With the Compliments of the Publishers W. B. Saunders Company West Washington Square Philadelphia rice tt'. / a o .i-^iif: In Wv, - 1/ ' UNIVERSITY OF CAMPnRNIA CALIFORNIA COLLEGE Or MEDICINE LIBRARY IRVINE, CALIFORNIA 92664 Differential Diagnosis PRESENTED THROUGH AN ANALYSIS OF 385 CASES By 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. Copyright, 1912, by \V. B. Saunders Company 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 23 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. (c) The results, such as emaciation or muscular weakness, often produced by long-continued suffering. 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 24 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. (c) The taking of food. (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 29 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>n Piseasesof the .Nervous System, p. 863, Appleton, 190S. 36 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 37 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 39 " 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? (c) Does the pain recur at precisely the same hour each day? 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 41 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 43 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 ~ 44 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 , A* < j 1 yi'/jwi^/iy/i/uu i\/ */'J*/i>/ v 1 / / 1 " a W4' 103 lot* tor M 9* r r w ISO 1 1 111 4^=52= ?ii 1 . ' .N L. " . , . J Si . .* v* u ^si* p^ . r^ no so M to SO n w l I 1 ] . / i r, , * s 1 h -?r >TV * -v * * <^J s 1 1 1 t LJ 1 1 *'# V ! 1 r . i/W ^1 1 1 III II ; -.1 1. A - \ I / ! i i "\ r V\\\JaJ "^3 1 ' 11 1 w v^ *** L. X/q q ,t : j j JX^_j 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 45 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 47 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. (c) Headaches whose cause is absolutely unknown. 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 53 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. 54 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 59 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- 6o 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 !" UNI v^yyrr 1 1 1 1 fr . rrn" III 1 1 "" T""| Mom. V ', ft/i. 4 ,j. J iij J l k JjlJJ** J fUJ, J sJ J v si/ Jd/J J*l R - X 101 00* 97 96 160 130 ISO 110 70 00 to 30 SO j<>. I . .... .r IJ..I.1 ........ .....'. .... in. limn kk aX- 1 T , ". H~yr 1 r 5 i * l\ i / i\ / \ \ / V zr 1 > f\ ' M-v / K s, J *T v n 1 1 -^j " 1 _A-j "7- , u_ ht" x4- H ki iVf / j. / $ n t Z3 / ^ > /*/ | ... J , Si f X J ni So v_ i/\ T-S^ v*- ^ -4 j ' / 3 ' / \ tj 3 1 vs, ^ Li nJ ^ 1 i/i 1 n. * <*S u :iq1 i 1 ^ -7 3 ' /' ' i i"" v 1 K ^. a -j a II 1 ill! I 1 1 i ! < ,\*r~\ _ *- (*>*' 'i - ! . ..,-, i 3 1 J L4-L : J . L - 1 LU _L Fig. 5. Chart of case 12. 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 62 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 Im* i ' ",'J: " I." 1 11 " 1 " ii" i" / ""M'/ / FT ( '/- / //, / u?, , 11 jt 4 43 " m- "i ^ . . - * = " ^ ^ S W> -pf- 4 t J --S* it no \ M T 1 iw vj % t- A A 7 * 1 ~ ~ ' " no i i- * iw i ** F 1 l * I :o i-i- k-r S^^dL Ja_ A- -4 - ! * ) ft 1 i*y TTiiWWc/* 5,22^ * \j_ J, J/ M V y^ k-* * "- "*-*- & 2^ f A = ^p^ * -T-^ d t. * tB ^*5 = - - fc&H^I^ t -* ^ L, M H _. S i. * " A ^M^^aA*^^-^ Sa L *j J t A, \i 1 u \ ' * " ^y^Wk-.'Wii.'ffi'fcj^s * *_M_ V ^^^i1i^*b*"$j , f3 1* .(3i_ 6iJ.o^_ ij__a. U a a n |a ' 2- ^% -fT\- 1 z \-,!:e m s " "1 1 HO -* 5 ] . *- s z ^\ .** s. wo ^*Z J * " 3 . 3 Z**- ' \ = 2 2 jE Ij H JL. -^ I Z k % 2 ' Fig. 7. Chart of case 14. HEADACHE 65 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 DMoon ' 1 ' I - / j- | / r *>" >, n- *'-' *v -j . . Z 3 -. Z * l^lll^ Jl l Z * ^tl^lly- tZ iz *t^ - _ H> : " _r * * * * " *->l 1^2^ t- " *S<* M\f* *v w' 4 t it Wlk ! a \ ," f " 'y 1 % M, \ i -X_gg --SS^ &ik &fl.44L4 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 7 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. r ""< . M , < ,- , -- - T _ii i 1 1 1 4 1 1 1 ~-~- , , -/_;-//_/ - 1 , ,. 1 L 1 " ' ' ""' , .......t^ ... .,*,.. k,il"4<"K" " b lw \- z 1 "" ~1 4 ~1 H M ...T..Z.. . Y.\l.JV/J-*/*!,J!??-?-X7-<-i -w-k* M j-^- - -e 1 . % -4 * Z ~ ii \ \t\ Fii-- M l^:J^. ^ffly^j^ 2 *r$K. ^v/I 5 ^ 55:33 u* *-253Z22 M TJT *J J ^?^ 3-sv^ <=. a ,. /J J ^k^ ^ . J : ^1 ^ i * l

p^ i 1 . 3 it -1 = * i * < 1 t "t^AJ i ! -I Z lji-^r^ r ^J^y, Fig. io.- Chart of case 20. 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 75 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. Ldj > ') Jt> / 7 Hjktm / / -H E H 5- 101 IOC W M" M* U0 l 1M ISO 110 00 at M K * 1 I 1 11 I -' | O -V \ * <' ^ - ^ f \ Ij8l / \* / i 1 X 1 " ! 1 1 J - Pig. 11. Chart of case 21. 76 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 77 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. 78 DIFFERENTIAL DIAGNOSIS ajnjound 4Eqiunj jo 3insa^j + j .... +g d|EOS 40 jpau jo sapsnui u; sspou pajBjnpuj + oja 'Buiapa 'Xqdojj -jadXq 3tip -JED *BUnjpUI[XD 't: 1 a n u 1 ui n q j v 5 u = E ,0 + Trifling or absent. " Trifling or absent. sijiqdXs jo aouapiAa 4aqjo pU B A JO JSI JJ + siso.itum jo suSis 4aqjo + + + S + * rt 3 <( uo;jsa3 -uoo pEaq sqj jnoqe Buauiou -aqd 40}ouiosba + + + So saXa aql Su; -JB34J UJ04J jaipH + C/3 3 sairEuiouB 4Ernoo + + + + go .5 = o 3 P. 0*3 J3 cc 0.0 + Squints, pupillary and retinal changes. suioiduiAs lEooj 00 + uinuipp 'buiod 'suoisjnAuo^ .5 u *j i2 OS u< ^ X c -3 O 3 J3 O 1 c ' + +- uoij -oajui jo su3;s 43qW puB J3A3J + 4- + S 1 5 + S BIUaUJBlBD O} UOpB]34 allUlpfJ + '30U94 -4nD34 4B[n3ay; i % w g + 34ns -S94d jo 40 UIBd jo asuas jubjsuoq hi "2 S c a; ci + + + S + + + S + uo;iB4nQ 3 X d V d a * II in in J3 "* 3 a; 5 ft* 3 3 3 -O-C Intermittent over long periods. Usually 12 to 24 hours. 1* ; Hi "* 3 J! ; ? sSy .5 'm.S 3 ! V P3 >, 'So s g D 2 - 3^5 * Da_g| V 3 d O e 'n q > PL 4 r c c c j: c . b c J 3 O 3 3 rt 3 nT M 3 !z c J > -5 3 1. c E . 4 c c > If 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.) (n .> ...... . 1 1%-"**^*V^- , /7 J^'^*' ;fc\Jfc a ^fc^ r iryL^7 __Bfl -.g^v***^. g*.*. h-*-- ' - * -< jf J T - _.' - -t - " _j p. *" " " L - _* ^V'i^L" L*M |U S . M ^ ^^ r V% Jj_ 15 Z /._.._. flfl _____ __ 3 __ 4 E ._ .3_\Q7_.fi H -1- Fig. 13. Chart of case 25. 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 97 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 ^ ' - ' , . r M /4T'//1// / J\/\i 1 i\nf ..^..^.......^...a 10. ' ZKJ -a t- 1 t ' 1 a i / ' vT H -' 1 |fl ^ wbL^W^S " i * * j tr ... it -J " \~ 1M IM 10 ^ j i * " II *^\ 1 \ \ .= 110 7W 1 1 1 1\* 1 1 i n * V 1 \i ! 1 Aj"'1 1. J i ' M^ \.>Vi7* **W JO ,u i Mill " L L " III! 1 |r "\*&% \i 1 ill 1 h rs-bv^V W^Vl^^*' |p i j ' UkkkWigg 1^/D8jj3j3/JMJ3S_ 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 99 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- Iklxu.. m / 1. n 1 1 : 1 1, J_ 1 \- - / /, / j 10 ,.i-'KW""y> S"**""' " "* '". (? 0"*. 1 r - ',".7^7 Z_ I Z s t z 3 ! " : ^Y^itl r " ^ 1 Z J h J l - i" J^ M " *.^ 7 T"'^? jJC - P^^I - *, 1 "H , 1 , ,1 1 I- 1 1 : ,*'* ' ......,., . . * * '". J J 2."---i- -3"_:iicc_srsj -! 5 . , <; 3 !- m rrl 0-- -b !* u -^ 4 'judj 1.A J5__| _. "r^ v .^-TVvv*. Z 3 1> 3lj ^5 Ti u 1 ~ ~sj " Z * $Q I* - Z I . ^ f %a I ! 1 3LJ' 4 : = Z %dL4*zm iy : = Z 4 '% - % ? u "_l3 MA * *. AiSi ** ! Z ^^%-^f^^' r '^M ,.83 W U73j2.Tia22.23p3!a2i Fig. 16. Chart of case 32. 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. jarAm^iz44i>i t^litASuJ. Ssr.-^i ' ~A ; t-^n / 1 ' t- .t:""Mi:"""'" , ""' 104 1M \ "\r j ' L. -8-1 Is !!,VlZkJk7uf jXJ--H-* Zi *u^'if^ 5 ZU *V-*^-^ * E- ...JUA./W- "1 H jr t 1W jj HO | L ;"c I = " if 1 A rV" tip rf!|rt/ ^ ft j p* A ' "1 p* [!/ ^ L- " M' ~ " . f " "* x a ' P-J$ *\J{ *L* J\ m * | r 1 vy,< ** 10 ".<3 js. . # t _ ti\ r_is Fig. 17. Chart of case 23- 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. sci" p "-,3 ,, , f ,<. q /t^T?< mu ->jU [iOu ? ;.fX77 suTrtTjl'v ? * 1 // / / ~/-*//VV/\'' ,Wl 1 i i-i'.nh^Mr "*. - J 2 J^WU^zVV 2 ^ ^r^rpawb-rttr -* ** **:**- yu 3 5^.5<.g.g. .. 1 101' 10s' H ^i- t Stt ;;. .. ywWv wU^'- ^^w^^p?^* " ZlA '.'. - 5 V* ? \ J * V A T % I **- $\jtyj*zi L i^\^Z22 - * F^~ * $ tt ' u ^pi tg_?r & k f ^^ ** . T%_ L ft ^*^ZI \ ' "2WW2SjIo!^' ja * * l|%(UV''' J /i"^V* 10 w^ ' **?*! *^n , i -js^i V* 1 K3 1 Lfll 1 / iL ^ j_KV 6 2 " Fig. 22. Chart of case 42. 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 < JT* ^ ' J? 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 "5 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' 3 3 o-o 3-0 23 5 if i* [>r 5" C Ql 13-po. 2! *i tS-o 1 ^ - Jq ft < < c 5" 3 o- 5 3 3) -- r 1 - -1 D. c E.C e.a O 3 = re E. - " " 2. 3 e3 c o f p c s - 1 c 3 . o o oo 5'oo ccc : o o'i.iocco o ; o 4 -f- + o C I O l_(- Characteristic attitude. Evidence of in- fection (fever, leukocytosis, etc.). M ' ^ p ~ w c 1*1 5'=' 2 - 3 a o y - V K K -: '" K | ^ = *? Mode of relief. 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 42 29 11 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. Ul 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 t \r.>? |u IjIwMj. ' M. i * t 1. 1 tU * < *l . _J_ *. ^M ^L , t?jJ tt * 1 ~-TX- T : - " . t\ m r /V * _ A 1 J r^ X ^ MB **%t = :Li**z*5*!***i =t= 5 = ^ - *^ s* a n r v if | i y /p n/! , *| F ^l n **^' ,r * * M / *. j>* r yV "/ ,"|fl 6: .- A. :fi _[)_,,:- 1 1/3! n, Jb .0; 6 |fl fl fl_ A fcs fcj --- - = : ' - f-TT -t 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 TSTp If iO 3, 1 L iiJ-( 2.T 9 * / / ,/// / / /- / 1 f M* j "*.l *" \% '" t \ |f 1 .L^ 1\ ^ r Zi-* w - ~i?2X*>_ 1 j 1 ""j M i ""1 "* 1 HO j c .< M-t* 7 *U\. ; i .*?**- VA' W f- " t 80 i JO > W 4*lS> - " 1 - K *- **^-*;JP nJfy/i* ," ^y^#??L 6 Zi&\ & Fk -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 43 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 i5 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 c c H ' r r > y_. o 3 6 j n J 3 t 0. 5' P E. 6 3 rt 5' 3- rt P 3 5' p 3^ 5' o'i P S. a 3' r. p c 3 c 1 p 3 3.5- n S 1. 3 0' " * ' 3- C C " ET 1 J) a c c C3 if o 2. 3 S i I? g p S r = 2. 2*3 .;. a2 c p 3 " it p p. p-^ SSg p c p. p s p . r. 9 |i" *| r rr 3 3 c crp; a s? 7-' -1 c rt r, / c > 3 c tf P 3 3 vi p 2 31 < cr rt r. a 3 5'.- p c 2 3 =, p 3 E ' 3" C n p 3' c f re' .= 1 p 3 P 3 a ! 5' S r;3n 5. w - 2 !j. a X > 3" 2 "0 -? p -1' 3 ? a fQ o- 2. 5' ? !* ~S 7 ? H a 5 2 2 n 3 "' w re y, a "* SK Sk 3 c P t 3. 2 " 1 = P w 3.3 K ^ : f; g. T ' < 1 C 5" ] r. c C . ? jf jf ff-a 3 3 3 p ' rt 3 3 J V. 1 3 2 7; I-; 7= 5? p. : z 7, V. X I -= s 3 ~3- 3 2 ? P _ -> 7 E. P. p f! ^ W p f II X X z 5 /' V V. V = T * = z. -. -, 3 3 a ! ~ p 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 IN 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 7 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 II 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 5 2 ...s.a Nil >. Hi 3 P r C o u "** 2, 3 13 8.S o.^ 6 1= I i V fccl a ft bX3 OJ 5 u 6 2.3 s = s 1 -, * "a" "a. = gl g g U.!2jd -s.2 3 =< 3 i-S * .: i- 5 | J o - SSI I * J - c OT3 ] J. c w g i fe'l 3 8 5 J3 - ft 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 70 25 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 1 \ ' <-'- TFRW* *, 1 }/- / \/ \ , A ' fl'/l v> 1/ / .... 5j > U. ...... ... * * i- L 2L 1 1 . 1 ft] ! 1 | i T ... J A K 2 A ^iAt'i l l l- 1 filJ . t? A ? 'Li \*U['' /i^Vs.' 1 i\i > * nT : ! ' 1 1 1 1 1 I ...!..U~j |" . * u 1 " 1 1*0 3 U0 ! 1 1 A 3 i. w "'' * ft i ! I 1 y_ 1 z '. fwx* 1 .. ' L 1 -i r v % 1 , 1 ' I 1 N ; 1 ; ' * 1 , = ** j. f I" ~ 1 .(Mt^t ! i " :f * y .*." (31 j ifli./'l j ' &. .' ?. 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. (c) Retroperitoneal tumors displacing or pushing forward the liver. 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. & 1 ' x.o ,J-fc 7 Sir, 1 t>ij> . ! 1 1 ^ [Stelijbytt: *" * U.U-.mZl. L t-t.y. l\-\ r 1 ['ill "I ] Zl 1 '* I " 1 1 - "*t '" 1 z ;"t _j 1 i > Zu _, d *J\TJ**i. ~f\Tv\ "***\ " < r k . J - " I * "S 1,1 * 11* * r V*^-*^ J , ff,Kiua.i4a^a 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 r. C V3 + + O e rt 72.5 > c .2 3 3S % u V > u V T3 3 M s Usually 0. Sometimes palpable gall-bladder. a a e 1 a c u *- J 3 a . IS a S .3 > _ 3 O w 3 a a _>> "3 1 3 K 4J MS Mode of relief. Rest, depletion, and cardiac stimulation. Morphin. . jl 0. 2 JS < ._-3 |3 . ill "811 * > u to '3 men a cu P< JO .2-2 g 0. ,0 Passage of stone or operation. Absorption or operation. .2 .2 H. a Is. ,0 < .2-2 3. a 8 P. J= So c a 2 -s IIS U a 3 a a 3 a >> 3 = j 3 a i 3 ^ x\c 3 2 V O 3 'J 23 < a M 3 3 C Often other luetic lesions. Relation to food. 5 Relief by food. Recurs when stomach is empty. u c 3 1 1 : | a ' = 8 i 8" M ' 3 : ' 3 c O "a ^3 a u O Fever and leukocytosis. i " X 3 1-1 a + I 1 + O a O a + + + Occasional. Usually absent. Tenderness and spasm. "Marked, wide- spread. a "3 b .3 3 -J "3 Usually absent. In early days of attack. Deep and rarely severe. Slight. J3 55 '3 "3 . j3 J |S Sharp and constant. Comes at regular intervals after meals. Over kidney and along ureter. a 1 2 K u Not at all constant. Over ureter. Usually dull. >- . _>, 3 I "3 U V V 55 Age. Usually past 40. \ V 1 M a ^ i \ v + 1 : < ! a. : *3 u "^ 3 Causes. Passive congestion of Acute cholecystitis | 5 a .5 u 1 u . - "o - 3 ^ u ] a (r. Pneumonia or pleural inflammation . . . Perinephric abscess . 3 O >, O. O 1 > 1 > 1 LT 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. (c) Chronic appendicitis. (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 (c) One cannot grasp this tumor bimanually, while bimanual pal- pability is especially common in renal tumors. (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 21 17 5 4 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. 18 274 DIFFERENTIAL DIAGNOSIS .& < & c . o SB J3 3 M W.O ~% 2 c Si?-? Sv o So 5J H T^"' T3 O > X a> he S & " ^= . V SO'3 S - >."" u C = -a - uc !|<~ g'5 s bo Sb.e . ' u -~ ^ o 5^ c 2 3 *- Qj " &> t*^ a tf S i> b J= o. fc 3 :s u 5 = rt o - ..a So ||| > t/; O rJl ^ s- Causes of Left Iliac Pain PUS-TUBE AND PELVIC ADHE- } SIONS ECTOPIC GESTA- TION 29 DYSMENORRHEA H9B 24 OVARIAN CYST) WITH TWISTED [ HH 21 PEDICLE J URETERAL STONE 4 CANCER OF SIG- MOID } 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 - teFTTT^n rrxrTTij r-Ud - / 1 / ! \, ,.,-U- - 1 i~\ "*. ; "\l - 10 " 1 1 U 1M | q_ " ""' 1 d I m \ 1 . ^7 . ' " "'1 33 *->w X i Mi ** 1 r 1 M * ' ,y> " " 1 i . 'i! r L ' -* ' : n " " . . tort > . . . . t * : J j 1 V V f\N fcAW " 1 ' -U- " u : ^ra < : ..0 . .a [T3| io| @L= Fig. 43.- Chart of case i^S. 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 ar*,] 1 v 1" .- v-. >-.-- - * 4 4-1/ 1 , l --W--M- ,..*..lW.,Vi 4^. : -. '," ^tv"^ / ji x ttlZl I in' 12 Zt j-<- i_-j *" . . d T" - 1 '" n ! j 1- ,w I I " * ^ t^lt -.- ~pp *M r v^EV -^.^ I I u i . : #aT J 1 nu-p^f a* to r ""PKJ" -1 ''1 *E Y'i J rr ,' 1^-3 e S.V3J3 ajsila. lig. 44. Chart of case 139. 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. &V ^ 7 ! *L* U,.\,j, t - r.^ - . I T T-- 1 |l 103* 10* iwi 100' r (;' M* W IM 1(0 ISO IM no too to so M so as 90 tc to . 1 C / -* V W*v *~~? / T* 1 : r -< 2 j : * <$ i *\ i ' ' V f I ' i ? - -: < I ; : : I 1 1 \j 1 Ti p i d tn -^ Fig. 45. Chart of case 141. 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 a O *1 n H _ < a v- n 2 -1 5" 3 - X 3 1 t a * "5 1 p ft_ s rv j 5 < O. 1 n f S.o, 3 S c O 73 p *< W) W =r C n jj. 3 rc P 5 z 5' I 5 C IK! * 5 O S - 3 SL p d c 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. \Z't)/>\l/X>J.lj$ jfJi ~ 1> // /kTrf ' 1 * in* L w I lot' f ' r M' ' ISO HO IK t lw -; 110 *< 100 to so 70 OS to ; * m U M > ' | i * ? ** ' 1 s .' ^JZ^ t* \K *\ 'AS r - j 1 1 'i Fig. 47. Chart of 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- 1 iffoT 1 ! 1 1 1 1 1 1 J 1 1 J J I J J 1 1 J 1 > Ur tj la 4 i J v )' i 7 7 ; / 1/ 'L 'i /* '\' ' 11 '.'. V//W/ ////////- /M-fJiii/- 'I 11 nil r r / Z-u - ] Tt ""L 1 S".LL7^2W^ : i .r * 1 IZ\ Vljll j .. -t --i *- -*-s tw- - #- i-i-a -M ^j-*-*-( - f*fi*^Vtf%^ -4- . " Z\ 2* '$* - ZjiJ m T- _ p* ^ ;<-*-- ^%Y^VfuT Z _h : r ^n ^t-i-* < T ^ *' J ; 7 -V 1 ' ! i - "1 f i r i a t TV jl f l-i '* /I "i/j i^ ^ ^ < j[ . 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 33 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- 34 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- Mm - .Jtmr z * LtAlft^Lt^Z % 2- ' r Ki ( ' ' H* / i * * n, I^^ji i * i r " 1 "! 1 L * 41 r " i u. \i Z *-A A 7 ' l> ^ ft l\n n,V IN #" Z * * ' - ^ *i*VV** r . w*J,. " ' r ^ i , * * . 7. Ill 1 ""l f " i * " 1 i ! i ! i ru iw 2 U ! k^f* ; V **^ i FTV 1 = " + : r 'f : pi^jffiU ^ vw f i I mffiw K Lv ^*-^| ... i *^ 1 ' * i < ,"* * * V * 1 * K iM> T (iV| i\A*'.n* i = " i * 1 ;."a a '. i i H l<3 /3' 1 /J /^ : i/S Fig. 51. Chart of case 151. 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 37 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. rs?r 1 1 a Liu " X*" . _J W 1 1 ' "*' J 1 i 100' V- fci=*5 I "' J* _. ! ^2lJ 1 XI >.* HH 76 d " 1 M ! * -m S u V*d m ngjU Fig. 52. Chart of case 153. 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 3i 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. &.-;., j ajj^jjjjjj M JXLj.jj,.uj. KSSSpSSXSEEffip&B ^7^3 1'1'H M J -"U M44 4^ |::::":::::::::::|:::: 1 ,u ^Ep^ftt 1 1 777.--;-' h :-: . t >! 1 5 Jv ~r -? -fv^- -*** ~ ^ r 1 II II 1 1 J i^'rf k r j nt i - * - i i ~ "C r^-. -+- -t -1--1- c 1 1 "F ' \ 1 ' 'II ! i : 1 ' ..". j 1 1 1 It T ' f ' Up . W~\ r 5 1 H 1 til M 1 M 1 f J. n Tf^lfe-Wff# :i4uJdrmi.i3..i wr Ed 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 3 K n 3 1 5- a 2 3] r 5 3 V 3 3 3' Causes. Damp, cool weather. 3 3 w 3 a a n o c S- w 3 5' -3 g Alcoholism and other causes of low vitality. 3 c c c 3 5 Neuroses. Debility. " Cribbing." Favoring conditions. 3- Shooting, si 3" O w Dull. I pressure ste Z S- rt Nipple rt with I Dull, I constipa 3' 3 3 o S "2. 3 - "'^ P 3 c 3 reasc spii um. | = atbii 3 -a 3 r. - S" a O. Oq ? ^ ~ p n 2 3 3 S 2 s ~ C- ' 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 20 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* 1 i in ii ii I ! i i *sl *""* . E -- i BS' M' K* HO 130 120 100 00 80 to SO a 10 It m M ' " Ay ,* * \ ," . .* , , 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. (c) Digestion, especially if it be impeded in any way. (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 si 1 3. 2 3 2 t ? s > 3 t 3 5 ff c> o = - 5 3 n p r ^ =- a. 1 o 3" 3 5 ! . c 3 p u> n n 3 > O 3 *? o 3" p n-x ST sr p ' o' S' r ? |q & 3 o P 3 p 3 2 "^ n 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 56 46 44 3 I 29 14 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, f S-ril 'TT "" " "" - r=h h i ! 7 [i 2 '">'' 'J * *f n 5 A /Jji i -d j- -j( j i j / -ii J * il^-'/ ' * rf * * * * 1 "pn 2'jf!" ' 3 ll,|j" . ^ 101 . lia- " 1 fl Jj/Y ' * .it ^*^~j^Lt7vi 2 V-2--,-, ^l-,*,^? P^^J^/W%^t..ptJ._L. . ! J .1.1 .r.N.tal^^K^aiJipL^U f -'! . 1 [ { _J JL _, 't_C -J ;' " 31 ~v3 4S-^iaZL j ! r I M UM j4: f^^ii _y H _*5S _,^ F 3 1 ^ ] m ILQ^ uiWZ I U *;[ C, // ? , a a '-%<-> C -iSEil - - 4 ^ct **. g j i* i 1 i - ^43 -UN-.* 1 " 3 2 1 t \ no $<" '4-i' * - 1 * 1 ^ o r " S - t - -t ' 2 ' *>jpl 4. v 5 r 4 4 m it** n oY\ \ v ' J c ? c - m !*- "- 2-f- N >i >4 u .. : 1 W- H ?n^- l u ,] _^.-^ *">, ,j . 1 r ,.^" > N ,.. _ ... , -p* - hi 1 _i Fig. 58. Chart of case 1 79. The uppermost line represents the temperature; the 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. IrM ., ) '- 7 / /<- / /j ttf-HM. '' / 1 / // 101' 1M- KM' >' 1M - ior m- " ; M" It' IH HO 1M 110 100 M M 10 10 40 31 SO 10 " .... V 1 .. < l SJ 1 - I X u 1 1 1 } I' H % 1 ' - tf| h B Fig. 60 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 B 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 * '. A H - " * ^_^2i^v - " I2ttt 2 iZ A Tt^ \i . . H " ^Vj^_w*^% - l v -, -.-^2 * n ..^+ rr2~-- s-ia^P-- - -5s- a s s-i^**.? 11. 1 ,w "7 7 ~j "* ~jt~ *~ r *\ ~ 1 Sj 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- - i^ - \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. ar /V it /I 1} / ' ' E * - a IM' Mf' me mf if m- OT ' " tr u- r 1M 1*0 HO 1 no 100 to ft M M N \ a I J * J . * J ,1 i H U M U M m to 11 H .' 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 1 p T'b r > H~"~! til / i f i. M 107' 1M* 104" 1M' 1M' tar m' r tr 1M 1H> ISO no 100 M M :o 40 1 f]\ a 10 u v> tl II to - V fl ' ; L 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- 37 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 r 18 19 20 zr KT <> III mum \ - '2- -** V*t ; " ' l . '4\ x 1 * " 1 :N YT* ! #T! 1 ! ; Ml! I >. \, .73. _ ->3._ ,: ; ....>;._.J5 Fig. [88. Chart of case 366. 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. (c) Tumors of the larynx. (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 CJ Lu>ru->( Jo >i 1 JL J s (, *' ' 1 J.JJ. M. " J. JL n - 1 H : 1 . mi ma IIIIUIIIII in '**. m u* , ") " -^u*f&2i 2^wV"* "^ Z w ^ f ! w < *^s SZ js r ! T . K ^-t- +p . Z 2 TV 5 ^ ^ 5 " J ~j * * "S * A a , 353 P$i ti ^m " , -, \ f * &> 9 s w ;r Iff * Jp\: -. ' &*"* \ L * /T^^H/V^ -%^WL _jL 1 r P 1 r L io*>" /> -> { |73| (73 1 73 Fig. 189. Chart of case 356. 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 previous 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. (c) So-called catarrhal form. 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 26 17 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- ////- - 1 ,. ' ** * * p * a * . * 0* e <* . . . ! J ur ur j r A -a -.---, -_-* J5JJ/L ZJZj A ._. - - ^.p^^ft- tttt i - I m =4 * 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 J 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. (c) In the gall-bladder or bile-ducts themselves. Beyond this we cannot go. 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) Tuberculosis, perhaps involving the genito urinary tract. ^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 , 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. 17 738 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 74 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 ^SHh !TT -> i 1 ,0 ,, ,*-, 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 SAUNDERS' BOOKS on Pathology, Physiology Histology, Embryology and Bacteriology W. B. SAUNDERS COMPANY 925 WALNUT STREET PHILADELPHIA 9, HENRIETTA STREET COVENT GARDEN, LONDON LITERARY SUPERIORITY '^HE excellent judgment displayed in the publications of the house * at the very beginning of its career, and the success of the mod- ern business methods employed by it, at once attracted the attention of leading men in the profession, and many of the most prominent writers of America offered their books for publication. 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It contains chapters on the bacteriology of plants, milk and milk-products, air, agriculture, water, food preservatives, the processes of leather tanning, tobacco curing, and vinegar making ; the relation of bacteriology to household administration and to sanitary engineering, etc. Prof. Severance Burrage, Associate Professor of Sanitary Science, Purdue University . " I am much impressed with the completeness and accuracy of the book. It certainly covers the ground more completely than any other American book that I have seen." Buchanan's Veterinary Bacteriology Veterinary Bacteriology. By Robert E. Buchanan, Ph.D., Pro- fessor of Bacteriology in the Iowa State College of Agriculture and Mechanic Arts. Octavo, 5 16 pages, 214 illustrations. Cloth, $3.00 net. THE BEST PUBLISHED Professor Buchanan discusses thoroughly all bacteria causing diseases of the domestic animals. He goes minutely into the consideration of immunity, opsonic index, reproduction, sterilization, antiseptics, biochemic tests, culture-media, isolation of cultures, the manufacture of the various toxins, antitoxins, tuberculins, and vaccines that have proved of diagnostic or therapeutic value. Then, in addi- tion to bacteria and protozoa proper, he considers molds, mildews, smuts, rusts, toadstools, puff-balls, and the other fungi pathogenic for animals. B. F. Kaupp, D. V. S., State Agricultural College, Fort Collins. " It is the best in print on the subject. What pleases me most is that it contains all the late results of research. It fills a long felt want." HISTOLOGY AND PHYSIOLOGY. Diirck and Hektoen's General Pathologic Histology Atlas and Epitome of General Pathologic Histology. By Pr. Dr. H. Durck, of Munich. Edited, with additions, by Ludvig Hek- toen, M. D., Professor of Pathology in Rush Medical College, Chicago. 172 colored figures on yj lithographic plates, 36 text-cuts, many in colors, and 353 pages. Cloth, $5 .00 net. In Saunders' Hand- Alias Series. This new Atlas will be found even more valuable than the two preceding volumes on Special Pathologic Histology, to which, in a manner, it is a com- panion work. The text gives the generally accepted views in regard to the signifi- cance of pathologic processes, explained in clear and easily understood language. The lithographs in some cases required as many as twenty-six colors to reproduce the original painting. Dr. Hektoen has made many additions of great value. W. T. Councilman, M. D., Professor of Pathologic Anatomy, Harvard University. " I have seen no plates which impress me as so truly representing histologic appearances as do these. The book is a valuable one." Howell's Physiology A Text-Book of Physiology. By William H. Howell, Ph.D., M. D., Professor of Physiology in the Johns Hopkins University, Balti- more, Md. Octavo of 1018 pages, 306 illustrations. Cloth, $4.00 net. THE NEW (4th) EDITION Dr. Howell has had many years of experience as a teacher of physiology in several of the leading medical schools, and is therefore exceedingly weil fitted to write a text-book on this subject. Main emphasis has been laid upon those facts and views which will be directly helpful in the practical branches of medicine. At the same time, however, sufficient consideration has been given to the experimen- tal side of the science. The entire literature of physiology has been thoroughly digested by Dr. Howell, and the important views and conclusions introduced into his work. Illustrations have been most freely used. The Lancet, London " This is one of the best recent text-books on physiology, and we warmly commend it to the attention of students who desire to obtain by reading a general, all-round, yet concise survey of the scope, facts, theories, and speculations that make up its subject matter." SAUNDERS' BOOKS ON McFar land's Pathology A Text-Book of Pathology. By Joseph McFarland, M. D., Pro- fessor of Pathology and Bacteriology in the Medico-Chirurgical College of Philadelphia. Octavo of 856 pages, with 437 illustrations, many in colors. Cloth, $5.00 net; Half Morocco, #6.50 net. THE NEW (2d) EDITION You cannot successfully treat disease unless you have a practical, clinical knowledge of the pathologic changes produced by disease. For this purpose Dr. McFarland's work is well fitted. It was written with just such an end in view to furnish a ready means of acquiring a thorough training in the subject, a training such as would be of daily help in your practice. For this edition every page has been gone over most carefully, correcting, omitting the obsolete, and adding the new. Some sections have been entirely rewritten. You will find it a book well worth consulting, for it is the work of an authority. St. Paul Medical Journal " It is safe to say that there are few who are better qualified to give a resume of the modern views on this subject than McFarland. The subject-matter is thoroughly up to date." Boston Medical and Surgical Journal " It contains a great mass of well-classified facts. One of the best sections is that on the special pathology of the blood." McFarland's Biology: Medical and General Biology: Medical and Genera!. By Joseph McFarland, M. D., Professor of Pathology and Bacteriology in the Medico-Chirurgical Col- lege of Phila. i2mo, 440 pages, 160 illustrations. Cloth, #1.75 net. ILLUSTRATED This work is both a general and medical biology. The former because it dis- cusses the peculiar nature and reactions of living substance generally; the latter because particular emphasis is laid on those subjects of special interest and value in the study and practice of medicine. The illustrations will be found of great assistance. Frederic P. Gorham, A. M., Brown University. " I am greatly pleased with it. Perhaps the highest praise which I can give the book is to say that it more nearly approaches the course I am now giving in general biology than any other work." BA CTERIOL OGY AND HISTOL OGY. McFarland's Pathogenic Bacteria The New (6th) Edition, Revised A Text-Book Upon the Pathogenic Bacteria. By Joseph McFar- land, M. D., Professor of Pathology and Bacteriology in the Medico- Chirurgical College of Philadelphia, Pathologist to the Medico-Chirur- gical Hospital, Philadelphia, etc. Octavo volume of 709 pages, finely illustrated. Cloth, $3.50 net. FULLY ILLUSTRATED This book gives a concise account of the technical procedures necessary in the study of bacteriology, a brief description of the life-history of the important patho- genic bacteria, and sufficient description of the pathologic lesions accompanying the micro-organismal invasions to give an idea of the origin of symptoms and the causes of death. The illustrations are mainly reproductions of the best the world affords, and are beautifully executed. In this edition the entire work has been practically rewritten, old matter eliminated, and much new matter inserted. H. B. Anderson, M. D., Professor of Pathology and Bacteriology, Trinity Medical College, Toronto. " The book is a satisfactory one, and I shall take pleasure in recommending it to the students of Trinity College." The Lancet, London " It is excellently adapted for the medical students and practitioners for whom it is avowedly written. . . . The descriptions given are accurate and readable," HilFs Histology and Organography A Manual of Histology and Organography. By Charles Hill, M. D., formerly Assistant Professor of Histology and Embryology, Northwestern University, Chicago. 121110 of 468 pages, 337 illustra- tions. Flexible leather, $2.00 net. THE NEW (2d 1 EDITION Dr. Hill's work is characterized by a completeness of discussion rarely met in a book of this size. Particular consideration is given the mouth and teeth. Penniylvania Medical Journal " It is arranged in such a manner as to be easy of access and comprehension. To any contemplating the study of histology and organography we would commend this work." SAUNDERS' BOOKS ON GET A THE NEW THE BEST /\ HI F 1 C fc H STANDARD Illustrated Dictionary New (6th) Edition, Entirely Reset The American Illustrated Medical Dictionary. A new and com- plete dictionary of the terms used in Medicine, Surgery, Dentistry, Pharmacy, Chemistry, Veterinary Science, Nursing, and kindred branches ; with over ioo new and elaborate tables and many handsome illustrations. By W. A. Newman Dorland, M.D., Editor of " The American Pocket Medical Dictionary." Large octavo, 986 pages, bound in full flexible leather. Price, $4.50 net ; with thumb index, $5.00 net IT DEFINES ALL THE NEW WORDS IT IS UP TO DATE Dorland' s Dictionary defines hundreds of the newest terms not defined in any other dictionary bar none. These new terms are live, active words, taken right from modern medical literature. It gives the capitalization and pronunciation of all words. It makes a feature of the derivation or etymology of the words. In some dictionaries the etymology occupies only a secondary place, in many cases no derivation being given at all. In "Dorland," practically every word is given its derivation. In "Dorland" every word has a separate paragraph, thus making it easy to find a word quickly. The tables of arteries, muscles, nerves, veins etc., are of the greatest help in assembling anatomic facts. In them are classified for quick study all the necessary information about the various structures. In "Dorland" every word is given its definition a definition that defines in the fewest possible words. In some dictionaries hundreds of words are not defined at all, referring the reader to some other source for the information he wants at once. Howard A. Kelly, M. D., Johns Hopkins University, Baltimore " Dr. Dorland's dictionary is admirable. It is so well gotten up and of such convenient size. No errors have been found in my use of it." J. Collins Warren, M. D., LL.D., F.R.C.S. (Hon.), Harvard Medical School " I regard it as a valuable aid to my medical literary work. It is very complete and of convenient size to handle comfortably. I use it in preference to any other." PATHOLOGY. Stengel's Text-Book of Pathology The New (5th) Edition A Text-Book of Pathology. By Alfred Stengel, M. D., Professor of Medicine in the University of Pennsylvania. Octavo volume of 979 pages, with 400 text-illustrations, many in colors, and 7 full-page colored plates. Cloth, $5.00 net; Sheep or Half Morocco, $6.50 net. WITH 400 TEXT-CUTS, MANY IN COLORS. AND 7 COLORED PLATES In this work the practical application of pathologic facts to clinical medicine is considered more fully than is customary in works on pathology. While the subject of pathology is treated in the broadest way consistent with the size of the book, an effort has been made to present the subject from the point of view of the clinician. In the second part of the work the pathology of individual organs and tissues is treated systematically and quite fully under subheadings that clearly indicate the subject-matter to be found on each page. In this edition the section dealing with General Pathology 'has been most extensively revised, several of the important chapters having been practically rewritten. A very useful addition is an Appendix treating of th' technic of pathologic methods, giving briefly the most important methods at present in use for the study of pathology, including, however, only those methods capable of giving satisfactory results. The book will be found to maintain fully its popularity. PERSONAL AND PRESS OPINIONS William H. Welch, M. D.. Professor of Pathology, Johns Hopkins University, Baltimore, Md. "I consider the work abreast of modern pathology, and useful to both students and practi- tioners. It presents in a concise and well-considered form the essential facts of general and special pathologic anatomy, with more than usual emphasis upon pathologic physiology." Ludvig Hektoen, M. D., Professor of Pathology , Push Medical College, Chicago. " I regard it as the most serviceable text-book for students on this subject yet written by ar. American author." The Lancet, London "This volume is intended to present the subject of pathology in as practical a form as pos- sible, and more especially from the point of view of the ' clinical pathologist.' These subjects have been faithfully carried out, and a valuable t<-xt-b<>..k i- the result. We can most favorablv recommend it to our readers as a thoroughly practical work on clinical pathology." SAUNDERS' BOOKS ON Mallory and Wright's Pathologic Technique New (5th) Edition, Revised Pathologic Technique. A Practical Manual for Workers in Patho- logic Histology, including Directions for the Performance of Autopsies and for Clinical Diagnosis by Laboratory Methods. By Frank B. Mallory, M. D., Associate Professor of Pathology, Harvard Univer- sity ; and James H. Wright, M. D., Director of the Pathologic Labora- tory, Massachusetts General Hospital. Octavo of 500 pages, with 152 illustrations. Cloth, $3.00 net. WITH CHAPTERS ON POST-MORTEM TECHNIQUE AND AUTOPSIES In revising the book for the new edition the authors have kept in view the needs of the laboratory worker, whether student, practitioner, or pathologist, for a practical manual of histologic and bacteriologic methods in the study of patho- logic material. Many parts have been rewritten, many new methods have been added, and the number of illustrations has been considerably increased. Among the new matter are the following : Smith's staining method for encapsulated bacteria ; the antiformin method for detection and cultivation of tubercle bacilli ; Musgrave's and Clegg's method for the cultivation of amebic ; Wright's method for staining myelin sheaths in frozen sections ; Ghoreyeb's method for spirochetes ; Alzheimer's method for cytologic examination of cerebrospinal fluid ; Giemsa's new method for protozoa and bacteria in sections, and the Wassermann-Noguchi tests for syphilis. PERSONAL AND PRESS OPINIONS Wm. H. Welch, M. D., Professor of Pathology, Johns Hopkins University, Baltimore. " I have been looking forward to the publication of this book, and I am glad to say that I find it a most useful laboratory and post-mortem guide, full of practical information and weii up to date." Boston Medical and Surgical Journal " This manual, since its first appearance, has been recognized as the standard guide in patho- logical technique, and has become well-nigh indispensable to the laboratory worker." Journal of the American Medical Association " One of the most complete works on the subject, and one which should be in the library of every physician who hopes to keep pace with the great advances made in pathology." EMBRYOLOGY. Heisler's Text-Book qf Embryology Third Edition 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.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 111 urn 111 111 111 ii inn mi mi A A 000 097 196 WBlUl Cll6d 1912 Cabot, RicJhard C v.l Differential diagnosis Cabot, Richard C Differential diagnosi: WBlUl Cll6d 1912 v.l CALIFORNIA COLLEGE OF MEDICINE LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664