The bowels are
constipated; her appetite is poor.

On examination the patient shows loss of weight; the arteries are
palpable and tortuous above the elbow; the heart, lungs, and abdomen
are negative, except for a sharp edge felt underneath the right ribs.
The knee-jerks are not obtained. There is general tenderness over
the nerve-trunks of the legs. The grip of both hands is weak, and the
extensors of the wrist are likewise weak.

There is no lead line. The blood shows no stippling. The urine
is normal and contains no arsenic.

Discussion. Evidently this is a different type of weakness from
that of the cases we have been previously studying. It is referred
more 'definitely to legs, and appears suddenly. Especially when we
take account of the condition of the nervous system, as revealed bv
physical examination, we are clear that the case does not belong with
those in which weakness is due to cardiac or toxemic conditions.

The possible connection of lead with the trouble is naturally our
first thought, since the history mentions a lead pipe. It must be remem-
bered, however, that in the vast majority of cases, water coming through
lead pipe between the street main and the facet within the house does

558 DIFFERENTIAL DIAGNOSIS

not become impregnated with lead and does no harm to any one. More
over, in this patient the tissues most sensitive to lead and most apt to
show its influence as soon as poisoning begins, are here evidently un-
touched. There are no changes in the gums or in the blood, no colic,
no arthritis, no encephalopathy.

Arsenical poisoning has now gone out of fashion, partly, I believe,
because the neurologists have grown tired of it and are fonder of the
term "neurasthenia"' or "psychoneurosis," partly because our wall-
papers are now freer from arsenical dyes. The absence of arsenic
from the urine in the present case would probably be accepted as con-
clusive evidence against the presence of arsenical poisoning. On the
other hand, it must be remembered that a considerable proportion of
the community often passes arsenical urine from time to time while in
perfect health, so that the demonstration of the mineral is by no means
proof of arsenical poisoning. Negative evidence is here better than
positive.

Epidemic poliomyelitis is apt to occur in the hot summer months,
in one of which this patient was attacked. It is, however, very rare
at her age, does not often attack both legs or produce such incomplete
paralysis of the muscles involved. Tenderness over the nerve-trunks
is not common.

The tenderness just referred to enables us to rule out other types of
myelitis which would in any case be unlikely to produce so mild a
disturbance of motion, without increase of reflexes or involvement of
the sphincters. Alcoholic neuritis would produce practically all the
symptoms here complained of, but the amount of alcohol which she
admits having consumed seems insufficient to produce so severe a trouble.
If no other cause can be discovered, however, we may have to disbelieve
her story.

Beyond any reasonable doubt she has a multiple neuritis; as she has
had no fever, we cannot call it an infectious type of neuritis, and all
other varieties, except that referred to in the last paragraph, appear
to have been excluded. On the whole, alcoholic neuritis seems the
most reasonable diagnosis.

Outcome. Upon cross-questioning the patient later admitted that
she had been taking four bottles of ale daily for a number of months.
As a result of continued abstinence, with good hygiene, she recovered
entirely in the course of three months.

Diagnosis. Alcoholic neuritis.

WEAKNESS 559

Case 293

A freight-handler of twenty-six entered the hospital August 14, 1907.
He had always been previously well except for an attack of fever five
years ago. He began to lose his appetite and his strength two weeks
ago. A week ago he was so weak that he gave up work.

In the last ten days he has vomited almost everything he has eaten
and has had very little appetite. He has also had a cold in his head,
with a little cough and pain in the right side of the chest. His bowels
are regular, but he sleeps poorly.

Physical examination shows good nutrition; the heart's apex is in
the fifth space in the nipple-line, but the heart-sounds are also distinctly
heard to the right of the sternum.

There is dulness at the base of the right lung below the angle of the
scapula, accompanied by diminished vocal and tactile fremitus, dimin-
ished breath-sounds, and crackling rales.

Physical examination, including the blood and urine, is otherwise
negative.

Discussion. Without the physical examination we have no clue.
Even with it there seems to be but little to account for so much prostra-
tion, for it will be noted that the breath-sounds are audible, though
diminished over the whole of the affected side. We must be dealing
either with a very small accumulation of fluid or with a plastic pleurisy
resulting in thickening. Is this enough to explain so much weakness
and fever?

Yes, it certainly is enough, as experience has repeatedly shown us,
because it implies with reasonable certainty other tuberculous lesions
in the lung itself, in the internal lymphatic glands, or elsewhere. Very
probably that attack of fever live years previously was also due to tuber-
culosis, possibly also pleural in situation, though nothing of the kind
was recognized at that time.

Of course, we must run over in our minds and exclude by our ques-
tions or physical tests the other familiar causes of weakness, such as
anemia, . psychoneurotic conditions, diabetes, concealed sepsis, and
other infections. But this I think we can do with the aid of the data
here presented. Doubtless we are right in being influenced to favor
the diagnosis of tuberculosis in this case by our knowledge that many
other cases demonstrated by the lapse of time to be tuberculous have
begun just in this way.

Outcome. On the thirty-first a needle was inserted in the back. ?
inch below the angle of the scapula. The needle passed through

560

DIFFERENTIAL DIAGNOSIS

fully i* inches of thick, gritty, pleural exudate before any fluid was
obtained, and only J ounce came out.

The course of the temperature is seen in the accompanying chart
(Fig. 143).

!"-" / / "/, '"/ > "/ * '/ 'if il'll" li-il'-__t\i/- / 't ___t '_ 'il- lit

107

,M .

106

IIH

"* 1

s lw J

H ztt%l2*ti* : * : - ?-t

* ..

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1 Z I ^ i" 7/r ??

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6 J m as i #_ . * ^

Fig. 143. Chart of case 293.

The patient rapidly improved, and was discharged on the second of
September.

Diagnosis. Chronic plastic pleurisy.

Case 294

A shipper of thirty-eight was first seen April 9, 1908. He has been
in the habit of taking 20 glasses of beer a day, but his past history, as
well as his family history, is otherwise negative. He has had pneu-
monia three times, the last time four years ago. A week ago he had
the grip, from which he is now convalescing. He now feels pretty well,
but weak.

Five days ago some albumin was found in his urine and he was
put upon a milk diet. Lately he has vomited his milk. There has been
no swelling of the legs or face. A year ago he weighed 190 pounds,
now he weighs 170. He has had a good deal of cough and sputa during
the past week, but he thinks not previously.

On physical examination he was found to be rather stout. The

Fig. 144. Represents what was found to explain weakness following an attack called
"grip." (See also Fig. 145.)

Fig. 145. Signs found in the hack (Case 204) of a patient complaining of weakness after
an attack of "grip." (See Fig. 144.)

WEAKNESS

56l

heart is negative. The condition of the lungs is shown in the accom-
panying diagrams (Figs. 144, 145).

The abdomen was held firmly, and showed some dulness in the
flanks, which, however, did not shift with change of position.

The leukocytes were 15,600; hemoglobin, 85 per cent.; temper-
ature, 97.4 F.; pulse, 96; respiration, 24; blood-pressure, 125 mm. Hg.
Urine negative.

The liver dulness extended from the sixth rib to the costal margin.
The edge of the organ was palpable. The sputa showed large numbers
of pneumococci; no tubercle bacilli on repeated examination. The
ocular tuberculin reaction was negative.

Discussion. This man is said to have had the "grip." Can his
weakness be accounted for merely as a result of that disease? In the
epidemic of influenza occurring in 1889 and 1890 the convalescence
was notoriously slow and painful, but within the past few years I do
not believe that we have had any cases of that type, so that I should
doubt very much, even before scrutinizing the results of physical ex-
amination, any explanation of this patient's weakness as the result of
such a type of influenza as could have been acquired in 1908.

Such an albuminuria as is recorded above is quite often seen after
mild attacks of tonsillitis or nasopharyngitis i. e., a common cold.
The urinary findings, therefore, do not imply that the previous infec-
tion has been anything more serious than a cold. But the physical
signs in the lungs certainly do imply something more, and can be ex-
plained only as the result of some type of pneumonia or as the results of
tuberculosis.

Delayed resolution in pneumonia is so rare that one should never
make the diagnosis with confidence unless empyema, especially in the
interlobar form, pulmonary abscess, and tuberculosis can be excluded.
The negative tuberculin reaction is here of very considerable value.
The negative results of sputum examination are also of some importance,
especially as their number is considerable.

These two facts, together with the absence of fever and the presence
of a transient albuminuria, should incline us to decide against tuber-
culosis, and in favor of some acute infection of the lungs, now probably
in the stage of convalescence.

Outcome. April 17th the signs in the lungs were much less marked.
April 28th examination showed nothing abnormal, and the patient telt
quite well.

Diagnosis. Convalescence from pneumonia.

3fi

562

DIFFERENTIAL DIAGNOSIS

Case 295

A Jewish peddler of seventeen, never previously sick, entered the
hospital July 6, 1907.

He was in bed four months ago for a few days on account of a slight
cough and expectoration, which was never bloody. After a week he
returned to work, but then he had pain in his legs, relieved by flat-foot
plates. He still felt very weak and run down, and through the aid of
the Social Service Department was sent to a farm, whence he returned
after two weeks unimproved; indeed, since his return has been getting

weaker. He is very easily tired and short
of breath on exertion.

He says he has pains all over, a very
poor appetite, cannot sleep, and is feverish
and chilly at times. (See Fig. 146.)

The patient was found to be poorly
nourished. Physical examination was
otherwise entirely negative, save for sharp
lateral curvature of the spine to the right
in the midscapular region. Tuberculin
(0.1, 1, 5, and 10 milligrams) was injected
subcutaneously, but was not followed by
any rise of temperature or any constitu-
tional symptoms. The blood and urine
were entirely normal. Investigation of
the gastric functions with a stomach-tube
showed no fasting contents, a capacity of
40 ounces, and after a test-meal: free
HC1, 0.18; total acidity, 0.44.
Discussion. The onset of this illness is very characteristic of
tuberculosis. Cough, fever, anorexia, weakness, shortness of breath,
chilliness, insomnia all point in that direction. It will need the strong-
est kind of evidence to convince us that this boy is free from the tuber-
culous taint.

By continued observation, however, by repeated examinations of
the lungs, and especially by the negative results of tuberculin injections,
it was possible, in my judgment, to exclude tuberculosis.

The gastric functions were then carefully studied, but nothing of
any importance as evidence of disease was discovered. By the study
of the blood and urine we were able further to narrow the field of
possibilities. No evidence of syphilis or other infectious disease

w.,.,., [ :,',! 1- 1 *A 1 1 1 1 1

ft.
1

1 X

106

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Fig. 146. Chart of case 295.

WEAKNESS 563

could be found. The eyes and ears were examined, with negative
results.

After all these tests had turned out negative, it seemed justifiable
to return to that most obvious and yet most perilous diagnosis, a func-
tional nervous derangement. The age of the patient and his race
doubtless helped to justify such a diagnosis. The more one sees of
adolescence, the more one is astonished at the apparent gravity but
eventual transiency of the physical and mental symptoms exhibited
by some healthy people at that period. Boys and girls who turn out
quite healthy, sensible, and reliable in adult life, may be almost incon-
ceivably weak, vacillating, hypochondriacal, and turbulent at that
period. All their vital forces seem to be slowing down or hobbling
along as if about to stop altogether. This applies to all races, but more
especially to the Jews.

Outcome. By the twelfth of July he was eating better and behaving
as if he had some strength. He had received up to that time no drugs
except an occasional dose of veronal, 10 grains, for insomnia. His
blood-pressure on the twenty-second was 115 mm. Hg. At this time
he looked and felt much better, but did not gain in weight. Potassium
iodid was tried in large doses, but produced no improvement.

After eight weeks of observation, with careful study of the case, we
were convinced that the patient's mental attitude had a great deal to do
with his condition. After some reeducation he was discharged much
relieved.

Diagnosis. Psychoneurosis.

Case 296

A married woman of forty-three, of good family history, entered the
hospital May 22, 1908. She had "inflammation of the bowels' 1 twelve
years ago and was sick for two months. Before and since that time
>he has been well until two weeks ago, when she began to feel tired and
weak all over. She has had no pain anywhere, but her appetite has been
poor. For a week she has noticed chilly sensations, with a scanty, high-
colored urine. Two days ago she had a sore throat and took to her
bed. Xow the sore throat has disappeared. She lias not been exposed
to typhoid fever, so far as she knows. She has no cough.

The course of the temperature is seen in the accompanying chart
(Fig. 147). A systolic murmur is heard all over the heart's area, loudest
in the pulmonary area. The aortic second is louder than the pulmonic
second sound. The heart's apex is in the midclavicular line. )'. inches
to the left of midsternum.

564

DIFFERENTIAL DIAGNOSIS

The arteries and lungs show nothing abnormal. There is some
dulness in the flanks, but this does not shift with change of position.
The abdomen is otherwise negative. Blood cultures and Widal reac-
tion were persistently negative. The white cells at entrance were 10,700,
the urine normal. The urine was 25 to 30 ounces in twenty-four hours,
specific gravity 1010, no albumin, no casts or cells.

Menstruation came on about the time she was first seen, and was
profuse, but not abnormal.

Discussion. It is safe to assume that the fever and the weakness
should be grouped together as the result of a common cause.

Though there is a systolic murmur over the
precordia, it is not so situated or so supported
by other physical signs as to be in itself satis-
factory evidence of endocarditis or of any other
cardiac lesion.

Tuberculous peritonitis would account for
many of the symptoms, but we have no physical
signs sufficient to justify any such hypothesis.
In an abdomen which is otherwise negative,
dulness in the flanks means nothing of import-
ance unless it shifts with change of position.

We tried our best to make this case fit the
diagnosis of typhoid fever, but could never ob-
tain any positive evidence of it.

Urinary infection seemed very improbable,
as the sediment of the urine showed nothing
pathologic. Xo culture, however, was made from
it, and if another cause for fever and weakness
had not been discovered, bacteriologic investiga-
tion of the urine would have been in order.
The reader will, I hope, have noted that one method of physical
examination, essential as part of a thorough study in any obscure case,
is here omitted. Doubtless it was this mistake which postponed our
making the correct diagnosis. I refer, of course, to the pelvic examination.
Outcome. The cause of the weakness and fever remained quite
unexplained until May 30th, when the leukocyte count was discovered
to have risen to 30,000. This at last suggested a vaginal examination,
which showed that the uterus was considerably enlarged. To its left a
mass, the size of an orange, apparently attached to the fundus, extended
upward. Another rounded mass seemed to be attached to the anterior
uterine wall.

RT=S

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Fig.

147. Chart of
case 296.

WEAKNESS

565

An uncomplicated fibroid tumor would not have produced so much
weakness and fever. Were it strangulated, degenerated, suppurating,
or in process of producing a localized peritonitis, there should have been
pain. Fibroid must, therefore, be ruled out or recognized as a subor-
dinate part of the diagnosis. Cyst of the ovary or the broad ligament
should produce more acute symptoms if its pedicle were twisted, and less
fever if it were in a normal condition.

In view of these considerations, pelvic suppuration, probably de-
pendent upon a pus-tube, seems the most probable diagnosis.

Operation June 2d revealed a large pelvic abscess to the left of the
uterus and a pus-tube on the right. There were also two small fibroid
tumors attached to the fundus uteri. These were shelled out, the pus
was drained, and the patient made a good recovery.

Diagnosis. Pus-tube.

Case 297

An Italian laborer of forty-eight, of good family history and past
history, was first seen October 11, 1907. He had a nose-bleed ten days
ago, and has since then suffered from general malaise and weakness,
with moderate headache, ill-defined ab-
dominal pain, and slight cough.

Physical examination showed a swarthy,
well-developed man, breathing rapidly but
easily. (See accompanying chart, Fig. 148.)
He was almost without complaint when seen,
though his face was flushed, his breath very
offensive. The cardiovascular system was
negative. Breathing throughout the right
back seemed more feeble than in the left,
otherwise the lungs were entirely negative,
as was the abdomen.

The white cells were 7000; hemoglobin,
85 per cent.; Widal reaction, negative; the
urine averaged 50 ounces in twenty-four
hours; specific gravity, 1013; there was the
slightest possible trace of albumin; very
many hyaline and granular casts, some with
cells, and a small amount of fat adherent.

On the succeeding day the patient coughed up some stringy yellow
sputa containing many cocci and bacilli, but nothing distinctive.

Fig. 14S. Chart of ca

e66 differential diagnosis

An expert examination of the upper air-passages showed the foul
breath to be due to atrophic rhinitis.

On the fifteenth the patient began to raise mouthfuls of thick, reddish-
gray, odorless pus, looking like that from gangrene of the lung, but
without the characteristic odors. It contained a variety of organisms,
but no tubercle bacilli. On the seventeenth the lungs were so full of
coarse, bubbling rales that the heart-sounds were inaudible.

The right axilla was duller than the left.

On the eighteenth the abdomen began to be distended, the neck to
be slightly stiff. The face expressed extreme anxiety and dread. On
the eighteenth the sputum began to have a foul odor, and the right thigh
became generally tender on motion and somewhat swollen.

On the nineteenth the white cells had risen to 14,900. On the
twentieth an abscess appeared on the top of the left shoulder, and a
similar one, painful, indurated, and red, appeared in the right groin
below Poupart's ligament.

The patient lost strength rapidly; cyanosis and a foul, frequent
diarrhea developed.

Discussion. This case begins just like a typhoid, and at first there
seemed to be nothing else that we could call it, although there was no
Widal reaction, no rose spots or splenic enlargement, no bacilli by
blood culture, and nothing characteristic about the temperature-curve.
But as we could find no signs of tuberculosis, septicemia, syphilis, or
any other type of obscure fever, our best guess was typhoid during the
first four days of the illness.

When the pus began to come up and was found to be free from
tubercle bacilli, we began to search for further evidence of pulmonary
abscess. Nothing localizing could be found, but this, as experience has
shown, is often the case in abscess of the lung. Our present methods of
physical examination even when supplemented by radiography
are not sufficiently accurate to reveal the presence of pulmonary abscess
in all cases. We may have a little patch of dulness and diminished
breathing, or rales may be heard over a circumscribed area; but nothing
characteristic is often found, especially when the abscess is multiple
and small. It is quite possible that the pus came entirely from the
bronchi in this case.

When the peripheral abscesses began to appear, our attention was
no longer concentrated on the lungs, and it began to be clear that we
were dealing with a general infection. When the pericarditis developed,
there was no longer any reasonable doubt of the diagnosis.

Outcome. Blood cultures made on the twenty-first of October

WEAKNESS

567

showed the staphylococcus aureus without any admixture of other
organisms. The same coccus was obtained from the external abscesses.
On the twenty-fourth the patient died, no benefit having been obtained
from an autogenous vaccine.

Diagnosis. Staphylococcus sepsis.

Case 298

An unmarried stenographer of twenty-nine had lost her mother of
typhoid fever and one sister of acute tuberculosis two and one-half years
ago. She was first seen by me March 12, 1908.

The patient had bronchitis for a
whole year when twelve years old, but
has since been well until the previous
fall, when she became run down, lost
appetite, and had some pain in the left
upper chest. Her chief complaint at
this time was of weakness. She went
to the country and remained there two
months, with some improvement, so
that she was able to go to work again
on January 13, 1908; but as soon as
she took up her work again she began
to lose appetite, and felt very tired and
often chilly at night after her work.
She had no cough and no pain, and
continued to work until two days ago,
when she noticed fever and headache
and began to cough and raise yellow
sputa.

Yesterday evening her temperature was said to have been 104 F.
For the last two days she has had no sputa. She has now no pain any-
where. (For the course of the temperature see the accompanying chart.
Fig. 149.)

The patient is well-nourished, ruddy; the heart and vessels show
nothing abnormal. Over the right clavicle in front, and above the spine
of the scapula behind, there is slight dulness, increased whisper, in-
creased vocal and tactile fremitus, bronchovesicular breathing, and a
few fine crackling rales. Kernig's isthmus and the excursion of the lung
are equal on the two sides.

Physical examination, including the blood and urine, is otherwise
negative.

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Fig. 149. Chart of case 298.

568 DIFFERENTIAL DIAGNOSIS

Discussion. Many patients of this type have to suffer by reason
of a mistaken diagnosis of general debility, neurasthenia, or "grip."

The latter diagnosis is difficult positively to exclude. A few cases
are on record which prove that an influenzal bronchopneumonia may
be so localized at the apex of a lung as to simulate tuberculosis. Such
cases, however, are very rare, and for practical purposes may be dis-
regarded.

The physical signs of this case, though strongly suggestive of tuber-
culosis, are not in themselves, and in the absence of any longer pyrexia,
conclusive. The so-called bronchitis, which lasted a whole year during
the patient's childhood, doubtless inclines us to interpret any dubious
pulmonary signs as evidence of tuberculosis. But it must be remembered
that such signs may be the harmless residual effects of an old burnt-out
process which do not necessarily signify anything of importance at the
present time. One of the most difficult tasks that I know of in connec-
tion with pulmonary diagnosis is to distinguish, by physical signs alone,
the scars of an old healed process from the evidences of a new and threat-
ening one. In many cases the differentiation of the two is impossible
until the progress of the symptoms supplements our physical examination.

Despite several negative examinations of the sputa, our provisional
diagnosis was phthisis, the most decisive point in our minds being the
sharp, crackling quality of the rales, although they were elicited only
by cough.

Outcome. After repeated negative examinations of the sputa,
tubercle bacilli were finally found March 19th. On the twenty-seventh
she went to a sanatorium for the tuberculous.

Diagnosis. Phthisis.

Case 299

A housemaid of twenty-four entered the hospital July 15, 1908.
Her family history and past history are good. She has one child eight
months old. Ever since this baby was born she has complained of
weakness. Though the labor was normal and not difficult, she has
been able to walk since the baby was born but a few steps, owing to
muscular weakness and edema of the legs. These troubles have been
notable for two months, and have been accompanied by dyspnea on
exertion. Pallor has also been noticed ever since the baby was born.
For the past month she has also had some pain in the chest on taking a
deep breath. She has no other pain. Her appetite is good, her bowels
are regular, her sleep is fair. The course of the temperature is seen in
the accompanying chart (Fig. 150).

WEAKNESS

569

The patient is emaciated, pale, has one large submental gland, and
several small postcervical glands. The heart shows no enlargement
and no murmurs. The sounds are regular, clear, rapid. The blood-
pressure is 100 mm. Hg. The lungs are negative except for one or two
squeaking rales above the right clavicle and at the right base behind,
with slight dulness, and diminished breathing.

In the abdomen there is dulness at the sides, which, however, does
not shift to any extent with change of position.

There is a right lateral curvature of the spine, projecting somewhat
backward, and involving the twelfth dorsal and the first, second, and
third lumbar vertebrae. A pelvic examination is negative. Blood
examination shows marked achromia, and some
variation in size and shape. Urine is normal.
Reflexes normal.

On the eighteenth there was distinct evidence
of fluid in the abdomen, and the signs at the
apex of the lung were no less evident.

Discussion. At first sight the cardiac
symptoms appear to be in the foreground. The
edema, the dyspnea, the ascites, and the low
blood-pressure all point in this direction, but
the examination of the heart gives no support
to the idea that any type of heart disease is
present.

There is a good deal to suggest tubercu-
losis, especially the rather equivocal pulmonary
signs and the association of ascites with fever.
On the other hand, if the belly fluid were due to
tuberculous peritonitis, we should expect pain,
tenderness, or spasm, none of which is present.

From the blood examination it appears that the patient is anemic,
and much of her weakness is doubtless due to this cause, but the details
of the blood examination are such as to compel us to seek some further
cause for the anemia itself.

The spinal deformity might be either the result of some old quiescent
trouble or of a more recent disease. Since there are reasons to suspect
tuberculosis in other parts of the body, the thought of Pott's disease
should cross our minds. This leads straight to an .v-ray examination
as the next step in the study of the case.

Outcome. X-ray of the spine showed telescoping of the vertebra 1 .
It was subsequently learned that this prominence in the back had existed

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299.

570 DIFFERENTIAL DIAGNOSIS

for three years and had been accompanied by some pain in the back at
the beginning of an attack of "lumbago."

The patient was much relieved by a plaster jacket.

Diagnosis. Vertebral tuberculosis.

Case 300

A carriage painter of thirty-seven entered the hospital February
20, 1908. His father died of ulcer of the stomach, his mother of pneu-
monia, one sister and one cousin of pulmonary tuberculosis. The
patient has always been perfectly well. He denies venereal disease
and has good habits. Two years ago he overworked, and has since
had much to worry him, especially his wife's sickness (heart disease)
and the death of one of his children.' Apparently, as a result of these
troubles, he has been gradually running down, and last October had
to quit work on account of general weakness and stomach trouble. He
has an excellent appetite, but frequently vomits, especially in the morning
before breakfast. His bowels are loose, moving usually two or three
times a day. For three months he has been short of breath and has a
little cough and expectoration. For two months he has been troubled with
numbness in his hands and feet. For three weeks he has had night-sweats.
His average weight is 135 pounds. At present he weighs 118 pounds.

Physical examination showed a sallow, somewhat emaciated young
man with partial right wrist-drop; the chest entirely negative. The
abdomen was very rigid throughout, tympanitic, but not tender. The
blood was examined 20 or 30 times at weekly intervals. At entrance
the red cells were 1,062,000. From that point they rose by March 24th
to 1,880,000, after which they gradually declined, reaching 570,000 on
the twenty-second of June. The white cells ranged between 4000
and 7000. The hemoglobin at entrance was 55 per cent, and remained
always relatively high.

The differential count showed nothing remarkable. In the stained
specimen the red cells showed considerable stippling, some achromia
in the smaller cells, and deep staining of the larger ones. Megaloblasts
were always present and in excess of the normoblasts.

The urine was normal throughout. The stools were not remarkable.
Parasites were repeatedly searched for, but never found.

The skin showed a brownish pigmentation, which gradually increased
in tint, though no arsenic was given during his stay in the hospital.

The ocular tuberculin reaction was negative; the urine and stools
contained no lead. Throughout his stay in the hospital he complained
of nothing but weakness and numbness of the extremities.

WEAKNESS

571

By the thirteenth of May he had a chill, the temperature rising to
104.6 F. Previous to that time it had ranged between 98 and ioo
F. After that there was a moderate pyrexia 99 to 101 F. for about
one-half of the rest of his stay. No cause for the chill was found.

Discussion. Carriage painters often get lead-poisoning. Because
of this patient's occupation, as well as for other reasons presently to be
mentioned, plumbism is the first possibility which calls for investiga-
tion. Our patient has a wrist-drop, various troubles with his stomach,
and stippling of the red blood-corpuscles, all of which signs point toward
lead. On the other hand, the blood-picture is distinctly that of primary
anemia. His gums show no lead line and his wrist-drop turns out on
inquiry to be an affair of very long standing. The degree of anemia,
moreover, aside from its type, is greater than that seen in any but the
severest cases of lead-poisoning, such as exhibit extensive paralyses and
encephalopathy. Finally, the absence of lead in the stools and urine
decisively excludes plumbism.

The brownish pigmentation of the skin, steadily increasing at a time
when no arsenic was given, suggests Addison's disease of the suprarenal
capsules, rather than the anemia first described by him. The weakness
and stomach trouble are quite in harmony with this idea. On the other
hand, suprarenal disease is never, so far as I am aware, associated with
so severe an anemia except in the acutest and most fulminating cases.
In the great majority the anemia is very moderate. The negative ocular
tuberculin reaction helps to convince us that we are not dealing with
the commonest type of Addison's disease suprarenal tuberculosis.

Pernicious anemia, then, seems to be the most reasonable diagnosis,
although the patient is rather younger than most of those who suffer
from this type of anemia. The chill and sudden rise of temperature
on the thirteenth of May puzzled us somewhat. Fever, it is true, is the
rule in pernicious anemia, but not so sudden and sharp a rise. Probably
it is to be explained as the result of some secondary infection favored by
the great weakening of general resistance. I have seen a good many
similar attacks in the last few years, all of them passing off, as in thi^
case, without any indication of their source.

Outcome. The edema of the feet and the general weakness in-
creased steadily, so that by the first of July he was confined to bed.
Death occurred July 19th.

Autopsy showed the usual lesions of pernicious anemia. The
suprarenal capsules were normal.

Diagnosis. Pernicious anemia.

57 2 DIFFERENTIAL DIAGNOSIS

Case 301

A real-estate agent thirty-six years old consulted me February 15,
1909, complaining of weakness and headache. Although he has an
excellent appetite and perfect digestion, he has lost 25 pounds in the
last two years, 14 pounds of which were lost within the last three months.

His family history is good except that his father died of tuberculosis.

His past history was uneventful until September, 1901, when he had
typhoid fever. In 1904 he had a good deal of pain in his shoulders,
which passed off, however, within a few months, though no diagnosis
or treatment was given. For the next three years he was quite well,
but in December, 1907, he had pains in his left arm, diagnosed as neu-
ritis. By reason of this he was kept out of work in January and February,
1908, and in August and September of the same year.

November 7, 1908, he had an attack of vomiting, accompanied by
severe headache, and was kept in bed a week. Ever since that time
he has been troubled by headache, which is worse on waking in the
morning, and usually clears off at noon. It affects especially the vertex
and the frontal region, but is not changed in any way by the position,
by diet, or by the weather. His eyes have been examined by a specialist
and pronounced entirely normal except for a horizontal nystagmus of
almost minute excursion. His nose has also been carefully examined,
but nothing found.

He had no fever at any time, but his physician tells him that his
pulse is rarely below 100. From time to time he has had slight jaundice.
Since November 7th he has felt unable to work, and since December
he has passed urine once or twice every night after bed-time.

Physical examination shows rather poor nutrition; the internal
viscera are entirely negative, except that the pulse is 1 10 not an unusual
rate during an office consultation in patients of any tendency to nervous-
ness. The knee-jerks are unusuallv lively; the blood-pressure, 155 mm.
Hg.

The urine is of normal color; 40 ounces in twenty-four hours;
specific gravity, 1023, no albumin, no sugar. Several subsequent ex-
aminations showed essentially the same conditions. Blood normal.

Discussion. Loss of weight with a good appetite is a rather rare
combination of symptoms. Diabetes is its only quite familiar cause,
and that disease can be immediately ruled out of consideration in view
of the urinary findings.

Aside from diabetes I have met with this combination of symptoms
in persons who are losing a great deal of sleep by reason of pain or

WEAKNESS 573

emotional strain, in certain stages of arteriosclerosis, and in hyper-
thyroidism. This patient's headaches never prevented his sleeping.
He had no special causes for anxiety, and seemed to be in good spirits:
There was no good reason to suspect arteriosclerosis, and no external
evidence of that disease.

Hyperthyroidism (Graves' disease) should always be suspected
when a patient loses weight despite a good appetite, especially if there
is any tendency, as in this case, toward tachycardia. As I examined
this patient with special reference to hyperthyroidism, I found no trace
of goiter or exophthalmos, but quite a definite fine tremor of the fingers
when extended.

Outcome. Under a regime of overfeeding and rest the patient's
headaches became much less frequent, his pulse slower, and his weight
increased. In October, 1909, he was back at work.

Diagnosis. Hyperthyroidism (Graves' disease).

Case 302

I was consulted, September 4, 1906, by a widow aged sixty-four,
whose chief and most distressing complaint was weakness. Her weight
had shown no change; her appetite was, she said, "too good," and her
sleep excellent. She had no pain, cough, or vomiting, but she had
been losing strength steadily for years, and for the past twelve months
had been decidedly short of breath. In 1891 she had been treated by
Dr. Arthur T. Cabot for hemorrhoids, which never bled at all, as far
as she knew, until two years ago, when there began to be some bleeding
each month for a period of three or four days. For the past five months,
however, there has been no bleeding whatever.

Her color has been noticeably abnormal for at least six years. Four
years ago, she says, it was worse than it is now. Headaches have
bothered her some part of every day for many years. They are aggra-
vated by walking, and affect especially the occipital region. She is
markedly constipated, and notices a good deal of mucus in the stools.
Two years ago she had an illness which she fears was a "shock," and
since that time she talks slowly and with difficulty. All her symptoms
are aggravated in winter, and she feels the cold very much, though not
more, she says, than most ladies of her age.

Examination showed a yellow, waxy pallor of the skin. The patient
was somewhat obese, but nothing wrong was detected in the internal
viscera or in the urine. Blood examination showed:

Red cells, 3,600,000; leukocytes. 6000; hemoglobin, 45 per cent.
In the stained specimen there were 66 per cent, of polynudear cells, 32

574 DIFFERENTIAL DIAGNOSIS

per cent, of lymphocytes, and 2 per cent, of eosinophiles. The red
corpuscles showed marked achromia and slight deformities. There
were no nucleated forms or abnormal staining reactions.

Discussion. The- case was sent to me as one of pernicious anemia,
and her appearance bore out this diagnosis. The blood examination,
however, did not, but was indicative rather of a secondary type of
anemia. It did not seem to me that there was enough hemorrhage
(assuming the history to be correct) to account for this anemia.

Rectal examination and the study of the stools showed no evidence of a
rectal or intestinal cancer, and her good nutrition and freedom from pain
or diarrhea made it unnecessary to consider this diagnosis further.

I learned, during a subsequent visit, that she had difficulty in making
fine motions with her fingers. Following up this hint I tested the func-
tions of motion, sensation, reflex action, and nutrition without getting
any new information except that the skin was very dry and the nutrition
of the finger-nails notably poor. The association of this condition of
the skin with slowness of speech naturally suggested myxedema.

On questioning her I then learned that her hair had been coming
out very fast, though she had thought and said nothing of it, supposing
that her age accounted for the loss. It appeared, further, that she never
perspired unless the thermometer was above 90 F., a temperature very
grateful to her feelings.

Outcome. The patient was given thyroid extract, 2 grains three
times a day, gradually increased to 5 grains three times a day. January
1 6th she reported herself as wonderfully better. March 25th she wrote
that her hair was growing tremendously, so that it was now thick and
dark. Her speech had greatly improved, and her waxy pallor had dis-
appeared. Within a short time she was perfectly well, and has remained
so up to the present time (1910) . She still takes thyroid extract regularly.

Diagnosis. Myxedema.

In the table which ends the chapter and in the diagram which
begins it I have grouped causes of paralytic weakness without any
attempt to tabulate the cardiac or hemic types of weakness.

WEAKNESS

575

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CHAPTER XVIII

COUGH

There are, of course, many causes of cough which do not raise
diagnostic puzzles, and are, therefore, not suitable for this book. Thus:

(a) "A common cold" or mild infection of the upper air-passages,
whether by the influenzal or other bacilli, may produce cough by irritating
the pharynx, larynx, trachea, and larger bronchi. Diagnosis is sug-
gested by direct inspection of these parts, and by the absence of signs in
the lungs and other viscera. It is clinched by the short, mild course of
the affection.

(b) In infants and children diffuse bronchitis often stuffs the lungs
with squeaking or crackling rales, with or without considerable consti-
tutional signs. To exclude pneumonia is here the chief diagnostic task.
Occasionally this cannot be done. Usually the absence of marked con-
stitutional signs (continued fever, marked leukocytosis, cyanosis, drowsi-
ness) and of the physical evidence of solidification in any part of the
lungs excludes pneumonia.

(d) The so-called "stomach coughs," "uterine coughs," "liver
coughs," and other "reflex" irritations from a distance have not yet
demonstrated themselves in my experience.

(e) Nasal coughs and aural coughs still linger on in the pages of text-
books, but I can find no convincing evidence that they exist.

VARIETIES OF COUGH

(o) The distinction between a loose or productive cough, which is
associated with sputa [unless the patient is too weak or too young to
raise any], and a dry or unproductive cough, is very familiar.

(b) The brassy or laryngeal cough is a loud, ringing, usually unpro-
ductive effort, associated most often with aneurysms or tumors pressing
upon the trachea. It is not by any means distinctive, but in conjunction
with other and more precise signs it may help us to recognize a source
of pressure in the mediastinum. For this reason it is often called a
"pressure" cough.

576

Causes of Cough

1. PHTHISIS

2547

2. "BRONCHITIS"

2533

3. MITRAL DISEASE

2206

4. TONSILLITIS

1405

5. PLEURISY

763

6. PHARYNGITIS

751

7. MYOCARDIAL
WEAKNESS

587

8. PNEUMONIA

521

9. A O R T I C R E-
GURGITAT

IE- 1

ON J

517

10. " INFLUENZA"

388

1 1. ASTHMA

379

12. EMPHYSEMA

328

57:

cough 579

(c) Nervous cough is sometimes a life-long habit, showing itself
especially when the individual is embarrassed or when he desires to pre-
empt a pause in the conversation. Many patients will undergo a long
siege of questioning and physical examination without showing any sign
of cough until we ask them whether this symptom is troublesome. With
the first words of their answer there comes a cough.

Yet it must be remembered that in some cases of incipient phthisis
the cough seems to be of the nervous variety, and is believed to be such
by the patient and his family. The matter can be settled only by care-
ful watching and repeated examination.

{d) A barking cough often occurs in children at or before the age of
puberty. It has no special significance, though it often gives rise to
much alarm. Its explanation is not known, and it may be associated
with any of the commoner lesions of the upper respiratory tract.

(e) A prolonged suffering from cough is usually due to phthisis, to
emphysema, or chronic bronchitis with bronchiectasis; occasionally to
cardiac insufficiency.

(/) Cough on exertion is usually due to heart disease, but may be the
result of any of the causes mentioned in the last paragraph.

(g) Cough on change of position, accompanied by a profuse dis-
charge of sputum, usually indicates pulmonary abscess or bronchiec-
tasis.

(h) Winter cough recurring each year is usually characteristic of
bronchiectasis. The cavities remain comparatively dry and harmless
in the summer-time, but are prone to become infected, usually with the
influenza bacillus, in the winter-time. This is the affection usually
known as chronic bronchitis, though a considerable percentage of the
cases so diagnosed are really due to pulmonary tuberculosis.

Case 303

A mule spinner of forty-five, of good family history and past history,
was seen November 14, 1907. He took gas as an anesthetic twenty
weeks ago and had all his teeth pulled out. He had no trouble at the
time, but a week later he began to have pain in the right side of the
chest, worse on deep breath. Two weeks after the anesthetic lie began
to cough, and noticed that a bad odor and bad taste came into his mouth;
next day he coughed so as almost to choke him. Four days after this he
began to raise more foul sputum of a dark, greenish-brown color, with
dark red portions in it. On the third day he coughed up half a large
bowlful during the night. Sometimes the sputum came rush in sj; up in
large amounts with very little cough. The pain in tin- ritrht side, mean-

5 8o

DIFFERENTIAL DIAGNOSIS

time, had become less, the diminution coinciding with the period of
excessive sputa.

Eight weeks ago the cough diminished. His sputa became yellow
and less foul, and his appetite improved, as did all his other symptoms,
until live weeks ago, when, as he stooped to lace his shoe, blood filled
his mouth, and he spit up half a cupful of it. Four hours after he
raised about the same amount, and this continued for a couple of days
in decreasing quantities. Since then he has not raised any more blood,
but his appetite. has been very poor and his cough frequent.

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Two and one-half weeks ago the pain in the right side again became
severe, and he had to get up in the night in order to get breath. Since
then he has been short of breath on any exercise, and his sputum has
again been foul and dark, as at first.

He has had fever for fifteen weeks, off and on, with occasional night-
sweats.

He gave up work on July 20th on account of weakness, but he has
lost very little weight, as he was always thin. The course of the tem-
perature is seen in the accompanying chart.

The patient is emaciated, the breath rather foul, the heart negative,
the right supraclavicular space deeper and more capacious than the left.
A friction -rub is felt in the right axilla, and there is dulness throughout

Fig. 15:2. Area of rough and prolonged expiration in Case 303.

COUGH

58l

the right chest. In the right supraclavicular space and axilla the percus-
sion-note is almost flat. Over the area shown in the diagram (Fig. 152)
expiration is rough and prolonged, and there is a coarse friction -rub
extending through both inspiration and expiration over the whole
right axilla, and heard more faintly in front and behind.

During his stay in the hospital the patient raised daily 10 to 30 ounces
of mucopurulent, foul sputa, containing no elastic fibers or tubercle
bacilli. Its color was as described by the patient.

Later, on the twenty-eighth, the odor was a good deal less marked.

X-ray shows a deep shadow in the region of the right scapula, agree-
ing practically with the area shown in the diagram.

Discussion. Cough with foul sputa ejected in large quantities and
associated with fever and sweating suggests four possibilities:

(a) Pulmonary abscess, with or without gangrene. 1

(b) Empyema rupturing through the lung.

(d) Bronchiectasis.

Empyema and phthisis are improbable because of the history and
the condition of the sputa. The signs are not situated in the parts
generally most affected by phthisis, and when that disease produces a
cavity large enough to contain so much sputa, it is practically certain to
show bacilli in great numbers. Empyema is almost always post-
pneumonic, and we have nothing to suggest that this patient has ever
had pneumonia.

The sudden onset and the localization of the signs speak against
the ordinary type of bronchiectasis, namely, that associated with a
chronic bronchitis and affecting a great many bronchi almost equally.
Blood is far less likely to be raised in bronchiectasis than in abscess or
tuberculosis.

After discussing these alternatives, pulmonary abscess seems by far
the most reasonable diagnosis. \\c have no clear conception of the
reason or method of its origin ; it is difficult to connect it with the taking
of gas as an anesthetic unless we suppose that, under the influence of
the gas, he swallowed something "the wrong way."' The history gives
no hint of this. Only by surgical interference could one make the
diagnosis any more certain, and the results of such interference are not
brilliant enough to make us willing to urge it unless other forms of
treatment are obviously useless. This has not yet been proved lure.

Outcome. The patient improved a good deal in weight and strength

1 Pulmonary abscess and pulmonary gangrene arc essentially the same disease. The
one may pass into the other at any time if the organisms favoring gangrene supervene.

582

DIFFERENTIAL DIAGNOSIS

under forced feeding and sleep out-of-doors. He left the hospital on
December 27, 1907.

May 18, 1910, he writes: "I have not fully recovered from my sick-
ness. I am able to go around, but the trouble in my lung has not healed
yet. I still cough and spit as much as ever. I have had a number of
hemorrhages since I left the hospital. My stomach keeps all right, and
I can eat most anything that comes along. My doctor says he thinks
my lung will heal up in time."

Diagnosis. Pulmonary abscess.

Case 304

A mill foreman thirty-eight years old was seen May 4, 1908. He
had "congestion of the left lung" twelve years ago. His personal his-
tory and family history are otherwise excellent.

In December, 1906, he had a "bad cold" with a severe dry cough
which has continued in spells ever since. He sometimes coughs so
hard that he faints away, and it is very difficult for him to get his breath
at these times; yet he may go for a week without any cough whatever.
His appetite is good, his bowels regular and he sleeps well, except during
the spells of coughing. He has no digestive or urinary symptoms, and
has lost no weight.

Physical examination shows a finely developed, strong-looking man,
with a hoarse voice and occasional ringing cough. There are numerous
dark-red papules scattered over the chest. The pupils are equal, circular,
and react normally. Harsh, noisy respiration is heard over the whole
of both lungs. There seems to be some slight dulness toward the top
of the right axilla. The abdomen is slightly distended and held rather
firmly. It is tympanitic throughout. The patient seems entirely
comfortable, except for the coughing spells, at times excessively severe.
The urine is negative. The white cells are from 12,000 to 15,000.
There are no abnormal areas of dulness or pulsation. The heart is
negative. The right pulse is distinctly larger than the left; indeed,
the left is hardly palpable.

The patient went back to business on March 9th.

Discussion. Intense paroxysmal cough in children usually means
pertussis; in adults one would not make such a diagnosis without a very
circumstantial history unless we had heard the typical "whoop."

If the patient had had bronchitis for so long a period, he should be
either better or worse. He should have more sputa and more signs in the
lungs.

COUGH

583

If tuberculosis were at work, there would be more emaciation,
fever, and other constitutional symptoms. In tuberculosis, moreover,
the cough is not often so violent, paroxysmal, and intermittent.

Obscure and violent cough is often due to pleural irritation, such
as occurs at the onset of acute pleurisy or when foreign bodies irritate
the surface of the lung. But there seems no evidence of any source of
irritation in this case.

Malignant disease of the lung, pleura, or mediastinal glands should
always be considered in obscure diseases of the respiratory tracts.
Diagnosis, however, is impossible unless there is a pleural effusion,
some pulmonary signs corresponding to an infiltration of the lung or
pleura, or radiating pressure pains. Except for the slight dulness,
made out rather doubtfully toward the top of the right axilla, we have
nothing corresponding to any circumscribed pulmonary or pleural
lesions. This questionable dulness is not a sufficient basis for any
diagnostic hypothesis.

Most significant in this case, as in any involving hoarseness and a
ringing paroxysmal cough, is the difference between the two pulses.
indeed, in the presence of these three symptoms we should always
suspect aneurysm, with malignant tumor as a less probable alternative.
It is possible, of course, that the difference of the pulses may represent
nothing but a congenital anomaly. Such idiosyncracies are not un-
common, but they are rarely associated with the rest of the symptom
group above described. To arrive at any greater certainty regarding
the diagnosis we need, first of all, an examination of the vocal cords.
If one cord is found to be in the cadaveric position, we may conclude
that the left recurrent laryngeal nerve is being pressed upon by an
aneurysm or a tumor. Further evidence would be furnished by .r-ray
examination.

Outcome. Radioscopy showed a pulsating shadow corresponding
to that ordinarily found in aneurysm of the aortic arch. Examination
of the vocal cords showed no paralysis of the recurrent laryngeal nerve
and no obstruction of the trachea. March 9th the patient went back to
business, considerably improved by his rest, possibly also by the potas-
sium iodid which he took in 10-grain doses throughout the period of
treatment.

A notable feature of this case is the absence of any pain or any sign
of pressure other than the cough, the hoarseness, and the inequality of
the pulses.

Diagnosis. Aneurysm.

DIFFERENTIAL DIAGNOSIS

Case 305

A school-girl seven years old has had "asthma" about once a month
for the past two years, but has otherwise been well.

Two weeks ago she caught cold and had a bad cough, but stayed
at school until a week ago. Yesterday her cold was worse and she
went to bed. To-day she has vomited three times. Her bowels are
loose as a result of "Father John's Medicine."

At entrance, November 9, 1907, the breathing was rapid, but not
labored; cheeks flushed, lips dry and fissured. There was a crop of
herpetic vesicles about one corner of the mouth.
The glands in the neck, axillae, and groins were
somewhat enlarged. The heart's impulse ex-
tended to the nipple-line in the fourth space. Its
action was regular, and the sounds were of good
quality. The pulmonic second sound was louder
than the aortic second. In the right back the
breathing was rough from the apex to the angle of
the scapula, accompanied by squeaks and increase
of voice-sounds. The abdomen was flat, spastic,
and very tender throughout, especially in the right
lower quadrant. Nothing else could be felt. By
rectum, there was general tenderness, nothing
more distinctive.

The cour*se of the temperature is seen in the
accompanying chart (Fig. 153).

White cells, 30,200; urine, normal.
A surgeon promptly saw the case and thought
that her symptoms w r ere all due to the lung in-
volvement. Next morning the belly was much less tender, and by the
eleventh the lung signs were also very slight.

The child was pale and looked delicate. The sputum was repeatedly
examined, without any positive result.

From the fourteenth to the eighteenth the child got steadily worse;
she woke frequently in the night crying with pain, relieved to some
extent by flaxseed poultices to the abdomen. There was some dulness,
with diminished breathing in the right back and lower axilla. The
right thigh was now held flexed upon the abdomen.

Discussion. We have been warned so often of late that when-
ever a child seems to have something wrong in his abdomen we should
always consider and investigate the chest, that we naturally make the

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COUGH

585

effort to explain in this way all this little girl's symptoms. The thoracic
diseases which ordinarily produce abdominal pain in children are pneu-
monia and pleurisy, but this child shows no evidence of either of these.
A moderate degree of bronchitis, such as might be the outcome of an
ordinary cold or the beginning of a tuberculosis, is what we find. Neither
of these diseases is prone to make the abdomen spastic and tender, but
the presence of a herpes makes us wonder whether there may not be some
deep-seated pneumonic process which we have overlooked.

As the lungs cleared up, the condition of the abdomen did not.
Thereby the focus of attention was shifted, and we began to ask our-
selves more seriously what was wrong there. Appendicitis is not com-
mon in children of this age, and is not often associated with herpes.
Nevertheless, it seems more probable than any other condition. The
psoas spasm might be explained in this way, especially as there seems
to be no lesion of the hip, spine or urinary tract.

Some discussion arose in this case regarding the significance of the
leukocyte count. Since children have naturally a higher leukocyte
count and greater diurnal variations than adults, some of those who
saw this child were in doubt whether a count of 30,000 was markedly
abnormal under the circumstances. It seemed to me clear, however,
that such a count should be interpreted as a well-marked leukocytosis,
since, in children of this age, the blood has practically always attained
to conformity with the adult type.

Outcome. On the eighteenth the abdomen was opened and about
4 ounces of pus were removed from the region of the appendix.

There is no question that bronchitis was also present here, and after
the study of a good many similar cases some of which developed
appendicitis, others endocarditis or multiple arthritis, while still others
remained as an unlocalized pyogenic infection of the blood-stream
it seems to me at least possible that the appendicitis which results in a
case like that here discussed represents the outcome or localization of
a general pyogenic infection.

Diagnosis. Bronchitis and appendicitis.

Case 306

A Russian picture-frame maker, thirty-three years old, who lias been
three years in this country, entered the hospital September 24, 1007.
He has never been sick before. His habits and family history are
excellent. He was suddenly seized, three weeks ago. with chills and
lexer and pain through both sides of his chest. The next day he began
to cough, and the pain became confined to the left chest. The appetite

5 86

DIFFERENTIAL DIAGNOSIS

remained good, but for the last two nights he has slept poorly on ac-
count of dyspnea, which makes it almost impossible for him to lie
down.

When examined, he was breathing jerkily. His lungs were hyper-
resonant throughout, expiration prolonged, feeble, and accompanied
by squeaks and crackles. In the left axilla, from the fifth rib down-
ward, a friction-rub could be felt and heard. It was most marked
during expiration. Visceral examination was otherwise negative.

The white cells were 5000; the urine normal; there was no fever
during his week in the hospital. The patient was given an ice-bag
over the painful side; \ grain of codein every two hours when needed;
fluid extract of grindelia robusta, 20 minims every twenty minutes for
four doses; then 30 minims every three hours. His chest pain was
relieved by strapping the chest.

Discussion. When pain is complained of in both chests by one who
is suffering from a cough, it usually represents the result of muscular
soreness due to the cough itself. Occasionally it is produced, like
headache and backache, by the infectious agent which has caused the
cough. At first sight it seems that pleurisy would be a simpler explana-
tion, at any rate for the left-sided pain; but as we scrutinize the report
more carefully and note that the friction was most marked during ex-
piration, we begin to doubt whether it really was a friction i. e., whether
it was due to a pleurisy. Pleural frictions are almost never exaggerated
during expiration. The end of inspiration is the favorite time for their
appearance and their usual period of maximum intensity. But there
is another phenomenon not infrequently mistaken for pleural friction,
and especially apt to occur during expiration I mean the snoring rale
which can often be felt as well as heard, and which is apt to occur
in chests presenting the group of physical signs here recorded.

The most salient point, however, about this case is the presence of
cough without fever. Such a cough, associated with the group of
signs just referred to, is especially characteristic of the spasmodic or
asthmatic type of bronchitis. Indeed, one would proceed straight
way to make this diagnosis, provided he had adequately considered
two other possibilities which should always haunt us when we make a
diagnosis of asthma or asthmatic bronchitis. I refer to :

(a) Syphilis involving aortic aneurysm or stenosis of a bronchus.

(b) Pulmonary tuberculosis.

Any one who remembers, as I do, the disgrace of being confronted
at autopsy with aneurysm or syphilitic stenosis of the bronchus in a
case which he has treated during life for asthma will never be hastv

COUGH

587

again in making the latter diagnosis. The wheezing and coughing
produced by one of the varieties of syphilis above referred to may be
clinically identical with those of ordinary bronchial asthma. The
treatment often relied upon for asthma (large doses of potassium iodid)
may still further mislead us through the improvement it produces in
syphilitic infections. Indeed, one sometimes is led to wonder whether
this is not the explanation for the reputation of potassium iodid in the
treatment of asthma.

In a paper by Dr. Cleaveland Floyd * we are warned how frequently
cases of asthma and emphysema with chronic bronchitis mask the
development of a pulmonary tuberculosis.

Both these possibilities were considered in the present case, and
everything was done to discover evidence of their presence. Nothing
of the kind came to light, however, and with reasonable certainty these
haunting possibilities may be excluded by the outcome.

Outcome. By the thirtieth of September the physical signs were
gone and the patient was allowed to go home. His health has since then
remained good, though he has occasional attacks of wheezing.

Diagnosis. Bronchitis and asthma.

Case 307

A hospital nurse, twenty-eight years old, was seen May 4, 1907. She
was never sick until three weeks ago, when she had "grip," but kept on
duty until the right ear began to ache twelve days ago; the drum was
tapped ten days ago, with a copious discharge of pus containing strepto-
cocci. At the right base, below the angle of the scapula, were num-
erous crackling rales. Later these rales gradually extended over the rest
of both lungs. The white cells ranged between 18,000 and 21,000.
Physical examination was otherwise negative. Now she complains of
anorexia, insomnia, cough, fever, and weakness. There is no longer
any tenderness about the ear.

On the tenth the patient was mildly delirious, respiration shallow
and almost stertorous, pulse falling steadily, but of poor volume and
tension. Acute redness and tenderness now developed over the tendons
of both wrists. All this time there had been a continuous discharge
from the right ear, but there was apparently good drainage and no mas-
toid tenderness or edema.

The patient's extreme nervousness suggested cerebral irritation.
Accordingly, on the tenth of March the right mastoid was opened and
curetted, a good deal of pus being found and removed. The lateral

1 Boston Med. and Surg. J' air., iqoq, vol. clxi, p. 407.

5 88

DIFFERENTIAL DIAGNOSIS

sinus was laid bare, and a needle introduced into it. Pure sterile blood
was withdrawn. Infection of the sinus was thus excluded.

Discussion. In this patient we find the signs of bronchitis only,
but she is obviously too sick for mere bronchitis of the ordinary type.
This particular combination of the signs of bronchitis with constitu-
tional manifestations too grave to be thus explained is very familiar
in voung children, and under those conditions is well known to mean
bronchopneumonia, provided evidence of disease in other organs is
wanting. In adults this particular combination or contradiction is much
less common.

It is quite possible that this patient had bronchopneumonia, but
we do not need to assume it, for the lesions of the middle ear and of
the tendon-sheaths furnish abundant evidence of a generalized pyogenic
infection sufficient to explain why this patient is so sick.

It is just within the bounds of possibility for a generalized tubercu-
losis to begin in this way, but the presence of streptococci in the aural
discharges and the absence of tubercle bacilli from the sputa give us no
ground for following this idea any further.

After the drainage of the mastoids the pulmonary signs did not clear
up, and the sputum was repeatedly reexamined for evidence of tuber-
culosis, always, however, with negative results. In an older person
with a bigger heart we should have been probably in considerable doubt
whether the pulmonary rales were due to edema or to inflammation, to
a transudate, or an exudate. Not infrequently these two states are so
mixed up in elderly people that the fine gradations between bronchitis,
edema, hypostatic pneumonia, and lobar pneumonia cannot be dis-
tinguished. In the present case, however, there is no occasion for any
such speculation. The heart was of good strength throughout.

Outcome. In the course of two weeks the patient's recovery was
nearly complete, though some rales remained in the lung, even after
the mastoids were entirely healed.

Diagnosis. Streptococcus bronchopneumonia.

Case 308

A school-boy of seventeen entered the hospital January 20, 1908.
He had had pneumonia'' when he was four years old, and again when
he was seven. Four years ago he had "general peritonitis," for which
he was operated upon at the Boston City Hospital. He also had
measles and mumps in infancy.

For the last three years he has been bothered by a persistent cough
ivith abundant sputum. The cough is severe enough to make him

COUGH

589

vomit about once a week after breakfast. He loses much sleep on ac-
count of the cough.

Five times in the past year his sputum has been blood-streaked,
the last time four days ago, when there were small black clots in it.
He has no night-sweats, and, so far as he knows, no fever. (See chart
for temperature.)

His appetite has been good, his bowels regular, his sleep good except
when disturbed by cough.

Physical examination shows that the boy is distinctly undersized.
His present weight is 76 pounds. He has a "chicken breast." The
heart is negative. The lungs are tympanitic
throughout, with scattered rales of various
sizes, especially numerous in the right axilla
and at the right base behind. There are
two operation scars in the right and in the
left lower quadrant of the abdomen. The
fingers are markedly clubbed, the nails
curved horizontally and laterally; slight
clubbing of the toes also. The blood and
urine are normal. His sputum is of a very
offensive odor.

Discussion. Chronic cough associated
with clubbed fingers in a young boy with
a sound heart means usually one of three
things:

(a) Chronic bronchitis with bronchi-
ectasis.

(l>) Chronic pleurisy, serous or purulent.

(V) Phthisis.

A pulmonary abscess could not have lasted so long without produc-
ing more definitely circumscribed physical signs in the affected lung.
We should be practically sure, also, to find a history of the discharge
of large quantities of sputum within a short time when the cavity was
emptied out.

Returning now to the three alternatives mentioned above, it seems
certain that the physical signs would be far more marked and extensive
if pulmonary tuberculosis had been at work for three years. ( )f course,
the sputa must be carefully and repeatedly examined. A dozen negative
examinations in succession would constitute strong evidence against
tuberculosis.

All types of pleurisy can be easily ruled out. There would be marked

154.

590 DIFFERENTIAL DIAGNOSIS

flattening of one chest, displacement of the heart, and much more
characteristic physical signs than are here reported.

If tubercle bacilli are proved to be absent, the only reasonable
conclusion will be that this boy is suffering from a bronchiectasis,
probably with secondary infection of the dilated bronchi by influenza,
the usual inhabitant of such diseased tubes. Between the enlarged
bronchi, pulmonary tissue becomes condensed and more and more
atrophic.

Conclusive evidence may very possibly be obtained by means of
.r-ray examination, which is especially valuable in young subjects with
thin chest-walls.

Outcome. Examination of the abundant purulent sputa was per-
formed many times. Pneumococci, streptococci, and influenza bacilli
were present always; tubercle bacilli never. X-ray examination showed
shadows suggestive of a number of dilated bronchi. The diagnosis
of bronchiectasis seemed reasonably certain.

A vaccine made from the influenza bacilli isolated from the boy's
sputa, was injected a number of times, but had no obvious effect except
to increase the amount of sputum, a change which was noted after each
injection.

This patient reentered the hospital September 3, 1908, and died of
pneumonia after an illness of six days.

Diagnosis. Bronchiectasis.

Case 309

A rag-sorter of fifty-six entered the hospital June 13, 1907. He
has always been well except for a slight cough during the last three
years. His family history is excellent. He has been much more
annoyed than usual during the last four weeks by a cough accom-
panied by viscid, scanty sputa. He has had pain, first in the right
chest, now in the left. There has been no fever, but much weakness.
The arteries are palpable and tortuous, his fingers clubbed. Scattered
throughout the lungs are many fine and coarse rales; the lungs are
generally hyperresonant, the breathing strongly suggestive of emphysema.
The rales are more numerous at the base of each axilla. Near the verte-
bral border of the left scapula there is a patch of pure bronchial breath-
ing about the size of a silver dollar. (See Figs. 155 and 156.)

The leukocytes are 17,000; urine, normal; sputa abundant, muco-
purulent, containing a few pneumococci; nothing else of interest.

Discussion. The history, the social condition of the patient, the
physical signs, and the clubbed fingers suggest a chronic bronchitis with

Pig. 155. Areas of cardiac and hepatic dulness in Case 309; also position of rales (crosses).

H-. 156.

ill- of auscultation and percussion in Case ,;~<). Tim
cluhhed tinners.

ough;

COUGH

591

bronchiectasis, but from the nature of the present complaints it would
seem that something more acute must be going on, especially as there is
a patch of bronchial breathing in the left back. How is this to be
explained?

Bronchopneumonia and tuberculosis are the chief possibilities.
Of tuberculosis there is as yet no evidence, but we have not yet watched
the case long enough to have any right to confidence on this point.
Cases beginning with signs like these often continue for months and
years without any proof of our suspicions of tuberculosis, until finally
a sputum examination is positive. Many such cases deserve to be
treated as tuberculous long before we can prove them to be so.

It is quite possible, however, that we are dealing in this case with
nothing more dangerous than one of those attacks of bronchopneumonia
so apt to occur from time to time in the course of a chronic bronchitis
with bronchiectasis. Indeed, it is sometimes convenient to divide this
disease into three phases:

(a) The summer phase.

(b) The winter phase.

In summer it may be nothing but a little wheezing induced by exer-
tion or by laughing; in winter we get infection of the bronchiectatic
cavities with influenza; profuse purulent discharge and paroxysms of
coughing, diurnal and nocturnal, are the result.

At any time there may be acute febrile attacks, with or without
definitely localized, demonstrable foci of solidification, such as are here
described. The vast majority of such attacks run a favorable course
within a few weeks. They are associated with a good deal more wheez-
ing and a more abundant nummular sputum than is usual in lobar
pneumonia.

Outcome.- By June 21st the signs had practically disappeared from
the left chest, and the patient, though not well, was in approximately
the same condition as before his acute attack. He was accordingly
allowed to go home.

Diagnosis. Bronchitis; bronchopneumonia, bronchiectasis, and
emphysema.

Case 310

A nurse of twenty-four entered the hospital May 5, too;. She lias
always previously been well, and has an excellent family history. For
a week she has had a bad cold, with headache, loss of appetite, cough,
and frothy white sputum.

592

DIFFERENTIAL DIAGNOSIS

The course of the temperature is seen in the accompanying chart.
The breathing above the third rib, in the right front, is much-diminished,
occasionally of cog-wheel type, and accompanied by crackles and
squeaks. There is a friction-rub in the right axilla. Visceral examina-
tion is otherwise negative, as is the blood, the urine and the sputum.
Gradually an area of dulness developed in the right axilla and spread
over the whole right chest by the thirteenth of May, with flatness below
midscapula and intense bronchial breathing. Many crackles and

friction-sounds were heard over
this area. The white cells con-
tinued low (7000). The sputum
was repeatedly examined, with
negative results.

On the nineteenth a trocar
was introduced in the right pos-
terior axillary line, \ inch below
the angle of the scapula. It
appeared to enter solid lung, and
no fluid w r as withdrawn.

By the twenty-second she had
regained her appetite, and al-
though pale and emaciated, was
in good spirits. The physical
signs were as previously described,
except that the rales and the
pleural rubs were now practically
gone.
By the twenty-fifth dulness was less marked; the breathing broncho-
vesicular or vesicular.

On the twenty-ninth dulness persisted in the right axilla and a little
in front, but there was none in the back, and the breath-sounds were
there normal, while in front they were still bronchovesicular, with an
occasional crackle.

Discussion. -The case looks alarmingly like one of consumption,
in spite of its acute onset. The physical signs are by no means distinc-
tive, but through the earlier part of the disease are perfectly consistent
with tuberculosis. One could only attain greater certainty at this
period of the disease by repeated sputum examinations and by the
cutaneous tuberculin tests (valuable, if negative).

The onset is very unlike that of ordinary pneumonia. Flatness on
percussion, such as was observed about the thirteenth of May, almost

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COUGH

593

never occurs in true pneumonia, and in the great majority of cases
indicates free fluid. I am alluding here to flatness used in the strict
sense, and in contradistinction from dulness. It was for this reason
that the exploratory puncture was done despite the presence of bronchial
breathing and rales. It is of great importance to remember that fluid
has again and again been obtained through a needle inserted at a point
where bronchial breathing, rales, or both were clearly audible.

The result of tapping excluded fluid at that date, though it seems to
me quite possible that an effusion had previously been present. The
tapping seems to me entirely justified, for there was a good deal in the
aspects of the case on the nineteenth, which suggested a postpneumonic
empyema and only tapping could rule this out.

Once this result was obtained, the balance of probabilities was again
in favor of pneumonia. One further possibility, however, remained,
viz., interlobar empyema, a complication always difficult of recognition,
though not uncommon.

How is the low white count to be explained? The patient was never
in that condition of desperate illness which we associate with most cases
of pneumonia without leukocytosis. Indeed, she was never in any con-
dition calling for anxiety. In all probability the disease was due to
some organism other than the pneumococcus. Clinically, the course
was distinctly atypical. Both the physical signs and the leukocyte count
were distinctly "queer," but not enough is known as yet regarding the
pneumonias due to organisms other than the pneumococcus to enable
us to recognize the definite types, such as streptococcous pneumonia or
influenzal pneumonia.

Outcome. By June 2d the breath-sounds were everywhere normal,
the rales gone, the dulness very slight. Her convalescence was unevent-
ful thereafter.

Diagnosis. Pneumonia.

Case 311

A clerk of eighteen entered the hospital June 24, 1907. His family
history was excellent. He had never been sick until the present time.
A week ago he woke up coughing and raising bloody sputum; in all.
about two teaspoonfuls. He had thin no pain, vomiting, or fever.

From this time on he continued to have cough and began to be short
of breath. He has been weak and has kept his bed. (See chart lor
temperature, and diagram for condition of the lungs.)

Physical examination was otherwise negative; white cells. 8000;
urine normal. The sputa was examined three times for tubercle bacilli.

594

DIFFERENTIAL DIAGNOSIS

but nothing found. The patient had a good appetite, and did not seem
especially sick. During his stay in the hospital he raised no more blood,
but the signs extended until most of the left lung was involved. Later
the base cleared very much, but at the left apex, both front and back,
there remained bronchial breathing, crackling rales, and increased fre-
mitus. Near the anterior fold of the right axilla amphoric breathing
and "cracked-pot sound" were obtained.

Discussion. The onset is not typical of any of the commoner res-
piratory diseases, and pneumonia should have fever and leukocytosis
from the beginning, even when cough and sputa are absent. On the other
hand, the signs remind us more of pneumonia than of anything else,

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and as the condition persists it is natural to ask whether we may not
be dealing with a failure of resolution. I have already said, however,
in the discussion of previous cases, that unresolved pneumonia usually
turns out, in my experience, to be a mistake in diagnosis, the actual con-
dition being postpneumonic empyema.

One would hardly make a diagnosis of this latter condition, however,
unless one had better reason to believe in the original pneumonia. But
there is no such difficulty with the diagnosis of pulmonary abscess
which may be next considered. This disease may begin acutely and
without any hint of a cause. Blood may be raised, as in the present
case, and as there are no typical signs of abscess, we cannot quarrel

Fig. i 5<). Chest signs in Case 311. History: seven days' cough; bloody sputa.

cough 595

with those which this patient shows. Abscess may exist with almost any
combination of signs and without any signs at all.

Nevertheless, abscess of the lungs, arising in this way without any
known cause and without lesions in other organs, is distinctly rare and
the character of the sputa is not at all typical. One expects a larger
amount of pus and a foul odor.

Acute tuberculosis cannot be excluded. We very rarely observe
so rapid a progress in tuberculous disease, and the negative examina-
tions of sputa are of considerable though not of decisive importance.
Most cases of tuberculosis beginning with hemoptysis present no physical
signs at all within the first two or three weeks. Accordingly, the ordinary
course of affairs is as follows: The patient is much alarmed by the
hemoptysis, and soon calls upon a physician for examination of the
lungs. This examination reveals nothing whatever. The tempera-
ture is normal, the blood-spitting already beginning to seem ancient
history as the patient now feels perfectly well. The doctor allows his
wish to be the father of his hope, and, humoring the patient's urgent
desire to be told that he is not tuberculous, gives a clean bill of health
and surmises that the blood came from the throat.

Thus a golden opportunity is lost, and the patient is not treated for
tuberculosis until the more obvious signs make their appearance some
months later.

In the present case there is nothing that we can do but persist in the
sputum examinations. Either tubercle bacilli will appear or the sputum
will become foul and take on the other characteristics of abscess.

Outcome. Only on the fourth examination July 2d were tuber-
cle bacilli discovered. The patient went home July 23d considerably
worse.

T take this opportunity of enumerating and discussing briefly the
causes of hemoptysis. Leaving on one side the cases in which only
slight streaks or fragments of blood appear, mixed with mucopurulent
sputa, and also' the cases in which blood, obviously derived from the
nasal cavities, is expectorated, we may group practically all the cases of
hemoptysis occurring in temperate climates under the following three
headings:

la) Hemoptysis due to tuberculosis.

(b) Hemoptysis due to pulmonary infarct, usually from mitral
disease.

The last two groups can usually be recognized with case by the
history and the attending physical signs, cardiac or pulmonary. Prac-

596

DIFFERENTIAL DIAGNOSIS

tically all the cases of hemoptysis which we puzzle over are later ex-
plained as tuberculosis or else remain wholly unexplained. In the
unexplained group should be placed those traditionally charged up to
vicarious menstruation, to hysteria, and other mythical causes.

In hemorrhagic diseases, such as purpura, scurvy, hemophilia,
leukemia, and in the hemorrhagic forms of the exanthemata, we may
have blood-spitting, but diagnostic puzzles rarely arise in these diseases.
Occasionally a case of uremia obeys the mandate of nature to lower
blood-pressure by any and all methods, so that pulmonary hemorrhage,
instead of the ordinary uremic nose-bleed, occurs. There could be no
difficulty in recognizing the source of such a hemorrhage unless we
omitted to study the heart and kidneys.

In many cases a patient is alarmed by the expectoration of blood
which the physician sees, at his first examination, to come from a spongy
gum. In various forms of stomatitis the patient may awake in the
morning to find a blood-stain on the pillow. This often excites
great alarm, but the most casual examination of the mouth should
make clear the source of the bleeding. Nocturnal epilepsy, however,
should also be remembered in such a case, as the patient may be himself
quite unaware of the fit.

Summing up this discussion, I wish to emphasize the point that there
is but one important cause of obscure hemoptysis, viz., tuberculosis.
If the source of a pulmonary hemorrhage is not made clear by the
examination of the heart, lungs, gums, and nasopharynx, and if it is
not obviously the expression of some infectious or constitutional malady,
it is in all probability the first sign of phthisis. I do not deny that the
causes of hemoptysis are numerous, but I assert that the causes of
genuinely obscure hemoptysis in temperate climates may be reduced to
one pulmonary tuberculosis. I may refer in this connection to the
careful study of F. T. Lord, 1 in which it is demonstrated that in the great
majority of cases in which a young person has a pulmonary hemorrhage,
recovers at once, and remains well for the rest of his life, postmortem
examination proves the bleeding to have been due to tuberculosis which
healed without ever producing further symptoms.

Diagnosis. Pneumonic phthisis.

Case 312

A Canadian brakeman, twenty-seven years old, was jammed October
31, 1907, between two freight-cars and sustained severe contusions
over the sacrum and left thigh. The day after the injury he had a severe

1 Boston Med. and Surg. Jour., 1000, vol. cl.xi, p. 571.

COUGH

597

chill; another occurred while in the ambulance on his way to the hospital,
November 9th.

For the past ten days, while in the surgical wards, he has had cough
and continued fever.

Signs of solidification were found at last near the angle of the right
scapula, associated with a good deal of pain in that side. There was no
dyspnea at any time.

When seen November 9th the white cells were 18,600. The patient's
appearance distinctly suggested phthisis, but repeated examinations
of the sputa showed no tubercle bacilli, and by the seventeenth of Novem-

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Fig. 160. Chart of case 312.

ber the lung signs had nearly cleared up, though rough breathing and
a few rales were still heard in the upper left lung.

On the twentieth, there was dulness and diminished respiration
over a small area at the right base. A needle was introduced here and
penetrated thick, hard pleura into apparently normal lung. Soon after
this all signs disappeared. The patient was able to go home on the
twenty-second, entirely well.

Discussion. It is natural to ask at the outset whether this patient's
symptoms may be due to trauma; so severe an accident might easily
have wounded the lung. But the facts seem to be against this hypothe-
sis. Apparently, his chest was not injured, and if we take the record
on its face value, this is conclusive. At the postmortem table, however,

598 DIFFERENTIAL DIAGNOSIS

one sometimes sees strange revelations in cases of this kind. Fractured
ribs and fractured pelvis, wholly unsuspected during life, I have seen
demonstrated postmortem to the great chagrin of all concerned.

It is difficult to suggest in the printed record the strongly tuberculous
appearance of this patient. Any one in the habit of judging by facies
and the general look of the patient could hardly have doubted that he
was phthisical. If one adopted this hypothesis, one would have to say
that the tuberculous process was "lighted up" by the accident. We
have good reason to believe that a patient's general power of resistance
may be notably diminished by such an accident as this, so that he becomes
much more subject to infectious disease of any kind.

Doubtless this idea has been overworked in the innumerable suits
for damages brought against steam and electric -car roads by persons
who have been injured. The lawyer for the plaintiff can always succeed
in finding some doctor who will swear that the pulmonary tuberculosis
from which the patient now suffers in an advanced form did not exist
before the accident and must have been produced by it. But without
believing that anything of this kind often happens, one must admit
its possibility.

In the present case we must confess that the signs are quite compati-
ble with tuberculosis, though by no means typical of it. Further light
can be obtained only by the results of repeated sputum examination and
by the cutaneous tuberculin test.

Pleural effusion was seriously considered here, as is indicated by the
fact that the chest was punctured. The question, "Have we fluid or
solid in this chest?" is much more frequently a difficult one than text-
books would lead us to suppose. A small effusion at the base of the
lung may so compress and condense the pulmonary tissue above it that
all the signs of solidification are present. This is equally true in dropsi-
cal effusions due to heart disease and associated with edema of the
lung itself. I have known many such cases mistaken for pneumonia.

In view of the outcome of the case, it seems more than probable
that the whole affair represented that type of pneumonia known as
"traumatic" or "surgical," and, due to that very lowering of resistance
by traumatism which I have hinted above, is often falsely lugged in to
explain a long-standing phthisis. Doubtless it is because we are so
familiar with the fact that trauma can cause pneumonia by favoring
infection that we invoke the same theory quite unjustifiably in tubercu-
losis.

Many cases of "traumatic pneumonia" have much more insidious
onsets than this, not only without dyspnea, but without pain or cough,

Fig. 161. Signs demonstrated in Case 313. Complaint: twenty years' "winter couj

cough 599

and sometimes without fever. The latter is especially apt to occur in
elderly persons and remains wholly undiscovered unless routine physical
examination, performed as a sort of daily house-cleaning, brings the
disease to light.

Diagnosis. Traumatic pneumonia.

Case 313

A granite-cutter of sixty-five entered the hospital February 17, 1908.
His family history and past history were excellent. He has had a winter
cough for twenty-years, to which he has grown so used that he thinks
little of it; but for six weeks his accustomed ''bronchitis'' has been
somewhat worse than usual, and for the last three weeks he has done
but little work. He has distress after each meal, and abdominal pain
when he coughs hard. During the night he has to pass water every hour,
and it burns him. For many years he has had cramps in his legs. He
says they are most troublesome at the time of the new moon, and last
through the first quarter. When young, he weighed 175 pounds; now he
weighs 123, but he says he has lost no weight of late years.

The patient's face is pitted with small-pox; eyes show complete
arcus senilis on both sides. His pupils are small and irregular, the
right larger than the left. Both react to light and distance.

The heart-sounds are somewhat indistinct, but a careful examina-
tion of the organ shows nothing else of importance.

The blood-pressure is 135 mm. Hg. The arteries are palpable and
tortuous. The condition of his lungs is shown in the accompanying
diagram. Temperature, blood, and urine are normal. Underneath
the right rib margin there is a dull, resistant, firm mass, which shifts
little, if at all, with respiration. When examined in a warm bath, this
tumor disappears, but there is still more resistance in the muscles
of that region than elsewhere. The sputum is very profuse and
purulent. The patient seems weak and sleeps much of the time.

Discussion. Cough without fever is usually of no great importance,
especially in a person who lias had it every winter for twenty years.
Under these conditions it is natural to assume it an old man's bronchiec-
tasis with a more recent (possibly influenzal) infection of the cavities.
The physical signs are by no means typical of this condition here, but
they will do in case the sputa proves negative and no other good reason
for the cough can be adduced.

/;/ men of this age it is often difficult to distinguish " a heart cough "
from " a lung cough." ("ardiae weakness favors stasis in the lungs, with
malnutrition and increased susceptibility to infection. < >n the other

600 DIFFERENTIAL DIAGNOSIS

hand, any infection of the bronchial tract leads to increased work for
the heart and thus perhaps to cardiac stasis. This patient apparently
has arteriosclerosis (palpable and tortuous arteries), and his heart-
sounds are said to be feeble. But, on the whole, this does not seem
to me enough to make us consider the heart seriously as a cause for his
cough.

It is of the greatest importance to remember that tuberculosis may
at any time become ingrafted upon the lungs of a patient who has
suffered for many years from nothing more serious than a winter cough.
The only safe plan is to assume each time that one sees such a patient
that he may have contracted tuberculosis recently, and to test this pos-
sibility by repeated examinations of the sputa as well as by a temperature
chart and a study of the pulmonary signs. In the statistics of Dr.
Cleaveland Floyd, already referred to, this point is well illustrated.

Outcome. On the third examination, tubercle bacilli were found in
the sputum.

Diagnosis. Phthisis.

Case 314

A widow of thirty-five entered the hospital July 30, 1907. Her
husband died of hemorrhage from the lungs. Her family history is
excellent. She had pneumonia six years ago, in the Portland, Maine,
Hospital. Since the birth of her last child, three years ago, she has
had no menstruation. For a year she has been coughing and raising
much phlegm, but never any blood. Three weeks ago she began to
cough less, but has been much "choked up" and has felt very weak.
She has a splendid appetite and rarely vomits. Her bowels are usually
regular, but she passes water very frequently, both day and night.
She says she once weighed 200; at entrance she weighed 86. She says
she has not an ache or a pain, and complains at present only of great
general weakness.

On examination the patient is found to be emaciated, the skin
dry and rough, the pupils irregular, neither reacting to light, the right
larger than the left. The heart and lungs show nothing abnormal.
The abdomen is full, resistant in the upper half, soft and tympanitic
below. The liver dulness extends from the sixth rib to the umbilicus,
and the edge of the organ is easily felt there. The white cells are 4200;
hemoglobin, 70 per cent. The urine contains no albumin and no casts;
specific gravity, 1025; it contains considerable sugar. On the fourth
of August there was a positive Widal reaction, absolute loss of motility,
and agglutination in one hour in dilutions of 1 : 10 and 1 : 50. On this

COUGH 6oi

date there were many fine, moist rales at the base of each lung; a small
abscess formed at the top of the right little finger. It was opened and
a pure culture of staphylococcus obtained. The sputum was repeatedly
examined, with negative results.

On August 8th there was sudden severe pain in the hypogastrium,
with a falling temperature, a rising pulse, and increasing abdominal
distention. All symptoms disappeared after two hours.

By the thirteenth she was much worse, very toxic, noisy and
slightly delirious, with muscular tremor, veins bloated, rales growing
more numerous, and abdomen more distended. The diacetic acid which
was present in the urine at entrance had now disappeared, and the sugar
had fallen to 2 per cent.

On the fourteenth of September a patch of bronchovesicular respira-
tion with crepitant rales was heard in the right axilla, and there was
slight external strabismus. She died on the fifteenth, the diagnosis
being typhoid fever, diabetes mellitus, bronchopneumonia.

At autopsy there was found miliary tuberculosis of the lungs, spleen,
and kidneys, fatty liver no evidence whatever of typhoid. The patient
had stated positively that she had never had typhoid fever.

Discussion. I did not see this case during life, and I have no
reason to believe that my diagnosis would have been any nearer correct
than that which was made. Everybody was "bowled over" by the
Widal reaction, and assumed that the case was one of typhoid fever.
Looking back now from the standpoint of the autopsy, it is worth while
to consider by what signs we might have been warned against the mistake
which we made.

Obviously, we were dealing with a case of diabetes and not merely
with a symptomatic glycosuria. The long-standing weakness and
emaciation, despite a splendid appetite, point to this conclusion. But
diabetes is very seldom associated with typhoid infection. I have not
been able to find any such case in the records of the Massachusetts
General Hospital, though Curschmann has observed such.

1 1 is notorious that there is another infectious disease which diabetics
are especially prone to catch viz., tuberculosis. Of this, there is little
evidence in the present case, yet it should be noted that the patient has
been coughing and expectorating for a year, and that the pulmonary
signs, although not at present characteristic, are compatible with tuber
culosis. When the strabismus appeared in the last days of the patient's
life, the suggestion of tuberculosis became inevitable, before that the
repeated negative examinations of the sputa threw us olT the track, and
the lung signs were interpreted as a typhoid bronchitis.

002 DIFFERENTIAL DIAGNOSIS

As I review the results of autopsy experience in diabetes and recall
the number of mistakes, more or less similar to that made in the present
case, I feel inclined to formulate the rule that any pulmonary signs
(obviously not those of pneumonia) occurring in a diabetic should be
assumed to be due to tuberculosis, especially if the patient is in an ad-
vanced stage of this disease.

The Widal reaction remains a mystery, and furnishes an example
of the dangers attendant upon our modern habit of placing almost
exclusive reliance on signs of this kind in diagnosis. If this case had
occurred prior to 1896, it is probable that the mistake would not have
been made. We should have turned more attention upon the past
history and the present signs, as seen in the light of our general knowl-
edge of the complications usually occurring in diabetes.

Diagnosis. Miliary tuberculosis and diabetes.

Case 315

A married woman of thirty-eight was first seen April 1, 1907. She
was never sick until seven years ago, when she had a sore on the genitals
and in her throat. At that time her hair came out.

Two years ago she had an operation upon her breast-bone at the
Carney Hospital. For two years she has had severe headaches, with
"fits and faint spells." These last sometimes seem to be brought on by
anger or excitement.

In December, 1906, she gave birth to a child, which died three days
later at the Infants' Hospital and was said to have had syphilis.

For the past three months she has had a painful cough, with night-
sweats and thick yellow sputum. She is weak, dyspneic, constipated,
eats and sleeps poorly, has many headaches, and faints when she gets
angry.

On examination the patient is obese and shows enlarged glands in the
neck, axillae, and groins. The inner third of the right clavicle is missing.
An old operation scar occupies its site. On cough, the lung projects
through the hole thus left. The heart and peripheral blood-vessels show
nothing abnormal. Over an area extending from the right apex to the
third rib in front and to the scapula behind, expiration and inspiration
are very noisy and strident. There are occasional crackling rales in
this area. Elsewhere the lungs are negative. The sputum shows many
intracellular influenza bacilli, a few pneumococci. no tubercle bacilli.

A letter to the Carney Hospital showed that the lump excised
from the clavicle, which before operation had been taken to be tubercu-
losis, showed gumma when examined histologically.

COUGH

603

It was also learned that the patient had been eight months in the
Worcester Insane Asylum some years ago.

Tuberculin, 10 milligrams, was injected, with negative results.
(For temperature see the accompanying chart, Fig. 162.)

The patient was given mercury ; also iodid of potash in doses increased
from 10 to 100 grains three times a day. By this treatment, symptoms
and signs very markedly improved, so that by the eighteenth of April
she was able to leave the hospital.

The physical signs at this time
consisted of bronchovesicular breath-
ing and a few medium rales at the
right apex.

X-ray report by Dr. Walter Dodd :

"Apices. Both present hazy ap-
pearance. Left more marked than
right. At base of the right lung
there was a dense shadow observed
which started about 1 inch from
median line at level of sixth space.
Shadow was deep seated.

Diaphragm. Excursion on left
side normal. Could not see diaph-
ragm on right side. When patient
coughed the shadow at its base moved
upward about 1 inch and receded
immediately."

Discussion. It was clear enough that this patient was suffering
mainly from syphilis, but what of the pulmonary conditions? Tuber-
culosis, as is well known, often complicates syphilis, owing to the diminu-
tion of resisting power brought about by the syphilis. Ordinary types
of bronchitis, due to the influenza bacillus or other organism, are also of
frequent occurrence in syphilitics. There are no physical signs or clinical
features characteristic of pulmonary syphilis, so that the diagnosis can
never be made with any confidence.

Experience seems to me to show that it is safe to assume pulmonary
complications of this kind to be due to svphilis, provided, of course, that
we are convinced by sputum examination or otherwise that the case is not
one of tuberculosis. It was shown some years ago by Dr. E. (1. Jane-
way that patients who have fever, night-sweats, and pulmonary signs
like those ordinarily seen in phthisis may promptly recover under anti-
syphilitic treatment, after residence in a sanatorium for tuberculosis has

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Fig. 162. Chart of case 315.

604 DIFFERENTIAL DIAGNOSIS

failed to benefit them at all. It seems, therefore, the wiser course to
give every syphilitic the benefit of the doubt, and treat him with mercury
and potassium iodid while we continue to search his sputum for tubercle
bacilli. If marked and rapid improvement takes place under this
treatment, we may conjecture that we have been dealing with a case of
pulmonary syphilis, but as the pathologic anatomy of that disease is
practically unknown, it is difficult to make any positive statement on the
matter.

A point of great interest in this case is the patient's habit of fainting
when she gets angry. Ordinarily, one would call attention to such a
symptom as indicating a hysteric basis for any other complaints which
the patient might express. In this case we have reason to believe
that organic brain disease of syphilitic origin is present. Yet the patient
faints when she gets angry. It may be that a closer psychologic study
of the case would show that the fit of anger like the fits of running
which immediately precede some epileptic attacks is the first symptom,
not the cause, of the subsequent loss of consciousness. In anger we are
only partly ourselves; in fainting we cease to be ourselves at all.

Diagnosis. Syphilitic disease of the lung.

Case 316

A gardener sixty-one years old, with an excellent family history,
entered the hospital June 24, 1908. He states that he had dropsy
three years ago, while at the Boston City Hospital.

Five months ago he caught a bad cold, and has had a troublesome
cough, with profuse sputa, dyspnea, and poor appetite ever since.
For three months he has had orthopnea. The cough often keeps him
awake.

On examination he was found to be emaciated, orthopneic, markedly
cyanotic, and breathing with much difficulty; the rate was from 40 to
50 a minute. The lungs showed many coarse bubbling rales on both
sides. There was very slight dulness and harsh breathing above
and below the right clavicle in front, also slight dulness and prolonged
low-pitched respiration at the right apex behind. There was slight general
abdominal tenderness, and the edge of the liver could be felt i\ inches
below the ribs. On percussion, the upper border was at the sixth rib.
(For temperature, see the accompanying chart, Fig. 163.)

The white cells at entrance were 29.Q00; the urine, sp, gr. iooq
to 10 14, 30 ounces in twenty-four hours, with a slight trace of albumin,
many hyaline and coarse granular casts. The heart's impulse and dulness
were felt in the fifth space, inside the nipple-line. A systolic murmur

COUGH

605

was audible at the apex, and the pulmonic second sound was accentu-
ated. The first apex sound was very loud and sharp. The arteries were
palpable and tortuous, with a lateral excursion in the brachials.

Discussion. At this patient's age, with the evidences of cardiac
and vascular disease furnished by the physical examination, and in view
of the history of dropsy three years previously, it
would be natural to assume at the outset that the
pulmonary signs are due to stasis and insufficient
heart action.

Against this idea, however, is the presence of
fever and leukocytosis, neither of which should be
produced by the degenerative, non-infectious type of
heart trouble which we expect in people of this age.
The acute vegetative types of endocarditis and the
myocardial infections which might produce fever
and leukocytosis along with pulmonary stasis in a
younger patient, are rarely seen at sixty-one unless
as terminal infections. The present illness, however,
has been going on for five months, and cannot be
called terminal.

We are apt to forget the possibility of tubercu-
losis in people who have managed to worry through
sixty years of life without acquiring it, but recent
statistics give us no excuse for this form of absent-
mindedness, and warn us to search the sputum of
every patient who has any cough, whatever his age, especially when
the pulmonary signs seem to be most marked at the apex of the lung
involved.

Outcome. The sputa showed a few tubercle bacilli, though it had
in other respects the characteristics of pulmonary abscess and was at
times excessively foul. The patient lost ground rapidly after entering
the hospital, and died on June 30th.

Autopsy showed tuberculosis of the lungs, chronic interstitial ne
phritis, hypertrophy and dilatation of the heart, tubercular ulcers of the
intestine, and hypernephroma.

Diagnosis. See last paragraph.

Fig. 163. Chart
case 316.

Case 317

A weaver of twenty-four was seen August 20, TQ07. He had "stom-
ach trouble" three or four years ago. fie has otherwise been well.
A week ago he began to have cough, headache, and, after two (lavs,

6o6

DIFFERENTIAL DIAGNOSIS

vomiting, the vomitus containing some blood. Three days ago he had

a chill, pain in his left side, loss of appetite, insomnia, and constipation.

He has been in bed three days.

In the left back, close to the spine of the scapula, are heard harsh

respiration and a few fine rales. The lungs are otherwise negative.

Palpation of the abdomen causes severe paroxysms of cough. The
blood and urine are negative. (The temperature
is as seen in the accompanying chart.)

The next morning an erythematous eruption
appeared in the right half of the trunk, arms,
and legs. This disappeared after calomel \
grain every half-hour for six doses, but soon
broke out again, the wheals being, however, less
numerous the second time.

On the twenty-fifth of August the upper lip
suddenly became much swollen. The patient
was given calcium chlorid, i gram three times
a day, Carlsbad salts, i dram three times a day.
On the twenty-sixth he was practically well.

Discussion. This case is introduced merely
to exemplify one of the unusual manifestations
of urticaria. I have previously illustrated the
manifestations of urticarial lesions in the in-
testinal tract. (See p. 73.) In the present
case we have good reason to believe that the

bronchial tree was the seat of similar lesions, producing patches of edema

which corresponded to the signs recorded in the text.

It may be of some importance not to forget the possibility of a cough

produced in this way, since it would be likely to yield to treatment of

the same type, which, in some cases, is found to be effective against the

cutaneous wheals, viz., catharsis and attention to diet.
Diagnosis. Internal urticaria.

A.-,

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3

ft.

107"
104
100

101

10*

w*
w

140
130
1
110
100

to
to

7i\

Fit

164. Chart of
case 317.

COUGH

607

C (-N

2 en
I*

C
p?

= 3

s <

3T3

O p

K 3'

0.0

3 <

g 3

2 c

P y H
3 =

Squeaks and groans.

Rales of edema or
fluid at bases.

Usually solidification.
May be none.

Edema at lung-bases.

Often none. May be
those of bronchitis.

Lung signs.

Localized bronchitis

or solidification

at apices.

Scattered rales.

Edema or fluid at
lung-bases.

Friction rub.

Arhythmia.
Enlargement.

Enlargement.
I Hastolic murmur.

Systolic murmur.

Enlarged heart.

P. 2d +.

Heart signs.

Often sclerosis
and hypertension.

Jumping arteries

Irregular low-
tension pulse.

Vascular
changes.

c ' S. o -f- o

+ -S+ +

S) T T.

CHAPTER XIX

VOMITING

The act of vomiting must be distinguished, in the first place, from
the easy and more or less habitual regurgitation of the normal stomach-
contents. In young infants this presents itself as the familiar phenomenon
of "spilling over"; in older persons it is often a matter of habit, quite
controllable when explained, for, curiously enough, there are those
who act as though they believed that the stomach-contents have a
divine right to be ejected whenever it reaches the mouth. A little
wholesome advice is here of value.

In estimating the significance of vomiting we must take account also
of the patient's temperament and of some other habits besides that just
mentioned.

(a) There are people who have learned early in their career the
trick of emptying their stomachs on slight provocation, with or without

'the aid of a finger in the throat. To such people the slightest gastric
discomfort, the faintest retrosternal or esophageal irritation, is the
signal for a voluntary emptying of the stomach.

(b) At the other extreme, temperamentally or physiologically, are
those who may have gone through thirty or forty years of life without
ever tasting the experience of emesis. In a person of this type we may be
led to underestimate the importance of certain symptoms merely because
he does not vomit.

The first of these temperamental extremes is especially prominent
in the gastric neuroses, and when the existence of such a condition is
satisfactorily established, it may be our chief duty to make the patient
control the act. This can be accomplished sometimes by a simple
explanation, sometimes by scolding, sometimes by a sort of mental
counterirritation, the result of getting the patient busy, sometimes by
subpectoral infusions of saline solution, which the patient is distinctly
warned must continue until the vomiting stops. To break a habit is
the main object, whatever method is adopted. I have known an ap-
parently sensible working-man of thirty-five who vomited continuously
until four months had elapsed, and 55 pounds of his weight had vanished,
all from habit a?one a habit which was broken without much difficulty
in the course of a week's hospital treatment with subpectoral infusions
as above described.
t;08

Causes of Vomiting

1. TOXEMIA OF PREGNANCY

2. "ACUTE DYSPEPSIA"

3. ALCOHOLISM

4. SEA-SICKNESS

5. ONSET OF INFECTIOUS DISEASES

6. POSTOPERATIVE "SHOCK"

CASES TOO MANY AND TOO VAGUELY
\- ENUMERABLE FOR GRAPHIC REPRESEN-
TATION.

7. GASTRIC |
NEUROSIS*

8. ACUTEAPPEN-
DICITIS

9. CARDIAC DIS-
EASE

10. PEPTIC ULCER

11. "GASTRITIS"

12. INTESTINAL

OBSTRUC-
TION

13. GASTRIC \

CANCER I

14. UREMIA

15. TABES

2126
1819

1512

309
209

167

113

45
42

fiO't

VOMITING 6ll

IMPORTANT FACTORS IN THE PRODUCTION OF VOMITING

Three prominent elements may be distinguished:

(a) Cerebral.

(b) Gastro-intestinal.

Most of the so-called "reflex" causes of vomiting may be arranged
without much violence under the first of these headings. The vomiting
due to intense pain, that induced by fright and other strong emotions or
by fatigue, can probably be accounted for in this way. The majority
of toxic varieties of vomiting belong in the same group e. g., the vomit-
ing of pregnancy, cyclic or paroxysmal vomiting, and that accompanying
migraine and hyperthyroidism.

The pharyngeal factor is especially important in the morning vomit-
ing which accompanies many cases of alcoholism, but which is very
often due to the accompanying pharyngitis caused by smoking. The
patient has a smoker's throat, which he rasps and scrapes in the
clearing-out process when he wakes in the morning. The pharyngeal
irritation finally produces emesis.

Together with the ordinary gastric causes of vomiting, we must
remember the cases in which chronic or acute intestinal obstruction,
with or without peritonitis, causes the stomach to empty itself. With
many of the intestinal neoplasms we may have symptoms very closely
simulating those of cancer of the stomach, and the examination of the
gastric contents and functions may still further confuse us, since gas-
trectasis, hypomotility, and achlorhydria may be found. The vomiting
due to acute appendicitis or to strangulated hernia is probably of the
same type.

Finally, we may mention the prolonged attacks of emesis accom-
panying the gastric crisis of tabes dorsalis, the explanation of which is not
as yet clear.

Case 318

An Trish bartender of forty entered the hospital January 16, 1908.
He had catarrhal jaundice three times several years ago. His father
died of pleurisy. The patient has been a very hard drinker, consum-
ing a quart of whisky and 17 large beers daily. He denies venereal
disease.

For many years he has had stomach trouble. He vomits early in
the morning, and often after eating anv ordinary food, so that at present
he practically lives on liquor. He cannot remember to have been intoxi-

6l2 DIFFERENTIAL DIAGNOSIS

cated so that he could not do his work and take care of himself. His
appetite for everything but liquor is very poor.

The bowels move two or three times a day.

He is very shortwinded, and for two weeks has noticed scantiness
of his urine, enlargement of his belly, and some swelling of the feet,
face, legs, and hands. A week ago he noticed that his conjunctivae
were getting yellow.

Two years ago he weighed 195 pounds; now he weighs 236.

Physical examination showed a satin-like skin; no jaundice; feeble
heart-sounds; soft and apparently normal arteries; blood-pressure,
no. There was nothing abnormal in the lungs. He had an enormous
dome-shaped abdomen, with slight dulness in the flanks, showing
perhaps a little shift with change of position. The edge of the liver
not felt, though there is dulness for 2\ inches below the right costal
margin. There was slight edema of both legs.

Discussion. -This seems at first sight an obvious case of alcohol-
ism, but on closer study we notice that the heart-sounds are feeble,
that he has dyspnea, that the face and extremities are edematous, and
that, despite persistent vomiting, there has been a marked gain in body
weight. All these facts and especially the last one point toward
cardiac disease, which, as we know, is frequently a cause of persistent
vomiting.

But what cardiac disease can it be? There is no evidence of a valvular
lesion or of a weakened heart due to kidney trouble. Chronic fibrous
myocarditis was, in earlier years, a favorite diagnosis in cases of this
kind, but the autopsy so seldom confirmed it that many of us are grow-
ing more cautious. Personally, I am unwilling to make a diagnosis
of chronic myocarditis unless there is convincing evidence of arterio-
sclerosis, and unless all other causes of cardiac weakness can be satis-
factorily excluded. But there is no evidence here of arteriosclerosis,
and no good reason for the heart to be weak merely as a result of alcohol.

In any such patient cirrhosis must be considered, especially as it
might help to explain the persistent vomiting. Cirrhosis is always a
difficult disease to exclude, since we know that it usually exists for years
before it produces any symptoms. All we can say in a case like this is
that we have no positive evidence of it, such as ascites, enlargement or
shrinkage of the liver, hematemesis.

Of course, the gastric functions must be more thoroughly investigated
if the patient does not promptly yield to treatment based on some other
hypothesis. But after this survey of the case we have obtained, as it seems
to me, so little positive evidence of any disease other than alcoholism

VOMITING 613

that the first experiment to be tried all treatment is an experiment
is an anti-alcoholic regime. If that fails, the next step should be to
pass a stomach-tube and examine the physical and chemical functions
of the stomach; next, if that proves negative, to try the effect of cardiac
stimulation preceded by depletion.

Outcome. Alcohol was withdrawn entirely at entrance. The
patient was given a diet of liquids and soft solids, with 10 minims of the
tincture of capsicum before each meal, an ounce of magnesium sulphate
early each morning, and 2 drams of paraldehyd every afternoon. In
four days he was able to eat without vomiting and sleep without medicine.
In a week he felt perfectly well, but was much surprised to discover that
he could exist without rum.

Diagnosis. Alcoholism.

Case 319

A housemaid of twenty-four entered the hospital October 11, 1906.
She had always been well except for habitual constipation, the bowels
moving once in from two to six days. She has taken no breakfast for
some weeks and has occasionally vomited. A week ago the patient
was married. Her last menstruation was August 14th.

At 3 o'clock this afternoon she began to vomit, and soon after had
a sudden sharp abdominal pain, with faintness, and in the course of
the day six loose movements of the bowels.

Examination was negative save for slight dulness in the right flank,
slight tenderness of the epigastrium and along the right side. At
McBurney's point tenderness was very marked on dee]) pressure, and
there was spasm over this area.

Vaginal examination shows much tenderness high up on the right side,
but no mass.

The white cells were 16,800; urine, negative; temperature, pulse,
and respiration normal. The breasts were somewhat large.

Discussion. The vomiting here might well be due to pregnancy,
but no one could make any such statement without any further evi-
dence than is furnished by the physical signs here reported. If the
historv is taken as correct, that is, if her last menstruation was August
14th, there is hardly time enough for the development of an ectopic
gestation, which should, moreover, show more definite signs on vaginal
examination or more characteristic evidence of hemorrhage.

Patients of this type not infrequently take large doses of irritating
cathartic medicine in the attempt to produce a miscarriage. The
loose movements of the bowels and the vomiting mi^ht be thus accounted

6l4 DIFFERENTIAL DIAGNOSIS

for. No history of this kind, however, could be elicited, and the patient
seemed to be telling the truth.

The patient's habitual constipation might account for a good deal
of vomiting, but hardly for such an acute attack or for tenderness and
spasm in the right iliac fossa.

One always hesitates to make a diagnosis of appendicitis when the
temperature and pulse are normal and when there has been no previous
attack. Nevertheless, in the presence of very marked tenderness, with
spasm at McBurney's point and leukocytosis, appendicitis seems the
most reasonable diagnosis. A pyosalpinx might produce very much
the same physical signs, but would probably show a mass or induration
by vagina, and would not, in all probability, come on so acutely without
any other or previous symptoms.

Outcome. Operation October 12th showed acute appendicitis.
There were no old adhesions.

Diagnosis. Appendicitis.

Case 320

A married woman of fifty-three with an excellent family history
entered the hospital September 28, 1907. She has been strong and
healthy all her life, with the exception of a double inguinal hernia, for
which she was successfully operated upon in May, 1907. Since child-
hood she has been in the habit of passing water once at night after bed-
time.

About a year ago she began to have attacks of vomiting, in which
she was unable to retain any kind of food, the vomitus consisting at first
of the food previously eaten, unmixed with mucus or blood. Last
fall the vomiting ceased altogether, and she was in the Massachusetts
General Hospital for a Colles' fracture. During her stay here nothing
abnormal was noted in the digestive functions, but after her return
home vomiting began again, and has gradually grown more frequent
up to the present time. She has vomited every day through the past
summer sometimes three times a day. At no time has there been any
pain except after eating a large amount, and then only slight distress.
There have been no eructations of gas and no swelling of any part
of the abdomen, though the epigastrium has been somewhat tender
on pressure for two months.

Fifteen months ago she weighed 124 pounds; four months ago, 116:
now she weighs 100 pounds. Her bowels have gradually become
constipated. She has noticed no jaundice. She has never considered
herself nervou>.

VOMITING

615

The temperature and pulse were as seen in the accompanying chart.
The patient was poorly nourished and pale, though her hemoglobin
was 75 per cent, and the white cells were 7300. The heart and lungs
showed nothing abnormal. In the upper abdomen was a hard, tender
mass, descending with respiration. (See Figs. 165 and 166.)

Physical examination, including the urine, was otherwise negative.
The stools showed no occult blood. Vaginal and rectal examinations
were negative. Through the stomach-tube only 13 ounces of water
could be introduced without extreme pain, retch
ing, and struggling. There was no food in the
fasting stomach. After an Ewald test-meal the
gastric contents showed no free acid of any kind.
The benzidin test for blood was positive; the
wash-water used for lavage returned slightly
blood-stained.

Discussion. The early part of this history
reminds us of a gastric neurosis, because one
isolated symptom vomiting seems to make up
the whole clinical picture. When any single symp-
tom, such as vomiting, gaseous eructation, diarrhea,
or constipation persists over a considerable period
of time with little or no background of other
interconnected symptoms, it usually turns out
that we are dealing with a neurosis that is, with
a morbid habit. We can make such a statement,
however, only when we have exhausted all the
resources of physical diagnosis without finding
any evidence of organic disease.

We cannot attribute the vomiting to constipation or to the exhaus-
tion produced by any constitutional or infectious disease, since we
have no evidence of these conditions. A consultant suggested the pos-
sibility of cerebral tumor, and the fundus oculi was examined with
this possibility in view. Neither there nor elsewhere, however, could
we find any support for the assumption of brain disease.

As soon as the epigastric mass was clearly made out and the pos-
sibility of its being due to a fecal accumulation was excluded by free
catharsis, it began to be pretty evident that the vomiting was due either
to ulcer or cancer of the stomach. This became still more certain
when it was recognized that the capacity of the stomach was diminished
and its secretion of hydrochloric acid abolished. Tt remained to decide
the question: cancer or ulcer? Such a tumor is often produced by

"St.?

J_S

D^.,-,.

107'

lOi,

10s*

10*'

101 '

100

n*
H'
M*

130

no
to

mil

*..

,-;

\ l i\ L*

\JW

#&+

A ;,* ;

Fig. 167. Chart of
case 320.

6l6 DIFFERENTIAL DIAGNOSIS

a perigastric exudate around an old ulcer. But the history is dis-
tinctly against ulcer and in favor of cancer. Ulcers seldom begin in
persons who have lived to fifty-two years without gastric disturbances.
Thev are hardly ever characterized by vomiting without pain, and in
the earlier stages of their course there are usually long periods of free-
dom from symptoms and marked relief (even during the acute stages
of the disease) immediately after the taking of food.

One of the things that made it rather difficult to realize that cancer
was really the most reasonable diagnosis in this case was the entire
absence of pain. This, however, is by no means unprecedented. A
number of similar cases have been recorded.

Outcome. Dr. Maurice Richardson made a diagnosis of cancer
of the lesser curvature, without obstruction of the pylorus, and advised
against operation of any kind.

Under liquid and soft solid diet, with small doses of calomel and
magnesium sulphate, hydrochloric acid, 20 minims after food, the
patient ceased vomiting on October 4th and felt a great deal better.

Diagnosis. Gastric cancer.

Case 321

A married woman of thirty-five entered the hospital March 24, 1908.
She lost one brother by phthisis in the previous December. She has
had two children and no miscarriages. Her youngest child is seven
years of age.

Three years ago she was in St. Elizabeth's Hospital for ten weeks
on account of stomach trouble; dilatation and curetting of the uterus
were done.

Five years ago she weighed 144 pounds. A week ago she weighed 1 10.

During these past five years she has been having attacks of vomiting,
at first only before each menstrual period, later at other times. Her
vomitus was watery and contained undigested food, but never any
food eaten twenty-four hours before. She has not been free from
vomiting for more than two weeks since 1903. The vomiting relieves
sharp epigastric pain, which is usually worse after eating. In 1905
she vomited two cupfuls of dark blood. On a milk diet this ceased,
but returned eleven weeks later. In November, 1907, she again
vomited blood and had epigastric pain and tenderness. She was con-
fined to bed a week at that time; she has not vomited since, but still
has epigastric pain and tenderness, worse after food. Her appetite
is poor; the bowels move only with enemata. She has no headache.
Her eye-sight is good.

VOMITING 617

Physical examination is negative save for a blowing systolic murmur
limited to a small area near the apex of the heart. There is slight
epigastric tenderness, but no spasm. The right kidney is easilv felt,
its lower pole being on the level of the navel.

After a test-meal the gastric contents showed free HC1, 0.14 per
cent.; total acidity, .25 per cent.; guaiac test, negative. The stools were
also free from blood.

The patient did excellently well on a diet of milk and eggs, fol-
lowing roughly the formula of Lenhartz.

On the second of May she seemed well and was allowed to go
home.

The patient returned to the hospital August 3, 1908, stating that,
two weeks after leaving the hospital before, she had an attack of vomit-
ing with the menstrual period, and this vomiting had continued for
the two subsequent periods, though she was perfectly well between
them. The vomiting seemed to be entirely independent of the taking
of food. The vomitus contained no blood. At the time of these attacks
she had a good deal of epigastric pain, and has a little pain all the time,
slightly relieved by food and accompanied by gaseous and sour eructa-
tions. She sleeps poorly, on account of nervousness, she believes.

Physical examination shows marked pallor, the red cells, 3,050.000;
hemoglobin, 45 per cent. Two normoblasts, also considerable achromia
and deformities, were seen while making the differential count of 200
white cells. The polynuclear cells were 82 per cent. The urine was
negative.

The stools showed a slight but constant reaction to guaiac.

Stomach-tube examination showed essentially the same condition as in
the previous spring. There were no fasting contents. The patient did
excellently well on a diet of crackers and milk.

Discussion. In marked contrast to the previous case, the stomach
trouble is here of long duration live years or more- and occurs in a
young woman. In the early stages of the disease, and to a certain
extent throughout, the pain seems to be connected with menstruation,
as if it were a "reflex" nervous disturbance associated with the nervous
tension of that period. The relief of pain by vomiting and the attack
of hematemesis in 1905 still further support the diagnosis of peptic-
ulcer or hypochlorhydria, which had been already suggested by the
previous history.

In August, 1908, her symptoms still suggest chiefly peptic ulcer,
but we have now one symptom not easily accounted for on that hypothe-
sis, viz., the verv marked anemia. There has been no evidence of

618 DIFFERENTIAL DIAGNOSIS

hemorrhage for three years, and peptic ulcer does not produce anemia
unless there is sharp bleeding.

It is not likely to produce anemia by oozing or discharging blood
in small quantities. The marrow readily makes up these losses. Neither
is it likelv that a large amount of blood might have been poured out
at one time and discharged wholly by rectum without the patient being
aware of it. Such rectal hemorrhages produce so much weakness and
thirst that the patient is usually made aware that something has hap-
pened.

Nevertheless, it must be admitted that everything else in the case
save this one fact an unexplained anemia points to chronic ulcer,
and perhaps the anemia alone is not of sufficient diagnostic significance
to outbalance the other indications which favor ulcer. But since the
trouble has gone on so long and recurs so frequently under dietetic
treatment it seems as if the patient should be given the benefit of an
exploratory laparotomy, especially as there is at least a possibility that
the anemia may be due to something more serious i. e., to gastric
cancer.

Outcome.- August 14th the abdomen was opened. A cancerous
mass was found on the posterior wall of the stomach, with metastases
in the omentum. Gastroenterostomy was done. A month later the
patient was reported as eating well, sleeping well, and gaining in weight.

Diagnosis. Gastric cancer.

Case 322

A widow of forty-five entered the hospital August 14, 1906. She
lost her husband of consumption twelve years ago. Sixteen years ago
she had an attack similar to the present one, which was cured in two
weeks. A year ago she had another attack, and was in the hospital
for three weeks on rectal feeding, during which her weight fell from
137 to 117 pounds. Since then she has been dieting carefully, has felt
pretty well, and has not been troubled by indigestion.

Nine days ago she was suddenly seized with sharp abdominal pain
and vomiting. This pain has recurred frequently since that time.
It is relieved by vomiting, but shows no other relation to food. Occa-
sionally it requires morphin. In her attack of sixteen years ago she
vomited blood, but there has been none since. For the past three
months she has had occasional attacks of diarrhea, the movements
being preceded by pain and often containing blood.

For the past two days she has been fed exclusively by the rectum.
Her weight is now 120 pounds.

VOMITING 619

On examination the patient is very well nourished, but rather neuras-
thenic. There is a soft systolic murmur at the apex of the heart. The
pulmonic second sound is larger than the aortic second. The heart
shows no enlargement. The lungs are negative. The right side of the
abdomen is held rather rigid, owing to marked tenderness, greatest in
the middle quadrant.

Physical examination, including the vagina and rectum, is otherwise
negative, as are the blood, urine, temperature, pulse, and respiration.

The patient in the early days of her treatment seemed markedly
neurasthenic, but this ceased after the cessation of the menstrual flow,
and she was able to take solid food in moderate amounts for three days.

After this the patient began to vomit a great deal. Nutrient enemata
caused much distress and seemed to aggravate the vomiting. On the
fourth day she was able to take some champagne and some albumin-
water flavored with sherry, without any vomiting. The vomitus was
found to be strongly acid, and consisted mostly of clear mucus.

Sodium bicarbonate relieved her pain somewhat, but it was vomited
after a short time. Only morphin gave relief.

After a test-meal the stomach-contents showed an abundance of
free hydrochloric acid and a positive guaiac reaction. The stools were
foul smelling, dark, and bloody.

On the twentieth the patient complained a great deal of abdominal
cramps. The stool at this time was found to contain much fresh blood
and a considerable amount of pus and mucus. The blood showed:
Red cells, 3,676.000; white cells, 10,000; hemoglobin, 65 per cent.

The stained specimen showed nothing remarkable except achromia.
Further study of the stools showed that they contained almost no fecal
matter.

The subsequent examination of the abdomen showed on the right
side, low down, something which felt like hard lumps, which, however,
disappeared with the rumbling of gas. The capacity of the lower bowel
was measured with warm water, and only a pint could be introduced.
There seemed to be no distention of the transverse colon, but the region
of the ascending colon was persistently distended. The attempt to
introduce more than a pint of water by rectum was repeatedly unsuc-
cessful.

Discussion. We see occasionally in adults those unexplained at-
tacks of summer diarrhea and vomiting which are so common in younu
children; but we do not expect them to persist for nine days. True,
this patient is neurasthenic, so the record states, and that might account
for a great deal, especially as the attack has happened to occur at the

620 DIFFERENTIAL DIAGNOSIS

menstrual period. During the earlier days of her treatment we ac-
counted for her symptoms in this way. Among the other possibilities
considered was hypochlorhydria, which will next be discussed.

The previous attack of hematemesis was described by the patient
as similar to the present trouble. The illness of 1905 also suggests
hypochlorhydria or ulcer. The stomach-contents now show a positive
guaiac reaction and a large amount of free hydrochloric acid. There
is also blood in the stools. When all these facts came to light, we were
inclined to switch over from the idea of gastric neurosis to that of peptic
ulcer, all the more so when it turned out that sodium bicarbonate
relieved her pain.

It was not until the second week of treatment that the intestinal
symptoms began to seem more important, especially as we could find no
good cause for the well-marked secondary anemia. There had been no
recent hemorrhage to account for it, and it did not appear that the
diarrhea had lasted long enough in any of her previous attacks or in
the present one to produce so much anemia. It was, however, the con-
dition of the stools, especially the presence of pus, and the remarkably
small amount of fecal matter which led us further to investigate the
possibility of intestinal neoplasm. When we found that, on two separate
occasions, not more than a pint of water could be introduced into the
rectum, even when slowly and carefully given, the suspicion of intestinal
neoplasm low down in the colon became such that operation was ad-
vised.

Outcome. The abdomen was opened on the twenty-seventh of
August, revealing a cancer of the sigmoid.

This case and several others which I saw about the same time were
very instructive to me because I had never been warned of the pos-
sibility and the danger of getting our attention so focused on the gastric
manifestations of what turns out to be intestinal obstruction that the
possibility of the latter does not occur to us. If once we get a false start,
we may find a good deal to confirm us in our mistake. For example,
in a recent case, which turned out, like the present one, to be due to
a cancer of the sigmoid, everything seemed at first to point to the stomach.
A stomach-tube was passed, and proved the presence of gastric enlarge-
ment and the absence of free hydrochloric acid. The patient was fifty
years of age, and had never had any gastric symptoms before the present
year. All these facts seemed to point so strongly to gastric cancer that
we neglected to make a sufficiently careful examination of the abdomen
or to put well-directed questions concerning bowel movements, the
exact location of pain, and intestinal noise.

VOMITING 621

"Gastric neurosis" is the diagnosis on the record of another case
of causeless vomiting and diarrhea in an elderly woman, who was
promptly relieved in the hospital by a few days of diet and quiet
(1908). Dr. E. A. Codman insisted that intestinal cancer was present,
though no tumor was felt. The patient remained perfectly well for
several months, but Dr. Codman 's diagnosis was ultimately verified.

Diagnosis. Cancer of the sigmoid.

Case 323

A waitress of nineteen, born in Maryland, entered the hospital
January 14, 1907. She has a good family history and past history up
to eighteen months ago, when she began to lose strength and to have
dizzy spells, especially after breakfast. Her appetite continued good,
and she felt in other respects well until about two months ago, when she
began to have nausea, coming on about five minutes after eating, and
relieved at the end of about an hour by vomiting the food just taken,
together with considerable phlegm. She never vomits except after
breakfast, although she has considerable distress after the other
meals.

She has worked until a week ago, and still feels well enough when
her stomach is empty. She gets up once each night to pass water.
She has noticed a somewhat tender spot in the epigastrium. For three
months she has been somewhat pale and short of breath on exertion.

On examination the patient was found to be pale. There was a faint
systolic murmur in the pulmonary area; otherwise the chest is negative;
likewise the abdomen and urine.

The blood showed red cells, 4,012,000; white, 6800; hemoglobin,
55 per cent. Differential count normal; marked achromia; no other
changes.

Discussion. "We may rule out without further consideration the
long list of organic diseases, such as cancer, tuberculosis, and brain
tumor, of which vomiting is a symptom. The first point to be noticed
on the positive side is that nausea of this type, though not of this dura-
tion, is often seen in the early months of pregnancy a possibility which
should never be forgotten when we are dealing with obstinate digestive
disturbances. 1 once saw a patient who had been for sonic weeks
under the care of a distinguished specialist in gastric troubles, whose
treatment made it evident that he had never considered the possibility
of pregnancy, though the patient had, during the period of his treatment,
an amenorrhea and all the other usual evidences of earl} pregnancy.
When I saw her the condition was cjuite obvious.

622 DIFFERENTIAL DIAGNOSIS

Nothing is said about menstruation in this case, but inquiry showed
that it had been absent for the past three months. This fact, together
with the stomach trouble and a certain degree of bad conscience, had
considerably alarmed the patient. It was found on examination, how-
ever, that there was no uterine enlargement and none of the other
evidences of early pregnancy.

Many cases like this turn out on careful study to be the result of
the disturbances produced by constipation. There was nothing in the
history, however, to indicate that she was constipated. The testimony
of a patient is not always reliable on this point. Fecal movements
mav occur daily, and yet be so insufficient in amount that a considerable
accumulation takes place. One has no right to assume this unless
physical examination or the inspection of the stools demonstrates it.

Some eager surgeons would consider the evidence here presented
as sufficient for a diagnosis of peptic ulcer or chronic appendicitis, but
there is not the relief by food so characteristic of the earlier stages of
peptic ulcer, while the symptoms are too continuous and include too little
suffering from pain to give us any genuine indication of chronic appen-
dicitis.

But for the abnormalities of the blood-picture one would here be
forced to say that physical examination is negative, a conclusion which
lies very near to the decision: gastric neurosis. Is that slight anomaly
in the hemoglobin percentage and in the stained smear sufficient
to account for so much gastric disturbance? Yes, it certainly is, if
we take it as the outward and visible sign of a more extensive and
less comprehended malady, to which w r e give the superficial and un-
satisfactory name of chlorosis. Experience has often shown that
chlorosis may produce vomiting as severe as that complained of by this
girl, and in the absence of any other obvious cause one should plan
treatment upon this hypothesis.

Outcome. The patient was put to bed and given f grain calomel
every fifteen minutes for eight doses, followed the next morning by i
ounce of magnesium sulphate. Liquid and soft solid diet, with nux
and gentian before meals, was perfectly well borne. The patient
had no vomiting, no gastric symptoms of any kind, and by the twenty-
third was up and had an excellent appetite, although her blood showed
no gain whatever.

On the tenth of February the patient went home much stronger
and better, although her hemoglobin was only 70 per cent.

Diagnosis. Chlorosis.

VOMITING 623

Case 324

An unoccupied Irish girl of nineteen, of good family and past his-
tory, entered the hospital June 7, 1908. Five weeks ago she began
to have abdominal pain and frequent vomiting. The pain was colickv
and not localized. It seemed to have no relation to food, and had only
occurred three or four times in the past rive weeks, lasting an hour
or two. Yet since the pain ceased she has continued to vomit almost
daily whether she eats or not. Yesterday she vomited five times, though
she took only milk. The vomitus sometimes consists of undigested
food, sometimes of a yellowish or blackish sour fluid. It has never
been red or brown. The vomiting seems to have no relation to the
time or the character of food. The catamenia are regular.

The appetite remains fair, the bowels constipated, moving ever}'
day or two by enemata only.

On examination the patient is obese, ruddy. There is slight general
tenderness over the lower abdomen, with some voluntary spasm, pre-
venting satisfactory palpation.

Physical examination, including the temperature, pulse, respira-
tion, blood, urine, and stools, was not otherwise remarkable, though
the stools were found to contain many bismuth crystals.

Discussion. A diagnosis seems to me impossible here without a
therapeutic test. We should first get the bowels started and watch
to see if that does not check all the other symptoms. Suppose, then,
that the vomiting still continues, and we are still unable to find any
physical cause for it despite our most painstaking examination of the
internal viscera and despite the absence of any discoverable cause,
such as morphin, malaria, or starvation, what course should be pursued?

It is almost inevitable to assume that the case must represent some
type of neurosis and to plan treatment accordingly, yet this is never
a satisfactory basis of action unless we can obtain other evidence of
neurotic constitution besides the vomiting itself. 1 was great]}- im-
pressed, a few months ago, by the outcome of a case in which, owing
to the negative results of repeated and searching examinations, we
made the diagnosis of gastric neurosis and used a great deal of moral
suasion. Yet the man proceeded to die, and the autopsy (No. 2^14,
Massachusetts General Hospital autopsy records) showed absolutely
no cause for death. 1 do not believe for a moment that our diagnosis
was right here, yet it would be difficult to avoid making the same
mistake again.

In the present case we acted on the principle that it is always wise

624

DIFFERENTIAL DIAGNOSIS

to remove any possible cause for the patient's symptoms before com-
mitting ourselves absolutely to any diagnosis. The result is shown
by the outcome.

Outcome. As soon as the bowels were thoroughly evacuated by
cascara, olive oil, i ounce twice a day, and enemata, vomiting ceased;
and within a week the patient was eating ravenously without any dis-
tress or nausea. The bowels continued to be very sluggish. She was
advised to eat a great deal of green vegetables and as much fat as she
could tolerate.

Diagnosis. Constipation (neurosis ?).

Case 325

A housewife of thirty-eight, of good family history, was first seen
April 21, 1908. She had pleurisy six years ago and a still-born child a
year ago, since when she has been nervous and troubled with indiges-
tion. For three weeks she has had a great deal of indigestion, accom-
panied by "smothering feelings around the
heart." For ten days she has vomited
everything taken into the stomach, averag-
ing ten attacks in twenty-four hours. Even
water is rejected. She has sometimes vomited
as much as a quart of undigested food and
once about a teaspoonful of bright blood
which her physician said came from her
throat. Her indigestion and smothering feel-
ings are worse after eating and are relieved
by vomiting. She is very constipated and
belches much gas. During these three weeks
there has been palpitation of the heart. At
the beginning of this spell, ten days ago, she
also had numbness of the right leg and left
arm for two days.

When sixteen years old she had swollen
glands in the neck, which discharged for
about two years.

The patient is obese, the right pupil slightly larger than the left,
both reacting normally. There are four small irregular scars on the
left side of the neck.

The heart's apex is in the fifth space, \ inch outside the midclavicular
line. The sounds are normal. There are no murmurs. The lungs

Fig. 168. Chart cf case

3 2 5-

VOMITING 625

and abdomen are normal; reflexes are normal. The stools give no
reaction to guaiac.

(For temperature see Fig. 168.)

Discussion. An essential element in diagnosis is here omitted:
we have no account of the urine or of the blood- pressure, although
there is apparently a slight cardiac enlargement which might suggest
a chronic nephritis as the cause of the vomiting. This hypothesis,
however, was at once upset by the negative result of urinalysis.

Gastro-intestinal troubles of the type here recorded are not infre-
quently the first and most obscure manifestations of a tuberculous infec-
tion. It is very probable that she suffered from a cervical adenitis,
tuberculous in origin, when she was sixteen. The history of a dis-
charge from swollen neck glands and especially the duration of the
discharge, together with the present evidence of scars in the neck, leaves
no considerable reason for doubt upon this point. If she is correct in
supposing that she had pleurisy eight years ago, the probability of
tuberculosis still lingering somewhere in the system is still further in-
creased.

I do not think it is possible absolutely to exclude tuberculosis as the
cause of symptoms in this case, and I am aware that some persons
would consider the variations in temperature shown in the accompany-
ing chart as sufficient to constitute additional evidence favoring tuber-
culosis. On the whole, however, it seems to me that the evidence is
insufficient. A very large number of patients, demonstrably not tuber-
culous, have as much temperature as this chart shows owing to any of
a variety of causes. Repeated examinations of the lungs and other
viscera revealed absolutely nothing. The patient's nutrition was
excellent. I very much doubt whether she had any more tuberculosis
than the rest of us i. e., whether it was present in any active form or was
responsible for any of her symptoms.

The still-born child and the irregular pupils compel us to consider
for a moment the question of syphilis, but neither on questioning nor
by examining the sites at which syphilis most often leaves evidences
of itself could we find any reason further to entertain this suspicion.

The patient presented many neurotic characteristics not easily
to be described. Whether these were the cause of the constipation
or its results I cannot say; the question seems to me usually unanswera-
ble in such cases. The sensible thing to do, however, is to attack the
symptom-complex at anv and all of its vulnerable points. Let us begin
with the constipation.

Outcome. The patient was given a high oil enema. 6 ounces,
to

626 DIFFERENTIAL DIAGNOSIS

followed by a suds enema. Her gastric distress was relieved by J dram
of essence of peppermint. She was given fluid extract of cascara and
the enemata continued daily. Under this treatment the patient was
able to take liquid and soft solid diet and by the twenty-fifth could eat
anything with relish.

By the twenty -ninth all symptoms had disappeared, although the
patient still felt somewhat weak.

Diagnosis. Constipation (neurosis ?).

Case 326

A Canadian bolt-maker twenty-seven years old entered the hospital
October 14, 1907. He lost one sister of consumption some years ago.
His mother now suffers from "asthma"; otherwise his family history
is good, and he himself has always been well, save that for the past five
years he has hawked up a good deal of yellow material from his throat.
He smokes and chews five cents' worth of tobacco a day. His habits
are otherwise good.

Eight days ago, while at work and in his usual health, he became
nauseated and vomited, the vomitus consisting of the food last eaten.
He kept at work that day but felt weak and has not tried to work since
then. The first night he felt feverish, but he has not noticed this since
that time. The nausea and vomiting, however, have continued and
have been especially troublesome in the morning. He has no severe
pain, but a slight soreness in the epigastrium, rather more to the right
than to the left, ascribed by him to retching. There has been no chill
and no cough. His bowels have been rather loose for the last two days.
He has not been jaundiced.

On examination the temperature, pulse, respiration, and blood are
all normal. The urine shows a very slight trace of bile, and on careful
examination of the eyes a slight yellowing of the conjunctivas over the
peripheral portion of the eyeball is discerned. Near the iris there is no
yellowness.

The tonsils are slightly enlarged and reddened. The heart and lungs
show nothing abnormal. The abdomen is slightly rigid just below
the right costal margin and there is some tenderness at that point. No
soreness or spasm is felt elsewhere. The liver dulness extends one or
two fingerbreadths below the costal margin, but no liver-edge can be
felt.

Discussion. The presenting symptoms are vomiting and bile
in the urine. Whether we shall call the condition jaundice depends
upon our definition of this word. In all the more marked cases in

VOMITING 627

which the conjunctiva is stained by bile-pigment, the discoloration
extends not only over the deeper and less easily visible portions of the
sclera, but up to the outer border of the iris. In milder cases there is
a ring of white or bluish-white, unstained sclera around the iris. But
if the yellow coloration outside this ring is well marked, we do not
ordinarily hesitate to call it jaundice. The doubtful cases are those
in which it is only by drawing back the eyelids and by getting the patient
to turn the eye as far as possible to one side that any yellow coloration
can be seen. In most of these cases the tint is, moreover, a very pale
one. Our hesitation is further increased because we find so many
cases of this type, if once our curiosity is aroused to look for them. Never-
theless, it seems to me that the only defensible course is to use the word
jaundice whenever any degree of yellow discoloration is visible in the
sclera.

Proceeding on this basis we may say that the case under considera-
tion is characterized by vomiting and jaundice occurring without other
notable symptoms in a workingman of twenty-seven. Gall-stones
are unusual at this age, and we have no tenderness or palpable mass
in the region of the gall-bladder, no evidence of hepatic enlargement,
and no characteristic biliary colic. Nothing, indeed, suggests any
local trouble except the slight rigidity below the right costal margin,
and we have no fever or other constitutional manifestation of infection
in the biliary tract.

Under these conditions i. c, when jaundice occurs without any
obvious cause, without any marked toxemia or other evidence of infec-
tion, without any change in the shape or the size of the liver, and
without any evidence of gall-stones it has long been customary to make
a diagnosis of catarrhal jaundice. That the condition so named often
gives rise to very persistent nausea with or without vomiting is a familiar
fact. Therefore, although we do not know what we mean by the term
"catarrhal jaundice" in the sense of understanding its pathology, it
is reasonable to use the term in a case of this kind, at any rate as long
as nothing more serious appears in sight. If the jaundice does not go
off within six weeks, we begin to fear that something more important
is behind it viz., gall-stones or cancer. During those six weeks,
therefore, our diagnosis always rests on shaky foundations; indeed,
it is never confirmed until the patient is well.

Since examination has revealed no sufficient reason to fear that the
vomiting in this case results from any deeper and more obscure lesion
of the gastro-intcstinal tract, kidney, heart, or brain, catarrhal jaundice
seems to be our best working-and-talking hypothesis.

6 2 8 DIFFERENTIAL DIAGNOSIS

Outcome. The patient was given a diet in which carbohydrates
and fat were considerably restricted; calomel, \ grain every fifteen
minutes until ten doses were taken, followed in half an hour by \ ounce
artificial Carlsbad salts, and each morning thereafter by 30 grains
of sodium phosphate and an enema of plain water made 5 degrees
cooler each day up to the limit of tolerance. On the second day he
was given dilute muriatic acid 5 minims, with 1 dram of fluid extract
of taraxacum after each meal.

By the twenty-fourth the jaundice and other symptoms had practically
disappeared.

Diagnosis. Catarrhal jaundice.

Case 327

A sewing woman of thirty-six entered the hospital January 6, 1908.
She had lost one sister of consumption seven years ago. Her family
history is otherwise good. The patient has always been strong and
well and was in comfortable circumstances until the time of the San
Francisco earthquake in April, 1907, when she lost everything. In the
past year, though working very hard at sewing, she has been unable
to earn enough to give herself proper food and lodging. Her men-
struation has always been regular until recently, but its last appearance
was two months ago.

For the past four months she has been very much run down and so
nervous that she has not been able to work, though she has not been
constantly in bed for any length of time. She was in a hospital during
the whole of July and August, and was somewhat better after her stay
there, but not able to work.

Up to two weeks ago she had no symptoms except weakness and
an occasional headache. Two weeks ago she began to vomit and has
continued to do so very frequently every day since, rejecting all that
she eats and considerable yellow and whitish material besides. She
has seen no blood in the vomitus at anv time. Her abdomen is sore
all over, but there is no pain anywhere. Since the vomiting began
the bowels have moved once in two or three days. She has no head-
ache. Her eye-sight is good. She has taken only cereals, milk, and
water for the past two weeks.

There is a faint tremor of the lips and hands; well-marked arterial
pulsation in the neck. The aortic second sound is accentuated. There
is considerable pigmentation of the abdominal wall about the navel.
The urine shows a strong reaction for acetone and diacetic acid; the
amount averages 30 ounces in twenty-four hours; specific gravity,

VOMITING

629

from 1014 to 1017, with the slightest possible trace of albumin, a few
hyaline casts and a trace of sugar, later estimated to be 0.69 per cent.

Visceral examination, including the pelvis, is otherwise negative.
The blood shows nothing abnormal.

Discussion. As we review the results of physical examination, the
first point worthy of note is the tremor of the lips and hands and the
violent arterial pulsation in the neck. In women of this age such hints
should always lead us to examine the eyes for slight degrees of exoph-
thalmos, to scrutinize the neck for unobserved goiter, and to count the
pulse under various conditions all with reference to a possible Graves'
disease (hyperthyroidism) in larval form. Such a search was here
undertaken, but was fruitless.

The urine contains sugar and acetone bodies. Is it possible that
we are dealing with a diabetes, and that the vomiting is due to that
disease? Against it we may range the following evidence:

(a) The cardinal symptoms of diabetes thirst, polyphagia, poly-
uria, and emaciation are absent.

(b) The amount of sugar in the urine is very small, although the diet
has not been in any way restricted.

(c) Severe constitutional manifestations such as vomiting and head-
ache appear in diabetes late in the course of the disease, after the car-
dinal symptoms have been manifested for a considerable period.

(d) Acetonuria is very common as a result of severe and prolonged
vomiting from any cause.

(e) A slight glycosuria such as that here present is not at all
uncommon in persons of a nervous temperament and under any unusual
psychic strain.

There seems, therefore, no sufficient reason to treat this patient as
a diabetic. But if we are to disregard the acetonuria, the glycosuria,
and the tremor and find no reason for supposing them to point to any
organic disease which might account for the vomiting, there seems
to be nothing left but that old and much-overworked hypothesis
neurosis. This is made a little more plausible than ordinary in the
present case because the patient's circumstances, the nature of her work,
and the tragedy through which she passed nine months before are
such as to favor the development of a nervous breakdown. There seems,
on the whole, to be no better basis for work and talk.

Outcome. The patient was given a diet of milk, one third lime-
watery ounces every two hours. The bowels were moved by enema ta.
Within twenty-four hours she was so much improved that she could
take an ordinary mixed diet. Trembling and nervousness markedlv

63O DIFFERENTIAL DIAGNOSIS

lessened; acetone, diacetic acid, and sugar disappeared within three
days on full diet. She was somewhat sleepless, but was helped by 15
grains of trional for two nights, after which she slept fairly well without
any hypnotic.

On the eleventh the patient was allowed to sit up in bed. On the
fifteenth she tried to walk, but was very dizzy and weak. On the
twentieth she was able to walk, and thereafter gained rapidly.

Diagnosis. Exhaustion.

Case 328

A musician of fifty entered the hospital August 4, 1906. The family
history and past history are good. He denies alcohol and venereal
disease.

A week ago, without known cause, he was suddenly seized with
colicky epigastric pain, nausea, and vomiting. Since that time he
has vomited everything that he has eaten. There has been soreness,
but no marked abdominal pain, and no blood in the vomitus.

He gave up work five days ago. This morning he began to hiccup
and has continued for the past two hours. He has never had a similar
attack. His general health has been good. During the first four days
of this attack he had diarrhea.

On examination the patient is thin and wiry. His pupils are slightly
irregular and react sluggishly. There is no lead-line. The glands
in the neck, axilias, and groins are palpable, but not enlarged.

The chest and abdomen show nothing abnormal, although there
is same tenderness in the lower portion of the abdomen and the sharp
edge of the liver is palpable on deep inspiration.

The knee-jerks are lively, the fundus oculi negative, likewise the
blood and urine. Within a couple of days the pain was gone, the
patient very hungry, yet he vomited when solid food was given to him.

Discussion. At this man's age the sudden occurrence of vomiting
makes us think first of all of cerebral or cardiorenal disease, but we
find no confirmation of this idea in the results of objective investigation.

Gall-stones is a possibility to be reckoned with, but on that hy-
pothesis it is hard to explain why the vomiting should have continued
for a week after the pain has ceased. The same difficulty confronts
us if we try to reason that chronic appendicitis or nephrolithiasis may
have produced the pain. For peptic ulcer in the stage of perforation
the local manifestations are not sufficiently acute and definite; for any
other stage in the course of this disease the symptoms are too violent
and the vomiting too continuous.

VOMITING 631

I mention the phrase "ptomain poisoning" because I have so fre-
quently heard it used in cases of this kind, as well as in perforative
appendicitis, intestinal obstruction, and other acute abdominal emergen-
cies. The phrase seems to be a favorite "blind" behind which our
ignorance or error may be concealed. I have never yet known a single
case in which the diagnosis was justified by any sufficient chemical
examination either of the food supposed to be responsible for the trouble
or of the contents of the gastro-intestinal tract.

The patient has not been constipated, exhausted, or neurotic; he
is not at all of the type that vomits for lack of any other occupation.
We may be forced to make the unsatisfactory diagnosis of gastroneurosis,
but not until all other possibilities are exhausted.

Tabes dorsalis with gastric crisis was at first seriously considered,
but our seriousness was disturbed by the liveliness of the knee-jerks.
This symptom being out of agreement with our diagnosis, there appeared
to be nothing but the sluggish light reaction of the pupils on which to
base the diagnosis of tabes. There were no lightning pains, anomalies
of sensation, or sphincteric disturbances. Several confirmatory points
had, however, been overlooked, as was shown by the outcome.

Outcome. It was subsequently discovered that the Achilles jerk
was absent. The Wassermann reaction was positive, and the spinal
fluid showed an excess of lymphocytes.

The vomiting persisted, though less frequently, until the fifth of
September. After that it ceased and convalescence was rapid. Re-
peated examinations of the urine were negative. No treatment that was
given seemed to help him.

Diagnosis. Tabes with gastric crisis.

Case 329

An Irish laborer of forty-three, of good family history, entered
the hospital November 15, 1907. He has had no disease of im-
portance, though he has been in several dynamite explosions and
sustained various wounds and burns. Within the last eight years
he has taken no alcohol, and before that never drank to excess. He
denies venereal disease.

Since the last explosion in which he was involved ten months ago
he has vomited once or twice almost every day, generally in the morning
before breakfast. The vomitus consists of greenish mucus; it some-
times contains food eaten many hours before. He has seen no Mood.
His bowels are rather loose, moving three to seven times a day. He
has no pain, a fair appetite, and he has kept at work until seventeen

632 DIFFERENTIAL DIAGNOSIS

days ago, when the vomiting became almost incessant and he had to
give up.

On examination the temperature, pulse, respiration, blood, and urine
are normal.

The patient is obese, shows many powder-marks about his right
eye and some scars in the cornea of both eyes, which he says are due to
the old explosion.

Examination of the nervous system and internal viscera is through-
out negative. No contents could be obtained by the stomach-tube
from the fasting stomach, which held only 26 ounces without distress.
After a test-meal the gastric contents showed free HC1, 0.128 per cent.

Discussion. Is it wise to believe the patient's story on the subject
of alcoholic indulgence? Is it not more probable that the patient's
vomiting is due to the cause usually discoverable in such cases? How-
ever this may be, it should be noted that vomiting continued in the
hospital after the alcohol had been withdrawn. Moreover, his family
and friends confirmed his account of his habits.

I have never known concealed morphinism in a man of this type.
Nevertheless, it is always a possibility to be reckoned with in case of
unexplained vomiting, especially if there are wide-spread pains, insomnia,
and great restlessness associated with it.

A point of special importance is the patient's obesity, which proves
pretty conclusively either that his vomiting has occurred on an empty
stomach independent of food, or that he has not ejected the whole of
many meals. Many a patient fails to take account of the difference
between emptying the stomach and merely spilling over, as a baby does,
the excess of what has been eaten. This explains the astonishing dis-
crepancy often confronting us between the patient's account "I have
vomited every meal I have taken for weeks" and the excellent strength
and nutrition of his tissues, and spares us the necessity of assuming that
he is lying or consciously exaggerating.

As we go over the case afresh after a fruitless search for organic
lesions, we note that his vomiting followed immediately upon a dynamite
explosion. Further inquiry may perhaps show that deep impressions
made at that time may be connected with the habit and practice of
vomiting that, in other words, we may be dealing with a traumatic
neurosis. This must not be assumed without a careful study of the
patient's mental attitude, as it is apt to be revealed on close questioning
about the accident and what has happened since. It would seem strange
that a man who has been through several explosions should lose his
nerve for the first time in the last one. Only further inquiry and experi-

VOMITING

&33

ment can decide. Such an inquiry, though in rather an abbreviated
form, was undertaken.

Outcome. After some preliminary questioning, the house officer
gave the patient a long explanation of the theory and practice of trau-
matic neuroses, explaining the supposedly nervous origin, structure, and
development of the trouble. The patient accepted everything that was
told him as absolute truth, and began at once to eat and to smoke without
any discomfort or vomiting. After four days of entire freedom from
symptoms he was discharged well.

Diagnosis. Traumatic neurosis.

Case 330

A married woman of fifty-one entered the hospital July 15, 1908.
Her family history is good, and she has always been well, although
she has been subject to belching and nausea for many years. "The
amount of gas that forms in
my stomach is beyond belief,"
she says. She has taken three
cups of coffee and four of tea
daily. She passes water two or
three times at night. Catamenia
ceased fourteen years ago.

During the past winter and
spring she was having, as usual,
a good deal of trouble with gas
and distention of the stomach,
especially at night. Toward the
end of May she had an attack
of "bloating" somewhat severer
than the previous ones, accom-
panied by epigastric pain and by
vomiting of a sour fluid. At
this time she was put on a milk Fi - * 6 9--Char. of case 32 o.

diet and stayed in bed. Seven weeks ago she was put on rectal feeding,
and this was continued in the Hale Hospital at Haverhill for the last
four weeks. She has gradually vomited more and frequently, no matter
what she eats or drinks, even in the absence of all food by mouth. She
has always been allowed to take water by mouth. At the present time
her vomitus is green and bitter. About three weeks ago she noticed
about a teaspoonful of bright blood in the vomitus. Even morphin,
which has been given in considerable quantities for the last week, has

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634 DIFFERENTIAL DIAGNOSIS

not sufficed to control vomiting. She continues to have gnawing pain
in the epigastrium, running up the sternum to the throat.

On examination, the temperature is 101 F., the pulse 88, respira-
tion 24. The patient is obese; the pupils small, but reacting normally.
Her lungs and other internal viscera show nothing abnormal. The
blood is negative, likewise the urine, except for the presence of a small
amount of acetone and diacetic acid. The guaiac test in the stool and
vomitus is negative.

Discussion. In a patient who vomits with a temperature of 101 F.,
infectious disease is the first possibility to be investigated. I have
repeatedly seen a case which turned out to be pneumonia, but in which
constant nausea and vomiting were the only complaints for three days,
cough and signs of solidification being wholly absent. Less frequently
one sees the same prolonged nausea at the outset of typhoid or malaria,
and in children in almost any infection. Even if physical examination
is at first wholly negative, we should suspend judgment as long as
the temperature remains elevated, and continue to watch for the
development of some distinctive symptom betraying infection. Vomit-
ing itself does not produce fever.

Some type of organic gastric disease or some of the extragastric
lesions simulating it should next be looked for, although at present
there seems nothing definite enough on which to base a conjecture.

Leaving these possibilities for the present undecided, I wish to call
attention to two points of interest:

(a) That she has had morphin enough in the past week to prevent
her vomiting from ceasing if, by chance, it showed any tendency to do
so.

(b) That she is still obese and has, therefore, in all probability
retained and absorbed more food than her account would otherwise lead
us to suppose.

Since morphin may check pain or vomiting, many physicians are
slow to realize that when continued more than a few days it has a
tendency to produce in many persons both pain and vomiting.

The first move, therefore, should be to stop the morphin and study
the condition of the patient when free from its influence. The size and
functions of the stomach, the temperament and habits of the patient,
must be learned. Thus the diagnosis may be more definitely outlined.
But as a working hypothesis I think we have already evidence enough
to justify us in following the clue given by her account of her own flatu-
lence. A history of this kind usually points to a habit neurosis dependent
upon cribbing.

VOMITING 635

Outcome. The patient was found to be swallowing air constantly.
She was given at once a liberal diet of liquids and soft solids, with a
bitter tonic before meals, fluid extract of cascara for her bowels,
and Hoffmann's anodyne, a dram at night, if needed, for gas and
distress.

In the four days following her entrance to the hospital the patient
vomited only once.

Examination with the tube showed no fasting contents, no enlarge-
ment of the stomach, and after a test-meal, free HC1, 0.12. The patient
was kept for some time in the hospital on account of the slight fever,
which continued for something over two weeks, but in every other way
she seemed entirely well, and regained her confidence before the twenty-
fifth of July, when she was allowed to go home. The cause of fever
was not found.

Diagnosis. Gastric neurosis.

Case 331

A single woman of thirty, formerly a buyer for a dry-goods house,
entered the hospital March 1, 1907. Four years ago she weighed 125
pounds and was strong and vigorous. She then began to have frequent
stomachaches and much doctoring, both of which have continued and
got worse each year. She had an osteopath for two years, with consider-
able relief to her stomach symptoms.

For the last year vomiting has been her chief symptom. It has no
relation to the quality, quantity, or time of food. Some days she can
eat and retain her meals. Other days even a mouthful makes her
vomit.

Three weeks ago she was operated on for a floating kidney. Since
then she has vomited everything. She is convinced that the operation
was unnecessary and harmed her stomach. She is hungry and sleeps
well, but is very weak and weighs only 67 pounds.

On examination the patient is much emaciated and nervous, but not
despondent. The glands in the neck, axilla?, and groins are slightly
enlarged; the heart-sounds weak and valvular; a systolic whiff is
closely confined to the apex region; no enlargement; the pulmonary
second sound is slightly louder than the aortic second sound.

The blood-pressure is 95 mm. Hg. Occasional rales are heard
over the large bronchi. The lungs are otherwise negative.

The aorta and the iliac arteries are easily palpable, but the abdomen
shows nothing abnormal. Hemoglobin. 75 per cent., white cells, 5200.
Temperature, pulse, respiration, and urine, normal.

6 3 6

DIFFERENTIAL DIAGNOSIS

The stomach-tube showed the gastric capacity to be 46 ounces.
The outlines of the inflated stomach were as shown in the accompanying
diagram (Fig. 171). There was food in the fasting stomach. HC1 was
absent both in the fasting contents and after a test-meal. There was
no reaction to guaiac in the stools or gastric contents.

Discussion. Though there is nothing in the physical signs to
suggest tuberculosis, one must always search with extra care for evi-
dences of this disease when a patient is so emaciated and presents such
marked gastric symptoms at the age of thirty. The low blood-pressure
also points in the same direction, but in the entire absence of fever, and
without more definite physical signs in the lungs,
abdomen, bones, or glands, we cannot take another
step.

Cancer of the stomach is very rare at this age,
yet the emaciation, the evidences of gastric stasis,
and the absence of hydrochloric acid compel us
to give it consideration. As bearing on this ques-
tion it is of importance to note that the symptoms
are of long duration and gradual onset very un-
usually so for gastric cancer. The good appetite
is another point against cancer, likewise the absence
of blood in the stomach-contents and in the stools.
The patient is so thin that we should expect to feel
a tumor if any were present, especially as the disease
has lasted so long. On the whole, it seems well to
adopt some other working hypothesis.

The position of the upper gastric border of
the stomach proves that we are dealing with gas-
troptosis as well as gastrectasis, and makes it
quite possible that the enlargement may be due wholly to the dropping.
Whether any " benign " form of stenosis is present at the pylorus can be
determined only by palpation, and by the results of our efforts at induc-
ing the stomach to empty itself more thoroughly. Even in a warm
bath and with the most perfect relaxation of the abdominal walls, no
induration could be felt in the region of the pylorus, which was unusually
accessible to the hand, owing to the low position of the whole organ
(afterward demonstrated by bismuth and x-ray picture).

As a result of these investigations and of a good many studies of the
patient's mental state it seemed clear that we were dealing with a vicious
circle. The patient's fruitless regrets and fulminations about the
apparently useless operation doubtless helped to aggravate, and were

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170. Chart
case 331.

Fig. 171. Shows percussion outlines (also visible) after inflation of the stomach in

Case 331.

VOMITING 637

in turn aggravated by, the stasis in her prolapsed stomach. Such a
vicious circle usually has some point of least resistance either on the
physical or the mental side. We break it by striking at that point,
ascertained by experiment or as a result of previous knowledge of
similar cases. In the present case it seemed well to attack first the
gastric stasis, and, by conquering that, to improve the general nutrition,
thereby mitigating the mental fermentation. Other cases may be best
attacked from the mental side.

It may be well to say a word in passing of the dangers of under-
taking any operation in such a patient except in genuine emergencies.
I may here refer to the interesting and suggestive article of Dr. Stuart
McGuire on "Latent and Active Neurasthenia in its Relation to Sur-
gery," Jour. Amer. Med. Assoc, March 26, 1910. As the result of a
slight orthopedic or cosmetic operation done at an unfavorable time
in a neurasthenic patient, I have seen acute and intractable exacerba-
tion of all the patient's previous troubles reinforced by a host of new
ones which tortured the patient and his friends for a year thereafter.
The present case was a comparatively mild one of this type, but I have
no doubt that the operation made her far worse than she was before,
whether the kidney remained in place or not.

Outcome. Under daily gastric lavage, liquid and soft solid diet
for the first two days, and then six meals with dry diet, 15 drops of
dilute hydrochloric acid after each meal, and the same amount of tincture
of nux vomica before meals, the patient steadily improved.

The food residue in the fasting stomach had diminished by March
19th from 10 ounces to 3 ounces. The patient was much less nervous,
up and about the ward daily. On the twenty-third she weighed 79
pounds and was very markedly improved.

Diagnosis. Neurosis ; gastroptosis.

Case 332

An Irish teamster of forty-six, of good family history, entered the
hospital February 21, 1908. He has had attacks of stomach trouble
like the present one on and off for ten years; nevertheless he has kept
at work practically all the time, has smoked 35 cents' worth of tobacco
a week, and averaged one whisky a day. He denies venereal disease.

All through the summer and autumn his stomach was in bad condition.
but for the past four weeks he has been having an increasing amount 01
distress. He vomits almost daily, often four or the times a day, and
usually in large amounts two or three pints at a time. His vomitus
consists of food, at times mixed with brownish material. Sometime- he

6 3 8

DIFFERENTIAL DIAGNOSIS

has seen in the vomitus food eaten forty-eight hours before. There
has been no blood recognized as such.

He has also epigastric pain, which radiates to the back and abdomen,
severe, but always relieved by vomiting. Neither pain nor vomiting
bears any relation to meals, so far as he knows. His appetite is excel-
lent. He eats everything, as he finds that he vomits as much on a milk
diet as when eating solid food. He insists especially that he is all right if
he " keeps quiet," but that he finds it hard to get along if he tries to
work. Nevertheless, he has worked up to February 20th. His average
weight is 135 pounds. Now he weighs 105, though
he does not think that he has lost much weight of
late.

He has no symptoms except those above mentioned.
On examination the patient is emaciated, with a
dry, somewhat pale skin; the cervical, axillary, and
inguinal glands are slightly enlarged. The pupils are
normal in all respects. The tongue is clean. The
arteries are palpable and tortuous. The brachials
show a lateral excursion.

Physical examination is otherwise negative, except
for slight rigidity of the right rectus abdominalis.

White cells, 15,400; hemoglobin, 85 per cent.;
urine negative; temperature as seen in the accom-
panying chart.

Examination by means of the stomach-tube showed
that the stomach held 60 ounces, though its lower
border reached only to the level of the navel after infla-
tion, and no fasting contents were obtained. After an
Ewald test-meal the contents showed free HC1, 0.266 per cent.; total
acidity, 0.348; no reaction to guaiac. On examination in a warm bath
a hard, irregular mass the size of a plum was felt in the right upper
quadrant of the abdomen. It was very movable, but not tender. It
could be grasped in the fingers and moved freely from a point below
the umbilicus until it disappeared behind the ribs. It was not obliterated
by inflation of the stomach.

Discussion. We are dealing here with a case of long-standing
stomach trouble which leads, in the patient's forty-sixth year, to that type
of persistent vomiting which points to gastric stasis and dilatation. It
is to be noted that vomiting relieves pain and is associated with a good
appetite, a clean tongue, and a high gastric acidity. The presence cf a

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Fig. 172. Chart
of case 332.

VOMITING 639

very movable intra-abdominal tumor is the chief remaining point of
importance.

- Tumors of extreme mobility, as to whose nature any doubt is enter-
tained, almost always turn out to be connected with the pylorus. Float-
ing kidney is usually recognized with ease if its mobility is extreme, and
there are no other tumors of this type. Those connected with the gall-
bladder may have considerable mobility, but their other characteristics
usually serve to distinguish them.

Tumors at the pylorus result either from cancer or ulcer. Against
cancer in this case is the long duration of symptoms, the retention of
appetite, the high acidity, and especially the marked relation to exer-
tion; but as we know that cancer may become ingrafted upon ulcer,
it does not seem possible to be any surer of our diagnosis without lapa-
rotomy. On the whole, though, the evidence points very strongly toward
ulcer.

Outcome. On the twenty-eighth the abdomen was opened. An
area of induration, with glandular enlargement in the neighborhood,
was found near the pylorus.

Pylorectomy and gastroenterostomy was done, about 10 cm. of the
lower end of the stomach being removed. In this operation there were
two ulcers, one about 4 cm. above the pylorus, 1.5 cm. in diameter,
with sharply punched-out edges and deep excavations. Its base was
firm and gristly, but consisted only of chronic inflammatory tissue.
Another ulcer about 2 cm. in diameter, with a similar gristly wall, is just
above the pyloric ring.

The patient left the hospital on the twenty-eighth of March, seemingly
quite well.

On the fifth of April, 1909, the patient reported that he was in good
health and working regularly. He has no gastric distress, but has to
eat five times a day in small amounts. He has gained markedly in
weight and strength.

Diagnosis. Gastric ulcer; pyloric stenosis.

Case 333

A barber, thirty-seven years old, whose father died of Bright's
disease, was first seen June 19, 1907, complaining of vomiting spells
which began when he was sixteen years old and have continued about
twice a year ever since, though less frequent in the last ten years. He
feels a "lump like lead" in the epigastrium all the time at present,
and cannot remember when he did not feel it. All food distresses
him about equally. His appetite is good, and he eats slowly and at

640

DIFFERENTIAL DIAGNOSIS

regular intervals. The bowels are always constipated unless he takes
laxatives.

Ten days ago he began to vomit without known cause, and has
since then rejected everything except malted milk. The vomitus is
chiefly phlegm in small amounts. During these ten days he has per-
spired during the earlier part of the night, and felt very cold the rest
of the night. His sleep has been dull and heavy. He thinks he has
lost weight. He has been able to do no work for this same period.

The course of the temperature is seen in the
accompanying chart.

The patient is well nourished, slightly pale,
shows some concretions of blood in the nose.
Heart and lungs are negative, likewise the ab-
domen and the urine. The blood shows 4000
white cells and 60 per cent, of hemoglobin.

Discussion. Our first impression of this case
would be that it is one of chronic indigestion of
unknown cause (gastric neurosis, chronic ulcer,
chronic appendicitis), with an acute exacerbation
perhaps due to constipation or some temporary
nervous disturbance. But for the negative ex-
amination of the urine and the absence of head-
ache, one might suspect chronic Bright's disease
or cerebral tumor, both of which I have known to
show themselves in this way in a patient with a
similar history, reaching back indefinitely into boy-
hood.

One feature, however, arrests attention: In the present vomiting
spell, which seems to be a good deal worse than the rest, he has had
night-sweats. Although the daily chart (the temperature being taken
morning and evening) shows no fever, it does not cover the period during
which he was complaining of night-sweats, and as it was only taken
in the day-time, there may well have been a febrile rise at night since
his entrance to the hospital, as well as before. This indication should
lead us to search for evidences of tuberculosis or other infectious disease,
more especially as there is a considerable degree of anemia manifested
by the lowered hemoglobin percentage.

Such a lowering of the hemoglobin should always lead us to the study
of a stained specimen. To one well trained in routine blood work
the stained specimen would have made clear the diagnosis in this case,
yet as a matter of fact the blood has already been examined and nothing

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110

100 I

Z% -* 2

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-J

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Fig. 173. Chart of
case 333.

VOMITING 641

found to suggest what was wrong with the patient. A good example
of the importance of competent blood examination is thus furnished in
this case by the outcome.

Outcome. A large number of tertian parasites especially the
young, unpigmented ring forms were found in the stained blood-smear,
together with some large atypical lymphocytes exhibiting phagocytosis
of red cells. Had the blood been examined unstained, as is often done
in cases of suspected malaria, these parasites would probably not have
been recognized.

The patient was given 10 grains of quinin and the dose was repeated
an hour later. After this he received 5 grains every four hours until his
ears began to ring, then enough to keep them ringing for three days. In
two days his blood was free from parasites and his vomiting had ceased.

I may add a word here concerning other atypical forms of malaria
i. e., those which do not begin with the familiar tertian chill. Among
the malarial fevers of temperate climates, almost all of which are due
to the tertian organism, I have noted the following unusual clinical
types :

(a) A case beginning with violent maniacal delirium without other
distinguishable symptoms.

(b) Cases beginning with intense headache and stupor, closely
simulating the onset of meningitis. '

(d) A group of cases already referred to (see p. 140) which simulated
appendicitis, owing to the severe pain in the right iliac region or in the
epigastrium.

(e) Cases in which headache, sleepiness, or muscular weakness re-
curred every day or every other day at the same hour.

Tn estivo-autumnal malaria persistent diarrhea may be the only
striking symptom. A very large number of cases occurring in children
are mostly or altogether latent. 1

In all these atypical cases diagnosis is comparatively simple, pro-
vided we are led to make a careful examination of the stained blood-film;
without this, diagnosis may be impossible.

Diagnosis. Tertian malaria.

'See Craitf, " Latent Infections in Malaria," l>ein^ Part III, Chapter IV, of his book
on Malarial levers.

642

DIFFERENTIAL DIAGNOSIS

Case 334

A sewing woman of fifty-nine, always previously in good health,
entered the hospital June 7, 1906. She felt perfectly well in the morn-
ing, four days ago, and went to call upon a friend. While there she
was suddenly seized with nausea and vomited several times. She was
taken home, went to bed, but felt mean and nauseated all the next day.
She has not been able to work, and has been in bed practically all the
time since, vomiting a little each day. She feels " all gone " and weak, is
very drowsy and sleepy, and has had rather a severe headache since the
onset. The bowels are moved with medicine. She gets up once or twice
at night to urinate; she has a very slight dry cough.

The patient is obese; the pupils are equal and react normally. The
tongue is clean, the heart and arteries normal. There are a few crack-
ling rales in both backs, especially at the bases.

For temperature, see the accompanying
chart.

The abdomen and reflexes are normal.
The urine averages 40 ounces in twenty-
four hours, 102 1 in specific gravity; no albu-
min; many hyaline and fine granular casts.

Discussion. The very acute onset and
the association with headache and drowsiness
suggest some implication of the brain. Men-
ingitis or brain tumor sometimes show them-
selves for the first time in this way, but when
we follow out the tests indicated by these
hints, there seems to be nothing to confirm
them. Nephritis also might indirectly pro-
duce cerebral symptoms like these, and the
habit of nocturnal urination, together with
the abundance of tube-casts, gives some war-
rant to this idea. The other characteris-
tics of the urine, however, do not bear it
out. and as there is fever in the case, the presence of casts can be thus
accounted for. The evidence would be more complete upon this point
if we had an accurate measurement of the systolic blood-pressure.

Other diseases which often begin in this way are pneumonia and
the gastric crises of tabes dorsalis. Occasionally a paroxysm of vomit-
ing is the only manifestation of an attack of nephrolithiasis. None of
these clues, however, turned out fruitful when followed up in this case.

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334-

>i case

VOMITING

643

The correct diagnosis was actually suggested for the first time by
the temperature chart, which shows, as will be at once obvious, a tertian
fever. Such fever is by no means pathognomonic of malaria; I have
known it to occur in tuberculosis and in various types of sepsis. Never-
theless, it could hardly fail to remind us that malaria may begin
with nausea and vomiting and thus lead us to a careful blood ex-
amination.

Outcome. The day after entrance the patient had a chill, and par-
asites were looked for, but in vain. It was not until the third day
that the malarial parasites were discovered.

On the fourteenth the patient had a rise of temperature and vomited,
though she had been taking quinin, 5 grain every six hours, since the
eleventh. After that day, however, she had no more fever or vomiting.

Diagnosis. Malaria (tertian).

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Case 335

A school-boy of sixteen was first seen August 24, 1907. His family
history and past history are excellent. Last winter he entered high
school and worked very hard. This spring he
seemed tired out, and had headaches, sup-
posedly due to eye-strain.

Two weeks ago he began to vomit. For
four days he could retain no food, and for a
week more vomited each morning. The bowels,
meantime, were constipated, but the appetite
was good throughout. During these two weeks
he has frequently been chilly or feverish, his
hands and feet being cold. He has complained
of headache and pains in his back and legs,
with slight cough. Throughout he has been
very weak. For the past three days there has
been delirium.

When seen, the patient was in a muttering
delirium, with twitching of the face. He was
poorly nourished. The course of the tempera-
ture is seen in the accompanying chart. The
chest showed nothing abnormal. The abdomen
was fiat, rather tense, tympanitic throughout,

and apparently not tender. Reflexes were normal. There were no
rose-spots. There was incontinence of urine and feces, but the urine
showed nothing abnormal.

LHXl .LJLt

ra : 7& :

Fig.

175.- Chart
cast' 335.

644 DIFFERENTIAL DIAGNOSIS

White cells, 7000; hemoglobin, 80 per cent.; Widal reaction, entirely
negative.

The case was believed to be one of typhoid fever with meningeal
irritation.

Discussion. When a boy of sixteen is suddenly attacked by fever
and vomiting in the middle of summer, no exanthem or other obvious
cause being visible, malaria is one of the first diseases to be considered.
It was easily excluded, however, in this boy's case by blood examination.

Brain tumor, especially solitary tubercle of the cerebellum, some-
times begins in this way, and without an examination of the fundus one
can hardly exclude it with certainty. It would be unusual, however,
to find no hint tending to localize the trouble in any particular part of
the brain (vertigo, staggering gait, strabismus).

Typhoid fever was the diagnosis actually made in the early days of
this illness. The negative Widal reaction seemed to be of no great
significance, since this reaction is so often absent in the earlier stages
of typhoid. The early onset of delirium and the relaxation of the
sphincters were accounted for by meningeal irritation (meningismus) .
In all such cases, however, experience has taught me that it is wise to do
lumbar puncture. Several times I have known typhoid mistaken for
tuberculous meningitis and a hopeless prognosis given in consequence.
When the child got well and the diagnosis of typhoid became obvious,
the family were not pleased with the prognosis previously given by the
medical attendant. In the present case the opposite mistake was made,
and a falsely hopeful prognosis was given.

Outcome. On the twenty-seventh his neck was found to be stiff.
Lumbar puncture showed 10 c.c. of clear, colorless fluid, the sediment
of which showed 95 per cent, lymphocytes. A culture of blood-serum
remained sterile.

The Widal reaction was tried daily, but continued negative. The
ear-drums were examined without result.

On the twenty-ninth the neck became more relaxed and the patient
quieter.

A second lumbar puncture, September 1st, gave essentially the same
results as before. Some of this fluid was injected into a guinea-pig.
The patient became unconscious on the second of December and died
on the fourth.

Throughout the first week of his stay in the hospital he was treated
for typhoid; later he was fed by stomach-tube, milk, beef-juice, and
eggs being introduced in this way.

October 7th the guinea-pig which had received the spinal fluid inter-

VOMITING 645

peritoneally was killed, and showed tuberculosis of the spleen and
lymphatic gland.

Diagnosis. Tuberculous meningitis, [presumably with general mil-
iary tuberculosis].

Case 336

A married woman of thirty-four, of good family history and past
history, entered the hospital March 9, 1908. She had a miscarriage
five weeks ago, in the fourth month of pregnancy, following a hard
day's work of washing. There was considerable hemorrhage both
before and after the miscarriage. She was curetted at the time, but has
been very weak and confined to bed ever since. During the first three
or four days after the miscarriage she had two chills, but there has been
no fever, so far as she knows.

For the past three weeks she has vomited persistently and has been
able to retain no solid food. It is chiefly for this symptom that she seeks
advice.

On examination, the pulse, temperature, and respiration are normal.
The patient is well nourished, slightly pale, pupils equal and reacting
normally, the tongue thickly coated white, the left tonsil slightly enlarged,
about half of the teeth missing. The heart's impulse is not seen or felt.
The sounds are best heard, and the left border of dulness found, in the
fourth space, five inches to the left of the midsternal line, one inch out-
side the midclavicular line. The sounds are regular and of good quality,
the pulse of low tension.

The lungs are normal, the abdomen considerably tender above the
symphysis and at McBurney's point. The patient has many varicose
veins in the right lower leg, and two white scars said to be due to previous
ulcers.

Blood and urine not abnormal.

Discussion. The salient facts appear to be as follows: Obstinate
vomiting following miscarriage and associated with slight enlargement
of the heart and abdominal tenderness especially marked in the appendix
region.

This group of symptoms does not easily cohere into any of the tradi-
tional groups which we call diseases. The cardiac signs arc slight-
obviously too slight to account for the vomiting as a result of jussive
congestion. There is no kidney change to account for the cardiac
enlargement, or to suggest uremia as a reason for the vomiting. There
are no brain symptoms, and though a fundus examination would be
a satisfactory completion of our record, it i< not urgentl) called for by

646 DIFFERENTIAL DIAGNOSIS

the other symptoms of the case. Malaria and other infectious diseases
are ruled out by the entire absence of fever.

The abdomen deserves, of course, our special attention. Is it
possible that the general tenderness may be the result of some type of
peritonitis, a low-grade septic infection, or tuberculosis? The evidence
is, on the whole, insufficient to justify any such belief. There are no
muscular spasm, no free fluid or masses nothing more, in fact, than
one finds after a miscarriage in a great many uncomplicated cases. In
the absence of fever, leukocytosis, elevated pulse, or more distinctive
local evidences appendicitis seems unlikely.

A more thorough investigation of the pelvis is indicated. Although
we know very little about the connections between the vomiting center
and the genital tract, connections whereby so-called reflex vomiting of
pelvic disease is supposed to arise, it is a very familiar fact that a variety
of low-grade inflammatory changes in the puerperal uterus, complicated
no doubt to a greater or lesser extent by absorption from incompletely
organized thrombi, may lead to well-marked constitutional disturbances,
of which vomiting is one. Whether this comes about through the
nervous system, by the aid of the vomiting center, and favored by psychic
disturbances, or whether it is in some way a more direct result of infec-
tion, I know no way of determining at the present time. But, however
this may be, it seems clear that, when we have finished our task of
excluding the other possibilities mentioned above, the best remaining
hypothesis on which we may base treatment is that which assumes that
the vomiting is in some way connected with the residual effects of the
miscarriage.

Outcome. The patient was put to bed and given 30 minims of fluid-
extract of ergot at once, and 15 minims three times a day after meals.
There was some reddish vaginal discharge without odor. The uterus
was moderately enlarged, freely movable, and somewhat tender. By the
twenty-second the uterus was much smaller and less tender. The
vomiting ceased after the third day. The treatment consisted of laxa-
tives and a daily suds enema.

Diagnosis. -Incomplete miscarriage.

Case 337

A stationary engineer of fifty-seven was first seen January 21, 1907.
Two of his brothers and one sister died of consumption. His wife is
said to have died of tuberculosis of the bowels. He has himself been
well except for so-called rheumatic pains referred to the muscles of the
back and extremities. These he has had for many years.

VOMITING 647

Eight years ago he was poisoned by steaming oxalic acid, and was
sick a week, with vomiting, diarrhea, and abdominal pain. Since that
time he has had occasional attacks of a similar nature about twice a year,
lasting three or four days.

His usual weight is 184. He has passed urine frequently at night
for a number of years.

Seven months ago he began to have frequent attacks of vomiting,
coming on quite suddenly during a meal, or soon after it, and without
any pain, nausea, or distress. He has vomited every day for some
months often two or three times a day. There has never been any
large amount of vomitus, nor any indication of food eaten the previous
day. The appetite has been poor, his bowels very loose. He has lost
color, weight, and strength very rapidly. Six months ago he was obliged
to take to bed, where he remained two months, and got somewhat
better. Diarrhea and vomiting improved decidedly, and he gained in
weight, but at the end of another month he relapsed and had to take to
bed again for most of the succeeding months. His complaints are now
the same as they were seven months ago. He has never vomited blood.
The character of the food has apparently no effect on the vomiting.
Seven months ago he weighed 184 pounds; four months ago, 142; three
months ago, 153; now he weighs 125 pounds.

On examination the patient is pale. The heart's apex is in the fifth
space, inside the nipple-line; there are no murmurs, no accentuations
of any sound. The pulses are of high tension, the artery wall apparently
somewhat thickened. The abdomen shows distinct resistance in the
epigastric region and beneath the right costal border. Otherwise it is
negative.

The blood showed: Red cells, 2,796,000; white cells. 9400. of
which 84 per cent, are polynuclear, the rest lymphocytes. There is
no achromia and no other change except slight deformities in the red
cells.

The urine is 30 ounces in twenty-four hours, and contains a large
trace of albumin, many pus-cells, no casts. Gravity, 1012-1016.

The stools are negative to guaiac and show no abnormal fcod residues.

Discussion. The family history of tuberculosis is so threatening
in tin's case that one would naturally begin diagnostic investigations
with a search for evidence of phthisis or some other form of tuberculosis.
This was done, but without result.

Since his occupation does not involve any constant exposure to the
oxalic acid by which he was poisoned eight years ago, there appears to
be no reason to connect his symptoms with this poison.

648 DIFFERENTIAL DIAGNOSIS

The loss of weight, the anemia, the age of the patient, and the method
of onset suggest ulcer or cancer of the stomach. The symptoms have
lasted so long, however, that stasis would probably have manifested
itself before this time. It is remarkable also that the food he takes
has apparently no relation to the vomiting.

Gastritis and enteritis, without some obvious cause, such as alcohol,
uncompensated cardiac lesions, tropical dysentery, or chronic nephritis,
are distinctly rare diseases in a man of this age. There is nothing in the
study of the stools or of the vomitus to justify any such belief; neither
of these diseases is apt to be accompanied by severe anemia unless a
great deal of blood has been discharged.

It is often profitable, in the discussion of such a case, to begin with
the well-established fact of secondary anemia and study the rest of the
disease from the point of view of the possible cause of such an anemia.
I have previously referred to a case (see p. 539) in which severe anemia
was produced by long-standing hemorrhoids with bleeding, altogether
unknown to the patient. Such a cause was sought for in the present case,
but not found.

Obscure anemia in a patient of this age very often turns out to be of
cancerous origin. It did not seem to me, at the time that the case came
under my observation, that the possibility of gastric cancer had been
sufficiently investigated, and, accordingly, I advised further study of
the gastric contents and functions. Nothing of importance was elicited,
however. The capacity of the stomach was within normal limits,
there was no stasis, and although the amount of free hydrochloric acid
was very small, this fact could not be interpreted as of any importance
in relation to the possibility of cancer, since it could be explained in so
many other ways. The guaiac test was negative in the gastric contents.

Chronic nephritis was next considered, since it is a familiar fact
that long-standing irritation of the stomach and intestines, with or
without a catarrhal inflammation, often complicates, and is the main
cause of, distress in this disease. Little could be found to support this
idea. There was no demonstrable enlargement of the heart. Un-
fortunately, the blood-pressure was not measured, so that we could not
be certain that our digital impressions really corresponded to hyper-
tension, as they were supposed to do. The urine was not incompatible
with nephritis, but not characteristic of it a very familiar and
baffling state of things.

Although the patient's habits were supposedly excellent, the resist-
ance beneath the right costal border, the unexplained anemia and per-
sistent vomiting, made us speculate concerning the possibility of a cir-

VOMITING 649

rhosis, but we found no means of advancing beyond the region of specu-
lation upon this point. In the end the diagnosis was very uncertain.
Fewer objections were raised against the diagnosis of chronic nephritis
with uremic vomiting than against any other, but none of us felt satisfied.

Outcome. The patient grew progressively weaker, and died on
the twenty-eighth.

Autopsy showed chronic interstitial nephritis, a very firm, rubbery
dark liver, enteritis and gastritis, with chronic colitis, and terminal
streptococcus septicemia.

Diagnosis. (See above.)

Case 338

A barber of thirty-five with an excellent family history and past history,
entered the hospital January 11, 1908. He has been having business
reverses for the past four weeks, during which he has slept poorly and
become very nervous.

On the night of December 27 he fell down eight or nine stairs and
bruised his right hip, which has improved somewhat under poulticing,
but is still lame and stiff and has confined him to bed.

The night after this fall he began to vomit, and has continued to do
so three or four times a day, and once at night ever since. The vomitus
at first consisted of food in considerable amounts; later, of a frothy
liquid and mucus. Once or twice there has been a small streak of
blood. His bowels meantime have moved from two to six times a day,
with considerable griping pain and gas. Throughout there has been
a dull, steady pain in the epigastrium, with a sense of dragging when
he stands or sits up, but no especial pain. His food has been milk,
eggs, oysters, and cool drinks.

On examination, the temperature, pulse, respiration, blood, urine,
and internal viscera are all negative, except that the abdomen is held
rather rigidly and that there is some ilattening of the right lower chest
in front, apparently connected with a funnel-breast deformity.

Examination of the stools showed no blood to any test and no abnor-
mal food-remains.

Discussion. Gastro-entcritis is the usual diagnosis in such a
case, but while it is impossible positively to exclude such an affection.
I think it is unwarrantable to assume its presence when the stools and
the gastric contents furnish no better evidence of intlammation. The
presence of mucus in the vomitus and the occasional small streak of
blood are in no way distinctive. Almost anv case characterized by
persistent vomiting shows such products now and then.

650 DIFFERENTIAL DIAGNOSIS

The abdominal rigidity leads us to think, at least for a moment, of
.some type of peritonitis, but there is not a single other fact to support
this idea. Surely there would be some change in the temperature,
pulse or blood, were peritonitis present. Moreover, any patient who
has recently vomited a good deal is apt to hold his abdomen rather
rigidly when the palpating hand explores it.

It is worth noticing that the vomiting came on immediately after
the patient had been confined to bed by the injury to his hip. The
isolation, the inactivity and the deprivation of all occupation or interest
produced by putting a patient to bed will give him a splendid opportunity
to dwell upon the worried and depressing events which had previously
made him nervous and sleepless. One is justified in laying stress upon
these factors in a case of this kind when careful physical examination
furnishes no explanation of the symptoms. Treatment should be
planned in accordance with the possibility that the symptoms may be
psychic in origin, though greatly aggravated, no doubt, by physical
exhaustion and starvation.

Outcome. The patient was given a liquid and soft-solid diet,
gentian and nux before meals, and trional, 15 grains, at night for two
nights. In the three days following the beginning of this treatment he
had no vomiting whatever, and declared that he felt perfectly well.
Doubtless the reassurance given him as the result of a negative physical
examination contributed to his recovery.

Diagnosis. Nervous exhaustion.

Case 339

A motorman of forty-four entered the hospital May 8, 1908. His
family history and past history are rather uneventful, but he admits
that he has lost much weight. Four years ago he weighed 210 pounds;
now he weighs 159. He has not worked since October, 1907, because
of stomach trouble. For the first two weeks of his illness he vomited
everything that he had eaten, the sour vomitus consisting of undigested
food, but never containing blood.

Soon after recovering from this he had " the grip," and was in bed
for several weeks. Since then he has had wandering pains, "like rheuma-
tism," in the shoulders, hips, and abdomen. He has not been confined
to bed, and he was able to walk to the hospital, though he complains
of considerable weakness. He has had a cough all winter until last
week since then, none. His appetite is poor, likewise his sleep.
The bowels are moved daily. (For temperature, see the accompanying
chart.)

VOMITING

The patient is emaciated, the heart's apex in the fourth interspace,
inside the nipple-line, the sounds of good quality. The pulmonic
second sound is slightly accentuated.

At the apex of the right lung there are a few fine crackles after cough
and a slight prolongation of expiration. In the left back there is a tri-
angular area of dulness, with its apex at the spinal column, ii inches
above the lower angle of the scapula ; thence it slopes out into the mid-
scapula. Over this area tactile and vocal fremitus are absent, breathing
distant and bronchovesicular. Just above this area the voice has a
nasal quality. The abdomen, blood, and urine are normal.

The sputum was twice examined for tubercle
bacilli, with negative results.

Discussion. The onset of well-marked gas-
tric symptoms in a man of forty -four whose
stomach has never troubled him previously,
should always compel us to consider gastric
cancer, but more especially so when the physical
examination of the rest of the body reveals
nothing which might be a cause for the gastric
disturbances. This can hardly be said to be the
case here, so that our attention is properly concen-
trated first upon the extragastric causes which
might lead to his present gastric symptoms.

Nothing is said regarding the reflexes in this
record. Without a knowledge of their condition
it would be impossible for us to exclude tabes
dorsalis with gastric crises. Further investiga-
tion, however, showed that all the reflexes were
normal.

The most important abnormalities discoverable on physical examina-
tion are in the lungs, and though these signs are not extensive, they
lead us to ask whether so much emaciation and stomach trouble could
be produced by any well-known disease affecting the lungs. This ques-
tion must be answered in the affirmative. Nothing is more familiar
than the production of such a clinical picture as a result of pulmonary
tuberculosis. But have we evidence of enough pulmonary disease to
explain such severe constitutional manifestations? This point I have
discussed in previous cases. Experience has made us very familiar
with the discrepancy often existing between the extent of the discovera-
ble physical signs and the severit) of the constitutional manifestations,

, -.

E
H

101-

1ST

IW
IW
NT
1M*
l
M'

i
xm

lie
M

M
So

M
u

V-

/,/

i i

>*[

i V

a *!

tf\/l

"4 Mil*"

flsLLJLLlfl.

Fig. 176. Chart of
case 339.

652 DIFFERENTIAL DIAGNOSIS

such as fever, sweats, chills, emaciation, and gastrointestinal disturb-
ances.

It is quite possible that some degree of secondary gastritis may arise
as a result of lowered powers of resistance produced by tuberculosis,
but postmortem evidence does not compel us to make any such assump-
tion.

No weight should be laid upon the absence of tubercle bacilli in the
sputum examined in this case. Such tests are of importance only when
many times repeated.

Outcome. X-ray showed a deep shadow over the lower part of
the left chest. The upper margin of this shadow had an irregular out-
line, and did not suggest the existence of any considerable pleural effu-
sion. There was also a slighter shadow corresponding to the left apex.
The patient was discharged to a sanatorium for tuberculosis

Diagnosis. Phthisis.

Case 340

A woman of fifty-six, a post-office clerk, of good family history and
past history, entered the hospital January 9, 1908. She passed the
menopause six years ago without trouble. Throughout the past summer
she has been bothered by sour stomach and flatulence.

Five days ago she ate canned salmon for supper, and that night,
after going to bed, she felt very chilly, headachy, vomited and sweated
profusely. The next two days she also vomited a good deal, and during
the last two days has been extremely nauseated. Throughout these
five days she has had aching all over her body, has slept very little, and
has felt feverish. The matter vomited has been either food or a greenish-
colored material. The bowels have moved twice in five days. She has
eaten practically nothing.

For the last three days she has had a constant, irritating, dry cough.

Physical examination was negative, save that in the left upper chest
and in the right axilla, at the extreme base, were a few transient, fine
moist rales. Temperature, 102 F.; pulse, 100; respiration, 20; white
cells, 19,500; hemoglobin, 90 per cent.; Widal reaction, negative;
urine, negative.

Discussion. The acute onset of symptoms in this case naturally
and properly turns our attention for the time being away from the long-
standing causes of vomiting, such as have been discussed in previous
cases. It is true that some of these chronic diseases such as brain
tumor, nephritis, gastric cancer, or neurosis may suddenly be "lighted
up" or roused to unusual activity after having remained latent for a long

VOMITING 653

time, but few if any of them would then be associated with such marked
fever, leukocytosis, and general constitutional signs pointing to infection.

It is reasonable, therefore, to consider whether any well-known
infection is prone to begin in this way. Infections of the gastro-intestinal
tract are uncommon and still more uncommonly recognizable. Typhoid
sometimes starts out with prolonged gastro-intestinal disturbances,
but the high leukocyte count is sufficient to exclude any uncomplicated
type of this disease. The same is true of acute or incipient tuberculosis,
except in the meningeal form. The unknown infections, usually termed
"grip" or "ptomain-poisoning," are much less likely to produce such
leukocytosis and such continued vomiting than is one possibility next
to be mentioned.

Of all the severe infections which are apt to attack elderly people
in or near the month of January, pneumonia is the one most often
beginning with gastro-intestinal symptoms alone. The leukocytosis,
the cough, and the trifling chest signs are all quite consistent with this
idea. Yet no one could make a positive diagnosis of pneumonia from
the facts here presented. A blood-culture might enable him to do so,
since the pneumococcus is not infrequently to be found in the circulating
blood before any evidence of solidification has become manifest in the
lungs. Without culture one can only suspect pneumonia, the practical
significance of which act consists in what it leads us to say to the family,
together with the focusing of our attention on the results of repeated
examinations of the lungs. In many cases with exactly such signs as
are here recorded, the stethoscope reveals nothing characteristic, but
with the free ear against the chest-wall we may be able to detect a dis-
tant but quite distinctive tubular breathing.

Outcome. Twenty-four hours after the above record was taken
there appeared in the left upper lobe, below the clavicle in front, dulness,
diminished breathing, diminished voice-sounds, and many fine and
medium moist rales. Although the breathing was of diminished intensity,
the expiration and the whispered voice were high-pitched and relatively
intense. The patient had no dyspnea and no pain.

On the eleventh the white cells were 28,000; on the thirteenth, 24, 600:
on the fifteenth, 7600.

There were no sputa at any time and practically no cough. By
the sixteenth the abnormal sounds were less; by the twenty-second
they were gone.

The patient complained very much of abdominal distress and numb-
ness. She vomited occasionally on the following day-, and it was sug-
gested that she ought to have a special nurse and be \a\ by the bowel.

654

DIFFERENTIAL DIAGNOSIS

February ist she announced that she would like to sit up, and her appetite
began to return; this was not until her temperature, pulse, and respira-
tion had been normal for seventeen days.

On the third of February she complained of being paralyzed all
over. On questioning, "paralysis" turned out to mean numbness, and
there was not the slightest sign of impaired motion nor of impaired sensa-
tion anywhere.

Diagnosis. Pneumonia.

Case 341

An unmarried Canadian woman of twenty-seven, of good family
history and past history, was first seen November 21, 1906. She has
had occasional indigestion for the past two or three years, and of late
has been run down and anemic. Catamenia have been absent for the
past two and one-half months. For eight weeks she has had nausea
and vomiting almost every day, sometimes several times a day. Vomit-
ing may follow food, but at times she
retches when the stomach is empty. Loss
of weight and strength has been such that
ten days ago she was obliged to go to bed,
in spite of which vomiting has continued.
Five days ago she began to have dull
pain in the lower left chest, increased by
deep breathing or cough. At the same
time she began to be short of breath. For
two weeks she has had cough, occasion-
ally raising thick, yellow, blood-streaked
sputum. (See accompanying chart for
the temperature.)

On examination the heart's apex is

not seen or felt. The right border of

cardiac dulness appears to extend 3^ inches

to the right of midsternum. The sounds

are clear, but are best heard to the right

of the sternum. The condition of the

lungs is shown in the accompanying diagram (Figs. 178 and 179). The

abdomen shows nothing abnormal. The reflexes are also normal. The

white cells are 5500; the urine negative.

On the twenty-second 74 ounces of yellow, slightly turbid fluid
were withdrawn from the chest. Specific gravity was 1018; albumin,

-IS

- 1 -

Z m ,

H.n-.-.

h
-

105"
103"
101*
t*
M*

\iit
110
100

II Y

-W 1

f .

f n>

1 *

,'.

srY

SilL i ; OL

Fig. 177. Chart of case 341.

Fig. 178. Signs recorded in a case characterized apparently by vomiting (eight weeks'
duration); only within live days have pain and dyspnea appeared.

Fig. 1 ;q. Signs as recorded in Case 34T. Xole absence (if any record of paravertebral
dulncss ((Irocco's sign) on the right. In iyo<> we had not been taught to look for it.

VOMITING 655

4 per cent. In the sediment small lymphocytes made up 98.5 per cent.
No tubercle bacilli could be demonstrated from the digested clots.

After the tapping the patient ceased vomiting and felt finely. By
December 1st there was no vomiting at all; then it returned in occa-
sional attacks, and by the twelfth it was causing a great deal of trouble.
Free fluid had reaccumulated in the chest to a slight extent only, but
the patient seemed to be losing ground.

Discussion. The pleurisy which was so easily demonstrable in
this patient's chest seemed at first a sufficient reason for her vomiting.
We were, therefore, surprised that the vomiting continued after the
effusion had been tapped. Neither the temperature chart nor any
of the other signs in the case seemed to indicate that the tuberculosis,
presumably in the background of this pleural effusion, was the cause
of the vomiting.

There appeared to be no reason to suspect organic disease of the
stomach, brain, heart, or kidney. There was no constipation or toxemia
apparent. We might have been tempted to settle down on the unsatis-
factory diagnosis of "gastric neurosis." One fact, however, still re-
mained unexplained namely, the amenorrhea. This was not to be
accounted for by anemia or by any obvious psychic cause. Clearly,
it was our duty to investigate the possibility of pregnancy.

Outcome. Tuberculous salpingitis was suspected. Vaginal ex-
amination showed a mass in the pelvis, distinguishable from the uterus,
softer and more fluctuant on the right than on the left. A great
number of remedies for vomiting were tried, among them sodium
bicarbonate, 1 dram in half a glass of hot water, sipped, Hoffmann's
anodyne, 1 dram in hot water, ginger-ale with sodium bicarbonate in
sips, mustard leaf to the epigastrium, bismuth and beta-naphthol,
cerium oxalate, 2 grains every two hours, and various diets. Finally,
on the fourteenth of December she was put on nutrient enemata and
all food by mouth omitted. As the patient continued to vomit and
retch at times, though the nutrient enemata were well retained and did
not cause discomfort, it seemed best again to explore the pelvis, with
a view to freeing the adhesions and perhaps stopping the vomiting in
this way. Accordingly, on the twenty-first the abdomen was opened and
showed nothing but a large, presumably pregnant uterus, with normal
tubes and ovaries. Within five days after this expl oratory operation
vomiting ceased altogether.

Diagnosis. Vomiting of pregnancy; pleural effusion.

6^6 DIFFERENTIAL DIAGNOSIS

Case 342

A Russian tailor of thirty-seven entered the hospital April 28, 1908.
He has found himself unable to work for several months, because when-
ever he tries to move about at all he vomits. This vomiting is accom-
panied by shortness of breath and palpitation. He has also a slight
cough, anorexia, constipation, and insomnia. He has noticed no
edema.

On examination, the right pupil is slightly larger than the left. The
heart's apex is in the fifth space, one inch outside the left nipple. At
the apex there is a murmur which lasts through the whole of diastole
with a crescendo toward its end. The first apex sound is very sharp,
and preceded by a palpable thrill. The pulmonic second sound is not
accentuated. There are crackles and squeaks scattered throughout
both lungs, especially at the base behind, where there are slight dulness
and diminished fremitus.

In the abdomen there is a little dulness laterally when the patient
is lying down, this dulness shifting with change of position.

Physical examination, including the blood and urine, is otherwise
negative.

Discussion. Attention should be arrested by an unusual com-
bination of symptoms present in this case viz., vomiting, excited,
apparently, by exertion. This is a very significant grouping of facts,
and may be interpreted to mean either that vomiting is dependent
upon some circulatory disturbance which exertion increases, or upon the
shifting of the position of some viscus when he assumes the upright
position.

Since the vomiting is associated with other symptoms suggesting
disturbance of the circulation and the physical examination reveals a
cause for this disturbance, we must ask whether mitral stenosis, which
is apparently the lesion present, is capable of producing such persistent
vomiting, even when compensation is not very seriously disturbed.
Experience shows that we may answer this question in the affirmative,
although, as a rule, troublesome gastro-intestinal symptoms do not
occur until rather later in the course of an uncompensated cardiac
lesion.

Since physical examination gives us no hint of any other cause for
the vomiting, it is proper to treat the patient with reference purely to
his circulatory disturbance, and to anticipate that he will stop vomiting
when his compensation is improved.

Outcome. The patient was kept in bed, given an ounce of magne-

VOMITING 657

sium sulphate each morning, and a bitter tonic before meals. Occa-
sionally he needed 10 grains of trional to induce sleep, but no cardiac
stimulation seemed called for. After a week's rest he was in good
condition and had no symptoms as long as he did not exert himself
violently.

Diagnosis. Mitral stenosis.

Case 343

A Swedish tailor of fifty, with a good family history and past history,
entered the hospital June 12, 1907.

About February 1, 1907, he began to have abdominal pain and
vomiting. At first his pain was relieved by belching sour gas, but it
gradually became more severe, especially after eating meat or heavy
food, less after milk or crackers.

For the past two months the pain comes three or four hours after
eating, and is very severe and grinding, passing from right to left across
the epigastrium, and relieved by vomiting, which is apt to occur once
or twice every two or three days, usually after a siege of pain. He has
often seen in the vomitus food eaten a day or two before. Usually the
vomitus contains the unchanged food and bile-stained mucus, never
more than a pint at a time, never dark or bloody.

He has constantly lost weight, strength, and color. In February he
weighed 152 pounds, now he weighs 131. He is constipated; sleeps
well. He gets up two or three times at night to pass water. His appetite
is excellent. He worked until two days ago.

Examination showed emaciation, pallor, negative chest and abdomen.

White cells, 5000; hemoglobin, 75 per cent.; urine, normal. The
stomach held 70 ounces of water; after a test-meal, free HC1 was absent
on two occasions. Total acidity, 0.12 and 0.2. Stools altogether
normal. The fasting stomach contained considerable food remnants.

After a few days in the hospital on a dry diet divided into six meals
daily, HC1, 20 minims after meals, and 2 drams of Carlsbad salts each
morning, the symptoms disappeared.

There was at no time any visible peristalsis.

Two days after leaving the hospital the pain recurred and a profuse
diarrhea began.

On July 24th, 1Q07, he reentered the hospital, complaining that
he had had since his last entry live or six attacks similar to that just
described, beginning with severe abdominal pain followed by vomiting
and diarrhea. Most of these attacks have followed some indiscretion
in diet. As in the previous illness, he has noticed in what he vomits

658 DIFFERENTIAL DIAGNOSIS

food eaten a day or more before. The appetite is good, bowels con
stipated. He sleeps well except during the attacks of pain.

The abdomen now shows marked rigidity and tenderness in the right
lower quadrant, but no masses are made out. The hemoglobin has now
fallen to 50 per cent.

Discussion. Gastric cancer is strongly suggested by this history.
Here is a man who has lived on peaceful terms with his stomach for
forty-nine years and then, without any discoverable cause, begins to
have trouble with it. The regular recurrence of pain three or four
hours after eating is, however, less characteristic of cancer than of
ulcer and some other diseases. Quite obviously we have stasis, emacia-
tion, and anemia, presumably of the secondary type. These facts,
together with the absence of hydrochloric acid, still further support the
hypothesis of cancer, especially as no hemorrhage or other cause for the
anemia is manifest.

Though we were much inclined toward the diagnosis of gastric cancer,
the disappearance of symptoms after a few days' stay in the hospital made
us more doubtful. Marked improvement does, however, occur in
cases of undoubted gastric cancer, and I have often known a false con-
clusion based upon such improvement. Doubtless the secondary
irritation of the gastric mucous membrane resulting from the stasis is
itself the cause of many of the symptoms in gastric cancer, When this
stasis is relieved by diet and lavage, the symptoms improve, though the
cancer does not.

By the time of his second entrance to the hospital we had begun to
notice certain anomalies in the clinical picture, which made it difficult
to identify it with that of gastric cancer. First of all, it was notable
that the pain passed across the epigastrium from right to left i. e.,
against the current of the gastric contents. This is unusual in pyloric
obstruction. Next, we were forced to observe that the pain had not
the steady, grinding character usually seen in the more painful types
of gastric cancer, nor was it confined to that indefinite distress and
sense of weight which characterizes the less painful types of the disease.
This man's pain came in distinct paroxysms of great severity, separated
by intervals of complete freedom. This is more suggestive of intestinal
than of gastric cancer. Hie profuse diarrhea following his last stay
in the hospital, and the constipation which has been a feature of his case
throughout, fall in very well with this idea.

If we are dealing with chronic intestinal obstruction, as this last
interpretation of the symptoms seems to indicate, there is reason to
believe that cancer is its cause, both because the great majority of

VOMITING 659

such cases occurring in men of this age turn out to be cancerous and
because the anemia is not otherwise explicable.

Outcome. Subsequently a hard mass with indefinite outline was
made out on the right side of the abdomen, at the level of the navel.

Rectal examination was negative, but the stools now exhibited a
marked reaction to guaiac. After a test-meal the stomach-contents
showed free HC1, 0.018.

Leukocytes, 4100, among which 59 per cent, were polynuclear, 30
per cent, lymphocytes, 11 per cent, eosinophiles.

Operation on the twenty-seventh showed cancer of the ascending
colon.

Diagnosis. Cancer of the ascending colon.

Case 344

A married woman of fifty years was first seen in September, 1903.
for major hysteria. After this she passed out of my ken and I did not
see her again until December 8, 1908. During this time she had got
into the habit of taking brandy at the rate of about a quart a week at
irregular intervals; also a spray of cocain, which she used two or three
times a day for most of the time. Besides this, she had a prescription
for amylene hydrate, originally given her by Brown-Sequard, and con-
tinued by her at intervals ever since.

She has been more or less hors de combat, owing to the influence of
hysteria and drugs, for a considerable portion of the time. Two and a
half weeks ago she got overtired with shopping and the theater. Within
a day or two she began to have persistent vomiting, headache, and
great irritability, which at times amounted almost to delirium, and was
accompanied by suicidal impulses. This continued until within the
present week, when she became very quiet and drowsy most of the
time, but continued to vomit. As far as can be estimated, she has
consumed about a quart of brandy in the last three days.

For the past four days it has been noticed that the amount of urine
has considerably diminished. Yesterday afternoon it was examined
and found to contain 0.5 per cent, of albumin. It was smoky in color.
and in the sediment were a great many casts, chiefly fine granular
and brown granular, with a smaller number of the hyaline and cellular
types. It was subsequently learned that she had had albumin in the
urine four years previously, but its other characteristics were not known.

For the past twelve hours she had been semiconscious, and as we
went upstairs the attending physician said to me that the case seemed
to him very grave; he doubted somewhat whether she could be roused.

660 DIFFERENTIAL DIAGNOSIS

We stepped to the bedside. "Mrs. D.," said he, "here is Dr. Cabot.
Do you remember seeing him some years ago?" "Yes," said she, "and
a bigger fool I never knew." All of which seemed to argue that she
was not so badly off after all ; yet she soon slipped off again into a semi-
unconscious condition, in which the pupils reacted very sluggishly.

On physical examination there was decided muscular negativism.
The heart and lungs showed nothing abnormal ; the blood-pressure was
not high ; the abdomen was negative. There was no muscular paralysis,
but the knee-jerks could not be obtained, and there was an extraordinary
degree of flabbiness in the calf muscles almost no muscle left. Else-
where nutrition was fair. Blood examination showed nothing wrong
in that direction.

Discussion. As there was no muscular tremor and no suggestion
of alacrity in the psychic responses, there seemed no good reason to
anticipate delirium tremens.

Uremia was seriously considered, and could not be excluded. The
points against it were the low blood-pressure and the muscular relaxa-
tion, also the emphatic statement by the husband that she had often
" been as bad as this before," but had always come out of it all right when
alcohol and drugs were taken away.

On the other hand, it seemed difficult to account for the bad condi-
tion of the urine as a result simply of alcoholism and cocain. On the
whole, I was inclined to think her uremic and to give a bad prognosis.

Outcome. Alcohol and drugs were stopped, and she was kept on
a diet of milk and water for twenty-four hours, after which she rebelled
and nibbled a considerable quantity of various objects. Within a week
the urine had cleared up and the patient was decidedly active and bad
tempered, but insisted on running her automobile, which she drove
herself. So far as could be ascertained, the attack had passed off with-
out leaving her any worse than before, and without producing any per-
manent damage in her internal viscera.

The case taught me a lesson not unfamiliar to those who deal with
acute alcoholism and drug-poisoning, viz., that there is almost no limit
to the amount of albumin and casts which may be excreted in the urine
of patients during an acute attack of narcotic poisoning, without leaving
any evidence of permanent damage to the kidneys after the attack
passes off. One should attempt no judgment about the condition of the
kidneys until we have been able to eliminate the present effect of alcohol
and other narcotics.

Diagnosis. Hysteria; alcoholism; drug habits.

VOMITING 66 1

Case 345

AnneK., a laundress of forty-eight, entered the hospital March 14,
1909. She has always been well and has an excellent family history.
She passed the menopause a year ago. On the morning of Christmas,
1908, after a hard day's work preceding, she vomited "half a washbowl
of phlegm" when she first got up. She noticed no food or blood in the
vomitus. She breakfasted and worked as usual that day. Through
January and February, 1909, she considered herself perfectly well, though
her bowels had been more than usually constipated, and when once started
by catharsis there had often been a slight diarrhea for several days.

Three weeks ago she took a dose of salts one morning for one of her
usual spells of constipation and immediately began to vomit bile-stained
phlegm. Her vomiting continued all day, though she kept at work.
She spent the next three days in bed and continued to vomit after eating.
She then went to a friend's house for a rest. There the vomiting soon
ceased, and in five days she was able to resume work.

A week later, March 8, 1909, vomiting recurred for the third time.
Nevertheless she kept at work until March 12th, the day previous to her
entering the hospital. The vomitus has always been small in amount
and apparently free from blood or food residue. She says she has had
no pain at any time except a "griping" after taking a cathartic.

Appetite poor, sleep excellent, weight (a year ago) 150 pounds.
Her mistress says that she has always been reticent and uncomplaining.

On examination her weight was found to be 151 pounds, and she
seemed distinctly obese, though it was also noted by one of the consult-
ants that "her flesh hung on her body with wrinkles and folds," suggest-
ing that she had previously been heavier.

Physical examination, including the blood and urine, was wholly
negative, save for a very slight degree of abdominal distention. After the
bowels had been started by a glycerin enema of 4 ounces on March 13th
and a high oil enema of 6 ounces March 15th, they continued to move
normally. The stools were not remarkable either in number or appear-
ance, and showed a negative guaiac reaction March 16th, 17th. and
20th. After the 18th she was able to take milk and crackers without any
vomiting or distress. March 29th she was taking a full diet without any
symptoms, and April 1st she was discharged well.

Discussion. The diagnosis of gastric neurosis ami constipation was
made in this ease. The basis for this was chiefly the negative physical
examination, and the prompt recovery of gastric and intestinal function
under rest and diet, with enemata.

662 DIFFERENTIAL DIAGNOSIS

We were, therefore, quite astonished and somewhat amused when
Dr. E. A. Codman, who saw her March 18th, made a diagnosis of chronic
intestinal obstruction, probably due to cancer. Yet the outcome showed
that Dr. Codman was in all probability right. The facts which guided
him (and should have guided us) to this diagnosis were (a) the presence of
slight abdominal distention on March 18th after five days of partial
starvation and free catharsis; (b) the occurrence of vomiting in a middle-
aged woman who had been previously well and had no special cause for
a nervous breakdown; (c) the history of periods of constipation alternat-
ing with diarrhea; (d) the griping pain which, though attributed by the
patient to the action of cathartics, did not seem to Dr. Codman explain-
able thereby.

Outcome. After leaving the hospital April ist, she stayed at a
friend's house for three weeks; she then returned to her work as a laun-
dress and seemed perfectly well through May and June. I inquired
after her this time and noted, with great satisfaction, her continued good
health, confirming, as I thought, my diagnosis of gastric neurosis. In
July she had her fourth attack, which came on this time with great sud-
denness. She was seen at once by a physician who found distention
and vomiting, but under his treatment she seemed well again within a
few days and resumed work. A few weeks later her mistress happened
to go into the laundry and found that Anne had a fifth recurrence of her
old trouble vomiting. Another vacation was advised, but after three
weeks' rest at a friend's house her symptoms returned in great force.
In this, the sixth attack, the vomiting finally became fecal and there was
intense abdominal pain and rapid emaciation. Dr. John T. Bottomley
saw her in consultation. In answer to my inquiry he writes as follows:

"She presented a picture of the terminal stage of an intestinal ob-
struction; distended abdomen, anxious face, fecal vomiting, empty
rectum, etc. A mass was indistinctly felt in the upper abdomen and was
believed to be malignant."

It seemed too late to operate and the patient died soon after.

Diagnosis. Chronic intestinal obstruction, probably due to malig-
nant disease.

Case 346

Called at noon February 10, 1910, to see a Syrian housewife of
twenty-nine (childless) whose groans and cries reached me in the street
as I came to the house. I found her writhing in intense pain, referred
to the epigastrium, and accompanied by so much retching that I could
hardly get her history between the spasms.

VOMITING 663

Six days previously she had begun to vomit without obvious cause
the act being immediately preceded by epigastric pain and relieved by
emesis. The early morning was her worst time in this respect.

Until this morning she had slept well and had suffered no pain between
the vomiting spells, but at 5 a. m. to-day, after a sleepless night, the pain
began again and her vomiting no longer relieves it.

Her bowels moved after an enema yesterday, and again this morning.

I examined her as well as I could between her spasms of writhing
and vomiting. She was a stout, flushed, powerful woman. No percus-
sion dulness, no tenderness or muscular spasm, no palpable mass could
be felt through the belly-walls by rectum or by vagina. The tempera-
ture was 97. 6 F., the pulse 100, the respiration 30. The vomitus
consisted of mucus and bile-stained, watery fluid. The urine con-
tained no albumin or sugar. The blood was negative.

The woman's sufferings seemed as intense as those of acute perfora-
tive peritonitis, yet I could find no objective evidence of that disease.
The pain was such as I have seen in gall-stone disease, yet until this
morning it had been merely an accompaniment of the vomiting and
relieved by it.

All the complaints pointed to an abdominal emergency of some kind,
yet I could find none on physical examination.

Discussion. I felt very much puzzled by the case. The loudness
and vigor of her cries and her healthy appearance inclined me to believe
that she was free from any serious disease. On the other hand, the
attending physician had evidently felt much alarmed about her. When
he had previously telephoned me and found that it would be an
hour before I could get there, he said he was not sure she would live so
long. In the hullabaloo going on in the room it was very difficult to
think, but as I made the effort, my eye roved about the room and fell upon
the center table, which contained a huge Turkish hookah, two boxes of
cigarettes, and a hypodermic syringe. The last was the clue that I wanted.

Inquiry showed that it belonged to the doctor, and that he had given
morphin once or twice daily for the last five days. As soon as I came
to look at the patient with this in mind I saw that her outcries, tossing,
and thrashing about the bed, and her vehement, though inchoate desire
for something, she knew not what, were very characteristic of what I
had so often seen in morphin habitues deprived of their drug. Inquiry
showed that she was not a habitue, but had acquired a strong need
for the drug in five days.

Outcome. -The subsequent course of the case showed that there
was nothing else the matter with her; her original attack of vomiting

664

DIFFERENTIAL DIAGNOSIS

was brought on by overeating and constipation. It had been intensified
and prolonged by the unwise use of morphin in a neurasthenic. After
the evacuation of a large fecal accumulation, the withdrawal of the
morphin, and a sensible diet, she recovered completely, though with a
good many relapses.

Diagnosis. Neurosis; morphin.

TABLE XVIII. VOMITING. Signs and Symptoms.

Causes.

Suggestions from
the history.

Physical
examination.

Vomitus.

Mode of relief.

c History of preg-
Toxemia of pregnancy . . . . nancy

Enlarged uterus.

Comes espe-
cially in A. M.

Diet. Time.
Sometimes emp-
tying uterus.

Irritating food or
drink.

Food recently
eaten.

Starvation and
rest.

Obvious.

Evidence of alco- \ Odor of Starvation and

holism.

alcohol.

rest.

Not

characteristic.

,. , . r ,. Exposure to mfec- Fever. Eruption.

Onset of infectious diseases . . r t 1 .

tion. Leukocytosis.

Postoperative "shock" .

Obvious.

Not
characteristic.

I
Gastric neurosis Previous neuroses.

, i- u .. i Right iliac spasm

Acute appendicitis Previous attacks. * ff .nrWnr-ss

Often brown Time and

(changed blood 1. lavage.

Not

characteristic.

Reeducation.

Not Absorption or

or tenderness. ! characteristic. operation

Cardial disease

Peptic ulcer .

Evidence of cardiac Failing heart,

disease. Stasis.

Not
i Depletion

characteristic- ~ . ' .

Rest

;pleti(
Stimulation.

Chronicity.

Intermittence.
Regularity.

Relieves pain. 7 . .
t\c. u Diet or opera-

Otten hvper- *

Excess of
mucus.

Intestinal obstruction

Previous attacks
with constipation.

Distention. Vomit-
ing. Peristalsis i '.'i. Finally fecal. Operation.
Tumor.

Blood (occult i in ^. - s

Gastric cancer Onset after 40. stool. Gastrectasis. '. ',-.' ' ,',' 1 Operation.

^ . ... ... and often blood. r

Anaciditv. 1 umor.

Headache. Cardiac Edema. Albumin >.- , .- r > ,

, X> 1 No relation to Depletion,

troubles. Nose- and casts 111 urine. ( , f..

Meeds. Edema. Enlarged heart. l0 d - J -" et -

Syphilis.
Lightning pains.
Bladder troubles.

Pupils Knee-jerks. No relation tt
Ankle-jerks food.

Causes of Hematuria

1. ACUTE NEPHRITIS 1

2. CHRONIC NE-
PHRITIS

139

RENALCALCU-
LUS

TUMOR OF
THE BLAD-
DER

T U B E R C U LO-
SIS OF KID-
NEY

6. TUMOR OF)
KIDNEY /

7. ACUTE CYSTITIS

8. OXALURIA

9. UNKNOWN i

CAUSE /

1 The special limitations of my material make it impossible for me to estimate
accurately the proportion of cases in which hematuria is a feature of acute nephritis, but
I believe it to be the commonest type of bleeding from the urinary tract.

e,m

CHAPTER XX

HEMATURIA

The term is applied only when blood is visible in the urine by the
unaided eye. It does not apply to cases in which the microscope alone
enables us to detect red corpuscles in the urine. It is also distinguished
from hemoglobinuria, a rather rare condition, in which the urine
contains free hemoglobin, but no corpuscles.

It is important to make sure, before deciding that we are dealing
with a case of hematuria, that all admixture of vaginal discharges is
avoided.

CAUSES AND TYPES OF HEMATURIA

Since a very large proportion of the varieties of hematuria are not
such as lend themselves to the method of differential diagnosis by case
analysis which I have used throughout this book, I shall not be able to
exemplify them all by discussable cases presenting diagnostic difficulties.
I shall, therefore, mention them in more than usual detail in this intro-
ductory section.

It is convenient to divide the cases of hematuria into those due to:

i. Trauma.

2. Nephritis, acute or chronic.

3. Renal disease (other than nephritis).

4. Vesical disease.

5. Hemorrhagic diseases and diseases of the blood.

6. Poisons.

7. General infections.

Traumatic hematuria is most frequently seen as the result of severe
crushing accidents, as, for example, when the body has been run over
by a heavy wagon. It also occurs as the result of injuries in the perineal
region and after instrumentation. It rarely presents any diagnostic
difficulties.

In nephritis, hematuria frequently occurs as part of an acute process
without leading to any puzzles in its interpretation. In chronic nephri-
tis it may appear out of a clear sky when the underlying disease is quite
latent, and under these conditions mistakes of diagnosis often occur.

668 DIFFERENTIAL DIAGNOSIS

The best methods of guarding against them will be discussed in connec-
tion with some of the cases presented in the latter portion of this chapter.

Excluding nephritis, we have left a group of diseases of the kidney
ordinarily termed ''surgical," and including (a) The irritations pro-
duced by oxaluria, with or without gravel, or by stone; (b) renal tuber-
culosis; (c) renal neoplasm; (//) cystic kidney; (e) unknown cause.
All these will be exemplified later, and, accordingly, are not further
discussed here.

Vesical hematuria may be due to (a) Cystitis of unknown origin;
(b) stone in the bladder; (c) tumors, benign or malignant; (d) acute
prostatitis and prostatic hypertrophy; (e) tuberculosis of the bladder;
(J) the sudden and complete emptying of an overdistended bladder, as
in cases of acute retention; (g) bilharzia disease, which is seen only in
tropical climates or in patients recently returned from such a climate.
Most of these will be discussed later on in this chapter. Bilharzia
disease is recognizable by finding the eggs of the parasites in the urine.
When once seen, they are easily remembered.

The vesical jorms of hematuria are generally distinguishable from
the other types above mentioned because other vesical symptoms, such
as urinary frequency, tenesmus, or pain, are associated with the hema-
turia. This rule, however, is by no means invariable, since renal
tuberculosis may produce marked vesical symptoms, while, on the other
hand, bladder tumors may remain wholly latent save for the occasional
presence of blood in the urine.

In the hemorrhagic diseases, such as hemophilia, scurvy, and the
various types of purpura, blood may appear in the urine as well as else-
where. The diagnosis of the underlying condition is usually obvious,
and gives us a clue to the explanation of the hematuria. The same is
true of the hematurias occasionally seen in connection with leukemia
or pernicious anemia.

A large number of poisons occasionally produce bloody urine, but
among the drugs which are often used at the present time there are
very few that lead to this accident. Cantharides, turpentine, and
phosphorus are not often used to-day in such doses as are capable of
producing hematuria. Tn factories where coloring-matters, especially
fuchsin, are manufactured, gases are evolved which not infrequently
produce a severe hematuria, but obviously not many of us are likely
to encounter cases of this origin.

Tn the hemorrhagic forms of various infectious diseases such as
typhoid, typhus, small-pox, yellow fever, and septicemia, blood is occa-
sionally discharged with the urine, but its origin is usually clear enough.

HEMATURIA 669

Case 347

A housemaid of twenty-five, whose mother and one uncle died of
consumption, entered the hospital December 23, 1907. She has had
bladder trouble for eight weeks. She was in the Boston City Hospital
three years ago. Three months after this time she passed a tumbler
of clotted blood, but was well in a few days. The same thing occurred
again in three months. Nine months ago she again passed liquid and
clotted blood for three days, but recovered without treatment. Her last
attack was about four weeks ago, and, like the others, was over in three
days. The attacks have no relation to the time of menstruation. Two
days ago she passed a small clot and some bloody urine. After that her
urine was normal for twenty-four hours. Yesterday afternoon hemor-
rhage was again profuse. In these attacks she occasionally has a little
pain during or at the end of micturition. There is no frequency of
micturition, but she passes urine twice in the course of each night. In
all other respects she feels perfectly well.

Her physical examination is negative except for some tenderness
in the lower part of the abdomen, especially on the left side. The
leukocytes are 8000; hemoglobin, 75 per cent. The urine is not remark-
able, except for the presence of a large amount of blood. An .v ray
of the bladder and kidneys showed no evidence of the presence of stone.
Cystoscopy showed that the blood was coming from the right kidney.
Catheterization of the ureters gave clear urine from the left, nothing
from the right. There was evidence of ulceration here and there in
the left upper portion of the bladder. Rectal examination showed
tenderness in the region of the right ureter and in the region of the
ulceration on the left side of the bladder.

Discussion. The essential feature of this case is the intermittent
hematuria persisting for three years in a woman of twenty- five with
long intervals between the attacks and perfect health in the intervals.

V>y the study of the urine we obtained no evidence of nephritis,
genito-urinary tuberculosis, or Iithiasis. There are no bladder symp-
toms pointing toward tumor, benign or malignant, nor toward any
type of cystitis. The .v-ray evidence supports us in excluding stone.

Under these conditions cystoscopy is obviously indicated. By the
combination of cystoscopy and rectal examination we obtained the
following additional information: that the blood comes from the right
kidney, that the bladder is ulcerated, that the ureter i- tender, and
probably stenosed. These facts, together with the family history,
point distinctly to tuberculosis of the kidney and Madder. There is

670 DIFFERENTIAL DIAGNOSIS

no other common lesion which produces unilateral renal hematuria
with tenderness, partial obstruction of the ureter, and ulceration of the
bladder-wall.

In view of this evidence it is not necessary to delay the beginning
of treatment until a guinea-pig can be inoculated with the urinary sedi-
ment and allowed to ''ripen" six weeks. This procedure should,
nevertheless, be carried out at once.

Malignant disease of the kidney, especially hypernephroma, has
been known to produce hematuria lasting over a period of three years.
But with hypernephroma we should not expect ulceration of the blad-
der or tenderness of the ureter, and after the lapse of three years we
should expect local tumor, metastases, and constitutional disturbance.

It should be noted how very good this patient's general condition
appears to be, despite the apparently long duration of the disease. In
this connection we may remember that in the kidney, as in the lung,
tuberculosis may pursue an entirely "silent" and symptomless course.
I have recently seen the results of such a tuberculosis at autopsy, although
the patient had never had any symptoms remotely suggesting any malady
of the genito-urinary tract.

Outcome. December 28th the right kidney was cut down upon,
found to be enlarged and cystic, the ureter full, enlarged, and in places
constricted. It was removed together with the kidney.

The histologic examination of the kidney showed tuberculosis, with
complete blocking of the ureter near the kidney.

The patient made an uneventful recovery.

Before the operation a specimen of urine removed by catheter
(December 18th) was injected into a guinea-pig. Autopsy, January
17th, showed tuberculosis of the animal, and tubercle bacilli were re-
covered in cover-glass examination.

Diagnosis. Tuberculosis of the kidney and bladder.

Case 348

An Irish shop-clerk of twenty-eight entered the hospital March 28,
1908. One brother and one sister died of phthisis. For two years
he has noticed frequent micturition. Two months ago, for periods
lasting about eight days at a time, he passed bloody urine with clots.
There was some pain during micturition. Ten days ago this was
repeated twice. There have been no other symptoms. He feels per-
fectly well.

Physical examination was negative, except for some tenderness on
deep pressure in the right Hank. On the night when he was first seen

HEMATURIA 67 1

he passed some urine entirely free from blood. The next morning the
urine was excessively bloody. X-ray of the kidneys was entirely nega-
tive.

The urine drawn by catheter showed the following characteristics:
Amount in twenty-four hours, 26 ounces; color, bloody; specific gravity,
1023; albumin, very slight trace; sediment, considerable blood, normal
and abnormal. Some pus, no casts. Few acid-fast bacilli.

Cystoscopic examination showed on the anterior wall of the bladder
a single small, shallow ulcer surrounded by a reddened area.

Discussion. The age of the patient and the duration of the case
are against malignant disease of the kidney or bladder. The x-ray
evidence tends to exclude stone. Single circumscribed ulcers of the
bladder are not infrequently due to tuberculosis, and the family history
supports this idea. Further certainty cannot be obtained without a
further study of the urinary sediment for confirmation of the finding of
acid-fast bacilli. A guinea-pig inoculated subcutaneously with 35 c.c.
of urine on the second of April was killed May nth, and showed
tuberculosis of the lymph-glands, spleen, and liver, from which
tubercle bacilli were recovered. There was no evidence of renal
disease.

Outcome. In May, 1908, an ulcer of the bladder-wall, apparently
tubercular, was excised. May 11, 1910, the patient's physician writes:
"I am more than pleased to let you know that Mr. F. has been feeling
very well since his operation. He works every day."

Though positive evidence relates only to the bladder here, it is
more than possible that the kidney was also involved.

Diagnosis. Tuberculosis of the bladder. Renal tuberculosis?

Case 349

A child of four years was first seen June 29, 1908. In the previous
July he fell off a ladder, after which lie was poorly and was thought to
have malaria. Six weeks ago he fell off an express wagon, striking on
his left side in the lumbar region. Soon after this he began to pass
bloody urine, and within the last six weeks he has had three such attacks,
lasting each a couple of days; and soon after his fall, six week- ago, a
lump was noticed on the left side of the abdomen. It has rapidly
increased in size since that time. The presence of this lump, together
with the fact that he has fever every other day, has led to a diagnosis
of malaria. He comes from a very malarious village. He has been
rapidly losing weight for the past six weeks.

On physical examination the child show- no anemia and no malarial

672 DIFFERENTIAL DIAGNOSIS

parasites, but is poorly nourished. Examination of the head, neck,
and chest reveals nothing abnormal. The left upper portion of the
abdomen is prominent, and contains a large, firm, irregular mass, dis-
tending on inspiration. (See Fig. 180.) The air-distended colon passes
in front of the tumor. The edge of the liver is felt two inches below
the costal margin, in the nipple-line.

Discussion. The time of year at which this illness occurs, the fever,
the age of the child, and the presence of the tumor which may represent
enlargement of the spleen, naturally suggest malaria, which was,
indeed, the diagnosis at the time when the case was first seen. Malaria
of the severer type may be associated with something resembling
hematuria, i. e., with hemoglobinuria, but there is no blood and no
true hematuria, only free hemoglobin discoloring the urine. We must
have some other explanation, therefore, for the bloody urine in this case,
especially as no malarial parasites were found, despite careful search.

Leukemia might give us a similar clinical picture, and is not infre-
quently complicated by hematuria. That disease, however, could be
excluded in the present case because the stained blood-smear was quite
free from any suggestion of leukemia. It is true that leukemia may for
a short time exist without a typical blood-picture; under treatment
with arsenic or v-ray the blood may return altogether to normal, and
the same change has been known to occur as the result of a complicating
infection (pneumonia, erysipelas, etc.), or even without known cause.
All these possibilities, however, are extraordinarily rare, and we have
no good reason to consider them here.

Large abdominal tumors occurring in young children are not common.
If bilateral, they are usually due to congenital cystic kidneys; if unilateral,
some form of renal neoplasm is usually the diagnosis. The other pos-
sibilities are very few. In this child there is no reasonable doubt that we
are dealing with a new-growth of the left kidney. The hematuria,
the tumor, the poor nutrition, and the fever are the usual features of
such a disease. Renal tuberculosis is almost unknown in a child so
young, and would not have produced a tumor of this size without mani-
festing itself in the urine by the presence of pus and probably by vesical
irritation.

Malignant disease of the kidney may be difficult or impossible of
diagnosis in its earlier stages, before the tumor is large enough to be
palpable. A metastasis in some distant organ, usually in some bone,
may be the first hint of the renal neoplasm. In other cases we have
long-standing, intermittent hematuria, such as we have already exempli-
fied in genito- urinary tuberculosis. This is unfortunate, because earlv

Fig. 1S0. Outline plotted by palpation in a case of intermittent hematuria of a week's

duration.

HEMATURIA 673

diagnosis and early operation give the only hope of cure. When the
tumor is well marked, as in the present case, the diagnosis is not usually
difficult.

Outcome. The child died July 19, 1908. There was no autopsy.

Diagnosis. Renal neoplasm (?).

Case 350

A married woman of fifty- two, a shoe stitcher by profession, was first
in the hospital in 1905 for acute nephritis, recovering at the end of a
month. Although there were still a very slight trace of albumin and a
few fine granular casts in the urine at the end of her treatment, she
felt perfectly well and showed no cardiac enlargement.

She was next seen November 18, 1907, complaining of hematuria.
She has worked without a vacation since her last illness, though last
spring she fainted several times while working. Since last M ay she has
had much dyspnea on exertion, and has felt very tired most of the time,
but has not again fainted. A week ago the sight of her left eye began
to blur. She says that she had similar trouble with her right eye
twelve years ago. She has noticed a slight swelling of her ankles off
and on during the last three months. Her appetite has been poor, and
her weight has fallen from 187 pounds last May to 119 pounds at the
present time.

For the past week she has noticed bloody urine and has had cough
and pain in the chest. She has had no headache or vomiting.

On examination the temperature, pulse, and respiration were normal.
The apex of the heart was in the fifth interspace, anterior axillary line,
the action slightly irregular, with a tendency to gallop rhythm. There
was a soft systolic murmur at the apex, transmitted to the axilla, and
the pulmonic second sound was accentuated.

The blood-pressure was 175 mm. Hg. X-ray of kidneys and bladder
negative. The blood was negative.

There were many coarse and medium crackling rales scattered over
both chests. Otherwise they were negative. There was no edema.
The abdomen and extremities were apparently normal. The urine was
smoky, 101 r to 1014 in specific gravity; the twenty-four-hour amount,
from 40 to 50 ounces, with albumin from 0.1 per cent, to 0.0 per cent.
In the sediment were enormous numbers of fresh red cells. At tirst there
were no casts. Later on, moderate numbers of hyaline, fine and coarse
granular casts appeared, some with cells adherent. The hematuria
ceased in ten days. At no time was there any edema, headache, vomit-
ing, or oliguria.
1:;

674 DIFFERENTIAL DIAGNOSIS

Discussion. By reason of the symptoms alone a diagnosis of
pulmonary tuberculosis had previously been made in this case. The
cough, the chest pain, and the emaciation led to this mistake, which
was easily rectified when the chart and chest were examined. At no
time was there any fever or anything suggesting the usual signs of
pulmonary tuberculosis in the lungs.

We had no evidence of the ordinary causes of hematuria, such as
stone, tuberculosis, or tumor. There was nothing to call attention
to the bladder or to any disease, primary or secondary, in its walls.

The high blood-pressure, the urine, and the condition of the heart are
such as we expect to find in chronic nephritis of the glomerulonephritic
or interstitial type, especially the former. But we do not ordinarily
associate hematuria with chronic nephritis. It is in the acute cases
that we expect blood. Nevertheless, it has been repeatedly pointed
out, as a result of surgical experience within the past ten years, that
the kidneys in chronic nephritis may bleed profusely without any evi-
dence of an exacerbation of the renal disease itself. Why this occurs
we have no idea, but a number of surgeons have proved the fact when
searching the kidney for evidence of stone or other cause for the hema-
turia. Doubtless many of the cases of apparently causeless hematuria
belong to this group.

Outcome. -The patient was fatigued on the slightest exertion, and
was very slow in regaining her strength. Considerable improvement
took place, however, in the course of her two months' stay in the hospital.
Treatment consisted of diet, with an occasional bitter tonic.

Diagnosis. Chronic nephritis.

Case 351

A lady of seventy, of excellent family history and past history, en-
tered the hospital June 25, 1907. She has had nocturia (1 to 2) for
ten years. For about a year she has had to pass water frequently /'. c
about every two or three hours in the daytime, and seven or eight times
at night. During most of this period she has frequently noticed the
presence of fresh blood in her urine, together with small, blackish clots.
The urine has never been foul, and there has been no pain or burning
on micturition. There have been periods of a month or two during
the past year when she was free from her present trouble, but for the
last three months it has been constant. She has been gradually losing
weight for a number of years, but for the past year her appetite has
been very poor and emaciation has been rapid.

On physical examination the heart's apex was not seen or felt. The

HEMATURIA 6/5

sounds were best heard in the normal situation. There were no murmurs
or other abnormalities. The tension of the pulse was apparently in-
creased, but the blood-pressure was only 125. There were slight general
abdominal tenderness and a small umbilical hernia.

Several examinations of the urine showed essentially the same condi-
tions: Amount in twenty-four hours, 30 ounces; color, very dark
brown; specific gravity, 1016; albumin, 0.3 per cent.; bile and sugar
absent; sediment, large amount of fresh blood with numerous round,
mononuclear cells, somewhat larger than the erythrocytes. Occasional
small macroscopic blood-clots.

Vaginal examination was entirely negative, as likewise was the .x-ray
of the kidneys and bladder. Cystoscopic examination showed ulcerated
nodules in the wall of the bladder.

Discussion. Without a cystoscopic examination no diagnosis is
possible in a case of this kind. From her age, the urinary data, and the
bladder symptoms, one might suspect bladder stone or malignant
disease, but nephritis, genito-urinary tuberculosis, and renal tumor
would also be possible.

Genito-urinary tuberculosis is very rare at this patient's age. The
urine would probably contain more pus and less blood. Renal tumor
would probably be palpable after a course as long as that indicated by
this patient's history. The condition of the heart and arteries is not
such as we expect in chronic nephritis. Acute nephritis is almost
unknown at the age of seventy, especially in the absence of any infection
or poisoning.

Even without a cystoscope, then, the diagnosis of some bladder
trouble was rendered probable by the exclusion of renal disease. Bladder
stone would probably produce more discomfort than this patient suffered.
Cystitis is not likely to produce such long-continued bleeding. Tumor,
therefore, seems most probable.

The ocular evidence through the cystoscope left no considerable
doubt as to the nature of the case.

Diagnosis. Cancer of the bladder.

Case 352

A blameless cook of fifty years entered the hospital January 1 1 . 1007.
She had previously been there in rSo6 for "chronic cystitis." but ot
late years she has been very well. A year ago she fell down stair-, ami
although she kept about and on her feet after it, she became very much
exhausted, had pain in her back, and had to be sent to the Boston Cit}
Hospital. Two days after arriving there she passed blood} urine.

676 DIFFERENTIAL DIAGNOSIS

She went home convalescent six weeks later, and has since then been
very well.

Last Sunday (five days ago) she walked two miles to see Mrs. Mary
Baker Eddy's home. When she got back her urine was bloody, and
she had much pain on micturition, with tenderness over the bladder
and in the left lumbar region. She has been passing blood ever since.
She is very nervous, and says that her heart turns somersaults. She
has been steadily at work since November 1st the previous year. For
the past three years she has persevered in the habit of reading in bed
until 2 o'clock in the morning.

Physical examination shows an obviously cyanotic woman, with
slight tenderness in the lower abdomen, but without any other evidences
of disease except in the urine, which is bloody and shows in the sediment
much fresh blood and triple phosphate crystals. Xo casts or pus.
During her stay in the hospital the urine was approximately 45 ounces
in every twenty-four hours, specific gravity from 1010 to 1013, alkaline
in reaction, with a very slight trace of albumin. The colon bacillus was
recovered in pure culture from the urine. A r -ray of the kidney and
bladder was negative.

The patient had numerous chills, not accompanied by any rise of
temperature. The bladder was carefully sounded for stone, but none
was found. She was given uro tropin 10 grains three times a day,
abundance of water, and by the twenty-first of January the symptoms
were rapidly clearing up.

Discussion. Such bladder symptoms in a woman of this age are
often due to renal tuberculosis, but the alkaline urine, without any
considerable amount of pus, without fever or renal tumor, incline us
to look elsewhere for the cause of the symptoms.

The low gravity urine and the trace of albumin, together with the
age of the patient, lead us to consider chronic nephritis with one of
the periodic hemorrhages already referred to as an occasional complica-
tion of that disease. Against this idea, however, is the absence of any
cardiac enlargement and the fact that we can account for the small
amount of albumin present as a result of the hematuria itself.

The increase of symptoms following a walk, even though it was a
walk to the residence of the founder of Christian Science, suggests
bladder stone and led to the careful investigation of the bladder by means
of the sound. Since no stone was thus discovered, it did not seem
necessary to use a cystoscope.

Bladder cancer or papilloma is possible, and should the symptoms
recur a cystoscopic search will be indicated.

HEMATURIA 677

It seemed reasonable to try next the therapeutic test, based on the
idea that we were dealing with a cystitis of unknown origin, and pending
the results of animal inoculation with the urinary sediment.

Outcome. The sediment of the urine was injected into a guinea-
pig January 23d. When the animal was killed six weeks later no evi-
dence of the tuberculosis was found. By this time the patient was
convalescent, the urine almost normal. On the thirtieth of January
she went home apparently well.

Diagnosis. Cystitis due to the bacillus coli.

Case 353

A stationary fireman forty-nine years old was first seen on July 22,
1909. One sister died of cancer of the stomach; his family history and
past history are otherwise good.

Twelve years ago his urine began to be cloudy and occasionally con-
tained blood. At this time there was also pain at the end of micturition
on various occasions. He had acute retention nine years ago, and
was operated on at the Boston City Hospital by Dr. Watson through
a suprapubic incision. He believes that he had spasm of the neck
of the bladder. After seven weeks in the hospital he was able to be at
work, but his urine has ever since then been passed frequently and in
small amounts.

At the present time there is no pain. He passes water about every
two hours, and now and then there is blood in it. For the past six
months he has had a poor appetite, and has frequently vomited during
the day after drinking water. He has also had a great deal of sour
stomach and belching. Within the past year he has lost 28 pounds,
but he still weighs 187.

There was a systolic murmur at the apex of the heart, transmitted
to the axilla, and associated with accentuation of the pulmonic second
sound, but without cardiac enlargement. The abdomen showed
nothing abnormal. The urine was very turbid, but not at this time
bloody. The kidneys were not palpable. The cutaneous and sub-
cutaneous tuberculin reaction was negative.

Cystoscopy showed a normal bladder. Thick pus was seen coming
from the left ureter, while normal urine came from the right ureter.
A'-ray of the kidneys and bladder was negative.

Discussion. The case looks like one of tuberculous kidney, and
this disease cannot be positively excluded. In a case which has lasted
so long we should expect a palpable kidney, but as we do not know
with any accuracy the duration of the disease, this point is not of great

678 DIFFERENTIAL DIAGNOSIS

importance. More significant is the absence of fever, and especially
the absence of tuberculin reaction. The evidence against tuberculosis
could be strengthened by repeated search for tubercle bacilli in the
urinary sediment and by animal inoculation.

Hematogenous infections of the kidney would explain almost every-
thing in the case except the hematuria, but so far as I am aware hema-
turia has not yet been reported in connection with this type of disease.

Stones in the kidney may be divided into the "silent" and the "ob-
streperous"; the largest branching stones are often entirely latent and
symptomless, discovered first at autopsy or by the x-ray. Their size
makes it very unlikely that they will be overlooked in an x-ray plate,
such as was taken in the present case. On the other hand, the small
stones, such as might be missed in x-ray examination, are very much
more likely to cause pain. In this case we have no pain and no x-ray
shadows. Stone may be, therefore, in all probability excluded.

What are the other possible causes of a unilateral renal pyuria, such
as was here demonstrated by cystoscopy? I can think of but two:

(a) Pyonephrosis of unknown origin.

(b) Renal neoplasm.

Renal suppuration with a normal bladder and without tuberculosis
is not common except as a result of hematogenous infection, which I
have already discussed and excluded. Pyonephrosis of unknown origin
is usually intermittent, like hydronephrosis, the material accumulating
for a considerable period while a tumor gradually forms, then emptying
with a gush into the bladder, with disappearance of the tumor. There
is no history of anything of this kind in the present case.

Renal neoplasms are not prone to suppurate. Nevertheless, we do
find pus in varying amounts accompanying the hematuria or alternating
with it. It is impossible, therefore, to exclude neoplasm in this case.

Outcome. Operation August 3d showed that the left kidney was
converted into a pus-sac, which at the time was thought to be the result
of tuberculosis. Under the microscope, however, the wall of the sac
showed the structure of papillary cystadenoma. The kidney and ureter
were removed. The recovery from operation was satisfactory, but the
patient soon passed out of observation.

Diagnosis. Papillary cystadenoma of the kidney.

Case 354

An iron-molder of forty- two entered the hospital April 6, 1906.
His uncle has recently developed bloody urine. His wife has cancer
of the uterus. His past history is, nevertheless, uneventful.

HEMATURIA 679

One month ago he noticed that his urine was dark in color, and
except for one day, it has been of this same tint ever since. There
has been no pain at any time, and no other symptoms. Xo clots or
gravel have been noticed. The color of the urine varies a good deal,
but is never normal. Cystoscopic examination by Dr. Lincoln Davis
showed considerable intravesical enlargement of the prostate. The
bladder was normal. From the right ureter came a jet of blood-tinged
fluid, from the left, normal urine.

Except for a mild secondary anemia, physical examination was
otherwise entirely negative. The blood, pulse, and temperature were
normal. The urine averaged 35 ounces in twenty-four hours, with a
specific gravity of 1027 to 1031, a large trace of albumin, but no sugar.
The sediment was made up of normal blood and a few leukocytes. New-
growth of the kidney was thought to be the most likely diagnosis.

Arrays of the kidney and bladder were negative. The sediment of
the urine was repeatedly investigated for tubercle bacilli, with negative
results.

On the eighth of April there was no blood in the urine, but on the
tenth it was again present.

During these three days urotropin, 10 grains, was given every eight
hours, with abundant water.

Discussion. As a result of the cystoscopic examination we know
that the blood comes from the right kidney, not from the bladder. YVe
have no evidence of stone or of tuberculosis in the kidney. The urine
and the condition of the heart do not suggest nephritis. We find no
calcium oxalate crystals or other source of local irritation. Xo drug
or poison capable of inducing hematuria had been ingested. The
patient has no form of hemorrhagic or infectious disease, no anemia
or leukemia, no cachectic condition, such as might be complicated by
renal bleeding.

When all these possibilities are excluded, as is often the case in
the differential diagnosis of hematuria, two alternatives remain. We
may be dealing with hematuria due to:

(a) Renal neoplasm.

(7;) Unknown cause.

It has already been stated, in the discussion of a previous case,
that diagnosis of renal new-growths is often impossible until the tumor
has reached a considerable size or has produced metastases. There
may be months or even years of latency with nothing but an occasional
attack of hematuria, perhaps without even this. A- no tumor can be
felt in this case, we have no definite reason for the diagno>i- ot new-

680 DIFFERENTIAL DIAGNOSIS

growth, but we can by no means be sure of its absence except as the
result of exploratory incision.

A very large number of hematurias perhaps the majority of them
all are due to causes altogether unknown to us at the present time.
After we have distinguished and excluded chronic nephritis as a cause
of otherwise inexplicable hematuria, we have left the bleedings due to
minute varices or vessels in the renal pelvis. In many cases not even
these slight lesions can be found when the kidney is opened at opera-
tion or at autopsy. Vague guesses like "vicarious menstruation," smart
phrases like "renal epis taxis," do not help us, and for the present we are
altogether in the dark regarding the cause of a large group of hematurias.

Outcome. The kidney was cut down upon April 18th, and found to
be entirely healthy both within and without. A month later the patient
wrote that he had remained perfectly well since leaving the hospital.

Diagnosis. Hematuria, cause unknown.

Case 355

A physician of forty, always previously well, was first seen August
26, 1908. About eleven that morning he noticed that his urine was
bloody. The urine passed the night before was normal. He has been
having a cold, with some cough and hoarseness for six days, and at the
onset of this illness much headache and chilliness. At the present time
the cold is practically gone and his urine is exceedingly clear.

Physical examination of the internal viscera was wholly negative.

A'-ray of the kidneys and bladder showed no stones. The urinary
sediment consisted of blood with many large calcium oxalate crystals.
On the morning of the twenty-seventh the urine was normal in color.
Later in the day it was again bloody, the amount of calcium oxalate
varying directly with the amount of blood.

Discussion. In the absence of fever, pyuria, and local bladder
symptoms, tuberculosis seems here unlikely. A careful study of the
urine and of the kidneys by .r-ray showed no evidence of stone, nephritis,
or vesical parasites ibilharzia disease). Cystoscopy was considered, but
since there were no bladder symptoms or other definite indications to
guide the search, it was postponed. Malignant disease of the kidney
and tuberculosis were considered, but no concrete evidence could be
found to support either idea.

We were much impressed with the close parallelism between the
degree of hematuria and the amount of calcium oxalate present in the
urine from hour to hour and from day to day. So close was this paral-
lelism that it seemed wise to base treatment upon the idea that the

HEMATURIA 68 1

calcium oxalate might be causing sufficient irritation to produce the
hematuria by some means or other. Nevertheless, we felt by no means
convinced that this hypothesis was correct, and looked forward with
much interest to its confirmation or refutation through the outcome.

Outcome. The patient was given a diet from which tomatoes,
spinach, berries, cocoa, tea, and pepper were excluded. The carbo-
hydrates of the diet were also moderately limited. Water was given in
abundance; also 30 grains of sodium phosphate before each meal. By
the twenty-ninth of August the bleeding had wholly ceased. Eighteen
months later there had been no return of the symptoms.

Diagnosis. Renal irritation from oxaluria.

Case 356

A man of forty-eight, who had had lead-poisoning four years before,
entered the hospital January 21, 1903.

Eight years ago he had an attack of pain in the region of the right
kidney and thinks he passed a small calculus. Two years ago he
began to notice blood in his urine, and this was almost constant for six
months. When it stopped for a day or two, he usually had pain over
the right lumbar region, relieved when blood reappeared in the urine.

Tn the next six months hematuria came for about twenty-four hours
every week or two. Between these attacks he had dull pain in the right
renal region, relieved, as before, by bleeding. When bleeding occurred,
he also noted pain at the end of the penis. He was now losing strength
and had to give up work. Hematuria continued off and on until two
months before he entered the hospital, when it ceased altogether. He
has lost 50 pounds.

Physical examination showed emaciation, anemia (hemoglobin, 60
per cent.). Temperature, 99 to 101.2 F.; chest and extremities
normal; in the right hypochondrium a nodular, insensitive mass,
extending 9 cm. below the ribs, descending with dee]) inspiration.
Urine bloody, otherwise normal; leukocytes, 6500.

Discussion. The renal pain makes it altogether probable that the
kidney, rather than the bladder, is the source of the hemorrhage. The ] >res-
ence of a palpable tumor in the renal region points strongly in the same
direction. Tuberculosis, stone, and neoplasm are the chief possibilities.

Stone never produces a tumor having these characteristics: it may
lead to a small accumulation of pus and cheesy material in the renal
pelvis, but not to anything like the mass here described.

The emaciation, the fever, and the renal tumor are quite consistent
with tuberculosis, but we expect pyuria, less profuse bleeding, and more

682 DIFFERENTIAL DIAGNOSIS

bladder symptoms, such as urinary frequency, burning, and pain.
Nevertheless, tuberculosis cannot be excluded without cystoscopy and
animal inoculation.

The occurrence of pain relieved by bleeding is distinctly suggestive
of renal tumor, also the long duration of the bleeding without any check.
Indeed, the most prolonged attacks of hematuria which we recognize
clinically usually turn out to be due to renal neoplasm. In nephrolithiasis
the bleeding is usually brief, and accompanies the pain, instead of
relieving it.

Outcome. Operation showed a hypernephroma which weighed
i^oo grams, and measured 16x14x12 cm. This was successfully
removed. Nine months later the patient wrote that he was steadily at
work and had gained 40 pounds.

Diagnosis. Hypernephroma.

Case 357

An Irish stableman of twenty-eight entered the hospital August 18,
1906. His family history and past history are negative.

Two months ago he noticed that his urine was bloody. He experi-
ences a dull pain in his back, more or less constant. A considerable
portion of the time since then, he has had pain in the epigastrium, in-
creased by food, and has vomited frequently.

Physical examination of the chest and abdomen is negative. In
the right back, just below the angle of the scapula, was a tumor the size
of a small English walnut, freely movable beneath the skin, not tender,
and was said by the patient to be due to a bullet which entered just
below the right nipple in the front and lodged in his back. The patient
showed evidence of marked anemia, the red cells being 3,300,000, hemo-
globin, 40 per cent., white cells, 9000. The stained specimen showed
nothing remarkable except achromia. The urine contained a large
amount of normal blood, but no casts. It was sufficient in amount,
and not abnormal in any other respect. Tuberculin reaction (cutaneous)
negative.

A'-ray of the kidneys was negative. Through the cystoscope blood
was seen spurting from the left ureter. There was no evidence of trouble
in the bladder.

Discussion. Left renal hematuria associated with well-marked sec-
ondary anemia occurring in a young man who complains of no bladder
symptoms presents a clinical picture distinctly puzzling at the outset.
We have done what we could to rule out stone, nephritis, calcium oxa-
late, and other toxic infectious and constitutional sources of hematuria.

HEMATURIA 683

Tuberculosis rarely produces so marked an anemia except in ad-
vanced cases with well-marked pyuria, fever, or tumor. Against tuber-
culosis we have the absence of the above signs and the absence of a
tuberculin reaction.

Renal new-growth is always a danger threatening such patients
i. c, patients with unexplained hematuria. The nodule in the right
posterior thorax is not so situated as to correspond with any of the
ordinary sites for metastasis from a renal or suprarenal tumor. There
seems no good reason to doubt that the patient's idea about the origin
of this nodule is correct. If the case be not one of renal tumor, we
have no other plausible alternative to suggest. Very possibly it may
be one of those cases of "idiopathic" bleeding discussed on p. 680.
Further certainty can be obtained only by operation. As the patient
does not seem to be improving and has a very considerable degree of
anemia, exploratory incision seems justified.

Outcome. In the pelvis of the left kidney there was found at
operation one or two clots of blood. A section of the kidney was re-
moved for examination and showed absolutely normal kidney tissue.

September 2d: The patient, who had made a good recovery from
the operation, though he still continued to pass considerable amounts
of fresh blood, began to complain of stiffness in his neck and jaw muscles,
with pain, and was unable to open his mouth more than an inch. Later
in the day he began to have convulsions, and died at 9 p. m.

Autopsy showed ulcer of the stomach, no cause for hematuria, and
nothing else of importance.

The results of the autopsy indicate that the anemia was in all proba-
bility due, in part at least, to the gastric ulcer. Our attention had been
completely diverted from this side of the case by the more spectacular
symptoms, especially the hematuria. In the retrospect we say to
ourselves for the hundredth time that a major operation should never be
lightly undertaken.

Diagnosis. Gastric ulcer. Hematuria; cause unknown.

Case 358

A Jewish schoolboy ten years old was seen October 15. 1908. Ik-
had measles when he was thirteen months old. Six weeks later he
began to have incontinence of urine, which he has had ever since. The
trouble is mostly nocturnal. This morning his mother saw in his bed
some blood, which she thinks was passed during the night. The boy
did not know it. but since that time has continued to pa exceedingly
bloody urine, with clots.

684 DIFFERENTIAL DIAGNOSIS

Physical examination was entirely negative; the urine contained only
blood with pus and large mononuclear cells. Catheter specimen remained
sterile on culture-media. No tubercle bacilli found. Cystoscopic
examination showed general reddening with areas of ulceration. No
stone. The stream from each ureter was clear.

Discussion. Sudden hematuria occurring in a boy of ten without
previous evidence of cystitis is distinctly rare. Stone in the bladder
was my first thought after going over the case. The renal causes of
hematuria, such as have been discussed in the previous pages, are all
of them, very infrequent in children, with the single exception of renal
new-growth, of which we had no evidence in this case.

The results of cystoscopy showed that we had no reason to suspect
the kidney as the source of bleeding, and indicated that we were dealing
with a cystitis of unknown origin. What may have been the duration
of this cystitis we have no means of judging; it gave no signs of its pres-
ence until the day on which he was seen, unless, indeed, we reckon
the eight years of nocturnal enuresis as such a sign. I see no good reason
for considering the enuresis in this light.

Outcome. The patient was given urotropin, 5 grains three times
a day. October 25th the urine was free from blood and the incontinence
had almost ceased. By the first of November he seemed perfectly well
and entirely able to control the flow of urine. This improvement was sub-
sequently maintained. A guinea-pig inoculated with the urinary sedi-
ment was killed seven weeks later and showed no evidence of tuberculosis.

A point of considerable interest in this case is the sudden stoppage
of a long-standing and obstinate enuresis. Can we suppose that the
cystitis was of a chronic type and represented the cause of the incon-
tinence? It does not seem probable, for at no time had the boy's
symptoms differed from those of any other case of enuresis. He can
hardly have had the cystitis since his thirteenth month.

Another possible explanation presents itself: May it not be that
the instrumentation itself the cystoscopy cured the enuresis? It is
a well-known fact that enuresis is prone to cease after an operation of
any kind, presumably because the operation makes a strong impression
upon the child's gray matter, both cerebral and spinal. In the present
case the boy had no reason to suppose that the cystoscopy was done
for the relief of enuresis. He knew that he was being treated for the
hematuria, and that nothing was said about curing the other and older
habit. Nevertheless, he may have drawn his own conclusions in his
own way we cannot tell.

Diagnosis. Cvstitis; enure-is.

HEMATURIA

68 5

<* o

Bl 1>

3 _'

3 _

2 ?

k r:

CHAPTER XXI

DYSPNEA

It is, on the whole, best to maintain the usual distinction between
dyspnea and polypnea, and to use polypnea for a quickening of respira-
tion without any evidence of effort or distress, objective or subjective.
Such a polypnea is seen most often in infectious fevers, such as typhoid
or septicemia, less often in the terminal coma of diabetes. In its extreme
form it is to be witnessed in hysteria, which produces the most rapid
breathing to be met with clinically.

Nevertheless, the distinction above explained is neither so sharp nor
so logical as we might desire. When a healthy man begins to run, his
breathing is first quickened, polypnea, then, at the end of a variable
period, it begins to be slightly difficult, until at last true dyspnea is
reached. So it is in cases of failing cardiac compensation, and occa-
sionally in general infections such as those above mentioned. In the
early stages of the disease the breathing is quickened; later it becomes
difficult as well. We might agree to say that dyspnea begins when
the accessory muscles of respiration are called into play. But this is
rather an arbitrary distinction. The movement of the ala nasi begins
in some patients before the breathing has become even distinctly
quickened, yet this movement must, I suppose, be reckoned among
those involving accessory muscles of respiration.

For these reasons it seems to me that we can maintain the distinc-
tion between dyspnea and polypnea only as one of convenience, and in an
approximate sense.

Dyspnea and short breath are not always used as equivalents. Some
patients puzzle us very much by complaining of short breath despite our
inability to find any sign of disease on physical examination. More
careful questioning sometimes brings out the fact that by short breath
the patient means a feeling of inability to get as much breath as he
thinks is owing him. His breathing may not be quickened or difficult,
but he has the sense that he cannot fully till or distend his lungs. This
is complained of most often by those who are overworked, underfed, and
short of sleep, or who. for some other reason, have allowed themselves
to get run down. Beyond this I have no idea of its explanation.
680

Causes of Dyspnea

1. EXERTION AND EXCITEMENT | CASES TQO MANy AND JOO VAGULY ENUMERABLE

[ FOR GRAPHIC REPRESENTATION.

2. INFECTIOUS DISEASES

3. CARDIAC DIS-
EASE

3780

4. PHTHISIS

2037

5. CHRONIC

BRONCHITIS

913

6. PNEUMONIA

805

7. CHRONIC

NEPHRITIS

718

8. ASTHMA

380

9. EMPHYSEMA

328

DYSPNEA 689

Among the types of difficult breathing we may distinguish :

(a) Inspiratory dyspnea.

(b) Expiratory dyspnea.

The last is by far the most common, and is seen in the great majority
of uncompensated cardiac cases, in pneumonia, pulmonary tuberculosis,
and other cardiac and respiratory affections.

Inspiratory dyspnea is comparatively infrequent, and occurs especi-
ally as the result of some obstruction in the upper air-passages, for
example, in laryngeal diphtheria, edema of the glottis, "croup," tumors
of the larynx, foreign bodies in the larynx, trachea, or primary bronchi,
postpharyngeal suppurations, Ludwig's angina, and similar conditions.
If the obstruction is below the primary bronchi, we do not see dyspnea
of this type.

Expiratory dyspnea, usually accompanied by wheezing noises, occurs
chiefly in emphysema and asthma, occasionally in pulmonary edema.
It is apt to be more or less paroxysmal, whatever its cause.

CAUSES OF DYSPNEA

Heart disease, phthisis, and pneumonia are doubtless the commonest
sources of dysjmea, but one sees the slighter degrees of the condition in
a great many anemic or debilitated patients, perhaps as the result of a
slight cardiac insufficiency not recognizable by other means.

Very acute and alarming dyspnea is seen at the onset of pneumo-
thorax, although both the frequency and the distress disappear altogether
within the course of a few days or weeks after the thoracic cavities and
their contents have adjusted themselves.

Occasionally in miliary tuberculosis one sees a dyspnea so extreme
and a rate so rapid that hysteria is sometimes falsely diagnosed. A
careful history and a thorough physical examination should set us
right.

Increased intrathoracic pressure due to mediastinal tumors, to
aneurysm, and occasionally to pericardial effusion may produce dyspnea,
sometimes of a paroxysmal type, which is difficult to understand, since the
cause persists unchanged.

A high diaphragm pushed up by pressure from an accumulation ot
fluid or gas or by some solid tumor causes a certain amount of polypnea,
and occasionally dyspnea, by reducing the amount of space available
for respiration.

690 DIFFERENTIAL DIAGNOSIS

THE EFFECT OF POSITION AND OF THE TIME OF DAY

Probably for the reason referred to in the last paragraph (high
diaphragm) dyspnea is always increased by the recumbent position
and eased by sitting up. In extreme cases the patient leans forward
over his knees and much prefers to sit in a chair, owing to the cramped
position of his legs in bed. Mountain-climbers at extreme elevations
instinctively assume a similar position when endeavoring to rest.

All types of dyspnea are apt to be worse at night. This is not wholly
due to the fact that at night the patient is usually trying to assume a
recumbent position. Even with bed-ridden patients, whose position
varies scarcely at all in the twenty-four hours, dyspnea is much more
annoying after dark. This has been explained by Hoover and others
as due to the fact that the respiratory center goes to sleep and allows
the respiratory act to become almost suspended. The patient then
wakes with a horrible gasp. It is in accord with this theory that the
most troublesome dyspnea of most cardiac patients is in the earlier
hours of the night, when sleep is deepest. Later in the night they can often
lie down and get some rest.

CHEYNE-STOKES BREATHING

Regularly recurrent or periodic variation in the depth and frequency
of respiration, with intervals of apnea alternating with dyspnea, receives
the name of Cheyne-Stokes breathing. If there is no pause or apneic
period, but merely a rhythmic quickening and slowing of respiration,
the name of Biot's breathing is applied.

Either of these types of breathing may occur in healthy infants
during sleep. In adults they usually complicate severe disease of the
heart or kidney, less often of the brain, but also occur in the more
critical stages of acute infectious diseases, such as pneumonia, and
under these conditions may not be the harbinger of death. In cardiac
and renal troubles such breathing is a bad prognostic sign, though I
have known it to occur during sleep for many months before the fatal
termination.

Case 359

A German messenger-boy of twenty-two was first seen February 18,
1908. His family history was negative. Seven years ago he was thrown
from a horse and trampled on; his left thigh and many of the ribs on
the left side were broken. He was in the hospital for eighteen months,
and states that he was unconscious for the first six months of this time.
In December, 1907, he was in the Boston City Hospital for three days
on account of a cough of four days' duration, accompanied by blood-

DYSPNEA

691

Hot ^acAuxt> ha^t

Im HOUff LtTCH.

streaked sputum and pain in the left axilla. Physical examination
was negative, and he was discharged in three days. He again entered
the same hospital on the ninth of January, 1908, complaining of chest
pain, sore throat, and a slight cough. Careful physical examination
and x-ray examination showed nothing. Since that time he has felt
weak and run down, but has worked steadily up to this morning. For
a week he has noticed that his left ear was not as good as is the right,
and for the same period he has had sensations of pinching on both sides
of the chest near the left nipple,
and in the neck a feeling as if it
were being scraped.

For the past four days he has had
frequent cough with bloody sputum.
He thinks he may have raised as
much as half a pint of blood in the
whole four days. During this time
his breathing has been very rapid.
He has been restless and wakeful at
night, and has vomited everything
that he has taken. When on his
feet, he is dizzy and faint. He has
had frequent chilly sensations, but,
so far as he knows, no fever. This
morning while at work he fainted
away, but walked .to the hospital
without assistance.

On physical examination the
patient showed a remarkably rapid
respiration, 80 to the minute,
though his pulse was only 72, later
slowing down to 50. Temperature
was 99. 4 F. He lay flat upon the

accident room table, and seemed to be half asleep, except when spoken
to; then he was notably alert, answering all questions in a strong, clear
voice. There was an occasional slight, dry cough. The throat was
somewhat reddened, the pupils equal and reacting normally, the heart
absolutely negative, the lungs slightly less resonant in the right front
than in the left. In the same region the voice-sounds are very slightly
increased. Inconstant bubbling rales are heard in the right front and
back. Physical examination, including the nervous system, blood, and
urine, was otherwise entirely negative.

Fig. 181. Anesthetic areas demon-
strated in a case of polypnea.

692 DIFFERENTIAL DIAGNOSIS

During the first week of his stay in the hospital the patient's respira-
tion continued at from 80 to 95 a minute, while his pulse was from 50 to
60. His hands, arms, and lower legs were cyanotic, congested, mottled,
showing marked sluggishness of the capillary circulation. The face
was flushed, but not cyanotic. He was as comfortable when lying down
as in any other position. The fundus oculi was negative.

Discussion. Summing up the past history of this boy, we find two
sets of events, one or both of which may bear upon his present dis-
turbance of breathing. The first of these, however, the accident of
seven years ago, seems rather too much in the past to be of any impor-
tance in relation to his present trouble. The pulmonary injuries arising
from broken ribs are matters of immediate importance within a few
days or weeks after their occurrence, not after the lapse of seven years.
Questions of this kind are raised in connection with suits for damages
supposedly due to accidental injuries, and it is often claimed that an
injury of this kind might be the source of long-standing pulmonary
disease. I do not believe that there is any sufficient ground for this
idea.

The two attacks of axillary pain with cough are very much more
recent, and are probably connected in some way with the present trouble.
Tuberculosis is strongly suggested by the hemoptysis, as well as by the
nature and position of the pain (pleuritic?). I have known polypnea
similar in many respects to that here described, and due, as it afterward
turned out, to miliary tuberculosis. This, indeed, was my first thought
in the case here under discussion. The absence of cyanosis, the remark-
ably slow pulse, and the perfect comfort in the reclining position first
aroused our skepticism, which was further increased by the nearly
negative results of physical examination.

No blood was expectorated during his stay in the hospital, and we
had no independent account of the fact of blood-spitting only the
patient's own statement. The other symptoms complained of the
fainting and dizziness, the sensory disturbances in the chest and neck,
the curious mental state, and the mottling of the skin all pointed toward
a functional nervous disturbance as at least a part of the cause of these
symptoms. It will be recalled also that he is stated to have been
unconscious for six months after his accident of seven years ago a
condition strongly suggestive of hysteria. This hypothesis accordingly
was followed up and led to the additional observations recorded in the
outcome.

Outcome. It was noticed that when actually talking to his friends,
his breathing slowed down to the normal, and that any interruption or

DYSPNEA 693

surprise would slow his respirations for a few seconds. During the
night he got but little sleep, but when he dozed off, it was noted that his
respiration fell to 21. The patient's friends say that he has been very
peculiar and untruthful for a long time.

The patient's bed was screened off and he amused himself by reading.
When thus occupied, his breathing would at times fall to normal. At
times his pulse was as slow as 45 and his respiration as rapid as 100.
The patient's headache was entirely removed by an ethyl chlorid spray.
Areas of absolute anesthesia, as shown in the accompanying diagram,
were demonstrated by Dr. Fitz at a clinic. Half an hour later the>
were not present.

It was later learned that he had worked for a long time in the hospital
at Baden, Germany, and was interested in medical subjects; also that
seven weeks ago he received news of the death of his father, the last of
his immediate relatives. Since then he says he feels that he has no one
to live for. On the twenty-fourth of February it was noticed that he
had no palatal reflex. On the third of March he said that he had
swallowed a safety-pin. He did not say whether it was open or closed.
X-ray showed a doubtful shadow in his stomach. The patient said he
could feel the pin in his throat.

At this time the respiration became more normal and remained so,
but the next day he said he could feel the pin in the region of the left
sacro-iliac joint. The patient was dry-cupped at this point, and re-
assured. His respiration still remained normal, and he was allowed
to go home.

In view of all these facts we had no hesitation in making the diagnosis
of hysteric polypnea. Of the four cases of this disease which have come
under my observation, three have occurred in male patients. In all,
the rapidity of the breathing was greater than in any but the terminal
stages of organic pulmonary or cardiac disease. From these it may be
distinguished by the following criteria:

(a) Hysteric polypnea is not associated with any demonstrable
lesions of the heart or lungs; the cough is generally very trifling.

(b) The rapid respiration does not continue throughout the twenty-
four hours; it may often be interrupted, as in the present case, whenever
the patient can be led to talk with interest, and frequently ceases during
sleep.

(r) Other evidences of hysteria are usually demonstrable for
example, the susceptibility to suggestion, areas of anesthesia, and wide
deviations from the truth which seem like ordinary lying, but are more
probably due to the peculiar mental state.

694 DIFFERENTIAL DIAGNOSIS

(d) The distress, cyanosis, orthopnea, and other evidences that
breathing is difficult (true dyspnea) are absent. The breathing is rapid
but not labored, and its rapidity is usually much greater than that asso-
ciated with any organic disease of the heart or lung.

Diagnosis. Hysteric polypnea.

Case 360

A collector, sixty-four years old, was first seen March 10, 1908.
He has had dyspnea for eighteen months. For the past four or five
weeks it has become worse, and he has slept every night in a chair.
For two or three weeks he has had a cough with yellowish sputa.

Physical examination shows obvious loss of weight. The left pupil
is larger than the right, and slightly irregular. The heart's impulse
is in the fifth space, f inch outside the nipple. There is no obvious
enlargement to the right. The action is irregular and the sounds are
indistinct. The second aortic sound cannot be heard. A coarse, dis-
cordant, squeaking murmur is heard with systole at the apex, and is
transmitted to the axilla. At the base there is a rough systolic murmur,
and along the left border of the sternum a low-pitched diastolic murmur.
In the third right interspace near the sternum is a systolic thrill. The
arteries are palpable, tortuous, and show a lateral excursion. The
pulses are of small volume, low tension. There is no capillary pulse.
Coarse bubbling rales are scattered throughout both lungs, and there
is dulness, diminished respiration, and fremitus at both bases behind.
The abdomen shows dulness in the flanks, shifting w 7 ith change of
position.

Discussion. A long-standing dyspnea in a man of sixty-four
associated with a cough which is of very recent origin is almost invariably
due to cardiac disease. Since there are well-marked cardiac lesions
shown on physical examination, and nothing in the lungs except what
is easily explained by passive congestion, it is proper to assume that
the heart disease is the cause of the dyspnea, unless evidence is pre-
sented suggesting another cause.

A to-and-fro murmur in the upper half of the precordial region,
associated with absence of the aortic second sound, a systolic thrill, a
pulse of small volume, and moderate cardiac enlargement is strong
evidence of aortic disease with stenosis and regurgitation. The diagnosis
of aortic stenosis is one of those most often made erroneously. In my
opinion it should never be made unless there is also evidence of aortic
regurgitation in other words, so-called pure aortic stenosis probably
does not exist. At any rate. 1 know of no convincing evidence of its

DYSPNEA 695

occurrence. Stenosis accompanied by regurgitation is a proper con-
clusion under two sets of conditions:

(a) In any case exhibiting signs essentially identical with those just
given.

(b) In any long-standing rheumatic case showing an aortic regurgita-
tion in a person under twenty-five, whether there are physical signs of
stenosis or not. This latter conclusion is the result of postmortem
observations. I have never known a case of long-standing heart disease
in a young person in which pure aortic regurgitation was discovered at
autopsy. Stenosis always accompanies it, because the rheumatic type
of endocarditis does not stay long upon the aortic valve without produc-
ing stenosis. In older persons aortic regurgitation without stenosis is
very common, and the presence of a systolic murmur without the other
signs recorded in this case should never be considered as sufficient
evidence for the diagnosis of stenosis. In the present case we have all
the cardinal signs.

Outcome. Under rest in bed, with digitalis and purgation, he
improved very much within three days. Blood and urine were normal,
temperature constantly subnormal; pulse and respiration not remarka-
ble. Under 15 minims of digitalis tincture three times a day the patient
was able to be up and about by the twenty-first. On the twenty-fifth
digitalis was omitted, and the patient was able to walk about without
distress. A half-ounce magnesium sulphate was still given every morning.
On the twenty-ninth he was allowed to go home.

Diagnosis. Aortic stenosis and regurgitation.

Case 361

A school -girl eight years old was first seen November 19, 1907.
The mother now has consumption. Two sisters have died of pneumonia.
The child had the measles and chicken-pox five years ago. Four years
ago she visited the Boston Dispensary and was told that her heart was
enlarged. Three years ago she was kept out of school for the whole
winter, and seemed about as she is at present, but picked up in the
spring. For three weeks she has been short of breath on exertion, and
has complained that her feet were sore. In the same period she has been
growing pale and thin, and has been heard to moan in her sleep. Two
or three times in the last four days she lias coughed up a teaspoonful of
blood.

The course of the temperature, pulse, and respiration are seen in
the chart (Fig. 182). The child is very pale, though her hemoglobin
is 75 per cent. The apex impulse is difficult to place, but seems

6o6

DIFFERENTIAL DIAGNOSIS

to be in the sixth space, \ inch inside the nipple-line. At the apex there
is a palpable presystolic and systolic thrill. When the child is lying
down, a systolic impulse can be traced as far out as the seventh space,
and nearly to the posterior axillary line. No left border of dulness can
be marked out. (See Fig. 184.) Cardiac pulsation can be felt over the
dull area to the right of the sternum. A loud to-and-fro friction rub
is heard in the exposed space. (See Fig. 183.) In this area the heart-
sounds cannot be clearly made out. In the anterior axillary line systolic
and diastolic murmurs are heard. Posterior to this point the first sound
is very sharp. The right lung seems normal. The left lung is hyper-
resonant at the apex, but below that dull, gradually increasing to flatness

-.'....- ,,UwL.^j*j J*Xj.jL , * 3 - s <. -7 fr? ..[.. ...U ~|>rU ,XfUU

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-. Z\X* X

s z ?Eu ^ z\z x

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ill II

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i K

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Fig. 182. Chart of case 361.

at the base behind, where the breath-sounds are bronchial, though
feeble. Above this many fine and medium crackles are heard. The
edge of the liver can be felt across the upper abdomen, as seen in the
diagram.

Discussion. As I have definitely stated that a to-and-fro friction
rub is audible in the exposed space, there can be no reasonable doubt
that we are dealing here with pericarditis. If the friction were pleuro-
pericardial in origin, one would not describe it by the words here used,
and there would be some note regarding its change or disappearance
when the breath was held.

But acute serofibrinous pericarditis does not cause dyspnea unless

Fig. 183. Results of palpation, percussion, and auscultation in a patient complaining
of three weeks' dyspnea.

Fig. 1S4. Signs in back (Case 361). (See also Fig. 183.)

DYSPNEA 697

the amount of effusion is large. We see postmortem many a shaggy
heart {cor villosum) which has developed as a terminal complication
in chronic nephritis without producing any dyspnea whatever. In the
present case, therefore, the important question is: What else have we
besides such a pericarditis?

It is to be noticed, in the first place, that the child's heart has been
known to be enlarged for at least four years; in the second place, that
there is apparently decided enlargement now, although it is impossible
to say just where the left border is. There is a double apical murmur
and thrill which, in itself, aside from the other conditions present,
would lead us to suppose that the mitral valve was narrowed and incom-
petent. But to any one who has had a considerable opportunity to
verify his cardiac diagnoses postmortem it will be an old story that, in
markedly enlarged hearts, systolic and presystolic murmurs at the apex
have no diagnostic value. They may be present with or without valvu-
lar lesions.

The observations of the last ten years, especially in England, have
made it clear that in the heart troubles of childhood the whole heart
endocardium, myocardium, and pericardium is usually involved. In
the inflammatory process attacking the heart, the part borne by the
valve is usually far less important than that borne by the myocardium
and the pericardium. In other words, pericarditis is much more
common than endocarditis in the heart troubles which occur in child-
hood, with or without joint infection (rheumatism) and chorea. But
in all cases the affection of the myocardium is the all-important element,
though we have no direct auscultatory evidence of its changes, such as we
often have when the endocardium or the pericardium is attacked.

A point of practical importance in these cases is this: Xo matter
what murmurs arc present we are not bound to assure ourselves or the
family that an incurable cardiac malady is present. If only the myo-
cardium has been severely inflamed, we may see an almost complete
restoration of the cardiac functions with the disappearance of the mur-
murs and a return of the heart almost or quite to its normal size. This
result, however, comes only after months of rest and careful watching.
In the great majority of cases digitalis does harm.

Outcome. Under rest in bed, with tincture of digitalis 5 minims
every four hours, the temperature and the friction rub gradually sub-
sided. After the 1st of December she was carried out-of-doors each
day and gradually improved. By the fifteenth of December the friction
rub had disappeared and the sounds in the left lung were reduced to very
slight dulness at the extreme left base, with cogwheel respiration, but no

698 DIFFERENTIAL DIAGNOSIS

rales. On the twenty-first of December the cardiac apex was in the
sixth space, 3^ inches from the median line. There was a palpable
thrill and a rough presystolic murmur, followed by a loud systolic murmur
at the apex. The child could walk about without dyspnea and seemed
nearly well.

In this case presumably the mitral valve was attacked, as well as the
myocardium and the pericardium.

Diagnosis. Infectious endocarditis, myocarditis, and pericarditis.
Mitral stenosis and regurgitation.

Case 362

A married American woman, forty-one years old, was seen March
13, 1908. Her family history and past history are excellent. For
six months she has noticed that she has been short of breath. There
has been no cough, no edema, no orthopnea. For four months she
has been getting weaker, but has kept at work until four weeks ago,
when she fell over at her work. She was not unconscious, but, she says,
"I had no pulse and no heart-beat and they worked over me for two
hours before I was better." She has been in bed since that time, and
while quiet, feels well enough except for a little pain around her heart.
There has been some bloody vaginal discharge for a considerable portion
of the time in the last five years; there are few days in the month
without bleeding, though the amount is small.

Physical examination showed no anemia and nothing demonstrably
wrong in the chest or abdomen; normal urine. During the subsequent
week she had more or less continuous bloody vaginal discharge, asso-
ciated with slight anteflexion and retroversion and a little erosion about
the cervix.

Under gas and ether on the nineteenth of March a jet of hot steam
was introduced into the uterus, the vagina being protected by a con-
tinuous stream of cold salt solution passing around the uterine tube
during the process. The steam was continued for forty seconds, and
after a few minutes' intermission, for thirty-five seconds. Following
this the uterine discharge ceased.

Discussion. The hyperplastic endometritis which doubtless was
present in this case must have produced an undesirable and in some
ways debilitating drain upon the system, though it cannot have been
of very great physical importance, since no anemia was produced. But
psychically such a drain has a very great effect on most women, especially
when the knowledge of its presence is given a solemn and ominous

DYSPNEA 699

significance by the hints and fears of kindly neighbors who have "seen
what such things come to."

Nothing in the physical examination gives us any definite knowledge
of an organic disease to which this dyspnea may be made secondary,
but it is a fact very familiar to clinicians that "short breath" is com-
plained of by a great many patients in a variety of debilitated conditions.
In some of these patients cross-questioning showed that no true dyspnea
is present, for by "short breath" they mean not a rapid and difficult
respiration, but a certain sensation as if they were unable to draw as
full a breath as they desired. It is thus a sensory, not a motor, phenom-
enon, and as such should be distinguished from true dyspnea. Just
what is the significance of this sensation I have no idea. One meets it
in a great many neurasthenic persons and sees it pass off under reassur-
ance and work-cure without any change in the condition of the circula-
tory or respiratory organs.

One also sees a great many cases of true dyspnea which are never
fully explained. The symptom is indeed much more common than is
often realized, because we often forget to ask for it, and unless questioned,
patients often do not mention it. It may be surmised that these unex-
plained types of dyspnea are due to mild forms of myocardial insuf-
ficiency which recover without our being able to be sure that they exist
or to recognize their cause. It seems altogether probable a priori that
such types of insufficiency occur and that they will assume greater
importance in the future.

One often hears from patients the history of an attack like that
suffered by this woman four weeks ago an attack in which a doctor
is called "and works over the patient for hours before she is better."
From a considerable experience of the outcome of such cases I have
come to believe that this very process of "working over people for
hours," together with the alarm reflected from the medical attendant
to the patient via sympathetic relatives, is itself the cause of most of the
symptoms; in other words, I believe that these attacks are largely
hysteric in nature, and are much aggravated by the treatment which
they receive. If neglected or made light of, such an attack will often
pass off in a few minutes, but if inhalations of amyl nitrite, alcoholic-
stimulants by mouth, subcutaneous injections of strychnin, and heat
over the precordia are given, the patient takes the hint, faces the
worst with courage, and proceeds to suffer accordingly.

Diagnosis. Hyperplastic endometritis; debility.

OO DIFFERENTIAL DIAGNOSIS

Case 363

A canvasser seventy years old was first seen April n, 1908. His
family history is excellent. Since his twentieth year he has had epilep-
tic attacks, once in two or three weeks at first, for the past thirty-five
years much less frequently. He is unconscious for a few minutes, but
never falls, as he knows when his attack is coming. He never bites
his tongue, and has no incontinence. Since his twentieth year he has
also had involuntary twitching of the muscles of the left hand, for
which he wears a glove, with relief. He denies venereal disease. For
the past month he has had much dyspnea, increasing within the last
few days to orthopnea, and associated with a cough and profuse sputum
\ of a cupful of thick, greenish sputum in twenty-four hours.

On physical examination the blood-pressure is found to be 160 mm.
Hg; the nocturnal urine is more than the diurnal. Respiration is rapid
and wheezing; there is a frequent loose cough, with mucopurulent sputum.
The heart shows nothing except unusual faintness of the sounds and
accentuation of the pulmonic second. The chest is hyperresonant on
percussion throughout, obscuring the cardiac dulness. Expiration
everywhere is prolonged and accompanied by coarse squeaks and
groans. The sputum contained many eosinophiles, many mixed
bacteria, no tubercle bacilli.

Discussion. We have no reason to doubt that this patient has
epilepsy, though there are some symptoms which lead us to conjecture
that it may be of the secondary type, and that some source of cortical
irritation may be present. In all probability, however, this long-
standing malady has no special connection with the symptoms from
which he now is suffering.

Dyspnea combined with high blood-pressure, nocturia, and innumera-
ble pulmonary rales may be associated with chronic myocardial weak-
ness, with acute pulmonary edema, or with some pulmonary infection
(bronchitis and bronchiectasis) . Presumably the heart is enlarged in this
case since we find blood-pressure high. Tf the symptoms had appeared
with great suddenness in a patient previously in good condition, and
if the sputum had been very profuse, watery, and pinkish, acute edema
of the lungs would be the most probable diagnosis. But as the onset
has been a gradual one, we have no reason to consider that mysterious
and dangerous disease.

It remains to distinguish between (a) Dyspnea due to chronic
pulmonary stasis with edema, the result of myocardial weakness, and
(b) respiratory infection. The pulmonary hyperresonance makes it

DYSPNEA 70I

impossible for us to estimate the size of the heart; accurate ausculta-
tion is rarely possible when all the sounds are obscured by noisy rales.
In cases of this kind, which are very frequent in general practice, our
chief reliance must be upon the pulse. In the present case the pulse
was regular, not rapid, or in any other respect remarkable. The cervical
veins showed no distention or unusual pulsation. The distribution
of the rales in the lungs was not that usually seen in chronic edema due
to stasis, and the number of bubbling and crackling sounds was less than
that usually heard in edema. The examination of the sputum further
inclined us to believe that the dyspnea was due to the condition of the
lungs rather than to any form of cardiac insufficiency.

Putting together all these facts, therefore, it appears that the dyspnea
is due to emphysema and bronchitis, with very possibly some bronchiec-
tasis as well. One recognizes, however, that the occurrence of such
infections is greatly favored in case any weakening of the circulation
supervenes, as it is always prone to do in men of this age.

Outcome. He was given potassium iodid, 10 grains three times a
day, atropin sulphate yi^r grain three times a day, morphin -J- grain
occasionally for dyspnea and sleeplessness. By the twentieth his
bronchitis was nearly gone and he was having good nights. He was
then given a cough mixture in the following recipe for cough:

Codein 3 grains

Chloroform 15 minims

Syrup of wild cherry 3 ounces

A teaspoonful of this mixture even' two hours, when needed, for cough.

Diagnosis. Bronchitis and emphysema. Epilepsy.

Case 364

A housewife, aged twenty-six years, of good family history, was first
seen January 16, 1907. She had never been sick in bed until seventeen
months ago, when she had "typhoid fever"; at this time she was in
bed five weeks. Eleven months ago she had "bronchitis" and was in
bed a week. Eight months ago she had pleurisy with effusion, and
was tapped, but only about a teaspoonful of clear fluid was drawn for
diagnosis. During the past summer she has been somewhat short of
breath on exertion, with considerable wheezing cough and the raising
of thick, greenish phlegm in the morning. For the past month the
wheezing and rattling in her chest has been almost constant and not
affected by cough. Dyspnea has grown worse, and she gets out of
breath very easily. The wheezing comes in paroxysms lasting an hour

702

DIFFERENTIAL DIAGNOSIS

about twice a day. They are usually brought on by exertion and are
relieved by rest or by coughing. She has had no fever, no chills or sweats.
Six months ago she weighed 112; now she weighs 115 pounds. She
feels well and strong, and has not been confined to bed, but complains
that any exertion brings on shortness of breath and wheezing. The
course of the temperature is seen in the accompanying chart.

I .? Ik - T ,t ,i l. k. >mw

;. 1

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= Z ^%^

1 -s-r N ^ '

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Fig. 185. Chart of case 364.

The patient is well nourished, rather nervous, and fidgety. Coarse
rales can be heard at some distance from the chest, and the nostrils
move with each inspiration. The heart's apex is seen and felt in the
fourth space, 5 inches to the left of midsternum, 2 inches outside the
nipple. The dulness extends also as low as the sixth rib. The sounds
are regular, of good quality, and there are no murmurs. The condition
of the lungs is shown in the diagrams (Figs. 186 and 187). The liver dul-
ness extends three fingers' breadths below the costal margin. Its edge is
not felt. The blood showed a continuous leukocytosis varying between
16,000 and 28,000, with 84 per cent, of polynuclear cells. The urine
is not remarkable. The head, abdomen, and extremities are negative.
The sputum shows an abundance of various bacteria but no tubercle
bacilli.

On the seventeenth the right chest was tapped, and 40 ounces of
fluid removed, with great relief to the patient. This fluid was turbid
and deposited a considerable whitish sediment. It was odorless, 1023

Fig. 186. Results of physical examination in Case 364. (See also Fig. 1S7.)

Fig. 1S7. ( 1 rapine, representation of the signs observed in a case characterized l>y dyspnea
leight months) and wheezing (one month).

DYSPNEA 703

in gravity. The sediment consisted mostly of disintegrated polynuclear
cells, very few mononuclears.

Discussion. This case is characterized by the occurrence of
paroxysmal dyspnea and wheezing, brought on by exertion in a patient
who otherwise feels well. The physical examination indicates at once
that the heart has something to do with it. But when we have such
marked signs in the right chest, we must always question whether the
displacement of the cardiac impulse is due to hypertrophy and dilata-
tion or to the pressure of an effusion in the right chest. Doubtless the
heart's action is embarrassed when it is made to beat in this unusual
position, even though no cardiac disease is present. But until we
know what is the position of the cardiac apex after we have tapped the
pleural effusion, we have no way of being sure of any lesion in the
heart itself.

What is the malady in the chest? The leukocytosis indicates that it
is not due to hydrothorax or serous pleurisy. The specific gravity
of the fluid obtained by tapping and the character of the sediment
point to an infection which will soon result in frank pus (empyema).

Aside from traumatic cases, we recognize two types of empyema within
which almost all purulent effusions fall:

(a) Postpneumonic.

(b) Tuberculous.

(a) In a considerable portion of the postpneumonic cases the pneu-
monia is so mild and rapid that it is altogether unrecognized, and the
empyema is supposed to be "primary." The study of the fluid, how-
ever, almost always reveals pneumococci more or less degenerated, and
on careful questioning we can usually elicit a history that strongly sug-
gests the original pneumonia. Latent cases are especially common in
children. Practically all the postpneumonic empyemas get well and
stay well. Their prognosis is far better than that of serous pleurisy,
as I proved some years ago by following up the end-results of a large
number of cases of both diseases.

(b) Tuberculous empyema has usually a gradual and insidious
onset like that described in this case. The fluid is often at first serous,
and the doctor may blame himself (quite unjustly) when it becomes
purulent after tapping. In a minority of cases there is obvious tuber-
culosis of the lung or pneumothorax, preceding the appearance of the
empyema. Often there is evidence of tuberculosis in other organs. In
perhaps the majority of cases, however, it is the failure of the empyema
to clear up after drainage which first makes us suspect tuberculosis.
I have never known a tuberculous case to get well.

704 DIFFERENTIAL DIAGNOSIS

Outcome. In the sediment of the chest fluid a few small clump? of
tubercle bacilli were demonstrated, though none could be found on re-
peated examination of the sputa.

Though the patient felt very well through the later days of January,
and was out-of-doors daily in a chair, her temperature ranged higher
and higher, and on the sixth of January a friction-rub was heard all
over the precordia. On the seventh the right chest was again tapped
and a thicker and yellower fluid was withdrawn. The patient was then
transferred to the surgical ward and several pints of thick, odorless,
creamy pus liberated; specific gravity was 1030, the sediment as before,
but containing no tubercle bacilli, while pneumococci were easily culti-
vated from it. For twelve weeks after this the patient continued to run
a high, irregular temperature, but finally recovered, and when heard
from eighteen months later, was in excellent general health, though with
a small discharging sinus. A guinea-pig inoculated with 30 cm. of the
chest fluid withdrawn January 17th was killed six weeks later, and
showed marked glandular tuberculous lesions, from which tubercle bacilli
were recovered.

Diagnosis. Tuberculous empyema and (presumably) phthisis.

Case 365

A young woman of twenty -two, a typesetter by profession, was seen
April 3, 1907. Her menstruation has always been irregular, occurring
about every six weeks. Two years ago she almost choked to death
while eating tea and cake. Ever since that time she has been very
short of breath on walking, and suffers a gnawing pain in the left chest
and shoulder on any exertion. Cold weather always makes her worse,
and some days she can scarcely walk for shortness of breath. This,
however, never interferes with her regular occupation. She has no other
symptoms. Her appetite, bowels, and sleep are normal.

The heart's impulse and dulness reached to the sixth space, mid-
axillary line, 8 cm. outside the nipple. The right border of cardiac
dulness seemed to be at the right sternal margin. Cardiac action was
regular, rapid, 112, the first sound short and valvular, the pulmonic
second very much accentuated. There were no murmurs and no
venous pulsation in the neck. The pulse was of small volume, moderate
tension. Blood-pressure, 115. The lungs were normal, save for an
occasional bubbling rale at the left base. There was a trilling edema
of the hands and feet, together with marked coldness. Blood and urine
showed nothing abnormal, and there was no indication of stippling in
the red cells.

DYSPNEA 705

Discussion. This patient's right ventricle seems to have given
way; at any rate, the heart is enlarged, and the cause for such an
enlargement does not appear to lie either in valvular disease, in
syphilis, or in any renal affection. Our problem is to find some other
etiologv.

In a woman of this age we can hardly suppose that we are dealing
with a hypertrophy and dilatation due to a chronic fibrous myocarditis.
It is true, however, that myocardial weakening, with or without demon-
strable fibroid changes, does occur in young people as a result of an
acute infectious disease of the same type which w r e call rheumatism
when the joints are involved. When a heart is thus weakened, dyspnea
may result either from the gradual and progressive dilatation, or acutely,
as the result of some strain, such as mountain climbing.

Chronic adhesive pericarditis, which may occur without the patient's
having been aware of its earlier stages, often produces hypertrophy and
dilatation of the heart, with resulting dyspnea. We cannot exclude this
disease in the present patient, but there is no definite evidence of it, no
retraction of interspaces in any part of the chest during systole, no
restriction of the normal cardiac mobility when the patient lies on the
left side, no history of acute pericarditis in the past.

We must beware of an incipient Graves' disease (hyperthyroidism)
in any case presenting the symptoms here under discussion, The
cardinal symptoms (tachycardia, thyroid tumor, exophthalmos, tremor)
may be so slight as to be easily overlooked, and the cardiac weakness
and enlargement may thus occupy the foreground of the clinical picture.
Some evidence of the cardinal symptoms must, however, be detected
before we can go beyond a suspicion of Graves' disease. In this case we
could find no such evidence.

Acute dilatation of a previously healthy heart I have never known
to occur except during acute infectious diseases, such as pneumonia,
bronchitis, articular rheumatism, or influenza; yet 1 have seen a number
of cases like that now under discussion in which we had no definite
evidence of any disease such as would weaken the myocardium, and
were confronted, therefore, with an apparently "primary" dilatation,
acute or subacute. So far I have never followed such a case to post-
mortem examination without finding evidence of a previous myocar-
ditis. When, therefore, we find no causes such as an acute infectious
disease, hyperthyroidism, or adherent pericardium, and when valvular
disease and nephritis can be excluded, 1 think we should conclude, as
T do in the present case, that we are dealing with a chronic myocarditis
of unknown origin (syphilitic?), with a complicating acute dilatation.

;o6

DIFFERENTIAL DIAGNOSIS

Only by the results of treatment can we ascertain whether the dilatation
is temporary or permanent.

Outcome. Under rest, purgation, magnesium sulphate, and 5
grains of veronal at night, the patient was remarkably improved within
four days. On the seventeenth the heart showed no enlargement and
no murmur, and the patient was able to walk about without symptoms.

No evidence of syphilitic infection was obtained.

Diagnosis. Acute cardiac dilatation, cause unknown.

Case 366

A widow of fifty-two who had lost two sisters of cancer and had
previously suffered from typhoid fever, several attacks of pneumonia,
and from one severe attack of diphtheria many years ago, was first seen
January 10, 1908. She had several uterine operations four years ago, the
last of which was a partial hysterectomy. Three years ago the left

kidney was removed on account of
an injury to the ureter at previous
operation.

For three weeks she has had a
cold in the head, with sore throat.
A week ago she became dizzy and
almost lost consciousness while on
the street, but managed to get
home, when she had chilliness,
sweating, and pains all over her
body. Since that time she has had
fever, dry cough, nausea, and short-
ness of breath. The course of the
temperature is seen in the accom-
panying chart. Her throat is red-
dened and swollen. There is herpes
on the nose and upper lip. The
glands at the left angle of the jaw
are enlarged. The heart-sounds
are faint at the apex, but show nothing else abnormal. The heart is
not enlarged. The pulse tension appears to be slightly increased.
There is slight edema of the lower legs. The abdomen and the urine
are negative.

Soon after her entrance to the hospital the patient had several attacks
of inspiratory dyspnea, with a high crowing inspiration and croupy
cough.

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DYSPNEA 707

Discussion. In all the cases discussed so far in this section the
dyspnea has been of the ordinary type seen in the vast majority of cases
due to pulmonary or cardiac disease. It has been ''mixed" i. e., it has
affected both inspiration and expiration alike.

From this, which is by far the commonest type, we distinguish:

(a) Inspiratory dyspnea.

(b) Expiratory dyspnea.

Expiratory dyspnea is seen especially in emphysema, in asthma,
and in the cases of bronchitis or bronchiectasis complicated by asthmatic
attacks. The breath seems to go in easily enough, but comes out with
a prolonged wheeze and so imperfectly that the chest does not
return to normal expiratory shape but remains in the position of full
inspiration.

Inspiratory dyspnea, such as was present in the case now under
discussion, is due always, so far as I am aware, to an obstruction of the
upper air-passages i. e., the pharynx, larynx, trachea, or primary
bronchi. The laryngeal types of obstruction are by far the commonest.
Among these we may distinguish:

(a) Ordinary catarrhal laryngitis, which in children is called
"croup."'

(b) Diphtheria, involving the larynx or trachea.

(d) Laryngeal syphilis.

(e) Paresis or paralysis of the vocal cords.
(/) Tuberculosis of the larynx.

Next in frequency come the causes which exert pressure upon the
trachea or primary bronchi from without. Such causes are found in
tumors of the mediastinum and aortic aneurysm. Postpharyngeal
abscess, acute or chronic, produces a peculiar type of inspiratory dyspnea,
with a "whoop" like that of pertussis, and a curious cough which
reminds one of the bark of a small puppy or the cry of some bird ("cri
dc canard" 1 ). I have heard such a sound again and again echoing
through the halls of an out-patient department, and seldom found
myself wrong in the "snap diagnosis" of postpharyngeal abscess.

Syphilitic stenosis of a bronchus may produce inspiratory dyspnea
of a paroxysmal type, which precisely simulates bronchial asthma.

In the present case we have reason to suspect, in advance of an
accurate diagnosis by means of the laryngoscope, that acute laryngitis
will be found because the patient has evidently been invaded by an
acute infection involving the upper air passages. Such an infection
verv commonlv reaches the larvnx. Nothing more can be said until

708 DIFFERENTIAL DIAGNOSIS

the larynx is thoroughly examined, but we have no reason for suspecting
any of the other causes listed above.

Outcome. Tracheotomy instruments were kept at hand, and
inhalations of steam, with a laryngeal spray of Dobell's solution, used
at frequent intervals. Wine of ipecac, i dram, was given several times
with relief when laryngeal dyspnea became extreme. It was later
noticed that the palatal reflex was entirely absent. Subsequent ex-
amination of the throat and larynx showed a very marked atrophic
rhinitis, with acute laryngitis and tracheitis. The patient continued
very hoarse until the twenty-eighth of January, though the lungs were
nearly clear by the nineteenth. By February 5th the patient was able
to go home.

Diagnosis. Acute laryngitis.

Case 367

A school-girl of six was first seen November 29, 1907. About an
hour before her entrance she was seized with cough, frontal headache,
vomiting, and rapid breathing. Previous to that time she had been
perfectly well, as far as her mother knows. The child looked healthy,
but breathed very rapidly and with a pronounced inspiratory wheeze.
The tonsils were large and injected. On account of gagging further
examination was impracticable. There was frequent brassy cough.
The breathing was everywhere normal. White cells were 15,500;
urine, negative. Physical examination was otherwise entirely negative.
After a teaspoonful of wine of ipecac the dyspnea promptly ceased.
Next day the child was* well.

Discussion. This case is included merely to show what I mean,
and what I think most physicians mean, by "croup." Since we have
come clearly to distinguish the cases of laryngeal diphtheria which were
formerly mistaken for "croup," some clinicians have been inclined to
assume that the familiar clinical entity which for generations has passed
under that name was abolished. The reason for retaining the name
is that in children acute laryngitis is apt to appear at night suddenly,
and, as it were, out of a clear sky, and to terminate abruptly before
morning, while in adults the clinical picture is quite different because
the laryngitis appears and disappears so much more slowly.

This difference is due, doubtless, to the accumulation of adenoid
tissues about the throats of children and its subsequent disappearance
in adults.

Diagnosis. Croup.

DYSPNEA 709

Case 368

A barrel-maker of twenty-three, whose family history, past history,
and habits are good, was seized two weeks ago with headache, vertigo,
and vomiting. Despite these symptoms he managed to work until a
week ago, when he began to be markedly short of breath. In the past
two days he has had considerable cough and scanty yellow sputa. The
patient mentions no other complaints.

On physical examination the cardiac apex is in the fifth space, 1-]-
inches outside the nipple-line. The right border corresponds with the
right sternal margin. The aortic second sound is accentuated. Blood-
pressure is 175 mm. Hg. The arteries show no sclerosis. The chest is
everywhere hyperresonant, expiration prolonged and difficult, accom-
panied by innumerable squeaks and bubbling sounds. The abdomen
is distended and shows shifting dulness in the flanks.

The temperature, pulse, and respiration were normal for ten days.
The white cells on the twenty-sixth were 16,000; after two days of
treatment they had fallen to 5000; hemoglobin, 60 per cent. The
urine averaged 20 ounces in twenty-four hours, 1016 in specific gravity.
A large trace of albumin was found, and very many hyaline and granular
casts, with much fat adherent.

Discussion. As the dyspnea is here associated with cardiac
enlargement, it is proper, first of all, to inquire whether cardiac disease
is its cause. We find no evidence of valve trouble. Fibrous myocarditis
is not common at this age. Acute dilatation is a diagnosis which we
make only as a last resort when no trace of any cause can be found.
Adherent pericardium cannot be ruled out, but has no definite facts in
its favor. We have no evidence of incipient hyperthyroidism.

The high blood-pressure makes us suspect the kidney, and as soon
as we turn our attention to the condition of the urine, we perceive that
its characteristics are not those ordinarily associated with heart disease
and renal congestion. I have known but two cases of passive renal
congestion with a urine of low gravity. The opposite is the almost
invariable rule.

Nephritis, then, is in all probability the cause of the dyspnea and
the other symptoms, but what type of nephritis is it? Certainly not
acute nephritis, since the heart is hypertrophied. Probably not chronic
interstitial nephritis, since this disease is rare at twenty-three and is
not often associated with any considerable degree of anemia. In all
probability we are dealing with the chronic glomerulonephritis of Coun-
cilman and Wrhdit, the secondarv contracted kidne\ of the Germans.

7IO DIFFERENTIAL DIAGNOSIS

Outcome. The patient was given magnesium sulphate, 2 ounces,
at the time of entrance, and i ounces every morning thereafter; also
hot-air bath every second day. His liquids were limited to two pints
daily, and his diet was restricted as for acute nephritis. Under this
treatment his tormenting headache, his nervousness, and edema dis-
appeared in four days. His dyspnea persisted three days longer, but
was not marked after four days. The dimensions of the heart, how-
ever, showed no change. He was allowed to finish his convalescence
at home after the fifth of October, the diet no longer restricted.

Diagnosis. Chronic glomerulonephritis.

Case 369

An electrician of sixty-two, with an excellent family history, past
history and habits, entered the hospital November 12, 1907. He
had been perfectly well until he began, nine months ago, to suffer from
shortness of breath. Two months ago the dyspnea compelled him
to quit work for two weeks, and a month ago he had to give up for good.
At times he has been unable to lie down at night. There has been a
slight cough, with a little grayish sputum. He has slept very poorly,
and has sweated much at night during the past week. Two years ago
he suffered for five or six weeks from quite marked edema of the legs
at night-time, entirely without any other symptoms. For years he has
risen once at night to pass water.

The patient was orthopneic at entrance. The heart's apex was in
the fifth interspace, one inch outside the nipple, the right border 1]
inches to the right of the sternal margin. The heart's action was slightly
irregular" with a slightly accentuated pulmonic second sound. There
were no murmurs. Blood and urine showed nothing abnormal. There-
was no edema or hydrothorax. The edge of the liver was felt almost
on the level of the navel. There was dulness and diminished breathing,
voice, and fremitus, with coarse bubbling rales below the angle of each
scapula. Temperature, pulse, and respiration were normal throughout
his stay. The sputa, twice examined, showed a variety of bacteria,
but no tubercle bacilli.

Discussion. This case exemplifies a type extremely common in
general practice. Since the urine is normal and the blood-pressure
apparently not elevated, we have no good reason to suspect that com-
monest cause of dyspnea and edema in elderly men chronic interstitial
nephritis. The examination of the heart gives us no reason to believe
that the trouble originates in disease of the valves or of the pericardium.
We have no chronic pulmonary disease which might weaken the heart,

DYSPNEA 71I

especially the right ventricle, in the attempt to force blood through
capillaries decimated by emphysema and chronic pneumonitis.

Only one alternative remains so long as our present conceptions
of circulatory disease are adhered to. The myocardium must be insuf-
ficient. What the nature of this insufficiency is seems to me wholly
problematic. We can no longer assume, as of yore, that a demonstra-
ble fibrous myocarditis underlies the insufficiency of the heart muscle.
It has been abundantly proved that we may have fatal myocardial
insufficiency without fibrous myocarditis; also that we may have exten-
sive myocarditis without any cardiac weakness. The same thing is
true of the microscopic forms of myocardial change: they are very
common both with and without the clinical evidences of myocardial
weakness, but we have no reason to assume that they are its cause.

The modern studies of defective conduction in cardiac impulses
may in time give us the key to our difficulty, but for the present we must
state our diagnoses in functional or physiologic terms. When con-
fronted with a case like that above narrated, our diagnosis should be
myocardial weakness or myocardial insufficiency, not myocarditis.

Outcome. Under rest in bed, with J grain of morphin at the time
of entrance, magnesium sulphate, 1 ounce, every morning, -^V grain
strychnin three times a day, the heart became more regular, stronger,
and a well-marked systolic murmur appeared at the apex. By the
seventeenth the edema had gone from the lungs, and the patient was
well as long as he avoided any exertion.

Diagnosis. Myocardial insufficiency.

Case 370

A Russian carpenter of thirty-four, never previously sick, was first
seen December 22, 1906. While lifting a heavy piece of timber four
months ago he felt something "give way in his chest." He was carried
home and has not worked since, owing to dyspnea on the slightest
exertion, palpitation, and dry cough. He needs three or four pillows
at night, and sleeps poorly. His appetite and bowels are normal. He
has no urinary symptoms. Despite treatment his symptoms increased
four days ago and he has had complete orthopnea and steady pain under
the right costal margin. There lias been no edema of the feet at any
time. Dyspnea, cyanosis, engorgement of the cervical veins, were the
striking features at entrance. The heart's impulse was seen and felt
two inches outside the nipple in the sixth inter-pace. There was
delirium cordis. A systolic murmur was heard at the apex and in the
axilla. The first sound was verv sharp, and occa^ionallv, perhaps one

712

DIFFERENTIAL DIAGNOSIS

beat in every four or five, was preceded by a short presystolic roll. The
pulmonic second sound was accentuated and double. There were
many more beats audible at the apex than palpable at the wrist. (See
chart.) There were many fine bubbling rales at the base of both lungs,
and slight dulness at the right base. The tender edge of the liver was
felt two inches below the costal margin in the nipple-line. The upper

border of the organ was in the fourth
interspace. Blood and urine were
normal. No ascites.

In the chart (Fig. 189) the line be-
low that representing the temperature
stands for the number of heart-beats.
Just below this is the radial pulse
curve.

Discussion. The kidney seems to
be all right; the heart is obviously dis-
eased. It is there that we should
look first for the cause of the dyspnea.
Apparently it is the right ventricle
which is laboring hardest. There are
no evidences of stasis in the peripheral
circulation, but the lungs are evidently
congested, while both in the superior
and in the inferior vena cava stasis is
obvious. The cyanosis and engorge-
ment of the cervical veins betray back pressure in the domain of the
superior cava. The pain under the right costal margin, the tenderness,
and the enlargement of the liver give evidence that the inferior cava
cannot empty properly. All this points to insufficiency of the right
ventricle.

When the right ventricle is insufficient, the cause is usually to be
found in disease of the mitral valve, much less often in chronic emphy-
sema or other long-standing pulmonary disease. The clinical picture
of acute tricuspid regurgitation due to dilatation of the right ventricle
without previous mitral disease has been insisted on, especially by
Gibson and other writers in Great Britain, but as yet I have not been
able to verify their accounts in my own experience.

What form of mitral disease is present in this patient? Besides
mitral regurgitation, of which we have all the ordinary classic signs,
we have a very sharp first sound, such as rarely accompanies an uncom-
plicated mitral regurgitation. Even without the occasional occurrence

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DYSPNEA 713

of a short presystolic roll we should be right in assuming the presence
of mitral stenosis because of the great irregularity of the heart and the
sharpness of the first sound at the apex. The doubling of the second
sound in the pulmcnary area still further justifies this assumption.

Outcome. The patient was given a dry diet in six meals, tincture
of digitalis, 10 minims, every six hours, | grain morphin subcutaneously,
repeated later in the night and on two subsequent nights; magnesium
sulphate, ij ounces every morning. Under this treatment the heart
was much steadier by the twenty-fourth, though still irregular. The
area of dulness was smaller, and the left border had retreated almost
to the nipple-line. By the twenty-seventh he was able to sleep well
without morphin. The presystolic murmur was then much louder,
the heart still rapid and irregular. By the third of January the cardiac
apex was inside the nipple-line, the patient was able to move about
without dyspnea, all the edema had disappeared, and the liver had
retreated behind the costal margin. By the seventh he was able to go
home.

Since the heart diminished so markedly in size as the result of treat-
ment, we may assume that we are dealing at the start with a case of acute
cardiac dilatation supervening upon a long-standing disease which had
narrowed the mitral valve and prevented it from closing tightly.

Diagnosis. Mitral stenosis and regurgitation.

714

DIFFERENTIAL DIAGNOSIS

TABLE XX. Dyspnea. Signs and Symptoms.

Causes.

Suggestions
from historv.

Local signs.

Constitutional
disturbances.

Source of con- t~. , u . j.

T , . ,. ,, , 'Depend on what disease

Infectious diseases tagion. Mode r . Dresent

of onset.

Fever. Often leu-
kocytosis. Pros-
tration. General

aches. Vomiting.

Cardiac disease

Hypertrophy. Arhyth-
. Gradual onset, mia. Murmurs. Stasis
in lungs, liver, legs.

Weakness.
Insomnia.

Rest.
Depletion.
Stimulation.

' r. ., , . ' Circumscribed apical

Phthisis Family history bro ch iti S or solidifica-

. ot tuberculosis. ,.

tion.

Cardiac hypertrophy.

n * i ... ! r , , , Hypertension. Noctu-

Lhronic nephritis Gradual onset. Jr . 1V , t.- i

r ria. Albumin. Edema.

Headache.

Chronic bronchitis (usually ' Winter Bilateral rales,

with bronchiectasis) . . . exacerbations Nummular sputa.

Fever. Emacia-
tion. Dyspepsia.
Weakness.

Hygiene.

Climate.

Vomiting.
Weakness.

Rest.

Depletion.

Diet.

Climate.
Hygiene.

i, c j i Axillary pain. Lobar

l'neumonia Sudden onset. . , i r re

or lobular solidification.

History of

paroxysms.

General hyperreso-

nance. Piping rales.

Eosinophilic sputa.

Fever. Herpes.

Leukocytosis.

Vomiting.

Weakness.

Slight.

Morphin.
Nitrites.

" Barrel chest." Fx-

Emphysema Gradual onset, tension of lung borders.

Hyperresonance.

Slight or absent.

CHAPTER XXII

JAUNDICE

There is no authoritative statement or logical rule which settles
the minimum amount of discoloration which shall receive the name
"jaundice," but the general consensus of usage applies the term to all
cases in which there is distinct yellowing of the conjunctiva, whether
the skin and urine show any demonstrable change or not. This con-
junctiva yellowing must be distinguished from the yellowish patches
of subconjunctival fat to be seen in many eyes.

In the milder cases of jaundice we can see around the iris a ring
of bluish-white sclera over which there is no discoloration. In the
more intense types the yellow color meets the iris.

Like all judgments depending upon a color test alone, the decision
whether or not jaundice is present is by no means an infallible one.
Careful inspection of the deeper portions of the conjunctiva in many
healthy persons shows a faint shade of yellow from time to time, and
it is always more or less arbitrary where we draw the line between this
supposedly physiologic condition and true jaundice. If the skin
and urine are not discolored, and if none of the symptoms of gastro-
duodenal catarrh, gall-stones, or cancer are present, it is customary to
overlook and disregard many a faint shade of yellow upon the eye-
ball, but I am not sure that this practice is wise.

TYPES AND CAUSES OF JAUNDICE

The distinction between a hematogenous and a hepatogenous
jaundice has gone, never to return. Its immortal soul survives in the divi-
sion between (a) Jaundice which owes its origin in the first instance
to an infectious disease, such as puerperal sepsis or malaria, and ib)
jaundice due to mechanical obstruction, such as gall-stone or cancer.
All jaundice is hepatogenous in its production, but the original cause
may be infectious or mechanical.

Doubtless the most common cause of jaundice is the unknown one,
which produces it in so large a percentage of all newborn children,
and usually occasions no diagnostic difficulties. In clinical work we

Tl">

71 6 DIFFERENTIAL DIAGNOSIS

are apt to be puzzled especially by cases of jaundice resulting from three
causes :

(a) Gall-stones.

(b) Cancer.

Less common and less puzzling in diagnosis are the cases due to :

(d) Cirrhosis.

(e) Syphilis of the liver.

All these are of the obstructive type, and are therefore distinguished
from the infectious varieties mentioned above. Rare and obscure
causes for jaundice are exemplified in :

(f) Acute liver atrophy, with or without poisoning by chloroform or
phosphorus.

(g) Weil's and the other types of infectious jaundice of unknown
origin.

(h) Family hemolytic jaundice.

The so-called catarrhal jaundice is probably the commonest of all
the forms just mentioned. It is also the least understood. The old
idea of a catarrh spreading up into the common bile-duct from the
duodenum has very little support either in postmortem demonstration
or in the clinical course of the disease. Many of the cases bear all the
external evidences of a mild general infection and are indistinguishable,
when they occur sporadically, from Weil's disease, which is a name given
to epidemics of jaundice associated with a fever lasting from four to
nine days, a sudden onset with muscular pains and sometimes with a
palpable spleen.

Both catarrhal jaundice and Weil's disease are distinguished from
acute yellow atrophy of the liver only by their course, and, for aught
we know, may be, in fact, mild forms of the same infection. The liver
is notoriously strong in its power of regeneration after injury, and it
may well be that the cases which we now term acute yellow atrophy
represent merely its occasional failures, while catarrhal jaundice and
Weil's disease exemplify its much more frequent victories over some of
the poisons that lead to necrosis.

ASSOCIATED SYMPTOMS

A slow pulse, a tendency to mental depression and to uncontrollable
oozing from any wounded surface, are usually associated with the
severer types of jaundice. More troublesome and more interesting is
the itching, which is frequently but by no means always a concomitant
of jaundice. A patient of mine suffered two attacks of severe jaundice

Causes of Jaundice

1. ICTERUS NEONATORUM ]

] CASES TOO NUMEROUS AND TOO VAGUELY ENUMERABLE

2. SEPSIS

FOR GRAPHIC REPRESENTATION.

3. GALL-STONES i^HHHBBMBHBHHMBMHHHHHH^^^H 369

L }

4. "CATARRHAL
JAUNDICE

7. CANCER OF

Bl LE-DUCTS
AND GALL-
BLADDER

8. CANCER OF |

PANCREAS)

10. CANCER OF
DUO

EROF |
DENUM /

131

5. CANCER OF LIVER I^^HI 57

6. CIRRHOSIS 48

9. GASTRIC CAR-O

CINOMA i 12

717

JAUNDICE 719

within six months. Both were due to gall-stones and ran approximately
the same course, but in one he was tormented with itching, in the other
he was wholly free from it. About half the cases itch and half do not.
This proves to my satisfaction that the itching is not due merely to the
presence of bile in the skin and subcutaneous tissues. Some other and
less constant factor must be present when itching occurs.

INTENSITY OF JAUNDICE

As a rule, the deepest discoloration occurs in complete and permanent
occlusion of the bile-ducts by cancer. In gall-stones the depth of the
yellow staining is apt to vary from week to week. In the so-called
catarrhal forms the color is usually paler, but there are striking excep-
tions to this rule. The jaundice of infectious disease, of hepatic cir-
rhosis, and syphilis is generally moderate in degree.

Case 371

A laboratory worker, forty-seven years of age, entered the ward
July 30, 1906, with the following history. Two weeks ago, while on
his vacation, he felt some discomfort after eating and lost his appetite.
A day or two later his skin turned yellow, his urine dark. Five days
after this his stools became clay-colored. He has vomited only twice,
yesterday and the day before. He has no pain. His bowels move
daily. He feels very mean and seedy and is troubled with itching.
Two weeks ago he weighed 161 pounds, now he weighs 142. He has
never had an attack similar to this.

On examination, the edge of the liver is easily felt below the costal
margin. The jaundice is fairly well marked. In other respects the
physical examination, including blood and urine, is negative. The
patient seemed unaccountably weak and continued so even up to the
twelfth of August. At that time his color began to fade.

Discussion. A jaundice of four weeks' duration, associated with
enlargement of the liver, loss of weight, and marked prostration in a
man forty-seven years old.

He has had no pain, no chill, fever, or palpable gall-bladder in this
attack. He lias had no previous seizures. So far as this evidence goes,
it is against the diagnosis of stone, though it is perfectly possible that
stone may exist.

Malignant disease was much feared by the patient, who could not
understand why he was so weak and thin unless there was some very
serious disease underlying his symptoms. But of malignant disease,

720 DIFFERENTIAL DIAGNOSIS

as of stone, we have no positive evidence. After four weeks of complete
jaundice one expects to find ascites, enlarged gall-bladder, or nodular
liver if the jaundice be due to malignant disease. The absence of any
history of previous stomach trouble is also a comforting consideration,
since malignant disease involving the liver is usually preceded by cancer
of the stomach. In particular, however, it should be said that emacia-
tion during an attack of jaundice is no evidence whatever regarding its
cause and is just as likely to occur in a gall-stone attack as in malignant
disease.

Of the other common causes of jaundice, such as cirrhosis, syphilis,
or acute infectious disease (toxemic jaundice), we have no evidence.

Under these conditions, when we have exhausted our efforts in the
attempt to find evidence of stone, cancer, and the other less common
causes of jaundice, we fall back upon the old term "catarrhal jaundice,"
one of the most insecurely founded of all the diagnoses that are in good
standing at the present time. If the facts were known, it would probably
turn out that a considerable number of the cases called "catarrhal
jaundice" are really due to stone and that the remainder are, like
purpura, the expression of various unnamed infectious processes.
Jaundice is almost as general and indistinctive a manifestation as
fever.

Outcome. By the sixteenth of August the patient's appetite had
returned, and after a short vacation in the country he came back to work
apparently in perfect health. Up to the present time (May, 1910) he
has remained entirely well.

Epicrisis. This case is fairly illustrative of two points:

(a) The vague opportunism of our diagnoses of catarrhal jaundice,
which must be changed at any moment if more distinctive symptoms
pointing to gross organic disease make their appearance. At best such
a diagnosis is justified only by the outcome of the case, and at any time
we may have to eat our words if colic, ascites, or a palpable mass appears.

(b) The frequency of emaciation in jaundice of any type. I have
known a physician to be seriously alarmed about his own condition
during the course of an attack of jaundice, obviously due to gall-stone,
because, as he said, "How can a little stone stuck in a duct make me
lose 40 pounds in two months?" Nothing but the removal of the stone
and his rapid return to his former weight and health convinced him.
Whether the emaciation in cases of this kind is wholly the result of
anorexia and insufficient food, or whether there is some more obscure
reason connected with the functions of the liver, I do not know.

Diagnosis. Catarrhal jaundice.

JAUNDICE

721

Case 372

A stableman of forty- two entered the hospital June 16, 1908. Within
three years the patient has had three attacks of rather persistent indiges-
tion, characterized by sharp, colicky pain localized about the umbilicus
and sometimes needing morphin. He says he has never been jaundiced.
Two years ago he weighed 180 pounds; two months ago, 170, now he
weighs 134. He averages two glasses of beer a day and twenty cents'
worth of tobacco a week.

For the past two weeks he
has been in bed most of the
time, complaining of drowsi-
ness, anorexia, slight fever, and
aches all over his body, es-
pecially in the lumbar region.
He saw a physician for the first
time four days ago, who told
him that he was jaundiced. At
that time his skin began to itch
and his stools to be a light clay
color. The urine has been dark
for a week. The course of the
temperature is seen in the ac-
companying chart.

Examination showed moder-
ate jaundice and nothing else ex-
cept that the white cells were
17,000 at entrance, declining three days later to 12,000. The urine
was always normal, except for the presence of bile. Blood-pressure
was 145 mm. Hg.

Discussion. In the discussion of a previous case I referred to

the humiliating fact that in many cases of jaundice we have to wait

for time to show whether our conjectures are right or not. Experience

has shown that most cases of so-called "catarrhal'' jaundice clear up

within six weeks, and that most of those which run over this limit turn

out to be due to gall-stones or malignant disease. The period referred

to is, of course, a perfectly arbitrary one, based upon averages, and

with very little anatomic evidence to support it. The present case ran

its course within this traditional limit without the development of any

pain, ascites, nodular mass, or toxemic state.

Nevertheless, we can by no means be sure that the attack was not
40

>>MOO 'fet
1 "St* /f If If ,9 u> -1/.M AHvjJ-.uLj.lf j.; J / Jl 4 - - C

J "*" " 11 1 1- - /'" T"t : W- ////- -

,. ' ** * * p * a * . * <x *> 0* e <* .

! J

r A -a -.---, -_-* J5JJ/L ZJZj A ._. -

- ^.p^^ft- tttt

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i ^

z *

m ^

w * -,Ssk - ft -

*> t J %Jj i 'kT A \

*> \ m,* lILFLj T Af'sC/il

* A * &,% ^ .1 s^Vi

" -p^Q^jL *s

ssI

* . .,*

1. * 1 -&[_ re jrci n . ..74 .(3

Fig. 190. Chart of case 372.

722 DIFFERENTIAL DIAGNOSIS

due to gall-stones, especially as he has had three previous seizures
which remind us very distinctly of that disease. If, at any time within
the next few years, the patient has a typical gall-stone attack, it will
seem more than likely that the present attack, as we view it in retro-
spect, was also due to gall-stones.

Although the relation of alcohol to cirrhotic liver (a possible cause
of jaundice) is not clear, we certainly know enough to say that this
patient has not taken enough beer to put him in peril of chronic inter-
stitial hepatitis. Of the nature and development of that disease we
know so little from a clinical standpoint that we are unable to make
positive statements about its earlier stages and their relation to symptoms
like those here described. Certainly, however, no one would be justified
in giving more than passing consideration to cirrhosis in the present case.

Outcome. On the twenty-seventh the jaundice was much less
marked and the patient was hungry. On the eighteenth of July the
jaundice had completely disappeared, the patient had gained six
pounds since entrance, and felt entirely well.

On the first of September he reported that he had been perfectly
well and had worked ever since leaving the hospital. His weight was
151 pounds. There was no evidence of jaundice.

Diagnosis. Catarrhal jaundice.

Case 373

A schoolboy of thirteen, always previously well, consulted a physician
with the statement that for two months he had been jaundiced and had
intermittent dull pains across the upper abdomen. At the onset of his
illness he had a chill and considerable vomiting for three days, but these
symptoms have not recurred. He was first seen September 4, 1907.

Examination showed deep jaundice. The spleen and liver easily
felt. (See accompanying diagram, Fig. 191.) The edge of the spleen
was hard, the whole organ freely movable. The white cells numbered
3800; hemoglobin, 100 per cent.; stained specimen normal, as was the
urine. The feces were not bleached. Later it was ascertained that
a year ago he had had chills and fever every other day for a considerable
period.

The boy was given liquid and soft solid diet, sodium phosphate, h
dram every morning, and under this treatment rapidly improved. He
was able to take full diet by the seventh, was much less jaundiced by
the ninth, and by the fourteenth had no visible discoloration of the skin or
conjunctivae. In view of the history it seemed best to give him 1^ grains
of quinin three times a day for ten days.

Fig. 19T. Shows results of physical examination in a case of jaundice of two months'

duration.

JAUNDICE 723

Discussion. This patient had absolutely no complaints at the
time when this history was written. His parents wanted to know
why his eyes were yellow, but he himself did not feel sick at all.

The presence of an enlarged hard spleen and the history of a chill
at the onset remind us that malaria is a not infrequent cause of jaundice.
Yet certainly at the present time he has no active malarial infection. Is
it possible that the icterus may be a relic of a past malaria? Certainly
in the more severe types of the disease jaundice often persists when no
parasites are discoverable in the peripheral circulation and when the
temperature is steadily normal. In the milder tertian infections of
New England one does not often see this, especially when the attack
has not destroyed enough corpuscles to lower the hemoglobin, which
was 100 per cent, in this case. On the whole, therefore, this hypothesis
seems unlikely.

Gall-stones are rarely found in boys of this age. The pains which
previously troubled him were never such as to suggest biliary colic,
and the fact that the stools were never decolorized makes it seem improba-
ble that the stone has never blocked the ducts.

Catarrhal jaundice may occur at this age, though it is not common.
If we use the term to include any brief icterus of unknown origin and
sporadic occurrence, it will doubtless cover such cases as this, even
though no digestive symptoms, such as should accompany a gastro-
duodenal catarrh, were complained of. In all probability the jaundice
represents one manifestation of an acute infectious disease. Had it
occurred in an epidemic form, it might have passed as Weil's disease.

Outcome. On October 16th the boy returned to the physician to
report that two days previously he had had a chill and fever. The
boy had gained considerably in flesh, and looked entirely well. The
spleen was still palpable, the liver no longer so. Malarial parasites
were now demonstrated in the blood. In view of this fact it seems,
on the whole, probable that his jaundice was due after all to malaria.

Diagnosis. Tertian malaria.

Case 374

A housewife of thirty-eight, of good family history and past history,
entered the hospital September 3, 1007. She began six months ago
to have what she calls "a ball " in the stomach, starting at the epigastrium
and moving toward the left hypochondrium. Apparently she has
steady, dull epigastric pain, not radiating, accompanied by heart-burn,
anorexia, a bad taste in the mouth, distress and flatulence after eating,
constipation, and occasional vomiting of the food last taken. Through-

724 DIFFERENTIAL DIAGNOSIS

out this six months she has had jaundice, varying in intensity. She
has had also occasional chills, followed by profuse sweating, and always
by an increase in the jaundice and in the color of the urine. At no
time has she had any sudden or sharp pain anywhere. She has lost
30 pounds in the last six months. She sleeps poorly on account of
flatulence.

Examination shows an obese, jaundiced woman, with an indefinite
resistance under the costal margin and in the median line. Physical
examination, including the temperature, pulse, respiration, blood,
and urine, is otherwise negative, save for the presence of bile in the
urine.

Discussion. If this jaundice had not already lasted for six months,
it would very probably deserve to be called "catarrhal," as no doubt
it was called in the earlier weeks of its occurrence. No one maintains,
however, that the term "catarrhal" should be extended to cover cases
of six months' duration.

The variations in the intensity of the jaundice and the occurrence
of chills without malarial parasites in the blood lead us to favor the
diagnosis of gall-stones. But can one have gall-stones without any colic ;
indeed, without any pain except such as might be attributed to flatulence?
Thanks to the surgeon we may now answer this question with an un-
qualified affirmative. Colic is a common but by no means an invariable
accompaniment of cholelithiasis.

The loss of weight which occurs in all forms of jaundice has been
discussed in the previous cases and shown to have in itself no diagnostic
significance. The age, the sex, and the obesity all favor the diagnosis
of gall-stones.

Outcome. Operation September 6th revealed a stone in the lower
end of the common duct. The bile-passages were otherwise free, the
liver and pancreas not abnormal. The patient's convalescence was
uneventful, and after October 6th she seemed and remained entirely
well.

Diagnosis. Gall-stones.

Case 375

An Irish housekeeper of thirty-eight, whose husband now is con-
sumptive, entered the hospital August 29, 1907. She has always been
well, and has a good family history. For nine years she has had fre-
quent sick headaches, accompanied by vomiting. For two years she
has had gradual loss of weight and strength, her weight declining from
159 pounds two years ago, to 119, at the present time.

Fig. 192. Shows conclusions drawn from examination of a case of intermittent painless
jaundice lasting three months.

JAUNDICE 725

For three months she has had jaundice, varying in intensity. She
has had no pain at any time. Two hours after eating she not infre-
quently vomits, the vomitus consisting only of food. Her appetite is
good. The bowels move with the aid of sodium phosphate. She sleeps
well. Her present complaint is of weakness and jaundice.

Physical examination shows the jaundice to be heavy. The chest is
negative. The condition of the abdomen is shown in the accompanying
diagram, Fig. 192. Blood and urine are normal. The coagulation
time of the blood is one minute five seconds with the Brodie-Russell
instrument.

Discussion. A gradual decline in weight and strength during
a period of two years, leading up to a jaundice of three months' duration
and of variable degree, and accompanied by occasional attacks of
vomiting, is rather an unusual clinical picture in a woman of thirty-
eight. Why should the loss of weight have preceded the jaundice unless
some form of malignant disease is present? Yet if any such disease
were present it should, by this time, show more obvious evidence of
itself. Without ascites, marked gastric symptoms, or palpable tumor
we certainly cannot make a diagnosis of such terrible significance to the
patient. Yet from our own minds it is difficult to exclude the thought
of cancer.

Cirrhosis or syphilis of the liver would probably show more definite
signs of their presence after an illness of this length.

Under such conditions, when a jaundice has lasted rather too long
to be called "catarrhal," yet has not produced any of the more ominous
evidences of cancer, cirrhosis, or syphilis, the outcome usually shows
that we are dealing with gall stones. We have to be governed largely
by statistical evidence in such cases; direct examination yields very
little of value. Indeed, there is no class of diseases in which we depend
so largely upon the history and upon general statistical experience as
we do in diseases of the liver. Physical examination plays here a smaller
part than in the diseases of any other organ with which we deal on terms
of any confidence.

Outcome. At operation, September 6th, several large stones were
found in the gall-bladder and one in the cystic duct. Xo obvious
reason for the jaundice was found; there was no swelling extending
down from the blocked cystic duct to the hepatic or to the choledochus
an explanation which is often invoked to explain jaundice when the
stone is in the cystic duct. No other reason could be found.

Recovery was complete and permanent.

Diagnosis. Gall stones.

726 DIFFERENTIAL DIAGNOSIS

Case 376

An Italian widow of sixty, of negative family history and past history,
was first seen March 9, 1908. She had noticed a year ago that she
was jaundiced and had a swelling in the region of her liver. After two
weeks she was cured of her jaundice, but the swelling continued and
increased. Seven months ago the jaundice returned and has been present
most of the time since. She has not lost much weight, though her
appetite is poor. She has much nausea, no pain, and no vomiting.
For two weeks she has had edema of the feet.

Physical examination showed a deeply jaundiced patient. Both
pupils were irregular, the left larger than the right. Both reacted
normally. The heart's action was at times irregular in force and
rhythm, and a blowing systolic murmur was audible all over the precordia.
The pulmonic second sound was louder than the aortic second, the
apex beat in the fifth space just outside the nipple-line. The pulse
was of low tension. The lungs showed nothing abnormal. The
abdomen was enormously distended, dull in the epigastrium and in the
flanks, otherwise tympanitic. The circumference was 40 inches. The
umbilicus protruded. The edge of the liver was easily felt 5 inches
below the costal margin. Its surface was smooth, hard, not tender,
somewhat irregular. The spleen was not felt. There was considerable
soft edema of the legs and of the anterior abdominal wall. The shape
of the abdomen suggested encysted rather than free fluid. Blood and
urine were normal.

On the eleventh 233 ounces of fluid were withdrawn by tapping the
abdomen. It was bile-stained, 1009 in specific gravity. The sediment
showed 60 per cent, of lymphocytes to 40 per cent, endothelial cells.
After tapping, the surface of the liver was apparently smooth, and
extending down from its edge in the region of the gall-bladder was a
dense, fluctuant, rounded mass the size of an apple, not tender. (See
Fig. 193.) After tapping, the fluid rapidly reaccumulated. The
patient seemed entirely comfortable, complaining of nothing at all.
She was again tapped on the third of April and 164 ounces removed,
the characteristics of the fluid being essentially the same as before.
About this time she ran a moderate, irregular fever, reaching as high
as 101 F. at night, and being normal in the morning. This subsided
after about ten days.

Discussion. With jaundice of seven months' duration, a liver
markedly enlarged, ascites, and swelled legs, we should have no con-
siderable doubt that malignant disease is present were it not for the

Fig. 193. Results of physical examination in Case 376. Jaundice has lasted one year.
No pain or emaciation.

JAUNDICE 727

fact that the patient has also an enlarged and irregular heart, whose
action is presumably insufficient to maintain satisfactory circulation.
The ascites and edema may be due to cardiac weakness rather than to
malignant disease.

On the other hand, the irregularity of the liver surface, if it be a
fact, is of decisive importance in this connection; for such irregularity,
if gross enough to be palpable through the abdominal wall, means one of
two things in practically all cases, viz., hepatic cancer or hepatic syphilis.
If the first physical examination be correct, then, the cardiac condition
is probably not responsible for the dropsy.

As between cancer and syphilis, we should be influenced, in the first
place, by statistical considerations; cancer is by far the commoner of
the two as the cause of jaundice and ascites. The absence of splenic
enlargement is also against syphilis. Less important is the absence
of any history of syphilis and of any evidence of its ravages in other
parts of the body.

If we are dealing with cancer, what is its site? Probably not the
substance of the liver, since hepatic cancer is usually secondary to similar
disease at the pylorus. This patient has been free from gastric symp-
toms. If not in the liver itself, the cancerous obstruction which has
produced the jaundice is probably at one of three points :

(a) At the duodenal papilla.

(b) In the head of the pancreas, compressing the common duct.

Outcome. April 12th, after more than a month in a hospital, she
showed absolutely no loss of weight and we were rather shaken in our
confidence that cancer was the correct diagnosis. Nevertheless, opera-
tion was performed April 14th, as the patient showed no signs of improve-
ment after a thorough course of antisyphilitic treatment. A cancer of
the head of the pancreas was found.

Diagnosis. Pancreatic cancer.

Case 377

An American timekeeper of twenty began, in 1903, to have epi-
gastric pain, after eating, in intermittent spells lasting a month or two.
In January, 1907, this pain became much worse, and he vomited fresh
blood. In March, 1907, he entered the hospital and was found to
have a marked hyperchlorhydria, which, taken in connection with the
above symptoms, led to an operation, which showed adhesions about
the pylorus and considerable thickening of the pylorus, without evidence

728 DIFFERENTIAL DIAGNOSIS

of cancer. A posterior gastro-enterostomy was accordingly done. The
patient did excellently well, and went home free from symptoms on the
seventh of April, 1907.

He returned a year later (April 24, 1908) with the following history:
A month ago became suddenly jaundiced immediately after taking
some sulphur and molasses. He has remained so ever since, though
his color has been becoming lighter. At the same time he has com-
plained of rather dull pain, felt from time to time in the lower abdomen.
For a week this has been absent. For two weeks he has not worked,
and has been on a milk diet. During this time he has had a slight
cough , with yellowish or greenish sputum. He has a great deal of itching,
and has noticed that his urine is dark. Yesterday at half-past four he
ate a very hearty dinner. Later in the day he vomited and gradually
became unconscious, possibly from the effects of morphin which was
given in the evening. There is no headache, no fever, no loss of weight.

Examination shows normal temperature, pulse, and respiration.
There is marked jaundice. The patient is semicomatose, with dilated
pupils which do not react. The chest is negative. The abdomen is
level, rather rigid, tympanitic; nothing else is made out. The liver
flatness reaches from the fifth rib to the seventh space, measuring 2\
inches in vertical diameter in the nipple-line. The urine is high in
color, specific gravity 1020, with a very slight trace of albumin in the
sediment, no casts, a large amount of leucin and tyrosin. The white
cells are 9200; hemoglobin, 75 per cent.

Discussion. We will take first the second chapter of this patient's
case, after his recovery from the gastro-enterostomy.

In the earlier weeks of his jaundice the brittle and unsatisfactory
term "catarrhal" was as usual applied, and one could hardly have
done otherwise until the appearance of one very distinctive and ominous
symptom, stupor. None of the milder and more curable causes of
jaundice produce this symptom. We never meet it in the catarrhal
forms, in gall-stones, or in malignant disease previous to the terminal
stages. In the infectious forms of jaundice, stupor appears only near a
fatal issue.

Only in two forms of liver disease which are accompanied by jaundice
does stupor appear in cirrhosis and in acute yellow atrophy. Either
of these diseases might be present here, although we have no history of
alcoholism such as usually appears to enter into the causation of cirrhosis,
at any rate, as one factor. Another point against cirrhosis and in favor
of acute yellow atrophy, is the rapidity of the shrinkage apparently
demonstrable by percussion of the liver outlines. Shrinkage of the

JAUNDICE

729

liver can very seldom be demonstrated during life. When the area of
liver dulness appears to be less than normal it usually turns out to be
obscured by a distention of the colon which pushes the liver backward
out of reach of the percussing finger.

In the present case, however, the area of dulness was again and again
measured, and showed apparently a progressive shrinkage. This fact,
taken in connection with the deep jaundice, the increasing coma and the
presence of leucin and tyrosin in the urine, made us tolerably confident
that a rapid atrophy of the liver was in progress. No hint of its etiology
was obtained; the patient had not inhaled chloroform or ingested
phosphorus in any form.

Outcome. On the morning of the twenty-sixth the liver dulness
was only if inches in vertical diameter; the jaundice had considerably
decreased. The patient continued semicomatose. On the afternoon
of the twenty-sixth he developed edema of the lungs and died.

Autopsy showed acute yellow atrophy of the liver, obsolete tuber-
culosis of the right lung and bronchial lymphatic glands, acute degen-
eration of the kidneys.

Diagnosis. Acute yellow atrophy of the liver.

TABLE XXI. Jaundice. Signs and Symptoms.

Causes.

Favoring Accompanying Constitutional Relief

conditions. signs 1 local). manifestations.

Severe Depends on type . , ,, - Drainage.

r , ',.,.-' sis uisuallvi. -i-

infection. ot infection. , 1 11 \ lime.
Chills. Anemia.

Hillary colic, oft
Fat "Id women. Tenderness, oft

Chills, often. Passage of

I'yphoid. Knlarged'galT lever, often. .. st "", e .-

" ,, ,. ... Kniaciation often. Operation.

bladder, often.

Catarrhal jaundice"

Sometimes Depression. Tonic (under

enlarged liver. Slow pulse. six weeks:.

Enlarged nodul.i
f.astrii
tumor ': .

Kmaciation.
Fever. Anemia

( 'irrhosis of liver

I ,iver usually en-
larged. Portal l-'.m.-u iation. Tapping

stasis. Splenic Anemia. < 'pel

tumor.

.uirer of bile-ducts and gall- , ....

,, 11 loiter middle ,, ,. 1 .

bladder, pancreas, or duo- ,.. 1'ig gall-bla

ilfiium

F.maciat i' ii.
Anemia.

CHAPTER XXIII

NERVOUSNESS

The uses of this word are so vague and various that one may be
seriously misled unless one cross-questions the patient as to just what
he means when he calls himself "nervous." Thus, for example, ner-
vousness may be

(a) Motor, wholly or largely. The patient may have what is
called "the fidgets," and be unable to keep still or to control the motions
of some part of his body, as in Sydenham's chorea, or in the habit
choreas and muscular twitchings so common in neurotic people. The
tremors of general paralysis or hyperthyroidism are sometimes referred
to by the patient as "nervousness."

(b) Sensory. When people start at any slight noise or jar, when
they are abnormally sensitive to light, to odors and tastes, they often
speak of themselves as "nervous."

(c) Psychic. Perhaps the commonest usage of the word "nervous-
ness" is in connection with a variety of predominantly psychic mani-
festations, such as lack of self-control, emotionalism, fearfulness, cause-
less and transient depression, irritability, and the sense of unreality in
things.

(d) Visceral and secretory neuroses often occur in connection with
one or another of the types above mentioned, and may constitute the
most prominent part of the clinical picture, but they are not apt to be
referred to by the patient as "nervousness." The patient is more apt
to believe them due to some more or less serious organic disease.

Interpretation of Nervousness. The most important point is
that identical nervous symptoms may occur with or without organic
disease behind them. A patient whose underlying malady is arterio-
sclerosis or chronic glomerulonephritis may yet present typical symptoms
of hysteria or neurasthenia, and the latter are so insistent and so irritat-
ing that we are apt to neglect a thorough search for something else in
the background.

Mistakes are especially apt to occur in persons over forty years of
age. When nervousness of any type has appeared for the first time
after the fortieth year in a patient who has never previously shown

730

NERVOUSNESS

73 1

anything of the sort, a diagnosis of neurasthenia or hysteria usually
turns out wrong or seriously insufficient and leads us to give a faulty
prognosis and to misdirect our treatment.

In younger persons nervousness is often falsely treated as the com-
plete diagnosis when, in fact, it is merely an expression of an under-
lying pulmonary tuberculosis. A great many of the cases of nervous
dyspepsia and of pallor miscalled "anemia" turn out to be the earliest
manifestations of tuberculosis.

Other types of mistake will be exemplified in the cases to follow.

Case 378

A Russian housemaid of twenty-four, with a good family history,
was first seen April 27, 1907. She has never been strong. She has
suffered from headaches and dysmenor-
rhea for the past seven years. These
pains just now are not so troublesome as
formerly. Of late she has been weak,
faint, and worn out. Two weeks ago she
was operated upon for hemorrhoids at
the Boston City Hospital. Since that
time she has had a great deal of nervous-
ness with pain scattered throughout various
parts of her body ("Schmerzen Uberall"),
pressure about the heart, eructations of
gas, dryness of the mouth, and the fre-
quent discharge of pale urine. Her ap-
petite is rather poor, the bowels regular.
The patient has a cyanotic look. At
entrance to the hospital her "cribbing,"
nervous vomiting, convulsive chills, and
moans disturbed the whole ward. Vis-
ceral examination was negative
seen in the accompanying chart.

Discussion. Obviously, we are dealing with a psychoneuro>is,
but are we sure that there is nothing behind it? We are told that
visceral examination is negative, but visceral examination is not always
taken to include a study of the blood and urine. Among the possibilities
which could be eliminated only by such a study are the following:

(a) Chlorosis.

{!>) Trichiniasis.

^C? CjUt K) ,1c I^IJ.J 'i } i t It

! "~~ "'J /' 1 n \. , ;

,.,';,,, ........ ....

>> J

- '*

t "* 1

'" V" T

I Z MJU -ft 1

- ^ j'f*- **/- r-P"

-"^

m <s^ dtt^

- m t ft M ^O^M<J

" 1 rp* %f**

* 1 H r 1

h i ! f i ^

l-F d ,.

3 ? >

, i i .

a w VCV-V 1 ^* "V" *V L"

u l-l- 1 4_*

L _j 2 .^ T ^a_a 1 _. f S

Fig. 194. Chart of case 378.

The course of the temperature is

732 DIFFERENTIAL DIAGNOSIS

{d) Nephritis.

(e) Hyperthyroidism (Graves' disease).

(J) Diabetes.

(g) Chronic poisoning by acetanilid or other drugs.

Chlorosis might give very similar symptoms, but it was here easily
excluded by the blood examination.

Trichuriasis, suggested by the wide-spread pain, was not positively
to be excluded, as no search was made either in muscle or venous blood
for the embryo trichinella. The blood showed no eosinophilia and we
were diverted from following this hypothesis any further because another
and commoner disease soon appeared as a cause for the symptoms.

The urine showed nothing to justify any suspicion of genito-urinary
tuberculosis. Pulmonary tuberculosis may certainly exist for a con-
siderable period in the lungs without our having any definite evidence
of it. In the present case we could find no such evidence, though we
could by no means exclude the earlier "silent" stages of the disease.

Nephritis, drug-poisoning, and hyperthyroidism were easily excluded
by a study of the history, blood, and urine.

As soon as the urine was tested for sugar we came upon the object
of our search, the cause, to all appearances, of the patient's "nervous-
ness."

Outcome. The urine was 40 ounces in twenty-four hours at the time
of entrance; specific gravity, 1028; 4.1 per cent, of sugar; 0.2 albumin;
in the sediment much pus, no casts. She was given paraldehyd, '>
dram, twice a day, sodium bromid, 20 grains three times a day, and by
May 2d was much quieter and said she felt better than for months,
though she still cribbed. Under an antidiabetic diet the urine was
freed from sugar in eight days; the weight increased from 112 to 121,
and the reactions for acetone and diacetic acid were present for the
first week of treatment and as long as any carbohydrates remained in
the diet, disappeared. Her speech and nervous control greatly improved,
and by the nineteenth of May she seemed like a different person, sleeping
soundly without any hypnotic, and perfectly content with her diet.
She was allowed to go home on the twenty-second of May, the urine
being free from albumin and sugar, though remaining distinctly increased
in amount 80 to no ounces on the average. The gain in weight was
8 pounds in sixteen days.

The question might be asked: "Are we dealing here with diabetes
or merely with glycosuria?" Since the distinction is wholly one of time,
only the outcome can furnish us with the answer to this question.
Acetone and diacetic acid appear much more frequently in the long-

NERVOUSNESS 733

standing glycosurias, which we call diabetes, than in the transient form.
There is no doubt that neurotic, high-strung people are more often
the subject of temporary glycosurias than are the more phlegmatic
members of the community. On the other hand, the nervousness may
well be symptomatic, the result rather than the cause.

It will be noted that much pus was found in the urinary sediment.
Such a datum should always be followed up, and the first thing to do is
to make sure that the pus comes from the urine and not from the vaginal
secretions. In the present case a specimen of urine drawn by catheter
was found to be free from pus on the same day when the specimen
spontaneously passed had contained it. Accordingly, no further investi-
gation was made, and as the glycosuria improved, the pus disappeared.

Diagnosis. Diabetes mellitus.

Case 379

A married Irish woman, forty years old, with an excellent family
history, entered the hospital September 17, 1907. She has been nervous
all her life, especially since her seventeenth year. She is very easily
worried or frightened, and has many weak spells. Last winter she felt
underneath her right breast and in the right back a pain, which was
sharp on deep breath. This lasted a month. When nervous, she cries
very easily. She has been married twenty-three years and has had nine
children. Her last period was nine months ago. She takes about six
cups of tea a day, but no alcohol. Since her husband was admitted to
the Massachusetts Hospital last January she has been much overworked,
taking boarders and caring for her children. For the past two months
she has been especially nervous, and felt more tired in the morning
than at night. She has slept very little, and her food has seemed to stop
at the bottom of her breastbone and to lie there as a heavy load. For
the past week she has vomited everything that she has taken, though
her diet has been reduced to milk and weak tea. Of late, she has had
no pain anywhere except a tired ache between her shoulderblades.
Her appetite is fair; the bowels move once or twice a day. When
nervous, she passes urine very frequently. For the past two months
she has had a slight cough with a little white sputum.

On physical examination the pupils are somewhat irregular, but
react normally. The tongue comes out straight, but has a marked
coarse tremor. The throat is reddened and atrophic; the heart is
negative, except for a slight accentuation of the aortic second sound.
The lungs are negative, save for slightly higher-pitched respiration at
the left apex and occasional scattered rales throughout. The abdomen

734 DIFFERENTIAL DIAGNOSIS

is held rather stiffly, but is otherwise negative, save for a swelling extend-
ing from the left anterior-superior spine to the neighborhood of the
symphysis, and giving a marked impulse on cough. It is easily reduci-
ble by pressure.

Discussion. As this woman has had no menstruation for nine
months and is obviously not pregnant, our first thought is that the
symptoms may be due to the menopause, that very convenient but
dangerous explanation for such a multitude of heterogenous symptoms.
Such a diagnosis should never be made until every other reasonable
alternative has been excluded. Moreover, the vasomotor symptoms
usually present as a part of any disturbance dependent upon the meno-
pause are not at all marked in this case. Only the nervous frequency
of urine suggests them.

It was the fashion, a few years ago, to explain a great number of
debilitated conditions as the result of the abuse of tea, especially when
the physician was able triumphantly to point out that the patient kept
the tea- pot on the stove continuously and took a "nip" every now and
then throughout the day, thus getting the full benefit of a strong decoc-
tion ol tannin. In the eleven years of out-patient service involving
four years of female medical clinic I have seen less than half a dozen
cases in which the symptoms appeared to me due to the abuse of tea.
Doubtless it often does harm by taking the place of food, and in the
present case this is distinctly suggested. Overwork may likewise have
been a factor in her breakdown.

The hypotheses suggested in the last paragraph cannot be definitely
refuted, but against them the following consideration may be urged.
The overwork and the tea-drinking have lasted for many years, the
symptoms for less than one year. Why should the breakdown have
come just at this time, after the patient had borne her overwork and
faulty habits for so many years without apparent detriment? Some
new and determining factor must have come into the case the same
factor, I believe, which accounts for most of the seemingly causeless
dyspepsias and run-down conditions which we are apt to attribute to
this or that food, overstrain, or a surgical lesion. In a large number of
these cases tuberculosis later makes itself obvious; in many others, I
believe, it is conquered by the patient's own vitality, while we think we
are curing his dyspepsia or his " debility" with one or another remedy.

The pulmonary signs in this case are, indeed, very slight. If pre-
cisely the same signs were present at the right apex, one could not, with
confidence, attribute any meaning to them; but at the left apex even the
slightest abnormalities are of importance if unaccounted for by any

NERVOUSNESS 735

pathologic condition of the heart or abdominal organs. Even signs
so slight as this should make us follow the patient very carefully and
examine the lungs, the sputa, and the temperature chart for confirma-
tory evidence. If, after we have done our best by such an examination,
the condition of the lungs seems still doubtful, and no other diagnosis
has in the mean time suggested itself, we should always treat the case as
tuberculosis.

Outcome. For some days no sputum could be obtained, but in the
first satisfactory specimen tubercle bacilli were demonstrated. The in-
guinal hernia, present on the left side, was fairly well held up by a truss.

Diagnosis. Phthisis.

Case 380

A telephone girl of eighteen entered the hospital September 21, 1907.
One brother of fifteen is said to have consumption. Two grandfathers
and one grandmother died of consumption, the last one ten years ago.
The patient has always been strong and healthy. She had typhoid
fever eight years ago, measles four years ago, followed by a mastoid
operation. Her hearing is excellent. Her menstruation has been
irregular for the past two or three years, and painful, so that she has to
be in bed two or three days each month. She has recently been in
the surgical wards, and has been curetted.

Since early childhood she has had a poor appetite, constipation,
distress, and burning stomach without regard to the character of food
or the time of taking it. She has sick headaches every two to five weeks.

Eight weeks ago she fainted when she got up in the morning, and
did not work that day. After working the next day she took to bed,
where she has remained since, vomiting almost every fifteen minutes,
day and night (?). Rectal feeding has been carried out. She has no
definite pain, but her vomiting is preceded by a burning sensation at
the epigastrium. For the last three days there has been partial loss of
vision. She cannot recognize persons or see more than their outlines.
There has also been gradual loss of ambition and slowness of speech.

On examination the patient is fairly nourished, the skin dry and
harsh, the pupils widely dilated, but reacting normally. The chest
and abdomen show nothing abnormal. An attempt was made to pass
a stomach-tube, but the patient struggled violently and pulled it out.
It was finally replaced, and fasting contents, consisting of mucus and
white froth, obtained; no food. After a test-meal there was no free
HC1 by any test, no lactic acid, and no blood. Inflation showed that the
stomach was not in anv wav enlarged.

736 DIFFERENTIAL DIAGNOSIS

Examination of the fundus showed an optic neuritis in the right eye,
numerous small hemorrhages about the disc, and one large one near the
nerve in the left eye. The urine was entirely negative, likewise the
blood.

During the first two days after admission the patient vomited four or
five times, after that very rarely, the vomitus consisting of colorless
mucus. Salt solution, 8 ounces every six hours, was well retained by
rectum, and the skin soon began to be less dry. After this the patient
took milk and lime-water in small amounts for the first few days, after
that cereals and gruels. By October 1st eggs were added, and by the
tenth she was taking plenty of all sorts of food and the enemata were
omitted.

On October 1st the patient complained of numbness below the
waist, later of numbness over the whole body, but there was no diminu-
tion of the pain sense. She had one hysteric attack, with tremor of the
muscles, following rigidity and slight opisthotonos. The patient
seemed irrational and fretful, at times spoke very slowly. Her vision
was restored by the sixth, and her appetite was then excellent. She
seemed in a very pleasant state of mind, constantly expressing her
gratitude to the nurses.

On the ninth of October a tumor was noticed, rising above the
pubes almost to the umbilicus. A catheter was introduced, and 85
ounces of high-colored urine with a heavy sediment was withdrawn.
Eleven hours later 59 ounces of urine were withdrawn. At this time she
said that she was unable to move her legs, and had to be turned in bed.
Soon after she had involuntary defecation. On the thirteenth she was
somewhat improved, but said she could not speak above a whisper.
About that time a rectovaginal fistula developed. Vomiting began
again on the seventeenth of October, and was accompanied by cyanosis
and difficult respiration. The same day tracheal rales were audible.
She seemed too weak to clear them.

Under strychnin, -^ grain, and atropin, y^- grain, this attack passed
off and she breathed normally, though she continued to vomit in small
amounts and the pulse was not of good quality.

Seen by a neurologic consultant on the seventeenth of October, the
diagnosis was hysteria plus some toxic process.

Discussion. The advent of marked slowness of speech is an
unusual symptom, which should always attract our attention. It
occurs in myxedema, in many depressed and melancholic states, in
multiple sclerosis, and occasionally in hysteric states. In multiple
sclerosis it is apt to be associated with nystagmus, increased reflexes ;

NERVOUSNESS 737

and intention tremor, none of which is present here. This girl was
rarely depressed or hysteric, and showed none of the cutaneous or mental
symptoms of myxedema.

The stomach symptoms were very marked and had led to a diag-
nosis of gastric ulcer before she entered the hospital. The quick clearing
up of the gastric symptoms under treatment, however, and the absence
of any gastric or rectal hemorrhage and of any evidence of stasis, makes
it obvious that, at all events at the present time, her chief sufferings are
not due to that cause.

Hysteria naturally occurs to our minds in a patient who has muscular
tremor and opisthotonos, is fretful and irritable, and has a great deal
of unaccountable vomiting. But the condition of the fundus oculi
cannot be thus explained, despite the dictum of the neurologic consultant.
What, then, is the cause of the optic neuritis and retinal hemorrhages?

Brain tumor might account for her vomiting and for the psychic
disturbances. We should expect, however, to find headache, vertigo,
and focal disturbances of some kind (localized paralysis, spasm., anes-
thesia, aphasia of some type, astereognosis) .

Of meningitis we have no important evidence, and there is nothing
in the case definitely to suggest syphilis.

Nephritis is the only other common cause of retinal hemorrhage,
with or without optic neuritis, but of this neither the heart nor the urine
gave us at the outset any hint. Later the urine was so constantly in-
voluntary that none was collected for examination. In the light of the
outcome it would appear that such an examination might have been
of the greatest importance.

Outcome. A few days after this she began to have fever ranging
from 99 to ioi F., and continuing until the day of her death, October
27th. Autopsy showed a chronic nephritis with suppuration, an
extensive bronchopneumonia, and an obsolete tuberculosis of the mesen-
teric lymph-glands. The stomach, brain, and cord were normal.

This case is one of those which have most strongly impressed upon
me the dangers lurking in the diagnosis of "hysteria." it is the fourth
case that I have known to die with this diagnosis. Jn two of these
absolutely nothing was found postmortem, and in these we might, if
we were so inclined, consider the diagnosis verified. But when we say
"hysteria," we ordinarily mean a disease which cannot in itself, and
apart from starvation (as in anorexia nervosa), prove fatal. To my mind
these cases simply indicate some of the blind spots in our diagnostic
retina.

Diagnosis. Suppurative nephritis.

738 DIFFERENTIAL DIAGNOSIS

Case 381

A widow of sixty, first seen October 9, 1907, has been treated in
the out-patient department of the hospital for some time under the
diagnosis of neurasthenia. She has always been a healthy woman,
except that she has had eight miscarriages, attributed by her to horse-
back riding during pregnancy. She has five living children, all healthy.
Last autumn she had an attack of diarrhea and vomiting, and was in
the Chelsea Hospital for a week. Since that time she has been more or
less run down. In March, 1907, she fell into a hole in the floor, bruising
her foot and right side, and since that time has had occasional pains in
the right side of the chest, sometimes severe enough to make her leave
off her corsets. For the past seven weeks she has had a great deal of
nausea and has been extremely nervous. Five weeks ago she was
examined in the out-patient department and told that she was " simply
nervous." A week later her right chest was tapped, and z\ quarts of
bloody fluid withdrawn. An equal amount of the same character was
removed six days later.

On examination the patient was excellently nourished, slightly obese,
the face flushed, the mucous membranes of good color; the lips and
finger-tips somewhat cyanotic. The heart's impulse was in the eighth
interspace, behind the anterior axillary line, 6| inches to the left of mid-
sternum. The right border could not be determined. The sounds were
normal. The whole right chest was dull, with flatness in the lower half,
and rapid and shallow respiration. Breath-sounds were very indistinct,
vocal and tactile fremitus absent, except at the apex. The left lung
seemed to be normal. Physical examination was otherwise negative,
including blood and urine. The chest was at once aspirated, and no
ounces of bloody fluid, with a specific gravity of 1019, was removed.
Differential count of the sediment showed lymphocytes, 97 per cent.,
endothelial cells, 3 per cent. No tubercle bacilli could be found in the
sediment of the digested clot. Under ordinary culture-media the fluid
remained sterile, and in a guinea-pig 10 minims of the sediment pro-
duced no disease in six weeks. In four days the fluid had reaccumulated,
and tapping had to be repeated about every four days until November
9th.

Discussion. But for this patient's age, it would be natural to
assume, after reading the history and previous to the physical examina-
tion, that we are dealing with a traumatic neurosis which originated
in the accident of March, 1907. In my judgment, however, it is always
unwise to make a diagnosis of any type of neurosis when the symptoms

NERVOUSNESS 739

arise first after the fiftieth year. I have never known such a diagnosis
confirmed. The mental characteristics of this patient were, indeed,
very much those which we associate with the neuroses, but diagnoses
based upon mental characteristics alone are always most vulnerable,
even within the field of the alienist, still more markedly so outside it.

After the chest was tapped we assumed that the patient was suffering
from a pleural effusion of the ordinary (i. e., tuberculous) type. Even
in advance of our own physical examination, however, we ought to have
suspected that something more serious was in the background. Ordinary
tuberculous effusions (/. e., 99 per cent, of all the serous effusions which
we meet with) are rarely bloody, and very rarely reaccumulate within
six days. One tapping suffices, in the vast majority of cases, and bloody
fluid does not suggest tuberculosis, despite the oft-copied statement of
many text-books.

The age of the patient and the rapid reaccumulation of the bloody
fluid should have suggested to us at once the diagnosis of malignant
disease involving the pleura, lungs, or mediastinal glands.

Doubtless there was a period (before any fluid had accumulated)
when diagnosis was difficult or impossible, and when the psychic pecu-
liarities were sufficient to explain, though not to excuse, the diagnosis of
neurosis. At this period our proper attitude would have been expressed
by saying, "We do not know."

Outcome. The x-ray showed a diffuse shadow over the whole
right side, and an unexplained mass near the hilum of the left lung.
The patient had frequent dyspnea, more or less relieved by morphin,
amyl nitrite, and oxygen.

Autopsy showed endothelioma of the pleura, with extension into
the lungs, pericardium, diaphragm, right thoracic wall, bronchi, and
retroperitoneal lymphatics, liver, stomach, and left adrenal; acute sero-
fibrinous pericarditis and general arteriosclerosis.

Diagnosis. (See last paragraph.)

Case 382

A housewife of thirty-three was first seen November 4, 1907. She
has lost one sister of consumption. Her family history was otherwise
excellent, and she had never been ill except that four years ago she had
blood-poisoning after childbirth, but recovered entirely in three months.
Fifteen months ago she gave birth to a child after a normal labor. She
felt unusually well during the pregnancy. Immediately after she became
very nervous, with spells of trembling and restlessness lasting an hour,
once or twice a day. These symntoms persisted until four months

DIFFERENTIAL DIAGNOSIS

later; the child, who had been doing excellently well at the breast, had
to be weaned. During this period she also had severe burning micturi-
tion, but since the weaning of the child this has not troubled her. Four
months ago she ate a considerable quantity of green corn, and was at
once attacked with diarrhea, four or five green watery movements a
day and five or six at night. This diarrhea persisted until two weeks
ago, when it was diminished by medicine, and for the past two days her
bowels have not moved. She has been in bed for the past five weeks,

complaining chiefly of dizziness, weakness,
rumbling in her head, and dryness of the
mouth. For two weeks she has had a
cough and raised considerable greenish
sputa.

The course of the temperature is seen
in the accompanying chart (Fig. 195). The
patient is pale and emaciated, the tongue
moist and slightly excoriated along the an-
terior edge, the mouth and throat other-
wise normal. A systolic murmur is heard
over all the precordia, loudest in the pul-
monary area, otherwise the heart shows
nothing abnormal. The lungs, abdomen,
and reflexes are normal. There is slight
spinal curvature in the dorsal region, with
a concavity toward the left. Examination
of the sputa shows nothing abnormal. The
same is true of the urine.
Discussion. The family history, the spinal curvature, the fever,
greenish sputa, and painful micturition might be taken as hints of a
tuberculous infection, though its localization is not clear, and nothing
in the further study of the case gives support to any such hypothesis.

Acute endocarditis might produce a murmur with the characteristics
here described, although it is much more common to find it in the mitral
or aortic area. Especially when fever, without known cause, is present,
any cardiac murmur must be thought of in the light of a possible endo-
carditis. Yet in this case we cannot advance beyond the stage of con-
jecture with such a diagnosis, as we have nothing but the facts just
mentioned by which to support it. Leukocytosis, evidences of peri-
pheral embolism, tender finger-pads (Osier), marked urinary abnormali-
ties, chills, and sweats are all absent.

Doubtless if this patient had been of the male sex, the diagnosis

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Fig. 195. Chart of case 382.

. NERVOUSNESS 741

would have been much earlier suspected. Her recent labor, and the
rather indefinite ill health which we are accustomed to tolerate in many
women at such a time without feeling obliged to make a diagnosis,
probably prevented her physician from thinking earlier of the importance
of a blood examination, the tell-tale indicatiqns of which are revealed
in the outcome.

Outcome. The blood showed red cells, 640,000; white cells, 6500;
hemoglobin, 13 per cent. A differential count of 200 white cells showed
polynuclears, 57 per cent.; lymphocytes, 43 per cent.; two megaloblasts
and one normoblast were seen during this count. The red cells were
markedly oversized, deformed, abnormally stained, and stippled. The
fundus oculi showed numerous retinal hemorrhages. The patient
steadily failed, and died on the sixteenth of November, without any
marked change in the symptoms.

Diagnosis. The diagnosis was not in doubt after the first blood
examination, as all the characteristics of pernicious anemia were present.

Case 383

An optician of fifty-six was first seen May 28, 1907. He has lost one
brother of consumption, and his wife died of the same disease. The
patient had pleurisy seven years ago, and was sick with it for three or
four days. Seven years ago he began to have nervous depression, and he
has never been quite free from it since. He has had periods of depres-
sion and despondency, and has been confined to bed many times for
from one to eight weeks. His habits are good. He denies venereal
disease.

Ten days ago he began to feel "all smashed up" considerable
headache, nausea but no vomiting, stiffness of the legs and neck,
shortness of breath, insomnia (apparently due to nervousness), and
moderate constipation. His appetite has been good, and he has been
very anxious to make a business trip to Ohio, but has been prevented
by this present illness. Of late his hands and arms have begun to
tremble, and his left foot drags a little when he walks.

On examination, the patient is well developed and nourished. I lis
right pupil is slightly irregular and larger than the left; both react
normally. The heart's apex is in the fifth space, just outside the nipple-
line. There is no enlargement to the right. The heart-sounds are irreg-
ular in force and rhythm; no murmur or accentuation. Blood normal.
Blood-pressure is 120 mm. Hg. The lungs and abdomen are negative.
In the left axilla there is a gland the size of a walnut. The left leg is
moved with great difficultv. Sensation is even where good. There is

742 DIFFERENTIAL DIAGNOSIS ,

fibrillary twitching over the arms and body, and a coarse twitching of
the hands and face. The patient is very sleepy, but when aroused,
speaks without difficulty. A neurologic consultant said, "probably
psychoneurosis," but advised us to continue observation before con-
cluding that there is nothing further.

Discussion. From the family history, from the previous attack
of pleurisy, and from the presence of an enlarged gland in the left axilla,
tuberculosis is naturally the first cause for this man's nervousness which
we are led to consider. Such a consideration, however, proves fruitless,
as nothing in the physical examination bears it out.

Some cerebral lesion was the next thing that occurred to me in
studying the case, especially in view of the headache, the nausea, the
irregular and unequal pupils, and the paresis of the left leg. The mental
state, moreover, was very abnormal, especially considering the age at
which it first appeared, and the muscular tremor seems likewise significant
of a lesion of the central nervous system. Had the blood-pressure been
high, we should doubtless have thought of chronic nephritis as soon as
the slight cardiac enlargement was discovered, but the normal pulse
tension threw us at first off the track.

We remained in the dark regarding the diagnosis, trying to figure
out some type of thrombosis, softening, or slight hemorrhage in the
brain which could account for the condition of the left leg. Dementia
paralytica was considered, but the mental state, the pupils, and reflexes
were not at all characteristic of this condition; nor, on the other hand,
were they wholly inconsistent with it. At this point most of our difficul-
ties were cleared up by the receipt of a full report upon the condition
of the urine, details of which follow.

Outcome. The urine averaged 60 ounces in twenty-four hours;
specific gravity, ion; the slightest possible trace of albumin was found,
and a rare, finely granular cast. There was marked soft edema of the
feet and lower legs. By rest in bed, 10 minims of digitalis every four
hours, 1 ounce of magnesium sulphate every morning, diuretin, 15 grains
four times a day, and limitation of liquids, the patient was greatly im-
proved by the second of June. By the third the edema was gone. By
the ninth he was sitting up, feeling well, passing a large amount of
urine, his heart's action much stronger and steadier, his leg motions
nearly normal. On the eighteenth he was allowed to go home in excel-
lent spirits.

Diagnosis. Chronic interstitial nephritis.

APPENDIX A

As mentioned in the Introduction, certain statistical articles and
monographs were used in the preparation of the " gridiron " diagrams.
The most important were as follows:

i. Rolleston: "Diseases of the Liver" (W. B. Saunders Co.).

2. Bramwell: "Clinical Studies," Jan. i, 1910, vol. viii, part ii, p. 97.

3. Garceau: "Renal Tumors" (Appleton, 19 10).

4. Howard A. Kelly: "The Vermiform Appendix" (W. B. Saunders Co.).

5. Tauquerel des Planches: "Monograph on Plumbism," Paris, 1839.

6. Starr: "Text-book of Diseases of the Nervous System."

7. F. C. Shattuck: "Tuberculous Peritonitis," Trans. Assoc. Amer. Physicians,
1902, p. 137.

8. Thomas McCrea: Article on "Typhoid Fever" in vol. ii of Osier's "Modern
Medicine."

9. Xaunvn: "Klinik der Cholelithiasis," Leipsig, 1892.

10. Grecnough and Joslin: Article on "Gastric Ulcer," Boston Med. and Surg.
Jour., Oct. 19, 1899.

11. E. A. Codman: "Subdeltoid Bursitis," Boston Med. and Surg. Jour., May 31,
1906.

12. Berger: "Occupation Neuroses," Osier's " Modern Medicine," vol. vii, p. 793.

13. Osier: Article on "Aneurysm," Medical Chronicle, 1906, vol. xi, p. 69.

14. Osier: Lumleian Lecture on "Angina Pectoris," Lancet, March 12, 19 10.

15. Henry Phipps' Institute: "Annual Reports" (1906-1909).

16. Musser and Norris: Article on "Pneumonia," Osier's " Modern Medicine," vol

ii, P- 5^3-

17. Dickinson: " Uremia," in " Allbutt's System," 1897, vol. v, p. 367.

18. Savill: Lectures on "Hysteria, Etc." (Win. Wood, 1909).

19. F. T. Lord: "Diseases of the Pleura," Osier's " Modern Medicine," vol. iii, p,
7S0.

20. Keyes: "Diseases of the Genito-urinarv Organs" (Appleton, igioV

21. Bevan: "Renal Tuberculosis," Jour. Amer. Mid. Assoc, Oct. 9, 1906.

22. Albarran: "Les Tumcurs du Rein," Paris, 1903.

23. Robson and Cammidge: "Diseases of the Pancreas."

24. Benj. Tenney: "Renal and Ureteral Calculi," Boston Med. and Surg. Jour.,
June 8, 1905.

25. F. B. Greenough: "Herpes Zoster," Boston Med. and Surg. Jour., Dec. 5, 1SS9.

APPENDIX B

I. Typhoid Regime at the Massachusetts General Hospital (West

Medical Service)

1. Bed until temperature is normal.

2. Four-hourly chart.

3. Four-hourly mouth-wash and spray.

7i;i

744 APPENDIX

(a) Swab tongue, cheeks, and gums with equal parts of
Boric acid (saturated aqueous solution),
Lemon-juice, j-ona cotton stick

Glycerin,
(b) Dobell's solution, i part

c Spraved with an atomizer.
W ater, 3 parts )

4. Four-hourly bath whenever temperature reaches or exceeds 102.5 F. (by mouth).
Baths are given with water and 40 per cent, alcohol, equal parts. Duration, twentj

minutes (if reaction is good).

Temperature of bath, go F., if mouth temperature is 102.5 F.
Temperature of bath, 85 F. " " 103.0 F.

Temperature of bath, 8o F. " " 103.5 F -

Temperature of bath, 75 F. " 104.0 F. or more.

5. Suds enema every second day, if needed.

6. Cocoa butter to lips, p. r. n.

Typhoid Diet (as Introduced by Dr. F. C. Shattuck in 1897 1 ).
I. Breakfast:

1. One egg on a slice of toast with butter.

2. One of the following drinks

(a) Milk, 3iv, with cream (20 per cent.), oij, and milk-sugar, oss to 3j.

(b) Malted milk, ov.

(d) Coffee.

(e) Mellin's food.
II. 10 a. M.:

Lemonade, orangeade, grape-juice, or albumen-water with oij, milk-sugar.

III. Dinner:

1. Milk, cream, and sugar mixture as above.

2. One of the following solids

(a) Fgg with toast and butter, as above.

(b) Minced chicken with toast and butter, as above.

(d) Blanc mange or wine jelly with sugar and at least 5 j of cream.

IV. 3 p. M. :

One raw egg beaten up with milk, iv; 20 per cent, cream, oss; and milk-sugar, oj

V. Supper:

1. Milk, cream, and sugar mixture, as at breakfast.

2. Baked apple or banana-whip, with o j cream, or one-half slice of toast with butter,

VI. During the Night:

Two drinks consisting of

Albumen-water, 1

Crape -juice, i , .,, , ~ .

T , with milk and sugar, o 1.

Lemonade, 1 J

Orangeade, J

Or,

Cocoa, 1

Malted milk, - with milk.

Chocolate, \

This diet supplies about 2900 calories.

1 F. C. Shattuck, Journal of the Amer. Med. Assoc, July 10, 1897.

APPENDIX 745

IL Regime for Cases of Peptic Ulcer Gastric or Duodenal as Used
in the West Medical Wards, Massachusetts General Hospital

A. Rest in bed.

B. Diet as follows:

i. For first three days give every two hours (when awake)

Milk, 2 ounces, with two powdered scda-crackers (2J inches square) and
Cane-sugar, 1 teaspoonful (if relished).

2. For next two or three weeks every two hours

Milk, 6 to 8 ounces, with four powdered soda-crackers and
Cane-sugar, 1 to 2 teaspoonfuls (if desired).

3. For next two months (more or less) a diet consisting of average portions of the

following articles
Milk and crackers, as above.
Cornmeal mush with cream and sugar or salt.
Potato puree.

Milk with whites of 2 eggs.
Soft custard.
Chocolate.
Pea puree.
Water is given according to the patient's desire.

C. For pain or sour burning eructation a saucer of sodic bicarbonate and a spoon are
put at the l)edside and the patient is told to take the soda in amounts sufficient to relieve him.

APPENDIX C
THE CLASSIFICATION OF NEPHRITIS

Throughout this l)ook I have adopted the classification used in the autopsy records
of the Massachusetts General Hospital, and identical in its main outlines with that
used by Senator and by Councilman. The gist of it appears to be as follows:

Leaving out of account the acute destructive lesions, such as may be produced by
mercurial poisoning, suppurative nephritis, etc., the renal lesions distinguishable by a
group of clinical and anatomic characteristics are:

1. Glomerulo-nephritis, early or late.

2. Interstitial nephritis. 1

The former results from an injury produced in the glomeruli by some irritant
usually the poison of an acute infectious disease, such as scarlet fever, pneumonia, or
acute endocarditis. Kdcma, anemia, and often uremic manifestations occur. In cases
lasting over six weeks there is usually cardiac hypertrophy. If tin- injurv to the glomeruli
is relatively slight and limited to a few, recovery takes place after an acute or, rarelv, a
subacute course of the disease. If the injury is more serious, the disease may go on in a
latent and well-compensated form for months or years, finally ending with a burst of
'acute" symptoms (edema, anemia, uremia, cardiac failure'. In the more chronic
cases the histology of the kidney and the condition of the heart and urine may closely
resemble those of the type next to be described.

Chronic interstitial nephritis is relatively uncommon, especially in the first half fi
life. The lesions do not appear to originate in the glomeruli, and the islands of intact
glomeruli are relatively few. The change represents a more generally distributed dis-
ease whose cause is obscure, though in many, perhaps most, cases ii seems to be related
to arteriosclerosis.

1 Not including Councilman's " acute interstitial nephritis.''

INDEX

[Words and page numbers printed in heavy type correspond to illustrative cases; other words
and numbers, to minor discussions.]

Abdominal aneurysm, 172
angina, 165, 169, 182

cause of epigastric pain, 155
pain, 26

causes of general, 128
general, 128

considerations, 24
on diagnosis of, 286
tuberculosis, 264
tumor, 115, 134

cause of general abdominal pain, 129
Abortive typhoid, 444
Abscess, cerebral, 510
deep axillary, 334, 484
' fixation," 207

hepatic, 80, 230, 231, 318, 462, 475
ischiorectal, 368, 400, 481
liver. Sec Abscess, hepatic.
lung. See Abscess, pulmonary.
multiple renal, 111
perinephric, 86, 91, 318, 411

cause of lumbar pain, 81
perirectal, 411

pulmonary, 21S, 462, 566, 579, 589, 594
renal, 1 11
subdiaphragmatic, 135, 229, 318

cause of right hypochondriac pain, 204
tubal, 233

tuberculosis with, 33S
Acetanilid, 40

Acid (oxalic) poisoning, 647
Actinomycosis, 320
Acute yellow atrophy of liver, 727
Adams-Stokes' disease, 435, 492, 518, 520
Addison's disease, 535, 571
Adenitis, 31 2
mesenteric, 357
syphilitic, 281
Adenoma, simple, of thyroid, 40
Adherent pericardium, 2i(>, 700
Adhesions, pelvic, cause of left iliac pain, 276
of right iliac pain, 259

Adhesions, pleural, 185, 301
pleuropericardial, 185
pyloric, 174

cause of epigastric pain, 154
Adhesive pericarditis, 51

chronic, 705
Adolescence cause of headache, 35
Air, bad, cause of headache, ^^
Alcohol cause of headache, 7,^
Alcoholic gastritis, 214
neuritis, 373, 555, 557

cause of pain in legs and feet, 351
Alcoholism, 77, 158, 167, 170, 177, 192, 195,
270- 350- 3QO. 447, 475, 501, 517, 538,
611, 632, 659
cause of coma, 486
of convulsions, 486
of vomiting, 600
Amyloid metamorphosis of liver, 318
Anal fistula, 317
Anemia, 140

cause of headache, 32

pernicious, 146, 150, 540, 549, 570, 574,

739
secondary, 151, 539
Aneurysm, 165, 190, 202, 207. 2qq, 327, 337,
340, 344, 345. 582
abdominal, 172
aortic, 80, 100, 142, 206
called rheumatism, 327
cause of brachial pain. 325

of lumbar pain, 108
of spine, 1 iS
thoracic, 315, 341
Angina abdominalis, 165, 169, 1S2
cause of epigastric pain. 155
pectoris, 26, 177. 1S2. 295, 207. 308. 313,
310. 343, 344
cause of brachial pain. 3 2 3
functional, 243
low, 168
Anginal pain, four occasions tor. 344

74 8

INDEX

Anginoid pain, 26

Ankle, sprained, cause of pain in legs and

feet, 351
Anorexia nervosa, 436
Aorta, dynamic, 141, 143

syphilitic heart and, 296
Aortic aneurysm, 86, 109, 142, 296
insufficiency, 297
regurgitation cause of cough, 577
stenosis and regurgitation, 694
valves, fibrous endocarditis of, 215
Apoplexy, 389, 497, 510
cause of coma, 487

with hemiplegia cause of paralysis, 533
Appendicitis, 89, 93, 101, 131, 133, 136, 138,
179, 192, 260, 262, 263, 267, 268, 356,
419, 445, 613, 646
acute, 64, 264

cause of short fever, 404
of vomiting, 609
and bronchitis, 128, 584
cause of epigastric pain, 155
of general abdominal pain, 129
of right iliac pain, 259
chronic, 191, 622, 630, 640
fear of, cause of right iliac pain, 259
peptic ulcer and gall-stones, 192
Appendicular colic, 270
Appendix, " high," 207, 209, 236

cause of right hypochondriac pain,
204
Apprehension, 542
Arm and shoulder, neoplasm of, cause of

brachial pain, 325
Arms, pain in, 326
Arsenical poisoning, 558
Arterial spasm, 30

Arteriosclerosis, 31, 32, 51, 181, 301, 353,
540, 541, 600, 612
cerebral, 521
general, 521
Arthritis, 66, 180, 332, 343, 379
acute, cause of short fever, 404

of hip, 369
atrophic, 334, 353. 384

cause of pain in legs and feet. 351
gonorrheal, 66, 350, 392
hypertrophic, 334, 352, 384
cause of lumbar pain, 81

of pain in legs and feet. 351
spinal, 89

radiations from, cause of axillary
pain, 289

Arthritis, infectious, 381
cause of long fever, 403

of pain in legs and feet, 351
of hip, 368

of left sacro-iliac joint, 107
of spine, 107

cause of lumbar pain, 81
osteo-. See Osteo-arthritis.
pneumococcus, 375
rheumatic, 66, 365, 384
sacro-iliac, 179
of shoulder-joint, 338
various types of, cause of brachial pain,

325
Artificial menopause, 302

Ascending colon, cancer of, 657
Ascites, 315
Astasia abasia, 529
Asthma, bronchial, 316

and bronchitis, 595

cause of cough, 577
of dyspnea, 687
Ataxic paraplegia cause of paralysis, 533
Atrophic arthritis, 334, 353, 384

cause of pain in legs and feet, 351
Atrophy of liver, acute yellow, 727
Attempted miscarriage, 613
Attention, expectant, 206
Atypical forms of malaria, 641
" Auto-intoxication," 301
Axillary abscess, deep, 334, 484

pain, 290

Back, acute sprain of, cause of lumbar
pain, 81
strain, 96
Backache, " functional," 79, 87, 103
" kidney group," 86
" orthopedic group," 80, 86, 90, 91, 101,

118, 120
" postural," 79

"pressure group," 86, 108, 109, 118, 119
sacro-iliac, 79
" uterine," 79
Bad air cause of headache, 33
hygiene, 132
j Balance, defective, cause of lumbar pain,
81
Banti's disease, 551
base of skull, fracture of, 54
j Basedow's disease, 51

" Bed fever," 457
I Bile-ducts, cancer of. cause of jaundice, 717

INDEX

749

" Biliousness," 35

cause of headache, 33
Birth palsy cause of paralysis, 533
Bismuth poisoning, subnitrate of, 228
Bladder cancer, 278, 674, 676

gall-. See Gall-bladder.

stone in, 279, 675, 676, 684

tuberculosis of, 280, 669, 670, 680

tumor of, cause of hematuria, 666
Blood. See Hematuria, Hemoptysis, etc.

cultures, 74
Bones, tuberculosis of, 346
Bowel, cancer of, 86, 170. See also Colon.

ulcer of, 86
Boys of fourteen and fifteen, infections

common in, 445, 469
Brachial neuralgia, 336, 338

neuritis, 338
Brain, concussion of, 55

softening, 77

tumor, 55, 61, 70, 75 77, 423, 4Q r >. 5 IO >
517. 523- 5 2 8, 615, 640, 642, 644, 737
cause of coma, 487
of headache, 33, 38, 46

" wet," 77
" Brain-fag," 525
Breur, 372
Brewer, G. E., 100
Bright's disease, chronic, 254, 353, 625, 640,

673, 676
Broken rib, 292
Bronchial asthma. 316
Bronchiectasis, 581, 588, 509

influenzal infection of, 304
Bronchitis, 304, 582, 603

acute, 471

cause of short fever, 404

and appendicitis, 12S. 584

and asthma, 585

and emphysema, 700

bronchopneumonia, bronchiectasis, and
emphysema, 590

cause of cough. 577

chronic. 218

cause of dyspnea, 687
Bronchopneumonia, 51 5

bronchiectasis, emphysema, and bron-
chitis, 590

streptococcus, 587
Hulio. 2S2

" Burning pain." 22^,

Bursitis, subacromial, 330. 333. 335, 336, 338
cause of brachial pain, 325

Calculus. See Stone.
Cancer, 97, 260, 269, 725
of bile-ducts cause of jaundice, 717
of bladder, 278, 674, 686
of bowel, 86, 170

cause of long fever, 403
of colon, 196, 252, 255, 257, 281, 618. 657
of duodenum cause of jaundice. 717
of gall-bladder cause of jaundice, 717
gastric, 86, 144 156, 159, 161, 163, 166,
175, 184, 189, 104, 223, 252, 536, 548,
614, 616, 636, 648, 651, 658
cause of epigastric pain, 155
of jaundice, 717
of vomiting, 609
hepatic, 157, 196, 211, 220, 370, 408, 550,
720, 727
cause of jaundice, 717
of right hypochondriac pain, 204
intestinal, 147, 159, 277, 574
of liver. See Cancer, hepatic.
of pancreas, 186, 224, 230, 726

cause of jaundice, 717
rectal or intestinal, 574
of rectum, 150
recurrent intestinal, 146
of sigmoid, 281, 283, 618

cause of left iliac pain, 276
of spine cause of lumbar pain, 81
of splenic flexure, 252, 255
of stomach. See Cancer, gastric.
of uterus, 381
Cardiac cases, sudden death in. 40(1

dilatation, acute, 40. 51, 297. 314. 704, 700
disease, 40, 22b. 54O. 569, 005. 012. 709,
7 10
cause of dyspnea. 687
of vomiting, 000
hypertrophy and dilatation, 40. 207
insufficiency, 701
Cardiorenal disease. 630
Caries sicca, 334, 338
Catarrhal jaundice, 210, 454, 626, 717. 719,

721, 723. 724, 72S
" Cathartic method." 372
Cecal region, tuberculosis of, 2(>i
Cellulitis, 336, 340

infectious, 332
Central pneumonia, 447
Cerebral abscess, 5 10
arteriosclerosis, 5 2 1
concussion, 53

cause of heada< lie. ;s

75o

INDEX

Cerebral hemorrhage, 70, 76

softening, 77
syphilis, 57

tumor. See Tumor, brain.
cause of headache, 33, 38, 46
Cerebrospinal syphilis, 391
Cervical rib, 327, 336, 337, 340
cause of brachial pain, 325
Charcot joint, 383

Charts and diagrams, explanation of, 22
Chest, malignant disease of, 312, 316

wall, malignant disease of, 320
Childbirth cause of lumbar pain, 81
Children's fevers, 417
Chills, 461
causes of, 461
" creeping," 461
" nervous," 461
occurring in typhoid fever, 480
Chlorosis, 160, 397, 544, 621, 732
Cholangitis, 210
Cholecystitis, 101, 191
acute, 219

cause of right hypochondriac pain, 204
typhoid, 210, 238
Choledochus, stone in ductus, 224, 232
Cholelithiasis, 86, 113, 164, 165, 169, 170,
174, 175, 176, 182, 187, 192, 197, 198,
206, 210, 235, 252, 265, 307, 483, 630,
719, 722, 723, 724
cause of chills, 460
of epigastric pain, 155
of jaundice, 717

of right hypochondriac pain, 204
with perforations, 178
Circumflex paralysis, 334, 338
Cirrhosis of liver, 145, 187. 196, 213, 225,
232, 246. 318, 550, 612, 648, 725, 728
cause of jaundice, 717
of long fever, 403
Claudication, intermittent, cause of pain in

legs and feet, 351
Clubbed lingers, 390
Cobb, Farrar, 100
Cocain habit, 132
" Colds, common." 48

cause of short fevers, 404
Colic, 26, 515

appendicular, 270
lead-, 131
renal, 144
Colica mucosa cause of right iliac pain, 259
Colitis, chronic, 150

Colitis, mucous, 126, 131, 269
perforative, 149

tuberculous, 146
Colon bacillus infection, 103

cancer of, 196, 252, 255, 257, 281, 283,
618, 657
Column, spinal. See Spinal column.
Coma, 488

causes of, 488
Comatose or convulsive patients, examina-
tion of, 488
" Common colds," 48

cause of short fevers, 404
Common duct, stone in, 224, 232

infections cause of headache, 35
Concomitant nephritis, 59
Concussion of brain, 55
Congestion, gastrohepatic, due to cirrhosis
or cardiac disease cause of epigastric
pain, 155

hepatic, 195, 318

cause of right hypochondriac pain. 204
Constipation, 133, 152, 159, 161, 162, 166,
170, 173, 175, 177, 195, 198, 280, 614,
623, 624, 661

cause of epigastric pain, 155
of general abdominal pain, 129
of headache, 32

(neurosis?), 623, 624
Constitutional headache, 48
Constriction, pain with a sense of, 26
Contusion, 335

Convalescence from pneumonia, 560
Convulsions, 501

causes of, 488
Convulsive patients, examination of coma-
tose or, 488
Costal tuberculosis, 320
Cough, 576

causes of, 576

" heart," 599

mixture, 601

varieties of, 576
Courvoisier's law, 187
Craig, Charles F., 641
" Cramp, writer's," 524
Crisis, gastric, 128, 166, 630, 642, 651

vascular, 31, 181, 387, 432, 510, 511, 521
Croup, 708
Cultures, blood, 74
Curschmann, 601
Curvature, spinal, 380
Cyst, hydatid, of liver, 221, 230

INDEX

75 1

Cyst, ovarian, 267, 269, 272
cause of left iliac pain, 276

of right iliac pain, 259
ruptured, 266
strangulated, 283
with twisted pedicle, 263, 265
renal. See Cystic kidneys.
Cystadenoma, papillary, of kidney, 677
Cystic kidneys, congenital, 86, 115, 221, 246,

256
Cystitis, 669, 675, 683
cause of hematuria, 666
chronic, 280
gonorrheal, 280
of unknown origin, 675

Death, sudden, in cardiac cases, 496
Debility, 101, 120, 158, 225, 227, 562, 698
Defective balance cause of lumbar pain,

86
Deforming osteitis, 48
Deformity, round-shoulder, 342
Degree of pain, 25
Delirium, salicylate, 364

tremens, 660
Dementia paralytica, 67, 6q, 521, 525, 742
cause of coma, 487
of paralysis, 533
Dercum, Dr. C. T., 80
Diabetes mellitus, .51, 140, 362, 434, 502,

517, 551, 553, 572. 600, 629, 731
Diagnoses, causes of incorrect, 17
Diagnosis, vulnerability of all differential, 19
Diagrams and charts, explanation of, 22
Diarrhea cause of epigastric pain, 155

of general abdominal pain, 129
Diet, Lenhartz's, Dr. H. F. Hewes's modifi-
cation of, 253
Dilatation, acute cardiac, 49, 51, 297, 314,

704, 700
Diseases frequently diagnosed as rheuma-
tism, 320

not considered in tin's book, 21
Dislocation of humerus, 335
Displacement of liver, 221
I )istomiasis, 31 7
Disturbances of sensation, 20
Diverticulitis, 284
Dorsal tabes, 132. 161, 387, 535
with gastric crises, 042, 651
I >ropsy, 40, 301 . 353

pleural, 314
Drug habits, 659

Drug poisoning, 732

Ductus choledochus, stone in, 224, 232

Dunn, Dr. Charles Hunter, 217

Duodenal ulcer, 131, 140, 139, 163, 166, 167,

169, 176, 212, 234
Duodenum, cancer of, cause of jaundice, 717
Dynamic aorta, 141, 143
Dysentery, 399
Dysmenorrhea, 26

cause of left iliac pain, 276
of right iliac pain, 250
Dyspepsia, 177, 319
Dyspnea, 686

causes of, 689

inspiratory and expiratory, 707
Dysuria, 423

Eclampsia (puerperal) cause of convul-
sions, 500

Ectopic gestation cause of left iliac pain, 276

Edema, acute pulmonary, 305

Edinger, 35

Effusion, dropsical, 301
pericardial, 205, 314
pleural, 299, 300, 306, 353, 439, 598, 654,

739
purulent, 318
I^mbolism, 70
Emotional excitement, its relation to pain,

2 7
Emphysema, 88, 300, 590, 700

cause of cough, 577
of dyspnea, 687
Empyema, 229, 318, 429, 482, 547, 581

interlobar, 415, 503

necessitatis, 320

postpneumonic, 63, 415. 593, 594. 703

tuberculous, 545, 701
Endocardial fever, 420

infection, 465
Endocarditis, 95, 180, 375, 469, 544. 364,
695

acute, 740

fibrous, of mitral and aortic valves, 215

gonorrheal, 302

mitral. 365

ulcerative (or malignant), 02. 430
Endometritis, hyperplastic, 698
Endothelioma, pleural, 738
Enteritis, (14s

cause of epigastric pain. 1 35
of general abdominal pain. 1 :8

gastro-, 143, 040

752

INDEX

Enteritis, tuberculous, 256

Enuresis, 683

Epidemic meningitis, 57, 441, 508

poliomyelitis, 558
Epididymitis, tubercular, 115
Perigastric pain, 156
Epilepsy, 501, 505, 517, 521, 524, 700

cause of convulsions, 500

Jacksonian, 392, 524

nocturnal, 509
Erysipelas cause of short fever, 404
Iirythematous lesions, 73
" Essential " headache, 48
Estivo-autumnal malaria, 420, 456
Evidences of pain, 24
Evils of obesity, resulting, 373
Examination of comatose and convulsive

patients, 488
Excitement cause of dyspnea, 687

emotional, and its relation to pain, 27
Exertion cause of dyspnea, 687
Exhaustion, 477, 628

nervous, 649

postepileptic, cause of coma, 487
" Expectant attention," 206
Expiratory and inspiratory dyspnea, 707
Extra-uterine pregnancy, 262

cause of general abdominal pain, 129
of right iliac pain, 259
Eye-strain cause of headache, ^^, 42, 67

Fatigue cause of brachial pain, 325
of headache, 32, 33, 525
of lumbar pain. 80, 81

poisons, 32
Fatty metamorphosis of liver, 318
" Febricula." 138
Fecal impaction. 424
Feet, pain in legs and. 352
Femur, sarcoma of, 383
Fevers, 401

" bed-." 457

of children. 41 7

endocardial, 420

gall-stone, 40S

glandular, 452

long. 401. 40,

non-infectious. 405

short, 401, 405

slow, 301

urticarial, 457
Fibroid tumor of uterus, 173, 263. 283

uterine, 1 73, 2f)^

Fibrous endocarditis of mitral and aortic
valves, 215

myocarditis, chronic, 612, 705, 709
Fingers, clubbed, 390
Fistula in ano, 317
Fixation abscess, 207
Flat-foot, 366, 371, 379, 385, 388, 395

cause of pain in legs and feet, 351
Flatulence, 200. 244, 313, 319

cause of axillary pain, 289
Flint, Austin, 216
Floating kidney, 225, 273, 639
Floyd, Dr. Cleaveland, 587, 600
Food, relation of pain to taking of, 28
Food-strain, acute, 372
Fracture of base of skull, 54

of humerus, 334, 335
Fractured pelvis, 366

rib cause of axillary pain, 289
Freud, S., 372
Frontal sinus, disease of, cause of headache.

42
Functional affection of spine, 108

angina pectoris, 243

backache, 79, 6, 103, 108, 118

neurosis, 265

Gall-bladder, cancer of, cause of jaun-
dice, 717

disease, 157

enlargement of. 221

gangrenous, 176

infection, 131, 397
Gall-stone disease, 475, 663

fever, 408
Gall-stones. See Cholelithiasis.
" Gastralgia.'' 164
Gastrectasis. 07
Gastric cancer. See Cancer, gastric.

crisis, tabes dorsalis with, 128, 166. 630,
642, 651

flatulence. 200

hepatic congestion due to cirrhosis or
cardiac disease cause of epigastric pain,

155
neurosis, 162, 189, 190, 257, 615, 622, 631,
633, 640, 655. 661
cause of epigastric pain. 155
of genera! abdominal pain, 129
of vomiting. Ooq
tumor. 115

ulcer, 86. 157. 187, 191, 616, 637, 64S.
682, 737

vtAAjvA

INDEX

753

Gastric ulcer, perforated, 89, 277
Gastritis, 648

alcoholic, 214

cause of vomiting, 609

phlegmonous, 472
Gastro-enteritis, 143, 649
Gastro-intestinal disease, psychic causes in,
163

tract, infection of, 653
Gastroptosis, 635
" Gefasskrisen," 30

Genito-urinary tuberculosis, 669, 675, 732
Gestation, ectopic, cause of left iliac pain,

276
Glandular fever, 432

tuberculosis, 338, 471
Glomerulonephritis, chronic, 49, 60, 467,

709
Goiter, 51
Gonorrhea, 139, 180, 260, 369, 376, 384, 387

cause of long fever, 403
Gonorrheal arthritis, 66, 350, 392

cystitis, 280

endocarditis, 302
Gout, 365, 373, 376, 387, 529

cause of pain in legs and feet, 351
Graham, Dr., 192
Graves' disease (hyperthyroidism), 49, 552,

572, 629, 705, 709, 732
Gregg, Dr. Donald, 332
" Grip," 54, 91, 95, 138, 294, 403, 412, 443,

465, 484, 506, 561, 653
Gumma, hepatic, 156
Gummatous tumor, 345
Guthrie, Dr., 192

Habit, cocain, 132
drug, 659

" Habit " pain, 29, 85, 317
Hagenbauch, 222

Head, Henry, 29, 248
Headache, ^2

causes of, 39

constitutional, 48

due to trauma, 44

" essential," 48

general considerations on, ^2

indurative, 33, 35

its position and nature, 37

" neuralgic," 71

" neurasthenic," 48, 54, 67

of psychic origin, 47, 73

" rheumatic," 36, 42

Headache, " sick," 50

syphilitic, 43

of unknown origin, 68

uremic, 49

vasomotor, 26, 37
" Heart cough," 599

Heart, dilated, difference between peri-
cardial effusion and, 314

disease, 40, 226, 546, 569, 605, 612, 709,
710
congenital, 522

hypertrophy and dilatation, 49, 297

syphilitic, and aorta, 296

weak, 305
Heberden's nodes, 390
Hematogenous infection of kidney, 86, 91,

98, 678
Hematoma, 335
Hematuria, 667

cause unknown, 678, 682

causes and types, 667
Hemolysis, 367

Hemolytic jaundice, chronic, 537
Hemoptysis, causes of, 595
Hemorrhage, 549

cerebral, 70, 76
Hemorrhagic conditions, 317
Hemorrhagica, purpura, 317
Hemothorax, 301
Hepatic abscess, 89, 230, 231, 318, 462, 475

atrophy (acute), 727

cancer, 157, 196, 211, 229, 370, 408, 550.
720, 727
cause of jaundice, 717
of right hypochondriac pain, 204

congestion, 195, 318
cause of right hypochondriac pain, 204

diseases, 421

displacement, 221

gumma, syphilitic, 154

infection, 473

and pulmonary abscess, 462

syphilis. See Syphilis, hepatic.
Hepatitis, chronic interstitial, 722
Herpes zoster, 86, 93, 360

cause of lumbar pain. Si
" High" appendix, 207, 200. 230

cause of right hypochondriac pain. 204
Hip, acute arthritis of, 3O0
infection of, 368

disease (tuberculous), q6, 360

infectious arthritis of. 368
History of injury sometimes misleading, 339

754

INDEX

Hodgkin's disease, 318, 453, 471, 483
Humerus, dislocation of, 335

fracture of, 334, 335

osteomyelitis of, cause of brachial pain,

3 2 S
sarcoma of, 338, 339

septic osteomyelitis of, 334

tuberculosis of, 333, 336
Hunger cause of headache, 32, 33
Hydatid cyst of liver, 221, 230

infection, 213
Hydronephrosis, 86, 115, 221

cause of right hypochondriac pain, 204
Hydrothorax, 218, 703
Hygiene, bad, 132
Hyperchlorhydria, 159, 165, 167, 170, 251,

2 57
cause of epigastric pain, 155
Hyperemia, vascular, 26
Hypernephroma, 255, 670, 681

metastatic, 344
Hyperperistalsis, 26
Hyperplastic endometritis, 698
Hypertension, nephritic, 31
Hyperthyroidism. See Graves' disease.
Hypertrophic arthritis, 334, 352, 384
cause of lumbar pain, 81
of pain in legs and feet, 331
spinal arthritis, 89

radiation from, cause of axillary pain,
289
spondylitis, 80
Hypertrophy and dilatation of heart, 49,

297
Hypochlorhydria, 167, 251, 617, 620
Hypochondriac pain, left, 241

right, 205
Hysteria, 57, 385, 464, 493, 494, 502, 505,
604, 659, 737
cause of convulsions, 500
and epilepsy, 505
minor, 236
Hysteric affection of spine, 108
polypnea, 690
suggestibility. 507

Icterus neonatorum cause of jaundice, 717
Iliac pain, left, 277

right, 260
Impaction, fecal, 423
Incarcerated uterus. 1 26
Incomplete miscarriage, 045
Indigestion, 443

Indigestion cause of epigastric pain, 155

of headache, 32, ^^
Indurative headache, ^^, 35
Infantile paralysis, 391

spasm cause of convulsions, 500
Infarct, renal, 86
Infection, acute, of hip, 368
cause of headache, 35
colon bacillus, 103
endocardial, 465
gall-bladder, 397
of gastro-intestinal tract, 653
general, 109, 118, 207
hydatid, 213

influenzal, of small bronchiectasis, 304
of liver. 473
localized, 451
perirenal, cause of right hypochondriac

pain, 204
pharyngeal, 449
pneumococcus, 446

general, 435
of puberty, 445, 469
pyogenic, 364
general, 363
renal, 86, 98, 99, 101, 250, 406, 416, 678

cause of right hypochondriac pain, 204
" scattering," cause of long fever, 403
staphylococcus, 65
terminal, 353
unknown, 54, 95, 293, 443
urinary, 104, 564
Infectious arthritis, 381

cause of long fever. 403

of pain in legs and feet, 351
of hip, 368

of sacro-iliac joint, 107
of spine, 107

cause of lumbar pain, 81
cellulitis, 332

disease cause of dyspnea, 687
of lumbar pain, 81, 85
of pain in legs and feet, 351
onset, cause of headache. ^^,, 35
of vomiting, 609
endocarditis, 695
osteo-arthritis, acute, 118
polyarthritis, acute, 328
spondylitis, 107, 110
thrombosis. ^,^2
Inflammation, pain due to, 328
Influenza, 54, 91, 95, 138. 294, 401, 412, 443,
465, 484, 506, 561, 568, 653

INDEX

755

Influenza cause of cough, 577

of long fever, 403

of short fever, 404
Influenzal infection of small bronchiectases,

304
Injury, history of, sometimes misleading,

339
Insolation cause of headache, 35
Inspiratory and expiratory dyspnea, 717
Insufficiency, aortic, 297

myocardial, 61, 701, 710
Intensity of jaundice, 719
Intercostal neuralgia, 319

cause of axillary pain, 289
Interlobar empyema, 415, 593
Intermittent claudication cause of pain in

legs and feet, 351
Interpretation of nervousness, 730

symptoms and their, 29
Interstitial hepatitis, chronic, 722

nephritis, chronic, 511, 513, 646, 709, 710.
741
Intestinal cancer, 147, 159, 277
recurrent, 146
obstruction, 51, 151, 152, 161, 198, 199
cause of epigastric pain, 155
of general abdominal pain, 129
of vomiting, 609
chronic, 135, 166, 188, 658, 661
stricture, 174
Intrathoracic tumor, 336
Irritation, pleural, 583
Ischiorectal abscess, 368, 400, 481

Jacksonian epilepsy, 392, 524
Janeway, Dr. E. G., 603
Jaundice, 715

catarrhal, 210, 454, 626, 717, 719, 721,
7 2 3- 7'4< 7-8

chronic hemolytic, 537

intensity of, 710

symptoms associated with, 716

types and causes of, 713
Johns Hopkins Hospital report, 480
Joint, Charcot, 383

illicit ion of left sacro-iliac, 107
of shoulder, 338
Joints, syphilitic disease of, 365

Kidney abscess, 1 1 1
congenital cystic, 86, 115, 221, 246, 250
floating, 225, 273, 639
group of backaches, So

Kidney, hematogenous infections of, 86, 678
neoplasm, 86, 209, 221, 254, 256, 279,

671, 678, 679, 683, 684
papillary cystadenoma of, 677
pus in, 310

tuberculous, 310
stone in. See Nephrolithiasis.
" surgical," 112

tuberculous, 59, 86, 112, 209, 221, 243,
254, 256, 272, 279, 669, 670, 672,
676, 677, 683
cause of hematuria, 666
tumor. See Renal tumor.
Knee, septic, 383

sprained, cause of pain in legs and feet,
351

Laryngitis, acute, 706

Lead colic, 131

Lead-poisoning, 39, 86, 109, 132, 140, 144.
151, 157, 160, 166, 169, 174, 175, 177,
242, 257, 295, 391, 426, 517, 527, 554,

557; 57 1

cause of epigastric pain, 155

of general abdominal pain, 129
Left hypochondriac pain, 241

iliac pain, 277
Leg bones, sarcoma of, cause of pain in legs

and feet, 351
Legs and feet, pain in, 352
Lenhartz's diet, Dr. H. F. Hewes' modifica-
tion of. 253
Leukemia, 73, 247, 252, 255, 282, 318, 408.
453, 470, 672

cause of long fever, 403

lymphoid, 144

myeloid, 247, 555
Leukocytosis, 468
Lipoma, 387
" Lithemia," 35
Lithiasis. See Stone.
Liver abscess, 89, 230, 231, 318. 4O2, 475

acute yellow atrophy of, 727

amyloid metamorphosis. 318

cancer of. See Liver, malignant disease of.

cirrhosis of. 145. 1S7. 196, 213. 225. 232,
24(1, 31S, 350. 612, 648, 723. 72S

congestion of, [95

displacement of, 221

enlargement of, 3 1 8

fatty metamorphosis. 318

hydatid cyst of. 221. 230

infection of, 473

756

INDEX

Liver, malignant disease of, 157, 196, 211,
229, 37o, 408, 550, 720, 727
passive congestion of, 195, 318
syphilis of. See Syphilis, hepatic.
" torpidity of," 35
tumors of, 229
Lobar pneumonia, 314, 415
" Localized " infections, 451
" Long fevers," 401, 403
Lord, F. T., 596
Lovett and Reynolds, 80
Lumbago, 37, 80, 86, 90, 96, 102, 108,
no, 113, 114, 119, 296
cause of lumbar pain, 81
and sciatica, 396
Lumbar neuralgia, 86
neuritis, 86
pain, 79

causes of, 86
due to aneurysm, 108
to fatigue, 80
to functional causes, 108
to infectious disease, 85
to osteo-arthritis, 108, 362
to parturition, 85
infectious group, 91

orthopedic group. See Backache, or-
thopedic group.
postoperative, 85, 87
pressure group, 86, 108, 109, 118, 119
psychoneurotic, 84
renal group, 90
Lung, abscess of, 218, 462, 566, 577, 589,

504

malignant disease of, 426, 583

syphilitic disease of, 602
Lymphangitis, 332

cause of short fever, 404
Lymphoid leukemia, 144
Lymphoma, malignant, 346

Malaria, 40, 48, 54-56, 60, 66, 74, 75, 77,
190, 407, 412, 427, 463, 468, 472, 479,
634, 644, 646, 671
. atypical forms, 641

cause of general abdominal pain, 129
estivo-autumnal, 420, 456
in New England cause of chills, 460
tertian, 121, 148, 294,639,642,722
Malarial poisoning, chronic, 537
Malignant disease, 42, 59, 340, 342
of chest-wall, 312, 316, 320
of kidney, 200, 254, 279, 671

Malignant disease of liver, 157, 196, 211,
229, 370, 408, 550, 720, 727
of lung, 426, 583
of mediastinal glands, 426, 583
of pleura, 426, 583
growth in or near spinal column, 91
lymphoma, 346
McGuire, Dr. Stewart, 637
McKenzie, James, 29
Measles, 442

Mediastinal glands, malignant disease of,
329, 426, 583
tumor, 328, 347
cause of brachial pain, 325
Melancholia, 193
Meningismus, 310, 480

complicating typhoid, 122
Meningitis, 55, 69, 72, 77, 121, 359, 391, 431,
435, 445, 48o, 482, 502, 515, 517, 523,
524, 642, 737
acute, 291
cause of coma, 487
of convulsions, 500
of headache, 33
of long fever, 403
epidemic, 57, 441, 508
tuberculous, 53, 56, 57, 75, 158, 643
Menopause, 734
artificial, 302
Menstruation cause of headache, 33, 35

vicarious, 317
Mesenteric adenitis, 357

gland, tuberculosis of, 357, 427
tabes, 128, 264, 358, 369
Metamorphosis, amyloid, of liver, 318

fatty, of liver, 318
Metastatic hypernephroma, 344
Metatarsalgia, Morton's, cause of pain in

legs and feet, 351
Methemoglobinemia, 39
Migraine, 38, 46, 61
Miliary tuberculosis, 56, 74, 239, 304, 454,

600, 692
Miscarriage, attempted, 613

incomplete, 645
Mitral and aortic valves, fibrous endocar-
ditis of, 215
disease, 493

cause of cough, 577
endocarditis, 365
stenosis, 51, 656, 695, 711
Morphin, 662
Morphinism, 98, 538, 632

INDEX

757

Morton's metatarsalgia cause of pain in legs

and feet, 351
Motion, its relation to pain, 28
Mucous colitis, 128, 131, 259, 269
Multilocular ovarian cyst, 282
Muscular lesions, 343

pains, 328

strain, 119
Myelitis, 558

acute, 391
Myeloid leukemia, 247, 555
Myocardial insufficiency, 61, 710

weakness, cause of cough, 577
Myocarditis, 306, 695

chronic fibrous, 612, 705

fibrous, 709
Myositis, chronic, 36

septic, 332
Myxedema, 40, 543, 573

Neoplasm, 109, 335

of arm and shoulder cause of brachial

pain, 325
of kidney, 86, 671, 678
mediastinal, 329
pelvic, 380

retroperitoneal, cause of right hypochon-
driac pain, 204
spinal, 86, 118
Nephritis, 51, 61, 158, 200, 434, 477, 517,
541, 642, 669, 675, 732
acute, 709
cause of headache, 33, 46

of hematuria, 666
chronic, 254, 353, 625, 640, 673, 676
cause of dyspnea, 687

of hematuria. 666
glomerulo-, 49, 60, 467, 709
interstitial, 511, 513, 646, 709, 710, 741
suppurative, 735
Nephrolithiasis, 58, 50, 86, 111, 119, 208,
253, 272, 270. 355. 630, 642, 678, 681
cause of hematuria, 666
of lumbar pain. 81
of right hypochondriac pain, 204
psoas spasm due to, 355
" Nervous chills," 461
Nervous exhaustion, 649
Nervousness, 41 2. 730
cause of chills, 4O0
interpretation of, 730
Neuralgia, 60, 321, 330, 331
brachial, 33". 33S

Neuralgia cause of brachial pain, 325
intercostal, 319

cause of axillary pain, 289
lumbar, 86

trigeminal, cause of headache, ^3j 35
" Neuralgic " headache, 71

pain, 26
Neurasthenia, 114, 526, 619
Neurasthenic affection of spine, 108

headache, 48, 54, 67
Neuritis, 94, 98, 105, 198, 382
alcoholic, 373, 555, 557

cause of pain in legs and feet, 351
brachial, 338
cause of paralysis, 533
lumbar, 86
peripheral, 537, 540
saturnine, 555
with herpes zoster, 360
Neurosis, 128, 134, 139, 152, 159, 162, 177,
209, 248, 271, 312, 635, 662
cause of epigastric pain, 155
and constipation, 623, 624
functional, 265
of spine, 118
gastric, 162, 189, 190, 257, 615, 622, 631,
633, 640, 655, 661
cause of epigastric pain, 155
of general abdominal pain, 129
of vomiting, 600
occupation, cause of brachial pain, 325
postoperative, 136
traumatic, 324, 335, 631, 738
New-growth of kidney. 221. 250, 679. 683,
684
pelvic, 362

renal. See New-growth of kidney.
New-growths cause of lumbar pain, 108
Nocturnal epilepsy. 500

Obesity, 543

resulting evils of, 373
Obstruction, chronic intestinal, 135, 166.
188, 658. 661
intestinal, 51, 151, 152, 161, 10S, 199
cause of epigastric pain, 155
of general abdominal pain. 120
Occupation, effect of, its relation to pain. 27

neurosis cause of brachial pain, 325
Opium-poisoning, 22S
( )n hitis. syphilitic, 1 72
Orthopedic group of backaches, 80. So. 00,
91 , 10 1 . 1 1 S, 1 20

758

INDEX

Osier on " Urticarial Lesions," 448
Osteitis deformans, 48

tuberculous, 384
Osteo-arthritis, 120, 381
acute, 108

infectious, 118
cause of lumbar pain, 108
spinal, 86, 96, 114, 362
Osteomyelitis, 65, 66
cause of pain in legs and feet, 351
of humerus cause of brachial pain, 325
septic, 334, 338-34O, 383
of humerus, 334
of rib, 320
tuberculous, 333, 335, 340, 383
of rib, 320
Otitis media, 291, 451, 468, 46Q, 514

cause of headache, 35
Ovarian cyst, 267, 269, 282
ruptured, 266
strangulated, 283

with twisted pedicle, 263, 265, 282
cause of left iliac pain, 276
of right iliac pain, 259
tumor, 260
Overwork, 734
Oxalic acid poisoning, 647
Oxaluria, renal irritation from, 680
cause of hematuria, 666

Paget's disease, 48
Pain, 24

abdominal, 26

anginal, four occasions for, 344

anginoid, 26

in arms, 326

axillary, 290

" burning," 223

causes of general abdominal, 129

darting, 26

degree of, 25

due to inflammation, 328

epigastric, 156

evidences of, 24

functional lumbar, 108

general abdominal, 128
considerations on, 24
on diagnosis of, 286

habit, 29, 85, 317

in left hypochondrium, 241

in legs and feet, 352

left iliac, 281

lumbar, 79

Pain, muscular, 328
nerve, 328
neuralgic, 26
radiations of, 30

its relation to effect of emotional excite-
ment, 27
of motion, 28
of occupation, 27
of season and weather, 28
to poison of body, 27
to taking of food, 28
to time of day, 27
relief of, 28

rhythmically recurring, 26
right hypochondriac, 205

iliac, 260
shooting, 26

theories regarding its production, 29
thoracic, 26
throbbing, 26
types of, 26

with a sense of constriction, 26
Pal, J., 29, 508
Pancreas, cancer of, 186, 224, 230, 726

cause of jaundice, 717
Pancreatitis, acute, 177

cause of epigastric pain, 155
chronic, 186
Papillary cystadenoma of kidney, 677
Papilloma, 676

Paralysis, circumflex, 334, 338
general, 67, 69. 516, 521, 525, 742
infantile, 391
Paranephric abscess, 86
Paraplegia, ataxic, cause of paralysis, 533
Paratyphoid, 457

Parkinson's disease cause of paralysis, 533
Paroxysmal tachycardia, 61, 62
Parturition, 123, 528

cause of lumbar pain, 85
Passive congestion of liver, 195, 318
Paul, W. I-:., and G. L. Walton, 32
Pelvic adhesions cause of left iliac pain, 259
of right iliac pain, 204
new-growth, 362, 380
peritonitis, 173
thrombosis, 367
Pelvis, fractured, 366

Peptic ulcer. 170. 174. 175, 182, 185, 190,
192, 194, 198, 200. 223, 228, 246, 252,
617, 620, 622, 630
cause of epigastric pain, 155
of vomiting, 609

INDEX

759

Peptic ulcer, perforated, 89, 177, 277
Perforative colitis, 149

peritonitis, 135, 144, 151, 193, 663
Pericardial effusion, 205, 314

and dilated heart, difference between,

3U
Pericarditis, 177, 113, 313, 695
acute, 179

adhesive, 51, 216, 705, 709

cause of epigastric pain, 155
Pericecal tuberculosis, 146, 233, 258, 261,

426
Perinephric abscess, 87, 91, 318, 411

cause of lumbar pain, 81
Periosteal lesions, 343
Periostitis, 338

syphilitic, 41, 397, 398
cause of headache, t,^
of pain in legs and feet, 351
Peripheral neuritis, 537, 540

thrombosis, 367
Perirectal abscess, 411
Perirenal infection cause of right hypo-
chondriac pain, 204
Peristalsis (visible), 308
Peritonitis, 101, 174, 177, 646, 650

acute perforative, 663

general, 149, 151

cause of general abdominal pain, 1 29

pelvic, 173

perforative, 135, 144, 151, 193

tuberculous, 134, 142, 156, 158, 172, 174,
188, 197, 247, 315, 419, 427, 456, 480,

551- 504, 509
cause of general abdominal pain, 129
Pernicious anemia, 146, 150, 540, 549, 570,

574- 739
Pertussis, 582
" Petit mal," 529
Pharyngeal infection, 449
Pharyngitis, acute, cause of short fever, 404

cause of cough, 577
Phlebitis, 340

cause of pain in legs and feet, 351
Phlegmonous gastritis, 472
Phthisis, 133, 217, 229, 298, 302, 304, 316,
317, 341. 409, 413, 428, 463, 470, 471,
567, 581, 586, 580, 503, 597, 599, 604,
650, O74, 701, 732, 733
cause of chills, 460
of cough, 577
of dyspnea, 687
pneumonic, 593

Piles, 539

Plastic pleurisy, chronic, 559

Pleura, endothelioma of, 738

malignant disease of, 426, 583
Pleural adhesions, 185, 303
dropsy, 314

effusion, 299, 300, 301, 306, 353, 439, 598,
654, 703, 739
purulent, 318
irritation, 583
thickening, 64
chronic, 244
Pleurisy, 88, 109, 123, 180, 206, 251, 252,
255, 293, 294, 311, 313, 317, 370, 445,
482, 546, 585, 586, 589
cause of axillary pain, 289

of cough, 577
chronic plastic, 317, 559
double, 473
tuberculous, 424, 475
Pleurodynia, 293, 319, 323
Pleuropericardial adhesions, 185
Plumbism. See Lead-poisoning.
Pneumococcus arthritis, 375
infection, 446
general, 435
Pneumonia, 85, 88, 100, 121, 180, 206, 251,
288, 292, 294, 299, 304, 306, 375, 399,
407, 429, 431, 435, 441, 442, 444, 447,
475, 479, 484, 538, 548, 585, 591, 594,
634, 642, 652
cause of axillary pain, 289
of chills, 460
of cough, 577
of dyspnea, 687
of short fever, 404
central, 447

convalescence from, 560
lobar, 314. 415
traumatic, 596
unresolved, 64

diagnosis made at the Massachusetts
(ieneral Hospital, 437
Pneumothorax, tubercular, 87, 298
Poisoning, arsenical, 558
chronic malarial, 537
drug, 732

lead-. See Lead- poisoning.
opium-, 228
oxalic acid. 647

" ptomain," 301, 443. 631, 653
sodium phosphate. 537
subnitrate of bismuth, 228

760

INDEX

Poisoning, tea-, 734
Poisons of fatigue, 32
Poliomyelitis, 416

cause of paralysis, 533
of short fever, 404

epidemic, 558
Polyarthritis, acute infectious, 328
Polycythemia, 40
Polypnea, hysteric, 690
Position of body, relation of pain to, 27

and nature of headache, 37
Postepileptic exhaustion cause of coma, 487
Postoperative lumbar pain, 81, 85

neurosis, 136

shock cause of vomiting, 609
Postpneumonic empyema, 63, 415, 593, 594,

703
Postural group of backaches, 79
Pott's disease, 86, 97, 98, 106, 108, 109, 347,

358
Pregnancy, 122, 260, 262, 269, 544, 613, 621

extra-uterine, 262

cause of general abdominal pain, 129
of right iliac pain, 259

toxemia of, cause of vomiting, 609

vomiting of, 654
Presenting symptom, 17
Pressure group of backaches, 86, 108, 109,

118, 119
Prolapsed uterus, 122
Pseudoleukemia, 282
Psoas spasm due to nephrolithiasis, 355

tear, 357
Psychic cause of headache, 47, 73

causes in gastro-intestinal disease, 163

origin, headache of, 47, 73
Psycho-analysis, 372

Psychoneurosis, 118, 132, 136, 179, 226,371,
381, 538, 562

cause of headache, t,^
of right iliac pain, 259
Psychoneurotic lumbar pain, 84
" Ptomain poisoning," 301, 443, 631, 653
Puberty, infection of, 445, 469
Pulmonary abscess, 218, 462, 566, 579, 589,

594

disease, 700

edema, acute, 306

tuberculosis. See Phthisis.
Pupillary changes, 67
Purpura hemorrhagica, 317
Pus-kidney, 310
Pus-tube, 563

Pus-tube cause of left iliac pain, 276

of right iliac pain, 259
Pyelitis, 100
Pyelonephritis, 474
Pyloric adhesions, 174

cause of epigastric pain, 155
stenosis, 637
Pyogenic infection, 364
general, 363
sepsis cause of chills, 460
Pyonephrosis, 86, 221, 678
cause of right hypochondriac pain, 204
with stone, 244
Pyosalpinx, 260, 268

Radiations of pain, 30
Rectal cancer, 150, 584
Recurrent intestinal cancer, 146
Recurring pain, rhythmic, 26
Regurgitation, aortic, cause of cough, 577
stenosis and, 694
mitral stenosis and, 695, 711
tricuspid, 504
Relief of pain, 28
Renal abscesses, in
colic, 144

cyst, 86, 115, 221, 246, 256
disease, 118, 120, 196, 216, 223, 306, 434
group of lesions, 109

lumbar pain, 90
infarct, 86

infection, 98, 99, 101, 250, 406, 416
cause of right hypochondriac pain, 204
hematogenous, 86, 91, 98, 678
irritation from oxaluria, 680
lesions, 108, 120, 357
neoplasm. See Neoplasm of kidney.
new-growth. See New-growth of kidney.
stasis, 51
stone. See Nephrolithiasis.

cause of lumbar pain, 81
suppuration cause of lumbar pain, 81
tuberculosis. See Kidney, tuberculosis of.
tumor, 272, 675

cause of hematuria-, 666
of lumbar pain, 81
Retroperitoneal glands, tumors of, 196
neoplasms cause of right hypochondriac

pain, 204
sarcoma, 114
tumor, 221
cause of lumbar pain, 81
Retroverted uterus, 122

INDEX

761

Reynolds, E., 80

Rheumatic arthritis, 66, 365, 384

" Rheumatic headache," 36, 42

Rheumatism, 66, 206, 328, 352, 364, 374

aneurysm called, 327

diseases frequently diagnosed as, 329

sciatic, 362
Rhythmic recurring pain, 26
Rib, broken, 289, 292

cervical, 327, 336, 337, 340
cause of brachial pain, 325

septic osteomyelitis of, 320

tuberculous osteomyelitis of, 320
Rickets, 48, 406, 515
Right hypochondriac pain, 205
, iliac pain, 260
Rose spots, 542

Round-shoulder deformity, 342
" Rum-fits," 502, 511
Ruptured ovarian cyst, 264

Sacroiliac arthritis, 179

backache, 79

disease, 86, 00, 96, 102, 108, 120, 381
cause of lumbar pain, 81

joint, infectious arthritis of left, 107
lesion, 362

lesions cause of right hypochondriac pain,
204

strain, 96, 07, 3Q5
Salicylate, delirium from, 364
Salpingitis cause of short fever, 404

tuberculous, 655
Sarcoma, ioq

of femur, 383

of humerus, 338, 339

of leg bones cause of pain in legs and feet,

35i
retroperitoneal, 114
of testis with metastases, 171

Saturnine neuritis, 565

" Scattering " infections cause of long fevers,

403
Schmidt. Rudolf, 31. 86
" Sciatic rheumatism," ^(>o
Sciatica, 359, 3(10, 396

cause of pain in legs and feet, 351

primary, 381
Sclerosis, lateral, cause of paralysis, 533
Sea-sickness cause of vomiting, (>oq
Season and weather, their relation to pain, 28
Secondary anemia, 151. 539
Sensation, disturbances of. 20

Sepsis, 48, 91, 366, 394, 402, 427, 429, 437,
439, 445. 646
cause of jaundice, 7 1 7

of long fever, 403
pyogenic, cause of chills, 460
staphylococcus, 565
streptococcus, 449
with thrombi, 308
Septic infection. See Sepsis.
knee, 383
myositis, 332

osteomyelitis, 334, 338, 339, 340, 383
of humerus, 334
of rib, 320
thrombosis, 410
Septicemia. See Sepsis.
Serous pleurisy, 301, 703
" Shingles," 86

cause of lumbar pain, 81
" Shock," postoperative, cause of vomiting,

609
Shooting pain, 26
Short fevers, 403, 405
Shoulder deformity, round-, 342
Shoulder-joint, arthritis of, 338
" Sick headache," 50
Sigmoid, cancer of, 281, 283, 618

cause of left iliac pain, 276
Sinusitis, 42, 55, 6o, 71
cause of headache, ^t,
of short fever, 404
Skull, fracture of base of, 54
"Slow fever," 301
Softening, cerebral, 77
Spasm, arterial, 30

infantile, cause of convulsions, 500
psoas, due to nephrolithiasis. 355
Spinal aneurysm, 118

arthritis, hypertrophic. So

radiations from, cause of axillary
pain, 280
column, disease of. 320

malignant growth in or near. 8(>, 87, qi,
1 1S
curvature, 380
disease, 102

osteo-arthritis, 86, q6, 114
tuberculosis, 86, qi, 10O-10X. 115. 117,
1 20. 13(1, 1S4. 342. 568
cause of general abdominal pain, l jq
of lumbar pain, 81
Spine, functional affection of, 10S
neurosis of. 1 18

762

INDEX

Spine, infectious arthritis of, 107
cause of lumbar pain, 81

osteo-arthritis of lumbar, 362
Spleen, obsolete tuberculosis of, 49

tumor of, 248
Splenic enlargement with anemia, 556

flexure, cancer of, 252, 255
Spondylitis, 293

acute, 118

hypertrophic, 80

infectious, 107, 110

typhoidal, 115
Sprain, acute, of back, cause of lumbar pain,

81
Sprained ankle cause of pain in legs and
feet, 351

knee cause of pain in legs and feet, 351
Staphylococcus infection, 65

sepsis, 565
Starvation, 320
Stasis, 315, 605

renal, 51
Stenosis, aortic, 694

mitral, 51, 654, 695, 711

pyloric, 637
Stiff neck, 37

Stokes-Adams' disease, 435, 492, 518, 520
Stomach, cancer of. See Cancer, gastric.

tumor. See Gastric tumor.

ulcer of. See Gastric ulcer.
Stone in bladder, 279, 675, 676, 684

in common duct, 224, 232

gall-. See Cholelithiasis.

in kidney. See Nephrolithiasis.

pyonephrosis with, 242

renal. See Nephrolithiasis.

in ureter, 264, 268

cause of left iliac pain, 276
of right hypochondriac pain, 204
iliac pain, 259
Strabismus, 68
Strain, acute foot, 372

back, 96

eye-, cause of headache, 33 42, 67

muscular, 119

sacro-iliac, 96, 97, 395
Strangulated ovarian cyst, 283
Streptococcus bronchopneumonia, 587

meningitis, 121

sepsis, 308, 449
Stricture, intestinal, 174
Subacromial bursitis, 330, ^^s> 335- 330, 338
cause of brachial pain, 325

Subdiaphragmatic abscess, 135, 229, 318,
475
cause of right hypochondriac pain,
204
Subnitrate of bismuth poisoning, 228
Sudden death in cardiac cases, 496
Suggestibility, hysteric, 507
Suppurative nephritis, 735
Surgical kidney, 112
Symptom, presenting, 17
Symptoms associated with jaundice, 718

and their interpretation, 29
Syncope cause of coma, 487
Syphilis, 43, 45, 54, 73, 75, 77, 118, 134,
139, 154, 179, 188, 213, 214, 216, 234,
246, 338, 355, 370, 382, 386, 389, 385,
407, 413, 419, 422, 447, 453, 471, 497,
504, 529, 549, 551, 625, 737
cause of long fever, 403
cerebral, 57
cerebrospinal, 391
hepatic, 186, 196, 220, 725, 727
of liver. See Syphilis, hepatic.
visceral, 477

with stenosis of a bronchus. 586
Syphilitic adenitis, 281
disease of joints, 365

of lung, 602
gumma, hepatic, 156
headache, 43
heart and aorta, 296
orchitis, 172
periostitis, 41, 397, 398
cause of headache, ^^

of pain in legs and feet. 351

Tabes dorsalis, 132, 161, 177, 182, 198, 243,
257, 270, 364, 387, 519. 537- 557

cause of pain in legs and feet. 351
of paralysis, 533
of vomiting, 609

with gastric crises, 128, 166. 630, 642.

651
mesenterica, 264, 358, 369
cause of epigastric pain, 155
of general abdominal pain, 129
peritonitis cause of epigastric pain, 155
Tachycardia, paroxysmal, 61, 62
Tapeworm, 164
Tea-poisoning, 734
Teething, 515

Temperament, its influence on the reaction
against infections, 466

INDEX

763

Tenosynovitis cause of pain in legs and

feet, 351
Terminal infection, 353
Tertian malaria. See Malaria, tertian.
Testis, sarcoma of, with metastases, 171
Tests to make in puzzling cases of headache,

38
Tetanus, 124
Thickening, chronic pleural, 244

pleural, 64
Thomas, H. M., 32
Thoracic aneurysm, 315, 341

pain, 26
Throat, disease of. 317
Throbbing pain, 26
Thrombophlebitis, 336
Thrombosis, infectious, 332

pelvic, 367

peripheral, 367

septic, of lateral sinus and jugular vein,
410
Thyroid, simple adenoma of, 49
Time of day, relation of pain to, 27
Tinea versicolor, 226
Tonsillitis, 48, 91, 291, 309, 393, 522

cause of cough, 577
of short fever, 404
" Torpid liver," 35
Toxemia and pregnancy cause of vomiting,

609
Trauma, 254

headache due to, 46
Traumatic neurosis, 324, 335, 631, 738

pneumonia, 596
Trichiniasis, 66, 332, 732
Tricuspid regurgitation, 504
Trigeminal neuralgia cause of headache,

33, 35
Tubal abscess, 263
Tube, purulent infection of, 563

tuberculosis of right. 268
Tuberculosis. 42, 48, 76, 269, 335, 355, 376,
382, 3S3. 385, 3qo, 412, 419, 421, 431,
453. 457- 460. 482, 537, 545. 561, 562,
583, 588, 391, 592, 603, 625, 636, 640,
04(1. 047, 653, 692, 740, 742

abdominal, 264

acute, 505

of bladder, 280, 669, 670, 680

of bones, 346

cause of long fever, 403

of pain in legs and feet, 351

of cecal region, 261

Tuberculosis, costal, 320
general, 358, 369

genito-urinary. 669, 675, 732

glandular, 338, 471

of hip, 369

of humerus, 333, 336

of kidney. See Kidney tuberculosis.

of mesenteric gland, 357, 427

miliary, 56, 74, 238, 304, 454, 600, 692

obsolete, of spleen, 49

pericecal, 146, 233, 258, 261, 426

peritoneal. See Tuberculous peritonitis.

pulmonary. See Pltihisis.

renal. See Kidney, tuberculous.

spinal, 86, 91, 106-108, 115, 117, 120. 136,

184, 342, 568
cause of general abdominal pain, 129

of lumbar pain, 81
of tube, 268

vertebral. See Tuberculosis, spinal.
with abscess, 338
Tuberculous colitis, 146
empyema, 545, 701
enteritis, 256
epididymitis, 115
kidney. See Kidney, tuberculous.
meningitis, 53, 56, 57, 75, 158, 643
osteitis, 384
osteomyelitis, 333, 335, 340, 383

of rib, 320
peritonitis, 134, 142, 156, 158, 172, 174,

188, 197, 247, 315, 417, 427. 456. 480.

551, 564, 560
cause of general abdominal pain. 129
pleurisy, 424, 475
pneumothorax, 87, 2q8
pus kidney. 310
salpingitis, 655
Tumor, 327, 337, 66q
abdominal, 115, 134

cause of general abdominal pain, 129
of bladder cause of hematuria, 666
brain, 55, 61. 70. 75, 77. 423, 496, 510,

517. 523, 528. 613. 040. 642. 644. 737
cause of coma, 487

of headache. t,t,, 46
cerebral. See Tumor, brain.
fibroid, of uterus. 173. 263
gastric. 1 15
gummatous, 345
intrathoracic, ^j, 6
of kidney. Sec Tumor, renal.
of liver, 220

764

INDEX

Tumor, mediastinal, 328, 347
cause of brachial pain, 325

ovarian, 260

renal, 272, 675

cause of hematuria, 666
of lumbar pain, 81

retroperitoneal, 221

cause of lumbar pain, 81

of retroperitoneal glands, 196

of spleen, 248

stomach. See Gastric tumor.
Types and cause of hematuria, 667
of jaundice, 717

of pain, 26
Typhoid, 48, 52, 56, 57, 65. 72, 75, 77, 85,
91, 95, 107. 122, 135, 137, 294, 301,
303, 359, 402, 409, 411, 413, 423, 427,
429, 431, 435, 442, 467, 478, 482, 538,
542, 564, 566, 601, 634, 644, 653

abortive, 444

afebrile, 423

brief, 420

cause of long fever, 403

chills occurring in, 480

cholecystitis, 210. 238

diarrhea and tenderness due to fecal im-
paction in, 424

meningismus complicating, 122

onset cause of chills, 460

with relapse, 418
Typhoidal spondylitis, 115

Ulcer of bowel, 86
chronic, 640

peptic, 170, 174, 175, 182. 185, 190, 192,
194. 198, 200, 223, 228, 246, 252,
617, 620, 622, 630
cause of epigastric pain. 155

of vomiting, 609
of duodenum, 131, 140. 159, 163, 166,

167, 169, 176, 212, 234
of stomach, 86, 157, 187, 191, 616, 637,
648, 682, 737
perforated gastric, 89, 177, 277
Ulcerative endocarditis, 92, 420
Unknown cause of hematuria, 678, 682
infection, 54, 95, 293, 443
origin, cystitis of, 675
headache of, 68
Unlocalized and widespread infections, 207
Unresolved pneumonia, 64

diagnoses made at the Massachusetts
General Hospital, 437

Uremia, 31, 55, 61, 70, 200, 509, 513, 528,
645, 660
cause of coma, 487
of convulsions, 500
of vomiting, 609
Uremic headache, 49
Ureter, stone in, 264, 268

cause of right hypochondriac pain, 204
Urethritis, 343, 388, 391
Urinary infection, 104, 564
Urticaria, internal, 605
Urticarial fever, 447
lesions, 73
discussed by Osier. 448
Uterine fibroid, 173, 263
group of backaches, 79
Uterus, carcinoma of, 381
fibroid tumor of, 173, 263
fibromyoma of, 283

prolapsed, retroverted, incarcerated, preg-
nant, 122

Valves, fibrous endocarditis of mitral and

aortic, 215
Valvular disease, chronic, 495

Varicose veins, 282

cause of pain in legs and feet, 351
Vascular crisis, 31, 181, 387, 432, 510, 511,
521

hyperemia, 26
Vasomotor headaches, 26, 37
Vertebral tuberculosis. See Tuberculosis,

spinal.
Vicarious menstruation. 317
Visceral syphilis, 477
Volvulus, 151
Vomiting. 608

important factors in production of, 611

of pregnancy, 654
Vulnerability of all differential diagnosis, 19

Walton. G. L., 32
Weak heart, 305
Weakness. 534

causes of. 535
Weather and season, relation to pain, 28
" Wet brain." 77

Widespread and unlocalized infections, 207
" Writer's cramp," 524

Vellow atrophy of liver, acute, 727

Zoster, herpes, 86, 93, 360

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A Text-Book of Embryology. By John C. Heisler, M.D., Pro-
fessor of Anatomy in the Medico-Chirurgical College, Philadelphia.
Octavo volume of 435 pages, with 212 illustrations, 32 of them in
colors. Cloth, $3.00 net.

WITH 212 ILLUSTRATIONS, 32 IN COLORS

The fact of embryology having acquired in recent years such great interest
in connection with the teaching and with the proper comprehension of human
anatomy, it is of first importance to the student of medicine that a concise and
yet sufficiently full text-book upon the subject be available. This new edition
represents all the latest advances recently made in the science of embryology.
Many portions have been entirely rewritten, and a great deal of new and impor-
tant matter added. A number of new illustrations have also been introduced and
these will prove very valuable. The previous editions of this work filled a gap
most admirably, and this new edition will undoubtedly maintain the reputation
already won. Heisler's Embryology has become a standard work.

PERSONAL AND PRESS OPINIONS

G. Carl Huber, M.D.,

Projessor of Embryology at the Wistar Institute, University of Pennsylvania.
" I find the second edition of 'A Text-Rook of Embryology' by Dr. Heisler an improve-
ment on the first. The figures added increase greatly the value of the work. I am again
recommending it to our students."

William Wathen. M. D.,

Professor of Obstetrics, Abdominal Surgery, and Gynecology, and Dean , Kentucky School of

Medicine, Louisville, Ay.
" It is systematic, scientific, full of simplicity, and just such a work as a medical student
will be able to comprehend."

Birmingham Medical Review, England

"We can most confidently recommend Dr. Heisler's hook to the student of biology or
medicine for his careful study, if his aim be to acquire a sound and practical acquaintance with
the ; ubiect of embry 'ogv."

io SAUNDERS' BOOKS ON

Wells' Chemical Pathology

Chemical Pathology. Being a Discussion of General Pathology
from the Standpoint of the Chemical Processes Involved. By H.
Gideon Wells, Ph. D., M. D., Assistant Professor of Pathology in the
University of Chicago. Octavo of 549 pages. Cloth, $3.25 net.

A PRACTICAL BOOK

Dr. Wells' work is written for the physician, for those engaged in research in
pathology and physiologic chemistry, and for the medical student. In the intro-
ductory chapter are discussed the chemistry and physics of the animal cell, giving
the essential facts of ionization, diffusion, osmotic pressure, etc., and the relation
of these facts to cellular activities. Special chapters are devoted to Diabetes and
to Uric-acid Metabolism and Gout.

Wm. H. Welch, M. D.

Professor of Pathology, Johns Hopkins University.

"The work fills a real need in the English literature of a very important subject, and I
shall be glad to recommend it to my students."

Lusk's

Elements of Nutrition

Elements of the Science of Nutrition. By Graham Lusk, Ph. D.,
Professor of Physiology at Cornell Medical School. Octavo volume
of 302 pages. Cloth, $3.00 net.

THE NEW (2d) EDITION TRANSLATED INTO GERMAN

Prof. Lusk presents the scientific foundations upon which rests our knowledge
of nutrition and metabolism, both in health and in disease. There are special
chapters on the metabolism of diabetes and fever, and on purin metabolism.
The work will also prove valuable to students of animal dietetics at agricultural
stations.

Lewellys F. Barker, M. D.

Professor of the Principles and Practice of Medicine, Johns Hopkins University,
" I shall recommend it highly to my students. It is a comfort to have such a discussion
of the subject in English."

HISTOLOGY.

Bohm, Davidoff, and
Huber's Histology

A Text=Book of Human Histology. Including Microscopic Tech-
nic. By Dr. A. A. Bohm and Dr. M. von Davidoff, of Munich, and
G. Garl Huber, M.D., Professor of Embryology at the Wistar Insti-
tute, University of Pennsylvania. Handsome octavo of 528 pages, with
361 beautiful original illustrations. Flexible cloth, $3.50 net.

THE NEW (2d) EDITION, ENLARGED

The work of Drs. Bohm and Davidoff is well known in the German' edition,
and has been considered one of the most practically useful books on the subject
of Human Histology. This second edition has been in great part rewritten and
very much enlarged by Dr. Huber, who has also added over one hundred origi-
nal illustrations. Dr. Huber's extensive additions have rendered the work the
most complete students' text-book on Histology in existence.

Boston Medical and Surgical Journal

" Is unquestionably a text-book of the first rank, having been carefully written by thorough
masters of the subject, and in certain directions it is much superior to anv other histological
manual."

DrewV

Invertebrate Zoology

A Laboratory Manual of Invertebrate Zoology. By Oilman A
Drew, Ph.D., Professor of Biology at the University of Maine. With the
aid of Members of the Zoological Staff of Instructors of the Marine Biolog-
ical Laboratory, Woods Holl, Mass. 121110 of 200 pages. Cloth, 5U.25 net.

A LABORATORY WORK

The subject is presented in a logical way, and the type method of study has
been followed, as this method has been the prevailing one for many years.

Prof. Allison A. Smyth, Jr., Virginia Polytechnic Institute

" I think, it is the best "laboratory manual of 7.<u>iogy 1 have yet seen. The large number
of forms dealt with makes the work applicable to almost any locality."

SAUNDERS BOOKS ON

Norris' Cardiac Pathology

Studies in Cardiac Pathology. By George W. Norris, M.D.,
Associate in Medicine at the University of Pennsylvania. Large octavo
of 235 pages, with 85 superb illustrations. Cloth, $5.00 net.

SUPERB ILLUSTRATIONS

The wide interest being manifested in heart lesions makes this book particu-
larly opportune. The illustrations are superb and are faithful reproductions of
the specimens photographed. Each illustration is accompanied by a detailed
description ; besides, there is ample letter press supplementing the pictures.
Considerable matter of a diagnostic and therapeutic nature has been interwoven.

Boston Medical and Surgical Journal

" The illustrations are arranged in such a way as to illustrate all the common and many of
the rare cardiac lesions, and the accompanying descriptive text constitutes a fairly continuous
didactic treatise."

McConnell's Pathology

A Manual of Pathology. By Guthrie McConnell,M.D., Professor
of Bacteriology and Pathology at Temple University, Philadelphia.
l2mo of 523 pages, with 170 illustrations. Flexible leather, $2.50 net.

NEW (2d) EDITION
Dr. McConnell has discussed his subject with a clearness and precision of
style that make the work of great assistance to both student and practitioner.
The illustrations have been introduced for their practical value.

New York State Journal of Medicine

" The book treats the subject of pathology with a thoroughness lacking in many works of
greater pretension. The illustrations many f them original are profuse and of exceptional
excellence." * z

Hektoen and Riesman's Pathology

American Text-Book of Pathology. Edited by Ludvig Hek-
toen, M.D., Professor of Pathology, Rush Medical College, Chi-
cago; and David Riesman, M.D., Professor of Clinical Medicine,
Philadelphia Polyclinic. Octavo of 1245 P a g es > 443 illustra-
tions, 66 in colors. Cloth, $7.50 net; Half Morocco, $9.00 net.

HISTOLOGY. 13

Dtirck and Hektoen's

Special Pathologic Histology

Atlas and Epitome of Special Pathologic Histology. By Dr. H.

Durck, of Munich. Edited, with additions, by Ludvig Hektoen, M. D.,
Professor of Pathology, Rush Medical College, Chicago. In two parts.
Part I. Circulatory, Respiratory, and Gastro-intestinal Tracts. 120
colored figures on 62 plates, and 158 pages of text. Part II. Liver,
Urinary and Sexual Organs, Nervous System, Skin, Muscles, and
Bones. 123 colored figures on 60 plates, and 192 pages of text. Per
part : Cloth, $3.00 net. In Smolders' Hand-Atlas Scries.

The great value of these plates is that they represent in the exact colors the effect
of the stains, which is of such great importance for the differentiation of tissue.
The text portion of the book is admirable, and, while brief, it is entirely satisfac-
tory in that the leading facts are stated, and so stated that the reader feels he has
grasped the subject extensively.

William H. Welch. M. D.,

Professor of Pathology, Johns Hopkins University, Baltimore.

"I consider Diirck's 'Atlas of Special Pathologic Histology,' edited by Hektoen, a very
useful book for students and others. The plates are admirable."

Sobotta and Huber's
Human Histology

Atlas and Epitome of Human Histology. By Privatdocext Dr.
J. Sobotta, of YVi'irzburg. Edited, witli additions, by G. Carl Huber,
M. D., Professor of Histology and Embryology in the University of
Michigan, Ann Arbor. With 214 colored figures on 80 plates, 68
text-illustrations, and 248 pages of text. Cloth, S4.50 net. hi
Saunders' Hand-Atlas Series.

INCLUDING MICROSCOPIC ANATOMY

The work combines an abundance of well-chosen and most accurate illustra-
tions, with a concise text, and in such a manner as to make it both atlas and text-
book. The <;reat majority of the illustrations were made from sections prepared
from human tissues, and always from fresh and in every respect normal specimens.
The colored lithographic plates have been produced with the aid of over thirty colors.

Boston Medical and Surgical Journal

" In color and proportion they arc characterized by gratifying accuracy and lithographic
beautv."

14 SAUNDERS" BOOKS ON

Bosanquet on Spirochaetes

Spirochaetes : A Review of Recent Work, with Some Original Ob-
servations. By W. Cecil Bosanquet, M.D., Fellow of the Royal Col-
lege of Physicians, London. Octavo of 1 52 pages, illustrated. $2.50 net.

ILLUSTRATED

This is a complete and authoritative monograph on the spirochaetes, giving
morphology, pathogenesis, classification, staining, etc. Pseudospirochastes are
also considered, and the entire text well illustrated. The high standing of Dr.
Bosanquet in this field of study makes this new work particularly valuable.

Levy and Klemperer's
Clinical Bacteriology

The Elements of Clinical Bacteriology. By Drs. Ernst Levy and
Felix Klemperer, of the University of Strasburg. Translated and
edited by Augustus A. Eshner, M. D., Professor of Clinical Medicine,
Philadelphia Polyclinic. Octavo volume of 440 pages, fully illustrated.
Cloth, $2.50 net.

S. Solis -Cohen, M. D.,

Professor of Clinical Medicine, Jefferson Medical College, Philadelphia.

" I consider it an excellent book. I have recommended it in speaking to my students."

Lehmann, Neumann, arid
Weaver's Bacteriology

Atlas and Epitome of Bacteriology : including a Text-Book of
Special Bacteriologic Diagnosis. By Prof. Dr. K. B. Lehmann
and Dr. R. O. Neumann, of Wiirzburg. From the Second Revised and
Enlarged German Edition. Edited, with additions, by G. H. Weaver,
M. D., Assistant Professor of Pathology and Bacteriology, Rush Medical
College, Chicago. In two parts. Part I. 632 colored figures on 69
lithographic plates. Part II. 511 pages of text, illustrated. Per part:
Cloth, $2.50 net. /;/ Saunders Hand-Atlas Series.

PATHOLOGY, BACTERIOLOGY, AND PATHOLOGY. 15

Eyre's Bacteriologic Technique

The Elements of Bacteriologic Technique. A Laboratory
Guide for the Medical, Dental, and Technical Student. By J. W.
H. Eyre, M. D., F. R. S. Edin., Lecturer on Bacteriology at the
Medical and Dental Schools, London. Octavo of 375 pages, with
170 illustrations. Cloth, $2.50 net.

American Text-Book of Physiology second Edition

American Text-Book of Physiology. In two volumes. Edited by
William H. Howell, Ph. D., M.D., Professor of Physiology in the Johns
Hopkins University, Baltimore, Md. Two royal octavos of about 600
pages each, illustrated. Per volume: Cloth, $3.00 net; Half Morocco,
$4.25 net.

" The work will stand as a work of reference on physiology. To him who desires to know
the status of modern physiology, who expects to obtain suggestions as to further physio-
logic inquiry, we know of none in English which so eminently meets such a demand."
The Medical News.

Warren's Pathology and Therapeutics second Edition

Surgical Pathology and Therapeutics. By John Collins Warren,
M. D., LL.D., F. R. C. S. (Hon.), Professor of Surgery, Harvard Med-
ical School. Octavo, 873 pages, 136 relief and lithographic illustrations,
33 in colors. With an Appendix on Scientific Aids to Surgical Diagnosis
and a series of articles on Regional Bacteriology. Cloth, $5.00 net;
Half Morocco, #6.50 net.

Gorham's Bacteriology

A Laboratory Course in Bacteriology. For the Use of Medical,
Agricultural, and Industrial Students. By Frederic P. Gorham, A. M.,
Associate Professor of Biology in Brown University, Providence, R. I.,
etc. i2mo of 192 pages, with 97 illustrations. Cloth, $1.25 net.

" One of the best students' laboratory guides to the study of bacteriology on the mar-
ket. . . . The technic is thoroughly modern and amply sufficient for all practical pur-
poses.'' American Journal of the Medical Sciences.

Raymond's Physiology New (3d) Edition

Human Physiology. By Joseph H. Raymond, A. M., M. I)., Pro-
fessor of Physiology and Hygiene, Long Island College Hospital, New
York. Octavo of 685 pages, with 444 illustrations. Cloth, 3.50 net.

" The book is well gotten up and well printed, and may be regarded as a trustworthy
guide for the student and a useful work of reference for the genera": practitioner. The
illustrations are numerous and are well executed." The Lancet, London.

16 BACTERIOLOGY, PHYSIOLOGY, AND HISTOLOGY.

Ball's Bacteriology Sixth Edition, RevUed

Essentials of Bacteriology : being a concise and systematic intro-
duction to the Study of Micro-organisms. By M. V. Ball, M. D., Late
Bacteriologist to St. Agnes' Hospital, Philadelphia. i2mo of 289 pages,
with 135 illustrations, some in colors. Cloth, $1.00 net. In Saunders'
Question- Compend Series.

" The technic with regard to media, staining, mounting, and the like is culled from the
latest authoritative works." The Medical Times, New York.

Budgett'S Physiology New (3d) Edition

Essentials of Physiology. Prepared especially for Students of Medi-
cine, and arranged with questions following each chapter. By Sidney
P. Budgett, M. D., formerly Professor of Physiology, Washington Uni-
versity, St. Louis. Revised by Havan Emerson, M. D., Demonstrator
of Physiology, Columbia University. i2mo volume of 250 pages, illus-
trated. Cloth, $1.00 net. Saunders' Question- Compend Series.

"He has an excellent conception of his subject. . . It is one of the most satisfactory
books of this class" University of Pennsylvania Medical Bulletin.

Leroy's Histology New (4th) Edition

Essentials of Histology. By Louis Leroy, M. D., Professor of

Histology and Pathology, Vanderbilt University, Nashville, Tennessee.

i2mo, 263 pages, with 92 original illustrations. Cloth, $1.00 net. In

Saunders'' Question- Compend Series.

" The work in its present form stands as a model of what a student's aid should be ; and
we unhesitatingly say that the practitioner as well would find a glance through the book
of lasting benefit." The Medical World, Philadelphia.

Barton and Wells' Medical Thesaurus

A Thesaurus of Medical Words and Phrases. By Wilfred M.
Barton, M. D., Assistant Professor of Materia Medica and Therapeutics,
and Walter A. Wells, M.D., Demonstrator of Larvngologv, Georgetown
University, Washington, D. C. i2mo, 534 pages. Flexible leather,
$2.50 net; thumb indexed, S3. 00 net.

American Pocket Dictionary New 17th) Edition

Dorland's Pocket Medical Dictionary. Edited uy W ". A. New-
man Dorland, M. D., Editor "American Illustrated Medical Dic-
tionary." Containing the pronunciation and definition of the principal
words used in medicine and kindred sciences, with 64 extensive tables.
610 pages. Flexible leather, with gold edges. $1.00 net: with patent
thumb index, Si. 25 net.

" I can recommend it to our students without reserve." J. H. HOLLAND, M. D., of
the Jefferson Medical College, Philadelphia.

Date Due

printed in u.s.a. CAT. NO. 24 161 (**f

UC SOUTHERN REGIONAL LIBRARY FACILITY

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CALIFORNIA COLLEGE OF MEDICINE LIBRARY

UNIVERSITY OF CALIFORNIA, IRVINE

IRVINE, CALIFORNIA 92664